Session 245: Egg Freezing & Fertility

Session 245: Egg Freezing & Fertility

Dr. Joy: Hey, y'all! Thanks so much for joining me for Session 245 of the Therapy for Black Girls podcast. We'll get right into the episode after a word from our sponsors.

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Dr. Joy: As black women, many of us are often drafting and revising our vision boards to include our career aspirations and our financial goals. But how many of us are also including our reproductive desires in our five-year plans? Consider this question: what does reproductive health look like for me? What would I like my parenthood plan to be and how can I make steps towards the future I want? For many people, the process of creating a family comes with its own unique set of challenges. For those dealing with infertility, issues with their fertility, or even those considering fertility preservation methods, the process of becoming or not becoming a parent begins with asking yourself a series of questions, often in partnership with a health professional.

Joining us today to chat about some of these questions is Dr. Tia Jackson-Bey. Dr. Jackson-Bey is a black reproductive endocrinologist and infertility specialist in Brooklyn, New York. As a dedicated fertility expert focused on nontraditional family building, Dr. Jackson-Bey knows the unique challenges black women face while navigating infertility, and processes like egg freezing and in vitro fertilization. Dr. Jackson-Bey and I chatted about patient options when faced with infertility, demystifying the egg freezing and IVF processes, and some of the economic, social and psychological hurdles black women face in the fertility process. If there's something that resonates with you while enjoying our conversation, please share it with us on social media using the hashtag #TBGinSession. Or join us over in the Sister Circle to talk more in depth about the episode. You can join us at Community.TherapyForBlackGirls.com. Here's our conversation.

Dr. Joy: Thank you so much for joining us today, Dr. Jackson-Bey.

Dr. Jackson-Bey: Thank you, I'm happy to be here.

Dr. Joy: Yeah, very excited to chat with you. I'd love for you to just get us started by talking about what you do as a reproductive endocrinologist.

Dr. Jackson-Bey: Absolutely. I'm a reproductive endocrinologist and infertility specialist. For most people, that just means that I'm an infertility doctor. I usually see persons who are actively trying to get pregnant and realizing that they're having some difficulties. But along that spectrum, I also see persons who may have issues that affect their fertility, so things like uterine fibroids or endometriosis or even different endocrine conditions that can affect your fertility in the future. We may work on those in the process so that we can avoid some issues later down the line. I also see a fair amount of patients who are seeking what we call fertility preservation. These are ways of kind of holding on to your current fertility for your future use, so that may include freezing eggs, sperm or embryos to use later.

Dr. Joy: Got it, okay. At what point would someone see someone like you? I'm guessing it probably comes through referrals.

Dr. Jackson-Bey: That is a great question because once upon a time it was very referral based, and many subspecialists will probably remember you had to always go through your primary care to get a referral to go on. Depending on insurance companies, you can book consultations with a subspecialist without a referral and so it is important for individuals to realize when they should seek care or not. For persons who are trying to get pregnant and realizing that there may be an issue, typically under the age of 35, if you've been trying for one year and they have not achieved a pregnancy or have not had a successful pregnancy that's gone on to a live birth, that would be an adequate time to be seen by a reproductive endocrinologist.

For anyone 35 or older, six months is the time limit that we give. And the reason being you could have more issues trying to get pregnant as you age, and 35 is where we start to see that happen, and so we just don't want you to go too long without us seeing maybe if there are some issues that we can address sooner. For persons who are over 40, I actually recommend for them to be seen right away and not to wait more than two or three months of trying. And again, that's really just because they could have more issues trying to conceive and so we may want to intervene sooner. For anyone who's considering something like fertility preservation, they can see us right away. They can book consultations, they may have to have a referral or not. Sometimes we do these consultations on an urgent basis. Maybe if someone's having emergency surgery or even has a cancer diagnosis and needs treatment before their cancer treatment starts, then we would see them quickly.

Dr. Joy: Got it. This age of 35 comes up quite often. Can you tell us what is it about the age of 35 that indicates there's a higher level of concern or we need to be paying more attention?

Dr. Jackson-Bey: Your peak fertility or what we call fecundity–your ability to achieve a pregnancy–really occurs sometimes when persons aren't really concerned about becoming pregnant. In your early to mid-twenties all the way up to maybe early thirties is really when you have the best chance for success on a month to month basis. Around age 35, that chance starts to decrease, and over age 37 it decreases a little bit more rapidly. We use 35 as that inflection point to say, okay, we know that it may be a little bit harder around this time.

