Posted on November 25th, 2020by RMANY

Ep 39: Hope and Healing: The Infertility Journey

Fertility Forward Episode 39:

In the next installment of the Hope and Healing panel, host Rena Gower is joined by three guests, who each bring their unique experience and share their perspectives on the infertility journey. We welcome back Dr. Lucky Sekhon, a reproductive endocrinologist at RMA, and we also hear from Ariel Schnur, a fertility nurse at RMS, and Rachel Rachel Hess, who provides a patient perspective. Find out about the pros and cons of procedures like IUI and IVF, why the waiting game is the most emotional part of the process, and why not every retrieved egg is useful. The panel addresses the roles of the fertility nurse, doctor, and patient when it comes to discussions about unsuccessful treatments and miscarriages, and Rachel shares her experience as a patient while Dr. Sekhon explains what the most difficult parts of her job are, including admitting she doesn’t have all the answers and remaining objective when a patient is in emotional pain. Ariel describes what it is that a fertility nurse does, and she shares why she hopes her patients reach out to her with questions, and each of today’s guests provides their advice for someone going into fertility to take advantage of what it has to offer – including the expertise of their doctor – and, simply, to take care of themselves while they are on this journey. Tune in today to find out more!

Transcript of Episode 39

Rena: Hi everyone! We are Rena and Dara and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice from medical professionals, mental health specialists, wellness experts, and patients because knowledge is power and you are your own best advocate.
Rena: First of all, thank you everyone for coming today. We really appreciate it. I know it’s a crazy time because of the holidays, so I'm really happy we could squeeze this in and this will be available for people to access after both on the fertility forward podcast and RMA YouTube channel so people can access it any time. So I think that this is sort of part two of what we've called our Hope and Healing panel. The first one was last month also with myself and Dr. Sekhon and we focused on pregnancy loss and infant awareness for that month. And we had also a patient perspective and a mental health professional from a pregnancy support program. And so the goal of this panel is we are now bringing on besides myself and Dr. Sekhon we have Ariel Schnur who is a nurse at RMA and we have Rachel Hess who is going to provide a patient perspective. And so for this panel, I just wanted to focus on fertility treatment in general. So more of just an umbrella perspective of this is what it's like to be a patient. This is what it's like to be a nurse and a doctor in this space and then I'll provide the mental health commentary. And we can just sort of have an organic flowing discussion to hopefully shed light on what this process is like for both current patients, potential patients, and then also family and friends, um, for people that have loved ones going through this, who kind of don't understand. So I hope this really can serve to, um, to educate a wide variety of people and just shed light on something that affects so many people as all of us in this space know, but I think people outside of it still kind of don't understand. So I guess without further ado, I would love to have Dr. Sekhon start by just sharing the medical perspective. What is IVF? What is IUI? Tell us kind of the broad facts about those treatments and then we'll go from there.
Dr. Lucky Sekhon: Sounds good. Um, so I could talk about this forever, so make sure you cut me off if I'm taking too long, but, um, yeah, no, I mean, I spend day in, day out talking about this with patients and this is something I'm really passionate about. I think there are a lot of misconceptions when it comes to our fertility. We don't really receive any sort of education about our own biology other than how to avoid getting pregnant for the first half of our lives. And I think a lot of patients who come to me, especially if they're coming to me for a reproductive checkup and they haven't really gotten deep into trying to conceive, a lot of people are shocked when they find out how inefficient human reproduction is. And that's for everyone. I'm not talking about for anyone with an actual diagnosis of infertility. I'm not even talking about patients who have been trying on their own. In general we know that there's about a 15, 10 to 15% chance of achieving pregnancy from any given ovulation and it's because there's just so much drop-off, and it's so different from the biology of certain animals. I mean, humans just have the most inefficient system starting with the fact that you are limited to trying during this two-day, three-day window, every cycle. Not everyone gets a cycle every month, right? So that's the first point of inefficiency. And then the second thing is that even if you time everything perfectly, if you have a clockwork cycle, it doesn't guarantee that every egg is going to be fertilized, turn into an embryo, be genetically normal and healthy, and actually find the right spot of the lining of the uterus implant. So it's all of these independent events that we're expecting, you know, to line up perfectly and it can be really frustrating. And one thing that I always explain when I talk about assisted reproductive technology, ART, or different types of fertility treatments, is that they're really just geared towards trying to improve upon inefficiency and make it more efficient. And there's laid back approaches where you're not doing anything, you know, that aggressive, but you're doing small things. You're tweaking things here and there to try to improve the odds. It's almost like gambling, like taking medications to release two or three eggs instead of just one egg every month. And then at the same time, you know, taking the sperm, concentrating it and injecting it at the top of the uterus - that's called an intrauterine insemination - in the hopes that you're just improving the odds of getting the sperm in the egg to interact. And that helps, but it's a marginal improvement on that 10 to 15% chance of success. So maybe it improves your chances 5 to 10% max, right. So I always tell patients when you're thinking about the lower tech treatment options, so options outside of IVF, usually, you know, lower on the ladder of aggressiveness if you're thinking about it that way, when you compare the different types of treatments, um, it, it does make sense that persistence pays off in that type of treatment option for some patients, right? And it is unrealistic to think that just doing one