Sexual Intimacy & Trying To Conceive

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Hello hello. I am excited to be with you here for another conversation. I am super excited for today's topic. The goal for today is a really good talk and it's talking about sexual wellness during the infertility journey. And I'm really, really excited for today's guest. She is the go-to person in this.

So good to have you on. Likewise, I'm excited to be here today. Yes, so uh, you know this is a topic. Sexual wellness during the fertility journey. I can tell you for a fact that as providers, we don't talk about it, but I know that it is something that deeply affects the couple as they're going through this. I want to give Dr. Yaz a proper introduction because she has many, many letters after her name. So Dr. Yaz, she is a board certified OBGYN. She is the founder and CEO of Alray Direct OBGYN Care practicing in Raleigh North Carolina. And she is also a Fellow of the International Society for Study of women's Sexual Health. So I'm really, really excited to have you here today.

Dr. Sueldo: -I want to just start by asking you an intro question, how did you become interested in this and sort of what led you to become sort of interested and develop this specialty?

Dr. Yas: -That's a great question, you know, like you, I was an OBGYN, the mainstream OBGYN, delivering babies, lots of babies and doing surgeries, hysterectomies and take out the ovaries if there is any problem. But then I was really lost when my patients would ask me this sexually intimate questions like low libido or sexual pain or lack of orgasm or vaginal dryness. I mean other than the focus of hormones like estrogen or something that you can give as a premerin or something over the counter like lubricants and moisturizer, we didn't have much answers to that. You know, we don't dive deeper, like, you know, in medical schools and residencies, we are not really given a curriculum to study about female sexuality.

So it opened up my mind saying there's a huge gap in the knowledge and care in this area, so I kind of enrolled myself to become a sexuality counselor, and I went to the University of Michigan in Ann Arbor in the Midwest and did a one-year postgrad certification to become a sexuality counselor, which is kind of certified by the AASECT and AASECT is the governing body that we have in our country here for sexuality counselors and therapists, you know, so that's the long answer.

Dr S: -No, amazing, and I could not agree with you more. I think that our training and our exposure as students and residents is so limited that then when we go to practice, it's really not something that we're comfortable talking about. So we don't. That's really not, you know, it's not the best care for the patient. So I guess the first place I want to start is: when patients are trying to conceive intercourse now takes on a whole new meaning. It becomes mechanical, it becomes a chore, and it can affect a couple's intimacy journey. So can we talk a little bit about: 1. Do you see that in your practice and then 2. What are some things that patients can do to combat that or to counteract that?

Dr. Y: -Absolutely you know what happens in fertility or any other chronic illness where we are trying to achieve some outcome. Sex becomes like sex on demand. There is a medicalization of spontaneous sex, so everything rotates in fertility around your ovulation, your fertility window, your opks, your ovulation predictive kits and your ultrasounds, your medications. So you lose that spontaneity, in sex or intercourse or outer courses or whatever way that couple is engaging in pleasure. So the piece of sexual pleasure and connection is slowly ebbing out of that relationship and the focus is mainly on the task of conception. So when that happens like you are trying to conceive and have a baby, baby-making is the main task. But you forget that there is connection and pleasure as well surrounding it and the couples lose that and when they lose that it becomes more of mechanical becomes more of medicalization. Okay, when is my relation due? When is my cycle? When is my philology positive and that is something that I tell my patients. I see this pretty often in fertility treatments in other forms of treatments, so I tell my patients to not combine these two things. The task of enjoying and having sexual pleasure is not just baby-making but to look beyond it, like keep up the connection in that relationship, seek for sexual pleasure rather than the task of achieving pregnancy.

Dr. S: -And I feel like and thank you for putting it. So it's such a great visual, so one is the task of conception baby making, pregnancy like you said medicalization of that aspect. But the other is the sexual pleasure that so far up until now had come along with that and I'm really interested in the impact, the division that happens in the couple when you lose that sexual pleasure. I mean, I know in my specialty, I have seen couples divorce because of infertility and the toll that it has taken on their relationship.

