Tuesday, December 8, 2009

How Does Anyone Have a Baby?

If you are having difficulty getting or staying pregnant, you are not alone. At some point, infertility affects 15% of all couples. Recurrent pregnancy loss affects another 3% of couples.

If you are one of these couples, you may feel isolated and depressed. You will get all sorts of helpful and unhelpful advice from people (including yourself) who really do care. Perhaps one of the worst things someone can tell you is to “relax” or “quit trying so hard.” This advice generally has two effects:

To make you even more tense.

To make you think it’s all your fault.

At Tennessee Reproductive Medicine, we understand the stress that infertility and pregnancy loss causes. While it is true that in extreme cases stress can cause a woman to stop ovulating, very rarely is stress a cause of infertility. If stress isn’t causing the infertility, as so many people commonly think, let’s consider what is normal and abnormal in the world of conception so you can take charge of your fertility. 

Normal Conception Rates
After one year of adequate unprotected intercourse, 85% of couples ages 20-40 will be pregnant. Of the 15% who aren’t pregnant, half of those will be pregnant within the second year. The monthly chance of conceiving among couples in which the woman is less than 32 years old is approximately 20-25%. This illustrates that human reproduction is very INEFFICIENT! It may take some couples many months to conceive and this is within the range of normal. After age 32, monthly conception rates start to decrease slightly, then more significantly after age 35 to about 10-15% chance per month.

When Should I Seek Help Conceiving?
Infertility is considered the lack of conception after 12 months of unprotected regular intercourse (timed adequately during the suspected time of ovulation). All couples who have not conceived after 12 months warrant a full evaluation. While some couples will spontaneously conceive after 12 months of attempts, most will need some form of fertility therapy and further attempts at natural conception may be wasting precious time.

Furthermore, many couples warrant a sooner evaluation if there is a history suggestive of:

-ovulation disorders
-tubal disorders
-male reproduction disorders
-female greater than 35 years old
-female with prior radiation or chemotherapy treatments

Do I need a fertility specialist?
Sometimes this is an easy question to answer, sometimes it's difficult. Consider your situation and conditions by taking this TRM Quiz at http://www.trmbaby.com/welcome/do_I_need_fertility.shtml. If the total number of points equals or exceeds 15 points, and you wish to conceive, strong consideration should be given to seeing a fertility specialist, specifically a reproductive endocrinologist.

Wednesday, November 18, 2009

Interpret With Caution!

It’s been a while since I’ve written anything here. Quite frankly, I’ve been a bit busy, and no topic seemed particularly inspiring. Until yesterday.

I was asked to make a comment for a local television station, WRCB TV3 Eyewitness News, which was running a story on a New York fertility doctor (Dr. Sami David) who says that too many couple use IVF to get pregnant and that many of those couples should try alternate methods first. He notes that his favorite fertility drug is antibiotics.

What I am about to write may at first sound like a preamble to denouncing this doctor’s claims, or like a build up to a defense of IVF.

It really is neither.

The "Caution" Part...

I am saying there is a lot said about fertility and infertility treatments which should be interpreted with caution. In this post I’m going to elaborate on some of the ways any news story you might encounter can be misinterpreted.

This post is also an expansion of what I would have like to have said if the news station actually had the time to air it. My response to the news story was limited to about 8 seconds and the reporter was only able to highlight a couple of sentences of my response. Such is the nature of broadcast journalism. I am very grateful to Channel 3, the NBC affiliate, that they gave me what time they could spare to my point of view. I am also very happy that they put my entire response on their website.

It appears that the story was filmed by a New York affiliate station and sent to local NBC affiliates from the network. Local affiliates could interview local physicians as time permitted. In case the link above does not work, I’ll give you the skinny on the news story:

Dr. Sami David performed the first IVF procedure in New York and he has not done one since that time. He says that IVF has a high failure rate and that many people who resort to IVF could get pregnant without it. He said doctors need to pay more attention to treating the man and looking for not-so-obvious causes of infertility and treat those causes. The story illustrates the proof of this concept by interviewing a woman who went through three IVF cycles but miscarried all three times. She then saw Dr. David, conceived and now, happily, has a child. Dr. David has now written a book explaining much of this. It is called Making Babies.

Unavoidable Bias

There are several inherent and hard to avoid biases in stories like this. For example, simply by saying Dr. David is offering an alternative, this does not mean many people in our field aren’t also incorporating some of the same treatments. Much of what Dr. David promotes and what your typical fertility would promote will be similar. The implication is that most fertility doctors push a lot of people to IVF.

As a matter of fact, fewer than 10% of our patients ever require IVF. Dr. Scotchie and I try very hard to use IVF as a last resort.

Another unavoidable bias is that simply by reporting this story, makes the information seem like its new. Just because this story is in the news, this does not make it new. The reason Dr. David is in the news is not because of remarkable success rates. The reason he is in the news is because he has written a book. He is promoting the book and he seems to be doing a good job with that. By saying this, I’m not trying to imply that Dr. David wrote this only to promote his practice and to make money. I have not read the book, but until I see proof otherwise, I’ll assume that he wrote it to get the word out that for some people, there are alternatives to IVF. Quite frankly, if I were a reporter, I’d be inclined to write a story about it, because there people who would be interested in it.

My First Thought

My first thought upon hearing what Dr. Sami has to say is: I agree that some people get thrust into IVF too quickly. I think some doctors don’t do enough investigation to find out if there is a treatable cause. This is especially true of male factor infertility. I know this because I get to review a lot of medical records as a second opinion, and not just from Tennessee or the surrounding areas. Friends from all over the country refer their friends to me to give them my assessment.

