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Episode 22: Dr. Meggie Smith on Fertility and Family Planning
87 Plays4 years ago
We hope you enjoy this fascinating conversation with Nashville-based reproductive endocrinologist Dr. Meggie Smith. She is everything you’d want your doctor to be: open, honest and transparent. We talk about the issues surrounding family planning and how we can best make use of the latest medical advances.
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Transcript
Changing Perspectives on Having Children
00:00:05
Speaker
I definitely think people only saw themselves childbearing with someone else. And hopefully as it becomes more normal for people to have children kind of uncoupled from traditional marriage, that people will see themselves as a mother, even if they're not a wife.
Podcast Introduction and Focus
00:00:22
Speaker
Thank you for listening to Doorknob Comments. I'm Farrah White. And I'm Grant Brenner. We are psychiatrists on a mission to educate and advocate for mental health and overall wellbeing.
00:00:32
Speaker
In addition to the obvious, we focus on the subtle, often unspoken dimensions of human experience, the so-called doorknob comments people often make just as they are leaving their therapist's office. We seek to dispel misconceptions while offering useful perspectives through open and honest conversation.
00:00:48
Speaker
We hope you enjoy the podcast. Please feel free to reach out to us with questions, comments, and requests.
Dr. Maggie Smith's Expertise and Journey
00:00:54
Speaker
Dr. Maggie Smith is an OBGYN who specializes in reproductive endocrinology and infertility. Based in Nashville, Tennessee, Smith is a lifelong athlete who uses her medical expertise paired with her personal experiences to help women better understand their bodies. Smith strives to use relatable practical advice with all of her patients by connecting with them on a personal and professional level.
00:01:15
Speaker
Welcome. Thank you guys for having me. I'm really happy to be here. Yeah. We're so happy to have you and so interested to hear a little bit about your path and kind of what led you to, to where you are. Yeah. So, um, well I'm, uh, Dr. Maggie Smith, like you said, and I'm a reproductive endocrinologist and infertility specialist. Um, I'll be starting my practice in Nashville March 1st of this year.
00:01:40
Speaker
I don't want to say I always knew I wanted to go into medicine, but probably around the time of high school, I realized that that was a pretty good match for my personality and what I wanted to do. And I actually thought I wanted to be a dermatologist for a long time until I got to medical school and didn't really like dermatology so much. And I really liked OBGYN and women's health.
00:02:04
Speaker
I liked particularly being with women at very important times in their life. In my case, I get to be with people longitudinally for really intense periods in their life and not in their entire reproductive lifespan, but for a good portion of it. Ultimately, what drove me to pursue reproductive endocrinology and infertility was
00:02:27
Speaker
A few things. The first I think was particularly that infertility is not always viewed as a disease by everyone, and the WHO does classify it as a disease now.
Infertility Misconceptions
00:02:38
Speaker
People often think it's something they're doing wrong or some sort of, you know,
00:02:42
Speaker
biologic failing that is not true. And so I think helping people understand that it's not their fault and that there are reasons why people are infertile. And then I think, you know, ultimately, for me as well, family is one of the most important things in my life. Helping people, no matter their circumstances, have that I think was really something that drove me to pursue this field. So far, it's been great.
00:03:09
Speaker
Yeah, you bring up a really important question or issue about stigma, certainly around gender politics as well in terms of what does it mean for a woman in particular, or of course to be able to have children and to encounter challenges there. I'm curious how that comes up and how do you help people with that part of it?
00:03:32
Speaker
Ultimately, if people are really struggling or if I think it's something beyond that just like reassurance on my part or education can help, I do actually refer, if possible, to reproductive psychiatrists because often these people have been struggling with
00:03:50
Speaker
this for years or months prior to seeing me. And no matter what I tell them, it may not be enough to overcome, you know, there's a lot of anxiety and depression that goes along with infertility. I think, you know, there's a couple of, there's a lot of reasons why people can be infertile. Far and away, one of the greatest right now is that women are just delaying childbearing.
00:04:10
Speaker
longer than we used to. And so most women are waiting until their 30s to have children, which just biologically is when you're not as fertile as you were in your 20s. And I think some people feel some intense guilt about that, but realizing that it's not your fault that you were pursuing your career and doing amazing things. And I do think there is a bit of a fault on the media for making it look like pregnancy at 40 or even 50 is really attainable.
00:04:39
Speaker
And not, you know, people don't understand that the reason Janet Jackson had a baby at 51 was not because she had a baby with probably her own egg, unless she had frozen eggs. It was probably a donor egg or something like that. So I think kind of demystifying a lot of it for people is key. And then if they're
00:04:58
Speaker
If the demystifying and kind of explaining it to them doesn't do much, I always refer them to a specialist because I've, especially if they're already struggling with anxiety and depression in the pre-pregnancy period, we know that they're at risk for postpartum
Understanding Fertility in Younger Years
00:05:15
Speaker
depression.
