Click here for episode 1

When patients make it to 12 or 13 weeks gestation, they graduate. We have a small ceremony and give them gifts. They celebrate freedom from taking their progesterone shots. We make a DVD of their baby doing back flips in their final first trimester ultrasound so they can watch it over and over. They say goodbye to us as they transition to their OB, relieved to be out of the first trimester, usually the most common period of pregnancy loss.

For Irene, she was not entirely free. She had to stay on her heparin and aspirin. Over the past two months, we had seen her every week and the pattern was consistent. We would show her the baby’s heartbeat on the ultrasound and she would be so relieved and happy. And then, at home, over the course of the week, the fear and anxiety would gradually gnaw at her insides so that by the time she came back for her next ultrasound, she was a complete nervous wreck.

Now on her last visit, she seemed panicked about saying goodbye to us. I knew it was because she realized that with her OB, she would be only getting visits every 3-4 weeks, which meant to her 3-4 weeks of not knowing how the baby was. I promised her she could drop by any day for a quick heartbeat check ultrasound all the way until 20 weeks when she would start feeling the baby move. At that time, she would have her own way of reassuring herself that the baby was fine.

We kept in touch with her less and less, until one day, we got the call from her husband that she had delivered a beautiful 7 pound 6 ounce baby girl, thanks to the benefits of heparin!

Click here for episode 1

Imagine that four times in your life, you have been pregnant and imagine that all four times have ended in miscarriage. It’s pretty understandable that now, in your fifth pregnancy, every twinge of abdominal pain can make your heart race with panic. Every time you use the restroom, you dread wiping for fear of discovering that first brown spot or even worse, that bright red flow. Your nights are sleepless as your mind fills up with the big question of when will disaster strike again? This is the predicament that Irene was in.

I got an instant message from my staff telling me that Harold was on the phone and he sounded very distraught. I took the call. He apologized for calling, but he didn’t know what to do. Irene was falling apart. She was not sleeping and not eating. I had them come in to talk in person.

