Today, while I was tidying up our bedroom, my 20 month old reached into a bathroom drawer and pulled out a bag my mom keeps at our house filled with essential toiletries. My parents (and in-laws) live across the country, but my mom used to (pre-COVID) visit frequently. To avoid buying new toiletries whenever she arrived, we started keeping a bag for her so that it would always be ready for the next trip.

My heart was heavy when I saw that bag. Who knows when the next trip will be? We canceled our trip last month as well as the upcoming one in July. She canceled her trip in June. The big unknown is August. Will she come out for this baby’s birth? She has been such an integral part of each child’s early days that I have no idea how we will handle it alone. And if school doesn’t open in the fall, how will we handle a newborn and a 2 year old while homeschooling a preschooler and kindergartener?

There are so many things to worry about. If she travels, are we putting her at risk for getting COVID? Would she need to quarantine for two weeks upon arrival? Would she be stuck here for the second surge of this pandemic? What if my father gets sick and she is unable to be there right away (and would she need to quarantine upon arrival)? Is she at higher risk of getting COVID around my kids than she would be at home?

Of course I want her to be here, but I also feel that it would be a selfish request. We’ll talk more about it as the date draws closer, but I’m going to prepare for the newborn days without her.

This pandemic has highlighted the distance between us. My husband and I have lived away from our families throughout the entirety of our 13 year relationship. We moved to California a decade ago. There have been times when it felt farther than others, but we always knew we were a (relatively) short flight away from home and our families. COVID-19 has changed everything. Flying feels so risky and it seems silly to endeavor it when we are so carefully sheltering in place in every other respect. I don’t see this changing any time soon, and the prediction is that this is going to last months to years. My hope is that our families stay healthy during this time, but I also recognize that we don’t have limitless years left with our parents and it is such a shame to missing out on time when they are well and able to enjoy their grandchildren.

So much to be sad about during this unprecedented time. For now, I’m going to keep my mom’s toiletry bag tucked in the bathroom drawer, hoping that her next trip is not too far away.

Pandemic Pregnancy

When I became pregnant, COVID-19 wasn’t even a thing. It was mid-December and I don’t recall hearing anything about what was happening in Wuhan until January at the earliest. So it was probably a thing, and there were cases, but the thought of closed schools, clinical work on hold and shelter-in-place were not on my radar. I was honestly mostly focused on the application process for private school for my two oldest kids. They were (and I recognize how ridiculous this sounds) applying for entry to pre-K and K, and my biggest worry was where they would be going to school the following year. Now I’m doubtful that they will even get to attend said school in person, but that’s a topic for another day.

On February 25th I screened positive for Trisomy 21 and perseverated over that for a week until my normal cell-free DNA results.

We slowly began to take precautions at work to screen for COVID-19. It began with questioning patients prior to their visit to see whether they had recently traveled from Wuhan (this eventually expanded to all of China, and as everyone knows that question soon became obsolete). We also asked about cough and fever. Carts with PPE were positioned outside of these patient rooms.

I developed a cough on March 6th, which was terribly awkward to have while everyone was on high alert regarding COVID (for the records, I have had a negative COVID-19 PCR and also negative IgG and IgM antibodies). One of my patients even sent me a personal note saying that he was worried about me because I had been coughing (I wore a mask in every patient room during this time) and seemed short of breath. I had to, with some embarrassment, tell him that I was short of breath due to climbing 3 sets of stairs while pregnant. Fortunately he was a patient I knew quite well.

I had an ob appointment March 10th and my ob was pretty close to 0% concerned about COVID. She told me the reports out of China were reassuring. Pregnant women seemed to fare well and there were no cases of vertical transmission. She also told me to drink a glass of wine, which was interesting because she usually errs on the conservative side (also for the record, I did not drink a glass of wine).

My close colleagues, however, were more concerned and ended up encouraging me to drop one of my higher-risk duties – seeing patients in the hospital. I stopped doing that the week of March 2nd. The week of March 9th I made a huge pivot in my career and left one of the clinics I had worked at for 6 years. Too many things weren’t working out. I was losing staff, knew I wouldn’t have any when I returned from maternity leave again (it was a drawn-out nightmare the last time) and was so exhausted from pregnancy and turning 37 that I knew it was finally time to call it quits.

March was a month of major upheaval. Our world paused in March – with school canceled starting March 12th (initially only for two weeks but that eventually progressed to no school for the rest of the school year) and shelter-in-place coming 5 days later. Everything was being canceled. It was such a crazy time.

We largely stopped seeing patients in person, with my last real clinic held on March 16th. Everything has been virtual since. To be honest, it’s been challenging. Some conditions in dermatology are easy to treat virtually (acne, for example). Other things, like checking over someone’s skin to look for skin cancer, are impossible. I have been seeing 1-2 patients a week for skin biopsy and evaluation of more serious rashes, but always wearing ample PPE (I have my own that I cycle through). We have just started talking about opening up clinic more robustly, and I am concerned about the plan (or lack thereof). It doesn’t sound like anything is changing, other than spacing out clinics and appointments to encourage social distancing. Of course, we are asked to wear PPE, although it is unclear whether this is readily available.

