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The American Fertility Association’s Monthly Newsletter

June 30, 2008

FEATURE WELL

Dr. Robert Greene

Laurie Tarkan

WHAT YOUR HORMONES TELL YOU ABOUT FERTILITY
(Part 2)
Reproductive endocrinologist Dr Robert Greene and co-author, New York Times’ health writer, Laurie Tarkan finish the conversation they started in last month’s Connections, about the role of hormones in fertility. This is one Q&A that you just might find worth eavesdropping on.

Dr Robert Greene’s just-published Perfect Hormone Balance for Fertility: The Ultimate Guide to Getting Pregnant, is a book for anyone trying to have a baby, whether they’re just starting out or having trouble getting pregnant. Dr Greene has seen, through his research and his practice, that fertility can be compromised by hormonal imbalances caused by lifestyle factors, like being overweight, overstressed or overtired. He and his wife, Morgan, did use Assisted Reproductive Technology to have a child as well, so he speaks empathetically from his personal conception trials as well.

Laurie Tarkan: Where should someone embarking on fertility treatment begin?

Dr Greene: One of the first questions I ask all my patients, and I encourage everyone to consider, is this: In an ideal situation, what would your family look like, how many children would you have, how far do you want them spaced apart and how important are these goals? By the time people get to see a specialist, many are already so frustrated and might say, ‘at this point, we’ll settle for one child,’ or, ‘I’m getting so old, I want to have two at one time.’ These are compromises. If you think of your goals, then you can create a plan and see how reasonably close you can come to achieving that goal. If a center is able to tailor the treatment to each person’s unique goal, that’s where the personalization comes.

LT: What do you mean when you say fertility centers do not individualize treatment and rely too heavily on protocols?

Dr G: Most centers have less than 10 protocols, which are like recipes. You do this combination of drugs at this dosage for X number of days. There are also diagnostic protocols—lists of tests you need based on your profile. Trying to fit all the different types of people into a handful of different approaches is not giving people the individualized attention they need. The other problem is that because we’re in a rapidly changing field, you have to be willing to change with the evolving research, and not rely on the same protocols you did five years ago. At my center, I start out with about two dozen protocols, but use each protocol as a starting point, and then say here’s how we want to change it in order to meet your needs.

LT: You have a very thorough section of the book on assessing your own fertility. Why can’t people leave this to the reproductive endocrinologists to do?

Dr G: One of the things that is so troubling to most couples is feeling a loss of control. Most people feel incapacitated by that. They want to regain that power and I think they should. I always tell people the best treatment paradigm is when the patient and health care provider form a partnership. Patients should be able to have the ability to ask questions and be comfortable with the answers they get. By understanding your factors and what options you have to treat them, you will have more control over your fertility. I’ve seen a lot of anger from patients because their prior doctors didn’t offer a treatment I was offering them, or because their doctor refused to give them certain treatments or bother to explain why they’re refusing. When you understand your own fertility better, you can better avoid these situations.

LT: If you’re already in the midst of infertility treatment, and it hasn’t worked yet after a cycle or two, what advice do you have?

Dr G: Review everything you’ve done. The primary goal of fertility treatment is to achieve a pregnancy, but when a treatment fails, the secondary goal is to learn something from what you did. A lot of healthcare providers just do the same thing over and over again, believing that if they try it enough times, it will work. That’s a missed opportunity. If you review what worked and what didn’t, we can say here’s what we should do differently the next time. After Morgan and I went through one IVF cycle and failed, the very first thing that was suggested was that we should get more aggressive and do more things and I said, no, no, no, we had good egg quality and a high fertilization rate. We learned that Morgan produces great eggs and my sperm fertilizes those eggs. With those positive results, I recommended that we should go back to doing intrauterine insemination rather than IVF. They laughed at us, but we did that and Morgan became pregnant.

LT: When you’re in the midst of treatment and getting all these different hormones, why do a person’s “natural” imbalances make a difference? Wouldn’t these hormones override your own imbalances?

Dr G: If you go back to the concept of the mobile, every hormone affects every other. In the process of doing treatment, in some ways, we create a greater imbalance. You’ll go from a deficiency in one hormone to an excess of that hormone. That’s why it’s so important that you do pay attention to your lifestyle—your diet, your stress levels, your sleep. For example, stress hormones can prevent implantation of healthy embryos. It’s important to have as balanced hormones as possible as a baseline for treatment. Plus, the goal of fertility treatment is to get pregnant. When pregnancy begins, you want to be balanced so you can have as healthy a pregnancy as possible.

LT: Both you and Morgan live a healthy lifestyle, you’re not overweight, you both exercise, you do yoga. So what do you attribute your own infertility to and how do you think you overcame your own issues?

Dr G: It was age for us. The thing that biology cannot overcome is age. We used enough treatment to help us overcome the limitations of our age. We did have a healthy diet and lifestyle, but we made it a little bit healthier. We dined out less. We don’t normally take vitamins, but while we were going through treatment, we both took vitamins and minerals that enhance fertility. Morgan also started yoga and paid more attention to the stress in her life. The reality is that many couples in their 40s are still not getting pregnant with standard treatments. I believe it’s because they’re only relying on the treatment and not doing all of these lifestyle factors we talk about in the book. There’s a lot more to fertility treatment than what happens in the office.

