When to Schedule Consultations & More with Nurse Practitioner Steph Kagan!

From an Instagram LIVE interview with Steph Kagan on September 16th, 2020

Schedule a consultation with Steph right through your Premom app!
We're really excited to have Steph here today. She is one of our Premom virtual consultants right in app. We're super excited to have her. And you can get to know her a little bit and see if she's someone you'd like to work with. Steph, why don't you start by telling us a little bit about who you are, what's your background, your experience and all that great stuff? 

Sure. I grew up in Florida, and I'm actually currently living in Colorado. So I've been a nurse since 2012. I was a labor and delivery nurse for about three years. Went to University of Central Florida. And then I decided I wanted to pursue women's health further. So I went to Thomas Jefferson University in Philly and got my master's degree there, specifically in women's health nursing. And ever since then, I've been in the field of reproductive medicine or reproductive endocrinology, which is specific to women's fertility. So, I have spent the last five years working in a reproductive office doing things like inseminations, IVF cycles, oral cycles, like Clomid, letrozole, things like that. Really managing fertility cycles for patients.

Fantastic. Wow. 

Yeah. So I've kind of seen both sides of the women's health field. I started in labor and delivery. And now I'm back on the other side helping women reach that goal. So it's pretty cool to have seen the whole spectrum from start to finish.

Yeah, that really gives a complete picture I'll bet. Why did you choose to work with us at Premom?

Actually, I was really excited about this opportunity. Premom, I think is an essential step to helping women get to that goal of expanding their family, whether it's their first baby or third baby. A lot of these reproductive offices that I work in are not so accessible to patients. So this really changes the game for people, to allow them to have access to providers like myself, who work specifically in there, you know, some of these offices don't take insurance, or they don't take the insurance that the patient may have. So this really gives them that opportunity to get all that quality information from being at home and not using their insurance or anything like that. And it's much more affordable for patients. And sometimes it's pretty intimidating to really make that call to an infertility clinic and say, hey, I need help. So this is a little bit more comfortable from your home. You can sit there with your partner, your husband, your wife, and really kind of have that safety net of being home, not being so exposed. They can choose to just chat if they don't want any type of video, face to face or the video face to face is awesome. I've done phone calls, we've done secure chat. It's really been great for patients to ease their way into that field of taking that next step of seeking help for fertility.

Fantastic. What do you specialize in your work?

When I work at or when I work at the IVF clinic, it's mostly IVF cycles and things like inseminations. We do cycle monitoring. We're watching very closely, LH surges, patient's hormones, how they're changing. And then we specialize and I personally specialize in nutrition for women's health. So I also have my own small business called Nourish Mama, where I help women who are trying to conceive currently pregnant and postpartum with the nutrition aspect of pregnancy and everything related to it. Because unfortunately, while there's so much information out there, it kind of pulls you in all these different directions. It's kind of like which one do I follow, which one do I start. So I don't believe in anything restrictive any extremes. I don't think you have to give up carbs forever. I don't think you have to never eat dairy again. There's really healthy ways to kind of promote your hormone balance and everything. So a lot of the clients that are using the Premom app and they're tracking their cycles are really paying attention to hormones, but then we can also start adding in the nutritional component and try and help regulate cycles. I specialize in a lot of unexplained infertility PCOS. A lot of the PCOS patients that I work with have a metabolic or nutritional component. They're at risk for high blood pressure, metabolic disease, like heart disease, things like that. So when you pair that hormonal irregularities of PCOS with the nutritional component, I really work on matching those two things up to make sure we're getting the longest strides we can towards reaching the goal.

Fantastic. So who do you enjoy most working with? Do you enjoy working with those who are struggling with PCOS or similar challenges for fertility? 

Yeah, I really enjoy PCOS. I had a huge PCOS pop following back when I was working in Pennsylvania of patients who really were able to utilize the nutritional component. But really, the most important thing to me is being adaptable, being willing to implement some changes. I can give you all the advice in the world, I can guide you, I can tell you, hey, these hormones we need to pay attention to or we need to draw this lab. Or make these changes, but if you're not willing to adapt or change, it makes it much more difficult. So anytime I see a patient -- no matter what culture their from, or what their struggle is -- everybody has their own struggle, whether it's a weight struggle, PCOS struggle, endometriosis, something like that. As long as you're flexible and adaptable and willing to try some new things to help push you towards that goal. I'm all game.

Awesome. And you guys should definitely check out her Instagram. I was poking around there a little bit today. "nourishedmomma." I thought that I saw you have a recipe or two in there, and you have a lot of great pictures there.

