This is a continuation of my previous post with my opinions regarding the new California laws that go into effect for 2009.

Mobile homes: Requires, at time of sale, all mobile homes and manufactured housing to have smoke detectors in all rooms designed for sleeping and to have seismic braces on gas-fired water heaters.
I have smoke detectors in my home, but that was by my choice. Hmm, I don’t have any Radon detectors and I certainly hope I’m not forced to get some.

National guard: Authorizes a state employee who is a member of the National Guard or reserves to receive government benefits for four additional years, if they were ordered to serve on or after Sept. 11, 2001, as a result of the war on terrorism.
It’s a nice gesture, but again, who is paying for this? This could be potentially very costly for the state of California.

Oil drilling: Permits development of additional oil reserves beneath submerged lands of the Wilmington oil field.
I don’t know enough about the details, but offhand, I would like to have more American oil sources and rely less on OPEC.

Pets: Provides for enforcement of “pet trusts” set up by animal owners to pay for continuing care of their pets after the human owners die.
I’m all for this. People should have a right to show love for their pets. Personally, mine are not getting a penny from me.

Phone cards: Requires refund within 60 days to any holder of a card if the provider’s services fail to operate in a commercially reasonable manner. Also mandates that phone-card firms maintain a toll-free customer service telephone number.
It’s odd that there should be a specific law to state this. I thought this was a given. Any business should be held to a standard that if they don’t deliver the services they promise, then the consumer has the option of a refund.

Press freedom: Prohibits discipline of high school and college journalism advisors for the content in a student newspaper.
The way I read this, it’s giving freedom to school journalism advisers when they themselves give freedom to their students who are doing the writing. So I support this.

Privacy: Makes it a misdemeanor to use radio waves, without consent, to remotely read another person’s identifying information. The measure is in response to the practice of having personal identification information included on government-issued identification cards that can be read with radio-frequency identification devices.
This blow for personal privacy is very important, but will be difficult to enforce.

Real estate: Allows the state Department of Real Estate to suspend or bar a person who has committed a violation of real estate laws.
What’s the point of having a supervisory board if they don’t have the power to discipline someone who violates the law anyway? This should have been another given and not requiring a separate law to state the obvious.

Schools: Allows Los Angeles Unified School District and other districts to continue tapping state funds even as they withdraw from a program to fund multitrack, year-round schools.
I honestly don’t know what this is all about. Can somebody explain it to me, please?

Senior homes: Assisted-living homes are required to show potential customers their history of rate hikes, tell local prosecutors about suspected abuse and plan for emergencies such as blackouts.
If this is a move towards more transparency, I agree with it. Consumers choosing a home for their loved ones should be armed with adequate information on which to base their decisions.

Smoking: Allows the state director of the Department of Mental Health to prohibit the possession or use of tobacco products on the grounds of state mental hospitals.
Remembering what I learned in medical school about the high prevalence of smoking among psych patients, this could well cause a few riots.

Spousal abuse: Prohibits jailing of alleged victims of domestic violence for refusing to testify against their abusers.
I realize many domestic violence victims call for help when they are imminently threatened, but then are caught in a quandary about leaving their abuser, so they refuse to testify. I don’t profess to know the answer to this complex problem. I would be open to hearing the views of those who work in this field whether jailing of the victims is or is not helpful to the overall situation.

Tax breaks: Allows taxpayers to exclude forgiven mortgage debt from their incomes for state income tax purposes.
I don’t know too much about this and this would be of no personal benefit, but you know me. I’m generally in favor of lower taxation for everyone.

Taxis: Allows local agencies to disconnect the telephone service of a taxicab operator that fails to obtain proper permits and insurance if other enforcement remedies have failed.
The role of the government is enforcement when people violate the rights of others. So if a taxi operator failing to obtain permits and insurance constitutes a violate of other people’s rights, then giving more ammo for enforcement agencies to do their job is a good thing.

Teacher crimes: Includes “no contest” pleas in the definition of convictions when the Commission on Teacher Credentialing decides whether to suspend or revoke teaching credentials.
If I read this correctly, prior to this law, teachers accused of violations could opt to plead “no contest” and then not be held accountable for those incidences when decisions are made to revoke their credentials. This law closes that loophole. Good.

Toll roads: Allows local transit agencies to create carpool lanes that can be used by lone motorists willing to pay a toll on stretches of the 15 Freeway in Riverside County and portions of the 10 and 110 freeways in Los Angeles County.
If this end up easing traffic, then I’m all for it. People should have more choices.

Used cars: Allows police officers to impound vehicles of anyone cited for acting as a car dealer without a license.
I don’t know what it entails to obtain a car dealer license.

