Why Can't I Stop Ruminating? The Hospital-Based Internist on the Fertility Journey
You can run a code, titrate three pressors, and hold a room steady when everything is falling apart.
And still lie awake at 2am replaying your last cycle.
That's not a personality flaw. That's what happens when an analytical, algorithm driven brain meets a specialty that has no algorithm.
This week continues my series on why certain specialties make the fertility journey especially hard in their own way. This episode is for the physician who can solve almost any clinical problem and is struggling with the fact that this one doesn't have a clear algorithm — the ICU physicians and hospitalists among you will recognize a lot of this.
In this episode:
Why the analytical brain that makes you excellent in critical care can turn on you during the fertility journey
The midnight PubMed rabbit hole: why it feels productive and why it usually makes things worse
How disrupted sleep and circadian rhythm can affect cortisol, inflammation, and sympathetic tone, and why that matters for your fertility journey
Practical scheduling strategies: clustering appointments during off weeks, arranging call swaps, and what actually helps
Why having a trusted REI and coach who can distill the science is the antidote to rumination, so you're not carrying that mental load alone
Turning the inner critic into an inner coach, and why self compassion improves performance, not just how you feel
Trusting a process with no fixed endpoint is one of the hardest things we ask of a physician brain. Give this episode a listen when you need the reminder that you don't have to figure it out alone. 💜
With Love and Science,
💜 Dr. Erica
P.S. If you're the physician who has read every study and still can't quiet your own mind at 2am, I built the Private Fertility Consult for exactly this moment — a working session where we bring clarity to the data and the decision in front of you. Book a consult here. I'd love to connect.
Also, be sure to check out our website: loveandsciencefertility.com
Follow us on social media:
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Please don’t let infertility have the final word. We are here to take the burden from you so that you can achieve your goal of building your family with confidence and compassion. I’m rooting for you always.
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Erica Bove, MD (00:01)
Hello, my loves, and welcome back to the Love and Science Podcast. Today we're gonna talk about something very important, which continues our series in why the fertility journey is so hard for people in specific branches of medicine. Today we're gonna be talking about what it's like to be an ICU doctor or hospitalist undergoing the fertility journey. Okay. So I have helped numerous people who work in critical care or who are hospitalist, and there's so many ways in which
This is a very, very difficult experience to be undergoing infertility treatment. Let's start with the analytical brain, right? Like I remember being a medical student and being on internal medicine rounds and ICU rounds and the thinking and the overthinking and the analysis, you know, I think it just lends itself so well, and I put that in air quotes, to this thing we call analysis paralysis. I think some of the internal medicine doctors are some of the smartest doctors I've ever met, and
You know, I always say our reason is wonderful when it works for us, but when we are in these rumination loops, when we are in analysis paralysis, when there's maybe not one clear right answer in the algorithm, but many different possibilities that are, you know, equally acceptable, medically speaking, that can be you know, a real cause for some panic. And also I will say, like OBGYN and REI, which are very procedural fields.
You know, those can be very different ways of thinking than internal medicine. You know, what I remember from those areas of medicine is that there's usually a way that it makes sense, right? I mean, I know we're REI, which involves endocrinology, but I will say in REI there's a lot of gray. Like when we're talking about potassium, or when we're talking about, you know, ABG values, or when we're talking about EKGs, or when we're talking about other things like
To me, and again, please correct me if you feel like I am misspeaking here, but to me it seems like, you know, it usually is a little bit more clear-cut. And it, you know, maybe if somebody's not getting better and things on paper look okay, but somebody's super sick, I mean that that happens, I understand. But I think there are way more algorithms in the internal medicine ICU space, in the hospitalist space, maybe even in the ER space, than there are in, you know, OBGYN and REI. And
Admittedly, we have a lot of data free zones, which I think can be really, really hard for people who are so good at thinking and who want concrete answers. So the the well the well oiled sort of neurological connections that are wired for reasoning and figuring out conclusions and using data and coming up with algorithms. Like I always tell my patients and my clients, and like I know there are many ways forward.
