Join hosts Dr. Abby Eblen from Nashville Fertility Center, Dr. Susan Hudson from Texas Fertility Center, and Dr. Carrie Bedient from the Fertility Center of Las Vegas as they dive into the role of three key hormones in pregnancy: thyroid hormone, prolactin, and insulin. In this episode, we discuss the thyroid’s function and why it’s problematic if it works too fast or slow. We explore common thyroid tests, how thyroid issues can impact pregnancy, and their connection to prolactin levels. We also break down prolactin’s role, what affects its levels. We discuss the difference between a micro- and macro-adenoma and treatment for both. Additionally, we touch on galactorrhea, a condition causing unexpected breast discharge, and the importance of discussing it with your doctor. We then shift to insulin and its link to diabetes. We explain type 1 diabetes (an autoimmune condition) and type 2 diabetes (where insulin doesn’t work effectively), along with the importance of hemoglobin A1C testing. Maintaining proper blood sugar levels before pregnancy is crucial, as poorly controlled diabetes can lead to birth defects, pregnancy complications, and delivery risks. Tune in for expert insights on optimizing hormonal health for pregnancy.
This episode was brought to you from ReceptivaDx and RMA of New York.
Episode Transcript:
Susan Hudson (00:01)
You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.
Susan Hudson MD (00:22)
This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test used to help detect inflammatory conditions on the uterine lining, most commonly associated with endometriosis and may be the cause of failed implantation or recurrent pregnancy loss. Take advantage by learning more about this condition at receptivadx.com and how you can get tested and treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx, because the journey is worth it.
Abby Eblen MD (00:54)
Hi everyone, we’re back with another episode of Fertility Docs Uncensored. I’m one of your hosts, Dr. Abby Eblen from Nashville Fertility Center, and I’m joined by the dynamic duo of Dr. Susan Hudson from Texas Fertility Center.
Susan Hudson MD (01:07)
I like being part of a dynamic duo.
Abby Eblen MD (01:09)
And Dr. Carrie Beatty from the Fertility Center of Las Vegas. How are you guys doing?
Carrie Bedient MD (01:14)
Aren’t we more of a terrific trio?
Abby Eblen MD (01:16)
I was just thinking when I said that I’m like, well, where does that leave me then if you guys are dynamic duo?
Susan Hudson MD (01:22)
We’re a duo of the trio.
Abby Eblen MD (01:24)
That’s right.
That’s right. It is. is. So, Carrie, you were just talking about you’re having a little backyard issue at your house. Tell us a little bit about that. Sounds interesting.
Carrie Bedient MD (01:26)
It’s starting to sound like a math problem. Yeah, so these are admittedly first world problems. My neighbors put up these big iron panels to give more privacy to their yard and they extend about two, three feet above the wall that we share together. And so we’re looking at the backside of these iron panels, which could be worse, but also could be a lot better. And so…not a whole lot. The only thing we do, which makes me think of a ton of really inappropriate questions is we will throw a ladder over our back wall because we live right next to a park. And so we’ll hop the wall, which as part of doing that, we can see into the corner of their backyard. But that said, are all of these houses are close enough together. So if you’re skinny dipping in your backyard, like we were going to see you anyway, regardless of whether we were going over the wall, because there’s just not that much privacy. And so…
Susan Hudson MD (02:32)
What is this wall you’re describing? So for those of us who don’t live in the city, I mean, like, is this like a privacy fence? Like, you’re calling it a wall. So I want to know how this thing is constructed.
Abby Eblen MD (02:47)
So like cinder block or?
Carrie Bedient MD (02:48)
It’s a five foot cinder block wall. And so it’s five feet on our side, but I live on a hill. And so it’s probably at least seven or eight feet on their side. But I can stand next to this wall, turn my head and look over because I’m more than five feet tall. So I can really easily see it. And so they put up this privacy thing. And so I’ve been wanting to do something to that wall because it is cinder block and just ugly as hell.
And so I’ve been trying to think about, what do I do? But I haven’t had any pressing reason to do it. Well, now that there are these ugly ass panels here, I want to do something to cover it up. But my husband does not see in 3D. Like I can describe, well, what if we do this and this and this and this and this? And he’s like, I have no idea what you just talked about. So I made a PowerPoint. I’m a little compulsive.
Abby Eblen MD (03:38)
Because you’re OCD.
