Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."
Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.
Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.
I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.
"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.
I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."
A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."
I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."
"No," said Victoria, "I wasn’t on the patch anymore."
"What?!" I exclaimed.
"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."
"Wasn’t there anyone else in her office who could refill it for you?" I asked.
"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."
I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.
And when she ran out of contraceptive patches, she didn’t get them refilled.
Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.
Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.
The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.
Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.
After all, we have them ourselves.
Dr. Rockoff practices dermatology in Brookline, Mass.