At that same age, miscarriage starts to increase and also the number of eggs that you have as well as the quality of the eggs that you have does change. And this is a continuous process, it's not an unnatural thing. It actually is a natural biological function of our ovaries but it doesn't always match up with how we're living our lives today. Because of that, we'd like to see people around that age, or see them sooner over age 35, just with the anticipation that there could be some more issues around that time.

Dr. Joy: Got it. And so when you're 21, 22, you likely may not be thinking about like “okay, do I want to have a baby later,” but sometimes that matches up with peak fertility. Can you share more about what that conversation is that you like to have with your clients?

Dr. Jackson-Bey: Absolutely. It kind of starts with the dichotomous question of do you want children or not? Because for some persons, I think they'll feel pretty convicted that, no, that's not part of my life plan, and that can be helpful. But if it is part of your life plan, I feel like the next question is: do these children have to be biologically related to you or would you be open to something like adoption or embryo or egg donation as a way to achieve your family? Because that also helps us to know which way may make the most sense for you.

For persons who feel strongly about having their own biologic children, either alone or with a partner, then I think it's helpful to have just an idea, a roadmap, a plan in place about when you would want that to happen and how you want it to look. How many children you want to have. To think about these things very much in the way that we think and plan our education and our careers and finances. Everybody talks about like your five-year plan but your five-year plan really should include “what does reproductive health look like for you?” What is your parenthood plan or strategy and how are you making steps towards the goals that you want?

Dr. Joy: You mentioned some of the societal issues that sometimes impact this for black women differently. Can you say more about that?

Dr. Jackson-Bey: Absolutely. One thing that is interesting is worldwide–women are delaying childbearing. People are having less kids overall, particularly in industrialized countries, but people are also starting their families later. And this is due probably in most part to increased education for women, increased work outside the home, increased higher education for some persons seeking masters and doctorate degrees. Unfortunately, it's just still not as easy to start a family or build your family while you're doing all of these different things. Persons also get partnered later. For all of these reasons, the average age at first child has now shifted.

Some persons may find themselves in their thirties considering their first child whereas 100 years ago, people were wrapping up reproduction in your late thirties, certainly by early forties. And so that's a major cultural shift that is actually not... our ovaries haven't really caught up with that. Just acknowledgement of this kind of contrast between how we're living our lives and what our bodies are programmed to do is really important because we have to honor it and be aware of some of the limitations of age on reproduction. Similarly, for persons who are on career tracks or on different education tracks or just don't feel like they are where they want to be in their life in order to start a family, I think kind of having an idea of maybe what are some ways that they can preserve their fertility may be important.

Dr. Joy: One of the ways that you've talked about preserving fertility is through the freezing of eggs. Can you tell us more about what that process is and how it works?

Dr. Jackson-Bey: Yes. Egg freezing is a technology that's come about from in vitro fertilization. A lot of times, when persons want to know if I freeze my eggs, do I have to do IVF in the future? The answer is you actually already did it because the processes are very similar. It involves taking injectable medication for a little over a week, about a week and a half, and during that process, the injections help your body to create multiple eggs in one cycle. Your default is actually to grow and mature one egg for ovulation each month. But using these medications, we can help the ovaries to grow many eggs in one cycle so that the eggs can be removed, frozen and saved for use in the future.

In order to access the eggs, you'll have to go back to your provider, let them know. They would thaw the eggs, inseminate them with sperm to create embryos, and then the embryo would be placed inside of the uterus in order to create a pregnancy. It still involves quite a few steps. In freezing eggs, the whole goal is that (hopefully) even if you use these eggs at a later age, your reproductive potential should be that of the age at which you froze the eggs. And so that can be a very important kind of fertility preserving strategy for someone who maybe is in their late twenties or early thirties, knows that they don't want children maybe for a few years, but doesn't want to fall into some of those issues that you can encounter in your late thirties or early forties.

Dr. Joy: Where are the eggs held after they're frozen? Is that in your office or some other facility?

Dr. Jackson-Bey: That is a great question. The eggs are actually frozen the same day that they're retrieved from the body and then they can be stored long term, either at the facility where you do your egg freezing. Some places will store what we call offsite in larger kind of cryopreservation warehouses. Similar to how sperm is stored in major locations all around the country, eggs and embryos can also be stored long term in the same way.

