(This couple has given permission to share their story. Their names have been altered. The dialogue words are not 100% exact, but are loosely reconstructed from memory, with the intent of conveying an accurate representation of their clinical story)

Things did not get off to a good start between Darryl and Caroline and me.
CAROLINE (blurting out the second she sat down): Doctor, before we get started, I should let you know that I’m only here because I have heard good things about you from my co-worker, ___ _____. You helped her get pregnant with her son. I’ve been to other doctors and instead of helping me, they all tell me to lose weight. If you tell me that, I will be out the door before you finish your sentence. Do you understand?
ME (pause): OK.
CAROLINE: OK?
ME: OK. Caroline, I hear you loud and clear. (smile). And I certainly don’t want to do or say anything to make things worse or to make you feel bad. I was wondering if we could try this. In the course of our conversation today, if I venture too close to stirring up bad memories of what OTHER doctors may have thoughtlessly said to you in the past, can I get the courtesy of a warning from you? Just yell out “WARNING. WARNING.” Is that fair? That way, I won’t have to walk on eggshells all afternoon. That would be too stressful for all of us.
CAROLINE (anger melting from her face, breaking out in laughter): Ha ha. OK. That sounds fair, but I’m warning you that I mean what I say.
ME: Certainly. Is that OK with you, Darryl?
DARRYL (shrugging and smiling): I’m OK with that. (moving closer to Caroline and putting his arm around her)
ME: First of all, I’m assuming that you two are here because you would like to have a baby. Correct? (they smile and nod) Have you been wanting one for a long time now?
DARRYL: Well, we were married in ____ of ____ (19 months ago) and we’ve never used any birth control.
ME: OK. Fair enough. That’s definitely a long enough time of trying on your own. I see here, Darryl, that you’re 42 and Caroline, you are 35.
CAROLINE (smiling nervously): Yes, soon to be 36.
ME: Now, Caroline, have you ever been pregnant before in your life? Any miscarriages or anything?
CAROLINE: Nope. Never.
ME: Darryl? Have you ever gotten anybody pregnant?
DARRYL: Nope. Not that I know of. (Caroline punches his arm)
ME: OK, I see. Now what were your expectations back when you got married? I mean, did you think you’d get pregnant pretty easily?
DARRYL: Well, I’m a little older, but I did expect that we’d be pregnant by now.
CAROLINE: Yes, I definitely didn’t think it would take this long, even though we got married late.
ME: If you would allow me to ask a personal question, how often do you two get together?
CAROLINE: You mean sex? About twice a week. It depends.
ME: I see. Now is there any difficulty? Is it painful for you?
CAROLINE: Nope, other than for the first time. It was the first time for me, not for Darryl. But after that, it’s been fine.
ME: OK, and no performance difficulty for you, Darryl?
DARRYL (pause, then smile): Nope. Never.
ME: I see. Well, it’s certainly a mystery why you haven’t gotten pregnant yet. You might know that of couples who have regular sex at least 1-2 times a week and who don’t use birth control, the expectation is higher than 80% that they would be pregnant within six months. And for you two, it’s already been three times that long, so there’s definitely something fishy going on. Now, we usually start by exploring the three main areas that contribute to problems – the sperm, the eggs and the anatomy. (holding up a miniature model of the uterus). By anatomy, I’m referring to tubes and uterus — the plumbing, so to speak. So these three areas are where we will get started.
DARRYL AND CAROLINE both nod.
ME: Now, I see that you have brought some records from your OB/Gyn. I have a semen analysis which says that Darryl’s sperm has a count of 212 Million and a motility of 61%, so no obvious problem there. We might come back and revisit this, but for now, sperm problems are low on our list of suspects. OK? Caroline, let’s talk about your periods. What are they like?
CAROLINE: I have always been pretty regular, like every 30 days, every 32 days maybe.
ME: OK, and are they painful?
CAROLINE: Not a bit. But I should let you know, I have been doing the ovulation testing and I’ve never had it turn positive.
ME: Even though you have regular periods?
CAROLINE: I’ve tested it on six different months and it never turns dark.