00:05:15
Speaker
Yeah, definitely. And thank you for doing that. Is there an ideal sort of age or time in life? I think a lot of people who let's say are finished with undergrad, let's say in their early 20s are not really thinking about their fertility. What would you kind of want them to know about their options or, you know,
00:05:35
Speaker
Yeah, I think the biggest thing is first to look at your individual circumstance. So some people will know like my mother went through menopause early. I have a regular periods because I have TOS or something like that. So looking at those.
00:05:49
Speaker
individual factors that maybe, you know, a doctor has put you on a birth control pill because you had a regular periods. Well, why are you having regular periods? This will be because I see a lot of women who say, oh, I went on the pill when I was 18. Now I'm 33. Come off it. I don't have my period. What's going on?
00:06:08
Speaker
So I think that's one thing when you're at least in your, you know, late teens, early twenties, understanding maybe why you're going on a certain form of contraception, and then also understand your familial risk factors for potentially having infertility. And then I kind of tell patients that between the ages of 30 and 35 is when you kind of have to have a
00:06:30
Speaker
You know, like a serious conversation with yourself, what is important to you and kind of start to make decisions based on that. The biggest reason reason is that egg freezing is available and it's great.
00:06:43
Speaker
but it's not a hundred percent guarantee. And unfortunately a lot of women will say, oh, I'll freeze my eggs when, you know, I'm 36, 37. And while that's fine and plenty of women do it, the caveat there is often it will take multiple cycles of egg freezing to accrue the number of eggs, to give you a statistically good chance of having a life first from them. And so I think sort of approaching that on that discussion with yourself earlier,
00:07:13
Speaker
when egg quality is better and the yield per cycle when you do egg freezing is going to be better is important, so I think if you're someone who's younger potentially thinking, do you see yourself having biologically related children will your life be not complete without that some people, you know.
00:07:31
Speaker
there's so many paths to parenthood with adoption or egg donation. If it comes to that, that if people say, you know, I will love this child, however, it comes to me, which I think ultimately pretty much everyone does. But if you also say my life will be absolutely incomplete if I don't have a biologically related child, then really having that discussion of do I want to preserve my fertility if I'm not having children by a certain age is sort of important to think about.
00:07:58
Speaker
Yeah, absolutely. I think that's good. Really good advice, sound advice. I have this conversation with a lot of my younger patients who are women.
00:08:09
Speaker
And my experience is even when they're aware of the data, a lot of times it's very difficult for people to think about these types of questions. And even your earlier point about knowing why you're taking oral contraceptives, I'm often surprised and quite happy to be helpful when I can be that people in general don't always know why their doctors are prescribing what and what the implications are for them.
00:08:35
Speaker
Right, even a basic question like will my future fertility be affected?
00:08:40
Speaker
I see this kind of
Egg Freezing and Contraceptives
00:08:41
Speaker
frequently. I have women who come in their thirties who have been on birth control pills for many, many years. Now they came off and are having trouble getting pregnant and they associate it with taking the birth control pill when that's not, you know, not what is going on. Probably what has happened is, you know, their ovaries have aged as they would have no matter what. And now when they're trying to get pregnant, um, you know, they're hitting that kind of age related fertility decline that's natural.
00:09:09
Speaker
but they're now going to associate it with being on the birth control pill, which is unfortunate because they place blame on themselves for continuing to take it and whatnot. I see this all the time when people are even, I show them charts and graphs of this is how many eggs you need to potentially make a baby. It sometimes doesn't quite hit home that whatever I'm doing for them isn't a guarantee. I think that's a really hard
00:09:33
Speaker
hard emotional piece for people to grapple with. They're sort of, I tell them that you're sort of grieving the loss of the life you thought you might live. No woman dreams of freezing her eggs. And so it's often, it's a consequence of something not working out the way you had planned. And I think people are sad about that. And it's hard for them to sometimes realize that they're really emotionally dealing with that.
00:09:58
Speaker
Well, I think there's a cultural piece there, and especially as our culture changes and people are in the workforce longer, you could make a strong case that people should be aware of these issues, even in something like high school health class.
00:10:14
Speaker
Oh, for sure. Right. Yeah, for sure. Because I, you know, I don't think I think we do a really poor job of educating people about both contraception, depending on what area of the country you live in, about both preventing pregnancy and the fact that fertility isn't forever. So understanding where your priorities lie in terms of how many children you want to have, I think also
00:10:37
Speaker
The other thing I talked to a lot of my egg freezing patients about is, would you do this alone? Because that is something that is becoming, I think, at least in my practice is becoming more and more commonplace. I think particularly in the pandemic with people
00:10:53
Speaker
not as comfortable dating. I think some women are just saying, I'm going to have a child. And not everyone is in the financial position to do so. But I think having that conversation with yourself, if and at what age, would you just pursue having a child on your own? And I think that's not talked about as much. But I think that is something that we will probably see
00:11:16
Speaker
more likely in big cities like New York and Los Angeles, but something that becomes more and more common as kind of reproduction is uncoupled from traditional marriage.
