If you’re like me, the two most common reactions you see from people when politics comes up in casual conversation are negative ones. Either you get an avoidant rolling of the eyes, “Ugh. Not politics again, please” or an angry “I hate those _____ (insert name of party or special interest group)”. Never do you see the giddy passion that people display when discussing exotic desserts, the Super Bowl, James Cameron movies or girly vampire books.

One of the reasons for this is that you have instinctively learned to associate politics and government with a general yukky feeling of dread within the pit of your stomach. Why is this? Isn’t government just another business that we patronize. After all, when we deal with government, how is it different from when we deal with a regular free-market non-government business? In both instances, we pay a price in exchange for something. In the case of government, that price is money (via taxes) and loss of freedom (via regulations). What we get back is a whole other matter and subject to a whole other discussion. For today, let’s dissect the reasons how government interactions differ from other transactions and we’ll better understand why we love shopping but why we hate politics.

You may or may not agree with me on this at first, but I sense that in the end, your gut feeling will be one of agreement. There are two important things that shape whether or not a particular business entity will make us happy. The first is the presence of COMPETITION or from the consumer’s viewpoint, the presence of choices. The second, which helps keep the competition honest, is ACCOUNTABILITY.

Allow me to expand on this, OK? Let’s begin with the concept of COMPETITION. If you think back to some of your best experiences as a customer, what were they? Was it a 5-star restaurant or some luxury resort hotel? Was it that clothing store in the mall with the great deals or that friendly-service mom-and-pop grocery store? Now contrast this with some of your most frustrating experiences. You all have your own. Was it the DMV or the traffic court system? Was it that doctor’s office that you are forced to go to because of your HMO?

Let’s analyze the differences between the good experiences and the bad. Is there a correlation between how good something is and the degree of competition that they face? You bet! And why? Well, it’s just natural that a business can’t afford to be bad and have unsatisfied customers if it is to survive in the face of nearby competition. When disgruntled clients can easily walk away and take their business elsewhere, you can bet that the business will bust their butt trying to be the best it can be. However, if there is no competition and it’s the “only game in town”, or if people are forced to spend their money at that business no matter what, then of course, there’s little drive for the entity to excel.

When it comes to politics, there’s really zero healthy competition to give us options. Sure, there’s this illusion that we can choose between the Democratic and Republican candidates. But really, what kind of choice is that? Pardon the bluntness, but it’s like telling a slave that they should be grateful for having a choice of slavemaster for the next four years. I know that this is a little different because we have the option to leaving this country, but is that really a valid excuse? We, the people, own this country. It’s not the handful of people called politicians who own it or who own us. Our economic and social freedoms are increasingly being squeezed away by both parties in this alternating back and force dance where one side gains power and saps our economic freedom and then power switches to the other side who then suck away our social freedoms without returning a single inch of what the other side stole. Deep down inside, what most of us want is individual liberty and the chance to thrive as a free community. So if that’s the case, then why doesn’t a candidate run on the platform of reducing government and increasing freedom? Well, that’s what they often do, but once they get into office, they are no longer bound to deliver what they promised. And as for the honest candidates who will abide by their promises, well, THEY never make it onto the ballot. The barrier to entry is too great. In order to even make it onto the ballot, you would have to have played the politics game and survived for quite a while. And by that time, you’re already bought-and-paid-for by special interest groups with their fat political contribution checks.

That’s where the second factor, ACCOUNTABILITY, comes into play. If you walk into a free-market store and they treat you rudely, you have the absolutely liberating choice to smile and walk out. If you’re so inclined, you can even eliminate the smile and add a rude gesture back. If you have a bad experience in a restaurant, then you have the option of making that the very last time you ever bring your dollars to that particular establishment, and even leaving a bad review on Yelp to warn others. How does this differ in politics? Like night and day. Once a politician is elected, he is set for the entire term, usually four years. If politicians renege on their promises, it matters little to them because accountability is now out the window. By the way, it’s certainly not just our current president who is egregiously guilty of breaking promises. The one before him who asked you to “read my lips, no new taxes” was every bit as bad. I won’t go into the technicalities and semantics of “new” taxes vs just raising preexisting ones, but clearly, the spirit of the promise was broken without regard. Another thing that reduces accountability is the great distance between the controller (the politicians) and the controlees (we the people). If it’s our mayor or our neighborhood association president who does something we hate, we can let our voices be heard. But if it’s some politician 2000 miles away, you can just give it up because in that case, our voice is heard as strongly as a whisper at a rock concert. Our current system of a representative democracy where a few out-of-touch people control the lives of a great majority, is horribly flawed and clearly not the best way to live.

