Dr Beth's Blog

Dr Beth Taylor MD, FRCSC

 

 

 

 

 

COVID part 2

I survived COVID-19.  Googling how I can get that on a bumper sticker now.

I feel great again. It was a terrible flu but it passed and I have been released from isolation by the Medical Officer of Health.  Now, I move around the world with some confidence as I am immune.  While there are two strains of the COVID virus, reinfection or infection with the other strain is not common. I will still take the same precautions everyone is taking to avoid getting sick again, though.

Because I am immune I carry antibodies against the virus. My next plan is to see if I can donate my blood plasma to help others who might be fighting COVID.  

Patients who I saw in person while I had the virus have all been notified.  It has been more than 14 days since their exposure to me, in all cases, so it seems I did not transmit the virus. I didn't transmit it to my family either (at least no one has gotten ill).  What a relief.

Stay safe everyone!

 

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

COVID-19

COVID-19 has caused massive distress, disease and confusion. I have to admit I was confused.  After all hearing that 8 or 9 elderly people died didn’t sound that different from a usual flu season.  Things have changed, and keep changing, though and it has become apparent that COVID is much worse than the typical flu.

 

It spreads faster, it lasts longer, and it causes a very severe pneumonia that is far more likely to kill people than the flu.

 

Last week I started to feel unwell: cough, chills, muscle aches.  I was swabbed Thursday morning and tested positive for COVID-19. I’m now in isolation in my basement for the next week. So far my family is well.

 

I am a completely healthy 46 year old.  The only illnesses I have ever had was the flu about 17 years ago and a gastrointestinal infection while travelling in Malaysia about 20 years ago. Honestly, I have never taken a Tylenol before. I have taken Advil after my c-sections to deliver my children.   No other medications, ever.

 

This flu feels terrible.  I hope it does not progress into pneumonia but time will tell. I feel a bit better today so am feeling optimistic.

 

I have been in contact with the Medical Officer of Health.  He indicated that I likely did not exposure patients to COVID-19 because I was not working when I got sick. There were three days before I stopped work when I did see patients and at that time I had a runny nose. Those patients (March 10,11, 12th) will be notified to watch for symptoms for 14 days from seeing me, as there is a very small chance I could have had the virus those days (many days before I got truly sick with COVID so that was likely just a non-COVID cold or allergies). Those patients will be getting a letter by email.

 

Our clinic has shut down for in-person physician visits except for the last few patients finishing IVF and a few pregnancy scans.

 

Why does an IVF program need to shut down?

 

  1. We want to limit person-to-person contact and transmission of the virus between patients and staff
  2. There is a risk our staff become sick causing us to be short staffed and unable to perform our work
  3. The impact of COVID-19 on pregnancy is unknown so it is not prudent to encourage pregnancy at this time.  So far, there is no evidence of harm to the fetus, but the illness in pregnant women is more severe.
  4. We want to donate our resources to the hospitals to help them help sick patients

 

 

How long will we be closed?

 

We truly don’t know.  If we can get handle on it and “flatten the curve” like China and South Korea have, I think we will be open in 6-8 weeks.  If we cannot get on top of it, then we may go the way of Italy and closed 3-4 months.

 

What happens if I need help and the clinic is closed?

 

Ok, we aren’t completely closed.  Administrative staff and doctors are all still working full-time.  We are doing phone calls instead of in-person visits. We have a group of nurses also still working to answer calls and give guidance. The only part that is closed it the IVF lab portion: the part where IUIs and IVF are done.

 

We are still here for you.  If you are worried call us - someone will talk to you. Email me if you need, as well:  btaylor@olivefertility.com

 

The good news for me is I will soon be immune to the virus.  While there are two strains, it is my understanding that having had COVID-19 I will be immune (likely to both strains for the rest of this pandemic.  Then I can resume in-person visits and help out my friends and neighbours who should not or cannot leave their homes.

 

Stay inside. Stay away from the elderly. I hope no one else gets sick!

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

blocked tubes

About 15% of our patients have tubal factor infertility, meaning we think blocked or diseased Fallopian tubes are the reason they are infertile. We assess the tubes with a hysterosalpingogram (HSG). The HSG is also called the “dye test” because dye is passed up through the uterus and out the tubes. An x-ray is then taken and the radiologist can sort out whether the tubes are open or not.

 

If the tubes are blocked, the blockage can be in one of three places: proximal, mid or distal. Proximal is near the uterus. Distal is at the end of the tube near the ovaries. Mid is, of course, part way in between. Both tubes can be blocked or just one. Distal tube blockages generally require surgery. Mid tube blockages generally cannot be fixed and the person will need IVF. Proximal tube blockages can often be opened by a tubal cannulation.