Carrie Bedient MD (03:41)
And so I took a picture of the backyard and then I’ve taken all of these various internet pictures of things that I’m considering doing, different tiles or, treated wood surfaces or things like that, like how to put in plants, lighting, all that. So I’ve got all of these superimposed pictures over my PowerPoint and I’m going on at least four different versions that I will then show him. And I may or may not put in an over the top version that I always do. So it makes the ones that I really want more reasonable.
And it’s unfortunate. Shit, he’s listening to these. He started listening more. Honey, I love you.
I love you dearly, darling. Mwah!
Susan Hudson MD (04:20)
I was just thinking about this. I was like, historically my husband has been the one that listens the most, but I know Carrie, you mentioned that Mark has been listening to more of them.
Carrie Bedient MD (04:30)
Yeah, I think he wanted to keep up with Brook and to be more supportive. So he’s now started listening to things which, I love you, honey.
Abby Eblen MD (04:38)
Maybe it’ll be wild. Maybe you already have your fence by the time he listens to this one.
Carrie Bedient MD (04:42)
entirely possible, but he just rolls his eyes and laughs at me. Like, he knows that I’m putting this PowerPoint together, and really the ones that are way over the top are not things that either of us would want to do anyway, so it’s kind of tongue-in-cheek in doing it, but it’ll still be fun.
Susan Hudson MD (04:58)
PowerPoints are kind of like a love language. Like for Brook, would be putting something into a spreadsheet. Like if I really, really wanted something, if I designed a very nice spreadsheet for him, that would be the way to his heart.
Abby Eblen MD (05:04)
There you go.
Carrie Bedient MD (05:13)
Yeah, yeah, we married nerds. It’s pretty great.
Susan Hudson MD (05:16)
We did.
Abby Eblen MD (05:18)
We’re very good. So what question do we have today, Susan?
Susan Hudson MD (05:21)
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Susan Hudson MD (05:52)
All right, so our question today is, hello docs, I absolutely adore your podcast and have listened to all your episodes some more than once. So thank you so much. You have provided me with so much knowledge and comfort as I navigate through my IVF journey. I have been preparing for egg retrieval number two and I’m worried about flu season. I know that sickness fevers can negatively impact sperm, but but do they have any impact on egg quality, fertilization or implantation? I’m doing IVF for PGTM male factor and this is my last round before insurance runs out so I’m trying to do everything I can for success. Thank you so much.
Carrie Bedient MD (06:32)
So sperm doesn’t like fevers, eggs don’t particularly like them either. When you look at some of the information, and this hasn’t been like super well studied, but at least a little bit, cycles where somebody had a fever had a lower number of follicles that were obtained. So that would be something where for sure if you get a fever during a cycle, definitely want to let your clinic know. There’s implications both for the egg quantity and quality as well as just the safety of doing the retrieval. We put you to sleep, you still have to breathe on your own. If you are coughing a lot or if you have a lot of congestion with post-nasal drip that’s making you cough, that’s impairing your ability to breathe, nobody wants you to go under anesthesia in those circumstances, especially not for something that’s elective like infertility where…It’s not as though you are going to die tomorrow if we don’t do this procedure. It is much better to say, okay, let’s stop. We will figure out how to eat the cost of the medications and we’ll just do it again when you are feeling better because we all want the best for you, for your eggs, what’s safest. The goal is happy mama, happy family. And one way to do that is to avoid obvious illness throughout the course of the retrieval. So if you’re thinking about doing flu shots, if you are thinking about whether or not to push your limits and go to whatever event where there’s gonna be a lot of sick people there right around the time you’re doing an egg retrieval. Maybe this’ll push you in one direction or the other to figure out, maybe I should avoid that right now at this moment in time.
Susan Hudson MD (08:00)
Great.
Susan Hudson MD (08:01)
Exciting news from Fertility Docs Uncensored! Our long-awaited book, The IVF Blueprint, is now available on Amazon. Go now to pre-order your copy to learn everything you need to know about IVF, egg freezing, and embryo transfer.
Abby Eblen MD (08:14)
Agreed. Well, very good. Today we’re going to talk about, and we’re known as reproductive endocrinologists. So there’s several different reproductive hormones and you may be most familiar with estrogen and progesterone, but today we’re going to talk about three that maybe you’re not as familiar with, probably thyroid hormone, your doctors talked to you about that. But we’re also going to talk about prolactin and we’re going to talk about insulin, insulin, if you lack that, you’re diabetic. And so we’re gonna talk about those three. Why don’t we start out with thyroid first? That seems to be one that we talk to patients about frequently. So Susan, why don’t you start and tell me a little bit about the thyroid and why we’re worried about that thyroid hormone in people that are trying to get pregnant.
