Last week, the scary health story du jour plastering the airwaves concerned a research study that found a link between high caffeine consumption and miscarriage. While some news outlets were relatively objective in their reporting with headlines like "Best evidence yet of caffeine-miscarriage link" and "caffeine is linked to miscarriage risk", others distort the truth a bit and proclaim "Too much caffeine increases the risk of miscarriage" and "Caffeine consumption raises miscarriage rate", ignoring the fact that correlation and cause are not the same thing. In other words, if women who drink more caffeine end up having more miscarriages, it doesn’t prove that the caffeine was the cause of the increase in miscarriage rate. Many of my patients asked for my comment on this and I didn’t know how to answer them because I didn’t have the actual study available to read. I searched the American Journal of OB/Gyn website and still couldn’t find the article even though I have login access. Fortunately, I was able to ask the editor of the journal who is a friend and respected mentor of mine. He was kind enough to send me a preview copy last week, which I just got done reading.

This was a two-year study which recruited patients from Kaiser Permanent in the San Francisco area. Every patient in their system who had a positive pregnancy was invited to join the study. Starting out with the 2729 women who were eligible to be in the study, in the end only 1063 (39%) actually participated. The rest were too busy, too far along in the pregnancy or refused for other reasons. While this study has many strong points, this vulnerability to selection bias is one of the weak points. The study consisted of detailed interviews about caffeine intake, demographic information, alcohol and smoking habits, Jacuzzi use and exposure to magnetic fields as well as data on nausea and vomiting.

Here are some of the interesting findings regarding the population studied:

• Of the 1063 women in the study, 172 (16%) of them suffered a miscarriage. This is in agreement with the common belief that about 1 out of 6 pregnancies naturally end in miscarriage.
• General breakdown of caffeine use. Of the 1063 women in the study, 25% consumed no caffeine during pregnancy and 60% were light caffeine users taking in less than 200mg daily. High caffeine users, defined as having intake greater than 200mg daily, comprised 15%. By the way, 200 mg was described as being equal to about two cups of coffee or five caffeinated sodas.
• The oldest group of women (over 35) were more likely to be high caffeine users than the youngest group (under 25). In the younger group, the no-caffeine group outnumber the high-caffeine group 4 to 1. While in the older group, there were just as many in the high-caffeine group as the no-caffeine group.
• Racial differences in caffeine intake. White women were proportionately more likely to be high-caffeine users than blacks, Hispanics or Asians.
• Previous miscarriage history. Women who never had a miscarriage before were twice as likely to be no-caffeine than high-caffeine. On the contrary, women who had 1 or more miscarriages in the past were a bit more likely to be high-caffeine than no-caffeine.
• Morning sickness and caffeine. Of all the women, 40% had vomiting during the pregnancy while the other 60% had no vomiting. In the yes-vomiting group, the no-caffeine users outnumbered high-caffeine users 2:1. In the no-vomiting group, there were 155 no-caffeine users to 116 high-caffeine users.
• Smoking. Smokers were 4.5 times as likely to be high-caffeine as no-caffeine, while nonsmokers were twice as likely to be no-caffeine as high-caffeine. This strongly confirms the previous idea that smokers drink caffeine more than non-smokers.

The bottom line is that the high-caffeine group were not identical to the no-caffeine group. They were associated with many characteristics that could be miscarriage risk factors. They tended to be older, have a history of previous miscarriage, and have habits of smoking, alcohol consumption and Jacuzzi use, so it would not be surprising if the high-caffeine wound up having a higher miscarriage rate.

Here are the results with respect to miscarriage:

• First of all, BEFORE accounting for the differences in risk factors, the miscarriage rates were different in the three groups. It was 12% in the no-caffeine group vs 15% in the low-caffeine group vs 25% in the high-caffeine group. This, in itself, is not really that exciting, precisely because of the confounding factors. It’s clear that the high-caffeine users had a lot more risk factors for miscarriage independent of their caffeine intake.
• I have to admit, I don’t know enough about the math of the statistics used for this, but the authors stated that they recalculated the relative risk of miscarriage using formulas that adjusted for maternal age, race, education, family income, miscarriage history, vomiting, smoking, alcohol and Jacuzzi use and exposure to magnetic fields. Even after adjusting for all this, they found that compared to the no-caffeine group, the low-caffeine group had a higher ratio of miscarriage that was likely somewhere between .93 to 2.2 times higher. The high-caffeine group had a miscarriage ratio that was likely somewhere between 1.3 to 3.7 times higher.
• It would have been nice to see if high-caffeine users could show a lower miscarriage risk if they actively cut down on their caffeine use once they found out they were pregnant, but the authors stated that there weren’t enough people in this group to offer any statistically significant results.
• The impact of caffeine on miscarriage risk was less in patients who had other risk factors. This makes sense because those are patients who are more likely to miscarry anyway, for other reasons. So being caffeine-free will not help them. Bearing in mind that over 50% of miscarriages are due to something wrong with the fetus, so no amount of being caffeine-free is going to save those pregnancies.

