Prevention of Ectopic Pregnancy

Over the years certain patients really stick out in your memory. This week one of my favorite fertility veterans brought in a whole box of homemade cookies to the office. Needless to say, they were consumed within 45 minutes and I got one or two but almost lost my hand in the feeding frenzy that occurred. In any case, this young woman had really been through the ringer. Low responder, high FSH, pregnancy loss, antiphospholipid antibodies requiring Lovenox, male factor….and the list always seemed to keep growing. However, the low point was an ectopic pregnancy after an IVF cycle while she was on Lovenox. Ultimately, it all worked out and they ended up with 2 beautiful children (her own eggs) who were romping around the office this week as the cookies were being delivered.

So how do we avoid a repeat ectopic pregnancy in our patients? Well, there are some ways to try and reduce the risk but even with ultrasound guided embryo transfer, those little buggers can still float out into the tubes. There are reasons that I am losing my hair and why I am getting more grey and it is not always from my own kids.

As I try to get back in the blogging routine here is another kernel of knowledge from the book soon to be made into a major motion picture: 100 Questions and Answers about Infertility.

30. If I had a previous ectopic pregnancy, what should I do to avoid another one?

The reported incidence of tubal or ectopic pregnancy in the general population is 1%. Women who have experienced an ectopic pregnancy generally have a 10% to 15% risk for another ectopic pregnancy. The good news is that most women who have had an ectopic pregnancy will not have another one. The bad news is there are no therapies available to eliminate this risk. All women who are attempting to conceive inherently are at risk for an ectopic pregnancy. Even women with absent or obstructed fallopian tubes can experience an ectopic pregnancy if the embryo becomes implanted in the section of the fallopian tube found within the muscle of the uterus (called an interstitial or cornual pregnancy). The rate of ectopic pregnancy following IVF is usually 1% to 2%, far lower than the 15% recurrence risk with a spontaneous pregnancy. Fortunately, most ectopic pregnancies are readily diagnosed very early in pregnancy using blood hormone assays for beta human chorionic gonadotropin (HCG) combined with transvaginal ultrasonography. It is now uncommon for such pregnancies to go undiagnosed or to lead to tubal rupture, hemorrhage, or death. Most ectopic pregnancies can be treated medically using low doses of methotrexate (a type of chemotherapy that selectively destroys the pregnancy tissue), thereby avoiding surgery. This medical therapy is 80% to 95% effective.

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Hydrosalpinx, hydrosalpinges and IVF

Again the weeks have just flown past with no additional blog entries by yours truly. I have no excuse really. Just too busy, too tired, too overextended…yadda, yadda, yadda. So beat me, slap me and call me dirt.

The issue of blocked fallopian tubes is a very important one, even in patients undergoing IVF. Now on the surface this makes little sense because if IVF is used to bypass the fallopian tubes then who really cares if they are abnormal? A reasonable concern and one that for many years we agreed with as we entered patients into the IVF process. But then a funny thing happened….papers started appearing that suggested that the IVF success rate was lower in patients with blocked and dilated fallopian tubes (hydrosaplinx – as described below). The logical question was then whether removal of the hydrosalpinx would cause pregnancy rates to return to the expected level and the answer was a resounding “yes”.

So now fertility MDs are often placed in the unusual situation of removing the tubes after years of training in how to fix them…go figure.

A few years ago we had a patient with bilateral hydrosalpinges as a result of several operations for Crohns disease. We had to remove her tubes with the help of her general surgeon and ultimately she conceived IVF twins. One day I was visiting her in the hospital and the residents said that she was mad that we took out her tubes needlessly since we had planned to do IVF all along….I popped into her hospital room and we chatted for a while and then I raised the topic of her tubes. In spite of many documented discussions on this topic she said that she really could not remember any such topic being reviewed. Finally, the light bulb over her held lit up and she said “Oh yes, know I remember….the tubes had that nasty fluid in them…” Bingo.

So after weeks of waiting patiently here is today’s relatively pathetic post from the book that needs to fund my 401K from here on out…100 Questions and Answers about Infertility.


28. Why should blocked fallopian tubes be repaired before IVF is attempted?

When the fimbria of the fallopian tubes become damaged, it may result in a tube that is blocked at the very distal end—the part farthest away from the uterus. If the tube then becomes filled with fluid, it is called a hydrosalpinx (“hydro” refers to water; “salpinx” refers to the fallopian tube itself). Women who have a hydrosalpinx should have their fallopian tubes either removed or cut prior to undergoing IVF. The surgery usually involves a simple outpatient procedure called laparoscopy. The tubes are cut or removed so that the tubal fluid, which would be toxic to an embryo or adversely affect the receptivity of the endometrial lining, does not flow backward into the uterine cavity, preventing implantation of the embryo.

It is now well recognized that women with an untreated hydrosalpinx have a substantially reduced chance for pregnancy with IVF. In addition, an untreated hydrosalpinx may increase the chance that a woman will experience a spontaneous abortion or miscarriage. For all these reasons, treating a hydrosalpinx should both increase the IVF pregnancy rate and decrease the chances for an early pregnancy loss. A patient with a single normal fallopian tube and a hydrosalpinx will also have a higher chance of achieving a spontaneous pregnancy after removal or ligation of the damaged tube. A hydrosalpinx, if present, is usually identified during the infertility diagnostic evaluation with a hysterosalpingogram (HSG). This simple x-ray study should be performed in all infertile women unless a diagnostic laparoscopy has already been performed. Preoperatively, we advise all patients that we recommend removal or ligation of her tube(s) if a hydrosalpinx is discovered at laparoscopy.

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ASRM Update 2009

Well I must apologize for being very bad about blogging this past month. I was in San Francisco for the ASRM meeting and then up to Boston to check on Dad who has had some real health issues this summer.

San Francisco was great to visit and I had not been back there since I left to join Long Island IVF in 1996. There is a pretty high freaky person quotient around the convention center and the weather was pretty cold and rainy but it was good to see old friends.

Several topics were on my mind and I will address these in future posts. Today I want to address an issue that was new to me and that is the relationship between genetic parents and their gestational carrier.