Veterans: Requires the state Department of Veterans Affairs to develop plans to reach out to National Guard members or veterans returning to California from combat, and assist them in obtaining a screening for post-traumatic stress disorder and traumatic brain injury. Another law authorizes, after local approval, veterans whose vehicles display one of a number of special-recognition license plates to park free in metered spaces.
I profess to having limited knowledge regarding the prevalence of PTSD among National Guard veterans. My reading is that this law goes beyond just rendering the standard care to veterans, but instead pushes the limit towards hand-holding grown men and women and assisting them in just getting screening. It is already controversial whether or not the label of PTSD is overused as a way to tap into money from the government.

Wave pools: Requires operators of wave pools at amusement parks to increase safety steps, including assignment of lifeguards, provision of life vests and restrictions on children shorter than 42 inches.
All operators of public venues should take responsibility for the reasonable safety of participants. Whether or not these arbitrary guidelines constituted a good balance of safety and individual choice remains to be seen.

Overall, my personal views are founded on a healthy respect for other people’s freedoms and rights. In general if we were to ask if our lives today would be made better by more government control and less individual freedom or less government control and more individual freedom, I think it’s pretty clear where I stand. The balance needs to shift back towards the middle, or our standard living will stop growing or even go backwards, while the standard of living in China and India continue to inprove for their people.

If you think your life has already been overrun by an obsession for fertility, you might be interested to know that it can always get worse. Apparently there are people out there who want to get text messages reminding them when to have sex. There is no medical proof that the timing established by this service is even accurate. By the way, I am not endorsing this in any way, shape or form. Reading about it might be good for a laugh, though.

After just one glass of wine the other night, I had a strange dream. It provided the inspiration for this post.

Imagine the journey for a baby as being like a race. The runners begin at the starting point, staring up into the distance at a road that stretches as far as the eye can see. The runners are told that their baby might be waiting for them somewhere up the road. It could be near. It could be far. Or it could be not at all. The runners can make the choice of when they wanted to start up the road, but the longer they waited, the farther away their babies might get moved. So one by one, couples made their decision to start walking up the road. The luckiest couples walked a few hours and came upon their babies right away. They rejoiced, took their babies into their arms, laughed about just how easy it was and left the road to enjoy a brand new life with their child. The rest of the couples congratulated them and continued walking. Some of them had to walk for a long time, but just as they were tiring out and almost giving up hope, they arrived at their babies. They, too, took their babies into their arms and breathed a sigh of relief that they were able to finally reach their goal. They gave thanks and were much more grateful than the first couples, but they realized that they still had it pretty easy. The remaining couples continued walking and walking and still, no baby. Some of them decided that they would remain patient and just keep walking, for as long as it took. Others quit the race and gave up in exhaustion, sadly resigning themselves that they would never be united with their baby. Still others decided in frustration that this was not working, so rather than keep walking, they stopped and rented horses. Now they were galloping along at about five times the speed of the walkers. For about half these couples, this strategy worked and they reached their baby. They realized that had they kept walking, they probably would have eventually reached their baby anyway, but it would have taken years. They were glad they took the horses instead because they were able to get there much sooner and even had time to get back on their horses in the future to go for a second or third baby. However, not all the horse riders met with success. Some of them kept riding and riding and still didn’t see any baby in sight. A few of these gave up, returned the horses (after all, feeding them was getting a bit expensive) and went back to walking. Still others got fired up and decided to look for better alternatives. They found out that they could rent cars. Now, they were roaring down the road at 70 mph and most of them happily reached their babies, but only after covering a huge stretch of distance. Of course, there were still some couples who had walked until they had blisters on their feet, rode horses until their butts ached and drove and drove until they could no longer afford the car rental and still, never reached their baby. Fortunately, not too many people fell into this category. The irony of it was that some of these couples could have reached their baby, if only they had decided to drive cars a little bit sooner. But by the time they decided, it was too late.

In reality, the pursuit of a baby is a lot like this silly story. Trying to get pregnant naturally is like walking. Doing low tech treatment, such as IUI’s and fertility medications is like riding a fast horse. Doing high tech treatment such as IVF, is like driving an even faster car. Back in ancient times, everybody walked. If they couldn’t reach their destination by walking, then they were out of luck. Then, as civilization advanced, some people could afford horses and were able to get where they wanted much faster. As the years have passed, in countries like the US, people now drive cars everywhere. True, just as there are still some underprivileged countries where cars are but a wishful luxury, for some people in the US, infertility treatment, especially IVF, is out of reach. Over the years, the effectiveness of IVF has skyrocketed and the prices have come down well ahead of inflation, but it still all comes down to a choice of where to spend your earnings. So. Do you keep walking? Do you try getting on a horse for a few months? Or do you go all out and start driving?

