Among the well intentioned things that were said to me after my first miscarriage; both Co-worker and my Lead Physician commented, "you'll be even more emphatic to your patients who are miscarrying". Maybe I was a little more sensitive in that state, but I took their words as a criticism. Although I would never deny that there is always room for improvement, after delivering such news a few hundred times, I feel I've at least become proficient. Yet, in spite my many years of experience, it is still one of the most difficult and dreaded aspects of my job. As soon as I recognise that the ultrasound findings are not what they should be, my heart drops into my stomach, which then twists into knots. Once I'm satisfied with my scan, I'll instruct my patient get dressed. Somehow it just seems worse to recall that you were half naked when you learned this awful diagnosis. Often I'll stand outside the door and listen for when the movement stops, so I can re-enter the room as quickly as possible.
Once I start my spiel, the words just seemingly flow, but I still stutter to deliver the opening lines, "I am so sorry to be informing you of this situation. I know this was not what you expected this visit to be..." My mouth goes out auto-pilot while my mind is reading my patient. What does she seem to need right now? An answer or an explanation? A plan for what to do now? Reassurance for the future? Even before my own miscarriage, I could appreciate how overwhelming this situation must be. I know we many not be able to address every issue at this time, but I need to figure out what is the most important piece of information she needs to take with her now. Watch her eyes. Sometimes we need to stop to cry. There are times I'll leave the room for a bit to let my patient and her partner console each other. If she's alone, I'll offer my own shoulder and I'll almost always embrace her before she goes. Some patients have even thanked me for the way I supported them at that time.
As part of her campaign for grandchildren, my mother tried to appeal to my professional ambitions "You'll be a much better provider to your patients if you've experienced a pregnancy and motherhood yourself..." I actually had some anecdotal evidence to counter her argument. I've heard some comments from patients who noted that they preferred a male obstetrician or a nulligravida female one for the fact that they hadn't ever been pregnant. Some found that the parous practitioner spent a lot of time talking about her own pregnancies; and in particular if she hadn't had any complications, she couldn't necessarily relate to her patients. While I didn't have a particular criteria, I must admit I felt a bit relieved when we settled with a male RE. I knew I'd never hear any stories about his ovulation, and although he's put on some weight, I knew he'd never enter the exam room displaying a baby bump. As far as I know, he has not fathered any children and I don't even think he's married, although the absence of a wedding ring doesn't mean anything, as I don't wear mine. Actually, as he once complimented my toe nail polish and commented that black is a good colour on me; I'm not sure if he's straight.
Interestingly, I've found there have been a few occasions where pursuing pregnancy has made me slightly less empathetic. During my final days of stimming, I had a newly pregnant 30 year old PharmD student in my exam room toward the end of my afternoon session. I had been on and off the phone with New Girl for most of the afternoon, as we were scrambling to find an extra dose of my antagonist, since my RE was pushing my retrieval yet another day forward. Admittedly, my patience was worn pretty thin. When it came time to do the ultrasound, she became very fearful of the vaginal probe. "Can you do it abdominally?" she begged. Unfortunately not, she was just over six weeks and was rather 'fluffy'. I showed her that only a small part of the probe goes inside the vagina and it is actually less invasive than a Pap smear. She was still reluctant and was retreating on the exam table in a manner that was surprising given her age and the fact that she is a health care professional. It took all the restraint I could muster not to burst out, 'do you know how many times I've had a transvaginal scan done just this week?' 'Oh, and I'm sorry that your boyfriend has a small dick.'
A week earlier, I was having a particularly shitty day. I had four new OB patients on my schedule, and the first three were non-viable. For the record, it marks the third time in my career when I've had three non-viable patients within one day. After the second, I wanted to cry and go home. After the third, I suggested to my medical assistant that she should think up some reason why we had to cancel the last patient. Our LVN looked at the scheduling comments, "she should be 14 weeks, so she'll be good for you." I had seen this woman for her annual earlier in the year, so I reviewed my notes: planning to conceive toward the end of the year. "So here you are right on time!" I greeted as I entered the room. "Well actually, we had decided to wait a little while longer, but then it happened anyway..." There was a clear tone of annoyance in her voice.
My first thought: STFU, do you know you are talking to an infertile woman who just told three patients that they are miscarrying? Suddenly I remembered the words of my mentors when I first started volunteering in a family planning clinic. "Never presume how someone will feel with a positive or negative pregnancy test. Always ask before you offer any comments." Maybe she or her husband may be facing job redundancy. Maybe they wanted to delay as they have a trip planned -I know someone who can relate to that. All I knew at that point in time was that she was viable. I didn't need the ultrasound to reveal that she was going to be having her fourth baby, while two of my no-go women were trying for a second and the other one was pregnant for the first time. Still, she was my patient and she deserved my empathy.
There is another case from over a year ago that also stays with me. She was about my age and was diagnosed with atypical PCOS. My colleague had her go through six unsuccessful rounds of Clomid before referring her to an RE. She went for her consultation and was preparing to start injectable IUI treatments when her next cycle started. Only AF never arrived. She called our office asking for a prescription for Provera in order to induce a withdrawal bleed. The pre-requisite pregnancy test was positive. At her visit, we laughed as she was now one of those couples. The ones who get pregnant spontaneously right before their appointment with the fertility specialist. As if the threat of injections and other invasive procedures seemingly intimidates the gametes into cooperating.
Unfortunately, her ultrasound revealed a small empty sac that measured about five weeks. As her last period was months ago and she had no idea about possible ovulation, I had no basis for dating, but her HCG was much higher that she should be if she truly were only 5 weeks. I was quite confident that she was non-viable, but as I didn't have any reference other than her HCG levels, I couldn't exclude the possibility of an early pregnancy. Thus, she would need to return in a week for follow up. I always hate these situations, and sometimes feel that they can be worse than a clear-cut miscarriage as it drags out the process and dangles the faintest sliver of hope. I truly hoped there was still some special magic to her story and her subsequent scan would deliver a miracle. Unfortunately, I've been doing this job for too long...
I thought about her during my run on a Sunday afternoon. Her follow up visit was on Monday morning and I was dreading confirming the inevitable with her. I hate informing anyone of a non-viable pregnancy, but it just seemed so much harder and so much more unfair with someone who is also infertile. However, she took the news exceptionally well, and admitted that she had accepted that this was a miscarriage after her first scan. Maybe infertiles are just more accustom to disappointment. I was in the middle of my own two week wait and was unaware at that time that the exact same situation would unfold for me. Positive pregnancy test right before starting an IUI cycle. Suspiciously small and empty gestational sac on my scan. By the time she came back to me for her follow up visit, I had completed my own miscarriage. I didn't have to live through the same experience to affect the amount of empathy I had for her.
I especially didn't need to go thought it twice.