Using a gestational carrier represents an option of last resort for some couples but it can lead to some very heart-warming outcomes. Unfortunately, there can be some really bizarre legal cases as a result of the use of gestational carriers so it pays to have good legal advice. One piece of helpful advice was to make sure that the gestational carrier and the genetic parents of the embryo secure separate legal counsel. Just as you should have separate attorneys for a home purchase, so also should you have separate attorneys in this case.

I suppose that this makes sense but I feel bad to add yet another expense to the couple who is using a gestational carrier. On the other hand, going to court for years because of some misunderstanding in the contract between the parties isn't so great either!

I am interested in hearing from all of you that have opinions on this issue: Does your gestational carrier have her own legal representation?

More on hot topics from the ASRM real soon!

DrG

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Fertility After A Tubal Ligation

Several times a month I am asked about tubal reversal surgery. Performing a tubal reversal is actually something of a vanishing art among reproductive endocrinologists. Personally, it has been over 10 years since I last did one and if a patient really wants to pursue this option, then I refer them to Dr. Gary Berger in Chapel Hill, NC. Dr. Berger has a great set-up for doing tubal reversals and his price is hard to beat along with his level of experience. And I do not receive any kick-backs from Dr. Berger. In fact, I am sending business out the door, but I really believe that it is not appropriate for a patient to pay more to have me do this surgery when she can have it done for less with a guy who can put tubes back together in his sleep. This surgery is often done with the operating microscope and requires steady hands as all movements are greatly magnified under the scope.

During medical school I asked a famous RE how he kept his hands so steady? “Well, John” he replied, “the key is to have sex the night before the surgery!” “Yeah, “ the resident told me later, “his wife is getting pretty sick of him doing so many tubal repairs!” So with that bit of gossip, let’s turn to that great repository of knowledge: 100 Questions and Answers about Infertility for the Question of the Day.

29. If I had my tubes tied, can I have them untied?

Fertile women who have had their “tubes tied” (tubal ligation) may do very well and achieve pregnancy with tubal reparative surgery. Pregnancy rates of 70% to 80% are noted in women who undergo a tubal reversal procedure, depending on their age, the type of tubal ligation procedure performed, and the presence (or absence) of other infertility factors.

Most often, this repair (tubal reanastamosis) requires a laparotomy, which involves opening of the abdomen. This major surgery requires 2 to 4 weeks for recovery, and most insurers do not cover it. Some physicians have reported good success with laparoscopic tubal reanastamosis, but this approach can be more technically challenging. As a consequence, most female patients choose to undergo a nonsurgical IVF procedure instead. Studies have shown that IVF is usually more cost-effective than surgical reanastomosis of the fallopian tubes. Specifically, if the surgery fails to establish a pregnancy, then IVF may be necessary anyway.

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Can Fallopian Tubes Be Repaired?

As readers of this blog are aware…my family is not really sure that I am a “real” doctor since I am not a general surgeon. As IVF success rates have climbed, the number of reproductive surgeries perfomed has plummeted. When I was a Duke medical student I still remember the REs scheduled 5-10 laparoscopies every day that they were in the operating room! My how times have changed. The problem with most surgeries aimed to improve fertility is that they often don’t help very much. In addition, since infertility is a couple’s disease and half the problems are with the men, fixing tubes or zapping endometriosis doesn’t help much if his “swimmers” are more like “floaters.”

So here is today’s Question of the Day from 100 Questions and Answers about Infertility.


27. Can fallopian tubes be repaired?

Prior to the advent of IVF, surgical repair of damaged fallopian tubes was considered standard medical care. Unfortunately, most patients did not become pregnant following this procedure, and 10% to 20% experienced tubal (ectopic) pregnancies. Today, IVF has replaced reparative tubal surgery for most patients with damaged fallopian tubes for two reasons: (1) IVF is a nonsurgical treatment and (2) it results in excellent pregnancy rates, especially for patients with tubal disease.

Some patients ask, “Why is it so difficult to repair damaged tubes?” Unfortunately, the problems that cause tubal disease, such as pelvic infections, usually damage the tubal fimbria—that is, the delicate finger-like projections at the end of the tube that are responsible for capturing the egg when it is released from the ovary. Pelvic infections may also damage the tubal muscle and inner mucosa, leaving behind a scarred, nonfunctional organ that is not amenable to surgical repair. In general, most patients with tubal disease are best treated using IVF. Tubal reparative surgery is usually not effective and, in fact, it may increase the woman’s risk for having an ectopic or tubal pregnancy. If a couple is not interested in IVF or if they are not deemed to be good candidates for IVF, then tubal surgery may be the only option available to them in terms of fertility treatment.

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How Expensive Are Infertility Treatments?

The economic news lately has been sobering to say the least and certainly a drop in the economy usually forces patients to carefully assess their options when considering various treatment options. Fertility treatment can be very expensive and life would be so much easier if I had a crystal ball that allowed me to predict with 100% certainty when and through what means a couple (or individual) would achieve success. But life is not like that and so we are left to counsel patients using our best advice as to how to proceed.

We have certainly seen an increased interest in Natural Cycle IVF as the cost per attempt is less than traditional stimulated IVF and not much more than for a clomid/IUI cycle. Still, the more expensive, more invasive treatment options tend to work better. I tell all my patients that I cannot compete with traditional adoption in terms of return on investement, but this is a pathway to parenthood that may not be acceptable to all patients. Embryo adoption/donation is another path that is very successful and less expensive but is limited by the laws of supply and demand.

So in returning to that famous repository of infertility advice...here is the Question of the Day from 100 Questions and Answers about Infertility. If you don't already have this book, then go to Amazon.com and order it right away ... and make sure that you post a 5 star review ... and tell all your friends to buy it... and come by and visit me at Dominion Fertility or come to the MidAtlantic RESOLVE meeting on October 18th to tell me how much you love this blog. Also, for those of you who missed our recent stint on the Kane show on 99.5 here in Washington you can listen online as they have it set up as a podcast. My kids thought I sounded halfway intelligent which is heady support from teenagers...