Yeah, thanks. I'd like to talk about specifics, nutrients like choline and folate versus folic acid, beta carotene, all of those little micronutrients that can really add up and make a difference in pregnancy. Things that when the baby's eyes are developing in the womb, when we need to be focusing on certain nutrients. And then when you're trying to conceive certain things that you want to cut out like canola, oil, vegetable oil, all of those things are very, very inflammatory. And when you're trying to conceive, keeping that inflammation in your body as low as possible is absolutely crucial. They help a lot of moms -- and women who are trying to conceive that aren't yet moms -- really just reduce inflammation, regulate your cycle. The more regularly you're ovulating, the easier this all becomes. So Premom is fantastic. Because it really helps you  -- the app helps you figure out each month when you're ovulating through all of the science and the data behind it. So, if you start adding all these things together, we're really stacking the odds in your favor.

I wanted to ask you one more question. I don't know if everybody knows the difference between nurses and nurse practitioners. Can you talk a little bit about the different specialists in the app and what you do specifically, like the difference? 

Sure. I've been both a nurse and now I'm a nurse practitioner. The difference is really the scope of practice. So as a nurse practitioner, I can really treat you as my patient when I'm working in the office, I can prescribe you medications, I can come up with a treatment plan, I work very closely with physicians to really implement the plan. As opposed to when I was a nurse, it was a little bit more the physician gave me the plan or the nurse practitioner gave me the plan. And I helped outline those steps for the patient. As a nurse practitioner, we've been educated to take in data, come up with different diagnoses. If you give me the data, I can say okay, it could be A, it could be B, it could be C, and then you work together with a patient and create that diagnosis to really help problem solve. Instead of -- as a nurse -- you're following steps, you're doing step one, step two, step three. to help the patient. As a nurse practitioner, you're saying, hey, we need to think about what could step one be? What could step two be? As a nurse practitioner, I can really help create and understand what's going on, rather than just kind of say, hey, do these steps in this order. It's more figuring out what those steps really are.

As a nurse practitioner, it's nice because we're kind of a middleman. A lot of offices will call us "mid level," which some PAS and NPS don't like, but it is what it is. We really are kind of that middleman between physicians and nurses. With a physician, sometimes they don't truly have time to sit down and go over the fine details. But as a nurse practitioner, we have usually more time. Our schedules are a little bit more flexible. Being an NP I specialized in women's health specifically, so I spent my whole entire nursing education on women's health specifically. As a physician, you get to do a whole bunch of different things and really be broaden, but then sometimes they know a little bit of everything, and then sometimes it's great to work with it a women's health NP who really that's their niche. 

That was a great description.

Yeah, I would love it if some of the clients that are using the app are following here on Instagram could send over some questions and stuff.  We could talk about nutrition and pregnancy, etc. I have a question:

When do you recommend to see a specialist? And when can you expect during a consult

Typically, in the infertility world of insurance diagnosis, anybody under 35 has to try for a year in order to be billable or your insurance covers any type of infertility treatment. If you're over 35, it's six months. That being said, if you do have any other underlying conditions like PCOS or endometriosis, those timelines don't really apply.

There's two different things I want to clarify for that person who asked it. Seeing an OB/GYN versus seeing a reproductive endocrinologist are two very, very different things. Seeing an OBGYN, they can technically prescribe you Clomid, they can give you that medication and say, hey, this might help you regulate your ovulation.

However, when you go see a reproductive endocrinologist or nurse practitioner, like myself, that works in infertility, the way we give you that medication and the monitoring that goes along with it is very, very different. We would give you the medication, but we would draw hormones on day two or three of your cycle, we would draw them again on day 10, 12, 15 until we absolutely confirm ovulation.

The difference in seeing your OBGYN is that they kind of hand you the medication and say, "Okay, good luck; I hope this works." But with a reproductive endocrinologist and people who specialize in fertility, it's: "Here's this medication. Now we're going to see back five more times this month, and we're going to tell you within 36 hours of when you're ovulating."

That's what's nice about the Premom app too, is with that LH it tells you "Hey, you're ovulating now," not just "Hey, with Clomid you might be ovulating in the next five days." Over 35: six months. Under 35 -- one year trying or just even actively, you don't have to be trying trying, but you can say: "Hey, it's been a year, I've been off birth control. We haven't been trying, but we haven't been not trying." That's when you should go see a specialist. If you have PCOS or endometriosis, you should start that process sooner.

Somebody else asked a question about successful tips for IUI. If you're doing an IUI in a reproductive endocrinologist's office, you want to make sure that going into that cycle, your weight is optimal, you're exercising, you're doing all of those little things that can really add up and stack the odds in your favor. I always recommend patients to be taking a high quality fish oil. But there's a few different options for fish oils, things like that, really, you want to go into your IUI feeling as good as possible. And I do want to touch on weight, because weight is the one thing that you kind of do have control over. Sometimes, we don't get to pick the stack of cards that were dealt when it comes to fertility, but a 5% reduction in weight more towards your optimal weight -- or even 5% gaining weight if you're severely underweight -- can really really boost fertility chances. So for the person who asked about IUI, I obviously don't know you personally or what your weight is like, but just kind of make sure that's in line. 