And I know we could look at what's often done in these situations, but like let's come up with a thoughtful plan based in science, like based on authentic hope, which is hope-grounded in science based on the data. But like let's not try to think of the algorithms because the algorithms are actually infinite in this realm. And so to get so many steps ahead when there's so many data points and so much changes, even every day or every other day, I think it can be really, really counterproductive to think about like 15 steps ahead when
The algorithm branch is just this infinite web of things, many of which may not even come to pass. So that's that's what I want to say, first of all, is like the the brain of somebody who is trained to do the work of critical care and internal medicine and hospitalist work, that's a very different thought process than what we do in, you know, OBG Way and an REI. Also, the fluorescent lights. I feel like there's this scene from Joe versus the volcano.
where, you know, he basically talks about how the fluorescent lights are silently killing him. My mom was recently in the ICU and I have nothing but mad respect for the people who work in those settings, who take care of the sickest patients, who work in hospitals, like, gosh, you know, having a family a sick family member recently like was very humbling in terms of the dedication and the environment and the whole systems that exist within in like intersecting with the respiratory care and the like, you know, the cross
Cross, you know, collegiality of like different specialties and everything. Like it's something that as like an REI who is largely outpatient and procedural, and like we often kind of keep to ourselves, right? We do the IVF and then the patients go home. We generally take care of young, healthy patients. Like to see how intricate the hospital system is and the ICU system and how very, very, very different it is from what I do every single day, I have med respect. And at the same time.
It is a much different scenario. Like most hospitals like do have fluorescent lights and they kind of smell a little bit funny. And you open yourself up to all sorts of like hospital-borne infections when you're there, and there's a certain culture. And you know, maybe you are working as a hospitalist, like my former spouse is a hospitalist. I I have an appreciation for his schedule. You work several days in a row, and that can be super hard to arrange for like call swaps, and what if you're doing IVF and how does that work?
You try to cluster stuff in the week that you're off. Maybe you take some extra night shifts to make it more doable. But it's kind of like being on like a vampire schedule, right? Like you go in super early, you may not know when you get out. You take up extra night shifts. Maybe you, you know, try to arrange for some swaps. Like it's it is a it's hard on the body to do the hospitalist work because especially with how the hospitals are going and you have more and more patients on your panel, and then the patients are sicker and sicker. Like I understand that there is stress of that and
The hospital environment, let's just be real. We're not like in a garden in nature, we're not breathing fresh air. The food that we have available to us is often, you know, hospital cafeteria food, and that sometimes that's better, sometimes that not. That's not. You know, if you're a nocturnist and it's two AM, you may have very limited options to you when you're actually hungry. And maybe you've, you know, your sort of thermoregulatory system even gets disregulated. And so I don't know, I think about sort of what does the body need to
be in sync. We know that altered sleep schedules can affect circadian rhythms. I have a whole podcast episode talking about that. We know that that increases stress and that increases cortisol and that increases inflammation and like all the things that we're trying to combat against and restore to morphysiology. It can be really, really hard as a hospitalist or an ICU doctor to have a set schedule that is the same every single day, that is kind and gentle to the body.
that is sort of in the natural rhythms. And and I'll be real too. Like when I'm doing IVF, I'm not like in nature in a garden. Like that's not my environment either. I actually practice in a hospital-based setting. So I do have somewhat of an appreciation for what it's like to be kind of in that environment in some ways. But I always try to like, you know, if I have 15 minutes, like take a step outside, maybe like find a patch of sun where there's an open window, go to the healthiest cafeteria and see if I can
get something green or vegetable, like those are things, but I understand that when you are doing hospitalist medicine and when you are doing, you know, ICU shifts, those can be much, much harder to make happen. So there's just the environment I think that does not welcome an optimal physiology. I also think that when we think about you know, the rumination loops, I I really want to give a little bit more time to that. So
What I will say is there's these decision points in the fertility journey, such as like, okay, I've done three IVF cycles with my own eggs, and like it's not panning out. What do I do? Do I think about donor egg? Do I need a gestational carrier? Like, why aren't things not working? Like that's sort of one decision point. Or maybe it seems like maybe there's like a male factor issue and the sperm are not doing well, the embryos are not progressing from day three to day five in a good way, and you know, you want some more clarity on that.
