SEVEN

FRIDAY

The office was silent save for the muted tick of the ornate grandfather clock that stood in the corner.

Jon snorted at the irony of the audible metaphor.  In this room of all places he was painfully aware of time's solemn march, every second pulling their dream a little further from their grasp.

He turned to Cate and saw she wasn't paying attention to the clock or to anything else in the room.  She was lost in her thoughts, staring unseeingly across the desk and out the window.

Jon's gaze traced slowly over her profile, his heart squeezing as he once again noticed the dark circles under his wife's tired grey-blue eyes.  The little lines at their corners were deeper now than they had been just a few months ago.   

This had been hard on her, he knew.  Hell, it had been hard on him.  But each month, when once again she was faced by her body's betrayal, Cate put on a brave face.  She tried to pretend she wasn't disappointed, forcing a smile and gently telling Jon they had to be patient, it would just take time. 

But then she silently disciplined herself, adding another task to her growing list of sacrifices and rituals to try to gain control of her rebellious body.  With every passing day and week and month Jon could sense Cate’s desperation growing, despite her calm façade and her quiet platitudes. 

Time was working against them.

Finally feeling Jon's gaze, Cate slowly turned her head and gave him a weary half-smile.

"You okay?"  Jon's soft voice held a husky note, betraying his unease.

"Yeah."  The word was more of a sigh as Cate nodded slowly.

"Wanna tell me?  Where you were just now?"

Cate shrugged and turned her eyes back toward the big mahogany desk in front of them.  "Just thinking."  She slumped a little further into the leather wingback  armchair.  "That I've spent almost as much time in this office the past few weeks as I have my own office."  She chuckled half-heartedly.  "You too."

Jon smiled wryly.  "Yeah. I've read every damned magazine in the waiting room.  Twice.  They need to get some new fucking literature."  He chuckled softly as he watched Cate's nose crinkle at his lame attempt to lighten the mood.  "But it will all be worth it, today."

Cate turned her face back to Jon, mild surprise registering in her look.  "You think so?"  

"Yeah.  I do."  Jon smiled reassuringly though he didn't feel the least bit confident in his prediction.  "Today's the day we figure it all out."

As if on cue the rhythmic tick-tock of the clock was interrupted by the loud click of a turning doorknob.  With a rustle of fabric and paper the doctor strode across her office and rounded her desk.  She dropped a thick white file folder on the desktop before settling into her leather chair.

"Well, hello again, Bongiovis."  Dr. Seuss smiled warmly at her patients.  "And how are we today?"

"Fine, thank you," Cate replied quietly. 

"Good."  Jon echoed his wife's lie.  "Hopefully about to be a lot better."  He gave Cate's gynecologist one of his most charming smiles, as if the gesture might convince her to share good news.

Dr. Seuss chortled softly as she pulled the reading glasses dangling from a chain around her neck up to perch on her nose.  As one of Manhattan's top OB/GYNs she had many patients who were married to handsome, charming, wealthy captains of industry and hard-charging executives.  Most of those husbands were reduced to nervous, stammering adolescents when they accompanied their wives to this office.  

But not this one.  Dr. Seuss had long suspected Jon's dazzling grin was an automatic defense to mask to his unease, judging from the way his blue eyes darted around her office when he thought she wasn't watching.  She was fine with that; there were worse ways to spend a half-hour every other week than with a smiling rock star and his lovely wife. 

"So.  Cate, Jon... I have the results of your tests."  Dr. Seuss opened the white folder and peered down at the sheaf of papers inside.  “We have a few things to talk about.”

Automatically Jon reached for Cate's hand, his fingers curving over hers on the leather chair's armrest.  He looked at her profile and saw her expression was stoic as she stared at the file on Dr. Seuss’ desk.  He squeezed her hand, then looked back to the physician.

“Okay, Doc.  Let’s hear it.” 

Dr. Seuss nodded before flipping through the top few pages of the file.  Her voice was calm and professional when she began her report.    “Jon, we’ll start with you.”

She glanced up, peering over the frame of her reading glasses giving Jon a reassuring little smile.  “Dr. Klein sent over the results from your blood work and your last three semen analyses.  As far as your blood work, everything looks good.  No factors, nothing out of range, no infectious diseases.  All clear.”

Jon nodded and glanced again at Cate.  She hadn’t moved.  Still she sat silent, staring ahead.

Dr. Seuss flipped another page and ran her finger down a column of numbers.  “As for semen tests, again, no abnormalities.  All three recent tests show good sperm morphology and motility.  And your sperm count is in the high-normal range, which is good.”  She paused and looked up. 

“Quite frankly, Jon, that was one of my concerns given the rather lengthy period of your sterilization prior to your vasectomy reversal.  But everything seems normal for a man of your age with your reproductive and medical history.” She smiled at his visible sigh of relief.  “You probably have a combination of good genes and excellent physical health to thank.”

