Infertility is a heartbreaking ordeal, with psychological ("what's wrong with me?") and social ("what do I tell everyone?") ramifications. Whether it's one of my disadvantaged patients or one of the wealthiest women in the world, the invasive testing and complicated treatments are brutal. But to look at celebrity pregnancies, it appears that infertility is extremely uncommon. There seems to be an epidemic of "spontaneous" twin pregnancies, particularly among stars in their late 30s and 40s. While a few are open about their struggles - two members of the Dixie Chicks and Brooke Shields have told their stories beautifully--it's more common to keep them hidden. Many people assume that certain celebs are secretly undergoing infertility treatments, which generate no of . Truthfully, I too can't help speculating and thinking snarky thoughts, and I'm not the only blogger to notice that while the latest couple to announce a twin pregnancy disavowed use of Clomid and IVF, they didn't mention the intermediate step (the use of injectable medications to stimulate ovulation).

Dr. Kate,

I have three beautiful children and am at the point where I know I have all that I can handle. My husband keeps saying he will get a vasectomy--but he keeps putting it off. I am tired of taking the pill and condoms are out of the question. I was thinking about getting my tubes tied but that sounds scary and I have heard some nightmare stories about the hormone inserts. Do you have any other recommendations for long term or permanent birth control? Have you heard of something called Essure? I heard about it on the radio and it sounded intriguing.

Unsure

Dear Unsure,

The three best options for long-term birth control are the IUD, tubal ligation, and tubal occlusion (with Essure):

• The IUD comes in two flavors, the Paragard (copper-based, no hormones, lasts for 10 years) and the Mirena (progesterone-based, lasts for 5 years). Both are over 99 percent effective--just like sterilization--and can be placed in your doctor's office in 3 minutes; certainly easier than surgery. Best thing about the IUD is that it's reversible, just in case you change your mind in the future.

I'm glad that HPV is getting lots of media-love, especially if it prompts my patients to come in for their annual exams and Pap smears. But I'm hearing more and more lately, "Test me for everything, especially for HPV." Unlike chlamydia and HIV, testing for HPV is not nearly so straightforward.

Dear Dr. Kate,

Back in March I had an 8 centimeter cyst removed from my left ovary when the cyst caused my ovary to twist on itself. The cyst was removed by cutting into my abdomen (bikini cut). As I was recovering from surgery, I began getting the same stomach and back pain as before the first surgery. An ultrasound showed that another cyst had formed (4 centimeters) and had to be removed the same way as the first surgery. Pathology reports showed that the ovary and fallopian tube contained endometriosis. My doctor said that my right ovary, tube, and uterus looked perfect during the surgery. I have since been put on the pill (Femcon) and am recovering from the second surgery. 

My question for you is: Do you think I should be looking into harvesting my eggs for the future? I'm worried that the endometriosis will return in the right side and ruin my chances of ever becoming a mother. I'm 28 years old, and I've never been so stressed out and worried in my life. We all have dreams of being parents, and the possibility of no kids just doesn't sit well with me. Is there anything else I can be doing or telling my doctor to do in order to keep my remaining reproductive parts healthy?

Endo Impaired

I've talked about how to discuss news of an infection with your partner. What's had me thinking lately is how you talk about news with your doctor. We gynos do lots of tests during your check-up, and we know that you want to hear their results immediately--within hours if possible. Some test results come back the next day (like the test for anemia), while some results return within two or three days (most STDs, including HIV) and some take weeks (your pap smear). Different labs take different amounts of time as well. Even though I know that most of my patients are anxiously awaiting their test results, I can only communicate with each of them once--I simply have too many patients to call them all multiple times. And I know that some gynos' offices don't always tell patients their results at all. Their policy is "no news is good news." As a patient myself, on occasion, this would make me nervous: what if something gets lost?

Dr. Kate,

I have read about the black box warning on Depo-Provera and I am worried about my health. It warns not to use the medication for more than two years, and I have been on it for eight years. My doctor told me that I am healthy and I should be fine. I may be fine now, but am I setting myself up for osteoporosis in the future? I have asked several pharmacists, and have gotten a different answer from each one. I would love to trust my doctor, but I feel some doubt since there is a warning out. The only thing that keeps me from switching birth control is that I love that I only have to worry about it every three months, as well as the fact that I have not had a period in years. Would you advise me to switch birth control, or do you think it is ok to continue it?

