There are many things I love about being an RE, one of which is the chance to participate in the transformation of peoples’ lives, as they go from having no baby to suddenly becoming happy parents. That one is pretty obvious. Besides that, there’s another thing that I like and that’s the daily suspense. You see, every day, we run pregnancy tests to see if our patients are pregnant or not. There is no way to predict ahead of time who is going to be positive and who is going to be negative. Often, patients whose cycles seem like sure things, end up not being pregnant. Other times, patients whose cycles offer small hope end up defying the odds and winding up pregnant. This daily feature of not knowing the results really keeps things fresh and interesting for me and my staff.
Another thing that keeps us in suspense is the metformin follow-up visit. I would estimate that about 3 out of 4 first-time metformin patients demonstrate some very positive changes in their lives with regards to weight loss, increase in energy level and sometimes even normalization of their periods together with spontaneous ovulation and pregnancy.
Three weeks earlier, when Caroline was first started on the metformin, we had checked her weight in the office. Initially, she wasn’t thrilled to be weighed, but eventually gave in. Her weight had been 245# on our scale. As I picked up her chart today, for her follow-up visit, I was pleased to see that her weight today was down to 240#. With that in mind, we began our conversation.
ME: So, Caroline, I’ve asked you back today to discuss how you are responding to the medication I gave you three weeks ago, the metformin. How have things been different since then?
CAROLINE: Well…I must admit you were right, when you said that it could help me lose weight. I saw that I’m 5 pounds less than the last time I was here. I feel it too.
ME: That is wonderful news. So if you had to say, what do you think are the reasons for this weight loss? Are you eating fewer carbs?
CAROLINE: Well, I definitely don’t crave carbs and sweets as much. I mean I’ll still have a little bit, which is still enjoyable, but then I no longer want to have much more.
ME: And any side effects?
CAROLINE: Hmm.. the first two days, I got bad diarrhea, just as you predicted, but it really was just for those first two days. I think I lost the most weight during those first two days, because I felt miserable and didn’t feel like eating anything. However, even after the diarrhea cleared up, I still continued to lose weight. So happy! Oh and you know what? I really noticed a difference. I don’t get so sleepy in the afternoons any more. It’s been wonderful.
ME: Good.
CAROLINE: But I still have a long way to go. I know you’re going to say that.
ME: Actually, I was going to talk with you regarding our options at this point. But first of all, are we in agreement that the metformin is doing well for you and that we should continue it?
CAROLINE: Definitely!
ME: Then the next question to ask ourselves is what to do regarding getting you pregnant. We still have the task of making sure you ovulate. Now one thing to keep in mind is that there might come a point where you lose so much weight that things start working right and you begin to ovulate regularly. Of course, if we had all the time in the world, this is definitely one option, just to keep you on the metformin, allow you to regulate your carb intake the way you have been doing so well and allow you to ramp up your exercise habits. Then we just sit back and watch the progress. However, for several reasons, we DON’T have all the time in the world. Therefore, I have a suggestion.
CAROLINE: I’m so glad you said that, and that we’re not just going to count on weight loss to solve our problem. I mean, I’m happy with these past three weeks, but look at me. I still have a lot of weight to lose. And I’m old.
ME: You’re not older than a lot of my patients, Caroline. Come on. But I’m with you in that we should be proactive. OK, let me share with you what we can do. One. We can give you gentle pills to try and help you ovulate, or we can give you more expensive, but more powerful injectable medications. It’s basically a choice between Clomid or injectables. Either choice is reasonable for you, although I’m a little more in favor of the injectables, because of the very fact that you have already failed Clomid.
CAROLINE: OK, doctor. If you will, let me tell you what Darryl and I discussed. We really feel that the metformin is doing something. Now let me ask you, is it possible that my body has now become more normal because of the metformin and that I might respond to the Clomid now even though I didn’t respond to it before?
ME: Hmmm, that’s the big question. It’s certainly possible, but again, I think the odds would be better with injectables, or at least a combination of Clomid and injectables.
CAROLINE: Well, how about this? I really was gung-ho and ready to be aggressive, but I want to try one cycle of Clomid. Is that OK? One cycle.
ME: It’s your choice, Caroline. We can be as conservative or aggressive as you like, within reason and doing one more cycle of Clomid falls in the range of what I consider within reason.
CAROLINE: Great.
ME: One suggestion is that we monitor it. That way, we at least know if you are ovulating or not.
CAROLINE and DARRYL look at each other and nod.
The plan was set. Caroline would call us with her next period and we would bring her in for a baseline ultrasound before starting her on a monitored cycle of Clomid. With the conclusion that the metformin was a success for her general health, I refilled it for another four months. In addition, I chose to repeat the liver test to confirm that she did not have any unusual hepatic reaction to the metformin. The couple left my office very encouraged.
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