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The Infertility Conundrum

Posted by MDViews on March 25, 2014

Tears spilled on my desk as she described her four-year trial with infertility. Married for six years, she and husband actively tried to achieve pregnancy for four years prior to her visit with me. After one year of no success, she saw her OB/GYN doctor. After testing, her doctor determined her to have open tubes, normal labs and a fertile husband. Try another year, she was told. After no success, her doctor tried her on Clomid, a medicine that caused ovulation2, even though she ovulated every month. After six cycles of that without success, she visited a Reproductive Endocrinologist (RE), a doctor who finished an OB/GYN residency and an additional two years of training in Reproductive Endocrinology. The RE recommended Clomid and intrauterine insemination or IUI3. If no success after three cycles, she recommended Follistim shots4 and IUI for three cycles. If that failed, she recommended in vitro fertilization.

My patient and her husband tried the Clomid and IUI, but couldn’t afford the Follistim and IUI or the in vitro fertilization.

She returned to her OB/GYN doctor and received more Clomid, again, without success. She and her husband, both Catholic, lived with the guilt of trying IUI, a fertility procedure not approved by the Catholic Church. Her complaints of severe pain with her periods and pain in her pelvic area fell on deaf ears as her OB/GYN told her in vitro fertilization was the most effective way to achieve pregnancy, and recommended a return to the in vitro clinic.

Pregnancy rates after an in vitro cycle average 30%. I checked three fertility clinics in the Twin Cities and found one charged $16,500 for each in vitro cycle, another $22,000 and a third clinic $23,000 per cycle.

Pregnancy rates after one cycle of a fertile couple who has unprotected intercourse are 25 to 30%. Last I checked, the cost was $0. Pregnancy rates after one cycle for a couple with endometriosis5 is lower than that, often around 5% to 10%. As excellent medical studies have shown, however, surgical treatment of endometriosis and pelvic scarring improves pregnancy rates, often greatly. Not only that, surgical treatment constitutes a one-time event that often relieves pain and increases pregnancy success for many cycles.

If a woman has a 20% success rate per cycle after surgical treatment of endometriosis, her chances of pregnancy at the end of one year are much higher than the 30% chance after one in vitro cycle, or the slightly higher chance after two in vitro cycles. I rarely find a patient who has tried three or more in vitro cycles.

She heard about our clinic and underwent surgery at which time I discovered and surgically treated her severe endometriosis by careful handling of tissues, thorough treatment of endometriosis and placement of adhesion barriers to prevent recurrent scarring.

The surgery brought relief of her pain.

She conceived on her own the next month.

She is now on baby number two since the surgery.

In order to understand the tragedy this represents, you need some history. Back when I did my residency in OB/GYN, the Reproductive Endocrinologists were the best surgeons in the department, often the entire hospital. They performed difficult endometriosis surgery, tubal reconstruction and treated scarred tubes, which often required the operating microscope. Now, RE’s in my area do not come to the hospital, much less perform surgery. At the two hospitals where I work, not one Reproductive Endocrinologist performs surgery in spite of in vitro clinics in our service area.

In the last five to ten years, in vitro procedures for infertility have become the default treatment to the elimination of all other treatments. General OB/GYN doctors in my community have a laissez-faire attitude toward the surgical treatment of endometriosis and make little effort to treat the disease thoroughly surgically even if they find it at laparoscopy6. This, in spite of good data on the effectiveness of surgical treatment to improve fertility and relieve pain7.

1) Fallopian tubes – tubes that carry the egg to the uterus from the ovary. Fertilization actually happens in the tube.
2) Ovulation – When the egg pops out of the ovary and can be fertilized.
3) Intrauterine insemination (IUI) - A procedure in which a semen sample is specially prepared for safe insertion into the womb, or uterine cavity itself.
4) Follistim – A hormone given in daily injections to cause the ovaries to make eggs, sometimes several eggs.
5) Endometriosis - A female condition in which uterine lining cells implant in the pelvis and cause pain, scarring and infertility.
6) Laparoscopy - A minimally invasive surgery to look inside the abdomen in order to diagnose and treat a condition, often endometriosis or infertility.
7) UpToDate states in the section Reproductive surgery for female infertility, "laparoscopic surgical treatment was associated with a significant increase in the ongoing pregnancy/live birth rate..." October 2013.