 

Tubal cannulation is the passage of a wire up through the uterus to the blocked tube. The wire is then pushed through the blockage, hopefully opening the tube. I want to talk about proximal tubal blockage/occlusion because I just finished reading a meta-analysis of studies on cannulation of proximal tubal blockages, so it is top of mind.

 

The meta-analysis is the most recent one, though published in 2017. It analyzed over 1700 patients from 27 studies on the topic. They looked at women who have just one tube blocked proximally, or both tubes blocked proximally, who underwent tubal cannulation to open the tube(s). They then follow these women for several months to see if they got pregnant. Interestingly, if you have cannulation of one tube or both tubes the pregnancy rate is about the same:

  • 6 months after the cannulation 22% of couples are pregnant
  • 12 months after the cannulation 26% of couples are pregnant
  • 24 months after the cannulation 27% of couples are pregnant

 

There is a 4% risk of an ectopic pregnancy (pregnancy in the tube).

 

So, tubal cannulation is like a lot of fertility treatments we do: if you are going to get pregnant it will happen within the first 6 months of treatment (generally speaking).

 

Should you have a tubal cannulation? If you are older or have a low egg count you might not have time to wait to see if the cannulation has worked. These patients should consider IVF. If you are younger and the rest of your fertility testing is normal (normal uterus, good egg count, normal sperm), then you should consider cannulation. In BC tubal cannulation is covered by our provincial health plan. IVF has a higher pregnancy rate than cannulation but comes with cost.

 

It is worth having a conversation with your doctor if your HSG has shown blocked tubes. A cannulation is a simple procedure and might just help you conceive on your own.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

Reproductive Health for All

I like to think most of us are feminists.  That word is a bit loaded, but if we define a feminist as someone who believes in equality of genders and works to promote the health and well being of women, I hope most of us are feminists.  I consider reproductive health a feminist issue.

 

It’s always baffled me that reproductive health is considered separate from overall health.   Several countries and many insurance plans fund all parts of health EXCEPT reproductive health.  For example, in several countries health care is funded fully except contraception , abortion and fertility care. Why did we decide to pull out reproductive health from other parts of health?  A cynic would say it was because reproductive health mostly involves women.

 

There is a positive story here though, as some companies are starting to cover reproductive health, including IVF and egg freezing.

 

Facebook, Starbucks, Johnson & Johnson, Apple, Amazon are some of the large companies covering all parts of reproductive health, including IVF and egg freezing for their employees.

 

Nearly half their work force is female and the majority of them are of reproductive age. Plus many of their consumers are female. Covering IVF and egg freezing makes sense. Coverage for IVF and egg freezing is often heralded as a “perk” but it should not be separated out at a “perk,” like we don’t separate out coverage for hernia surgery or blood pressure medication.  Coverage for reproductive health should be standard.

 

While I think every company should fund reproductive health, and certainly those who benefit directly from the work of women and their money.

 

I’d like to see companies, and governments alike, walk the talk of supporting women and their health - all parts.

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

Receptiva

It was kind of odd and I had never been asked this before, but a patient asked me “why do you do what you do?”  It was like she was Barbara Walters and it was 1994.  I squirmed in my seat.  I know why I do what I do in my heart but it’s pretty hard to articulate.  It’s like when someone asks you why you love your partner.  You can come up with a laundry list of the attributes you like about them but it’s hard to put “love” into words.

 

There was a long awkward pause after she asked me this while I decided to whether to give her a thoughtful answer or the kind of answer that moves the conversation along.  I like her as a person and I had lots of time so I thought I’d just try and put why I do what I do into words.

 

In retrospect I didn’t really answer the question but I did give an answer that I think reveals my motivation for why I do what I do.  I said that when people come to see me as their doctor I want them to get an honest, thoughtful, thorough opinion on their fertility and to get the best possible care.  I said I wanted to look people in the eye and know I am giving them the best possible chance… like they couldn’t go to some other doctor anywhere else and get a better standard of care or a better chance of conceiving.

 

I suspect most fertility doctors want this very same thing for their patients and their practice.

 

There are a lot of parts to doing this. One part is keeping up with the science.  What’s the latest thing we should be trying, doing, thinking about for patients? One example is what’s happening with BCL6 and endometriosis.

