In Loving Memory of Tatiana Gomez (1980-2007)

It is hard to blog with a broken-heart and so for the past few weeks I have been unable to summon the emotional energy to contribute to the blog as much as I have desired.On Thanksgiving morning (November 22, 2007), Tatiana Gomez, a kind hearted, gentle and caring young woman was tragically killed in an accident while driving an ATV in Fairfax, VA. Tatiana had served as the IVF and Donor Ova Coordinator at Dominion Fertility for the past several...

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Progesterone: shots vs suppositories

I really think that most doctors are actually afraid of shots. I remember as a Duke medical student the scene during my first year when we were all lined up to get our hepatitis vaccines….what a bunch of weenies. Boy, we were shaking in our boots over a stupid little shot. Of course, now I am on the other side of the needle.So why do we use the barbaric progesterone in oil shots after IVF or for an FET or donor egg cycle? Honestly, there is no really satisfactory answer. We know that progesterone suppositories work as well and yet we have a hard...

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HSG vs HSC vs H2O sono...What is the difference?

Medical terminology can really give patients fits and no where is this more apparent than in the distinctions between hysterosalpingogram (HSG), hysteroscopy (HSC) and hysterosonogram (H2O sono or water sono). In fact, these three tests are very different although similar information can be gleaned from them depending upon the clinical situation. Taking an accurate medical history is so very important. We ask our patients to recount specific details...

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Who should evaluate the infertile couple?

Patients end up seeing a Reproductive Endocrinologist as a result of a multitude of factors. Some are referred by friends and co-workers. Some are sent by their primary care provider or by their Ob/Gyn. Many are self-referred and end up seeing us because of advertising, the internet or because they read this fantastic book titled “100 Questions and Answers about Infertility.” Actually, I have yet to see a patient who came running to see me because of the book, but you never know what will happen once Oprah makes it a selection for her Book Club....

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Why are we not getting pregnant?

What is the problem? That question is at the heart of most of our initial consultations and yet sometimes even after extensive testing we still are not sure why a couple is infertile. Overall, it is important to remember that infertility is a disease of couples. Often the male partner is less than enthusiastic about his role in the testing process but more than half the time male factor infertility plays a role in the couple’s situation. I always...

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What is Assisted Hatching?

Older brothers can certainly torment younger ones a great deal. My brother Steven is a typical middle child. As my eldest brother (and my protector in the family), Mike, always wanted to be like our surgeon father, it fell to Steve to be the “black sheep/bad boy” of the family. Part of this mission was to torture his younger, spoiled brother…yours truly. His favorite means of torture was psychological, although physical brutality, such as making...

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Can PGS improve IVF outcome?

So as we get ready for Halloween and all those cute little goblins and princesses let’s tackle the million dollar question: Does PGS improve IVF outcomes? The lunch debate between Munne and Hughes at the ASRM sought to discuss that issue. Basically, Dr. Munne presented evidence that in their hand IVF outcomes are better and miscarriage rates are lower. However, the improvement was modest and not the amazingly high pregnancy rates that one would predict. Dr. Munne also criticized the recent article from Europe in the New England Journal of Medicine...

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Is PGD safe?

As Gandalf said to Frodo “Is it safe?” That is certainly an important question to examine. If we pursue PGD we certainly do not want to shoot ourselves in the foot.First of all, how could PGD create a problem? Well there are several steps that could cause potential problems. The embryo biopsy could result in damage to the remaining cells in the embryo. The removal of 1/8th of the cells in the embryo could alter the development of the embryo. The biopsy of the embryo could result in an embryo that is less tolerant of cryopreservation (freezing)....

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What is PGD/PGS?

What a difference a couple of weeks can make. Several weeks ago the Red Sox seemed doomed to another “close but no cigar” type of season and here they are in the World Series. Over October 12-16th the annual meeting of the ASRM was here in Washington DC. It is tough to have the meeting in one’s hometown as working while attending the daily meeting can be problematic…although not as problematic as going out at night to parties and then working the next AM. However, as a fairly boring the Eagle Scout straight arrow nice guy who prefers to be in bed...

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How many do I put back?

On the INCIID bulletin board I am often asked to comment on how many embryos to transfer. It amazes me that anyone would value the opinion of the cyber-RE over their actual RE. This decision is too important to just gloss over and give it only a passing thought. Transfer too many and we have to deal with twins…or worse. Transfer too few and the next thing you know the patient is requesting records to zip off to the RE down the street. How easy things...

