EIGHT

“...My diagnosis is Age-Related Unexplained Infertility."   

The doctor’s quiet words sent a chill down Jon’s spine.  He swallowed hard, then looked at Cate.  The sight of her bowed head made his heart ache.

He had to be strong for her. 

Jon took a deep breath and shifted in his chair.  Giving Cate’s hand another squeeze of reassurance, he leaned forward and stared intently at Dr. Seuss.  He wanted to be sure the doctor knew she had his full attention.

“You’re the expert, Doc.  But I think you’re wrong.”  Jon’s voice was firm and carried a hint of challenge.  “There has to be some explanation.”

Dr. Seuss looked back at Jon, her kind green-eyed gaze locked with his icy blue stare.  Her expression didn’t change, but she inwardly smiled at his defensiveness.  Good for you, Jon, she thought.  Fight.  It’s what your wife needs you to do. 

 “There may well be, Jon.  Without further, more extensive testing we won’t know whether there’s something else coming into play here.”  Dr. Seuss quietly smoothed the papers back into their stack and closed the folder, then sat back in her chair.  


“But sometimes medicine doesn’t have an answer.  Approximately 15 percent of the couples who experience infertility receive an ‘unexplained’ diagnosis.  A few of them go on to have normal, unassisted pregnancies, but many of them undergo assisted reproductive procedures, with varying degrees of success.”

“So this is far from hopeless.”

Dr. Seuss saw Cate’s head raise and slowly turn toward her husband’s words, then toward her.  The doctor gave Cate a reassuring smile before responding to Jon’s statement.  “It’s not hopeless at all, Jon.  There are still options.  But they aren’t options I can provide you here.”

Jon nodded and glanced at Cate, then sat back in his chair.  He pulled their clasped hands onto the armrest of his chair and covered them with his other hand, silently telling her everything was going to be fine now.  He was taking charge. 

“Okay.  What’s our next move?” 

“I will refer you to a fertility specialist.  If you wish, I will continue to monitor your care and consult with whomever you choose, but what I can do for you in this practice is limited.”  Dr. Seuss reached for her tablet and pushed the button at the top to activate the display. 

“Jon, you had your semen analysis done by Dr. Klein’s office.  As you probably know, he is one of the foremost fertility specialists in Manhattan.  I highly recommend you consider consulting with him, or I can give you a few more names.”  She tapped at the screen of her tablet, pulling up her list of contacts before looking up at the couple.

“If Dr. Klein’s the best, then he’s the one we want,” Jon answered firmly.

Dr. Seuss arched a brow at Jon’s declaration, then looked at her patient.  “Cate, what do you think?”  While she appreciated Jon’s assertiveness, she wanted to be sure he didn’t completely discount his wife’s wishes.

Cate nodded slowly, then looked at Jon before speaking.  “Dr. Klein’s reputation is excellent.  And if Jon’s comfortable with him…” 

“There is certainly an advantage in going with Dr. Klein, in that he’s already familiar with your case,” Dr. Seuss agreed calmly.  “Unfortunately, time is a factor for you.  If you choose to proceed with any assisted reproductive technologies you need to begin as soon as possible.  But…” She paused and smiled gently.  “A second opinion is rarely a bad thing.”

Cate shook her head.  “He would be the second opinion, Jane.  You’re the first.  I trust you.”  She sighed resignedly.  “If you recommend Dr. Klein, then that’s who we’ll see.”

“Okay.”  Dr. Seuss dropped her gaze again to her tablet and tapped several times at the screen to bring up her colleague’s website.  She and Barry Klein, MD, were longtime friends and partners in the practice of reproductive medicine.   As such, they shared an agreement to schedule their referrals in each other’s calendars without making their clients go through the normal, time-consuming channels of waiting for a rare open appointment.

“It looks like Dr. Klein has some time open next Friday morning… Are you both available?”

“Yes.” Jon answered immediately, before Cate could speak.  “We’ll make it work.”

Dr. Seuss looked up at Cate, momentarily ignoring Jon’s declaration.  “Cate, that good for you?  Or do you need to check your schedule at work and get back to me?”

“No. It’s fine.”  Cate gave Jon a long look, her expression softening as he returned her gaze with a gentle smile.  “I’ll make it work.”

“That’s my Girl.”  Jon’s voice was gentle as he pulled Cate’s hand up to his lips and planted a soft kiss on its back.  “The sooner the better, right Doc?”  He addressed his question to the gynecologist though he never turned his smile away from his wife.

