Trying (and Trying) to Conceive
Our fertility journey began when I manually removed my IUD on my living room floor while on the phone with my husband.
I think that sentence says a lot about me.
I was excited for us to try to create a human together. A couple of my patients had recently conceived within the first week after I removed their IUDs, and I was hoping I could be just like them.
My first true period came, and I was overall fine with it. I knew I couldn’t have reliably predicted when ovulation would occur after suppressing my periods with IUDs in place for 8 years total.
A few months passed. I was a little frustrated but carried on
My periods were wonky. A normal menstrual cycle ranges every 21-35 days, but each individual person lingers around an average somewhere in there. Mine, ultimately, were on a spectrum of 20-35 days, without much for consistency.
People, let me tell you, periods blow for me. It was interesting that they were terrible in different ways than they had been before IUDs. In high school and college, I had horrifically heavy periods that required me changing a super tampon every 2 hours on the heaviest days *and still bleeding through*. After my IUD removal, they weren’t heavy anymore, but they were very crampy. They were also cruelly preceded by nausea, mood swings, and headaches, which can often occur in early pregnancy. I ultimately became incredibly emotional with each period. Part of it was likely simply adjusting to my body’s natural hormonal shifts. A lot of it was the loss of the hope that had begun throughout the weeks before and heightened during those days of wondering, “Are these pregnancy symptoms?”.
I used over the counter ovulation predictor kits to try to gain some sense of control. Ovulation predictor kits detect a surge in the level of a hormone that correlates with ovulation. The user pees on a stick daily on specific days in their cycle. The type I used shows a blank circle until the high fertility window is reached, at which point there’s a flashing smiley face. On the day of peak fertility (ovulation), there’s a persistent smiley face. Each time I used such a kit, I saw that smiley face at the appropriate time. Although I wanted to see it, I started to despise that smug grin.
Six months in, my OB/Gyn curiosity got the better of me. I decided it was time to perform a mid-cycle transvaginal ultrasound on myself to see if it appeared that I was actually ovulating, since often ovulation doesn’t occur consistently with very irregular cycles. I knew the ovulation predictor kits couldn’t 100% tell me if my ovaries were really doing the right thing at the right time and this would give me more information. Now, if you haven’t experienced a transvaginal ultrasound before, you probably breezed through the second sentence in this paragraph without a second thought. A transvaginal ultrasound is no cup of tea under normal circumstances. A long probe is placed internally with the patient positioned lying down on an exam table with feet in stirrups. The probe has to be maneuvered just right to obtain appropriate visualization. It’s connected to what looks like a giant old school computer positioned to the side of the exam table, which has all the buttons for image control and processing. Assessing the uterus and ovaries with a transvaginal ultrasound can be hard enough for one person to do optimally when evaluating another person. Doing it well on yourself while operating buttons behind you and trying to take cell phone pictures of the findings is a true feat, and I need you to be impressed. I was luckily able to see that my right ovary had what’s called a dominant follicle, which meant it was preparing for ovulation. I felt encouraged. I would ultimately perform such an ultrasound on myself many times.
We didn’t conceive that cycle. My periods continued to be wacky. I asked my OB/Gyn – one of my practice partners - to perform an ultrasound for me early on in the next cycle just to make sure there wasn’t something I was missing. This helps evaluate what the anatomy looks like before any stimulation for ovulation occurs and when the lining of the uterus is thin. Everything looked fine. I felt better.
Another few periods came and went. I bawled uncontrollably when the bleeding started. My husband was patient and loving, but I know it was a lot for him to handle, especially because I was placing my full emotional load on him by not talking about this with anyone else. I don't like feeling vulnerable and admitting that I'm not okay. I don't like making others worry about me or feel bad for me. At work, it felt a lot easier to separate my professional self from my personal problems by not letting others know what I was going through. I internalized a lot and then let the mess of emotions out just for him.
Each period was a re-set of expectations. I’d mentally plan my whole life around the potential pregnancy that could conceive that cycle. I’d think of upcoming events and activities with friends and family and where they would fall in pregnancy timing. I thought up what lies I would tell about why I wasn’t drinking alcohol or participating in other activities before I would actually share pregnancy news. Bleeding would begin, and all of that was erased and started over again.
