As a fertility nurse, I know that we often receive emails from the front desk asking us to call a patient about a particular question or problem.

Although fertility treatments, and the challenges inherent in them, can be incredibly stressful (and this is not meant to minimize that) you might get a laugh from some of these. Whether you are a nurse or patient, I’m sure you can identify with many of these scenarios.

The following is a list of some recent (and real) email subject headings as well as a description of the situation and outcome.

• 1) “Patient’s husband can’t leave a sample because there was a bat in the house and he’s very stressed out.”

We often joke about the male partner’s role in fertility treatments. The female has to do the bulk of the ‘work’: mix and administer injections, undergo blood draws and vaginal ultrasounds…etc.

All the man has to do is to provide the sperm sample. Well, we need to remember that the ‘act of providing’ the sample is somewhat dependent on the male being relaxed and in the mindset to ‘produce.’  Having any kind of added stress can be deleterious to the production process, to say the least. So in this particular situation, after chasing a bat around the house in the early morning hours, the last thing this poor guy wants to think about is producing into a cup. This can happen in even less eventful situations, like having an important work meeting or just feeling the stress of a positive ovulation predictor kit month after month.

If you think this might be an issue for your partner or your patient, have a back-up plan. Consider a frozen sample, or renting a local hotel room (seriously, sometimes the proximity to the office or escaping an office-like atmosphere can help). Although we often focus most of our care and attention on our female patients, this serves as a reminder not to forget about the men.

• 2) “Please call patient, she has a meeting and can’t have her egg retrieval today.”

There are many variations of this: husband unable to bring in his sample due to traffic, unable to come in for a blood test or ultrasound due to bad weather … etc. Yes, there are many components of a fertility treatment cycle that are precisely timed, but there are some that can be modified.

Usually, the most flexibility occurs earlier on in a treatment cycle, so if you have to miss or reschedule an appointment, it can often be done then. If you have ‘blackout dates,’ or those days that you are unable to come into the office due to vacations or work conflicts, we can often plan around them, if we know in advance. There are some procedures, though, that are specifically timed and can’t be rescheduled, such as having an insemination or retrieval after your trigger shot. It’s still worth calling the office if you have a change in your schedule to see what can be rearranged and what can’t, but just know that some timing is beyond our control and rescheduling might be detrimental to your cycle. Regarding the semen sample timing, most centers are comfortable with the sample arriving within 45 -60 minutes of production (check with yours to see their policy). The sample should be kept close to body temperature, not frozen, for example, we had one male partner put his in a cooler with frozen veggies as he thought he would run errands on his way home from the grocery store.

• 3) “Patient sneezed and her embryo fell out. She saved it, though, and can bring it in.”

So…this one, or some version of this, has come up almost every year since I’ve working in REI. Even though a blastocyst (an embryo at its implantation stage) is only the size of a period on a keyboard, infertility patients will obviously do anything to protect it and facilitate implantation.

We can only be so proactive to help implantation take place. Even when we do IVF, where we transfer the embryo directly in the uterus, it still floats around and finds a comfortable spot on its own, which can take a day or so. No amount of pressure (such as sneezing and going to the bathroom) will expel the embryo. Likely, what is being seen or felt is residue from vaginal medications, mucus or (yup) urine. So don’t worry if you sneeze or cough or yell. Your blastocyst is safely ensconced and is looking for (or found) its cozy spot.

• 4) “Patient sent a picture of her butt and wants to know if she gave injection in the correct spot.”

Well, I have seen many butts, stomachs, and thighs over the years, and even seen some remotely (and abruptly) over FaceTime or Skype. Patients are taught how important it is to give the proper amount of medications, in the proper spot, and avoid big veins and the sciatic nerve. It’s no wonder they are so careful about where to give the injection. Even though we are happy to draw circles on their butts, when it is time to actually give the injection, it is still scary and nerve-wracking to give yourself or your partner an injection.

One of my patients asked her grandmother to help, because she is diabetic and used to giving injections. However, she didn’t take into account her grandmother’s poor eyesight issue, which generated an interesting injection site and caused some pain for the next few days. Also, sometimes, no matter how careful someone can be, there will be a little bleeding at the injection site, even moderate bleeding, because there are superficial blood vessels that can’t be avoided. Hitting these is ok, it just might cause a little bruise. We know that you’re nervous, so we are happy to draw circles, help with injections or look at your butt whenever necessary.

