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What You Need to Know About Fertility Treatments: Between Age 35 to 40 If you and your partner have been tying to get pregnant between 35 and 40, you may want to speak with a fertility specialist.…
October 7th, 2021
Dr. Jones: So you've done everything you can to get ready to start a family, and now it didn't just happen. When should you get help?
You are a 38-year-old woman and you've been trying for a while to get pregnant. You stopped your birth control, and it didn't just happen. When should you get help? Well, it depends. Of course, it depends, and it depends on a lot of things -- your health and history and the male part of getting pregnant part of the business. But we usually start with age.
And we're doing this in three parts. So if this isn't your age or the age of the person you're worried about, check out our other podcasts.
Here in The Scope virtual studio with us is Dr. Erica Johnstone. She's a specialist in reproductive endocrinology and infertility and an associate professor at the University of Utah.
So let's say you're between 35 and 40, maybe you're 38, and you've been trying to get pregnant for a couple of months and you're a little worried. You've been reading ladies' journals and you know the clock's been ticking. When should you get help? And does the age or health of your partner make any difference?
Dr. Johnstone: Absolutely. So for sort of the typical woman between the ages of 35 and 40, we usually recommend trying for about six months before you seek help. Now, who's the typical woman? This is a healthy woman who generally has regular periods coming about every 25 to 35 days, and a woman who doesn't have serious underlying health conditions.
We would think about seeking help earlier in the case of serious underlying health conditions, irregular periods, or a woman who has previously been treated for cancer with chemotherapy or radiation.
Then when we think about the partner. Some of it, we think about some of the same key things. Generally, six months, but reasons to seek help sooner would be if he has been treated for cancer with chemotherapy, radiation, if he's had testicular cancer even that was treated surgically, if he has other serious health problems, particularly if he has other serious health problems that may be affecting his erectile or ejaculatory function. Again, these would all be reasons to seek help sooner than six months.
Dr. Jones: Who should you see to get help and what will they do?
Dr. Johnstone: In this age group, some women may choose to start with their general OB-GYN for their evaluation, but many women will choose to start with a reproductive endocrinologist. And one of the main reasons for this is that . . . It's important to know for most women between 35 and 40, they will be able to successfully get pregnant, but time is more of the essence for women between 35 and 40.
It could hurt to lose time if you spend several months with your OB-GYN, then get a referral to a reproductive endocrinologist, and potentially it takes another couple of months to be seen. So again, many women in this age group will start with a reproductive endocrinologist.
Those early visits will involve a very thorough evaluation. Key pieces of this evaluation will be asking you a lot of questions about your menstrual history. If you keep menstrual journals, it's wonderful if you have them available for your visit. A very detailed look at your medical history, medications you're taking, surgeries you've had, lifestyle habits, things like alcohol, tobacco use, exercise, etc.
For a male partner, we would look at the same things, medical history, surgical history, key lifestyle factors, and factors affecting sexual function. Then as we go into evaluation, we would start for the male partner, typically, with a semen analysis where we would ask him to give a sperm sample. And then we would look at the number of sperm, how many of those sperm are swimming forward, and how many of those sperm have normal head shapes.
Dr. Jones: So reproductive endocrinologists aren't completely common. There are many people who might be listening to our podcast who live in towns that are not big metropolitan areas.
And so sometimes a reproductive endocrinologist is a long ways away, and that sometimes going to be difficult for people to pack up and drive three or four hours to see somebody. And that could be stressful.
So does stress increase difficulties getting pregnant? I just thought I'd throw that in there because some of us are really stressed out.
Dr. Johnstone: Absolutely. So there've been a lot of studies on this subject and they've been mixed in their findings. So I wish I could say stress has no effect at all. I couldn't say that, but I can absolutely say that stress is not a complete block to pregnancy.
And so I recommend to anyone who's trying to conceive to look for ways to reduce and manage their stress. But the number one reason to do that is because it can take time to get pregnant and we never know how long it's going to take.
And so, for your overall health and for the health of a relationship, it makes sense to try to find ways to manage and reduce that stress. But know that it's okay that there's stress. And the fact that you're worried about this, and the fact that it's hard to try to conceive doesn't mean that you won't get pregnant.
Dr. Jones: I remember a study years ago that just getting an appointment to a reproductive endocrinologist, to a referral fertility center, increased the chances of getting pregnant in the next six months. So that was just people who got an appointment and it was four or five months away compared to people who just tried on their own.
So sometimes doing things that will help alleviate your stress, even though you might have to travel for it, getting an appointment means that you've taken a step to move forward, and sometimes that itself makes you feel a little bit better.
Dr. Johnstone: Absolutely. And I should mention we currently are doing a lot of telehealth visits, and that means you may have the opportunity to gain a lot of information and get a lot of questions answered while sitting comfortably in your home, even if that's several hours away.
And I think that's one of the few bright lights that have come out of the COVID pandemic, is that there is greater availability for telehealth. And again, I think this is something that can really be helpful to couples in making access much better and also in giving you the opportunity to talk about these things from the comfort of your home as opposed to being in the doctor's office.
