Fertility: Trying to Conceive, Cycle-Tracking and When to Seek Care

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob-Gyn time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi, everyone. I'm your host, Dr. Erica Newlin. Welcome to our very first episode. During this season, we are focusing on topics related to infertility. On this episode, I'd like to welcome Dr. Christine Hur, who'll be talking to us about trying to conceive and when to see a doctor. Hi, welcome Dr. Hur.

Christine Hur, MD:

Good morning. How are you doing?

Erica Newlin, MD:

Doing great. Can you tell us a little more about your role at the Cleveland Clinic and a little more about your background?

Christine Hur, MD:

Yes. So, I am the senior, the third-year reproductive endocrinology and infertility fellow. What this means is that I went through four years of OB/GYN residency actually with the host here, Dr. Erica Newlin, and subsequently went on to do an additional three years of training which I'm gonna complete in the summer. These three years have been focused on reproductive medicine, reproductive surgery, and helping women and couple grow their families.

Erica Newlin, MD:

That's great. Congrats on almost being done.

Christine Hur, MD:

Thank you so much. I really appreciate it.

Erica Newlin, MD:

And just to clarify, we'll be using REI to mean the term reproductive endocrinology and infertility.

Christine Hur, MD:

Yes, that sounds great.

Erica Newlin, MD:

So, can you discuss a little more detail in what an REI does on a day-to-day basis, and how that might differ from an OB/GYN that someone might see for their annual or family planning visit?

Christine Hur, MD:

Yeah. So, an REI has really focused their scope of practice into seeing couples and women and other individuals with primarily infertility or recurrent pregnancy loss. Here at the Cleveland Clinic, we have a really strong reproductive surgical field, and so we also additionally see patients with fibroids, endometriosis, really anything that could affect one's fertility. So normal week for me includes one or two days of surgery, taking out fibroids, treating women with endometriosis, one or two days of IVF, or in vitro fertilization. So that includes procedures like embryo transfers and oocyte, or egg retrievals, and then one to two days of clinic where I get to see and counsel individuals about how we can best achieve their goals of growing their family.

Erica Newlin, MD:

Great. So, someone may see their OB/GYN as a first line to just establish the relationship, and then maybe get a little bit of the workup done if they're struggling to conceive, and then after that, go on to see you to help.

Christine Hur, MD:

Yes, exactly right. So, the OB/GYN specialists here are excellent at doing a first preliminary evaluation as well as letting patients know if they need to see us sooner rather than later.

Erica Newlin, MD:

And then when someone is starting to try to conceive or maybe having difficulty conceiving, what kind of lifestyle interventions would you recommend as a first line?

Christine Hur, MD:

Yeah. So, you know, our goal as REIs is not only to get individuals pregnant, but also to have them have a healthy and successful pregnancy. And so, a lot of those things' kind of fall hand-in-hand. So usually, I recommend just overall good lifestyle changes, healthy lifestyle changes. So, if a woman or individual is overweight or obese, typically we would recommend incorporating cardiovascular exercise and dietary changes to help improve, decrease their weight. In addition, we usually counsel if someone's a tobacco user or use other drugs, just marijuana, that they would abstain for those things and use alcohol in moderation or not at all.

Erica Newlin, MD:

What about caffeine?

Christine Hur, MD:

Yeah. So even in pregnancy, a small amount of caffeine is permitted. And so usually, I go in line with the ECOG or our governing body's recommendations. And so typically, I tell patients they can have one cup of coffee a day.

Erica Newlin, MD:

And then can you briefly discuss kind of optimal timing for sex when trying to conceive, and just a little more about cycle tracking?

Christine Hur, MD:

Yeah, for sure. So, I love a good menstrual diary. So, when patients come to see me, we frequently look through their apps or their calendars together, because it's a really, really helpful tool. So, what I recommend for women to do is document their first day of their period each month as well as their flow, any associated symptoms that they're having such as significant pain or other changes that they're noticing with their body. In regard to when to try to conceive or timing intercourse, it does vary based on the cycle length. But typically, I recommend that 10 days after their cycle first started, that couple start having intercourse every other day, and then continuing that until either they get a peak on an ovulation predictor kit, which I can talk a little bit more about or 12 days before they would expect their next period.

