Thursday, 21 March 2013

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.


  1. Oh my gosh, this reminds me so much of the stories I hear from my mom (a GP who specialized in women's medicine for years)... so many patients have absolutely no concept of how their bodies work, even at the most basic level, and yet they often aren't able to accept their ignorance and trust their doctor, either. So they just go in circles, from care provider to care provider, not ever really solving the problem. I would say I'm shocked that this woman hadn't even TRIED regular timed intercourse for her second, but then frankly, nothing shocks me anymore!

  2. I often think that not much shocks or surprises me, but this case stayed on my mind for weeks, and now years latter still bothers me. In a way, I feel she was 'targeted' as she was dealing with her miscarriage, very trusting and wealthy. Granted I only have her side of the story, and I kept thinking 'this doesn't add up, it doesn't make sense' but if her story is accurate, I really feel that she may have been swindled.

  3. Wow. I can't even wrap my head around how she thinks a shot to help her ovulate will somehow protect her from miscarriage but ovulating and conceiving on her own means certain miscarriage. I agree that RE really did a number on her and probably took advantage of her. It's the only explanation other than complete stupidity.

  4. Interesting. It kind of amazes me that there are people on there who don't seem to understand the processes that they're putting their bodies through with fertility medicine, and yet they exist. There's a girl in my office who has been going to the same clinic (we bumped into each other waiting for bloodwork one day) and when we got to chatting about why we were there, she didn't even really seem to know. Her regular gyno (not even an RE) had told her she might have PCOS since she didn't seem to ovulate regularly (but like your girl, she has none of the physical signs of that). Turns out her gyno had been putting her on various drugs and even injectibles without even referring her to the RE for a full workup her gyno was just using the clinic for bloodwork. It seemed like "throw stuff at it and see what sticks" kind of thing. I was pretty surprised she hadn't researched or asked questions, but she's just trusting that way I guess. I suggested she seek a consult with an RE just for a second opinion, but I have no idea what ended up happening. I'm just far too curious and obsessive and controlling to trust anyone (even a medical professional) without trying to at least understand things myself!

  5. I am dumbfounded. It just seems so rediculous that she would refuse to try on her own, convinced she would have another miscarriage. Not to minimize the emotions and heartache of a miscarriage (I've had one so I do know its hard) but it sounds like she was traumatized by hers. Seems crazy that she would go straight to IVF and in this case I'd have to question that RE too.

    1. Totally agree, I see so many patients who feel they need to do something different with the next pregnancy following a miscarriage in order to prevent it from happening again, but going all the way through IVF just seems a bit extreme.