Doctors are partly to blame, and there are various reasons for this. High tech treatments do generate more income for the practice than low tech treatments. Also, high tech treatments are generally far more likely to be successful than low tech treatments. A pregnant patient is usually a very satisfied patient. It makes the patient feel good. It makes the doctor feel good.

It can be difficult for patients to know if a doctor is pushing you too quickly into IVF. Second opinions can be valuable here. However… CAUTION must be exercised when getting a second opinion. (I promise to write about this VERY soon. But this is too big a topic to tackle here.)

Sometimes the doctors push for IVF too quickly and, truthfully, sometimes the patients push themselves into IVF before they’ve tried all other reasonable options.

My Biggest Fear

My biggest fear about this story is that there would be people who would interpret Dr. David’s message in a way that would cause them to delay seeking the advice of a fertility specialist.

I worry especially about women approaching their mid- to late-30s who spend several years trying on their own, or using herbal or homeopathic remedies. By the time they reach my office, they have significantly decreased chances of conceiving due to age, or due to the limited number of remaining reproductive years with which to attempt pregnancy.

Despite treatment, it can take some couples years to conceive. I should know. My wife and I were one of those couples.

Dangers of Interpreting Success

It is sometimes hard for doctors to know if it was treatment or time which cured a patient.

I am careful to counsel my patients that I may not know if it was our treatment which helped them conceive. In some cases, all we can say is that we increased the odds of conception in a given month.

It is a happy reality of my practice that some patients will conceive spontaneously before, between or after an infertility treatment.

In cases when patients get pregnant between treatments, patients usually understand that they did not conceive due to treatment. I will know it, too.

Some practitioners have a difficult time in knowing if a patient got pregnant because of treatment or simply because it was a patient’s time to conceive. For example: Suppose I am a doctor who gives everyone an antibiotic or an herbal remedy. A portion of my patients would have conceived anyway. But since all of my patients are “under treatment” at all times, I would be likely to think that the therapy was what made the difference. The patient would think so, too.

Under a lot of alternative regimens, patients are always technically in treatment. In these cases, it can be very difficult to know what actually caused the pregnancy. In my experience, the assumption of the practitioner and the patient is to give credit to the treatment.

In certain situations, I downplay my role to patients. Still, when they get pregnant, they give me the credit, even when it’s more likely that I was not the difference maker.


If I do surgery on 12 infertility patients and remove low-grade endometriosis and then do no other treatments, studies have shown that 3 of them will get pregnant within the next 12 months. All three who conceive say “the surgery worked” and that’s why they got pregnant. All three give me the credit.

The truth is, if I had not done surgery, 2 of the 12 would have conceived on their own.

This means, I must do 12 surgeries to get one additional pregnancy than doing nothing. This is called number needed to treat, NNT, to get 1 different outcome.

I tell patients this beforehand. Still, EVERY single patient who has gotten pregnant after surgery remarks something like, “The surgery worked!”

I usually say something like, “Maybe, there’s a 33% chance that it did.”

This example illustrates the point that doctors and patients can be very likely to give or accept credit more often than deserved.

Even when it is more probable that my intervention had something to do with the pregnancy, I am careful to counsel patients that the only thing we did was increase the chance.

For Example:

If I do an intrauterine insemination (IUI) on a patient and the patient gets pregnant, I cannot always say that the pregnancy was due to the procedure or due to intercourse that she and her partner had a few days earlier. All I know is that the IUI increased their chances of conception that month.

The news story used an example of a patient to represent Dr. David's success. In this example, the patient had failed to have a baby after three IVF attempts. She was then treated by Dr. David, and after an unspecified amount of time, she got pregnant. Did Dr. David's treatment get her pregnant? Or was it just her time to succeed? Clearly both the doctor and the patient have given him the credit. In all honesty, neither of them could possibly know.

I am wary when anecdotes are used as evidence that a treatment is successful. It does not mean I don’t try some of those same treatments myself, but both the patient and I must still be wary about interpreting the results.

My Final Thought

I’m sure there is a lot more I could write. But my wife is cleaning the house for family members of mine that are arriving from out of town, and it seems somehow wrong that she is doing all of the work, so I’ll leave it at this.

I have not read Dr. David’s book, yet. My suspicion is that I will agree much more than disagree with it. I do think it is very sensible to not turn your back on any practical ways to improve your ability to conceive.

There are many recommendations out there for stress reduction, optimal supplements, exercise, sexual positions. I’ll try to address some of these issues in future blogs.

I think I’ll write about the pitfalls of second opinions next.

But first, I have to mop.

Tuesday, August 11, 2009

What to expect when you're not expecting - or, the slow erosion.

Infertility can make you crazy.

In some previous posts, I discussed how the advice from others can contribute to a sense of anxiety. What we in the world of medicine must also acknowledge is that the infertility investigation and treatment can also be maddening.

Couples embarking down this path need to be prepared for the emotional landmines that can occur. While many couples have very different causes of infertility or may get different treatments, they do share many of the same frustrations.

How it begins:
The first maddening aspect of infertility is that getting pregnant should not be difficult. After all, some people get pregnant with a single act of intercourse. Teenagers get pregnant…. some more than once. Women on the pill get pregnant. We hear women say, “He’d just walk by me and I’d get pregnant.”

So it’s frustrating to have difficulty in an area that seems to be easy for most people. This frustration can turn into guilt, hopelessness, a sense of inadequacy, a sense of injustice, sorrow or anger… or all of them at once.

