Note to Paul: Warm the speculum.

I have spent some time considering the question of selecting an obstetrician — more time than the situation strictly warrants, given how few choices I truly have. Here are my options:

• OB/GYN practice affiliated with local hospital. I have something of a history with this practice, since it was they who initially referred me for fertility treatment. They have performed upon me a grand total of two Pap smears, one excruciatingly painful IUI, and one excruciatingly painfuller HSG.

  My doctor of record at this practice is, well, a prick. My last encounter with him was before this last cycle, when I needed some cervical cultures done. He asked a few questions about my treatment thus far; apparently my answers annoyed him because he finally sighed dismissively, rolled his eyes, and said, "You know what? I'm just going to shut up and do the swabs." Do, thought I, bracing myself for the onslaught.

  I object to being treated by him. There are other doctors in the practice and a whole mess of midwives, so I probably shouldn't rule out the entire practice, but since my every encounter with the office staff has been, oh, infuriating, I am not inclined to give them further consideration. They have lost my test results, then failed to send them to other doctors when asked, then refused to give them to me without an immense amount of static. ("No, in fact, the doctor does not have to give his consent for me to have them. They are my property, so go eat a bag of dicks and get me my records.")

  I have, uh, problems with this practice.

  Unfortunately, they seem to be the only game in town. The hospital itself, with which they are affiliated, is approximately ten minutes away from my house. This is an enormous advantage when we consider that I'll be delivering in February in New England. So I mastered my revulsion and called for an appointment.

  They can see me in three weeks. "I wish you'd called earlier," the receptionist said in a regretful but censorious tone as I politely (no, really) marveled about the wait. "I couldn't," I told her calmly (I swear). "I had to make sure another baby hadn't died on me before being released by my RE, you callous whore." (Okay, I exaggerate, but only a little.)

• OB/GYN practice affiliated with hospital 40 miles away. This practice is the home of a doctor who comes highly recommended and who is, I have been given to believe, downright promiscuous with the ultrasound wand. The distance is a concern. Although I am sure Paul is perfectly capable of driving safely at 3 AM in the middle of a blizzard when the road is sheathed in black ice and I am keening hideously next to him —

  Hm.

  However, given the unsatisfying exchange with the local practice, I called for an appointment anyway. "How about tomorrow?" the receptionist asked brightly. "That'll be great," I said happily (no, really).

• Prenatal care and homebirth presided over by Paul. "Maybe you could hurry up and go to med school," I suggested. "No need," he answered enthusiastically. "For prenatal care, how's this? Take your vitamin and put down the vodka bottle." He paused. "And how hard could amnio really be?"

I've been dreading the start of obstetrical care. I am not ready to ask many of the questions that a patient customarily asks — delivery policies, C-section rate, position on inducing labor, et cetera — because I'm still not convinced I'll get that far. It feels like daring the universe, a prideful challenge it won't be able to resist.

Nevertheless, I'll go. I'll pee in a cup, I'll allow myself to be weighed, and, if I'm lucky, I'll see a heartbeat. For all his good intentions, Paul has not yet been able to engineer a homemade ultrasound machine that satisfies my exacting requirements, so I'll have to make do with a board-certified physician.

We'll just see about that.

Last week I met the midwives at the practice 40 miles away. They are a lovely bunch, kind and warm, supportive and reassuring.

I don't think they know what hit them.

Every time one of them would say something like, "You're going to have a baby!" I would feel an irresistible urge (which I did not, therefore, resist) to say something hideously pessimistic in response, like, "We'll just see about that."

"And then in February..." one would start, and I would add, "...If we get that far..."

"By then your baby will be..." one said. "...Not dead, I hope," I finished.

(Okay, I only thought that last one.)

There's no reason to believe that my pregnancy is currently at risk. There's no reason at the moment to think it will be anything but routine. But by the time I left, the nice ladies were tight-lipped and rattled-looking. I think my lousy attitude convinced them that I'm so impossibly broken that I was about to miscarry on the floor right in front of them. I think one of them even called pre-emptively for a bucket and a mop.

On the one hand, I feel awful, alarming them when they were so kind to me. On the other hand, since my obvious mental disturbance convinced them to order an ultrasound earlier than usual, the end may justify the means. Score one for the power of negative thinking.

A supposedly fun thing I'll never do again

My future fertility was decided by committee two days after Charlie was born, by people I didn't know.