There's another question here. If the blood test shows you aren't ovulating, is that a fairly easy thing to fix?

Yes. So I'm not sure what blood test you had, but probably a progesterone level. If that progesterone level showed that it's low, less than three that indicates the ovulation did not happen. In that kind of situation, what we would do is prescribe a medication called Provera. Provera is a progesterone withdrawal supplement. What happens is your body thinks you have progesterone, the progesterone goes away, your body says "Oh! No more progesterone," and your cycle starts. Then we would give you something like letrozole or Clomid to help stimulate your body to make a mature follicle.

So to kind of touch on just the physiology of your cycle: the first half is estrogen- dependent, and the second half is progesterone-dependent. So estrogen is when your ovaries are working, working, working, growing that follicle,  estrogen's rising. And then you have your LH surge -- which is what Premom prides itself on is really monitoring that LH surge -- the LH surge spikes, and then within 36 hours after that you typically have ovulation. After ovulation, your estrogen kind of plateaus and then stays steady, but your progesterone spikes up. So for the person who's asking me about the blood test showing that you aren't ovulating, I'd have to talk more to them specifically. You can feel free to message me on nourishedmama, and I can answer some basic questions for you. But if you want to set up a consult in the app, I can really go into detail with you. But, we can fix it with modern science. Also, there could be some things that we could do to just see if your hormones are -- or inflammation is -- a little bit out of balance, to help you get ovulating.

I have a four centimeter cyst on my right ovary. My doctor says it's nothing to worry about. Would an IUI be successful with the cyst?

So it depends on the type of cyst. But yes, there are two types of cysts. There are functional cysts and simple cysts. Simple cysts are not producing hormones. They're kind of a bug. Sometimes they can cause you some pain or some discomfort, but they're not pumping out hormones that would impact your cycle. However, if your doctor draws your estrogen level on day three of your cycle, and it's through the roof, which it shouldn't be, then that cyst is making hormones, and it's called a functional cyst. That could interfere. However, if your doctor I'm sure is monitoring your blood work and your hormones as well, you can certainly be successful with an IUI and an ovarian cyst at the same time.

Next question: my husband and I are trying to start a family. I haven't been to a doctor in five years, but I'm 30, periods are regular, and I'm very healthy. Should I go to the doctor to get checked out?

Yes. So I do think you should go to the doctor and get checked out just because you wouldn't want to be four months pregnant, and then find out "Hey, I haven't done a pap smear in five years. And now I have this stage 2 something that needs to be taken care of." But then it's too high a risk to do it while pregnant. Most likely, you should hopefully be very successful in your pregnancy and getting pregnant quickly, I hope for you. But it's always a good idea to go into it and say "Hey, what's my hemoglobin a1C, what's my cholesterol look like?" Because pregnancy -- although you feel young and healthy and great -- can really change things, and you don't want to end up with preeclampsia, or high blood pressure or anything that can make your pregnancy high risk. Because we want to remember, the goal is one healthy baby, healthy pregnancy, healthy mom, healthy baby. Just touch base with your doctor. It doesn't have to be anything invasive. But just some simple blood test to make sure that you're safe to be pregnant is the best thing that you can do for yourself.

I also have never peaked over .8. Is that low? Am I ovulating? It looks like this person here is asking a question about her LH tests. The data that Premom uses and the science behind it, the numbers are quantified by how dark your test line is to your control line. That may be different for everybody. Some may come up at 1.31 and some may come up at 0.8. I don't want you guys to stress the numbers. If you're showing a change in you're getting negatives, negatives, negatives, but still getting positives and then back to negatives, it's still showing that LH peak that we're looking for. If you want to talk more about whether you are ovulating, set up a consult. I'd be happy to talk with you more about it, but you could definitely still be ovulating with that .8.  

Each month LH surges are different in everybody, That LH surge may be 30. Anything over 30 is a true surge when you're looking at blood levels. Premom app, luckily because it's so noninvasive, is not looking at your blood levels. It's looking at just that control line versus your test line. I don't want you guys to stress the numbers. .8, 1.0 1.1 -- no big deal. As long as we're ovulating, having regular cycles, we can still be successful.

I had a chemical pregnancy -- am I more likely to miscarry again? 

