My private desk is at one end of my office suite and our blood test lab is at the other end. So it would take a pretty loud noise to travel the distance. This morning, my door was open and I heard a distant happy group-scream coming from that direction. My office manager, whose desk is near mine, shouted back to the screamers. "Who’s pregnant?"

This is a common ritual in our office. Patients come in and get their blood drawn to see if their fertility treatment resulted in pregnancy or not. The tests take a half hour to run, and as the results are coming off the machine, there is the familiar clicking of the internal printer, sounding a lot like the dot-matrix printers of old. If you don’t remember the 1980’s, you probably don’t know what that is. Some days, my staff members run back there upon hearing the noise, wanting to be the first to see the results roll off the printer, especially if the test is for a favorite patient of theirs. If a scream follows, it means somebody is pregnant. If there is silence, then the results are negative.

This machine has served us well for nearly a decade. It has always delivered accurate results and we have always passed the government-mandated quality control testing. However, as with anything, time marches on as technology advances. Next week, we will retire Old  Betsy and replace her with a new state-of-the-art analyzer. The good thing is that the new machine is faster, more automated (requiring less labor to prepare and load the trays), can be run without batching tests and will ultimately be more cost-efficient to operate. The results are supposed to be even more accurate, but there’s not much room for improvement over Old Betsy in that department. As excited as we are about the new silent-running machine, we will certainly miss that familiar sound that has heralded the good news for nearly 400 babies.

Although I haven’t actually delivered a baby in the past 8 years, I did deliver over a thousand during my years as a medical student and OB/Gyn resident. Even so, it wasn’t until I saw this computer simulation that I gained a better understanding of the dynamics of cervical dilatation and childbirth. Watch and be amazed. 

I came across this link via the Street Anatomy website, a great place to find beautiful medically-related visuals.

If it is your wish is to be a parent, the choices you make today will affect the odds of you actually having a little one in your home one year from now. The concept of our decisions affecting our future is true of anything in life. However, in difficult matters such as infertility, it is very easy to fall into the trap of emotional paralysis when you should really be focusing on correct decision-making. True, the heartbreak of infertility can be overwhelming for many reasons. However, in life, while we can’t always control our feelings, we CAN control our actions, so it becomes of utmost importance for every infertile couple to concentrate on making the right choices, despite the temptation to let emotions rule.

Everybody’s personal case is different, of course, but one universal way of viewing the dilemma of infertility is that of AVOIDING MISTAKES. One mistake to avoid is that of inappropriately pursuing powerful, aggressive medical treatment when it is not necessary. For example, if you are 26 years old, try for three months and then decide to spend $14000 to do IVF, although this will likely result in you getting pregnant instantly, maybe even with twins, you have lost out on the chance to get pregnant naturally and will likely have spent that money unnecessarily. The opposite mistake is to NOT take advantage of available treatment options when they in fact ARE necessary. For example, if you are 35 and have been trying for 10 years and you only get your period twice a year, by allowing your sadness to paralyze you and thereby not seek treatment, you run the danger of passing up your best reproductive years and winding up permanently childless. So how do you determine the right decisions?

You have already successfully taken the first step by allocating some of your precious time today towards visiting this and other sites. There is a great collection of valuable information (and harmful misinformation) out there on the internet. Your task is to diligently evaluate and synthesize what’s out there and make up your own mind.

After gathering information and increasing your knowledge, the next step is to face the fact that you can’t escape having to make choices. Even if you decide in frustration to throw away your thermometer, ovulation kits and charts and just give up, that too is a choice in itself and can have important ramifications.

KEY POINTS TO TAKE AWAY:

• Now and in the future, remember to keep asking yourself on a regular basis, “What decisions do I need to make today, this week or this year to get what I want?”
• When gathering information, keep an open mind. Don’t rely solely on one source for your information and don’t get too set in your ways. If you find new information that contradicts your old beliefs, weigh the two sides objectively to see if you should change your opinion.

People want babies. That’s what keeps my practice busy. But the reason for this is not as obvious as you would think.

There are two different schools of thought concerning why we behave the way we do. One extreme viewpoint is that everything is LEARNED, meaning that we think the way we do because of the influences we got from our families, friends and the environment while we were growing up. The other extreme is to think that everything is GENETICALLY PROGRAMMED into our brains. As is often the case, the real truth is somewhere between the two extremes.

Sure, our parents make repeated statements about how happy they will be when we give them grandchildren. We are happy for our college classmates when they become proud parents themselves. We gleefully watched on TV as Monica (with some help), Rachel and Phoebe had babies. But, is this what is driving us to want babies?