Posted in Doctoring, Family, Medical Issues | 1 Comment »

The Happiness Canard

Posted by MDViews on January 31, 2013

Many times have I had a patient, or friend or acquaintance speak of their wayward adult/teen/adolescent children through tears saying, “I just wanted him (or her) to be happy,” As in, “What a simple request I’ve made of them. I’ve demanded nothing of them. I’ve paved the way for them. I’ve not insisted they be a sport star, or a straight “A” student, or have a perfect room, or do chores day and night.” But then something happened to disappoint them and their poor offspring was in trouble with the law/divorcing/on drugs/flunking out of school/ and on the list goes.

Few goals a parent may have for a child lack parental insight more than “Be happy.” It’s an easy trap to fall into, but one we should avoid.

First, you are their parent, the authority figure, the one in control of the car keys, the money, the house and the schedule. You are not entertainment, a bank, a car dealer, an endless chauffeur, a video game dealer or a social calendar organizer. You must make decisions for your child and discipline your child which leads to great unhappiness with tears and raised voices and angst. Now, you can try to be their buddy and best friend, but it isn’t what they want and certainly is not what they need. Be the disciplinarian you need to be. Study it. Buy Christian books on it. Read the Bible and pray for your child. Be good at parenting. But don’t think leniency will lead to a happy adult child. A child raised with loving but firm boundaries will fare much better in the world.

Second, once your child is an adult, you can offer advise or counsel, but your adult child can refuse it, listen to it and reject it or just get really angry you are butting into his or her life. MYOB, may be the reply. But whether or not they are “happy” by that time is up to them, not you. Don’t sweat it. In fact, unhappiness, trials and torment can be a great teacher. Don’t try to relieve them of such a valuable teacher.

Third, what is the source of happiness? More stuff? Better sex? Bigger bank account? Better advanced degree? Dying with the most toys? Is the source of happiness random acts of kindness? Serving turkey at a shelter on Thanksgiving? Helping others? Is the source of happiness being “true to yourself?” Looking out for #1? Following eastern religion by meditation and navel gazing? Getting your piece of the pie, whatever it takes? If you, dear parent, can’t answer that question with a resounding confidence, how can you expect your child to find this elusive “happiness” state of mind?

I would posit the ultimate source of happiness is to glorify God and enjoy Him forever. The first question of the protestant catechism wasted no time or words in getting right to the point of the most important question faced by man. The question? “What is the chief end of man?” The answer? “To glorify God and to enjoy Him forever.” John Piper would change the “and” to “by” making the answer read “To glorify God by enjoying Him forever,” meaning enjoying God, taking pleasure in God, making God your ultimate goal and satisfaction is accomplished by glorifying Him forever. Our ultimate joy comes from God and the realization that we are depraved individuals, dead in our sin and unable to see God’s glory and beauty and desirability unless He awaken in us that desire. We deserve Hell and eternal torment. Thus our commitment to Christ, our walk with Him, our joy in making much of God and worshiping Him is totally His wonderful gift. We didn’t “clean ourselves up” to be acceptable to God. We didn’t choose God because we were so smart and good and upstanding. Even our best is as filthy rags to him. It’s only through the cross and God looking at us through the beauty of his son who is perfect and blameless and who presents us as perfect and blameless to God that we have this joy.

Thus the source of our joy.

Knowing God is sovereign and in control and has chosen us to spend eternal bliss with him one day is more than “pie in the sky in the sweet by and by.” It’s our rock, our fortress, our stronghold, our strength. It’s a promise in which we can always take hope.

Does that mean Christians are bubbly happy, always smiling, “chipper” (John Piper’s word!), never down, always trying to prove to the world that “we Christians are happy and have fun, too!” like I seem to hear again and again on some Christian radio stations? No, of course not. Those bubbly, chipper sorts are play-acting in my book. How can we “bubble” when so many in the world are bound for hell? How “chipper” can you be knowing that in the congregation each week sits someone wondering if the cancer has spread, wondering if their husband will file for divorce, wondering if their teenage son is drunk again, wondering if they will miscarry again, wondering how to deal with the guilt of having had an abortion? Church is not “chipper.” Church is a serious time of serious worship to the creator of the universe, the one who hung and named each star, the one who grants the next breath I will take, the one who provides my purpose for living.