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Is Possession 9/10ths of the Law?

Readers of this blog may recall that my MacBook Pro was stolen from my car while it was parked in my driveway on a residential street in Bethesda, MD. Like a complete idiot I had left it in my unlocked car overnight and like an even bigger idiot I had not password protected the computer (huge gasp of shock from the reader). Fortunately, the computer was fully backed up just 48 hours earlier and I successfully restored all of my files (including the photo of me in my Boy Scout leader uniform which I have mercifully deleted from the blog).Last night...

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Doctor Personality Issues

All doctors have different styles and as a patient I truly believe that you need to be comfortable with your physician. There is a level of trust that must exist between patient and physician and this relationship goes both ways. Some patients want to abdicate all decision making responsibility and others want to agonize over every minor point sending their RE emails several times a day.Overall, I think that I have a pretty good rapport with my patients and thus I am puzzled by the fact that twice in as many weeks I have had patients comment to...

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IVF for Dummies (Part 2)

The stimulation part of the IVF cycle can be the most problematic. If patient is prescribed too little medication then she can get cancelled for a poor response. Give a patient too much and she can develop OHSS which really sucks (as was pointed out in a comment recently by one of my 5 regular readers-my Mom not included). How do we pick the protocol? Well first of all I consult my Magic 8 Ball toy that I bought on Ebay…then I spin a big wheel in my office and then I review it with Dr DiMattina, my partner, who usually changes the dose all around...

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IVF for Dummies (Part 1)

Clearly Reproductive Medicine changed forever after the birth of Louise Brown in 1978. The first US IVF baby did not arrive until 1980 with the birth of Elizabeth Carr. I was up on Capitol Hill a few years ago on a committee promoting insurance coverage for fertility care and Elizabeth was on the panel with me. I asked her why her Mom had remained in the hospital in Virginia for the entire pregnancy and why they had come down from Massachusetts. She explained that IVF was not available in Massachusetts at the time and may have even been illegal....

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Are Babies from IVF Normal?

The astute reader of this blog may come to the conclusion that Dr Gordon is not normal. I mean the guy likes Monty Python, couldn’t get a date in high school, tells bad jokes and yet somehow managed to convince a PhD in Engineering to marry him and reproduce with him. Go figure. What really does it mean to be normal? I banged my head on the kitchen counter this morning when I saw that the Red Sox lead over the Yankees was down to 2 and a half games. Is that normal behavior? Well, for a Sox fan it is but that is besides the point.So many questions...

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Sex, Drugs, Rock and Roll....

Back in high school I was the well-behaved, straight A student, Eagle Scout, nice boy who would never do drugs or drink…so of course, no girl would give me the time of day. My wife believes that the real cause of my high school social isolation was the fact that I was a science fiction fan who went to science fiction conventions and had dinner with noted authors like Hal Clement (my high school chemistry teacher), Larry Niven, Isaac Asimov to name drop a bit… She reminds me that this part of my history was kept concealed along with the Monty Python...

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Is there any hope?

We are often asked the difficult question of whether there is any hope when the beta levels are not rising appropriately. The short answer is that there is always hope and yet I wish that I could know the outcome as soon as possible so that I could spare patients that roller coster ride of emotions when things are not going according to the textbooks. However, I have become very cautious about writing off pregnancies too early. There are several patients who love to write at the bottom of their Christmas cards little reminders like “The little...

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You say tow-mah-tow and I say tow-may-tow

I agree that the medical profession has too many abbreviations and that it is hard to know how to act knowledgeable in front of your RE. So here are some helpful hints about how we on the other side of the desk pronounce various abbreviations:RE (reproductive endocrinologist): are-eeIVF (in vitro fertilization): eye-vee-effGIFT (gamete intrafallopian transfer): gift NOT gee-eye-eff-teaZIFT (zygote intrafallopian transfer): zift NOT zee-eye-eff-teaFET (frozen embryo transfer): eff-ee-tea NOT feteICSI (intracytoplasmic sperm injection): ick-see NOT...

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Labor Day at Dominion

Labor Day is not a real funny holiday for fertility patients. It is really an obstetrical holiday and having worked a fair number of Labor Days during my residency everyone thought that it was so clever to quip about being in labor on Labor Day…yup, a real yuck fest.Of course, for REs the funny holiday is Easter. Not for the religious significance but of course, for all the Easter egg jokes. Same phenomenon of really bad jokes occurs as patients who undergo egg collection on Easter are participating in an “egg hunt” of sorts.Hey, I don’t make this...