Dr. Jones: We also know that women as they get into their late 30s are a little more likely, unfortunately, to miscarry if they do get pregnant. And we know that sometimes by the time you've lived on the planet long enough, you've accumulated some illnesses, diabetes, hypertension, other conditions that might make pregnancy riskier.
And of course, just being over 35, some people think makes you a riskier pregnancy. But if you have any kind of medical conditions that you take medicines for, it's important to kind of think about how you get yourself in the best shape to be the pregnant person that you want to be for this baby you want to grow.
Dr. Johnstone: Absolutely. I think one thing I would add to that . . . So, one, if you have health conditions, check in with your doctor, but we also might refer you to a maternal-fetal medicine specialist to prepare for addressing those health conditions. How will your pregnancy affect your diabetes, your high blood pressure? How will your high blood pressure or diabetes affect your pregnancy?
Another thing to think about is some couples begin their fertility journey when they haven't had any medical care for a number of years. And so, if you are starting to try to conceive and you have not seen a health care provider in several years where it's possible that you may have high blood pressure or pre-diabetes that isn't diagnosed, it's a good idea to just get a general checkup at some point within that year before you try to conceive so that we can find these things rather than finding them once you're pregnant. We can do a better job of treating them and preparing you for pregnancy if we know about them first.
Dr. Jones: Exactly. So we aren't so fertile as a species to start with on a month-by-month basis, and we aren't so fertile as we get older. Peak human fertility starts to decline in the late 20s. So if you're in your late 30s, don't wait too long to get help if you aren't getting pregnant right away because we can help.
Thanks to Dr. Johnstone and thank you for listening on The Scope.
If you and your partner have been tying to get pregnant between 35 and 40, you may want to speak with a fertility specialist. The fertility treatments available to you greatly rely on the age of the woman trying to have a child. In this episode, Dr. Kirtly Jones speaks with fertility expert Dr. Erica Johnstone about helping women in their late 30's to become pregnant.
If you and your partner have been struggling to get pregnant, it may be time to consider speaking with your doctor about fertility treatments. It’s important to realize that the conception…
September 30th, 2021
Dr. Jones: You've done everything you can to get ready to start a family, and now it just didn't happen. So when should you get help?
So you're a 28-year-old woman, and you've been trying for a while to get pregnant. You stopped your birth control, and it didn't just happen. When should you get help?
Well, it depends. Of course, it depends. It depends on a lot of things, your health and history, and the male part of getting pregnant part of the business. But we usually start with your age. We're going to do this in three parts. So if this isn't your age, or the age of the person you're worried about, check out our other podcasts about when to get help getting pregnant.
Here in The Scope studio virtually with us is Dr. Erica Johnstone. She is a specialist in reproductive endocrinology and infertility, and an associate professor at the University of Utah. Welcome, Dr. Johnstone.
Dr. Johnstone: Thank you.
Dr. Jones: Well, we're so glad you're here. So let's just say that you, the listener, are between 25 and 35. Of course, you could include 20 to 25. So let's just say you're under 35 years old, and you've decided to try to get pregnant, and you're so excited, but it didn't happen in the first three months. When should you consider getting some help?
Dr. Johnstone: So generally, for women who are under 35, we recommend trying for a full year before you seek help. And that's because it often happens. Close to half of women will conceive within those first three months. There are plenty of women and plenty of couples with perfectly normal fertility for whom it will just take a little bit longer.
Now, there are a few exceptions to that, situations when it might make sense to seek help sooner. One of those is if either the woman or her partner has previously been treated for cancer with chemotherapy or radiation.
Another of those situations is if a woman is having very irregular periods, going 45 days or more without a period, or potentially having no periods at all. Those would be times when you'd want to seek help sooner.
Dr. Jones: I know that people who want to have a baby, when they're finally ready, they want to do it right now. "I just want to have a Christmas baby," or, "I want to have a spring baby. I don't want to be pregnant in the summer." But what should you be doing while you're going to try on your own for a while? What do you tell people when you say . . . It's hard to tell someone to go away and come back in six months. What can you tell people to be doing while they're trying to get their 12 or 13 cycles of trying in?
Dr. Johnstone: Sure. So, first of all, things we think about are just being ready to be pregnant. So some key parts of this. One, take a prenatal vitamin every day. Two, if you're a smoker, I recommend that you quit smoking. The same is true for vaping, any sort of illicit drugs. You want to really limit your use of alcohol and caffeine. I recommend that every woman who's trying to conceive, make sure that she's up to date on her vaccines, including the COVID vaccine.
Then when it comes to actually trying to get pregnant, we think that probably, over time, one of the most effective strategies is just to have frequent sexual intercourse throughout the menstrual cycle, ideally about every other day, three times a week. This should work well. And with this approach, then you don't need to strictly worry about timing intercourse, just frequent intercourse throughout the cycle.
Dr. Jones: Right. Some people really struggle because they want to buy a kit that will tell them when they're ovulating, or they want to use their symptoms. But it turns out that just doing it is the way people get pregnant.
Dr. Johnstone: Absolutely. As it turns out, as many kits and products as there are now, the human race existed for many, many, many generations before the existence of those products.