A lot of companies that make pens, paperweights, post-its and mugs might be feeling the economic crunch from this new policy.  But at least I will be prescribing with a clear conscience. Meanwhile, my office manager will be making more frequent runs to COSTCO this year.

Each year, the government insidiously passes more laws to intrude further into our lives. Some laws make life better for society overall, but I really think that most laws make our lives worse. Even if a law is written with a good intention in mind, the overwhelming costs and bureaucracy inherent in the conception, approval and enforcement of that law costs taxpayers a great deal of money and a lot of lost efficiency in life, so most of the time it is just overall not worth it.  Just because something might be bad, it doesn’t necessarily mean we need to come up with a law against it. Otherwise, we would have pages and pages of laws against profanity, laziness, obesity, telling lies to our parents, picking our noses, wearing flip-flops with dress pants and singing in public with your headphones on.

I confess that I don’t know all the exact details of all the following new laws for 2009, but I’ll offer my opinion on them based on my initial impressions. In all fairness, I will open-mindedly welcome any feedback and education if I’m reading things incorrectly. The list of laws is all taken verbatim from this article as my only source.

Text-messaging while driving: There is a new law “prohibiting the use of text-messaging devices — including cellphones, BlackBerrys and laptop computers — while driving“. Furthermore, “Motorists may not text at a stoplight“
On one hand, when I am driving, I would like the right to my own safety and not have to worry about some other driver causing an accident because of distracted driving. But isn’t unsafe driving already forbidden? If a driver is applying eye shadow while driving, shouldn’t it also be subjected to the same rules? I’m in favor of this law because I personally believe that text-messaging DOES lead to significantly riskier driving and because it affects others.  On the other hand, if there were a hypothetical scenario where a drivers are 100% sure that their driving does not affect other people’s lives and property, then I would not care. In that case, let them make the decision whether or not to take the risk of text-messaging. But since our highways and roads are public domain, my rights to safer driving are preserved by this law, enough that it worth the $$$ required to enforce it.

Increase in traffic ticket prices: A separate law, aimed at paying for new courthouses, will raise the price of traffic tickets starting today. Infractions will carry a new $35 assessment, and the fee to process a request to attend traffic school and keep the ticket off the driver’s record will be $49, up from $24. Fines imposed upon convictions of misdemeanors or felonies will result in an additional $30 assessment.
I have mixed thoughts on this. The prices and add-on fees for traffic tickets should reflect a balance between discouraging dangerous driving and not causing outrageous hardship for first-time offenders. Make it costly enough that drivers will think VERY SERIOUSLY before ever considering driving drunk or drag racing, but don’t let making a rolling stop or failing to wear seat-belts result in sending someone to bankruptcy.

Hospital employees anti-snooping law: There is a new law “creating a new state office with the authority to investigate and impose harsh new penalties on hospital workers who snoop without permission in patient medical records”
While it is certainly wrong for a hospital employee to look at one’s medical records for their own kicks, we do not need to create another taxpayer-supported new state office to deal specifically with it. It would be preferable that hospitals that fire employees for this infraction be protected from lawsuits for so-called “wrongful termination”. Many times, hospitals have their hands tied from disciplining or eliminating bad workers out of fear of this type of lawsuit.

Nutrition laws: The nutrition law, which affects restaurant chains with 20 or more outlets, requires brochures to be supplied to diners beginning July 1 and calorie counts on menus starting in 2011. Another measure requires that fruity beverages known as “alcopops” be prominently labeled as containing alcohol, starting July 1.
This law is a waste of paper and time. A few years ago, I grew quite fond of the prime rib sandwiches at Quiznos. In a rare fit of health-consciousness, I grew curious as to how many calories they contained. I googled high and low and found nothing. I then contacted Quiznos corporate office to inquire. They informed me that they don’t have that data available for the public. I was surprised and a little irked. Therefore, I stopped being their customer. Let people choose where they wish to eat. If today’s health-savvy customer truly cares about knowing how many calories are in their restaurant meals, then they should reward the restaurants that make the information easily accessible. I might be more supportive of a rule requiring them to produce the information on demand, but I am against the wasteful regulation of requiring reprinting of menus and brochures. My friends own a restaurant (albeit a mom-and-pop place and not a chain), but if you ask them, they’ll tell you it’s a struggle to keep in business. They don’t need further regulations to waste their time and money. As for the alcopops, personally, if I were ever to order a $9 “Tropical Electric Berry Lemonade”, it’s common sense that I pretty much expect there to be at least $1 worth of rum or vodka in there. Is there really a need for a costly new law?