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Back to Basics

Ah, the end of summer. How sad that always made me as a little kid. It meant loading up our station wagon and driving back from Cape Cod after spending the whole summer in West Dennis. It meant no more mini-golf and no more trips to the beach and of course, the beginning of a new school year. Fall was not a favorite of mine as it meant classes and homework and the approach of winter. But times change and now I relish the change in the weather, especially here in DC where August is so hot and humid (pretty much like June and July!). And since I...

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What's the Plan?

Patients can usually be divided into active and passive subtypes. Active patients read books (like this one), cruise the internet, pepper their RE with questions and engage in extensive discussions of the options available to them. Passive patients look across the desk at us and say “Doctor, you decide what is best.” Although at the end of the day, the active patients can certainly leave you feeling exhausted, I really enjoy these interactions and the challenge of making a treatment plan with them. I worry about the passive patients. Do they really...

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Going to Blast! Part 2.

So yesterday we discussed blastocyst transfer in general and today we get down to brass tacks…You know, it amazes me that some of the Residents and Medical Students that I teach do not know some of these quaint little sayings like the one I just used. I have said to them “a watched pot never boils” and received just blank stares. Is this a sign of advancing age on my part or is it because they watched too much TV as kids? I have no idea. All I know is that it still really disturbs me that the 80s music that I listen to in the operating room was...

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Going to Blast!

“Going to blast” is different than “having a blast.” When your RE talks about going to blast he/she is referring to the stage of embryo development at the time of the embryo transfer. When I began practicing infertility in 1996 most embryo transfers were done on the second day after egg collection (egg collection is day zero). However, most clinics moved rapidly to day 3 ET to allow for better embryo selection. The move to day 5 ET was a bit more...

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Why is nothing working?

Clearly the million dollar question that all patients usually ask is "why is it not working?" The "it" can range from natural attempts at conception up to and including IVF. In some cases we really don't understand what the problem is and are faced with approaching fertility treatment with the "more eggs, more sperm...in the right place at the right time" approach. This logic is really the basis of most of our treatments. However, paradoxically we often recommend the most expensive and invasive treatment to those without an identifiable problem..why?...

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How to do an FET

In my last blog post I discussed the general concept of frozen embryos which is certainly a bit of a mind bending concept by itself. But I want to emphasize how important the option of having cryopreserved embryos can be to a patient’s overall chances for success. Many times over the years we have ended up with success by using the last frozen embryo that a patient had to work with after multiple failed cycles. Of course, the natural response would be that if we were really smart, then we should have known which embryo out of the whole bunch would...

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To Freeze or Not to Freeze...

The previous post discussed egg freezing which is a much more difficult technique compared with embryo freezing which has a much longer, proven track-record. We will discuss egg freezing some other time. In general, if there are high quality embryos that are not going to be transferred it is always a good idea to consider freezing them for future use. However, the mere fact that these embryos exist has led to other concerns that are not only medical but social, philosophical, ethical, and moral. What obligations do a couple have to their frozen...

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Cross Generational Egg Donation and Beyond

A recent case in Canada raises some very interesting ethical questions. A women with a young daughter with Turner Syndrome wished to undergo IVF with cryopreservation of the unfertilized eggs so that her daughter could use them later in her life in order to conceive rather than rely on another egg donor to provide her this opportunity for parenting.http://www.associatedcontent.com/article/221699/medical_first_mother_to_daughter_egg.htmlNever a dull moment in the world of reproductive medicine! In the above situation the girl would give birth to...

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How to Choose a Fertility Clinic

Not a week goes by when a couple asks during a consultation "Why should we come here instead of clinic X." I know that many fertility books advise patients to ask this question but what response are they looking for....This question always takes me back to my college, medical school and internship/residency interviews and to tell the truth I usually interviewed badly. My Harvard undergrad interview was particularly memorably bad and I remember my high school guidance counselor shaking his head slowly and asking what happened. I blew it. In retrospect...

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Where has Dr. Gordon been??

I know that the 5 people who read this blog have been wondering that for the past 2 weeks. Gee, he was so good about posting questions from that fantastic book and then...POOF..he disapparated. Well, the answer is that I have been here but too overwhelmed to post to the blog. Sorry but true. When returning from vacation you always get hit hard and this month was no exception. So my patients in cyberspace had to take a back seat to the real flesh and blood patients.And then last Friday night disaster struck...Upon returning from dropping off the...

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