Dr. Joy: Is there a date by which you have to use the eggs if you're planning to?

Dr. Jackson-Bey: Technically, there is no expiration date. I do like to tell patients to have a plan in place (as you see, there's a theme) and just have an idea of what you would want to do with the eggs. You know, I tell a lot of patients that you may not need these eggs in the future. Many of my patients are either single or partnered but unsure if they want to have a family with their current partner and so that's why they're choosing to freeze eggs. They're not people who have tried to get pregnant on their own, so you don't know if you're fertile or not. In the future, you may just conceive without any assistance and have your family that way, but if you ever need the eggs in the future, then they would be there for you. Having some sort of plan in place to say, okay, would I come back for these eggs in five years, would I come back for these eggs in 10 years? What am I comfortable with doing with them if I don't come back for them? Things like that, I think is important.

Dr. Joy: Are those things you have to have answers for before you start the process?

Dr. Jackson-Bey: You don't have to have this magical plan in place from the beginning. In most cases, there may be some sort of annual storage fee for the egg and so I think that in a way that paying that fee may also serve as a reminder of “Eggs are there, they're doing okay, they're frozen until I need them. How much longer do I want to continue to have them frozen?” Maybe you already have your children or you met your family building goals and you say, okay, maybe I don't feel like I need these eggs any longer, and you would just contact the facility to let them know.

Dr. Joy: Got it. You mentioned the fee, that there's sometimes like an annual fee for storage. What are some of the other fees associated with this process? And are they covered by insurance, typically?

Dr. Jackson-Bey: That's a great question, too. Egg freezing is not typically covered by health insurance. There are an increasing number of plans that are covering egg freezing and sometimes it's covered if it's what we call medically indicated. A medical indication may be if you're having a surgery or a cancer treatment with chemotherapy that we feel will be toxic to your ovaries. And so in order to preserve this fertility potential for the future, we may freeze the eggs in advance, you go ahead and have the treatment, and then we'll figure out how to help you achieve a pregnancy in the future.

Some other medical conditions can qualify for insurance to cover it too, but unfortunately, we're at the mercy of the insurance company's rules. And so at this time, egg freezing remains something that is paid for out of pocket by most people. There are some employer-provided plans that also provide egg freezing benefits. You may have heard of in like big tech companies, some healthcare companies, even big financial and law firms started adding this as an employee benefit. Which I think is great because these young people are working incredibly hard, would like to pursue their careers and really give a lot of themselves, but these are actually during your prime reproductive years. By affording them the option to freeze eggs or create embryos or freeze embryos, that gives them some sort of backup plan for the future.

Dr. Joy: Do you know of price range? Like if I wanted to pay out of pocket for this, how much should I be expecting to have to pay?

Dr. Jackson-Bey: It depends, greatly based on the market, so location where you live or where you choose to do your egg freezing. I would say anywhere on the low end from maybe $5,000 per cycle to upwards of maybe $10,000. But that does not often include the medication that is required for egg freezing and so that could be another $3,000 to $5,000 just for the injectable medication.

Dr. Joy: This is by no means a cost-effective kind of a process, right? This is not something you can just save a couple of hundred dollars for, this is something that you would probably need to do some long-term planning for.

Dr. Jackson-Bey: Yeah, and that's why I think it's worthwhile to really introduce this early. Because we talk about families who maybe put their kids through college because they don't want them to have debt, or help you with a down payment on your first home or something like that–in the future, we may be helping our kids with an egg freezing fund. Maybe that's a college graduation gift instead of a new car or something like that, and it could take planning. Sometimes I have patients, they speak to family members. The power of potential grandparents is pretty strong and, you know, if they understand your desires and career aspirations and want grandkids in the future, this may be a way to help do that.

Another thing is that I think, like so many things, it's an investment. You talked about cost effectiveness but I think anyone who's ever had to use donor eggs to conceive later in life would tell you that they wished they had the opportunity to freeze their eggs for a much lower fee when they were younger, so that they would essentially act as their own egg donor. Even someone who's had to maybe pay out of pocket for IVF or (even if it was covered) used the time at a later age for fertility treatments like IVF, would wish that they had made this kind of investment years prior.

Dr. Joy: It sounds like you encourage having this conversation or at least thinking about it really as soon as you can, like early twenties when you are at peak fertility kind of thing. Would someone just talk with their regular OB-GYN about this and say, “hey, I'm interested in knowing more about this” and then they get a referral to somebody like you?

Dr. Jackson-Bey: Absolutely. And I think primary care providers, pediatricians and OB-GYNs can be a great kind of first line about egg freezing and the options. And just because you talk about it early doesn't always mean that you would have to do it that early in life or that you should feel pressured to do it. Just to know that it's an option, I think it's really important. To know maybe some transparency about pricing in case that's something that you want to plan for or save for could be really advantageous. I have a lot of patients who say, oh well, this is a covered benefit by my job but I didn't even know people were doing this. And so sometimes it's nicer to just have been exposed to it early.

Dr. Joy: Yeah. More from my conversation with Dr. Jackson-Bey after the break.

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Dr. Joy: Besides the costs being a potential barrier, are there other barriers to egg freezing that you can think of?

Dr. Jackson-Bey: I think there might be some kind of social or cultural barriers. I have had some persons suggest that they don't like the idea of egg freezing, that it could be unnatural and not really how they wanted to build a family. Sometimes it can be quite emotional actually, and some people feel that this isn't how they would have liked to have their family start or something like that. And so I think that those are definitely some factors that can play a role in preventing people from taking this step.

Other things, even though it's actually a short time commitment–about two or so weeks of seeing us pretty frequently in the office–we do have to have some sort of time for you to come in for frequent doctor's visits. Early in the morning is typically when we’ll see patients for ultrasounds and for lab work so that we can monitor your progress as the eggs are growing and determine a time to remove the eggs. I always try to tell persons, make sure that you don't have any big travel plans because we have to be able to see you frequently. We want to keep you safe through this process. Sometimes, especially with work from home, I think that's been a great time to freeze eggs as people had a little bit more flexibility and maybe able to make these appointments, whereas if they had to go into the office it might be a little harder.

Dr. Joy: What are you doing during these frequent doctor's visits with you?

Dr. Jackson-Bey: Great question. It all starts with the first day of your period. So many of our treatments and evaluations all kind of revolve around the menstrual cycle because, really, we're trying to commandeer the menstrual cycle to do what we want it to do instead of what your body's natural default is. The default is to grow one egg per cycle. By starting these medications which include a hormone that your body naturally makes called follicle-stimulating hormone, by starting that in those first few days while you're actually still bleeding, it gives the ovaries a big rush and makes them want to produce multiple eggs.

And so when we're seeing you for these very frequent visits, we are actually looking at the ovaries on ultrasound. We can't see the eggs but we can see where the eggs are growing in the ovaries and so we monitor those follicles by looking at them, by measuring them, and then we correlate that with some hormone levels in the blood. So it is frequent blood work, it's frequent vaginal ultrasound–which can seem a little bit invasive and understandably so but it's really the best way for us to gauge what's going on with the ovaries and to keep you safe. Because we want you to make a lot of eggs but not too many so that you feel sick or bloated or have any other complications. That's the reason for those frequent visits and sometimes they can be as frequent as every other day or every day.

Dr. Joy: Let's say someone has gone through the process of freezing their eggs and then they decide five years later like, okay, I think I am ready to thaw the eggs. I don't know if that's the correct terminology, but I'm ready to maybe use my eggs. What do they do then?

Dr. Jackson-Bey: The biggest things are to get back in contact with whoever it was that you froze your eggs with. The things that I always like to know is what's your current state of health? Are you ready to get pregnant now? What is the source of sperm? Do you have a partner that I need to meet? Are we using donor sperm? Is it an anonymous donor, someone who contributed to a sperm bank? Or is it someone who's acted as what we call like a designated or a known donor? Because there may be some tests and some kind of processes that we need to do in that event.

And then we can thaw the eggs, inseminate them with the sperm, and then over the course of just a little less than a week, the eggs will turn into embryos, that’s if they fertilize. We’ll have the option to assess grading and quality based on how well the embryos develop. And also, at the same time, we can get the uterus ready for the transferring of the embryo. The uterus has to have a very characteristic kind of hormonal environment and appearance and that's how we can determine when is the best time to put the embryo back inside.

Dr. Joy: That is how you would then create the embryo? It would basically be in vitro?

Dr. Jackson-Bey: Yes, and that's why I say that it's very much in vitro fertilization, it's just been two parts. Like a now and a later as opposed to persons who are going through in vitro that they're doing it all “now” essentially.

Dr. Joy: Okay, so let's transition into talking a little bit more about that. It sounds like for the more traditional in vitro, you would be going through the process of taking the hormones, trying to create the eggs and harvesting it all in real time, as opposed to having them frozen somewhere.

Dr. Jackson-Bey: Yeah. There still is the possibility for persons who know that they don't want to have children now, think that they want to wait a few years, or maybe they’re partnered now, or maybe they're even choosing to make embryos with donor sperm. But you can also go through that process upfront–make the embryos right away and then freeze the embryos to have for a later use–and that's something that we've done for years at this point.

From in vitro fertilization, because we get so many eggs and create embryos, once upon a time we would transfer multiple embryos and that's why you see “Jon & Kate Plus 8” kind of shows. But nowadays, the technology has become so sophisticated and we have so many ways of really discerning which are the highest quality embryos from maybe lesser quality, that we really recommend to put back one at a time. But that may mean that there are extra embryos and so we would freeze those and similarly they stay frozen and they will pretty much always think it was the day that it was frozen until you're ready to thaw them for use in the future. That's another option of preserving your fertility that may be best for some categories of women.

As I mentioned, if people are already partnered and feel confidently who they're going to have their family with, then making embryos upfront could actually be advantageous. Similarly, sometimes we may not have the best response to the medications. Our goal is to have as many eggs as we can but for women who are older, they may not make many eggs in response to the medication. Or we know that the chance that those eggs may give rise to an embryo with an abnormal number of chromosomes is higher. And so sometimes having that information sooner rather than waiting for years in the future could be helpful for them. And so in those cases, instead of maybe freezing only eggs, we would say let's make them into embryos and freeze the embryos for later use. That's similar to the IVF process.

Dr. Joy: We are talking about this and not necessarily in the spirit of, “okay, you do this and then you get pregnant,” but we know that there's also a lot that can happen on the other end, right? The assumption can't be made that just because you freeze an egg or freeze an embryo, that it will be like a smooth sailing kind of pregnancy with just a little bit of morning sickness. It does seem like... I don't know if it's a higher number of miscarriages, but I definitely hear more people talking about that publicly. Can you say a little bit more about the numbers in terms of how successful pregnancies tend to be after in vitro fertilization or something like that?

Dr. Jackson-Bey: Absolutely. When you freeze eggs, that's the start of this whole embryonic development process. For that reason, we usually like to freeze more eggs than we would need for one child, one baby that comes home from the hospital. The number recommended to freeze can change based on how old you are when you freeze your eggs. Because we know that younger women are probably going to have eggs that are more resilient, that are more likely to result in a pregnancy with a normal number of chromosomes, and therefore that kind of gets this notion of higher quality, so they may not need as many eggs to result in one baby that comes home from the hospital. Versus if it was someone who's older–over 35, over 37, over 40–you actually may require quite a few eggs in order to have that same chance of success. And that is just because of the intrinsic factor of the eggs to turn into embryos and to survive that whole process.

Versus if we're doing IVF for some persons, we're going through that process right away. Usually, if someone is going through IVF, they've already been diagnosed with infertility. Infertility means that they've been trying at least for a year, or in some cases for six months if they're over 35, and have not been able to achieve a pregnancy. And so there may be intrinsic factors to that population that increases their risk for a miscarriage even with IVF. One of the biggest is the age of the woman–that can increase your risk overall.

It's not that it's an automatic pregnancy from any of these processes. It doesn't take away the risk for miscarriage that's just due to intrinsic factors. As you know, miscarriage is very common, probably about one in four women will experience some sort of pregnancy loss in their lifetime. And so this doesn't take away that risk (which is very hard considering the amount of work that goes into it) but it's a way to get over that first hump and get you to the positive pregnancy tests. Sometimes from there, we’re making sure that there are different what we call maternal factors, the uterine environment, making sure mom is healthy in order to continue the pregnancy.

Dr. Joy: In theory, if I froze my eggs at 22 and then I decided, okay, I'm ready to be a mom at 38, is there anything (just off the top of your head) that should make it difficult, beyond just the likelihood of miscarriage that everyone has when they're trying to have a baby? Is there anything about me being 38 using my 22-year-old eggs that would make the pregnancy more difficult?

