The morning started out terribly. One of our favorite patients had a miscarriage confirmed. There had been a heartbeat seen on their last ultrasound, but there was none today. As the patient herself admitted, it didn’t come as that much of a surprise, because she had been bleeding, her hCG levels had not been rising briskly and there was an observed slowdown in fetal growth seen on the last ultrasound. Being over 40, she was already at increased risk of miscarriage. Still, we had been hoping for one of those amazing recoveries that I’ve seen happen before. It was very sad for her and her husband and it was sad for our whole office, too. We had a 30-minute discussion regarding where to go from here.

I then rushed to the consultation room to meet with still another patient who had recently miscarried. We were able to spend a long time talking things over, discussing what happened, discussing what options to pursue next and discussing life in general. She reads this blog and out of respect for her privacy, I won’t share any clinical details. Suffice it to say, it added greatly to the sad morning.

I then got a short break doing some routine follicle-check ultrasounds and an IUI before going to the consultation room again.

This time, I got some devastating news from a patient. Again, without going into too many clinical details, we had not seen her for several months. She had abruptly cancelled treatment before we could finish her first cycle. She and her husband had just disappeared and today, I learned why. Apparently, her previously healthy husband had gone that day to the Emergency Room with a cold that wasn’t going away. He was admitted for pneumonia. The doctors were shocked as his condition worsened daily until he passed away in the ICU thirty days later. I listened as the patient shared with me the story of their amazing twenty-year marriage. As I listened to her recount what she had to endure in the past few months getting her life in order since his passing, I marveled at how brave she was. She shared how she wished that they had gotten to the point in their infertility treatment where they would have frozen his sperm, because then she would have the option of having his child still. She gave me a program booklet from his memorial service and invited me to read his life story and the testimonials from his friends.

I felt drained. I didn’t suffer any of those tragedies myself, so my sadness pales in comparison to the patients’ own misery. However, it was still emotionally painful to share a continuous two hours of back-to-back-to-back discussion with those going through such suffering.

The next patient was another prenatal ultrasound for which we saw heartbeat the time before. I’m by no means superstitious, but I was starting to get a bad feeling that this was the morning of doom. This was a patient for whom I had transferred a single embryo that had been confirmed by PGD to be a normal 46,XY. When I did the ultrasound we were all in shock. There were two babies! We now had identical twins who had split off from a single embryo. My assistant was jumping with joy and amazement. The patient and her husband were beaming! They had wanted twins, but there had only been one genetically-normal embryo to transfer. I called the embryologists to let them know and I’m sure it made their day too. This wasn’t anything worth writing up in a journal ever since someone recently reported a single embryo transfer that had split into triplets, making our news very drab in comparison. Of note, the twins were in the same chorionic sac, but in different amniotic sacs, which made it much safer. As the patient came out and proudly showed her ultrasound pictures to the rest of the staff, the energy was contagious!

After that much needed pick-up, another former patient visited unexpectedly. I was now done seeing patients for the morning and had time to let her show us her baby. As I held the eight-month boy, my staff talked with him and called his name, each time eliciting a huge smile and gurgle of laughter from him. It seemed rare for such a young baby to be so alert, so interactive, but his mom said that he was always like that. As I gently bounced him in my arms, I had a fun conversation with his mom, all the while with my staff surrounding us and cooing at him. It felt really good. After being in a dank pitch-black cave a few hours earlier, it was like walking out into the scorching midday sun at Laguna Beach.

I don’t really know what it feels like to be manic-depressive, but I can imagine.

Click here for episode #1

ANTHONY and CORA are a young couple who have not been able to conceive yet. They have already had the basic workup done. The current thinking is that the problem lies not with the sperm or eggs themselves, but with their ability of the sperm and eggs to physically come together. Cora’s tubes have been damaged by endometriosis. Instead of being able to scoop up eggs easily, there is a good chance that Cora’s eggs are failing to make it into the tube.

I explained to the couple that every month when a woman ovulates, there is a random chance that the egg will make the journey successfully from the ovaries into the tubes. If the tubes are scarred, then the target is smaller. If the ovaries are stuck far away from the tubal openings, then the journey is a lot farther. If there is inflammatory endometriosis, then the journey is more perilous and there is a good chance that the egg won’t survive long enough to make it to the target. Because Cora’s tubes are scarred, the chance of the egg getting in is small and therefore, they are unlikely to get pregnant on their own.

ANTHONY: Doc, I don’t understand. If Cora’s tubes are open then why can’t her eggs get in.

Since Anthony understood football better than anatomy, I explained it this way.

Imagine you a field goal kicker in football. Typically, you are asked to kick the ball and make it through the uprights which are 18 1/2 feet apart. This can be easy or difficult, depending on the distance from the goal posts.

Now imagine that someone took the upright bars and squeezed them together so that instead of being 18 1/2 feet apart, they were now only 1 1/2 feet apart. You can see how difficult it would be to squeeze the ball through that narrow gap. This is what happens with scarred tubes. Not only that, with there being endometriosis, the egg has to travel through inflammatory areas on its way into the tube. rather than through calm air. This increases the risk that the egg will be damaged or sidetracked on its way to the target. An egg traversing a scarred, inflamed pelvis is like trying to kick a football through the swirling crosswinds of a snowstorm.