19. How Expensive are Infertility Treatments?

The cost of fertility treatments may be covered by some insurance plans. In those patients without insurance coverage, the cost of fertility treatments varies widely depending upon the specific treatment utilized. For example, a cycle of ultrasound monitoring without the use of fertility medications culminating with intrauterine insemination may cost $1300 to $1500 in many clinics. Compare this with the cost of IVF with ICSI, freezing of extra embryos, and assisted embryo hatching and the price tag can reach approximately $14,000 to $16,000 plus the cost of injectable fertility medications which may cost $2,000 to $4,000. The use of donor-egg IVF, although extremely successful, is also very expensive as the cost of reimbursing the donor for her time and effort must be included in the treatment. The typical price range for donor-egg IVF is between $25,000 and $30,000 depending upon the clinic.

In most cases the more expensive, more invasive fertility treatment usually results in the highest pregnancy rates, and therefore couples are advised to carefully consider the proposed course of treatment and the costs that may be involved. Around the country several IVF centers offer money back refund programs. In these situations a couple accepted into the program pays a premium which covers several fresh IVF cycles as well as frozen embryo transfers. If they fail to conceive or are deemed no longer to be appropriate candidates for treatment, then all or a percentage of their initial payment is refunded. These programs have remained somewhat controversial but can allow couples to pursue other options if IVF is unsuccessful.

According to the ASRM Ethics Committee Statement of June 2006: The controversy surrounding such programs relates in part to the concern that such arrangements “appear to violate long-standing ethical prohibitions against paying contingency fees in medicine. This concern is based on Opinion 6.01 of the AMA Code of Medical Ethics, which states, “a physician’s fee should not be made contingent on the successful outcome of a medical treatment.”

Furthermore, the Committee Statement (which can be found on the ASRM website at http://www.asrm.org/Media/Ethics/ethicsmain.html) concludes, “the risk-sharing form of payment for IVF is an option that might be ethically offered to patients without health insurance coverage for IVF if certain conditions that protect patient interests are met. conditions are that the criterion of success is clearly specified, that patients are fully informed of the financial costs and advantages and disadvantages of such programs, that informed consent materials clearly inform patients of their chances of success if found eligible for the risk-sharing program, and that the program is not guaranteeing pregnancy and delivery. It should also be clear to patients that they will be paying a higher cost for IVF if they in fact succeed on the first or second cycle than if they had not chosen the risk-sharing program, and that, in any event, the costs of screening and drugs are not included.

“The Committee was especially concerned about incentives that risk-sharing programs create for providers to take actions that might harm patients in order to achieve success and avoid a refund. For risk-sharing programs to be ethical, it is imperative that patients be aware of this potential conflict of interest, and that risk-sharing programs not overstimulate patients to obtain a large supply of eggs or transfer more embryos than is safe for the patient, fetus, and prospective offspring. Patients should be fully informed of the risks of multifetal gestation for mother and fetus, and have had ample time to discuss and consider them prior to egg retrieval.”

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A Face for Radio

My older brother Steve always told me that I had a great face for radio.....maybe he was right but in any case Dr DiMattina and I will be back on the airwaves tomorrow morning at 9 am on WIHT-FM (Hot 99.5) here in Washington DC. You can listen via streaming audio on their website at the Kane Show website. So go ahead and light up the airwaves with all those great questions for your 2 favorite fertility physicians.

Hey, if the Reproductive Endocrinology thing doesn't work out there is always stand-up comedy I suppose....

In any case, pray that Dr.G makes it from Arlington to Rockville tomorrow AM as I have to do 2 egg retrievals before I hop in my car and try to navigate the DC traffic disaster on my way to do the show.

Back to medical topics later in the week!

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Who is my doctor?

I am a 3rd generation physician, which means that as a little kid I was given no choice as to what I was going to me when I grew up... "So, you are so smart little Johnny, I am sure that you want to be a doctor just like your father and grandfather and brother and uncle etc etc." You get the idea. My grandfather had his office in his house. He ate breakfast and then walked across the hall, opened the big sliding doors and Voila! he was in his office and its waiting room. What a great commute!

My father had operated on so many citizens of Quincy, Massachusetts that he was always leery of eating dinner at Quincy restaurants because so many people would rush over to see him that he never got to finish his dinner. Every Christmas we received hundreds of thank you notes from grateful patients. He was their doctor, they were his patients.

I have always tried to practice in the same way. I want to know who my patients are by sight. I want to walk out in that waiting room and pick them out from the crowd. Is this a crazy way to feel in 2008? Maybe.

Everyday I answer posts from patients who seem unable or unwilling to discuss their care with their "real" doctor. So they turn to the internet doctor instead. But I rarely have all the information that I need to respond in a really insightful way. Yet they are appreciative of the time that I take to discuss it with them.

Today I saw a new patient with a hydrosalpinx (blocked and fluid filled tube) and she had seen another fertility MD who (correctly) recommended a laparoscopy and possible removal of the tube if it could not be repaired. The patient wanted a 2nd opinion but really felt that her former MD had not explained why the tube may need to be removed. She is a very nice woman and I just don't understand why she wasn't treated better.

I want to practice medicine one patient at a time. To me it is not satisfying to perform 25 egg collections in a day on patients that I have never seen before. If I wanted that type of job then I would go work at Jiffy Lube (no slight intended on those who actually work at Jiffy Lube, but you get my drift). I just don't think that patients should be herded along like cattle and treated as just another statistic. You have to consider all aspects of the patient when planning treatment: financial, physical, emotional, spiritual and philosophical. One size does NOT fill all in terms of fertility.

So decide for yourself if it is important that you know who your doctor is....some patients don't mind fertility care by committee with a revolving door of specialists as long as they are well-trained. But don't expect to find me there. If I have to practice that way then I will pack it in and run my publishing company instead. Medicine should be practiced between a patient and her/his doctor.

I'll take my lumps when things don't work out but I hope that all my patients realize that I am trying my absolute best for them every day (including a lot of weekends).

So when all else fails, go ask your doctor and if you are not sure who your doctor is then consider whether you may do better in a different sized practice...

Not much medical advice today but it is Friday and it has been a long week...

