Lasts

• Today was my last day of my first month of intern year! I'm actually kind of sad because Gyn was a very nice and easy first rotation.
• This might be the last time I'm alive and breathing.... or at least walking normally. I head to Yosemite tomorrow for what appears to currently be a plan to hike Half-Dome (I will still try to do some persuading otherwise in the car ride on the way in tomorrow). That 17-or-whatever-mile hike would be the closest I will have come to a marathon, which I hear can be very tough on the body for a while. I really hope I don't go over a waterfall. There will be no gum-chewing for me.
• This is last day/weekend I will likely, for a while, have any semblance of a social life. I start OB nights on Sunday and will probably just be coming home after a shift, going to sleep, not talking to anyone, and then going right back into work come 6:00 p.m. Now, the advantage of the day/night-float system is that weekends are covered by the general OB call pool (the reason why, even though I wasn't on L&D this month, I was on call a couple of weekend days), so I think I may have next weekend off. But I can't say I think I'm going to be doing much "hanging out" with anyone with my schedule. From nights it goes to 14-hour days, and then onto Internal Medicine at the VA, which is also apparently kind of butt-kicking.
• Which is why I have to make up for it now. Yesterday, Kate and I checked out a "Third Thursday" jazz concert at the Crocker Art Museum downton. It was very relaxing-- we just sat out on the lawn and listened to the mellow band. (I actually want to invest in a couple of low lawn-chairs or cushiony-thingies, as I anticipate I might be doing a lot of lawn-sitting while I'm living out here). In about an hour or so, I'm meeting Alex and Lucy (2 of my OB co-interns) downtown for Tapas (and likely sangria :)). Later, I hope to make it over to Phi's mansion for an FP get-together, also celebrating the end of rotation block 1 (for some; I know people who have to work through the weekend- yuck!). But since I have to get up before the crack of dawn to be on the road by 5, it may not be a very late night.
• It was my last half-day at the REI clinic, which also makes me sad. I looked forward to these half-days more than I think any other parts of the rotation and continued to learn TONS from Dr. W. Some stuff we saw/I learned today included (*WARNING*, there are lots of medical things and uses of the word, "sperm", so skip the rest of this post if you get bored easily or don't like bodily fluids!):
• Spinal cord injury is bad for male fertility. While paraplegic female patients often have no trouble getting pregnant, male SCI patients, in addition to having "sexual dysfunction" in general, for some (neurally-mediated) reason, have "lousy sperm." I learned that, for these male patients, urologists can go in with a rectal probe to near the spinal cord and pass a current that allows the collection of a semen sample that can then be used for insemination. I had never even heard about this.
• REI places used to restrict treatment to "married" couples; now, this is considered discrimination. If a lesbian couple wants to get pregnant with donor sperm, these centers do it. If I (or any other single person) wanted to try to get pregnant with donor sperm, they would do it.
• Bad cervical mucus, as well as uterine malpositioning, can be major factors contributing to infertility. Luckily, if discovered, these can be overcome quite easily with IUI. We saw patients with both today. I actually saw a pt in FP clinic a few days ago with a practically non-locatable cervix. I could feel it on pelvic exam (which I went ahead and did after about 2 minutes of hunting with the speculum)--it was very deep, anterior, and way, way, way tilted sideways, but could not for the life of me get a speculum to get it into view and had to call for doctor back-up so that I could do the Pap smear :). Not surprisingly, this patient was having trouble getting pregnant (if I couldn't find the cervix, how in the world could a blind little sperm find the os?! :)).
• Saw a patient who, after a couple of children with her first husband, had had a tubal ligation. Then her husband left her. She is now in a "wonderful" relationship with another man, "the man she wishes she would have met first," who doesn't have any biological children and wants to have them with her, but she has this infertility issue which is generally not reversible.
• Money is a huge issue. There are some countries who are wonderful about insurance benefits for infertility treatments (Scandinavia having some of them), and there are four U.S. states-- Mass., Illinois, Rhode Island, and Maine, which apparently mandate insurance coverage of infertility treatments; nevertheless, most insurance plans do not. If you have an individual, as opposed to a group policy, you are generally out of luck. Cycles can be extremely expensive, i.e. thousands of dollars (even not talking about IVF)-- close to $400 for IUIs, plus medications, ultrasounds (which, at UCD, cost about $400/each), medications (Clomid is relatively cheap but FSH isn't). Dr. W. told me people about getting a second mortgage on their house to pay for treatments. And then there are the people who don't have insurance and have to self-pay everything out of pocket-- one woman called in today wondering if she could just take a "rest cycle" rather than coming in for another mid-cycle ultrasound because she really didn't think she saw a positive ovulation response on her home urine test and didn't want to spend more money without any gain (she hadn't moved yet to paying for insemination). Whether or not infertility treatments should be covered by insurance is a topic of debate, and everyone has their own opinions. But it is totally heartbreaking to see people who just don't have the resources to try more than maybe one time with ART (assisted reproductive technologies). Or at all-- there are, of course, all the many, many, others who never even hit the REI clinic door because they just can't pay. I would love to be able to round up the equipment, appropriate lab stuff, etc., to work on being able to do this (inseminations at least-- it is really quite straightforward and takes like 1 minute) for low cost for people with little or no insurance.
• Getting older is bad (very bad) because it is really one of the few factors that cannot be overcome with even the end-of-the-line fertility treatments such as IVF. As we age, we have very poor quality eggs left. I learned that about 1/3 of women who get pregnant in their 40s miscarry, mostly because of poor egg quality. Dr. W almost universally will refuse IVFs to women over about age 41 because the likelihood (about 3-5%) of them going home with a baby are so low and he doesn't want women to waste their money. We saw a 43-year-old patient today who we basically told, "you are too old to even have a successful chance at IVF." She was very disappointed, but thanked us for being honest.
• So what would someone like her, who still wants children, do? Either move towards adoption or look into egg donation IVF. With a 20-something's egg, that 3-5% can go up to 50%. Now, this is very expensive (like $20,000), but actually an interesting solution. I sat there with her and starting thinking, "Man! How could we tell her that pregnancy is just 'not possible' for her. Maybe I could donate my eggs (she kinda sorta maybe looks like me... ). They're still fairly young and will certainly not be used for a while!" There's all this rigorous screening for egg donors (like there is for sperm donors) where you have to answer questions about medical history, genetic diseases, as well as "Do you smoke?" "How much do you drink?" "Are you athletic?" "What did you major in/how many degrees do you have?" :)) to find "high quality" donors. Recipients can then actually search for people of similar ethnicity/looks (there are catalogs!), and with traits they desire (much like you can do in selecting sperm donors). You don't even have release eggs on your own (normally) to be a suitable donor, b/c they pump you up with FSH and all kinds of stuff to stimulate your ovaries. But it's kind of a complicated process and means that, as a donor, you probably have to be flexible enough to be able to drop what you're doing and fly somewhere random so that they can harvest your eggs, mix them with the male sperm, etc. , in preparation for transfer into the recipient. Probably not going to happen while I'm an intern. But I really might look into this. Do you think someone would want my eggs? :) Apparently they pay egg donors well, but I'd definitely give them away for free. :) Along with maybe a kidney.
• Okay, enough blabbing. This is the last bullet point of this post.