• 5) “Patient’s dog ate her estrogen and she is wondering what to do.”

Fertility patients are very protective of their medications and with good reason. They are expensive, not easily obtained, very time-consuming and dose-specific. It can be overwhelming to receive the big box that is shipped and wonder, “what goes in the fridge?” or, “what needle do I use with what medication?” …etc.

I usually suggest separating and batching the medications and syringes, that is, putting stuff next to each other (or rubber banding it) that goes together. So, progesterone with progesterone needles, leuprolide with leuprolide needles…etc. As for the pills, many of them are not used until later, so they can be put away until you’re told to use them, in an effort to avoid any confusion and stay organized. It is helpful to keep the medications in a safe, climate-controlled area (unless they need to be refrigerated) away from kids, pets and nosy mother-in-laws who might snoop. Maybe in the master bathroom or in your bedroom, but out of reach. We have had cats knocking over and playing with medication vials, birds flying off with syringes, and dogs eating pills. By the way, the dog was ok, just a little breast tenderness.

Many of my colleagues and I really enjoy our roles as fertility nurses. We love taking care of our patients and helping them through the process, and absolutely understand that questions arise along the way. Hope that this answers a few of them and in the future, we will pick on the men a little more.

Ok, so you are starting fertility treatment. Overall, it’s exciting to have a plan to be able to achieve the family you have envisioned. At your appointment, your health care provider reviews the basics with you, discusses medications, next steps, treatment strategies, percentages. You hear most of it, and will probably ask a few questions.

Then, he or she sneaks in, “Oh, and by the way, no drinking, no recreational drugs, no high-impact activities and either schedule or abstain from sex depending on where you are in your cycle.”

Umm… what? Immediately, you’re probably thinking, “Let’s be clear. You guys are going to, arguably, create stress for me in my life and take away my methods of stress release?” What are we supposed to do now to keep from going crazy? Most likely, you either are embarrassed to ask, or you may not get a solid answer.

As a nurse with over 20 years of experience in reproductive medicine, I can tell you that yes, it feels unfair. I can also tell you that we are not really taught or advised what we can offer you as a substitute for your usual methods. We understand that we are asking a lot of you, and because of this lack of training, often we’re just hoping you don’t realize that at the time, or you are so excited to get started that you’ll think, “Well, ok, I can give up anything if it means that I’ll have a good outcome.”

Most people will have a good outcome – at some point. However, it won’t necessarily be on the first cycle. So, you might get a call with a negative result, and not be able to have wine to relieve that stress. Or in the midst of a cycle, you might want to go for a long run and realize that you aren’t supposed to be doing this.

Even though it is asking a lot, there are reasons why we impose these restrictions, mostly because you are attempting pregnancy and need to limit any alcohol, drugs, and smoking, plus taking fertility medications will enlarge your ovaries, which means that there is a limit on your exercise as well. So, what can you do?

The following are some suggestions that I recommend to my patients for self-care that you can use during your fertility cycle:

• 1) Surround yourself with people who “fill your tank.” This means limit toxic people, or those who are time-consuming, negative or just annoying. You can do this. It is absolutely ok.

Right now, while you are somewhat stressed and focused on a certain outcome, it’s important to interact with people who are helpful or make you happy. You know who these people are – every time you see them or get off the phone with them you seem lighter somehow. Maybe you are smiling more or just feel like you have more energy. Then there are those who require maintenance and hard work. Be kind to yourself at this point and trim the address book. Limit your interaction with people who take more than they give. You have enough to think about without worrying about your mother’s bunions.

• 2) Research “hygge” and incorporate it into your life. Hygge is a Norwegian word that means doing something that generates a feeling of contentment/happiness/well-being (Wikipedia.com). Just do yourself a favor and don’t try to say it, because it is not pronounced the way it is spelled and you might feel like an idiot saying it incorrectly at a dinner party – definitely not the kind of stress you need.

In the summertime, incorporating hygge into your life can mean growing herbs or flowers, or going for a walk and noticing beautiful scenery or smells. In the cooler months, maybe covering yourself with a cozy throw or taking a warm (not scorching hot) bath. There are several books on the topic, as well as examples on Pinterest and other sites.

