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.

The following is an email sent from one of my favorite patients. After a tough journey, she has been blessed (abundantly) with triplets. While having three at a time is not the preferred way to be blessed, she is an inspiration in many ways. During her prolonged hospital stay prior to the delivery, she made the most of her time there, sharing her faith and giving inspiration to the other mothers on the hospital floor who were also on bedrest. After the babies were born, her family and friends rallied around and showed their love by helping out the new parents of three. The following is an actual email sent out to her family and friends (and to me). She has given permission to share this with the rest of the world in the hopes that it can be a reminder that loving family and friends are the most important treasures on earth.

To: (list of friends and family)
Sent: Wednesday, August 13, 2008 7:30 AM
Subject: Two home, one to go!

Well, I do not know if you all will believe me but I am sitting on the computer, kids are sleeping in their cribs, dishes are done and house looks pretty good. We have had a busy couple of days. Steve and I brought home Madeline and Nicklaus on Monday evening. We were both so excited to get them home, but very sad to leave our little Gracie. She is doing great she just gets so tired during her feeds that she needs a little more love in the NICU. It must be that she loves her nurses, especially Sally and Sheryl. As you can imagine things are slightly crazy. My Mom stayed the night with us the first night and we did not sleep but five minutes here and there. Madeline has a very odd breathing pattern and to be honest it is sometimes scary. Nicklaus just loves to look at the world and never wants to sleep. Thank goodness that is changing. We bathed them last night and I think that it wore them both out. My Mom and Dad both stayed last night and I was able to get six hours of sleep. I cannot say that my Mom has had that but I woke up early this morning and sent her to bed. Today we meet our Pediatrician for the first time. I am excited to see if the kids have gained any weight??? Then we will go visit Grace and back home for the night. Please pray that the kids continue to eat well and that Grace will be home with us soon. It is very hard to have a split family. I went to visit her yesterday and then Steve went after work to give her quality Daddy time. She is in great spirits but we want her home. Many of you have offered help. I thank you and yes I could use it. It would be helpful to me that if you call you tell me when you can do it. I am drawing up a calendar and scheduling people in. If you feel like you are a night owl and can handle a shift that would be great. My parents are here helping but I need to give them a break too. Day-time cuddlers are needed too. Thank you to everyone for everything. Steve and I realize that we could not do this alone and all the support has been so great. Christy

No matter what all these anti-child news articles say, I strongly disagree with people who claim that having children is inherently bad for the earth or bad for the economy. Sure, they have a right to say whatever is on their mind, but I will fight them if they ever try to restrict the rights of other people to have children.

Back when I was interviewing for medical school, my views on people having a lot of children were influenced by a story that I read. It was a science-fiction short story that later got made into the 1973 movie  — SOYLENT GREEN, starring Charlton Heston and Edward G. Robinson. The story was set in a future where overpopulation was so out of control that there were massive food shortages. Rather than eating meats and vegetables, people were forced to eat nasty processed wafers made from plankton. With great desperation to reduce the population, people were given incentives to kill themselves by offering them a final deathbed view of wonderful nature scenery of the way earth WAS before overpopulation destroyed it. Once you got to watch the final nature show, you were given a poisonous drink and allowed to pass away in peace. Spoiler Alert: In case you want to rent this movie, skip to the next paragraph. Otherwise, I’ll share the kicker of the movie which was that Soylent Green was NOT made from plankton but rather from the recycled people after they were put to death! Yechh.

The movie made me a strong advocate of population control. When it came time for me to interview for med school at UCLA, I found myself talking to a doctor from their OB department and somehow the conversation wandered to the topic of contraception and sterilization and I let forth with a passionate unedited outpouring of my views on population control. I immediately sensed a strong negative reaction from my interviewer. In the end, I would up wait-listed at UCLA and eventually accepted. However, by that time I was accepted, it was so late that I had already decided to accept a spot at UC-Irvine. On the day I received my acceptance from UCLA, I had already moved and gotten settled in with a place to live in Irvine. It turned out to be one of the most fortunate turns of events in my life because UC-Irvine had the very best OB/Gyn program in the country, allowing me to meet a great mentor who would inspire me to enter the field of OB and eventually to specialize in Reproductive Endocrinology.

Later in my career, when I was an infertility Fellow at UCLA, I ran into that same doctor who interviewed me and found out that he was a fertility specialist who strongly advocated people having more kids.

