by Megan Sperry
Allison's graduation from Columbia School of Nursing. Have you ever wondered about IVF and other reproductive health procedures? What are all these acronyms? What should a patient expect if they visit a fertility clinic? And, hear why being a women’s health nurse practitioner in the fertility space is a fascinating mix of close patient care and cutting-edge science.
I have interviewed people in many strange spots for this blog, but I think my most recent conversation may win oddest interview venue. Me, sitting cross-legged in the bathroom while Allison Bitto did her make-up. We were prepping to go to a friend’s birthday party and talking IVF therapies. Totally normal! Beyond the odd choice of venue, this interview was special because it was with someone I have known for a very long time. Allison and I met in middle school after she hurt herself in gym class and I took her to the nurse’s office. Through high school, college, and even more school for both of us, we have remained friends.
Today, Allison works at the Weill Cornell Medical College Center for Reproductive Medicine in New York City as a nurse practitioner. I was not only interested in what she does day-to-day, but also what a woman should expect if she is faced with the challenge of infertility or is supporting a friend through the process. Here is what I learned.
Fertility medicine is a super specialized field that is rapidly evolving.
Even for people in the medical field, the fertility space requires a lot of specific training and attention to detail. “I didn’t know a lot about any of this [before starting my current job]. Even in school to become a women’s health nurse practitioner, we probably spent a day on IVF and that type of stuff. It’s why I picked it, because I wanted to learn more, do something new. I wanted it to be challenging. And it totally is. I’ve learned so much in the last few months.”
And, it is a field that is constantly changing based on new scientific evidence. “A few nurses who have been in the field a long time told me that if I told a patient [today] what they said to patients ten years ago, the patient would think I was crazy. That’s how much this field has evolved in the last ten years. It’s just completely changed.”
The current director of the Center is Dr. Zev Rosenwaks, a pioneer in assistive reproductive technologies (ARTs). He founded the United States’ first egg donation program, developed many ovarian stimulation protocols to make ARTs successful and reduce complications, and is currently investigating better methods to enable single embryo transfer and avoid multiple pregnancies.
And, it is a field that is constantly changing based on new scientific evidence. “A few nurses who have been in the field a long time told me that if I told a patient [today] what they said to patients ten years ago, the patient would think I was crazy. That’s how much this field has evolved in the last ten years. It’s just completely changed.”
The current director of the Center is Dr. Zev Rosenwaks, a pioneer in assistive reproductive technologies (ARTs). He founded the United States’ first egg donation program, developed many ovarian stimulation protocols to make ARTs successful and reduce complications, and is currently investigating better methods to enable single embryo transfer and avoid multiple pregnancies.
Every woman is a special case and requires personalized care (including daily phone calls!).
“I spend a lot of time talking to patients, mostly on the phone. You do get very close to your patients. They call you about everything and expect to hear from you every day.” The process—whether it is ovulation induction, in vitro fertilization (IVF), or donor egg transplants—is time consuming and stressful for the patients. “It’s a huge commitment: time, money, emotional stability. Eventually with IVF, you have to come in pretty much everyday. It’s nothing you would go into lightly.”
There is a hierarchy of infertility treatment options, from monitoring the natural cycle to IVF and even donor egg and sperm—each with their specific details and challenges.
Allison works in ovulation induction and IVF therapies, so she has the most experience with these treatments. However, the Center offers a wide array of options for patients, a few of which we talked about.
- Ovulation Induction: “Ovulation induction includes patients that come in to naturally monitor their cycles or to have medicated cycles. Then they will have an intrauterine insemination (IUIs) or we will give them timed intercourse instructions. I like doing the intrauterine inseminations—you get to interact with patients and it’s the main procedure I do, so I like that.”
- IVF: “IVF includes [ovulation] induction, egg retrieval, and implantation of the embryos.”
- Cryopreservation: “We also do oocyte cryopreservation, embryo cryopreservation. We get cancer patients who come in to freeze eggs before going through chemotherapy. We have people as young as 15 or 16 years old who come in to freeze eggs before they go through chemo.”
- Frozen Embryo Transfers (FETs): “Then there is the FETs. Most of the time we are just monitoring the natural cycle to know when to implant the frozen embryo. I make those decisions based on their bloodwork and ultrasound.”
- Donor egg and sperm: If you cannot ovulate, have a disease, or have other fertility issues, “…you can use someone else’s eggs. They try to match you very well based on looks, religion, and general background."
Allison as a nurse practitioner in training!
Often, infertility is due to male factor, especially in some populations. There are new therapies that can allow patients to overcome this challenge.
“Sometimes it’s the man. It’s a lot of male factor. The doctor I work for is Orthodox Jewish and in that population there is a high rate of azoospermia.” A newer procedure, testicular sperm extraction (TESE), allows for removal of sperm from the testicles themselves and subsequently IVF for the female patient.