Susan Hudson MD (08:56)
So the thyroid gland is a little gland in your neck and it’s actually the major metabolism gland in your body. So thyroid hormone helps control your heart rate. It helps regulate your hair and skin and nails and it actually helps regulate how your body functions in reproduction, whether it’s getting pregnant or staying pregnant or healthy baby brain development. So thyroid hormone is something that we’re relatively obsessed about. Things to know about thyroid is it can either be underactive, which is hypothyroidism, or it can be overactive, which is hyperthyroidism. Now hyperthyroidism is way, way, way less common than hypothyroidism. We diagnose a lot of hypothyroidism in our practices. And the hormone that we most commonly test for is something called TSH or thyroid stimulating hormone. And this is one of those things where it’s a little upside down topsy turvy in that a high TSH is indicative of hypo or low thyroid hormone. And so, the nice thing about thyroid hormone is it’s not cycle dependent, okay? You can get that tested at any time in your cycle and really that spot check can provide us a lot of initial information.
Abby Eblen MD (10:22)
So Carrie, what kinds of symptoms would people have if they had hypothyroidism?
Carrie Bedient MD (10:28)
You can have an enlarged thyroid gland. Like Susan said, it’s a butterfly-shaped gland that’s on your neck. If you think about the physical exams we do, we usually put our fingers just lightly over your neck and have you swallow. We’re feeling for your thyroid gland, feeling for any nodules or any fullness in that area. Some people have difficulty swallowing. That tends to be pretty late stage, so you’re fairly far along in this if you have difficulty swallowing.
More commonly, there’s temperature instability, meaning everybody else in the room is totally comfortable and you are freezing your little buns off. There’s hair brittleness or losing hair. There’s feeling kind of sluggish. There’s gaining weight. Everybody who comes into any doctor’s office who is considering weight ever, the first question is always, you test my thyroid? Because it’s true, when it is really off, it can change your metabolism and you can be more prone to gaining weight. Those are some of the biggest things that we notice with thyroid. Sometimes you see drier skin as well, unless of course you live in the desert, in which case your skin is dry no matter what your thyroid is doing, regardless.
Abby Eblen MD (11:32)
Just ignore it if you live in the desert, right? So Susan, there’s a normal range for thyroid, but being the OBGYNs that we are, we know that we want the thyroid to run in a little bit different range. Can you explain what that means?
Carrie Bedient MD (11:34)
Yeah, pretty much.
Susan Hudson MD (11:45)
Right, so generally when we’re looking at TSH levels, when you get your labs drawn at whatever lab job place of choice you’re at, around 4.1 or less is generally considered a normal TSH. However, when you’re going into pregnancy, we know that there’s this gray zone between 2.5 and that 4.1. And if that is where your TSH lives, we’ll often look to see if there’s any thyroid antibodies, little cells within your body that may be attacking your thyroid. And if those are present, that is an independent indicator that you might have better pregnancy outcomes if we start you on a low dose of thyroid medication and help bring that TSH level down to less than two.
Abby Eblen MD (12:41)
So Carrie, if someone starts on the thyroid medicine, what’s the medicine of choice for you usually that you like to use?
Carrie Bedient MD (12:48)
So my default tends to be Levothyroxine. It’s a synthetic version. Synthroid is the brand name. Given the option, it is nice to have the brand name in this case because thyroid and many hormonal medications are very sensitive to subtle changes. And the difference between a generic medication versus a brand name is in part related to the specificity and exactly how much is in that dose. The generics are allowed a little bit more wiggle room or room for error as opposed to the brand names which are held to a more specific standard of if you say that you’re getting X amount, you have to have X amount within a very small window. Generics, you have to have X amount within a larger window, not much larger, but larger. And so, especially for people who have very sensitive thyroids, doing levothyroxine and synthroid in particular can be really helpful. There are some other types of thyroid medications. There’s nature thyroid, armour thyroid, those are the big ones that come to mind that I see.
Susan Hudson MD (13:46)
Tirosint is another good one going into pregnancy. It has very good quality control.
Abby Eblen MD (13:51)
So Carrie, what about Armour thyroid? Is that an option for patients? Would you typically give that in the place of Synthroid? Or tell me the pros and cons there.