Dr. Jackson-Bey: Yes. That's because of some of the different things that our bodies go through by the age of 38. One thing I always like to know is how healthy are you now? How is your weight for your height? Do we need to work on weight loss before doing an embryo transfer? Because having excess weight can increase your risk of miscarriage. Things like high blood pressure or even diabetes or pre-diabetes, if they're present or if they're poorly controlled, then that can increase your risk factor as well.

We would always do an ultrasound of the uterus to take a look and see if there are any things like uterine fibroids, which are overgrowths of the smooth muscle layer of the uterus. Fibroids are very present and more common in African American women and they don't always universally cause an issue. The ones that are most important to us are the ones that are inside the uterus where pregnancy would grow and so those may require removal before we go ahead and transfer the embryo. Similarly, if the fibroids are very large or bothersome, then we may also discuss fibroid removal before pregnancy.

Dr. Joy: Okay, so this isn't like I can decide “my 30th birthday is coming up, I think I'm ready to be pregnant on my 38th birthday or three months after.” I can't call you on Monday and say we're going to transfer the embryo on Friday. This is still a series of like questions and assessments that you're making before you find the ideal or the most ideal time to transfer the egg or the embryo.

Dr. Jackson-Bey: I would say I think give it a lead time of two months. Let's see you in the office, we'll do some ultrasound, we'll do some blood work. I'd like to meet this partner if you have one, or understand where your sperm is coming from, to make sure that you guys aren't carriers for the same genetic conditions–things like sickle cell or cystic fibrosis. And just all these different factors to consider and then make sure I look at the inside of the uterus to make sure that it's smooth and easy to transfer the embryo and then we'll make the plan of when to do it. We could set it for a certain date; you’ve just got to come in a little while before that.

Dr. Joy: We’ve got to give you a little bit of lead time. You brought up something about bringing the partner in to be able to do an assessment. Let's say somebody brings a partner in and you run some tests and you realize, oh, this may not actually be a good match (so to speak) in terms of what we hope to be a successful pregnancy. What kinds of things are you talking with him about if that comes up?

Dr. Jackson-Bey: You know, when we meet the partner, this is assuming a male partner, we go over a lot of the same things that we would when I met the patient years before. Just overall medical history, surgical history, things like that. Are they on any medications for chronic medical issues? Anything that could possibly affect sperm quality. Things like smoking or tobacco use, drug use, or even alcohol use if it's excessive. We'll talk about those kinds of things and see what ways that we can modify behavior. A standard evaluation would be with a semen analysis as a first step, to make sure that there are sperm there, that they swim well, that they look normal in shape. We use that as like our first evaluative tool.

Another thing that we may do, as I mentioned, is a serum test or a blood test to look for genetic carriers for certain inheritable conditions. Things that don't necessarily affect you as an adult but they could present in children if both of you are carriers. That's something else that I usually like to make sure is done before we embark on making the embryos. The reason being, if you're both carriers for the same genetic condition, once upon a time maybe they would tell you that, “hey, this is not a good partner for you,” but we do have the technology now to screen your embryos for that genetic condition if you're both carriers. For example, if you're both carriers for something like sickle cell anemia, we would take blood samples from both of you, create kind of a genetic probe that can look for this area of sickle cell-causing gene mutation in the embryo. We can actually screen the embryos for that so we can know which ones are affected with sickle cell or not affected, or carriers themselves, and we can make a plan to transfer embryos based on that information.

Dr. Joy: Got it. So much information, it definitely sounds like lots of conversations, lots of meetings, probably lots of individual research for people to do when they are taking on this process.

Dr. Jackson-Bey: Yeah, it can be and it can definitely be a somewhat overwhelming experience. I think something that can be difficult, especially for black women in this space, is visibility. Feeling like maybe they're the only person going through it. I think for so long they thought that infertility issues did not apply to them. There is the common cultural social stereotype of black and brown women being very fertile. While the vast majority of women will not struggle with infertility, there are some who will, and part of that may be (as I mentioned) with people starting their families later in life than we did 50 years ago or 100 years ago. I think women need to know that there are other women who look like them in this space who are going through what they go through, so that they can feel a little less alone and less isolated through this process.

Dr. Joy: More from my conversation with Dr. Jackson-Bey after the break.

