By comparison, this woman and this woman make Nadya look like Mother of the Year. I haven’t decided yet what is the solution for preventing grossly irresponsible women from becoming mothers. Any ideas, besides withholding welfare handouts to women until they can prove they are practicing safe contraception? So sad.

I’m OK. Thanks for asking.

It’s good to know that my two-week absence from blogging has elicited such caring inquiries from many of you, asking about my well-being. Now I need to be a bit more honest. I’m actually NOT OK.

Well, to be more precise, I’m just about as OK as anybody else who lives in the United States, or even more specifically, in the state of California, which at the moment, is not that great. For the first time since perhaps the 9/11 incident, I am questioning the security of our way of life. To put things in perspective, if you were to ask me any time in the past five years this question: “How sure are you that in the next year, you, your friends and your neighbors will continue to have adequate food, water, electricity, lines of communication and safety from people with criminal intent?”, I would have thought “Huh? What kind of silly question is that?” and then answered 99%+ sure. After all, we live in modern-day America, not some impoverished third-world country and not in medieval times. However, if you ask me that same question today, I would say that I am only maybe 70% sure. The significance of this difference to me is HUGE.

We have grown to take for granted that we will always have access to food, water and emergency medical care and that we will always be able to count on the police to protect us from criminals. But reality reminds us that we can’t always do that. The two most glaring examples that come to mind are New Orleans during Katrina and LA during the riots. I learned a lot about the reality of life during Katrina during my trip to New Orleans for the ASRM meeting a few years ago. I befriended a taxi driver and some other locals and learned their war stories firsthand. The tales were surreal, giving me a grim reminder of how quickly life as we know it can revert back to the barbaric conditions of the Middle Ages. I’m also reading a fictional book, “The Tin Roof Blowdown“, which contains some of the most gory graphic descriptions of the chaos that occurred during Katrina.

Just as I went into medicine partially out of a burning curiosity about how our bodies work, I love to regularly research psychology, sociology, history and politics to satiate my desire of knowing how the world works, and I am now of the opinion that there is uncertainty, enough uncertainty that I am officially “concerned”.

Bear in mind that I look with amusement upon the globing warning alarmists or the religious zealots who predict the Apocalypse is coming this week or that week. But I am not fanatically ranting that the world will end tomorrow, or even next year. However, let’s just say that based on my own research AND based on what my own eyes see happening in the real world all around me, I know in my heart that this country is headed in the wrong direction.

Prior to this recent revelation, the life for my staff and me consisted of working our hardest for our patients, which for me, meant willingly giving up around 60 hours per week (including many weekends and some late nights) seeing patients, talking to patients, reading up on new advances and blogging. Some friends would feel bad that I worked so hard, but I reminded them that this was my calling in life. The reward of helping people have babies makes it intrinsically fun for me. Also, as a very important added component, in return for my sacrifices, I was shown gratitude by patients, who paid fair financial compensation so that I was now empowered to accomplish my many other goals and leisurely pursuits. It was a very fair system and is basically the American way, or at least, the American way that was originally laid out by the writers of the Constitution. Equally fitting, my patients were out there productively working their hardest using whatever their own talents were to make life better for THEIR customers, patients and clients. And as a result, they were paid adequate compensation so that they could pursue their goals for happiness, which just so happened to include doing medical treatment to have babies. In this system, everybody had the freedom to choose how hard they worked, with the corresponding reward in return.

However, as I mentioned earlier, things are changing for the worse. Now, I, for one, was  glad to see George W. Bush leave office. I disagreed with his specific policies which led to a further shift in the balance from individual freedom to excessive government power. I was optimistically open-minded (but cautiously skeptical) that maybe Obama’s promises of a “change” were more than empty political promises. But, BAM! Out of the gate, like a slap in the face, the new president showed his true self. My friends tire of me reminding them time and time again that we should judge people by their actions and not by their words. Well, the president’s first major action, deceptively called a “stimulus” package, is what he should be judged by, not by his sweet words of promising to make the country a better place for the people. No, I have not read the entire word-by-word rendition of the package. But then again, neither have any of the politicians who voted for it. However, I have studied it enough to render my strong opinion that it has little to do with helping people and more to do with increasing the massively growing domination of political power.