Balancing Career, Parenthood, and Benefits
00:11:28
Speaker
Which I think is ultimately a positive thing, but you're right that it really means looking at what are the priorities. It's a priority is becoming a mother and not wanting to delay it, but also having a good idea of how your
00:11:44
Speaker
career choices might play into that. And so if you know that you're going to go to school for the next eight years, that might be freezing your eggs maybe at the beginning of that or prophylactically or whatever.
00:12:00
Speaker
You know, we did it my prior institution when I was at USC, we offered a discount to residents and like trainees because yeah, it was great because and most people took it. A lot of people took advantage of it because just a they're not in a financial position to really pay what it.
00:12:18
Speaker
You know what it actually costs, but they are people that for whom this will be beneficial. Many of them are not going to want to start having kids till they're finished with their training, particularly if it's a surgical subspecialty. And then by the time they're mid 30s by the time and that happens and it may be a lot more difficult for them to get pregnant.
00:12:37
Speaker
I know that there are some companies that will pay or cover that cost. And I think people, a lot of people I saw when like Apple or Google started covering egg or embryo freezing for people.
00:12:53
Speaker
We're thinking that the messaging there was, you know, don't have children now so you can work more. And I didn't really see it as that. Honestly, I saw it as like, these people are probably going to want to work until a certain age and start having children later. You're giving them this benefit that they now, you know, can at least preserve their fertility now and don't have to worry about this five to 10 years down the road.
00:13:13
Speaker
It might serve commercial interests as well as the interests of employees, which, you know, which is much harder for people to get your heads around. Cause I, in general, you know, we have less trust and with good reason of insurance companies and large employers, you know, someone who says they're looking out for you, um, we're, we're, we're all maybe going to be tiny bit skeptical. Yeah. I can see where their hesitation came from, especially with the big tech companies that, you know, uh, you know, prioritize productivity.
00:13:42
Speaker
Yeah. On the other hand, you know, it's really important to be free to focus on what's important and especially in a career like medicine or law or really any career where you really want to be fully available and not have to worry about factors like am I going to be able to have a child later on the way I
Acceptance of Non-Traditional Families
00:14:01
Speaker
want? It's wonderful to have the technology. It's really, it's the dawn of a new era. Like you said, it's uncoupling reproduction from sex and relationships.
00:14:12
Speaker
which I think has it's like good and bad, but I think, you know, as my, I just turned 35 and I feel like a lot of my, outside of the South, a lot of my generation is not married. I kind of see this like shift in people seeing, you know, marriage and childbearing a little bit separately. Some people want, and I think a lot of, you know, growing up, you always think of them coming together, like marriage and children, and then you see people that,
00:14:39
Speaker
want to be married, do not want to have children, which is when people talk to me and say, you know, is it bad that I don't want to have children? I'm like, no, absolutely. There are a lot of work and a lot of time and money. I mean, I only have two dogs, but they're very expensive and time consuming. So I think it's good when people know that I think the harder part now is the women who
00:15:01
Speaker
usually desire having a partner but haven't found the right person and that's becoming more and more difficult and they still want to have children and they're not really sure what to do. I think that's a really a fairly large group of patients that I see fit into that category which they're sort of in this no man's land. Sort of no pun intended.
00:15:21
Speaker
But I do think that in big cities, it's a little bit easier just in terms of the dating scene, having kids, not having kids. It could be that they end up becoming a single mother by choice and then meeting someone two years later. In New York, particularly, I lived there for so many years, you definitely see that that people aren't going to wait or take things into their own hands and then
00:15:46
Speaker
maybe meet their spouse afterwards. One nice thing about New York is that there's a lot of untraditional parenting and I think that opens up for the conversation for what makes a family and really it's just love and you know, do the people, as long as the child is loved and cared for,
00:16:02
Speaker
That's, you know, that's really all that's needed. And so I think, I think hopefully that will trickle down to other, you know, other cities in America. Cause I think, yeah, I think, you know, people want to be parents and they want to care for a child and love a child and raise a child. They should be able to do that.
00:16:17
Speaker
It's more empowering in places like New York and the difficulty with identity, the identity of having a child outside of a traditional relationship. And even on dating platforms, it's fairly common to see someone say, I have a child and you're dating us.