How it perpetuates:
To get control of the situation, many women start monitoring their menstrual cycles. She and her husband have sex when the calendar tells them to. (Fun at first…. but this can lead to a loss of intimacy.)

Other couples seek the advice of physicians. For many couples, the problem resolves here… problem is found and fixed… medicine is taken… pregnancy happens. But if you’re not one of those fortunate couples, the sense of inadequacy grows, as does a sense of anxiety.

I’ve been on both sides of the desk on this. When my wife and I started seeing doctors to try to get pregnant, it seems every time we had an appointment, we received more bad news.:

“You’re not ovulating…”
“You did not ovulate with the medicine”
“Your tubes are damaged.”
“We tried to fix your tubes, but they’re damaged beyond repair.”
“You need IVF.”
“We got 25 eggs. Half fertilized. Only 5 are still growing.”
“You’re not pregnant.”


Then there those times when the news it at first good, but then turns bad.

Early on, before each IVF cycle, we were told that we were excellent prognosis, but with each attempt, we had the same outcome - failure.

Then there was the time we finally got pregnant. My wife's hormone levels were rising wonderfully. I will never forget the serenity that took over me and my wife at this point. I remember going to the driving range and hitting golf balls while she read “What to Expect While You’re Expecting.” We had 2 weeks of unbridled bliss.

Then, my wife started to experience pain. A friend performed an ultrasound, and where we should have seen an embryo, there was just the smallest amount of fluid in the uterus. Over the next few days, the pain escalated and finally she saw her doctor. She was still in pain, but that didn’t matter. Her emotions soared as he performed her ultrasound. He saw the baby. He showed it to her. It looked normal. It had a robust heart beat and little arm buds. He was saying everything looked good when his assistant tapped him on the shoulder and whispered something. Suddenly the doctor stopped talking and looked closer at the screen. He scanned for a moment, and then looked at my wife.

The other shoe dropped.

It seemed that this perfectly formed baby, with a robust heart beat was not in the uterus, but in the fallopian tube.

Within 3 weeks, we had been taken from the heights of happiness to a breathless sorrow. It was so cruel to be given hope, only to have it taken away. In our hearts, we knew there was nothing wrong with that baby. It was a victim of geography.

The loss of that child has changed me forever. Whenever my wife and I talk of that time, we are crushed. And when I see someone else who is losing a pregnancy or a child, I am swept back in time and feel a rent in my soul.

This is how life was for us. We were given hope. Then hope was dashed.

Still, by some accounts, my wife and I had it easy. There are couples who don’t have infertility at all, but suffer repetitive pregnancy losses. There are couple’s who have identified problems, but lack the financial means to undertake treatment. Then there are those 10% of couples in whom we can find nothing wrong. This can be especially frustrating for them.

There are many roads to the madhouse. Many infertility patients will find themselves on that road. For some, it can ruin a marriage, or enjoyment in life. For some people, the trauma suffered from infertility is not completely healed by getting pregnant or even having a baby.

Infertility patients are likely to be more worried about things going wrong in pregnancy than someone who never had trouble conceiving. I see this in patients, and it was true for me and my wife. If you've gone through a lot to get pregnant, if you've suffered many disappointments, you just simply feel like the pregnancy is high risk. You keep waiting for the other shoe to drop. You've been trained to know that it will.

In my final year of Ob/Gyn residency, when my wife were at what we thought was the end of our IVF journey (we were going to try one last cycle), we got pregnant. At the time a woman misses her menses, the average hCG level is supposed to be around 90mIU/ml. My wife's was 53. We were told that this was okay in an IVF cycle, but we were still deeply concerned. In two days, the hormone did rise as it was supposed to. Two days later, it doubled again.

It was an agonising 2 weeks until our first ultrasound. We were trying to be cautiously optimistic (which, as an aside, never actually worked for us.) I'll never forget how scared both of us were, waiting for our physician to enter the room to perform the ultrasound. Finally, once the scan began, the doctor was quiet what seemed like an eternity. I was looking closely at the monitor, but couldn't see very well from my vantage point.

She withdrew the transducer and put it aside and told us: the embryo was only half the size it should be and it didn't have a heart beat. She recommended returning after the weekend to confirm that the pregnancy was not viable. She said it wasn't hopeless, that sometimes embryos play "catch up," but the truth was all over her face. She was clearly in pain when she said this to us.

I will say without shame that my wife and I broke down. I tried to go back to work, but seeing the condition I was in, my friends volunteered to cover my shift on labor and delivery. I went home. I was badly shaken and felt absolutely abandoned. There was so little hope. Every time I had grasped at hope, I had come up empty.

Fortunately, friends around us had not given up. It's almost like they willed our outcome to be different. When I returned home, Robert Strauss (a mentor and friend at UNC Hospitals) called me and said that he just didn't believe that we didn't have a heartbeat. He said that he would be on call tomorrow and that he wanted me and my wife to come back in and get an ultrasound on the high resolution machine then.

The next morning, we got the scan with Dr. Strauss. The embryo was normal size. There was a heartbeat. A Niagara of relief and thankfulness crashed upon us.

Within days, we once again had been taken on an emotional roller coaster, and now we were on the uphill again.

Of course none of this made me less nervous. It seemed that the very earth beneath our dreams was so fragile. After that, about 3 times per week, my wife came to the hospital where I would do an ultrasound on her. We were almost paralyzed with fear before each scan.

