Liz's Medical School Journey

Her* CC (chief complaint) was “nausea.”  Although I hate to sound like the proverbial adolescent doctor, my first thought was “pregnancy test.” The nurse was way ahead of me, and had already done it.  “Negative,” she whispered to me, before I entered the room.

I rattled through the long list of possibilities in my mind.  Gastrointestinal infection? Side effect of medications?  Abuse? I took a history and performed my physical exam, and exited the room still feeling confused.  I presented the patient to my attending physician.

“A 15 year-old female otherwise healthy, chief complaint of nausea, who reports acutely feeling nauseous while eating dinner last night.  The nausea self-resolved, then she awoke this morning with one episode of about 100ml yellow, watery emesis (=she threw-up a little).  Then felt hungry and ate normally.  No fever/ chills, no abdominal pain, no diarrhea, no light-headedness, no head-aches, no unusual foods.  Her last episode of emesis was ‘stomach flu’ a few years ago and ‘this does not feel the same.’”

“No medications or allergies, no past medical or surgical history.  She lives with mom and dad, has “good” peer relationships- non-smoker, no alcohol, no illicit drugs, she is sexually active with one male partner, denies violence or abuse. Physical exam unremarkable. Beta HCG (pregnancy test) negative.”

Then, I eloquently explained that I wasn’t sure what was going on.  Maybe an early gastrointestinal infection?  But it didn’t really fit.  Puzzling!

“When was her last LMP?” my preceptor asked.  I admitted that  hadn’t taken a detailed menstrual history because pregnancy had been ruled out.  “Well, let’s find out.”  We went back in the room together, and he asked her directly.

“Oh, I just got my period today actually,” she replied.

AHA!  A light bulb went off for us.  “Wow,” I thought, “my preceptor is brilliant.”  Obviously he has been working with adolescents for many years.  He knew not to expect adolescents to volunteer all the relevant information.  His expression didn’t change, and he calmly began explaining how prostaglandin release during ovulatory cycles can cause a variety of symptoms, including nausea and vomiting, and how to block the prostaglandin release with ibuprofen or naproxen.

This illustrates why I love working with adolescents.  They are straight-forward, but do not make health correlations on their own.  This leaves more detective work for health professionals, and requires stronger history-taking skills and critical thinking. They have made the “Sherlock Holmes” aspects of my job much more interesting this month.

*Please note all patient identifying information has been intentionally changed or omitted.  While the details are modified, my overall experience remains true.

The first transfer I saw was in a delivery room, although the woman was not pregnant.  Her position reminded me of somebody giving birth, but instead her belly was full of urine.  She had been drinking water all morning to expand her bladder, straighten her uterus and allow for a better view.  How uncomfortable!  Her husband stood by her holding her hand.  In a room a few doors down the hall, the embryologist prepared two embryos, which were now a few days-old.  I thought of everything she did to get herself here.

I did not know the extent that women must go to seek ART (Assisted Reproductive Technologies).   First, in order to diagnose the reason for infertility, both the man and woman must undergo testing, like uncomfortable imaging of the uterus, blood draws and sperm analysis.  Then, most of the medications prescribed are injected and require ultimate compliance, which can involve alarms during the night.

Finally, in order to assure the timing of ovulation perfectly, women undergo vaginal ultrasounds every 48 hours as their ovaries begin to respond to the drugs.  So a woman might come for 10 vaginal ultrasounds before her procedure is scheduled.  It requires serious commitment to come to the doctor early in the morning to have a probe inserted inside you.  Most women came alone, and had to disclose this very private and sensitive issue to their workplaces.

If the cycle failed (no pregnancy), they would start all over again.  Meanwhile, the treatments were expensive, and the medications made many women feel depressed or emotional.  I wanted these patients to have children dearly, but I was surprised by what they endured to reach their goals.  These women were some of the strongest I have met with hidden stories of trauma, multiple miscarriages, unexplained infertility and rare diseases.

The woman in the bed was undergoing IVF (In Vitro Fertilization), the most successful, but also the most invasive and expensive of all the treatments.  A few days earlier I had helped her when she went under general anesthesia to have her eggs retrieved.  Her husband had been present that day to donate fresh sperm, but he had to leave for work immediately afterwards, leaving her alone in our care.  The fertilization occurred in a plastic dish about 2 inches in diameter.

Now the embryos appeared to be tiny clusters of cells, too small to reveal their genetic content.  The doctor took several minutes to carefully insert a practice catheter (without embryos) into the uterus through the cervix.  A nurse pressed constantly on the patient’s bladder with the ultrasound probe, so we could visualize the placement of the catheter.  When the doctor was satisfied, she was ready for the real catheter with embryos.

We all were quiet as she injected the embryos into the uterus, a process that took only a few seconds.  And then, she sent the catheter back down the hall for a microscopic check to make sure all the embryos were emptied.  We waited.

“It’s clear,” the embryologist announced after a few seconds.  And then, we were done.  It would take about 2 weeks to know whether these embryos resulted in a pregnancy.  I wondered what was going through the woman’s mind.  I imagined babies being made in a loving sexual partnership, but here we were trying to make a baby in a sterile field with uncomfortable probes and catheters.  Yet, I felt warm, and noticed that she glowed with hope.

While many of our patients did get pregnant, this first transfer patient did not.  Two weeks later I saw her, tearfully waiting in the office for a follow-up visit.  I knew instantly the procedure had failed, and I felt a wave of sadness for her loss.  And more importantly I felt her anger and fear that despite all she endured, she may never experience biological motherhood.  I left with a new appreciation for the uncontrollable aspects of pregnancy, a powerful miracle that so many take for granted.

My month at the Reproductive Endocrinology clinic was not without a few faux pais, and some special new lessons:

1. This clinic is also known as the “fertility clinic,” not the “infertility clinic” (think positive here).

2. Be silent when human embryos are in the room.

3. Embryos are “transfered,” not “transplanted” into the uterus.

4. Put the condom on the vaginal ultrasound probe BEFORE the patient comes into the room.

5. RPL stands for “recurrent pregnancy loss,” not to be confused with RPR (the lab test for syphilis).

6. HSG is a histosalpingogram, not to be confused with SHG, a sonohistogram. Both are imaging studies of the uterus.

7. Eggs are “retrieved,” not “harvested,” thus the procedure is “Egg Retrieval,” not an “Egg Harvest.”

8. Do not leave anything with photos of babies anywhere near the patient exam rooms.

9. Finding the left ovary on vaginal ultrasound is the most difficult part.  Save that for last.

10. Infertility treatments are physically and emotionally exhausting.  Always keep plenty of tissues on hand.