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.

Not ready to get professional fertility help? Many times, the uncertainty of what to expect during the initial visit to a RE makes some people hesitant about taking that first step. So to help you out, here’s a typical example of the progression of events.

Let’s picture that you want to be pregnant and have been trying for almost a year. With your job and all your other obligations, you just haven’t seen any opportunity to take action on this just yet. Besides, you and your husband are healthy and can clearly picture it happening naturally, right? Occasionally, during random moments of browsing the internet, you see some flashes of information that makes you inspired to take action, but then the motivation fades and you are back to your busy life. Over the next year, the pages on your calendar cascade down month after month, and still nothing has happened. Now it’s been two years, so you stare at your phone and eventually pick it up and call.

The voice on the other line is pleasant and you are told about the office policies, the initial consultation fee and you are given a choice of times. You and your husband decide to take the leap and book an appointment.

You arrive at the unfamiliar office and are warmly greeted with a smile, but you are immediately taken aback by the pile of forms to fill out and sign.

The first is a demographic sheet asking for your contact information, so we can facilitate reaching you, especially in an emergency. Besides the personal data, you are also asked for any insurance information that is needed. So this has practical value and you don’t mind filling it out.

The next form you will have to read and sign is the HIPAA agreement. You will have to bear with me while I gripe, but this is another reason why we should hope and pray that government-run universal healthcare never becomes a reality. Sure, everyone agrees that privacy is important, but it should not be the way it is, where physicians are made to be so terrified of a perceived infraction that we are all forced to take drastic measures. Anything that takes up our undue attention will distract from the pool of attention resources we can devote to more meaningful things, such as patient care. So we had to pay attorneys to draw up legal documents for our patients to sign. You see, while the government mandates us to abide by the rules, they don’t provide any acceptable standard documents that we can use, so we have to expend major time and energy each time there is a HIPAA revision. Also, we used to have a convenient sign-in sheet. But now we had to hide it. Technically, we also can’t risk saying hi to anybody by their name if it can be heard by anybody else in the waiting room. Basically, we walk on eggshells for something that was never a significant problem even before HIPAA. And yet, ironically, now with HIPAA, it still doesn’t prevent those news stories of people leaking celebrity medical information to the press. OK, thanks for listening. Let’s go on.

The next piece of paper is the Arbitration Agreement outlining that any disputes will be addressed by a legal professional and not by a random jury of medically unsophisticated people.  This document benefits us by protecting us from lawsuit abuse in many ways. It sets up a fair system and it also weeds out the litigious fringe problem patients who jack up the costs for everyone.  There have been a handful of people who refuse to sign the form and therefore, refuse to be our patient. One such person went on to see another doctor whom she wound up suing for something silly. She also sued her landlord for mold and sued her employer and this one store she went to. (I later found these cases listed on the internet). With an arbitration agreement, while we can still be sued if we do something wrong, it’s less likely that someone is going to file an nuisance suit against us just to exploit and intimidate us. And actually, it also benefits the patient. How? Well, in almost 13 years of practice, I have yet to be named in a lawsuit, so that helps keep our malpractice costs low. Don’t underestimate the significance of this. Due to arbitration and legal protections (MICRA) against lawsuit abuse, OB/Gyn’s in Orange County CA pay about 50K each year in malpractice costs. In contrast, OB/Gyn’s in Long Island NY pay 168K and those in Dade County FL pay 203K per year. You can probably already guess that these costs will get passed down to the patient somehow. I believe it also gives good doctors an incentive to avoid those places, thereby depriving the people in those regions of more good doctors from which to choose.

So after all this gruelingly painful paperwork, you will finally get to meet with the doctor, which we’ll discuss next post.

Before you take that first step and make an appointment with an RE, you might appreciate a preview of what to expect. The following describes this important first visit, which we officially call a New Consultation visit.

In my practice, the couple will sit across from me and we’ll spend about an hour together. Sometimes it’s just the wife who comes by herself and other times, both partners are present. There are several goals to accomplish for this visit:

I get to know the couple. I find out what their daily lives are like, what their priorities are with regards to fertility treatment and what their specific concerns and special needs might be.

