Fertility Beth Tinder, N.P.

Transcription

1 Fertility Beth Tinder, N.P. Kavin Desai, M.D.: Welcome to the Kaiser Permanente Health Cast. Today in our studio, we have Beth Tinder who is a nurse practitioner in Women s Health and a clinical nurse specialist in adolescent medicine. She works out of the Kaiser Permanente Medical Center in Hayward in both department of Obstetrics as well as the Teen Clinic. She has been with Kaiser Permanente for over 20 years. Welcome Beth. Beth Tinder, N.P.: Thank you very much. Kavin Desai, M.D.: So Beth is here today to talk to us about issues that people that are having difficulty getting pregnant face. Beth, what would you say is the number one problem that you see when people have trouble getting pregnant? Beth Tinder, N.P.: Most of the time women don t really know what their menstrual cycle is, and that seems to be one of the biggest stumbling blocks. So a lot of the teaching that I do is I teach the women to calendar their cycle. I don t like to have them do basal body temperatures, where you take your temperature every day, that s really a pain in the neck, but if they just keep a calendar of when they start their period to when their period starts again, that s their menstrual cycle. Many women believe that the menstrual cycle starts when you end your period until the next one. So they ll come in and say I don t bleed for a week and then I have a period again, but they don t consider the time frame that they bleed before. So the calendar from the date you start your period until the day you start your period. That s important because ovulation occurs two weeks before the period begins, not two weeks after the period ends. So if you have a short cycle, you have a normal day cycle and you wait until day 14 to have sex to get pregnant, it s going to be past ovulation, you re not going to get pregnant. You ovulated about a week before then. So keeping track of the cycle is very important. There are four things I tell my patients in order to get pregnant. You ve got to have eggs, that means you have to have a regular cycle. You ve got to have sperm, there s got to be enough moving number of sperm and there has to be a percentage of them moving. They ve got to get together. You have to have sex, and you have to have sex at the right time. And the fourth one is the tubes have to be open. Tubal damage is probably one of the last things that we would look for in a beginning work-up. So, does the woman have a regular menstrual cycle? Are the couple having sex at the appropriate time which would be around ovulation depending on what her cycle is? That s really very important. Kavin Desai, M.D.: And that cycle timing, is that always two weeks? I mean, is that always so regular, it s predictable? Or does that vary from woman to woman? Beth Tinder, N.P.: The follicular phase, the first part of the cycle, varies from woman to woman, from cycle to cycle. The last part, the two weeks before your period starts is called the luteal phase and that s pretty fixed at about two weeks, I mean give or take maybe even hours let alone a day. But that s pretty fixed at two weeks. Page 1

2 Kavin Desai, M.D.: And so what would you tell them as far as timing is concerned then? Beth Tinder, N.P.: Okay, what I tell them is keep track of your cycle for two or three cycles, so you get an idea from the day you start your period to when you start your period. It s not going to be exactly 28 days. It s not going to be exactly anything. If you have a 28 day cycle, it could be days, anywhere in there, so you know you re in the ballpark. You look at your cycle from the day you start, and you know if you have a 28 day cycle, then you can look at day 14 as probable ovulation, but you want to have sex earlier than that. You want to start about four to five days before you think you re gonna ovulate. And I tell patients to have sex every other day, and I use my hand and I say if ovulation was on day 14, then you want to have sex on day 10, 12, 14, 16, and 18. Every other day around the time you think you re gonna ovulate. Kavin Desai, M.D.: It requires a regular period though. Beth Tinder, N.P.: Exactly. Kavin Desai, M.D.: If it s irregular, then that doesn t really work. Beth Tinder, N.P.: Well, irregular meaning if they have a period and then one month later they have a period, then three months later, they have a period. That irregularity is difficult to plan a pregnancy. If they have a 26 day cycle and then a 29 day cycle and then a 25 day cycle, that s more regular, there s a timeframe.. Kavin Desai, M.D.: If you average the days or something like that.. Beth Tinder, N.P.: Exactly. Kavin Desai, M.D.: Okay, if you have the timing right, then what s the next step? If you still can t get pregnant. Beth Tinder, N.P.: If you still can t get pregnant, usually they would wait one year attempting. If they re under age 35, they wait one year with the timing trying to get pregnant. If they aren t able to achieve pregnancy, then they would come to me. I would do tests for some hormones. We would go over the calendar. I would do a semen analysis. And we would make sure that there was no medical reason for them not to get pregnant. I would then refer to our Fremont Reproductive Endocrinology or our Infertility Clinic in Fremont. Kavin Desai, M.D.: That s if all those four points that you made are already tried and failed. Is that correct? Beth Tinder, N.P.: Exactly. We would start with the basics. Are you having relations as often as you re supposed to? Is your cycle okay? Certainly, before the year is up, if Page 2