Normally, I wouldn’t be too concerned. But last week, at my follow-up ob visit, my doctor was suddenly very concerned. She told me there had been new reports of COVID-19 found in placentas, IgM antibodies in newborns, vertical transmission (from mom to body), second trimester miscarriages, stillbirths and premature births. The numbers of reports were small, but there was definitely more alarm. Moms are tested at the time of delivery at our hospital and COVID-19+ moms are recommended to separate from their newborns. Having had three kids, I can’t imagine how heartbreaking that would be.

In sum, I’m starting to worry about ramping up capacity to see more patients. I’m not reassured by the plan currently in place and now I’m much more anxious about doctoring while pregnant. At the same time, I feel a bit silly, because I don’t work in an emergency room or ICU, and certainly don’t do any high-risk procedures (any biopsies I do near the face are usually relatively quick and nothing compared to an intubation). I also feel a strong obligation to my patients. I know how scary it can be to have a spot that you are worried could be a skin cancer, or a rash that keeps spreading. Our patients have been so wonderful these past few weeks, understanding that we are taking every precaution to keep them safe, but I certainly don’t want anyone waiting months to be seen. Since I am taking maternity leave, I would be gone until early 2021. Finally, I care deeply about my colleagues. Although they might not be pregnant, they could have co-morbidities or take medications that make them immunosuppressed, live with elderly parents or in-laws or immunosuppressed children and spouses. I don’t want to burden anyone else with having to see my patients because it seems to imply that my pregnancy is more important than their personal circumstances.

It’s an uncertain time for all and I don’t envy our management who has to make some tough decisions moving forward. For now, I’ve reached out to my ob to see if she can give me some clarity on making a decision. If need be, I’ll reach out to my colleagues to see how to best mitigate risk. I’m taking leave at 35 weeks so essentially only 13 more weeks to go. Hoping those 13 weeks are as smooth and uneventful as possible!

Parenting after infertility

Tuesday was my anatomy scan for my fourth child. (I know this doesn’t sound like a typical infertility post, but bear with me.) I was a nervous mess. My husband came with me but wasn’t allowed into the room because of COVID precautions. My ultrasound tech was a woman of few words, who mostly complained about having to wear her surgical mask all day (another COVID precaution).

Some women announce their pregnancies the second they know about them, with elaborate pregnancy announcements and social media posts. I’m in the other group – moms who worry every step of the way. It’s exhausting. As soon as I find out I’m pregnant I worry that I will miscarry in the first trimester (for the record: I have never had a miscarriage). I hold my breath at every ultrasound until the doctor finds the heartbeat. I worry about the results of my nuchal translucency/first trimester screen (perhaps for good reason: I have tested positive – false positive – for Trisomy 21 twice now). I hold my breath waiting for the cell-free DNA results (normal 3 of the 3 times I have had to take this test). The anatomy scan is the worst, because by 20 weeks I tend to look pretty pregnant so people know, and how would I break the news to everyone that the baby had some terrible congenital abnormality that was incompatible with life? It sounds ridiculous as I am typing this out, but this is the world inside my head. When I was pregnant with my first, I refused to wash any of the clothing we had purchased for him until late in the third trimester. I couldn’t imaging folding it all up and putting it away if something terrible happened. With each pregnancy, I have worried about the baby not moving enough. With my first I vividly recall drinking orange juice at night and jostling my belly around to get him moving. Perhaps that is why he was born a night owl! Just today I took a 5 minute break to lay on my side in bed because I hadn’t felt this baby move in some time. Last year, my best friend lost a baby at 31 weeks. It was every mom’s worst nightmare. My heart aches for her, thinking of how she waited for labor to start days after she had learned that her baby was not okay, and ultimately delivered a stillborn baby. I flew out to see her right after the birth and there were no words to remedy how unfair and cruel the world can be.

My struggles have been minimal by comparison. I had hypothalamic amenorrhea and stopped getting my period for a decade. When I got married and decided to have kids, it (surprise!) did not suddenly make an appearance. In retrospect, I can summarize the story like this: I had hypothalamic amenorrhea and started eating more, gaining weight, and working out much less in order to promote natural fertility. I eventually got pregnant with minimal assistance from a fertility clinic. My subsequent pregnancies occurred without any intervention. However, the period from May 2012 to March 2014 was so more stressful than that paragraph reflects. I had no idea why I wasn’t able to get pregnant. I knew hypothalamic amenorrhea was playing a role but what if (a) it was irreversible and (b) there was something else? What if I would never be a mom? What if I had messed up my body so much that I would never carry a baby?

Once you have had any degree of infertility, you never take being a parent for granted. My first wouldn’t sleep. He had a strong startle reflex and broke through every swaddle combination we tried. He would cry all day and night unless we held him. I remember being exhausted to the bone, crying on the phone to my friend, telling her how guilty I felt for not savoring every waking moment after everything I had been through to have him. This has been my thought process on repeat for every child and for every step of the way. Every decision I have made for them has been fueled by the knowledge that their lives may not have been if things had worked out differently.