I’m not alone in being intrigued by yesterday’s turn of events in Massachusetts, what is rightfully being hailed as the political “Upset of the Century”. It stunned me and has given me a glimmer of hope for this country. Why? Because, it could well be interpreted as a sign that the Star of Accountability is trying to shine again in politics. Hooray! Recall that in November 2008, a new president was elected on promises of hope and change by a nation sick and disgusted by the corruption and oppressive practices of the former president. However, once the new guy gets into office, he proceeds to unleash a surprisingly bold set of unpopular policies to further destroy our country’s freedom and economy. It got to the point where this new president and his ruling party got so arrogant as to try and shove down the people’s throats a massive government takeover of the enormous sector known as healthcare. Then, with no remorse, when the people voiced that they didn’t want this, the politicians proceeded to resort to every last bit of political trickery to bribe a vote here and there, just to pass something that the people don’t want. In the past, the collective passive mind of the American people would have been tricked into going along complacently. But thanks to the power and transparency of the internet and our gradual liberation from a biased media, last night’s shocking results give some hope that people are actually getting smart enough to say “enough is enough” and caring enough to do something effective. Wow!

One more thing. It’s certainly tempting to give in to the adversarial two-party game of politics, with half the country cheering raucously at yesterday’s Massachusetts results, and taunting the other side, just as that other side cheered and taunted when Obama was elected, reminiscent of when UCLA beats USC in football or vice versa in basketball. But the wiser approach is to realize that we’re all in it together and cheer it as a minor victory of the people vs the corrupt oppressive big government.

Now before all of us freedom-loving people can rest and celebrate, we have to be wary. What if the Republican party continues this trend of regaining power, but then does nothing to offer tax relief, nothing to lessen oppressive regulations and nothing to reduce runaway government spending? It has happened before and might happen again. Stay tuned and stay alert. But for now, we can focus on the positive, that maybe there is some hope that political accountability is slowly emerging.

In any case, as unpalatable as it can be, we can’t afford to ignore politics, because it’s not merely a remote scorecard of who is in office and which side has more. It’s a matter of what you can eat, whom you can marry, what your children are taught and what you are allowed to do in your life. It’s a matter of how much money is stolen from you every month and how much killing and bombing is being done with that money. So let’s all discuss, read, learn, debate, reason and question as if our lives depended on it, because, as you all know, it really does!

Dear Doctor,
Hello, I would be very grateful if you could help me. I ahve GP in the Uk, that unfortunately only gives you 10 mins for a meeting. He told me that my test results were noraml but does not go into anymore detail.
I reaaly need an insight into what the hormone levels mean in terms of fertility.
my plasma FSH is 9.8 iul/L,?LH 4.51?serum testosterone 1.9 nmol/L?serum presterone 1nmol/ L
serum oestradiol 83pmol/L
apart from the FSH, I do not understand what thes figures mean, could you please give me some indication and direct me some websites whereby I can learn More . Thank you

Daniella

Dear Daniella
Thanks for the question. I’m sorry to hear that you were only given 10 minutes with your doctor on a complex issue such as infertility. I understand that you have government-run healthcare over there in the UK, but do you have any option to choose another doctor? The thought of being given 10 minutes with zero choice of choosing a different doctor would scare a lot of the people here in the US as we try to fight off our own government’s attempts to take over this vital part of our lives.
In any case, with respect to your question above, what you have shared are test results regarding your hormones. The FSH and LH are made by your pituitary and are involved in your body’s way of modulating your ovaries to make eggs. The next three ( testosterone, progesterone and estradiol ) are the products of your ovaries.
Depending on your age, you could have a less than average chance of conceiving or an average one. Based on those tests, you probably wouldn’t expect to have a higher-than-average chance of conceiving. As for what you should do, it depends on your age, how strongly you want to have a baby, how long you have been wanting one and what treatments you have already tried in the past. The value of doing those tests is not that great unless one of them comes back as off the charts and grossly abnormal. That’s about the best answer that I can give you without knowing your history and goals. Good luck!