insemination with one round of Clomid is going to get you there. It's great if that works the first time, but that's, that's not the norm because you're working with really low efficiency still and low success rates, but it can improve and it might address the one thing that's standing in your way, right? But most patients who do that type of treatment, they're going into it mentally prepared hopefully that this might take three or four rounds. And depending on your situation, depending on the urgency, factors such as age, um, and just, you know, your own feeling about it, like some patients are coming to me after trying to conceive for 18 months on their own, and they don't want to do something with a 15% chance of success or a 20% max chance of success for six full months. They're ready to move on. Um, you know, I think everyone's situation is different and that's a conversation to be had and something that needs to be looked at in an individualized fashion with one's doctor. But that's kind of like the lower tech treatment option that is considered, you know, the pros are, it's considered more laid back. Most of the time you're just taking five days of an oral pill which is easier than taking injections every day. You're, you know, it's definitely cheaper if you're paying out of pocket. It's more likely to be covered by insurance upfront because insurance companies will want to cover the least expensive treatment option and see if they can get away with that, right? And it's just less invasive too. There's no procedure involved other than the intrauterine insemination, which honestly is one of the least invasive things that you can undergo. It's, it's like having a pap smear. It involves a speculum, there's really no pain involved and it takes about five minutes. So that's kind of the first approach where, um, the idea is, like I said, it's almost like gambling. If you release more than one egg, maybe you're, you know, improving the chances that at least one of them will get to the finish line and get past all of those different barriers or points of attrition that can take place and prevent reproduction. That is in sharp contrast to IVF. And, you know, IVF is a completely different ball game in that you don't worry about stimulating too many eggs. And because the downside of the first treatment option I just talked about is the gamble is, is that you could release, you know, multiple good eggs, healthy eggs without knowing, cause you can't tell by looking at it on the ultrasound.
Dr. Lucky Sekhon: And sometimes it works too well. And you end up with twins, um, or multiple pregnancy. And that can happen 3 to 8% of the time, not the most common thing, but we view it as a risk because twins are high risk pregnancies. So IVF is different because you can more aggressively stimulate a woman's ovary and your goal is actually to try to get every egg that is available because every month we as women make a certain number of eggs available. We recruit a certain number of our eggs to the surface of the ovary. And those are the ones that we have access to that can actually respond to treatments to the injections that we’re, we’re being given. And our goal is to extract all of them because at the end of a cycle outside of treatment when you recruit those eggs to the surface of the ovary, if you don't ovulate them, you can't reuse them. They're basically, you know, they, they, they go away and they can't be reused and they don't come back. So IVF doesn't dip into the supply of eggs that you would have for future use for future cycles. It's basically salvaging what's available that given month and we give you injectable medications for 8 to 10 days to try to access those eggs, salvage them. And at the end of it, you know, we're bringing you in for monitoring ultrasounds during the 8 to 10 days of injections. If we see on the ultrasound, it looks like we've gotten as many of them to grow as we possibly could and we don't think that there's any use in pushing any further and giving you more days of medication, we’ll tell you to stop the medications. And two days later, we bring you for the egg retrieval procedure and the egg retrieval is a procedure that is invasive. It is what we call minimally invasive as doctors because there are no incisions. It's not a major abdominal surgery, but it does require anesthesia. And, um, you're put under light sedation. The whole thing takes 5 to 10 minutes. And the ovaries sit right on top of the vaginal canal. A lot of people think that, you know, all the pictures they see in the textbook of the uterus and the ovaries out here is, is reality, but it's not. They actually hang out down by the vaginal canal. So it's really easy to get to the ovaries, um, with a long thin needle that passes through the vaginal canal, through the vaginal wall, into the ovary. And we drain all the fluid we can get from those fluid filled spaces called follicles that each have one egg floating inside. And that's how we access the eggs on both sides. We're taking eggs from both ovaries because remember these eggs are being thrown out anyways at the end of the cycle. And once that part is done, I would say the most intense part of IVF, at least from a physical standpoint is over. And now I think is the more intense, emotional part, which is the waiting game because, you know, the next day you're going to, you're going to find out on the day of the equity wall, how many eggs were retrieved. Now, one thing that people don't focus on or think about is that not every egg that is retrieved is useful. They have to go through different phases of maturation and mature eggs or what we were looking for. And, you know, an ideal successful stimulation, the majority of what's retrieved will be mature and can be injected with sperm, um, or can interact with the sperm. And basically the next day, you're going to find out how many fertilized, how many of the fertilized eggs turn into embryos over the course of the week. And so you're just kind of waiting for these updates and I've actually, I should preface this whole conversation by saying I've been through IVF myself. As a doctor I think that gives me a very unique perspective. And I can tell you that even with all of the information and being able to intellectualize and use those defense mechanisms, it's still very difficult to be on the other end as a patient and wait for those numbers and wait for the call to tell you how many of your eggs fertilized and you know, to actually see the drop off, even though I know, 60% of fertilized eggs will turn into an embryo, that's the average type of drop-off that we're expecting, which is really significant. It hurts when you see it happen to your own