Monday, 22 April 2013

I wish that I knew what I know now when I was younger...

One of the most compelling scenes in 'The Cider House Rules' is when Dr Larch, Homer and Buster are burying a young girl who died from an illegal abortion. Well actually, Homer and Buster are the ones digging, while Dr Larch watches over them. "What did she die of?" Buster inquires. "She died of secrecy." Dr Larch lectures sternly. "She died of ignorance!" he finishes sharply. 

I hate ignorance. I hate misinformation. I hate how ignorance breeds misinformation. I have often declared that I want to hunt down the person who started the rumour that women need to start birth control pills when their period ends. However, one of the greatest challenges in medicine is keeping up with new information and new developments that often require professionals to retract or sometimes contradict previously disseminated messages. I can remember at some point in my training (prior to specalising in women's health) learning that women should use alternative contraception and wait three months before trying to conceive after stopping birth control pills. Some of the rationalisation for waiting three months is to allow for a woman to start prenatal vitamins for an optional amount of time before a potential conception, and it allows a woman to observe her own natural cycles and determine her fertile time. Unfortunately, the suggestion of waiting three months seems to have been translated into a presumption that one can't get pregnant until three months after stopping birth control pills.

I know I obviously have advanced knowledge of pharmacology, but it is too logical to follow that if you need to take the birth control pill at the same time every day in order to prevent pregnancy that it can't take three months to flush out of your system? I thought back to when Myrtle told me that the friend who told her it would take six months to conceive after stopping the pill, also conceived within a month or two of her final pill. At that moment, I chose to ignore the comment, especially as I was annoyed at her for flaunting the fertility of others in front of me. Referencing my title for this post, I wish I had comeback with "Well, she obviously knows what she is talking about." said in an acrid and heavily sarcastic tone. Ah, coulda, woulda, shoulda...moving on...

"What do you have for me?" I asked my medical assistant
"She's here for her annual, but also wants to talk about fertility..." I sensed from her pause that there was more to the story
"She stopped her birth control pills and hasn't had a period, and she mentioned that her boobs hurt, and I know my boobs hurt when I was pregnant..."
"Cut to the chase scene, please."
"Her pregnancy test was positive."
Well, this development makes the fertility talk easy, I thought; but I would soon discover that her case was anything but simple.

She was 31 years old and her history was quite complex. When she was 17 she was rushed to the hospital with what the school nurse thought was an acute appendicitis, but it turned out to be ovarian torsion and she lost her right ovary. When she was in her second year at University, she was diagnosed with Hodgkin's lymphoma and battled her cancer with several rounds of chemotherapy. Quite predictably she was concerned about the effects of her chemo on her surviving ovary. I asked her about her fertility plans. She wanted to conceive in about three years, she and her current boyfriend had only been dating for seven months, but she felt that he was the one. I asked why she stopped her pills now. "I've heard that it can take a long time to get pregnant after stoping the pill." I followed by asking where she heard that notion "It took my sister a year to get pregnant, so I figured it would take me even longer."

The news of her positive pregnancy test was a complete shock to her. While she was happy to learn that she had overcome her potential biological limitations, she was not prepared to be pregnant at this time. She had just completed her master's degree in library science and received a coveted offer to work for the National Institute of Health in Washington DC. As a way of celebrating her graduation, she had booked a trip to Central America for two months before her cross country move. Her boyfriend wasn't planning to move to DC with her until he found a job.

I think the most infuriating aspect about ignorance is that most people are oblivious to their ignorance and may be blissfully unaware of the potential consequences. It makes me think of one of my grandfather's favourite  sayings, "I wish you were a little smarter, just so that you would know how dumb you are." What I found so frustrating was the fact that she thought that stopping the pills without using any other contraceptive method in order to conceive in three years was a sound strategy. Yet at the same time, I had quite a bit of compassion, as given her history of having her one ovary prematurely aged by the effects of chemotherapy, I felt that I could very easily be following her infertility blog.