Doubting Depo


Dear Doubting,

A lot of my patients who use Depo-Provera share your concerns. I'm happy to say, though, that there's no reason you have to stop using Depo. The black-box warning comes from studies that show that women who use Depo for more than two years have some bone loss--in some cases "osteopenia," or weaker bones than normal for a woman of that age. But there are some important points that I counsel my patients about:

There's a bit of confusion--even among well-educated women and their doctors--about the innocent IUD. For years, gynos have withheld the IUD from any woman that was not in a monogamous relationship, had no children, and had a history of chlamydia or PID. Despite changes in the labeling for the IUD, many doctors persist in their beliefs that the IUD is linked to pelvic infections and infertility.

Here's the truth about IUD and infections: After an IUD is placed, there's a risk of infection in your pelvis for the next three weeks. This risk is related to the act of putting in the IUD; if there's an infection in your cervix, the IUD insertion "straw" can push that bacteria up into your uterus. Knowing this, most gynos will screen you for infection first. Years ago--in the era of the Dalkon Shield--we didn't know about chlamydia and rest of the STI gang. So women with active cervical infections had IUDs placed, inadvertently giving them PID. And one of the worst possible consequences of PID is scarring in your fallopian tubes, making it difficult (or impossible) to get pregnant on your own.

There seems to be some confusion lately--especially by the current administration--about how exactly the birth control pill works. Em & Lo started the discussion, but I wanted to weigh in with the medical point of view. The birth control pill prevents pregnancy in several ways:

• Primarily, the pill prevents ovulation. No egg, no chance of pregnancy. Most months, a woman taking the pill won't release an egg.

• The pill changes your fallopian tube motility. If an egg is released, the pill makes it harder for it to travel to the uterus.

• The pill thickens your cervical mucus. This thickening makes it difficult for sperm to get to an egg if one is there.

• The pill alters your uterine lining. So if an egg was released, and if it manages to get through the fallopian tube, and if sperm were able to get to the egg, and if the egg was then fertilized--and that's a whole lot of ifs--the different lining makes it harder for a fertilized egg to implant. So at no point does the pill interfere with a fertilized egg: it just makes it less likely that the egg will land and become a pregnancy. It is this function of the pill that causes such a ruckus among those who hold that disruption of implantation is the same as an abortion--even though this function of the pill rarely comes into play.

Dr. Kate,

I'm currently on a 21/7 pill, and it's working beautifully for me, but I have a question about the placebo week's effect on the body. After reading the post about the different lengths of placebo weeks, I'm wondering: Is a placebo week even necessary? Is that withdrawal bleed an actual period? Would you recommend skipping the placebo week several months in a row, or is it healthier or safer to take that week and have the subsequent withdrawal bleed each month? Okay, that was three questions!

Puzzled by Placebos

Dear Puzzled,

I'll take your second question first. The withdrawal bleeding is just that--your body's reaction to the withdrawal of hormones; it's not a true period. Once you start manipulating your cycles with hormones (that sounds so diabolical!), you no longer have what gynos consider "periods"--just regular, hopefully scheduled, bleeding.

So the placebo week isn't truly necessary. When the pill was first manufactured in the 1960s, its creators came up with the 21/7 pattern to mimic the natural cycle, hoping it would be more acceptable to both women and the Catholic Church. The pope didn't buy it, as we know, but many women have felt reassured by seeing bleeding every month. But as I've posted before, that bleeding isn't necessary for good health. 

In the end, it's totally fine to skip the placebo weeks whenever you want (it's not healthier or safer, it's simply another option), with a few caveats:

Dear Dr. Kate,

For the past six months I've been having never-ending periods. They last almost the entire month, and I only have one or two days of no bleeding each month. My periods never came normally but the longest they used to last was like two weeks. What can I do to get my period normally, or to just last three to five days??

Tired of Going With The Flow

TOGWTF,

It may be nothing, but your bleeding could be a sign of something more serious, and your doctor will likely want to rule out some or all of these conditions:

• Hormonal problems. Thyroid disease and pituitary disease can cause dysfunctional bleeding. Your doctor can check for these with blood tests.

• Structural problems. You can think of these as unwanted house guests in your uterus. Polyps and fibroids can both cause prolonged bleeding, and can usually be detected with an ultrasound.

• Blood clotting problems. Especially if you're young, prolonged bleeding can be a sign of clotting problems. Your gyno may do some blood tests or send you to a hematologist (a blood disorder specialist).

• Hyperplasia. This is a precancerous condition in your uterus. Depending on your age and other risk factors for cancer, your gyno may want to do a small biopsy of the lining of your uterus.