eggs, right? Because you really want every, every single egg to make it. But it's, it's a fact of nature that there's just going to be that attrition. And there it is a numbers game and numbers do dwindle down. But you know, if you're doing genetic testing, then that's an additional step where on day five, six or seven, after the egg retrieval, you're going to get another update about how many of those embryos that resulted could actually be genetically tested. IVF is a unique treatment option because it's the only one that allows you the opportunity to get that information, to find out how many chromosomes each embryo has. When you're ovulating eggs inside your body, you have no idea about the quality and our body doesn't have a quality control process. It's just at random. But when you do IVF, there is a lot more control and precision because you can get that genetic information and then we can freeze embryos. There's so many options available. You can freeze embryos, you can put an embryo back fresh, meaning not frozen, you know, a week after the egg retrieval. And there are nuances and differences between the different treatment options, but in general, the main differences between IVF and the first treatment option we talked about, which is called ovulation induction and IUI is that IVF has a higher success rate. It is more efficient because you're working with as many eggs as you can possibly get from the ovaries in that given cycle. And it allows you the ability to do genetic testing, which means if you're able to find a genetically normal embryo, your risk of miscarriage is lower than if you were to get pregnant on your own or get pregnant with IUI because you've already weeded out the embryos that you know, are at highest risk of miscarriage. Um, and because if you're, if you are genetically testing an embryo, when you know that it's a high quality embryo or it's someone who you presume will have embryos that have a very high chance of implanting, you're only going to put back one. So the risk of twins is much lower. Again, I'm saying risk because they're just higher risk pregnancies. The risk is probably like 1 to 2% because an embryo could split, a single embryo can split, but it's not very common. And those are the main differences. Now the downsides of IVF are, it's a lot more work. It's more expensive, especially if you're paying out of pocket and you don't have coverage. And I think it is more emotionally taxing because of the physical, emotional, and financial investment. And a lot of patients are, if they're transitioning from a lower tech treatment option, like IUI to IVF. And if that, for some reason, isn't going well, or, you know, the, the drop off is sharper than expected, it can be really disappointing because a lot of us view IVF as this magic bullet it's, you know, going to be the successful aggressive treatment option that you can lean on if all else fails. And so it is definitely more emotionally taxing to go through IVF. Those are the main differences in my mind.
Rena: Thank you so much for such a comprehensive overview. I think that was really incredible, really detailed, and hopefully shed some light for people. I think the one thing I, I would say is, I think a lot of people, they get super overwhelmed because it's so much new information. It's a lot and most people really come in and they have no idea that there is that there is even, you know, different phases of the menstrual cycle. They had no idea. And so I always tell people, you know, you don't need to know all of this, like everything you just shared, no one needs to know that. That's what the doctors are for, but we'll walk you through this, explain things to you, you know, there's, there's great ways, you know, videos, reading, et cetera, to understand this. Um, and I think at the beginning, you know, I remember myself when I was a patient it was super overwhelming because you're faced with all these options and it's a lot. And so I think, um, you know, to also understand you don't need to do all of that. Um, it's definitely a learning curve and a process. And that's what, you know, someone like I'd love to bring Ariel into the conversation, you know, fertility nurse. So what exactly does a fertility nurse do?
Ariel: That's a great question. I've been a fertility nurse at RMA for five years now, over five years, and it's a definitely different type of nursing than the traditional idea of what people think a nurse is because we are dealing of course, utmost importance with the safety, physical safety of our patients and safeguarding that aspect. But we're also dealing with an emotional, mental, and social aspect of everything that the patient's going through. So we are at a privilege, basically to walk alongside each patient as they go through treatment and we're delivering their results, their instructions, we're explaining things to them, breaking things down, telling them what to expect next and then also supporting them with everything they're going through as they give us feedback about how they're feeling physically, mentally, everything they're going through. So a huge part of it is just listening and hearing patients out. And, you know, as nurses, we, you know, caring is just part of our job description, but especially it's applicable for patients going through fertility treatment because they really need someone to walk beside them and kind of get them through it. And we also get to see, you know, so many patients go through it and see so much good on the other end. And sometimes we're able to shed a little bit of light for patients who feel like they're really in kind of the muck of things or in kind of the intense phases of things and they can't really see the other side, but when we've seen so many patients experience different road bumps and experience different twists and turns in treatment, but yet come out on the other side in a positive way, we're able to kind of encourage patients to continue to keep going and persevering so that they get to that point too. So it's definitely, it's an interesting and, and really, um, intense at times position to be in, but also definitely a privilege. And it's extremely rewarding.
Rena: I think, you know, people are so lucky to have people like you who care so much who are there and understand that it's multifaceted, right? It's not just about the medical as well. So I'd love to now bring Rachel into the conversation to talk about you know, what was it like for you the first time you walked in the door as a patient, dealing with all this new stuff, medically and your nursing team and all that, what did you remember back, you know, what it felt like to be dealing with fertility treatment for the first time?