• 3) Employ all of your senses. I sometimes recommend essential oils to those who are interested. They have many uses and certain ones can help with relaxation when added to a carrier oil and applied or diffused. Many are safe to use in pregnancy.

Aside from that, take your dog for a walk, or enjoy curling up with a purring cat. Listen to your favorite songs, maybe make a few new playlists, one that is happy and one more contemplative. Have a cup of coffee (yes you can have some caffeine during your cycle) or better yet a great herbal tea. Sometimes just the scent of it is calming.

• 4) Reading or journaling. I know that these are two separate interests, but most people like one or the other. Journaling is great because you can get your thoughts on paper, and out of your mind for the moment, even the ones that don’t seem ok, that you might not admit that you are having to anyone but yourself.

Some experts recommend keeping a gratitude journal to remind yourself of all of the positive things in your life (preferably do this at night or in the morning) when the other, less positive thoughts feel overwhelming. If you don’t like to write, I have advised people to keep an online album of photos that make them happy that they can refer to when they don’t feel so happy, a good memory such as a picture of a concert that you loved. A picture of your walk on the beach or along a tree-lined path. A picture of the great dinner that you made and enjoyed with friends. For me, I love to read, so a good book is my ‘go-to’ for stress relief. Sometimes fiction, but recently I’ve found myself drawn to inspirational books, those that have a message that resonates with me. I just recently finished an excellent book, “The Universe has your Back” by Gabrielle Bernstein. It was so good, that I originally purchased the Kindle edition, but found that I wanted to bookmark so many pages and underline so many phrases that I also bought the paper copy.

Pinterest is also a great resource to find suggestions for books, either by the year (I.e. the best books of 2017) or by the subject. There is also a Facebook site, The Modern Mrs. Darcy, that is great if you need a few book recommendations.

• 5) Don’t give up on movement and exercise. Just because we limit the high-impact activities, doesn’t mean that you can’t still move. Physical activity produces endorphins (feel-good hormones) and even short bouts of it can be helpful and have lingering, positive effects.

Instead of running, you can walk with water bottles, so you can stay well-hydrated, but the weight of the water also provides resistance and requires extra effort. Yoga is great, both for its physical activity but also mental benefits. Some centers, like RMA of CT, even offer yoga in-house. Low-impact group exercise is great, if being in a group is more motivating for you, as is swimming. How do you monitor if you are pushing yourself too hard? You should be able to speak in a sentence at a time. If you are huffing and puffing, and can only string together two-three words at once, you need to bring it down a notch.

• 6) Get a massage or, even better, schedule acupuncture. I put this one last, not because it’s the least important but because it can be expensive to go to multiple sessions. Yes, regularly scheduled appointments are better but, like exercise, even a few sessions can help.

You know how your spouse/partner/friend/family member is always asking you what they can do to help? Ask them for a gift card to a massage place (make sure that you tell the therapist that you are hoping to get pregnant or could be pregnant) or to pay for an acupuncture session (also tell the acupuncturist about attempting pregnancy). Acupuncture has the added benefit, in some studies, of increasing blood flow to the uterus, relaxing smooth muscle (which the uterus is) and promoting relaxation.

Congratulations on taking the next step in building your family. I forgot to mention a very important resource during the process – your nurse! We are here for you, and nothing you say or do will shock us (we have heard everything, which is the topic of another blog post that will be coming out later in the month), and we might even have some suggestions other than the ones listed above. Please feel free to ask us or let us know that you need some advice. It’s ok to say that you are not feeling ok.

And we apologize in advance for the demise of your wine during your cycle. You can always write about us in your journal. We’ll never know.

I spoke to my female patient about her weight the other day. Wait, you say. Isn’t that against “Girl Code”? Tantamount to replying “yes” to the “Do I look fat in this” question?

Actually, I would counter that discussing excess (or not enough) weight, as a nurse to your fertility patient, is not only appropriate, it’s necessary. Here’s why.

There are many studies that show that being obese has detrimental effects on getting pregnant, staying pregnant, and on the baby. One study showed that natural fertility rates declined comparable to a year in age for every BMI (body mass index) unit over 30. That means that your ovaries act ‘older’ the higher your BMI category, and everyone knows that age and fertility are natural foes.

