Doctor's Blog | Arizona Reproductive Medicine Specialists

A Father's Eyes...or a More Sure Path

Friday, 10 June 2011 19:47

By Drew V. Moffitt, MD

"A small boy's definition of Father's Day: It's just like Mother's Day only you don't spend so much." – Author Unknown

Last week I received a call in the morning from a patient I had not seen in a while. I called him back and he told me that he and his wife had decided to adopt, but the adoption fell through at the last minute. He said they had the baby for three days and then the birth mother changed her mind and took the baby back.

I have had this happen to my patients before but it had never seemed quite so immediate. He was anxious to talk about options and was wondering how quickly they could get in for a visit. I sensed urgency in his voice and told him I would see what I could work out. It was a Friday and after some back and forth, the only time we could all meet was around 4:45 that afternoon.

He arrived before his wife did and I brought him in. My goal was to get a sense of what they were thinking of and how his wife was feeling. Her biological clock was a little advanced and I wanted to be careful about what I said so as to not upset her. When we sat down to talk, he thanked me for fitting them in and then he told me that the baby was taken away just yesterday evening. When he told me that, I saw a deep grief and pain fill his eyes. I did not know what to say other than, “I am so sorry.” He said it felt like his baby had just died.

The words to the song, “Empty chairs at empty tables” from the musical Les Miserables kept coming to my mind…”a grief that can’t be spoken, a pain that goes on and on…”

As I write this, I can still see that look in his eyes.

As I look back on this encounter, I realized that I was so focused on how to help with the emotional trauma of his wife that I took for granted his emotional pain. As I think about this coming Father’s day, I wonder how “taken for granted” the men feel in this fertility journey.

I remember my own journey as an infertile partner. I am not sure I even acknowledged my feelings during this process. I was too focused on trying to be the knight in shining armor that was going to take control and fix everything. The only real emotion I recall was guilt that my wife had to go through all of these things while I just stood around watching.

The conventional wisdom has been that men are not as emotional or stressed about infertility. Recent research now seems to show that men have comparable responses to infertility as women(1). Unfortunately the word hasn’t really got out yet - especially to the men experiencing infertility.

I know what I see most often. In the book, “Men are from Mars, Women are from Venus” men are categorized as wanting to fill the role of the knight in shining armor - the one who is going to protect their princess and solve her problems. Infertility significantly hinders his ability to fill that role. There is not a lot he can do to solve the problem himself, and he is relegated to watching his princess go through procedure after procedure and heart break after heart break. He can neither solve nor protect. And sometimes it is no more complicated than the fear and sorrow of the possibility of a life without piggy back rides, catch, and butterfly kisses after bedtime stories. And then to have that hope realized for three days and then ripped away. I have no idea what that feels like, but I know now what it looks like because I saw it in that father’s eyes.

I have always thought that adoption is a beautiful thing. It turns hopelessness into happiness and fatherlessness into family. But what happened here just isn’t right. This couple spent close to $40,000 dollars to get to the point they did in the process, only to have their hearts broken. The majority of this went to pay for the birth mother’s expenses. They will only get back a small fraction of this amount.

Clearly the birth mother has a side to this story that I do not know and deserves protection during what can be a very vulnerable time . Having said this, there is too much money flowing in one direction to not ask hard questions and consider other options.

If there is no more guarantee than what this couple experienced, how does this compare to alternative solutions? One is egg donation. Egg donation is the most successful fertility treatment known to man. Success rates are routinely in the 50- to 75-percent range. They are so consistently in this range that some clinics are able to offer a complete refund if a couple does not take home a baby, usually at a cost significantly less than what this private adoption cost and failed to deliver. The couple is in complete control. They are able to pick the characteristics of the egg donor. They are able to control the environment of the baby in the womb. And with the onset of egg freezing, they can be in complete control of the schedule.

Perhaps most important of all, a couple choosing egg donation has zero chance of experiencing what this couple has had to experience.