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Natural Cycle IVF Update

In two previous posts (Jan 9, 2008 and Jan 10, 2008) I discussed the use of unstimulated (Natural Cycle) IVF. Since 2007 we have been offering this option to our patients with the understanding that it is not going to be as successful as stimulated IVF for the majority of patients. Our prediction was that we could generate acceptable pregnancy rates in those patients with the best prognosis (younger, regular cycles, well-defined cause of infertility) and our data suggests that we have been successful.

However, our discussions with the leadership of the Society for Assisted Reproductive Technologies (SART) and the Centers for Disease Control (CDC) have been less successful. Currently the results from unstimulated and stimulated IVF are combined to yield a clinics IVF success rates as published in print and online as dictated by the Wyden Act that regulates the reporting of pregnancy rates by fertility clinics. Since maximum human fertility is 20-25% per reproductive cycle, there is no way that Natural Cycle IVF could yield a higher pregnancy rate than this level. So if you use Natural Cycle IVF on any patient whose stimulated IVF success rates should be >25%, then you will be shooting yourself in the foot as you knock down your reported pregnancy rates in order to offer this less expensive, less invasive option. This does not make for a hard decision when clinics consider whether or not to offer Natural Cycle IVF...

Hopefully, we will be initiating a study to evaluate physician attitudes concerning the use of Natural Cycle IVF in the US. In Europe and in many other foreign countries Natural Cycle IVF is used extensively, but not here at home where only a handful of clinics use unstimulated cycles to perform IVF. So if you want to see Natural Cycle IVF gain a foothold here in the USA, please keep asking your RE about this option!

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Tough Transfers

Sometimes you just want to pack it in and head for the islands... There is nothing quite as stressful as a tricky embryo transfer. Here you are in a darkened room with a patient who is not very comfortable as a result of having a full bladder and enlarged ovaries. There may be a concerned spouse/partner sitting at the head of the bed watching you like a hawk and the whole time you are trying to push a wet spaghetti noodle through a pinhole. Well maybe it is not that bad but it can be pretty frustrating.

Years ago in Long Island we did a study to determine if letting the catheter sit in the uterus for 2 minutes following the ET would increase pregnancy rates. I couldn't stand just sitting there watching the clock while 2 minutes ticked off the dial. So I hit upon the idea of playing a song that was about 2 minutes long. When the song ended I could just remove the catheter and we would be good to go. But what song would be appropriate for such a momentous interlude in a couple's life? Ultimately I chose Sam Cooke's hit song "You Send Me." I got so used to listening to the song that even after the study ended I continued to play it during all embryo transfers. It is now an inside joke at my clinic as all the patients remember that I play that song during all transfers. One patient snapped at her husband when he suggested a different song. Hey, if something works I stick with it!

So when an ET goes smoothly it looks like this:


But sometimes the ovaries are so large that the uterus gets pushed out of position, or the bladder isn't full or the picture isn't clear etc etc. Previously, we didn't use ultrasound for ET but this seems insane in retrospect. By filling the bladder, the position of the uterus improves and by visualizing the path of the catheter we can be sure that we are inside the uterus! Hard to get patients pregnant if you don't put the embryos in the right place!

If the transfer if nearly impossible then it is always the better part of valor to consider freezing the embryos and come back another day in another cycle to do the transfer. Once in a blue moon I will use IV sedation, as if for egg collection, in order to do the transfer. I am not a sadist and really want my patients to have a good experience and get pregnant along the way. If it is too tough then we bail out and reassess.

Many studies suggest that difficult transfers do not ultimately reduce pregnancy rates. That may be true but boy, it sure turns your hair gray and/or makes it fall out faster and I don't have that much hair to spare!

So if the transfer is not going well I will usually try the following:

1) Do a mock/trial transfer with an empty catheter
2) Fill/empty the bladder
3) Use a large q-tip to change the uterine angle
4) Pass a very small dilator through the cervix to map out the path
5) Try local analgesis / IV sedation
6) Freeze the embryos and try again in an FET cycle

Good luck to all of you and may all of your bladders be full, your transfers go easy and your embryos be above average! (with apologies to Garrison Keillor)

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Infertility Emergencies

Some nights you just have to roll with life's little surprises. Last night we had a delivery at 9 pm and the delivery man accidentally rolled his handcart over my dog's front leg. Poor Indy ran off yelping at the top of her lungs and when I finally found her she was huddled up against the kitchen sliding door. As I am not a veterinarian I bundled her off to the Animal Emergency Clinic in Rockville where we spent the next couple of hours. Ultimately, the xray showed the leg was not broken and they dosed her up with doggie morphine and doggie super-Motrin. This morning she was pathetic but putting a little weight on the leg. The damage to my Visa card was almost $300. Oh well.

Last week the resident physician from Georgetown who rotates through our practice asked what constituted a RE emergency. Sometimes it is hard to know what is an emergency and what isn't as a fertility patient.

There is an old Ob Gyn joke that goes like this....

It is 3 am and the emergency pager for the Ob Gyn doctor wakes him up from a deep sleep. He calls the number and the patient is so appreciative that he has called her back.

"Doctor," she says, "I have a terrible sore throat and think that I may have a sinus infection."

"Gee," he replies, "that sounds bad but why are you calling me....I am your Ob Gyn and I don't recall that you are pregnant or have any current Ob Gyn issues?"

"You're right but as it's 3 am I figured that my family doctor is asleep, but I assumed that you were awake delivering a baby or something."

The doctor prescribes an antibiotic but doesn't address her logic in calling him.

3 nights later he is on call delivering a baby at 4 am and calls the patient. "Hi Mary, it's Dr Jones. Since I was awake delivering a baby I thought that I would give you a call to see how you were making out with that sinus infection!"

Mary got the message.

Now, I am not advocating that patients suffer in silence but some phone call can wait and some cannot.

So here is the Question of the Day, but it is NOT in the book 100 Questions & Answers about Infertility. It is a never before seen question that has leapt from my mind to the computer...

101. What is an infertility emergency?

Clearly there are certain clincial conditions that are an emergency and need to be addressed right away.

1) Bleeding in pregnancy. Spotting is probably OK to wait to call until the morning but heavy bleeding may need to evaluated in the emergency room or first thing in the AM. Unfortunately, about 50% of fertility patients can have some bleeding so this is a frequent call.