Alternative fuel: Allows drivers who run their vehicles on restaurant kitchen grease to skip most of a $300 fee previously required of anyone who hauled used vegetable oil or other grease away from an eatery. Veggie-oil users will now have to pay $75 for a license.
Reading this was a bit confusing to me. I guess I’m in favor of reversal of a previous wrongful tax. I would not be in favor of the government taking $300 from someone who simply wanted to haul used veggie oil away from a restaurant, so I guess I should be happy that they are reducing it. If this would encourage McDonald’s not to reuse their oil as much or if it will decreased gasoline consumption, then why not do away with the old tax altogether, rather than pass a new law to modify an old law that should not have been in place anyway? Ugh.

Computer bullying: Allows school officials to suspend or recommend expulsion for pupils who engage in bullying by electronic means, including over the Internet.
Do we really need a specific law for this? Bullying is by definition a crime of one student against another. Schools should have the authority to take action to remedy this situation whether the bullying consists of posting nasty things on someone’s MySpace or of incessantly chanting “Fatty fatty two by four. Can’t get through the kitchen door”

Carpool lanes: Makes it a crime to forge, counterfeit or falsify a clean air sticker issued by the DMV to certain low-emission vehicles, allowing them to be driven in high occupancy vehicle lanes. A separate law permits drivers of fully enclosed three-wheel motor vehicles to use carpool lanes.
Isn’t falsification of government-issued documents and stickers already illegal? I wonder how much it costs in time and money for somebody to come up with these things. I get the sense that there government agencies feel driven to manufacture busywork so as to justify their existence.

Dangerous chemicals: Requires the Department of Toxic Substances Control to adopt a plan to identify and evaluate dangerous chemicals in consumer products.
Red light. Red light. I am suspicious when a law calls for “adopting a plan” or “appointing a committee” or “launching a fact-finding mission”. It usually means let’s give somebody a job, paid for by taxpayers to delude ourselves into feeling good that we are doing something.

Drunk driving: Drivers on probation for DUI convictions face suspension of their license and towing of their vehicle if they drive on California highways with a blood or breath alcohol level of .01% or higher.
This would only apply to drivers who have already been convicted of a previous DUI, so I think it’s fair. My understanding that mouthwash an hour ago or a slice of chocolate rum cake would not result in levels even this high. It would take at least one alcoholic drink. Anyway is it a good idea for drivers previously convicted of DUI not be allowed to drive even if they’ve had just one beer? Yeah, why not?

Emergency calls: Increases penalties for people who knowingly use 911 emergency lines for calls other than emergencies. The penalty is a written warning on first offense, $50 on second, $100 on third.
About time we had this law. I have heard of people using ambulances to get a ride. Someone wants to visit their friend who lives close to the hospital. They call 911, get the benefit of the world’s speediest chauffeur service and then sign out AMA when they get to the ER. Even though, it doesn’t sound very harsh the way it’s written.

Emergency planning: Merges the governor’s Office of Emergency Services and Office of Homeland Security into a single cabinet-level agency.
Er, is this consolidation and downsizing? Sounds good if it is. The cynical side of me doubts the government would be voluntarily reducing their own scope. I don’t know enough about this to have a strong opinion.

Fire prevention: Improves measures to prevent damage from wildfires, including a requirement that homeowners clear brush from a 100-foot perimeter around their houses. Another law requires California forests to be better managed against tree-killing pests and to make it easier for fire departments to access firefighting equipment.
As you know, I’m usually against government telling us what to do with our homes and property, but since this affects other people, at least in theory, I would tend to support it. As for the second part, it sounds like another example of vague talk. How can you pass a law requiring the government to have better management. Is this in contrast to the current official policy of the government having crappy management against tree-killing pests.

Foreclosure consultants: Provides a registration and bonding process for foreclosure consultants and bars such consultants from entering into certain agreements with homeowners.
I’m not as excited about this law as most people. Yeah, of course it’s bad when consumers get ripped off or misled by the shadier foreclosure consultants as opposed to dealing with the registered, bonded ones. So it’s necessary to have anti-fraud measures in place. However, the opposite extreme occurs when you get too far in the direction of protecting people against their own stupidity. Maybe it’s not quite the same thing, but if I’m going to have my hair cornrow braided by an unlicensed cosmetologist as opposed to a bonded, registered, licensed one, that is the risk that I take.

Green jobs: Requires the state to develop a comprehensive approach to the needs of California’s workforce associated with its budding “green” economy.
Read the wording. I’m sure you know my view on this. Sounds all nice and fluffy.

GPS devices: Allows a global positioning system device to be mounted on the windshield of a motor vehicle only in the 7-inch square in the lower corner farthest from the driver or in the 5-inch square in the lower corner nearest the driver.
You mean drivers are forbidden to stick a GPS device right in front of their faces? By all means, let’s institute an expensive law to explicitly forbid this. But, oh I think a 5-inch square is not strict enough. But let’s just institute this and next year, we can kill a few hundred hours of busywork revising it to a 4-inch square.

