The Exception and the Norm

She was only 23 and wasn't planning a pregnancy, but she and her 25 year old boyfriend were very excited about the prospect for a baby. Naturally, they were devastated when her ultrasound revealed a blighted ovum. Her mother accompanied her to the follow up appointment and sat quietly as we discussed that a miscarriage is quite common, there wasn't anything she did or didn't do that caused it to happen, and there wasn't any reason to believe that she wouldn't go on to have a healthy baby. Her mother finally spoke, "Well, I just don't understand how this could happen." There was a slight smugness to her tone. "I had four pregnancies and four healthy children." My first thought: what a bitch! Nice to make your daughter feel even worse. My second thought: that is totally something my mother would say. I replied, "Then you are very lucky. To have four normal pregnancies without any complications is more of an exception rather than the norm."

That encounter occurred last summer, but I started to think a bit more about the exception and the norm more often. (Endnote: The patient conceived about 3-4 months later and gave birth to a healthy baby boy a few months ago) As Myrtle offered her advice of trying to conceive in Husband's childhood bedroom, as my in-laws slumbered in the next room, or recounted how she wore post coital socks during the two months she was TTC, I bit my tongue to prevent myself from saying what was really on my mind. "Do you want to know the reality Myrtle? You got lucky. For someone your age to conceive so quickly is the exception rather than the norm, so please do not think you have any wisdom to offer me." Although it would have be cathartic and may have been effective in shutting her up, I knew those words would be harsh to her ears; but I also knew I really needed to say it to myself. I needed to be reminded that she was the exception and not the norm, and I needed to stop comparing myself to her.

I often think about the exception and the norm when I hear pregnancy announcements. I can't be surprised when young seemingly fertile couples become pregnancy quickly and easily -that's the norm. I shouldn't expect similar success when I hear about other couples with moderate male factor conceiving spontaneously or with IUI -as they're the exceptions.  However, this past week was a bit unusual as I saw a high number of cases that represented exceptions rather than the norms.

Case #1 I looked over her form and saw that she had a female partner and cautiously asked her how she conceived. The donor was an acquaintance of her girlfriend and lived in another state. He was visiting for only three days and during that time they did one at home insemination (yes, with a turkey baster). I asked her if she was doing any ovulation predictor testing. She didn't know what such tests were. They just took a chance as he was in town. 'Oh, to be 23 and fertile' I thought, but still acknowledged that her story was rather exceptional.

Case #2 A lovely couple in their mid-thirties. Infertility work-up diagnosed male factor and they failed three IUI cycles. As they were deciding their next steps, they travelled to Aruba for a friend's wedding, where they conceived spontaneously.

Case #3 I included this case as it was unusual. She was in her late twenties and had been diagnosed with unexplained infertility, this was her second pregnancy achieved with IVF. The nurse who did her intake commented that she had an odd affect and seemed really preoccupied with her four year old son and didn't seem that interested in this pregnancy. She seemed a little reluctant to talk about her IVF process, but when I asked her when her embryos were transferred (she went to an out of network REI and I didn't have any records) she didn't know the date! How do you not know your transfer date? She was also surprised that I would be doing a transvaginal ultrasound.  Really, you're not used to being scanned via your hoo-ha yet? I started to wonder if she was really invested in this pregnancy (maybe it was her husband's urging) or maybe this was some form of self preservation.

Case #4 I first saw this patient over a year ago. It was her annual exam, she had just turned 40 and wanted to talk about fertility. Her first pregnancy occurred at age 37 and was unplanned, but very much welcome. When he was two, they started trying for a sibling and had come up on the year mark without success. I ran her labs; FSH 10.4 with AMH 1.22. I strongly urged her to seek an RE consultation if she wanted to optimise her chances to conceive. She came back to see me a year later this past March, feeling ready to proceed with an RE referral, although she did not want to pursue IVF. We rechecked her labs, FSH was 7.0 but her AMH dropped to 0.92, consistent with a declining reserve. You should have moved on this last year... I thought to myself. We completed her workup with an HSG (normal) and sent her husband for semen analysis. I called her to review the results; his count was low at 13.9 million with motility at 45%. I felt that their collective results still placed them in consideration for IUI, but discussed that success rates are low and prepared her that the RE would probably suggest IVF. The next day she started her cycle which led to a spontaneous conception. Tears of joy flooded her eyes as we saw a viable single fetus at 8 weeks and 4 days on the ultrasound.

Case #5 She is 26 and stopped birth control pills in August 2011. Her cycles were very erratic and irregular. She came in for her annual exam in April 2013 (the day of my BFN from IUI#1) I reviewed that she had some features suggestive of PCOS and  ordered labs. We discussed the implications of PCOS and I suggested trying to induce ovulation with Clomid. (I know there is debate about the utility of unmonitored Clomid cycles, but our local RE's prefer us to try Clomid for 2-3 cycles in women with established anovulation) She just shrugged her shoulders and noted that it took her mother 2 years to conceive both her and her sister, so she wasn't too surprised and wasn't yet ready to intervene. Her period had started just a week before that visit and she conceived that cycle. She also mentioned they forgot about trying to get pregnant that month.

Cases #6-9 I included these two cases to illustrate that there are exceptions within the norms. #6 is 31 years old with two children. I removed her Copper IUD so she could try for her third and she had a BFP three weeks later. I think she literally conceived that night. #7 presented for pre-conception counseling (on the day of my BFN from IUI#2) before she removed her Nuva Ring. She conceived on the next cycle. #8 is a 26 year old who presented for a consult after 6 months of infertility (also on IUI#2 BFN day). She conceived right after her hystersalpingogram. #9 stopped breastfeeding as soon as her son turned one year. Three months later she still hadn't started a period, so she took a test and it was positive. "I was shocked" she told me "We've only had sex once this year..."

Cases #10-11 Case #10 is a 31 year old female with classic PCOS, but had three spontaneous conceptions. Case #11 had three normal healthy pregnancies and was diagnosed with multiple uterine fibroids. She was told that she wouldn't be able to conceive and was further instructed to stop her birth control pills as they could increase the size of her fibroids. Two months later, she had a positive pregnancy test.

Case #12 38 year old female who had a miscarriage at 10 weeks that was attributed to uterine fibroids. She had an abdominal myomectomy and needed to wait quite a length of time before she could attempt to conceive again. She finally conceived, but miscarried again at 6 weeks. A year and a half later she had a BFP after she and her husband went to Vegas for a weekend and decided "just to have fun".

Case #13 This one was included for comedic value. My medical assistant went into the room and introduced herself. "Hi, I'm Tammy-Lynn" the patient replied. She then quickly corrected herself, "Oh, sorry! That's my stripper name!"

While I feel it's important to pay respects to the exceptions and the norms, I also acknowledge that I'm applying to be one of the exceptions. My spontaneous conception was described by my RE as a 'fluke' and I feel that I've been giving my one and only pass to have a spontaneous conception prior to treatment. I'm estimated to have a 40% chance with IVF -that hardly seems like a norm. Myrtle and I are both exceptions -but on different ends of the spectrum.