Erica Newlin, MD:

Yeah. What about ovulation predictor kits? Do you recommend that people use those frequently, infrequently?

Christine Hur, MD:

Yeah. So, you know, having regular cycles is actually the most indicative thing of whether or not someone is ovulating or releasing an egg each month. And so, I think the ovulation predictor kits are very useful tools, but by no means necessary for someone to conceive. And so, I think that for some people, having that guidance on when to time their intercourse is really, really useful, but for other people, it can be very stressful, kind of undergoing the journey of trying to conceive is already so stressful for some individuals. So, for those couples, you know, if they have regular cycles, I just recommend that they time it based on their cycle length. So, it really depends on the individual.

Erica Newlin, MD:

For sure. I found in my practice; it can be stressful. Did you get the smiley face?

Christine Hur, MD:

Yes.

Erica Newlin, MD:

Did you get the flashy smiley face?

Christine Hur, MD:

Yes, yes.

Erica Newlin, MD:

How dark was your line?

Christine Hur, MD:

Yes.

Erica Newlin, MD:

I think that sometimes it can be very stressful for people.

Christine Hur, MD:

And they're not without cost. Like, some of them are very expensive. And so, you know, if someone gets positive ovulation, like, two to three months, I often times say moving forward, they generally know when they ovulate, so just to kind of use that historical data moving forward just to kind of decrease their workload as well as the cost associated with having to buy those ovulation predictor kits.

Erica Newlin, MD:

What kind of symptoms might someone have that tells them that they're ovulating without an ovulation predictor kit?

Christine Hur, MD:

Yeah. So, some women experience a pain called mittelschmerz.

Erica Newlin, MD:

I love that.

Christine Hur, MD:

Yeah, I know. It's a funny word. And that's actually pain associated with ovulation. So, some women feel this very strongly. They know exactly which ovary they ovulated from. But some women really don't feel very many symptoms at all. Other things that people track or can notice are a change in their basal body temperature or changes in their vaginal discharge. But because those things are so subjective, sometimes it can be hard for a person to kind of keep track of.

Erica Newlin, MD:

For sure. And then just going into what is considered the definition of infertility? When should someone start to see a doctor or consider some sort of workup?

Christine Hur, MD:

Yeah. So, the clinical definition of infertility is over a year of regular ovulation, so you're having regular cycles and appropriately timed intercourse, and still not conceiving. But because we know that age and fertility are so closely linked, after the age of 35, we recommend that individuals see us after six months just so that we can have them evaluated on a slightly shorter timeline. But other things that should bring someone in are if someone's not having regular cycles, that individual does not need to wait a whole year, because the likelihood of them ovulating is pretty low.

Or if someone has a history of recurrent pregnancy loss or if someone has genetic conditions that they want to test for potentially using assisted reproductive technology, those are all people that we recommend coming see us sooner. And I think that going to your routine OB/GYN visits and talking to your OB/GYN is a great way of kind of screening whether or not that's something that you should come for sooner versus waiting.

Erica Newlin, MD:

For sure. I think that's a great point. I love seeing people for their family planning visits, and then that way when they're thinking about trying to conceive, being able to look over their medical history and trying to decide whether they should meet with a high-risk specialist beforehand or whether there are certain things that they might want to see infertility specialists for.

Christine Hur, MD:

Yes, definitely. But we're always happy to see anyone.

Erica Newlin, MD:

For sure. And then can you just briefly, I know that there are many causes of infertility, but go over what some of the primary causes are?

Christine Hur, MD:

Yeah, of course. So primary causes include things like male infertility, so inadequate or poorly functioning sperm; uterine infertility, so any kind of structural abnormalities with the uterus that could be causing issues; tubal infertility; or anovulation, meaning not being able to release that egg on a monthly basis. It is important to note, though, that nearly a third of women and couples will be diagnosed with unexplained infertility, which means essentially that all the testing is performed and comes back normal. And so, I don't think that it means that there's no explanation for their fertility, but rather modern science hasn't been able to identify exactly what's causing their fertility at this time. And I know that can be frustrating for patients.

Erica Newlin, MD:

Yeah. Think you've mentioned before that infertility's a very young specialty overall, so I think that there are new discoveries each year.