Dr. Jones: And so who should you see to get help? If you're still a relatively young woman and a relatively young couple, and it's been nine months and you're picking up the phone to make an appointment, because you might not get the appointment next week, who should you be calling?
Dr. Johnstone: So I think for women under 35, it's reasonable to start with your OB-GYN, particularly if you already have an OB-GYN who you've established care with, who you might be able to get in to see sooner. It's also always an option to see a reproductive endocrinologist. And so, for women in this age group, either is a good option.
Dr. Jones: And so what would they do? Let's say you've been trying and it's got to be 10 months or something like that, and you got your appointment and you want to kind of be ready for what kinds of things they might do when you go to visit them. So what would they be doing in this first part of your visits with them and your evaluation?
Dr. Johnstone: One of the first things will be a very detailed history. We'll look at a woman's menstrual history. We'll look at her medical history, any surgeries that she might have had, any symptoms she might have related to her periods, pain with intercourse, things like this. We'll look at a general health history, health habits.
And we'll do the same for the male partner in terms of his general health history, any issues with things like erectile dysfunction, or difficulty with the ejaculation, etc.
And then we'll start with some tests, typically for both partners. So, for the male partner, we will usually do a semen analysis. And so this is collecting a sperm sample after about two to five days of abstinence, so that we can look at the number of sperm, we can look at how many of those are swimming and swimming in a progressive fashion, and how many of the sperm have normal head shapes. And this helps us to say, "Do we think there's a male factor making it harder to conceive?"
For the woman, we will often do some general health labs. Essentially, women in early pregnancy get a lot of blood tests done that are screening tests, looking at blood counts, maybe looking at their thyroid, their blood type, checking their immunity to different diseases, infectious disease testing. We know that every single one of these tests, it would be optimal if there's a problem to find it before pregnancy.
We'll also look at ovarian reserve. And what that means is does a woman have a normal number of eggs for a woman her age? Is it higher than most women her age, or is it lower than most women her age? And one of the important things to know about that is while it's really useful as we talk about treatment, it is not a predictor of who will and who won't get pregnant.
Dr. Jones: It just may help direct what kind of treatment is most likely to be helpful and which might not be?
Dr. Johnstone: Yes, exactly. We'll also typically do an ultrasound to look at a woman's uterus and ovaries, look to see if we see abnormal ovarian cysts, fibroids, polyps, any sort of structural or anatomic findings that might be contributing to the difficulty.
And finally, we would do a test like a hysterosalpingogram or a saline infusion sonohysterogram to assess whether a woman's fallopian tubes are open.
Dr. Jones: Right. So those are the beginning tests, and it helps guide a future therapy, I think. There are circumstances that would make it important to at least get information or get help sooner. You already mentioned that if women's cycles are really irregular, or if either the partners have had treatment for cancer when they were younger, it might mean that they don't have as many eggs and sperm.
But if a woman or her partner has a pretty serious medical condition, we want to make sure that that medical condition is in really tip-top shape before they get pregnant. So sometimes do you recommend people see a specialist, like an OB specialist, before they get pregnant?
Dr. Johnstone: Absolutely. So for women who have significant underlying health conditions or something in their history that might make their pregnancy higher risk than for other women, we'll recommend that they see a specialist in maternal fetal medicine before conceiving to talk about, "Are you on the best medications for your condition? How is that health condition going to affect your pregnancy? And how is your pregnancy going to affect that health condition and the treatment options?"
Dr. Jones: Right. Well, remember, it takes normal eggs and normal sperm, and fallopian tubes, and a uterus to get pregnant and grow a baby. And in humans, it often takes a little time. But don't wait forever. We can help. And thanks to Dr. Johnstone and thanks to you for joining us on The Scope.
If you and your partner have been struggling to get pregnant, it may be time to consider speaking with your doctor about fertility treatments. It’s important to realize that the conception strategies and medical options available to you greatly rely on the age of the woman trying to have a child. Learn the methods to help young women under 35 become pregnant.
A daughter’s first period marks her entry into womanhood. For a lot of parents—mothers in particular—this is also a time of new anxieties and concerns about their child’s…
July 2nd, 2021
So your daughter just had her first period. What's normal, what's not, and what to expect now.
A girl's first period marks her entry into womanhood. It's called menarche. And many parents, especially moms, seem to have a lot of anxiety and questions about it. Many moms readily admit to me that they have forgotten what periods were like when they started. So if something doesn't seem right, they get incredibly nervous that something is wrong with their daughter. Some worry that their daughter has started too early or too late. Actually, any time between ages 9 and 15 is normal.
Some worry that their daughter doesn't have a period every month like clockwork and that they need their hormone levels checked or some sort of treatment to make their periods regular. Well, it is hormones to blame for this. However, it's because hormones are still settling themselves out. It can take two to three years before periods become regular. If there is a family history of irregular periods, they might never be regular. And that's okay too. Parents really worry if their daughter's periods are not regular. But unless their daughter is sexually active or they go months between periods after having them for about a year, there really isn't anything to worry about. Irregular periods by definition happen either less than three weeks apart or more than five weeks between periods. Otherwise, they're normal.