Social ecologists say no. They believe the answer lies in the innate programming that is imprinted in our minds even before we are born. Imagine back in our ancestral environment as primitive men and women roamed the earth. There were some people who possessed genetic traits that made them pursue behaviors which would result in their having more children and in their caring for their children so as to help them survive to reproductive age themselves. Some of these behaviors would include seeking out and attracting fertile mates, having lots of sex and protecting oneself and one’s family from enemies and nature. Those people who performed these actions best would be more likely to have children and pass on their genes. Those others whose genes led them to avoid sex, avoid taking care of children and avoid taking care of themselves would be less likely to pass on their genes. After several centuries, the genes that make people more likely to pass on their genes would exist in much greater abundance in subsequent generations of the population. That’s where we are today.

Think about it. Each and every one of us alive today is descended from a hundred generations of ancestors on both sides who were healthy, hard-working and lucky enough to survive to reproductive age, attractive enough to convince someone to mate with them, fertile enough to bear offspring and “parental” and protective enough to help those offspring survive to someday reproduce for themselves

The world has changed much from those primitive days of hunting buffalo and foraging for food. Behaviors that used to be beneficial in a low-food environment, such as the tendency to eat sweet and fatty things, which would be high in caloric value and thereby help people stay alive, are now detrimental. In this day and age, where abundant Whoppers and shakes are within five minutes access for all of us, it is not advantageous to have brains hardwired to seek sweets and fat. However, the lag of evolution is great and it will be many many generations before our brains change.

When it comes to reproduction, many of my patients inquire if infertility is hereditary. Not really. There aren’t many people who can say “I’m infertile because my parents and grandparents were infertile”. However, this statement is no longer entirely true. For example, men with certain micro-deletions in their Y-chromosomes, making their sperm all but incapable of fertilizing eggs naturally, can now fairly easily have children with the help of IVF-ICSI. Without technology, these men would have failed to have children and would not have passed on their genes. But now, it is very possible that their sons will inherit these “infertile” genes and someday need IVF-ICSI themselves to reproduce. And so on.

It used to be that in order to reproduce, one had to be very good at finding a mate. This, too, is no longer the case. Now what it takes is the capability to afford donor sperm, donor eggs and/or a surrogate. In fact, in countries where government entitlements pay for these services, you don’t need to be fit enough to afford anything. You just need the good fortune of being born into such a society.

The world may have changed, but evolution is patient. Thus, we are all still prone to behave in ways that were a winning strategy in the game of life as it existed centuries ago. So as you sit and wonder why you are so driven to get pregnant and have children, don’t fight it. With bombardment by messages all around you in conjunction with centuries of hard-wired genetic programming, it’s a wonder you’ve waited as long as you have.

Update FEB 23 2009: There are some people who strongly disagree with this.

One very sweet new patient came to me with a tearful story of her two-year struggle with infertility. After she had failed to conceive in her first year of marriage, her well-intentioned mother-in-law stepped in to offer some "advice". The mother-in-law was convinced that this patient was failing to get pregnant because she was not resting enough. So, in a radical move, the patient reluctantly quit her job and spent the better part of the past year at bedrest. She described how each cycle, after her ovulation test turned positive, she had gotten together with her husband and then obediently stayed confined in her bed, getting up only to use the bathroom, and even then, not without feeling a bit guilty for leaving the bed. Despite her faithful adherence to this rigorous bedrest regimen, and despite compliantly consuming the wide array of Chinese herbal concoctions that the mother-in-law thrust at her, her period would eventually come, bringing with it mixed feelings of sadness for not conceiving, yet some relief at being temporarily free from her confinement. After a year of this suffering with no results, she came for medical help. Ironically, it was her mother-in-law who had asked around, found my office, and had made the appointment for her.

While this woman’s story is one extreme example, it’s by no means the only example. Several women I’ve encountered have had it in their minds that the reason they are not conceiving is because they are not resting enough. So the question comes up of what exactly is the role of bedrest is in helping fertility. And my answer is NONE. Well, almost none. Bedrest is not necessary in order to get pregnant, either for patients trying to conceive on their own, nor for patients undergoing treatment with IUI, nor even for those doing IVF. In exploring this issue, let’s remind ourselves that there are two ways to get to the truth scientifically - LOGIC and EVIDENCE.

