Monica Moore is a Women’s Health Nurse Practitioner, specializing in REI (reproductive endocrinology and infertility). The founder of Fertile Health, LLC, she works to educate REI nurses and other practitioners, giving them the tools to provide a caring and productive experience for each individual patient. She is also an amazing advocate for PCOS sufferers, being one herself. She can help navigate the winding and often confusing path of infertility and PCOS. Find out more at: http://www.fertilehealthexpert.com/.
What led you to a career in fertility?
Interestingly, although I can’t imagine doing anything else, I wasn’t initially drawn to it. I had just graduated with my Women’s Health NP degree, moved to NYC and tried to find a job in an OB/GYN office but couldn’t. I interviewed at Cornell’s infertility center as a nurse. The physicians there didn’t really know what a NP was or could do (this was 20 years ago). We made a deal. I would work “as a nurse” for 6 months and learn reproductive endocrinology and infertility (REI) and if, after the 6 months, they thought that I could add value to the practice as an NP, then they would segue me into that role, and it worked. I’m forever grateful that they believed in me and gave me a chance.
You started Fertile Health, LLC as a way to teach providers and others how to empower patients. What led you to do so?
I love the comments, texts, holiday cards and other little thank-you’s that I receive from patients. On one occasion, my daughter was in the same class as my patient’s son and she never failed to recognize or thank me at every single school occasion. Made me feel so proud of doing what I do, but I realized that I wanted to make an impact on a greater level, if I could.
When I was in graduate school for a Master’s in Women’s Health, I was taught REI for 1 day. I had a total of only 2 classes the whole time that I attended school there, and my Master’s was in Women’s Health! Then, when I started my first job in infertility, I was taught REI on the fly by a smart, knowledgeable and well-meaning, but very busy nurse. There was no formal orientation program and the learning materials were suboptimal. They were still using a slide projector for their patient teach class. We converted it to power point and made the slides more robust and informative. It was very clear to me that we were lacking a formal infertility teaching program and that this led to nurses feeling a bit less empowered and confident, which bothered me. I started making my own learning modules that I used to train nurses where I worked, and other centers asked me to help them. After that, I had a graphic designer make special images, just for me, and have created 9 learning modules, of which I’m very proud. I’m also hoping to make an online course for REI nurses so that they can log in and review the information when they get a free moment, and I will be available for added support.
What are the most common issues you find for nurses who work in fertility practices?
For sure, there is a lack of comprehensive orientation for fertility nurses. There are some online options through the American Society of Reproductive Medicine (ASRM) and drug companies but, in my opinion, they are not very interactive. Many small to medium REI practices don’t have a dedicated nurse educator, so the new nurse’s orientation can be sub-par. Again, many of the nurses and physicians are incredibly smart and talented, but might have time constraints and/or poor materials. When I hear some nurses answering question on fertilization results, for example, I can tell if they have a true understanding of meiosis (cell division) or if they could benefit from some enrichment in that area. Also, infertility can be a stressful field. It takes a special person, one who has empathy and compassion, yet can multitask and have a sense of urgency, to succeed. In my experience, that combination is difficult to find and when you do, you have a special nurse who really excels in this field.
You state that each patient is unique and you work to teach nurses how “to provide a considerate and productive experience.” I love this because I think people can often feel as though they are just one of a million patients that day, and their providers are just going through the motions without listening to their concerns. Can you talk a little more about what you mean by this?
I have learned, over time, to treat every patient as if they were my sister, friend, or special person. I can tell you, though, honestly that there was a time when I was newer to REI that I rushed patients off the phone after a negative pregnancy test or out of the room after a bad pregnancy ultrasound. This was not because I didn’t care, but because I was uncomfortable being the bearer of bad news. I felt like I was breaking their heart and their spirit in those moments. So, I did my best to escape them, an admission about which I’m embarrassed now. Then, I had my own pregnancy loss and realized that I could be a real resource for these women when they really needed it. As a result, I spend the time I need with patients, sometimes comforting them, sometimes just listening, sometimes being the target of a venting session. Whatever someone needs. My hope is that I can instill the need to do this in all fertility nurses and that they won’t need to have had their own loss to empathize with those who have suffered one. I’m happy to share this experience with them when I teach my Early Pregnancy learning module as it’s just as important to understand the grieving experience as it is to understand the physiology of loss.
I find nurses to be the heart and soul of pretty much all health practices. What are some things you tell fertility nurses in particular that are helpful in treating patients?
Fertility patients are incredibly savvy and usually hungry for knowledge. We can’t always tell them why their cycle didn’t work, but we can teach them about their bodies and and the process that they will be experiencing. Also, don’t assume that women have a good understanding of the menstrual cycle. Most of us are taught to ignore it or combat the symptoms of it, now it seemingly runs our lives for the entire process of the fertility journey, and this often isn’t an easy shift to make in terms of our thinking.
People often assume providers know everything there is to know about treating patients. As an educator for these providers, what questions do they most often ask you?
I get a lot of questions on the intricacies of the endocrine system and on cell division. Many nurses barely learned about these in school and, if they did, don’t remember the details (probably due to PTSD after these intense, and often, boring lectures). Also, I am often asked how best to deliver bad news, such as a negative pregnancy test. Finally, male factor issues come up a lot. Since we barely see male partners, nor have we learned much about male anatomy, this is always an area in which I find a large knowledge gap.
What changes have you noticed over the years in regard to providers and practices in the field of infertility (besides medical advances). For example, are more practices incorporating or suggesting other forms of treatment (yoga, counseling, acupuncture, etc.)?