Dr. Y: -Absolutely, absolutely, because what happens is. I have seen couples like they are not sexually active till that ovulation window, because there is so much pressure, there's so much expectation both for the male partner or female partner or whoever is in that relationship. The pressure is mounting to reach that fertility window and we focus mainly on that fertility window of five days or seven days in a month and you are putting everything in that phase. So when you do that, what happens the expectations on both the partners is so high they don't enjoy that sex to be really pleasurable or enjoyable or connecting or emotionally connected. So if something does not get achieved as a product, like as a pregnancy outcome of that sexual intimate encounter, they are frustrated, the couples are frustrated ‘Oh my God, nothing happened this month. My pregnancy test was not positive’. So that builds up resentment, that builds up frustration. And there is one partner, usually what we have seen as sexologists and sex medicine doctors, one partner is probably complaining and criticizing when there is not a positive outcome and the other partner gets withdrawn and defending. So what happens in the long run if this task of trying and trying and trying for pregnancy goes too long, libido is out of the window like sex drive is out and then creeps on other areas of sexual dysfunction. I hate the word dysfunction because I don't like it. Sexual dysfunction, there's nothing like sexual dysfunction. I think it's all here and the genitals, so I hate that word. But there is some form of a disconnect that happens in the couple where their libido goes down and everything is like mechanical. ‘Okay, I'm getting into my bed. This is my day 12. Day 14 I have ovulated. I need to have sex because I need a positive pregnancy test which is the product of this sexual encounter.’ So I think to not focus only on that fertility window and to keep your sexual experiences spread out throughout the month, like the follicular face.

Dr. S: There are two kinds of groups of patients, so one group is maybe just starting their fertility journey. They’re maybe just starting to try. They're sort of early on in things, what preventative measures can they do to not get to that point? So that's the first group and then the second group I want to talk about: Maybe they've been in the journey for a while. Maybe they've experienced trauma from a loss or an ectopic pregnancy or something like that, and they're really in a not good place sexually as part of their intimacy and what can they do to sort of get back to a healthier place of more pleasure? Well, It's really about fulfillment in their relationship right like there's so much more that goes behind that sexual connection. So I want to focus on those two groups of people. Maybe first, let's start on the preventative techniques and maybe some preventive measures that you would encourage and you would advise patients to do as they begin this journey.

Dr. Y: -You know ideally the situation ends up in the same place, so it's kind of the same strategies for both these groups that you're telling. We incorporate these strategies earlier on for your younger group which is starting the journey. But we are taking all these strategies to another group which has walked this journey for a few years or a few months, but it's pretty much the same foundation. The first and foremost is acknowledging and having good sexual communication with your partner. Right from the getgo. You can say that there is a crisis in achieving a pregnancy. That's why they are seeing you as a fertility doctor. They're coming to your clinic and they are focusing and achieving a pregnancy because something did not happen spontaneously. So they're seeking fertility treatment, whether they are in the beginning of this journey or a couple years into this journey, I would say an open communication with your partner like you acknowledge that this is a rough path. We are going to go through this journey. We don't know how long it's going to be. Our sexual life is open like we are not having spontaneous sex in the privacy of our bedroom. My doctor, my nurse, my MA, everybody's going to talk about my intercourse and there is going to be medicalization. And we have to show grace and empathy to each other. We got to share feelings. We got to share what your feelings in this journey are to begin with. And I think this is so important for your starter groups like with the ones who are starting this journey to say, ‘Yeah like you know, this is going to be a rocky road. Let's talk about you and I are going to be open communicators. You're going to tell me how are you going to feel when you don't have sex or what you don't like about this. And when am I going to feel that I'm sexual? I want to be connected? Are we just going to focus on this fertile period'?’ So acknowledging that is very important.

