Saturday, 27 April 2013

Zero Sum Game

Even before I was a passenger on the TTC and later infertility roller coaster, I would cringe a little when I saw the tag line 'We're making dreams come true!' on an REI clinic brochure or website. It annoyed me as not only does it sound cheesy and hokie, it defies reality. I'm surprised their legal counsel doesn't recommend rewording the sentence to: 'Making some dreams come true. Individual results will vary. See take home baby statistics.' Unfortunately, it's not a fairy tale and not every one gets a happy ending.

Apparently, a bunch of OB patients after my first IUI wasn't any kind of omen, so I wonder what it means that there was an infertility theme to my schedule on the morning of my BFN. The comments for my first patient noted that she wanted a referral for an infertility specialist. I was more annoyed about the fact that she was only given a fifteen minute time slot (she was an established patient to the office, but first time seeing me) as I've asked the schedulers not to start a session with a discussion of infertility, menopause or herpes, as it is setting me up to run behind. She had a 9:00 appointment, and needed to change her insurance when she checked in. After her intake was done and she used the rest room, I walked in at 9:12. I reviewed her history; she and her partner were healthy and her cycles were regular, there were no readily identifiable issues. Probable male factor or unexplained, I thought to myself. I reviewed the process for the work up and gave her the list of local REs. It was 9:40 when I finished and I felt that I totally rushed her. I asked my medical assistant to review the instructions with her and I sent her an email asking her to contact me on the first day of her cycle to confirm the timing of her testing.

I was 25 minutes behind when I started with my next patient. She had an unplanned pregnancy last year and had an abortion. Now she wants to conceive, but she had an irregular cycle last month and was concerned that it indicated damage from her abortion. I reassured her that a single irregular cycle did not imply any compromise to her fertility and I reviewed how to chart her cycles and predict her fertile time. I had the feeling I would seen her back soon. My first new OB patient was newly married and was surprised that she conceived so quickly. I've been in clinical practice for over ten years and I am still astonished when a patient admits to not taking any precautions, and then is shocked when she learns that she is pregnant. I asked why, and she revealed that she was very inconsistent with using birth control and yet never got pregnant; so she figured she had fertility problems. I reviewed that taking chances and being fortunate not to encounter an unplanned pregnancy does not equate to an infertility diagnosis.

My next new OB patient was someone I saw over a year ago; she also had an unplanned pregnancy, but wanted to continue the pregnancy (she had two prior abortions). Unfortunately, it turned out to be a chemical pregnancy. She used birth control pills for six months and then decided she wanted to become pregnant again. Last month, she came into the office and expressed concerns that she hadn't conceived after four months, and was given orders for hormone testing. Her period never showed up for her to do the day 3 testing. The final OB patient experienced two years of infertility before her work up identified male factor issues. She conceived spontaneously before her scheduled appointment with a reproductive specialist. Both she and her partner commented that they had "relaxed" and stopped the stressful process of timed intercourse. I also had two postmenopausal patients on my schedule that morning. I was never so happy to talk about incontinence and hormone replacement therapy.

Although only two of my patients had legitimate infertility issues, and the others had more misguided fertility concerns, it did get me thinking about who are the infertility survivors? I know there are some established formulas that can try to predict an individual's potential for success, and many REs will offer conjectures based on their experience, but the factor of the unknown is such a prominent variable. There are stories of women who conceive against multiple odds, and couples with ideal conditions who do not. Ultimately, your treatments will either work or they won't and you truly have a 50/50 shot at being part of the take home baby statistics, which can make infertility feel like a zero sum game.

Aramis introduced this issue eloquently in her post The Infertility Probability Theorem, so I am continuing to explore some of the themes she identified. When you learn about an infertile woman's success, does it make you feel optimistic (particularly if her situation was more challenging it can inspire thoughts of -it worked for her, it can work for me!) or does it prompt a sense of despair? While being extremely happy for her, you start to feel that it will be less likely to happen for you. No, there are not an infinite number of pregnancies, but there also isn't a 100% success rate with infertility treatments. Someone has to represent the other side of the take home baby statistics. It does seem like pregnancy announcements are a kin to finding one of Willy Wonka's golden tickets. As each one is claimed, your odds of finding one diminish.

I know that our own statistics for the probability of spontaneous conception are very low, given my erratic ovaries and Husband's anemic sperm counts. Even though it happened once, my RE described it as a "fluke" and my cheeky second option consult also agreed that we shouldn't try to conceive on our own too much longer. Sometimes I can't help but wonder if that pregnancy was our only shot. I wouldn't feel that way if I saw a patient with my details, but somehow I just can't convince myself. I fell further into the trap of illogical thinking during this past IUI. On the fertility forum, there were 33 women reporting their statistics for IUI treatment this past month. On the day of our procedure, which used only 4 million sperm, I initially felt encouraged when I learned that a woman succeeded with only 5 million. However, it now felt even less likely that within this small sample of 33, you would see two women conceive with lower sperm counts. Even more preposterous; there was another woman who did her IUI at the exact same time as me. When she announced her BFP, it seemed like it was a lot to ask the Universe to grant success to two people at the same time.

There. I've let the irrational side of my brain say what was on her mind, and now I'll go back to focusing on my own lane and disregarding the noise around me. The only trouble with engaging in the sensory deprivation of swimming is that it allows too much opportunity for thinking. I need to re-invoke my 'no maths before 9 AM' rule.


  1. I am fairly new to your blog and I had no idea that you are an ob/gyn. (So, I take it that even a doctor doesn't have the secret formula?) I think you are so courageous. I cannot imagine dealing with OB patients after a BFN. I could relate to so much of what you wrote--about others getting pregnant. As always, thanks for being so honest and articulating things so well. I am thinking of you.

  2. Thanks for the shout out, Jane! Not that you asked me, but I think you should try and view these IUIs as "free spins" on your gestational wheel of fortune. As in, they're paid for by your insurance, but they're essentially just "enhanced" timed intercourse. So if you get something great out of it, you win! If not, you haven't lost anything, and you'll use them and then take your next turn (IVF?). Of course I'm not trying to make light of the disappointment of a BFN, and I know as well as anyone the crazy-making of doing fertility math. Just food for thought.

  3. Man. You and I were on the same sunny page this weekend, eh? I don't believe that I'll ever be one of those people who is able avoid this type of thinking. I'm just too much of a catastrophizer. I preach the whole "if they can do it so can I thing" when I am reading blogs, for example, of other women who have become pregnant after infertility, and I am able to believe in this broad, general way. But when it comes to the small details - how many eggs I'll produce from a particular medicated cycle, whether or not IUI will work for me, if I'll have another miscarriage one day - I always picture myself on the bad side of the coin toss.

    It's almost like I believe, deep down, that yes. I will get pregnant some day. But I also believe that nothing that I am doing is going to work. How can I make such little sense?!

  4. To work in the OB field and see stuff like this regularly while ttc... I admire you. How can you not look into it with a greater sense of reality when you see that reality every day? However, I am still holding out hope for you. I like Amaris's approach, take the covered IUIs and see what happens. That's a good way of looking at it.