Despite now having a pregnancy on its way, my wife could not give up her progesterone shots and I could not let go of my sense of dread.

I could not give it up until the day I called Jenifer Behrins, a friend of mine who had 4 children but had suffered severely in each pregnancy from intractable nausea and vomiting and multiple hospital admissions. I confided my fears to her. I told her how worried I was, despite how well everything was going. She listened while I spoke, then paused. Then she gave me some of the best advice I've ever received. I share her advice with nearly all my newly pregnant patients who I imagine feel much like I did about our pregnancy.

Jenifer said, "You need to enjoy this. You never know what's going to happen. You need to enjoy every moment of your pregnancy. You need to enjoy every moment of that child's life. Don't worry if he's doing everything he should be, what stage he's at, if he's advanced, or if he's slow.... just enjoy it. Enjoy every stage for what it is, because you never know for sure that you'll get another stage. You never know what the future holds."

To someone else, her advice may have seemed someone dark and pessimistic. To me, it was liberating. She gave me permission to celebrate the here and now. I realized that if I didn't enjoy the small blessings, I might not ever enjoy the big ones. It was my first step out of the madhouse.

I know not all patients enter this madhouse I allude to. Some people weather this much better than I did. I envy them. I don't know if this experience makes me a better doctor, but I'd like to think it does. I do know that it feels very personal to me when a patient does not get pregnant or has a loss. Those old emotions are like live wires, hidden just below the surface.

I know my experience affects some things that I do. When I do an ultrasound for a heartbeat, I look for the heartbeat and tell the patient as soon as I see it. With that out of the way, I go about my measurements.

I've also realized that infertility doctors can make you feel very high risk, especially if we bring you back for ultrasounds every week of the first trimester. It's a double edge sword. On the one hand, seeing an embryo grow everyweek is reassuring. On the other hand, if I bring patients back every week, it can make them feel like things are more in perile than they actually are.

The truth of the matter is this: as long as things are going well and there is no bleeding or history of recurrent pregnancy loss, once you see a normal heartbeat, the miscarriage rate drops dramatically. For most women under 35 years old, once you see a heartbeat, the miscarriage rate is about 4-7%.

The sad truth for me is that the sooner I get a patient back to her doctor, the more likely she is to feel like a normally pregnant woman. For sure, it can be hard for me to let go. It can be hard for her to let go, too. In the end, it's what we all must do, and we're all better off for it.

Wednesday, July 1, 2009

Playing God - Part 2 and Part 3

The Pope and I are having a disagreement. Not a full-fledged brawl. But it’s a fight. And quite frankly, I’m a bit peeved at him. He is opposed to not only what I do for a living, but to how I conceived my children. He says I’ve violated their rights.

You read correctly. Pope Benedict XVI says my wife and I have violated my children’s rights by conceiving them the way we did.

I know this from his writings that are available through the Vatican Web site. This would probably bother me a lot, if I were Catholic. As a Presbyterian, I can be a bit more, well, philosophical.

Before he became the Pope, in 1987 Cardinal Joesph Ratzinger was the principle author of the Catholic Church’s position statement on treatments for infertility. I wanted to see how the Church justified its opposition to IVF, so I read it. The paper is titled, “Respect for Human Life” and is also known as the “Donum Vitae.” Translated literally, the Donum Vitae means the “gift of life.”

I was shocked by what I read. It wasn’t the conclusions that surprised me, but the rational and the basis for the rationale. At a minimum, I expected a scripturally-based argument. But it was (and is) not.

All told there are 64 references in this paper. Of these 64 references, only three are biblical passages. The remaining references are Papal and other Vatican writings.

The first quoted scripture noted that man should have dominion over earth. (I thought this sounded like an argument for IVF.) The other two scriptures said we should value life:

God created man in his own image and likeness: "male and female he created them, entrusting to them the task of "having dominion over the earth" (Gn. 1:27-28).

In the light of the truth about the gift of human life and in the light of the moral principles which flow from that truth, everyone is invited to act in the area of responsibility proper to each and, like the good Samaritan, to recognize as a neighbor even the littlest among the children of men (cf. Lk. 10:29-37). Here Christ's words find a new and particular echo: "What you do to one of the least of my brethren, you do unto me" (Mt. 25:40).

If that were all there was to the Donum Vitae, we would not really have an argument.

I agree that man, scripturally and by default, does have dominion over the earth. I also think we should value human life.

So exactly what is my beef with the Donum Vitae?

First let’s look at some of the declarations made by the Donum Vitae, then we’ll discuss them. I’ve paraphrased some of what comes below, because much of what the Church declares is obfuscated in ornate language (like this sentence.). The Donum Vitae says:

  1. The child has the right to be conceived, carried in the womb, brought into the world and brought up within marriage and from marriage.

  2. Donor insemination is immoral because it violates the rights of the child; it deprives him of his filial relationships with his parental origins and can hinder the maturing of his personal identity. Donor insemination is also wrong because it violates the child’s right to be conceived and brought into the world in marriage and from marriage.

  3. Donor eggs are immoral for the same reasons as donor sperm.

  4. Masturbation to achieve sperm is immoral.

  5. Artificial insemination is permissible only when the procedure is not a substitute for the sexual act but instead facilitates the sexual act to have a child.

  6. Fertilization achieved outside the body is immoral.

  7. The freezing of embryos is immoral because an embryo may not survive and it deprives them temporarily “of maternal shelter and gestation, thus placing them in a situation in which further offenses and manipulation are possible.”