Moms also get concerned about cramps. Sorry, but cramps are part of periods. Your daughter should not miss school or stop being physically active because of cramps. Being physically active has been shown to decrease cramps. I have parents wanting me to write letters so that every month their daughter can miss school during her period. Periods normally last 3 to 10 days. So that's a lot of school missed. I try not to do these letters and instead discuss ways to help their cramps. Over-the-counter naproxen really helps and so does a heating pad.
Some girls will even have nausea or vomiting with their periods due to hormone fluctuations. Treating them supportively with anti-nausea medicines can help.
Moms also get concerned about their daughter's becoming anemic. This does not happen usually. Girls normally lose between 30 to 40 milliliters per period. This is six to eight teaspoons of blood. So while it looks like a lot of blood during a period, it's not as much as it seems. If your daughter has something called menorrhagia, that is excessive blood loss and that is 80 milliliters or more of blood loss per period. And these girls normally pass blood clots that are larger than a quarter. These girls will usually soak through a pad or tampon every hour for several hours during the heaviest portions of their periods. They may also need double maxi pads for protection. If this is the case, then you should talk to your daughter's pediatrician about ways to help.
I often get asked by moms if their daughters could have endometriosis or fibroids or other gynecological issues. As a pediatrician, I can do basic period management and gynecology. I can do oral or injectable birth control to help with periods. But often the best thing for me to do is to refer my patient to a gynecologist if it's more than I can address. They are much better at diagnosing and managing female concerns.
Finally, moms also ask me if their daughters need Pap smears now that they have started their periods. No. That used to be the case, and it's pretty traumatic for a young girl. The current guidelines are if a girl is 21 or has been sexually active for three years, then they get a Pap smear, and that would be done by a gynecologist, not a pediatrician.
Bottom line, most period concerns are actually part of normal development. Your pediatrician can let you know when something is not normal and refer you to a gynecologist who sees teenagers for additional help when needed.
A daughter’s first period marks her entry into womanhood. For a lot of parents - mothers in particular - this is also a time of new anxieties and concerns about their child’s health. What to expect now that your daughter has had her first menarche.
Mindfulness practices can help with stress, depression, and anxiety—but research has shown that they can also help with physical conditions. Trinh Mai with University of Utah Health's…
May 18th, 2021
Interviewer: I think many of us have already heard or know that mindfulness can help with stress and depression and anxiety, but did you know mindfulness can also help with a lot of physical conditions as well, such as pain management, high blood pressure, diabetes, heart disease, AIDS, cancer? It can help improve your sleep, stomach issues, and even eating disorders.
Trinh Mai is a mindfulness educator at The Resiliency Center at University of Utah Health. And mindfulness can help all these physical ailments as well, huh?
Trinh: Yeah. Isn't that wild?
Interviewer: It is wild. Tell me more about that. I mean, how does that work exactly?
Trinh: What all of those conditions share in common is that chronic stress can contribute to all of those conditions — hypertension, diabetes, heart disease, digestive conditions. Often stress is at the root of it, and stress is also the outcome of a lot of health conditions. So if there's a practice like mindfulness that can help you to better manage stress, then it's going to help you to better manage those symptoms.
Interviewer: This isn't something right now that I think a lot of physicians necessarily do. I bet you I could go to my doctor and say, "Hey, tell me about mindfulness and how that could manage my diabetes." You might get a blank stare. So are more and more physicians kind of adopting it, or how is this manifesting itself in traditional healthcare?
Trinh: Actually, how I came to mindfulness was my neurologist. I don't just teach this, I practice it and I'm a believer because I went to my neurologist about 10 years ago and said, you know, "I'm having all these neurological issues, pain, numbness." And we did a workup, and luckily I didn't meet any particular diagnoses, but she said, you know, stress often contributes to pain.
So she actually recommended that I take mindfulness-based stress reduction, and that's a course that I currently teach now so I feel really lucky. But that course changed a lot for me. It helped me to become more aware of what triggered my pain, and then it helped me to be aware of, you know, how I react to my pain can actually reduce it or exacerbate it. Sometimes the reactions actually make things a lot worse than the initial problem.
And then I, through the practice, actually became more aware and then I hopefully have been able to reduce my pain in other aspects. Hopefully, I'm less of a pain as a parent and as a partner. But yeah, it's awareness. That's what mindfulness is. And when you're aware, then you have more choices of what course to take.
Interviewer: I know a lot of people personally, and probably even me a few years back, if a physician in medicine would have told me what your neurologist told you, I'd be like, "Oh, they just can't figure out what it is. This is ridiculous." I can almost hear somebody going home and go, "Yeah, they told me I need to be more mindful. How's that going to help? Give me a pill, give me a diagnosis, tell me what's wrong."
And I think a lot of us have a hard time believing that stress can cause some of these other health conditions. So that story was great because I think it just really illustrated, you know, it did, it made a difference in your life and it can make a difference for a lot of people.
So let's get to the question now. So somebody is listening to this podcast, maybe they're suffering from one of the things we mentioned, maybe it's something else. How do they do it? Let's give somebody a first primer and then we'll give some resources.