00:16:36
Speaker
Yeah, yeah, for sure. Yeah, definitely. And there's a lot of guys who also have kind of put off family. And as you said, it's not it's not necessarily about having the biological kids. It's really about having a loving family.
00:16:49
Speaker
Yeah, for sure. I think one of the things that patients that come that are potentially pursuing sort of an untraditional family, they worry about what everyone else is going to say. And I think hopefully as it becomes more and more common, people will have less to say because truly what is the difference of buying donor sperm and having a child on your own versus
00:17:10
Speaker
having an unintended pregnancy when you're younger. There's not really much difference in terms of how you're raising the child as long as the child is loved and cared for, and either way, it's going to be fine. What do you think is important for people to know just in terms of the process and where to get started and what to
Fertility Treatment Processes
00:17:30
Speaker
expect?
00:17:30
Speaker
I mean, to be honest, like initiation, like first consultation to initiation of treatment is not as long as people think it can for egg freezing. It kind of depends on most of that depends on when you want to do it. And if you've been on long-term birth control pills, I do have patients come off for two to three months.
00:17:48
Speaker
Just because usually they're so suppressed, it may diminish their, um, their response a bit. Um, but kind of depends on their circumstances. And then with once we've established that they want to do it, it's really what works good for you work wise or life wise. Um, just making sure it kind of lines up there for infertility.
00:18:08
Speaker
It depends on where you are in your workup. But typically, you can get a workup done within a month within someone's menstrual cycle, depending on when they see you. You could initiate treatment as soon as the next menstrual cycle, depending on where they start with you. It's not that long to get into treatment, which is good. Can I ask a clarifying question about something you said? When you say if people have been on birth control, it can take a while because they're suppressed. What does that mean?
00:18:37
Speaker
Yeah, so basically because birth control pills are giving you a constant level of estrogen progesterone it shuts off your own hypothalamus pituitary ovarian access. So, your hypothalamus and pituitary aren't making you know FSH and LH, like they would normally to then speak to the ovaries.
00:18:56
Speaker
what we want in an egg freezing cycle is also to have some of your own of those hormones. Even though we're giving you those hormones in injection form, we think that those that your brain makes are a bit more potent. They're better. Yeah. We just want to make sure that you're off of it enough time that that wakes back up. Taking oral contraceptives essentially tells the brain, hey, you don't have to make all these hormones and it takes a few months for your brain to wake up.
00:19:24
Speaker
Yeah, for sure. It's basic birth control pills essentially trick your brain into thinking you're pregnant.
00:19:29
Speaker
Right. Right. Your brain isn't going to make the, all the hormones that, you know, control the cyclicity of the menstrual cycle. And so you're just, you know, you don't have that anymore. And so it kind of takes some, for most people coming off of it, they'll restart their period, um, within the next, you know, the next menstrual cycle, um, with it. So within the next few weeks, um, but for some people it might take a little bit longer and we want to make sure that we have enough time that that, especially since like freezing is so expensive too.
00:19:57
Speaker
I'm sure you see a lot of variability so one of the take home messages if you're thinking about your fertility, remember that if you're taking oral contraception it may take a little while to be able to do fertility work. Yeah, for sure. Yeah. So, and, you know, just kind of depends on.
00:20:15
Speaker
how long you've been on it, why you went on it. For someone who has PCOS, I don't expect them to get their period when they come back off of it. So that's a different conversation to have with your doctor of why you went on the birth control pill and what to expect when you come off
Emotional and Relationship Challenges
00:20:31
Speaker
of it.
00:20:31
Speaker
People think infertility treatment lasts a really long time. Like in the old days of IVF, a cycle was quite long. Now in IVF cycle, really the injection process is anywhere between nine to 11 days. And then your retrieval and egg retrieval where we go and surgically remove them happens on the 11th through 13th day.
00:20:51
Speaker
So that timeframe isn't that long, but it's pretty intense in that you're coming to the office almost every day, almost every other day and towards the end every day. I think the thing that's most difficult, there's always an expectation and then there's the potential that that expectation isn't met. And so it's sort of like a little bit of a depression induction cycle because you're
00:21:15
Speaker
constantly having your expectations maybe not managed. We try as best as we can to tell, give you realistic expectations while also being optimistic. But no matter what, maybe your follicle count goes down, the estrogen doesn't go up as much as you'd like. You don't get as many exit retrieval as you wanted. And all of these things can set you up for a lot of
00:21:39
Speaker
Disappointment, despair, anxiety, which I think that is the hardest part probably of infertility treatment. Sort of emotional roller coaster and how do people cope when there's such extremes of hope and disappointment and so much uncertainty?
