A Christmas Carol - The Other Ghost

It was just before Christmas about 9 years ago. I was at the Streets at Southpoint, an indoor-outdoor mall in Durham, NC. It was a pretty mall, with a pedestrian street that was lined with stores glittering like Rockefeller Center. The bounty of the season was everywhere. The aroma of hot cider from the kiosk and the carols swelling up from the speakers disguised as rocks along the path, enveloped the crowd, bundled like they were trekking on an expedition to the North Pole itself.

I was trying to figure out what to get my mother, my father, my brothers, my sister, and my wife for Christmas. I confess that I rarely find things at the mall which make suitable gifts; however, I’ve always taken comfort in browsing and confirming my suspicion that this was not where I wanted to make my purchases. I guess this sort of made me an outsider, in a way. While I was glad to be surrounded by the holiday cheer, I did feel a bit disconnected. If I was honest with myself, I was actually a little sad and I couldn’t put an exact finger on the reason.

Then, as I walked down the path past a Crate and Barrel, I saw The Children’s Store. Moms and dads were bustling into and out of the store. As I stood outside the store, peering in the display window at the reindeer jumpers, elf pajamas and angelic ball gowns for little girls, I could see my reflection in the glass. Looking through my own reflection at the warm holiday interior, I began felt like a ghost: empty, vacant, barely a whisper. I felt like the Ghost of the Christmas That Would Never Be.

For people who have lost a loved one, for those separated from their families, for those without a family, with financial woes, with illness … we all know this is a tough time of year for some people. Watching other people, happy families apparently living the life of which you’ve been deprived can seem particularly unfair, or make you feel like a failure if you’ve not achieved these things.

This time of year can be especially difficult for people suffering from infertility. All the hopeless feelings, all the lonely feelings of isolation that infertility brings are magnified by the merriment of the season, the energy and bustle, the long lines at toy stores, by the crowds of twittering kids waiting to sit on Santa’s knee. All the holiday cheer can seem to just mock the pain of childlessness.

To make matters worse, if you feel like you’re on the outside of all of this Holiday fun and you see someone who is apparently blessed in ways that you are not, and you hear them complain about what seem to you trivial issues of the season… it can just make you mad.

In the end, most of us really do want to be happy. The question is, how is a person to rescue themselves from the sadness the season besets upon them?

Few solutions are perfect, but here are some things I have tried. Here are my suggestions, and I’m open to new ideas:

Own your feelings. Acknowledge them for what they are and ask yourself if you want them. If so, embrace them. Sometimes we need to do this first, before we can move on. It may be a miserable December, but it may be the first step to healing.

1. If you do not want these feelings, you should recognize that you may not be able to completely shake them. You may go for hours or days without the negative feelings resurfacing; however, it doesn’t mean you’ve been defeated when they do.
2. Focus on what the season is really about, for you. In my family’s tradition, Christmas, the season is a reminder of the gifts we have received – even though we were not worthy to have received them. Because of the gift already received, the season is about giving to others. (I know we all have different backgrounds and beliefs, but I do think the spirit of the holidays, Joy and Peace, can be enjoyed by all. When I was at my lowest, and thought I’d never have a child I would pray. I did pray that we would be given a child, but more than that I prayed that I could find peace in the event that we never did.
3. If being around children is too much for you, some people say you should avoid areas that are likely to be filled with them. I find this to be an impractical solution for many people, but you should not feel guilty for protecting yourself.
4. Consider devoting your time to someone else in need. This can be healing for you can for them.
5. Get plenty of rest. (Fatigue makes nearly everything worse.)
6. Get plenty of exercise. (This makes you feel vibrant and boosts your metabolism.)
7. Surround yourself with supportive people.
8. Seek counseling. If needed. If you’ve wondered if you should get counseling, then you probably should. I know a lot of wonderful people in the Chattanooga area and can make recommendations.

For some people this year, the Christmas season is going to be something to be survived, not enjoyed.

If this is you, plan ahead. If you need to, give me a call…. do something to help reclaim your life.

The Patient I Failed

Part 1: The First Digression

We doctors don’t always take failure too well.

I’ve talked with some colleagues about this and have heard lots of good theories as to why. The arguments go something like this: To get to medical school and through medical school, residency and then fellowship training, you have to negotiate a tough series of hurdles, and for most of your training and professional life you will successfully clear those obstacles. Bottom line, doctors aren’t accustomed to failure.

Perhaps.

On the other hand, I’ve talked to some friends outside of medicine and I think they are only half-joking when they say something akin to: Most doctors hate being reminded they are not God.

Perhaps that’s true, too.