Robert Greene, MD, is the medical director of the Sher Institute for Reproductive Medicine in Northern California.

Laurie Tarkan is a health writer for the New York Times.

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The Silver Lining of Infertility
Jill S. Browning

After three years of trying desperately to have a baby, there were only two people who were genuinely happy for me after hearing the news that I was finally pregnant. One was my brother-in-law, a man who is a faithful follower of scripture, powerfully pro-Jesus and pro-life, and my now-deceased grandma, who was 80 at the time. And the reaction from other family members and friends? They weren’t so thrilled.

You see, I wasn’t just pregnant. I was overly pregnant. The fertility drug “Repronex” had caused my ovaries to explode with ripe follicles, and the timing of the intrauterine insemination was impeccable. The result: I was pregnant with triplets.

Unlike others, my grandma and brother-in-law didn’t grasp the full implications of what being pregnant with triplets meant. It was a high risk proposition all the way around. A pregnancy with higher-order multiples, defined as triplets or more, can be fraught with complications. Not only was there more risk to me during pregnancy from conditions such as high blood pressure and diabetes, but there was the almost guaranteed result that my husband and I would have premature babies—if they even survived at all. After making it through a complex pregnancy, there was then the reality of caring for three infants. That it would be disruptive to our lives was a serious understatement.

Remembering my dad’s remark after he heard the news still stings me, eight years later. He asked, rhetorically, “What do you say when your daughter tells you she’s pregnant with triplets?” (I understand now that he was just worried about my health.) He passed the phone to my mom, who was speechless, which made for an awkward conversation. My mother-in-law also floundered, stunned. Not knowing what else to say at our announcement over brunch at the country club, she quickly turned the topic to that morning’s funny papers.

I can’t say I blame anyone for their natural reaction to the unnatural fact that I was with child, three times. But after going through infertility treatments, the last thing you want is to be different. You’ve felt different for years, waiting on the sidelines while every friend and co-worker announces that she’s pregnant--and you’re still not. You go to baby showers, wishing the mom-to-be well and also wishing that you could stop feeling intense jealousy. The pain and emptiness are only magnified when questioned endlessly by family members. (Just when was I going to give my niece a cousin?)

I thought I could lay infertility to rest once we had finally achieved our goal of pregnancy. But ironically, even though we were going to have more children than we had ever even dreamed of having in the first place (two seemed ideal), infertility was still a presence in my life. I wanted to shout with joy that we were going to be parents, at last. Instead, I was ashamed that we had messed with nature. My stomach bulging with babies, measuring weeks ahead of normal, our unique pregnancy opened us up to all sorts of comments and stares.

Ah, but the doctors had a cure for that. There was a chance to retreat to normal. At my first obstetrician appointment, the high-risk pregnancy doctor let me know that “selective reduction” was an option for us. It is a procedure that involves injecting poison into one of the embryos to stop its heartbeat, conveniently reducing triplets to twins. The clinical term couldn’t disguise the ugliness of what it meant. It meant aborting one of the babies that we’d worked so hard to meet. We couldn’t do it, and felt relieved that we weren’t pregnant with more than three. If we had been pregnant with more, we might have been resigned to sign up.

Few other mothers-to-be are presented with making this heartbreaking choice, other than the ones who have gone through infertility, since triplets are rarely conceived without fertility drugs.

Even if I hadn’t been pregnant with triplets, I know pregnancy wouldn’t have been entirely enjoyable, since infertility had trained my soul to expect disappointment. I believed that every twinge, even if my stomach was grumbling for food, was a miscarriage in the making. Every time I went to the bathroom, I inspected the toilet paper for traces of blood with the same intensity as a member of a CSI team. I delayed setting up the nursery until my sister literally shook me into reality. “You are going to have three babies—you need diapers!” she implored.

After the babies were born, I thought I could become part of the normal parenting scene. As an “obvious infertile” pushing a triplet stroller, though, I had to deal with unwanted attention and ignorant questions at every turn (“Did you do it three times in one night?” strangers asked). I’ve also felt another significant, distinct separation from other moms throughout the years, though. I will never identify or align myself with moms who grumble about pregnancy or their naughty two-year-old, for example. Not that it’s their fault, but parents whose kids come as easily as the morning newspaper will never understand the desperation my husband and I felt when facing the possibility of childlessness. As a result, I resist as much as possible being, or being around, a complaining or cavalier parent. Not that every day is an image of one big happy family for us--far from it--but we do have a constant appreciation that it is a privilege for us to have children in our lives at all. The childless alternative was almost our reality.

As crazy as it sounds now, I’m thankful for infertility. It improved my parenting personality and has made me a better mother. I’m more patient. I recognize that tantrums are temporary and that whining is always solved by reading a good book aloud. My strong preference for perfection and control has been tempered forever. Just as I couldn’t control when I had kids, I now understand that I can’t always control three crying kids at once, or their muddy shoes, or lack of musical aptitude. I’m not perfect—and neither are my children. To me, after infertility, parenting well is about being able to live without perfection--to see other people’s flaws, and to love them anyway.

I suppose that’s why my grandma and brother-in-law were elated. They were unaware of the downside of our pregnancy predicament. It wasn’t going to be perfect. They simply relished the fact that new life was on its way. Whether it was one baby coming or three didn’t matter. Life was life. There were new people to meet, flaws and all.

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