In a way, we are all ignorant about our own fertility. No one really knows how their reproductive organs will perform until they are taken for a test drive; but sheesh, don't walk into a dealership unless you're ready to buy a car! I've been asking myself if I knew then, what I know now, would we have done anything differently? As we're technically defined as being sub-fertile, if we had started TTC years earlier, we'd be more likely to conceive spontaneously, allowing more time for the stars to magically align. Yet it would have stretched out the process of watchful waiting much longer. I can honestly say that although Husband was prepared, I wouldn't have been ready for a pregnancy too much earlier before we started trying.  I represent the rate determining step, and he's the rate limiting step.  I definitely wouldn't have worried about being pregnant at Myrtle's wedding, nor used Plan B to avoid missing our Olympics trip. We could have started to pursue procreation six months earlier, and if it had happened -everyone would have found a way to deal.


  1. I was told by my primary that I needed to use backup BC for three months after stopping my BCPs. Let me tell you, all those condoms were a waste of time. You are right, we all are in this huge learning process with our bodies. I am glad she got pregnant, but it is definitely very ignorant.

  2. It's true, we don't know anything about our reproductive organs until we are desperate for them to do their job. I used the rhythm method for about a year and never suspected a problem. Despite the fact that my Dad always had a joke: "You know what they call people who use the rhythm method? Parents!" Even now, I've done two cycles of IVF without having a hysteroscopy. Now my mind is running a mile a minute wondering if they will find something when I have it done. I've always assumed I was a fertile myrtle married to a seriously infertile man... Now I am wondering if there is more to our story.

    My best friend is in a serious relationship, and will be 30 in September. She wants to wait until the "right time" to start TTC, and knows that by then she may experience some age-related and weight-related issues. Because of everything my husband and I have gone through, she wants to do some fertility testing soon to rule out any other underlying issues. I think that would be a good idea for any woman! It's better to know sooner rather than later if there are any issues.

    This turned into a really long comment, I just really agree that the more you know, the better when it comes to infertility.

    1. OMG, I love your dad's comments! I can't believe I've never heard it before and I am so going to use it with one of my patients!
      Regarding your friend: If she were to pursue any testing, I would suggest an Anti-Mulleran hormone level and semen analysis, both can identify any game changing issues.
      At the fertility conference I attended last year, one RE discussed that uterine anomalies are often identified after failed IVFs and an HSG has a 38% false negative rate, and he raised the issue of routinely performing a hysteroscopy prior to IVF. I know others who also have had success doing an endometrial biopsy prior to transfer.

  3. My doctor told us to use protection for the first month after stopping birth control because if we did get pregnant, we would likely miscarry.

    Just curious- was your patient going to keep the baby? I know that the baby wasn't in her timeline, but she was pretty lucky to get pregnant in the first place....I hope that she doesn't end the pregnancy and then have trouble getting pregnant in the future.

    Friends of ours once said that there is no good time to have a kid. It completes turns around your life no matter what so you can never be fully prepared.

    1. Seriously! where do they come up with this stuff -did it not feel ironic that you were using birth control pills or Lupron (the ultimate contraceptive) just before your IVF cycle!

  4. I can at least say that there's not much I could have done differently. M and I got married when I was already 35 and my periods had started getting wonky. I'm pretty sure that if we had started TTC even from our first date things wouldn't have been that much different as I was on my year-long period absence after stopping BC. At least that's one thing I don't have to blame myself for.

  5. stories like this make me look back and laugh at the month that we went off teh pil but used condoms, since I was still drinking and just trying to regulate my cycle. some days I can laugh about it!

  6. Okay, last comment of the night. There is so much conflicting information and experience out there. I, too, had heard that it can take three months for your body to return to normal after taking the pill for many years, but I also had more than one set of friends who got pregnant the first month after stopping the pill. Go figure....

  7. "I wish I knew what I know now when I was younger." A sentiment I'm sure we all have to some degree! Sometimes I just find myself shaking my head at what some people believe. I'm sure you find yourself doing this on a daily basis. Lol

  8. Great blog! As a chemist, I especially appreciate the reference to "rate limiting step" in a post! ;0)