Something tells me though, that it’s more than either of those two things. First, I don’t think the hating failure is unique to medicine. No one likes failure.

I think that’s one thing that’s so frustrating for couples with infertility. What comes so easily for some couples is so elusive, that it frequently causes one or both partners to feel like a failure, like they have let their partner down. This brings me to a key point: I think most of us can handle small failures pretty well. It’s when those failures are tied to another person, that’s when they become difficult.

For example, kids who play sports know someone has to lose. By and large it’s the kids who feel excessive pressure to win from their parents are the ones who are bothered the most by failure. They feel like they’ve let their parents down.

It’s particularly painful when you didn’t just let yourself down, but another person as well. I think this is the hardest part about medical failures… someone was counting on you and you didn’t deliver.

Part II: The Second Digression

When I first began the practice of infertility, I thought most patients were going to be like me and my wife – saddened by failure, but undaunted. We had our failures, but we kept trying, even after some people encouraged us to just stop.

In some ways, we had an advantage over most patients. Since my wife had no fallopian tubes our choice was simple: do IVF or don’t have our own biologic child. This is in contrast to a lot of patients with unexplained infertility. In those cases there is nothing to say that they can’t get pregnant on their own. While my wife and I knew for a certainty that we needed help to get pregnant, many patients don’t have that certainty and it leads to uncertainty regarding if they should continue therapy.

These patients are at risk for quitting treatment because, theoretically, they could get pregnant on their own. Sometimes these patients will take very long breaks from treatment. Sometimes they get pregnant. Sometimes they return years later only to find out their chances of pregnancy are actually much worse.

Part III. The patient I failed.

A few years ago, I was treating two women with PCOS. Neither woman ovulated on her own or with oral medications, so both needed injections to conceive. Each of them completed one cycle of injections and IUI (intrauterine insemination) without success.

Both women had an excellent chance of pregnancy if they had elected to continue on their current path, but both of them were extremely frustrated by their failure to conceive.

The first patient told me that this failure was more than she could handle. The idea of doing another cycle was overwhelming her and she said she just could not handle the stress of doing another month of treatment. She quit treatment and I have not seen her again. The sad part is, she might decide to try again one day. When she does, she’ll be much older, and her chances of success will have decreased substantially.

The second patient also told me she couldn’t do another cycle. She said she could not handle the waiting. She asked to do IVF. I tried to reassure her that she most likely didn’t need IVF, that she was good prognosis. She could not be swayed, she’d had enough. She was determined to do IVF. So, we did IVF. She conceived. Now she has a beautiful child.

In some ways, I think I failed both of these patients…. but I think it’s pretty obvious which patient I failed the most… the first patient.

I failed her because I assumed that most patients would be stubborn like me and my wife. I had failed to assess her emotional tolerance and fortitude prior to recommending treatment. If I had learned this about her, I would have warned her and perhaps have offered her the therapy that would have given her a very high chance of giving her a child.

Part IV: The Aftermath

Every patient reacts to failure differently. There are patients even more stubborn than me and my wife. But many are not. For many, the burden of the infertility is so heavy, that one failure is just too much to bear.

Realizing this has forever changed the way I counsel my patients. These days, I do my best to warn patients that any failure will strip some people of their will, of their hope, of their emotional reserve. I alert patients to this fact. I tell them that they need to be very honest with themselves and with their partner about how much emotional and physical energy they have in their tank.

If they are running on fumes, they should start with the therapy that gives them their greatest chance of getting pregnant.

Ultimately, I’m fine if a patient decides to walk away from treatment, especially if they have exhausted the options which they find acceptable choices for them.

Walking away by choice, I’m fine with that.

It’s when a patient can’t walk back… and they’ve left viable options on the table…

That is hard to handle. Those are people I ache for.

New World Health Organization Semen Parameters

Following a large multi-national investigation of sperm parameters in fertile men, the World Health Organization (WHO) has changed the reference ranges used in semen analyses.[1] The new normal values are based on men who took 12 months or less to help conceive a child. Parameters above the 5th percentile are considered normal. In other words, 95% of fertile men have parameters which exceed the new WHO values. We will reflect these changes on our future semen analysis reports.

In all cases, the new normal reference values are lower than the previous WHO reference values. However, the new WHO criteria are actually more in line with how we at Tennessee Reproductive Medicine (TRM) and Tennessee Reproductive Laboratories (TRL) have already been interpreting semen parameters.[2]

Below are the old reference ranges, our interpreted range and the new reference range:




As you may have noticed, the biggest difference between the new WHO value and the TRM/TRL interpreted normal range is in strict morphology. Morphology is the most subjective variable within a semen analysis, and centers may calculate it slightly differently.

