Transcript of 9th Session between Charles Balis, M.D. and Ms. Sylvia Bows, Tuesday, September 3rd, 1996 at 4 pm.

Ms. Bows: Hello, Doctor. It's nice to see you. How was your weekend?
Dr. Balis: Hello, Sylvia. I had a good weekend, thank you. Took some time to explore the city a bit more, get to know my neighborhood. How was your weekend? Did you get into the tree house place you were talking about?
Ms. Bows: Yes. Victor's sister came through. Although we only got Sunday and Monday night. They were completely booked on Friday and Saturday. But we still drove down there early Saturday. They have a couple of hiking trails and the hostess was nice enough to make us a picnic lunch. We had a great time.
Dr. Balis: Have you been friends with Victor long?
Ms. Bows: It's hard to say. I met him at one of the SII functions a couple of years back. I immediately liked him. And even though we never tried to make a specific time to see each other before this, we never missed an opportunity to say hello and have a brief conversation. When I found out that he was on my list, I was very happy to extend our friendship. If he didn't mind, of course.
Dr. Balis: Doesn't sound like he had a problem with it.
Ms. Bows: No, I found him very cooperative.
Dr. Balis: I see. Did you have a chance to have a little talk with Richard?
Ms. Bows: Not yet. But I made a date with him tomorrow and we'll talk then. I really don't think it's going to be a problem, Doctor. As I said before, Richard is very open minded. I don't think he will have a problem with my nonexclusivity, shall we say.
Dr. Balis: Perhaps not.
Ms. Bows: I told Victor and he was okay with it.
Dr. Balis: You mentioned that you prefer not to use condoms and since you know the medical histories of your partners, I understand that you are not particularly worried about HIV. But how about them? Did you tell Richard or Victor that they are on your safe list?
Ms. Bows: I didn't think that telling them about my list was a good idea. As open-minded as they are, they might not understand and could even be offended. And I don't want that. I want them to feel good.
Dr. Balis: So how do you handle this situation?
Ms. Bows: Since all of us have been tested recently, we all know. As the moment approaches, I say that I would prefer not to use condoms, if they don't mind. So far they have all volunteered the information about their HIV status. They are the ones that tell me not to worry, and reassure me, and tell me to do what feels comfortable to me. And I let them.
Dr. Balis: That's a bit manipulative, don't you think Sylvia?
Ms. Bows: Perhaps. But I don't mind, they feel good, and I get to have sex the way I want.
Dr. Balis: By the way, I don't remember if you told me or not, but what are you using for birth control?
Ms. Bows: Why?
Dr. Balis: Aren't you worried about getting pregnant?
Ms. Bows: No. I'm not worried, Doctor.
Dr. Balis: Why not?
Ms. Bows: Because I think I am.
Dr. Balis: What?
Ms. Bows: I think I'm pregnant. I haven't been to the doctor yet, but I peed on the stick and...
Dr. Balis: Was this on purpose?
Ms. Bows: What do you think?
Dr. Balis: You mean you intentionally tried to get pregnant?
Ms. Bows: Doctor, you shouldn't be that surprised. I did fuck everyone in sight.
Dr. Balis: Sylvia, are you trying to shock me again?
Ms. Bows: No. I want you to be happy for me.
Dr. Balis: I wish you told me what you were up to.
Ms. Bows: I couldn't. I don't think I would have the guts to do what I did without the medication and I really do want to have a child. I told you that during our first meeting.
Dr. Balis: The medication! You're not supposed to take this medication while you're pregnant!
Ms. Bows: What?
Dr. Balis: There are no adequate and well-controlled studies of Zoloft intake in pregnant women. Animal reproduction studies are not always predictive of human response. And from what I remember...
Ms. Bows: Doctor, I need to know for sure. Where are your references?
Dr. Balis: Hold on. Here is the PDR. And I would also like to get on-line and check out the latest.
Ms. Bows: Give me the book.
Dr. Balis: Sylvia, please calm down. I will look it up right now. Please sit down.
Ms. Bows: Oh god. Please don't let anything be wrong with my baby. Oh, Doctor, please hurry! I've got to know.
Dr. Balis: Okay. As I thought, there are no human studies. Reproduction studies have been performed in rats and rabbits at doses up to approximately 20 times and 10 times the maximum daily human dose. There was no evidence of teratogenicity at any dose level. At doses approximately 2.5-10 times the maximum daily human dose, sertraline was associated with delayed ossification in fetuses.
Ms. Bows: Oh god!
Dr. Balis: This is at extremely high dozes. And from everything it says here, the effects of taking Zoloft during pregnancy is just not known. Now, let's just slow things down here a bit. How many weeks pregnant do you think you are?
Ms. Bows: I don't know. I didn't care about that. Oh god, I didn't even want to know.
Dr. Balis: Sylvia, this is our ninth session together. My records show that you've been taking Zoloft for only seven weeks. What is the date of your last menstrual period?
Ms. Bows: I have never been particularly regular. My last period was just before I met you. But it doesn't mean anything. I could have been ovulating at anytime!
Dr. Balis: So you are maximum seven weeks pregnant. Do you have any idea of who the father is?
Ms. Bows: No! I didn't want to know.
Dr. Balis: Well, this definitely explains your recent behavior. What we need to do is get you to an obstetrician right away. Do you know one?
Ms. Bows: Yes. My gynecology group does obstetrics also.
Dr. Balis: Good. Please see them as soon as possible. I'll do some research too in the meantime. Sylvia, it's going to be okay. I'm not an obstetrician, but a fetus at 7 weeks is generally not at risk of birth defects from these types of drugs. If there's a problem, it is catastrophic and there would be a miscarriage. You might have to worry about losing the baby, but you don't have to worry about some form of birth defect as a result of your previous intake of Zoloft. From what I see here, the consequences of taking Zoloft during pregnancy are just not known. And at the bottom it even says that for patients who require Zoloft it could be administered but under strict supervision.