This has been one of the most exciting and encouraging areas of growth in the REI field, in my opinion. There are numerous studies about the positive clinical effects of acupuncture, such as relaxing smooth muscle (such as the bladder and uterus). Acupuncture, yoga, exercise, and massage, are such great self-care interventions, which are crucial during this process. The fact that REI centers now offer some of these services in-house reflects the fact that we are finally learning to treat the infertility patient holistically. The importance of having many options self-care cannot be overemphasized as we remove many or our stress-release methods as part of preconception counseling (like alcohol consumption and strenuous exercise) right when patients are often the most stressed. Seems unfair to do this and not offer other options.
You have personal experience with PCOS. Have you found that this has affected your professional life, working in the field of fertility?
In a word, greatly. PCOS patients (like myself) often have fragmented and suboptimal care. You see a dermatologist for acne, a pediatrician or GYN for the menstrual irregularities, maybe a medical endocrinologist if pre-diabetic, and no one communicates with each other. I have seen friends with PCOS being diagnosed with seizures and migraines when really, what they are experiencing, is hypoglycemia as a result of the insulin resistance that is inherent in PCOS. I have seen PCOS girls placed on high-androgen activity birth control pills, just because they were low in estrogen. High androgenic activity is exactly what they don’t need! When the REI center where I work (RMA of CT) would get a PCOS patient referral, we would provide them with comprehensive care, communicate with all of their other providers, but only see the patients once a year or so, and really more follow-up was needed. As a result, the medical director, Mark Leondires, M.D., agreed not only to starting a PCOS clinic within the practice but also to hiring a nutritionist who specializes in endocrinology (this is very important) who works in-house. It has been so incredibly positive for our patients! The nutritionist also refers them to other complimentary care providers, such as psychologists, exercise physiologists, and acupuncturists so that their mental and physical needs are addressed.
Can you talk more about what PCOS is and how it affects fertility?
Simply put, PCOS is a disease the creates an environment in the ovary that is not conducive to follicular growth and ovulation. As a result, women with PCOS rarely ovulate, which can lead to infertility and endometrial hyperplasia (build-up of the lining of the uterus). We think that the “culprit” in this disease process is insulin resistance. Insulin is the ‘key’ by which blood sugar (glucose) is let into the cell where it can function as energy for cell processes. Patients with insulin resistance produce insulin in response to glucose, but the cells are not sensitive to it, so the pancreas keeps pumping out insulin, a process called hyperinsulinemia. Both hyperglycemia (excess glucose outside of the cells) and hyperinsulinemia are damaging to the cells (and body as a whole) over time. Excess insulin results in elevated androgen (male hormone) levels that already plague PCOS patients in the form of excess hair growth, acne, and/or male-pattern hair loss. Hyperinsulinemia also has metabolic consequences, such as high cholesterol and triglycerides, an increased risk for type 2 diabetes mellitus and other cardiovascular risks. Being overweight or obese exacerbates these risks, so the key to managing PCOS (and it can’t be cured, just managed) is to strive for a healthy weight and to eat and exercise in a way that promotes insulin sensitivity.
What would you tell someone who has just been diagnosed with PCOS?
I see PCOS as a ‘disruptor’, and I mean that term as defined as something that creates a challenge, a roadblock, takes you out of your rhythm or comfort zone. But the beauty of a disruptor is that it causes discomfort, which makes you decide to make a change in your life, usually for the better. In business, disruptors can lead to innovation. PCOS has been that for me, it provided the incentive that I needed to make mental and physical health a priority in my life. I would caution a newly diagnosed PCOS patient that it can feel overwhelming and frustrating at first, but it is manageable, controllable and might actually put you in a better place than your peers. For example, many of my friends who don’t have PCOS and are now in their 30s or 40s are struggling with weight loss after pregnancy or just an accumulation of weight over time. They could eat and drink whatever they wanted when they were younger and it eventually caught up to them. I was already disciplined by the time I had kids and it was a blessing in the long run.
Are there any tips you can give someone diagnosed with PCOS?
Come to terms with the fact that you have to eat differently than your friends or peers. Ultimately this is a good thing because it is the basis for a life-long approach to nutrition but it’s hard, at first, to see your friends eating pizza or pastries or ice cream and not gaining a pound, whereas you are more likely to gain weight and feel badly. Combining a ‘slow’ carb (usually one that is not white, like brown rice, quinoa…etc) with a healthy fat (such as avocado or natural nut butter) and a low fat protein in each meal can help avoid hyper- and hypoglycemic (low blood sugar) episodes. I’ve gotten to the point that I know what to eat to feel great and how I feel when I eat sub optimally. For example, I cannot have a meal that is solely carbs, like most breakfasts. I have had to automate my breakfasts because I know what works. I have either steel cut oats, eggs or avocado toast. By automating meals, it takes the indecision out and also assures that I have the ingredients in my house because it’s likely that I’ll be eating one of those three things every morning, so I have them on hand at all times. Automating meals, like breakfast and lunch and having a day for meal prep (mine is on Sunday) are huge in terms of being committed to healthy eating.
What advice would you give to someone about to begin the process of infertility interventions?
I would say to realize that the outcome is most likely going to be good because the great majority of people who undergo fertility treatments are able to achieve a pregnancy. The journey, though, can be bumpy. It can actually suck, if I’m allowed to say that. It’s so important to identify some forms of stress release that you can employ when attempting to conceive. I also advocate being “selfish” and let me explain what I mean about that. It’s ok to not go to everyone’s baby shower. It’s ok to feel sad or annoyed at pictures of babies that seem to have taken over social media. It’s ok to not want to listen to everyone’s problems or issues. It’s ok to have good and bad days, to feel that you go two steps forward and one step back. And it’s ok to lean on people, like your partner, friend and absolutely your nurse. No question is too stupid, no emotion too intense, no choice is wrong. I can’t emphasize that enough.