I have an interest in discussing these details in future posts and I plan to do so, even at the risk of you readers eventually telling me “Enough politics already! Get back to writing about fertility!”, but for now, I just wanted to share with you why I have been absent from blogging these past few weeks. I compare my recent world view to that of a not-entirely-unsuspecting New Orleans resident in the few days before Katrina. Sure, the news keeps warning us something bad MIGHT happen. Sure, we can see the wind and skies outside ourselves. But we don’t really know if, when or how hard it will hit. Meanwhile, though, we’re getting ready stockpiling food, setting up emergency generators, boarding up our windows and making contingency plans to get out of New Orleans. So, in this instance, how am I getting ready for a future collapse of this country? By researching and learning so that I can share information with others. Because, unlike a hurricane descending upon us, the upcoming social and economic disaster IS potentially preventable. I am hopeful that we, as a people can wake up and reverse the ever-growing shift from government dominance to individual freedom. We’ll see.

But don’t worry, I’m still practicing medicine. In fact, things have been busy and pregnancies have been coming in bunches (little bunches, not 8-fold bunches) and I still have lots of good stories and insights to share in future posts. I just realize now that we all have to prepare for a potential disaster that I hope will never come.

This bizarre story illustrates how time and time again, turkey basters and alcohol don’t mix.

In the previous post, we introduced the setting, describing what’s going on in Georgia. A trio of politicians are pushing for the adoption of new laws governing what people can do with regards to in-vitro fertilization. Today, we’ll begin dissecting the actual meat of this proposed legislation to see if it really is the best way to prevent cases like the octuplets from ever happening again.

I tried to be open-minded. I really did. But, right away, looking at the very name made me fight with every ounce of energy to avoid rolling my eyes. This act is cited as the “Ethical Treatment of Human Embryos Act”. Ethical treatment of a microscopic cell? I do understand that physical size is not the sole criterion of how significant something is, but it does lead to some amusing perspective to imagine cruelty being done against something that can’t even be seen. A human embryo is smaller than the specks of particles that you stir up when you blow on a dusty old countertop. In fact, you can’t even see an embryo with the naked eye. I can visualize images of torture against human beings in North Korea. I can even imagine people being cruel to a kitten. And of course, there is a tiny part of my humanity that mourns for the life of the little ants, right after I blast them with Raid. But my limited imagination falls short when I try to conjure up images of evil scientists in the lab inflicting pain and suffering on macroscopically invisible entities.

OK OK. So size isn’t everything. One can argue that an embryo can become a golden-haired blue-eyed little girl some day. That’s certainly true. But it’s still a huge fallacy to compare the humanity of an embryo with the humanity of a baby. A sperm CAN become a person someday, if it meets the right egg, but most of them don’t. An egg CAN become a person someday, if it meets the right sperm, but most of them don’t. An embryo (union of sperm and egg) CAN become a person someday, if it is normal and encounters the right environment, but most of them don’t. As somebody who works with this day in and day out, I do not think of an embryo as having constitutional rights. And I take issue with the people who scream, “Eggs, sperm and embryos can’t defend their own dignity, so we have to do it for them.”

OK OK. I know. These people are not screaming for the rights of eggs and sperm (gametes) — only for the embryos that form after the two combine. So if you present these esteemed politicians with a culture dish with an egg in it, I understand they’ll just yawn and say “oh that’s just a fleck of biological dust”. If you then show them a droplet of sperm, they’ll likewise agree “move on, move on, nothing to see here”. However……..(drumroll)…..the moment that the droplet of sperm is added to the dish with the egg in it, these politicians begin having heart palpitations and start drooling and dancing around the dish, ranting about preserving the dignity of the contents of that dish.