Christine Hur, MD:

Yes, yes. You know, it's wild because one to two percent of all babies born are born using assisted reproductive technology, so it seems just so prevalent in our society. But really, the first individual born from IVF was born less than 50 years ago.

And so, when you compare it to other fields such as cardiology, which is study of the heart; nephrology, the study of the kidney, it is really just so young. And so, our field is moving so quickly, and we're learning so much on a week-by-month-by-year basis, and that's part of what I love so much about the field.

Erica Newlin, MD:

And then I know that there's a lot of things online. I have a lot of patients who are just worried about the future of infertility, like, not planning to try to conceive at the moment, but just worried about getting their hormones checked, if there's any sort of lab work anyone can get to see if they're fertile.

Christine Hur, MD:

Yeah. There are quite a few people that I see who just kind of want a preliminary exam to see whether or not there are concerns for their future fertility. So, for those individuals, I think, like, history is really important. So, if they have anything that would make me concerned such as prior exposure to, like, radiation or chemotherapy, or prior surgeries on their ovaries or on their reproductive organs, those are big things that I would want to potentially learn more about and kind of investigate further. But for someone without that history, you know, it's hard to do a complete exam that would, like, predict their future fertility. There are lots of commercial companies who are trying to sell kits to help survey your future fertility, but really, there's not one test that will tell you whether or not that you will struggle with infertility in the future or not.

One test that's frequently asked for or discussed is called an anti-mullerian hormone, otherwise known as AMH. And this test is a test for one's ovarian reserve. So, there are all these small resting eggs in your ovary, and they create this hormone called AMH. And so AMH is an indicator of how many of those resting eggs do you have there, and it's a really good test at detecting that, but it's not a good test at determining whether or not someone will be able to conceive spontaneously on their own. And so, ordering these tests for individuals who have not yet started trying or do not yet struggle, like, with infertility, it's hard because, you know, it may cause significant alarm when really that individual might not have trouble conceiving at all. There's a lot of good data showing that even with a low ovarian reserve or low egg count as determined by the AMH, that individuals, they have the same likelihood of conceiving if they're trying on their own.

Erica Newlin, MD:

So, just to use an example, if I have someone who comes, and they are 37 wondering if they may have difficulty conceiving just due to age, having a low AMH may not mean that they'll have difficulty conceiving.

Christine Hur, MD:

Exactly right. So, it does not predict at all their likelihood of conceiving on their own. The one thing to know is that for women who are 37 who might have a low count, you know, that might be someone who after six months of trying I would try to have seen the infertility specialist more expeditiously just because we know that fertility does decrease quicker in the later 30s of a woman's age.

Erica Newlin, MD:

For sure. I always hated those graphs when I was training Because you very much feel like time is moving quickly in your 30s.

Christine Hur, MD:

Yes, yes. Definitely.

Erica Newlin, MD:

It's not fair, mother nature.

Christine Hur, MD:

Yes.

Erica Newlin, MD:

And then, can you expound a little on those, those online businesses? Do you have people come with hormone panels? Are they accurate when people get those online?

Christine Hur, MD:

Yeah. So, they are overall pretty accurate. You know, there are some differences from lab to lab, especially in the AMH number, but when we have patients with AMH levels who we've repeated testing on, it's pretty consistent.

Erica Newlin, MD:

And then when someone goes to see an REI for their first visit, what kind of things can people do to prepare, what can they expect for that visit?

Christine Hur, MD:

Yeah. I think that the number one thing that is useful during a visit is that menstrual diary, you know, because it really gives us a good idea of what your cycles are doing. You know, the number of times I've seen people who say that their cycles are regular, but then as we're scrolling through their flow app, I see that their cycles are actually somewhere between 25 and 35 days, which is actually not quite regular. And so, I think that that's a really good way for us to get down to the nitty-gritty of what could be going on. But in addition, I think just any questions that they might have, goals that they want to come out of the visit with I think are really important, as well.

Erica Newlin, MD:

And just on the topic of cycles, what would you consider normal, because I know we say 28 days, but I'll have people be like, "Well it was 27 days.”

Christine Hur, MD:

Yeah. You know, a very small fraction of individuals actually has perfect 28-day cycles. But really, anywhere from 25 to 35 days is normal. But the biggest thing that I'm looking for is that it's normal from month-to-month. So, if someone has a 33-day cycle that is 33 days pretty routinely throughout the year rather than being 33 days one month, and then 25 days the next month.