2) Significant pain after egg collection. It is usual to be somewhat uncomfortable after egg collection but severe pain or nausea and vomiting needs to be addressed. Same with a fever after egg collection although infection is a rare complication. The first sign of OHSS is often pain but sometimes the pain quickly resolves within a day or two of egg collection.

3) No medication instructions. I tell my patients that if you were in for monitoring and did not get a call-back then that IS an emergency. Don't wait until midnight to think about checking in with the nurse or RE! Get your instructions before dinner so everyone is happy. We are all human and sometimes a patient may just not get a call for various reasons: wrong phone number, answering machine glitches, nurses didn't drink enough Starbucks...who knows. But the point is that you, the patient, need to be your own advocate and make sure that you understand your instructions.

4) A family emergency arises and you need to leave town but you are in the middle of a cycle. This information is crucial for your treatment to work. Sometimes we can stop and restart stimulation later or arrange for monitoring out of town. In any case, this is an emergency for us.

5) Your DH cannot do his "thing." If we don't have sperm then this is a big problem. Egg freezing doesn't work that well compared with embryo freezing. If there is any concern that he may have performance issues or travel problems then cryo sperm ahead of time.

6) You run out of meds. Years ago in Long Island one of my patients went to take her HCG for IVF only to realize that the box in her medication stash was empty as it was from the previous cycle! She freaked out (as expected) and called me at 11:45 pm which is 3 hours after my bedtime. I jumped in the car and met her at the office where we kept some extra meds. She was very thankful and the cycle was a success but they still didn't name the kid after me... So don't run out of meds unless you want to see DrG in his PJs. If you do run out, then don't suffer in silence.

These are not the only RE emergencies but they cover probably 90% of the issues that patients face when undergoing treatment. Feel free to add your thoughts.

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What Happened to August?

Wow, I knew that I was behind in my blogging but missing a whole month is pretty bad! In my defense, I was on vacation for part of the month and DrD was on vacation for several weeks as well so it was a pretty crazy time here at DFE.

The end of summer is always very bittersweet. It brings back memories of driving back home from a summer on Cape Cod with the station wagon absolutely heaving from all the junk plus a wet dog and usually a container of Sea Monkeys. The return to school was usually not a high point for me...hard to imagine considering how many years I spent in school...but summer remains my favorite season. Of course, now that I have school age kids I can appreciate why fall is not so bad as getting back into a routine is sometimes a relief.

Speaking of routines I think that fertility treatment can sometimes become a routine or even a second job for some patients. The hardest thing to tell a patient (or couple) is when it is time to move on with their lives and consider other paths. These can include adoption, embryo adoption or child-free living.

Making these recommendations is not easy, especially in patients who respond well to medications but ultimately fail to conceive. I never say that a couple has no chance unless there truly are no eggs, no sperm, no tubes or no uterus...anything can happen but my ability to make it happen faster really drops after multiple failed attempts.

Years ago I received a letter from one of my New York patients. The letter started "Dear Dr. Gordon, thank you for failing to get us pregnant with IVF." Oh boy, I thought here comes the part where I am told to expect a lawsuit or a baby photo from success at another clinic. But the comment was a sincere one. The patient continued "If you had succeeded then we never would have adopted our daughter from China and she is the light of our life!"

What a great letter. I still have it and when I have had a rough day I often read it over thinking to myself what a gift it was for them to have expressed that sentiment to the doctor who tried but failed.

More posts to come in September!

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Ureaplasma, Mycoplasma and Cervical Cultures

As part of the routine fertility evaluation we usually obtain cervical cultures including a test for mycoplasma and ureaplasma. These are bacteria that have essentially no symptoms but may decrease fertility and may also influence the chance of pregnancy loss and even preterm labor and delivery. However, the data is not particularly good and thus, many clinics do not routinely perform these cultures.

Years ago when I was in practice in Long Island I was doing an examination and sonogram on a new patient. I carefully explained each step and while doing the speculum exam I said that I was going to take some swabs of the cervix to check for infections that may be related to or cause infertility. She said fine and then after the exam left the office. An hour later she called irate. How dare I do such a test on her without her consent! She was going to report me to the Board of Medicine for being such a lousy doctor!

Needless to say I was completely unprepared for this assault. I reminded her that I had asked her permission to do the test…That doesn’t count, she said, because I had her in a compromised position and how could she say no? When I told her that I could just throw out the samples and not send them she was suddenly relieved and much happier.

I have always wondered exactly what set her off. Perhaps she had STD risk factors that she didn’t want to share with me?? Who knows. In any case, sometimes the simplest things can be blown up into major issues. I do not take any testing lightly, but seemed like a bit of an over-reaction.

So here is today’s Question of the Day from 100 Questions and Answers about Infertility.

13. What is ureaplasma, and how did I get it?

Most reproductive endocrinologists routinely obtain samples from the cervix (cervical cultures) to assess their patients for gonorrhea, chlamydia, ureaplasma, mycoplasma, and other bacteria. Gonorrhea and chlamydia are sexually transmitted diseases that can cause tubal damage and infertility when these infections are passed back and forth between sexually intimate partners. Patients with gonorrhea may have a yellowish discharge associated with pelvic pain and fever. Although chlamydia can be associated with these symptoms, chlamydial infections are often silent; despite their lack of symptoms, these infections may result in significant tubal scarring and damage.

Ureaplasma and mycoplasma are somewhat more problematic to label as reproductive tract pathogens, because they are often found in fertile, healthy couples in addition to those
with infertility. These bacteria have been hypothesized to play a role in both infertility and miscarriage, but the specific mechanisms by which they alter fertility are unclear. Whether
ureaplasma or mycoplasma can cause reproductive tract damage or whether their presence increases the rate of miscarriage is controversial. As a consequence, many clinics do not test
for ureaplasma or mycoplasma routinely. If the cultures for ureaplasma and mycoplasma are positive, both the patient and her sexual partner are treated with antibiotics. As these bacteria are may be present for many years without causing any symptoms, the finding of ureaplasma and mycoplasma on cervical cultures does not in any way indicate infidelity or sexual misconduct.

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Medical Mysteries!