00:21:58
Speaker
So much uncertainty and I think as well, you know, there's a lot financially that they're putting into this, which I think really just makes it all that more intense because you're not only wanting to work so bad because you want a child, but also you know that you're spending $25,000 on this and that's not a, you know, a small sum of money. And so it all, all of these factors combined can make it,
00:22:25
Speaker
a really intense period in people's life. I think a lot of people correlate the injections as making you quote crazy. Whereas I don't necessarily feel that's actually true. I think it's more the entire process just can kind of make you
00:22:43
Speaker
It's an emotional roller coaster, for sure. We see that in psychiatry a lot, which is kind of like for listeners, how do you know if a medication is having a side effect? And how do you know if it's like a placebo effect, if it's positive or a nocebo effect, if it's negative? And what I hear you saying, Maggie, is that it's so loaded emotionally
00:23:03
Speaker
And we haven't even talked about the potential issues for couples that it can stir up that when people are getting the initial first week or two of hormone injections, they're likely to assume almost that any kind of emotional things they're having are related to hormonal shifts. And I want to say maybe some of that is also related to gender bias.
00:23:24
Speaker
Yeah. And I definitely feel, you know, as your estrogen does go higher, people can either feel more emotional, more like cry more easily. Some people feel happier. Yeah. Um, most people, I think, yeah, I think a lot of people, they're unintended. They don't realize how happy they are with a lot of estrogen. Um, and so, and then when they lose that after the retrieval, they're, you know, it's kind of like a postpartum period almost, um, a crash.
00:23:50
Speaker
A crash for sure. I think there's so, and especially when you mentioned the couples, that's another good point because a lot of times the couples are very, you know, well-matched in what they want and what they desire, but there are some times in which one partner wants to smart than the other or is willing to participate more in care than the other. I rarely ever see any sort of blaming or anything on one partner or the other.
00:24:15
Speaker
I think there's also an interesting sometimes when it's like a male factor infertility, the guys seem to not deal with that very well. Yeah, I was going to ask you about male factors. Yeah.
00:24:27
Speaker
Yeah. A lot of times I feel like they think it's an affront to their masculinity, which similarly to female partners, when we tell them something they did wrong or it's, it's not your fault that you have PCOS, you know, that or, or, you know, endometriosis. Um, I think a lot of times the male partners can be a little bit, they feel like it's an affront when you tell them their sperm count, is it good? You know, it could be from a variety of factors, you know, whatever depends on their individual circumstance, but they,
00:24:56
Speaker
I think they feel as a front to their masculinity. And a lot of times I've seen this often that they feel very protective over the female partner and you're kind of going through all these situations and then they're saying, why is it not good? Is it the person in the back? It can be a lot of emotions for them too.
00:25:14
Speaker
There's some tendency to deny it and have difficulty accepting it. I know guys will also tend to joke about things like this. And there's a tremendous amount of relief when their sperm is okay. Stereotypically, men will say something like, my boys can swim. There's a lot of projection going on. Do you find that men are reluctant to get tested?
00:25:39
Speaker
Definitely, it's a lot harder to get the men probably in the door than women. I would often say it's the women driving the men to come in. I think with COVID, it's been different as well because we're not seeing people as physically in the office as much anymore.
00:25:56
Speaker
the male partners can be on the Zoom consultation a lot easier than sometimes if they had to take off work and come similar for women too. But I think definitely men are much more reluctant to, I think, pursue treatment than women for a variety of reasons. I don't know if it says.
00:26:13
Speaker
masculinity thing or just it will get better type of thing.
Male Fertility and Lifestyle
00:26:18
Speaker
Yes, emotional approach. Since we're talking about the male factor anyway, are there any age-related issues that men should think about or couples should think about?
00:26:29
Speaker
There's definitely an association with advanced paternal age with things like autism and actually psychiatric disorders, particularly schizophrenia. The exact age at which that happens is a variable. The other thing to know is that men over the age of 55, at least at my prior institution, we often would go ahead and do what's called intracytoplasmic sperm injection where you take one sperm and inject it into the egg just because of age, but there are plenty of men who have
00:26:58
Speaker
got one minute pregnant at the age of 55 without IVF. Is that ICSI? ICSI, yeah.
00:27:06
Speaker
So those are the biggest issues, I think, you know, while there is a component of male, like age-related fertility decline with males, it really doesn't happen until the older, much older ages, which there's not as many men reproducing at that age. It's not as early as females. So not as much. I have had patients ask, should I freeze my sperm? Because, you know, I'm 35 and not ready to have children. And while you can, it's not something that we routinely do because
00:27:36
Speaker
Men can still produce sperm that work just great at 45. The risk benefit ratio isn't as high. So for men, you would look at things like sperm count, what the sperm look like, which is called morphology, whether they move normally, which is called motility. And I guess you might look at some male endocrine factors in some cases.