I just went to the Re office for my 3 day fsh level to start ivf last month it was 10.5 and e2 was 69 this month i wanted to start and now my fsh is 15.5 and e2 is 89 my follicle count was 9 no other problems is it possible i need egg donor they told me I have to wait till it goes down what would my options be at 37

Tracey

Dear Tracey,
At 37, your options would be to go ahead and attempt a stimulation and then see how many follicles your body produces or to not take a chance, but go directly to donor eggs. Without knowing the rest of your history, I can try and assume that you have never done IVF before. Depending on how much it would cost you if you were to have a cancelled cycle and how much value it is to you to try with your own eggs, you would balance these two factors out and make a choice that is best for you. Best of luck!

hello
in 2007 I had a fsh of 6.9 in 2008 I had a successful ivf resulting in my little girl.?from that ivf I got 9 eggs out of 13 follicles.with low drugs
we have been considering ivf no2 in the hope for a sibling
my fsh is now 10.2 ( which is the higher end of normal ) and my AMH is 8 not sure is that is normal ???
I am 27 and ivf is the only way for me as have no tubes ( 3 ectopics )
so my question is with my fsh on the rise should I be having ivf sooner rather than later ? are my levels abnormal for my age ?
any advice would be much appreciated
natalie

Dear Natalie,
Yes, assuming that your FSH was drawn near day #3 of your cycle, then the value is considered less favorable than what would be expected in the average 27-year-old. As for going after your second baby sooner than later, in general, you know that conceiving at a younger age results in higher odds of success, lower risk of miscarriage and lower risk of birth defects. So if you mentally and financially ready and are really sure that you want more children, then what’s the reason for waiting? Right? Good luck!

Hi Dr. Lee,
I have followed your blog for several months now. It has been so helpful, and I thank you for that. My husband I have been trying to conceive for 3 years now, and under the care of an RE since October of ‘08. We’ve had 5 IUI’s and 2 IVF’s. Long story short, the first IVF resutled in OHSS and the 4 embryos were frozen. The second IVF only resulted in 2 embryos surviving to day 5 and they were both transferred, but I was hospitalized with the flu AND we got a negative on a pregnancy test. We had a FET this past summer and transferred 2 of the embryos. (Many details to my story but they believe the blood thinners helped us as I was diagnosed with MTHFR.) I had a successful, singleton pregnancy but delivered stillbirth at 20 weeks, 5 days. I was diagnosed with an incompetent cervix. I have read on line that this is not uncommon in infertility patients. In a nutshell, I was wondering if you would consider blogging about any of these topics in the future: blood disorders like MTHFR, recurrent pregnancy loss, incompetent cervix, and high risk issues in IF patients like incompetent cervix or placent previa. Thanks for your time, Jennifer A.

Dr. Lee,
So sorry… I left a few things out in my post. I was diagnosed with PCOS and poor egg quality. My husband was diagnosed with slightly low testosterone (I want to say just two points below normal). He had the varicocele surgery and now the urologist in the IF practice says his testosterone levels are ‘great.’ The most important part I left out was this; I have two frozen embryos left. We want to try another FET. What could/should I know about incompetent cervix that could make a different and save the next baby’s life, or is it a ‘crap shoot.’ Also, would it be safe to trasnfer two? If we chose to transfer only one at a time, are we lowering our chances of that ‘one’ embryo implanting? I have heard that women often transfer several because it increases their chances at getting pregnant. So, does that mean transferring only one will ‘lower’ your chances? Hoping my story will inspire future blog topics for you to research and discuss. Thank you again, Jennifer A.

Dear Jennifer,
In my 14 years of practice, I’ve encountered at least 20 patients who after getting pregnant with IVF or IUI have gone on to be diagnosed with incompetent cervix. Most of them went on to have a healthy baby in future pregnancies. In the majority of cases, the presence of an incompetent cerivix is picked up only after a tragic pregnancy loss. The only other way to detect it would be to monitor the cervical length meticulously. For you next pregnancy, I take it you will be under the care of a high-risk OB specialist who will likely discuss with you the option of having a cerclage, which as you may know, is a stitch to tighten up your cervix. As for your question of transferring one vs two embryos, bear in mind that each embryo you transfer gives you one “roll of the dice” to get a baby. So, of course, rolling the dice twice makes the odds of hitting a winner more likely. However, you would have the same general chance in the long run whether you transferred both embryos in two separate transfers or if you transferred them both at once. I hope that makes sense. I have discussed recurrent pregnancy loss in previous posts, but I appreciate your suggestion and I will likely revisit this issue in future posts. I hope all goes well with your next pregnancy.

