Fertility options

Some people would do anything to become pregnant: undergo painful procedures, borrow money, mortgage their homes –anything, it seems, to have a child. While this is certainly understandable –parenthood is perhaps the raison d’être of our genes- it seems a shame that fertility would be something denied to some while granted to others. Arbitrary at first  glance, it sometimes remains so even after extensive investigations. And yet there has been a lot of progress in understanding the mechanisms that both allow fertilization to occur and, maybe even more importantly, implantation of the egg and subsequent successful development of the pregnancy.

Obviously, there is a whole cascade of events each having to unroll in the proper order –such things as development of a viable and healthy egg in the ovary; its ovulation and successful encounter with a (hopefully) normal sperm; a clear and unimpeded route to an appropriately developed uterine lining… And these are just the early requirements for the long journey to l’accouchement. But, like a planning a trip, it is more likely to arrive at its destination if the car is sound and there is gas in the tank.

There are many roadblocks along the way, however, not the least of which are the body’s defence mechanisms which try to destroy foreign proteins that might pose a risk to the health of the organism. A fertilized and developing egg contains a mixture of just such foreign material from the male, and so in some cases might be construed as an attack. Although the uterine cavity is designed as an immunologically privileged site to thwart such a mistaken identity, for some reason it doesn’t always work. While this can be a subtle issue and difficult to detect, it can be an even more difficult thing to correct. There have been attempts to do this with medications to increase success during IVF (in vitro fertilization), but with few breakthroughs so far.

Sometimes my patients know more about this than I do, or perhaps pay more attention to disparate media reports that view every paper published, even in obscure journals, as fodder -landmark achievements. The job of journalists is to interest their readers, not to critically analyze the data and research whether or not the findings were merely a one-off that has not been validated by others in the field. A crash is news; a non-crash is not. Or am I being too cynical?

Last year, I remember seeing Janice, a woman who had been trying to become pregnant for several years. She told me that all of her tests that her GP had ordered had been normal as were those of her partner. Because she was already approaching 40, I immediately suggested that she would likely benefit from being assessed at an infertility clinic to see if they could expedite things. I wasn’t sure that I could help.

She shook her head. “I’ve already been to a clinic…” she said, with a sad expression on her face. “They wouldn’t listen to me.”

“Listen to you? What do you mean?”

She probed my face with her eyes for a moment to see if I was likely to listen to her. Then, apparently reassured, she sighed and sat back in her chair. “Well when they saw the normal test results they added their own versions of the same things but still couldn’t find anything wrong. So they suggested IVF. Time’s running out, they said.” She straightened in the chair and uncrossed her legs. “We can’t afford IVF,” she said, all the while staring at her lap where she was alternately wringing her hands and straightening the fabric of her dress. “They basically shrugged and told me to think about it and come back if I changed my mind.”

I waited for her to continue. There must have been some reason her doctor had referred her to me.

“Anyway,” she said after a long thoughtful pause and a quick gulp of air, “I went on the internet to do some research on other options…”

I managed to stop my eyes from rolling but I have to admit she caught me holding my breath. I never know how to react when a patient innocently offers a totally unorthodox and largely un-researched idea that they’ve found on some website lying in wait in a dark corner of the web.

But she noticed my expression and chuckled at my obvious discomfort. “You must get this all the time from desperate women, eh?” I smiled, embarrassed at being caught. “I’d been trolling through some weird stuff and then noticed a reference to a paper published in the journal Science –it was dated 2015, so not very old. It was only the abstract, though, and I wasn’t really all that sure that I understood it correctly…” she said, no doubt to head off any criticism before I could formulate it. “But there was also a reference to a BBC article talking about it so I looked at that as well.” She handed me a piece of paper with its address so I could look it up as well:  http://www.bbc.com/news/health-34857022  and then to show she meant business, the abstract from Science: http://www.sciencemag.org/content/350/6263/970

When I didn’t immediately punch it in on my computer, she decided to explain. “There’s a parasite that increases a woman’s fertility, doctor,” she said, now intently studying the panoply of expressions that flitted, untended, in quick succession across my face. “Not all of them do, of course,” she added quickly, to show me that she wasn’t that foolish. “I mean, I don’t want to try one, or anything. I just wanted to know what you thought of the idea.”