Jon chuckled quietly and nodded.  “Thanks, Doc.”  Again he turned his head to look at Cate.  He saw her swallow, then her lashes fluttered briefly.  Jon gave his wife’s hand another gentle squeeze as he realized she was steeling herself for the worst, for the alternative to his clean bill of health.

Dr. Seuss also noticed her patient’s subtle reaction.  She knew very well what was going on in Cate’s mind; many of her patients who struggled to conceive carried the same guilty fear:  What if it’s me?  The gynecologist paused and looked at Cate for a long moment, until Cate’s tired blue eyes raised to meet hers.  She gave her patient a motherly smile before continuing.

“Cate, your basic blood workup looks good as well.  Again, no negative factors, no infectious diseases, your hemoglobin is normal and your white count is in the low-normal range.  Your thyroid appears to be functioning normally.  And your cholesterol and sugars look excellent.”  She nodded approvingly.  “Your diet and exercise regimen has certainly paid off in the general health department.”

Cate gave a small nod, her first sign of acknowledgement since the doctor had begun her report.  She took a deep breath and slowly released it.  Her hand moved under Jon’s, turning her palm upward against his.  Without looking she laced her fingers between his, the gesture a silent request for his reassurance as she waited for the other shoe to drop.

Dr. Seuss flipped a few more pages of the chart.  “Now, as for your hormones…” She paused while she evaluated the figures, then looked up at the couple before her.  She gave Cate a little smile, making sure she had her attention.  


“We analyzed your early blood draws for natural levels of the hormones associated with reproduction.  Now, I know you’ve done some research and we’ve discussed this.  But for your husband’s benefit..."  The doctor turned her smile to Jon, whose expression had sobered to match his wife's.  "... Here’s what we look at in an initial fertility workup."  

“A couple weeks ago, before onset of menses… before your wife got her most recent period… Cate submitted a blood sample for a full fertility screen.  We wanted to see if all the hormones that affect her ability to get and stay pregnant were within normal ranges, without being influenced by any medication or supplement.”

Jon nodded his understanding, thankful that Cate’s doctor was dumbing down her explanation for his benefit.  He had a rudimentary understanding of the female reproductive system, but he would be the first to admit he had no idea how it all really worked.  “Okay.  So what’s the verdict?”

Dr. Suess smiled patiently at Jon’s nervous question.  “What we found out was that Cate’s reproductive hormones seem to be normal for a woman her age.  Now mind you, that doesn’t mean her levels are optimal for fertilization and implantation of an egg.  We rarely see optimal levels in women over 35 due to age-related changes in their bodies.”  The physician turned her gaze again to her patient.  “However, for a woman of 43, Cate, your levels are right around where we’d expect.”

This time Cate’s relief was more visible.  Her shoulders slumped as she exhaled softly, and her tightened jaw relaxed a bit.  But when she spoke, her voice was quiet and cautious.  “What about the other tests?”

Jon’s brow furrowed at Cate’s response, and he turned his questioning gaze to Dr. Seuss.  “Yeah, what about all those other trips to the lab Cate had to make?  Were those for something different?”

“Sort of.”  Dr. Seuss nodded before continuing her explanation.  “In a fertility screen we pay particular attention to a couple different hormones that affect the production and release of the egg and the implantation and sustainment of the embryo.  As you might expect, these hormone levels fluctuate throughout the menstrual cycle.  But if those levels are exceedingly high or low at a given point in the cycle, they can indicate problems with ovulation or uterine hospitality.” 

Seeing the frown of concentration on Cate’s husband’s face, Dr. Seuss paused her explanation to give him a moment to catch up.  When he nodded slowly she continued, speaking directly to him.  “Jon, since you went through multiple pregnancies with your first wife, you may have heard of some of these hormones or terms.  But I’ll give you a quick rundown anyway.” 

“In Cate’s initial fertility screen we looked primarily at levels of FSH, LH, estradiol, progesterone, and androgens in her blood.   FSH is follicle stimulating hormone, which stimulates the development of the egg.  LH is lutenizing hormone, which triggers the egg’s release from the ovary into the fallopian tube, which is where fertilization occurs if the conditions are right.  Estradiol is also known as estrogen, and it is the hormone that stimulates the preparation of the cervix and uterus for implantation of the fertilized egg.  Progesterone stabilizes the uterine lining and supports early development of the embryo, once it has implanted in the uterine wall.”

The doctor paused again, giving Jon a little smile.  “You with me so far?” 

Jon nodded.  “I follow.  And yeah, I’ve heard of those things before.  Just never really paid enough attention to learn what they did.”  He gave the doctor a guilty little grin.  "In one ear and out the other."

Dr. Seuss chuckled warmly.  “Well, that’s an honest answer.  And you’re paying attention now, so that’s what counts.”  She glanced at Cate and was heartened to see a small smile from her patient.