3 the husband wants to, he can go to his doctor and get a semen analysis, but usually that s done with the appointment that the woman sees me. Kavin Desai, M.D.: So is that a combined appointment then? How does that work? Beth Tinder, N.P.: The appointment is more for education. Kavin Desai, M.D.: I see. Beth Tinder, N.P.: So that I would do lab tests. I reinforce when to have sex and the issues of getting pregnant. We would do a semen analysis. If the woman has ever been exposed to chlamydia, which is a sexually transmitted infection, there is always a possibility there could be tubal damage, so we would go on to look at the tubes by doing an x-ray type of test. Kavin Desai, M.D.: And this is before any formal infertility clinic referral would be made? Beth Tinder, N.P.: Correct. Kavin Desai, M.D.: Okay, and so you wait the year and then after that is when you would make a referral to infertility clinic. Beth Tinder, N.P.: Correct. And when the couple is trying to get pregnant, I encourage them to act pregnant meaning no drugs, no alcohol, no tobacco. The woman should be taking a multiple vitamin at least, because that s got an adequate level of folic acid in it, before she gets pregnant. She wants to have that onboard before. You don t wait anymore to get pregnant to start prenatal vitamins. That s not necessary. Kavin Desai, M.D.: And is there any diet plan, exercise regimen, anything specific that increase your likelihood, increase the chances of getting pregnant? Is there any connection? Beth Tinder, N.P.: Not in particular. I mean, being healthy is very important so, again, while patients are talking about getting pregnant, I encourage them to have a good diet, a good, balanced diet, and to start exercising because when they do become pregnant, exercise is always helpful during the pregnancy. So if you start doing some form of exercise usually, you can do that same exercise on through your pregnancy. I had a woman who kick-boxed for exercise. Now she can t have contact, but she can do a lot of the maneuvers and the exercises that they do in the classes. So she can get her exercise that way. Kavin Desai, M.D.: Right, but not necessarily changing your probability of getting pregnant. I mean, it s good, of course, to do that for the pregnancy itself, for the baby, et cetera... Page 3

4 Beth Tinder, N.P.: The only time a diet might be something that would be helpful would be that if a woman had a bit of an irregular period, meaning she didn t have a period at least one a month, it was about every six weeks, and she was overweight. If you lose maybe even five or ten pounds, that may kick into a regular cycle which may increase her ability to become pregnant on purpose. Kavin Desai, M.D.: So let me clarify that. That s an interesting point. Are you saying that if you re obese, you re more likely to have irregular menses and therefore losing weight would make your periods more regular? Beth Tinder, N.P.: It s a possibility. Kavin Desai, M.D.: I see. Beth Tinder, N.P.: And obesity is relative. I mean, they don t have to be, 50, 60, or 100 pounds overweight. Even 30 or 40 pounds overweight sometimes can be enough to throw off a menstrual cycle. Kavin Desai, M.D.: Got it. No what about stress? You always hear about stress causing difficulty in getting pregnant. And the advice is once you go take a vacation, a cruise, whatever. Any truth to that at all? Beth Tinder, N.P.: Scientifically, to my knowledge, there have been no scientific studies that have been done. But certainly we know that stress plays a part in womens menstrual cycles. If they re stressed, they re not going to have regular menstrual cycles. If you re stressed you re not going to want to have sex. And that s a very integral part in getting pregnant. So, the go away, take a vacation and relax, is not certainly something that I write a prescription for, but it s not a bad idea. If you are in a situation where you re working really hard and your husband is working really hard, and you guys barely meet, and it s more of a chore to get together than it is a pleasure, it s not going to stop you from getting pregnant, but it certainly may make the whole working at it not so fun. Kavin Desai, M.D.: But you know, sometimes the regimens that we prescribe, you know, the watching of the calendar, these dates, every other day like you said, that s regimented, and some of that induces its own level of stress and I m wondering if there have been maybe not studies, but even some anecdotal evidence that that sometimes interferes with people s ability to get pregnant. I mean, I ve heard stories where people have been working with a specialist for a year or maybe even two, and then they kind of give it up, take their cruise, and they get pregnant. Again, nonscientific, but related to stress and perhaps even some of the stress induced by the medical recommendations that we give people. Beth Tinder, N.P.: I ve certainly had patients who had difficulty getting pregnant the first time and because they re more relaxed, they ve had a child and they re not really trying to, they end up getting pregnant very easily a second and a third time. I ve had patients who ve had to have medication to have a period, they have regular periods, but Page 4