Carrie Bedient MD (13:59)
So, Armour thyroid is a more natural form of thyroid and the reason it’s a more natural form of thyroid is because it’s from pig thyroids that are then ground up and turned into medication form. And so, it is absolutely the more natural form. Would definitely not qualify as kosher. But there’s more variation in it. So, if you remember when I was talking about Synthroid versus Levothyroxine in brand versus generic, this is a totally different category because it is from natural thyroids. And so some may have more and some may have less hormone in them. And so it’s a bit less precise in that fashion.
Susan Hudson MD (14:36)
So another thing to think about is not only is this important to understand before you’re getting pregnant, but your body’s need for thyroid exponentially increases in early pregnancy and can move throughout pregnancy. So if you have thyroid issues, your thyroid should be checked monthly during pregnancy. And so if we are chasing a moving target with a moving target, it makes it a whole lot harder for us to get you exactly the right amount of medicine to make you what we consider euthyroid or have normal thyroid hormone levels.
Abby Eblen MD (15:15)
Susan, can you talk a little bit more about thyroid antibodies? I know there’s a lot of different tests that we can all do. TSH is probably one of the more common ones. But thyroid antibodies, people may have questions about because sometimes that changes what we do if we find that somebody has thyroid antibodies.
Susan Hudson MD (15:31)
Right, so the two main types of thyroid antibodies that we look at are TSI antibodies as well as TPO antibodies and we’re just going to keep it at that because you don’t really need to worry about the big differences in those. The TPO antibodies have more of an association with a condition called Hashimoto’s thyroiditis which is a autoimmune condition, which is the reason why we’re talking about antibodies and the TSI antibodies are more related to a condition called Graves’ disease. Now, Graves’ disease generally, initially is going to make people hyperthyroid, have too much thyroid hormone. Those are the people who are more likely to have things like heart palpitations, weight loss. They also can have some skin, brittle nail, hair issues, those types of things.
Carrie Bedient MD (16:23)
Temperature intolerance on the hot side instead of the cold side.
Susan Hudson MD (16:26)
Right, they’re feeling hot. I actually personally have Graves’ disease and it can also be related to some other autoimmune diseases as well. So those antibodies are what can drive you to have some issues. There’s not a lot you can do other than taking the medications to help control the presence of the antibodies and what your actual thyroid hormone levels are.
Now realistically, most of the time we’re not getting rid of the antibodies. So a lot of times people will be like, can you recheck my antibodies? I mean, we can recheck them, but they’re not going to disappear. It’s really giving you the best thyroid hormone profile to give you the best obstetric outcomes.
Abby Eblen MD (17:12)
And that’s usually at the point when I find that somebody has thyroid antibodies, I may start them on Synthroid, but then usually at that point I’m like, this is not gonna be just an issue right now. This is gonna be a lifelong issue. Probably best for you to speak to your primary care doctor or your endocrinologist and set up an appointment because this is gonna be a lifelong issue.
Susan Hudson MD (17:28)
In the long term, I think all of us do very well managing these people in the short term, but in the long term, if you have antibodies, you should see an endocrinologist. So we are reproductive endocrinologists. So we did OBGYN training and then reproductive endocrinology. Endocrinologists are internal medicine doctors who then did fellowship in endocrinology. And those are the people who are really going to need to follow you for the rest of your years.
Abby Eblen MD (17:56)
Yeah. Very good. All right. So we’ll switch gears here. Let’s talk about prolactin, Carrie. Tell me a little bit about prolactin, what it is and what it does.
Carrie Bedient MD (18:05)
So prolactin is a hormone that’s released from the pituitary, which is the same organ that releases a lot of the other signaling compounds that we see in the body. So TSH, thyroid stimulating hormone comes from the pituitary. So does FSH, so does LH. A lot of the organs, a lot of the hormones that we really like to play with all have the originating instructions starting in the pituitary. And so prolactin is a hormone that comes out of the pituitary and it is most commonly associated with breast milk production, but even though that’s its big headliner billing, it also is present in many other organs as well. So we see it in the amniotic fluid, we see prolactin receptors all over the body. And so when someone has an elevated prolactin level, the biggest thing that we tend to hear about is, I have nipple discharge. And that is true whether or not you are breastfeeding or have had any…kind of history breastfeeding. And so that’s something that we tend to pay pretty close attention to because it’s got reproductive interferences if you’ve got levels that are too high.