 

BCL6 in the endometrium is one of the latests “things” in fertility care. A doctor named Bruce Lessey has been researching this marker in the uterus for a while but only recently has testing become available to patients.  There is very little research on BCL6 testing for infertile patients but more research is being done and we want to be part of that knowledge acquisition.

 

The group of doctors here at Olive have been talking about a new test called Receptiva which tests BCL6 levels in the uterine lining (aka endometrium).   

 

Let me explain.  About 1 in 6 couples who come to see us have unexplained infertility.  We know some of those women will actually have endometriosis as the cause of their infertility but we cannot diagnosed endometriosis unless we have them do a surgery called laparoscopy.

 

Laparoscopy is a minor surgery during which a woman is put to sleep (at a hospital) and a camera is inserted through her belly button to look inside at the uterus, tubes, ovaries, bowel and bladder.  Scar tissue, unusual anatomy and endometriosis can all be diagnosed, and potentially treated, by laparoscopy.  In Canada, laparoscopy is funded by the health system.  The wait is typically 4-8 months to get this surgery.

 

We can diagnose severe cases of endometriosis by ultrasound. Laparoscopy is needed when you cannot see endometriosis on ultrasound - usually when it is milder.

 

It would be really great if we could diagnose milder endometriosis without putting women through the wait for and risk of laparoscopy.  We do know that the endometrium in women with endometriosis is different from those who don’t have endometriosis.  Exactly how it differs has been defined, and one main difference is in levels of BCL6. Women with endometriosis have abnormally high levels of BCL6 in their endometrium.

 

This newly available test, called Receptiva, involves taking a sample of the endometrium and sending it to a lab in the USA.  That lab them reports back the BCL6 levels.

 

If you have unexplained infertility and the level is normal - you likely do not have endometriosis (< 10% chance).

 

If you have unexplained infertility and the level is high - you likely do have endometriosis.

 

Those people who do IVF with endometriosis benefit from suppressing their endometriosis prior to an embryo transfer. This suppression typically takes 2 months. So, for example, if you have unexplained infertility, you do IVF and get embryos. Then you do Receptiva (and often an ERA test which is explained in a different blog).  If the Receptiva shows high BCL6 you would be suppressed with medication for 2 months prior to a frozen embryo transfer into your uterus.  If your BCL6 levels are normal then you would not be suppressed for two months and just go right into a frozen embryo transfer.

 

Lots of questions still remain about optimal suppression medication protocols, whether those with unexplained implantation failure (multiple failed IVF embryo transfer, even if their infertility wasn’t “unexplained”) would benefit, etc.

 

It is a lot to put women through these biopsies - they hurt, they take time and they cost money - so we need to really think hard about who would benefit and research this as we go along.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

pubic hair

When I was thinking about applying to medical school I met with a family friend who was a physician and asked her for advice.  She only had one piece to give me: read everything.  She went on to encourage me to read constantly and read from a variety of sources.  Great advice.

 

One way I make it easier for myself to read is by using an app called READ Qx (on the advice of Dr. Jason Hitkari).  It’s an app that searches (reputable) journals and finds papers relevant to my topic list.   Almost daily I get a new list of papers to browse.  I read 1-2 of them and get a science-y, gynaecology-infertility “fix.”

 

Today, while on vacation, a paper popped up on pubic hair grooming.  Now, normally I would swipe past this but who doesn’t want a fluffy read on vacation?

 

When I see a patient for the first time in consultation (and many other times afterwards) I will examine them by transvaginal ultrasound.  We give people a heads up about the vaginal ultrasound in our welcome email, but I appreciate that some people will not read every line of the email, so it comes as a surprise to about 30% of women.

 

At the vaginal ultrasound, and at other times when women are undressed for an examination (e.g. hysteroscopy, endometrial biopsy, egg retrieval), women often lead with an apology for their leg hair or pubic hair or some other part of their body, like:

 

  • Oh I didn’t know so I haven’t prepared
  • I’m on menstrual cycle day X, is that ok?
  • I’m going for waxing later this week
  • Oh God this is going to be mortifying

 

Let me reassure you there is no gynaecologist I know who cares about any non-medical part of your appearance, that cares about the status of your hygiene or even if you are having your period for an ultrasound.  It does not matter.   We are examining you to try and find a way to help you - to look for disease.

 

Please let this reassure you.

 

Now, in the paper I just read on pubic hair grooming: about 80% of women do some kind of grooming and 40% will groom specifically before seeing a gynaecologist.  White women, and college/university educated women were more likely to groom than others.

