Pregnant Women are Smug

DISCLAIMER: Firstly, not all pregnant women are smug, and if you survive infertility hell and become pregnant or are an adoptive parent, you have earned the right to be smug. The title references a song from the folk duo Garfunkel and Oates who are sort of a female version of Flight of the Concords. They sing about everything from the ease of accessing medical marijuana, the inability to perform a good hand job and unexpected pleasures whilst go-kart racing. This particular song was inspired when one member was visiting with three pregnant friends and one asked her "So, what do you even do all day?" Perplexed by the question, but before she could even respond, the Smug Pregnant Friend (SPF) interjected, "I can't remember what I even did before I was pregnant, as it all seems so meaningless..." I highly recommend watching the Youtube Clip of their performance if you need a good laugh, and can relate to having an SPF who seems to reference her pregnancy every chance she can (you know, just in case you forgot) or who subtlety implies that her life is superior to yours now that she's great with child.  Again, not all pregnant women are smug, but it's great that someone called out the ones who are.

I first discovered Garfunkel and Oates and this song while randomly flipping channels and stumbled on their featured performance on Comedy Central's Half Hour Comedy show just a week or two before I flew out for Myrtle's shower. I watched the clip on my phone before the shower started and I sung the song in my head at times during the shower. To be fair, with the exception of one moment, Myrtle really wasn't smug at all during her pregnancy. When she came out to visit, she explained that she takes her prenatal vitamin during dinner and placed the bottle on my dinning room table and asked me to remind her to take it. Well, on the first night we went out to eat and returned home around 11 pm, when she discovered that she hadn't taken her vitamin. Her first response was to blame me for not reminding her. I simply pointed out that it wasn't time sensitive like birth control pills and she could just take it now (and shut up). She protested that she couldn't as she had already brushed her teeth (?) and she continued to chastise her husband and mine individually for not reminding her about her vitamin. Geez, were we going to have to prompt her to feed the baby once he or she arrives? Seriously, why couldn't she just have quietly taken the damn vitamin. She was one more mention away from having the line "Maybe the Dingo ate your bab-ah" thrown at her. Maybe I was being over sensitive, but I suddenly felt like such a loser for diligently taking my prenatal vitamin when I wasn't even pregnant.

Anyway, this post was inspired by my interaction with the most smug pregnant woman that I have ever met, which considering how many pregnant women I interact with everyday is saying something. I was attending Husband's company holiday party. I feel this requirement should be included in the marital vows: Do you take thee in sickness and in health and agree to spend an awkward evening with a bunch of people that you don't know, don't have any common interests and the food may or may not be any good? I had wandered over to the food table where I was soon joined by two other women. One was approximately 6-7 months pregnant and she looked as if she was in her mid, if not late 40s. My first thought was that she probably had many years of infertility issues and now was finally expecting her rainbow baby. The other woman was gushing all over her pregnancy, so the pregger gave her all her details. This was her third and she was 44. When she mentioned the ages of her other children, I quickly did the math in my head. She had her first when she was 39, second at 41 and now third at 44 or 45 depending on how old she would be at the time of delivery. Wow, thanks to science, I thought to myself, but was wrong again. She went on to describe that all her conceptions were spontaneous. When she and her husband first tried, they succeeded on their second or third attempt. When that baby was a year old, her Ob/Gyn advised her to try as soon as possible if she wanted a possible second and she conceived that month. They debated about having a third for a while, but once they made the decision to take the plunge, she stopped breastfeeding and conceived two months later. Now I was truly impressed, I don't think I've ever had a patient with two spontaneous (and successful) pregnancies after the age of 40. I could almost allow her to be a little smug with that accomplishment. However, she took it to a whole new level. "I'm living proof that you can do it," she started to explain "You can wait to start your family later in life." If she didn't already comprehend how rare her situation was, she expressed how oblivious she was, "I don't understand how people struggle with fertility. You just have to understand the science and get the timing right."