Rachel: So I actually, I had coming into this whole fertility process, I actually had some underlying health conditions. I had and still struggle with chronic headaches and also a rare form of colitis called lymphocytic colitis. So I was already juggling that before I embarked on the journey of fertility and my partner and I we actually got pregnant naturally the first time in 2017. And that was, sorry. We started trying in 2017 and ended up taking nine months to get naturally pregnant in the summer of 2018 and ended up miscarrying at around eight weeks. We tried for the rest of that year, but at that point, this was something that we really wanted and my, considering health issues, that I was already carrying, we wanted a second opinion. So I did start with RMA and I did go and we did consult a doctor there to start and we decided to start with IUI. So basically we did 4 rounds of IUI, all of which were unsuccessful.So that was with some oral medication. And I mean, it was emotionally draining as well as, as well as like, I deal with headaches on a daily basis and stomach issues. So also physically draining to adjust also the hormone levels in your body. But I mean, the RMA team from the doctors to the nurses, I was lucky enough to work with Ariel who was amazing throughout everything. So, you know, it was kind of always nice, even though it wasn't the results we wanted to have like a familiar voice on the other end of the phone delivering those results, which I did appreciate having that consistency of care at RMA. After the fourth round of IUI, we decided to try IVF because this was still something that we were really passionate about. We had already suffered one loss and that was, you know, it was definitely difficult for my partner and me since this was like a major goal in our lives at the time. And we wanted to pursue a more sure thing. So we did one round of IVF. From our retrieval we only had at the end of that whole process that Dr. Sekhon described, we only had one viable embryo to use for transfer which we did use and it was unsuccessful. So we had to go through the whole process again. And, you know, it was just difficult because everything felt like a loss from the miscarriage to when it doesn't work. So it's really important, you know, to have someone there. Ariel was amazing and the doctors at RMA were amazing. You know, I have terrible veins. I made friends with all of the clinicians who drew my blood at RMA. And it's, it's a lot for IVF at the beginning for the first stage of it. You go in like every couple of days for blood work and an ultrasound to make sure everything is progressing smoothly. So we did do another retrieval for IVF and we got more viable embryos this time. And the second time we had the transfer we were successful. So in the summer of 2019, we were pregnant again. And then at around 10 weeks, I miscarried again. And this was like an unbelievable loss. We were, you know, told, you know, by a lot of people miscarriages happen and you know, this is a story that I actually haven't shared until recently with people. A lot of my extended family didn't really know it, just cause I felt it was like, I didn't want to spend all my time talking about it. It was difficult to do. My husband and I, we felt like we were talking about our losses constantly and it was kind of dominating our relationship. We just couldn't get out of it. It was really important for me to have someone like a social worker, like Rena, to also have to process these losses emotionally and deal with the fact that the future that we were planning for wasn't panning out and our hopes were high because this was IVF. We had all these embryos that were given like a good grade. We made it past the point of the first miscarriage. So we were really, really hopeful and absolutely devastated when the second loss occurred. So because it was a second loss, we were uncomfortable moving forward without further testing because we were like, this happened now twice in a row. So it did turn out that I had fibroids and I needed them surgically removed. So this January of 2020, I started this year having surgery. I took a few weeks off work to recover and then I was told that I had to wait three months post-surgery so that I could recover before I could resume IVF. And just being told that you have to keep waiting, you know, there's time between each cycle and when you're able to do IVF again. So the waiting just make, made it that much harder. It just felt like a lot of time wasted. But, you know, we were reminded that the surgery was a step in the right direction. They got the advice from people at RMA that, you know, seemed like it could be negatively impacting the pregnancies and, you know, we remained hopeful because we had gotten pregnant, you know, a couple of times already. And so we waited those three months and then of course COVID hit, which it seems like we both had at the beginning of March. So when I had what we thought was COVID, we couldn't get tested at that time. It took my colitis out of remission. And so my stomach issues were too bad to resume IVF then for another couple of months. So after all of that waiting, we were finally able to resume IVF in the summer. So that's kind of where we left off and we, you know, we're really happy with the treatment and like the care that we've gotten at RMA. They have like amazing counseling services, which has been really, really wonderful, especially because I was uncomfortable going to any kind of support groups. I didn't really feel like I wanted to be all around people that necessarily were struggling and it was a lot to take in. So I, you know, I was able to be connected with another patient at RMA who, you know, it turns out we actually have a lot in common past out fertility issues. And we, you know, we have become kind of like friends, pen pals, and text most days of the week. And it's just kind of a nice support that doesn't have to feel like as intense as a support group and like sitting in that space dwelling on it. But it's nice to know that someone understands the situation. And I think that's one of the reasons I wanted to open up was because I think having miscarriages is quite a common thing, which I didn't realize before. And it's so not talked about. I feel like the discussion is taboo. And I feel like when I always heard people's stories and it resonated with me, I felt more empowered to share with them my own story. So, you know, I think that it's important to hear other people's stories, especially if it's something you're struggling with so that, you know, you're not alone and that you have people there who understand what you're going through.
Rena: Thank you so much for sharing all of that. I think, I mean, that is so brave to open up and share, and really, you know, what a journey you've been on from, you know, your overlying health conditions and then also going through this through COVID. And I think you touched upon something that is one of the most difficult parts in this is the waiting. And I think a big part of this, I know for me, when I was a patient, it was before I got into this field, but it's what shaped me to going into this work is I constantly felt as though my life was on hold and it was 2 steps forward and 5 steps back. And I think understanding how to deal with that and talking about that is really important, because it's tough. And maybe you can speak more, you know, after you had this surgery and you had to wait for three months, how did that feel? Um, I know for myself, something similar happened to me and it was sort of, I just felt like I was like a sitting duck. Like all I wanted to be doing was trying to conceive, my life was on pause and it was like, what was I supposed to do? Go pretend that everything was fine and I had some semblance of normal life? It was really difficult and I think it's something that so many people experience.