OK OK. So maybe I should be a little more serious. Again, I work with this day in and day out. I fully agree with the sanctity of family and of human life. People rely on my labor to help them have little babies. This thrills me without end and gives meaning to my existence. I respect that out of the bodies of the husbands and wives we can take tiny tiny biological cells and put things in motion so that maybe, possibly, one of these combinations MIGHT end up causing a baby to start growing inside the womb (or so we hope), which is why, I immediately become protective when someone starts to impede our mission, and for what? For the purpose of preserving the dignity of an embryo.

The utter ludicrousness of this might be more evident when you consider that were this bill to become law, it would be illegal and punishable, for you to put an embryo dish on the counter at room temperature and allow it to sit long enough to become nonviable. But, (now this is just mind-boggling), if the embryo were transferred into a woman’s uterus and it happened to implant (most of them won’t by the way) and if this implanted embryo were to grow and grow to become a moving fetus with heartbeat and everything. OK, THEN, in the state of Georgia, it would be completely legal to terminate it. How can you argue to give rights of embryos that supercede the rights even of successfully implanted fetuses? Whether we agree with it or not, we live in a country where first trimester terminations are not illegal.

OK OK. I am aware it is very likely that the same people who want to make it illegal to treat embryos “unethically” are also in favor of banning abortion, which raises the obvious question of what’s going on here with this bill. Is it to improve the quality of life for people as a whole? Or is it an indirect way to advance a political agenda? You be the judge. Now many of you may be curious as to my view on abortion. I do have a view. There is a 99%+ chance that no matter what I say about it, somebody from either side of the debate will egregiously misinterpret what I say, and twist it around, so I’ll choose my words judiciously in asserting that I am emphatically OPPOSED to abortion, specifically to the concept of aborting a known healthy fetus that is very likely to be born normal, just for the sole purpose of not having it be born. However, there is a difference between being opposed to something and necessarily thinking that it absolutely must be made illegal. The question is will making abortions illegal stop them from happening, or even lessen their occurrence? What is the tradeoff in harm, if any? I am opposed to murder, rape and abortion (as defined earlier in this paragraph). And I agree that murder and rape should be fully punishable, because if we were to make murder and rape no longer criminal, life would suffer greatly as a whole. The laws against murder and rape don’t prevent them 100%. Every day, these horrible crimes occur. BUT, to make it legal is not only silly, but also would result in things being much much worse. This concept is not as clear-cut when it comes to the matter of making abortion illegal. Criminalizing abortion might make the number of abortions go down somewhat, but cases of deaths or reproductive injury to young women would very likely go up from horrid back-alley procedures. This is more than just a theoretical argument. My beliefs about human behavior along with historical observations convince me of this. So before I get too off topic, I would assert that if I were a politician, I would vigorously enact changes that could lead to fewer abortions. But for me, those changes would be targeted at changing the mindsets of people regarding how much risk they are willing to take when subjecting themselves to the chance of an unwanted pregnancy. In other words, I greatly favor doing what we can to prevent abortions, which I feel could best be done at the level of preventing unwanted pregnancies in the first place. Now as to what policy changes I think would lead to fewer unwanted pregnancies? That’s a whole other lengthy post, maybe for another day.

So after taking this entire post to address the very title of this proposed bill, I’m guessing this is going to take more than two posts to address. Stay tuned as we dissect this further.

The fears of many infertile couples regarding kneejerk government reaction to the octuplets case have now been validated. On February 18, the Georgia senate referred a bill calling for certain restrictions. Here is the official wording. Many thanks to the readers who called this news to my attention.