So today, when I stumbled on yet another anti-child article, I took the time to reconsider what my stand is on this issue. My opinion has definitely evolved over the years.

Here goes: I believe that all potential parents have every right to have as many children as they want to, provided that they can raise them happy and healthy without reliance on the government or on other handouts. I believe that part of being a good parent, besides just caring for children is the ability to guide your kids into becoming adults who contribute to the world rather than just take from the world. Simple?

This morning, we had a 5.8 earthquake centered pretty much where we are. I was in my office doing charts and by the time I made it to a doorway, things had stopped. I called up the embryologists, concerned about my patients’ embryos and got the good news. Everything had held up. We had taken the precaution of bolting the incubators to the walls and that move had paid off big time. A few alarms went off, probably because of the incubators sensing there was motion. There had also been a crashing sound from the back of the embryology lab, but nobody ever figured out what caused that. Hmmmm. Anyway, it was reassuring that our precautions had been fruitful, and that we could feel safe about our embryos even in the midst of a significant quake. Now if only I could get rid of this recurring nightmare about the big quake and my dogs wandering the countryside fending off danger and hopelessly searching for me.

I’m proud of my staff. They are the best. The first time I heard this said, I wasn’t sure of its sincerity or if it was just something nice that pharmaceutical reps say. However, after hearing it spontaneously from three different reps, I’m pretty convinced. Plus, I agree with its truthfulness. According to one rep, we are really different and seem like a happy family rather than a corporate office. In the words of another rep, we have a really sharp bunch, who ask smart medical questions, much smarter than any other offices called on by that rep. Still a third rep noted that while a lot of practices had some pretty dysfunctional staff politics with low morale and high turnover, ours seemed like such a cohesive happy team.

Another reason I know that our staff is different is that I’ve worked with different staff in the past, during my training and before I started my own practice. And even after I started my practice, I have a lot of contact with different practices and have even shared weekend call with other practices. So I do know what other offices are like. Most importantly, PATIENTS notice the difference, especially those who have been patients elsewhere. They often ask me what our secret is. The “secret” is really many different small secrets.

One secret is emphasizing selection over development. In other words, when people want to know how to train a staff to be so great, I remind them that it’s much easier if you first make some extra effort to CHOOSE the right people to start with. In the past, I used to go through an average of 40 resumes for each position. Lately, it’s been more like 1 out of every 25. This is attributed to better efforts at clearly announcing the details of the job description, so as to get fewer resumes from totally unqualified applicants. So, one secret to getting your staff to be excellent is to hire people who are fundamentally good in the first place. So, given a choice of applicant A: Someone who is very experienced, but not as great a person vs applicant B: Someone who is a hard-working, smart, good-hearted person with no experience, I would take B. It’s much easier to train a sharp, industrious, caring person the details of infertility treatment than to train an experienced infertility nurse how to be smart, hard-working and caring.

However, in all honesty, no matter how great a team is, there are always going to be moments of friction, especially when you are running a high-stress task such as competitive sports, fighting a war or providing high-tech fertility treatment. Recently, one thing that has really helped was to take into account everyone’s personality type. Many of you are familiar with the Myers-Briggs classification system. Well, there is one I like even better, called the Enneagram system. If you haven’t tested yourself yet, take a few moments to do so. If you also test your partner, you might gain some valuable insight into the dynamics of your interaction.

I started having all job applicants take the Enneagram as part of their application process. Right now, our office is a good mix. Just as a good NBA basketball team is not going to have eleven speedy point-guards nor eleven big centers, a good medical team is not going to have people all of a single personality type. In case you’re interested, we happen to be a Type 7 / Type 3 (me), a Type 7 / Type 9, Type 2 / Type 9, a Type 6, a Type 2 and a Type 2 / Type 8. In order to see how each of these types interact, check out these write-ups. The other day, when we were having some conflicts, I printed out these descriptions and had everyone read them. The tension melted and was replaced with rolling-in-the-aisles laughter regarding how uncannily accurate those descriptions were.