Logic dictates that being immobilized is not a normal human state. When women have sex while they are immobilized either due to spinal cord injury or leg fractures, there is no increased fertility observed. Also, understanding the mechanism of how the Fallopian tubes pick up the ovulated eggs would suggest that adopting a variety of different body positions could actually ENHANCE egg pickup by allowing the end of the tubes to fall into different locations at different times, exposing them to more possibility of picking up an egg.

Evidence from studies comparing bedrest after IUI and after IVF embryo transfers show no advantage of bedrest. There is one exception and that pertains to a short 10 minutes of bedrest after IUI. During IUI, the sperm is delivered as a volume of liquid into the uterus. By staying flat for 10 minutes afterwards, the sperm can disperse better. In my practice, we take it one step further by using our electric beds to tilt the patient upside down for those 10 minutes. Note that this principle does not apply to regular sexual intercourse. The difference is that with IUI, the sperm in inside the uterus already. Being upside down will help it flow into the tubes which is where we want it. With sex, the sperm is not deposited directly into the uterus, but rather just into the vagina. So going upside-down after sex merely results in the sperm pooling in the upper corners of the vaginal vault and not into the uterus. Even with IUI, after those 10 minutes of resting slightly upside-down, we encourage patients to resume normal activity for the rest of the day on.

What about bedrest after embryo transfer and IVF? Historically, when IVF first came out back in the 1970’s and 1980’s, patients were instructed to be at bedrest for days or even weeks afterwards. This was not based on any evidence, but just on playing it safe because we didn’t know better. Over the years, research studies have confirmed that prolonged bedrest after IVF is not helpful and might even be harmful, presumedly due to increased stress brought on by the confinement.

In my own practice, the approach is to have the patient stay home in a happy peaceful safe environment for the day of and the day after embryo transfer. The focus is on being at peace. By staying home, no unexpected things such as minor car accidents can happen. This probably is not necessary, but any attempts we’ve made to tell our patients to have no bedrest at all are met with violent protests, so we have just fallen into this routine and have great success rates to show for it. Bear in mind that for some patients, bedrest is very stressful and is comparable to being a prisoner isolated from ones favored usual daily activities.

I have a memorable example of a patient who underwent IVF four times (two fresh and two frozen cycles). Out of those four transfers, the patient, who is herself a doctor and in her residency, went on overnight call immediately after her transfers three times. Those were the three instances that she became pregnant and went on to delivery a single healthy baby each time. The one time where she was on vacation and decided to take advantage of bedrest was the one time she didn’t conceive. At the risk of offending any statisticians out there, I do not advocate drawing any scientific conclusions from this one isolated case. However, it’s fun to mention it.

One final exception is as follows. If you have a horribly hectic schedule and you want to experiment taking off one month or two, either vacationing in Tahiti or just being at bedrest, watching DVD’s and doing Sudoku puzzles, then by all means, give it a shot. Who knows? You might end up pregnant and make for a very good story. (Please share with me if this works). If not, don’t let your mother-in-law keep you at it for a whole year, because this would violate the first rule of getting pregnant, which is "If the way you are trying is not working, try something different".

Also, bear in mind, all this discussion pertains to getting pregnant, not what happens AFTER you are pregnant. Once you are pregnant, there are several situations in which bedrest is good, but that’s for the 2nd and 3rd trimesters - a whole different story.

Conclusion: Ten minutes of bedrest after insemination can be helpful in conception. All other situations (conceiving naturally, IVF cycles) do not benefit from bedrest.

By the way, the first couple with the strict bedrest was surprised when further investigation revealed that their problem was a sperm problem. They went on to have two IVF cycles, each time delivering a healthy baby. Everyone is happy now, especially the mother-in-law.

One phrase which has grown trite is the motto "Work hard, Play hard". I hear it often from my high-achiever friends. There are several nuances to the interpretation of this phrase. The most obvious one is that of balance, making sure after your tough 40-hour week living in your cubicle that you take that Mediterranean cruise to unwind. I definitely subscribe to the whole balance philosophy.

However, where my world view diverges from that of most others is the directionality of the two components. Many people see it as work hard IN ORDER TO to play hard. Their view is that paying your dues in your daily grind at work will earn you the financial resources so you can afford leisure activities. If they were to inherit millions or win the lottery, they would quit their work and just play. For me, I get great intrinsic fulfillment out of my work of helping people have babies, so that it is a reward in itself. However, after intensely working nonstop, I start to lose my energy and I need to do some play in order to recharge. So the reason I play is to replenish my ability to work. Funny, I probably spend as many hours, if not more, playing than those other people, but thinking of it the way I do somehow just feels more satisfying.