A Day in the Life

As soon as my RE's office was open on the Monday morning after my BFN, I called to schedule my WTF appointment. I knew that AF would be arriving soon, and I wanted to make sure I could start stimming or FET prep with this cycle. I looked through my schedule and found two blocks of time where I could leave the office without having to move any patients. Unfortunately, my RE wasn't available during either of those options. "How about tomorrow at 11:45?" the practice manger offered. I would have to take it. That was the best I was going to get. I looked at my own schedule. I would have to move three OB patients. The reason I needed to leave? How about we have some statements from our international bank accounts that need to be notarised for our tax return. Do such documents need to be notarised? Sure, why not? Oh, shit. I forgot that our practice manager's husband is a CPA and could expose my cover up. One of my swim teammates took an afternoon off from her job to compete in our championship event and cited that she needed to meet with her divorce lawyer. Hmmm. I need to consider that one. That would really conceal our intentions.

Two of those patients were 38 plus weeks, so hopefully they would be flexible about rescheduling as they're not currently working; maybe one would even deliver overnight. The last patient of my morning was only 12 weeks. Earlier, she sent a message to Co-worker asked if I could do an ultrasound at that visit and if so, she was going to have both sets of grandparents accompany her. The provider in me felt so guilty as I heard my medical assistant reschedule her, "I am so sorry...I understand that you and your family arranged to take time off work..oh, you were planning to go out for lunch afterward as well?...once again, I'm so sorry..." I was ruining their family event to celebrate their upcoming arrival so that I can figure out why I can't have a baby...

It is a 25 minute drive between my office and my RE. As the traffic can be unpredictable, I try to allow 30 minutes for travel time. Although New Girl once told me that my RE almost always runs 10-15 minutes behind, I don't intend to take advantage of that window. I needed to be in my car ready to leave by 11:15 -11:20 at the latest. "So guess who is pregnant again?" one of my medical assistants greeted me as I walked in on Tuesday morning. It was a patient who delivered in May of 2013, she has no idea of her last period. She was just seen in primary care and had a positive test. I looked at my schedule, one of my term OB patients had delivered (although not one of the ones I had moved). I offered that I could see her just to do a dating scan and then she could schedule a new OB visit for another day.

Her uterus felt about 18-20 weeks on exam. Now it would take longer to do her scan. Sure enough, her composite measurements put her at 19 weeks 6 days. "Did you have a period after your delivery?" I asked "I stopped breastfeeding in August, and I think I had one in September and one around the end of October..." she answered. Hmmm those dates line up exactly... As she was already half way through her pregnancy, I felt obligated to coordinate her care at this time. She needs her prenatal labs, as she barely passed her glucose test last time, I should have her do it now. She has chronic hypertension, but stopped her Labetalol when her prescription ran out and needs a refill. I needed to give her the requisition for her anatomy ultrasound. "Your only option for genetic screening is a Quad marker" I informed her "You have until the phlebotomist arrives to decide if you want to do it." Man, I sounded like a bitch. This has become a 25 minute visit in a 10 minute slot. Not the way I want to start a day when I need to leave at a precise time. I remembered that one of my mentors once told me, "there's no such thing as a quick dating scan..."

Later that morning I had a new patient who was scheduled for an annual visit and she wanted to discuss fertility. They had been together for three years and never used birth control. Initially they just took an 'if it happens, it happens' approach but in the last year she tried using ovulation predictor tests, although she admitted that she wasn't consistent with using them every day. Friends told her that she should have sex one week after her period and one week before her period starts. It wasn't clear if they were optimising her fertile window. It's tough to explain to a patient that while I can appreciate the duration of three years, it's not quite the same as if you've actively been pursuing pregnancy by taking advantage of every monthly ovulatory episode. While she was getting dressed, I organised her orders for her lab work, HSG and her partner's semen analysis. Her cycle started over a week ago, she would need to do her testing next month. "Oh, my insurance switches to Kaiser next month. Actually we're effective with Kaiser right now, but I still have this insurance until the end of the month. After three years, we're just so anxious to get our family started..." I suppressed a sigh. Selfishly, I thought about how she just wasted much of my time, but she probably didn't know that the work up requires a series of tests that are coordinated with her menstrual cycle. Perhaps she was hoping that I had a single easy answer for her. Nonetheless, she would have to start anew with a Kaiser provider.

I managed to leave the office in time to be prompt for my own appointment when it was my turn to be a patient. "You can go on back to his office" the office manager instructed me as I walked into the waiting room. Apparently, he was also running on time. The door was ajar, but I knocked before entering. Dr Somebody that I Used to Know briefly stood up and motioned for me to sit down. He expressed his disappointment over our failed transfer and then led with "so, um...we'll proceed with your next transfer once your cycle starts..." Oh, surely someone so brilliant who possesses dual Ivy League degrees would be smart enough to determine that I wouldn't come all this way to discuss a plan that could be conveyed over the phone. I quickly informed him of my intentions, "So, what was your analysis of my IVF cycle...?"

Ah, he probably thought this would be a quick and easy visit just before lunch. Instead, we reviewed my stimulation cycle and ran through my questions as I tried to take diligent notes. Although I didn't say it out loud, I was acknowledging to myself that he wasn't quite saying what I wanted to hear. The experience from my first cycle offers some suggestions for modifications, but we may only see a marginal improvement. He noted that he discourages patients from entering into a treatment with the view that this will be the last or final option, as it places a heavier emotional burden on the process. "I am aware that there are winners and losers in the game of infertility treatments, and it's starting to resonate that we may be on the losers side." He replied by sharing his observations on how much I have evolved during this time. "You've responded as situations have changed -this is a good thing." While I was thinking that he was subtly raising the issue of donor gametes or embryos, he commented, "you've progressed from someone who never wanted to do IVF to wanting to start another cycle before you completed your last one!" He then offered to do my baseline scan in the event that we wanted to pursue the FET. "That would be great, as I wouldn't have to schedule another appointment." I accepted with genuine appreciation.

It was 12:30 by the time I got back into my car. I had just enough time to make it back to my office. My afternoon session starts at 1:30, but I had agreed to see the 12 week patient and her family at 1:00, after they finished their lunch date. I had become that patient visit who was not so quick and easy and after spending so much time discussing a second IVF cycle, I elected to follow the original suggestion of transferring our remaining embryo. Sigh...