We received a phone call this morning from a couple who wished our help to get pregnant. They said they were ready to do IVF using donor eggs. It’s not often that you come across someone who expresses their readiness to commit $25K or so to having a baby. However, before the patient could make an initial appointment with us, we knew enough to know that we were not willing to take on their case. The problem? The couple was in search of an IVF program that would be willing to do an egg donation cycle using a relative who was 16 years old. They said that the donor was willing and had her parents’ approval as well. In the past, we had a stated policy that our preferred egg donor age range was 18-27, but now have amended it to 21-27. In any case, I support the freedom we have in the United States, where doctors are the primary decision-makers in such matters, rather than non-medical lawyers and politicians. So we exercised our responsibility to say NO and explain that all egg donors have to do so willingly of their own consent, which necessitates that somebody must be of an age that CAN give consent and 16 was too young.

The caller than asked if we could refer them to another program that would take their case. I knew right away about another center that in the past has taken on cases that we had refused on ethical grounds, but again, we made the decision not to be accomplices in this, no matter how remotely. Given how much that other center spends on marketing, it’s likely that this couple will find them on their own. We can only hope that my colleagues adhere to the general guidelines and act accordingly out of the desire to practice sound ethical medicine, even though these guidelines are not 100% strictly enforced.

This question was posed by a future medical student:

I’m entering med school this fall, and women’s health and REI is a great interest of mine due to personal and familial reasons. Once you completed your Ob gyn residency, how difficult was it to enter into the REI fellowship? How long was the fellowship? I’ve also considered Perinatology– what are your thoughts on that field?

When I made the decision to go into OB/Gyn, I did not know I would end up in REI. I didn’t even consider it initially, mostly because I didn’t know much about it. As my residency progressed, I found a great mentor in one of my faculty who was once president of the American Board of OB/Gyn. His field was Gynecolgical Oncology and he encouraged me to go into that field. I was initially greatly drawn to Gyn/Onc because it involved a wide range of very skilled surgery, including GI surgery and urological surgery in addition to medical knowledge of chemotherapy. However, when I discovered REI, it became my new love. When my mentor learned of this, rather than being upset, he was fully supportive and did all he could to help me enter a fellowship at UCLA. Each person’s situation is different, so if I were to answer your question of "how difficult was it to enter into the REI fellowship", it was very difficult only in the sense that I had to go to the right med school and the right residency and earn the respect of the right people. Other than that, it was easy.

I can also help answer your question by presenting last year’s statistics:

Match Results Statistics
Obstetrics/Gynecology (OB/GYN) Fellowship

Match Day October 31, 2007
Appointment Year 2008

STATISTICS BY SPECIALTY

Updated 11/09/2007

As you can see, in Gyn-Onc, there were 49 positions available, of which 45 filled. In perinatology, also known as MFM (Maternal-Fetal Medicine), there were 77 positions available, all of which filled. In REI, there were 38 positions available, all of which filled. The newest subspecialty is Pelvic Surgery, of which 27 of 29 positions filled. There wasn’t a breakdown of the different subspecialites with regards to number of applicants, but overall for all the fellowships, there were 343 total applicants. Of those, 55% matched somewhere and 45% failed to match anywhere. I would estimate there are just over 1000 graduating OB/Gyn residents nationwide. There are also some foreign applicants adding to the pool. These data also don’t include applicants who were accepted outside of the match system.

When I counsel medical students regarding a career in REI, one recurring theme is the need to be happy doing general OB/Gyn as there is a very real scenario of OB residents failing to get into a REI fellowship and ending up practicing OB. A minority of students give up on the idea of going into REI because they don’t feel that they would be happy doing OB. As many students will attest, OB seems to be a polarizing rotation in the 3rd year with a greater % of students feeling the extremes of really loving it or really hating it.

I know many RE’s and many doctors in other specialties. There are happy RE’s and disgruntled RE’s. There are happy FP’s and disgruntled FP’s. I will offer an opinion that from my observations, RE’s tend to lean towards being more satisfied with their work than being less satisfied. As for myself, I’m an extreme when it comes to that question, being very very happy with my choice of specialty. Bear in mind that about 1 out of every 700 doctors is a RE, so we are very much a minority.

Finally, in answer to your question on my opinion on perinatology, I love the perinatologists with whom I work. They save us when we end up with triplets or more. I’ve witnessed some incredible work by the MFM miracle workers who rescue those of our IVF babies who happen to be born prematurely. When you ask a perinatologist what they think of RE’s, they might give a mixed answer of dreading the occasional sets of triplets and quads they get from us, but also acknowledging that we definitely keep them in business.

