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

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

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

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

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

Click here for episode 1

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

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

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

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

Check back for episode 7 when published

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

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

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

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

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

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

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

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

Click here for episode 1

Irene’s testing came back with a positive result, for a test called Lupus Anti-Coagulant (LAC). Instead of being depressed about having something abnormal, she was actually happy, especially when she learned that there was a way to address this problem.

The name, Lupus Anticoagulant, is paradoxically misleading. Most women with Lupus don’t have a positive LAC. Most women with a positive LAC don’t have lupus. Furthermore, it’s not truly an anti-coagulant. In fact, the miscarriage issues stem from it being a PRO-coagulant, meaning it causes excessive blood clotting. One way to think of this is that Irene’s immune system is overachieving. Instead of merely attacking germs and foreign substance invaders to her body, the immune system is also attacking her own cells, leading to unpredictable outcomes, one of which is recurrent pregnancy loss. The important thing to remember is this. Patient with a history of recurrent miscarriage and a positive LAC would most likely benefit from some form of true anticoagulation.

With a focus on the practical implications, we now had a plan. The next time Irene got pregnant, we would give her something to counteract the harmful effects of the positive LAC.

Irene now had the following concrete game plan. She would call us as soon as she missed a period and come in for a pregnancy test. If it was positive, then we would put her on heparin, a blood thinner. We had to also have a backup plan. In case she wasn’t pregnant within six months, we would re-evaluate to see if she would like us to do something to speed things up.

Click here for episode 6

Dear Dr , I have been through each and every section of your website and it
is really very informative for people like us who sometimes wish to know ,
why this treatment , what would it do? It has really encouraged me to ask my
RE politely about various things and treatments she suggests.

My goal is not to make extra work for my colleagues , but there are certainly times in which part of being an RE is communicating with patients and not just being an egg and sperm engineer. I personally get a lot of satisfaction from teaching, not just teaching medical students, but also teaching my patients and my blog readers.

There is this one thing about which I’ll like an opinion from you. I’ll
try to be brief but explanatory about my history , please advise me , I
really need your advice.

My Problems - TTC for 3.5 years now, I am 29 now.
- Irregular periods(since the age of 21, was on provera to get my periods)
- Married at age 25(BCP for 6 months)
- Detected with PCOS, Insulin resistance and hypothyroidism(currently on
metformin 1500 mg, synthroid 50mg) after 6 months of marriage
- Vaginismus - to top all the above problems , I have this, I sometimes
want to run away from this truth but I just cannot , my brain just does not
let my husband in and I don’t know whether we have ever had a successful
intercourse. I had a surgery to remove the hymen which the doctors thought
might be causing pain. I have been able to get all vaginal ultrasounds and
IUIs but I still can’t let him in. I just can’t state my helplesness and
wish somebody could understand it.

Infertility problems are divided into problems of sperm, eggs and anatomy. You haven’t mentioned sperm yet, but the irregular menses suggest an egg problem and the fact that you can’t effectively have sex creates an anatomical problem. Over the course of my practice, I have encountered quite a few married couples who never have sex. There are obviously many emotional implications in addition to the fertility implications. Dyspareunia is the medical term for painful sexual intercourse. This is further divided into deep dyspareunia and superficial dyspareunia depending on if the pain is felt deep in the pelvis or on the skin and surface. Vaginismus is a case of superficial dyspareunia. Your case, while severe is not as severe as those women who can’t even get ultrasounds.

I have been working on my above problems, I started with an aggressive
approach this year when my RE said that inseminations will overcome the
vaginismus factor. I have had 3 IUIs , 2 IUIs with clomid cycles and one
with Injectables. In both the clomid cycles , I had good mature follicles
always on my right ovary on cycle day 18 . The first cycle , I had 3 that
measured 2.1, 1.8 and 1.7 but my lining was only 0.5 cms. Next cycle with
clomid on my right ovary I had only one mature follicle on day 17 of 1.9 cm
and my lining was agin a 0.6. My RE said that clomid is causing the thin
lining and moved me to Injectables with the low dose of 75 IU. I had 5 good
follicles this time on cd12 and they were 1.9, 1.8, 1.8, 1.6, 1.5 and my
lining was 1.07 cms.I had the HCG shot at 12:00 in the night and went for
IUI at 9:30 on cd14.My doctor said the chances are very high and I was
started on progesterone on cd14 itself and on CD21 the progesterone levels
came as 38.3 but I wasn’t pregnant.

My questions
1) Is one IUI enough for me, knowing my situation that aur love making is
not successful , should we go for 2 IUIs in one cycle and if 2 what should
be the timings of them?