 

It should be noted that pubic hair grooming can be a health concern as waxing can open pores/cuts in the skin increasing the risk of transmission of herpes and HPV.  Laser hair removal in the genital region can cause chronic vulvar irritation.  In my opinion it is low risk, though, to groom your pubic hair but please remember - you are doing it for yourself, not your gynaecologist or infertility specialist.  We do not care!  Come as you are.

 

I’m going to keep reading. I promise the next papers will relate to fertility.  Haha

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

plans for 2020

We survived 2019.  For that we get to celebrate all that was gained this year.  For hundreds of our patients that means a pregnancy.  For others at different stages in their fertility journey, they gained a realization that they need help getting pregnant, or they gained an understanding of why they are not getting pregnant, or they gained knowledge as to what steps they are going to take in 2020 to get pregnant.

 

Whatever happened in 2019 I hope there was growth, knowledge or some new understanding that empowers you for 2020.

 

One thing I realized about myself this year is that this is who I am. There is not going to be some new, better version of myself that will emerge.

 

I often think to myself that I will one day take more time to exercise and then I will be really fit and be amazed by my body in the mirror.  I think that one day I will have all my photos organized into photo books.  I imagine a time when I always have nice nails and good hair every day.  I think there will be a time when my email inbox is all caught up.  I think there will be a time when I will listen to all my father’s stories so I will have a real understanding of our family’s origin story.

 

Since I am now 46 and none of those things have happened, I don’t think they will unless I consciously make them happen.  Given that I have not made any gestures mentally or physically to bring about these goals, they must be low enough on my priority list that they will likely never happen.

 

So I guess this is me: out of shape with craggy nails and a full inbox.  This is me with 40,000 photos I won’t ever organize and only a limited knowledge of my family history.   I have to believe I am still a good enough version of myself to have value.  A dramatically better version of myself is probably not going to emerge.

 

I suspect I am not alone in my struggle to be content as I am. I don’t know many women who do not want to lose 10lbs, work less, and take more time for friendships.  If women stopped wanting these things and were completely content, the beauty industry would collapse and half of the grocery store magazines would go unsold.

 

A little better version can emerge though and that’s what I’ll work on for 2020. A little more exercise, a little more time on my appearance, a little more time culling my inbox and a few more conversations with my dad.

 

So, whatever you realized this year I hope you find contentment and even optimism for the small changes you can make in 2020.

 

And, if some of your goals relate to fertility I hope we can help.   Let’s make 2020 the year we are all a little better and achieve our goals.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

apps

As I approach “the change of life” as my mom would call it, I thought I’d start tracking my periods.  I started a few months ago and I have to say its creepy and disappointing when your phone tells you “today it day one.” I’m also pretty sure my phone will start to use this data to send me ads for tampons or anger management classes the week before my period is expected.

 

Period tracking has been done for a very long time, mostly for women to predict when their period might come, assess their menstrual/hormonal health and get a sense of ovulation timing when trying to conceive.

 

When I first started practice many women would bring in notebooks with period dates written in columns, or a paper day-timer calendar with a red star marking each day of menstrual bleeding.  Nowadays, women show me their phone with the app open to a sophisticated data sheet.

 

Apps like Flo, Glow, Ovia, Period Tracker, and such are usually free and let you log the days of menstrual flow, amount of flow, timing of intercourse, and make comments on cervical mucous.  They all try to tell you when you are ovulating so as to guide when to have intercourse, if you are trying to conceive.

 

I ask my patients about their periods and if they have done any tests for ovulation (e.g. urine LH test strips, luteal phase progesterone level, basal body temperature).  I’ve noticed that the answer is often “yes I am ovulating… the app tells me.” I want to clarify that apps do not tell you if you are ovulating or not.  Apps make the assumption that women ovulate 13 or 14 days prior to their period.  So, when you enter your period the app subtracts 13-14 calendar days and says that’s when you ovulated.  It then predicts, from the menstrual pattern you enter over a few cycles, which day ovulation is occurring.   It really does not know for sure if you are ovulating. To know this you would need to:  have a positive LH surge in your uterine, an elevated luteal phase progesterone level in your blood or a basal body temperature that rises 1-2 days after ovulation.

 

Now, most women who have a period every 25-33 days ARE ovulating at the time the app predicts.  If your periods are less than 25 days or more than 33 days it’s quite possible you are not ovulating even though the app says you are.

 

I suspect most women already know this, but my public service announcement for tonight is to do some other thing beside using an app to confirm ovulation, especially if your period timing is outside the 25-33 day range.

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility