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Why Can’t I Get Pregnant Again? Secondary Infertility Explained · Life After Birth by Her Health Room

• 0:00
  Remi Mogekwu: you've had a baby before and now you're trying to get pregnant again and it's not happening, this episode is for you.
• 0:05
  Remi Mogekwu: Maybe the first time was quite quick, and now month after month, you're in a cycle of hope and disappointment.
• 0:11
  Remi Mogekwu: not alone, and also, you shouldn't just be grateful because you've had a baby before.
• 0:15
  Remi Mogekwu: I'm joined by Dr.
• 0:16
  Remi Mogekwu: Nagla, who is a fertility specialist and obstetrics and gynecology doctor, and doing great things on Instagram and TikTok with education, just to really get to the bottom of what secondary infertility is, what it means to you, what actions you can take and if IVF does play a part, what you need to know about it before you go down that route.
• 0:35
  Remi Mogekwu: So thank you for joining us today.
• 0:37
  Nagla (2)Nagla: So thank you for having me.
• 0:38
  Nagla (2)Nagla: Happy to be here.
• 0:39
  Nagla (2)Nagla: So I'm Nagla.
• 0:40
  Nagla (2)Nagla: I have trained in obstetrics and gynecology alongside Remi at times, in London.
• 0:47
  Nagla (2)Nagla: and for the last sort of two, three years, I've been working exclusively in a fertility clinic and just seeing people on essentially all parts of their fertility journey, whether they are thinking about egg freezing or they are coming in as a couple experiencing infertility or they just wanna have an MOT and know a bit more about what is going on.
• 1:05
  Nagla (2)Nagla: So seeing people really through all different parts of their fertility journey, including secondary infertility as well
• 1:11
  Remi Mogekwu: How would you explain secondary infertility to someone who's never heard of the term before?
• 1:20
  Nagla (2)Nagla: Yeah, so essentially you've had a child before, and you are having difficulties having another child.
• 1:28
  Nagla (2)Nagla: And, there's lots of different reasons why that might be the case.
• 1:33
  Nagla (2)Nagla: Sometimes it's just a lot of time has passed.
• 1:36
  Nagla (2)Nagla: We see people who perhaps have had a child in maybe their 20s or even younger at times, and then particularly if they then meet another partner much later in life and they struggle to conceive, time obviously is a really important factor.
• 1:49
  Nagla (2)Nagla: And then there are lots of other reasons which I'm sure we're gonna get into as well.
• 1:52
  Remi Mogekwu: I find when I meet people who are trying to have a baby, socially it can be quite awkward'cause the assumption is you've had a baby before and everyone just like casually asks,"Oh, when's number two coming?" do you find that in your consultations with them, the emotional side of it comes up where people just assume that they are fertile and therefore should be carrying baby number two, three, or four, whichever they choose?
• 2:18
  Nagla (2)Nagla: Yeah, definitely.
• 2:19
  Nagla (2)Nagla: I think there's a real, there can be a real element of shock particularly if your first pregnancy, I've met people who have fallen pregnant in their first month of trying and have gone on to have a live birth from that.
• 2:31
  Nagla (2)Nagla: And the assumption is that is gonna happen again, and so when it doesn't, it can be quite shocking, and it's that, that difference between what we expect and what the reality is that can be really painful
• 2:44
  Remi Mogekwu: Know how common it is for secondary infertility?
• 2:46
  Remi Mogekwu: Or is there another name that you guys have for it that might be a bit less harsh?
• 2:50
  Nagla (2)Nagla: Yeah.
• 2:51
  Nagla (2)Nagla: A lot of medical terms, we know are not the, the k- the kindest, have-
• 2:56
  Remi Mogekwu: yeah
• 2:57
  Nagla (2)Nagla: softest, yeah.
• 2:58
  Nagla (2)Nagla: T- terms like failure and things don't really have a place.
• 3:02
  Nagla (2)Nagla: But yeah, unfortunately the language is not the best, but that's what we have at the moment.
• 3:06
  Nagla (2)Nagla: And it's hard to say.
• 3:07
  Nagla (2)Nagla: We know the general statistics around infertility is that it affects one in six couples.
• 3:12
  Nagla (2)Nagla: We think that maybe about one in 10 will experience secondary infertility.
• 3:17
  Nagla (2)Nagla: And yeah, one of the things that makes it more challenging is that element of shock.
• 3:23
  Nagla (2)Nagla: Also, the- there's a kind of a real emotional tension between the fact that you have a child, and you love the child you have, you're grateful for the child you have but you don't feel that your family is complete.
• 3:34
  Nagla (2)Nagla: And, there's this sort of thing where people feel that they can't really grieve because they should just feel grateful for the child that they have, and also perhaps where people around them are not holding space for their grief and their pain because they're like at least you have one," I always say in, in terms of talking about fertility or infertility, like anything that begins with at least just don't go there.
• 3:55
  Nagla (2)Nagla: Yeah
• 3:58
  Remi Mogekwu: maybe people just shouldn't say it.
• 4:00
  Remi Mogekwu: But you said time in the first answer to secondary infertility, but what other causes are there?
• 4:05
  Nagla (2)Nagla: If you have had any surgery, including how did you deliver your first baby, so did you have a cesarean section, because having a C-section can cause...
• 4:18
  Nagla (2)Nagla: it doesn't mean that if you've had a C-section that you will have difficulties having another baby, and it also doesn't mean if you're having difficulties then it's because you had a C-section.
• 4:26
  Nagla (2)Nagla: But it is possible to cause scarring, and it is possible to affect the fallopian tubes.
• 4:31
  Nagla (2)Nagla: So that's one thing to think about.
• 4:33
  Nagla (2)Nagla: The other thing that we are seeing increasingly, and, I'm gonna caveat this by saying that we don't know really how much of an impact it, it causes.
• 4:42
  Nagla (2)Nagla: But what we're seeing more and more people who ha- are coming in after a C-section and who have a cesarean scar niche.
• 4:48
  Nagla (2)Nagla: Just imagine that your uterus is like a balloon and the neck is the cervix.
• 4:54
  Nagla (2)Nagla: And, we- there'll be a scar basically on, on the uterus.
• 4:57
  Nagla (2)Nagla: But what we are seeing is that there's basically a defect in the scar.
• 5:01
  Nagla (2)Nagla: Now, that in and of itself is not necessarily a problem.
• 5:04
  Nagla (2)Nagla: What can become a problem is that when we see on scans, particularly when we are preparing for something like an embryo transfer, if there's fluid in the upper part of the uterus where we would hope that an embryo will implant and that a pregnancy will progress.
• 5:17
  Nagla (2)Nagla: So we don't know fully the extent that, cesarean scar niches are happening.
• 5:23
  Nagla (2)Nagla: We can't say for certain how much they will impact your chances of having a baby.
• 5:28
  Nagla (2)Nagla: Lots of people get pregnant with cesarean scar niches there.
• 5:31
  Nagla (2)Nagla: But in general, in fertility world, when we are preparing for an embryo transfer, when we are doing scans and things and preparing, we don't like to see fluid in the upper part of the uterus where we want an embryo to implant.
• 5:46
  Nagla (2)Nagla: So that's just something to be aware of.
• 5:48
  Nagla (2)Nagla: So yeah, so previous surgery, and it's not just cesarean sections.
• 5:51
  Nagla (2)Nagla: If you've had surgery for other reasons, say you have some inflammatory bowel disease or Crohn's or something, and you've had an operation, or surgery for endometriosis.
• 5:59
  Nagla (2)Nagla: Anything essentially that can cause scar tissue in your pelvis can also affect your fallopian tubes.
• 6:03
  Nagla (2)Nagla: And I know we'll go and talk about investigations, but previous surgery might trigger you to think about,"Okay, do I need to have a test to check if the tubes are open?" The other things to think about are particularly if you have had a miscarriage or recurrent miscarriages, is it, are there any underlying conditions like any clotting problems?
• 6:21
  Nagla (2)Nagla: The one, the big one that we think about is something called antiphospholipid syndrome.
• 6:26
  Nagla (2)Nagla: And if you are somebody who has experienced multiple miscarriages and you go through a miscarriage service, then that is something that will be investigated.
• 6:35
  Nagla (2)Nagla: You will have bloods to check your thyroid function, lots of other hormones, and to check for these antibodies that we see with antiphospholipid syndrome.
• 6:45
  Nagla (2)Nagla: And if you do have them, then it's something that can be managed.
• 6:48
  Nagla (2)Nagla: Just as a reassurance, it's not like we, there's nothing that can be done about it.
• 6:53
  Remi Mogekwu: Yeah, no, that sounds really good.
• 6:54
  Remi Mogekwu: And I think useful as well.
• 6:56
  Remi Mogekwu: I can think about five or six couples that I know who have had some form of delay in trying to conceive their second baby, and sometimes it happens with treatment.
• 7:04
  Remi Mogekwu: and a few of them would've had sections.
• 7:06
  Remi Mogekwu: So I think it's really important to sometimes make the connection,'cause even though we do sections all the time and we're like,"They're really straightforward surgeries," and you don't know how people heal.
• 7:16
  Remi Mogekwu: And I've actually got a video on the channel about like the longer term complications of having a cesarean section and had discussed the niche, hadn't, guess because fertility is not my specialty area, hadn't made the link between the niche being there and difficulty conceiving.
• 7:32
  Remi Mogekwu: So that's good information.
• 7:34
  Remi Mogekwu: And the other thing as well that you mentioned earlier is if you have a new partner, because sometimes women will go through life and assume it's them,
• 7:41
  Nagla (2)Nagla: Yeah
• 7:42
  Remi Mogekwu: There are two parties at play.
• 7:44
  Remi Mogekwu: And it could be that, the sperm or the semen isn't of good quality.
• 7:48
  Remi Mogekwu: How
• 7:48
  Nagla (2)Nagla: Absolutely.
• 7:49
  Remi Mogekwu: that?
• 7:49
  Nagla (2)Nagla: Yeah, this is what we see, a third of the time.
• 7:52
  Nagla (2)Nagla: It's a male factor, completely a male factor.
• 7:54
  Nagla (2)Nagla: And about a half of the time there's a male factor involved as well as something else going on.
• 7:59
  Nagla (2)Nagla: It is so common, and like you say, the men get forgotten about or left out of the equation.
• 8:04
  Nagla (2)Nagla: Which is so crazy,'cause you're like, you're, you are giving half of the genetic material.
• 8:09
  Nagla (2)Nagla: Of course the health of your sperm impacts not only the chances of conception, but the health of the pregnancy and the health of the child.
• 8:16
  Nagla (2)Nagla: And the good thing, and which I'm always banging on about for men, is that men produce sperm every single second.
• 8:23
  Nagla (2)Nagla: But it takes three months to reach the ejaculate.
• 8:25
  Nagla (2)Nagla: So there are a- actual things that you or your partner can do to improve your lifestyle to, and improve your sperm quality.
• 8:33
  Nagla (2)Nagla: Like quitting smoking, cutting out alcohol, reducing your BMI avoiding things that put a lot of pressure or heat on the testicles.
• 8:42
  Nagla (2)Nagla: So yes very important
• 8:44
  Remi Mogekwu: Now taking it back to the healthy egg or the quality of the egg.
• 8:48
  Remi Mogekwu: As you get older, we know that the quality and the quantity declines.
• 8:53
  Remi Mogekwu: But for each individual person, you wouldn't know when.
• 8:56
  Remi Mogekwu: what tests do you think for someone who is thinking about having a second or actively trying and maybe three or four months down the line it hasn't happened, maybe six months if you're going on the NHS and you're above 35, what tests would you recommend that they at least do, whether it's through the NHS or privately?
• 9:13
  NaglaNagla (2): Your GP will check a full blood count because you wanna make sure that you're not, really anemic, because we know that is associated with miscarriage.
• 9:20
  NaglaNagla (2): Or you want to check your vitamin D levels, because probably living in the UK you're likely to have low levels of vitamin D.
• 9:27
  NaglaNagla (2): And your GP will go ch- check things like your thyroid function, your prolactin.
• 9:31
  NaglaNagla (2): Those are all really important because they can also affect your cycles and in order to get pregnant, you need to be ovulating, which means you need to have a regular cycle.
• 9:39
  NaglaNagla (2): so those are the first things.
• 9:41
  NaglaNagla (2): And I think always start with the basics as well.
• 9:43
  NaglaNagla (2): Then if your GP refers you onwards to a fertility clinic, will also, if you self-refer, then obviously they will do those blood tests as well.
• 9:51
  NaglaNagla (2): Otherwise your GP blood test will be fine.
• 9:53
  NaglaNagla (2): And then you also have a blood test to check your AMH.
• 9:56
  NaglaNagla (2): AMH is anti-Müllerian hormone.
• 9:58
  NaglaNagla (2): It's basically a blood test which checks your ovarian reserve or how many eggs you have left in the bank.
• 10:05
  NaglaNagla (2): thing with AMH is that it's also available direct to consumer, so you can buy it online.
• 10:10
  NaglaNagla (2): You can do a home test and get the results back.
• 10:13
  NaglaNagla (2): Now, AMH is important in the context of fertility treatment because what it will tell you is somebody like me who's doing your IVF cycle, what dose of medication I'm gonna use for your treatment, and it will also help me to estimate, plus alongside your scan, how many eggs that we can retrieve from a cycle.
• 10:31
  NaglaNagla (2): What it doesn't tell you is how likely you are to get pregnant naturally.
• 10:36
  NaglaNagla (2): It has no impact on your chance of spontaneous conception.
• 10:41
  NaglaNagla (2): it also doesn't tell you when you will run out of eggs or when you're gonna go through the menopause.
• 10:46
  NaglaNagla (2): So it's useful in the context of fertility treatment, if you're not going through fertility treatment, it can cause a lot of unnecessary panic which I see all the time.
• 10:58
  NaglaNagla (2): And I'm sure
• 10:58
  Remi Mogekwu: Yeah.
• 10:59
  Remi Mogekwu: And I'm sure there are lots of direct-to-consumer tests that will promise you almost like a fertility MOT by giving you an A-AMH level.
• 11:08
  Remi Mogekwu: I remember covering a fertility clinic in secondary care, so not tertiary level, and a woman had an AMH of one.
• 11:14
  Remi Mogekwu: And the cutoff that you were talking about in the NHS is about five and a half.
• 11:18
  Remi Mogekwu: Whereas in, private IVF clinics, you can tell me what their personal cutoff is, but NHS is five and a half.
• 11:24
  Remi Mogekwu: And this woman had an AMH of one.
• 11:26
  Remi Mogekwu: And for all intents and purposes, she couldn't get referred to fertility services.
• 11:30
  Remi Mogekwu: And the message to her really from the consultant was very much like,"Look, it's really gonna be hard for you to conceive.
• 11:36
  Remi Mogekwu: Might not happen." And then she wrote back a couple of years later to be like,"Now I have a baby." Which I think just sums up that even with this test, even if it's really low, it doesn't mean that you won't have a baby.
• 11:48
  NaglaNagla (2): Yeah, for sure
• 11:49
  Remi Mogekwu: but when you say it doesn't predict or can't predict when you'd go into the menopause or pre-perimenopause, if you're having the test every year or every six months and you're seeing the decline, what's your view on that?
• 12:03
  NaglaNagla (2): I don't think that there is a reason to be doing serial AMH tests.
• 12:10
  NaglaNagla (2): There are studies that have showed that six out of 10 people who have a low AMH test result will retest, and it will be normal.
• 12:16
  NaglaNagla (2): So even for that purpose alone, know, outside of the context of fertility treatment, I think this, that this is a test that can actually a- at times cause more harm than good.
• 12:30
  NaglaNagla (2): if you wanna really get down to the nitty-gritty, ask somebody,"What is a fertility test?" Most people will be like what's my chance of getting pregnant?" It's a test of ovarian reserve.
• 12:40
  NaglaNagla (2): It's important the context of fertility treatment.
• 12:44
  NaglaNagla (2): It's just a normal part of a workup in a fertility clinic.
• 12:47
  NaglaNagla (2): It's not going to tell you your chances of getting pregnant naturally.
• 12:51
  NaglaNagla (2): I've seen people with undetectable AMHs get pregnant naturally.
• 12:55
  NaglaNagla (2): It's something I'm gonna be saying probably
• 12:58
  Remi Mogekwu: Forever.
• 12:59
  NaglaNagla (2): week until I die.
• 13:00
  Remi Mogekwu: Forever.
• 13:01
  Remi Mogekwu: Yeah, I think the, the issue is that I had my AMH done maybe over a year ago now, and it came back as three and I'm t- I was 37 or 36, I can't remember.
• 13:10
  Remi Mogekwu: But I was like,"Oof, okay, so if I do wanna have a baby, I probably need to get on with it." Because, no one wants to see that you're over, like ovarian reserve is low.
• 13:17
  Remi Mogekwu: I think the biggest issue is that when you are in a world where you feel like there are things that you can do to improve your chances, you're gonna take them.
• 13:25
  Remi Mogekwu: And if it, if the difference is a 200 pound test or going to your GP, you're gonna take the test regardless of how predictive it is, and then you're gonna run with it.
• 13:35
  Remi Mogekwu: But I completely, no, I completely agree with you but it has been marketed as a fertility test, which is, we'll move on from there.
• 13:41
  NaglaNagla (2): Yeah.
• 13:42
  Remi Mogekwu: than the AMH,
• 13:43
  NaglaNagla (2): we could spend
• 13:43
  Remi Mogekwu: yeah, exactly.
• 13:44
  Remi Mogekwu: You just--
• 13:44
  NaglaNagla (2): get
• 13:45
  Remi Mogekwu: And it is actually at this point quite academic'cause I, I imagine the person watching is like,"Okay, but I just wanna have a baby, so what do I do?" Other than AMH, a full blood count I imagine an ongoing hormone profile, check their thyroid function, things like that.
• 13:58
  Remi Mogekwu: What would be the next step up?
• 13:59
  Remi Mogekwu: I think also I would suggest that before they even got to a fertility doctor, maybe a semen analysis with their GP for their partner
• 14:07
  NaglaNagla (2): Yeah, yeah, y- I, not sure that the GP will do the semen analysis, but when you get referred, so yeah, if you're coming as a couple, then the woman will have a I'm obviously using very heteronormative language, but, you'll have a blood test and a scan and your male partner will have a semen analysis.
• 14:25
  NaglaNagla (2): Once you've had your bloods, you'll have a scan.
• 14:27
  NaglaNagla (2): Usually, it's...
• 14:28
  NaglaNagla (2): it depends where you go.
• 14:29
  NaglaNagla (2): For example, where I work, I would do the scan during the consultation and then have the whole kind of conversation.
• 14:34
  NaglaNagla (2): And the scan is so important'cause it gives you so much information.
• 14:38
  NaglaNagla (2): So we're looking at all of your pelvic anatomy.
• 14:41
  NaglaNagla (2): We're looking at your uterus, the shape of it, the size of it.
• 14:44
  NaglaNagla (2): Are there fibroids?
• 14:45
  NaglaNagla (2): Where are the fibroids?
• 14:46
  NaglaNagla (2): Are they pushing into the lining of the womb where an embryo might want to implant?
• 14:51
  NaglaNagla (2): Have you had a cesarean section?
• 14:52
  NaglaNagla (2): Can we see a cesarean section niche?
• 14:54
  NaglaNagla (2): Then we're gonna look.
• 14:55
  NaglaNagla (2): If there's nothing wrong with your fallopian tubes, and the tubes are really important'cause that's where fertilization happens, right?
• 15:03
  NaglaNagla (2): Then we won't see them on the scan.
• 15:04
  NaglaNagla (2): If there's a problem for example, it's filled with blood or there's some infection or something there, then we might see it.
• 15:12
  NaglaNagla (2): and then we'll also look at the ovaries, and we'll see how many follicles there are on your ovaries.
• 15:16
  NaglaNagla (2): So the number of follicles that you have usually roughly corresponds with your AMH.
• 15:20
  NaglaNagla (2): If you had an AMH of 10 and I saw eight to 12 follicles then that's totally expected.
• 15:26
  NaglaNagla (2): I wouldn't expect you to have an AMH of 10 and see one or two follicles, for example.
• 15:30
  NaglaNagla (2): And that also, again, reflects your ovarian reserve.
• 15:33
  NaglaNagla (2): So when you go through the process of stimulating the ovaries to try and get lots of those follicles to grow, you can only work with what's there.
• 15:42
  NaglaNagla (2): So if there are 10 follicles, in a perfect world, you would stimulate all, all 10 of them would respond to the medication.
• 15:48
  NaglaNagla (2): They would all grow, and you would do an egg collection, and you would take out 10 eggs'cause one follicle can give you one egg.
• 15:55
  NaglaNagla (2): That's in a perfect world, so it doesn't alway- it never happens exactly like that.
• 15:59
  NaglaNagla (2): But, m- there's a drop-off at each point, but hopefully, the majority of them should give you an egg and then fertilize and create an embryo
• 16:06
  Remi Mogekwu: And so when would you say someone who's trying for another baby should start this investigation process?
• 16:13
  Remi Mogekwu: When should they stop powering through?
• 16:15
  NaglaNagla (2): So if you are under, if you're 35 under, then it's 12 months of trying, and if you're 36 and over, then it's six months.
• 16:25
  NaglaNagla (2): But there is a caveat to that in which if you know that there is a reason that could be causing a problem, then you don't need to wait that, for that long, right?
• 16:32
  NaglaNagla (2): So for example, if you're like,"Oh, I don't have regular periods.
• 16:35
  NaglaNagla (2): I have three periods a year," or,"My period comes once every two or three months," don't wait, right?
• 16:39
  NaglaNagla (2): Because there's a problem.
• 16:42
  NaglaNagla (2): You're not ovulating regularly.
• 16:43
  NaglaNagla (2): You have fewer chances of getting pregnant.
• 16:45
  NaglaNagla (2): Don't know when your period's coming, it's very difficult to predict, so when, when to even time intercourse.
• 16:50
  NaglaNagla (2): So then if you have a problem like your periods are really irregular or your periods are extremely painful or you know you have a condition like endometriosis or you know there's a background of fibroids, or your periods are extremely heavy, all of those things that are red flags for something else going on, should just go sooner because there is something there that could be impacting your chances of getting pregnant, so there's no need to wait for that length of time.
• 17:12
  NaglaNagla (2): I think it is worth saying that unfortunately, the funding around fertility treatment and IVF depends where you live.
• 17:19
  NaglaNagla (2): It is a postcode lottery, but almost everywhere, I think, and I think probably I would say everywhere, will not fund if you have a child already.
• 17:29
  NaglaNagla (2): So that's also one of the things that can be challenging financially, is that the funding isn't always available for people who have had children because that's just unfortunately how it is.
• 17:39
  NaglaNagla (2): You can still have investigations.
• 17:40
  NaglaNagla (2): You can still go, you can still be referred to a clinic, and you might still, have a consultation have bloods, have a scan.
• 17:48
  NaglaNagla (2): You may, as I was saying earlier, that if we're worried about anything with the tubes, you might have a further scan where we also put some dye inside the uterus, and we wanna basically see the dye spilling out of the tubes.
• 18:02
  NaglaNagla (2): It appears bright white on the scan'cause remember I said if there's no problem with the tubes, you might not see them.
• 18:06
  NaglaNagla (2): So yeah, Test just to tell us that the tubes are open.
• 18:09
  NaglaNagla (2): And that all falls under the realm of investigations.
• 18:12
  NaglaNagla (2): But usually where it comes to the point of treatment, if you've previously had a child, and in some places if your partner has had a child then you won't be eligible for NHS-funded treatment
• 18:24
  Remi Mogekwu: Yeah, and I think the whole postcode lottery sucks.
• 18:27
  Remi Mogekwu: But then there's also an element of it is funded from the public purse, so f- all things about fair distribution.
• 18:34
  Remi Mogekwu: I think in terms of just being really clear, although they might not be eligible for treatment, as we know, they can still get to the point of even a secondary fertility clinic to have all the investigations done.
• 18:48
  Remi Mogekwu: And I will often speak to people who they'll go to their GP, and their GP won't even refer them on because they've said,"Oh, you've had a baby before." Or, the GP might do some basic tests, and what you were saying about if you've got a diagnosis of endometriosis, fibroids, PCOS, we know that those are documented on the guideline, so it should mean that you get an earlier referral.
• 19:09
  Remi Mogekwu: But for people who have symptoms of those conditions and no one's even listened to them enough to get that diagnosis, they can often get stuck.
• 19:17
  Remi Mogekwu: So what sort of words would you give them to say to their GP to try and push the boat for a referral?
• 19:23
  Remi Mogekwu: Like, how can they be empowered to, to get their GP to listen to them?
• 19:27
  NaglaNagla (2): Yeah, for sure.
• 19:28
  NaglaNagla (2): So yeah, so just re- reiterating your point that whilst you may not be eligible for treatment, you are still eligible to have investigations, and that does still mean that you can be referred to a fertility clinic.
• 19:40
  NaglaNagla (2): In terms of if you're having difficulties with your GP, the first thing I would say is that if you're, if you just feel, if you're not connecting with your GP, if you feel dismissed, I would ask to see a different GP.
• 19:51
  NaglaNagla (2): Most practices will have a GP with a specialist interest in women's health.
• 19:57
  NaglaNagla (2): They're more likely to be able to support you.
• 19:59
  NaglaNagla (2): I would always, and I think, look, we know the state of waiting lists and things in this country for gynecology, it's awful.
• 20:08
  NaglaNagla (2): But we also know, and especially when it comes to fertility, is that Black patients and people of color face higher barriers to access.
• 20:18
  NaglaNagla (2): then there's also this kind of parallel where we go and if we get pushback, we're like we don't wanna be seen to be too pushy or Aggressive." That's always the, the thing, isn't it?
• 20:28
  NaglaNagla (2): But in reality, you actually have to push more because you are going to face greater barriers to to get through, to the, get through the system anyway.
• 20:37
  NaglaNagla (2): So Get a second opinion if you're not, know, gelling with your first doctor.
• 20:43
  NaglaNagla (2): I think it's good to take somebody with you, especially if you have a friend or someone in your family who's maybe a healthcare professional and knows a little bit more about how to navigate the system.
• 20:53
  NaglaNagla (2): Write down your questions because, as soon as you're in the door, you're under the spotlight, you're probably gonna forget, and you're gonna remember everything as you walk out.
• 21:00
  NaglaNagla (2): I think if a referral is denied, I think it's okay to ask why and ask for that to be documented in your notes.
• 21:11
  NaglaNagla (2): again, I think it's this worry about being seen to be combative, but we have to advocate for ourselves.
• 21:16
  NaglaNagla (2): That's just the reality of things.
• 21:19
  NaglaNagla (2): and the truth is, I'm will be the last person to bash GPs.
• 21:22
  NaglaNagla (2): GPs have such a hard job, and also they are expected to be up to date with so much information.
• 21:27
  NaglaNagla (2): These documents, they are called...
• 21:29
  NaglaNagla (2): So the funding for fertility treatment is decided by an ICB, your integrative care board, and that changes.
• 21:36
  NaglaNagla (2): That depends on where you live and Regularly, so your GP may not be up to date with the latest information.
• 21:41
  NaglaNagla (2): I recently saw a patient who came the GP said,"Sorry, you're over 40.
• 21:46
  NaglaNagla (2): I can't refer you." The criteria in the area had changed that you had to start treatment before your 43rd birthday.
• 21:53
  NaglaNagla (2): So she now came at the age of 42, having wasted some absolutely critical time because her GP gave her the wrong information.
• 22:00
  NaglaNagla (2): And again, it's not about, GPs, but yeah, as I say, this stuff is constantly changing.
• 22:05
  NaglaNagla (2): You can actually access a lot of it in the public domain.
• 22:08
  NaglaNagla (2): Not Will publish their documents, but, for example, I work in South East London.
• 22:12
  NaglaNagla (2): You can type in South East London ICB fertility, and it will tell you all the criteria for referrals.
• 22:17
  NaglaNagla (2): So you could access that information yourself and come armed with that information
• 22:22
  Remi Mogekwu: Yeah.
• 22:23
  Remi Mogekwu: And I think sometimes, when you, when we think about Black and brown people, we think about them not wanting to be pushy.
• 22:29
  Remi Mogekwu: But also if a lot of us are from cultures that respect a hierarchy, that respect positions of power, so then don't feel like you should be questioning someone who knows more than you or tell someone how to do their job.
• 22:42
  Remi Mogekwu: Yeah I think it leads quite nicely onto the fact that you were recently a panelist at the Black and Brown Fertility Show.
• 22:48
  Remi Mogekwu: And I, yeah, I guess the question I have around that is that are you seeing any trends in how they present or when they present, how long it takes them to present?
• 22:57
  Remi Mogekwu: And specifically within the realm of secondary infertility, do they present at all?
• 23:01
  NaglaNagla (2): So in the global majority, we know that HFEA released their trends report a few weeks ago.
• 23:08
  NaglaNagla (2): They say that, patients are presenting on average one to two years later, and that's...
• 23:12
  NaglaNagla (2): Yeah, I will take the population data, but anecdotally, I feel like it's much,
• 23:16
  Remi Mogekwu: Longer.
• 23:18
  Remi Mogekwu: Yeah
• 23:18
  NaglaNagla (2): And I, I work in southeast London in an area that is very densely populated with Black people, but so the representation of Black people in a five-mile radius versus the percentage of patients that we do egg collections for are vastly different, right?
• 23:35
  NaglaNagla (2): So that tells you already that even in an area that is densely populated with Black people, they're not presenting, proportionately.
• 23:43
  NaglaNagla (2): so people don't present or they present many years later.
• 23:48
  NaglaNagla (2): We know of course, we know that fibroids affects everyone, Know that in Black women, that they present earlier, and they're more severe.
• 23:57
  NaglaNagla (2): So that's one of the big issues that I see as well, is that people are coming already way later, and then they're coming with really complex fibroids and potentially needing surgery.
• 24:09
  NaglaNagla (2): And if it's, and it can be a really big operation, which Be waiting six to 12 months for, and then another six to 12 months recover before having treatment.
• 24:17
  NaglaNagla (2): So yeah, it's a huge, it's a huge problem, delayed presentation.
• 24:21
  NaglaNagla (2): Also, we know, for example, things like- we all, was thought to be like a white woman's disease and fibroid a Black woman's disease.
• 24:29
  NaglaNagla (2): So that then means that actually Black women with endometriosis w- are being under-diagnosed.
• 24:34
  NaglaNagla (2): And that's, that also complicates the picture as well.
• 24:37
  NaglaNagla (2): And then, when they go to, to see somebody, they have higher barriers to access, and they're not being referred as much.
• 24:44
  NaglaNagla (2): And then there's the actual systemic racism, right?
• 24:48
  NaglaNagla (2): We That's the bit that we can't say exactly what happens, but we You know, like even from I was listening to the, the, some people doing a study in Cambridge talking about maternal mortality and, like, how it's actually the physical manifest- manifestation or the weathering that happens in your body from experiencing racism.
• 25:07
  NaglaNagla (2): That's a bit harder to pin down, but we know that's a real impact.
• 25:11
  NaglaNagla (2): So
• 25:12
  Remi Mogekwu: Yeah
• 25:12
  NaglaNagla (2): it's really multifactorial.
• 25:13
  NaglaNagla (2): But yeah I, one of the things I really hope by having these conversations and putting ourselves out there and hopefully people seeing, doctors that look like them, is just to encourage people to be seen, to present earlier.
• 25:28
  NaglaNagla (2): I have this feeling a lot of the time where I just feel like we're starting on the back foot, and I find Painful.
• 25:33
  NaglaNagla (2): I'm like I just, I want, I just want people to come sooner.
• 25:36
  Remi Mogekwu: Yeah.
• 25:37
  Remi Mogekwu: No, I completely understand that
• 25:38
  NaglaNagla (2): still the stigma in our communities about infertility
• 25:42
  Remi Mogekwu: Yeah.
• 25:42
  Remi Mogekwu: And I think even when I've spoken to friends who have tried after having a baby, and it might be taking a year and a half, and they are-- some of them are doctors, and I say,"When have you gone and done testing?" Oh, I'll just give it a bit more time." And sometimes I wonder if there's also a fear of knowing the answer.
• 26:03
  Remi Mogekwu: If you can live in hope that it will carry on, like you can at some point conceive, you probably don't wanna be told something is wrong.
• 26:12
  Remi Mogekwu: And there is fear around that.
• 26:14
  Remi Mogekwu: But definitely in the clinical setting, I often, we all sit in gynae clinics and you're speaking to people who are in their early 40s, mid-40s, late 40s, and they're still desiring a pregnancy.
• 26:26
  Remi Mogekwu: And you say,"But what have you done about it?" And a lot of them haven't done much.
• 26:31
  Remi Mogekwu: But I also don't think you can ignore the financial side of it.
• 26:35
  Remi Mogekwu: So for someone who wants to conceive who won't get funded on the NHS, like what values are they looking at?
• 26:41
  NaglaNagla (2): Yeah so it varies depend- depending on where you go.
• 26:45
  NaglaNagla (2): But I would say on average a cycle of IVF can cost between roughly 5 to 8,000 pounds.
• 26:54
  Remi Mogekwu: Okay.
• 26:54
  Remi Mogekwu: Okay.
• 26:54
  Remi Mogekwu: That's actually not as much as I thought I was-- In my head I'd be like quoting close to 10, but yeah
• 26:59
  NaglaNagla (2): Yeah, it depends where you go and know, you can so the HFEA, which is the Human Fertility and Embryology Authority, and that is the governing body for all fertility clinics in the UK, they have a, we can put it in the notes, but they have something on their website called Find a Clinic, and you can look up the clinics that are geographically close to you.
• 27:17
  NaglaNagla (2): You can also see the data that they publish every year about their success rates, what their live births are per embryo transfer, per egg collection, et cetera.
• 27:27
  NaglaNagla (2): And you can go on their website and see their price list as well.
• 27:31
  NaglaNagla (2): It's, it is expensive and the drugs are expensive as well, so that's one For is that some IVF packages will encompass everything.
• 27:39
  NaglaNagla (2): Some of them will, you have to buy the drugs separately and that can be a significant cost.
• 27:43
  NaglaNagla (2): So you can contact clinics as well and ask them to give you a, a quote and things and yeah, there's no getting around the fact that it is, that it is really expensive and it's unfair
• 27:54
  Remi Mogekwu: Yeah.
• 27:54
  Remi Mogekwu: And I also think sometimes there's a cultural stigma.
• 27:58
  Remi Mogekwu: So I'm Nigerian, but Black British for all intents and purposes.
• 28:03
  Remi Mogekwu: And I feel when I speak to Nigerian or any Black British Africans, there's a concept of no, I don't wanna do IVF." But if I speak to Nigerians in Nigeria, they'll do IVF after the second or third month of trying.
• 28:16
  Remi Mogekwu: And It's interesting to me how the diaspora are a lot less keen to take it up, whether it's religious beliefs, cultural beliefs, the stigma attached to it, not feeling that they're able to discuss it with people.
• 28:30
  Remi Mogekwu: And obviously the cost is a big barrier.
• 28:34
  Remi Mogekwu: And then that's why you probably do see people going abroad.
• 28:37
  Remi Mogekwu: And if, say, someone was going abroad, what length of time would they need to give for a full cycle,
• 28:42
  NaglaNagla (2): so a typical cycle will start, it will, also have to allow a bit of time for your period because usually you start your in, in like a what's a, the typical and more common protocol, you start your injections on the second day of your cycle.
• 28:58
  NaglaNagla (2): So that's the hormone injection that you, that is gonna be stimulating the ovaries and those follicles to grow.
• 29:04
  NaglaNagla (2): And on average, people have about 8 to 12 days of injections, but you can call it two weeks.
• 29:10
  NaglaNagla (2): And then you have a trigger injection.
• 29:13
  NaglaNagla (2): and a half later, you have an egg collection.
• 29:16
  NaglaNagla (2): Now, there's two ways to do the embryo transfer.
• 29:20
  NaglaNagla (2): You can either have a fresh transfer, so your eggs are collected, then they are mixed in the lab with the to create embryos, and they are fertilized and cultured over about five days.
• 29:31
  NaglaNagla (2): So you can either have an embryo transferred five days after your egg collection, so we call that a fresh transfer, or you freeze the embryos, and then you come back, and you do it a month later or two months later, but again, timing it with your period.
• 29:45
  NaglaNagla (2): If you start from injections all the way to a fresh transfer, it's about six weeks
• 29:49
  Remi Mogekwu: And what are your personal opinions on people traveling or going abroad for IVF just to get it cheaper?
• 29:57
  NaglaNagla (2): It's tricky because, I don't know all of the clinics that people go to.
• 30:01
  NaglaNagla (2): I don't know about the regulation about, the experiences that people have.
• 30:07
  NaglaNagla (2): I have obviously seen people, we've seen people come Having had had their treatment abroad.
• 30:12
  NaglaNagla (2): People will always do it just because it's more accessible, but I would just urge people to do a lot of research before, before they go.
• 30:21
  NaglaNagla (2): It's tricky.
• 30:22
  NaglaNagla (2): If a clinic is offering to transfer three, four embryos at once, that's a huge red flag.
• 30:27
  Remi Mogekwu: Okay.
• 30:27
  Remi Mogekwu: Let's say it again so that people in the back can hear.
• 30:30
  NaglaNagla (2): Yeah.
• 30:31
  NaglaNagla (2): The thing is people always say, e- even in, in clinic now they say can't you just transfer two?" And I think a lot of the time people think, oh, twins or triplets, that's Think of the other side, which is
• 30:40
  Remi Mogekwu: Yeah
• 30:41
  NaglaNagla (2): how high risk these pregnancies are.
• 30:44
  NaglaNagla (2): We're not just thinking about getting you pregnant.
• 30:46
  NaglaNagla (2): We are wanting to get you to the end of a pregnancy with y- you healthy and a healthy baby in your arms, and the safest and the best way to do that is by transferring one good quality embryo at a time and having a singleton pregnancy.
• 31:00
  NaglaNagla (2): There's always the chance even w- in IVF when you transfer one embryo that may split and you might have twins.
• 31:06
  NaglaNagla (2): It's still quite low risk.
• 31:07
  NaglaNagla (2): It's slightly higher than the general population.
• 31:09
  NaglaNagla (2): But yeah, we get nervous around m- multiple
• 31:13
  Remi Mogekwu: Yeah.
• 31:13
  Remi Mogekwu: And I think as well I think I s- I say this a lot in all, in a lot of my videos, like what's paramount, I think, is your health.
• 31:21
  Remi Mogekwu: Like getting pregnant is great, but also being healthy, healthily pregnant is important.
• 31:28
  Remi Mogekwu: Having as healthy a delivery as you can possibly have, and then also having a long, healthy life at the other end of it to raise the child.
• 31:35
  Remi Mogekwu: Like there are so many things to consider, but I can completely understand how when people are narrow-minded and focused on just getting pregnant, that they forget about all the other risks.
• 31:45
  Remi Mogekwu: And I think it probably wasn't too long ago that I saw about a 48-year-old with triplets, and obviously they came at around 28-odd weeks and needed to be in the baby unit, and there was no unit that could have them, so all three of them got split up and Yeah, I'm human, so I can see the appeal for going abroad, but yeah, probably just be as safe as possible with it.
• 32:08
  Remi Mogekwu: I wanted to circle back to something that you had said.
• 32:10
  Remi Mogekwu: About the, the Black and Brown show that you did.
• 32:15
  Remi Mogekwu: Were there any other key takeaways that you would want people to know?
• 32:19
  NaglaNagla (2): I think, to be honest, I think advocating for yourself is key.
• 32:23
  NaglaNagla (2): Early diagnosis, early referral is really important.
• 32:27
  NaglaNagla (2): I think the education piece is really important as well,'cause Talk a lot about how so much of our sex education is just about really how to not get pregnant.
• 32:34
  NaglaNagla (2): And so there's this massive gap in the middle where, we just think once I take the contraception away, pregnancy is obviously gonna follow, and then it can be really shocking when it's not that easy.
• 32:44
  NaglaNagla (2): So it's a lot about understanding your cycle, your health, what's normal for you.
• 32:51
  NaglaNagla (2): What are the, these things that we've been conditioned to accept, like having really painful, heavy periods, Are just not normal, and they need further investigation.
• 32:59
  NaglaNagla (2): So working out what's normal for you.
• 33:00
  NaglaNagla (2): I think social media is really good because you...
• 33:04
  NaglaNagla (2): know, even I do it.
• 33:05
  NaglaNagla (2): If you're going through something, you type it into the TikTok search bar, because you wanna see people who have other lived experiences.
• 33:11
  NaglaNagla (2): But it's also really important to remember that somebody else's experience is not a universal truth, and just because something worked or didn't work for somebody else, doesn't mean it's gonna be the same thing for you.
• 33:21
  NaglaNagla (2): So you need to really take the time to understand your body, your cycle, have some investigations and a scan is so important.
• 33:30
  NaglaNagla (2): I would urge people not to just do a random AMH without any context.
• 33:34
  NaglaNagla (2): Ideally, do that in the context of a, a scan and a consultation.
• 33:39
  NaglaNagla (2): Often also, when you break up those, all those little tests, In one, it's cheaper.
• 33:43
  NaglaNagla (2): Yeah, so understand about your body
• 33:45
  Remi Mogekwu: Yeah, no, that's really great.
• 33:47
  Remi Mogekwu: And so if someone did wanna have IVF, you said the HFEA website, which I'll link down below.
• 33:52
  Remi Mogekwu: Other than looking at cost and you said sort of success rates, are there anything else that people need to be looking at on that website to help determine which clinic is best for them to go to?
• 34:04
  NaglaNagla (2): There's a good resource actually there's a website called Evidence Based IVF.
• 34:08
  NaglaNagla (2): So there's lots of as well as just the conventional IVF, there are lots of IVF add-ons.
• 34:13
  NaglaNagla (2): So these are like extra tests or procedures which are, in theory, going to help you or increases, increase your chances of having a live birth.
• 34:22
  NaglaNagla (2): And one thing that we didn't touch on, is genetic testing, Because that's one thing particularly if you're going into IVF older, that might be suggested to you, or if you've had multiple losses as well.
• 34:34
  NaglaNagla (2): And it's essentially just a screening test to tell you if a, the embryo that you're going to transfer has the correct number of chromosomes, because we know that's the biggest reason why embryos don't implant or Have a miscarriage.
• 34:48
  NaglaNagla (2): but it doesn't increase your your chances of having a live birth, it just reduces your chances of having a miscarriage, and it shortens your time to a live birth because you're just, you're not transferring any embryos that are not genetically normal.
• 35:00
  NaglaNagla (2): But then there are also lots of other add-ons.
• 35:02
  NaglaNagla (2): There's immunotherapy and lots of things that, don't have a huge amount of evidence behind them, and some of them can be incredibly expensive.
• 35:12
  NaglaNagla (2): So this website basically like summarizes all the evidence that is available for these add-ons, so you can understand what they are, what the evidence is, how much they cost.
• 35:23
  NaglaNagla (2): Because, you're, when you're in a situation where you really want a baby and it's such a deep and a visceral And somebody's saying,"Hey, maybe try this'cause it might help," you just gotta do a bit of your own research as well,'cause it,'cause you can be vulnerable in those situations
• 35:37
  Remi Mogekwu: I'll link it down below as well so people can have a look,'cause I think that's really important.
• 35:41
  Remi Mogekwu: And I remember the, the talk around fertility treatment and add-ons just never ends, and evidence base for all of it has been a topic I've heard since 2012 when I did my master's in it.
• 35:52
  NaglaNagla (2): Yeah
• 35:53
  Remi Mogekwu: So I think websites like that are really good.
• 35:55
  Remi Mogekwu: So I think hopefully if you could just say one thing for the woman who has had a baby, she's been trying for 18 months, she's not yet gotten help because she doesn't quite know how to or how to navigate the system, what would you say to her that we might not have already touched on?
• 36:12
  NaglaNagla (2): I think the first thing I would say which is not practical advice, but I would just say that your pain is real.
• 36:18
  NaglaNagla (2): Your desire to want another child, your desire to feel that your family is complete is valid, and that you can have a child and be grateful for that child, and you can still grieve and still feel pain around the fact that your family doesn't feel complete.
• 36:33
  NaglaNagla (2): I think if motherhood teaches us anything, it's that there are so many contradictions.
• 36:37
  NaglaNagla (2): Both of those things can be true at once, and it's okay to just hold space for both of those emotions.
• 36:41
  NaglaNagla (2): And just because you have a child doesn't mean that you don't warrant or deserve or to have a better understanding of what is happening.
• 36:50
  NaglaNagla (2): That might not look like going for IVF for everyone, but it might look like being seen in a clinic, having a test to check your tubes.
• 36:59
  NaglaNagla (2): There are things also that we can do to improve our general health and our chances of pregnancy, even if we're not going through fertility treatment.
• 37:06
  NaglaNagla (2): For some people, that might be quitting smoking or weight, that might restore their ovulation or, and then that gets them pregnant.
• 37:14
  NaglaNagla (2): So there even if you feel like that's not for, that IVF, that's not for me, that doesn't take you out of the conversation, that there's still always space for everyone.
• 37:23
  NaglaNagla (2): And there are also other ways to have a family that are not represented in our, cultural imagination.
• 37:33
  NaglaNagla (2): It's always worth having a conversation
• 37:35
  Remi Mogekwu: And also tracking things that you can track without a test, right?
• 37:38
  Remi Mogekwu: Have your periods changed?
• 37:40
  Remi Mogekwu: Are you having regular periods?
• 37:42
  Remi Mogekwu: Have your periods become heavier?
• 37:43
  Remi Mogekwu: Do you have new signs of a new gynae condition?
• 37:46
  Remi Mogekwu: And things like that.
• 37:47
  Remi Mogekwu: So yeah, no, I think that's been really helpful.
• 37:49
  Remi Mogekwu: I love how you said there are other ways to have a family that our culture don't necessarily accept.
• 37:54
  Remi Mogekwu: I know I would challenge that, because I do think, again, if I think back to if I'm in Nigeria and I've got lots of cousins who were raised by people who weren't their mums,
• 38:04
  NaglaNagla (2): Yeah
• 38:05
  Remi Mogekwu: and it was actually really normal to take kids in and I wonder if that's because of the history of sort of higher rates of maternal mortality and a child needed to be looked after.
• 38:14
  Remi Mogekwu: So I do think there are so many things that are in our culture or have been part of our culture that we just once we're in a diaspora act like they're taboos, which is really interesting.
• 38:24
  Remi Mogekwu: But yeah, a completely separate topic.
• 38:26
  Remi Mogekwu: I think the information is really great and I imagine will speak to a lot of people.
• 38:29
  Remi Mogekwu: If you have any questions like leave them down in the comments below.
• 38:33
  Remi Mogekwu: I'll also tag Naglaa wherever you can find her and she's doing lots of really good education around fertility and like I remember actually commenting on one of your videos once'cause my periods had gotten shorter.
• 38:44
  Remi Mogekwu: I was worried that I wasn't ovulating and I was like,"I'm pretty sure my luteal phase is seven days or something," and you were talking about it in the context of fertility.
• 38:52
  Remi Mogekwu: I remember like texting you about it.
• 38:54
  Remi Mogekwu: So do reach out to her.
• 38:55
  Remi Mogekwu: She's really responsive.
• 38:57
  Remi Mogekwu: But yeah.
• 38:57
  Remi Mogekwu: Perfect.
• 38:58
  Remi Mogekwu: Do you have any things you wanna leave us with or any last words?
• 39:02
  NaglaNagla (2): I just actually wanted to touch back on a point that you said You know, have your periods changed or anything.
• 39:06
  NaglaNagla (2): When you go to see your doctor, I think having a diary is really helpful because, when you go in you're like,"Oh, I think it changed.
• 39:12
  NaglaNagla (2): Maybe maybe this." But if you're like,"So my period is normally, my cycle is five days long and in January it changed, and then it, they became really heavy and then I started passing clot- And if you, if it's really like you've got that, those quite powerful.
• 39:27
  NaglaNagla (2): So yeah
• 39:28
  Remi Mogekwu: Yeah, no, completely agree.
• 39:29
  Remi Mogekwu: Yeah, track it on your whichever way you want to track it.
• 39:31
  Remi Mogekwu: Even if you're, like, digital averse, you could put it in a diary and take it in.
• 39:36
  Remi Mogekwu: It makes a world of a difference to the doctor that you're talking to.
• 39:40
  Remi Mogekwu: Thank you very much.
• 39:41
  Remi Mogekwu: So yeah, so if you want more content like this, feel free to subscribe to this channel, find Magda on her channels and then drop some comments down below so we can carry on the conversation there.
• 39:50
  Remi Mogekwu: But until next time