In the past 8 years that I have moderated the IVF and High Tech Pregnancy Bulletin Board on the INCIID website, the most frequently asked question has been: Should I try again? A simple question but one that is so difficult to answer. The costs of fertility treatment are financial, physical, emotional, psychological and social. Fertility treatments can consume people and wreck marriages and relationships as well as drain your bank balances quicker than the Nigerian Foreign Minister who only needs your bank account number and social security number...
samedi 30 juin 2007
vendredi 29 juin 2007
It is so tempting to just snatch one of those Clear Blue Easy kits off the shelf and run home and cheat…but do you really want to do that? Using home pregnancy tests after IVF is not uncommon. I usually know who did it because they are bouncing around the office on the day of the blood test (having seen positive home tests every day for 5 days). However, I have seen positive blood tests in spite of a negative urine test and vice versa. So what can I say. If you do it and cheat you can always post anonymously on the INCIID board and I will give...
jeudi 28 juin 2007
Several years ago I had a patient undergoing IVF who was at risk for developing ovarian hyperstimulation syndrome (OHSS) so we planned to retrieve and freeze all embryos. Following the retrieval and freezing the patient did well but failed to get her period. Finally she called and said she was confused as I had told her that her period would certainly come within 2 weeks of the egg collection. I asked her to come in for a sonogram and bloodwork.When I did the sono I was shocked to see a normal intrauterine pregnancy! The couple had sex a single...
mardi 19 juin 2007
There are few entities in reproductive medicine as puzzling and frustrating as endometriosis. It can grow silently for many years and then present as an emergency visit to the hospital when the chocolate looking fluid begins to leak out of an endometrioma. I have seen minimal endometriosis in patients with terrible pelvic pain and severe endometriosis in patients in whom I expected a laparoscopy to be completely normal.So let's start with some basics about endometriosis and its diagnosis. Here is the "Question of the Day" from 100 Questions and...
lundi 18 juin 2007
I still remember the day that my Dad came home the hospital completely outraged over the actions of one of the other surgeons practicing at Quincy City Hospital (where my Dad had served as Chief of Surgery and President of the Medical Staff at various times over his 30 year career). Wow, I figured the guy must have done something really bad as even my Mom was shaking her head and lamenting how far the medical profession had fallen. The crime that the physician in question had committed? He had taken out a display ad for his practice in the Yellow...
dimanche 17 juin 2007
Life would be much easier for me if I had a crystal ball at work. Then I could be sure who needed ICSI and who didn’t. I could always be 100% sure of when to trigger with HCG for IVF and no one would ever get OHSS (ovarian hyperstimulation syndrome). Clearly there are honest differences of opinion between physicians and this can be confusing to patients who sometimes believe that there is an absolute right answer to medical questions. Sometimes there is an obvious answer but not always. So what do you do when 2 well-trained, well-educated physicians...
samedi 16 juin 2007
Several years ago I was having a beer with one of the Chief Embryologists at a well-known fertility clinic. The conversation turned to ICSI and I asked him what criteria he used to determine whether ICSI was indicated. He replied, “we only do ICSI on patients who really need it.” When I suggested that his >70% ICSI rate seemed a bit high, he walked off to chat with someone else…Oh well, so much for friendly professional banter which is why I am terrible at cocktail parties.So can a physician be absolutely certain that ICSI is needed? The following...
jeudi 14 juin 2007
As a teenager growing up in the Boston suburbs I spent a lot of my Saturdays in Harvard Square playing video games at the arcade that was next to the Orson Wells Theatre. My kids can’t imagine why I would go into Boston to play video games. They can’t believe that there was no Nintendo, no Playstation, and no X-box at my home . They laugh at the screen shots from my Atari. I still remember spending a lot of money feeding quarters into the Defender game or Robotron or Galaga. My Dad thought this was a complete waste of time, but in fact it was...
Every year physicians who are training in Obsterics and Gynecology (interns and residents) have to take a yearly test called the CREOG (Council on Resident Education in Ob/Gyn) exam. Almost every year there is a question regarding severe male factor that asks which treatment option is the most cost-effective. Given their training by Reproductive Endocrinologists (like yours truly) most residents immediately choose the IVF/ICSI answer. But that is incorrect. Donor inseminations using high quality cryopreserved sperm actually work quite well. Success...
mercredi 13 juin 2007
In most cases of infertility the male role is important but certainly pales in comparison to what our female patients have to endure. Although I offer to provide the couple with syringes filled with saline so the male partner can experience the joy of taking fertility shots, not a single guy has taken me up on this offer so he can better commiserate with his significant other. However, in men who require a testicular biopsy there is a more equitable distribution of effort as the couple moves through fertility treatment. Just remember that testicular...
mardi 12 juin 2007
Over the years I have seen many men with the absence of sperm in the ejaculate (azoospermia). Some went on to have children with IUI because they had retrograde ejaculation, some conceived with IVF/ICSI and others through donor sperm or adoption. The ability to conceive in spite of azoospermia is truly one of the medical miracles of the past 20 years. During medical school at Duke I took an elective in Reproductive Physiology. In that class we learned about the number of sequential steps required to ensure that normal fertilization took place....