While I gathered my thoughts, she explained. “I went back to the fertility clinic and asked their opinion about the worm… Ascaris lumbricoides –I memorized the name,” she said and immediately blushed. “Anyway, when I mentioned it to the clinic doctor, he just laughed at me. I don’t think he meant to, but it just kind of escaped from his face before he could stop it…” Janice suddenly leaned across my desk with a serious look on her face. “Of course I thought the doctor was being rude and dismissive, so I walked out on him and headed over to my GP’s office. At least she was more patient with me, but I could still read the disgust in her eyes. We managed to talk about it for a few moments, and then she decided to refer me to you. You’d listen, she assured me and then walked me out of the room…escorted me, almost. I think she just didn’t know how to handle the idea so she passed the buck.”

There was a sudden twinkle in Janice’s eyes that I almost missed –a mischievous expression that flirted briefly with her mouth, then disappeared. “My GP obviously didn’t think I needed an urgent appointment –although I did remind her of my age- so it took me a while to get in to see you.” She smiled a more ordinary smile this time, although it was still nuanced. “Several months, in fact.” I could hear the italics around the word from across the desk. “You’re a busy man, doctor.” I think I blushed.

She waited for a moment to let the thought embed itself in the desk. “So, what do you think of the worm idea?”

I struggled for words initially. It was an unusual idea, but I remembered a brief flurry of rumours when I was in medical school about fashion models infecting themselves with intestinal parasites to help them to stay thin. Perhaps they were just that: rumours, but the idea at least was not without precedent. “Well, I suppose if we could be sure that it wouldn’t affect the developing baby in any way… or you!” I paused for effect. “And that we could reliably get rid of the parasite when it had done its job –again without harming you or the baby- then…” I had run out of words. I had no intention of endorsing the idea, but I didn’t want to dash her hopes entirely. Hope is what keeps us going. I leaned across the desk towards her and smiled. “Let me just say that if you were my daughter and you had honoured me by asking for my opinion, I would have to say that some things are just not worth the risk.”

“You mean you’d advise against it?” She seemed relieved.

I nodded carefully, sensing I was being led into a trap.

A smile almost split her face in two and her eyes lit up and sparkled like lights on a Christmas tree. “Well, I’m pregnant now,” she said, italicizing the important word again and leaning across the desk as well. “It took so long to get to see you, I thought I’d use the time constructively.” My eyes must have betrayed something, because she suddenly extended her hand and grasped my arm. “Don’t worry, doctor, my husband and I decided against the worms. He said he was really worried about them…”

I relaxed my expression and was about to say something about a caring partner, when I noticed another twinkle in her eyes. “Yes,” she added before I could open my mouth. “He was afraid of getting them from me.”

Scientific Fraud

Science –whose Latin etymology denotes knowledge- started off as a branch of philosophy and gradually morphed into its present form. Recently, however, it seems to be resting on a progressively unstable foundation with the general public. By its very nature, Science accumulates its knowledge by induction: observations elicit explanations which suggest experiments designed to test these. The results are always contingent –a classic example might be that of swans: if all we see are white swans, it might be reasonable to conclude that all swans are white –until, that is, we find a black swan. So knowledge is couched in probabilities –everything is potentially refutable and our statements about it must reflect how likely it is to be a continuing truth. This is fine unless we crave certainty.

In an increasingly uncertain world one can understand the appeal of religions, if for no other reason than the assurance that the mainstream variants project. But historically, even the supposedly eternal truths revealed by religions have been contingent upon success in battle, or survival in times of environmental or social disasters. Certainty is a horizon that shifts and recedes whenever it is approached. However close we may feel we are, it is, like the rainbow, forever out of reach.

Of course, many do not agree with this; many feel that certainty is attainable and harbour a lingering suspicion of any system that cannot provide it. Why should faith be piled onto something that accepts that it is open to being refuted -welcomes it, in fact?