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Dr. Joy: I’d love for you to talk a little bit more about the mental health impact of this process because, again, I've seen lots of people just share the toll that it can sometimes take. I think particularly when people are doing these IVF cycles. I'm imagining some of it is just related to like the increased hormones, right? Taking all these shots and, you know, I’ve got to do all this stuff, but also when the cycle may not be successful. Can you talk a little bit about the mental health impact?

Dr. Jackson-Bey: Absolutely. I think there's a huge psychosocial component to what we do that can be neglected, I think, sometimes in standard medical care. I think anything having to do with reproduction is so emotional for women. There's this notion of what your body should do and we know the shoulds can be dangerous. But, you know, what you should be capable of as a woman, how does it define you? And you can really call that into question. It can challenge your relationship in terms of finances, in terms of goals. What if one person wants to continue with treatment and the other one wants to stop? Both partners can have their own trauma from the experience and sometimes communicating that can be really difficult.

It can add stress in unknown ways. I think sometimes people struggle with whether or not to disclose that they're going through this, they can be afraid of how people will view them. Sometimes, you know, in-laws or older family members can be very rough. Or even just friends and colleagues not knowing what to say and maybe saying “the wrong things.” Oh, you'll just be okay, or take a vacation, or you need to relax. Adding these little anecdotal things that actually are not very helpful whereas what would be helpful is what do you need from me? How can I be there for you?

Another unforeseen stress is work related stress. With the frequent doctor's visits and insurance coverage issues, needing to disclose to your job that you have to have some time off every morning for the next two months or something while you're doing different testing and processes, and that can be very stressful as well. So I think there's definitely a role for mental health support as you're going through this process but again I think the stigma and the shame of people who are in it also is just so much to manage. It can really prevent you from getting that well rounded care that you need.

Dr. Joy: Do you tend to work with mental health professionals a lot, Dr. Jackson-Bey? Or do you frequently make that referral or even have somebody in your office?

Dr. Jackson-Bey: Absolutely. We have a mental health professional in our practice who's available to all of our patients and she'll let you know I refer all the time. I also have mental health professionals that I work with in the community. Some of them have different areas of expertise, some do include specifically issues of reproduction or what we call peripartum, anxiety or depression or any kind of traumatic issues. As you can imagine, sometimes this also feels like trauma. If you've ever gone through multiple cycles and it didn't work or you’re going through a pregnancy loss, there's grief and trauma associated with that. I have a little catalog of people who are able to help my patients through this process because I do recognize that that plays a huge toll in your overall success, actually–how well you're able to navigate some of the mental health side of things. And specifically for African American women, they may drop out of care before getting to a successful outcome because they lacked those kinds of resources available to address mental health issues.

Dr. Joy: We know that high levels of stress and stuff can determine whether a pregnancy is going to be successful, so in the questioning and evaluation approach that you're taking, is that a part of it? Like evaluating whether stress levels are okay to be able to undergo this process?

Dr. Jackson-Bey: Absolutely. I would say probably eight out of 10 of my patients are reporting stress, even from having gotten to my door. Because if you've made it this far, you've recognized that there's an issue and there's a lot of anxiety around that. And so that's why I always bring it up–closed doors, this is a safe space, what do I need to know, let me know if I need to have you here or put the partner out for a little while so we can talk. Or if you want to bring your mom, sure, whatever kind of works for you. But then also to make sure that I include a mental health plan very early in the process. Because even for egg freezers, we take it for granted this is a process that should be very liberating and be very hopeful. You're doing this for your future. But for some persons, it feels like this is not how I was expecting my reproductive plan to go. I would have liked to be married by now, I would have liked to be having children by now. And so it can be very stressful in that way.

Just bringing it up early, making sure that they are aware that we have mental health services within our practice and that I can refer to the community as well. Or if they are already working with a therapist, I tell them like make sure you bring this up so that your therapist can help as you go along as well.

Dr. Joy: Got it. Is there anything that we haven't talked about today that you find yourself talking about frequently, or that you think people should know?

Dr. Jackson-Bey: I think some of the biggest things is just the stigma of it all. It's out here, we are here, and there are solutions for you. I think it can be a very scary place to find yourself in need of a fertility specialist. The other part of it is, you know, I do a lot of research on disparities in infertility care and why is it that black women have different outcomes than any other group? Like why does anybody have different outcomes? Some of it is related to the traditional practice of infertility care in affluent areas and therefore they may not be physically located in areas that are more diverse. They tend to be mostly concentrated on the coasts and in big cities and not necessarily in smaller cities and things like that.