I think I’ll wrap things up a little differently by saying what I advise you NOT to conclude from all these and other scary news stories:

• MYTH: Pregnancies are so fragile that a cup of coffee will kill your baby!
• MYTH: Miscarriages usually happen because of something you did or ate, like lifting too heavy a weight, or getting into that argument with your boss.
• MYTH: Miscarriages are rare, so if you have one, there must be something that you did wrong.
• MYTH: If you have had four or more miscarriages, it is pretty much impossible that you’ll ever have a healthy baby.
• MYTH: If you have a miscarriage during your first pregnancy, you should go see an RE and get a full workup.
• MYTH: You can prevent a miscarriage by going on complete bedrest.

All of the above are common false beliefs that I’ve heard from patients.

My take on all this is as follows:

• Reevaluate your life before you get pregnant. In general it is always better to be healthier. How can you modify your diet, your habits, your stress level, your weight, your exercise routine and your smoking and alcohol habits?
• Once you are pregnant, do not exceed two cups of coffee per day. Ideally, stopping coffee completely would be best, but if it’s too difficult to do so, then at least cut down to one cup daily or less.
• Remember it is the job of journalists to sell newspapers and gain TV viewers and they do this best by inciting emotions, including fear. Keep this in mind if you are being pulled into a sense of panic by what you see in the media.
• Do reality testing. Is caffeine really that deadly to pregnancies? Out of the millions of healthy babies being born, how many of their mothers do you think are heavy coffee drinkers? I don’t know the exact answer, but I’m pretty sure it’s not zero.

I’ve been on faculty at a University of California medical school for over 10 years now. Last year, I was invited to additionally join the faculty of a second medical school. At the first school, students graduate with an M.D. degree, which is the degree that the general public typically associates with "medical doctors". At the second school, students graduate with a D.O degree. This confers on them the title of Doctor of Osteopathic Medicine. While DOs, for the most part, have equivalent training, privileges and abilities as MDs and while they function in the world the same as MDs, they are unjustifiably left with the short end of the stick when it comes to public relations. They are often confused with chiropracters, which are a whole different profession entirely. MD’s and DO’s are the only professions who can have the opportunity to pursue practicing in all aspects of medicine.

I think if I were hired to run a marketing campaign for DOs, the first thing I’d suggest is changing their name. All too often, I’ve heard stories from DO’s of patients questioning their credentials and asking to be seen instead by "a real medical doctor". I’ve worked side-by-side with DOs all throughout my medical career and I’ve had the opportunity of hearing many of their rants regarding the public’s misperception regarding their status. One memorable story told of a DO who was at a party trying to impress a girl. When he told her he was a doctor, she asked "You’re an MD"? When he corrected her and said he was a DO, the blank look on her face led him to add "Doctor of Osteopathic Medicine". When she answered back, "Er…I’m sorry, I don’t know what that is. Doesn’t that have something to do with feet?", he said at that moment, he knew his night was shot and it was time to move on.

Today, I gave my first lecture to a class of about 40 or so DO students. In the past, I’ve lectured to well over 1000 MD students. I would have to say that if I were blinded as to which group I was speaking to, I would not be able to distinguish at all between the two. Mind you, my lecture style is very interactive, meaning I regularly call on students all throughout my talk. The number of correct answers I got back on easy and difficult questions was pretty much the same as when I speak to MD students. In fact, one of the students today asked me one of the most insightful questions I’ve heard in a long career of lecturing. We were specifically discussing IVF and the advantages and disadvantages of doing ICSI. I described the dilemma of how doing ICSI had the advantage of minimizing the risk of failed fertilization, but NOT doing ICSI had the advantage of more adherence to the principles of natural selection in that sperm are permitted to fight it out and compete to let the better sperm win in fertilizing the egg. I told how many of my professional colleagues had a strategy of doing ICSI on 99% of their patients just to play it safe, while I tended to do ICSI on closer to about 70% of my patients. In reality, on many of my ICSI patients who make an excess of eggs, I will divide the eggs and do ICSI on some eggs and do conventional IVF on the others. However, I never mentioned that in my lecture. This student came up to me after the talk and impressed me by asking, "I was wondering. You said that in many IVF patients, you can generate a lot of eggs. Wouldn’t it be possible to do ICSI on some of them and not on the others?" This type of creative thinking from someone obviously unfamiliar with the field wows me more than any amount of rote memorization skills ever can.

Back to the distinction between DO’s and MD’s, I will offer my official opinion. It is clear that DO’s suffer from being a minority. There are about 7 MD schools in the US for every DO school. Because they are a minority and because DO schools emphasize primary care over specialties, DO graduates end up having fewer residency options than graduates of MD schools. A DO can theoretically get into any specialty he/she wants, but in practice, it is much more challenging than if he/she were coming from an MD school. DO’s disproportionately enter primary care fields as compared to MD’s. In fact, I’ve come to ironically look at DO’s who are in highly desired medical specialites as being exceptional, knowing the greater barriers they had to overcome to get where they did. Now because of the perception by medical school applicants of life being tougher for DO grads, this leads to it being more difficult, IN GENERAL, for students to get accepted into MD schools than DO schools. There is nothing inherently wrong with that. It was a little easier getting into the state MD school that I went to rather than an Ivy League school, but so what? While IN GENERAL, students given a choice tend to choose MD schools over DO schools, I personally know of a few excellent students who actually chose a DO school over another MD school.