Before we dissect this, I want to take a moment to remind everyone of one fundamental, indisputable fact of life. PEOPLE MAKE DECISIONS AND TAKE ACTIONS THAT SERVE TO MAKE THEIR OWN LIVES HAPPIER. It sounds ridiculously obvious, but I take the time to mention it because recognition of this universal truth is critical in helping us evaluate the realities of this bill. In an ideal society, the rules are set up so that when people are driven by their own happiness, it also results in the happiness of others. Win/win. Case in point. We may wishfully like to think that the mission of a restaurant owner is to provide the best food and best service for their customers at the cheapest prices. Let’s call this these the IDEAL GOALS. But in reality, from the personal viewpoint of the restaurant owner, his mission is to do maximize his own happiness, plain and simple. Depending on his personal values, that happiness might entail making more money or enhancing the reputation of his establishment (and himself) and/or minimizing the labor, time sacrifice or stress that he has to put into running the place. Usually it’s some balance of all of these. Let’s call these the TRUE GOALS. The beauty of a fairly governed society is that the attainment of the TRUE GOALS are highly dependent on the achievement of the IDEAL GOALS, meaning that in a society where people are free to make their own decisions, the owner can best achieve his goals, by providing a product that is as yummy, pleasant and modestly priced as possible. This will entice patrons to very willingly flock to his restaurant and hand him money. They do this not out of a favor to the owner, but they do it because it is worth it to them to come and enjoy sitting in a romantic environment and consuming prime rib medium-rare, amazing creamed corn, crème brulee and a bottle of fine Merlot.

Now let’s talk about politicians. The THEORETICAL GOAL of a politician is to serve the public, ie make legislative decisions that will enhance the quality of life for the people as a whole. Agreed? However, the TRUE GOAL, in their minds is to get elected, so that they can continue to enjoy the prestige, power and financial perks of their position. There’s nothing wrong with admitting that, because, in an ideally governed country (and I am clearly not so naïve as to think that we live in such), the THEORETICAL GOALS and the TRUE GOALS would go more hand-in-hand, meaning that the more that politicians do to improve the quality of life of the people, the more likely they are to get elected. But in truth, there is a greater disconnect between these two thing in politics than there is with restaurant owners or other free-market based businesses.

Bearing this in mind, let’s ask ourselves what truly motivates politician to introduce new laws? ONE, they are acting with sincerity to improve the quality of life of the people. TWO, they are promoting the illusion of busy-ness to look as if they are actually doing something. THREE, they are maneuvering to give themselves more and more power.

How can we judge which of these things is going on? By dissecting the facts of the situation, we can get clues as to which of these three things is going on.

First of all, let’s ask if this bill was conceived out of careful thought about what legislative changes would make life better for people OR was it just a knee-jerk reaction to a sensational isolated current event. In other words, did the politicians one day, after due diligence of careful homework and thought, conclude, “You know, the taxpayers who elected me really really want more restrictions regarding people’s embryos, above and beyond what the current law provides. By golly, we’re going to give it to them.” OR did they one day say, “This single isolated octuplets incident has really stirred up some emotion. Now, while the iron is hot, is the ideal chance to exploit this anger and outrage to get votes in the future. Hopefully, I can get a bill out of this with my name on it.” So which was it? I clearly know my opinion on it and encourage you to make your own as we consider things further.

The outrage in this case is that it combines two different hot topics - the increasing use of advanced technology to override nature in the arena of human reproduction AND the concept of taxpayers supporting children born to parents who can’t care for them. We can separate these two issues by changing the scenarios and seeing how it changes how we feel.

Imagine if this were a case of octuplets born to Bill and Melinda Gates after fertility treatment, who out of respect for what’s right declare “We would like to thank the doctors and nurses who worked so hard to deliver our babies safely. We know it would be unfair to force anybody else to pay for all that hard work, so we have asked for an itemized bill and have paid every penny ourselves. It’s only right. We have even voluntarily made a generous donation to the hospital. Also, rest assured that we will be working hard to support these babies of ours and not burdening anybody. We will create eight new nanny jobs with full wages and benefits paid out of our own pocket to further help the economy. Thank you for all your letters of congratulation. We have a long road ahead, but will work hard to raise eight children who will be happy, healthy and contribute greatly to society as much as Microsoft has, er with the exception of Vista, of course.”