Rachel: Yeah. And I mean, I think a lot of the time leading up to the surgery, I think it was, the emotional work was around accepting that I'm getting the surgery and there will be three months that we’ll not be able to move forward with IVF. And I think that by the time I had the surgery, I had come to terms with the fact that, you know, after talking with a lot of people, my husband, you know, counselor, friends, family, that I did share with, you know, we decided to view it as these are three months that I'm taking to get my body into the shape to make it more likely for a viable pregnancy to occur. And one that might, you know, continue to term. So viewing that, viewing it that way, I was able to recuperate and give myself that time. And of course it was a big blow after those three months, but getting COVID and then the stomach issues again, to have to wait even longer, you know, that felt like a loss even though it wasn't necessarily a miscarriage loss, it was definitely a loss on the journey to continuing. And it was, it was definitely hard, you know. There's tons of anxiety throughout this whole process, you know, especially after a loss, you're always worried about the next time, what if something goes wrong and how can I go through that again? And I think, you know, I think sharing when I did find out that I was pregnant each time, you know, I think sharing that with immediate family was really helpful because I don't know how I could have gotten through the miscarriages if no one had known I was pregnant. And I hadn't been able to tell anyone I needed the emotional support from so many different arenas and it's impossible for one partner to provide all that. And, you know, like, even though he wasn't the one getting the injections and the transfers and everything, it was a loss for him too. It was his future that also changed. So I think keeping that in mind, like having the support system and, you know, being able to feel comfortable and opening up was really something that has been helpful, especially the latter part of this fertility journey is that, you know, realizing that I can depend on those people and especially learning as I've gone through it about other friends and family who have been through similar situations.
Rena: I think that's, I mean, you touched upon everything that's so important. I think, you know, it definitely takes a village for this process and whatever that village means to you. If you're comfortable in support groups, an individual therapist, or whatever resources you choose to put together. I think that it certainly takes a village and it, this is a marathon, not a sprint and I think it's important people build out support so, you know, as you said, you can't rely on one person to fill all of your needs, and so I think that really is a very important part of it, for sure. And then I guess I would ask both Dr. Sekhon and Ariel, what would you guys say is the most difficult part of your job? You know, hearing Rachel's story and, and the personal aspect of it, you know, as much as we may try and create boundaries and separate ourselves, you know, and have work life balance, I think, you know, the it's, so this, our work is so, you know, we're working on something so personal for people, right? To help people family build. What would you say is maybe the hardest part of your job working in this space?
Dr. Lucky Sekhon: For me, I think as a doctor, people look to you for guidance and my comfort zone is when I know exactly what to do, I know exactly what's wrong, and it's like the algorithm just kicks in and your training kicks in and you feel like you’re in your comfort zone and you've got this. I think the hardest thing to do to deal with is when you don't necessarily have all the answers. And I think the most important thing as a doctor in this space is to be able to admit that. There are certain things we can't test for in our field, there are certain limitations, and we're not always going to know why, for example, a genetically tested embryo doesn't implant or why a miscarriage happens. We're not always going to have the answers and that is one of the hardest things because that's what we want to provide. We want to be able to give closure or comfort, a solution. And that's the thing that I struggle with day in day out when there is a lack of answers and I make a concerted effort to be as honest and forthcoming about that as possible because I think a lot of people, you know, come into this, especially if they don't know a lot about IVs in the process, I think a lot of people overestimate sometimes what science can achieve and what we can test for like, there's this misconception that you can do every test there is and really drill down to what the issue is and come up with a solution. And I think, you know, just being really real about the fact that that's not the case and just providing support to patients and providing support without having to have all the answers. I think that's a challenge.
Ariel: Yeah and piggy backing on that in addition to not always having scientific answers and reasons, there's also no magic words that we can say to make the situation less devastating and less upsetting and to make it feel better which is what we want to do so badly. And delivering the news that someone's pregnancy test is negative or that someone's had a loss or that their genetic testing results are not what we had hoped for, all of that is very, very hard to do and it never gets any easier to do. And, you know, that's really where just the listening aspect comes in and being a support to just be able to listen to whatever feelings and emotions that brings up for the patient. And, you know, it is just difficult not having any magic words to say, and just to not be able to make it feel any better and not, not knowing when, you know, it will be made better or how it could be made better. It is, it's definitely difficult in that aspect.
Rena: I agree. I think a lot of times I tell them, I wish I had a crystal ball, so I could tell you what's going to happen and hang in there. It's better. And we don't and I think that is one of the hardest things when we're seeing a patient struggle and we can't tell them, well, okay, just one more cycle and you got this or just two more cycles and we have to just walk the journey with them and do what we can to help them find their strength and find their path.
Dr. Lucky Sekhon: I also think, I just want to add, there are so many aspects to our reactions to how these treatments go that are human nature and our intuition. And I think one of the most challenging parts of my job is when a patient's embryo doesn't implant I think everyone always wants to do something radically different because it will make them feel like we're doing something different, you know? And I think it's really hard for any patient to be told, you know what, there's a 66 to 33% chance that this will work versus not work because that's just the limitations of the technology and the treatment option that we're working with. And, you know, unfortunately I think you just fell into that one-third group where the embryo didn’t implant, but there isn't an identifiable reason. So I don't, you know, have a knee-jerk response where I want to do things that aren't proven that might have potential harms, but there's so much misinformation on the internet from, you know, just a variety of sources. And it's hard because I'm, you know, every doctor has their own style. My style is to be very rooted in evidence and wanting to take logical steps. And I think it's sometimes very difficult to kind of bridge that gap because everyone, no matter who you talk to, no matter what their training and background is, something doesn't go your way, logically, you want to switch it up, do something really different. It feels bad to go into a situation with the exact same parameters. When, you know, you just had a bad outcome or something didn't go your way. And that's the hardest thing because I don't sometimes I think making radical changes and taking on interventions that don't have any proven benefit and that could have potential harms is not in the best interest of the patient. So navigating that conversation is a huge challenge for me.