 We weren't trying to conceive at that time, but as a professional in women's health, I was extremely offended by her lack of sensitivity and oh, say general awareness. I usually don't reveal what I do for a living at these functions, as I've got into some heated arguments regarding some of the more controversial topics in women's health and I feel that I have to be on good behaviour as these are husband's colleagues. However this time, I couldn't hold back. There are so many fertiles who think that conception should be as easy for everyone else as it was for them, but the fact that this women didn't seem to appreciate that she was the exception to every norm and rule of expected probability that really got to me. I started to lecture that it's more than just science and timing, there are many more requirements; quality sperm and eggs, patent tubes and a functional uterus. Not to mention that even when all these conditions are satisfied, nearly half of infertility is still unexplained. "And what do you do?" She demanded to know my qualifications. She wasn't humbled at all. "Well, I didn't have any of those problems." she said. Smugly.

 I walked away and headed to the bar to numb myself with a strong drink. I would later learn that she's a high ranking scientist within the company and apparently no one challenges her. (Fortunately, she works in a different department than Husband, so I didn't have to worry about any threats to his job) Not only had I stood up for women experiencing infertility, I had earned some credibility among Husband's scientists colleagues. This party might be enjoyable after all...
                             

An Unconventional Relationship

A few years back, one of my older patients asked me if my mother and I were close. I paused before responding, which she interpreted as an answer of no, but I was thinking that it depended on how one defined a close relationship. As I became an adult, my mother and I successfully transitioned our relationship to a genuine friendship, one that is based on love and mutual respect. She is my confidant, the one I turn to for career advice, or when I need to complain about my in-laws. We shared a few private laughs over Myrtle's poor wardrobe choice for her engagement photos. We go shopping together, we bake cookies.  We just don't discuss any personal details.

When I was growing up, I observed even at a young age that Myrtle and her mother seemed too close, which felt a bit awkward to me. As an only child, your life is in a fishbowl, and I felt the need to hide what I could. Not that I had anything major to conceal, but I just didn't have the need to share every detail that occurred during the school day with my parents in the way that Myrtle did. As we both entered into our teenage years, Myrtle and her mother became even closer, which prompted many to wonder how Myrtle would handle leaving home (not well, was the eventual answer) and encouraged me to become even more independent from my parents.

Myrtle was the first to start her period, which was devastating to my pre-teen angst. Menarche would visit me a week later while I was at summer camp, inviting my mother, as well as Myrtle and her mother, to speculate if I made it up a la Nancy from Are you there God, It's me Margaret. Despite my protests of  "this is miserable, why would I lie about it?" I still had the feeling that no one believed me, and I questioned it myself as three months went by and I hadn't had another period. My mother was wondering the same thing and came out and asked me one day, "So, did you get your period again?" I shook my head and she responded, "Oh poor Jane," in a rather demeaning tone, "You haven't crossed the bridge to womanhood yet" and just to be a little more condescending, she tapped my cheek with her hand. Fuck You, I thought, but reached for my best know-it-all voice and pointed out that it was common for girls to have an irregular cycle in their first few years. Ha, I knew my physiology of menstruation even then. More so, I knew there was no point in sharing any information with my mother if I wasn't going to be believed.

AF would decide to make her next appearance within that month as I was taking gymnastics classes. Co-ed gymnastic classes, mind you. I only had one option; procure some tampons and learn to use them. I most certainly would not be asking my mother for help. I would figure it out myself. I had a regular baby sitting job every Friday night, so I stole a few tampons as well as the instructions (where was the Internet when I needed it then?) from her bathroom. I quickly got the hang of it, and once I did, there was no going back! In fact, ever the budding gynaecologist, I convinced many friends to erode their hymens with the best invention in the world. I knew I would arouse too much suspicion as the mother of my baby sitting charge would wonder why I needed to use 3-4 tampons within a 6 hour period every Friday night. Fortunately, (thanks to tampons!) I was selected for the gymnastics team, which trained at the high school once a week. Practices at the high school meant access to a vending machine that dispensed tampons! I would steal dimes from my dad's change jar and empty the machine. I wonder if the custodians ever noticed that they had to refill the machine every Wednesday morning...