I know how fortunate I am to have these children. Once you are pregnant with your fourth (and to some degree your third), people start commenting on your reproductive decisions. “Isn’t the world populated enough?”, “Yeah, probably not a good idea”, “Why would you have another child?”. Quite frankly, it’s rude. In the same way I was hurt and offended when I couldn’t get pregnant and people asked me when I was planning to have a baby, I am hurt and offended by these comments. I don’t push back though – I’m never going to convince people who say those words out loud to consider another viewpoint. I know how much my children mean to me and my husband, and that’s all that matters. Although I would have preferred not to have gone through those years of infertility, I am grateful that they provided me with this perspective.

No more cornflakes

Today is Day 38 of no school for my kids and Day 33 of shelter-in-place. It’s 1:48am and I am up again. We’ve been battling bedtime with one of my kids for what seems like an eternity (a year perhaps?). With the extra time at home, less need to be at work first thing in the morning, and generally more exhaustion, I have started falling asleep on the floor of his room (his preferred sleeping arrangement) more often than I would like to admit. After sleeping a good 3-4 hours, I find it tough to seamlessly transition to my own bed. Thus why I am up right now – writing for the first time in ages.

The past few weeks have been an adjustment, to say the least. Before I go into details, I first have to say that we have been very fortunate. My husband and I are still employed and no one we know or love has been ill with COVID-19, despite much of our family living in New York and New Jersey.  I work at a hospital but my department has made patient, faculty and staff safety a priority, and this has helped to relieve a lot of exposure anxiety. I am also 19 weeks pregnant and my colleagues immediately volunteered to take over some of my riskier patient care responsibilities, as the evidence regarding COVID-19 and pregnancy continues to evolve (fortunately, it has been mostly reassuring, but we are learning more each day).

We are very blessed and acutely aware of this, but also affected by the monumental change that occurred in our lives these past few weeks as well as the uncertainty regarding the future. What began as a two-week hiatus from school after there was a confirmed positive in the larger school community was gradually extended, until they just recently announced that school would be out until the fall. Summer camps have started to cancel. There is talk of the 2020-2021 school year looking dramatically different.

I do feel fortunate that my children are young (1, 3 and 5). Mostly they have reacted to the news with glee. For them, it is an extended vacation and their parents are home all day on most days (I am currently going into the office one day a week for essential procedures). They say they do not miss school or their friends. We live in a warm climate where they can go outside each day – even if it is only in our backyard or a short trip around the neighborhood. But I do worry about the change in structure. This week in particular was tough became it came with some change in behavior. My 1 year old is undergoing a sleep regression – often crying before bed, waking up in the middle of the night (he woke up as I was typing this), and a few mornings waking up before 5am. My 3 year old finds his way into our bed more often than not (perhaps related to my falling asleep on his floor most nights?). My 5 year old, who is generally very well-behaved, started to act out this week. Small things, for sure, but they pile up quickly when my husband and I are home all day, trying to fit work into any snippets of time we can find, and generally exhausted/operating on fumes. Parenting 3 kids 5 and under while both working full-time was hard at baseline and then COVID happened and it seemed almost impossible. (But I remind myself daily that at the height of my struggle with infertility I would have prayed for this conundrum. No matter how many kids I’ve had, there is no way to forget that burning desire for motherhood, the disappointment that came with every negative pregnancy test, and the fear of it never coming to fruition.)

And yet. Today was a hard day (also a hard night, it seems, with 2/3 of the kids already up 2 times each) and I started thinking about one of my favorite books from childhood – No More Cornflakes by Polly Horvath. I had forgotten the general plot and had a good chuckle when I read the Amazon synopsis: “Hortense seeks the advice and friendship of her eccentric Aunt Kate when her mother spends her days eating cornflakes and hopping around in public, pretending to be a rabbit”. It is about a girl growing up in a changing household – her mother is pregnant (and apparently losing her mind?  I should go back and read this now that I am an adult), her older sister is out more/becoming more independent, and she finds solace in a deepening relationship with her quirky aunt. The one thing I vividly recall, even decades later, is her aunt’s advice to find an “oasis”, a small ritual you have for yourself each day – one that is yours and only yours, one that brings joy always.

I love this concept even more now. As our world has become smaller – confined largely to the walls of our home – as our social interactions have become non-existent, as our opportunities for experiences, vacations, etc., have dissipated before our eyes, how do we find solace in our day? What can we do to bring a sense of peace, calm and fortitude into our lives? I’ll be thinking about this deeply in the next few days, as we continue to refine our daily schedules, to bring small rays of sunshine into our lives.