Such Christians are joyfully sorrowful–joyful in the service and worship of the King, but sorrowful for all the reasons above. In other words, Christians face the world as it is knowing and recognizing the hurting and pain and suffering that eventually visits all of us in one terrible form or another, but recognizing the Blessed Hope of our dear Savior and the promise to spend eternity with Him one day. Thus our unending joy when surrounded by tragedy, poverty, pain, hurting and death. And, more importantly, our unending joy when tragedy, poverty, pain, hurting and death visit us personally.

I have a hard time imagining how the sprightly, vivacious and chipper Christians handle bad news–really bad news–without going to pieces and denying their faith. Because, if being a follower of Christ is supposed to make you upbeat, bubbly and chipper–then, if you are not upbeat, bubbly and chipper because of the terrible calamity visited upon you–what do you have left? Nothing but questions without answers.

Not that joy in Christ is a slam-dunk. We must fight for joy. How? By staying as close to God as we can through worship, prayer and study. By realizing these trials are temporary and the best is yet to come. By realizing this is not our home, we are just passing through. By associating with like-minded Christians for love, encouragement and support. By serving God with all our hearts, an activity sure to take your eyes off of ourselves and onto Christ, the source of joy.

So, please, don’t tell me “I only want my child to be happy.” It’s an unachievable goal sure to disappoint you and frustrate your child. Rather wish for them commitment to Christ in all His glory. The “happiness” will take care of itself.

Posted in Faith and the Glory of God, Family | 4 Comments »

The Contraceptive Mandate

Posted by MDViews on January 8, 2013

Birth control. Who can be opposed to birth control?

Isn’t birth control just having the babies you want and no more? Isn’t that just common sense? Who can afford more than two kids anyway? Who wants more than two kids any way? Do you have any idea how expensive day care is? And who wants to clean some rug-rats bodily fluids off the leather seats in the back of your Beemer? Do you have any idea how the other passengers look at you if you take your kid on an airplane to go to the Bahama’s for a vacation? Besides, maybe you’re a teenager and a pregnancy would ruin you life. Shouldn’t you be on birth control? Come to think of it, maybe you should be required to take birth control. I mean, isn’t over-population a big problem? Shouldn’t we all have fewer kids, like China? And how are you going to climb the corporate/educational/governmental ladder if you have to worry about day care/dance lessons/soccer/after-school care? Kids! What a noose around your neck! Plus, what if you end up with some disabled kid who cost even more? Do you know what day care is for a kid with autism? (Well, I think they have homes you could put someone like that in, don’t they? I mean, you shouldn’t have to care for a kid like that, should you?)

Let the Duggers have 19 kids. Let those weird Catholics who actually believe Pope John Paul’s Humana Vitae use natural family planning and have 8 kids. (Is it legal to have that many kids? Maybe we should do something about that, too. )

And anything that’s as important as birth control should be covered by insurance, shouldn’t it? I mean, $4 a month at WalMart seems like a lot to me.

And so it goes. The arguments for birth control in general and the contraceptive mandate in particular.

But let’s separate some facts from the fog and see what this contraceptive mandate is really about.

First, define birth control, because you cannot separate birth control from abortion.  Most of you probably don’t know that the government, drug companies, IUD’s companies, birth control pill companies, progesterone-only birth control companies and the “morning-after” pill companies define abortion as pregnancy loss after implantation. That means an egg is fertilized, becomes an embryo, travels down the fallopian tube over 4 or 5 days, but then, instead of implanting in the wall of the uterus, passes through unnoticed because the “contraceptive” made the uterine wall hostile to implantation. One package insert said it prevents the “egg” from implanting in the uterine lining! To those entities above, that is birth control, not abortion. All of the package inserts for the birth control pill, IUD’s, progesterone-only birth control pills and shots and the “morning-after” pill companies list a hostile uterine environment as one of the mechanisms of action. (For birth control pills, the primary method of action is stopping ovulation, but it doesn’t stop ovulation all the time.)

For those of us who are pro-life, that mechanism of action means 1) possible, occasional abortion for the birth control pill, 2) likely abortion for IUD’s and progesterone-only pills and shots and 3) almost certain abortion for the “morning-after” pill.