This was my routine until I was able to drive and shop for myself. However, around my 14th birthday, our family went to visit my Grandmother. We were shopping at the Star market and as we passed the aisle of sanitary products, my Grandmother asked my mother if I had started my period -embarrassingly, right in front of my dad too. When my mother replied "no", my Grandmother suggested that she take me to a doctor. I wanted to yell right in the middle of the Star market "I've had my period for two years, you bitch!", but I quickly realised she probably thought I still hadn't started my period as she didn't have to buy me any pads. Worried that she would take me to a doctor and it would be revealed that I obliterated my hymen with virginity tampering tampons, I came up with a new plan. A month or two later I discovered her shopping list and added 'pads for Jane, please put them in my bathroom'. She obliged and we never spoke of it. To this day, she would likely answer that I started my period when I was 14, and not 12.

As I recount these memories, I'm struck by how one off-hand comment seemed to influence the direction of our relationship and if I do become a parent, I realise how easy it is to screw up. My mother and I would never engage in close personal discussions. We never had the sex talk. Once I went off to University, I became involved in many women's groups and started working at a family planning clinic, so she knew I had found sources for accurate information. When Husband and had been dating for a few months, she wrote in a letter, "have you taken any serious steps yet? I'll be happy for you if you did!" I never answered her, but felt somewhat pleased that she gave her endorsement for pre-marital sex. When she reached menopause, she made a ceremonial attempt to give me her supplies of sanitary products. I laughed to myself, as thanks to my Mirena IUD I probably had gone longer without a period than she just did, but I quietly accepted her offerings and brought them to the clinic for patient use.

I would later discover that our non-disclosure policy works in both directions. Months after the event, I learned from my dad or maybe Myrtle's mother that my mother had some postmenopausal bleeding and was worked up with an ultrasound and endometrial biopsy. "Why didn't you tell me any of this?" I asked, probably more bothered by the fact that I wasn't consulted as a second opinion. "Well," she explained "I really didn't know too many specific details or what was going to happen, and I didn't want to look stupid in front of you." Facing a possible cancer, this was my mother's primary concern...

So maybe our relationship is not one that many would define as close, but I appreciate our friendship for what it is and not what it isn't. If I do get pregnant within the next year, I'm not sure how much about our infertility or treatments I'll reveal. If we come up empty at the end of our journey, I'll likely disclose much of our story, just so she knows how hard we tried to make her a grandmother. I feel that either way, we'll start a new page in our relationship.

Staying in the Closet

The greatest challenge about going home to visit my parents will be how to navigate any conversation that addresses the issue of procreation. My parents are under the impression that we (namely me) are not interested in having children. That we're too career driven, too engaged to the freedoms of a child free life and resistant to the sweet charms of a young one. When we started TTC, and when I thought fertility was mine to command, I wanted to keep them in the dark so that we can unveil one of the biggest surprises in their lives.  Admittedly, it is a bit petulant on my part, but as almost nothing in this procreative pursuit has gone according to my intended plans, I want to hold on to this aspect. Perhaps it is the only detail in my control. There are a lot of other pragmatic reasons for keeping my parents out of the loop; My mother doesn't always display the most tact and I can envision her blurting out something like, 'Well, you shouldn't have waited so long!'. More importantly, I don't want to endure her asking any inappropriate questions. Myrtle was practically still smoking the post coital cigarette from her honeymoon when she announced her pregnancy, and yet my mother asked  "Did Myrtle have to do anything to get pregnant?" Yes, she had S-E-X, I explained to her, referencing the birds-and-the-bees conversation we never had when I was younger. My own infertility panic hadn't set in at that time, but I did take note to her line of thinking; woman at the age of 36 is pregnant -must have had help. I know my parents have been dealing with their own feelings of jealousy following the arrival of little Myrtle, and I don't want to coat those feelings with added disappointment from an infertility diagnosis. I'd rather let my parents believe that their future grandchild is being denied by my stubborn attitude rather than our biological limitations. Most importantly, I don't want to invite any additional pressure on ourselves. I don't want my parents to wonder if we are delivering news any time we phone. I don't want them to follow the disappointment of failed cycles. I know they would likely offer financial assistance, which would be very generous of them, and not to seem ungrateful (especially if we need to accept their hypothetical offer someday) but it would add another layer of awkwardness. Maybe there will be a day when I share this experience with them, but for now, I need to keep this fascet of our life to ourselves. I think we were offered a pass with a comment from a family friend. Earlier this year, she was recounting that her newly married 38 year old younger sister announced to their mother that she and her husband were trying to conceive. "Idiot!" the friend expressed, "You don't tell the parents that you're trying for a baby -that's asking to have problems!" Husband and I just looked at each other, acknowledging that you don't need to disclose your intentions to have problems, but we were relieved for my parents to hear that it can be customary not to inform the parents.