00:27:57
Speaker
Yeah. The biggest thing we look at is what's called the total modal count of sperm. And that's by taking, you know, the volume of semen, the concentration of sperm and the percent for their modal. And once we get that, and then the morphology as well, we can kind of, if someone is on the, you know, lower side, that's when we really start to pursue a workup of, is it an endocrine disorder?
00:28:20
Speaker
Obviously, if they've had something like chemotherapy in the past, that is a big tip off that this now affected their sperm production. The total modal sperm count is our biggest parameter that we really look at. You can do a lot.
00:28:36
Speaker
because in the lab you can get the modal sperm and you can introduce them to the egg very closely. So that's the good news. People, they also worry about things like marijuana smoking. Are there any myths or truths to things that men should be careful about?
00:28:50
Speaker
That's it. The marijuana is a tough one just cause we don't have really good data. I would say I tell patients if they are daily smoking marijuana, they should probably stop. Um, just because we don't know much yet, but there is a negative effect of nicotine on sperm production and on eggs. And so, you know, until we have more data, I recommend that they, they quit in terms of if men are doing a lot of hot tubs, a lot of long bike riding and like tight shorts that can negatively affect sperm production.
00:29:19
Speaker
And the biggest one as well as if they're taking like testosterone, um, they often forget that that's sort of like a male contraceptive. Um, so it works similarly to female contraceptives and that now you're giving your body testosterone. So your brain, uh, male's brain thinks I don't need to make my own testosterone anymore. And so it shuts down.
00:29:39
Speaker
testosterone production, which then negatively affects sperm production. I think also making sure that they're not taking steroids or testosterone is another thing that people sometimes overlook. Fortunately, with male factor infertility, you can work with a very small number of sperm, which is good because we're able to help people with even very severe male factor infertility have biologically related children.
00:30:05
Speaker
Are there any things that you have noticed, like over the course of your practice in terms of partners supporting each other, or even just friends and family, knowing how to support someone through a time like this?
Support Systems During Fertility Treatments
00:30:19
Speaker
Some people are intensely private with this type of thing. With fertility treatment, they
00:30:24
Speaker
aren't ready to share or don't want to tell people, which it's fine. Personally, I was open to sharing when I froze my eggs. I put it on Instagram. For me, it was more fun to share with people. I think one main thing is not asking numbers or questions or how many eggs do you think you're going to get? That is a huge source of anxiety for pretty much every fertility patient, egg freezing or infertile.
00:30:49
Speaker
Not focusing on numbers, but just, you know, do you need anything after your trip? You know, do you need someone to pick you up from your ag retrieval is like very useful. You do have to have someone drive you home. I think not focusing on numbers or when is your first HCG after the pregnancy test, after the transfer, maybe not harping on those little things. Cause those are already sources of huge anxiety, but I think asking how, what ways you can help them out through this, um, it is helpful.
00:31:17
Speaker
Yeah, I agree. I think it's nice for people to have the support if they do choose to share. And there's, I think what people find too, when they share is that there's a lot of other people they know that have done it and they didn't know as well. Yeah. I think the less stigma there is and the more openness there is generally the better sort of normalized it is and better for everyone.
00:31:39
Speaker
Definitely. Because once one person says, oh, I had to do IUI, even what was infrared or an insemination, which is kind of the step before IVF, then it kind of, oh, I actually had to see a fertility specialist as well. And so then it kind of opens the door for people. One in eight couples is infertile. And so I think a higher number than people realize. And so once someone starts sharing, you start to realize that
Infertility Stigma and Mental Health
00:32:09
Speaker
you're not alone in this. Yeah, which is I think why I am so grateful for people who are vocal about it. And I think in that sense, reproductive endocrinology and psychiatry have a lot in common because there is that stigma where people might not want to share in the same way. I think hopefully with infertility, at least people are coming to see that more as a disease, and that this is not something a moral failing on their part or anything.
00:32:39
Speaker
I'm hopeful that the same will be true of mental health. Personally, as someone who's gone to a psychiatrist and therapist, I told my, I was like, I feel like everyone should do this at least once a year. You know, it's a pretty like important. I mean, I think, I think there's a lot of misconception that even people that are high functioning must not need that. And often people that are very high functioning
00:33:02
Speaker
are doing quite well, but maybe need to check in every now and then. And at least my personally going to a psychiatrist and therapist, my main misconception was that this was going to be like some sort of like tear fest where I was going to cry. And it really wasn't. I mean, I was like, it really was mostly a session of like, how are we going to help you live your life better? And I think that's what people don't quite realize that it's almost like
00:33:28
Speaker
It's just as important as getting your cholesterol checked in my opinion. I hope so too. I think that people, it's a family history thing. It's a childhood and a trauma, but I do think that almost everyone could probably benefit from the same way we get our skin checked, our eyes checked, go to the gynecologist. One conversation
00:33:51
Speaker
can actually really go a long way in terms of looking at what are people's goals? Are they living their lives with intention? And yeah, and especially I think people think you have to go quite frequently. And now I probably, you know, I get calls them reminding me like, Hey, like, do you need a follow up?