As you can guess, many of the tasks that we reproductive endocrinologists do throughout the day are highly repetitive, such as measuring follicles, performing inseminations, reviewing blood test results. Even the most critical tasks such as egg retrievals and embryo transfers are actions that we do over and over again.

The one part of my work that has the greatest variety, and a “you-never-know-what-you’re-gonna-get” component to it is the New Patient Consultation. If you want to know what keeps my work day fresh and exciting, well… this is it. Picture this. I’m sitting in my office working on charts when I get a notice on my computer screen from my staff that a new patient is ready and waiting. I leave my desk and head for the consultation room. I pick up the blank chart and all I see are the patient’s name and her date of birth. And then the fun begins. When I open the door to greet the patient or couple who are waiting, I know that I will spend the next hour engaged in a fascinating conversation with someone whose goal is to have a baby and who is researching to see if they want to enlist my help.

The first few minutes consist of simply introducing ourselves. There is great value in really getting to know someone, learning about a patient’s life, her philosophies, her values and her anxieties. This requires time. I sympathize with my medical colleagues in other fields who are called upon to see five or more new patients an hour. Of course, if a patient is in the ER with a laceration that needs suturing or a sprained finger that needs splinting, then a more specific problem-oriented approach might be OK. But in our field, it doesn’t work that way. Ironically, I’ve brainstormed and toyed with that notion in the past - specifically conjecturing about the feasibility of someone opening up a dedicated artificial insemination express station so that infertility patients could have the option of being helped without an extensive doctor-patient relationship. For patients who wish to save money and time, but who just wanted to have an IUI done, they could choose to assume responsibility for  predicting their ovulation day on their own and then go to some novel walk-in IUI center. Bring the sperm in. They’ll prep it and inseminate it. No questions asked. While something like that might work theoretically and might have some economic advantages, it would never fly in the real world given the strict regulations that govern us. For one thing, here in California, we need to have a set of infectious disease screening tests done on the husband before we can even process the sperm. Anyway, as I said earlier, there is great value in getting to know a patient, because in the field of infertility, there are usually multiple options available for some patients and the choice of the best option is based not solely on cold hard medical criteria, but also on personal preferences of urgency, frugality, risk aversion and religious views.

So, while the patient and I gradually get acquainted, we will intersperse the communication with me asking them questions about their health and with them asking me to explain some of the medical aspects of their situation. It’s a very fun process, because both parties get to learn. While I am learning about their medical history, I am intermittently teaching them about the medical facts and ideas which pertain to their case. Some of my questioning is done in a rigid checklist style, because I always need to know about certain mandatory things such as their drug allergies and past surgical history. However, a lot of this process is done with a great deal of improvisation. I teach the medical students at UC-Irvine and Western University of Health Sciences during their OB/Gyn rotations and over the years, I’ve tried to come up with the best way of teaching how to take a history on an infertile couple. I’ve come to learn that it’s hard to teach, because unlike other fields of medicine where the history taking is more amenable to a checklist approach, infertility requires a lot of improvisation. That’s why I’ve decided that the best way to teach it is through role-playing. The times in the past where I had a kind student volunteer offer to play the role of the infertile patient being interviewed are the times that were the most educational. If you are a regular reader of this site, you might have noticed that the previous posts with the detailed case histories were especially helpful to you, again, for this very reason.

So after we’ve gotten acquainted, processed all the mandatory medical information and sufficiently answered the patients’ questions, we wrap up the visit by exploring if we’ve achieved the following objectives.

1. The patient now has a better understanding of her fertility situation, with regards to what might be contributing factors, potential options and overall prognosis.
2. We have outlined the potential treatment options with a rough estimate of how much they will cost, what risks they involve and what is the estimated chance of success.
3. The patient knows a bit more about my own values and philosophies which will greatly shape my role as their guiding physician.

Then the patient will go home and decide, based on my medical suggestions, which treatment option is right for them, if any, and then we move forwards to do the next step that it will take in order to get them a baby.