Dr. Seuss nodded her agreement as she again dropped her gaze to the tablet.  She quickly tapped in Cate’s name, filling the open slot on Dr. Klein’s electronic calendar.  Then she linked the appointment to Cate’s profile on her own site, so her patient would have access to it via her own iPad and phone.

“So Jane… what are we looking at? Other than meeting with Dr. Klein, I mean.” 

The doctor set the tablet on top of Cate’s medical file, then moved them both aside.  She clasped her hands and rested them on her desk, ready to give her patients what she knew they needed now:  as much information as she could give them.

“Well, Jon, Cate… your next steps will ultimately be determined by how you decide to go forward.  These days there are a number of options available to couples trying for a child, which is good news.  But some of them take quite a bit of time, which is to your disadvantage.  So, you will have to make a decision pretty soon about how you want to proceed.”

The doctor paused and watched the couple exchange a look, then Cate nodded.  She looked almost guilty as she spoke. 

“I’ve been reading up on… options.  Just in case.  IVF, IUI, hyperstimulation…  They all sound so…”

“Scary,” Dr. Seuss finished gently.  “I know, Cate.  But I’m glad you’ve been doing your research.  As you've said, you can never have too much information.”  She smiled warmly.  “But before you get to that point, there are a few other steps first.”

“Like what?” Jon spoke up.  “More tests?”

“Yes.  For Cate, anyway.”  Dr. Seuss nodded.   “If you want to continue to try for a child, I am almost certain Dr. Klein will want you to have few more significant and invasive tests.  Most likely he will want you to have both an HSG and a laparoscopy, since right now we’re looking at an ‘unexplained’ diagnosis.”

“Aww, Christ.  More acronyms.”  Jon grinned gently as he made his mock complaint.  He looked at Cate and was glad to see her smile in response.

Dr. Seuss laughed.  “Yep, sorry Jon.  More acronyms.”   She took a breath before launching into her practiced recitation. 

“Cate, Dr. Klein will most likely first order a hysterosalpingogram, or HSG, to check the patency of your fallopian tubes.  It's a radiological test where a special dye is inserted through the cervix into the uterus and fallopian tubes, then x-rays are taken to evaluate the reaction of your reproductive organs to the dye.  It also can identify physical blockages or impediments to pregnancy such as cysts, fibroids, or scar tissue.”

She paused and waited for the couple to nod their understanding before continuing.  “And, based on your medical history, Dr. Klein will most likely also want you to have a laparoscopy to evaluate the physical condition of your reproductive organs.

“Wait a minute,” Jon interrupted  “A lapper… whatever.  A scope.  Is that a surgery?”  His brow creased with concern.

“Yes, Jon, it is an outpatient surgical procedure.”  Dr. Seuss confirmed.  “It’s similar to what you had done on your knee this past summer after your injury – an arththroscopy.”  She paused to smile at the “Aha!” expression on Jon’s handsome face at her analogy.  “It’s quick in and out, with minimal recovery time.  But it is an invasive surgery, performed under general anesthesia.” 

Dr. Seuss took a breath before continuing.  “In a laparoscopy the doctor inserts a fiberoptic telescope into a small abdominal incision to examine the outside of the ovaries, fallopian tubes, and uterus.  Through the procedure the doctor can detect fibroids, scar tissue, or other physical defects that might impact fertility.  If the defect is minor it can often be immediately corrected or surgically repaired during the procedure.”

Again Jon frowned as he considered the doctor’s explanation.  “You said Dr. Klein will probably want Cate to have a laparoscopy because of her medical history… Why?  What’s in her records that make you think that?”

“Scar tissue.”  Cate answered quietly.  “From my shooting.”

Dr. Seuss nodded at Cate’s answer.  “Yes.  Because of the proximity of your injury to your reproductive organs, it is possible there was physical damage and scarring.  If that is the case, it most likely went unnoticed during your initial treatment and recovery.”

“How soon?”

“As soon as possible.  Dr. Klein keeps one day of his schedule clear each week for surgical procedures.  You will do the HSG at a radiology lab, but he will perform the laparoscopy himself.”  


Dr. Seuss consulted her tablet, sliding her finger across the screen to move the windows.  “I see that you have had intercourse twice within the ovulation window, so it’s possible you could be pregnant now.  Of course we won’t want to interfere with a potential developing pregnancy, so any invasive tests would be done only after a negative determination.”

“In other words, after my next period.”

“Yes.  And as soon as possible after, before you ovulate again.  You are considered an urgent case, Cate, due to your age and your medical history.  You’ll go to the front of the line.”