Closer to Fine

As I had the day off, I went swimming immediately after my sonohystogram. It had been nearly a month since I had been at the pool. Following a two week break for the holidays, I came down with a bad cold and then we entered one of the worst cold streaks in recent history. My swim group meets at 6 AM. Before I started swimming, I never considered myself to be a morning person. I once tried going to the gym before work and nearly fell asleep on the treadmill. However, swimming in the morning is so invigorating, especially when you're sharing a lane with 3 or 4 other swimmers as our coach is yelling at us. Every now and then, we'll be near the end of a set, and I'll hear her call "last one!" (which I should know by now really means the penultimate one), and I'll use every last bit of energy for the final lap, thinking I'm just yards away from touching the wall and easing into a cool-down. Then, she'll announce, "Okay, one more time!" There are some days when I'm able to throw down my best time of the day during this bonus final lap. I head to work carrying a feeling of invincibility and I feel ready to take on anything that will be thrown my way.
During my no good, very bad week, I felt that I was presented with a gut check to determine if was actually fine, or whether I had just been telling myself that I was fine. Once I had granted myself permission to accept that maybe I wasn't really fine, I was able to see what changes I needed to make. The first was realising that I needed to take time off from work, the second was getting back in the pool.  I was finished with my appointment in time to attend the noon swim class. As soon as I dove into the water I was reminded why I love swimming so much. The water felt amazing and the sensation was enhanced by having sunlight on my back. After taking a few warm-up laps, I broke into a sprint for a few yards. It makes me appreciate the feeling that I'm flying. The other great aspect of swimming is that is allows for partial sensory deprivation. I can't hear much when I'm in the water, which means I'm alone with my own thoughts. Particularly if it is a day of interval training, I can do some of my best thinking in the pool. Although I shouldn't have had work on my mind, since I was out of the office for the day, I flashed to some of the events from the week. Co-worker was on my schedule for her new OB visit, which was her way of revealing the announcement. As our colleagues reacted, I stood next to her and smiled, feeling like an unattached bridesmaid at a wedding who wonders if it will ever be her turn. More importantly, I didn't have the urge to hide in the bathroom and cry, as a week earlier, I had feared that I would. I also had a patient who presented with an unplanned pregnancy and needed options counselling and interestingly, it was after completing her visit that I realised that maybe I am truly feeling normal again. My emotional hangover had finally lifted.
I guess sometimes it's hard to understand what really makes us feel normal. Whether it be getting up early in the morning to swim when it's cold and dark, or realising that professionally I am good at a job that can be difficult for me personally at times. I think it's just more important to embrace whatever it is that brings you closer to fine.

Everything I wanted to know about my Uterus...

In anticipation of my upcoming sonohystogram, I scheduled an appointment to get my bits waxed. I've always done this for all my gyn exams, even before I stated seeing Dr Somebody that I Used to Know. Then I read on Overworked Ovaries that Jen S prepared for her appointment by getting a pedicure and I was inspired to do the same. As a consequence of years of sports, I have such horrible toes and I never saw any point to getting a pedicure, since I would quickly ruin the work of the manicurist. Then, I recalled how when I was in school, my mother used to advise me to dress well on the day of a big exam. Her theory was that if you have a positive self image, you'll feel more confident approaching the test. I decided that by covering the embarrassment of my flawed toes, I could feel even better about myself, which could help me as I received the news of my results.