Then the other thing is you protect that union, that you are coming together to make a baby. As prevent other intrusions from outsiders like, you're in a family, you're going through fertility treatment. You're creating your support network around you. So the support network that you're creating. You need to be very choosy and selective as to which person in that network is going to know about your sexual struggles, your trials and tribulations. You don't want judgments. You don't want opinions from people eroding that relationship or that fertility treatment, so I would really guard that. I would tell that couple. ‘Yes, you need to guard your sexual intimacy from extra people and extra intrusions that are going to happen’.

The third thing is as you said sexual pleasure goes beneath like sexual emotional intimacy connection. This is both for the later group and the early starters. Don't just focus on that fertility window of five to seven days. Focus on connection, emotional intimacy, fulfillment that you said the joy and being in that relationship throughout the month. You know, like, make it the entire month of having sexual experiences in the follicular phase. After the ovulation phase, bring in novelty and curiosity.

Don’t don't just think, ‘Okay. I need to have intercourse. This is to make my baby’. Go and have a great sex. Don't do boring sex. Go and have sex in front of your living room, like on a rug in front of the fireplace, not in the bed. Not something that you routinely do to achieve the task of baby making. Create some, think about some creative ideas, take a hotel room, have a sexual experience somewhere out of your ovulation time. Keep up that spiciness and keep up that connection and that intimacy outside of that ovulation window. And that takes a long time. It will help you throughout the journey whether you are successful or whether you get that product of pregnancy or not but constantly checking in with each other like your partner and yourself, that would be great.

I actually gave a little exercise to my patients. I give them a paper or like a workbook and I tell them to write to each other what they like, what they don't like, for example ‘I don't like this, you touching me here or I don't like this during my fertility time’ or you know something that they are not open enough to tell their partner you could just write in like colorful pieces of paper or something nice like like a letter in an envelope and exchange that over a dinner. You know, somewhere outside your bedroom where you're not very vulnerable somewhere where you can really talk about these things. So I think communication is the key and to maintain that intimacy and that connection outside of your fertility window is the key.

Dr. S: -That's awesome and I actually have a couple follow-up questions. One question that came up prior to today's talk was to know when and how often should people try to conceive. And so what I typically explain to patients is that if you are having regular monthly cycles and you are able to track ovulation typically with an ovulation predictor kit, you don't need to do basal body temperatures, you don't need to do an app, although most of my patients have an app really. The idea is, if you are getting a positive ovulation predictor kit, you have intercourse the day of the positive and the day after. That's it. The rest of the month should be for you guys, so I completely align with what you're talking about in terms of keeping up that connection. In fact, when you're going through fertility treatment and you have an IUI, an insemination or you have an egg retrieval, it makes it that much easier, because then it's like, well, all you have to do is rely on that. So in terms of the baby-making piece, everything else, all the other sense, pleasure, pleasure and connection. So I completely aligned with that. But that was one question that had come up Now, a follow-up question to you is. Where can couples start when they're already on the other side when they are completely burnt out, when the connection is lost, when the intimacy just isn't there anymore, or if it is, it's completely mechanical and medicalized. What can they do to sort of jumpstart or ignite sort of that return back to that connection?