On Monday morning, when I was finally allowed out of bed, I combed my unwashed hair, put on the single pair of filthy socks I possessed, and made sure my ass wasn't showing through the peekaboo slits in my hospital gown. Then I shuffled slowly down to the NICU to see Charlie, anxiously shadowed by my mother, who stood at the ready to break my fall if I decided that the 100-yard walk was too far.

You know, it almost was. When we walked in, the nurses surrounded me in a protective swarm and ushered me to a chair. "We're just doing rounds," one of them said. "We're about to talk about Charlie." I sat hunched uncomfortably over my incision and listened.

The doctor who was speaking looks sort of like an elf — the cartoon Keebler kind, not the ethereal Lord of the Rings kind. He's short and pink, baby-faced with silvery hair, and I'd find him reasonably pleasant if he were offering me cookies baked to a golden brown inside the cozy recesses of a hollow tree. But, no, he is instead a somber elf of doom: just the morning before he'd sat in my hospital room saying gloomy things like, "Well, we don't have a crystal ball..."

Now he was going over Charlie's case, using a lot of acronyms I didn't understand at the time, summarizing for the benefit of two physicians' assistants, three nurses, two other doctors, and a gorgeous young medical student. He conducted rounds like a fey tiny Socrates, starting sentences but demanding that others finish them. He covered the urgency of Charlie's birth by holding his ball-point pen aloft — "And he had to come out right away because Mom's platelets were...?" — and dropping it onto the floor with a noisy clatter, then turning expectantly to the student. She pursed her pretty mouth like a guppy, her lips making impotent nibbling motions, unable to come up with the right words.

Don't let her touch my baby, I prayed.  I know full well what guppies do to their young.

The doctor sketched out my medical history in some detail. Four IVFs, two prior losses, complete placenta previa, gestational diabetes, HELLP syndrome. He looked expectantly at the group as he finished: "And would it be a good idea for Mom to get pregnant again?"

I looked, too. And seven heads shook solemnly side to side. (The student was too busy gumming her tasty, tasty plankton to offer an opinion.)

I had already come to that conclusion myself, during my bouts of teary wakefulness the night Charlie was born. It had all been terribly hard. So hard to get pregnant, so hard to stay pregnant, so hard to face what lay ahead with Charlie in the NICU. And not only hard, but dangerous. And not worth the future risk.

• Gestational diabetes. This is a complication a lot of women experience, and for most of them and their babies it's little more than an inconvenience. But it left Charlie's lungs unusually immature, making his first few weeks painful and frightening for him and for us and perhaps leaving him especially vulnerable in the future to respiratory problems. The recurrence rate of gestational diabetes is around 65%.
• Placenta previa. Placenta previa isn't a common condition to begin with (.3-.5% of all pregnancies). It's even more unusual for it to be complete and to persist to term. It is not especially likely to recur (4-8%), but the risk increases with increasing age (check), parity (check), and previous C-section (check). If it were to recur, I would be looking at a 50-60% risk of pre-term delivery. And a pre-term delivery coupled with gestational diabetes puts us where we are now — or, more troubling, where we were almost a month ago.
• HELLP syndrome/preeclampsia. Studies vary on how likely HELLP syndrome — which I had, which is more immediately dangerous than garden-variety preeclampsia — is to recur. Estimates range from around 5% to 27%. There is agreement, however, that women who've had HELLP are at increased risk (40-50%) for complications in future pregnancies, including preeclampsia, pre-term delivery, IUGR, placental disorders, and perinatal death. Even without HELLP, though, in my case the recurrence rate of plain old preeclampsia is about 40%. (It would be about 60% if I'd developed preeclampsia before 28 weeks. The earlier in pregnancy it occurs, the greater the chance it'll happen again.) And a frequent necessity in cases of severe preeclampsia? (Imagine the med student chewing kelp, and an incredulous silence descending as we wait in vain for her to answer.) Preterm delivery.

Now don't get me wrong. I am not sorry; I don't regret anything that's happened because it's brought us Charlie. After the fact, he is worth what we've endured. And I'd believe that of any other child Paul and I managed to conceive. But "Has it all been worth it?" is a very different question from "Knowing the risks, could I jeopardize my own health and the health of a baby I'd have come to love by the time it was endangered?"

I realize that I'm not likely to pull off a hat trick again, with so many hair-raising complications jam-packed into one measly pregnancy. I know I'm not likely to have any of the above again except for diabetes. But I also know I wasn't likely to get them to begin with. And that there are a thousand other complications I haven't even Googled. And that I could only get pregnant through expensive, heroic effort. Could it possibly be worth the risk?