ME: Thank you for coming in. What’s been going on?
IRENE: No, thank YOU for seeing us on short notice. I am embarrassed. I can’t believe that I’m acting this way.
ME: What way do you mean?
IRENE: I can’t sleep. All I can think about is losing this pregnancy. I know it’s not healthy for me to be like this. Everything panics me. Last night, I had a stomach ache after eating some ice cream and I immediately expected to start bleeding, even though it wasn’t the same cramping pain that I had with the miscarriages. I hate it.
ME: What you are feeling is very normal, considering what you’ve been through. Let me summarize your situation, OK? We have done a thorough investigation of your case and we have discovered a very significant finding, namely that you have a positive Lupus Anticoagulant test. You remember that, right?
IRENE and HAROLD nod.
ME: There is a good chance that this is the main contributor to your miscarriage history. We have the means to address this problem and we have instituted the right action. You are taking the heparin daily, correct?
IRENE: Yes. Every day.
ME: How’s that going, by the way?
IRENE: Not bad. I do have some bruising though.
ME: OK, I’ll take a look at it shortly, but a little bruising is normal. It’s not severe, right?
IRENE: Can I just show you? (raises the bottom of her blouse a little to expose some mild bruising on her abdomen)
ME: Yes, that looks fine. Anyway, as I said, we have this in place. You are on heparin and aspirin, which is intended to counteract the harmful effects of the clotting disorder. (I flip through the chart). Your first hCG level was 88. We then repeated it in two days and it was 169. This is an excellent rise. Then yesterday, we repeated it again. It was 625, which considering it was four days after the 169, is still a very good rise. At this point, all we can do is keep checking your hCG level every four days to give you the peace of mind that you need to know that everything is OK. At some time very shortly, I will do the first ultrasound. After that, we will do a second ultrasound in which we can see the heartbeat. I have a feeling you will feel a lot calmer after that. Meanwhile, we all just have to wait.
IRENE: Thank you. I feel a little better, but I know that when I get home, I’ll look around and be reminded of the places in the house where I experienced the other miscarriages and I’ll panic again. Is there anything safe for me to take that will calm me down?
ME: It’s best for you to avoid any tranquilizers or medicine. Unless you are feeling like hurting yourself or hurting Harold or you are totally unable to eat or to care for yourself, I would prefer not to prescribe anything. That’s not the case, right?
IRENE smiles.
HAROLD: Doctor, right now we are in your office and we feel safe, but I know that the moment we get home, it’s going to happen again. I have to get some sleep so I can do my work and I can’t spend every moment worried about this.
ME: Irene, what do you suggest? Do you have any ideas of what can make you more at peace, other than for us checking your levels and giving you reassurance with the results?
IRENE: In my mind, I trust what you are saying, but I can’t control my thoughts. Honestly, it just builds and  builds until I’m crying and ready to scream.
ME: I see. Well, let me think about this. I have two suggestions. One is for you to stay somewhere other than your home. It sounds to me that the environment is triggering bad memories because the rooms in your house are where you had the bleeding and the cramping that led to the bad outcomes. Can you stay with your parents or Harold’s parents or anyone?
IRENE: I see what you’re saying, but I’m not going to stay with Harold’s parents. His mom would drive me crazier and I don’t want her to force me to take that herbal stuff again.
ME: Hmm, OK. Well, I have another suggestion, but I have to warn you that it’s really silly.
IRENE: What is it? (almost smiling)
ME: It’s something that one of my patients taught me. She tried it and it helped her. Right now, you feel very safe in my office, right?
IRENE: Yes.
ME: What if I asked you to remember your miscarriages, to picture them in your mind right now, as vividly as you can? I know it sounds cruel and crazy, so you don’t have to if you don’t want to.
IRENE: I … I think I can do it right this moment, but how is this going to help?
ME: This is a little mind trick to help calm the association that you have between your memories and your emotions. Visualize your worst memories of the miscarriages and THEN I want you to replay the scenes over and over in your head like a movie, but I want you to shut out the sound and instead, insert a movie soundtrack. Choose music that is silly and happy, like something you would hear in the circus with clowns and animals running around. I bet you think I’m crazy, but maybe you could just try it.
IRENE: OK. It sounds so crazy I am thinking it might work, haha.
ME: OK, start now and do it over and over. You can do it too, Harold. Well, I’m going to go do some ultrasounds, but I’ll be back in 15 minutes to check on you.

When I came back, there was a sense that the tension in the room was greatly diminished. Both of them were smiling, although Irene was very obviously tearful. They left my office with hope.

My nurses checked on them the next day. Irene was still very anxious, but she admitted that things were a little bit better.

Click here for episode 9

Despite Nicole Kidman’s assertion that swimming in the waterfalls near Kununurra, Australia helped her fertility, I would not recommend making the trip all the way out there. Now if you happened to already live nearby, then it might be worth a try.

Click here for episode 1

Irene had started her injections on day 3 of her cycle. After five days of injections, it brought us to day 8 and she was here for her ultrasound. This is what we saw:

RIGHT OVARY: (14×13) (15×14) (13×13)
LEFT OVARY: (16×14)

Lining = 8mm Triple Layer

This was a great stimulation. There were enough follicles to give a good chance of pregnancy, but not so many that we needed to be concerned about quadruplets. The follicles were not quite ripe yet, but they were close. I continued her on the same dose and brought her back after two more days.

This is what we saw:

RIGHT OVARY: (16×16) (17×16) (13×13)
LEFT OVARY: (21×18)

Lining = 8mm Triple Layer

It was a tossup whether to trigger the ovulation today or to wait one more day. I decided to go ahead and trigger and bring her back two days later for the insemination. In general, for first time patients, I trigger at around 5PM in anticipation of ovulation in the morning two days later.

Irene came back two days later and had her insemination. She was started on progesterone supplementation.

Twelve days later, she came for her pregnancy test. It was positive! Her hCG level was 88 IU/L !