Hospital infections: Requires hospitals to develop more comprehensive policies and procedures to ensure that patients are not infected in medical facilities.
I think you’re catching on by now. You can never ENSURE that patients are not infected, nor ensure against any adverse event in medicine. Requiring the “development of policies” means somebody is going to spend many hundreds of hours writing down some rules like “All nurses will wash their hands for 60 seconds every 20 minutes with sterile water running at a stream of no less than x feet per second and have each handwashing event witnessed and signed off by a minimum of 2 supervisors “, with no real evidence that it would do more good than harm.

Human trafficking: Voids any provision of a contract that purports to allow a deduction from a person’s wages for the cost of the person immigrating and being transported to the United States.
Human trafficking is terrible. But I really don’t think this law will put a dent in it. How many of the really bad cases of human trafficking even involve some sort of legitimate contract? Human trafficking is already a crime. Just enforce it.

License plates: Creates a California Gold Star Family license plate for families who have lost loved ones in wars.
Warm fuzzy gesture. How much is this benefiting working Californians? Is this the best use of our state budget?

Meat safety: Makes it a misdemeanor to buy, sell or butcher sick and some disabled animals for human consumption.
This is currently not illegal? I’m not sure of the specifics. If a healthy cow slips and strains his ankle on the way to the slaughterhouse, does this disqualify him from becoming food. Sniff. Just thinking of all this will make me teary-eyed the next time I have kal-bi.

Medical care: Requires doctors treating terminally ill patients to give them comprehensive information about end-of-life options, such as hospice care at home and the right to refuse treatment.
I am a doctor, but I don’t care for terminally ill patients, so I don’t know how much information they actually have regarding their options. To me this sounds like another sheet of paper for patients to sign to add to the killing of trees, but I’ll reserve further comment other than saying quality doctor-patient communication is a very good thing. New regulations specifically dictating what we should or should not say is not a good thing.

Medical insurance: Requires that when insurers cancel someone’s coverage, they allow other members of the family to keep theirs.
No. No. No. Don’t dictate details. Then consumers will have limited choices. Leave things alone and give consumers an option. Do they want to give their business to the insurance company that has this option? Or would they prefer to give their business to the other insurance company that doesn’t have this option but has other things they want, like lower premiums and better mental health coverage?

Another law prevents insurers from refusing to pay the medical bills of customers injured while under the influence of alcohol or drugs.
Again, allow the insurance companies and consumers to agree on this ahead of time. If I anticipate falling down in a druken stupor and injuring myself on a regular basis, then I sure better choose an insurance companies that does not refuse to pay under these circumstances. However, if I feel reasonably confident that I can avoid these types of injuries, then allow me to do business with an insurance company that has other perks that are more attractive to me, but which will not be responsible if I injure myself while drunk or high.

A third new law requires insurers to pay for HIV screening.
Give me a choice. I can either buy insurance that will cover my screening, or I can buy the other insurance that doesn’t cover it, but has other things I want, like lower cost.

Medical techs: Requires California’s Emergency Medical Services Authority to establish and maintain a statewide registry of the status of emergency medical technician licenses. Also mandates that beginning July 1, 2010, all EMTs undergo mandatory criminal background checks.

I’m not sure how EMTs are screened nowadays. However, in general, I think it should be the decision of the employer. I wonder how much the database companies which sell background checks contribute to the lawmakers who passed this law. What’s next? Mandatory criminal checks for waiters who handle our food and vets who care for our dogs?

Click here for part two.

This came out a few months ago, but I just came across it now.

There is a double-headed fertility problem in the UK. The great fertility of the teenage population produces 50,000 pregnancies each year to mothers under age 18, more than any other European country. On the other hand, the spread of STD’s among teens leads to infertility problems in the future. By no coincidence, the UK is the epitome of nanny-state government where policies are in place that lead people to be more dependent on big government for everything (now including the teaching of relationship values) and less dependent on parents, traditional extended families and friends for this. So what is their proposed solution? Give government even MORE control, starting in 2010, to force sex education to kids even as young as age five. Yes, FORCE. There is no freedom for parents to opt out. So whom do you trust to make the best decisions about teaching your kids the facts of life? Some school board administrator or yourself?

The laughable thing is this pertains not only to lessons about anatomy, but also to lessons about relationships. I’m sure the school board is furiously working on the teachers’ manuals for that right now to make sure that no child is left behind on learning how to have healthy relationships with the opposite gender. =)

Entrusting more and more to the government and taking away control from parents may or may not be the cause of Britain’s teen pregnancy problem, but I personally don’t think it is a coincidence at all. The problem results in more unplanned pregnancies AND to infertility later in life, due to the spread of STD’s. But the UK has a solution for that — government-funded IVF.