Ms. Bows: Are you saying it is okay for me take Zoloft?
Dr. Balis: No. I would recommend that you stop taking it completely, now.
Ms. Bows: I agree. It's just not worth the risk. And it's served its purpose.
Dr. Balis: Right. You'll go get an obstetrician and we'll get his opinion on all this. Now you had severe set of symptoms of post traumatic depression. Zoloft was responsible for stabilizing your physical and mental symptoms. After you stop taking Zoloft, I suspect that these symptoms will return. If they return, I think we would need to figure out another medication.
Ms. Bows: No, Doctor. I will handle whatever happens. I would rather not jeopardize my baby.
Dr. Balis: I don't want to do anything that would put your baby at risk. But your symptoms included dramatic weight loss, insomnia, anxiety attacks, and loss of concentration. All of those are not good for pregnancy. I will work with your obstetrician to figure out the best therapy for you and your baby.
Ms. Bows: I would like to do some research, too.
Dr. Balis: Sure. I'll give you some references including Internet resources. But before you come to any conclusions, please talk to me. There is a lot of information out there. It's quite complicated and not all accurate. And any self diagnosis might lead to problems.
Ms. Bows: I understand. But I would like to feel like I'm in some kind of control of the situation. And I always believed that a person should try to be as informed about their medical situation as they can.
Dr. Balis: That's a very sound attitude. Now, you should start feeling the absence of Zoloft in the next couple of days. Please monitor you symptoms and call me if you start to feel like you are starting to lose control or you notice new physical symptoms. During the first trimester of pregnancy, you could be experiencing nausea, tiredness, urinary discomforts, unusual appetite tendencies. It will be hard, at first, to sort out the true cause of your symptoms. But with careful observation...
Ms. Bows: I'm used to treating myself as a lab rat. I got very good at running through my check list.
Dr. Balis: Have you felt any pregnancy symptoms so far?
Ms. Bows: I think so. I'm unusually tired, especially in the early mornings. I'm eating more and, when I get just a little bit hungry, I need food right away or I feel like I'm going to pass out. I haven't experience any urinary discomforts yet. And I only had two nausea spells so far.
Dr. Balis: This all sounds perfectly normal.
Ms. Bows: That's what I thought too. I have been reading a lot on this subject for years.
Dr. Balis: That's good. Now, you've mentioned that you not only don't know who the father is but specifically avoided knowing. At some point you will begin to show and some of your men will notice. Not to mention that Tom will notice. What are your plans? Are you going to tell Tom?
Ms. Bows: Remember when I mentioned to you that I went to see a lawyer?
Dr. Balis: Yes. In our first or second session. You wouldn't tell me much more then that at the time.
Ms. Bows: I asked her what would happen if I got pregnant but was still married to Tom. She said that under California laws, any child conceived during the marriage is legally recognized as the child of the husband. This is regardless of any genetic issues. So even though this child is not Tom's, Tom is still considered to be the father.
Dr. Balis: You want Tom to be the father of your child?
Ms. Bows: Yes. I want Tom to be the legal parent of my child. Of course, I will file for divorce as soon as I meet with my obstetrician.
Dr. Balis: You mean you just want Tom to be responsible for the child financially?
Ms. Bows: I think it is appropriate for Tom to have this responsibility. Don't you?
Dr. Balis: Well...
Ms. Bows: He lied to me, Doctor. His lie could have cost me my motherhood. My little indiscretion is nothing compared to that. Besides, he agreed to have a child two years ago, the bastard! And if he wanted it to be his, he shouldn't have had the vasectomy. Now, he will have all of the responsibility and none of the fun.
Dr. Balis: Sylvia! I...
Ms. Bows: Doctor, it's okay. I'm just still very angry and wasn't really able to talk about it with anyone including you. I will file for total custody of the child. Not to mention the story he could tell to his friends and associates. I'm sure they will all be very sympathetic to him. I've found the best divorce attorney in the state and I'm going to bleed him dry, the bastard!
Dr. Balis: Sylvia, you sound very bitter.
Ms. Bows: I'll get over it. I now have what I wanted. Actually if I don't think of Tom, I'm very happy. Now I just need to figure out the Zoloft problem. But you have put my mind at ease somewhat. If there were women that had to take Zoloft during pregnancy and there were complications, I'm sure it would have been mentioned even as anecdotal evidence. Since the PDR doesn't mention that, it makes think that it's not really all that bad.
Dr. Balis: I still would like to do more research and talk to your obstetrician.
Ms. Bows: Of course. I'm insisting that you do.
Dr. Balis: Okay. Our time is up now. Please give me a call after you see your obstetrician and I would like to arrange to speak with him.
Ms. Bows: No problem, Doctor. I'll e-mail you the information tonight. What's your e-mail address?
Dr. Balis: I'm Thank you. I would also like for you to call me in the next couple of days just to check on how you're feeling. I do think that you might have to continue taking an antidepressant of some sort. And I'll discuss this with your obstetrician.
Ms. Bows: Nothing that would harm my baby.
Dr. Balis: Of course. So same time next week?
Ms. Bows: Tuesday at 4 pm. I'll be there. Goodbye, Doctor.
Dr. Balis: Goodbye, Sylvia. Please take care.
Ms. Bows: I will. And I think I will stay with Rene for the next week or so. You understand.
Dr. Balis: I do. I will reach you there, if necessary.
Ms. Bows: Thank you, Doctor.
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