“So anyway, we also look at androgens, which are “male” hormones such as testosterone that are produced naturally in minimal amounts by the female body.  The reason we check androgens is to be sure there are not excessive levels that may interfere with follicle stimulation or cervical mucal production.  In other words, we want to be sure the male hormones aren’t overpowering the female hormones and preventing them from doing their jobs.”

“Releasing the egg and keeping the womb ready for it to land.”  Jon finished the thought for the doctor, grinning proudly.  He turned his head to give Cate a smile when he heard her quiet chuckle.

“Exactly.”  Dr. Seuss nodded back at Jon before turning her attention to her patient. 

“Cate, here’s what we found in your case.  Your LH and androgen levels were normal, which rules out Polycystic  Ovarian Syndrome.  I didn’t really expect to find any abnormalities there, since you are not symptomatic of PCOS.” 

Dr. Seuss fell back into her typical pattern of explanation with Cate, not bothering with layman’s terms.   She knew Cate preferred clinical terminology in their professional discussions; it enabled her to separate fact from emotion.  Dr. Seuss had no doubt her patient's preference was partially due to occupational habit, but she suspected it also was an unconscious defense mechanism:  one that allowed Cate to shove her emotions aside until she was ready to deal with them on her own terms.

The doctor waited for Cate’s nod of understanding before continuing.  “Your FSH and estradiol were slightly elevated, but not enough to be a major concern, especially once we compared those levels to your later test results.  Conversely, your progesterone levels were on the low end of normal, but still within parameters.”

“Well, that’s good.  Right, Jane?”  This time Cate’s voice carried a faint note of hope.

“Yes, it is a positive sign.  But the other tests are more indicative of your reproductive function.”  Dr. Seuss thumbed through several more pages of the thick medical chart.

“So, once these baselines were established we did more blood tests to further evaluate your ovarian function.  The test we did was called a CCCT, or a Clomiphene Citrate Challenge Test.”  She glanced back at Jon and saw he was following along, though clearly concentrating hard.  “ In plain English, we wanted to see if you were ovulating normally.” 

“Specifically, what we were looking for was the reaction of the FSH and estradiol levels to artificial interference.  Cate, we tested your FSH and estradiol levels on the third day of your menstrual cycle and again found them slightly elevated.  Then you took a course of clomiphene citrate for five days, and we tested you again on day ten.  On the tenth day your FSH levels had declined, indicating normal ovarian function.  And you noted in your basal body temp record that you ovulated approximately three days later, which is normal.”

A relieved sigh escaped from Cate’s lips, causing Dr. Seuss to pause again and give her a little smile.  Cate exchanged a look with her husband, then her blue-eyed gaze turned back to the doctor.

“So, if my hormone levels are all within normal range and I’m ovulating normally…”  Cate’s question trailed off as she remembered Dr. Seuss’ advice from her last appointment.  Though it may seem counterintuitive, if these tests show something it’s actually a good thing.  They will tell us what to treat.  That’s a step in the right direction.

Dr. Seuss saw in Cate’s crestfallen expression that she knew what was coming.  She felt a twinge of sympathy for her patient as she again regarded the chart.  Though she had delivered this news thousands of times to thousands of patients of whom she was fond, it never got any easier.  But it was her duty to be thorough and honest.

Dr. Seuss softly cleared her throat and continued.  “As for other factors, you are having frequent and well-timed intercourse.  Cate, you have reduced or eliminated any lifestyle factors that could affect normal body function, such as smoking, alcohol, caffeine, and various foods and additives.  You are healthy and active.  I noted no abnormalities in my most recent physical pelvic examination and your Pap was clear.”

“But…” Cate’s voice was hoarse, laden with disappointment.  “If there’s nothing wrong… if the tests show nothing wrong…”

Jon’s heart sank at the sadness in his wife’s unfinished question.  He may not comprehend all the biochemistry of these tests, but he had paid attention to the research Cate had shared with him over the past few months.  He had even done a little of his own, to try to understand what she was going through and what obstacles they may be facing.

Jon squeezed Cate’s hand, clasped in his, before speaking.  “If the tests are normal – for both of us – that means…”

Dr. Seuss reached up to pull her reading glasses from her face.  She gave the couple a sympathetic smile and nodded slowly.

“Cate, Jon, I’m sorry.  I was hoping we’d get some answers from all of these tests, and we did, in a way.  We know that your body chemistry is normal, and it’s likely not to blame for your inability to conceive thus far.  But without further, more extensive and invasive tests, there’s just no way to identify a problem.” 

Cate looked down at her lap as her eyes moistened with frustrated tears.  She blinked rapidly, trying to will them away.  She knew what Dr. Seuss was going to say.  In a way it was almost worse than the now ruled-out alternatives, that Jon’s sperm was abnormal or that she was not ovulating properly. 

It meant there was no one or nothing to blame, that there was no factor to control.

“Again, Jon, Cate… I’m sorry.  But at this point, my diagnosis is Age-Related Unexplained Infertility."