Trinh: Yeah. So let me start with, first of all, I think that a lot of people that I've taught they'll tell me, "Oh, yeah, it's not for me because my mind races and I just can't make it stop," or "I can't sit still, that makes me too nervous." Well, you know what? I totally get that. I come from generations of people, particularly women, that cannot sit still. Like my mom, she's 70 something, she's retired, but she does not sit still. So I totally get that.
And it's like anything, the more we do, the stronger our muscles are to be able to do it, and the better we get. The other thing I think it's important to know is that you don't have to make your mind stop. So I'm going to just repeat that. You do not have to make your mind stop. We can't necessarily control that, but what we do have control over is if we pay attention to it or not, and we can bring attention to our bodies.
So for example, if I were to ask you now, can you bring attention to your feet on the ground and feel the surfaces of the ground? And if you can do that, you're practicing mindfulness.
Interviewer: That's it?
Trinh: Yes. And, you know, your mind's going to wander off to, "Oh, well, I got better things to think about." And that's cool. But when you notice that, you can bring it back.
So now I'd like to invite you to bring your attention to your breath and maybe see if you can pay attention to three breaths, the inhale, the exhale, feeling the air enter the nostrils, and opening up your body. Exhaling completely, feeling the body contract.
The mind wanders off. You notice. That means you're aware and you bring it back to your breath. And then at the end of the next exhale, maybe just check in and notice how you feel. See if there's any shifts.
Interviewer: I feel more relaxed already, and we did that for like, what, 18 seconds. That was amazing.
Trinh: Thanks for practicing along, Scot.
Interviewer: That was fantastic. So it doesn't seem like it's hard. You just kind of have to be paying attention. I'd imagine there's a lot of resources that you can get to it. There's apps I hear advertised or probably YouTube videos. Is there any place, in particular, you'd like to go for somebody who just wants to start?
Trinh: So, you know, I'm biased. I work for Wellness and Integrative Health here at the University of Utah, so I am going to invite you there first. You might want to check out the University of Utah Wellness and Integrative Health YouTube channel, and it's under Be Well Utah. So that's the series that you can check out.
And then, you know, taking courses, trying a class is a lovely way to get support and structure and a community to start a habit. So we have two courses. We actually have three. We have Everyday Mindfulness, which is an introductory course, and it's four weeks. And then we have the gold standard, which is Mindfulness-Based Stress Reduction. And that's the one that John Kabat-Zinn started and has decades of research behind it. And that one is nine weeks.
And then I just started a self-compassion course during lunch, and that's only an hour long for four weeks. So a few options for you to just, you know, try it out and see what it's like for you.
Mindfulness practices can help with stress, depression, and anxiety—but research has shown that they can also help with physical conditions. Explore the treatment of chronic stress through mindfulness practices and how it can help manage health conditions like chronic pain, blood pressure, and heart disease.
Research from the University of Utah and Planned Parenthood shows evidence that the hormonal intrauterine device or LNG-IUD is an effective option for both long-term and emergency contraception. Dr.…
February 18th, 2021
Dr. Jones: So you ran out of your birth control pills and the condom broke or something like that. You really don't want to get pregnant right now or anytime soon. What do we know about your options?
Many women know about emergency contraception, and many don't, something you can do to decrease your chance of pregnancy if you had unprotected or under-protected intercourse. There are two types of emergency contraceptions approved by the FDA that are available in the U.S., and they are pills, and they decrease the chance of pregnancy if they're taken within five days of unprotected intercourse. But there are other types of birth control that would work and keep on working if you're looking for contraception for more than this month.
With us today is Dr. David Turok. He is an OB/GYN specialist in family planning and chief of the division of family planning at the University of Utah. Thanks for taking some time for us, Dr. Turok.
Dr. Turok: Thank you.
Dr. Jones: What were the background reasons to ask the question of whether the levonorgestrel IUD, which is what we're going to be talking about, would work for emergency contraception? What made you do this question?
Dr. Turok: Well, I speak with people a lot about emergency contraception because I'm very interested in it, and I think it's amazing that you can use something after you've had sex to prevent pregnancy. And every time I talk about it with people during grand rounds or during educational presentations, people always, always, always ask . . . because we know we have great data to say that the copper IUD works very well for emergency contraception, people always ask, "Well, what about the hormonal IUD, the levonorgestrel IUD? Can you use that?" So 10 years ago, we started trying to gather data on this topic, and finally we have an answer.
Dr. Jones: So people came to the clinic wanting emergency contraception and they walked into the clinic thinking that they might get some pills. How did you get so many women to participate in the study when they came for just pills?
Dr. Turok: Like in many aspects of life, Utah is unique. And currently, one of the forms of emergency contraception pills is available without a prescription. You can just walk into pharmacy or supermarket and get them. Sometimes it's behind the counter, you might have to ask, but you can get it without a prescription.
In Utah, because there are many limitations for people, young people especially, with insurance coverage, people seek out the cheapest place to get it, and that is Planned Parenthood where there's a sliding scale and where people have known for a long time that they can get the pills.