Now imagine, if this were a case of the theoretical Suleman sisters, five women from the same family who are all single, living off of disability, unemployment, food stamps, welfare and defaulting on their debt. In the past five years, all the sisters, out of their love of having children, decided to keep getting pregnant naturally through various liaisons, and now have given birth to three or four children each, one at a time, without fertility treatment, so that now this lovely family collectively has sixteen fatherless children running around. They clearly intended to have these children deliberately, but they did it without involving doctors, but just persuaded various men with no medical education to inseminate them the old-fashioned way. Now their crowning achievements have given them access to going on the talk show circuit and crying about how difficult it is to be a single mom nowadays.

Each of these two scenarios would create buzz in itself, but the fact that Nadya’s case involves both elements really gives it media sex appeal. And as could be predicted, new legislation has been drafted to address this situation. Bear in mind that there have not been an epidemic of octuplets this past year, nor even quadruplets. Until this case surfaced, reproductive restrictions ranked well below the bottom 5% of today’s concerns.  But all it takes is one case and all of a sudden, there is the sudden NEED for changes to the law. OK. Fine. Let’s assume for a moment that there is such a need. In the next post, let’s look at this bill in detail and see what these proposed changes entail and whether or not they really are the best way to serve their intentions.

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.

To the best of my knowledge, this pregnancy did not involve IVF. There seems to be a lot of news lately involving pregnancies in which the identity of the father is unclear. If any of you are worried how a 13-year old and a 15-year old are going to support a child, rest assured that everything is well-taken care of.

What a coincidence that it happened in a country which is even more of a nanny-state government than the US. Well, than we are so far anyway.

For those wondering what actions our regulatory board is taking, here’s a letter from the esteemed Executive Director of our society that I received yesterday by email:

I am sure all of us have followed with interest and concern the unfolding story of the Suleman octuplets in California. I wanted to take a moment to share with you some of what ASRM and SART have been doing in response.

Our Public Affairs office began taking calls (after business hours on the East Coast) the evening the birth of the octuplets was announced on Wednesday, January 28. In these early days of the story we focused on reminding the media that while the successful delivery of the octuplets was novel, such a high order multiple birth should not be considered a desirable medical outcome.

On Friday January 30th an interview with the children’s grandmother made it appear that IVF treatment had indeed been involved. That morning we released a statement from ASRM President Dale McClure MD. That statement emphasized that we did not have the facts in this case, but that in recent years ASRM and SART had been working very hard, and with a fair amount of success, to reduce the number of high order multiple births. (That statement, and all our press releases are available at www.asrm.org.) By weeks end the Public Affairs Office had responded to well over 100 calls, and ASRM staff and leaders had done dozens of interviews.

Over the course of the next week, the volume of media calls remained very, very high. However, since no new information emerged, the media questions and coverage became increasingly speculative in nature. Because we did not feel it was responsible to engage in that speculation, we began to curtail our responsiveness. Meanwhile, SART sent a communication to its membership seeking any information anyone had on the situation.

As the Today show began to air its interview with the mother on February 6, she indicated all her children were the result of IVF and all from the same physician, and subsequent media reports named the physician. On Monday February 9, ASRM President McClure issued another statement, again emphasizing the field’s success in reducing the number of high order multiples, and indicating we were interested in looking into the matter. On Tuesday, February 10th I sent a letter to the California Medical Board stating our interest in this matter and our willingness to assist them in their inquiry. SART President Elizabeth Ginsburg, MD sent a letter to the physician named in media reports to ask for information about the treatment of this patient.