For most first time pregnant women, this would be a great moment of joy. For Irene who had four miscarriages in four pregnancies, this was the beginning of the scary time.

As planned, she was started on daily injections of heparin.

Click here for episode 8.

I’ve always taken issue with the lie that the poor or middle class pay more taxes than the wealthy. This article summarizes it nicely. Money is just a way for society to keep tabs on how much people are working to contribute to the world. In general, the people with the money are the ones who are making things and providing services that people want. People want these goods and services and because of that, they choose to pay the providers of such goods and services, thereby making them wealthy. I agree with the notion that politicians like to rile up the voting public and have a scapegoat to rail against. And one group against whom it is politically acceptable to direct the venom are the wealthy/productive people.

Yesterday, I saw a couple who were back for a third baby. Four years ago, they had done their first cycle of IVF and wound up with twins. After delivering a boy and a girl and enduring sleepless nights feeding them and changing diapers, they apparently did not feel they had suffered enough, so they were now back for a third baby. As our conversation wound down to the financials and the $3K they would have to invest to do a frozen embryo transfer for their third baby, the husband could not help but proudly ask me if I wanted to hear about the "wisest investment decision" he had made. His wife broke into a huge smile, as if there were some huge private joke. I was surprised to hear an off-the-wall comment about investing come out of the blue like that, but part of me was interested in hearing what he meant, because with the recent events in the stock market, it would seem that wise investments are few and far between.

He went on and told me about a coworker of his. Apparently, the two of them shared many parallels. They shared the same first name and were the same age. They worked in the same department of the same company and originally bonded when they struck up a conversation about a the dangers of nuclear attack. One of them was Israeli and greatly concerned about an Iranian nuclear attack some day. The other was South Korean and worried about a launch some day from North Korea. This was what first drew them together as friends. One was an avid Dodger’s fan, while one loved the Angels. They were both married for about 3 years and still childless. Their wives were just four years apart in age. One day, about three years ago, when the company awarded their employees a large bonus, they discussed where to invest it. One of them proudly put it into the stock market and started growing it. The other one decided to take the money and come do an IVF cycle. As a result, one wound up building quite a sizable investment portfolio, getting richer as the stock values increased, while the other friend wound up with twins, a boy and a girl. While one of them continued to grow his money, the other one expended money, first by spending $14K on infertility treatment, and later, by spending close to $1000 per month on various baby expenses for the twins.

Fast forward to a month ago, four years later. The friend who had chosen the investment route now found that he and his wife were four years older, but had a lot of money on which to spend on infertility treatment. They were ready to do treatment, so they could boast that they had both, a secure nest egg and a family. Then all of a sudden, the bottom of the market dropped out and their investment value plummeted. So now, while they still have enough to pursue fertility treatment, they are newly hesitant about dipping into their relatively meager savings (as compared to before the market crash). So now, one of the friends has two lovely children and some frozen embryos for the future, while the other one has about $20K in the bank, which they will have to decide if it is to be spent on infertility treatment.

Life is really about choices and options. Having children is an investment, just liking putting money in the stock market. I wouldn’t advocate going bankrupt pouring all your money into your children, but I would not recommend the opposite extreme either.

Click here for episode 1

Six months had passed since Irene’s positive LAC (Lupus Anti Coagulant) test. The initial relief and excitement she had felt had gone away and she came in to discuss her options. After all, she had suffered four miscarriages, but then finally learned a reason for the miscarriages. We were ready with an intervention for her next pregnancy, but it had now been a year and a half and still no pregnancy. That had never been a problem in the past. She was surprised. She really thought she would have been pregnant already.

When they came in, I asked for an update on their lives. They were both still working the same jobs (nursing for her and the painting business for him), busy as always. They were paying attention to Irene’s ovulation dates and trying to be diligent about having intercourse during those days.