I am making gaping fish faces, chewing on the only answer that makes sense to me.

Loaded for bear

Today I'm going to see my OB/GYN for the first time since before Charlie's birth. I am not sure how to handle this meeting, since my feelings about her are deeply ambivalent. I could use some advice. How should I greet her?

1. A warm smile, a firm handshake, and the willingness to let near-death experiences bygones be bygones;
   
2. A busy but sullen silence, which will make her stare at me and ask, "What?...What?...Christ, what is your problem?" (I will of course answer, "Well, if you don't know, I'm certainly not going to tell you!" Then I'll flounce around the examination room slamming cabinet doors and rattling stirrups angrily until she throws up her hands and announces that she's going to sleep in the other room.)
   
3. A sharp and dangerous bear trap cleverly concealed where only an OB/GYN dares to go

And if your vote is for option 3, do you think I should call ahead to make sure her nurse has a tourniquet handy?

I liked this doctor very much during my pregnancy. I found her competent and kind, matter-of-fact enough to reassure me that my complications were manageable, and attentive enough to make me believe they were being managed. But after the fact, I'm uneasy about the care I received.

An example. I'm embarrassed to admit it, since I take unseemly pride in being a well-informed consumer of expensive medical services, but I didn't know until after everything went haywire in November — known hereafter as The Incident — that the standard of care calls for a urine dipstick test at every late-pregnancy prenatal visit to check for protein secretion. I remember giving a urine sample once at my first visit so they could verify that I was actually pregnant, and not, I assume, just hallucinating those four early scans before being released from my RE's care. But beyond that, I don't remember ever peeing in a cup. I could have, I guess, but I don't remember it. And I am certain beyond doubt that I didn't at 28 weeks, my last appointment before...The Incident.

That's, well, that's kind of bad, right?

And I'm still unhappy about what happened on That Fateful Day — you know, the day of...The Incident. I was initially happy to learn she was the doctor on call that weekend, because she was familiar with my history and would, I felt, understand and share my concern. And at first, it seemed that she did. When I contacted her about the awful abdominal pain I was having, she told me she couldn't prescribe anything over the phone, but that I should get my blood pressure checked and go to the hospital if it was 145/90 or higher, good advice we immediately took. Paul drove me to the nearest grocery store, I wedged my vomiting bulk into the little booth, slipped my arm into the cuff, and away we went. 140/90 — close enough, I figured, and tried to notify her that we were going to the hospital, leaving a message to that effect. But That Fateful Day was to be a long and upsetting series of missed connections. The local OB never managed to get in touch with her before Charlie was delivered almost 10 hours later. I could perhaps forgive that, since I'm sure she was busy with more important things on...a...um, Saturday...night. What I am still having difficulty forgiving is that despite the messages the local OB left, despite the messages I left, she didn't call to check on me again until the following Monday. Not two-days-later Monday; the Monday after that.

I'm leaning toward bear trap myself.

I've set up this appointment for a few reasons. First, I need a Pap test and some form of contraception. (Stop laughing — I know I'm infertile, but it happens.) Aside from the possibility that I might spontaneously conceive — a possibility as remote as Pluto, which is to say far away but still visible with the Hubble space telescope — I want never to bleed again. Despite what some say about endometriosis receding after pregnancy, my periods are as crippling as ever and I would like to eradicate them entirely. Hello, continuous birth control pills.

Second, I want to get a referral to a maternal/fetal medicine specialist so I can get an opinion on just how foolhardy it would be for me to conceive again. (See above, "Stop laughing." See also "future IVF cycle," "wish, death" and "pipe, crack.") I know what Dr. Google says, and I know what the Keebler elves say, but I would like to speak with a specialist who has my medical history in mind, rather than relying on generalities.

Third, I need to know exactly what happened on That Fateful Day. Were there signals we should have noticed, harbingers of The Incident that we (and by "we" I mean "my OB," but I like to seem like a team player) ignored at our (and by "our" I mean "my") peril? Did my blood pressure, always low, steadily rise during my pregnancy as I seem to recall? How much weight did I gain? Did I really not ever pee in a cup?

Because that, well, that would be bad, right?