So about my uterus... It's been a pretty peaceful co-habitation for most of my life. My menstrual cycles were rather benign. No cramps that kept me from missing school or sporting events. No heavy bleeding that caused the humiliation of stained clothes. When I started birth control pills during my quest to be deflowered, there wasn't too much change with my happy-go-lucky period. Then during a routine visit, it was discovered that my blood pressure was 150/110, and I was ordered to stop the pill immediately. Not wanting to face the weight gain with Depo Provera, or the reduced efficiency with condoms, I started researching other alternatives and discovered the Mirena IUD. Hypertension would become the best thing to happen to my reproductive life! Not only did I have a method that was more effective and convenient than the pill, but the period that wasn't too bothersome disappeared completely.

After more than ten years of amenorrhea, I was prepared for AF to return with a vengeance when my IUD was removed. I went to Costco and purchased a large multi-pack of tampons. (Seriously, why did it take manufacturers so long to come up with the multi-pack box?). AF announced herself with barely a whisper. I only need 3-4 light tampons on my first day. The second day I can get by with one pantyliner and on days 3 and 4 (if there is one) I'm just noticing a few spots on the TP. Even during my miscarriage, I hardly had any bleeding. I've scoured all my texts books and there is little written regarding the 'pathology' of hypomenorrhea. I can't recall even having a patient complain about a menstrual cycle that is 'too light' and 'too short'. I gave Co-worker all my medium and super tampons and she went through both boxes before I finished the box of light absorbency ones.

My RE thought it was likely a normal variant. As I was ovulating, I wasn't hypothalamic, and I didn't have any risk factors that would contribute to Asherman's syndrome. It was noted that I may have a slight septum during my initial evaluation, and he had agreed to evaluate with a sonohystogram. The saline infused ultrasound confirmed it's presence and estimated 25-30% depth. He noted that it isn't always clear how much a septum of my size contributes to infertility or pregnancy loss, but he recommended moving forward with a hysteroscopic resection. For the record, I had scheduled a sonohystogram in August, wanting to evaluate my uterus while we waiting for Husband's Clomid to take effect. The appointment needed to be rescheduled and I wasn't able to come in during the required time. My RE examined the films from my hystosalpingogram and thought the septum if present, was only slight and likely insignificant and deferred the sonohystogram at that time. But I am digressing... I'm pleased that he was decisive with the decision to go forward with resection, rather than taking a more conservative 'wait and see' approach.

I must admit I am a little surprised. A part of me thought I'd go in and learn that my uterus is normal and I've been over analysing my scant flow. I feel validated that I pursued having this study done, although it now means another procedure and more waiting. Better to wait and do it right with my new and improved uterine cavity.

Welcome to the Occupation

A few friends IRL have asked what it has been like for me to work in obstetrics while we're struggling to conceive. For the most part, it doesn't bother me. I've been in this job for so long, and for the majority of my career I wasn't interested in procreating. I learned a long time ago to divorce myself from the emotional aspect and view pregnancy as a clinical process. At the most, I'm finding it hard to distract myself right now. I see all of our newly pregnant patients and perform their initial ultrasound. It's truly a privilege to be able to share that experience with those couples who have a viable pregnancy and when it's a heartfelt, happy moment. Lately, I've been wondering if I'll ever have that experience on the other side of the ultrasound wand. At the point in time when I wasn't interested in getting pregnant -and even in the early months of trying to conceive- I had a blasé attitude toward my own potential ultrasound. It's what I do all day, so wouldn't be anything surprising or exciting. Myrtle and a few other friends tried to tell me, 'but it will be different when it's your own!' I couldn't appreciate it at that time. 'No, it will still look the same...' I countered. Co-worker suggested that the appreciation during my scan would not necessarily be seeing the ultrasound images (which are so familiar to me), but seeing Husband's reaction to them. Okay, I relent. If I ever have a viable pregnancy, I will perceive the experience of seeing our baby for the first time as a big deal. I may even shed a tear or two. Previously, I had also rejected the notion of doing the "3-D" novelty ultrasound. It's a lot of money to obtain creepy alien-like images of your baby. I changed my mind when I saw a mother with her daughter during her first ultrasound. I want my mother to have this experience too.  There were a few instances this year when I had a newly pregnant patient who had the same last menstrual period date as I did, and her ultrasound images confronted me with a reminder of what could have been if our procreation was successful. Following my miscarriage, I had a few patients who had an LMP a day or two off from mine, but so far no one with the exact date. Then one day I had a patient who hadn't restarted her period after stopping breastfeeding, and she had no idea how far along she was. I was using our older ultrasound machine, which doesn't automatically calculate the due date. While the patient was getting dressed, I went back to my office and spun her measurements in the gestational wheel of fortune. There it was. 5 August 2013. I laughed quietly to myself and set the wheel down. This particular patient was diagnosed with diminished ovarian reserve and endometriosis during her infertility work up. After successful IVF, she delivered twins less than a year ago and consistently used progesterone only birth control pills while breastfeeding. Ever reminded that fertility is a such a fucker.