Do I see a reproductive urologist? Do I not? Do I do DNA fragmentation testing? Do I not? Like you can go down the AI rabbit hole, which I think is a particularly intense problem for people, you know, who are listening to this podcast, who are hospitalist or ICU specialists because there's so much data, right? There's so much information. We love to consume information. But like this sort of thinking in the r the rumination loops of like, what do I do? What are the pros? What are the cons? Like, what do the data show? And then and then we start to drive ourselves crazy.
And so just thinking about it, like what actually helps in these situations, understanding the hospital environment, understanding the altered sleep schedule, understanding the stress of taking care of various patients, understanding that there are, you know, like fo real food issues that can come with being in a hospital setting, like understanding that there's a lot of gray in REI versus maybe some other aspects of medicine that are not not black and white, but maybe a little bit more clear cut, like what actually helps?
Okay. So I think the first thing is to have a good relationship with your REI, you know, and possibly a coach too, a coach who can distill this information so that you can calm that rumination algorithm brain, put that aside, and like reason through the evidence, come up with a thoughtful plan for you that is based on your values and your priorities, and then move forward understanding that you have a thoughtful plan.
Because when there's like five competing different options and each one seems equally like, well, you could do this or you could do that, and there's no real clear pathway forward, you know, I could take care of like two different patients who look the same on paper, but I might make very different treatment recommendations, understanding, you know, their goals, their response to medications, you know, even the Lupron versus so you know surgery conversation when people have suspected endometriosis, that's a very nuanced conversation, understanding like
How have people responded to hormone shifts in the past? How do I think someone might handle two months of being on Lupron? You know, how risk-averse is somebody to surgery? Like these are all things that I think about. And so having somebody that you can lean on to understand you as an individual and not just a number and not just like a person in a study or a series of studies on PubMed or open evidence, like that is really crucial to help you make those empowered choices because otherwise that brain, it gets going and it has a really, really hard time.
calming itself. Okay. The other thing that I find particularly helpful is embodiment. And that is a very big term to use. But what I find is that some of the best thinkers are also the same people who have the hardest time like dropping into their body and understanding the inner landscape, understanding the feelings, understanding the thoughts, you know, allowing that process to unfold. And so I really, really love when people are stuck in this analysis paralysis.
Helping people take some deep breaths, dropping into the body. Sometimes it takes several deep breaths to do that. To understand the feelings that are coursing through the system, to breathe through those feelings, to let them go. And I know this might sound woo. I feel like I sound that way on a lot of my podcasts, but I say this stuff works, right? And I have endocrinologists in my practice right now who have benefited so much from dropping from the mind into the body and finally being able to disarm themselves of that like hyper cerebrality.
And to tune into the body's inner wisdom that actually helps them make their most empowered choices. And I'm not saying we ignore the science. That's not what I'm saying at all. I am one of the most evidence-based people you will ever find. I hold myself up in the hospital cafeteria while my fellows are inseminating the world because I need to be on premises and I'm like, you know, reading the studies and reading F and S and making webinars for female physicians. Like this is one of my favorite things to do. So I always say, let me help you. Let me distill the science. Let me
You know, critically appraise the studies. You do not need to be doing this at 11 p.m., midnight, one a.m., whatever it is, because you know, you can read any study that will lead to any conclusion, and you can literally drive yourself crazy. But the point is to say, like, what does the evidence show? Who am I? What is my background? What are my goals? What is my identity? And how can I apply the existing evidence to me and my situation to increase my chance of the most successful outcome? And I will say that also paired with
The physiology that is most receptive to fertility treatment working. And that might be uterine receptivity in the way of an embryo transfer. That might be actually like taking a step back and not doing IVF that month. And I've had numerous patients and clients, you know, actually conceive once we realign their mind and their body, and their their their their physiology started to work again. Again, I cannot explain exactly why this works.
It is a miracle every single time it happens. I cannot ever guarantee that this will happen to you. But I will say is that when we have mind-body dysregulation, when we have, you know, excessive stress, when we have this feeling of hypervigilance and threat that this isn't gonna happen for us, that increases our sympathetic tone in such a way that our anxious brain starts going, our nervous system is definitely skewed towards the sympathetic, and it's really, really hard to conceive in that situation physiologically. And so again, sometimes it's like looking at the environment.