  8. Life begins at conception.

Of course there is much more in the Donum Vitae about genetic testing and scientific research. I’m not going to focus on those issues during this entry, mainly because it would take too long, and only a small fraction of patients ever opt for these treatments.

Life Begins at Conception

The overriding issue addressed by the Donum Vitae is respect for human life. A key question is when does life begin? A reasonable position is the Church's position: life begins at conception. After all, an embryo is human; an embryo is alive. This is a reasonable assumption.

Others might argue that life begins in the sperm and the egg before fertilization. After all, the sperm and egg are both human, and both alive. Of course, we could argue that neither is a complete being.

So is an embryo a complete being? It usually has the genetic material to become one. But clearly an embryo is vastly different from a fetus, which is vastly different than a child, which is different from an adult. All are human. All are alive.

At what point does an embryo become a human life?

I would contend that if life is a gift from God then no matter the level of intervention, man cannot create life.

For example: in the lab, we cannot force a sperm to fertilize and egg. We cannot force the embryo to grow. We cannot force the embryo to implant in the uterus and to prosper. If we could do these things, our success rate would be 100%. As a specialty, we fall woefully short of this. All we can do in the lab is to create situations where fertilization is more likely, statistically. We can nuture embryos to the best of our abilities. But we cannot create a baby. Way too much is out of our control. This is at once humbling and reassuring to me.

It’s conceptually easy to believe that the human soul enters the embryo at the time of conception. After all, an embryo is alive. An embryo is human. Of course, these two points don’t make it a human being, no more than a fetus is a child, or a child is an adult. These are all points on a continuum and we don’t have the real ability to say when someone leaves childhood and becomes an adult. All we have are conventions. One convention says we become an adult at age 16, when we can drive. Another says 18, when we can vote. Another 21, when we can drink. Another 24, when we can rent an RV (at some rental shops in Colorado.)

I say all of this to show that it is convention to say that life begins at conception. Quite frankly that is how I have always, and continue to look at it.

But what if I’m wrong. If God is the giver of life, then when does He give an embryo a soul? Does this happen at the moment of conception? If so, then why are 50% of naturally achieved pregnancies lost prior to the onset of menses and the woman never knows she was pregnant? What would be the purpose of this? The truth is, we cannot know. The best we can do is to make our own assumptions. I look at it this way: an embryo is alive and it is human, but I know it’s not a child – yet. It is a potential child. For this reason, I would not elect to destroy my embryos.

This brings us to statement number 7, that Egg Freezing is immoral. The Church’s argument against egg freezing is that it places the embryo at risk and deprives it of maternal shelter. My response to this is that twin, triplet and quadruplet pregnancies can all do the same thing. High order gestations can create an environment that is unsuitable to sustain a pregnancy or might cause harm to the unborn child.

If I am creating embryos with IVF and not all of the embryos will be used, some of them might die if I freeze and thaw them. I am not trying to dispose of them. Rather, I am giving them a chance at life that they didn’t otherwise have. I am also maximizing their chance of having a safe pregnancy.

New freezing techniques are not perfect, but very few embryos are lost. Those that are lost, the intent is not to kill them, it is to save them so that they can be used. Yes, we place embryos at risk. How is this much different from a woman who is high risk for pregnancy who decides to conceive naturally? These pregnancies can be lost, too. Did she do something wrong? According to the Donum Vitae, this woman should not use contraception either.

Statement 6, saying that fertilization is immoral if it occurs outside the body. I don’t quite know what to say here, except, “According to whom?” Obviously, this is not in the Bible, so it is difficult to make a scripturally based argument against this. I think suitable scriptures to argue against the Church would be: “Man shall have dominion over the earth” and “Be fruitful and multiply.”

Statement 5, limiting the use of artificial insemination. Though the Donum Vitae doesn’t say this implicitly, this implies you can use a condom that has a small hole in it to allow some sperm to escape during sex, but you can then recover much of the sperm from the condom and use it for artificial insemination.

I at once welcome this exception, and yet I see the hypocrisy in it. The Donum Vitae is very clear that a child should be born of sexual relations between a man and wife. If the purpose of the sex is really to get sperm for IUI, rather than the IUI assisting the sex, it’s more likely that the sex act is assisting the IUI.

Statement 4, masturbation is immoral because the Church says so. No scripture is quoted to support this claim. I have looked for Biblical references on this. There is a lot about lust. Masterbation is not mentioned. So if lust is removed, then I see little to say this is wrong, espeically if it is being done to "be fruitful and multiply."

The story of Onan is commonly used to promote the idea that masterbation is wrong. However, as noted below, Onan's sin was not "spilling his seed" per se, but disobeying his father by refusing to help his dead brother's wife conceive a child.

Admittedly, we can get sperm from a Catholic-Safe Condom (one with holes in it); however, the results are less reliable.

Statements 2 & 3, donor egg and sperm are immoral because they deprive the child of its right to be conceived in the womb and of and from marriage. The reasons given by the Church have no basis in Biblical teaching. I hope I don’t go to Hell for what I am about to say, but even Jesus was conceived out of wedlock with 3rd party reproduction. Mary had the ultimate donor!

There is also reference to donor sperm, in Genesis. Onan was commanded to impregnate his dead brother’s wife, so that the brother’s clan line could be continued. When he refused to complete the act of sex and spilled his seed upon the ground, he was killed.

Onan was killed for disobeying the command to partake in the Biblical era's version of artificial insemination. He disobeyed his father and was killed for it.