I don't, of course, trust this doctor any longer, though I suppose she's competent enough to reach up on in there with a speculum and an oversized Q-Tip. ("Oh, so that's where I left my bear trap! You have no idea how long I've been looking for that!") This isn't going to be a dramatic confrontation of any kind, mostly because I excel at those only after the fact in my fond imaginings, but also because The Incident is safely confined to the past and not a situation I will find myself in again (under her care during late pregnancy). I just need to know what happened, which she should be able to tell me based on her records and those of the OB who presided on That Fateful Day, and I need to know what's next.

Oh, and I need to know about the tourniquet.

But I did like the comment about the Yoda action figure.

You know, maybe I'm a little bit touchy, but comments like these:

I can't believe that you're going there without a lawyer, and with the intent to undress.

...are starting to bother me. As well meaning as I know they are, they seem to carry the uncomfortable implication that I'm...you know, kind of dim. Foolish not to adopt an adversarial stance. Incapable of making good decisions about my own medical care.

Those things could be true, I suppose. But when you comment, I'd ask you to remember that I'm making choices based on a full understanding of the situation, which you, despite my efforts to invite you into the stirrups with me, simply can't have. That I'm an adult in full possession of my faculties and a fair amount of medical information. That I'm navigating an extremely difficult situation as best I can.

For the record, I have no intention of suing my OB. Nor do I have any intention of letting her go all Dead Ringers on my ass (although, come on, admit it, you think so, too: Jeremy Irons plus lithotomy position equals fantasy gold).

I didn't go there seeking satisfaction from her. Somehow I seem to have given that impression, though I thought I'd made it clear that I simply wanted a recap, a review of what we saw during my pregnancy, a step-by-step explanation of what happened in Connecticut. I need to know, not so I can ascribe blame or write a strongly-worded letter or sue the glittering toe rings off my well-pedicured OB, but simply so I'll know.

I don't believe my prenatal care was bungled. In looking at my records, I saw that I was mistaken about my blood pressure; while I had a couple of readings that were higher than others, there was neither a pattern of a rise nor any single reading that was cause for alarm. In fact, my blood pressure was, as it usually is, on the low side. My weight gain was normal, with no suspicious jumps. And although my OB allowed that they should have taken a urine sample on my last visit at 28 weeks — "and I don't know why it wasn't — I'll talk to [the colleague who saw me on that visit]" — in this practice they don't test for protein until 28 weeks and beyond. (Apparently the usefulness of a dipstick test for proteinuria has been called into question, especially in the absence of hypertension. Could the standard of care be changing?)

At any rate, with normal blood pressure at 28 weeks, I can't argue that I was writhing on death's doorstep much before The Incident. The scary thing about HELLP is how quickly it can set in, without any warning at all. Although it would be tidier if my doctor could point righteously to my chart saying, "See? See?!" I can't assume a dipstick at 28 weeks, almost two weeks before delivery, would have shown any proteinuria to speak of.

If anyone were to blame for all this — and I don't think anyone truly is, nor did I ever — I'd have to blame myself. When I first felt stomach pain a few days before That Fateful Day, I called my OB and made an appointment, but when the pain receded I cancelled it. If anyone was negligent — and I don't think anyone truly was — it was I, in not being willing to be inconvenienced for the good of my own health.

In summary, although I would not choose this OB to manage a complicated pregnancy in the future, I feel all right about the care I received.

The exception, of course, is her delay in contacting me after Charlie's birth. I spoke to her about that and received an apology of sorts, an acknowledgement that she should have been in touch. Yes, she should have, and a mournful nod on my part communicated everything I wanted to say on the matter.

Where I did seek satisfaction was in a review of my records from the hospital in Connecticut. I'd requested that my entire chart be sent in anticipation of this visit. Unfortunately, the records appeared to be woefully incomplete — without the lab results on my bloodwork, there was no way for her to explain just how sick I was. And that's what I wanted most.

Kiss of the Spider Woman

The only thing the title has to do with this entry is that the maternal/fetal medicine specialist we consulted was wearing a pilled black acrylic sweater festooned with silvery Lurex spider webs and giant sequined spiders.

It just got more gothic from there.

I've been putting off writing about our so-called preconception consultation for one simple reason: I'm not at all sure yet how I feel about it. But many of you have asked, so I'll just lay it out here, rapid fire, without too much commentary and with, alas, little finesse.

Let me start with a short primer on HELLP syndrome, so that the particulars of my case will make more sense.