Rena: I love that you said that because I think that's a big part of my work too, is, you know, it's pretty Pavlovian, right? It's like for a lot of our patients that they haven't gotten what they wanted, it's almost it's negative reinforcement. So they feel like, okay, well, why would I keep sticking my finger in a socket and getting electrocuted, I'm going to stop. And then they say, well, I want to find somewhere else because they're going to do something radically different. And then a lot of my job will come in to help them unpack. Okay. Why, why are you doing that? You know? And is that really the right place to go, somewhere where they're telling you that this has no, it’s not science-based or it might be extremely risky and let's kind of unpack why you're having that reactive response. And I think when people take the time and often this is really time sensitive, a lot of what I do in the mental health profession is very time sensitive because you're working with people that are in time-sensitive situations and being reactive to help them understand, okay, actually I'm doing that, right, as this sort of Pavlovian response, but is that actually, you know, the right one and a big part, I think is trusting your team, trusting your doctor. I think advocating for yourself. I know that Ariel and Dr. Sekhon are both super available to patients and get a time to have a call with your doctor and ask them, okay, well, why are you repeating this protocol if it hasn't worked and let you explain it to them, this is why. And I think, I think sometimes people are afraid or think that they don't have the ability to set up a call with their doctor. And, you know, I'm big on patient advocacy and knowledge is power and for people to understand, you know, okay, this is why, because what you said makes total sense. And so I love that, you know, we're doing this to help people understand too, that this treatment should be really accessible. And I don't know if Rachel can speak to that for ability, um, or if it was helpful for her to really, you know, directly ask questions of her doctor and make sure she understood what was going on. And if she felt that that made the treatment and her journey easier instead of kind of just nodding her head saying yes, and going along with it, but then, you know, questioning, what was she doing. So I don’t know if you want to touch upon that.
Rachel: Yeah. I mean, I definitely think, and Rena you on more than one instance, you definitely encouraged me to reach out to the team which I wouldn't always think to do. You know, we, we all know doctors are very busy and don't like to bother anybody. So, but I think that if, when we were concerned about, you know, something that was, or wasn't changing, or whether we were concerned about whether or not we were getting the results told to us in a way that made us feel comfortable, being able to approach the team definitely made it, I think better for both parties, because then we got some of the knowledge we needed about the decisions that, you know, on the doctor end, which of course we don't really know the biological and medical explanations for the decisions that the doctors are making, it definitely helped to hear, you know, why maybe one medication is increasing at this time, or maybe we're going to do the same thing that we did last time even if you miscarried. That definitely helped to hear the scientific and medical, like explanation with the evidence from previous studies. And it made us feel more secure. This wasn't just like, they're not changing anything. And also, you know, it's, it's a lot to wonder, like we've all mentioned, the waiting is really tough. And just kind of, even when like the transfers were positive and we were going through, you know, you have to wait a week for your next appointment. And then you're always wondering what's going to happen between now and then, and you don't always understand, you know, what the next stage that you're looking for is like, what can I expect my next visit to look like? And being able to speak that aloud to my team really helped cause then my partner and I, when we went to the next appointment, we understood what they were looking for and what potentially could be a pitfall if they didn't find, or it might just be too early to tell. So I think just like having that knowledge made it easier to manage our expectations.
Rena: I think that's something I definitely encourage a patient is to come up with a plan. So you always know what's coming next and usually I work with people so they know what's going to happen regardless of the outcome. So if you're going into a transfer cycle, I'll have them come up with a plan. So they know what are the next steps if the transfer gives them a positive result or what are their next steps if it gives them a not positive result. So people always know where they're going forward. So, um, and I guess I love that, you know, RMA is run with these collaborative teams and people can reach out to their coordinator and nurse, and it's really accessible. And again, I think sometimes it's just making the patient aware that that's, you know, you're right. And I think advocacy is important. And I know the doctors and nurses are always really happy to answer questions and have these conversations with patients because I think it makes for better care. You know, I think this is a really integrated collaborative approach. It's something that's so personal and meaningful, you know, trying to family build, it is it's huge that, you know, majorly impacts somebodies life. And, you know, as I think Ariel and Dr. Sekhon said, it really is an honor and a privilege to be led into someone's journey. And so I think we all want to do anything we can to honor that and, and help you through that.