I recently completed an interview for a medical student website, after which I asked them not to use my real name in keeping with how I don’t have my real name on this blog. My reason for the anonymity, as many of you know, is a minor one. I do have another website for my practice which is a pure marketing tool, intended to help patients decide to come see me. I wanted to distance this site that you are currently reading from being a marketing tool. Many more readers come to this site than they do to my regular site. What they want is authentic information and opinions, not a sales pitch to increase my patient volume. Granted it’s a minor thing, as many of my colleagues, patients and those who first visit my main site will know who I am by the time they come HERE.

The interesting thing is after I requested my name be withheld, the author of this interview decided to make up a fake name for me without informing me. So you can call me Dr. Lawrence Terra. i believe they are sending me a whole dossier including passport, fake ID and biographical cover story so I can begin doing undercover assignments for the CIA.

The morning started out terribly. One of our favorite patients had a miscarriage confirmed. There had been a heartbeat seen on their last ultrasound, but there was none today. As the patient herself admitted, it didn’t come as that much of a surprise, because she had been bleeding, her hCG levels had not been rising briskly and there was an observed slowdown in fetal growth seen on the last ultrasound. Being over 40, she was already at increased risk of miscarriage. Still, we had been hoping for one of those amazing recoveries that I’ve seen happen before. It was very sad for her and her husband and it was sad for our whole office, too. We had a 30-minute discussion regarding where to go from here.

I then rushed to the consultation room to meet with still another patient who had recently miscarried. We were able to spend a long time talking things over, discussing what happened, discussing what options to pursue next and discussing life in general. She reads this blog and out of respect for her privacy, I won’t share any clinical details. Suffice it to say, it added greatly to the sad morning.

I then got a short break doing some routine follicle-check ultrasounds and an IUI before going to the consultation room again.

This time, I got some devastating news from a patient. Again, without going into too many clinical details, we had not seen her for several months. She had abruptly cancelled treatment before we could finish her first cycle. She and her husband had just disappeared and today, I learned why. Apparently, her previously healthy husband had gone that day to the Emergency Room with a cold that wasn’t going away. He was admitted for pneumonia. The doctors were shocked as his condition worsened daily until he passed away in the ICU thirty days later. I listened as the patient shared with me the story of their amazing twenty-year marriage. As I listened to her recount what she had to endure in the past few months getting her life in order since his passing, I marveled at how brave she was. She shared how she wished that they had gotten to the point in their infertility treatment where they would have frozen his sperm, because then she would have the option of having his child still. She gave me a program booklet from his memorial service and invited me to read his life story and the testimonials from his friends.

I felt drained. I didn’t suffer any of those tragedies myself, so my sadness pales in comparison to the patients’ own misery. However, it was still emotionally painful to share a continuous two hours of back-to-back-to-back discussion with those going through such suffering.

The next patient was another prenatal ultrasound for which we saw heartbeat the time before. I’m by no means superstitious, but I was starting to get a bad feeling that this was the morning of doom. This was a patient for whom I had transferred a single embryo that had been confirmed by PGD to be a normal 46,XY. When I did the ultrasound we were all in shock. There were two babies! We now had identical twins who had split off from a single embryo. My assistant was jumping with joy and amazement. The patient and her husband were beaming! They had wanted twins, but there had only been one genetically-normal embryo to transfer. I called the embryologists to let them know and I’m sure it made their day too. This wasn’t anything worth writing up in a journal ever since someone recently reported a single embryo transfer that had split into triplets, making our news very drab in comparison. Of note, the twins were in the same chorionic sac, but in different amniotic sacs, which made it much safer. As the patient came out and proudly showed her ultrasound pictures to the rest of the staff, the energy was contagious!

After that much needed pick-up, another former patient visited unexpectedly. I was now done seeing patients for the morning and had time to let her show us her baby. As I held the eight-month boy, my staff talked with him and called his name, each time eliciting a huge smile and gurgle of laughter from him. It seemed rare for such a young baby to be so alert, so interactive, but his mom said that he was always like that. As I gently bounced him in my arms, I had a fun conversation with his mom, all the while with my staff surrounding us and cooing at him. It felt really good. After being in a dank pitch-black cave a few hours earlier, it was like walking out into the scorching midday sun at Laguna Beach.

I don’t really know what it feels like to be manic-depressive, but I can imagine.