One area where the Catholic Church and I can agree is that there is danger to this sort of reproduction. One of the ethical concerns with 3rd party reproduction is that children may grow up with a sense of loss if they do not know their genetic parents. This can be especially frustrating if it is thought that the parent is still alive and does not know.

It is in our nature to blame our anxiety on our circumstance in life. For example, if I were a minority and got bad service at a restaurant, I might wonder if it was the color of my skin. Or if I were a woman passed over for promotion so that a slightly less qualified man could be hired, then I might assume race or gender discrimination was a factor. Similarly, if a child is born from donor egg and sperm, he or she is also at risk for blaming the troubles in life on the fact that the biologic parent is unknown.

This is a very legitimate concern and while not all offspring suffer this, it is important to be aware of this potential problem prior to using donor eggs and sperm.

Statement 1, a child has the right to be conceived within the womb and born of and from marriage. I do not see this written anywhere that this is a child’s right. However, this has been frowned upon in the scriptures and through the ages. Jesus was sometimes referred to by Jews who opposed him as, “The Son of Mary,” meaning he was born out of wedlock.

I do believe that the best environment in which to be raised is in a loving home. I want there to be a mother and father in the house because this was how I was raised.

Final thoughts....

I think much of the debate around the Donum Vitae surrounds what is "natural." God's laws and natural laws are often seen as the same. But to say that an IVF baby was conceived unnaturally is to say that we are above God's laws, above nature. As a human, I am part of nature. Everything I do is part of nature. Kevlar is a natural product if man made it.

It is the hieght of vanity to assume that what man has made is above or outside of nature.

To an automobile is unatural is to say an anthill is unatural. The anthill was constructed. It's primitive, but constructed.

So my children, conceived with IVF were not conceived outside of nature. They were and are the product of a loving, committed relationship.

So, I did not violate my children's rights through their conception with IVF. The Pope owes me, and them, an apology.

I won't hold my breath waiting.

Thursday, June 25, 2009

Playing God - Part 1

A few weeks ago, before an embryo transfer, my embryologist recited a Bible verse to me that she had given to my patient. The patient, had written down this verse on a scrap of paper and was taking it into the room to get her embryo transfer.

When Shan recited this verse and told me that the patient was carrying it, I felt a lump in my throat, a lump that is usually associated with great sorrow, or overwhelming joy and relief.

"That's strange," I thought and wondered why it made me feel so unexpectedly emotional.

It was like an aroma that transports you back in time, to a specific place, by-passing the normal circuits of memory. I was at once filled with specific and vague memories and feelings of joy, despair, love, shame and remorse. It was a tidal wave of regret and gratitude.

It reminded me of how small we are compared to the forces at work in the universe.

Despite my religious upbringing, I honestly could not recall ever seeing that verse. More likely, I hadn't been prepared to see it before.

It's humbling to realize that this was there all along, and it sums up something that took me years to understand.

So what was the verse?

1st Corinthians 2:9, "No eye has seen, no ear has heard, no mind has conceived what God has prepared for those who love him."

With that, let me get to the actual blog entry.

What I am about to write is not something just for people with a religious inclination. I think even an atheist will fall prey to some of the thinking that I talk about in this entry. If nothing else, perhaps it will help somebody else understand how another person feels (and fears). So hopefully, this entry will be of benefit to everybody.


When I was an Ob/Gyn resident, I told a nurse that I wanted to be a Reproductive Endocrinologist. As she looked back at me, a look of disgust spread across her face. “Why would you want to do THAT?” she asked. “It’s so immoral. It’s playing God.”

She proceeded to lecture me along these lines for several minutes before finally concluding that if people weren’t meant to have kids, then they should not have them and they had no right to be parents.

I asked her if she thought that my wife and I should not be allowed to have children.

“I didn’t say that,” she said.

“Yes, you did,” I told her.

This exchange allowed us to have what is sometimes called a teachable moment. Probably for the first time in her life, she saw what she said in context of an actual human being rather than a person on paper or in her imagination.

I told her that I didn’t know what God intended for my life. Despite using all the technology available to us, my wife and I had not conceived. Was this punishment for trying to play God? I had no way of knowing. But I did know this, no matter what I did, if God did not want me to have children this way, then my wife and I would be childless.

I think her mind changed that night. What changed it was not an argument, but a realization.

As my wife and I struggled with infertility, we wished there were clear signs telling us what we were supposed to do. Were we supposed to just stop? Or were we supposed to take advantage of all the treatment that God put before us? Was IVF a path to the garden? Or was it the forbidden fruit?

With each failure, in the midst of each great sorrow, we asked the same questions again… what were we supposed to do? Were we being sinful, or prideful wanting to have children that were biologically related to us? Were we following God’s commandment? Or were we pushing our wishes ahead of God’s will?

In the absence of signs, we persevered. We knew only one thing for sure: if we did not try, we would not conceive we would regret our decision later.

I personally have not met any patients who I thought were trying to play God. I’ve met people suffering from infertility, people like me and my wife, struggling to understand the plan, if any, for our lives.

Wednesday, June 17, 2009

The Unspeakable Truth

It was something we didn’t talk about.

Because we were both secretly ashamed of it, my wife and I didn’t admit it to each other. We barely wanted to admit it to ourselves. We certainly didn’t discuss it with even our best friends – some of whom may be reading this now.

And before I go on, let me say that I believe what I am about to tell you says much more about me and my wife than it does about our friends. At the same time, what I am about to describe is a nearly universal experience for couples with long-standing infertility.

So here goes.

