November 19, 2017

First visit with a Reproductive Endocrinologist Part 3. The discussion

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 forĀ  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.

  • Jennifer A.

    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.

  • 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.

  • http://infertility-fertilityinformation.blogspot.com/ Fertility?Overcome fertility

    Hello Dr.Lee,Nice to meet you.Thank you for your good information?We(my wife and me) are currently suffering with infertility.But,We never give up to conceive a baby.I’m looking forward to see your future posts.