5 we can give a medication that can sometimes help to ovulate to get pregnant, and that one cycle they don t take the medicine and they get pregnant. Now was it because they had the medicine last month? or was it because they weren t trying to get pregnant this month? So again, there aren t any studies, and I do agree with you stress definitely plays a part in it. I tell the patients it s work, that those five days that you need to have sex, it s work, but it s all what you bring into it. If you can keep in mind the brass ring, what you re trying to achieve and be a little creative, sometimes that s helpful. Kavin Desai, M.D.: Are there people that have trouble getting pregnant on subsequent pregnancies? You think that once you get over that hurdle, then it s a piece of cake and the next one will be easy, or the situation where your first one was easy, but then the second one..is it statistically the first or the second pregnancy much easier, in terms of getting pregnant? Are these issues more or less likely to occur in subsequent pregnancies? Beth Tinder, N.P.: No. There have been times when patients have had a little more difficulty the second time, and that oftentimes is associated with weight gain from the first pregnancy that they ve had difficulty losing. And so they really didn t have too much trouble getting pregnant the first time, but aren t having regular cycles after having the baby and so they are having more trouble getting pregnant a second time. Those are the ones that I encourage the weight loss. There are rare occasions with a pregnancy that during delivery or after delivery there was a mild infection that could have caused some blockage to the tubes that can be dealt with. If the tubes aren t badly scarred, they can be cleaned. Sometimes just the diagnostic test we do to look to see if the tubes are open or not can open things up and make pregnancy more easily achievable. Kavin Desai, M.D.: And what about age? How s that a factor in this? Beth Tinder, N.P.: Age is a very big factor. There is a 5-11% infertility rate from puberty, basically early 20s, to age 35. That dramatically goes up right after 35. It goes up to about 30%. It s quite a dramatic rise. Kavin Desai, M.D.: So a 36-year-old has a 30% chance of having more trouble getting pregnant? Beth Tinder, N.P.: Not NOT being able to get pregnant, but may have more trouble, and that s why the six month window. After 35, we don t make them wait a year to come in to get all the tests done because of time. Now, it doesn t mean at you can t get pregnant, but if you re having trouble getting pregnant we don t have as much time to fix that trouble. Kavin Desai, M.D.: Well, Beth, that was very informative. I think our audience, especially people that are having trouble getting pregnant, are going to be very appreciative of this information. If you had one thing to tell somebody, a couple that was having difficulty getting pregnant, what would you leave them with? Page 5

6 Beth Tinder, N.P.: Don t give up. It s really very difficult. Every period is like a failure, but it doesn t necessarily mean that there isn t something that can t be done to achieve the pregnancy. Do your best as far as your diet and your exercise and your substances, not using drugs, alcohol and tobacco, and don t wait any longer than you have to. Don t wait more than a year. If you can t get pregnant, come in and see us. Kavin Desai, M.D.: Thank you very much, Beth, for joining us today. Beth Tinder, N.P.: You re welcome. Kavin Desai, M.D.: And I d like to take the time to thank our audience for joining us today. If you d like more information about issues surrounding pregnancy, please feel free to visit the Kaiser Permanente web site at If you d like to hear other Health Casts, please visit us at If you have any questions or comments, please us at castmaster@kphealthcast.org. Once again, we have reached the end of our Health Cast and, as always, don t forget to get out there and find more ways to Thrive. Page 6