One candid thing I’ll say that might invoke some ire from DO’s is that I don’t buy into the claims that some of them try to make, claiming that because they are taught special physical manipulation techniques in addition to standard medicine, that this somehow makes them better than MD’s. At least, in my field, I have yet to be convinced that osteopathic manipulations have increased a woman’s chances of getting pregnant. I am, however, open-minded to the effects of nutrition, stress reduction and overall wellness on fertility, but in no way do DO’s have an upper hand in these areas over MD’s, at least with the increased recognition of these holistic factors by all doctors as a whole.

I know that DO’s are often forced to defend themselves a lot, so this post might be the first ever documented case of an MD defending DO’s. I ask you all as patients to be open-minded. There are great MDs and bad MDs, great DOs and bad DOs. Get to know your doctors and give them a chance to prove themselves to you individually.

What exactly are you paying for when you spend your money on medical services? This question was inspired by a post on another blog that I regularly visit. It’s pretty obvious when you go to the supermarket, you come home with bread and eggs in exchange for the dollars that you leave there. When you go to the electronics store, you can exchange your dollars for a wide screen TV, XBOX or an IPOD. However, in medicine, you are paying for a service, not a product. Your money is not going towards the purchase of a material object. More precisely, you are paying for a set amount of your doctor’s time. For example, if you go to the hairdresser, you are paying for 45 minutes of that person’s time. When you watch a movie, you are paying for the cumulative time of the actors, the screenwriters, director, crew, distributors and for the time and energy that the producers put into gathering all these players together in the first place.

When I enter into a doctor-patient relationship, I see it as a prime example of how the world’s economy works. We, as people, engage in mutually beneficial exchanges of our time to make life better and safer for each other. My patient, the piano teacher, spends her time enriching the musical growth of students, for which their parents pay her. My patients, the policeman and his wife, give their time to make my world less dangerous for me and my loved ones. I could go on and on, but you get the point. Everybody contributes their time and energy to make the world better and gets money in return, as a less-than-perfect, but better-than-nothing way of keeping score of how much they contribute. Then, that money can be exchanged to make their own lives better. Every economic interaction involves people contributing something to make someone else’s life better, with the exception of occupations that involve taking money from people by force, without giving anything of benefit  in return.  Examples would include overt criminals and people who engage in legally-sanctioned unethical behavior. But those are just the exceptions.

When I talk about my being paid for my time, I’m not talking just of the time I spend talking with patients, examining them, performing procedures on their behalf and directly interacting with them. I am also referring to the past time I spent in school, studying and learning to acquire the knowledge that I have. I’m referring to the time I spend carefully screening my staff and diligently training them. I’m referring to the time I spend making decisions and carrying out actions so that there is a safe, pleasant environment (my office) where I can interact with patients. I am referring to the sleep lost when I wake up at 6 AM to do surgery or the personal time lost when I stay at work until 8 PM on particulary hectic days.

This weekend, for example, we are replacing the carpet in our office, so I need to come in and supervise the process. This is time I will not be spending with my family and friends, reading my favorite magazines, nor training my dogs. However, I realize that this is just part of life. I am blessed to have the chance of doing something that I truly love every day and I am even more thankful that by doing what I do, I am compensated with the means and options to pursue other worthwhile things in life, as well as prepare food and shelter for my future, when someday, I am no longer able to work.

If you feel that this post has been silly and/or obvious, then you might not be aware of how some other people think. So many people approach life with the question "How can I get money?" My advice to people who are contemplating this question is to think of a different question. Instead, ask yourself what it is that you can do now (or eventually learn to do someday) that will make other people’s lives so much better that they will be willing to pay you well for it. Those who are happy, successful, productive members of society have already asked themselves this and taken the right action.

So back to my case specifically, I view my past and current life choices as taking a series of steps to learn the skills I have so that I can assist people in boosting their chances of a healthy pregnancy. I sell my time and services. I do not sell a product. On the contrary, if you consider the 500 or so babies as a "product" that I’ve helped people conceive and multiply that by whatever dollar figure you try to put on a life, then paying me THAT would easily provide for me in my retirement years.

I realize I’ve not been posting with my usual frequency. I know that some people use their blog for venting. I promise not to abuse this, but I will take my privilege this one time.

There are a few reasons for by absence lately. Most notably, we’ve had more new patients this month than ever before. Yes, I do view that as mostly a GOOD thing. However, lately, it seem that more than half of our new patients come after having failed at other programs, and as such, are more challenging to care for properly. Part of my job is to hunt down their old records and review them in detail to see what new ideas I have for doing things differently, so that they might finally get a baby. One patient in particular has already failed six IVF cycles and three FETs elsewhere, but based on a few things I’ve noted (all of her cycles was done exactly the same cookbook way at the exact same center, without any innovative adjustments learned from each failure), I’m still optimistic there is hope for her. Three patients are coming to see me from Europe and two from Asia, and as such, require extra work to coordinate logistically. I’ve so far been able to maintain the level of attention that keeps my current patients happy, but if I get any busier, then something has got to give a little. So either I’ll have to cut back 5% on the time I give personally to each patient, cut back on the number of new patients I accept, cut back on my blogging, cut back on my social time, my workout time, my reading or my sleep. I chose to sacrifice blogging time.