Erica Newlin, MD:

And if someone has a longer or a shorter cycle, how does that differ in time of ovulation?

Christine Hur, MD:

Yeah. So, there are actually two phases, or two parts of the menstrual cycle. The first part is the body getting the egg ready for ovulation, and then there is ovulation, then there's the time after ovulation. So, the time after ovulation is pretty consistent amongst individuals. It's usually around two weeks. And so, if someone has a 35-day cycle, they may ovulate closer to 21 days compared to someone if they had a 28-day cycle; they would ovulate closer to 14 days.

Erica Newlin, MD:

And so, people who have a shorter cycle, so they'll ovulate earlier.

Christine Hur, MD:

Exactly right.

Erica Newlin, MD:

Can you just briefly kind of describe a short luteal phase or go more into detail about luteal phase support?

Christine Hur, MD:

Yeah, of course. So luteal phase is that second part of the menstrual cycle that I was talking about. It's the time when you've already ovulated, and the reason why it's called a luteal phase is because the cyst where the egg comes from is called the corpus luteum. And so that's kind of what's supporting that phase of your menstrual cycle. And so, there's been a lot of talk about something called a shortened luteal phase where someone's not really meeting that 14-day mark of the length in that time. And so really, we get concerned if the time from ovulation to the time of your next menstrual cycle is shorter than 10 days. And there is some thought to give those individuals progesterone, which is what usually kind of determines the length of that part of the cycle in order to potentially improve their fertility.

But there is some controversy about how helpful that is in order to conceive.

Erica Newlin, MD:

Yeah, for sure. And then what kind of lab work should someone expect during, like, a workup for infertility?

Christine Hur, MD:

Yeah. So, you know the lab work really varies depending on what someone is showing up with. So, if someone has irregular cycles or just like their cycles are 20 days one month, and then 35 days the next month, typically we'll order some hormone testing, which will include thyroid testing as well as a hormone that's made from your brain called prolactin. But if someone's having very regular cycles, typically we don't have to order any hormones because that's indicating that their hormonal system is working well and is in line.

Erica Newlin, MD:

Mm-hmm. And what I often recommend to people as far as lab work is just optimizing their general health, making sure that their screening lab work is done that I know sometimes you'll order it or sometimes I'll order it as far as immunity to things to certain diseases that might affect the pregnancy.

Christine Hur, MD:

Yes, exactly right. And other things like checking someone's cholesterol, their sugar levels, things just so make sure that when women and couples do get pregnant, that everything is as optimized as possible.

Erica Newlin, MD:

Mm-hmm. Can you touch briefly on carrier screening when should people have carrier screening and what is that?

Christine Hur, MD:

Yeah. So, carrier screening looks for recessive conditions. What that means is that, you know, individuals have two copies of each gene. And so recessive conditions are inherited from your parents if you have two of a broken gene. But if you have one broken gene and one normal gene, then that broken gene is masked by that normal gene. And so, what carrier screening looks for is testing for those recessive conditions amongst two individuals who are looking to conceive together. The reason why is because, for example, if I have one broken gene for cystic fibrosis and one normal gene, and then my partner has one broken gene for cystic fibrosis and one normal gene, neither of us will show the symptoms of cystic fibrosis, but we could both pass down our broken gene, and then have a child affected by cystic fibrosis. And so, the genetic community as well as the OB/GYN community recommends screening for a handful of these conditions prior to conceiving. And so as REIs or as an OB/GYN, you know, these patients who are coming to see us before they conceive, it's really our job to make sure that they're aware that that's an option so that if someone does, in fact, test positive for the same broken gene as their partner, we actually have technology within REI to screen out embryos that may be affected so that someone could have a much higher likelihood of having a child not affected by that condition, which is pretty wild to think about.

Erica Newlin, MD:

For sure. I know that's a conversation I get into a lot in pre-conception counseling. And then it can be really helpful sometimes to see a genetic counselor, too.

Christine Hur, MD:

Yes. Yeah. Our genetic counselors are wonderful. You know, they really get down to the very details of your genetic history, your family's genetic history. And so oftentimes, if someone tests positive for something, we will have them see the genetic counselors, and they learn, like, such a wealth of information about themselves and their families.