I’m an OB/GYN doctor and have wrestled with these issues in my conscience for many years. I quit placing IUD’s shortly after I started in private practice, but did place them during my residency. I quit prescribing progesterone-only pills and shots many years ago and I quit prescribing the birth control pill two years ago. I feel good about all of those decisions.

So defining “birth control” helps us, I think, realize why the “contraceptive” mandate is a deep moral affront to pro-life people on its face. “Contraceptives” should be called “contra-gestational” agents, meaning they prevent a pregnancy from “gestating” or growing in the uterus, but don’t prevent “conception.” At least not all the time. In that regard, they are all potential abortifacients, some more than others.

Second, our devout Catholic friends, both patients and doctors, are required by the teachings of the Catholic church to only use periodic abstinence (natural family planning) to prevent pregnancy. I’m much more aware and informed of that teaching now that I work in a clinic with all Catholic physicians who hold to the teachings of the Catholic church. That means they advocate for natural family planning, (specifically NaPro Technology) and never prescribe any artificial birth control agents. It’s easy to see why the mandate would be unacceptable to them. Also, that means requiring a Catholic organization or a Catholic employer to pay for condoms, spermicides, tubal ligations and vasectomies in addition to those other forms of  “birth control” is a moral outrage and mocks our first amendment right of freedom to practice our religion as we choose.

One can argue that our taxes already pay for abortion in the United States, and that is true in some states (Minnesota, for one, where I live) through the Title 19 program.

But our tax dollars already fund program after program I find morally objectionable. I have no choice about paying taxes. When Jesus said to give to Caesar what is Caesar’s and to God what I God’s, the Roman empire was not exactly a morally upstanding place.

However, requiring payment for “contraceptives” by purchased private health insurance when health insurance is a voluntary fringe benefit offered to employees from an organization or employer bears no similarities to a tax. It’s the government interfering in a private fiduciary relationship between an employer and an employee.

It is clearly the heavy hand of government violating the first amendment right of freedom of religion for those organizations and employers who find “contraceptive benefits” morally objectionable.

As my little vignette above describes, the real reason secular people (and many evangelical Christian and Catholic couples) use birth control is, well, because they don’t understand the gift of life. Children are a de facto burden, not a blessing; a curse to be avoided, not a life to be cherished; a pet to be shown off when convenient then shuffled off to daycare, not an integral part of the family to be fully accepted, loved, valued and included; a carbon footprint to be viewed with a jaundiced eye, not a treasure created in the very image of God.

Pro-life Christians and Catholics are in cross-hairs of the liberal establishment because we embrace a morality from outside of who we are, a morality codified first in the tablets from Mt. Sinai and expanded by Jesus and the apostles in the New Testament. Liberals fly by the seat of their pants inventing their morality as they go along, mostly by what ever would increase their personal happiness at that moment in time, whether morally right or wrong (situational “ethics”, or a better description, situational lack-of-ethics). We now live in a liberal echo chamber in which the establishment has never met a death (embryo, fetus, handicapped baby, or elderly ill person) it didn’t like–except for those convicted of capital crimes in which death is a deserved punishment–those deaths they fight against always.

It makes sense, dear Christian friend. God is not surprised, fooled or unaware. Their behavior is nothing new. Read what the Psalmist says in Psalm 106:36-39 and see if it doesn’t describe the current state of our culture to you.

They served their idols,
which became a snare to them.
They sacrificed their sons
and their daughters to the demons;
they poured out innocent blood,
the blood of their sons and daughters,
whom they sacrificed to the idols of Canaan,
and the land was polluted with blood.
Thus they became unclean by their acts,
and played the whore in their deeds.
(Psalm 106:36-39 ESV)

And, we know that we will suffer for Christ’s sake if we take a moral stand. It’s a guarantee from God. Paul’s phrase from I Thessalonians 3:4 makes it clear he knew he was to suffer affliction and then did suffer affliction.

