You are currently browsing the Dr Licciardi blog archives for July, 2007.

A Bit More on Seeing Your New Doctor

Thanks for the great comments. I will just finish up where I left off and conclude this topic.

2) Foolish. This one she made me understand. It’s like driving around with a broken car for 6-12 months and the mechanic telling you that you really messed things up by not coming in sooner. Or like being afraid the stockbroker will tell you that if you had come sooner, you would have made a lot more money (or lost less as the case may be). So I kind of get it. But if you get to a good doctor, mechanic or broker, you will not be treated as any thing other than someone who deserves time and explanation.

3) Guilt. You are on your own here. We all feel guilty for the past “the right decision at the time”, and some of us feel guilty for…, well you name it. Throw it out the window and move forward. I know, easier said than done, but do the best you can.

In summary, hopefully your doctor will gladly anticipate your arrival. He/she will make you feel empowered by educating you and helping to make you feel at ease. So get on in there, better late than never. Think about all of the other women not taking the first step and you will feel better about what you are doing. And don’t get discouraged if the doctor is not for you. There are plenty of other doctors who can’t wait to see you.

Dr. Licciardi

Meeting Your Doctor: What are You Thinking, What is the Doctor Thinking?

This topic was suggested by a woman who had been my patient years ago. We continue to communicate regularly and she recently told me of the thoughts and feelings that she brought into my office at the first visit. She told me that she had a number of beliefs that made her at first very uncomfortable. They had nothing to do with me as she had them before we met.
I was surprised by what she now said, and I explained that her assumptions were really off the mark, but she insisted that she was not alone in her thoughts. So let’s see what you think.

She thought:
1) She felt that she was going to be a burden on me. She figured I was really busy doing important things, and seeing her was just an interruption to my demanding day.
2) She was worried I was going to make her feel foolish.
3) And of course, if she were to foolish, she would by default go on to feel guilty for being a fool.

I thought:
1) I probably checked my schedule a week in advance to see who was coming to see me. I really like when my day is full. I don’t like packed, but I can control that. I leave a full hour for my new patients because I don’t want to rush. I need to enjoy what I am doing and I can’t do that overbooking my day. The truth is that even though I had never met her, I couldn’t wait to see her. I think seeing a new patient is the best part of my job. Everyone and has a story (at least one) and everyone is a puzzle. I just like meeting new people. My first priority is doing what I can do to help them. My secondary objective is getting to know them as well as possible. I like hearing where people grew up, where they went to school, what they do now, etc. My father has been selling real estate for most of his life, and he would typically come home from work and tell us enjoyable stories about the new people he met that day. I like doing the same thing.
It’s also about the connection. I have 1 hour to connect, and really I better connect a lot sooner than that. It reminds me a little of the job of a journalist. Of course a journalist needs to be smart, write well, get the story straight. But the best ones connect immediately with their interviewees because this way they will get more from them. It’s the same for me. If I can connect I get to be closer to some nice people, but also the communication will be better and that is a positive for patient care. That is the way I want to practice medicine.
As far as the medical side goes, when I am asking patients questions I feel like Sherlock Holmes. Solving the puzzle is important, challenging and fun. Yes sometimes the history is rather straight forward, but most of the time’s it is not. Almost all of my patients have seen another doctor before me and some have been to many fertility specialists. I really want to fish through the history to see what is missing, what has been overlooked. Sometimes it’s nothing, sometime it’s more a matter of opinion sometimes its something very obvious.
So I was not too busy for her, I wanted to be busy seeing her.
We’ll talk about some of the other things next time.
Dr. Licciardi

Miscarriage, Infertility, Antibodies and the Immune System

We are entering the world of unknowns. You will see me contradict myself a bit, but I will try to explain why.
I will start by saying that no one has ever shown well that any of this matters at all. There have been no good studies showing that antibodies of any type have an effect on the ability of someone to get pregnant or keep the pregnancy (outside of the women with Anti-phospholipid Syndrome mentioned last time). Now I know there are small studies out there proving x, y, and z, and some of you have been treated with success, but as far as large well designed studies showing antibodies matter, they don’t exist. The same is true for levels or activity of natural killer cells, platelet activation, factor 5, protein c and s, and the list goes on and on. In fact, the American Society of Reproductive Medicine has put out a statement saying treating abnormalities of anti-cardiolipin antibodies is not recommended.
So if having the antibodies or clotting issues may not matter, how will treatment help? Good question. Many of you know that blood-thinning drugs, like heparin, fragmin, Lovenox, are given to tons of women. Also IVIG, which is supposed to lower the immune response, is given out rather frequently. But again, no one has ever shown well that these drugs are doing anything. This is hard for me to deal with because it would be very easy to the right study. Just give 100 women Lovenox and 100 none, and look for a difference. The same for IVIG. I am sure that the practices that use this stuff like water could easily do a study.
And these drugs are not risk free. You can bleed from blood thinners and there may be unknown risks of IVIG, which is made by pooling human serum.
So here is the contradiction. I do have a very small group of patients who are getting these treatments from other doctors. Why, because they are in the hole of last resort. They have tried for a long time without success. They feel good that a doctor has found a possible problem and feel good that something is being done. I am sure many of you are in the same hole. And guess what, some of them get pregnant and have a baby. If they didn’t get the treatment, would they have had the baby? Probably, but we will never really know.
I know there will be many detailed questions on this topic but this is about as far as I can go. There are too many unknowns, and not enough proof.
If you are considering these treatments, be sure your talk to your doctor about possible risks, and remember to see disclaimer 5/17/06. Dr. Licciardi

References:

  • Porter TF, LaCoursiere Y, Scott JR. Immunotherapy for recurrent miscarriage. Cochrane Database Syst Rev 2006; (2): CD000112.
  • Kaandorp S, Di Nisio M, Goddijn M, Middeldorp S. Aspirin or anticoagulants for treating recurrent miscarriage in women without antiphospholipid syndrome. Cochrane Database Syst Rev. 2009 Jan 21 ;(1):CD004734.
  • Stephenson MD, Kutteh WH, Purkiss S, Librach C, Schultz P, Houlihan E, Liao C. Intravenous immunoglobulin and idiopathic secondary recurrent miscarriage: a multicentered randomized placebo-controlled trial. Hum Reprod. 2010 Sep; 25(9):2203-9.