Dr. Y: -Take away the focus, take away the focus of trying for pregnancy during ovulation. The key to peace is communication. I, being a sexuality counselor and a doctor, I get these couples in my office to sit in front of me because sometimes these women and men or women and women, they take a long time to reach this journey and they don't even communicate to each other because that relationship is so burnt out with the task of trying and trying and trying, it's hard for them to open up a communication. So I kind of become a person like a sexuality counselor to initiate that conversation. To say you both have challenges. I mean even the partner who's not trying to conceive, but who's not the uterus carrier or a male partner or another person who's not carrying the pregnancy also has challenges like we'll talk a little bit about erectile dysfunction in a minute, but they also have challenges because they are feeling they are not coming up to the mark of giving you the good quality sperm. They're now giving you the good pregnancy, so they have guilt, they have expectations, they are fearful, they are ashamed, and they have their own baggage. But nobody's there to ask them. So I think going to a doctor or a sexuality counselor because doctors can only be sexuality counselors and we have therapists who are mental health professionals. And I have a lot of sex therapists who are attached with my office. And I'll tell you when I send patients to sex therapist as well. Because there is an important role for a sex therapist in my practice is when I see there is trauma or there is something that I cannot do as a doctor and as a sexuality counselor, I will seek the help of a sex therapist who is going to dive deeper into what is causing this relationship issue. What has made them sit at two ends of the room and just come for the appointments for fertility? What has made them be a sperm donor and an egg donor and really not emotionally connected? So I feel if the partners can initiate that conversation and really rescue that relationship or really kind of take that relationship back in their control, it's okay to ask a doctor who is comfortable talking. You know, the majority of the OBGYNs are not comfortable talking. Yes, majority 99 percent. Unless they are are sexuality counselor or somebody who's sex certified or maybe a sex therapist, they will just outright tell you ‘Oh, we are not going to do that’, but you look for that kind of a doctor. You know if you go under AASECT, you will find people like me like AASECT Certified sexuality counselors. You will find therapists and you can seek the help of these people and start communication and open up that box of communication and then rebuild it from there.

Dr. S: -So my followup question my last question before we move on to another topic. What happens when the couple is not on the same page? So you have maybe one partner who wants to connect and one partner who really just does not. The connection is lost or whatnot when they're not in the same place or ones, libido is higher and one is just not there for. X reason how? How can you? How can you reconcile that?

Dr. Y: -That is such a big problem in this world, Dr. Sueldo. I see that all the time it's called the desire mismatch. So the desire mismatch one person's libido is very high. The other person’s is somewhere here. That is something that we try to normalize in as sex medicine gynecologists or sexuality counselors. It's okay for your wife or your husband or your partner to have a libido here and the other person being here, you both meet in between. You don't have to jump and go to the top end and the other person doesn't have to fall down and that is initiated again by conversation and by also meeting somebody like a counselor or a therapist and trying to work out what are the causes for low libido and what are the causes for high libido in that person? What is making that person feel that your partner has low libido or low sex desire and the other person saying ‘you know, she has no desire’ or ‘he has no desire’. What is the basis for that? So we need to dive deeper. It's kind of a psychosocial lens that I use to look because as a doctor we look at libido in three areas. One is the biology of the body like we have taught in medical schools and residencies, look at uturists, look at the vagina. Look at if there's any medical problem, ye and if there's no medical problem like you know, you don't find any dryness, you don't find any problem there, there's no infection, everything looks fine, there are no skin changes, she has no lichens, sclerosis, nothing at all. But then you look into the two other lenses, which is the psychology of that person and the social conditions like is there any pressure in the relationship? It’s the psychological barriers between the two of them that are causing this libido mismatch or the desire mismatch. So it is something that we see much more often than what people talk about and it is very pervasive in the majority of relationships like people come to me like menopausal or premenopausal, fertility patients after fertility treatment, they come to me and say ‘Oh my God. I had so much fertility treatment. Now my libido is in my boots.’ Like you know ‘my libido is zero. Dr. Yaz, what can I do for you? What can I do for myself?’ So that is very common. So I start with communication like Why is your libido low and why is his libido high and what can we do? And is there some relationship difficulties? Are there any psychological barriers? Is there any sexual aversion? Like you know, with all the treatment, the egg retrievals, the ultrasounds, the opks and all of that has caused some kind of a barrier in your brain.