There are enough confusing and seemingly contradictory studies published to challenge the Public’s trust in Science. At times, its credibility seems to be balancing on a knife’s edge; the slightest puff of scandal could well be enough to destabilize the already tenuous confidence. For some people, it is already gossamer thin.

It is with this in mind that my fears often migrate to the subject of fraud in science. For me, it is not only a question of how it could happen, but rather, why it would. I was intrigued by an article in an article in the Canadian Medical Association Journal from last year entitled: ‘Scientific misconduct or criminal offence?’  (http://www.cmaj.ca/content/187/17/1273.full) The article examines whether we should be treating scientific fraud as merely naughty ill-advised behaviour, incompetence, or criminally punishable conduct. The standard of proof needed to successfully achieve a legal conviction is apparently quite stringent and so, often in the interests of limited financial resources and depending upon the seriousness of the case, lesser sanctions are frequently used. In Canada there is a Secretariat on Responsible Conduct of Research. ‘The Secretariat is a government agency responsible for implementing the Tri-Agency Framework on Responsible Conduct of Research on behalf of Canada’s major federal government granting agencies… A researcher who breeches the framework may receive letters of education or admonishment. More serious cases could merit sanctions, including withdrawal of funding or even the ability to apply for funding.’ And each year, says Susan Zimmerman, the current executive director, ‘there are about 90 breeches of the framework, but very few, perhaps three or four, would be considered serious. Even fewer would constitute a criminal offence. And if one did, the Secretariat is already obligated to notify the authorities. Instead of trying to ferret out the rare egregious bad apple, the Secretariat, as stewards of public money, focuses on reducing unacceptable results. The agency considers that approach to be a more productive use of limited resources than trying to determine if a researcher made an honest mistake or acted in bad faith.’

All fine and good, I suppose, but I still wonder about the already suspicious Public Opinion about science in general. ‘In a 2014 BMJ article, Bhutta, who has a strong interest in research ethics, argued that scientific fraud can have huge consequences on public health and clinical practice, citing the damage to global vaccination coverage caused by the “fraudulent and discredited” research of Dr. Andrew Wakefield that linked vaccines to autism. There is little risk to committing research fraud, beyond damage to reputation, and the research community is doing an inadequate job of policing itself, according to Bhutta, who wrote that “additional deterrence through punitive measures such as criminal proceedings should be added to the repertoire of measures available.”’

If the results of a study were indeed woven out of whole cloth, the lack of legal consequences would feed the worst fears of an admittedly small segment of society which mistrusted western medicine’s perceived mantle of omniscience to start with. If it were fraudulent, they would wonder, then why wasn’t the doctor prosecuted? Was it because there was some uncomfortable truth to his findings that an embarrassed Medical establishment, which had been pushing the safety of vaccines for years, was trying to cover up? How many other studies are fraudulent that either haven’t come to light, or have been quietly hidden under the covers?

The point is not so much that infractions are few and often inconsequential, nor that the naysayers and critics are few in number, but that the the condemnations are loud and insistent. Without a visible and concerted effort to rebut their arguments, allay their suspicions, and demonstrate that there are consequences for deception, their doubts will only grow larger, and their trust in the scientific approach further diminish. Already we have seen the effects of an underlying mistrust in the uncertainties of science manifesting itself in the climate change deniers.

Add fraud to the inherent uncertainties embedded in the scientific method, and we can begin to worry about the punishment of Sisyphus condemned forever to roll a massive boulder up a hill then watch it roll back down again. Consequences must suit the action. Justice delayed is justice denied.

 

 

 

 

 

 

 

 

 

 

Once Upon a Time

Once upon a time, rumour had it that we were at the top of our game –nothing else came close. Well, maybe chimpanzees, but come on –they don’t even have a decent language, so how would we know? Anyway, we had no real competitors, and –just in case- we wrote the rules and we were the judges. Until now, that is.