I admit it…sometimes I do watch “real life” medical shows on television. Last year I was watching “Medical Mysteries” on Discovery (I think) and the show presented a young woman who wanted to conceive but had not resumed menstruating after stopping oral contraceptives. She noted that her doctor prescribed “pills” to induce ovulation but when she failed to bleed the doctor ordered additional tests to evaluate if she could be in “early menopause.” Although not exactly correct the story seemed appropriate thus far. Then the doctor called her and gave her the good news that she was not menopausal. Great, I thought, so what did the MRI show?

The woman was then told to just keep trying and see what happened….not a great plan. A few months later she was in the movies and when she stood up she couldn’t see her feet! WARNING, WARNING, THIS IS A BAD SIGN! “So what did the MRI show!” I yelled at the TV (freaking out my wife, I must add who was quietly reading). The woman said that she thought that was weird but it wasn’t until she had a seizure 2-3 months later that her doctor was smart enough to order an MRI. “My doctor was so smart to think of doing that test,” she told the interviewer. Duh!

So the MRI showed a large benign brain tumor (meningioma). After it was removed her periods returned and she went on to have 2 kids….hooray. Happy ending but as you can read below the “smart” doctor was several months late in ordering that MRI! This whole mess could have ended up on the “Medical Malpractice Hour” if the patient hadn’t had such fondness for her doctor.

So here is today’s Question of the Day (which is not a daily feature…shame on DrG) from the book that was not on sale at the MIT Coop when I was in Boston last weekend, 100 Questions & Answers About Infertility.

26. If I don’t have either PCOS or POF, then what is my problem and why am I not ovulating?


Hormone abnormalities other than PCOS can also lead to irregular menstrual cycles. Such abnormalities include problems with the thyroid gland (which produces a hormone that controls metabolism), abnormal levels of prolactin (a hormone that induces breast milk production), and a lack of pituitary stimulation to the ovary known as functional hypothalamic amenorrhea (FHA).

The pituitary gland has been called the master gland of the body; it secretes hormones that control a wide range of functions, including reproduction, metabolism, response to stress, water balance, and growth. Women with irregular cycles should have their thyroid hormone and prolactin levels measured, because problems with the thyroid gland can indirectly lead to elevations in prolactin. Low levels of thyroid hormone (hypothyroidism) and elevations in prolactin (hyperprolactinemia) can be readily treated with medication. In fact, treatment of hypothyroidism with oral thyroid hormone (levothyroxine) can promptly restore normal menstruation. Similarly, hyperprolactinemia usually responds quickly to bromocriptine therapy, often promptly restoring normal cycles.

An elevation of prolactin in the absence of any thyroid disease requires magnetic resonance imaging (MRI) of the brain to evaluate its cause. In such cases, hyperprolactinemia usually results from an increased growth of the prolactin-secreting cells in the pituitary gland that forms a small tumor. If the prolactin-secreting tumor is less than 1 cm in diameter, then
it is called a microadenoma. A macroadenoma is greater than 1 cm in diameter.

Women without thyroid or prolactin issues who fail to have menstrual periods following treatment with progesterone are usually referred to as having functional hypothalamic amenorrhea (FHA). These women fail to produce normal levels of estrogen despite an appropriate complement of ovarian follicles. Women who are below ideal body weight and who exercise frequently and vigorously are particularly prone to developing this problem. Women with FHA are at risk for osteoporosis and should discuss with their physician the benefits of hormone therapy (such as oral contraceptives) when not attempting pregnancy. They should also undergo an MRI of the brain to rule out any structural etiology for their condition. Women who are below ideal body weight may resume normal menstrual cycles when they gain weight or decrease their exercise frequency and duration.

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Do I need a Laparoscopy?

As the son and brother of general surgeons I am often put in the position of defending the low volume of surgery that I perform as a reproductive endocrinologist. In years past, fertility physicians were often in the operating room spending hours repairing damaged fallopian tubes in an attempt to improve a patient’s fertility. However, as IVF technology has improved the need for laparoscopy has dwindled. I explain it to patients in this fashion: If I do a laparoscopy and find significant adhesions (scar tissue) and endomteriosis then IVF is your best option. And if I find minimal endometrosis and minimal scar tissue then IVF is your best option. And if I find that everything is normal then IVF is your best option.

So almost all roads lead to IVF so why do the laparoscopy? Well, not all patients can afford IVF or wish to try IVF. They may be afraid of the drugs, of OHSS, of multiples and I agree that those are good things to fear….and yet IVF really works better than our other options. Natural cycle IVF can remove some risk is more acceptable to some patients but it doesn’t work as well as stimulated cycle IVF. So do I need a laparoscopy? That is the topic of today’s question from 100 Questions and Answers about Infertility. So to honor my general surgeon father in light of the rapid approach of Father’s Day…here is my response…and it pretty much proves that I am not a “real” doctor in his eyes…

11. What is a laparoscopy, and do I need one?

A laparoscopy is an outpatient surgery usually performed under general anesthesia. Most laparoscopies are completed in a hospital, but some physicians utilize freestanding outpatient surgery centers. During a laparoscopy, the physician inserts a small fiber-optic telescope into the abdominal cavity through an incision made in the patient’s umbilical area (belly button). Most physicians initially distend the abdomen using carbon dioxide gas with a needle (Veres needle) to create what is called a pneumoperitoneum. A trocar—an instrument with a diameter similar to that of a pencil—is then passed through the umbilicus, allowing for introduction of the telescope (called a laparoscope) into the abdomen.

Using the laparoscope, a gynecologic surgeon can inspect the uterus, fallopian tubes, and ovaries. The appendix and upper abdomen are carefully inspected as well. Additional instruments may be inserted into the abdomen through incisions (ports) made along the hairline above the pubic bone. For example, the physician may use graspers, scissors, or suction irrigators to rinse the tissue and remove blood and fluids as needed. Some physicians insert a slightly larger telescope through the umbilical port, which allows them to use a carbon dioxide laser to cut scar tissue or destroy implants of endometriosis. Besides the laser, other instruments can be used to cut or burn abnormalities such as endometriosis or scar tissue.