While we are not sure of the exact mechanism of how weight affects fertility, we know that ovarian, uterine and sperm function are all affected (yes, regardless of your weight, an overweight male partner also puts you at a disadvantage). We know that as BMI increases, so does time to conception, the amount of fertility medications needed, and the chance the cycle will be cancelled due to poor response.

Once you are pregnant, elevated BMI increases the chance of stillbirth, or pregnancy complications, such as gestational diabetes, and labor complications. Finally, a suboptimal uterine environment, such as that caused by gestational diabetes or obesity, can cause gene mutations in the fetus that follow him or her into adulthood, such as Type 2 diabetes, obesity, and cardiovascular disease.

One of the most common questions I get as a fertility nurse practitioner, and I’m sure that you do too, is, “what can I do to improve my chances/outcome?”

We would then discuss any necessary lifestyle changes (such as stopping alcohol, smoking, etc), so why exclude a discussion about weight with someone whose BMI puts them in the very overweight/obese/morbidly obese category, giving them less of a chance to conceive than other age-matched patients?

Armed with the information above, I think we can now all agree that excess weight is not helpful when trying to conceive, but how do we discuss it with our patients? In my opinion, it can be done honestly, appropriately, kindly and in context.

Let’s start with how to appropriately introduce the topic when speaking to your patient. I was speaking to a patient the other day whose BMI was 46 and she asked me if there was anything that she can do while waiting to proceed with IVF (in vitro fertilization). In my mind, that number, 46, was like a flashing neon light in her record that I couldn’t ignore. Just as I would honestly and openly discuss elevated blood pressure or an abnormal lab value, that is how I treat BMI.

Someone’s weight doesn’t define them, but it can be an obstacle.  

So, I say something like, “Your BMI category is ‘x’ (underweight, overweight, obese, etc) and I fear that this is hindering your ability to conceive.” Realize that most people underestimate their BMI category, so obese patients think the they are “just overweight” and very obese patients think that they are “mildly obese,” etc.

The BMI category matters, because, as stated above, as BMI category increases so, potentially, do the adverse effects of it on a patient’s fertility potential.  I feel comfortable discussing the topic of weight mostly because I am passionate about it, but also, importantly, because I have the support of the clinicians in my practice, www.rmact.com, and we have an in-house nutritionist. This is important, because I don’t have to introduce a challenge without offering a solution.

You should develop your own “script,” or wording that you feel comfortable using, that you can refine with time and experience, while starting to impress upon the rest of the clinicians and staff at your practice the importance of support for patients of all sizes.

Once you have that script, when is it appropriate to broach the topic? I prefer to discuss a patient’s weight after I have established a relationship or rapport with her, maybe during her diagnostic cycle as that generates many phone calls and interactions.

I hope, that after having spoken with me, she realizes that I have an emotional investment in her and her child’s outcome, and discussing her weight is just another aspect of this. But sometimes, a patient’s BMI needs to be discussed during the initial consult, as perhaps your practice has a BMI cut-off for services that your patient exceeds. How, you may ask, can you initiate this conversation when you first meet a patient, before you have developed a relationship?

One way is to embed questions about weight in your new patient questionnaire, such as “Have you had a significant weight gain or loss in the last year,” or, “On a scale of 1-10, how motivated are you to make a change in your weight.”

Then, as you review the questionnaire with the patient, you can not only use the questions as a segue into a discussion about their BMI, but also assess their motivation to make a change at this point. Another way is to assure that you have a “healthy office.” This means an office that is equipped with the equipment (large blood pressure cuffs, cloth gowns and stools without wheels, etc) needed to properly care for overweight or obese patients. It is also one that has a staff who has been prepared to sensitively care for overweight and obese clients, keeping in mind the influence of weight bias, a form of discrimination that, arguably, most of our overweight or obese patients have experienced at some point by people who take care of them, including health care providers.

It is an office that has healthy magazines and maybe cookbooks in the waiting room to give clients a first impression that health is important to those who work there, which helps to facilitate a conversation about weight in the context of the general health of your patients. The clinical suggestions above and more are available from the UConn Rudd Center  (www.uconnruddcenter.org) which offers a great online course on this topic.