I'll try anything...

After rejecting all the bullshit advice from well meaning friends and family, "just relax," "keep your legs up after sex" or "wear socks!" what advice to you take from fellow infertiles? Admittedly, we're a pretty biased group. Following months, if not years, of failed attempts and treatments, it's hard not to believe that what you ate for breakfast contributed to the success, once it is achieved. Some alternative treatments  most often employed include acupuncture and vitamin supplements. The data is light, due to limited studies evaluating supplements, and difficulty analysing acupuncture effects without a true 'placebo' comparative. I came across a journal article that examined many different uses of acupuncture in an Ob/Gyn setting. While the authors noted that the use of acupuncture for infertility is increasing, the only statistically significant benefit was reducing pain during egg retrieval. Co-worker's RE recommended that she start acupuncture. Co-worker asked if she had some statistics to show that it helps achieve a pregnancy, but her RE claimed that it would help her with her painful periods and she asked her "what do you have to lose?" Um, money? thought Co-worker who was finding the bills for her fertility treatments daunting. She had been dealing with her heavy and painful periods since she was a teenager and had learned to cope. She wanted answers to why she has heavy periods and if it was contributing to her infertility and was frustrated that her RE was deferring her laparoscopy and was insisting on doing "one more IUI". It was the one that was successful in impregnating her with twins. A few weeks later, I encountered a local acupuncturist at a holiday party and decided to do a little recognisance work. She identified herself as an "infertility specialist", which I questioned if it was like the title 'Assistant to the Regional Manager'. Acupuncturist who specialises in infertility seemed a little more accurate. I asked a few specific questions on how acupuncture is thought to benefit fertility patients (specifically about increasing blood flow to the uterus) and when during a treatment cycle (i.e in the follicular phase, just before or after IUI or transfer?) should it be performed? She didn't answer any of my questions, but just discussed how all her patients get pregnant, and then she continues to see them and she flips breech babies and induces labour. Really? No one has a 100% success rate. Maybe she didn't want to answer my questions as I was disturbing the 'delicate genius' at a party, but I expected a little more substance from a 'fertility specialist'. She handed me a handful on her business cards. While not completely skeptical, I also wasn't convinced. I decided that doing acupuncture would cut into my exercise time, which also promotes relaxation and improves blood flow.
I was also a little hesitant to start supplements. When Husband first received the results of his semen analysis, he headed to GNC and purchased everything the Google reported would improve sperm counts and quality. Unfortunately, neither the supplements nor Clomid improved his semen analysis much, and the drawer in our bathroom still smells like dried leaves, as I suspect he's stopped taking them. However, I have heard some women reporting improvements with their follicle counts or lab results. Additionally, I was in the 'what do you have to lose?' mindset. Non Sequitur Chica posted a list of doctor recommended supplements on her blog. I picked up all the ones that target blood vessel and endometrial support for about $75. As long as I'm waiting to start treatment, I might as well try to make the most of it. I've also read that some women have tried eating pineapple during the time of embryo transfer to help thicken the uterine lining. I like pineapple and could very well be eating it at that time anyway. If grapefruit juice can cause significant drug interactions, is it that unreasonable to think that other foods could work in weird ways?