Last week, our city had a power failure, so the morning was lost and we had to move our patients to the afternoon. Not only was my productivity shot, but I lost some files on my computer related to this blog. I’ve since recovered them all, but it took a lot of time to do so. I’ve also had to spend time dealing with getting ready to file taxes. I am just beginning to get an idea of how much of our country’s productivity is eaten up by having to prepare a tax return. I now truly feel it would benefit our country to go to a simple flat tax system, but I have friends who are tax attorneys and CPAs who would be out of a job, so I guess I won’t wish too hard for that.

We are finally going to get new carpeting in our office after ten years, so we have to pack and move some furniture temporarily. I have a new academic position at a second medical school, so I have to allot some more time to schedule more lectures in addition to the lectures that I still give at the other school. Today, the Food and Drug Administration paid us a surprise visit. We have been expecting this for a year now, as most of my colleagues have been visited already. These inspections fall under the tissue banking provisions, because our handling of donor sperm and donor eggs constitutes a form of tissue and organ donation. Fair enough. We’ve done this type of dance before with the Department of Health every year, and we’ve passed each time, but it is certainly one of the most time-consuming processes. However, if the wisdom of our politicians has judged it is in the public’s best interest to send a team of non-medical personnel to sift through our charts every year to see if any regulation has been violated, then I warmly embrace this opportunity to spend our tax dollars towards making the world a safer place for all. . I’m also happy that this provides an all-important employment opportunity for another government inspector. I was amused to learn that according to the FDA, it is my responsibility to periodically audit all the labs that we send our blood tests to, in order to make sure that THEY are in FDA compliance. I showed them my collected copies of certificates that those labs provided me certifying that THEY passed their FDA inspections. Although some might think it sounds like a silly circular game, I personally take it very seriously, because I respect the power they have over me and my patients. With one stroke of the pen, they can shut us down and THAT makes me pay attention and smile politely. I have the same respect for the DMV employees who with one wave of their hand can judge my paperwork to be noncompliant with the law and banish me to the end of the line, where I will be doomed to consume another 30 minutes of my life that I’ll never get back.

So that’s the latest. I hope that things will settle down in a few weeks after the inspectors are finished. So for now, if I don’t reply to your emails, please don’t think that I don’t appreciate them. I still do. God bless you.

Baby born Jan 15, 2007 on Martin Luther King’s birthday. Just turned one year old. His parents were prepared to name the baby Hannah, if a girl and Noah, if a boy.

I really admire some patients. I certainly admire those who bravely endure difficult infertility treatment followed many months later by enduring hours of painful labor in their difficult first delivery. Yet, there is another patient I admire even more who happened to have a super easy forty minutes of labor in her first pregnancy. But she earned it. Here is her story.

Ann is 28 and she and her husband were first referred to me by her OB after a year and a half of infertility. The cause of their problem was pretty obvious. Her husband had great sperm. The HSG said her tubes were clear. However, she had periods about two to three times per year. So the working diagnosis was Ovulatory Dysfunction. In fact, she had already been started on injectable ovulation medications by another doctor and had already been on a high dose of it (Bravelle 225 IU) for three days by the time that I first saw her. I quickly dropped her dose to 75IU, but it was still not enough to slow down her ovaries and she wound up making TOO MANY follicles, so her cycle was cancelled out of fear of triplets. It was disappointing to have to cancel, but it was encouraging to know that she COULD make a lot of eggs with the injectable medications. At this point, I suggested we take a step back and try to figure out better why she had ovulatory problems in the first place. It was tricky determining the reason for her ovulation problem, because she was already known to have thyroid disease, but it was well-regulated on medication, so that wasn’t the problem. Now, all RE’s know that someone who doesn’t ovulate on her own, but then produces a ton of eggs on injectable FSH is a big suspect for having PCOS. Ann had a trim figure and certainly didn’t look like a classic PCOS patient. However upon further questioning, she reported that she exercised an amazing amount!

Ann’s typical exercise regimen consisted of working out 3-4 times weekly, either taking classes at the gym or running 30-50 minutes. Right at the time when she first came to see me, she had just finished six months of training for the California International Marathon in Sacramento, during which time she ran 4-5 times each week for up to an hour with an extra long 2-3 hour run each weekend. By the way, I don’t know how she does it, but Ann also manages to maintain a very rewarding career. Still, she was frustrated, because despite all this, she wasn’t losing weight! Of note, Ann shared that she had a sister who also had the same history of irregular periods. Her sister walks every day, but does not do the same intense exercise that Ann does. (Her sister has kindly given us permission to share that she is not happy with her current weight and would like to lose about 40#.)

Based on this information, what struck me was this might be a case where someone born with an inherited problem of insulin metabolism was able to overcome the effects of it by the sheer will power to exercise like a superstar!