Examining and learning from both successful and unsuccessful cases is a vital component of medical education and an important tool in improving clinical practice. We are seeking information so that all of us may better understand how to avoid additional extreme high order multiple births. Moreover, we have all worked too hard to improve care and reduce the number of high order multiples to allow one unfortunate outcome to taint the whole field. Both ASRM and SART have membership standards and disciplinary procedures and should the facts warrant, those procedures will be used.

It is important to note that we do not have all the facts. At present I would say we have very little information, and most of what we think we know has come from sometimes conflicting media reports. All of us need to be very cautious before coming to any conclusions. We will keep you  informed as additional information becomes available.

Robert W. Rebar, M.D.

Executive Director

American Society for Reproductive Medicine

The following excerpt from another recent press release shows just how much we, as a society, have accomplished in lowering the risk of high order multiple pregnancies.

We issued our first embryo transfer guidelines in 1996 and began to see a reduction in high-order multiple pregnancies the very next year. According to the CDC, in 1996 7% of fresh, non-donor ART cycles reaching embryo transfer and resulting in a live birth were triplets or more. By 2005, that number had fallen to only 2% of such cycles. This was achieved without hurting the pregnancy rates for our patients. In fact, during the same period, the success rate from fresh non-donor embryo transfers increased from 28% in 1996 to 34.3% in 2005.

I was watching this clip of Nadya Suleman’s interview and noticed a few interesting things. For one thing, I’m not a psychiatrist, but I have a strong suspicion of her having some Axis II psychopathology. What I AM more qualified to comment on are some medical inconsistencies in her statements. In part of this clip, she mentioned that what she did to conceive the octuplets was “the same procedure” as how she got her other six children. BUT, then later on, the narrator of the piece completely says the opposite by stating these eight babies came about as a result of a DIFFERENT procedure. Nadya herself then goes on to support this, saying:
“So then when I did this, I actually was very reluctant, because it wasn’t familiar to me. It was very new. And I thought it wouldn’t work at all. That was pretty ironic because he said ‘Oh No, it’s less invasive and maybe it will work with…you know. it’ll be the same, it SHOULD be the same.’ But we didn’t know.”

Her words are a bit disjointed, but still, what could this mean? I will feel a greater sense of clarity if/when the medical details of this case are corroborated by Dr. K himself. But, I wonder, what did she mean when she said that this procedure wasn’t familiar to her? Could she possibly mean that she had an IUI instead of IVF or FET as she keeps insisting? Again, this is purely conjecture on my part, but I was not alone in initially suspecting IUI rather than IVF in this case. It wasn’t until later when she publicly announced it was FET, that many of my colleagues and I finally backed down on our insistence that this was likely IUI, with its greater unpredictability, rather than a willful controlled transfer of a set number of embryos.

It would take a great number of eggs to bring about eight live births, but there are other stories coming out regarding other patients whom Dr. K allegedly stimulated aggressively. It adds to the mystery the fact that Nadya may have had ectopic pregnancies before. After a tubal pregnancy, sometimes the Fallopian tube on the affected side is completely removed and in other times, it is left intact with just the ectopic pregnancy itself scooped out. In still other cases, the ectopic pregnancy can be treated non-surgically with just medication to stop its growth. So, if one or both of her tubes are gone, it would lower the odds or even eliminate the possibility of this being from IUI.

A reader had commented on few things that didn’t make sense:
He brings still another doctor into this equation, the embryologist. He states that while the ultimate decision to implant six embryos (and remembering that Nadya claims six embryos were implanted each time she became pregnant)was Dr. Kamrava’s, the embryologist is the consulting doctor on the viability of each embryo implanted, the adjective “quality” comes to mind. In last night’s Dateline Nadya stated that her doctor told her that her reproductive system was prematurely aging, that if she wanted to do this, she needed to hurry up.
I’ve read that each cycle the ovaries are hyper-stimulated to produce multiple eggs BUT that there may be few OR many eggs produced each cycle, this does not mean each one is of the quality needed to produce a successful pregnancy.
Since Nadya stated each time six eggs were implanted (and that she was consulted each time it could result in multiple gestations)that would be a total of 36 eggs implanted in her.
That sure doesn’t sound like an aging reproductive system to me.
HOWEVER, in last night’s full Dateline, Nadya claims she had two failed procedures after the twins, one ectopic pregnancy. That would bring the total of all of her procedures to 48 total implanted embryos in one woman! It would also total EIGHT times Nadya had Dr. Kamrava treat her by IVF. Dr. Kamrava CLAIMS that his procedure has eliminated ectopic pregnancies because the embryos are implanted directly into the endometrial lining.
Does any of this make sense?