“Great.  The one time it pays off to be old.”  Cate’s half-hearted wisecrack sounded hollow.

Jon gave his wife a gentle smirk before addressing his next question to the doctor.  “Then what if those tests come back clear?”

Dr. Seuss looked Jon straight in the eye, knowing he wouldn’t like the answer.  “Then the diagnosis will remain Unexplained Infertility.” 

Jon’s jaw tightened as inwardly he bristled at the term.  Even at his and Cate’s first appointment with his urologist before having his vasectomy reversal, Jon had cringed at the word “infertility.”  He hated its negativity.  Coupled with “unexplained,” it was almost unbearable to hear.

“What would that mean for further treatment?”  Jon’s voice was controlled but challenging.

“Well, there are a number of options.”  Dr. Seuss sat back in her chair, pulling her hands onto her lap.  “One would be to do nothing, to continue to try to conceive naturally, as you have been.”

“But that’s not working,” Cate observed quietly.  “We’ve been trying for over six months.”

“Yes.”  Jane replied calmly.  “And taking your age into consideration, that’s not the course of action I would recommend.  I would tell you it’s time to consider ART.”

“What kind?” Jon’s question was pointed.  “I’ve heard of IVF.  But isn’t that a last resort?”

Dr. Seuss shook her head.  “Not necessarily.  There are a number of therapies you could try first, depending upon the diagnosis and your preferences.  And Dr. Klein’s advice, of course.” 

“What do you think, Jane?”  Cate asked, raising her gaze to meet the older woman’s.  “If you were me, what would you do?”

Dr. Seuss looked back at her patient and saw the thinly-veiled desperation in Cate’s eyes.  She smiled calmly, though under her professional demeanor her heart twinged sympathetically.  “Cate, I can’t answer that question.  It wouldn’t be fair to you, or to Jon.  And it would be unprofessional of me to give you my personal opinion, if I had one.”

“But you can at least tell us what some of the options are.”  There was a hint of panic in Jon’s terse command.  Dr. Seuss turned her gaze before answering.

“I can, in broad terms.”

Cate swiveled her head to look first at Jon, then back to the doctor.  “I think I have a pretty good idea, Jane.  But could you tell Jon, please?”  She curled her fingers against Jon’s, silently asking him to stay calm.

“Sure.”  Dr. Seuss smiled gently.  “Probably the first thing Dr. Klein will present for your consideration is ovarian hyperstimulation.  That means artificially stimulating the ovaries so that they release multiple eggs in the hopes that there will be more “targets” for fertilization.”

Jon settled into his chair, unconsciously taking his full-attention listening pose now that he was starting to get some answers.  He crossed his legs and pulled Cate’s hand onto his knee. “You mean fertility drugs.”

“Yes.”  Dr. Seuss nodded and glanced at Cate.  “Obviously the concerns with hyperstimulation alone would be achievement of multiple pregnancies.  But often this technique is used in tandem with other ARTs, to make them more successful.”

“Such as?” 

“Techniques in which artificial means are used to assist in fertilization of the egg.  One would be Intrauterine Insemination, or IUI.  That is a technique in which harvested sperm is inserted into the fallopian tubes via a tube passed through the cervix.  It increases the volume of sperm available to reach the egg upon ovulation, thus increasing the statistical odds of fertilization.” 

Dr. Seuss paused as she reached to move aside her electronic tablet and flip open Cate’s medical record.  “If I recall correctly…” She paged through the chart with one hand, then raised the sheaf of papers to peruse some writing.  “You had Jon’s sperm harvested and frozen during his vasectomy reversal…”

“We did,” Cate answered.  “But would we use that sperm for IUI?”  Her brow furrowed in confusion.

“Probably not.  Since Jon’s tests have been normal, most likely IUI would be attempted with fresh sperm.”

Jon raised a brow.  “You mean I’d need to… uh… provide a new sample… every time we wanted to try IUI?”

Dr. Seuss smiled.  “Yes.  Most likely.”

“Oh.”  Jon frowned slightly, then shrugged.  “Okay.  And what are the chances of success with IUI?”

“I can’t answer that question, Jon.  Success rates fluctuate dependent upon a number of factors.  But it is generally considered a reliable option for the right candidates.”

“So what about IVF?”  Jon dropped his chin and peered at Dr. Seuss.  “From what I’ve heard, that’s kind of the big deal.”