No, no, wait, let me start by telling you that to our consultation I wore my lucky shoes — you know, the ones that reduced my feet to seeping stumps, but nevertheless carried me ably through one of the best weekends I've had in years.

Now, about HELLP syndrome. I've always heard HELLP described as a variant of pre-eclampsia, or a severe version of pre-eclampsia, or even impossible to have without pre-eclampsia. But this doctor characterized the diseases as two ends of the same spectrum, with the classic symptoms of pre-eclampsia (high blood pressure, proteinuria, edema) occupying one end and the classic symptoms of HELLP (hemolysis, elevated liver enzymes, and low platelet count) on the other. Some HELLP patients display symptoms of pre-eclampsia as well; some do not.

At our consultation I learned I had not, at least not at the time I arrived at the hospital. My blood pressure was merely borderline; there was no protein in my urine; and I was having no headaches or visual disturbances. Even my initial bloodwork wasn't especially alarming. Although my liver enzymes were slightly elevated, my creatinine levels (which indicate kidney function) were normal and my platelets had not yet begun to decrease. Oh, sure, I had plenty of what diagonisticians dryly call "upper-right quadrant epigastric pain" but which I call "HOLY JESUS CHRIST I JUST DRANK A SNIFTER OF LAVA," but the important point is that when I arrived at the hospital, I wasn't yet that sick.

Later in the day, though, repeat bloodwork showed that my liver enzymes had risen sharply while my platelets had dropped dramatically. It was then that I went into surgery, with an unambiguous diagnosis of HELLP. "They did everything right," the specialist said approvingly about the hospital team in Connecticut. With blood pressure that stayed resolutely within acceptable limits, and kidneys that showed no sign of distress, it had been prudent to wait for that repeat bloodwork. And with the first sign of my liver kicking into overdrive while my platelets plummeted, it was imperative that we deliver. They did everything right. I had believed so, because, well, you kind of have to when a doctor tells you your baby needs to come so early. But it helped me to hear it was true.

Then, a surprise. For the first time, we saw the pathology report from my placenta. We were shocked to learn that it had an infarct — simply speaking, an area of dead tissue resulting from compromised blood flow. While it's normal for there to be some infarction in an aging placenta, it's never normal in one delivered prematurely. Such infarcts are often associated with placental abruption, intrauterine growth restriction (IUGR), and fetal death.

So it had been clear from my condition that Charlie needed to be delivered; my body obviously couldn't sustain the pregnancy. What we hadn't known was that there was another reason he needed to come out: if he'd stayed inside, the best-case scenario is that he would have become less healthy as his blood supply diminished. "He wasn't small when he was born," the specialist told us, "but he was on his way to being." I now find myself in the very strange position of being glad he was born so early, before anything worse could happen.

We discussed what kind of prenatal care would be warranted in a future pregnancy. Basically, the doctor seemed to be saying they'd advise me to acquire a comfortable refrigerator box and build myself a tidy little shantytown in the office's parking lot so that I might be available for close and frequent monitoring, including tests of fetal biometrics and uterine bloodflow. She would also prescribe baby aspirin, quoting studies that found not only a lower incidence of gestational hypertensive disorders in patients who took it, but birth weights that were higher by an average of 200 grams. (In preemie terms, a gain of 200 grams is enormous.)

Then she talked a bit about abnormal placentation, which was obviously at play this time around (complete placenta previa). She wondered aloud — and it was no more definite than that — about my other pregnancies (an ectopic and a miscarriage). Why, she wondered, did two of of my three pregnancies take hold incorrectly? And why did the third, which was a properly placed intrauterine pregnancy, not thrive? Was there something about my uterus that was inhospitable? Since that is mostly unknowable, she seemed more concerned than I was — though still not greatly — that placenta previa might in fact recur.

Almost as an afterthought, we all agreed with a great deal of jollity that we didn't even need to discuss my risk of a recurrence of gestational diabetes. As complications go, and especially as complications I've experienced go, that's a minor concern, and a manageable one at that.

And then we were suddenly in the thick of it.

Thanks to the vast medical library Google has kindly made available to me because I'm so excellently cool, I had read that the recurrence rate for HELLP is a matter much disputed, with any number necessarily being confounded by the fact that many, many women who've had HELLP never attempt a subsequent pregnancy. Nevertheless, some sources put the rate of recurrence at 4%; others put it as high as 27%. With the caveat that we don't know yet whether I have any interesting underlying conditions, for which ten vials of my blood are currently being tested, this doctor quoted my risk at 50%.

