Inside Reproductive Health, Ep 18
How Physician Fertility Can Impact Patients: Dr. Nichole Barker and Stephanie Fattal
This week, host Griffin Jones speaks to a provider and their patient to get a perspective on the fertility journey from both sides. Dr. Nichole Barker, a board certified REI practicing in Tacoma, Washington, is joined by her patient, Stephanie Fattal. Dr. Barker speaks about her own infertility journey and how that changed the way she practices medicine, and Fattal discusses how it felt to work with a REI that truly understood the patient’s point of view.
Griffin Jones: Today on the show we have a really interesting format. Because it’s National Infertility Awareness Week, I wanted to invite on a provider and their patient so we can both go through the infertility journey together, to see it through the eyes of a patient, through the eyes of a provider, and a provider that has also been through the journey herself. I’m joined by Dr. Nichole Barker, who is a board certified Reproductive Endocrinology and Infertility Specialist at Seattle Reproductive Medicine, in their Tacoma office. She went to medical school at Ohio University, she completed her OB-Gyn residency and her REI fellowship at University Hospitals at Case Medical Center in Cleveland. She has been published in several journals on several topics, and her special clinical interests include fertility preservation, PCOS, recurrent pregnancy loss, and lifestyle effects on fertility. I’m also joined by one of her patients. Stephanie is originally from Seattle, WA area. She is married to her husband Nick, and they have three beautiful children, all of whom are from IVF, from two different cycles, and she has been gracious enough to come onto the program to talk about this experience from both sides of the clinical perspective. Stephanie, Dr. Barker, Nichole— welcome to Inside Reproductive Health.
Nichole Barker: Good morning!
Stephanie Fattal: Thank you for having us.
GJ: I’m so excited to be interviewing two people. This is my first time interviewing two people on the podcast, and I think we have a really interesting lens for doing this because Dr. Barker, you went through the infertility journey yourself.
NB: I did. Yeah. And a lot of people ask me if it was because of that that I went into the field, but I actually, I found out kind of mid-training, or right at the end of my training, so… but I always say that it was one of the best experiences for me to learn. I would never trade it for the world. But yeah.
GJ: I’m looking forward to seeing how this parallels with our patient’s journey. Stephanie, you said you and Nick were trying to conceive for three years?
GJ: Can you talk a little about when you start noticing you were having trouble, and then where did the search for information and the decision making process and how you’re talking to people… how does it go from “We realize we’re having trouble now” to what it’s like to process that?
SF: Ok. So. At about the six month mark, I kind of took a pause for a minute and thought maybe there might be something, but after speaking to my OB-Gyn, I was advised it could take healthy couples up to a year. I needed to give it some time, and that we were young, and just give it some time. So I did that. And then after a year, I was given a referral over to SRM. Because everything that my OB could find, there was no reason why I shouldn’t have become pregnant. When I got the referral sent over, I started doing research on the different doctors at SRM, and that’s how I made the decision to go with Dr. Barker.
GJ: Are you searching for information on your own at this point, or do you go right to your OB-Gyn and say, this is what we’re going through.
SF: Well, during our trying to conceive journey, I had been doing research on line and joining forums and support groups online and on Facebook. There’s a large community out there, people trying to conceive and battling infertility, so I kind of used those resources and outlets for information, and then alongside my OB-Gyn.
GJ: The TTC community is really big. At this point, in your mind, is what you’re going through exactly that-- trying to conceive-- or have you thought about that this is infertility?
SF: I had not given myself the diagnosis of infertility yet. I just thought we were trying to conceive and maybe taking longer, but I knew that the trying to conceive community was huge and I was looking for all the tips and tricks and support and help, so that’s where I went.
GJ: So then you go to your OB, do they refer you right away? Do you go through some tests? Did they try any forms of treatment before they refer you?
SF: No, because they did ultrasounds, they did bloodwork, they did a bunch of testing on me. ANd I had some testing prior to, there was nothing-- my OB was stumped. She sent me over to SRM pretty quickly after that, once we hit the year mark.
