Unexplained Infertility

It took us a while to get into see the fertility specialist, or REI doc as I call them (they are OB/Gyn physicians who did an additional fellowship training in Reproductive Endocrinology & Infertility).  I was curious to get his thoughts on stress and acupuncture, but we spent most of the time discussing the plan and the reasons behind the options.

He confirmed that we have “unexplained infertility,” which means no explanation based on the usual tests.  Many couples fall into the categories of ovulatory dysfunction (not ovulating regularly, such as with PCOS patients), diminished ovarian reserve (age-related decline in fertility), or male factor infertility.

For many of us, there is no obvious reason.  We’ve had a child before, somewhat recently, so obviously things seem to be in working order.  There is a chance that I have developed hydrosalpinx, which is when you have a dilation and fluid filling of the fallopian tube.  A study called a hysterosalpingogram (HSG) can be used to assess for this, as well as to confirm that the tubes are open.  Given that it doesn’t seem super likely that this is what I have, I decided to hold off on the study unless we don’t conceive after several attempts.

In terms of the available options, we can use hCG (the same pregnancy hormone used in pregnancy tests), as an injection to help time ovulation more predictably.  From there, we could do timed intercourse vs. artificial insemination, aka IUI (intrauterine insemination).  IUI involves sperm washing- the semen is processed and spun down into a sperm concentrate, if you will.  Then it is injected directly into the uterus at the time ovulation is expected.  That way, you get way more sperm vying for the egg compared to the usual way.  Normally, the sperm have to make their way from the vagina and into the cervix, into the uterine cavity.  Only a fraction usually make it that far.  And then they have to make their way to the correct fallopian tube where the egg is waiting.  So IUI helps aid that process.

My labs confirmed that I am ovulating on my own.  If they hadn’t, then there is the option of a medication to help with ovulation.  He typically uses letrozole, though Clomid is another one many people are familiar with.  And then if all of that doesn’t work, then IVF would be the next step.

We decided to give the IUI a try to see if that gives us the extra boost needed to conceive.  So we’ll see how that goes with my upcoming cycle.  I still wonder, though about the contribution of stress.  He didn’t say too much on the subject, which I asked about in combination with acupuncture.  It seemed like he wasn’t super familiar with acupuncture for fertility, and reacted the way most of us doctors approach alternative medicines/therapies.  It’s probably safe, but he’s not aware of how helpful it is, and if it helps with stress, that’s not a bad thing.  He did caution using the herbs, as they can often contain ingredients that aren’t recommended to take in pregnancy.  One of the acupuncturists did recommend herbs, to take from the beginning of the cycle until ovulation.  So I suppose any effects on the fetus would be less likely given the timing, but nevertheless I’m skeptical on how helpful they’d be, so I’ve decided against taking them.

The biggest change I made this month is starting a part-time schedule.  For a long time, I’ve been struggling to keep up with the workload.  Even though I’m not ecstatic about cutting my salary, it was a necessary decision for my sanity, which also affects my husband.  So I will now have one day off a week.

I recently attended a fascinating conference on physician health and wellness, the American Conference on Physician Health.  The conference sold out, and was attended by physicians from all over the country, and even a handful from other countries.  It’s disturbing how prevalent physician burnout is.  According to Medscape polls, about half of all U.S. physicians have at least one sign of burnout, with the highest rates in emergency medicine and obstetrics & gynecology.

Traditionally, the culture in medicine has been that of toughness- that we’re able to, and expected to handle the difficulties of medicine.  It’s like a badge of honor- not sleeping for X hours, seeing X number of patients, working so much that we don’t have time to eat or pee.  Now, it’s becoming evident that physician burnout is costly to healthcare, which is why CEOs are finally starting to take notice.

This overworked, disgruntled workforce not surprisingly tends to have less satisfied patients, with more patient complaints.  Unhappy physicians are more likely to take more sick leave, and leave the practice or sometimes medicine altogether.  On the more serious side, physician burnout is linked to increased liability- meaning that they have more medical errors and more lawsuits.  Worst of all, the rates of physician suicide are much higher than that of the average American, and higher in women physicians.

There are many factors that contribute to physician burnout, such as insurance companies dictating care and reimbursement.  Excessive time spent on administrative duties is another huge factor.  I was fascinated to learn in a talk by Robert Wachter, MD that in any industry, there is a paradoxical delay in productivity increase when there is a change from paper to computers.  Even though you’d think the switch to computers would automatically increase productivity, it usually takes 10 years for that to occur.  That’s because the change from paper to computers isn’t enough to increase productivity.  The industry needs to figure out how to use technology effectively to increase productivity.

Well, in the case of medicine, given the additional rules and regulations, and patient privacy concerns, change is even slower.  So he estimates it will probably take 15-20 years.  Over the last 10 years, there has been the switch from just a few practices having electronic health records to the vast majority going electronic.  So that means we have at least 5-10 years before we actually develop the electronic health record into a system that is truly user-friendly and efficient.

I’m optimistic that the healthcare organization that I work for is recognizing that physician burnout is such a significant issue and is a priority to address.  With that said, I can’t wait several years for things to change gradually.  I am burnt out right now, and I made the decision to go part-time for the sake of my well-being.  Working one day less is not going to erase the fact that I’ll still be overworked on the other 4 days of the week, but hopefully will make life more manageable.

I do suspect that this burnout has been contributing to not getting pregnant.  Even though the data is inconsistent regarding stress and its effect on fertility, I can’t help but feel like that’s a contributing factor in my case.  Maybe that doesn’t happen for every woman, but it makes sense that my body is saying- you are not at a place in your life where it’s a good idea to put yourself in a situation that is going to require more of your body’s resources.  After all, a fetus is a little parasite that is going to make me nauseous and even more exhausted.