Dr. Lucky Sekhon: And I feel like it's important to find a doctor and find a care team that you can be honest with. That's always my goal. I've had some patients with really difficult cases and, you know, I'll often bring it up to them and say, you know, I think even if they're not questioning what I'm doing or they're asking for something radically different, like if it's a difficult case, and I know they're just searching for answers, I will oftentimes say, you know what, as a patient advocate, I'm telling you, you can go and seek a second opinion. And I think hearing that from your doctor, I think it relieves a lot of tension because a lot of people view that as something that might bruise one's ego or the awkward, and I never want a patient to feel like that because this isn't about me, this isn't about the clinic you're going to, this is about you and, you know, you feeling like you're doing everything that you can possibly do and kind of dispelling any bit of doubt that you might have in the back of your mind about the plan that you're embarking upon. And I think the biggest thing that I do for my patients who are interested in a second opinion is give them actual names, you know, because it's a small community. And I have colleagues that I know are not going to steer people the wrong way because they practice evidence-based medicine as well because there is a lot of misinformation out there and you want to make sure that whoever you're talking to has the best, your best interests at heart. And I think that's one way that, you know, makes me feel like I'm not just saying, sure, seek a second opinion. I'm making sure I'm actually helping guide them and giving them that direction. Um, and I think that that goes along way with, you know, the patient because they realize that it's not about me and it's not about things external to them. It's really about just trying to get them to that successful outcome.
Rena: I'm so happy you said that. And I that's, it's a, I mean, I think you're an amazing doctor and person for so many reasons, but I think that I speak so highly of you and so many patients who come to me and, um, you know, they say, well, I want to get a second opinion, but I'm really afraid my doctor will be mad at me and I'm scared and I don't know what to do. And, you know, and I say, look, I'm a patient advocate and no one's going to be mad. That's how it goes. And, and I do think sometimes a second opinion can be helpful mentally because maybe you go get a second opinion and the doctor said, well, I would do exactly what you're already doing. And at least it gives you peace of mind. I think sometimes it's, it's definitely an element of feeling in control, you know, like it's something to be doing if you're waiting, you know, and I, I totally agree and I so appreciate that you will give people the names of other good clinicians because my biggest fear is that someone ends up with somebody bad, someone who’s just trying to sell them, someone who's going to do something unethical. That is really my biggest fear and biggest heartbreak because as we know, finances are, are too often a factor in this. And so I just, you know, so appreciate that you are open and honest about that and help at least guide people to somebody good who is going to take good care of them. I think that's wonderful.
Dr. Lucky Sekhon: Well, I think our worlds is this, this world of fertility treatment is hard because it's not as transparent as other areas of medicine, which is, you know, more obvious like, okay, you have a lung problem. You're going to need this specific treatment. I think a lot of things that happen in the IVF lab are just so hard to understand. It's like behind a curtain, behind a wall, and a lot of those details are just so blurry. And I think that just adds to the lack of control that a lot of patients with infertility already face. And so it just kind of compounds the problem. So I think anything we can do to try to lift that veil and just be as transparent and open and honest as possible is going to help counteract that.
Rena: Totally agree.
Ariel: I think also, you know, we, as nurses want our patients to reach out to us and ask us the questions if they're not understanding why something is being done a certain way, or why something results in a certain way, we'd rather our patients come to us to ask us rather than rely on, you know, trying to search the internet and trying to go through tons of unrelated information, looking for the right answers when, you know, if we don't have the answers, we'll help them find the answers. You know, we'll go to the physician or go to the embryologist, go to who we need to go to, to get the answers for them and we want patients to reach out. So even if you know the answer isn't being handed to right away, that you were, you know, thinking of, if you come up with questions later, definitely reach out. Patients can call, patients can email, you know, we want to be a source where we can translate why something is happening a certain way.
Rena: Well, again, I think that’s why people are so lucky to be at RMA because it is so transparent and communicative like that. You know, I can say I did my fertility treatment before I was in the field and it was at a different clinic and I didn't have that experience at all. It was like, don't call us, we'll call you. And we're going to call you when you're in the shower and then you can’t call us back. And that's why I so appreciate how RMAis run, because you can get in touch with anybody, anytime. You know, we have these teams, you can email people, you can call. And I think that makes a huge difference. You know, this shouldn't be a healthcare situation where it's impossible to get in touch with your doctor. You know, as we've noted, this is time sensitive. It's fraught with emotion and playing around, waiting for someone to call you back at the one second you're not available when you put your phone away, you know, it's just so not conducive to helping people get through this process with grace and dignity. So it's really another reason that I think RMA is run so well with these teams and people who are, who understand that communication is so important. So I just, I want to be aware of everyone's time. So I would love to just wrap up and maybe ask Rachel, do you have, I guess each of each of the three of you, if you would have one piece of advice for someone coming into this process, what is one thing that you would say?
Rachel: I guess I would say, you know, take advantage of everything it has to offer. I was really lucky to start seeing Rena which I didn't even realize was a possibility right when I started at RMA. And I think, you know, I probably would've liked to start, you know, that earlier I was seeing an outside therapist that definitely wasn't a fit for me and didn't understand much about fertility and the journey of going through the process. So it definitely helped to be speaking with someone who had, you know, background in it and, you know, worked for RMA. And I think, you know, not being afraid to reach out if you have a question like you were saying, I think is important. You know, this was the first practice, medical practice that I'd worked with where I was able to get in touch with a receptionist for anyone, every time I called. And it wasn't like I had to call six times to get someone to call me back. And I really did appreciate that. And it did make me feel valued as a patient. So I think just taking advantage and asking about all those options. And I think that if you're struggling emotionally, like I think it was really helpful for me to be set up with someone else who had a similar experience with loss as I did. And that was another person that I could rely on who I could say something to her and no questions asked it was accepted and it was, and it was okay to feel that way, even if other people didn't understand my negative head space at the time like that person and Rena always understood where I was coming from. And it wasn't arguing with me about, you know, try this to be happy. It was accepted and let's work through it and unpack it. Um, so I think that was really helpful.