For now, I am trying to focus on the positives. I have had the opportunity to experience staying at home with my children (I went back to work with all 3 when they were ~4 months old). They have had the opportunity to experience a different childhood (I sometimes joke that it is my childhood) – one without planned activities, playdates, structure. We, as parents, are working on encouraging more creativity and independent play. We are trying to find small pockets of time for ourselves while the kids are awake, so that we don’t have to cling so desperately to the post-bedtime hours. My 1 year old’s language has taken off exponentially now that his brothers are home full-time. My 3 year old rode his bike for the first time today without training wheels. My 5 year old has been reading on his own and doing math. We are eating at home every night (we always ate together, but did often eat out) and I am so incredibly fortunate that my husband cooks for us every day. We are finding the time to complete random items on our to-do list that always fell to the bottom of our busy days.

One day, as long as everyone stays healthy and safe, we may look back on this time with some degree of fondness. I wonder if it is the closest we will ever be as a family. Soon, if we are still sheltering in place and socially isolating when this fourth baby arrives, we will be even closer!

Bad news

This month has been hectic. It started with a lovely get-away (without kids!) for my husband and I. It was lovely. We were away for a week and were able to sleep 10-12 hours per day, finish both our conversations and our meals, lounge leisurely by the pool (under an umbrella, of course), walk along the beach, read, and simply be.

As always, I returned home with a desire to incorporate some of that into my daily life: taking a few minutes per day to just be together, reading more for fun, enjoying leisurely meals, exercising. Except we came home to a 1 year old and a 3 year old and two full-time jobs so none of the above happened.

It’s also a busy time. I’ve been taking advantage of my second-trimester energy to complete a few projects, including submitting plans for a minor home renovation. I’ve also had a pesky cough since our time away and though it would go away but it didn’t, and the coughing would often rob me of my energy and cause me to feel even more tired than usual. To top things off, my oldest came down with hand foot mouth disease (HFMD) and was home the entire week prior to a flight I was taking solo with both kids. He was in pain and cranky the entire week (apologies to all of the moms I counseled on HFMD by saying it was merely viral and would blow over) and, the worst part of all was that he wouldn’t sleep through the night! So the first few nights my husband and I stayed up with him. And then my youngest got a fever (but fortunately did not erupt into HFMD) and then HE wouldn’t sleep through the night.

So I set off with both kids in recovery ALONE on a 6 hour flight and it was by far the worst flight we’ve ever had. My kids have traveled a lot because even though we don’t live close to family, I think it’s so important for them to spend time with them. They are usually shockingly well-behaved. I come prepared, keep them entertained, and they generally keep their crying and tantrums to a minimum. But last week was a different story. Both kids were on the mend, I felt like crap from a combination of not sleeping as well as fighting off this cough (oh and being pregnant), and they wouldn’t nap! So we kept things pretty together until the last 30-45 minutes. And then when the plane landed, all hell broke loose. Both kids wanted to be carried but I only had two hands and had to carry the carry-on bags (we only had travel backpacks with us but it was a lot to juggle!). Then my oldest started throwing a tantrum about everything – he didn’t want to let me into the aisle to organize our bags, he didn’t want his brother to sit by the window, and on and on and on. Meanwhile, I’m frantically trying to organize everything while his little monkey of a brother is climbing over the seats. My oldest won’t move from his spot so I tell him “I’m going to pick you up and sit you down here so that I can grab everything” and do just that. He loses his **** and starts yelling “Mommy you HURT ME!”. Meanwhile, I’m dying.  As calmly as possible, I tell him it’s time to get off of the plane. A very nice lady helps with one of our bags, I carry my youngest off the plane, and my oldest begrudgingly drags his bag and follows behind, complaining all the way.

At the gate, I have to find and unfold our stroller, which was a waste of effort because neither kid will sit in it (but at least I can pile some bags on it). The oldest is crying and blocking people as they walk off of the plane while the youngest just wants to be held. I hightail it out of there with the oldest hitting me on my backpack and throwing the world’s greatest tantrum. We are the last people off the plane and the pilots are begrudgingly walking behind us because (I learned on another trip) they can’t leave anyone behind when they leave the plane. Awesome. And then, to top it all off, I have to walk approximately 20 minutes with one kid in my arms and one kid whining the whole way because we have landed at a huge airport, at possibly the furthest airline!

It was a total disaster. I saw my parents at the exit, handed the kids off to them, and then walked off to baggage claim to burst into tears. I could tell the security guard knew I was going to lose it because he let my parents follow me to the baggage claim to help out with the bags.

Until yesterday, I thought that was the worst thing that had happened. Then, my ob called me. Before I left, I had a few third trimester labs drawn. Apparently, one of those labs was toxoplasmosis. I had already had this checked in January (at 7 weeks) and both IgM and IgG were negative. For some reason, my ob rechecked it. She admitted that this was controversial – that many people don’t recommend rechecking due to low likelihood of infection in our area and false positives. But then she told me that I had a new positive (IgM, with IgG still negative). She wasn’t sure what to make of it. She had spoken to the high-risk obstetrics group at my hospital and they would follow up with me and likely have me return for an ultrasound, as well as labs, maybe an antibiotic, etc. She told me not to freak out so I promptly did just that – freaked out.