Wait, wait, it gets better.

With a lot of disclaimers — "I'm being as conservative and pessimistic as I can on this one" — she estimated our risk of having another severely premature baby — "at 32 weeks or before" — at 50%.

"But," she hastened to add, "your chances of a good outcome are very, very high," especially if the bloodwork reveals any condition that's correctable with medication. In fact, she concluded, in language that is interesting in its ambiguity, "I would absolutely not advise you not to try again."

So what do you make of that?

One last thing. I must point out that when Paul and I left the appointment, we were rather more upbeat than not. It wasn't because the future was suddenly looking rosy, or because we finally had all the information we needed to make a choice we could live with. It had more to do with feeling we were in good hands, that I'd be cared for vigilantly if we chose to try again, that a pregnancy could theoretically be managed in such a way as to limit the danger to a baby and to me. And that we still, after all, have options.

No, wait, I lied. That's not the last thing. This is: I spent a large part of my morning investigating an unpleasant funk wafting through the back hallway where we hang our coats and leave our shoes. The source of the funk turned out to be an ectopic — get it? — deposit of cat urine, which was left, I presume, when the litter box was blockaded by a baby gate left inadvertently closed. And do you know where the cats had done the deed?

Why, right on my lucky shoes.

So what do you make of that?

Prediabooties

The last time I saw a doctor for anything non-vagina-related was more than five years ago.  I could argue that even that visit had pelvic origins; my primary care doctor was certain that the burning gastric pain I frequently experienced was the result of my monthly menstrual abuse of ibuprofen.  She refused point-blank to remove my gallbladder, prescribed a cocktail of Maalox and novocaine, and sent me off to make do with two chump-ass extra-strength Tylenol.

From this, I concluded that she was obviously a dangerous quack and resolved never to darken her doorstep again.  And in the succeeding five years, I never felt I needed to.  I am either very healthy, very stoic, or very stupid.

I had a battery of bloodwork run when we consulted the maternal/fetal medicine specialist, which uncovered Factor V Leiden.  In reviewing those results, my garden variety OB/GYN — the least specialized of my worldwide cadre of coochie doctors — noticed that I'd never had a followup glucose tolerance test postpartum.

You know where this is going, right?  Right?  C'mon, this is me.

Three more days of carb loading.  Ten more ounces of syrupy orange swill.  Two more hours of rolling my eyes, looking at my watch, and staring pointedly at the large-bellied woman sitting across from me knitting booties.  (I swear to God she was knitting booties.  Hey.  Lady.  Yeah.  You're pregnant.  We get it.)  And one more call from my gynecologist saying I'd flunked.

My fasting level was fine, but my final number was high — 140 is top end of normal, and I skidded in at a jaw-clenching, teeth-chattering, Jesus-gay-but-that-stuff-is-sweet 151.

That's not high enough to qualify as full-blown diabetes, but it's high enough to reveal that I have what's called impaired glucose tolerance, colloquially called prediabetes.  It's not a troublesome condition in and of itself, but rather a big flashing neon warning sign that I'm much more likely to develop Type 2 diabetes later in life, and am at elevated risk for heart disease and stroke.

Now, I already knew that based solely on family history.  (Parent with diabetes?  Check.  Parent with heart disease?  Check.  Parent with hereditary coagulopathy?  Check, please.)  But now my doctors know it, too, including my primary care doctor. 

My OB/GYN is a rotten goddamn tattletale, is what she is.

So now what's going to happen is that my primary care doctor, whom I couldn't pick out of a police lineup if she had "I am the real killer.  Please catch me before I kill again" tattooed on her forehead, will tell me I need to exercise more and watch my diet.  That's it.  To delay or perhaps even prevent the eventual onset of diabetes, the sole prescription is to lose weight — which I don't need to do, thanks to a cool 20 I recently lost — exercise more, and eat plenty of baconless leafy greens and colon-scouring fiber...which we all should be doing, anyway.

Hey!  Thanks for the help.

In other words, no surprises.  The most disturbing thing about this revelation is the fact that I'll be expected to do a glucose tolerance test every year.  That's an awful lot of bootie-knitters to glare at, you know.