GJ: So did they give you a few options to choose from-- here’s some clinics in the area, did they say, or SRM is a clinic that we’ve worked with a lot? ANd how did you find Dr. Barker from that?
SF: So… I was given a couple different options of ones inside or local to me, but they highly recommended SRM. ANd then I started kind of searching on my own, the doctors, and then reading reviews and doing all of that. ANd that’s how I came across Dr. Barker, and I’m very thankful I did.
GJ: Dr. Barker, your journey was, I got the impression from how you explained it, before REI training?
NB: Actually, I was a fellow at University, and I was in my third year, I think my husband and I got married when I was in my first year. It was interesting, because being in the field and immersed in it and studying it and getting prepared for it, it was always in the back of my mind, well I hope we’re ok. And my husband knew what he was getting into marrying me… he said, maybe we should get checked maybe before we get married. I was like, wait, wait, wait, wait, no, we’re not gonna jump ahead, we’re just going to do the normal thing. But because of where I was in my career and in my training, we’re not like the usual couple. We spent a couple of months, and because of some things that we were worried about up front, we got an evaluation pretty quickly. From that point on, it was pretty clear, almost immediately, like, you’re gonna have to have some help. And for me, and my journey, it was really hard, because I was at that point where I was starting to interview for jobs. And I had such a great support at my training, I just remember thinking that I don’t know if I can go on being a doctor in this field. I was just really scared because I didn’t know what was gonna happen with us personally. We were newly married, it was very stressful, I’m looking for a job, and I’m thinking to myself, I’m sitting here as a third year fellow, like… can I do this? What happens if I’m not successful? This is an emotional rollercoaster. How am I gonna handle myself through this? It was a pretty dark place for me and I was really scared, but I had a lot of support from the people who were in my training program and they helped me through my first IVF cycle. We did our first cycle in Cleveland. You know, we were very blessed that it worked the first time. I knew that going into my career going forward that I was successful at that point in time with my first cycle. But it was hard. It was all those different things happening all at once,and I knew this was gonna be my life career. I was struggling as a patient behind closed doors in the office, trying to put on a happy face and then going and congratulating a patient or helping them through their journey. It was a really hard time, but I think that it all happened for a reason. No book, no provider, no teacher, no surgery that I could learn from better than going through that myself. I would never change it for the world, and I have my two beautiful children, but it was interesting. It wasn’t beforehand, and it wasn’t during my practicing, it was during my training, right before.
GJ: I want to go back to something you said at the beginning of that, because your husband’s thinking, well, this is the field you work in, maybe we should both check things out before we start.. To me, that means ovarian reserve testing and semen analysis. And you didn’t want to do that. One of the things that’s so interesting to me as I talk to physicians, they say to me, Griffin, if I could have seen this patient two years earlier, I would have so many more options to help them, I’d be able to help them more quickly, their prognosis would have a better likelihood for success… can you talk to us a little bit about what that resistance was for you at that time?
NB: Sure. I just know myself. I’m a pretty emotional person. And that’s good and bad. But I think I was worried it would change my perspective on going into our marriage. I was really worried- I didn’t want that to muddy the water. I knew I wasn’t gonna waste too much time-- I wasn’t gonna let years go by. I knew that we’d be proactive about it, so in my mind, it wasn’t like I was gonna delay it for a long time, I just didn’t want to do it because I’d already made a commitment to this person, this was the man of my dreams, I didn’t want anything to change my thoughts about, oh, we just found out we’re not going to be able to have kids and we’re not even married yet. I was worried about that. It wasn’t necessarily that I was worried about delaying things too long, I just didn’t want to do it up front because I wanted to show my husband and myself that I was committed to this relationship regardless and we were gonna do this together. I didn’t want that to influence… If I found out that I had no eggs left, or he had no sperm, or whatever, I didn’t want that to change how we felt or how we acted to one another. That was why. And, I was 31. I was fairly young. It’s not like I was 38 or 39 or 40, so I knew that I had some time.