So, every month, you get one ball to kick to try and score. If you miss, you’re done for that month and have to wait to play again next month. Anthony and Cora have been trying for several years, and so far, all their attempts have missed.

One way we can help boost their chances is to do super-ovulation and IUI. This helps to increase the odds that sperm and egg will come together (shorten the distance of the kick) and it also helps to make multiple eggs per month (you get to kick more than one ball each month). In this couple’s case, we can certainly try this method, but it’s also possible that their task is so difficult that even having seven balls to kick will still result in failure after failure.

There is also another option - In Vitro Fertilization. With IVF, the rules change to greatly favor success. With IVF, we don’t have to do any kicking. Instead, we get to gather about 20 footballs, put them in a container and walk to the goalpost and then reliably pass them through the goal posts one by one.

In their case,  either choice is reasonable. We could try one cycle of IUI or we could go straight to IVF. They chose to do IUI. I answered their remaining questions. Then, Cora was instructed to call with her next period.

Click here for episode 3

At times when I’m getting ready to do an embryo transfer, waiting for the embryologist to load the catheter, husbands often joke "I sure hope he doesn’t drop the embryos". While we have never had any dropped embryos, it would appear that there are dropped babies out there.

Earlier this week, after a debate between me and my friends, I set out to settle the following question. What’s most important to people concerning marriage? Now, I’m not speaking of the truly important matters such as love, honesty, integrity, passion, trust. Instead, I am referring to just the more worldly matters. So, let me clarify. Out of the four big ticket MATERIAL items associated with marriage, namely the RING, the CEREMONY, the HONEYMOON or the HOUSE, which one would most women say takes priority in her heart? Obviously, not everybody will agree on the exact same answer, but is there a general consensus?

In a very unscientific study, I set up a poll inviting women’s input. The results, whether suprising to you or not, are certainly interesting. Here are the ongoing results so far. I would be grateful if you could also add your own answer and comments, either openly or anonymously.

As someone with great faith in the practical wisdom of today’s woman, I predicted ahead of time that most would choose HOUSE as the priority, at least those who were of a more mature age than let’s say… teenagers. I wasn’t so sure about those who were in their early 20’s. Perhaps they might be more romantic and choose the symbolic glittery ring as their primary focus.

This is just an informal poll, not a scientific investigation. The study design could be easily picked apart. First of all, there is great selection bias in that the answers are obtained only from women who are internet-savvy and have the energy and passion to visit a website and render their opinion. I also chose not to moderate, censor nor hide the comments, making it very likely that a respondent will read all the previous answers and allow the crowd mentality to potentially sway her own response. But I’m not rying to get this published in a journal, get a government grant or obtain FDA approval for anything. I merely wanted to generate some fun discussion and stimulating thought. And from the feedback of friends who have read the responses, that has certainly been achieved.

How does this have any practical value regarding fertility? For me, it serves as a reminder about how well or how poorly women (or people, in general, as I believe it’s just as true of men as well) know what they want. And even if they do know what they want NOW, they certainly don’t always know what they want in the FUTURE.

For example, the respondents who are on their second marriage show that their views on the priorities NOW (house is #1) differ greatly from their views when much younger (ring is #1). I see this often in patients who pour their hearts out to me saying , "Doctor, it’s so ironic. When I was 25, I would have sworn on a stack of Bibles that I never ever wanted kids. I was so sure of it that I would have signed a contract attesting to it. And here I am (at age 37) struggling with infertility and seeking expensive treatment. And now I can’t bear the thought of never having kids of my own."

Just a gentle reminder to those of you in your youth who are so sure that you don’t want children. Be proactive and reexamine your priorities from time to time. Be open-minded about your potential to change your mind and maybe you’ll be able to get a start on motherhood early enough so as not to need the services of an RE. But even if you don’t realize it early enough to do it on your own, we’ll still be here to help.

Thanks again for your participation in this poll.

ANTHONY and CORA (not their real names) came for their consultation wearing matching colors and holding hands. He was 27. She was 25. They were smiling much more enthusiastically than the average couple do on the first consultation visit, with no hint of the usual nervousness. Two things I noticed right away. They sat on the couch nestled cozily against each other, rather than with the usual spacing between them. Also, Anthony’s 220-pound frame was more than double that of Cora’s petite body.

I learned a little more about this cute couple. Anthony worked as a financial advisor and used to play high-school football back in Illinois. Cora had been a cheerleader at the same high school and currently worked as a headhunter, or as she put it, a corporate recruiter. They had been high-school sweethearts and had married shortly after graduating from the same midwest college. They had only recently moved to Southern California. For the first year of marriage, they had practiced contraception by the rhythm method. They answered no when I asked if Cora ever took birth control pills. Anthony chimed in and added that BCP’s were not allowed in their faith. I casually asked what their faith was, and he replied that they were strict Catholics. After some more pleasantries, I casually asked if they were Italian and he replied that they were Sicilian. He then asked if I was Chinese and I said I was Taiwanese. Now that the formalities where in order, we all had a good laugh and proceeded to the medical part.