The couple gets to know me. They get a feel of my communication style and my philosophies regarding the doctor-patient partnership. Some doctors are very dictatorial, meaning they pretty much call the shots regarding what happens. Generally, my style is different. I like to present options including the pros and cons of each alternative. After going over this in detail, then I’ll reveal which choice I would personally lean towards, but I prefer to let the couple make their own choice. However, it all depends on what the patient’s want. Some patients clearly don’t want to discuss the logic behind each decision, but would rather just leave it all up to me.
I gather all the medical information though questions and answers, as well as via an ultrasound examination plus review of any previous records or test results.

I offer treatment choices. Sometimes, there are a couple choices, all of which are reasonable. Then, as I previously mentioned, we’ll go over the plus’s and minus’s of each route before deciding on the final plan to take. Other times, there’s really only one best plan. In this case, we will spend time going over this process in detail, making sure to tackle all the questions that come up.

In the next post, we’ll describe an example of the paperwork involved in a New Patient Consultation visit.

I had to be a little bit sneaky today.

In the past week, three couples returned for a second baby. These three had similar stories in that all of them conceived with IVF within the past few years and were now back for another baby using their frozen embryos.  Two of these couples came back for their re-consultation as a family (husband + wife + baby/babies). One of the big perks of this job is the opportunity to actually see, hear and touch (sometimes even smell, ugh) the babies we helped conceive and to learn that they are happy and healthy and that the parents are glad they did the treatment. I have yet to encounter a couple who tell me “You know? It’s really a lot of hard work to raise a baby. I don’t know what we were thinking and now we wish we hadn’t done it.” Perhaps there ARE couples out there who feel that way, but they just are so mad at me for getting them pregnant that they don’t wish to ever speak to me again. Who knows?

Anyway, two of these couples came back all together with a whole family, but the third one came back as wife and baby alone. She said that her husband was too busy at work to make it. This created a problem for me – not a medical problem but more of a legal one. Hypothetically, how was I to know 100% for sure that this couple was still married since the time of the original IVF? How was I to know for sure that this was not a case of an ex-wife wanting to get pregnant again WITHOUT the blessings of the ex-husband? How was I to know that a disgruntled estranged husband, who is now on the hook for child support payments for a child that he did not wish to have conceived, won’t get mad at me for helping this to happen? Sure the scenario sounds far-fetched, but there have been lawsuits reported in just such a case.

I have to confess I may not have been as diligent about this ten years ago, but over the years, especially with this recent octuplets case, it has come to our attention that we, as RE’s can stand to be a little more aware of the overall picture of future social implications, rather than just be embryo-placement technicians. Even though there are consent forms required for the FET, which require signatures from both partners, it’s fairly easy to fake a signature. We don’t require notarization on our consent forms.

So I picked up the phone and played detective. I called her husband on the pretext of just saying hi. Then I subtly said, “Hi ‘John’, this is Dr. Lee. How are you? I just met with ‘Jane’ and we discussed the upcoming embryo transfer. I was wondering if you had any questions for me.”
He acknowledged that he had no questions. I then asked him if he was in agreement with our future strategy on how many embryos to transfer. He replied that he would not mind twins this time, but was really hoping for just one. We then exchanged a few friendly words regarding basketball and then ended our conversation. It took all of three minutes, but I was then able to document in the chart that I spoke with the husband and I am assured that he is on board with our upcoming baby-making project. Notice I didn’t overtly call him and say, “Hey John. I see your signature on the consent form here in front of me, but I need to hear from you explicitly that you are aware and in favor of Jane doing a frozen embryo cycle. You ARE, aren’t you?”

That would just sound too untrusting of me.

As a welcome relief from all the sadder posts about the octuplets, I’m reminded that there are many optimistic diligent students who might someday be the RE’s of the future. Here are some of their questions:

How do you become an RE? What classes do you suggest I take in highschool? in college? I’m a freshman in highschool and I think I might be interested in this career. Is there anything I should know?
And another afterthought, are there any depressing side effects like couples (mainly females, I assume) that break down?

Ashley

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I thought it would be appropriate to introduce myself. I am a third year medical student that follows your blog. I have always been interested in Ob/Gyn and have been fortunate to shadow a couple REI’s from my hometown in Wichita, KS.

I am an aspiring REI. I was wondering if you could give me some suggestions on how to reach this goal. Also, do you feel it would help if completed an M.D. residency rather than a D.O. residency? I did read the part of your blog where you address that REI is extremely competitive and to make sure to be happy as a general Ob/Gyn if you weren’t able to get a fellowship.