As I sat across from this couple and discussed this kind of a path, I could see the beginnings of hope rise like a phoenix from the ashes of the despair they had felt for the last 20 or so hours. I watched this father get up off the ground, dust off his shining armor and mount his horse again. I saw something new begin to stir in his eyes. Perhaps it was a vision of butterfly kisses after bedtime stories.

“Mothers-to-be” Day …Or the Power of A Smile

Friday, 06 May 2011 21:34

By Drew V. Moffitt, M.D.

She broke the bread into two fragments, and gave them to the children, who ate with avidity.

"She has kept none for herself," grumbled the sergeant.

"Because she is not hungry," said a soldier.

"Because she is a mother," said the sergeant.

—Victor Hugo

The other day I ran into another one of those patients who always makes me smile when I see her. She brought me up to date on what was happening in her life. It was a story of debilitating pain and multiple surgeries to try and relieve pain. Instead of relief she developed a tumor in the area that required more surgery. In the end, she was still in just as much pain and on chronic pain medication.

I expressed my heartfelt sympathy for what she has had to go through. She smiled and said she’s fine and that she is almost off of the pain medications because she is planning to see me soon to try to have another baby. She was coming off of the medications not because she didn’t have pain, but because she wanted to have another baby. I looked into her eyes – and her smile, and realized I am a better person for knowing her.

Mother’s Day is upon us. It is not the most welcome holiday for my patients. Gifts passed out at church or given by a well-meaning spouse do little to fill the void of yearning that brings patients to my office. We hear stories about the great love, sacrifice, and courage that mothers have for their children, but little is said about the incredible love, sacrifice and courage of “mothers-to-be.”

It takes incredible courage to acknowledge that there is even a problem. We all want to believe that we are in control of our lives. Just to acknowledge there is a fertility problem is to internalize a lack of control over this incredibly sensitive part of their lives.

It takes courage to seek medical attention. No one likes to see doctors (I’m over a year late for my own colonoscopy), and the trip to the fertility doctor is a particularly difficult journey.

It takes courage to undergo procedures that are not comfortable in an area where discomfort is particularly unwanted.

It takes courage to face the possibility of disappointment. Studies have shown that when a woman experiencing infertility has her period, indicating that once again she is not pregnant, she experiences the same degree of grief as if her brother or sister had just died. Most of us go through that only once or twice in our lifetime. Imagine going through that every month for years. Then imagine going through a specific procedure to get pregnant and having it not work.

It takes courage to hope that it will work the first time and proceed, and even greater courage to experience a failed attempt and then turn around and have the courage to hope again.

These women undergo great sacrifices.

They sacrifice the intimacy of what was supposed to be a wonderful and intensely personal experience with their partner for a doctor’s office.

They sacrifice time on repetitive visits for monitoring and procedures.

They sacrifice financial resources to have something that everyone around them seems to receive without thought and sometimes with disdain.

They sacrifice personal comfort, sometimes thinking that if they experience pain, they will be more worthy of the “gain” they so desperately seek.

Why do they do this? For the same reason a mother gives her bread and goes without. For love. The only difference is they do it for a deep abiding love for a child that they have not yet held, a voice they have not yet heard, a smile they have not yet seen, and a touch they have not yet felt.

My smiling patient had experienced infertility for 10 months when she first came to see me. It was clear that each passing month was difficult. She had endometriosis and her husband had a sperm problem. Unfortunately her biological clock was more advanced than it should have been. When two months of inseminations failed, she tried IVF. She required high doses of medication to produce nine eggs but only made four embryos, one of whom became her beautiful baby boy.

Sixteen months after delivery, she was back for his brother or sister. She tried IVF again, which resulted in a positive pregnancy test but the pregnancy hormone dropped, leaving her with a “biochemical pregnancy.” The pain from her medical condition reached a peak and she had to stop infertility treatment to manage the pain.

She returned two years later after many surgeries and no pain relief with the intent to continue but could not. She returned again, two years, later having experienced a tumor where her pain surgeries had been and having had an additional seven biochemical pregnancies – and she still wears a smile. She is the epitome of the courage, sacrifice, and love that characterizes mothers in general and the “mothers-to-be” that I have the privilege of associating with every day.