00:34:09
Speaker
Which was not true when I started, you know, I saw that, you know, more frequently, which is great that I'm in that place. I'm sure there'll be a place in my life where I need to see them more frequently again. But I think people, I think the misconception is that this like, you have to go once a week, which might be true at some points in your life, but not at all points in your life. Right.
00:34:28
Speaker
That's a traditional weekly therapy model. I like to think about the idea of deep self-care, where people are very open to the idea of eating well and exercise and sleep and even things like meditation, but really being in right relationship with yourself
00:34:46
Speaker
so that you're available for the other parts of your life is not a given. And like we were saying about reproductive self-awareness, same thing goes for kids growing up. There's a lot more schools that have like empathy training programs, emotional self-awareness. You know, the literature is very clear that for everyone, you know,
00:35:08
Speaker
people even without traditional mental illness developing good executive function, emotion regulation, you know, all of these things are, they're hard to pick up along the way. It's almost more like coaching. For sure. And I think, you know, like I see at least in my practice that a lot of people, you know, by the time someone gets to me and they're 37 years old and they're not married and they want to have children and now they're facing egg freezing and now their numbers aren't as good,
00:35:34
Speaker
they're typically not the hardest but it's you're working with things that you're telling them what they don't want to hear and I think those are people that can really benefit from as well like reproductive psychiatry but probably even before hopefully we'll get better at this at educating people about their you know not only reproduction but mental health and how to deal with their life maybe not going as according to plan and having that kind of you know not emotional regularity but I guess a way a way to cope with
00:36:01
Speaker
things not working out as they planned because I didn't even know for myself personally being 35. I never thought I'd be 35 and unmarried. I thought I'd have four children by now and so that's a definite like for me something that I had to like kind of parse out in my mind and I think probably being a reproductive endocrinologist made me think about it probably even earlier than other people
00:36:21
Speaker
So I know personally for myself, you know, at some point I will just have children on my own. But I think I'm in a very fortunate position that because of what I do, I thought of these things a lot earlier and I'm not having this all hit me at one time, which I think what happens to a lot of people around the age is like 37, 38, 39.
Positive Outcomes in Non-Traditional Families
00:36:41
Speaker
Well, you know, one way to think about it is in terms of identity or self-concept.
00:36:46
Speaker
Yeah, yeah, I definitely think people only saw themselves childbearing with someone else. And hopefully, as it becomes more normal for people to have children kind of uncoupled from traditional marriage, that people will see themselves as a mother, even if they're not a wife or father without, you know, not having a spouse as well. So I know, I know many gay couples who either adopt or use a surrogate and they just they have wonderful families.
00:37:15
Speaker
They do. Yes. I mean, that was in Los Angeles where I was previously practicing, I would say 30% of my practice was same-sex couples, same-sex female couples. It's, I don't know, is it easier, but you have less, um, you know, with same-sex male couples, you have to get both an egg donor and a gestational surrogate, which ends up becoming very expensive and, and, and whatnot, but they, um, they make some beautiful families. A lot of, I had a lot of single mothers, single fathers, a lot of people that just wanted to have a child. And I think that's great. If you know, there are plenty of people who.
00:37:44
Speaker
want to have children and raise them. And there are people who don't want to have children. I think that's fine too. Like what kind of keeps you going just in terms of, you know, we didn't mention, but like going through med school, then residency, then fellowship, it must have been really, really tough. Are there stories and like, like small victories or big ones that kind of kept you going along the way?
Rewarding Experiences in Infertility Practice
00:38:11
Speaker
yeah I think that once patients really like Thank you, I think it's like it's very simple, but when someone's like like Thank you for whatever you did that really helps keep me going, especially when. Especially in what I do when you kind of stick with people through something that maybe isn't being.
00:38:30
Speaker
Like I can think recently I had a patient who, you know, we were trying all of these different things and maybe this, you know, trying kind of not unconditioned, unconventional, but just like, what if we tried this, you know, and kind of sticking it sticking through treatment with them. And once you finally get them, she finally got pregnant and she was shocked.