We ran some tests. Ann’s insulin testing showed that three hours after drinking the yucky sweet drink we gave, her blood glucose was 89 mg/dL and her insulin, which was expected to be below 20 by then, was more than double that at 43 uIU/mL. She was promptly started on metformin for a three week trial. She returned to report a tremendous difference. Whereas before she used to have low energy and have to brutally force herself to exercise as much as she did, now she felt great and had a much easier time maintaining her workouts! Her craving for carbs was markedly decreased and she went from 131# to 128# in 3 weeks with a noticeable decrease in her waistline. This was very encouraging. At this point, we had to make a decision whether to just be patient and see if her periods would also respond as well to the metformin as the rest of her body apparently did. Then if so, we could let her try on her own for a few months, at least. She and her husband opted to be more proactive, so we tried another round of injectable FSH and got a much better controlled cycle with just 2 mature follicles developing. However, she did not get pregnant. Then something not all that surprising happened. While we were waiting for her to resolve the cysts from her previous cycle, she reported that she did a pregnancy test and got a BFP! We monitored her for the first trimester and she graduated from our office back to her OB carrying a healthy single baby.

Fast forward to this week when she came visiting with her beautiful three-month old, a beautiful girl with the blondest hair I’ve ever seen in a while. She told me great stories about how she exercised throughout her entire pregnancy, including the funny stares she got from the other gym members while her bulging tummy rocked side to side on the elliptical machine at 37 weeks. I would tell you the story of her labor, but she and husband tell it so much better in their own words:

Saturday morning (@1AM) Ann started having contractions that were somewhat painful but she was still able to sleep around them.  Having never been through this before she wasn’t sure if this was “it” or just false labor so she continued to go back to sleep (priorities in order!).  Contractions came every hour until 4AM at which point Ann woke Matt up and told him she thought she might be in labor (contractions were 10-12 minutes apart).  He was up with a start and asked what we should do so we grabbed our trusty Bradley book and starting reading about the various stages of labor and determined that we were in “early first stage labor” and decided to hang out and try to sleep more.  At 5AM contractions were 8-10 minutes apart and we were thinking we should pack our bags and start our day.  Matt took a shower and went to help a good friend get ready for a garage sale while Ann took a shower and tried to nap again.  Contractions varied everywhere from 3-7 minutes apart and lasted about 45 seconds in duration. 

 At 8AM contractions were about 5-7 minutes apart but varied in length and intensity so Ann’s friend Laurinda came by to offer distraction.  Ann and Laurinda decided to take a short walk down the horse trails by the house at about 9:30AM…the walk usually takes Ann about 20 minutes but due to the contractions they ended up walking for an hour!  During the walk Ann started getting horrible back labor pains and did the “giant hula hoop” maneuver to move the baby around and off her spine….the Yorba Linda walkers weren’t ready for a pregnant, laboring, hula hooping lady walking down the trails!  Regardless, the hula hooping worked and the contractions were now 4 minutes apart and 45-60 seconds long.  Once they got home Ann was hungry and ate a bowl of Life cereal which evidently is a massive labor starting meal as her contractions were right on top of one another and too difficult to talk through.  (At one point Ann may have told Matt in a stern voice that he needed to focus his attention on her and not the college football games). 

 The Ollivier’s decided that since Ann’s contractions were causing her to make a “serious face” it was probably time to go the hospital.  They left the house at 11:07 and Matt drove mach-10 down the Toll Roads with Ann’s contractions coming right on top of each other.  Ann attempted to talk herself into relaxation by reciting her mantra “I am relaxed.  I can do this.”  While Matt responded “Yes honey, you are relaxed,” or “No you aren’t.  You need to relax.”  They pulled into the parking lot of Saddleback Memorial Hospital at 11:17 and Matt raced inside to find a wheelchair since Ann was now unable to walk.  He waited, and waited, and waited for what felt to Ann like hours and raced back to the car with….no wheelchair.  Seeing that she had no ability to talk, much less walk, he ran back inside and commandeered (aka stole) a wheelchair from a room and ran back outside to his screaming wife.  Matt pulled Ann into the wheelchair and ran (literally) her inside to the elevators.  Once inside the elevators Ann had a MASSIVE contraction and was screaming all the way to the second floor, down the hall and into the labor and delivery area.

The nurses asked Ann to walk into the area to check her status and she gave them an evil look and stated that she could not walk there under any circumstances (she was barely able to breathe!).  Once on the table Ann was declared 100% effaced, 6-7cm dilated and Baby O was at -2 station.  She was told by a nurse that since it was her first baby she would most likely dilate 1cm per hour and to relax.  Ann continued screaming and trying to relax.  The nurses asked her how much water she had been drinking and told her that 16 oz an hour wasn’t enough and she was dehydrated and started an IV for fluids.  In the middle of having the needle jabbed into her arm her water broke all over the place and she felt the need to push.  The nurses yelled at her not to push and that she was only 6cm dilated.  She yelled back at them to check her again and they decided to draw a vial of blood instead.  Once they had their “essential” vial of blood, they checked her again and she was 100% effaced, 10 cm dilated and +3 station (aka. ready to push).  They raced around to get the room ready for labor and paged the MD on call.  The nurses raced Ann into the labor room and told her to relax (duh) while they got the room completely set up.  Four contractions later and Baby Ollivier entered the world at 12:08PM.  (For those of you “non-math” types that was 11:25AM arrival at the hospital and 12:08PM delivery….43 minutes).  The nurses were amazed (as was Ann) and Baby O let out a solitary cry and they proceeded to look around while her APGAR score was calculated (1 minute score=8, 5 minute score=9).  She flew into the world at 5lbs 9oz and 17 inches long with a full head of blond hair and all her necessary parts.  Her parents think she is beautiful.