GJ: Stephanie, for those who can’t see the video chat that we’re having, you’re nodding emphatically, it seemed that parts of Dr. Barker’s story really touched you. What was resonating?
SF: Just the relationship component that I can relate to. When Nick and I found out, we were fairly newly married still, and just how the heavy, the could that kind of comes over the relationship at first, I can really relate to.
GJ: So you come into treatment at SRM, presumably you’re coming in for some more tests or for the initial consult. Talk to us about how the treatment process began and how your relationship with Dr. Barker began?
SF: Ok, so, we met at our initial consult. Man, it seems like forever ago, but it really wasn’t. We talked about what had already been done and what needed to still be done, and one of the biggest pieces that had never been done, If I remember right, kind of came as a surprise to Dr. Barker, was that my husband had never been evaluated. So that was the first piece that needed to be done. So, we got an evaluation and then he met with the urologist, I don’t remember his name, a really kind older gentleman that worked at SRM at the time, I don’t know if he’s still there or not. We met with the urologist, and we were given, we were basically told that IVF was our only option. That the chances of us conceiving over our entire fertile life was next to nothing without IVF.
GJ: NIchole, is that common? That someone would come.. That an OB refers after they have done some testing, they’ve done blood work presumably, MH and FSH and the ultrasound for the female patient, but they didn’t do anything to have the male partner checked by their urologist or refer them to someone… is that common? That one….
NB: I kind of see it all over the board. I will see patients who neither have had anything because the provider is really telling them just go there, get it done under one umbrella. I have other providers that I know enjoy doing the initial workup with the couple and if they find something that they can’t address, then referring them on. For sure, a lot of times OB-Gyns are just seeing the female patient. I think that naturally it’s easier to just say, oh, let’s do these tests on you, but by the time they’re to see me, it’s gotta happen. I always say that this is two people involved here, typically. I think that having one half of the evaluation is literally having only one half of the evaluation. I can’t make a full recommendation, I can’t get you the help you need the fastest if I don’t have both partners tested. I wouldn’t necessarily… sometimes I’ll see the opposite. They’ll say, oh, I just had my doctor refer for a semen analysis, it was a cheaper test, it was easier for me to do, sometimes I’ll see just the guy coming in with his test done. It’s kind of all over the board for me.
GJ: And when meeting with a new patient in an initial consult, does your journey come up?
NB: Sometimes. I always say that I’m an open book. I’m active on social media, I answer questions about it, I wrote a blog post kind of saying a little bit about my story several years ago, so I’m an open book. A lot of times, some of my patients will say, Oh, I read that, so I kind of knew what was going on up front. But I don’t necessarily make a point to talk about it. If they ask about it, or if I feel like they’re struggling in some way that I could maybe interject, like, oh, I remember that time and maybe I’m talking to the couple about how they can interact with each other and support each other, I’ll say, Hey, when me and my husband went through this, we dealt with it differently, this is how he dealt with it versus how I dealt with it. Or oh, hey, I remember how much those progesterone and oil shots stung, let me tell you what I did. I don’t necessarily say, Oh, hi, I’m Dr. Barker, I’m an infertility survivor, hi, how are you doing? I think that if it’s an appropriate and if it comes up, I’m more than happy to discuss it. A lot of times, if they don’t know that I’ve been through it, they’re kind of like oh my gosh, thanks so much for telling me this. I’m so glad that you’re with me on my journey and you know what we’re going through. I’ve never had any bad vibes from anybody after talking about it. It’s actually always been a positive experience.
GJ: Stephanie, were you familiar with Dr. BArker’s experience as this is happening from the beginning?
SF: I don’t think I found out until my first transfer-- the day of my first transfer. She was in the room, another physician was actually doing the transfer, but she was in the room. It’s not super comfortable, and she was talking me through it, telling me what to expect, and she was talking as if she not just knew from a medical point, if you get what i”m saying, but actually KNEW knew. So I think that’s kind of how that conversation came about.
GJ: What was that like, just having… being able to work with someone who had also gone through it.