Toxoplasmosis!? That’s one of the terrible infections we learn about in medical school that can cause a slew of problems in newborns. WTF!? But I don’t own any cats…and I’m a vegetarian! I couldn’t believe it. I did what I always tell my patients not to do – turned to Dr. Google, and PubMed, and every person I know who is an obstetrician or infectious disease expert. I received a slew of responses: it’s probably nothing/a false positive, you definitely should not ignore this, you need serial ultrasound monitoring, they need to test the baby, there’s nothing you can do anyway because you’re 24 weeks along.

I’m also a bit annoyed at my ob. Why did she check it if it’s controversial? Her exact words were “I’ll probably change my practice after this”. And I am not entirely sure she knows exactly what to do at this time. She referred me to the high-risk ob, and that person called me, but I’m traveling and can’t be seen tomorrow, and she’s going to be out of town next week. The ID expert I spoke with told me to get labs ASAP, but the ob told me it wasn’t time-sensitive. Her exactly words were “I’m going to be blunt with you because you’re a doctor: if this is a true infection, there’s not much you can do at 24 weeks”. But shouldn’t it matter if it’s a true infection?

So I’m just waiting here, anticipating the worst. And it’s made me realize that I’m done having kids. I always thought I wanted a fourth, but pregnancy is too tenuous and stressful. I think about the experiences I’ve had with my kids – my pre-eclampsia scare with my first and him being in the NICU after birth (the briefest NICU stay ever, but seemed like the longest to me), my positive first-trimester screen with my second and having to see genetics for additional screening to rule out a chromosomal abnormality, and now this with my third. I pray that he will be healthy. That this is either a huge misunderstanding (false positive) or that he does not catch this infection. I’ll have an ultrasound in one week and hopefully will have some additional information at that time – and hopefully it’s all good news.

Updates from the 1st trimester

I’ve been thinking of all of the things I want to remember from this first trimester. With my first pregnancy, I journaled all the time. With my second, I journaled less. This time around I forgot the password to access my (very sophisticated) Word doc journal and haven’t written anything since before becoming pregnant.

So first I’ll start with early pregnancy symptoms. I hate early pregnancy symptoms because they can literally be anything, so when you’re trying to get pregnant every little twinge becomes a reason to obsess over whether you could be pregnant.

I honestly didn’t feel any different than I have during my last few cycles. A bit of back pain a few days prior, but I’m pretty sure that’s more related to my 40 lb 3 year old and 25+ lb 1.5 year old. We flew for the holidays and I felt incredibly nauseous on the descent, but didn’t think much of it as I had experienced nausea with some prior cycles. What really tipped me off was this: no hormonal acne. Around the time of my menstrual cycle, I develop a few cystic acne lesions. I had zero by day 30 and this definitely piqued my interest. When I went to bed that night, I thought I felt something developing on my chin, but it was gone by the next morning. And that was it-I took a pregnancy test the next time.

During these first few weeks, I’ve felt:

-general stomach uneasiness

-nausea, usually worse in the early evening

-cravings for: carbs, juice (orange and mango), pineapple

-no desire to drink coffee (usually a staple of my diet) and no real desire to eat chocolate (another staple of my diet)

-intense moodiness

-incredible fatigue

I’ve also felt great worry, which is a staple of my pregnancies. I honestly wish women didn’t start showing until ~week 20, after the anatomy scan. With this pregnancy, I am showing EARLY. A handful of people know for a number of pragmatic reasons, and this makes me even more nervous! With my first, we didn’t even tell my family until I was almost 12 weeks pregnant. I didn’t notify my new employer until I was 14 weeks pregnant, and my colleagues at the time didn’t know until almost 16-18 weeks! With my second, I didn’t say anything until honestly around 20 weeks+ (although our families knew right away). I was negotiating a new contract at the time and didn’t want my pregnancy throwing a wrench into the plans.

I had one bit of good news at 7 weeks: baby had a heartbeat. But this is only minimally reassuring. The miscarriage rate on a population level is still 5%, and I’m sure we all know people who returned for their second check-up to find that the baby’s heartbeat was gone. So I am trying to stay sane until my 11 week appointment. And the week after I have my nuchal translucency/first trimester screen and my appointment with a genetic counselor (I’ll be 35 when this baby is born so I’m adding Harmony/Panorama/non-invasive prenatal screening test onto my routine prenatal testing). I think if I can get past the next 2 weeks (which are also riddled with work deadlines), I’ll be able to breathe a little more easily. Although then I’ll have the anatomy scan hanging over my head.

Well, I feel fortunate to be pregnant for now, and will try to keep my anxiety in check while I count down the days! The crazy thing is that in just 2 weeks I’ll be done with my first trimester, and then there are only two to go!

The first trimester

The first trimester sucks. Of all 3 trimesters, it is by far the worst (for me at least). First of all, I always feel like crap. Nauseous, tired, cranky. During my first pregnancy, I would come from work, crash on the couch, and binge on Scandal until I passed out at 9pm. Now I have two kids under 4, so I can’t just lay on the couch watching TV.