Just when we get concerned that government has grown out of control in the US, we are reminded to count our blessings because it could be worse elsewhere. Isn’t it time now to halt the growing overreach of big government and get back to more traditional individual freedom? God save us.

A lot of people ask me about unexplained infertility. Well, allow me to explain the unexplainable in very practical terms. If you have gotten pregnant and now have a baby, you are obviously not infertile, so this would not pertain to you. On the other hand, if you’ve been trying for some time, but are still not pregnant, then obviously you are not happy about the situation. I don’t want to restrict the definition of the word infertility with a set time frame, because it differs for each individual. Some people are sad and miserable if they are not pregnant after four months. Others will patiently keep trying beyond three years without any intention of asking for help. So, let’s just say if you are not pregnant yet and you want to be and you have been having unprotected sex for at least six months, then this will be of interest to you.

Prior to any sort of investigation, all infertility is unexplained. After a proper infertility workup, MOST infertility is still unexplained. I will repeat this, modifying it a bit because it goes against what you may have read elsewhere. Repeat. After a proper infertility workup, MOST infertility is still somewhat technically unexplained. Why? It’s like this. When you have finished doing testing for infertility, there are three basic scenarios you could reach. One is the OBVIOUS PROBLEM SCENARIO. This means our testing has unearthed an obvious red-flag big problem. Under these circumstances, couples have essentially zero chance of getting pregnant without medical help. Examples of this include someone whose tubes are both blocked, or who has a husband with zero sperm or someone whose ovaries have completely shut down into premature menopause. If any of these conditions are found, then your search is over and you will have to directly address these issues, because you’re not going to have a baby without medical help.

The second scenario is the EVERYTHING NORMAL SCENARIO. In this case, everything that you have tested, and I’m talking about the basics of a semen analysis, HSG and documentation of ovulation, comes back normal, or even above-average. This is what is classically referred to an unexplained infertility. It means everything looks fine on paper, but yet you are still not getting pregnant. Very frustrating.

The third scenario that is found in reality every day, but is not classically defined by medical textbooks is the SUBOPTIMAL FINDINGS SCENARIO. In these cases, there are found to be one or more things that are not quite perfect, but yet are not bad enough to sentence you to zero chance of conception. These include things like a low (but not zero) sperm count, one-sided tubal blockage with the other side open, surgically-documented scar tissue or endometriosis or evidence of inconsistent, but not absolutely absent, ovulation, or just advanced ovarian age whether chronologically (you really ARE 36) or biologically (you are 26 but your ovaries act 36).

Sometimes, a patient comes to me feeling like they know their diagnosis. “Doctor, we have already been checked out by our OB and we now that the problem is my husband’s sperm”. For example, this might be said to me by a couple for whom the semen analysis shows a 13 million / cc count with 39% motility. This is certainly below average and even in the abnormal range according to set criteria. However, if you went to every first-grade class in the country, hunted down the biological father of every healthy child and subjected these fathers to a semen analysis, I would bet that you would find not one, but many samples which have counts less than 13 million. As an additional example, if you did an HSG on every mother, you would find quite a few who have one blocked tube. So basically, in these situations, you have found something, but it’s not necessarily enough to explain the infertility, because it can’t pass the litmus-test question “Can other people with this condition ever get pregnant?” By the way, having said that, in very rare cases, even couples in the first scenario, the OBVIOUS PROBLEM SCENARIO, have been reported to get pregnant. How can a woman with two blocked tubes get pregnant? One theory is that the test was a false positive, like perhaps her tubes went into spasm at the time of the HSG and showed up blocked when in reality there was still a tiny tiny passageway or perhaps the films were misread by the radiologist or perhaps a clerical error led to the report of someone else’s test under her name. You get the point. These situations are extremely rare, but not entirely impossible.

So as many of you know by now, my way of thinking is always focused on solutions, decisions and actions, so while it’s a fascinating intellectual exercise to discuss these definitions and scenarios, the key question is what do we do about it? In the first scenario, the OBVIOUS PROBLEM SCENARIO, you would directly address the obvious problem. Duh. Depending on which problem, some solutions would include IVF, sperm donation, egg donation or attempted sperm extraction.

For the couples in the SUBOPTIMAL FINDINGS and EVERYTHING NORMAL scenarios, there is overlap in the treatment options. The focus becomes more of a shotgun strategy, meaning we can just try to universally give everything a boost. Get some improved egg quality and quantity (ovulation medications). Send the sperm closer to the egg and with perfect timing (IUI). Minimize uncertainty by physically putting the eggs and sperm together in the laboratory (IVF). We do this even if that’s not the suspected problem. So we give fertility medications to a couple with low sperm, in the hopes that more eggs will make up for fewer sperm. It’s like a football team with a terrible defense signing a top free-agent QB and RB and WR to try and overcompensate for the shortcomings on the other side of the ball.