And we've done a few different surveys and a few different kinds of projects where we offer people walking in for emergency contraception IUDs, and it's around 12ish percent of people are interested in an IUD in that setting. And that's, I think, potentially driven in Utah by the fact that people don't have adequate insurance coverage and they're looking for opportunities to get better methods of contraception. And when there are low or no-cost options presented, people are interested.
So, at the peak before Plan B, one of the pills was available over the counter. Planned Parenthood statewide distributed more than 50,000 doses of oral emergency contraception. So people know, and lots of people come to Planned Parenthood clinics in our state for the service, and when you present them with IUDs, some are interested in it.
Dr. Jones: So some of them are really looking for something for longer than just this month?
Dr. Turok: Exactly. Yes.
Dr. Jones: Right. So you've known that the copper IUD . . . we've all known from data that goes back 20 years, really, that the copper IUD works. So you then offered them either a copper IUD or a hormone-containing IUD. And what did you discover?
Dr. Turok: So what we found in this study where we randomized people to get one or the other type of IUD, either copper or the hormonal IUD, we found that the pregnancy rate was low, very low, in both groups in the month after.
So with copper IUDs, we had 321 people who were assigned to that, and we got one-month outcome data on. And we expected in that group, zero or one would have a pregnancy. And it was zero.
And with the levonorgestrel group, we really didn't know. We had built into the study stopping points. Like, if there were a bunch of pregnancies early on, we were just going to stop. But what happened was there were 317 people who got the levonorgestrel IUD and there was one pregnancy. Lower than we thought and much better than the pills.
Dr. Jones: Right. That's important because the methods that are currently FDA-approved, that those 50,000 women who came to our clinics seeking pills, the failure rate or the ineffectiveness rate is much higher than what you found with the IUDs, either one of them.
Dr. Turok: Yeah. To me, one of the very cool things about the study is the other studies that got FDA approval for those oral methods, these were things that took a long time and hundreds of millions of dollars were spent to go through the FDA process to get that approval. And in this study, we took a method that was already FDA-approved and we just showed that it works for this as well.
And the upside relative to the pills is, as you know, that people who are getting this can get . . . this is not just better than the pills for this one event, but you can continue to use it as long as you want, up to seven years, or for the copper IUD, up to 12 years. And that is a set-it-and-forget-it method.
Then for the LNG IUD, there's this side benefit, which is why it's more popular than, I think, the copper IUD, in that it dramatically reduces or eliminates both menstrual bleeding and cramping. And that is a big upside. And that's why I think people really wanted an answer to this.
Dr. Jones: Well, we have some evidence from another big study that just gave women what they wanted when they asked for contraception and then followed them, that the IUDs were something like 20 times more effective than birth control pills in preventing pregnancy?
Dr. Turok: Correct.
Dr. Jones: So if a woman comes to our clinic for an emergency contraception and she wants long-term reliable contraception, would she be offered an IUD, do you think, in our clinics? Because now that the work was done around here, I'm hoping that our clinicians know that it's an option. Do you think it's going to be used in the clinics?
Dr. Turok: I want to say absolutely.
Dr. Jones: I do, too.
Dr. Turok: But I would also say as our team is working on getting this paper published, I would occasionally have these pangs of terrible thoughts that 10 years down the road, it's going to be like the authors of this paper and 10 other people that we know that know about this and nobody is going to ever have done any of it.
And so I started making lots of phone calls and sending lots of emails to people who I thought would be critical partners in disseminating the information. And one of the things that helps get the word out a lot is getting the paper published in a high-impact journal.
Dr. Jones: Right. It was published in "The New England Journal of Medicine," which is probably our premier medical research journal, I think, in the United States, or one of them.
Dr. Turok: One of the, I think, nice things about the study is "The New England Journal" publishes papers that change practice. That is their main motivator for selecting research articles. And you have a very low chance of submitting something and getting it published. But it was very reassuring to know that they felt this was important enough to be published there and that they were confident that it would change practice.
And there are lots of other organizations, professional organizations, a variety of health practitioners, and providers that can disseminate this to people who work with them.
I also have been working with the people from UpToDate to revise the article on emergency contraception to incorporate this and they were amazing. ACOG carried a piece on their listserv email and we're going to work with them to try to update Lark information in their emergency contraception information. So there are all kinds of ways to get the information out.
And a really important place to do that is also with Planned Parenthood Federation of America. As you know, they have something called the National Medical Committee that makes decisions on changes in practice. So I just sent an email and lately before this interview responding to questions from people who organize the National Medical Committee about this.
It's, I think, a great opportunity for Planned Parenthood Federation of America to lead on the dissemination of this because the information came exclusively from Planned Parenthood clinics. This is a collaboration between our team at the University of Utah and Planned Parenthood Association of Utah.
If you look at what gets published in "The New England Journal," the vast majority . . . and currently, probably nobody is a more fastidious reader and consumer of their publication than you. If you look at those trials that get published, most of them are these big, multi-site, and sometimes multinational studies with tons of sites and huge numbers of participants. This study is different.