Let me address some of those issues.

What is the role of the embryologist in deciding how many embryos to transfer?
It is true that the embryologist gives the clinician information about the embryos. This information (along with the patients’ age and history) is what we use to decide the number of embryos to transfer. I have two embryology labs that I work with, so the procedure is a little different at each one. But, generally, before each transfer I meet with the embryologist. He/she will show me a photograph of the embryos as well as a grade and description. We’ll discuss things briefly. Then I sit with the couple and explain to them my recommendation of how many to transfer. Often, I will give them a choice of two options, like 2 vs 3 or maybe 3 vs 4, depending on whether they want to be more aggressive (higher chance of pregnancy) or less aggressive (lower risk of twins/triplets). I DO ask the embryologists for input, but what’s nice is rather than just relying on a verbal description, I have the pictures as well, so I can see for myself. I’m not sure if someone is suggesting that the embryologist be partially at fault in this case? I personally can’t imagine how they could be to blame, because the decision is ultimately that of the physician.

Is it consistent that somebody’s reproductive system is prematurely aging and yet they have enough eggs/embryos to make octuplets? This is highly unlikely. However, I can imagine a scenario with frozen embryos where someone once made a lot of eggs in the past, had their retrieval, had the eggs fertilized and then had the embryos frozen. Years later, their FSH starts to go up, meaning their reproductive system is aging. Then, because of all the “young” embryos saved up from before when their age was less, they now have enough embryos to have many babies.

Can IVF result in ectopic pregnancy? It certainly can. This is very unfortunate. One would think putting embryos in the uterus would result in them staying there. However, it’s reported that about 1% of IVF cases can result in ectopic, only a little less than when compared with getting pregnant naturally. Apparently embryos can move after transfer. In the past, some thought that these ectopic cases were due to inadvertent transfer of the embryos into the wrong place, ie the tube. However, evidence now suggests that even if you make sure to put the embryos in the correct place, it can happen. I’m not talking about the silly hysteroscopic method that Dr. K describes, but rather, ultrasound-guided transfers, which many RE’s have already adopted as an accepted way to improve IVF success. I once had a case where the patient wound up with a healthy baby in the uterus AND a coexisting ectopic pregnancy, after IVF, indicating that one of them must have moved. By the way, my closest RE colleagues and I totally discount the “hysteroscopic implantation into the endometrium” technique advertised by Dr. K.

I’m still hoping that nothing ends up happening that will hinder the many patients who are being managed by us other RE’s as a result of this one doctor’s actions, but I certainly do understand the public’s gut reaction to all this. I feel it myself. I think back to years ago when an elderly driver plowed his car into a crowd of pedestrians, running over several of them. There was a similar uproar that arose demanding that all old people should be banned from driving or at least be subjected to greater scrutiny. And I know how I felt about that.

In closing, I’ll take this opportunity to address the readers who were offended by my entitling my first post on this matter, “Miracle Octuplets“. I truly find the fact that all eight survived to be a medical miracle pulled off by the amazing team of perinatologists at Kaiser. I do not think in any way that this case was positive from a reproductive endocrinology standpoint. Thanks to everyone for the input. The unfortunate infertile couples in the world and I are saddened, alongside the general public, with each new revelation about this case.