Medical moment

On the advice of my OB/GYN after I failed my more-than-a-year-postpartum glucose tolerance test, I recently visited my primary care doctor for the first time in five years. Three things of note happened at this appointment:

1. She glanced at my glucose numbers and barked, "That's not high. Why are you here?"

2. When I told her I'd recently lost weight, she asked whether I intended to lose more. I told her I'd like to drop ten more pounds. "And you think you can do that?" she asked, sounding more skeptical than I strictly cared for. "Sure," I answered heartily. "I've lost twenty pounds already. Why not?" She parried with a question: "When was the last time you were at that weight?" During my twenties, I told her. "That was fifteen years ago," she told me sternly, glancing at my birthdate, and changed the subject.

3. As we discussed Factor V Leiden, I told her my OB/GYN had directed me to stop taking the pill. "What are you doing for birth control now?" she asked. "Nothing," I told her. She looked incredulous, then said slowly, as if I were a very small, very slow child, "You know you could get pregnant."

So she doesn't think I can lose weight, but she does think I can conceive without assistance. I know: I'll show her. I'll lose ten more pounds and I'll fail to get pregnant, entirely out of spite.
...
I attended a long-awaited consultation with a hematologist about Factor V Leiden. Here is what I learned:

• On average, the risk of developing a blood clot (or a DVT, deep-vein thrombosis) before age 40 is about 1 in 10,000. Because I'm heterozygous for Factor V Leiden, my current risk is somewhere between 4 and 8 in 10,000.
  
• If I use oral contraceptives, my risk is 35 times higher.
  
• If I use drugs that stimulate estrogen production, such as in controlled ovarian hyperstimulation, my risk is 100 times higher.
  
• If I get pregnant, my risk is 7 times higher.
  
• These risks are based on my status as having Factor V Leiden alone, without taking into account my family history of DVTs.
  
• These risks are automatically compounded by increasing age.

Her conclusion: If I'm going to cycle again — a big if — I should do it now.
...
While lying on my chaise longue languidly eating bonbons and dangling a marabou-trimmed mule from one impeccably pedicured toe, I noticed that the most recent CDC stats are out. These numbers are for 2003, when I did three cycles at my local clinic, so I was eager to see how everyone else I saw dejectedly slumped in the waiting room did that year.

According to the clinic's reporting, which I have no reason to doubt, 52 fresh non-donor cycles were started for women in my age group. How many of those cycles ended with live births? 48%.

To contextualize that number, I'll point out that for the same year in the same age bracket, Cornell, widely regarded as one of the country's best clinics, came in with a 46.5% live birth rate. The nationwide live birth rate is a dismal 37%.

In summary, that year my local clinic kicked embryonic ass. But I know personally and intimately of three cycles that did not result in live births. So let's crunch the numbers. Say I'd gotten and stayed pregnant on my first cycle:

If, out of 50 cycles (52 actual - 2 of mine that failed), there had been 26 live births (25 actual + 1 of mine that hypothetically might have occurred), my local clinic's live birth rate for 2003 would have been 52%.

Say I'd gotten and stayed pregnant on my second cycle: the live birth rate would have been almost 51%.

Say I'd gotten and stayed pregnant on my third. 50%.

Or, heck, say I hadn't cycled at all. 49 cycles, 26 births. 51%.

So...hmm, carry the three, divide by pi...yes. By doing three unsuccessful cycles, I personally was responsible for knocking three whole percentage points off my local clinic's live birth rate.

Jesus, no wonder they suggested I consider donor eggs.

Nobody does it better

In the comments on my last post, Erin asked, "Will an IVF clinic do another cycle for someone who has a history of HELLP?"

If I were feeling cynical, I'd answer, "Oh ho ho ho, my friend, you have much to learn about the fertility business."  Then I'd adjust my monocle, chuckle wearily, temple my fingers, and caress an exotic pet.  Next I would give a detailed explanation of my secret evil plan.  Then, apparently having concluded that while a well aimed shot from a large caliber firearm is practically foolproof, it lacks subtlety and panache, I would nonchalantly swagger out of the room while my burly henchmen strapped Erin to some whizbang high-tech spy-killin' machine.  Under no circumstances would I actually stick around to make sure she was good and dead.  And by and by, my sinister plan would be foiled, my empire of darkness would crumble, and naked lady silhouettes would gambol across the screen behind the closing credits.

But my house is clean, I'm down another pound, and Charlie's off at day care, so I'm feeling positively sunny.  This one, I'll play straight.  Erin, you may live.