To each of them and to mothers everywhere, Happy Mother’s Day!

Friday, 22 April 2011 20:11

Journal Club: What goes in the freezer? or…. Changing the game.

By Drew V. Moffitt, MD

I consider it a great honor to have trained at the Jones Institute for Reproductive Medicine. In last month’s Journal, Howard Jones, MD, co-founder of the Institute with his wife Georgeanna, now 100 years old, published a review of where we have come as a specialty (1). I was fortunate to hear him present this lecture last October at our national meeting. It was amazing how clear and profound his thinking was. In his lecture he identified the 7 most significant advancements in IVF to date. Number 2 was embryo freezing (cryopreservation). I remember a comment that he frequently made nineteen years ago when we were talking about pregnancy rates. He would slap his hand on the table and say something like, “Ah, but what about what’s in the freezer?” Last month’s journal also included a report of a baby born from embryos frozen 20 years before(2)! This is a dramatic example of the need to consider the pregnancy potential of what is in the freezer. The feature article in our journal club last month was titled: “Prediction of pregnancy rate by blastocyst morphological score and age, based on 1,488 single frozen-thawed blastocyst transfer cycles”(3). This article carefully scored how embryos looked before and after freezing and then looked at how the morphology of these embryos correlated with pregnancy rates. There are several reasons why this study is important.

Monday, 04 April 2011 23:00

Does your Doctor Lie?.... or "The means define the end."

By Drew V. Moffitt, MD

You know how it feels when you find out you have been lied to? You get a kind of sick empty feeling in your gut. The other day I found out that I had been lied to. It was the bold, in your face kind of lie that makes you shake your head and wonder, “What kind of person is capable of that?” This isn’t the first time I have been lied to and I suspect it will not be the last. What was unique about this is that the person doing the lying was another infertility doctor in town and money was involved. I have been doing a lot of head shaking since then. You want to think that there are circles where people won’t sink below a certain level. I guess there aren’t. It reminds me of an episode from that epic TV show “Kung Fu” in the seventies (sorry to date myself). In one of the many flash backs the main character has to his childhood in the Kung Fu monastery, he and a friend are deceived by a stranger and robbed. When they return to their master, he asks each of them what they have learned. His friend says, “Never trust a stranger.” The master says, “Time for you to go” and kicks the kid out of the monastery. The main character (no pressure!) says, “expect the unexpected,” and gets the thumbs up from the master.

Wednesday, 09 March 2011 00:02

The ups and downs of progesterone or.. "It ain’t over ‘till its over.”

By Drew V. Moffitt, MD

My big manila envelope arrived. I must admit I don’t really get that excited about it. It is one of those things that is not necessarily fun, but is good for you in retrospect. I am talking about my Maintenance of Certification Part II REI ABC examination packet. I am a board certified obstetrician and gynecologist (Ob/Gyn) with subspecialty certification in reproductive endocrinology and infertility (REI). What all that means is that in addition to going to medical school, residency, and fellowship training, I had to take a written test, collect cases for two years, and take an oral test to become an Ob/Gyn, and then do that all over again to become an REI. Once that was done, I now get to “Maintain” that certification by doing several things each year including reviewing specific scientific publications selected by the American Board of Obstetrics and Gynecology (ABOG) and taking a test (open book!). The good news is that most of the articles they select for us to review are actually very good and important for us to know. The bad news is that it is not always easy to find the time to do it. I usually review the articles at 6 am while I am exercising on a recumbent bike at the gym. I do it then because I don’t really like riding the recumbent bike…. Ok it’s complicated.