When we were struggling to get pregnant and if you got pregnant… we hated you.

It’s true. (Though my wife denies this, officially.)

We hated you because you were so happy. We hated you because you didn’t want to tell us you were pregnant, because you didn’t want to hurt our feelings. We hated you because we felt abandoned. It was one more reminder that we were relatively alone in this predicament.

It was even hard to feel happy for other infertile couples who finally conceived. When they got pregnant we felt even greater abandonment.

Now there were times when I tried to soften this word, tried to work around it and redefine it. I’d call it anger at our situation. I’d call it envy, jealousy, resentment, spite…

But in the end, all those words and all those emotions still felt the same… they felt like hate or some other withering emotion.

And like hate, this emotion took much more of a toll on me and my wife than it did our friends.

In fact, I’m not sure anyone ever knew how we felt. My wife hosted baby showers for friends, visited new mothers in the hospital, held new babies and marveled at them.

So no, we weren’t totally consumed by these negative emotions, but they were always there… like a slacker college roommate who never left the couch. While our friends were largely unaware, we had to live with the negative emotion. We had to secretly wonder what it said about us. In some ways it was further confirmation that we were just bad people.

In talking to patients, I’ve come to realize how common these feelings are. With rare exception, patients have confessed that they feel this way, too. Nearly always, the patients are racked by guilt over these feelings. They think they are being petty and spiteful. They think they are terrible people because of it.

I tried to talk my way around these feelings, to shun them, to shut them out. But I have to confess, it was only after I could openly admit my feelings that I could begin to work through them.

These feelings were nothing, if not humbling. They were a reminder of my imperfection. But knowing how common these feelings are, knowing how imperfect so many of us are has also given me comfort.

Perhaps that’s why I’m so willing to share my experience with my patients. I can see the visible relief on their faces when I confess this story.

I give them permission to be angry. I am hoping they have the same experience I did: by embracing the pain, it starts to ease.

Jim Benton, author of the very funny “Happy Bunny” series writes: “Hate is a special kind of love we give to people who suck.”

Tuesday, June 16, 2009


If you are like me and my wife, most of the time you’ve got things pretty well covered. The world seems to run better when you’re in charge, and for the most part, things go your way.

I think that’s partly why the diagnosis of infertility was so frustrating to us. It seemed like everything about it was out of our control. To make matters worse, a lot of current medical advice encouraged patients to educate themselves about their condition. While this is a good concept, it has a major pitfall: mainly, it gives you the sense that you do have more control over the situation than you actually do.

The more we tried to gain control of it, the more elusive getting pregnant became. The more frustrated we became.

This frustration and desire for control had many implications. I saw this as a patient and I continue to see this as a doctor.

The first casualty in this quest for control was our self esteem.

Getting pregnant was so easy for other people. We could not go to the mall or the grocery store without feeling like we had stumbled into a stroller stampede. Happy mothers and families were everywhere.

If it was so easy for them, then something was wrong with us. We had a sense that we were somehow not worthy, or that we were being punished.

To make matters worse, during much of our journey, I was an Ob/Gyn resident. Daily, I cared for couples who seemed to take their fertility for granted. I saw women (drug addicts, alcoholic) who made very unhealthy choices for their pregnancies. I saw 13 year old girls who thought that pregnancy was a perfectly normal part of adolescence.

It made me wonder what sin I had committed to make me unworthy of being a father.

This blame made us somehow doubt that any treatment would work. Success seemed so far away.

This blame skewed our ability to interpret what the doctors told us. When we were told that an individual treatment would have a 15% chance of working we somehow focused on that 15% only. That 15% received 100% of our attention. So when the most likely thing happened -- we did not conceive -- our disappointment was out of proportion to what our actual chances had been. We thought each failure was an indictment, or a failure of the doctor.

As I sit here and write this, there are so many tangential directions I could go explore. There are so many examples of how we gradually lost trust that we would ever conceive, but I won’t elaborate on them right now.

I can say that I think I know what kept us going.

First, we kept trying because despite each failure, we would have regretted not trying one more time.

Second, I knew I was not yet ready to adopt. At that time in my life, it seemed like "second best". And as long as I felt that way, I knew that would not be fair to a child. (Of course I felt guilty about this, too, and it only reinforced my doubts about whether I was worthy.)

But ultimately, despite all the guilt, despite wondering if we were being punished, I was hopeful.

I was hopeful that our suffering was a gift.

I didn’t know what kind of gift it would be: compassion and understanding for those in my shoes; a greater love for a child (adopted or otherwise) should we ever have one; a cautionary tale for others.

In the end, I learned that no matter how much I tried, I could not control hope. It controlled me.

This was how I came to realize that hope is at once wonderful… and cruel.

Monday, June 8, 2009

Recalling Bad Advice

In my first entry, I talked briefly about the advice that people sometimes give couples who are having difficulty conceiving. I even confessed that there was a time when I thought stress was a major cause of infertility. I also promised to talk a little bit about “recall bias.”

I know.

A term like “recall bias” could make your eyes glaze over.

On the other hand, it may be helpful when arguing politics, sports, or many other topics.

Recall bias victimizes infertility patients on a regular basis. If you are an infertility patient, just knowing about recall bias can make your day better.

So what exactly is recall bias?

Simply put: recall bias is the tendency to remember extraordinary events with greater clarity than ordinary events.

Think of your wedding day. Unless you were six sheets to the wind, it is very likely you remember many details of your wedding day, almost like it was yesterday.