Two answers to this. If you had a chemical pregnancy and there was no fallopian tube involvement, no, you're no more likely to have another miscarriage. Usually a chemical pregnancy, what happens there is the embryo implants into the wall of the uterus. At that point, it's day five blastocyst. So that point is the cells are growing. The trophoderm around the embryo is expanding. And at that point when the embryo implants, the genetics, mitosis, meiosis, all of that's happening. And when those cells are dividing, and the DNA is all starting to line up, a chemical pregnancy is usually a misfire in the DNA. So when you have a chemical pregnancy your beta HCG, and your blood work is showing a positive pregnancy test. But luckily, at that point, there are no structures present. There's no fetal pole, no heartbeat. So chemical pregnancy shows that your uterus is able to implant an embryo which is the silver lining and all of it, that's great news. However, you know, it still is tragic. These patients feel usually pretty disappointed afterwards. But no, you should not increase your risk to miscarry again. However, if you tend to have a few chemical pregnancies in a row, I do recommend getting some genetics drawn because you want to make sure that you and your partner don't have something that happens to both be recessive genetic problems that are lining up. So most likely, the answer's no. But the only way to confirm that would be to draw your karyotype, which is your chromosomes and your partner's chromosomes and some genetic tests.

We also track with basal body temperature.

Yes, basal body temperature is a big part of the Premom app. BBT is great, because you get very in touch with your body. And that's what I like about Premom is it doesn't take you from, "Hey, we're trying at home" to "Hey, I'm thrown into an IVF cycle" right away. It's learning how your body responds, your cervical mucus, your basal body temperature . . . so keep charting your BBT; that also will confirm because we should really see that rise. So keep doing that. That's a good thing.

Can you have a consult without using the nine cycle tab in the app?

Yes, you can set up a consult by only being two or three cycles in. So I've worked with moms who have both done the six cycles and who haven't conceived yet. And they're part of that pregnancy guarantee, I've done those. And then you can come in right on in and set up a consult, no matter how many cycles you've done. Obviously, the more data that you've logged, the more it can help you just because I can see all of that information.

At the more tab, if you go to the bottom right of your app, it'll give you all those little bubbles, and one of them is "Schedule Consultation", so you can tap there and find everybody in there.

Yeah, then it will say like doctors, nurse practitioners, nurses. I'm under the nurse practitioner column. You'll find me there. My name is Stephanie Kagan, my headshot is there, and you would just click,  If for some reason there's not a time in the app that you're seeing that works for you, if you message me on here, I can try and open up some flexibility for you because the more moms I can help just one step towards that goal, the happier I'll be.

Next question: after ovulation my basal body temperature doesn't rise right away, usually taking three to four days. Is it a bad sign? Do I have low progesterone? 

The only way to diagnose low progesterone and a lot of people think they have low progesterone. It's very, very rare. It's okay if your body takes a few days to rise after ovulation. Because remember, ovulation is typically 36 hours after your LH peak. However, it may be 12 hours, it could be 36. So that day or two fluctuation is normal, I wouldn't stress it. However, if you're certainly concerned that you have low progesterone, there's a really easy test to do. And that would be a blood test. You can get it through your OBGYN or a reproductive endocrinologist. It would be drawing a progesterone level about seven days after you ovulate that progesterone level should be greater than 10. If it's greater than 10, you're good. Lower than 10 might have some low progesterone going on.

If your period is very irregular. Can one still schedule for a consult? Yes, absolutely. This is a big part of the patient population I work with, those who have irregular cycles. It's okay, that's what we're here for. We're here to help you understand that irregularity. If we can get it more regular, it's obviously easier to conceive. When you know that your window for trying is between day 13 and day 16 -- it's pretty small. When you have one cycle, let's say 28 days one month, and then 45 days the next month, and then 64 days the next month, it gets very, very broad. And the problem is knowing when you're ovulating is difficult. So for the lady that asked that, try and track as much as you can right now, it will help us kind of narrow it down. But also if you've done any testing for PCOS -- this would include testosterone testing, a whole bunch of different hormones -- all of those lab values can kind of help guide us to understand why you're having irregular cycles. Because the number one symptom of PCOS is cycle irregularity, which would mean anything greater than 35 days in one month, and then less than 35 days in another. Yes, you can still schedule a consult even if it's very, very irregular. Anyone that has questions, feel free to shoot them over, schedule a consult. Let's get the conversation started and get you closer to your goal.

Okay. Thank you. That's all about fertility, how awesome Steph is. Now you know a lot more about what she does and how she can help you specifically. You're amazing! Anything you want to leave us with?

No, all you girls out there trying: I believe in you. It will happen. We'll get you there. It's tough, but also reach out. A lot of people who are in this infertility struggle don't realize how many other people are also in it. So use your support system -- whether that's us and whether we can help you -- or talk to your friends, your family, talk to strangers and blogs, do what you need to to support your mental health. 

Okay. All right. Thank you for joining us today. Please message us, message Steph. And we'll see you on Premom. 

Yeah, I'll see you soon guys. 

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