It seems that the pigeon cartel has moved in on mammograms and apparently there is a push to read pathology slides as well: http://www.bbc.com/news/science-environment-34878151  Now I don’t want to come across as a Speciest, or suggest that I  wouldn’t welcome a family of them living down the street or anything, but it seems to me that we have draw the line somewhere. Jobs are going to be lost; an industry is in jeopardy. I mean, why would we train people for years and go to the expense of kitting them out in those long white coats that need constant laundering when it would be so much easier to head downtown and pull a couple of pigeons out the park? So what if they shed their feathers? Do we ever have enough pillows? And diseases they might carry? Show me a pathologist who is sterile and I’ll show you a hologram. And besides, you don’t have to put the pigeon on anybody’s breast, do you? They are experts once-removed –twice removed if you kept the cages in another room altogether. Mind you, the cooing sounds would help to allay the anxiety over the anticipated and legendary pain of pressing a perfectly good breast into an X-ray sandwich so compromises may evolve.

Now, I can foresee some difficulties in training the birds to use the standard-issue microscopes, though. Some thought will have to go into new designs for the eye-pieces, I suspect. Oh, and wing-activated focussing devices, too. For years we’ve been selfishly designing stuff for fingers and spectacle-wearing eyes straddling long and often itchy noses; it’s long since time to start thinking beaks and feathers.

But utilizing pigeons may just be the first tentative step in revolutionizing medicine –farming it out, as it were. The article also whispers about glimpses of giant African pouched rats detecting tuberculosis –something to do with stuff they keep in those pouches, I’ll bet. In breathless anticipation of a bespectacled, stethoscope-wielding animal with huge teeth and accompanied by the characteristic snaky tail, I was relieved that Google only displayed the nice ones you could feed peanuts to -the cute ones that nobody would mind crawling over her chest looking for little bits of TB. And maybe with a few modifications they could be induced to do mammography kinds of quests and check for cancer while they’re in the neighbourhood. Maybe, if they caught on as pets, we’d have a lot less disease to worry about. Oh sure, there’d be other stuff –fleas, for example, and maybe plague- but everything’s a trade-off isn’t it? We could train people in turn to learn to balance risks. Decide what’s really important to them or their families. I mean, don’t we already do this with sports and their attendant injuries? You have to admit that a lot more of us suffer from concussions than die from the Black Death nowadays. And then there’s the whole panoply of traffic –related issues. Uhmm, did I already mention war?

No, we have to look further afield than we have to date: new answers; new questions, even. I don’t know… I suppose it’s only a dream, but I’ve always felt we would all be better off using what’s around us, rather than destroying it. Joining the web of life, not tearing it down. We are Nature, for goodness sakes.

Who knows, this refreshing outlook might spawn new and exciting industries… I didn’t actually mean to use the word ‘spawn’. We haven’t yet enlisted salmon in our quest for laboratory help, although their legendary ability to see underwater might be a real boon to public health infrastructures –in waste treatment and the like. But don’t hold your breath; it’s coming. We’ve barely even splashed the surface!

Zoobstetricoses

 

Ever since I was a little knicker I had a dog, or a cat, or both. It was part of growing up –playing with the dog in the park, avoiding the cat’s claws as it grabbed for the piece of wool dangling temptingly in front of it. And then there were the times sitting curled up in the dog house just to see what it was like to live there, or sharing my ice cream cone with it because it looked hungry. Being licked in the face was also easier than washing before dinner… Memories, no doubt aggrandized with time, but nonetheless part of the mythology of childhood. My childhood; my mythology.

But I had somehow assumed that it was just a part of la Belle Époque for people of my age; something that the younger generations had long since abandoned for fear of contagion or changing perceptions of what a child should be allowed to do -or want to do. We live in a much more heterogeneous, sanitary society than we used to: a cultural melange that often accords animals a different role in our lives. Whether this is an advancement or merely a change in outlook didn’t much concern me: I’ve already had my past, lived my childhood.

But several months ago I happened upon a review article in the Canadian Medical Association Journal http://www.cmaj.ca/content/187/10/736.full on ‘Reducing the risk of pet-associated zoonotic infections’ and it got me thinking about my pregnant patients and their unintended risks. Of course, every health care provider –every woman, it seems- knows about not cleaning out the kitty litter in pregnancy (Toxoplasmosis) –and even avoiding the other end of the cat (Cat-scratch disease: gram-negative bacterial infections)- and yes, or the perils of eating some types of raw fish sushi too frequently (Mercury contamination). These all seem to be part of a societal mythos to which we are so often exposed, that one almost wonders if there is a gene that the placenta activates whose sole job is to send avoidance signals to the pregnant brain.