I just completed my required Ob/Gyn rotation, and I really loved it. My attending did quite a bit of infertiity for a general Ob/Gyn, including FSH injections because of her unique situation of being in a small town. It was a great rotation.

Keep blogging! Thanks in advance.
Paige

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Hi Dr. Lee,

I’m Jay, a third-year medical student at the University of Missouri School of Medicine, undergraduate degree from UCLA 2005. I know you’re probably inundated by millions of messages like this, but I am EXTREMELY interested in going into REI as a career choice. My father is a general OBGYN but I’ve determined that REI is the way for me. Do you have any pearls of wisdom as I embark upon the rigorous application process for OBGYN residency? Anything would help. Thank you so much Dr. Lee, and congratulations on all your success. I came across your blog from StudentDoctorNetwork and have bookmarked it now to visit daily. Thanks!

Sincerely,

Jay

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Hello Dr. Lee,
I recently came across your blog and it’s so informative. I am currently an OB/GYN intern at Meharry and I have had a longstanding intrest in REI. I was just curious to know how you knew that REI was what you wanted to pursue. I guess a part of me is hesitant due to the competitiveness of getting IN to the field, but I am also not trying to let my possible future escape me due to fear! Any advice?
Look forward to hearing from you,
Nke

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Thank you all for your questions. I’ll start with the straightforward part. Ashley, in order to become an RE, you first graduate from college, and then go to medical school for four years. Afterwards, you do a four-year residency in OB/Gyn and then an additional three years of a fellowship in Reproductive Endocrinology and Infertility. You’re probably thinking “That is a quite a lot of schooling”. I’m sure you can do the math yourself, but I personally took an accelerated route (started early and skipped one year) and even so, was already 30-years-old by my final year of fellowship. Other RE’s who take a less direct route are already over 40 when they finish their training. So one big question to ask yourself is whether or not you’re willing to dedicate such a big chunk of your life to learning the knowledge and skills that it takes to be a good RE. The good news is that you don’t have to commit to that decision right this moment. You can take it one step at a time, focusing now on making the most of your high school experience and doing your best to get into a college that is good for you. By the way, if you want to immerse yourself in the field of fertility and don’t want to go the long route to becoming an RE, you could participate as a medical assistant, nurse or Physician Assistant. I realize that it’s not the same thing as being an RE, but it has its good points too. You could also choose to be an embryologist, although the everyday atmosphere is very different in that you would interact mostly with egg, sperm and embryos rather than directly with patients.

Ashley, right now, while you are in high school, rather than restricting yourself to any specific MUST-TAKE classes, your best strategy is to make the right decisions so as to maximize your options. What does that mean? I’ll share with you an answer your teachers and school counselors may never tell you. Here’s the secret. When it comes to a career in something competitive like medicine or law, there is a delicate balance between doing what it takes to “play the game”, and doing what it takes to really grow and learn as a person. Shall I explain? On one hand, many pre-med students take the extreme “Cutthroat PreMed” approach and focus single-mindedly on what it would take to get into the best college or the best medical school. Somewhere along the way, they find themselves losing their humanity and falling into the trap where every major decision is geared towards getting accepted and not necessarily towards becoming a well-rounded doctor. “Hmm let’s see, I will need to spend next summer pushing wheelchairs at the hospital so I can say I have some hospital volunteer experience and I’m going to run for Assistant Vice-Treasurer of the Lithuanian Pre-Med Students Association so that I can have some extra-curriculars to list”. If you single-mindedly focus on getting great grades, great MCAT scores and a long list of activities on your resume, but ignore developing yourself as a human being, your odds of getting into medical school will still be pretty darn good, but you have sadly missed out on a some great years of your life. And worse of all, you might find yourself being a very depressed resident or graduated doctor someday.

On the other extreme, some people take the “Rebellious Anti-PreMed” approach. They adamantly refuse to the play the game. “I’m not going to waste time studying for Organic Chemistry since I know that 99% of doctors will never use it in their daily practice. And I refuse to obsess about the MCAT. How does my performance on multiple choice questions reflect how caring and empathetic I’ll be as a doctor? I’m going to focus my energy on the practical courses like microbiology and anatomy and then round myself out with a lot of psychology, literature and history classes, as well as enriching my writing skills”. While I personally agree with this in spirit, I also have to warn you that in actual practice it doesn’t work. This attitude of not taking things like Organic Chemistry and the MCAT’s very seriously is one easy way to NOT get into medical school.