This type of detailed variation is an individual choice between the RE and the patient. There is no clear data showing that two IUI’s are that much better than just one. The timing of IUI’s is also a personal judgment call. Many RE’s don’t time it down to the hour, but just schedule it sometime either 1, 2 and/or 3 days after the hCG shot. I like IN GENERAL, to do the IUI about 40 hours after the hCG shot, but it varies especially in patients who have had previous IUI’s in which case you can go back and see what they have done in the past, so as to fine tune the plan for future cycles.

2) can inseminations truly overcome the vaginsimus factor, if so , why do
doctors say to make love that night and the following night ?

IUI’s get the sperm deep inside the uterus. For patients with vaginismus, the sperm often doesn’t even get into the vagina. So, yes, IUI’s are mechanically very effective for overcoming the vaginismus factor. I’m not sure what you mean in your second question. We don’t typically tell that to our IUI patients.

3) Also, I think that I took the HCG shot quite late at night(As in one of
your case studies you said it should be 35 hrs prior to iUI). Please tell me
when should the HCG shot be taken and when should the IUIs be done to have
most chances?

Again, refer to my answer to question #1. It is not set in stone. By the way, please point out where exactly did I said 35 hours for IUI. It might be a mistake. Or are you sure I wasn’t referring to IVF? In that case, it is indeed about 35 hours between hCG and egg retrieval.

3)Also, my RE didn’t do a HSG for me and she wants to do it this cycle, can
I do an HSG and an IUI in the same cycle? Also, as they say HSG improves
fertility , is that true , would that really help?

Yes, it’s possible and often done to have an HSG and an IUI in the same cycle. The drawback is if the HSG shows both tubes to be blocked, then you’ve wasted the ovarian stimulation. In some patients, an HSG does improve pregnancy, both through natural intercourse and through IUI. The thought is that the dye flushes debris and "junk" out of the tubes making them cleaner than ever.

4)If due to vaginismus my chances are very low with IUI,should I just move
to IVF ?

If your only problem is vaginismus, then IUI should overcome it. Bear in mind you might have other problems, such as egg quality issues, if you truly do have PCOS, as you suggested. In general, if the tubes are open, my patients undergo 1-3 cycles of IUI before going on to IVF, but there are so many factors to consider that you had best leave the recommendation up to your own RE.

Thanks
Pia

Click here for episode 1

Irene bravely finished sharing the stories behind her previous four miscarriages. She gathered herself together and we began going down the list of possibilities, searching for a reason to explain her many pregnancy losses, and more importantly, hoping to figure out the right interventions to minimize the chance of a fifth one.

In no particular order, we started by discussing ANATOMICAL causes. A baby needs a certain type of safe environment in which to grow. If the uterine cavity is an abnormal shape, is an abnormal size or if it contains a mass pushing in on it, this can create a suboptimal site of implantation, thereby increasing the odds of miscarriage. In general, for patients with anatomical factors, I’ve seen more pregnancy losses later on in the pregnancy, rather than in the very early first trimester, as Irene’s had been.

Next, we discussed GENETIC causes. Sometimes, a husband or a wife who looks normal, carries what’s called a translocation in their genes. This leads to an increased risk of miscarriage, so that rather than the usual 15% risk of miscarriage for average couples, the couple in question will have over a 60% risk of miscarriage. There is no cure for it, but there are solutions, such as IVF with PGD to help pick the normal embryos. Another choice which is rarely taken is to use someone else’s sperm or egg (depending on which spouse carries the translocation). The strategy I see adopted the most by these couple is just to get pregnant frequently and often so that despite many miscarriages, eventually one will take.

We then discussed INFECTIOUS causes. Some women don’t realize they have a low-level chronic infection that is causing them to have trouble getting pregnant and/or sustaining pregnancies.

We also discussed AUTOIMMUNE / BLOOD CLOTTING issues. I put these two broad areas together in one category, because their treatments are similar. Some people have abnormalities with how their blood clots. If the blood clots TOO easily, then the blood supply to the baby will be compromised as the vessels clot up.

Finally, there are HORMONAL issues. This, too, is a general category as there are many different hormonal abnormalities that can affect miscarriage risk. Not every patients should have all these investigated. There are costs and risks associated with every action, so we need to customize the plan according to what’s best for each individual. The following are the specific conclusions we reached and the decisions we made as a result.