During a laparoscopy, the physician typically introduces a blue dye into the uterine cavity while directly visualizing the fallopian tubes. If the fallopian tubes are patent (open) but are located in an abnormal location because of scar tissue, then the surgeon may try to free the fallopian tubes to improve the patient’s fertility. If abnormal ovarian cysts such as endometriomas are present, then the physician may remove them during the course of the laparoscopy or, if necessary, perform a laparotomy.

A laparotomy is a surgery performed through a larger incision, usually made along the bikini line. It may require the patient to stay 1 to 3 days in the hospital following the surgery. In addition, a laparotomy requires a longer recovery period and may create more new scar tissue than laparoscopic surgery. Certain abnormalities cannot be easily treated through laparoscopy, including exceedingly large ovarian cysts, ovarian cysts that are suspicious for cancer, and fibroids that are deeply embedded in the wall of the uterus. Patients with these problems are probably better served by a laparotomy.

For many years, all women who were seeking fertility care underwent laparoscopy as part of the initial evaluation. In recent times, this practice has faded with increased utilization of IVF. Although IVF has essentially replaced tubal surgery in patients with tubal factor infertility, laparoscopy is still used to correct certain problems in patients prior to undergoing IVF. Complications of laparoscopy are rare but can include injury to the bowel, bladder, and blood vessels; a need for laparotomy; and even death.

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PCOS Ovulation Induction

When I was an Intern in Ob Gyn at Stanford, my friend and Senior Resident Jan Rydfors shared with me a helpful saying: “Like treats like.” He was referring to patients with polycystic ovarian syndrome (PCOS) and how to induce them to ovulate. He explained to me that since PCOS was a hormonal problem, its treatment should be with hormones (not surgery).

Surgery for patients with PCOS was popular for many years and prior to the introduction of clomiphene, one could indeed help women with PCOS by performing bilateral ovarian wedge resection. My father, a general surgeon, who trained when gynecology was still part of general surgery, performed many of these procedures and some of the patients did indeed begin to cycle normally and conceived. Unfortunately, the surgery sometimes caused tubal damage and pelvic adhesions, trading one reproductive problem for another. Surgeons also have a helpful saying: “A chance to cut is a chance to cure.” Doctors in non-surgical specialties have some pithy quips about surgeons, such as orthopedic surgeons are “big as a tree and half as smart.”

Although laparoscopic ovarian drilling has emerged as the modern form of ovarian wedge resection, few patients are forced to resort to this approach as our understanding of PCOS has improved. About 90% of patients will ovulate on metformin or metformin and clomiphene in combination. The remaining 10% usually respond to injectible fertility drugs but here one has to be careful about OHSS and multiples. So here is today’s Question of the Day from the book that my Mother thinks all women of reproductive age need to read: 100 Questions and Answers about Infertility.

25. I have PCOS and am still not having normal cycles with metformin. What comes next?


Patients who fail to respond to metformin may require ovulation induction with either clomiphene citrate (Clomid) or injectable fertility medications (gonadotropins). Clomid has been an FDA-approved treatment for anovulation since the late 1960s. This anti-estrogen has been used successfully in millions of women with few complications.

Clomid binds to estrogen receptors in the brain, causing the pituitary gland to resume normal release of FSH, and thereby inducing follicles to grow and ultimately release an egg. Patients should take the lowest effective dose of Clomid needed to induce ovulation. With increasing doses, the anti-estrogen side effects can reduce fertility by altering the cervical mucus and leading to a thinner endometrial lining. Many physicians initially prescribe a dose of 50 mg of Clomid to be taken on cycle days 5 to 9. The physician may perform ultrasound monitoring after day 12. Most patients will ovulate around day 17. If no dominant follicle emerges by this day, then an increased dose of 100 mg should be used in the next cycle. A dose of 150 mg is rarely prescribed, because the vast majority of Clomid-responsive patients will ovulate while taking the 50- or 100-mg dose.

Women with PCOS who fail to respond to Clomid can be treated with injectable fertility medications. Gonadotropins are prepared either using recombinant DNA technology (Follistim®, Gonal-F®) or by isolating these hormones from the urine of postmenopausal women (Bravelle, Menopur). By following a very-low-dose protocol (37.5 IU as the starting dose), approximately 90% of patients will achieve a single dominant follicle. If the treatment produces multiple follicles, however, the woman’s risk of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS) may lead to cycle cancellation. Almost all of the high-order multiple pregnancies (e.g., sextuplets) born today result from PCOS patients who took gonadotropins and demonstrated an excessive follicular response.

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Ectopic Pregnancy After IVF

My brother Mike is a real doctor. I mean it. He is a general surgeon in a small town in North Carolina and has not had a full night’s sleep in about 27 years. He is always being called out to the ER to help save someone’s life (or at least remove their appendix) in the middle of the night. The life of a fertility doctor is very different.

Some weeks are more reproductive psychiatry than reproductive endocrinology and emergencies are rare. We have an occasional patient with OHSS in the hospital and once in a while we have an ectopic pregnancy that requires laparoscopy but most of the time there are not a lot of medical surprises. However, among our surprises are the unexpected multiple pregnancy, ectopic pregnancy or heterotopic pregnancy.

Multiple pregnancies are always tricky to predict. Even if you transfer a single embryo, it can split leading to identical twins! Ectopic pregnancies after IVF are rare but not impossible (see below). Heterotopic pregnancies occur when one embryo ends up in the uterus but another one gets stuck in the tube.

Ultimately if you practice reproductive medicine long enough you will see quite a range of unexpected results. Fortunately, most patients do not get OHSS, most patients do not have ectopic pregnancies and most patients do not have heterotopic pregnancies.

So here is today’s Question of the Day from the book that my surgeon brother fell asleep reading: 100 Questions and Answers about Infertility.



55. How can you have an ectopic pregnancy after IVF?

As described in Part 3, an ectopic pregnancy can occur within the section of the fallopian tube that passes through the muscle of the uterus or within the short segment of fallopian tube that remains after surgical removal of the tube. The incidence of ectopic pregnancy following IVF ranges from 0.5 % to 3%, but this figure may be decreasing. For the past several years, embryo transfer has been routinely performed using ultrasound to properly guide the embryo catheter to the optimal uterine location. The exact mechanism responsible for an ectopic pregnancy following an IVF procedure is unknown. Some believe that embryo migration up into the fallopian tubes occurs because of local cellular activity or fluid mechanics present inside the uterus. Sometimes the opening of the fallopian tube in the uterus is dilated because of disease, making it easier for the embryos to enter the tubes.