SF: I felt… I felt empathized with in a way I can’t explain. I immediately felt this calm and this peace that… ok. They get it it. They understand. And it kind of made sense, in this way, because she was so diligent, and so thorough, and just seemed really invested in me, in us, and our journey to becoming parents, that it just made sense. She gets it. She knew. She really… so… it did. It made complete sense.
GJ: Let’s rewind a little bit. You find out from other specialists that IVF Was the only option for you. Did you get right into it then? Did you have to cost calculate? Did you need to think if this is something that we want to do? Did you need to learn more about it?
SF: I immediately did some research and did some talking about what the best avenue was. We weighed the cost and we did some research online, like, ok, iVF is not cheap. And having to come up with that money was a journey all in itself, something we could do a whole other interview about. But whether that was the best option or was there a cheaper option that would fit our family, but after we took a couple months to talk about it and really decide what was the best option, and so we decided that IVF was the option for us. And we had to buckle down and figure out how to raise that money.
GJ: Dr. Barker, how do you help people make that decision, because, even when the prognosis is good and there’s a high probability of success… it’s still not a hundred. And for some people, it really could be one outcome or another, and I remember the first time, having to experience this sort of dilemma with my family with other medical issues, but we’re making a decision with the family of what route to go and being frustrated that the doctor couldn’t just say, do this and exactly this will happen. And so how do you help people with that?
NB: Well, it’s really hard, because honestly… we live in Washington state, and most states as of now are not mandated, so most of my patients do not have benefits for treatment. And it makes it very hard. As soon as the patient comes into my office, that is.. It’s in the forefront of my mind. I want make the best recommendations for my patients clinically, but I know that they’re sitting across the desk from me and they’re kind of just waiting at the end, so how much does all this cost? That always comes up, and sometimes that’s the limiting factor of them even getting into my office. They’ve been told by the OB-Gyn already they should go see me, but they’re afraid that they’re going to be already as soon as they step in the door, their pocketbooks are gonna be drained. And so what we do is if they are talking to me about it, luckily if they have some insurance coverage, it will usually cover diagnostic testing. If it doesn’t, we go over, what is the most important things of diagnostic testing. What are the big hitters that we can just knock out that are the cheapest. We go over that, ok. They talk with our financial counselors the same day as well. I can give them ballpark figures and then they go get more solidified numbers from the financial counselors that are based on their plans, or if they’re paying out of pocket. But it’s definitely something that’s in the forefront of my mind. I try not to get too involved with it, because I don’t want that to necessarily sway what I’m recommending for my patients, but I take it into consideration when we’re having that conversation. However, in some cases, kind of like Stephanie’s where it’s like, well, it seems like IVF is gonna be the best route, and maybe even the only route, unless you’re considering alternative options of building your family. That is a huge cost, so then we turn the conversation into, ok, well, you are best prognosis age. This is not even your age, but let’s say, 28, and you have great egg reserve, and maybe we can hit the pause button while you guys buckle down and get those finances in check for the next year and a half or something like that, so a lot of times, especially where I’m at in Tacoma, the demographic is a little different than in Seattle proper, where a lot of times they might have insurance coverage to cover it. Down in Tacoma, that’s not necessarily the case. Especially with IVF, what we’re talking about is how much time do you need, and is that from a clinical perspective gonna be ok, where it’s not gonna jeopardize your chances of success. A lot of times, I see them at the initial visit, then they might not come back for awhile. Then I’m seeing them on my schedule, like maybe two years later, and they’re like, ok we’re ready. And that’s unfortunate, because I know that every day and every month as an infertility patient seems like an eternity when you’re trying to get your goal. What I can do…. I know we’re limited, until those change and I’m glad to hear New York is changing and different states are kind of hopefully getting on the bandwagon, so I’m hopeful, but that’s how I approach it. I talk about it up front because I know that they’re worried about it, and we try to kind of figure out together what is the best path for them, and what’s the best clinical path, and is that even feasible for them.
GJ: Stephanie, let’s talk about that eternity.