At TRM/TRL, we have not used morphology to determine what therapy to offer patients. This study and the new reference ranges specifically support this practice. For example, we do not tell patients that a morphology of 4% means that they need IVF. Rather, they should consider a special technique for fertilization if they require IVF.

In conclusion, these new WHO criteria will not dramatically alter how we interpret semen analyses. However, we believe these new reference ranges will help more labs generate a uniform recommendation. If you have any questions about the new parameters, or if you have questions about your previous analysis, please do not hesitate to call us.



1. Cooper, T.G., et al., World Health Organization reference values for human semen characteristics. Hum Reprod Update, 2010. 16(3): p. 231-45.
2. Guzick, D.S., et al., Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med, 2001. 345(19): p. 1388-93.

Tubal Reversal verus in vitro fertilization (IVF)

The Burning Question

One of the most common questions I get asked both by physicians and by patients around the Southeast is about tubal reversal surgery compared to in vitro fertilization (IVF).


It's easy to understand why there is so much interest. Millions of women have had their tubes tied. Inevitably, if millions of women are opting for "permanent" sterilization, many of them will later regret it.

I could spend a lot of time talking about who is likely to regret this decision. There is good data on that. But I'm not writing this blog entry for women who are trying to decide among different contraceptive options. I'm writing this for the women who find themselves in the unfortunate situation of wanting another child, but their tubes have been surgically blocked, cut, burned, clipped, tied, fried (and/or all of the above).


The bottom line is there are many people who regret their decision and they always ask me the same question: which is better, tubal reversal surgery (reanastamosis) or IVF?


The Universal Answer
One of my mentors drove a lot of residents and fellows crazy when they approached him looking for a quick answer to what they thought was an easy question.


To almost every question, his answer was, "It depends."

Then he'd launch into a 5-10 minute lecture on the pro's and con's and nuances, caveats, hard and fast rules, exceptions to those rules and so on.


I'll try not to do that to you.


If you want the short answer to this question, I'll give it to you and I'll tell you why. Just scroll to the bottom of this blog and read: "The Short Answer." But be warned, you'll miss some good stuff in between.


Critical Questions I Must Know to Answer the Question for You...
For me to know to best advise a patient, there are some absolutely critical questions I need answered.


1) How were her tubes sterilized?
2) How old is she?
3) How many more children does she wish to have?
4) Does her partner have adequate sperm?
5) Does she or her partner have a history of previous infertility?
6) Does she or her partner have any religious barriers to IVF?


Tackling these questions one at a time:

1) How were her tubes sterilized?

In general, the less damage to the tube, the easier the repair. Some methods,
such as the Filshie Clip, or the Fallope Ring create very little damage and
reconnecting these is a lot easier than if the tubes were burned in multiple
locations, or if large segments of the tube were resected. It can be
important for a physician to see the operative report from the tubal
ligation. If a lot of damaged tube has to be removed and there is not much
to put back together, the chances of success are much lower. In general, a
minimum of 4 cm of tube is required at the conclusion of the reanastomosis
to have a legitimate shot at getting pregnant.

2) How old is she?

Older women, especially in their forties, have less time to conceive and
their monthly pregnancy rates are much lower than younger women. After age 37, monthly fertility rates begin to drop rapidly. There are women at age 37 who get their tubes reversed, but if they have not had a baby in one year, then their chances of conceiving at age 38 are significantly lower. Each 6 months to a year, fertility wanes. For good prognosis patients, a single cycle of IVF is generally as successful as trying to conceive for one year on your own. In other words, you can pack a year's worth of treatment into two months.

Even for young women, ovarian reserve testing should be considered. This testing can tell you if your eggs are behaving their age, or
like a much older woman.

3) How many more children does she wish to have?

A young woman who wants to have several more children spaced out over several years may be the best candidate for tubal ligation reversal. When she's not trying to get pregnant, she'll need to use some kind of birth control, but this can stop when she's ready to try again.

On the other hand, a woman who wants only one child, or the older woman who wants more than one child may be a better candidate for IVF. If she only want one child, we can limit the number of embryos we place in the uterus. In some cases, we only place one embryo in the uterus. Once she delivers her baby, she still has her sterilization in place.

Finally, the older woman who wants more than one child may do best with IVF. In her case, we can be a little more aggressive about the number of embryos we place in the uterus, assuming she is willing chance the pregnancy will be twins. Also, if she gets pregnant and
delivers a single child, she may have embryos that we were able to
freeze. Months later, after birth, after she finishes breast feeding and
gets through the sleep deprivation of having a newborn, she can return
to clinic and use the embryos that are in storage. She will have
virtually the same chance of conceiving as she did when she was a
younger age.