I don’t enjoy the potential embarrassment that can be generated by a discussion about weight, but I don’t use discomfort as an excuse to avoid it.  In my opinion, this conversation must occur in order to provide comprehensive, individualized care to overweight or obese patients. In fact, I would argue that all staff in fertility settings should, at the very least, be sensitive to this patient population, be knowledgeable about the effects of weight on fertility and pregnancy, and strive to find ways in their office setting to incorporate discussions about weight.

If you are interested in this topic, please contact me at monica@fertilehealthexpert.com or surf this website to view services that your practice might find helpful.

Day 1 of the new website, and am both nervous and excited to start this journey.  I thought my first blog post should be an introduction to me and how Fertile Health, LLC, was conceived.

I, like many others nurses in this field, learned on the job. Even though I graduated with a Master’s in Women’s Health, we had just once class on reproductive endocrinology and it was so complex, that I just learned what I had to in order to do well on the test. Most graduate nurses that I spoke to related the same experience.

After I graduated, I got my first job in the field as a nurse practitioner at Cornell Medical Center in NY, where I interviewed with the medical director, Dr Zev Rosenwaks. At that time, NP’s weren’t commonly working in fertility centers and he wasn’t quite sure what to do with me or what role I would be able to take in a teaching hospital where they had fellows available to do the procedures that he perceived that I wanted to do.  To be honest, I, being new to both the NP role and reproductive endocrinology, didn’t know what to do with me either, but he seemed excited about the prospect of having someone like me, and I was excited to be there, so we compromised: he promised me that if I worked “as a staff nurse at Cornell” for 6 months to really ‘learn the ropes’ that he would find a place for me as an NP there.

He was true to his word. During this 6 months, one of my projects was to convert their teach class, which was on an archaic slide projector, to a PowerPoint presentation. While doing this, I realized that I loved to teach. After that first 6 months, I moved into the role of donor egg coordinator, which I loved, but still felt as though my passion was for teaching. Also, at this time, my friend, Karen Hammond, DNP, asked me to be a speaker at a national conference. I was both flattered and horrified. I had never spoken in front of an audience and wasn’t really sure what I had to say (that anyone would want to hear). But, I diligently worked on my slides for months, asking the fellows to help me revise them, and finally the day of the conference arrived. I was nervous, but gave the presentation and got hooked on presenting, also an important part of teaching.

After a few years, I got married and moved to Atlanta where I continued to work as an RE NP and found that most of practices that I knew of (or where I worked) didn’t have a formal nursing educator or orientation classes equipped with robust lectures, slides and helpful teaching materials. There were many knowledgeable, senior nurses, but they were so busy, that they didn’t have time to set aside to really teach. We all learned “in the trenches” so to speak and I found that some of the nurses didn’t feel confident answering patient questions or teaching classes because of a resulting lack of knowledge. Many didn’t know the latest research because we didn’t have access to an electronic database or journal clubs.

When I moved to Connecticut to work at RMA of CT, I found, in Mark Leondires, MD, a physician who was willing to support me and encouraged me to be a nursing leader by helping write abstracts and editing my presentations. I was lucky. In addition to a lack of formal training programs, most RE nurses, I find, don’t have this kind of mentor or support. I decided then that I wanted to be a nursing leader in my own practice, and for nurses in other practices, by providing them with the knowledge and support needed to accomplish their goals. As a result,  I edit papers, teach people how to do literature searches and pull articles, and help make PowerPoint presentations.

I wanted to go a step further and create learning modules specific to reproductive endocrinology that adhere to the principles of adult learning. One concept is that learning is enhanced by visual aids, instead of using just a bunch of text. I work with a graphic designer and artist to make my own images, ones that, I feel, give learners the visual stimulus they need in order to remember complex processes inherent in RE. Additional research has shown that making participants recall previously learned knowledge, right after the session, can help with learning retention. As a result, my learning modules are followed by either question and answer sessions or case studies in order to reinforce this knowledge and encourage the learners’ interaction and participation.

As a result, Fertile Health, LLC was formed. In my role, I continue to present these modules and lectures for RE practices, like RMA of NJ and Reproductive Biology Associates, in Atlanta, both in-person and remotely. In the next few months, I will be expanding my teaching services,  but also making the modules and/or the slides themselves available for purchase so that RE centers can use them as part of their nurse orientation programs.

I’m excited about this journey and look forward to seeing comments or questions in the months ahead.

Warmly.

Monica