Furthermore, Ashley, it’s so good that you’re already asking questions at this point in your life, trying to get an edge for your future. If I could go back in time and meet my past self when I was in high school, one of the many things I would tell myself (besides save all my paper-route money and invest in Microsoft) is to develop a habit of regular reading. Many smart thinkers throughout the centuries have “figured things out” and put their discoveries down in words. Even if you could gain just 1% of their pearls of wisdom, your life could be significantly easier and happier. Now I know there are people who scoff at self-help books because we probably all know a friend who reads them or goes to self-help guru seminars, but yet their lives are not something that we would care for. Reading self-help books but not acting on the advice learned is like trying to get in shape by buying more and more exercise equipment. It’s not as powerful if you just read and don’t apply what you’ve learned.

Now if you want to know which specific books I would recommend, I would start by telling you that I’ve read tons of books and some of them have been tremendously helpful to me and others have been a waste of time. There are people out there who have read my “waste of time” books and found them to be the most helpful while my “changed my life” books did nothing for them. So the point is that everybody is different. To get started, visit this site and print out the books listed. Check out a few from the library. Devote at least two hours every week (more if you can) to leisurely looking through them. If a particular book does nothing for you, let it go. By the way, even if a book does not thrill you today, you can always give it another try a few years later. If however, you DO find a book that grabs you, share it with a friend and discuss it together. Anyway, Ashley, thank you for your question. I hope I was of help. If my answer was not what you were looking for, I only ask that you revisit it every few years as you progress in school. One day it will click. Oh by the way, in answer to your question about dealing with couples who break down emotionally, you are correct in guessing that this field of medicine contains some of the most emotional extremes. lt comes with the territory. You will share the agonizing pain of many couples as they have failed cycles and miscarriages, but the trade-off is huge as you get to rejoice with the many more couples who end up as happy parents! I can’t imagine many jobs that have more of these types of highs!

Paige and Jay, since the two of you are already in medical school, congratulations! You have already set yourselves above the rest of the pack, demonstrating that you have figured out what it takes to succeed. Maybe you would be better suited to give high school students like Ashley advice, since the timeline for your successful decisions is much more recent than for mine.

As for what tips I can give medical students, there is nothing secret other than to get into a good OB residency. One question is this: Is it better to go to a great OB residency that does not have its own REI fellowship? Or better to go to a lesser residency that does have a fellowship program? The answer, as always, is ‘it depends’. First of all, the question is tricky because it assumes that we know what makes a program better than another and the fact is that we don’t. Keeping all this in mind, when you are deciding how to rank your program choices, my opinion is that presence or lack of a fellowship SHOULD come into the equation. The reality is that people do their fellowships at the same place they do their residency much more frequently than could be attributed to chance. There are several reasons for this. One is familiarity. As a fellowship director, it’s safer to take someone who is well known to you and to the other faculty in your department than someone who is a total stranger.

Paige, as for your question about DO vs MD residencies, my general advice is to aim for the most competitive program that you can get. As some of you know, I am on faculty at UC-Irvine College of Medicine as well as Western Health Sciences, so I regularly lecture to hundreds of MD students and DO students each year. And while it is more than possible to become an RE through the DO route (I personally know some excellent RE’s who are DO’s), it is much easier to get there through the MD route. Again, some of this is out of our control. It’s easier for a football team to win the Super Bowl by first winning their division and getting a bye than it is to win as a Wild Card team that barely made the playoffs. However, as the 1980 Oakland Raiders, 1997 Denver Broncos, 2000 Baltimore Ravens, 2005 Pittsburgh Steelers, 2006 Indianapolis Colts and 2007 New York Giants have proven, it happens more often than one would expect.

One general tip for medical students, residents and doctors is to realize that our lives are “different”. With so much expected of us, we really need to make the most of our God-given 24 hours each day. This means we should strive to always do the best thing at any given minute. This should NOT be interpreted to mean that we should always be studying or at the hospital, because sometimes the best thing to be doing at the time is to be watching the sunset with a loved one or to be sleeping or to be at a funny movie, because only then can we be recharged to go back into the hospital at our fullest energy level. There is a term called ‘lifehacking’, which I define as squeezing the most out of each minute of life. I am a big believer in the concept. That’s why I try to learn and find the most efficient ways to do things like setting up macros for repetitive tasks on the computer and listening to audiobooks during commuting or while at the gym to make the most double use of each hour. One specific book that I highly recommend is Getting Things Done. If you find that it completely changes the way you organize your life, please drop me a line to let me know.

