Case of the month June '08: Episode #2
Click here for episode 1
Darryl and Caroline are here for their first consultation. After breaking the ice and warming up to each other, we tackled some of the potential problems that could be contributing to their infertility. One red flag was the fact that Caroline has never had a positive ovulation test, despite taking the tests properly for six months now. The ultrasound exam further supported the diagnosis of Polycystic Ovarian Syndrome. After the US exam, we went back to the consultation room and continued our discussion.
ME: Caroline, when we first started today, you had mentioned something about the experiences you had with other doctors. Do you want to fill me in on that?
CAROLINE (sighs): OK, but it’s not easy for me to talk about it. However, if it will help you…When the first year had gone by, I went to my family practice doctor. She basically told me that it was unhealthy for me to have a baby and I should not even think about it until I lose some weight. That clearly was not the type of help I was looking for, so I went to my OB. She too, said the same thing, only maybe not so bluntly. She did try and help me with some Clomid. I took that for three months maybe four but it was making me nauseous and it wasn’t making me pregnant.
ME: Were you monitored for those Clomid cycles? Do you know how many follicles you made?
CAROLINE: No. No monitoring. But I did do ovulation kits and still, they never turned positive.
ME: So what was your OB’s plan?
CAROLINE: Nothing. Just Clomid and telling me to lose weight. I wasn’t too happy, needless to say. So THEN, I saw an ad on the internet for a reproductive endocrinologist. I went to see him and right away, the first thing he wants to do is IVF. I was happy for once that someone didn’t give up on me just because of my weight.
ME: I see, so did you actually do IVF?
CAROLINE: I almost did. But something just didn’t feel right. Maybe you can explain it. (turning to Darryl)
DARRYL: Yeah. He really didn’t bother to ask many questions. We almost got the feeling that he was just out to sell his IVF and we don’t have insurance coverage for it. I know a bad salesman when I see one.
CAROLINE: I felt the same way. And that’s when by God’s grace, I ran into my co-worker showing the office her new baby pictures and that’s when I started talking with her and decided that I should hold off on the IVF and come get your opinion first.
ME: Who was the doctor that you saw, if I may ask?
CAROLINE: Dr. ____. Do you know him?
ME: I do. Well, I actually know pretty much every RE in Southern California. We probably all know each other. The reason I asked is that there are many excellent RE’s out here and we often see each other’s patients for a second opinion. If one of the ones whom I trust says you need IVF, I would want to explore more why they would think that. But the one you saw is not one whom I know and trust very well, so I’m going to discount what they recommended for now. That’s not to say that we won’t be talking IVF someday, but there’s certainly a lot we can explore and try before going that route.
CAROLINE: Well, I’m glad that I did come see you. I feel very comfortable right now.
ME: Good. Well, let’s summarize what we know right now, OK?
CAROLINE and DARRYL nod in unison.
ME: You’ve been trying to get pregnant for a year and a half. The sperm looks fine. There is no obvious suspicion of a tubal problem (although we don’t know for sure yet that your tubes are open). The big suspicion is an ovulation problem. You’ve tried Clomid 3 or 4 months and didn’t get pregnant. Based on your ovulation kit testing, it doesn’t seem like you even ovulated. Therefore, it would make sense that our best strategy for now, would be to focus on helping you ovulate. Does that make sense?
CAROLINE (smiling and nodding): Completely.
ME: There are a few obvious things that we need to rule out, like thyroid disease, but I’m going to go over these records (pointing to the stack of papers they had brought) after we are done talking and see what’s been ordered in the past. I might get some more tests after seeing what’s missing. You said you never had a blood test in which you were given a sweet drink to drink, right? So we’re going to start with that.
CAROLINE: Doctor, you know what’s best, but if it’s OK with you, I’d rather not waste an entire morning getting this test. Can’t you just give me that medicine that you were talking about?
ME: Well, let’s talk about that. The medication is called metformin, or Glucophage. Have you heard of it?
CAROLINE shakes head no.
ME: It’s a medicine that is often given to diabetics and it’s quite safe compared to something like insulin, which is another medicine that diabetics take.
We spent 15 minutes discussing the side effects of metformin, as well as all of the possible benefits. Our plan was set. Caroline would have some blood tests drawn today to confirm the safety of taking the metformin. These were tests of her liver and kidney status. She was to try the metformin for three weeks, after which we would meet again to go over her progress.
Click here for episode 3
