Monday, 9 September 2013

You Can't Tell by Looking...

Although, I've been hopeful; I always tried to remain realistic about the low success rates with IUI treatments, especially with male factor issues. I especially felt that I wasn't naive enough to believe that it could work on our first treatment cycle. Nonetheless, after being sidelined for a few months, there was a certain excitement just to be back in the game, and the BFN after my first cycle definitely produced some disappointment. As soon as I got into work that day, I saw that my first appointment was a new patient, scheduled for an annual GYN exam and to discuss infertility. Personally, this was going to be tough as the last topic I wanted to discuss was infertility. Professionally, this was going to be tough as I was already behind schedule, and needed to cover a lot of ground without being rushed.

Fortunately, she was very prepared and had detailed answers for my questions. I always start by asking patients to describe their TTC efforts. I've learned not to make any presumptions, as I've noted over time that many people do not know how to anticipate when they ovulate. Some couples copulate too frequently and others not enough. A former colleague once had a particularly shocking case. They were a highly educated couple in their late thirties, and had been trying for two years before they presented for evaluation. They were convinced something was seriously wrong and pushed for a comprehensive work up. Multiple semen analyses were normal. Serial day 3 and day 21 draws indicated good ovarian communication and ovulation. Although her HSG showed patent tubes and no obvious cavity defects, she had a laparoscopy and hysteroscopy performed. When she came in for her post-op visit, the front office staff noticed she needed to update her health history form. A medical assistant reviewed it and discovered that she was listing 'condoms' as her method of birth control. "Why are you using condoms when you're trying to get pregnant?" The patient answered that she found semen to be "icky" and they didn't think condoms were effective as a friend become pregnant while using condoms. Rather than refer her to an RE, my colleague encouraged her to get over her "ick factor" and ditch the condoms. She conceived a few months later.

My patient had been tracking her cycles, which were very regular and was having unprotected sex at the correct times with appropriate frequency. She briefly used OPKs and received consistent results, but stopped as they didn't seem to be helping her get pregnant. Her history was pristine, and I couldn't identify any red flags for concern, so I thought there could be male factor issues or they could fall into the unexplained category. I reassured her that she was doing everything right, and it was time to evaluate. Knowing all the stupid 'tips' I received, I thought those were important words for her to hear. I placed all her orders, but as I needed to move on to my next waiting patient, I asked my medical assistant to review the timeframe her her labs and HSG. I still felt that I had rushed her, so I sent her a message on our online system encouraged her to let me know when she goes for her testing or to ask any further questions.

Three months later I saw an FSH and Estradiol for an name I didn't immediately recognise. She finally went for her testing. Her results (FSH 9.8 (E2 35) and FSH 1.08) gave me concerns for her ovarian reserve. She needed to see an RE now. A week later, I received her HSG results and was not prepared for the findings. Neither tube was patent. Without any risk factors present, she had a significant tubal factor to accompany her concerning ovarian reserve. Her husband is insured though Kaiser, so I didn't have any access to his results, but I hoped for their sake that his semen analysis was normal.

I felt reminded about how hidden and secretive infertility is. I used to counsel patients regarding the lurking threats of STIs, as most affected carriers have no symptoms. "You can't tell just by looking at someone" I warned. This situation feels very similar, you can't tell by merely looking at the surface and you won't know what you'll find until you look deeper. Thus, the recommendations to "relax" or "take a vacation" and "stop trying so hard" are not only inappropriate, but potentially detrimental, as they could delay a someone who is closing in on a narrow window of time.

I reviewed her results with her, describing a somewhat 'bad news, good news' situation. No one wants to hear that an abnormality was found, but sometimes it's comforting to have an explanation. I emphasized the positives; she is ovulating and IVF is a treatment to address tubal factor. She took the news rather well and quickly scheduled an appointment with an RE. I asked her to email me after her consult. A few days later, she replied that they would be starting IVF in somewhat of an excited tone.

There is a part of me that wants to reach out to her as a fellow IF sister. I want to let her know I personally know how much it sucks to need infertility treatments when your friends and family members conceive spontaneously. I know the difficulty of attending baby showers and birthday parties. There is so much more I could say to her, but I don't want to overstep my professional bounds. I wished her the best of luck and asked her to keep me posted. She replied "Thanks :)"


  1. I know I don't totally understand how to have to keep that professional boundary but I would feel even better if my Dr took a somewhat personal interest in my TTC journey. Especially if it was something she went through herself. I would feel like she was really on "my team" so to speak. I know not everyone would probably feel this way but I find it a comfort to some degree keeping up with someone else who is on the same journey as myself.

  2. I had to read the part of the condom couple to my husband. Shocking. It's amazing what you run into in healthcare ;)
    You sound like an amazing provider. I'm glad your patient is on the path to something. As someone who is "unexplained," it's frustrating to not have answers.

  3. What the heck, that highly educated couple thinking they could get pregnant while using condoms? How can you even stand it when cases like that come before you? Craziness. As for the second couple, I agree with Risa. You are an amazing provider and I am so glad these patients have you on their side. While you may not be able to reach out to them detailing your level of understanding, I am certain the extra care you provide goes a long way.

  4. just... wow. the condom couple. that's incredible, and kind of makes me feel a little better. my RE (a male) shared with my husband and i during our first visit with him that he and his wife used IVF to conceive their 17 yo daughter. that was really comforting. he is in his 60's now. but it was reassuring knowing he knows what we are going through.

  5. I am absolutely amazed that a highly educated couple really believed that the sperm didn't need to actually enter the vagina in order to conceive. Just Wow...

    And I've often had the same thoughts about infertility. Young, vibrant couples who I see in the waiting room at my RE's office. I think "You'd never think by looking at them!" but of course not, infertility is indiscrimnate.

  6. That condom thing...I mean, seriously? You're making that up, right? No, tell us. You are. RIGHT??

    I don't know what I expected infertility to look like, but I had the same reaction as Gypsy Mama when I showed up at my clinic the first time. A silly "well, they all look like me" kind of thought. As for your patient, I know I have appreciated when one u/s tech told me she'd gone through the same thing. You just feel a bit more understood.