Sure, there is plenty of medical evidence that women who exercise regularly have easier labors and less complicated deliveries. And for many people, that is enough to convince them. While I am a believer in properly conducted research studies, I also like stories. . Thank you so much, Ann, for sharing this with our readers. We love happy stories like yours.
 

I’ve always been a risk-taker, risking my own things, not other people’s. This includes taking huge risks such as starting my own infertility practice and making some high-risk high-yield financial investments, which have come to pay off very handsomely. However, I am prone to taking many near-trivial risks in life also, such as waiting for the gas tank indicator to get to the lowest possible point, showing completely empty, before filling up the tank. I’ve only fully run out one time in the past 15 years. That time, it was with a rental car for which I was not that familiar with the peculiarities of the gas gauge. Fortunately, it happened within very short walking distance of the nearest gas station, so it wasn’t all that painful a lesson. My parents are just the opposite in this regard, as they tend to panic and refill the tank if it gets below 1/4 full.

This morning, being a Saturday (yes, RE’s work on weekends), I left just enough to time to get gas and then get to work at the time when the first patients were scheduled. The tank had been at the completely empty mark (which I define not at as the point where you first get a warning flash, but as the point where the indicator could not possibly get any lower) since I got home late last night from going out with friends. It had been so cold and it had been late, and I calculated that I could leave home this morning with enough time to spare to refill the tank.

While pumping the gas this cold morning, I heard the familiar noise of a car’s wheezing and grinding as it attempted unsuccessfully to start, a noise I heard many times when I lived in the snowy Midwest. Apparently, someone had pulled up to the pump before me, gotten his gas and was now having trouble restarting the car. A tall old man about my grandfather’s age stepped out and in a raspy voice sounding like Homer Simpson’s dad, asked if I had jumper cables. I replied yes. You see, my car is well-prepared with a first-aid kit, jumper cables, two bottles of drinking water, a spare blanket, a hand-crank flashlight that doesn’t require batteries and a book in case I get stranded somewhere and need something to occupy my time while waiting for help to arrive. Although I am not afraid to take risks, I also try not to take any unnecessary risks. Waiting for the gas tank to get down low before refilling has a benefit in that it minimizes the hours of my life that I have to waste pumping gas, so I don’t see that as a completely UNNECESSARY risk.

I asked back to the old man "Can’t the gas station attendant help you?"
He grumbled back "You would THINK. But they don’t even have cables. I asked already."
That didn’t surprise me. Sitting in his warm office, was the bored Middle Eastern gas station attendant, watching his tiny black and white TV while surrounded by neatly arranged displays of chewing gum, lip balm, maps and lottery tickets scratchers, oblivious to the world except to interact with the occasional customer asking to get $40 on pump #3.

I processed the situation. I was probably going to be a few minutes late for work as it was. If I stayed and did the decent thing to help this poor old man, I might be an additional 10 minutes late if the best case scenario played out of a quick easy successful jump start. However, having jumped-started many batteries already throughout my driving career, I know that it could sometimes take an unexpected turn and require a lot longer than expected. It would not be fair to my patients to make them wait. I finished pumping gas, popped open my trunk with the remote and got out my coiled and wrapped set of cables. I handed them to the man along with my card, telling him he could wait for the next motorist or the attendant to help him and that I trusted him to drop them off at my office (2 minutes away) after he was done with them.

However, things were not to be so easy. After talking to him more, and observing his less-than-crystal-clear cognitive status and his apparent inability to read the fine print on my business card, I had a sinking feeling that after I lent these cables to him, chances were high I would never see them again. Still, the risk-taking decision-maker part of my brain had already clicked and I had already committed that I would gamble the loss of my cables if it meant a reasonable chance of making this other person’s day go easier. Suddenly, fate came to the rescue. A man who had apparently been nearby and who had overheard our conversation, walked up to us, looked at my business card and while walking into the office to pay the attendant turned back and said to us "I don’t have cables, but I can use yours to help him and then I’ll drop them back to you". Problem solved. The safe return of my cables was no longer at the whims of the elderly man’s mental faculties, but rested solely on the honesty of the second man.

I got to my office and started seeing patients. Each time, I came out of the room and back to my desk, I asked my staff if someone had dropped off the cables and each time, I became a little bit more disappointed with humanity when I got the answer. Almost an hour had passed and I got wrapped up in a lengthy graduation ultrasound for one of our patients. This is the final ultrasound done at about 12 weeks pregnancy where we burn a movie of the baby dancing around onto a DVD  to give to the patient as a small good-bye present before they leave us and go back to the OB who referred them originally. Caught up in the happy couple’s wave of excitement as I showed them all the baby’s parts, I had already forgotten about the lost jumper cables as I hugged the couple goodbye.