If I know this, reproductive endocrinologists certainly do: infertile women who conceive after treatment have a higher rate of complications than the general population.  There are any number of contributing factors at play.  We're older, for one thing.  We have a much higher rate of multiple pregnancies, and therefore of complications stemming from same.  Many of us have suffered various insults to the cervix and uterus through treatment or recurrent losses.  Certain conditions such as ectopic pregnancy and bleeding are more common after IVF.  And, oh, yeah, let's not forget we're infertile, a condition that carries with it all sorts of plausible reasons to expect a bumpy ride. 

So any reproductive endocrinologist knows that the pregnancies he or she helps bring into being could be risky, more so when a patient's previous pregnancies have been complicated.  And yet they do it anyway.  Why?

I don't know.  My working theory is that they know that even given the worst case statistics, the chance of a good outcome is still greater than the chance of a poor one.  And that they trust their patients to educate themselves and evaluate their own best interests with sufficient care. 

This theory aside, I'm not worried, because I think I'm just too goddamned attractive — in an entirely clinical, impersonal, aboveboard sense, good people of the ethics committee — to be turned away.  By reproductive endocrinological standards, I'm a very good patient.  I comply with any and all instructions.  I maintain impeccable personal hygiene.  I entertain myself during long waits.  I make jokes to dispel the tension; when I do cry, I'm quiet, not sloppy.  When I fail, I'm at least interesting.  And I do get pregnant, which is, from an RE's perspective, the point.  My checks don't bounce and my feet don't smell.  I ask you, who could resist?

I've heard of women being turned away by REs for only a few reasons: age, high FSH, and previous failed cycles, all of which doctors might see as predictors of a poor outcome.  I've never heard of anyone being declined treatment because of previous pregnancy complications.  Have you?

If so, I need to know, and soon.  It will take some doing to divert some of my secret evil budget out of the "diamond collar for venomous lizard" cost center toward "amoral cadre of expert forgers."  Those medical records aren't gonna falsify themselves, you know.

Question time

Tomorrow is my next consultation with my maternal/fetal medicine doctor.  I haven't spoken with her since I got the diganosis of Factor V Leiden, and I'm eager to revisit our earlier questions in light of the information now at hand.  Please let me know if you think I'm missing anything important.

1. With treatment, what outcome do you see most frequently for women with Factor V Leiden?


2. ...women with FVL and a history of HELLP?


3. ...women with FVL, a history of HELLP, and a prior premature birth?


4. ...women with FVL, a history of HELLP, a prior premature birth, and infertility?


5. ...women with FVL, a history of HELLP, a prior premature birth, infertility, and a speaking voice that calls to mind nothing so much as a warm, golden slide of honey dripping down the steaming buttered surface of a homemade buttermilk biscuit?


6. Am I annoying you yet?  Okay, just checking.


7. Now that we know I have FVL and can make a treatment plan, would you care to revise your assessment of my risk of a premature birth?


8. How about your assessment of my risk of pre-eclampsia and/or HELLP?  Because, doctor, not to put too fine a point on it, I thought those numbers sucked.


9. Hey, where are your numbers coming from, anyway?  Choose one:
   
   
   1. a thorough review of the current medical literature
   2. the entirety of your long and varied experience
   3. the deepest recesses of your illustrious accredited ass


10. Are HELLP and pre-eclampsia often associated with FVL?  Does having FVL raise my risk of developing either?


11. Would losing more weight significantly improve my chance of a good outcome?


12. Do I need to go on the gestational diabetes diet before pregnancy?


13. Hahahaha, you're funny.  Seriously, now: do I need to go on the gestational diabetes diet bef...oh, you were serious?


14. Let's talk previa.  Given that several of the risk factors — previous C-section, IVF, D&Cs, and advanced maternal age — now pertain, how worried should I be?


15. Great.  "Like lightning striking in the same place twice"?  Thanks a lot for jinxing me, doctor.
    
    
16. What happens if I get a blood clot during pregnancy?  I bet that's no big deal, huh?


17. What would you say the chances are that I'd be on bed rest for any length of time?


18. Assuming I got that far, what would my late pregnancy look like in terms of monitoring?


19. What can that monitoring tell us?  And what might it miss?


20. With my dazzling array of potential complications in mind, short of, um, dying, either in utero or soon after birth, what are the risks to a fetus?


21. But none of that will happen, right?


22. Promise?


23. Am I creeping you out?


24. Not even a little?


25. [Turning upper eyelids inside out.]  Yeah, well, how 'bout now?  [Spooky noises.]  WooooOOOOooo!