Deceived to Conceive? (part two)

My previous post Deceived to Conceive? explored the question 'how do you know you're getting a fair deal from your RE?' The discussion continues with an example from my case files...

It was the Friday afternoon headed into a holiday weekend and I had a new patient on my schedule with the words "fertility consult" in the appointment comment notes. It was taking my medical assistant a long time to do her intake -never an encouraging sign. Finally she emerged from the room and gave me a look that expressed, ''you have your work cut out for you." I walked in the room and introduced myself. The patient was a 30 year old woman and she had a beautiful 2 year old boy on her lap. I asked if her if he was hers and she nodded. Then I asked her to tell me about her history. She described that she had regular periods as an adolescent. She started birth control pills when she was 22 and stopped at age 27 when she wanted to become pregnant. She conceived on her second or third attempt, but unfortunately was found to have a miscarriage at 8 weeks. At the time of that ultrasound, she was told she had PCOS based on the appearance of her ovaries. After her D+C, she was referred to an REI and went through IVF immediately and succeeded on her first cycle. However, she had to pay out of pocket for IVF and was hoping for something less invasive and less expensive in order to conceive again.

As a point of reference, Polycystic Ovarian Syndrome (PCOS) is a very complex condition and our understanding of its etiology and expression is still evolving. The diagnostic criteria has changed a few times, and even renaming the entity has been proposed. It largely remains to be a clinical diagnosis and labs and imaging only support the diagnosis. However, there are many patients with atypical variants of PCOS, who present diagnostic challenges. Overall, no one single factor should establish the diagnosis and in particular, as normal women can have ovaries with a PCOS appearance, the diagnosis should not be based on ultrasound findings alone. This particular patient did not have any clinical features associated with PCOS. She was not obese, she did not have acne nor oily skin. She did not have evidence of hirsuitism. By her history she had regular menstrual cycles and she had conceived spontaneously. Admittedly, I didn't have any lab testing or other records for her, but I was in doubt of her diagnosis. More so, I was surprised that she was referred straight to IVF given how quickly she conceived after stopping her pills and had no established infertility. I began to question if she may have been sold a bill of goods.

I didn't know how to convey this to her, and I wasn't sure if was my place to tell her. I suggested that if she wanted the least invasive and least expensive course for conception, she could just try to conceive naturally -as it had worked for her previously. [Her periods returned after breastfeeding and she was having regular cycles, they were currently using condoms for contraception] "I can't." she informed me, "because of my PCOS, I'm going to miscarry again if I conceive on my own." WOW, I thought, while acknowledging that there can be a disconnect between what providers say and what patients think they hear. It seemed that her previous RE really did a number on her. Yes, some studies note a higher miscarriage rate in PCOS women (again, causation factors aren't completely understood) but this woman believes that spontaneous conception is some how dangerous.  I asked her specifically what she was looking for to help her conceive in a non-invasive manner.

"I was hoping you can ultrasound my ovaries today and give me a shot so I'll ovulate. My mother-in-law is going to watch my son and my husband and I are going to Napa for the long weekend."  At this point, I started to wonder if I was being set up with a 'secret shopper' patient to evaluate my recommendations. It seemed odd that a woman who went through stimulation and retrieval would think that I could just randomly induce her ovulation. More so, it was interesting that she thought that a trigger shot would some how protect her against having a miscarriage, as if it had powers to fortify the egg. I asked her if she conceived her son using her own eggs. "Yes." she snapped, a little surprised by the question. I reviewed that a trigger shot only affects timing, not the egg itself. Furthermore, I explained to her the need for follicle monitoring and informed her that it is not a service provided in our practice. I could not furnish her request as we don't even carry Ovidrel in our medicine cabinet. However, I was concerned about her going back to the RE who may have deceived her into an erroneous diagnosis and false need for IVF.

I reminded her that miscarriage is quite common, and is not prevented by assisted reproduction. Many women have normal healthy pregnancies after a miscarriage and (although I still questioned her diagnosis) I informed her that even women with PCOS can conceive spontaneously and have good outcomes, and encouraged her again to ditch the condoms and try on her own for a little while. "I already told you. I can't conceive on my own, I'll miscarry again." she reiterated, clearly becoming frustrated with me. It's always awkward to contradict another provider, especially when you don't have all the information, but I decided to be honest with her and revealed that I was suspect of her PCOS diagnosis. "I was diagnosed by experts at XYZ! [a prestigious university]" she put me in my place. I asked her to arrange to transfer her records from XYZ, so I could review and determine how best to help her. She thanked my for my time and walked out the door. I knew I would never see her again. I was only a lowly bread and butter Ob/Gyn provider looking out for her [Coach] pocketbook.