I also perceived each period as a sign of personal failure. I couldn’t complete this natural process. I couldn’t do what others can do seemingly effortlessly and what can often times happen without any intention. I couldn’t achieve a status that half of what I do for a living is all about. I felt broken. Although I was still excited to grow our family and tried to be as positive as possible throughout each month, this was feeling more stressful and defeating all the time.
Meanwhile, I was asked essentially *every day* if I had kids and/or when I was going to start having kids by patients, co-workers, acquaintances, friends, or family members. Those asking didn’t know how much it hurt me every single time.
Struggling with fertility as a type A OB/Gyn physician with certainly undiagnosed baseline anxiety is super suboptimal.
Making sure to time intercourse appropriately can complicate other plans such as visiting friends or family. It can be difficult as a physician with a call schedule and potential need to speed to the hospital at a moment’s notice. My husband joined me at a medical conference out of state so we wouldn’t miss our window that month. We had intercourse at times when we were too tired for it or annoyed with each other.
I knew it didn’t matter, but some months I would be like a more intense version of Maude in “The Big Lebowski”, trying to position myself just right after intercourse. This once led to me rolling off the bed and into a nightstand, sustaining a bruise the size of my palm on my thigh.
Eventually we pursued a more thorough fertility evaluation due to my continued cycle irregularity, with the thought of potential need for fertility medications driving the work-up.
My labs were normal.
I went through a special test called a hysterosalpingogram (HSG) that assesses the contour of the inside of the uterus and patency of the fallopian tubes by watching with an X-ray while dye is injected into the uterus via the cervix and flows out through the tubes. If the tubes are blocked, even if ovulation happens all the time, the egg's not going to get to the right place. My tubes were open. I overanalyzed the shape of my uterus, which truly was fine. I knew HSGs caused cramping, but holy hell, I did not imagine the intensity. I was glad I had it done but was also glad that it is a very quick test.
My husband had a semen analysis. His swimmers were in working order.
There were no big red flags. As I tell patients all the time, it can be frustrating not to find an obvious problem with a discrete answer.
After using contraception for so much of my life and fighting for others to be able to access contraception and abortion services, was this some cruel joke from the universe? Ha ha, sorry, should have used your parts when you were younger and completely unprepared to raise and support a child.
In cases of unexplained infertility – where everything appears to be functioning fine – the addition of interventions can still be helpful. I started taking a medication called letrozole, which stimulates growth of follicles to aid in ovulation. It gave me some hot flashes, night sweats, insomnia, and changes in appetite, but it also gave me dominant follicles, so it felt worth it. When there was a follicle of optimal size, I then gave myself an injection to trigger release of the egg it contained at a predictable interval.
We conceived on my second month with this process. Although I had been doing my best to think positively every other time I’d done a pregnancy test in the past, this time I really felt like I was going to get the result I wanted, mostly because of a *lack* of the symptoms I had become accustomed to leading up to my periods. I hadn’t had the nausea and mood swings this time. I was overjoyed that a pregnancy test finally showed me what I wanted to see (and that a second one confirmed it).
I experienced fatigue and breast tenderness, but that just meant more naps and gentler running. All was well.
At one day short of what would have been 7 weeks of pregnancy, my husband and I went to my office on a Saturday so I could perform an ultrasound on myself. I’d been incredibly private at work about trying to conceive, and I didn’t want people knowing anything until I was comfortable. The ultrasound sadly showed an irregular gestational sac and some swirling blood. The gestational sac didn’t contain the features that we should have seen by that point. This was a miscarriage.
Not wanting to act on anything based on doctoring myself, I planned to meet one of our ultrasonographers at the office early Monday to confirm my findings.
I was on call Sunday. Delivering babies was emotionally difficult. I cried a lot that weekend. I hated the feeling of wanting so badly to just bleed and get it over with after I’d spent so long hoping more than anything to never see blood.
My diagnosis was confirmed on Monday. I went home sick that day. I had one of my partners prescribe medication for me to pass the pregnancy. I sat on my couch with a heating pad watching Netflix and crying. I was already off Tuesday, and my mom came up to spend the day with me. We did the same activities I’d done the day before.
I went to the office Wednesday to see patients as scheduled. I saw two or three without a problem. The partner who is my OB/Gyn came over to check in, and I lost it. She brought me to an exam room where she supported me as I cried sitting on the floor. I went home sick again, where I continued to try to process my emotions.