Second of all, it is fraught with worry. Once a positive pregnancy test erases the worry of “will I ever get pregnant?”, I start worrying about whether this pregnancy will stick. So there’s the worry up until the first ob appointment (will there be a heartbeat?), the worry at every subsequent appointment (is there still a heartbeat?), the first trimester screen, and on and on and on.

To top it all off, you can’t even explain to your family, friends, colleagues, etc., why you have a short fuse. They just assume you’ve turned into a bitch. And then there’s the awkward turning-down-drinks component, when everyone is dying to ask you whether you’re pregnant but of course they don’t want to because you don’t quite look pregnant, do you?

My husband took the boys out for a bit so I could finally sit down and rest today (kids woke up at 5:30a this morning and it’s 4:00p). We are both wiped, but he’s taking one for the team, and that’s why I love him.

So I’ll go back to reclining horizontally on the couch, reading my book, and trying not to worry about this trimester.

The two week wait

For people who are trying to become pregnant, the two week wait is the worst of times. Here’s how it works: there are generally 2 weeks between ovulation and the time when you may be able to find out that you are pregnant. This translates into roughly 14 days that you can obsess about being pregnant/not being pregnant and swing from disappointment to elation to hope to relief.  The pendulum can swing either way and you have no control over it and you can’t force time to pass any more quickly than it is already moving.

With my first, for whom we underwent fertility treatment, I experienced a great number of disappointing two week waits. I am not a patient person, and I spent hours Google-ing any and all symptoms to see whether they could “correlate” with pregnancy. Slight abdominal twinge? Metallic taste in mouth? More sleepy than usual? Hair slightly curlier? Seriously – there was no such thing as low-hanging fruit. I can’t even tell you how much money I spent on ovulation strips and pregnancy tests! Sometime in March of 2014, a week and change after I ovulated, I experienced terrible cramps and was certain that I was out for that cycle (my fifth of oral ovulation induction). Then, a few days later – a positive urine home pregnancy test! Finally! It was the best of times.

With my second, I wasn’t sure when I ovulated (not a medicated cycle), so I took a slew of pregnancy tests around the 28-30 day mark until I was sure that I was not pregnant. However, because I was still late, I took another test a week later and, lo and behold, it was positive.

I am ruminating on this because we’d like to have a third. The situation is different now: with my first, I didn’t know if we would ever be able to have a child, so each two week wait was a truly emotional rollercoaster (would I ever be a mother? what was wrong with me?). With my second, it was more of a surprise (although not unintended). There was less stress and more joy. Now, I am torn between wanting to BE pregnant/closing this chapter of my life, and sticking with the familiar – two kids under three, a known chaos.

Acupuncture for infertility

When I was trying to get pregnant with my first, I turned to acupuncture. I should clarify that I turned to acupuncture in addition to (most importantly) seeing a fertility specialist (a doctor). I also: purchased and wore a fertility bracelet (how can it not be legit if it’s featured on Real Housewives of NJ!?), signed up for a yoga for fertility course, read countless books about infertility, and tried to meditate. In sum, I desperately wanted to get pregnant.

Although stressful at the time, I now have very fond memories of my acupuncturist. She was very close to my (then) home in southern California, close to downtown. She burned herbs during the treatment session so I always left smelling like I had just smoked weed. Once the acupuncture needles were in place, she lay some of the herbs on the acupuncture needles and burned them (or something of the sort). I don’t quite know because my eyes were closed the entire time, as I was trying to both meditate/unwind while also trying not to freak out about the needles.

I got pregnant after one such session. It was a Thursday in February and we had just finished our in-service exam (a test all dermatology residents across the US have to take to prepare for the actual boards). I fit in an acupuncture session before flying up to northern California, where my husband lived. I was pretty sure I was going to ovulate because the ovulation stick had shown a solid smiley face, which is different, apparently, than a blinking smiley face.

I parked my car in the downtown area, where they happen to have a farmer’s market on Thursday evenings. I completed my acupuncture session only to find that my car had been thisclose to getting towed. That would have put a real damper on the conception plans. In any case, to make a long story short: I made it to NorCal and our baby was conceived that night. When I am feeling particularly dramatic, I’ll say to my husband: “I got pregnant thanks to acupuncture” or “I got pregnant thanks to my fertility bracelet”, to which he’ll reply “I’m pretty sure you got pregnant thanks to medicine – aren’t you a doctor?” This is when I’m most proud of him, because I did get pregnant because of medicine, although I’m sure everything else helped a little bit.

My experience with hypothalamic amenorrhea

I started reading blogs when I began to suspect that I had hypothalamic amenorrhea (HA), so it is only fitting that one of my first posts should touch on the subject.

First, some background for readers who are not familiar with HA. Amenorrhea is the absence of menses. It can be divided into primary (a person never menstruates) or secondary (a person who previously menstruated stops menstruating). Secondary amenorrhea can develop when any of the structures involved in the menstrual cycle (hypothalamus, pituitary, ovary, or uterus) are affected. Hypothalamic amenorrhea with no pathologic basis can be triggered by nutritional deficiencies (including eating disorders), excessive exercise, and/or stress.