The choice of which strategy depends on many factors including medical ones (test results, past treatment and response history) and non-medical ones (financial choices, personal attitude towards medical treatment, sense of urgency). We will address the important issue of how to approach unexplained infertility in future posts. But just remember the take-home message. In a strict sense, MOST infertility is unexplained.

Grrr. This type of stunt is just infuriating. First of all, she lied to manipulate her boyfriend, even to the point of elaborately embellishing her story with internet photos. She then subjected everybody to unnecessary worry and had police waste their holiday time and energy on this false alarm. Merry Christmas!

QUESTION:

I am looking for some information on high FSH/high estradiol levels. I am 31 and had blood work done in November 2008 on day 1 of my cycle because my skin keeps breaking out, so my dermatologist was trying to figure out if my hormones were the culprit. Turned out my androgen levels were fine, but my FSH was 17.7. So, I went straight to my OBGYN who tested me on day 3 of the next cycle in December 2008. More bad news. FSH was 11.9 and estradiol was 89. He referred me to an RE and said I probably wouldn’t be able to get pregnant on my own (without drugs). Why is this happening to me at 31 years old? I don’t smoke, drink occasionally, and I work out and eat well. What could have possibly happened to me that, at 31, my hormone levels are indicating that my ovarian reserve is either low or of poor quality (or both)? I was on the pill (on and off, but mostly on) for about 12 years. I had a miscarriage (chemical pregnancy) back in October 2008 (I went off the pill in July 2008). I have a history of endometrial polyps, and had a polypectomy back in October 2006. The polyps have not come back, but despite that, I still have dull aches/cramps in my lower abdomen on a regular basis. However, transvaginal ultrasounds show no more polyps growing. I recently had a CT scan which showed a small cyst (less than 2 cm in size) on my right ovary, but the radiologist didn’t seem to think it looked too alarming. Could any of these things be related to my high FSH/estradiol levels? Is this POF/premature menopause? If so, wouldn’t my estradiol be low, not high? I’ve read that the one thing in my favor is my age. Is that true, or do high FSH/estradiol levels mean bad news, despite being only 31?

Megan

Dear Megan,

I am sad for you about your news. Your situation points out the fact that a woman’s ovaries could age faster than expected without any obvious signs. It doesn’t happen to many women, but it happens to about 1%. It’s lucky that some random quirk of fate involving your skin led you to get your FSH tested, so you discovered this now rather than waiting until after it gets above 25. Your results predict that you are likely to have a harder time conceiving as compared to other women your age who have normal FSH values. An elevated FSH at 31 years of age still gives you hope for getting pregnant, either naturally or with help. However, the odds of getting pregnant naturally are probably pretty low (less than 2% per month), whereas the odds WITH the help of medications or IVF are likely to be higher. High estradiol levels (greater than 80 pg/ml) througout one’s cycle are good, but on day 3, high values are bad. The reverse is true. Lower E2 levels on day 3 are good, whereas if they stay low throughout one’s cycle, that is bad.

As for factors that are related to this, the polyps that you mentioned are not related to the FSH. The cysts are also unrelated. Your past history of taking birth control pills would probably have been of benefit (or at least neutral), rather than contributing harmfully.

While it is a natural human reaction to want to know WHY something bad has happened, the utility of knowing why is strongest when it can guide us to do something to reverse or halt it. In this case, if your diminished reserve were due to intense smoking, chronic illness, chemotherapy, environmental toxins or surgical damage to the ovarian blood supply, then it would be helpful to think about changing our behavior. However, in many cases, diminished ovarian reserve is due to unknown causes or to factors that exerted their effect before you were even born. So asking why becomes less useful than asking “What can I do now?”

Your doctor’s action of referring you to an RE was wise. It could be very helpful for you to discuss your fertility options promptly. Some options would include injectable gonadotropins or even IVF. If you are currently using contraception to intentionally delay childbearing, you might want to rethink things promptly. There still seems to be hope, but you have been given an indirect warning signal via your dermatologist. Good luck!

OK, so you have decided you want to have a baby. Perhaps this means you are going to stop taking those birth-control pills that you’ve been on since your wedding day. Or perhaps it means you and your husband will simply stop using condoms. Or for some of you, who have been less diligent about birth control, perhaps it simply means no longer “pulling out” or no longer avoiding your supposedly fertile days, whatever you think those days may be. Your mind is innocent and worry-free. You are expecting that you will get pregnant so easily. You had no suspicion that you would ever find yourself hurled one year later into a world of taking your daily temperature and peeing on ovulation sticks. You never expected the day when 90% of your web activity is related to researching infertility. You never imagined a time when your every waking thought centers around why you’re not getting pregnant.