Compare your memories of your wedding day to the 3rd Saturday after you got married. Unless something extraordinary happened on that 3rd Saturday (or you have the memory of a supercomputer), it’s likely that you remember your wedding day and can’t recall a single event that happened on the third Saturday.

Practical Application:
How does this apply to the advice you get from others when you’re trying to conceive?

Well, imagine 10 infertile couples. All 10 couples have been trying to get pregnant for a number of years. After years of tests, fertility pills, injections and more negative pregnancy tests than any of the couples care to remember, they each decide to adopt.

The adoptions go well and all 10 couples get a brand new baby. Two months after the adoption one of the couples, the Williams, learns that they are also pregnant.

The Williams tell their friends and family this incredible story. After years of infertility, they adopted and then got pregnant! They reasonably assume that it’s either a miracle or that they just finally relaxed, or both.

But not only will the Williams give birth to a child, they will also give birth to recall bias. Recall bias emerges because of the way the Williams’ story is told compared to the other 9 couples.

For example, the Williams tell their friends, family, co-workers etc. of their miracle. As this is an extra-ordinary event, the story is more likely to be retold. It is also more likely to be remembered by people who don’t even know the Williams. And they remember the moral of the tale, if you just quit trying – it will happen!

As shown by the graphic to the right, the Williams’ story gets told and retold.

In contrast, who tells and retells the story of all the other couples who did not get pregnant after they adopted?

No one. Nobody retells those stories.

So, which story are you, as an infertile couple more likely to be told?

The Williams.

What’s the implication? If you relax, you’ll get pregnant.

That’s recall bias.

A final thought for today:

If you are reading this and are struggling with infertility, I give you permission to stress as much as you want to. If you need a prescription to show to your friends that I say it is okay to stress, I’ll write one for you. Aside from stress severe enough to prevent a woman from ovulating, there is no good evidence that worrying about infertility makes it harder to conceive.

If, however, your stress is affecting your marriage, your happiness, your work, or your family, I do strongly suggest finding a healthy way to manage it. Seek whatever outlet makes the most sense to you: a friend, clergy, psychologist, acupuncturist, massage therapist or even a personal trainer.

Stress is much more likely to have a negative impact on your work or relationships than it is on your ability to get pregnant.

Thursday, May 28, 2009

Infertility: From the Inside Out

On June 12, 1993, on a blistering hot Chattanooga day, I married Kristi Cheryl Poe. It was a big wedding. Lots of family. Even more friends.

There is a picture of my wife from our honeymoon in Bermuda. She is standing in the bedroom of an old house that has been turned into a museum. Her hands are cupped in front of her, her shoulders hunched and a guilty smile crosses her face as she looks back at the camera. She’s standing over a baby’s crib. The cradle at her feet and the guilty look speak volumes about the direction she wants our lives to go. It’s clear. She wants kids.

To be honest, I hadn’t given much thought to children at this point, but it was plain to see that this meant a lot to her. When we got back from Bermuda we placed that picture, among others, on the wall in our den. That picture reminded us of very happy times.

We thought our lives were fabulous. Like many young couples, we were not in a rush to start a family, but we also didn’t try to prevent it from happening.

So in the beginning, not getting pregnant in a given month was no big deal. We knew these things took time. So time passed.

More time passed. Months passed. Seasons passed, then years, and anniversaries and the births of friends’ children. Then birthdays of children.

Throughout all of this, month after month, the picture on the wall hung there, reminding us of what she, now we, wanted very badly. The picture on the wall had not changed. My wife still had the same smile on her face, but now instead of looking guilty, it started to look a little sad.

In fact, every time I looked at that picture of my wife, I secretly wondered if we were not meant to have a child. That made me sad. So much optimism, crushed.

I can’t say this didn’t wear on us a little. We began to lean on friends and confide in them. Most of them were absolutely wonderful. They just listened. But I have to confess, it was hard to hear advice from some people who had easily gotten pregnant.

“Relax,” they reassured.


“Oh, you’re just trying too hard.”


“I know someone who adopted, and then got pregnant!”


“I know someone who quit trying and then BAM, got pregnant!”

You get the gist.

If you’re reading this, you’ve probably heard these stories yourself. I was too early in my career to know anything about something called “recall bias” (more on this later in an upcoming post). I assumed that stress was a major cause of infertility. And I knew what these people were saying. It was apparent without reading too far between the lines.

They were essentially saying, “It’s all your fault. You’re causing this.”

If these people were trying to help us relax, I confess it had the opposite effect.

All of this occurred at the beginning of our nearly 10 year journey with infertility that would take us across more than 600 miles and to three fertility centers and more cycles of IVF than I can remember reliably. Over the coming months, I’d like to document that journey and use this as a touchstone to talk about infertility treatments and tests.

It is my hope that this blog will help two groups of people: those who are struggling with infertility, and those who are giving advice.

Every couple is different. Having been a patient and a doctor who treats these conditions, I’ve seen what infertility can do to people and to families. I’ve seen it from many angles and from the inside out. I’ll tell you what I’ve learned.

Our particular journey as a married couple started with a trip to Bermuda. That little picture on our wall is a reminder to us of who we were and what happened to us along the way. It is a reminder of the joy and the unspeakable sorrows, the hope and the disappointments we experienced along the way. For better or for worse, our experiences with infertility shaped us as a couple. These experiences shaped me as a doctor.

For me, that picture of my wife in Bermuda says so much. It’s a constant reminder of how cruel hope can be and of how fragile and how strong we all are. For these reasons, it is still one of my favorite pictures of my wife.