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. 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 to get pregnant for a year before coming to us at age 27. The initial evaluation indicated that her biological clock might be a little advanced for her age, but 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 in vitro fertilization (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 a fresh cycle and two frozen cycles. She then dropped out of treatment for 3 years because of illness, personal issues and significant stress.
She ultimately did return and attempted another IVF cycle. In that cycle, she produced fewer eggs (despite more medication) and the egg quality was the worst that our embryologist had ever seen. He commented, “I told her that in my 15 to 20 years I have never seen a case like this with so many abnormal eggs of this quality.” They did not develop and for the first time in my medical career I had to tell a patient that she did not have any embryos to transfer.
25 days later she was in my office again, discussing possible reasons for this worsening outcome and options for the future. There were no clear answers and just hints of what we might do to try again. She was determined to try one more time using her eggs.
Hints from the first and second cycle were used to select a slightly different treatment protocol. She responded well. There were more eggs than the second time, but there was still concern about quality (though not as severe). The best embryos were transferred and the rest were closely watched in culture. One went to the blastocyst and was frozen. The rest died in culture. She did conceive, but the pregnancy was barely hanging on. Low pregnancy hormones slowly increased for almost 2 weeks and then finally dropped. She had an early miscarriage – her second pregnancy loss. The first was eight years earlier. A series of blood tests were done to find a reason for the miscarriage, but none was found. She bounced back and presented for a frozen embryo transfer. The cycle was started but she did not respond well to the protocol and the cycle had to be canceled. We selected another protocol, which brought disappointment and more waiting.
The day of the transfer of her final embryo arrived. Then came a normal positive pregnancy test. Normal pregnancy ultrasounds…finally, after ten years.
I hurried out to see her and I caught her eye. She smiled, stood, then stooped down and picked up a beautiful 15-month-old girl that was hidden from my view. I smiled. She had returned for another. She did not mention a word of the difficult road she had traveled. A treatment plan was made and she embarked on another journey.
As I look back on this encounter, I am struck by my initial reaction – when I realized who my next patient was and watched her picture load on my computer. I did not immediately recall the details of the difficult journey, nor it’s outcome. I simply recalled what a nice person she was and how her smile, her kindness, and her optimism never failed to lift my spirits. After reviewing the difficult road she traveled, I am struck by the length of the journey and the magnitude of the struggle. But what I am most struck by is that despite all of that, what I remembered about her was that she always made me smile.
Every Christmas season, I read an obscure short story by Charles Dickens called, “The Battle of Life”. Near the end of the story, one of the characters says the following:
“It’s a world full of hearts,” said the Doctor, hugging his youngest daughter, and bending across her to hug Grace — for he couldn’t separate the sisters; “and a serious world, with all its folly — even with mine, which was enough to have swamped the whole globe; and it is a world on which the sun never rises, but it looks upon a thousand bloodless battles that are some set-off against the miseries and wickedness of Battle–Fields; and it is a world we need be careful how we libel, Heaven forgive us, for it is a world of sacred mysteries, and its Creator only knows what lies beneath the surface of His lightest image!”
I have not yet made any New Year’s Resolutions, but I think that one of them is going to be to face my battles with greater resolve and optimism, to live my life so that people will smile when they remember me, and to remember that it only takes one good egg.
Drew V. Moffitt, M.D., FACOG, is co-medical director and president of Arizona Reproductive Medicine Specialists (ARMS) and an assistant professor at the University of Arizona. He is also director of the Division of Reproductive Medicine and Infertility for the residency program at Good Samaritan Regional Medical Center. Dr. Moffitt has been in practice for over 17 years and has significant clinical experience in assisted reproductive technologies and reproductive surgery. To schedule a consultation, call (602) 281-9032.