SF: *Laughing* ok
GJ: So were the two cycles… you had three children from two cycles, were those the only two cycles that you went through?
GJ: Ok, no failed cycles. So. You start treatment, and then what is that like? Both from how you’re processing information and how you feel and what you think is gonna be next?
SF: So I’m hopeful and excited that all of this work leading up to this moment, you know, the years that it took to get us here, I’m excited, I’m hopeful, but I’m terrified. I’m terrified. We literally put all of our eggs in that basket. We literally put everything into this. And… I didn’t have as much anxiety the second cycle. I was pretty confident, pretty hopeful the entire time. But the first time around, we had [unintelligible] it was the first time, we didn’t know what was gonna happen. We didn’t know how my body was gonna respond and how everything was gonna come together and if we were gonna end up pregnant. So there was a lot of anxiety, but there was still a ton of hope underneath it all. But that waiting period was torture.
GJ: Does the success of the first cycle, does it make it easier to make the decision for the second cycle? Or do you feel like you’re going through the same exact thing again.
SF: I mean, we did have to… you know… especially with my particular situation. Doing a whole new cycle was an option, we did have another option, but our odds weren’t good. So that was the hardest part. When we made the decision to do the cycle again, it wasn’t quite as daunting as the first time around because we kind of knew a little bit about what to expect, what the process looked like, and we had had success before, so our likelihood and our odds were super good.
GJ: Is the two week wait as long the second time around?
SF: Yes. (laughing) Yes. It is.
GJ: Dr. Barker, you said you went through your first cycle back in Cleveland, is that to say that you did go through more than one of IVF?
NB: Mmhmm, I did my first cycle in Cleveland, and then I had my daughter and then I love them so much, I think they really, really tried to make some good frozen embryos frozen for me there, which they weren’t really good, but they kept them nonetheless, so I felt compelled to go back. I’d already established in Seattle my practice, and then after about a year, we decided to try again. I flew back to Cleveland and had my transfer and I didn’t get pregnant. And so we didn’t have any embryos. So at that time, I knew, based on how our first cycle went and how few embryos we had and what worked, that it was gonna be a gamble if we were gonna try again. Plus, I kind of had to go back and forth with myself to say now I’m gonna be kind of exposed in Seattle a little bit more opening up if I’m gonna be doing my cycle here as a patient and a provider, and am I comfortable with that. After being here, interesting enough, I think some people kind of withdraw a little bit in those situations, but for me, I was so comfortable with my practice and all of my partners and the nursing staff and everything that to me it made so much sense that I was in such good hands, that we were gonna try again. And so it wasn’t easy, because I put myself in the patient’s place from scratch, so I made an appointment with my partner, I sat down with her, and she picked out things that… she was like, well, you know, you’re gonna take your boards during this time, are you sure you wanna do it at this time, is this a good time, should we get Dan to see a urologist again, and all these things that I didn’t want her to say, that I was trying to doctor myself and just push on, push on. I’m so glad that I listened to her, because as a provider you start to try and doctor yourself and put your own experience into it. It’s really hard to take that step back. So we delayed a little bit because of my boards, which I’m happy about. As well as we delayed another three to six months for Dan to get on some medication and I will tell you, our cycle went much better, actually three years later. Me, now, 35, almost 36, and so that’s kind of really not usually the case. Usually you think you get older, it gets worse, but we actually had a much better cycle, better fertilization. I, unfortunately, though, got sick with hyperstimulation. I still was able to go to work, but I had to freeze all my embryos so that was another delay. I ended up having to do a frozen embryo transfer, and that one did work. So that was a little bit of a long winded answer for your question.
GJ: Does it change the relationship or add anything to the relationship with your partner, is it just seeing another patient and I’m seeing another doctor, or is it…
NB: No, I think it’s special, because you not only know this person is a good doctor, but you know them also on a personal level and they also know you, so you’re kind of invested, and sometimes it’s a little scary, because you know I’m also thinking about how they feel about being involved in my care and I know how stressful that is, because they’re... obviously we want the best for everybody, but when you’re somebody’s colleague and friend, it’s almost heightened, you know. It’s a special bond and it’s great, but at the same time, y’know, it’s hard. Because you kind of are wondering oh, if this doesn’t work out are people gonna find out that I’m not pregnant and not want to talk to me, or say something…. There’s a lot of things that is so many levels.