Abby Eblen MD (19:10)
So Susan, why are we worried about it if it’s too high and what kind of levels are we worried about?
Susan Hudson MD (19:16)
So when we’re looking, the reason why we’re worried about it being too high is one, it can mess up ovulation, okay, or the sensitivity of your ovaries to medications that we may be giving to you. And so as to an official level, again, it depends on which lab you have it drawn at, exactly what it is. I would say, somewhere between like, 25 to 35 is generally gonna be an upper limit of certain labs, okay? Now, prolactin can be elevated due to a lot of reasons. If you have recently eaten, if you have recently had sex, if you have had nipple stimulation, if you have fibroids, these are all, or take certain types of medications. These are all things that can cause you to have elevated prolactin levels.
And so whenever somebody does have an elevated prolactin level, we don’t just take it at face value. So what I do is I tell patients, I want to have you get your prolactin level drawn in the morning, fasting, water’s okay, no intercourse or nipple stimulation for 24 hours prior. And if that level remains elevated, then we need to actually do a little more investigation. So as Carrie mentioned, prolactin is secreted by a little gland in the brain and we need to do an MRI or an imaging test to see if there’s maybe a little growth that could be causing that. Now even if you have a little growth that’s usually not a big deal. The point where it becomes greater than a centimeter which is pretty darn rare is when we start getting more concerned actually mainly because it can cause start causing visual disturbances and if that happens, sometimes you may have to have surgery, which can sound a little scary, but the surgery is actually done through your nose. So it’s moderately not invasive. But like I said, that’s very, very, very rare. If we see that you have a little growth or no growth at all, we’ll often start you on some medicine, either something called cabergoline or bromocriptine. And these medications you will generally take until you get pregnant.
At the point that you get pregnant, we usually take you off of them. And the reason is, is because it’s actually natural to have elevated proactin levels during pregnancy. So at that point, it really doesn’t matter.
Abby Eblen MD (21:38)
That was a really good summary of prolactin, Susan. I don’t know that anything you’ve got to add on that, Carrie?
Carrie Bedient MD (21:44)
I think more along the random factoid version of one way that people know that their prolactinoma is bigger than perhaps it should be or that it’s growing is, like Susan said, visual field defects. having peripheral version get knocked out is the first thing that goes. And so I always tell people, if you’re driving and all of a sudden you’re like, where the hell did that car come from? Because your peripheral vision doesn’t work.
That is one way to pick up on those issues. Another random factoid is having a difficult blood draw can slightly elevate your prolactin. And so make sure you’re well hydrated going into it. There are different magnitudes of that elevation. So you figure the upper limit of prolactin is usually somewhere in the 25 to 30 region, depending on your specific lab and test. And so if somebody’s got a level that’s 33, we care, but really we don’t care.
We’ll repeat it, but yeah, if you start to hit double or triple or more, at that point, we start to really pay much more attention to it and think, all right, this is gonna be having an impact.
Susan Hudson MD (22:40)
You come back with a 60, we’re a lot more concerned.
And when I’m saying it’s rare, mean, I think I’ve seen those larger prolactinomas called macroadenomas. I think I’ve seen less than 10 of those in my entire career. And so they’re rare. So it’s really nothing to lose sleep over. This is really one of those tweaking things that we do to help maximize your chances. It’s probably not an all or nothing thing.
Abby Eblen MD (23:19)
Yeah, I have a general endocrinology buddy. He really says that these are really not tumors. They’re really more overgrowth of the tissue that produces prolactin, and that’s the way they think about him. And he also went on to say, because I actually had somebody this year, it’s been a long time since I’ve seen anybody with a macroadenoma, larger one, but I found a patient this year that was basically pretty asymptomatic. She had irregular cycles and we checked her prolactin, it was 200. And so I was like, ah!
And so she went and saw him and got on medication. And he said most of the time, he said, it’s really rare anymore that they do surgery on those. Great majority of time, even whether it’s a micro or a macroadenoma, it can be treated with medication. So, don’t panic if you find out that you have one, because, people tend to think this is a brain tumor and it’s really just an overgrowth, too much extra tissue and the medicine’s really effective in treating it.