As for the tricky fact that in order to do REI, you have to go down the OB pathway, I can say this for myself. I’m guessing that had I not gotten into an REI fellowship and was now practicing general OB, I would still be happy. I can’t imagine I’d be as happy as I am right now, but it wouldn’t be that terrible. I say this even though I realize that the work-day (and work-night) of a general OB is very different from the work-day of an RE. So if you think that you would love being an RE, but hate OB, then my advice is not to take the gamble. As you can see from a previous post, the ratio of applicants to acceptances is around 2 to 1.

Last but not least, Dear Nke. Congratulations on not only making it through medical school but already being in the world of OB/Gyn. I hear words similar to yours all the time, not with respect to applying to a fellowship, but with respect to trying infertility treatment. Patients sometimes are afraid to try even a Clomid/IUI cycle because they have a fear that it might not work. They don’t worry about the cost or the time commitment or the risk of multiples so much as they worry about the misery of doing a cycle and failing. Sure it’s sad to do treatment and not get pregnant, but is it really all that much better to remain not pregnant because you never tried to do any treatment? As for your question about when I decided to pursue going into REI, it wasn’t until I was on my way to applying to Gyn-Onc that I changed my mind.

Anyway, I commend your attitude. You have already committed to OB, so that’s one bridge crossed. Now that you’ve done it, I encourage you to explore it open-mindedly. After all, this is just your first year of residency. Who knows? You might end up loving Gyn-Oncology or Maternal-Fetal. But I agree with you in any case. Don’t let fear of not succeeding prevent you from trying.

I met with nine other RE’s and embryologists last night in Pasadena for our almost bi-monthly journal club. I was reminded then by one of the attendees that these journal club meetings originated from my own idea over a year ago. I don’t really care if I get credit for these meetings but I must say I love the fact that we have them. We are friendly competitors in a sense, but yet, we come together for the purpose of intellectual debate and the sharing of information and experiences, all to further hone our clinical decision-making skills.

The official topic of discussion was PGD, especially with respect to how PGD is sometimes used as a way to avoid the implantation of genetically abnormal embryos. I’ll make a note to possibly write here someday on this topic. But I’ll just share our conclusion that in general, it is NOT a good idea to use PGD in the hopes that it will increase pregnancy rates, because it just doesn’t work well that way. There are other good reasons for doing PGD, but the evidence shows that trying to use it to raise pregnancy rates doesn’t work. Basically, the bad outweighs the good.

One thing that I’m reminded during these meetings is the high dedication to innovation we have in our field, especially from the embryology sector. As clinicians, the people who deal directly with the patients, we can tweak our protocols here and there in an attempt to find better ways to do things, but the most significant advances in our field which have led to a huge jump in IVF success over the years, come not from the clinical side, but rather from the people in the lab. Every day, there are many people who never have contact with patients, but who are diligently working, coming up with better ways to nourish embryos so as to boost success rates. We all know that the better the value of the product that we can offer to our patients, the more business we will earn. This benefits our practices AND it benefits our patients. I can tell you that this would not be happening as successfully if there were no economic incentive to do so. If we had socialized medicine in a way that would give little financial incentive for new discoveries, then sure, scientists would still be trying to make new discoveries, but they would be like government workers, clocking in and clocking out, doing their time to collect their benefits and paychecks, but they would NOT be furiously burning the midnight oil, busting their butts to competitively get these improvements out there for the people as soon as possible. Look at how much postal service and public education has improved (or not) over the past twenty years. Compare this to how much cell phones and computers have improved. Regardless of your political beliefs, I would invite you to ask yourself – do people work harder when there is also a personal incentive driving them or do they work the same as when they are doing something solely for the so-called “public good”?