Rena: Good. And I guess I'll interject there. I'll say sometimes if you are looking for someone who has gone through this, a really great resource, it's called fruitful fertility and they're an app where you sign up for a mentor and you can be matched to someone who’s already gone through it who should hopefully be someone like Rachel found, you know, a connect who gets it, they don't judge you, they don’t tell you to sit back. So, um, fruitful fertility is a really wonderful resource. Okay. So Dr. Sekhon, what would your words of advice be?
Dr. Lucky Sekhon: I would say because some of the someone said something earlier about, you know, doctors being busy, I would say any patient going through this process, I would recommend not assuming that your doctor's too busy and that your doctor doesn't want to hear from you. I feel so guilty if I get an email from a patient telling me that they've been struggling for a while or that they were stressed about something needlessly and it could've just been rectified if they had reached out to me sooner and I could have just kind of nipped it in the bud. So I, my preference is always to err on the side of over-communication and if you have a problem or a concern or you're feeling lost in the shuffle, I had a patient recently, you know, I saw maybe it was because of COVID and everything getting kind of stretched out timeline-wise, but she wrote me this email that just like really got to me because it said something along the lines of, you know, I met you so long ago and now I'm finally ready to go through this process. As I'm sure you're aware of my cycles about to start in a few weeks and I just feel like it's crazy that I haven't talked to you and I'm feeling really disconnected. And I was like, okay, I'll call you tomorrow. Like, it's that simple? But, um, I think a lot of people assume that their doctor's too busy and that they should only bother them if there's an emergency or, you know, something really major going on. But, you know, I think it depends obviously on your doctor, but my personal take on it and I can speak for a lot of my colleagues is that we would rather, you reach that to us because we don't know if there's a problem, unless, you know, you alert us to the fact that you're struggling or that you need more support or that you don't feel like you have a clear understanding of the process you're about to start. So yeah, don't, don't be so overly considerate. I think it is important to advocate for yourself and reach out and ask for whatever it is that you need.
Rena: Ariel? That was beautiful, Dr. Sekhon.
Ariel: Yeah, I totally agree. And also so simple, but so important is for patients to take care of themselves, to do things for themselves during the process that will help them physically and mentally and something so simple as to pay attention to hydration and make sure they're getting enough fluids, make sure they're eating meals and having snacks, you know, throughout the day, doing things they enjoy, seeing people they enjoy or hobbies or television or laughing, you know, just doing things to make sure that they are well taken care of and in a good headspace. It makes the entire process, you know, easier. And, you know, if they need recommendations for, you know, things to do, we, we definitely have tips that we can give, you know, on what movies are funny or TV shows are funny and are distracting, but it is simple, but really important because, um, it takes strength to get through the process. And in order to replenish that strength someone needs to come from a place of, you know, at least being able to go through it from, you know, a healthier standpoint.
Dr. Lucky Sekhon: And I just want to add something. I always knew that the nurses played such an important role and that wasn't just the doctor and the patient, it's like this team approach, especially at RMA because I did my training at RMAas well. So I've always been aware of that, but since starting, you know, as an attending, meaning, you know, seeing patients independently and not being in training, I will say that I've really noticed that anytime I’m discharging a patient from our clinic and we're saying our goodbyes and it's on a positive note, I feel like the stronger bonds tends to be between the nursing team and the patient because they feel like they really are in contact with the patients so often on a daily basis, especially if they're going through IVF. And so it's almost like you become friends with your team and your nurse, especially because they play such an intricate part of the process. And I feel like they do a lot of handholding and emotional support. And I feel like our nurses are just amazing.
Ariel: We definitely try, try to do everything we can, but as a team, you know, everyone is here to help the patient. And it's definitely something that, thank God, you know, see more positive than negative overall. And, you know, we're just here to help continue that and keep improving on it and make it happen.
Rena: Well, I just want to say thank you so much to everyone. Again, I know we slated this to end at the end at six, so I want to be aware of people's time. So I just really thank you, Rachel. Thank you, Dr. Sekhon. Thank you, Ariel. Thank you anyone that attended this live, RMA for posting. I like to just wrap things up, always on a note of positivity, especially now I know that at the time of stress with the holidays coming up and everything, so I, you know, want to just say I’m so grateful for the three of you, each of you really amazing have touched my life in a different way. And it's so cool to be now on a panel collaborating with all of you. So I always say, I feel really grateful to be in this space with other amazing women. And I just really continue to feel this way. I know you guys are all, Rachel's a teacher, which I think right now is one of the most stressful jobs to have. And with Dr. Sekhon and Ariel are of course, respectively busy. So just to have everyone dedicate an hour of their time to talk about something that they truly care about, you know, I feel like I really live and breathe this work. And I think a lot of people in our field do. And so I'm just so grateful to be here with all of you and get your time to hopefully help other people and just shed more light and knowledge. So thank you so much. I really, really appreciate it and appreciate all of you so much.
Ariel: Thank you.
Rachel: Thank you. We appreciate you too.
Dr. Lucky Sekhon: Thanks so much, Rena. This was amazing.
Rena: Bye everyone. Take care.
Dara: Thank you so much for listening today. And always remember, practice gratitude. Give a little love to someone else and yourself. And remember, you are not alone. Find us on Instagram @fertility_forward. And if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.

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