4) Does her partner have adequate sperm?

A lot of centers which specialize in tubal ligation reversals do not require a
semen analysis of the male partner. I will acknowledge that in most cases, the male partner will have adequate sperm, but on numerous occasions, shortly before tubal surgery, I have found that the male partner's sample was wholly inadequate. Surgery would have put those women at unnecessary risk, with little hope of achieving pregnancy. If a physician does not offer or recommend a semen analysis be performed, I would be suspicious that he or she was not acting in my best interest.

5) Does either partner have a prior history of infertility?

If so, I would carefully consider your choice. In these cases spontaneous
pregnancy is much less likely and IVF would be favored.

6) Does she have religious barriers to IVF?

If so, tubal ligation should be preferred.

So who should you seek for advice?

The best people to talk to are physicians who perform both procedures. They are less likely to sway you toward one over the other. They will also try to put the statistics into real clinical context to help you understand what you're getting for your time, effort and money.

From them, you should get truthful statistics about real results. If you looked at a graph of how many pregnancies occur after tubal ligation reversal compared to IVF, you would probably run straight to surgery and have your tubes reversed - because in every age group, far more pregnancies are achieved per reversal than per IVF cycle (according to nationwide IVF statistics).

But not so fast! If you look a little closer, you'll notice the live birth rate only barely favors tubal reversal over the average national IVF success rate.

First, what happened to all of those extra pregnancies? Many of these tubal reversal pregnancies are located in the tube.

Another reason live birth rates are similar between tubal reversal and IVF is this: the statistical deck is stacked in favor of tubal reversal. That's because many tubal reversal clinics compare their success rates to "average national IVF success rates."

This is NOT a fair comparison.

Tubal reversal patients are the best prognosis patients for conception. To compare these patients to ALL IVF patients is like comparing apples to Orangutans.

Most IVF patients do not have proven fertility and voluntary sterility like tubal reversal patients do; most have multiple other more-serious fertility problems.

If you randomised these best prognosis patients to tubal reversal versus IVF, you would almost certainly see significantly higher live birth rates from IVF, with a much lower risk of tubal pregnancy.

The Short Answer

Ok, I promised you a short answer. If you've read this far, you're probably going to think I'm just going to recommend IVF, but I'm not going to do that. See which category you are in, and this is generally what I would advise.

1) Money is scarce and you can find a cheap tubal reversal and you're willing to sacrifice some chance of success - go with tubal reversal.
2) If you have religious conflicts with IVF - go with tubal reversal.
3) If you are a young woman who wants several more children spread out over a number of years - go with tubal reversal.
4) If you want to get pregnant but don't want to have to use future contraception - go with IVF.
5) If you want just one child - go with IVF.
6) If you're older and want several more children - go with IVF.
7) If you want the highest chance of pregnancy, period - go with IVF.


Conclusion

I hope this was simple enough. There are some details, some pros and cons of each choice that I have left out of this blog post. For any individual patient, there may be additional testing I'd recommend. I didn't discuss all the risks associated with each procedure, either.

If you have questions regarding which treatment is right for you, come see us. Dr. Scotchie and I will try to help you find it.

Second Opinions

Ok, last time I posted here, I promised I'd write about how to get the most out of a second opinion. To do this, I did something a little novel - and so it took me longer than I expected. While I have pretty strong opinions on how to get the most out of a second opinion, I queried a lot of doctors from around the country to see what they would advise.


I have to say, overall, I was a little disappointed. Most of the responses were some variation of "send the patient to me."


Most advice was also not very helpful. A lot of the advise was almost opposite from the advise of other physicians.


To be fair, not all the people who responded were reproductive endocrinologists, so they may be quite in tune with the issues infertility couples face.


However, of the people I polled, there were some excellent points and issues to consider.


Why Get a Second Opinion?
There are many reason patients consider a second opinion. Frequently, in our field of medicine, it’s because a person did not have success with their previous provider, because they were given difficult news with few acceptable options, or simply because they did not mesh with their first provider. Sometimes, it seems some people get a second opinion because it’s just what they do… they like more than one opinion.


How to prepare for a second opinion:
1) First identify why you are seeking a second opinion (be aware of your agenda).
2) Be aware that your first and your second doctor may have an agenda, too.
3) Gather your records and get them to the physician ahead of time if possible.


Agendas are critical.

Agendas may completely alter the advice you receive.