I developed hypothalamic amenorrhea because I ate too little and exercised too much. For many years, I focused excessively on what I ate and how much I exercised. I counted calories, drafted lists of my daily intake, and worked out 5-7 days a week. Not for a week, not for a month, but for YEARS. Approximately 10 years to be exact. I stopped menstruating 1.5-2 years into this routine, which means that for 8-8.5 years I did nothing to reverse it. I am not proud of that.

It is important for me to back up a bit and detail how this came to be, as it was never my intent to sabotage my fertility. My initial goals of eating clean and exercising regularly were borne out of a genuine desire to be “healthy”. I was a freshman in college and not feeling particularly great about many things – where I fit in socially, the freshman 15, my utter lack of exercise, being away from home, and my future career aspirations. So I tackled what I could: eating better, exercising more, and focusing on my pre-medical training. At first, it was wonderful! I started eating better, hitting the gym daily, sleeping more, waking up early, performing better academically, and feeling good about myself. But true to form, I didn’t stop at good. 5 pounds became 10, 15, 20, 25…I ultimately lost 60 pounds over the course of one year.

The thing is, I didn’t have 60 pounds to lose. I also became incredibly anxious about gaining the weight back. So when I stopped menstruating, my response was not “Hmm…I should ease up on exercise and gain some weight.” I was terrified to gain weight, and indeed gained only enough weight to shift the focus one iota from my excessive loss. And for the next nine years, that weight became my “norm”. As I distanced myself from college, everyone I met assumed that I had always been so slim. This made it harder and harder to gain weight.

I knew that my lack of menstrual cycle was a sign that something was wrong, but I didn’t want to dwell on that. I ignored the worry when we learned about the female athlete triad in college, when the nurse I saw at the student health center ordered a bone density test based on my low BMI, when my gynecologist checked labs and confirmed what I already suspected: I wasn’t ovulating. It gnawed at me, but I ignored it because I was 19 years old and the only thing I knew about pregnancy at the time was that I didn’t want it. What I did want was to continue fitting into a size zero.

Here’s the deal: if you don’t fuel your body correctly and if you then ask your poorly fueled body to draw from its reserves to exercise, it may shut down your reproductive system. And that’s exactly what happened. I remember my gynecologist recommending birth control pills and then saying that I would possibly need fertility treatments in the future if the amenorrhea persisted. We didn’t discuss my undereating and overexercising (I do not blame this on the gynecologist as I am fairly certain I did everything in my power to downplay how much I was exercising and to normalize my weight) and I went about my merry way, which is to say that I did nothing other than start birth control.

Fast-forward those nine years. I had graduated college, graduated medical school, and was a resident. I had gained a handful of pounds since my lowest weight in college, but my BMI was still low and I ate less than I should for the amount that I exercised. I was getting married and had stopped my birth control pill because I wanted to see whether I would menstruate on my own, since I knew that I wanted to get pregnant shortly after the wedding. To no one’s surprise, I did not get my period.

Four years and two babies later, I can still feel the raw frustration and immense sadness I felt during this time. How was it fair that bone-thin celebrities and acquaintances had managed to conceive without gaining weight? How was it fair that some women in the HA community were able to begin menstruating by only minimally decreasing their exercise and just barely increasing their weight? I fought against the “decrease exercise/increase weight” advice SO hard. I wanted to believe that it was stress (I was a resident after all) and turned to yoga, meditation, breathing exercises. I added “healthy fats” to my diet but only incrementally decreased my exercise. I had maintained my weight loss for nine years and resisted gaining weight, believing that it would negate all of my hard work.

However, my resolve wavered with each month that passed without a period. It was a confusing time and I felt torn between two forces – my long-standing commitment to what I had perceived as healthy (working out, eating “clean”, being thin) and my desire to become a mother. I slowly let the pounds pile on – at first, slowly and with remorse, and later quickly and without hesitation. I would plan my meals and then rebel, knowing that I was still adhering to rules. My main form of exercise at the time was long distance running, so I stopped. I would sign up for races, train irregularly, and then cancel. I joined different gyms and then willed myself to sleep in. I stopped waking up at 5:00 am to work out. The pounds piled on and I finally forced myself to buy new clothes. I donated bags full of clothing that no longer fit: I needed them visually out of my closet and physically out of my life as I didn’t want to be tempted to fit into them again.

During this time, multiple co-workers asked me whether I was pregnant. They were used to my being very thin and health-conscious, so pregnancy was a logical assumption as they observed my weight gain. Their questions were doubly insulting: first, they confirmed that others noticed I was gaining weight (this horrified me) and, second, they forced me to answer “no” when I was dying to answer “yes”, to actually be pregnant. My heart would break every time someone asked me whether we were planning to start a family. I know they meant no harm, but I wish they would have thought twice about prying. To this day, I never ask anyone about their plans to start (or expand) a family and I never ask anyone whether they are pregnant – not even if they are very obviously 9 months pregnant.