Dr. Jones: It is. It's really amazing that you have a very local group who was completely committed to answering the question. And I think that that's a phenomenal thing.
I think, at The Scope, we're trying to get the word out also to individual women so they might be willing to come in and ask. So not only do clinicians need to know, but if individual women say, "By the way, do you think I could get this IUD today? Do I have to wait?" that changes practice.
Dr. Turok: Absolutely. So the education and dissemination of information have to be from push and pull factors from supply and demand side. And as I had mentioned, we're already working on trying to get providers up to speed. But there's lots of opportunity that we're going to be working on to make sure that people who are seeking emergency contraception will know about this.
Obviously, the internet is a fabulous place to do that. And there are also some organizations that focus specifically on emergency contraception. There's a U.S. Emergency Contraception Consortium and an International Consortium of Emergency Contraception, and they are fabulous at providing consumers information about different products and ways to access them. So we look forward to working with them as well.
Dr. Jones: Right. Well, Dr. Turok, I am very grateful for your time, and we'll work at The Scope in trying to get people the information they need. But the research to answer this kind of question takes years and takes a team of dozens of nurses, and clinic staff, and researchers, and above all, it takes hundreds of women who are willing to participate, answer questions, and follow up. To all of them, we are very grateful because "I hope I just didn't get pregnant" isn't a very good birth control method. And it's been a long time coming and I'm so glad to see it here. Thanks a lot, and thanks for joining us on The Scope.
Research from the University of Utah and Planned Parenthood shows evidence that the hormonal intrauterine device or LNG-IUD is an effective option for both long-term and emergency contraception. Dr. Kirtly Parker Jones speaks with Dr. David Turok and what his team’s research means for women and OBGYN practice.
Seeing your hair turn shades of gray can be shooking, especially if you're not yet at the age when gray hair would normally start appearing. Why and how does hair turn gray, and why do some…
July 30th, 2020
Health and Beauty
Shades of Grey. Gotcha. When you clicked, maybe you thought I would be talking about what goes on in a very popular book series. Nope, not even. I am going to talk about whether your kid really can turn your hair gray.
We've heard our mothers say that someone stressed them out so much it turned their hair gray, or that an acute stress turned their hair white overnight. There are some references to it in the "Talmud," the Jewish holy book, and supposedly Marie Antoinette, the last Queen of France, had her hair turned white overnight between the time that she was sentenced to the guillotine to the next morning when she met with the guillotine. Of course, that's very unlikely, and maybe being a queen during the French Revolution was so stressful that her hair turned white over several months and she covered it with a wig. And when she took it off at her final performance, her hair was white.
First, a little discussion on the anatomy of the hair follicle. The hair is produced under the skin in a hair follicle that's lined with pigment-making cells called melanocytes. Melano means dark or dark-colored and cytes means cells. Melanocytes are in our skin and make pigment either naturally, given our genetics, or when we tan. For those of us who are freckled, we have patches of melanocytes that make more pigment.
In the hair follicle, the melanocytes arise from stem cells that replenish the number of melanocytes. As these stem cells divide, some become melanocytes and some stay as stem cells. This is a strategy for cells that are renewed all over our body. As we age, we run out of stem cells, so we don't make so many new specialized cells like melanocytes. That means no more color to the hair as we age. At least that's the theory. Genes and diseases, like autoimmune diseases, can determine when and if you go gray.
So back to the stress theory. Some clever researchers at the Harvard Stem Cell Institute just reported some interesting studies in mice in the journal "Nature." So, first, they thought maybe going gray was the loss of the melanocytes from an immune problem. It's known that some people with immune problems go gray. So they injected mice with capsaicin, the stuff in chili peppers, which is known to cause an immune stress response in mice. They did this in mice without immune cells, and the mice went gray. So it wasn't the immune system in this case.
The second was to stress out the mice in another way. They were exposed to short-term pain or stressful living conditions in their cages, and they went gray. But was this due to cortisol, which our adrenal gland and mice's adrenal glands make when they get stressed out? Or was it something else? So they took out the adrenal gland of the mice, and they still went gray. By the way, the human race owes the mouse race a serious debt of gratitude for all that they go through for medical research.
So maybe it was the sympathetic nervous system. Each hair follicle has nerves around it. Your hair stands up when you're scared. And when the mice were stressed acutely, their nerves were flooded with norepinephrine. When that happened, all the melanocyte stem cells got programmed to make melanocytes. So there were no more stem cells left to make melanocytes in the future. Now, this didn't happen overnight, but a relatively short period of time. And then the mice didn't have any more stem cells. They didn't have any more melanocytes, and they went gray. So this is a plausible reason for the old wives' tale that acute or chronic stress can turn you gray.
So what do you do about this? Well, having gray hair is a sign of wisdom. You let the gray hairs figure it out. Maybe people who've been through a lot of stress and survived it have a visible cultural signal of their resilience -- their gray hair. Of course, we could suggest that you avoid all stress, but that's pretty hard to do and impossible if you have any kids or any kind of extended network of people you love.