ME: Hmm, that could be our problem there. It’s pretty unusual for someone to have regular periods and never ovulate, but it is not entirely unheard of. We’ll definitely focus on this. Can you tell me what your energy level is like? I mean are you a hyper type of person? Or are you tired all the time? Average?
CAROLINE: I’d say I’ve been feeling pretty tired lately. I’ve been trying to go to the gym three times a week and it takes all my will power just to manage that.
ME: I see. Now, Caroline, I realize I might set off the warning alarm, but can you tell me more about your decision to go to the gym? Have you been doing that for a long time?
CAROLINE (laughing): Don’t worry, the warning bell is silent. For now. I have been going to the gym for the past four months. I swear and I know that you don’t believe me, but I eat only salads. I just want to cry, because no matter how much I exercise and how little I eat, I just keep gaining weight. The last time I checked, I was 240 pounds.
ME: How tall are you?
CAROLINE: I’m 5’7”.
ME: So what’s the story of your weight throughout your life? (writing down that she has a BMI of about 37)
CAROLINE: I’ve always been a little on the heavy side, but it just seems to get worse and worse as I get older. And I don’t know what to do because I don’t eat a lot and it’s not like I just sit around all day.
ME: OK, can I ask you if you have anybody with diabetes in your family?
CAROLINE: Yes. Both my parents, and all four of my grandparents. Pretty bad, huh? But I don’t have it. I’ve been checked.
ME: Caroline, even though I don’t believe that you’re diabetic, there is a good chance that you have inherited a PRE-diabetic condition from your parents. If this is the case, you could well have insulin resistance and you know what that causes?
CAROLINE shakes her head no.
ME: It could lead to unexplained weight gain. By the way, EXPLAINED weight gain is what happens when you eat a whole lot and never exercise, but from what you are telling me, yours is UN-explained. Let me go on, if you don’t mind. People with insulin resistance tend to concentrate their weight gain in the belly area. They don’t get big thighs or hips as much, but rather put it all in the abdominal area.
CAROLINE: Yep totally! That’s me! It’s all here (gesturing at her midsection).
ME: They often report a lot of sluggishness and sleepiness, especially after lunch.
CAROLINE: Oh my God! I can’t keep my eyes open after lunch.
ME: They often report craving sugar and carbs, even a few hours after eating. Does that describe you?
CAROLINE: Every day! Around 2:00, I need a soda or a cookie.
ME: The other problems that people with insulin resistance have are irregular periods and infertility. You don’t have irregular periods, but you do have infertility.
CAROLINE: Wow, how come nobody has told me this before?
ME: I’m not sure. But this is what I’d like to do. We have a couple of choices. I could have you do a blood test, one that will take all morning to do. You would come in without eating. We’d check your blood and then give you a really sweet drink to drink. Then we will check your blood 1, 2 and 3 hours afterwards. This is the test that they use for diabetes, but with a difference. Instead of just looking at your glucose (your sugar), we also look at your insulin. Now we have another choice in your situation. I’m willing, if you prefer, to skip the test and just treat you as if you have it, meaning I’d give you some medication and try it for three weeks and see how you do.
CAROLINE: What do you suggest? I don’t mind doing the test, but you have just described me exactly. I am almost for sure I have what you’re talking about.
ME: We’ll certainly come back to this issue. But before that, I want to ask a few more questions and do an ultrasound exam.

For the rest of the hour, we continued talking. I learned that Darryl is a heavy machinery operator, who likes his job. He’s laid back and does not smoke nor drink. Caroline teaches at a local junior high school and experiences a moderate amount of stress in her life.

Caroline’s exam showed a normal anteroverted uterus with ovaries of 15cc and 14cc volume respectively. They had the classic “string of pearls” sign characteristic of someone with insulin resistance and PCOS ( Polycystic Ovarian Syndrome ).

After the exam, we sat down again to finish our discussion.

Click here for episode 2

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