Erica Newlin, MD:

Yeah. What about imaging? Should someone imagine if they're trying to have a baby?

Christine Hur, MD:

Yeah. So, you know, I think that practices vary a little bit. I will say that it's pretty standard to get a test to evaluate one's tubes if someone's coming in with infertility. This test can either be an x-ray test or an ultrasound test. But what we're really looking for is to see whether or not the tubes are normal in shape as well as open so that that highway between the ovaries and the uterus is kind of open and can carry the egg where it needs to go. Also, like, in my practice, if someone has not had any imaging of their ultrasound ovaries, I will get a baseline ultrasound just so that I can make sure that there's no concerns with their ovaries or their uterus while carrying a future pregnancy.

Erica Newlin, MD:

In someone who, say, has super heavy periods or is having a lot of intermenstrual spotting may want imaging, too, to look for things like fibroids.

Christine Hur, MD:

Exactly right.

Erica Newlin, MD:

Yeah.

Christine Hur, MD:

Yeah, because fibroids could affect someone's quality of life with that heavy bleeding but also affect their fertility. Exactly right.

Erica Newlin, MD:

Sure. And we'll get more into structural abnormalities in a future episode.

Christine Hur, MD:

Yeah.

Erica Newlin, MD:

And then just since we have a little time, let's talk briefly about supplements.

Christine Hur, MD:

Okay.

Erica Newlin, MD:

Because I know that there's a lot online about different supplements. Is there anything that you'd recommend, anything you wouldn't recommend?

Christine Hur, MD:

So, I recommend that all women who are trying to conceive take a prenatal vitamin. If a prenatal vitamin is listed as being a prenatal, it has the adequate amount of folic acid, which is really what we're looking for women to take before they conceive. You know, there's a lot of supplements out there, and the value of the fertility supplement industry is just so, so huge. And while there is some data to support some supplements, the vast, vast majority of supplements do not have any data to support them. And oftentimes, they are not cheap. The individuals struggling with infertility make up a vulnerable population. You know, and so I would just hate for commercial companies and industries to kind of use that vulnerability to make a profit. And so typically, I say that unless they feel strongly that they forgo a lot of those supplements, besides the ones where there is data to support their use.

Erica Newlin, MD:

And you mentioned vulnerability. Can you talk briefly just about emotional support and things people can do to just help themselves and have good mental health and outlook while they're trying to conceive, because it can be very, very stressful.

Christine Hur, MD:

It can be incredibly stressful, especially as the months go on. You know, you're doing all of these ovulation predictor kits, getting a negative pregnancy test each month, like, it's incredibly hard. And so, I think that a couple of things I typically recommend to my patients is talking to them, whoever they feel comfortable with, like, their support system about it. There's a lot of really good community support systems that individuals can find on Facebook and social media. And then also I think that seeing a therapist, especially a therapist who specializes in infertility and is a huge, huge help. I wish that I could have that for all of my patients, because I really think that this journey is so hard that, for many individuals, having that support is really important.

Erica Newlin, MD:

For sure. And I think the online support communities are really nice, so people know that they're not alone.

Christine Hur, MD:

Exactly. You know, the good news is that infertility recently I feel like it has become much more normalized. But for so long, people were struggling with infertility silently on their own, and it can just feel very, very isolating. So, if someone feels comfortable, I really do think that it's beneficial to them and for the people around them to discuss what their journey has been.

Erica Newlin, MD:

Great. Anything else you'd like to add or anything else you'd like for people to just take away from this conversation?

Christine Hur, MD:

Yeah. I think that, you know, if someone is trying to conceive or has any concerns with kind of their fertility journey, I think that their OB/GYN, their person that they see year after year is really the perfect person to kind of assess whether or not they need to be refereed right away or need any additional testing. But, you know, people should not be nervous to come to us as an OB/GYN or as an REI, because we want to help them achieve their goals. And so really, just keeping an open path of communication with your healthcare provider can be really beneficial for us to help them achieve what their goals are.

Erica Newlin, MD:

Oh, great. Thanks so much for talking with us, Dr. Hur.

Christine Hur, MD:

Yeah, thank you so much for having me.

Erica Newlin, MD:

Thank you for listening to this episode of Ob-Gyn time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.