GJ: Stephanie, after cycle number 2, now you’ve got three beautiful kids, how would you describe where you are now in terms of the journey.
SF: I have a lot of pride in my husband and I and my care team, I just have a lot of pride. And you know through that entire journey, I tried to remain determined, even when it was hard to do so, so now I’ve funneled that determination elsewhere. To raising these three kids that I’ve been blessed with. That myself, my husband, and Dr. Barker worked so hard to be able to make a reality for us. I’ve just kind of funneled that determination into not missing a second and raising happy, healthy kids.
GJ: To conclude, what would you say to someone who is in the position now that you were when you were trying to conceive for three years, because there are people out there that put in one years, two years, three years, probably not seeking expert consulting before they should be. What would you say to those people.
SF: They have to decide what’s right for them, but once they’ve decided they want to be parents, seek help. Be loud about it. Don’t hide. There’s nothing to be ashamed about. There’s nothing to be embarrassed about. This community has meant more to me in the last four years than I can even express. The amount of love and support you’re gonna feel while you’re on this journey is unfathomable. And you don’t have to go through it alone— you’re not meant to. There’s certain things that we’re not meant to go through alone and I truly believe this is one of them.
GJ: Nichole, what about you, on one hand you also have beautiful children from this process, but then you put your jersey back on and the field is on the other side. What is the conclusion or ongoing feeling of the journey for you?
NB: Well, it’s interesting. Because like you said, I’ve now put the jersey back on, the helmet back on, and I’m back in the game, you know, day in and day out, and it seems like... my youngest is almost four, so it’s quite a bit of time that’s passed since I’ve been in the patient’s shoes, but I will tell you that experience forever leads you and I think that there’s something to be said though, too, for me as a provider, it’s almost interesting, and maybe it’s just unique to people who have been through it, and I know there’s many providers out there who have struggled and done treatment, but every time I see a patient, it’s almost like it brings me back a little bit to my own experiences. So for me, I still to this day struggle. I know that even if I probably didn’t go through it, I would feel awful when things don’t work, or my patient miscarries, or things didn’t go as planned. Stephanie and I were very lucky, because we had success. I think for me as a provider, it’s hard because I have many patients who are not at that goal and I’m still on my journey as a provider, how can I best help support them through that? I think that my experience just affects that ability. Sometimes it’s more of I want them to be more aggressive faster, yet I don’t want to influence them, because maybe they don’t want that. I’m using… I’m drawing back to my own experiences. So I have to balance me trying to put my own personal thoughts on a patient, what I think they should do. It’s hard. I have to try and stop myself and be like, Ok, clean slate, clinically here are the chances of success. Here’s what I recommend, but that might not be for them. I might have a patient like Stephanie and Nick, who say, you know what Dr. Barker, IVF is not our route. So what else can you do? How can you support me? For me, I think that it’s been a journey just in my career of how… how can I best support people through this. It is hard for me, because I want everyone to come out with their goal. It’s just that I can’t tell them when it’s gonna happen. I can’t tell them if it’s gonna happen. All I can do is give them their options and help support them.
I realize I did have a three-way conversation on the podcast, Sarah and Tracy from IVF Babble are gonna send me some angry text messages, but it was the first time I’ve ever had a conversation like this where I’ve been able to talk to two people who were both on different sides of the same journey. It has been a really enlightening conversation. I know that our audience of practice owners and physicians and practice managers is going to enjoy it, but also the infertility community that follows us on Instagram is also gonna benefit from this as well during National Infertility Awareness Week. So Stephanie, Dr. Nichole Barker, thank you both so much for coming on Inside Reproductive Health.
SF: Thanks for having me.
NB: Thanks a lot, guys.