Inevitably during the evening, after a few glasses of wine, the conversation turned to the topic of the octuplets. Some of us, specifically the RE’s from West LA, knew the doctor better than the rest of us. We discussed our experiences with this doctor and his brother, who is also an OB/Gyn. Some of us also shared our own “war stories” of our own cases in which we transferred five or more embryos. No, none of us ever came close to getting octuplets. Our most somber conclusion, at least in my opinion, is the very real worry that the California government will overreact to this outlier event by taking our ASRM guidelines on number of embryos to transfer and turning them into strict laws. For years, things have been good the way they are. But now, because of this one incident, we could find our hands tied and forced to practice medicine as dictated by politicians and not as dictated by our years and years of medical experience and training. It’s as if someone committed gruesome serial murders with a bowling ball and now the government will outlaw bowling balls. Who suffers as a result? Well, we RE’s will suffer with respect to having our autonomy curtailed, but we will also end up doing more cycles as the success rate drops. So in my opinion, the real victims will be infertility patients. Consider this sobering thought. Several years ago, if these guidelines would have been turned into strict inflexible law with no leeway for wise clinical judgment, then many happy children laughing in playgrounds today would never have been born. I am 100% certain of that.

I recently had an interesting journey into another world, all without leaving the comfort of my computer. One of the fun things about having your own website is to check out where the referring traffic is coming from. So whenever I notice a large number of hits coming from any new site, I will often go to that site and find the page or reference from which my site was linked. Well after the recent flurry of activity regarding the octuplets, I followed the traffic back to a certain site which turned out to be a bulletin board for a special-interest group. I could not access it without first registering as a member. So I went ahead and made a quick account under my old internet alias “IVF-MD”. I entered the site and spent a little time browsing. I found out it was a safe haven for people who call themselves “child-free” (the hyphen is my own doing). I have previously heard the distinction between childless (want children, but still don’t have any) vs. child-free (willfully do not want children) and this was a site for the latter group. The site was a place where they could safely congregate and support each other’s desire never to have kids without being judged, questioned or pulled into a debate. The members of the site were in an uproar about the octuplets, but then again, who isn’t? As I was navigating the site, I noticed a section at the top of the page announcing “WHO’s ONLINE” with a listing of the different members who happened to be online at the time, and my identity was pasted across the top of the list. There I was — “IVF-MD” on a website for people whose very worldview is generally not in favor of people who do fertility treatment. I felt like a male who had just stumbled into the ladies room by mistake. With a little sense of panic, I glanced at the FAQ of the site, where it encouraged people to “introduce yourselves”. I found the section of the site entitled “INTRODUCE YOURSELF”, and I went on and jotted the following apology:
“I am a physician who helps couples who want babies. This is one of the last places for me to come. However, please allow me to explain my visiting. I am likely perceived by many of you as part of the enemy. I apologize for upsetting you, if that’s how you take it. But, I’m never going to post anything further. I just came by to learn a little and to be open-minded and enlightened. I found your site when I noticed a number of hits to my blog from this site, meaning that some of you dropped by to visit ME.
Anyway, I strongly support your right to be child-free and I do counsel patients to consider that as another good option.”

In retrospect, I later realized that this was a mistake. Putting myself in the shoes of the members of the site, I later understood that this was their safe place, where they could support each other in their shared belief of not wanting children. In life, they are often inundated with questions from well-intentioned family members or strangers asking them “when are you going to have kids”. People would offer sympathy at their being infertile, and they would have to clarify (sometimes in a less than smiley-friendly tone) “No, I’m not infertile. I CHOOSE not to have children”. In their posts, they often talk about their encounters with misbehaving children. Having run into my share of unruly children at the mall, as I’m sure all of you have, I could certainly empathize with them in that aspect. Furthermore, I later learned that people with opposing views would sometimes come and invade their site for the expressed purpose of stirring up an argument. These were often people from the mommy special-interest-groups who would come over and be in-their-face with comments like “How could you not like kids? Kids are the greatest joy in the world!”

So anyway, I thought I would leave that apologetic post and be done with it. Well, after I posted, I started getting replies to my thread. The first one asked if I had any children. Apparently, if I would have taken the time to completely read their FAQ, I would have learned that parents, while welcome to read all they wanted, were not allowed to post anything on their site. I had said I would not post anything further, but I felt it rude not to answer a direct question so, I replied that I had two dogs, but was not a parent yet. I did add that I might like to be a parent in the future and reserve the right to be one someday. Next, another nice reply came, welcoming me “since you are childfree” and then went on to vent and direct my attention to many of the issues that child-free people face. One of the complaints was directed against doctors who refused to do hysterectomies or refused to do tubal sterilization on patients who did not have children already. I wasn’t aware that this was a huge problem, because most of the complaints I have heard in the past are about doctors who are TOO QUICK to sterilize or to do hysterectomies. I wrote a reply agreeing with the notion that doctors should not assume to know better than the patient what that patient wants. But, as to why a doctor would deliberately withhold treatment from a patient, doctors have to be careful of doing something even if a patient says she wants it because of later accusations that they didn’t counsel the patient enough. If a 22-year-old woman without children demands to have her tubes tied, any doctor that does it could be subject to a major lawsuit if that woman later changes her mind. Cases like this have happened.

