Case of the month June '08: Episode #8
June’s story has spilled over a bit into July 
Caroline slumped in the phlebotomy chair and offered up her right arm. She had been here many times before and she no longer allowed herself to get too emotional. Her last cycle had consisted of 13 stressful days of mixing together 5 vials of medications and then taking the injection in the arm. She was just now coming to terms with the disappointing stimulation. Her dosage was the highest ever, and yet she made fewer follicles than before. Still, there was hope, all resting on two follicles. She left our office and awaited the results.
An hour later, we called her with the bad news. Her test was negative.
Right now, there are some of you wondering why Caroline doesn’t just give up. Well, many in her situation would do that. There are also some of you wondering why she doesn’t do IVF. Well, even assuming she has the financial means to do so, we are still facing the dilemma of making enough eggs.
As painful as it is for me, the physician, to face this disappointment, I always remind myself that it’s obviously much more painful for the patients themselves. So I take the time to collect my emotions before the next re-consultation with Caroline and Darryl, and then we began our discussion.
We have a 20 minute talk and resolve the following questions.
Do they wish to continue trying? YES, most definitely. As many setbacks as there have been, they still are not ready to give up.
Should they get an HSG now to check Caroline’s tubes? YES, it would be a very good idea. With all the eggs that Caroline has had cumulatively, it’s now worthwhile to check her tubes before doing any more cycles.
Do they wish to stimulate the ovaries and do another IUI in the same cycle as the HSG? No. They can’t afford another cycle right now. The last cycle had cost about $2000 for the Bravelle, because of the high doses that Caroline required. They now really have to save up before doing the next cycle. Meanwhile, she could do the HSG while otherwise taking this month off.
The course was set. Caroline would call with her period and we would schedule her HSG. We would hold off doing another treatment cycle until they save up enough for the medications. This was our solid plan, or so we thought.
A few days later, Caroline got her period and she called our office. Unexpectedly, she requested to speak directly to me. My staff did their job and tried their best to address her question, but Caroline, who had always been easy to deal with and reasonable, told them adamantly that she wanted to speak only to me, and she added a polite "please". I took the call.
ME: Caroline, how can I help you?
CAROLINE: OK, doctor, please don’t think I’m nuts, but I don’t want to do the HSG after all.
ME: I see. What is making you change your mind?
CAROLINE: I know you and I talked before about how much Darryl and I have been praying. Well we finally decided to stop keeping this all to ourselves and last night, we shared openly with our Bible study group regarding our infertility problems. We have a couples’ group that we meet with every week. They kind of knew our struggles in a vague way, but last night I shared with them every last detail and we all ended up crying. I asked for them to pray for us. It was a huge relief. Then I went home that night and I had a dream. I dreamed that my tubes were clear. It was very clear and very vivid.
ME: Are you sure you don’t want to do the HSG to confirm that they are clear? I understand what your saying, but with all due respect, do you really want to base your treatment decisions on a dream?
CAROLINE: Let me ask you this, doctor. Suppose I didn’t have any dream and I just wanted to do another cycle without the HSG. Is this possible?
ME: Well, let’s see. You’ve had about six total mature follicles in all your cycles put together, right? So that’s a pretty reasonable number to expect at least one pregnancy by now. Even though you don’t have any risk factors for tubal problems, do you really want to invest another $2000 in medications without having some assurance that your eggs are even getting to where they should?
CAROLINE: How about one more cycle then? Please?
ME: Caroline, you know you don’t have to plead with me. I’m just giving you my sound professional advice, but I also respect your wishes. What if we were to do agree that after one more cycle, if it fails, we will not go on without an HSG.
CAROLINE: It’s a deal! So the next thing I want to talk to you about is…
(While I’m at my desk talking with Caroline on the phone, an instant message from my nursing staff flashes across my computer screen)
ME: Caroline, I just got a message with some good news. We have some free medication for you.
CAROLINE: Really? (very excitedly) From where?
ME: Well, one of our patients had ordered extra medication for more than one cycle, but she got pregnant on the first cycle, and she just graduated today after making it to her 13th week of pregnancy. Apparently, she wanted to donate the extra medication she had left over and immediately we thought of you. So you now have about $1000 worth of Bravelle waiting. You just need to save up for the remainder.
CAROLINE: (silence)
ME: Hello? Are you there?
CAROLINE: (tearful sobbing) I was just about to tell you. One of the sisters in our Bible Study group recently found out that her father needed emergency surgery out East. She and her husband were having some temporary financial problems, so we all took up a collection to buy her a plane ticket, so she could fly out and be with her dad. Well, things changed and it turned out he got completely better and didn’t need surgery after all. So she asked everyone’s permission to take the airfare money and give it to me and Darryl instead. We really fought it, but they all insisted, so anyway….wow.
ME: Wow indeed. So I guess it’s your choice then. We can start a cycle whenever you are ready. When did your period start?
CAROLINE: Last night.
ME: Do you want to come in today? or tomorrow?
CAROLINE: Yes! Yes!
ME: OK. I’ll transfer you back up front and you can schedule an US
Click her for episode 9 when published.