After two years of infertility, they had seen their OB, who had ordered preliminary tests, done surgery and then had referred them to me. They always had a suspicion that they might have fertlility problems because Cora had undergone surgery two times already for her extremely painful periods. Once was in college and the second time was her laparoscopy two months ago. Her OB had told her that she had severe endometriosis including large chocolate cysts in both ovaries. We acknowledged this as a likely contributor to their problem, but in the interest of being thorough, we went through the customary detective process, combing through the three major suspects of SPERM problems, EGG problems and ANATOMICAL problems.

SPERM ISSUES:
Anthony had already done a semen analysis. He had never been involved in any pregnancies in his life. His calculated BMI was 28, but it may have been slightly misleading as he was heavily muscled, and he did not seem that obese. He was a regular drinker, but did not smoke.
Count: 159 million per cc.
Motility: 50%
Morphology: 100% normal (This was what the HMO lab had reported, but is unlikely to be accurate, as nobody’s sperm is 100% normal)
COMMENT: Anthony’s test is normal.

EGG ISSUES:
Cora has always had regular periods every 28 days. She had done ovulation testing in the past a few times and they all indicated that she had a surge. Her BMI is 21. I had measured her ovarian volumes and they were actually quite good. It was fortunate that all that surgery had still left her with a significant amount of healthy-looking ovarian tissue.
COMMENT: It doesn’t seem like there’s any obvious problem here, especially at such a young age.

ANATOMICAL ISSUES:
I read Cora’s most recent operative report. During the laparoscopy, a 4 cm endometrioma had been removed from her right ovary. Another 4 cm endometrioma had been removed from her left ovary. Her OB reported seeing an obliterated cul-de-sac. This meant that the normal space between the back of her uterus and the back of the pelvic cavity was filled up with a wall of scar tissue. This was not a good sign. Her tubes were reported to be edematous (swollen) and the fimbria, which are the delicate fingerlike projections at the ends of the tubes, were all but gone. When the dye was injected, a trickle of blue came out both tubes, indicating that they were patent. There were scattered areas of endometriosis throughout her pelvis, on her uterus, on her pelvic side walls, on the bladder and on the ovaries. These had been cauterized. There was no mention of her uterine cavity and apparently, no hysteroscopy had been performed. So we couldn’t be 100% sure that the uterus was normal.
COMMENT: These findings are signficant. The fact that the tubes don’t look healthy is concerning. An obliterated cul-de-sac is another bad sign. The only redeeming news was that the tubes were both open, albeit barely.

Cora reported that her painful periods were still bad, but not as excruciatingly so, as they had been prior to the second surgery. The consultation took a lot longer than expected, due to Cora’s bubbly personality and her energetic manner of speech. A typical question and answer would go something like this.

ME: Anthony, do you have anybody in your family who has given birth to children with birth defects, learning disabilities or any other genetic abnormalities?
ANTHONY: No. All pretty normal.
ME: How about your side of the family, Cora?
CORA: Birth defects? No, we have a pretty big family and I want to say that everyone who has had kids so far has had healthy ones. I’m pretty sure. Hmmm. Let me think. My older brother and his wife have 2 kids who are both healthy. The boy is really bratty, but he’s cute and very strong. I kind of play favorites and I like the girl a lot better, because everyone says she looks a lot like me. I haven’t seen them in a while because they’re up in Chicago. Let’s see, my other brother is not married yet. He’s been dating his girlfriend for a long time, but I’m really not sure when they’ll get married.  My older sister just had a baby. I haven’t had a chance to see her yet, because they live in New York and she just delivered around last Christmas. Her husband’s a pilot, really nice guy, so you would think they would come visit soon with free airfare or whatever. In fact, I’m guessing they might be coming down to visit in another year or so, but if not, I’m hoping we can go see her some time, right, Anthony? She also has painful periods like me, and it took her and her husband a long time to get pregnant. Although I don’t think her periods as quite as bad as mine. And then I have two younger sisters and neither of them are married or even close to it. I think I have a cousin whose kid was born with something wrong with his lip, but they fixed it and he looks fine. I think he probably got it from the other side of the family and not from our side, because her husband’s family like to drink — A LOT. They can even outdrink Anthony’s family and that’s pretty hard to do, right, honey? Haha, I like to tease him about that. So, no, I don’t think we have any birth defects in our family.

At first, it took me some getting used to, but I’ve learned to politely cut her off when we were pressed for time. Otherwise, my staff and I enjoy her entertaining stories as long as we have time. (Right, Cora ?)

In summary, we have a couple with 2-3 years of primary infertility. The most obvious explanation for their problem is Cora’s severe endometriosis, which has left her with damaged tubes (that are still somewhat patent) and a badly damaged pelvis with a lot of scar tissue.

How would you counsel this adorable couple regarding their options?

Click here for episode 2