First, the patient’s agenda: Almost every patient has a reason for getting a second opinion. Nearly every doctor I polled said that patients should know why they want a second opinion. If it’s because they just didn’t get the answer they were looking for from the first doctor, the patient needs to recognize this and keep this in mind when seeking a second opinion.


It has been said that the very poor and the very wealthy are at greatest risk for receiving the worst medical care. The poor have no access. The very rich can doctor shop until they find physicians who will do whatever the patient wants. Michael Jackson could always find yet another surgeon to carve him up or help him sleep. If you're just looking for someone to tell you what you want to hear, you should be aware that this can lead to sub-optimal treatment.

My advice to patients is, to the best of your ability, don’t tell the doctor your agenda until he or she gives his opinion.

Here is why.

There have been many times when patients come to my office for a second opinion and it is very apparent that they simply did not like what they heard from their first physician.

If I realize that the patient is very unhappy with the first doctor because of the opinion, I have a tremendous advantage compared to the first doctor. I already know what information, or what type of information that a patient does not like to hear. Simply agreeing with a patient’s preexisting biases may strongly influence the way the patient feels about my advice.

I would like to think this knowledge does not influence my opinion or how I relay information to a patient. I hope that’s not wishful thinking.

If I don’t know a patient’s agenda, then there is no opportunity for me to be influenced by this.

Knowing which advice is the best is not always easy. These are not fool-proof clues to which advice is best, but here are my suggestions:

*Did each doctor support their opinion, with evidence from the medical literature?
*Did each doctor explain the diagnosis to your understanding?
*Were you given a full range of options and the likelihood of each being successful?
*Does the doctor’s advice make sense?

The Doctors’ Agendas
Dr. Deane Waldman, of the University of New Mexico Health Science Center said that physicians providing a second opinion would ideally just be providing an opinion and not be gaining financially from such an opinion.

I frequently tell patients this, too. If a physician has nothing to gain from giving the opinion, he or she, is less likely to be influenced by his or her own gain. This kind of opinion is least likely to be biased.

So how does the patient learn if the doctor has an agenda?

In general, physicians in our field of medicine should really be providing you with information to help you make the very best choices. If their advice is good, they should not be threatened by the thought of you getting a second opinion.


Red Flags
There are certain circumstances when a first or a second opinion should cause you concern. (Preston Parry, an REI at the University of Wisconsin pointed out some of what follows below.)


1) False choices: I have encountered patients who have been told they either need donor sperm or in vitro fertilization. One couple had actually had two previous pregnancies over the past two years. In this case, the recommendation was made on the strength of a minimally abnormal semen analysis. (Clue 1: this advise didn't make sense, based on the patient history. Clue 2: a minimally abnormal result, even a moderately abnormal does not always mean extreme measures need to be taken.)


2) Only the positives are discussed. Every treatment has advantages and disadvantages. If you are offered only one treatment and the physician does not volunteer the disadvantages and advantages of all the options, then be wary. This is not to say the doctor is incorrect. But unless you really understand the upsides and downsides to all treatments, how can you make an informed choice?


3) It's Natural: the doctor suggests an array of supplements/holistic medicines. (Trying to prove that their practice is more thorough; the reality is if these things had a dramatic effect, everyone would be using them.)

4) It's what we do: the doctor suggests protocol modifications, but can’t say why it is appropriate through evidence-based medicine. (“We do it that way for everyone,” is not science, it’s opinion.)

5) Only We Syndrome: the doctor claims that he or his group has a unique procedure that only he can perform.


6) Cherry picking: This is a common concern among REIs (reproductive endocrinology and infertility specialists). There are some clinics which report extremely high success rates by age group. There is a suspicion among some REIs that some of these clinics are only treating good prognosis patients and trying to funnel poor prognosis patients toward egg donation. Without naming them, I will say this: I have referred some young, fairly poor prognosis patients to certain clinics for a second opinion and they have been told things like, "We wouldn't do a better job than your local docs." This is code for "we don't want you to hurt our statistics." Even if you are poor prognosis, a good clinic will give you realistic odds and should still let you proceed with care as long as you understand the chances and the treatment is not overly dangerous for you.



Conclusion:

Second opinions can be tricky. Ultimately it will come down to a matter of trust. If you get a second opinion, be sure that the physician fully explains why a recommendation is being made. If he or she can't explain it to you so that you understand it, then it likely is not the best choice for you.

If an alternative treatment is suggested, the relative advantages AND disadvantages should have been discussed with you.


You can ask your referring provider what their experience has been with the doctor. Ask your friends. Watch for red flags. And, ultimately, if all else fails, you should trust your instinct.