lundi 11 juin 2007
Several years ago my good friend Dr. Bruce Gilbert, a Urologist in Great Neck, NY specializing in male infertility, presented a paper at the annual meeting of the American Society for Reproductive Medicine (ASRM). Dr. Gilbert’s presentation was on the debate between briefs and boxers for male infertility. When Bruce told me about the paper he was going to present I told him that I was sure that he would be interviewed by the press regarding that research. As predicted, Bruce was indeed interviewed by the usual media outlets for that story (CNN,...
dimanche 10 juin 2007
One week from today will be Father’s Day. So in honor of that completely manufactured holiday I think that we should spend the next week focused on the weaker sex…men.I honestly believe that if men had to be pregnant and go through labor & delivery that the human species would vanish in 1-2 generations. Men are chickens but hate to admit it in most cases. There are certain advantages to being a male gynecologist. If a patient tells me her periods are bad, she gets moody or she finds an exam uncomfortable I will always agree with her 100%. Since...
samedi 9 juin 2007
We all want explanations in life and it is human nature to seek out the answers to our questions. Unfortunately, life is not simple and sometimes there are questions that we cannot answer and outcomes that we cannot understand.Although we can often determine the root cause of infertility, sometimes we are at a loss to explain why a couple is not conceiving. The problem is that in such cases we are forced into treating empirically and hoping for the best. IVF can offer some insight into these cases but sometimes it is a hard concept to get across...
vendredi 8 juin 2007
Here is a true RE urban legend. Many years ago a very trustworthy and honest infertility specialist (not yours truly although I would hope to be described in this fashion) arrived at the office for his usual consultations. He was informed that Mrs. Jones (not her real name) was waiting for Dr. James (not his real name) in the exam room. She was scheduled for a postcoital test.Dr. James went into the room, said hello and then sat down to perform the postcoital. As he was placing the speculum he asked Mrs. Jones the usual questions: “What cycle day...
jeudi 7 juin 2007
Sometimes it is hard to get away from the office. Several summers ago we were vacationing on the Outer Banks of North Carolina. The weather was outstanding..hot, sunny and no hurricanes. Meanwhile back in the office I had a patient undergoing a mock cycle in preparation for a frozen embryo transfer (FET). We had frozen all of the embryos from her fresh IVF because of the risk of hyperstimulation and just like the patient that posted to me today on my INCIID bulletin board, this patient also had hypothalamic amenorrhea (more about that in a later...
mercredi 6 juin 2007
Writing a book is a very interesting proposition and there some ups and downs along the way. When Mike (Dr. DiMattina) and I started the project we were in contact with the nice folks at Jones and Bartlett Publishing and Chris Davis, the Publisher, came down to Arlington to meet with us. He is the only member of the team that we have met face-to-face. Everyone else has either been in contact with us by phone or by email. So this afternoon as I reviewed...
mardi 5 juin 2007
Although certainly some of our patients are single women or single-sex couples, the vast majority are married couples seeking to start (or add to) their family. As such, infertility is unique in that there are always 2 patients in every setting. Some of the men have been a bit shy of the spotlight to say the least...Why? I think that for many men the concept of being reduced down to a number is very anxiety provoking. It seems like keeping track of batting averages. Every man who has been told that his sperm count is great, suddenly puffs out...
lundi 4 juin 2007
Not a day goes by here when I am not faced with an insurance issue to address. It still amazes me that insurance companies can take your monthly payments and then go ahead and shut you out in terms of treatment. Clearly not all insurance companies are problematic but I will say that many of them are...Last year we had very productive discussions with Aetna and they were very open to discussing what we do here and how we do it. Other companies were not at all interested in our views.Here is a true story: Several years ago I had a patient whose husband...
dimanche 3 juin 2007
Growing up in a medical family can somewhat limit your career choices. My grandfather was a GP in Quincy, MA and did a lot of obstetrics. He was beloved by his patients and his office was actually in his big, white house on School St. Every morning he would have breakfast then walk across the entry hall to the big sliding doors that led to his waiting room. What a great commute! His patients paid as they could, sometimes with goods or services if they were short on cash. His son is a famous endocrinologist, Lewis Braverman. In fact, Uncle Lew wrote...
samedi 2 juin 2007
There is an adage in medicine that "problems come in 3s" and having now dealt with three recent potential cases of ovarian hyperstimulation syndrome (OHSS) this seems quite appropriate. OHSS is no fun. It is tough on the patient and tough on the doctor. It is hard to counsel a patient about a possible outcome whose prevention requires her to derail the chance of getting pregnant after working so hard to reach that point. However, I have NEVER regretted canceling a cycle or freezing all embryos to avoid OHSS, but I have been surprised to see OHSS...
vendredi 1 juin 2007
As a Reproductive Endocrinologist one of the toughest parts of the job is explaining things to patients that simply do not make sense and fly in the face of logic. A case in point: Several years ago I saw a patient that had been to another local clinic where she had spent over $70,000 on 4 failed IVF/ICSI attempts. She was 35 years old and not interested in donor sperm or donor eggs. Her FSH was 12 and her response to stimulation had been poor with 2 cancelled cycles. She had been told that ICSI was the only way the sperm would fertilize the eggs...
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