Their situation had now turned into a combination of infertility and recurrent pregnancy loss. They had gone a year and a half with no pregnancy and they still had their past track record of four pregnancies with four losses. I offered them a chance to boost their odds and speed up time to their next pregnancy. They enthusiastically agreed. I explained that we were going to do a standard cycle of ovulation induction to grow extra eggs. Then at the right time, we would inseminate Harold’s own healthy sperm into Irene’s uterus. Her instructions were to call with her next menses.

Three days after her period started, Irene came in. The baseline ultrasound was normal. The uterine lining was thin (not at all surprising because it had just bled out). I decided on a protocol of 150 IU daily injection of Follistim. She took the medication from days 3 to 7 and on day 8, we brought her back for evaluation to see what kind of follicular growth she had.

Check back for episode 7 when published

Compared to doctors, lawyers donate 7.5 times as much to politicians in order to extract political favors. It’s no wonder the rules of the game in this country are stacked way in favor of lawyers. The next time you need a doctor or lawyer, you can judge for yourself if this difference is fair and ethical or not. For a detailed account, check out this excellent blog post.

During my training, when I was a resident in OB/Gyn, before I subspecialized in REI, it was pretty much the norm for me to spend a few days per week at the hospital during 1 AM, delivering babies and handling the OB/Gyn cases that came through the ER. Ever since I shifted to doing infertility only, I have had to be in the hospital at 1AM only once or twice in 10+ years and those were for ectopic surgeries. That all changed last week.

A RE colleague of mine was going out of town to accompany his daughter for her first week of college this year. It just so happened that his partner was out of town also and he had three egg retrievals that were scheduled to go on the days he was gone, so I was asked to pinch hit. This is not uncommon in a large group practice, where the doctor doing the egg retrieval often has never met the patient. For me, this only happens when I sub in for other RE’s. I do this probably 6-10 times per year. The running joke is that for some reason, the cases that I tag-team with my colleagues have wound up with astronomical success rates. Higher than my own rates. Higher than their own rates.

So I got the call from my colleague asking if I could fill in, he added that his three patients had been a bit nervous about him not doing the egg retrieval, but they had read my website and my blog and felt really comfortable as if they knew me. One patient, in particular told me as I met her in the pre-op room that she had read every last word of my blog and that it had calmed her fears.

The surgeries were all scheduled for Friday AM. However, I got an unexpected call from my colleague again on Wednesday AM. He was profusely apologetic. A mixup had occurred. Usually, the nurses call the IVF patients and instruct them on when to take their trigger shot of hCG. In my practice, I have them take it 35 hours exactly before the egg retrieval is scheduled. This ensures the maximum chance that the eggs are mature, but have not yet released by the time we go get them. Well, this time, the doctor had wanted to be extra diligent and so instead of having the nurses call, he had called the patient himself and explained the time that she was to take hCG on Wednesday night was at 11PM in preparation for a Friday retrieval at 10AM.

For some reason, the patient thought she had heard incorrectly and wasn’t sure if she was supposed to take her shot at 11PM that night or 11AM, so she called back. Unfortunately, the office phone system was on the fritz or something and she kept getting a voice mail recording with no way to get a hold of anyone. She then made the panicked decision to take her hCG immediately some time after noon. By the time it was clarified, we were in a jam. She had already taken her shot. The eggs were now set to release Thursday night, shortly after midnight rather than on Friday morning.

It turned out to be kind of a fun thing for the anesthesiologist, nursing staff, and myself. We all met up at midnight to do her case. The patient herself was very sweet. She kept apologizing to us and thanking us for taking time out from our sleep to meet up with her at such an odd hour. She and husband even joked “I bet you are going to blog about this, aren’t you?”. The nurses were all touched because the patient’s cute little sister had made hand-crafted thank-you-cards for everyone, with enclosed gift cards to local restaurants.

Anyway, everything went smoothly. We got a lot of eggs and I am pretty sure her chances of a baby are quite high. I’m the kind of person who likes variety and it was certainly a different experience to do one time, although not something I would prefer to do on a regular basis. It did make me grateful for my job and it gave me renewed respect for my OB and ER colleagues who are out there giving medical care at all hours on a regular basis.