I went for a one-day trip this weekend to catch part of the 2008 meeting of the Pacific Coast Reproductive Society. Those of us who do IVF have many meetings we can attend where we can exchange ideas with each other. For, example, this year, ESHRE is meeting in Barcelona. I’ve never been to ESHRE, but I’ve been to Spain and I sure would like to go back. The other big academic meeting is the ASRM meeting, which I will almost for sure be attending, as its location this year, San Francisco, is relatively close. These two meetings consist primarily of people presenting their research. There is another annual meeting that is more like an IVF review course, and that is held each year in Santa Barbara, sponsored by UCLA, my alma mater (well my infertility fellowship alma mater, anyway). Go Bruins!

PCRS is a much smaller meeting, but unique in how casual and non-pretentious it is. In the registration materials, there was an actual statement to the effect that “anybody who shows up in a suit and tie will be asked to go back to their room and change into something more fun”. The presidency of the society, which changes yearly, is a thankless position undertaken by an RE who while still attending to the daily duties of his/her own practice, must somehow manage to find an average of five hours a week to deal with the administrative matters of the position, most notably organizing this annual meeting.

It just so happens that this year’s PCRS president is a friend of mine and someone whom I greatly admire. We go way back, to the time when we were OB/Gyn interns together. We finished four years of grueling, but fun residency together before we went our separate ways to different RE fellowship programs. He then went on to build a small empire with two IVF centers in different states ( One in Reno, Nevada. One in Boise, Idaho ). That in itself is quite a feat, but doing so while still maintaining a pristine reputation as one of the nicest, easy-going guys around is not easy. He has also been happily married for close to twenty years, with so many kids that I’ve lost count. That is a rarity among RE’s, who ironically, for being doctors in such a family-oriented field, in general aren’t always known to have the most stable family lives themselves.

I also got to spend time at the meeting with another doctor whose story is pretty interesting. We first became friends when I had started my IVF practice for a few years and he was just about to start one himself. He likes to thank me for my helping in his getting set up, but I didn’t really do much. At the time, he was already an established general OB/Gyn and professor in Hawaii who was well known for his laparoscopy skills. He was with a group of doctors who had been doing IVF together for a long time. Like some of the other IVF doctors in his group, he was succefully getting IVF pregnancies without ever having done a formal RE Fellowship. In fact, his group was pretty much THE only IVF program in Hawaii at the time. (Hawaii is a cozy place). I still don’t know what kind of amazing ambition bug bit him, but he decided to go back and hit the schoolbooks to become a certified embryology lab director. For those of you who don’t know the difference, if RE’s are like pilots, then embryologists are like the engineers who build the planes we fly. There are a few amazing RE’s who are skilled at both. Imagine a pilot taking the time to go back and study engineering so that he can build a better plane and then to go on and fly that plane himself. So here’s a guy who did just that, and since then, he has branched out and built a new lab that because of the success rates, is now recognized by the “locals” in Hawaii, as the best IVF program, and over there, pretty much everybody is a local.

During the meeting, besides the scientific talks, I also heard a different type of lecture, one about practice management. A doctor from the East Coast spoke about being the single RE in a program that does an astounding 1000 IVF cycles per year! That is just insane to imagine. Logic would dictate that patients would not like it very much when they don’t get to see the doctor for more than a few seconds, but this guy has his PA’s, NP’s, RN’s and other staff trained so well that patients love it! He manages his 88 employees with principles learned from Ritz-Carlton, such as regular staff pep-sessions and daily motivational emails. Along with five-star treatment, patients enjoy a relaxed spa-like atmosphere complete with facials, foot massages and comfortable Pottery Barn furniture. This is a doctor whose employee management skills put many CEO’s with MBA’s to shame. I don’t know anything specific about the medical care there and I would guess it’s good, but I was amazed that such a thriving practice could be built primarly around customer service and it’s at least made me think a little about some new ideas for my own practice. However, I still don’t think we’ll be offering massages any time soon.

The medical talks I attended got me up to speed on the latest in PGD, embryology topics and some interesting controversial issues regarding the integration of IVF with Traditional Chinese Medicine and acupuncture. I hope to write more on this in future posts.

Palm Springs was relaxing, yet productive. I met some great people, learned a little medicine, touched bases with old friends and got caught up on the latest gossip of who is now working whom in the musical-chairs world of IVF practices. All in all, not bad for one day.