As I went back to my desk, something caught my eye. There on the corner were my jumper cables, coiled even more neatly than they had been originally, and tucked securely back in the vinyl bag. The fact that it had taken an hour to make it back to me suggested that the nice man had spent a lot of time to help the old man. Also, next to the cables was a business card belonging to my tag-team partner good Samaritan. I kept his card for future reference. So, if you live in southern California and are ever in need of an honest contractor to remodel your kitchen, you might want to check out Abby Vasquez Construction 714-519-1400. I know nothing of his skills, but you can surprise him and tell him that you know all about his good deed helping an old man jump start his car that cold Saturday morning.

A minor miracle has happened and I can take no credit for it. To balance all the happy stories of babies for whom I was privileged to have a part in their conception, this patient has asked me to share her story to give a glimmer of hope to women who give up on treatment.

One day, our office received a happy phone call from a former patient who had not been in our office for three years, telling us that she was now pregnant naturally and had just come back from seeing heartbeat on ultrasound with her OB. Looking back, she had failed to get pregnant with us despite making four follicles and being inseminated with a good sperm sample in a single IUI cycle. She was 42 at the time and had one completely blocked tube. She and her husband were not financially prepared to invest in an IVF cycle, nor even in another IUI cycle, so they decided to take an indefinite break. Of note, prior to seeing us, she had had one miscarriage in her life during her 30’s and she had failed six cycles of Clomid with her OB/Gyn.

While it’s sad when patients have to give up, it’s also something that we all have to accept as a possibility, as not everyone has the same financial situation or the level of willingness to go on. I had a long conversation with her husband years back and wished them luck. I told them that at age 42, seven past years of infertility, one previous miscarriage and one blocked tube, it was estimated that they had less than a 1% chance of getting pregnant on their own each month, but it was not entirely impossible. They replied that they would keep trying on their own and if they ever changed their mind about doing any sort of treatment, whether IUI or IVF, they would be in contact.

When we received the good news three years later, she had just turned 45!! I was extremely surprised and even skeptical, until I got a chance to confirm it with her OB. Now, I have to admit that the possibility is not entirely ruled out that she snuck off somewhere and got pregnant through IVF with donor eggs, but I don’t think that’s the case here. So there you have it — one of the most improbable happy endings in a patient who had all but given up on treatment. Please don’t take this as a suggestion that trying on your own is the best way to go if you’re 42 with one blocked tube, but let it be a reminder that out of all the women in the world who are left with only a 1% chance of getting pregnant, each month, some of them (well 1% of them) will get pregnant.

I came across your website and decided to contact you just to get a second opinion.  Hopefully you can help.  I am 25 yrs old, married for two years and have been trying to conceive for the past 5-6 months.  Once we decided to have a baby, I started reading a lot online and decided to see an obgyn while trying to conceive that way we weren’t just "wasting" our time.  (I know, I’m very impatient)!  My ovaries, uterus, etc have been checked and everything seems to be fine.  I believe I have ovulation issues.  Although I have ovulated on my own in the past (positive opk and confirmation from blood test), I do not believe I have ovulated in the past few months.  My obgyn wanted to do an endometrial biopsy but I didn’t agree with that for some reason.  She also stated that I don’t have PCOS.  The impatient person that I am, I decided to seek a fertility specialist since insurance covered it.  So last month I went to a very well known specialist here in New York.  After tests and consultation, she advised me to start on 50mg of Clomid (days 3-7) and monitoring of follicles.  I really liked the fact that I was being monitored. 

Thank you kindly,
Sara

Thanks for the detailed email. I think our readers will benefit from many of the issues you raise. I will try to address most of the ones you mentioned if you promise not to take it as an official "second opinion" or as being specific medical advice to YOU only. Without knowing your medical situation in greater detail and without examining you, there’s no safe way I can advise what is right for you specifically. However, I’d have to say that your RE and I appear to have similar approaches. If you stick with her and discuss things with her, you’re probably going to be in good shape.