Jane nodded slightly and glanced at Cate before answering.  She knew that, like many of her patients, Cate held an unspoken fear of  In Vitro Fertilization treatment.  Though such fears were unfounded, the spectre of lab techs in white coats making babies in petri dishes still caused even the most educated and confident women a moment of pause.

“It is a very advanced procedure,” Dr. Seuss explained carefully.  “But it is one that has been used very successfully, to the point that it has become mainstream in treatment of infertility.” She saw Jon frown again as she used the diagnostic term.  


“In simple terms, a woman’s eggs are harvested, and sperm is collected from the male.  When timing is optimal to achieve implantation, the egg and sperm are mixed together in a laboratory, to achieve fertilization.  The fertilized eggs are then placed the woman’s uterus with the hope that they will implant.  If implantation is successful, pregnancy is achieved.”

Jon nodded.  “And don’t doctors usually implant more than one embryo,  to improve the odds?”

“That’s correct.” Jane nodded at Jon’s question.  “And that is also why IVF often results in multiple pregnancies.  It is not uncommon for twins or triplets to result.”

For the first time Jon cracked a genuine smile.  He looked sideways at Cate.  “You could be OctoMom.”

“God, No!” Cate exclaimed.  Then she smiled sheepishly at her outburst.  “Besides, that was kind of a freakish situation to begin with.”

Dr. Seuss laughed, relieved that Jon had lightened the intensity of his questioning.  “That’s right, Cate.  In fact, the ethics of reproductive technology are such that implantation of that many embryos would be frowned upon.  Most doctors would only attempt to implant three or four fertilized eggs in an IVF procedure.”

“So IVF is actually a pretty good option,” Jon remarked.  He slouched a bit in his chair, visibly relaxing. 

“It can be.  But the downside of IVF – or IUI for that matter – is that with each attempt, the probability of success diminishes.”  Dr. Seuss looked at Cate as she saw her little nod of agreement.

Jon pulled his lower lip between his teeth for a moment as he considered that fact.  “So, you want to get it right the first time,” he observed.

“Preferrably.  But obviously one can’t always predict or promise that.”

Jon turned his head to give Cate a long look.  “So, if we find the best doctors, the best labs, the best hospitals…” he mused out loud.

Cate gave Jon a melancholy smile.  She could see the wheels turning in his mind, just like they always did when he was confronted with a challenge.  She loved that about him, his optimism that with hard work and the right tools he could solve any problem.

Unfortunately, this time the problem may be beyond his control.

“Those things would certainly increase your chances of having a successful IVF experience, Jon.” Dr. Seuss answered for Cate.  “But they aren’t guarantees.  There are still a lot of human factors involved.”

Jon dropped his chin and gave Dr. Seuss a long look.  Cate couldn’t stop a weary little chuckle as she watched her husband attempt to stare down her physician.  She had no doubt that Jon’s stink-eye would have no impact whatsoever in this situation.

“Jane, I think that’s good for now,” Cate observed quietly.  “That gives Jon some ideas about a few of the options.  Assuming we’re candidates for them.”

Jon turned his gaze to Cate, his expression softening.  “Is there something else?”

“There are a few other options, Jon,” Dr. Seuss answered.  “Perhaps something to think about, depending on what further tests show.  If necessary, donor eggs or even surrogacy could become viable alternatives for you.” 

Jon saw the flicker of pain in Cate’s blue eyes at Jane’s mention of surrogacy.  His heart clenched.  Though he had thought ahead enough to realize IVF or some other scientific help may be in their future, he hadn’t even considered bringing another person into the picture.

His gaze swung back to Cate’s doctor, his handsome face now painted with concern.  “You think we might… might not be able to make a baby on our own?”

 “I didn’t say that, Jon.  But it is possible that you may want to involve a third party, if it comes down to it.”  Dr. Seuss smiled gently.  “But let’s not get too far ahead of ourselves, okay?  One step at a time.”

Jon slowly nodded, then looked back toward Cate.  “Yeah,” he agreed, his voice suddenly husky.  He gazed at her for a moment, then smiled.  “Besides, we’re not gonna get to that point, right Baby?”

“Right.”  Cate swallowed hard and mustered a smile.  She gazed back at Jon, willing herself to believe his platitude.

Dr. Seuss quietly watched Jon and Cate’s silent exchange.  This was the scene she had witnessed many times in her decades of practice, the moment when she could predict whether the road ahead of a couple would be smooth or rocky.  


What she saw here made her smile.  Jon’s devotion to his wife was unmistakable, his willingness to do whatever it took to support her, admirable.

But then again, there was a saying about a road paved with good intentions.