I knew I couldn’t stay home forever. I made it through a full day of patients Thursday, even holding it together to diagnose and counsel a patient about her miscarriage, ultimately performing a surgical procedure for her the following day. I shoved my own emotions down so I could be a professional and care for others. It was unimaginably difficult.
I know what I lost was an embryo and not a baby. I know likely there was a chromosomal abnormality or another factor out of my control that wouldn’t have allowed normal growth of a pregnancy. I know miscarriage is common. I know there’s nothing I did wrong.
This was the loss of all my hope. I had finally gotten what I longed for, and it was abruptly taken away. The pregnancy represented the future I wanted. After trying so long to achieve it and then quickly losing it, that future seemed impossible. A friend who had experienced miscarriage herself described it as one’s heart being ripped from their chest. It can be soul-crushing, and although I had counseled patients through this many times before, I never could have known what the experience truly felt like.
I searched for ways to blame myself. We’d had sex. I’d been running on the treadmill. I’d eaten a steak that wasn’t well done. I’d had some coffee. I’d had a sleepless night on call. (Side note: none of these things actually caused the miscarriage.)
It’s hard to have your trained, logical, medical brain battling your emotional, anxious, self-critical heart.
The week after I passed the pregnancy was Christmas. I let my and my husband's immediate family members know what happened, because I didn’t think there was any way I would manage not to cry at some point that I was with them over the holiday season. I didn’t tell extended family. It didn’t feel necessary, I didn’t want to make others feel bad at Christmas, and I didn’t want anyone to say the wrong thing. It wasn’t an easy Christmas.
After my next period, I started on letrozole again. My plan was to continue with the medical interventions we’d tried before and pursue in vitro fertilization (IVF) if not pregnant again by my birthday in May. We’d had a consult with an infertility specialist already the month before the miscarriage. We decided to keep the appointment even though it fell two days after my positive pregnancy test so that we would be informed and connected in the event of a loss. In later conversation, that specialist recommended that if starting IVF in May was the goal, I should go through labs again and a hysteroscopy (a procedure in which a small camera is inserted through the cervix into the uterus to assess the uterine cavity directly) in March in preparation. But after another two cycles of letrozole, I had a positive pregnancy test 3/18/2020, which is the beginning of a whole new story for another time.
Of course I wish I had never had to go through any of this, but I will say that it has made me a better physician and more understanding of the circumstances of others. I will always think of my own fertility process when patients share their worries about trying to conceive. I will always think of my own loss when I diagnose a patient with a miscarriage. I will always think of what it felt like to be on the other side of these issues. It's made me more compassionate and a better source of support.
That said, my experience is not universal, and I know that others have different reactions to the same situations. My experience is not by any means the hardest, and I know that many couples try to conceive much longer, go through multiple losses, lose pregnancies farther along when there's even more hope and happiness on the line, and/or never have a pregnancy that results in the live birth of a baby. I strive to be sensitive and supportive in all these situations.
We’re all going to have missteps here and there (I know that I’m guilty!), but let's all try to be more cognizant of how we’re communicating with others about what can be extremely sensitive topics. My recommendations for the general public:
1. Don’t ask people when they’re going to have kids. Some people never want them. Some people may be in the middle of a fertility struggle. Some people may have been told they will likely never be pregnant. Some people might be grieving a pregnancy loss.
2. Someone else’s reproductive journey is not your news to share. I was extremely hurt knowing people I’d specifically instructed to keep the information private told others about my fertility issues, my miscarriage, and my pregnancy.
3. Don’t offer unsolicited reproductive health advice. Most people are simply looking for support when they share difficult experiences in this area, and your well-intentioned tips can be offensive and harmful.
Fertility issues and miscarriage deserve more attention and conversation. I’m sharing my experience because it’s so important for others going through any of this to know that they’re not alone, their feelings are common, they can get through this, and support is out there. It’s equally important for those who have never had and will never have these experiences to understand what their loved ones (and strangers!) might be going through. I wish I would have felt strong enough to tell more people about what was going on when it was happening, but I couldn’t do it. By all outward appearances, I was frankly crushing it in life. Yes, my life was amazing in many ways and continues to be, but I was secretly suffering, as are many others you would never suspect. No matter what perceptions you have, always give everyone the kindness you would want in difficult times. If you're dealing with these struggles, please know that you can reach out for support.