    For when we were with you, we kept telling you beforehand that we were to suffer affliction, just as it has come to pass, and just as you know.
(1 Thessalonians 3:4 ESV)

So the contraceptive mandate is not a surprise to God and should not be a surprise to us. In our culture, what’s right is what’s wrong and what’s wrong is what’s right. Since liberals control the reigns of power in government, entertainment, education and large corporate businesses, we are at the mercy of the laws they pass, the courses they teach, the movies and TV programs they make and the rules they make for employment as they employ many of us. But we don’t have to watch their movies and TV programs which always portray us a incompetent, stupid, bigoted troglodytes. We don’t have to buy the products of those companies actively supporting the goals of more birth control and abortion. We can home-school and choose to attend conservative colleges and universities. And when the laws become too onerous to follow, we can use civil disobedience (and go to jail? Yes, and go to jail). In the mean time, we must fight, protest, vote our hearts and throw every roadblock we can in front of them whenever we can.

Posted in Abortion, Family, Medical Issues, Politics, Pregnancy | 4 Comments »

Purposeful Act of Kindness

Posted by MDViews on December 28, 2011

The following article I wrote after an experience I had in an ICU. I hope you enjoy the read.

“I WANT OUTTA HERE! GET OUT OF MY WAY! LET ME UP!” The shouts burst from ICU room 5. The ICU staff at the nurse’s station stiffened. The shouting quieted as I heard the soothing voice of his nurse speak gentle words to calm him.

Dementia. Alzheimer’s disease. That’s what I was hearing. I was in ICU consulting on a gynecology patient when I heard the ruckus. Dementia patients, I knew, could compensate for their declining mental function when in familiar surroundings with familiar people. But, put them in a strange place with strange people–and add to that an illness–and the disease really shows itself.

Dementia in most cases starts with the gradual loss of short term memory which is first noticeable to those closest to the person. As time passes, this always progressive illness affects ones ability to learn and retain new information, to handle tasks such as balancing a checkbook, to cope with unexpected events, to recognize familiar places and to find words to express ones self. Most troubling are the personality changes. Gentle, kind, caring individuals can become agitated, aggressive, angry, mean, harsh and can become abusive to their family and other care-givers.

Four million Americans have Alzheimer’s disease. No one knows the cause. Treatments do not stop the progression of the disease.

My mind reflected back to my father-in-law who developed Alzheimer’s in his later years. The family watched as this gentle man, a soft-spoken man of great faith, lost touch with reality and became angry, harsh and even abusive to his wife and to those around him.

Illness is messy, I reminded myself. It’s hard. It’s inconvenient, taxing and often depressing. Save the miraculous healing power of God, dementia patients as with my father-in-law follow a downhill course. Our family watched a daily decline, a slow death until he finally succumbed to this disease.

As I sat and pondered, I thought of the beautiful letter former President Reagan wrote to the nation upon learning he had Alzheimer’s disease. (http://www.americanpresidents.org/letters/39.asp) In that letter, he lamented, “Unfortunately, as Alzheimer’s Disease progresses, the family often bears a heavy burden. I only wish there was some way I could spare Nancy from this painful experience.” How true. How kind to acknowledge the burden Nancy would face, did face. He also acknowledged, “I now begin the journey that will lead me into the sunset of my life.” Quite an unusual admission for one so diagnosed since most people diagnosed with Alzheimer’s have no sense that they have the disease.

After I examined my patient, I returned to the nurse’s station to write my note. From the room, I could hear the voice of this man’s son. “Remember that picture, Dad?…Let me help you with that, Dad…The nurse is going to give you a small shot. Isn’t she wonderful, Dad? She’s here to help you.” On and on I heard his son speak loving and kind words to his father. I knew then, that the son got it. This son realized the angry outbursts were the disease talking, not his Dad talking. He realized the disease now spoke and acted in place of the father he knew. He realized that his Dad was still in there deserving of all the care he could give.

My eyes watered. What a gift this son gave his Dad. On a Saturday afternoon with football on TV and other responsibilities no doubt pressing in on him, he was here. In the ICU. Showing love to his Dad, his Dad who could not return the love in any way, who did not even know who his son was.

I thought of the thousands of other spouses and families caring for loved ones with Alzheimer’s disease and their equally significant gifts of unselfish love. I prayed as I left the ICU that God would grant this son the strength to see his Dad through to the end, and that, should they meet in heaven one day, he would hear his Dad say, “Yes, son. I do remember that picture.”

Posted in Doctoring, Family, Medical Issues | 2 Comments »