So the thread progressed into a civil exchange of ideas about doctors being too condescending in refusing to do what a patient wants vs doctors getting in trouble for doing something that the patient would later regret. It was an informative mutually respectful exchange. Then some more replies trickled in.

One of the replies simply reminded everyone that I may or may not be lying when I said that I had no children and that they can only take me at my word regarding that. Perhaps I was already in a hyper-sensitive state, but I was a bit irked at being falsely accused, albeit indirectly. Then two more replies came in questioning me further. They brought up the point that if I really intended to just come into their domain and lurk (ie silently read what others had to say but not say anything myself), then why did I do the direct opposite and not only introduce myself, but also continue to post rebuttals to their questions.

My first reaction was to defend myself (and I did), going into detail as I have above about how I happened to stumble on their site when I followed the traffic back from my own site. After giving it a little more thought, I was able to see it from their point of view. This is their official public policy about whether or not parents were allowed to post on their site:
“This board is a safehaven for the Childfree where we do not justify ourselves, thoughts, decisions, or actions to any non-CFers. This is a companionship board, not a debate board, and posts questioning the Childfree or extolling the virtues of parenthood will not be tolerated.
We’ve had parents posting here before. We’ve seen parents post at other childfree-only boards. What we have never seen is a parent who could carry on the sort of conversation we have here without getting offended sooner or later and pulling the “as a parent, I…whatever” out of their arsenal.
This board is not the place to discuss regrets, if any, about having children, because this board is not the place to discuss child-rearing issues of individual posters AT ALL. The places on the internet where those conversations are available are legion. The places on the internet where the childfree are free of parents are about 6.
Childfree non-custodial stepparents and fencesitters are, and have always been, welcome to post. Just as the intro says we do not care to hear the virtues of parenthood extolled, neither do we wish to hear the regrets.
You are to be commended for announcing yourself as a parent. Many people have tried to be a part of this community and lied about their childed status. Unfortunately, not one single parental poster on this board has ever managed to keep their kids out of their posts. We don’t care. We really don’t care. Every day in our jobs, in our families, we are inundated with people and their children. We come here to be free of that- childfree, in fact.
Parents should not post here. We ask you to respect the intention of the board. Feel free to read.”

So for me to intrude and engage in a debate, no matter how polite, was just not right. After that, I asked them to delete my account and I left.

As much as my profession sways me to be biased as to the virtues of having children, even to the extent of being proactive about it when it doesn’t happen naturally, I can see the arguments that the child-free make. If they don’t want kids themselves, who are we to judge them, question them or to tell them that they don’t know what they’re missing? I respect anybody’s right to want kids (that they will properly provide for) or to not want kids. Furthermore, the child-free make the point that government funding for IVF is unfair to THEM, because it adds insult to injury to make them incur the burden, as taxpayers, of paying for other people to have kids when they themselves are so against it. Before you get the idea that I agree with them completely, I have to draw the line when I hear some of them rant that they want to unilaterally ban people from having children, even if the parents fully support the children on their own with no government assistance. Their argument is somewhere along the line that each additional person is harmful to the planet and therefore should not be allowed. Some day, when I’m in the mood, I’ll debate this head-on, but I will not make the mistake of doing it on the sacred ground of the websites of the child-free. Rather, I’ll do it here on my own turf.

Anyway, this little adventure was a learning experience for me. I used to be a lot less tolerant than I am today. Nowadays, I make a conscious effort to at least try and see the other side’s viewpoint. One side argues that the government does not do enough to help infertile couples. The other side argues that it’s unfair to force someone to subsidize the conception, birth and maintenance of other people’s children. One side argues that unfit parents should not be allowed to raise children. The other side argues that the state is being too heavy-handed in taking children from their natural parents. I optimistically look forward to the way the world could be some day if we would all make a better effort to see the other viewpoint.

When is a one-pound weight gain a good thing? ANSWER: When you were anticipating a two-pound weight gain.