00:38:49
Speaker
you know, and I kind of went as well. But it was one of those things that then they really are appreciative that you didn't give up on them. I think that is really rewarding. And even patients who you don't give up on them and they don't get pregnant, they're still very appreciative that you gave them the chance. Unfortunately, there are some people out there that don't always give
00:39:11
Speaker
If you don't meet certain criteria, they don't let you do IVF for certain things. But when you do give people the opportunity to just try, a lot of times people just want to try. That's really all they want. And when they're so appreciative of that, that really is meaningful, at least to me. Well, you sound like a wonderful physician. It really sounds
00:39:28
Speaker
to me, like you have a humanistic approach. You know, as with surgeons, sometimes, you know, people will want to work with a surgeon who's an amazing technician, and they don't care, you know, about their bedside manner. It's a little different if you're having your shoulder repaired. But when you're going through something, it's really important. And if your infertility specialist isn't sort of getting the human connection, it really is a lot harder. So I feel happy that you're helping people.
00:39:56
Speaker
Yeah, I mean, I think if I ever have to have brain surgery, I would like my neurosurgeon to have somewhat of a GOG complex, but that would be kind of it. I guarantee he will. Yeah, exactly. My internists, I don't think they have to have that. We're dermatologists. Maybe an excellent neurosurgeon complex.
00:40:15
Speaker
Ultimately also in what I do for your listeners, the other really important piece of IVF is the lab.
Importance of a Quality Lab for IVF
00:40:21
Speaker
Um, and going someplace that, you know, if you can find a doctor that you really mesh with and that there's also a very good lab, that's really the, you know, the best of both worlds because as good as I can be with my ovarian stimulation, I don't do, you know, the egg freezing itself or, you know, watch, you know,
00:40:41
Speaker
caring for the embryos or doing the ichthy. So having a good lab that produces good results is really key to my work as well. And the administrative part, I've also heard of when people go to institutions often where the paperwork is really burdensome, it is just the end of the world.
00:41:02
Speaker
I mean, that's like one huge bear, especially because insurance may not always, depending on what state you live in, not every state has mandated fertility coverage in the paperwork. They can come with fertility treatment and applying for, you know, preauthorization and benefits can be overwhelming. Um, and I think it just can become so much and people are already upset or emotional. And then when you have, you know, slap them with a $5,000 bill.
00:41:27
Speaker
They're much less happy as well, understandably. Yeah, but that's where I think having a doctor like you or someone that they really feel connected to and who can sort of help walk them through it, even though it's not exactly your domain, just to kind of
00:41:43
Speaker
Yeah, exactly. Like, at least I can tell them, like, this is trying to also not divert their attention, but at least, you know, focus them on what we're trying to accomplish and that we'll get the billing worked out. And, you know, I can go and speak with the billing department and whatnot. Not that I know how to code or anything, you know, I can eventually help get that straightened out, but let's focus on what, you know, what we're, what we're here to do.
00:42:04
Speaker
This has been amazing. I know we're wrapping up. Thank you so much for your time today. Thank you for sharing your own experience as well. Oh, yeah, before. I always tell people about, yeah, my two, in fellowship, I froze my ex twice and I started seeing a psychiatrist. And I mean, I froze my ex probably the right time. I wish I had started seeing a psychiatrist earlier. Definitely. But, you know, that's it.
00:42:26
Speaker
Yeah, I try to tell people now because I'm like, it's the best I go. I, every time I go, I leave feeling better. So I'm like, why would I not want to go to this? Yeah. So yeah, that's awesome. Thank you for supporting our field. Yeah. And where can we find you, uh, or where can listeners find you? I'll be practicing at Nashville fertility center starting March 1st, um, seeing patients, um, there, I mean, it'll be,
00:42:52
Speaker
still virtual with COVID. And then online my website is meggysmithmd.com and my Instagram and Twitter is at
00:43:03
Speaker
MBS, thanks. So that's my initials MBS. And back in med school, I had a blog that was called the Think Like and Think. And that's where I came from. So it's kind of all carried over from years ago. Oh, cool. And for listeners, your first name is Megi, M-E-G-G-I-U Smith M-D dot com, right? Yeah, it's within E. It's from, I was born in 86. And so that was the year the Thornbirds came out, a mini series. And that's where my parents got my name from. So if anyone's familiar with it.
00:43:32
Speaker
All right. Great. Well, thanks again for all the work that you do. And thank you guys for having me. I really appreciate it. And hopefully people find this helpful. Yes. I hope everything goes great in Nashville. Yeah. They're lucky to have you. Thank you. All right. Thank you guys. Bye.
00:43:52
Speaker
Thanks for listening to Dornop comments. We're committed to bringing you new episodes with great guests. Please take a moment to share your thoughts. We'd love it if you could leave a rating and review on your favorite podcast platform. You can also find us on Instagram at Dornop comments. Remember this podcast is for general information purposes only and does not constitute the practice of psychiatry or any other type of medicine. This is not a substitute for professional and individual treatment services and no doctor patient relationship is formed. If you feel that you may be in crisis, please don't delay in securing mental health treatment. Thank you for listening.