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Monday, 14 February 2011 22:25

You're in Good Hands or … "Be a Valentine"

By Drew V. Moffitt, MD

I can always tell when I am going to get the attention of the guy during a visit with a couple. Most of the time they sit there with a glazed look in their eyes, but when I say, “Now let’s talk about the risks of the treatment,” they sit up, lean forward, and look at me with LAZAR beam eyes. I have even had them say with great deliberateness, “Doc, Let me make this perfectly clear. I just don’t want anything to happen to her. She is what is most important to me.” What a beautiful thing! It is also a good thing for me that I can say without equivocation that I feel exactly the same way. Our patient’s safety has always been a priority at ARMS. From the beginning we have gone beyond the norm to bring to our patients the highest chance of success with the lowest chance of a complication.

So once I have the attention of both partners, I go over the risks of doing an IVF cycle. I tell them what the probability of having a complication is, but don’t usually go into why it is so low. Here is the why.

Monday, 07 February 2011 22:25

Journal Club or “Why do we Need ICSI Again?”

by Drew V. Moffitt, MD

I remember my first journal club in Norfolk, VA. It was at the home of Howard and Georgeanna Jones. I was pretty nervous. I was going to be presenting an article for the first time. It turned out to be a very different experience than I was expecting. Perhaps this all needs a little explanation. A journal club is kind of like a book club. Each month a few scientific articles that were published in the most recent month’s magazine (journal) are selected to be reviewed by the “club”. The club members are typically the professors, residents and students at a given institution. Norfolk, VA is where I went for my fellowship in Reproductive Endocrinology and Infertility more years ago than I would like to admit. The institution is called, “The Howard W and Georgeanna Seager Jones Institute for Reproductive Medicine” which was the birthplace of IVF in the US. Dr.s Howard and Georgeanna (as we were expected to call them) were distinguished professors at Johns Hopkins University before they decided to retire to Norfolk where the political climate of the day would allow them to pursue research into IVF. They pioneered IVF and Dr. Howard, who turns 100 this year, still shows up for work on a regular basis. I consider it one of the greatest honors of my life to have been able to work with these great pioneers and to have trained at the Jones institute.

Friday, 07 January 2011 00:00

New Year’s Resolve – or “One good egg”

by Drew V. Moffitt, MD

It was near the end of the afternoon. I was dealing with the typical catch up that punishes all of us for having the nerve to take a vacation for the holidays. The medical assistant called in and told me that my next patient was ready to be seen. I looked at my schedule to see who it was and to my surprise it was a patient I knew very well after years of mutual struggle to help her conceive. I was surprised to see her on my schedule. For a moment a chill went down my back as I feared that maybe something bad had happened. I quickly looked at her chart to see what was going on. As is my custom, I clicked on her photograph before turning to her medical record. I knew what I would see before the picture loaded – a smiling face that never fails to lift my spirits. As the picture loaded, I smiled. I then opened her medical record and began to review her 10 year journey to realize her dream of having a family.

She had tried for a year before coming to us at age 27. Initial evaluation indicated that her biological clock might be a little advanced for her age but that everything else was normal. Five cycles of simple treatment showed that she was a good responder to common fertility medications. A diagnostic surgery to evaluate her pelvis showed a mild case of endometriosis. After one more cycle she decided to do IVF. She proved to require high doses of medication to stimulate her eggs and in the end, though she had a reasonable number of eggs, there was concern about the quality of the eggs. She did not get pregnant after the fresh cycle and two frozen cycles. She then dropped out of treatment for 3 years because of illness, personal issues and significant stress.

Thursday, 23 December 2010 23:26

A Christmas Carol

by Drew V. Moffitt, MD

I am sitting in my office after a long day. Everyone has left, rushing off to the bustle of their Christmas preparations. A quiet sets in, interrupted only by the sound of cars speeding by. As I sit here, I feel struck by the events of the last few days. Since Monday, I have done eight early pregnancy ultrasounds and called 6 patients with pregnancy test results. The majority have received wonderful news and have left the office with a special bond with the young pregnant woman who was making her way to Bethlehem this time of year so long ago. I think this will be one of the most special Christmases they will ever have.

Others have received mixed news. There are aspects about the tests that are not reassuring, and we have to wait and see what happens. They leave the office with a desperate hope as they cling to the life that took so much to take hold inside of them.

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