So most of these things we are able to tease out with just good communication and therapy and some exercises. Very rarely we have to use medications and there are two medications that got FDA approved for low libido and I use. I use that very often. In fact, just this morning I gave somebody. It's called Flibanserin or Addyi. The brand name is Addyi. and the other one is called Vyleesi. And it's a bremelinnaide injection. So one is an injection, the other is a pill. Flibanserin as a pill, it's it's also touted as Pink Viagra. Okay, so women do take that and both medications. One is a pill, the other is an injection. I could talk whole hour on these two medications, but just to say briefly, they work through central nervous system, it increases your dopamine, it increases your neurotransmitters, and it has nothing to do with your hormones. It has nothing to do with your testosterone, your estrogen, and your progesterone. So I use that if they are the right candidate, they've done all the psychosocial counseling. They've tried their best, and there is something that's missing, like in terms of neurotransmitter or something that we use these two medications.

Dr. S: - Okay, oh, that's really good to know. I learned something today, too. I appreciate that. And then one last thing I want to touch upon because believe it or not, we're almost a half hour in. I so appreciate it, because you know, as you said, most. Most providers, even most women's health providers, are not comfortable talking about this. So to have somebody who's willing to just go right into it and just jump right, it's so refreshing and I'm sure that this has been so helpful to many of my patients.

One thing I want to bring up now kind of shifting gears a little bit and going a little more medical. Talking about some of the underlying medical conditions that are commonly associated with infertility. So things like endometriosis, things like PCOS, diminished ovarian reserve (DOR), or premature ovarian failure where you see changes in the hormones and the impact that that can have on the patient. So I can tell you routinely, I get complaints of vaginal dryness, dyspareunia or pain with intercourse, particularly with deep thrusting. Vaginismus is another one and sort of pelvic floor therapy is something that I recommend. But can we expand a little bit on the underlying female medical diseases that could potentially impact sexual pleasure and libido?

Dr. Y: -Absolutely. And that's a big thing, you know, because if a woman is not feeling well in her genitals, she's never going to enjoy having sex, whether it's a penis in the vagina sex or just clitoral stimulation. So we, as sex medicine or gynecologists, what we do is we look at the entire vulva and there's not much focus on the vulva and medical schools and residency because remember we as residents in OBGYN and we focus on the cervix. We just go boom and get a Pap smear and we focus on the uterus and the ovaries. Because that is where we are taught the pathology of endometriosis and fibroids and PID and everything so in sex medicine, for a woman to have sexual pleasure and be away from this sexual dysfunction. What we call that is look at areas like clitoral inflammation, any skin changes like lichens sclerosis, any inflammation, any vaginal dryness, anything which causes very high tone in your pelvic floor muscles called the high tone pelvic flow dysfunction. The other name being vaginismus, like very tight muscles like you can't even penetrate with a speculum, a finger, a penis, a tampon. So I see patients for sexual pain in my office all the time and there are a number of reasons why they have ended up with that pain. I typically tell patients if you experience sexual pain with penetrative intercourse or even with self-stimulation or even with clitoral stimulation or labia stimulation if it happens twice, the third time you need to seek a sex medicine gynecologist because you need an exam, you just can't wipe knuckle through it and think that it is going to be over. Because what happens with that is if pain is recorded constantly, it goes into your brain and the brain responds saying ‘Oh my God, this is painful, this is not pleasurable’ and you make a central sensitization pathway. So you become extremely tense when you're anticipating something is coming into your vagina and that leads to vaginismus.

Dr. S: -Got it. So it's almost like adding fuel to the fire. It's worsening it.

Dr. Y: -Yes, yeah, absolutely. So when I was doing as a regular GYN my annual Pap exams, I used to always ask patients like ‘Do you have dryness? Do you have pain?’ And when they tell me ‘Yes. I have pain.’ I would say how long and if they tell me it's been going on for two or three years. I would start counseling. I would start looking for causes because we don't want that to delve a longer time in their bodies because their brain is recording. Because all these chronic pain syndromes are happening because this person has recorded pain for a long time. So you are conveying these pain sensations from your pain receptors. Believe it or not. They're called nociceptors and they are present in the vestibule of the vulva and from there the pain goes straight to your brain and you're like ‘Okay, I'm having this pain, I'm having this pain, I can't even sit now. I don't need to have intercourse or I don't need to have sexual stimulation. But I'm constantly in pain.’ So the situation goes from just intercourse pain or sexual pain to kind of a constant pain. So we want to protect that.