Getting as much sun and flowers, like we have like a little garden next to our cafeteria. So sometimes if I have five extra minutes, I might step outside and like literally smell the flowers and go back inside. I'm always like, okay, I'll have to get to that other note later, but like it's worth it to me to kind of re re-reinvigorate like a little bit of humanity. I also run in our GY I run our GY to ultrasound unit sometimes, like I'm like the attending staffing that clinic, and that's a very dark black room. We could also talk about radiologists on this call, but
You know, I think that ICUs generally don't have a ton of windows, or if they do, like the shades are drawn. And so thinking about how can we just restore a little bit more connection to the natural world, how can we nourish our bodies. And maybe it is if you're a nocturnist, maybe you do invest in like a meal plan where you have healthy meals delivered to your door that you can just grab and go and you don't have to do meal planning. Like I'm not saying you need to spend like all of your weekends grocery shopping and meal prepping and all those things. Like I personally do spend
you know, a decent amount of money on healthy food and food that can be easily prepared. And I even like as a disclosure, I hire somebody to cook healthy food for me so that I don't have to think about that aspect of my life because it's not one of my strongest skill sets. But I know that when I'm going to the hospital and I show up with like healthy food or I know I can access it at whatever hour I'm gonna be there, that to me helps me like know that I'm feeling with my body with like antioxidants and the things that are helpful.
And then I don't get in this like stuck rut of like, poor me, I'm in the hospital, there's no healthy food, or you know, I'm working overnight, like this is like, you know, I have no choice, I have no choice but to eat the chips and whatever else, the grim crackers. Like just think about there is a lot more agency than you might realize. And take these small opportunities where you can to combat the hospital environment, to combat the fluorescent lights, to get some fresh air, to like anchor your sleep schedules when you can. Like that's a big thing too, and I have a whole podcast on that. Like
How can we, you know, take the fact that we can't always control the timing of the hospital has shifts, but that we can, you know, when we are post-call, do certain things to reset and to kind of adjust our body over time to getting revving up to like what the new schedule will be. All those things can actually make a big difference, not just in how you feel day-to-day, which of course is important, but in giving you the optimal physiology for the fertility journey. So with that, I will say I always put in a plug for mindful self-compassion. I think that all physicians
Have this bent for a really strong inner critic, and part of the goal of like coaching is to actually turn that inner critic into an inner coach, and so which is a much more loving, affirming voice. There's actually data that when our frontal lobes are more online and we inject some self-compassion, our performance actually improves, not goes down in the other direction. I talked about this in my surgeons episode as well, thinking about mindfulness, thinking about common humanity, which is like anybody in my situation would feel this way.
thinking about self-kindness, which is the opposite of self-judgment, really, really learning these skills so that when you go to the hospital and you go to take care of patients and you're trying to fit in your fertility journey and your appointments and your you know ultrasounds and your blood work and your phone calls back from the nurse or portal messages that you know that you are held, you know that you can trust the process, and you know that you have a thoughtful plan, and most importantly that you don't need to stay so hypervigilant because you don't need to go back and second guess the plan.
You don't need to have self-doubt that something's be forgotten, that something's being forgotten because you know that you've got your A-Team, you know that you have a well-reasoned plan. And then at that point, the goal is to let go and trust the process and know that you're resourceful. If it works the cycle, fantastic. If it doesn't work, there will be a way forward. But just really, really trusting that, you know, you can be the patient, you can receive, and that in the end, just as in, you know, over 90% of my clients, that all will be well and you will grow your family.
So I hope this was helpful. I love, love, love helping my people. I love thinking about the various different scenarios in which people are working. Like I said, I think the hospital in the ICU is a very like unnatural situation with some schedule constraints that can make it really hard to do this. So I'm on your side. If you have any particular questions, send me a DM. I'd love to help you troubleshoot your particular challenges, your particular struggle struggle. But in the meantime, just know how much I love you. Until then. Bye.