At the time, it also felt like everyone I knew was becoming pregnant. I was genuinely thrilled for my friends, family, and acquaintances, but I would also cry whenever I had to attend a baby shower or congratulate yet another person. I am sure that my husband dreaded announcing someone’s pregnancy to me.

During the time that I was struggling to gain weight, rein in my exercise, and feel good in my newly expanded skin, I was referred by a new gynecologist to a fertility clinic. At this point, the diagnosis of hypothalamic amenorrhea had been confirmed by ruling out some other entities via laboratory testing and imaging studies. The first fertility specialist I saw said this: I could stop running and gain weight or I could undergo intrauterine insemination. I agreed with his exercise and weight gain recommendations, but our personalities didn’t jive and I wanted to minimize interventions, so I sought a second opinion from someone else in the same practice.

This fertility specialist was my saving grace. He was a kind, gentle man with a wonderful bedside manner. He had been in the business for years and had an optimistic perspective. He also did not push any interventions. I recall him sitting patiently during our appointments and answering all of my nervous questions. One day, he sat across from me and gently said: “This must be a very difficult experience for you – wanting to become pregnant, living far away from your husband [we lived 8 hours away from one another during my medical training], enduring the stress of residency.” I burst out crying. It felt like he truly understood what I was going through. He also provided a bright glimmer of hope when he told me that I was not infertile but SUBfertile. He believed that I would have a baby and I believed him.

I have noticed a lot of doctor-bashing in the HA world: doctors not understanding the diagnosis of HA, not counseling on weight gain/exercise cessation, pushing interventions to make money, not listening, etc. As a physician in the world of Google Medicine, I wonder whether some of this is unfair. Going through any type of infertility (or sub-fertility, as it may be) is an inherently emotional process that can taint our perception. There is also an urgency to it – and this may create dissatisfaction in a system that necessitates testing to rule out other entities, awaiting a specialty consult, multiple procedures, etc. Since there is no specific test that can attribute HA to exercise and eating habits, other diagnoses need to be “ruled out” before this can be “ruled in”. Even then, there is no test that 100% proves causation. I would like to think that doctors are educated in this complex realm and are providing the best possible assessment and treatment to these women. That being said, I recognize that my own perception is biased due to my truly wonderful, attentive, and supportive fertility specialist.

So what did I do? How did I finally become pregnant? When I had HA, I was constantly looking for the magic formula – just how much weight would I need to gain? How much exercise was too much? The truth is, everyone is so very different and there is no one size fits all “solution”.

To this day, I joke with my husband that I became pregnant after purchasing this bracelet. I did, but I also reduced my exercise dramatically (from 5-7x/wk to maybe 1-2x/wk), gained 30-35 pounds, slept in, practiced yoga (including Yoga for Fertility), started acupuncture, and underwent 4 cycles of clomiphene citrate and 1 cycle of letrozole. It was on that fifth cycle that I became pregnant with my first. I sometimes still think of him as my letrozole baby.

However, the most important (and most difficult) change I made was to stop caring about my weight. This was a slow and painful process. Letting go of the pressure and anxiety to be thin was hard. It feels so silly for me to say this now as I truly can’t believe that I spent so much time obsessing about something so trivial, especially with all of the very real problems in the world. Yet at the time, it was strangely important to me, and overcoming that mindset took strength and perseverance.

I loved being pregnant and I love being a mother. Every moment of pregnancy (x2!)and every moment of motherhood has been all the sweeter because there was a time when I truly doubted whether I would be able to have a baby. I know that I was very fortunate: I didn’t battle infertility for longer than 2 years, it was (relatively) rapidly reversible, and only minimal intervention was necessary. I was spared the financial and emotional consequences of undergoing more invasive fertility treatments. But any degree of infertility (or sub-fertility) takes its toll, and my heart truly goes out to everyone currently going through it.

After my first pregnancy, I never resumed working out regularly. I would exercise sporadically here and there (a slow run/walk, a family hike, a yoga class, a stroller work0ut), but never with the same intensity and commitment. My reasons were varied: I experienced “working mom guilt” and didn’t want to spend time away from work at the gym when I could be with my baby, sleep deprivation/low energy, fear of affecting my milk supply/production, and the desire to have another baby soon after the birth of my first. I also worried about whether I could truly exercise in moderation. Despite this, I lost my pregnancy weight quickly while eating everything under the sun. I also regained my cycle at almost 11 months postpartum (while still nursing) and was pregnant a month later with no medical intervention.

If you are struggling with HA, please know that there is so much hope on the horizon! There are also a number of wonderful resources out there, including:

  1. Nico’s blog is a must-read. There is a wonderful community of women formed around it, and also a book.
  2. This lovely endocrinologist’s post, linking to her personal experience
  3. Ashley’s older blog posts
  4. Janae’s perspective

And do feel free to contact me if you have any questions. I am by no means an expert in this field, but I can certainly commiserate.