While it may not happen right away, I’m hoping that this combination of working less, doing acupuncture, and trying IUI will help us finally conceive.



Pulling Out All the Stops

Since WZW was born, I never went back to being strictly on the Paleo diet.  Initially the sleep-deprivation made a huge impact, but even as that improved (thank goodness!), other factors continued to affect my lifestyle.  Time is the biggest factor- no longer could I leisurely exercise after work and come home at 8 pm.  Nor do I have the energy to prioritize meal prepping.

Instead, I’m spent after my work days, and feel like everything else goes towards dealing with a nonstop toddler.  I’ve grown accustomed to eating lunches made by Trader Joe’s, or eating what’s offered at work.  On Mondays, which are the busiest for me and my husband, we get dinner delivered by Munchery.  While we can choose options that aren’t totally carb-laden like pasta, the meals usually involve a starchy side.

A lot of it was my mindset as well- with the stress of work, and dealing with a toddler, I just felt like prioritizing eating was something I didn’t have the capability of doing.  So I got used to comfort eating, and not trying so hard.

But I started realizing that it’s expensive to be half-assing the Paleo lifestyle.  We spend extra money getting things like Paleo crackers and gluten-free bagels from Whole Foods.  It would be one thing if I was really following the diet, but since I haven’t totally been, it’s kind of a waste of money.  It’s like buying organic produce, and then eating Hot Cheetos.

A workplace “Biggest Loser” competition has also motivated me to focus more on my eating habits again.  One of the ladies at work decided to start a Biggest Loser challenge for those who are interested.  Her intent is to promote healthy living, so although there is a cash prize for the winners who lose the most weight, the contest will last 6 months, and among other rules, no fad dieting or other unhealthy methods of weight loss are allowed.

I decided to participate, not with the intention to win (because hopefully I’ll get pregnant during the 6 months), but as a motivator to eat better and also exercise more when I can.  I also wanted to help motivate and educate our staff participating.  So far we’re one month in, and I have been better about avoiding dessert, and being less lax about the carbs.  My husband has been monumental in doing the bulk of the cooking.  The exercising is more difficult due to time constraints, but I’m doing what I can.  Sadly, at the one month weigh-in, my weight still hadn’t budged, but I’m trying not to let that get me down.  I need to focus on the fact that I’m taking better care of my health by eating better.

In addition to the lifestyle improvements, I also decided to get referred to the fertility docs, the REIs as we call them (reproductive endocrinology and infertility).  After 6 months of trying, given that my age is over 35, I qualified for referral.  At that point, I asked my doctor/colleague to check my labs.  We checked my cycle day 3 FSH, which if elevated would indicate age-related infertility.  I was concerned that’s what the issue was, especially since my mom went into menopause on the earlier side.  The FSH was in the normal range.

So that’s a relief, but then what’s the issue?  It’s hard for me not to blame myself for not eating better/being at a healthier weight, and for being under too much stress.  Ultimately, I’m doing the best I can with the situation I have, and logically I tell myself not to get down.  But it’s hard not to beat myself up.

After another 2 months passed for a total of 8 months of trying, I decided I shouldn’t waste too much time and went ahead with the referral.  I have yet to meet with the REI doc- we have to complete our labs, and then schedule the consultation.  In the meantime, I decided to look into another modality to help me with fertility- acupuncture.

My first exposure to the concept was the episode of Sex and the City where Charlotte gets acupuncture to try to help herself get pregnant.  I don’t know much about it, and hadn’t thought about it recently until one of my patients mentioned using it to get pregnant.  That reminded me that one of my OB/Gyn friends had said she used it while doing IVF, at the recommendation of her REI doc.  She wasn’t sure if it helped, but at the very least it helped her destress.

Once I started asking colleagues and friends about it, there were all these mentions of, “Oh yeah, so-and-so was having a hard time, and finally got pregnant after doing acupuncture.”  Of course, it doesn’t work for everyone, and one of my colleagues said it didn’t work for her (she later succeeded with IVF).

Given that my insurance has coverage of acupuncture, I figured I didn’t have much to lose.  I still don’t know the data regarding acupuncture and fertility.  And I’m not sure how best to find a trustworthy practitioner.  But so far, I completed my first session.

I filled out a health questionnaire with some different inquiries than you’d find on a Western medicine form- things like the color and consistency of my menstrual flow.  The practitioner checked my pulses (done for a different purpose than in your usual medical office), and my tongue.  Then she proceeded to do the needles and left me for 30 minutes, during which I started to drift off.  It was similar to what people probably experience during a massage or savasana at the end of yoga.

Though I didn’t think I fell completely asleep, I did end the session feeling more energetic.  I’d also been feeling more anxious from my general stress, and that feeling improved as well, which was a pleasant surprise.

Interestingly, she said that she recommends eating in line with the Paleo diet more or less.  Her list of foods allows quinoa and buckwheat, but mostly everything else goes with Paleo.  She recommended eating lots of eggs.

One big difference is that based on the Chinese medicine recommendations, she advocates eating only cooked foods- that means no salads, no yogurt for breakfast.  That is going to be hard- especially avoiding raw fruit.  Now, these recommendations probably aren’t for everyone trying to conceive.  It’s based on my particular constellation of issues.

In my limited understanding of Chinese medicine, I know that there are various organs that are different from the same organs in Western medicine.  My acupuncturist said my “liver” is too strong, and the “spleen” is weak, which is the reason for the dietary recommendations.  My friend said that they generally work on the “kidney” system for fertility issues.

So we’ll see how it goes.  Hopefully between the healthier eating, acupuncture, and eventually seeing the REI doc, we will finally get pregnant.