Dr. S: -Yeah, super helpful. So I wanted to touch briefly because I know the men or the male partners tend to be the great forgotten ones during the fertility journey. And it's true as obgyns, our focus typically tends to be on the female patient. That's what we tend to see, and that's where we're more comfortable. But we do see and we do know that male infertility forms 30 percent, sometimes up to 50 percent of the

So basically you know, when we talk about erectile dysfunction (ED). I will start by saying that first and foremost most fertility specialists work with a reproductive urologist and so most of us would work hand in hand with a urologist to do the male workup, the male evaluation, the male treatment if indicated. But a lot of times we see erectile dysfunction associated at the psychological level that you were talking about and that pressure associated with the baby-making component. So the men do not have issues with ejaculation. They do not have issues with masturbation but are unable to have penetrative intercourse for this psychological reason. So I don't know if you want to add anything else to that.

Dr. Y: Yes, absolutely. I this that stems from the area of poor communication between that couple like if there is a fertility challenge and the couple are not communicating, that hits the sexual confidence of the male. They also had that expectation that I was not able to give my sperm to have that product which is the pregnancy. So we need good communication and communication itself is going to erase that psychological barrier in the couple. So I have seen when there is good solid communication in the partner, ED 20 to 30 percent is gone because even if the sperm count is good, the motility is good, they still end up because of psychological barriers and I think one of the studies said ED can happen between 10 to 60 percent in men who are going through this fertility treatment in that relationship and severe cases are one to three percent. Like you know, we do the communication, we do all of that and they still suffer with ED, Erectile dysfunction. I think just opening up the book of Communication and writing down, what are your challenges? Why are you feeling like this? I mean, we are both together in this journey. It's okay if we don't have this baby this month, we can do it other times and you focus on pleasure, intimacy and connection. And I think that takes them a long way and prevent from sexual dysfunction like erectile dysfunction in males.

Dr. S: -Absolutely, enlightening, you are fabulous. Thank you so much for joining me. I know I'm currently based out of California. I know you're currently in Raleigh. But if my people want to reach out to you, if they want to consult you, if they want to find you somewhere, you know, online, where can they find you? How can they work with you?

Dr. Y: -Yes, I have a medical license to practice as a sexual medicine gynecologist and a manifesto specialist in Raleigh in North Carolina, anywhere in North Carolina and Wisconsin. Because I started this practice in Wisconsin and moved to Raleigh.

So you can see me as a patient in these two states, but I do consultation everywhere in the country and I also do it in Europe and Asia everywhere as a sexuality counselor or as a just for consultation. You can talk to me and I can guide you. I can tell you what is going on in your relationship, what are the resources that you can look for? And how can you seek help? And how can you advocate for yourself? Like? What are the things that you can go to your doctor and ask for or go to your sex therapist and ask for? So I'm opened for consultation, so you just have to reach out to me through my website and I try to put other educational bits on Instagram as dryas.alraymd. You will find me that I'm sometimes dancing to crazy tunes and and also I am there on LinkedIn. I just started LinkedIn. I was not on that somebody told me I need to be there too, so it is just the idea of educating the idea of giving what is in my brain before I leave this planet.

Dr. S: -I have so many patients that I know would benefit from your but we didn't know you were there, so now we do and I'm so excited to have. Thank you. Thank you for everyone listening. Dr. Yas, thank you so so much for being here today. I truly appreciate it. Thank you. Dr. Sado. I really enjoyed it and thank you for having me absolutely.

And to all my people. If you guys want to see more of me, be sure to go to my instagram account drcarolinasueldo.

*This content is intended solely for educational purposes and is not to be construed as medical advice. For personalized recommendations concerning your specific healthcare needs, kindly consult with your healthcare provider.