How did she get pregnant?

It's the infertility Riddle of the Sphinx: why is it that so many women who aren't seeking a pregnancy, are able to conceive easily, unexpectedly and sometimes often, while others struggle with infertility?The answer is simple: they are fertile. We are not. Of course the larger question is why are they fertile at times when they can't appreciate it and why are we infertile? The only thing I can come up with is that life is unfair. Life is unfair in many ways.

There is a patient in our practice named Mary. She has been dealt some tough cards in her life and at times she seems like she's making strides to get her life in order, but her efforts often fall short. She's also smart enough to know how to manipulate the system and she can be a bit vindictive at times. I first met her about four years ago. She had a daughter five or six years ago and then seemed to have an annual abortion. As she hadn't had a period in months and felt nauseated, she suspected she was pregnant once again. Her pregnancy test in the office was negative, but as I noted that she seemed jittery and her heart rate was elevated, I ordered a thyroid panel. Her depressed TSH confirmed she had hyperthyroidism and I referred her to an endocrinologist who diagnosed Graves Disease. Fearing that she would gain with with treatment, Mary refused to take any medication.

A year and a half later, I saw Mary for an urgent visit. She called in complaining of pelvic pain and the front desk receptionist commented that she didn't look well. Her exam was suspicious for pelvic inflammatory disease (PID). An ultrasound noted the presence of bilateral hydrosalpinx. Concerned about the possibility of a tubo-ovarian abscess, she was admitted to the infusion unit for IV antibiotics. I spoke with my colleague who was on call for the weekend, he hoped she would respond, as he didn't want to perform a salpingectomy on a woman in her mid-twenties, but he also commented that she probably already has tubal factors present. Mary improved and was doing well when I saw her for a follow up two weeks later. However, she was back in the ER a month's time and was admitted for PID treatment again when her tests came up with the Gonorrhoea/Chlamydia daily double.

She kept coming back into the office for recurrent pelvic pain, likely residual adhesions from her recent bouts of PID. My colleague decided to perform a diagnostic laparoscopy to evaluate. However her procedure was cancelled when her pre-operative pregnancy test was positive. How? I asked my colleague. How is this possible? I noted that I wasn't asking as I felt I am more deserving or entitled. It was only a week or so after an au natural cycle where I thought I had implantation cramping and was especially devastated with AF's arrival. It was also a week before we learned the results of Husband's semen analysis. I clarified; I was asking HOW in the name of SCIENCE did she get pregnant?

My colleague just laughed and admitted that she couldn't explain it either. She reported that Mary herself was quite surprised. Oblivious to her own challenges, she thought her male partner was sterile as he was in his mid-thirties and had gotten anyone pregnant (to his knowledge). Mary has repeatedly declined any birth control methods as she describes that doesn't consider herself to be very sexually active (although there is evidence to the contrary; unless she selects really fertile and toxic bachelors). I was desperately trying to wrap my head around it. How? Hyperthyroidism increases sex hormone binding globulins which raises estrogen and LH levels and suppresses ovulation. What are the odds that she would engage in an infrequent act of coitus on the rare event of her ovulation?  How? The quick administration of strong antibiotics must have appropriately treated her PID and preserved the patency of her fallopian tubes. Studies have noted that even  subclinical infections can be severe enough to produce significant sequelae.

She had two episodes of clinically significant PID in a span of four months. I emphasize there is a distinction between true PID and presumed PID. I've noticed that many women who present to the emergency room with pelvic pain will be treated for PID as a diagnosis of exclusion. As the consequences of untreated infections are so significant in terms of fertility preservation, there has been a trend towards over-diagnosis and perhaps unnecessary treatment precautions. I once had to reassure a tearful virginal patient who had been diagnosed with PID in the ER that she was not going to be sterile from an immaculate case of VD, although non sexually transmitted bacterium can cause endometritis. There wasn't anything presumptive about Mary's presentation. She had the real deal. Twice.

Fast forward one year. It was the end of the two week wait after IUI#2. I was really optimistic that it may have worked. I had a good sized follicle and a decent endometrial lining. Husband had his first ever semen analysis where his total count was in the normal range -above twenty million. 8 million were selected for insemination. My RE had reported that 5-10 million was ideal; counts greater than 10 million don't necessarily have higher pregnancy rates. Yet, it was to no avail. My test was negative and I started cramping as I drove to work, indicating that AF's impending arrival would punctuate the BFN. I logged into our EMR and took a look at my schedule. There was an addition since I reviewed it before leaving the night before. It was Mary's name and she was coming in for an unplanned pregnancy consult. Oh Universe, you just really know how to rub it in my face...

It turned out to be a very busy morning and I barely had time to process the disappointment of my failed second cycle or the unfairness of Mary's unwanted fertility. I was finishing up with a patient when my medical assistant interrupted me to announce that Mary's pregnancy test was negative. I had her run another one, and for the second time that morning I was confronted with a solitary pink line and not a hint of blue. Mary was in disbelief and insisted that I do an ultrasound. Her uterus was as empty as mine. Her negative beta would preclude the possibility of an early pregnancy. Once again, I discussed the incidence of amenorrhea due to hyperthyroidism. Once again, I reviewed the dangers of untreated Graves' disease. Once again, I strongly advocated using an effective method of birth control as well as barrier protection. Once again, I suspect it all fell on deaf ears.

I had a smug sense of satisfaction. I felt as if science had prevailed. My world made sense. This was a win-win, as Mary did not want to be pregnant at this time. I wondered how long her luck would hold out, and I fear that someday she may want to become pregnant and will discover that fertility is not hers to command. As I called my RE to report my BFN and to schedule my baseline CD2 scan to start my next IUI cycle, I felt reminded that I will see many more cases that seem to defy scientific expectations. At least at that moment,  I felt that science was on my side.