Carrie Bedient MD (24:09)
There are sets of medication like Susan mentioned that are very common in elevating prolactins. If you happen to be talking with your doc or doing a little bit of Google research, remember Dr. Google went to a questionable medical school, but if you happen to be doing that and you realize, I’m on a medication that causes this, do not cold turkey, stop that medication. Many of them are medications that are very important that you are on for a reason and for the love of all that is holy, please do not cold turkey them and talk about it with your docs first, call them first, have a conversation because prolactin tends to be annoying, oftentimes does need to be dealt with, but not at the extent of the rest of your health. And so many of these medications are things you truly need to be on. So don’t manage your medications by yourself without any input from us because we love to be involved in your care.
Abby Eblen MD (24:57)
Well, the last thing I’ll say about prolactin, it’s one of those questions I feel like as a physician, unless I ask the question, people don’t usually volunteer the answer. And what I mean is, if you have breast discharge, and that means whether it leaks out of your breast on its own, or whether you can squeeze your breast and get milk to come out. Now, if you just had a baby recently, that’s a different story. But if you’ve never had a baby, or it’s been years since you’ve had a baby, and you can still have breast milk expressed from your breast, let your doctor know that’s important for your fertility care. It can make a difference if we find that and we treat it.
Susan Hudson MD (25:30)
I just thought of something else important. So we had just talked about thyroid disorders. So if you have hypothyroidism and you have a very elevated TSH, TSH can actually stimulate prolactin production. So sometimes we’ll see this, and I actually see this moderately commonly, where I’ll have somebody who has some mild hypothyroidism and we have a mildly elevated prolactin.
Once we get that TSH level down, the prolactin completely normalizes. So that’s another thing to keep in mind that these things kind of work together.
Carrie Bedient MD (26:07)
The other thing is pay attention to the color of the discharge. So if it’s that clear white milky-ish, maybe a little bit of yellowish, that tends to be related to prolactinoma and that tends not to be a major medical issue in terms of anything that’s really threatening to you. Needs to get dealt with, but not threatening. If it is red or bloody or kind of that greenish-blackish color, pay attention to that, go get that checked out right away. And some people will ask, do I have to be on this medication forever?
And the answer is maybe, probably, not always. And so sometimes you can go off of medications, but a lot of times within a couple years later, you may go off for a couple years, but then it’s gonna come back, and so you have to go back on it. So a lot of people are off and on throughout their lives, but in general, cabergoline in particular tends to be fairly well tolerated, and it’s like a once or twice a week medication, and so it’s not quite the same level of, crap, I gotta take this five times a day in order to function, so.
Abby Eblen MD (27:03)
So the other hormone we’re gonna talk about today is insulin, and so that relates to diabetes. So Susan tells us there’s a couple of different types of diabetes, generally speaking, so tell us the difference between those two different types.
Susan Hudson MD (27:15)
I’m gonna talk about more than just two different types. So we have type 1 diabetes, which type 1 diabetes means that you have to have insulin either through injections or a pump to process blood sugars. And type 1 diabetes is the least common of the diabetes we’re going to talk about. We also have type 2 diabetes, which is the type where we have actually called insulin resistance. So you have lots of insulin in your body, but your body doesn’t use it effectively. And so that causes you to have high blood sugars. Now, a step down from that is pre-diabetes. And we see that a lot. Nowadays, I usually use a hemoglobin A1c to screen my patients for pre-diabetes and diabetes. So if you have a hemoglobin A1c of 5.7 to 6.3, you’re in that pre-diabetes range. And then you also can have what’s called gestational diabetes. So diabetes that develops during pregnancy that can increase risk of pregnancy related complications. Now, how did these things really relate? Well, if you are coming to us as an infertility patient and you’re in that pre-diabetes range, that greatly increases your risk of getting gestational diabetes, the diabetes in pregnancy, which can cause complications for you as well as baby. But if you get gestational diabetes, that is an independent risk factor for getting type two diabetes later in life. So it’s kind of one of those dominoes that you kick down and it can really have a big impact for the rest of your life.
Abby Eblen MD (28:59)
So Carrie, if my blood sugar’s a little out of control and I’m trying to get pregnant, at what point would you say you really just need to work on this and not get pregnant right now? And once your sugar’s under better control, then it’s safe for you to be pregnant. What’s the number and why is that an issue?
Carrie Bedient MD (29:14)
So we’re oftentimes going by A1Cs as we’re looking at this, because that’s a measure of what the last three months have looked like. And so the nice thing about an A1C is that you don’t necessarily have to be fasting when you check it. And it’s not something that the last 24 hours of indiscriminate eating can have an impact on.