So you can love your gray. For American women over 50, we don't do that so much. It's been suggested that at some time 90% of women over 50 dye their hair. When you finally decide to go gray, you can dye your hair white, but that would be a shock. You could color your hair but put gray highlights and then let it grow out. You could color your hair gray with colored highlights and let it grow out. Best of all, you shouldn't even listen to me because I'm clueless. Talk to your colorist about what's the best way to go gray gracefully, but don't stress out about it.
Why and how does hair turn gray, and why do some people "turn gray" earlier than others? The science and medical research behind the old wives' tale that acute or chronic stress can turn you gray.
Sadly, miscarriages do occur for expecting mothers, and many women commonly want to know how long they must wait before trying to get pregnant again. Women's health expert, Dr. Kirtly Parker…
January 14th, 2021
If you've been trying to have a baby and unfortunately a miscarriage results, how long should you wait before becoming pregnant again? This is Dr. Kirtly Jones from the University of Utah Health, and this is The Scope.
Sometimes advice that clinicians give their patients isn't always completely scientifically based. Some examples include that you shouldn't feed a patient after a Cesarean until they pass gas. Actually, studies show that feeding patients when they feel like eating after a pelvic surgery actually gets bowel function moving faster than waiting. Another is "Don't have sex after birth of your child for at least six weeks or until your postpartum visit." Well, we now know that many women don't follow that advice, and many women don't come for their postpartum visit.When to Try Again after a Miscarriage
Well, what about miscarriage? After a miscarriage, how soon can you try to get pregnant again? In the United States, the most common recommendation was to wait three months for the uterus to heal and cycles to get back to normal. The World Health Organization has recommended six months, again to let the body heal. And there are some suggestions that it's important to wait for couples to finish the grieving process that might follow the loss of a pregnancy. And also, of course, the worry was that women who didn't wait maybe the uterus wasn't healed and they might have more complications with the pregnancy in the next cycle.
Well, there were no scientific randomized studies to look at the couples who wait and couples who don't. Around the world, there were millions of women who miscarry and don't have access to clinicians' recommendations so they just do what they want. The rate of spontaneous abortion in the first trimester, the first 12 weeks after pregnancy, is recognized clinically as about 15%. So this is really common, and very early pregnancy losses even before a woman actually has symptoms of pregnancy is even more common.Medical History Dictates Waiting Time
So how long should you wait? Of course, the answer is "It depends." So if the miscarriage happens early in the first trimester, in the first 12 weeks, and there are no complications, there's good information that women don't have to wait the WHO recommendation of six months. Actually, getting pregnant sooner in one analysis of several papers may decrease the risk of another miscarriage and does not increase the risk of complications with a successful pregnancy. For women who've an early miscarriage without complications, we now suggest they can begin trying to get pregnant after their next normal period.
Now, women who've had a stillbirth or a pregnancy loss after five months may have to wait until their ovulation start again. It may take six weeks to longer to have a normal period and have the uterus get back to normal. The loss of a pregnancy that far advanced has medical and psychological consequences, and there may need to be some testing or support to evaluate that pregnancy.
So when is it right to wait before becoming pregnant again? Well, about 50% of pregnancies in the U.S. are unplanned. That means about half of miscarriages might happen in pregnancies that weren't planned. Even unplanned pregnancies that miscarry can be felt as a significant loss for the mom who wanted to be. Women who aren't planning to be pregnant when they realize that they are often decide that they really are ready to have a baby.Preparing for the Next Attempt at Pregnancy
Trying again soon is fine, but planning hadn't been part of the original plan. And a woman should get the appropriate vaccinations and take folic acid before starting again. Meaning, okay, now you can take the time to plan it. Of course, if the miscarriage just met with a sigh of relief, you shouldn't just jump in and get pregnant again. Contraception and planning for your pregnancy and postponing another one until you're ready would be the right thing.
Now, some women have significant medical problems that are in adequately treated. When they seek medical care for the miscarriage, the underlying medical problem is recognized and it may take time to treat before becoming pregnant again. The prime example, of course, is diabetes. Uncontrolled diabetes can have a very significant adverse effects on a pregnancy including birth defects, and it may have even caused the miscarriage.
Taking several months to get blood sugar under control and evaluate if there are other problems caused by diabetes might be a concern in the pregnancy. And there are many other diseases that might be under control or be diagnosed at the time of the miscarriage that really needs a little time to check it out, work it up, get it under control before you get pregnant.Miscarriage Caused by Structural Abnormalities
Now, some miscarriages are caused by a structural abnormality in the uterus such as a wall in the middle of the uterus that a woman might have had since birth or a fibroid in the uterus. If the evaluation of the miscarriage makes the clinician suspect that the uterus might not be healthy for a pregnancy, you should wait, meaning really wait. Use contraception until the uterus is evaluated and possible surgical correction of the problem considered so you don't have miscarriage after miscarriage after miscarriage.
Of course, there are psychological and social reasons to wait before becoming pregnant again after a miscarriage, but if you're healthy, the miscarriage was early and uncomplicated, you don't have to wait. Your clinician may or may not know of the most recent studies but we're trying to get the word out. And thanks for joining us on The Scope.
How long to wait before trying again after a miscarriage?