And yet the article outlined many more diseases that animals can transmit to humans (zoonoses) that are more quietly under the radar –multidrug-resistant bacteria as an increasingly worrisome emerging threat, for example. So, in the interests of patient safety, I thought it incumbent upon me to add animals to my list of questions. There was no spot for them on the prenatal form, so I kind of slipped it in under ‘other’. Along with ‘occasionally’, I find that ‘other’ is one of the more important categories of words that I like to use.

One woman, Lorraine, seemed to find the questions objectionable however. It was almost as if she felt I was accusing her of uncleanliness, or maybe petophilia, or something.

“I’ve never owned a cat, doctor,” she said with a bit of a huff in her voice. “I’ve always thought they were dirty animals,” she added, as if to justify her vehemence. “They eat vermin when you’re not around.”

“Sometimes that’s a good thing,” I said, hoping to calm her down a little.

She pinned me to my seat with needles from her eyes. She obviously resented the inference of suboptimal conditions where she lived. I left it lying fallow.

“We do have a dog, however –my husband insists on having one,” she admitted with a little reluctant shrug, obviously wary of my reaction. “But it is only allowed on the rug in the kitchen –far away from the food preparation area- and it sleeps in the garage.” She stared out the window behind me, this time avoiding my eyes. “And he takes it to the vet all the time for its vaccinations and flea medication. Costs him a fortune, what with the price vets charge nowadays.” Her eyes flitted around the room, obviously tallying the cost of the pictures on the wall, and even the knickknacks on a little oak table that patients had given me. Obstetricians were clearly not immune to price-gouging –although in Canada with our healthcare system, the extortion was presumable aimed at the government.

Then she waxed reflective. “I had a dog when I was young, though. Boots was his name and he used to follow me to school –I lived in a small town with not much traffic,” she was quick to explain, lest I think she was careless about its safety. “We used to share everything, I remember.” She risked a quick, guilty glance at my face to see if she had transgressed, even at that age.

“And then I got parasites –cryptosporidium­. My mother made me memorize the word; she says I got it from being licked in the face by Boots. I remember I had terrible diarrhea and cramps, but I also remember her telling me that there was no treatment for it and that because of what I let the dog do, I was going to have parasites for the rest of my life… She had a drinking problem at the time, though, so she soon forgot about it… I didn’t.” She sighed somewhat theatrically and continued. “After that initial attack of diarrhea I never had the problem again, so like about so many other things, maybe she was wrong about that.”

I nodded reassuringly. “People with intact immune systems seem to be able to restrain it –keep it in check. And besides, how certain were they of the diagnosis back then?”

She shrugged. “It was just something my mother told me…”

A sudden look of panic attacked her face. “The immune system is dampened in pregnancy isn’t it?” But before I could explain what that meant, her eyes opened like she’d seen a ghost. “Am I going to give it to my baby?”

The answer, of course, is probably not –especially if the condition is not active during the pregnancy- but using a ‘probably’ would only inflame her anxiety. I find when there is a heightened level of concern that actually looking it up on the computer as they sit and watch, is very reassuring: I am then au courant. So I Googled the Center for Disease Control website for ‘infections in pregnancy’ (http://www.cdc.gov/ncbddd/disasters/infections.html) and printed it out for her. It wasn’t much, but it seemed to help. It didn’t do anything to foster a more tolerant attitude towards dogs, however…

That night, as I sat reading in the living room in front of a crackling fire and my own dog lay dreaming near the fireplace, I got to thinking about my own life with dogs. Was I at risk? But then, when I stirred in my chair and one of his eyes opened and stared at me curiously, I realized it didn’t really matter. The risk was worth it.

Umm, I did wash my hands this time after he wandered over and licked them, however; but I think he was just telling me not to worry about him