ANATOMICAL: Irene’s regular ultrasound exam looked perfectly normal. I performed it myself. This means there are no whopping obvious anatomical problems. However, in order to see more subtle anatomical lesions, one needs to do either an HSG or a saline-contrast ultrasound, tests which involve putting liquid into the uterus in order to see a clearer contrasting view. So should we get one of those tests? It always depends. Irene’s insurance did not cover the test, which can run anywhere from $500 to 1000 dollars or so depending on the part of the country and the specific radiological facility. Our decision to put off this test was based on the fact that we found something else positive. If we had nothing abnormal in any of the other categories, or if her regular ultrasound had been suspicious, or if it was free for her to get an HSG, then she would have more likely chosen to get it.

GENETIC: This category is tested by getting a karyotype on each partner. This is also an expensive test and wasn’t covered by her insurance. The main reason we did not do this test was because there was nothing we could do if the results came back positive. Irene and Harold were opposed to using donor sperm nor donor eggs, in case one of them came back as having a translocation. They also could not afford to do IVF with PGD at this point. Therefore, we decided not to do a karyotype yet.

INFECTIOUS: Instead of testing for a chronic infection, it turns out to be more practical to just give antibiotics to both partners. First of all the cultures are not very sensitive, so it’s possible for someone to have an infection and for the test to wrongly suggest that they are negative for it. Also, the test turns out to be more expensive than the antibiotics. I prescribed doxycycline 100mg twice daily for both partners. The downside is potential stomach upset for both partners and and potential yeast infection for Irene. There is also the bigger ecological downside of introducing more antibiotic resistance to the world’s bacteria. However, Irene and Harold decided there were perfectly fine with this option.

AUTOIMMUNE / BLOOD CLOTTING: We ordered some tests. Specifically, we checked Lupus Anticoagulant and Anti-Cardiolipin Antibodies. There are the two most common tests. There are other ones such as factor V Leiden, Activated Protein C Resistance, a fasting Homocysteine level and Factor II, but for cost reasons, we held off on those for now.

HORMONAL: After reviewing Irene’s history, we did not order any hormonal tests. For example, if she would have admitted to feeling tired or low-energy, I would have checked her thyroid. If she had evidence of PCOS, I would have checked her for insulin resistance. She did not have anything in her history that warranted any other tests. Irene was scheduled to come back and discuss the results with me in two weeks, by which time everything should be back.

Click here for episode 5

A 61-year old Japanese woman gave birth with the help of her daughter’s donated eggs. She carried the pregnancy for her daughter, who has no uterus.

Because of the patients I get from Japan who come all the way over here to California to do donor egg cycles, I was under the assumption that donor eggs and surrogacy were illegal in Japan. I stand corrected. They are not illegal, but just not conventionally performed by the medical community except by defiant doctors like the one mentioned in this article.

One brilliant relationship psychologist, John Gottman, did an analysis of couples and their communication styles. He was able to find four no-no’s that when present consistently in a couple’s interactions predicted a high likelihood of divorce. I have embraced his findings and I try my best to avoid these four in my interactions with EVERYONE. The four no-no’s are CONTEMPT, CRITICISM, DEFENSIVENESS and STONEWALLING.

Yesterday, I was peripherally watching Olympics coverage with some friends when I overheard the US women’s volleyball players Branagh and Youngs having a “strategy discussion” on the sidelines as they were losing to the Chinese team. They were obviously getting their signals crossed and not playing as a cohesive team. One of them said to her teammate something to the effect that “you need to talk”, expressing that their miscommunication was hurting their play. Her teammate shot back with “I AM talking”. Being the communication guru nerd that I am, I took this chance to share with my friends some comments on the concept of defensiveness.

Defensiveness is one of the bigger communication problems present in our world. To me, I define it as spending more energy protecting oneself rather than really listening to what the other person is saying. You can see why this is a problem for couples. If a wife says to her husband “You never spend enough time with me,” the PROPER useful response is to inquire lovingly into why she feels that way and what he can do to address the problem. However, because those words are usually fired in such an accusatory tone, the most common response from the husband is to defend himself with replies like “What do you mean I don’t spend time with you? I spent all Wednesday night at home and before that, we were at your mother’s all weekend. And I’m with you now. What do you want from me?” But as you can see, while defensiveness is the natural response, it doesn’t lead us down productive pathways.

Once I heard the volleyball players interchange, I was pretty sure they were headed for defeat and that’s exactly what happened, as they had more unforced errors and moments of miscommunication. I would have loved to hear an alternate reply like this.

“You need to talk”.
“OK, you’re right. Let’s do it!”

Such a small simple difference changes the whole tone and feel of the situation.