In the very early stages of this transition from happy-go-lucky to the fertility-obsessed, as you first become acutely aware of all your friends and neighbors and every woman at the supermarket being pregnant while you are not, what is the first question that takes shape in your mind? I’ll give you a hint. It is NOT “Why do all their husbands have good sperm and mine doesn’t?” or “Why are their Fallopian tubes so efficient and mine are not?” Nope. The first question that comes to mind for most women is “Why is everyone else having sex at the correct time and we are not?”

As human beings, our brains are quick to attribute a cause, whether real or imagined, to things that we don’t understand. In medicine, you see it all the time. For example, as a medical student, I remember a young man who came to the emergency room with a complaint of feeling sick, bleeding from the nose and having trouble breathing. Eventually, the workup revealed that he had leukemia. After the initial shock, his first question was “You know? Six months ago, I was in Mexico and I got really sick after eating some bad food. Do you think that’s what caused this?”

We see it all the time when counseling patients after a failed IUI or failed IVF cycle. They are quick to come up with a lot of potential explanations. “I was one hour late with my injections one day. Do you think that’s why it didn’t work?” “I noticed you said that my lining was only 8mm. I was talking to your other patient in the waiting room and she got pregnant with a 10mm lining. Do you think my lining is the reason I’m not pregnant?” “I heard that Brand X fertility medicine is better and I took Brand Y. Do you think that’s why the cycle failed?”

As women first begin to suspect they have a fertility problem, often their first inclination is to blame it on their not having sex at the correct time. Witness the booming industry of home ovulation tests, books that teach you to obsess about your mucus or websites with software for tracking your temperature. So, is poor timing truly the culprit for most infertility? No. No. No. With a mixture of common sense and looking at published reports, we can better get at the truth.

The truth is this: If you can have sex at a reasonable frequency (every 2-3 days) then just do it and completely forget about timing it. However, if you can only have sex once or twice a month, due to your schedules or for whatever reasons, then it’s very helpful to time it. A lot of couples make the mistake of obsessing about timing, when they already have sex frequently anyway. By trying to time things, they actually wind up having LESS sex than they normally would, thereby potentially reducing their fertility.

When can a woman get pregnant? In theory, the six-day period prior to ovulation is all a potential time for conception. To fine-tune it further, the two or three-day period prior to ovulation is the window period of highest fertility. Therefore, the BEST STRATEGY is to have sex every day. But doesn’t that result in depleted sperm? No. Contrary to myth, for men with good sperm counts, there is no significant depletion of the sperm parameters of count nor motility, even with daily ejaculation. I know this is counterintuitive, but research confirms it. Furthermore, there is even evidence suggesting that men with BAD sperm counts don’t even suffer a significant drop in these parameters neither. My own personal observations looking at samples from couples who do double IUI’s on back-to-back days confirms these findings. Most of the time, the second sample is better, equal to or just slightly worse than the first. Only rarely is it significantly worse.

OK, so what if daily sex is not practical for you? First of all, don’t feel bad. I can tell you from working with hundreds of married couples that daily sex is not the norm. Fortunately, a strategy of aiming for every 1 to 3 days is more than sufficient. By doing this, you absolutely ensure yourself of getting together during the 3-day window period. With the exception of ultrasound, all methods of trying to predict ovulation (temperature, ovulation kits, mucus checks, calendars) have inherent flaws and are not able to be 100% accurate.

So then you might ask, of what possible value is it to chart temperature, check mucus and do ovulation testing? Well, for most people it is of zero value. There is no research that suggests any benefit of all this diligent tracking over simply having sex every 1-3 days. But again, if you are unable to consistently have sex every 1-3 days, then charting or being aware of mucus can help you focus the general window period during which you should concentrate your frequency of intercourse. Just don’t obsess about predicting the one EXACT day of ovulation.

Having said all this, in my opinion, there are still two more possible ways that charting and timing might be of some benefit.

1. If you find it stress-relieving to be more in-control, then charting and timing might be of help in relaxing you. You are not doing anything to boost your chances of conception by timing things, but you might feel less anxious if you feel more in-control, and that could have positive benefits.
2. If charting and checking for ovulation results in clues telling you that you are NOT ovulating, then you will be alerted to seek medical help sooner than later.

So in conclusion, rather than obsessing about the proper timing of intercourse, just go for a sexual frequency of every 1-3 days and forget about the charting and the fertility awareness. Any questions?