This week, I saw five patients back for their post-metformin consult. In the course of investigating infertility patients, one common finding is insulin resistance, related to PCOS. One way to try and treat this problem is with a drug called metformin. Typically, I put some patients on metformin after their blood tests come back showing clear insulin-resistance. Other times, busy patients, wishing to skip the tedious three-hour blood test just opt to try the medication empirically, based on the existence of many clues supporting the assertion that she has insulin resistance. Some of these clues include family history of diabetes, weight gain out of proportion to what she eats, fat distribution concentrated around the waist (as opposed to hips and thighs), extreme daytime sleepiness/sluggishness (especially after meals), uncontrolled cravings for carbs and sweets, issues with facial hair, and of course, irregular menses and infertility.

I almost always bring patients back for a discussion after trying them on the medication for three weeks. Approximately 80% of the time, patients describe some success with the metformin. They notice increased energy, decreased cravings for carbs and sweets, weight loss, a noticeable slimming of their waistline, and possibly resumption of normal periods. The other 20% report no benefit and are usually discontinued off the medication.

When I pick up the chart on these patients who are returning after a 3-week trial of metformin, the first thing I glance at is their weight and the comparison to their weight BEFORE starting the medicine. If someone had a 10-pound weight loss during the three weeks, I can usually anticipate a discussion in which they will beam with excitement about the changes in their carbs cravings. If someone gained weight or stayed the same during this time, I can usually anticipate them to report no change in their carbs cravings and possibly just the usual bad side effect, which is bad diarrhea.

This week, something odd was happening. Some patients were coming back with negligible weight loss or even slight weight gain, but they were still raving about how great the metformin was, in helping them avoid cookies and soda. It didn’t make sense, because it stands to reason that if a person who usually eats a lot of carbs and sweets can drastically cut down their intake, then they should expect to lose weight. The mystery was solved after one patient elaborated. She had actually gone up from 149 pounds to 150 pounds in three weeks. But she was raving about how the metformin had wonderfully taken away her previous intense cravings. Whereas she used to absolutely require a cookie or soda 2 hours after lunch each day, she now had no desire for such junk. She reported that the difference was like night and day. When I expressed some surprise that despite this change, she had gained one pound, she explained that near Thanksgiving, she had participated in three big feasts, one with her family, one with her in-laws and one at work. Each year, she said, Thanksgiving would see her with a gain of four to five pounds easily. So the fact that she gained only one pound this year was not a minor setback, but a major victory!

In the future, I will remember to take into account the Thanksgiving Effect when assessing the success or failure of metformin.

I realize I haven’t been posting often this month.

Many factors have led to this and any one of them could be enough of an excuse.

1. I’ve had to deal with the IRS. This was arguably a huge waste of time that didn’t accomplish much. The matter is finished and ironically, it turns out that I have actually OVERPAID my taxes. I mean that in the legal sense, that I paid more than I was obligated to by law. If we look at in the moral sense, almost all of us overpay our taxes, seeing how the government surreptitiously takes more than a third of every dollar that we make in some way or another through federal tax, state tax, sales tax, property tax, social security, medicaid, disability, and those $1.58 surcharges we see in our cell phone bills. To further interfere with our freedom, the government then goes on to devalue our dollar’s spending power even more by diluting the money supply and contributing to inflation. In order not to get angry thinking about it, I just realize there’s little I can do other than move to a different country. Sadly, neither of the two current major political parties seem to have any interest in reversing this runaway trend. I’ve learned long ago to focus on being grateful for the chance to do something fun and spiritually meaningful every day and not think so much about the unfairness of our over-regulating government.
2. I’ve taken time to make many improvements to our office’s workflow process. This has been very exciting and I’ll share more about this elsewhere.
3. I’m had some exciting welcome distractions in my personal life, for which I’m always grateful.
4. Honestly, I got a little bored of blogging. It’s been close to one year already since I started this site. As it happens often in my life, doing something the same way for a long time leads to my losing interest. However, this type of boredom is GOOD NEWS, as it inspires me to shake things up and try new things. As you may have noticed, I have upgraded the look and feel of this site, and I will continue to do so. I am about to start another blog (more on this later). I also have some other very exciting related projects on the horizon. I don’t want to say too much yet, until I’m ready to deliver!

So please grant me this little break and I promise you’ll see bigger and better things soon!!

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.