• CANCELLING CYCLES: I’m sorry that your cycle was cancelled. I can probably write an entire post on the topic of cancelling cycles. When an RE initiates a stimulation cycle and prescribes ovulation medications, it is with the good INTENTION of growing a suitable number of quality follicles that month. Just because it’s the right intention doesn’t mean the ovaries will necessarily cooperate. As you astutely noted, proper monitoring is very nice to do, because it gives you the peace of mind of knowing exactly what’s going on. And in your case, it tipped off your RE to the fact that your ovaries weren’t responding this month. Whenever the ovaries don’t respond quite the way we like, we have to make a decision. Should we push it and see if eventually something develops or should we cut our losses and regroup. It’s a judgment call! Pretend you started a business, for example. Let’s say you opened a restaurant with the intention of packing it in with happy diners every night. However, after a year, you still have very few patrons showing up each night. You have to decide whether to stick with it, despite losing more money every month and hope things turn around or you can throw in the towel. The same applies to cancelling a cycle. You can make two types of mistakes. You can give up on a cycle too early and miss out on eggs that would have eventually shown up the next visit. OR you can make the mistake of getting sucked into the never-ending void of a drawn-out eggless cycle, thereby wasting a fortune in medication. Now in the case described above, because it’s a Clomid cycle and not an injectable cycle, there is no additional expenditure of medications. But based on the fact that it was already day 13 and still nothing had grown to the critical threshold of 13mm (which is a rough cutoff I use to distinguish between follicles that will go on to do well vs those that will fizzle out) AND based on the additional clue that your E2 was actually dropping instead of rising, I likely would have cancelled you as well. Remember. Even though you weren’t wasting additional medication each day, you WERE wasting your precious time.
• INCREASING THE DOSAGE: The minimal starting dose of Clomid is usually 50mg daily. If someone fails to make eggs with that, it doesn’t usually faze me. There’s plenty of room for improvement. Bear in mind that with respect to a first time Clomid cycle, there is a difference between failing to get pregnant and failing to ovulate at all. If on 50mg, someone makes eggs, but fails to get pregnant, there is a reasonable for sticking with the same dosage and trying one more time. However, if they completely fail to ovulate (as can be determined best by doing close monitoring), then it makes less sense to do the same thing over again.
• STARTING CLOMID ON D3 VS D5: Even among RE’s, there is general disagreement regarding the concept that starting earlier gives more follicles and starting later gives better-quality follicles. I don’t think the answer is clear cut and in the grand scale of things, it is not a critical difference when we’re talking about a relatively low-level form of treatment like taking Clomid.
• ENDOMETRIAL BIOPSY: EMB’s are very useful when used to screen for endometrial cancer. When used for infertility, it’s just a way to inflict torture on patients you don’t like. (In case you have no sense of humor and can’t recognize a joke, please ignore the previous sentence). During one of our round table dinners this past year, I remember a joking discussion on EMB’s with the consensus that out of the RE’s present, none of us did EMB’s any more. I personally have never done an EMB in my practice other than to occasionally screen for cancer in older patients with abnormal bleeding.
• METFORMIN: When you ask me how I feel about metformin, I KNOW I can write 10+ pages about it. I am definitely going to be inspired to write volumes about it at some other time. Suffice it to say that there are many patients that I put on metformin and many patients that I don’t put on metformin. As for the suitability for you in particular, I leave that decision up to your RE. If you were my patient and we had a nice one-hour chat and I got to evaluate you more completely, then I could better render an opinion on your case. But even with what you have told me, I can’t say more for sure. Sorry .
• WHEN TO DO AN HSG: The answer to this question is similar to the metformin question. It depends. In some patients, I do an HSG right away. In others, I push it back for later. Without going into detail, some factors that influence how soon I do an HSG include risk factors for blocked tubes (previous surgery, previous STD’s, painful periods), the suspicion of other fertility factors, patient’s aversion to discomfort, costs, and the exact history of failed attempts at treatment. Bear in mind that nothing is a perfect predictor. You can have an patient with painful periods and previous Chlamydia and a previous ovarian cyst surgery who ends up with a pristinely clean HSG result, just as you can have a perfectly healthy patient with no risk factors who ends up showing blocked tubes on HSG. You mention your age as a factor, but in reality, that’s not a good predictor of someone’s tubal status. I will answer your other question and say you are correct, for the  most part, tubal status and ovulatory status are independent factors and don’t influence each other directly. You can have blocked tubes and ovulate great or you can have fantastic tubes and not make eggs. The two are separate issues.

Sara, thanks again for your well-written letter. I know that other readers appreciate your taking time to share. Good luck in your quest! Be thankful you have a good RE there in New York. Perhaps I know her.

I take issue with cruel inconsiderate people who criticize infertility patients, accusing them of not accepting their fate and trying to change the "fact" that nature intended them to be childless. The other common stupid accusation is that people who do infertility treatement are selfish because they only want a baby for themselves, not for the sake of the baby. I find that rarely to be the case. As you may know, I spend a lot of time keeping in touch with my graduated patients. From hearing of the great sacrifices of late-night feedings, diaper changes and just overall giving over their entire life for the welfare and happiness of their new little ones, selfish s the LAST word I would use to describe parenthood. I truly believe that for the most part, people who desire to be parents, do so for the opportunity to GIVE love to their child. Time and time again, my patients confirmed for me that they now realize the fleeting agony of injections, doctor’s visits and uncomfortable procedures are a walk in the park compared to the difficult (but very welcome) trials of parenthood that will last for the next few decades.

However, I do concede that there do exist a small minority of people in the world for whom the concept of motherhood IS just all about what it can do for THEM and how it can make them feel and not about the baby. These women do not undergo fertility treatment. Under what circumstances is this indisputably true? When the baby is fake.

**WARNING** This video is creepy and you might prepare yourself to turn it off it gets too unnerving.

Perhaps critics who pick on women who are trying to get pregnant in order to have real babies to love will leave them alone once they see the obvious contrast here.