Allison’s favorite part of her job is calling patients with good news: “Congratulations, you’re pregnant!"
“Giving those calls is the best feeling ever—especially as I get to know patients longer, I can only imagine that those calls, the good ones, are going to be even better. I called a woman [who was pregnant] the other day and she started hysterically crying on the other end. I wanted to cry!”
However, Allison cautions that this is not always the case. “It’s not all happy, unfortunately. I make a lot of really sad calls too. Everyone wants positive results when they come in for their pregnancies tests, and most of them are not.”
However, Allison cautions that this is not always the case. “It’s not all happy, unfortunately. I make a lot of really sad calls too. Everyone wants positive results when they come in for their pregnancies tests, and most of them are not.”
She has to be particularly aware of the potential for “biochemical pregnancies” because Reproductive Centers are doing testing so early in the pregnancy.
“The one thing I didn’t know too much about [before working at the Center] is that there are a lot of ‘biochemical pregnancies’. A biochemical pregnancy is a pregnancy test that comes out positive, but the embryo never really implants, and it’s not a good [viable] pregnancy. With us, this happens all the time.”
“One in five pregnancies [in the general population] end in a miscarriage. It’s a high percentage in general. But with this process, you’re checking the pregnancy test on the first possible day you can check. So a lot of time, we are calling with levels that are lower than expected.”
Biochemical pregnancies can lead to a lot of disappointment for woman undergoing reproductive therapies. “If I see a really low level [in the pregnancy test], I’m cautious now. I tell the patient, ‘You are pregnant, the level is positive, but we need to watch it and make sure the level rises appropriately, and repeat it in two days.’ That way you don’t get their hopes up to a point where they are going around thinking they are definitely pregnant.”
However, it’s not all bad. “We still consider biochemical pregnancy to be a positive sign, you are pregnant.”
“One in five pregnancies [in the general population] end in a miscarriage. It’s a high percentage in general. But with this process, you’re checking the pregnancy test on the first possible day you can check. So a lot of time, we are calling with levels that are lower than expected.”
Biochemical pregnancies can lead to a lot of disappointment for woman undergoing reproductive therapies. “If I see a really low level [in the pregnancy test], I’m cautious now. I tell the patient, ‘You are pregnant, the level is positive, but we need to watch it and make sure the level rises appropriately, and repeat it in two days.’ That way you don’t get their hopes up to a point where they are going around thinking they are definitely pregnant.”
However, it’s not all bad. “We still consider biochemical pregnancy to be a positive sign, you are pregnant.”
There are a number of emerging and new technologies that are providing better outcomes, specifically in the realm of genetic testing.
Some patients are choosing to undergo intracytoplasmic sperm injection (ICSI), where one sperm is injected into the egg, leading to more successful embryos. However, this is more expensive than traditional IVF. In addition, genetic testing is becoming extremely popular. In the Center where Allison works, the egg is fertilized via IVF procedures and the lab allows the embryo to divide out and grow, and finally the embryo is biopsied for genetic testing. This is known as pre-implantation genetic diagnosis (PGD). “You are going through this whole process—so why put back embryos that are not viable.”
There are a number of ethical dilemmas that the fertility field faces.
“You’re playing the natural evolution of life—whether it’s gender selection or preventing abnormalities. It’s not something I feel strongly about, but it’s definitely something I have thought about. I think genetic testing is a great thing. I think the things we do are really good. But it is certainly an ethical dilemma.”
And, finally, why being a nurse practitioner is so great.
“[As a student], I heard so much about how people really liked their nurse practitioners and how they focused a lot on patient care and listening to patients. Taking more time to actually sit with patients and explain things.”
“Just last week I had my first really good patient connection. Now that I am fully trained, I am seeing people all the way through [the process]. I just met this patient. I had talked to her on the phone a couple of times and then we started emailing a little bit about her cycle and just getting her prepared. I was coaching and encouraging her because she was really nervous about a lot of it. She was just the sweetest person—I could tell already from email! So I ended up going in early one day this week so that I could start her [IVF cycle], and I sat with her for forty-five minutes and went through everything. She sent me a really sweet email about how I made the process good for her and she couldn’t imagine going through it without me. It was just the best feeling.”
“Just last week I had my first really good patient connection. Now that I am fully trained, I am seeing people all the way through [the process]. I just met this patient. I had talked to her on the phone a couple of times and then we started emailing a little bit about her cycle and just getting her prepared. I was coaching and encouraging her because she was really nervous about a lot of it. She was just the sweetest person—I could tell already from email! So I ended up going in early one day this week so that I could start her [IVF cycle], and I sat with her for forty-five minutes and went through everything. She sent me a really sweet email about how I made the process good for her and she couldn’t imagine going through it without me. It was just the best feeling.”