But some of it also has to do with catering to a certain group has now made black women, brown women, other persons feel like they're not included or they're not valued. That can actually keep people away when they should be seeing us and so there has been data that’s shown that black women have a longer period of infertility by the time they come through our door than other groups of women. Also that, as I mentioned, they discontinue care earlier than other women. And so thinking of how can we get more people in? How can we normalize this? How can we make it more acceptable? Those are the things that I'm always thinking about. How do we keep people engaged but also make them aware of what's normal and what's not normal? And so for anyone who's been trying for pregnancy for over a year without success, now is the time to seek treatment.

Dr. Joy: Mm hmm. Do you know the stats, Dr. Jackson-Bey, about how many reproductive endocrinologists are black?

Dr. Jackson-Bey: Oh, that's a hard question. We've tried to do this tally a few times and honestly, I don't know for certain. I know that overall of the workforce, black physicians make up about 5% of the total physician workforce in the US. And black women are about 2% of that, so the numbers really get very small. There are some tools and directories that are available where we're trying to build and make sure that persons who want to be connected with black REI can do that.

Dr. Joy: Got it. Just as you were talking even about some of the cultural stereotypes around black women being super fertile, we know that racism and these stereotypes infiltrate all areas of our lives. And so if we are seeing doctors who think that, oh, black women will just be able to get pregnant whenever, are they not having some of these conversations that they should be with clients?

Dr. Jackson-Bey: Yes. The short answer, unfortunately, is yes and we have seen these biases affect referral patterns and so that's why, again, I encourage people that check with your insurance provider. You may not need a referral from your GYN, you may be able to book with a subspecialist directly. But I also do a lot of education of providers just to also kind of dispel these myths, to make sure that you're giving everyone an equal chance to talk about different ways of engaging the community. Also to broaden their scope of how they accept payment. Somewhere that's cash only essentially may be very discouraging. Whereas if you were open to more types of insurance or empowering patients with maybe like third party payers so that they can have like payment plans and things like that, that broadens who's able to access the care. I actually engage in a lot of that kind of education.

Dr. Joy: I appreciate that, thank you so much. And are there resources for people who maybe want to look more into some of the things we've talked about today? Any things that you frequently recommend to your clients?

Dr. Jackson-Bey: Yeah, there are some different support groups. There is an organization, Fertility for Colored Girls, that is an incredible organization. It was founded by someone who actually experienced infertility herself. She's a minister and so she had like this spiritual component as well as being a black woman and created this great foundation that really serves to have support and prayer and just like a network of support groups. Now it's all virtual across the country, which has a lot of information. They put on a lot of webinars throughout the year.

I’m part of American Society for Reproductive Medicine which has a lot of patient information on their website. And sometimes people start with Dr. Google, and it's not all bad, but I just want to direct you to resources that may be most appropriate. And trying to understand a little bit about what the evaluation entails, maybe that could take away a little bit of anxiety about what's to come and (as I mentioned) what's normal and not normal. Because it always breaks my heart when someone says “I've been trying for five years,” and I'm like, oh, that was like four years too long. Unfortunately, we can't get those years back but we have to start where we can.

Dr. Joy: Got it. We thank you so much, Dr. Jackson-Bey. I appreciate you sharing all of this information with us.

Dr. Jackson-Bey: No problem, it's my pleasure. Thank you so much for having me.

Dr. Joy: I'm so glad Dr. Jackson-Bey was able to share her expertise with us today. To learn more about her and her work, visit the show notes at TherapyForBlackGirls.com/session245. And be sure to text this episode to two of your girls right now. If you're looking for a therapist in your area, be sure to check out our therapist directory at TherapyForBlackGirls.com/directory.

And if you want to continue digging into this topic or just be in community with other sisters, come on over and join us in the Sister Circle. It's our cozy corner of the internet designed just for black women. You can join us at Community.TherapyForBlackGirls.com. This episode was produced by Fredia Lucas and Ellice Ellis, and editing was done by Dennison Bradford. Thank y’all so much for joining me again this week. I look forward to continuing this conversation with you all real soon. Take good care.