Susan Hudson MD (29:35)
Or discriminate eating. It makes it hard. You can’t cheat on a HgbA1C.
Carrie Bedient MD (29:41)
Yes. And so when we’re looking at the hemoglobin A1C, if someone has a high level, eight, nine, 10 higher, for sure, we’re gonna say, put the brakes on everything, get this under control. Because when you have really poorly regulated sugars and your bodies are not dealing with them well, you start to run the risk of, in addition to all of the body complications that go with that, you have pregnancy complications as well. Difficulty getting pregnant?
You can have higher likelihood of miscarriages, and you can have a much higher likelihood of birth defects, particularly with the heart. And we all want you to be pregnant yesterday, if not the day before, just like you do, but not with a pregnancy that is going to leave you traumatized and scarred going through it. And so that’s one of those times where we will say, all right, if you’re for sure eight or above, and really most of us, like seven or above, we want you to get better control of the diabetes, whether that is through for sure lifestyle modifications, start moving your body, be very cognizant of what you’re eating, but also a lot of the times through medications as well to help that along.
Susan Hudson MD (30:48)
I’d say some of this depends on what type of diabetes you have. For me, if you are pre-diabetic or diabetic, I really want you to have a hemoglobin A1c less than six, because that’s really where we see less risk for those pregnancy related complications, especially the birth defects. If you have type one diabetes with your endocrinologist, we’ll generally come up with what number they feel comfortable with. Generally, that number is no more than seven.
But it’s going to vary some between that six to seven depending on your individual history. And so I would say that one’s a little bit of a gray zone. But again, that’s a much smaller segment of the population. Most of the people we’re seeing are going to be those pre-diabetics and type two diabetics.
Abby Eblen MD (31:34)
Yeah, what I see too from diabetic patients is I think a lot of people that have had diabetes for some time are really surprised at how tightly we want to control their sugars. And so a lot of times I’ll send patients to high-risk OB ahead of time to get them start jump started into that. I think sometimes even primary care doctors maybe because there’s not a need maybe to control it quite as tightly. Maybe your sugars are a little bit higher and your hemoglobin A1c is a little bit higher, but it’s it’s key that it’s safer for you and safer for the baby if we can get everything under control because, you become pregnant and you’re diabetic, even if your baby doesn’t have those risks that Carrie talked about, those malformations, we also worry that during pregnancy, if your sugars are out of control when your baby’s born, it can be macrosomic, meaning it can gain a lot of weight in its shoulders and its neck and be hard to deliver vaginally. And that can be really, really stressful for patients and for delivering doctors. Once the baby’s born, the baby can have some problems regulating sugars because the insulin that it’s been exposed to is so high. So there’s a lot of good reasons why we want your sugars under control, even during pregnancy as well.
Carrie Bedient MD (32:40)
The other thing that happens during pregnancy just as a function of this is that when someone is pregnant and that placenta is getting bigger and bigger, it leads to insulin resistance. That is a normal function of pregnancy. And so if you are starting out with increased insulin resistance and that only serves to increase during your pregnancy, that’s part of what leads to gestational diabetes. So if we can start you off in a better place, it means that we’ve got a longer leash to get you through without having to put you on medications and being really strict about checking your sugars and nutrition and all of those things.
Abby Eblen MD (33:13)
Very good. Any last words of wisdom?
Susan Hudson MD (33:16)
I would like to give a little shout out when we’re talking about diabetes. A lot of folks out there nowadays are on the GLP-1 agonists. So things like Ozempic, Mounjaro, pick your poison, whichever one it is. These are amazing, amazing medications. Okay. And so please do not take what we’re going to say as anything negative, but these are what we call neuroendocrine regulators. So, we really don’t have a full understanding of how these things affect pregnancy. And so if you are using these to help you control your blood sugars, you should reach out to your prescribing doctor and transition once you have your good blood sugars to something maybe like metformin or other medications that are more pregnancy friendly.
We ideally would like you off of those GLP-1 agonists for at least two months before trying to conceive.
Abby Eblen MD (34:13)
Very good point. All right, well to our audience, thanks for listening and subscribe to Apple Podcast to have next Tuesday’s episode pop up automatically for you. Also be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.
Susan Hudson MD (34:28)
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Carrie Bedient MD (34:35)
And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye.
Carrie Bedient MD (34:45)
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