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More About Stimulation Protocols...and Staying Sane

If you spend any time surfing the websites and bulletin boards concerning infertility, then you will certainly notice that stimulation protocols are discussed by patients all over the web. Some patients complain that their heads are spinning as some of the women posting in cyberspace seem to have physiology PhDs and know all of their estradiol levels and follicle sizes…yadda, yadda, yadda.

I think that informed patients are always the best patients but at some point I also think that you need to trust your RE to make sound decisions. There are many different approaches to IVF and IUI stimulations and one needs to remember that every patient is unique with her own particular history. Don’t be intimidated by the biology and the variety of protocols in use. If one protocol was absolutely superior to all of the others, then don’t you think that everyone would use it?

When a patient comes from another clinic to seek care here I always ask for the stimulation records as there is no better way to pick a protocol than to see how things went in the past. Otherwise, you are flying blind and there is no need not to learn from past experiences.

So ask questions, get sound advice and pick a doctor with a good reputation, a good laboratory and good communication skills. After all that, just hang in there and try not to get overwhelmed by the day to day minutiae of the cycle.

With that in mind here is today’s Question of the Day from the book that should be on your bedside table so you can stop taking Ambien…”100 Questions and Answers About Infertility.”


47. My doctor wants to use Lupron or Antagon during my IUI cycle. What are these drugs, and why do I need them? I thought they were only for IVF.

These medications can be used to prevent premature ovulation—that is, they can delay ovulation until the optimal follicle size has been reached. Premature ovulation during an IUI cycle can be dealt with by simply adjusting the timing of the IUI. These medications are primarily used in patients undergoing IVF rather than IUI. For most patients undergoing treatment with IUI, Lupron and Antagon are rarely necessary. These drugs are not routinely used unless a patient repeatedly experiences a premature LH surge during the treatment cycle. In such cases, these medications can allow for a more optimal
stimulation.

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Stolen Laptop Returned...Medical Treatment of Endometriosis

Ce résumé n'est pas disponible. Veuillez cliquer ici pour afficher l'article.

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Endometriosis and IVF

Sorry for the large gap between posts but I actually took some vacation and have been paying for it ever since. Usually it takes at least a week to catch up and handle all the questions that have been raised over the previous week. This torture explains why my vacation schedule is pretty sparse!

Once back here at Dominion I was interested in the Grand Rounds lecture given at Inova Fairfax Hospital this past Monday. The topic was the surgical treatment of endometriosis and infertility. Specifically the question of removal of endometriomas was raised and discussed. Basically, there are no good randomized studies so one is left with the choice of doing IVF with an endometrioma just sitting there, or taking a patient to the operating room before IVF. There may be an increased risk of infection after egg collections where an endomtrioma is pierced. However, the absolute risk of infection after egg collection remains very low. Removing the endometrioma removes this risk but may further damage the ovary reducing the egg count… Decisions, decisions…

Ultimately, there is no clear cut answer here so I try to individualize based upon the patient and her history. Hopefully, your RE will do the same.

So after much delay here is today’s Question of the Day from the book that we shamelessly promoted on the Kane Show (click here to hear us on the air) on 99.5 FM here on Tuesday .

37. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small amounts of endometriotic tissue can improve fertility by as much as 50%. In a large Canadian study, the monthly pregnancy rate following surgical treatment of minimal endometriosis rose from 3% to 4.5%. Although this finding represented a 50% improvement in the patients’ monthly chance of pregnancy, it does not compare very favorably with IVF pregnancy rates, which average around 30% for a single treatment cycle.

Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most doctors will destroy the abnormal endometriotic tissue at the time of the diagnostic laparoscopy by using either laser or coagulation techniques. In addition to improving fertility, surgery may often eliminate or improve symptoms of dysmenorrhea and pelvic pain. Ovarian cysts that contain endometriotic tissue may grow quite large. They are often called “chocolate cysts” because of the dark brown fluid found within them, although endometriosis cysts are more correctly referred to as endometriomas.

If left untreated, these growths may destroy part or all of the normal ovarian tissue, including the eggs. Endometriomas must be surgically removed, usually via laparoscopy. Sometimes, however, laparotomy is required. The ultimate choice of which surgery is performed depends on the operative findings and the skill and experience of the surgeon. Medical treatment of endometriomas is insufficient and will not cause these cysts to resolve.

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Fibroids and Fertility

Before I jump into today’s topic I wanted to put a plug in for a local patient information seminar sponsored by RESOLVE. The volunteers at RESOLVE do an outstanding job and this conference (April 12, 2008, 8 am til 5pm at the Bethesda, MD Hyatt Hotel) provides a real resource for patients especially in regards to adoption information. http://www.resolve.org.



Now back to our issue at hand…

Every week it seems that I discuss fibroids with my patients…and it is often a rather complex discussion. Fibroids are extremely common, benign tumors of the uterus. They are found in over 50% of women and can range in size from <1cm>50% inside the cavity may be removed with hysteroscopy but those that are not require laparotomy (bikini incision). I am not a proponent of laparoscopic myomectomy unless the fibroid is on a stem. I believe that the repair is inferior through the laparoscope.

Uterine fibroid embolization is a newer approach that should not be used in fertility patients as the technique leaves a large amount of devascularized (no blood supply) tissue and may thus adversely affect fertility.

So here is today’s Question of the Day.

96. Can fibroids or other uterine problems cause infertility or miscarriage?
Anatomical abnormalities can predispose a woman to preg- nancy loss. In particular, congenital uterine abnormalities such as a uterine septum (fibrous band separating the uterine cavity into two smaller cavities) or a unicornuate uterus (a small malformed uterus that is usually connected to a single fallopian tube) can lead to poor reproductive outcomes. Uterine malformations as a result of prenatal exposure to diethylstilbestrol (DES; see Question 66) can also increase a woman’s risk of a poor pregnancy outcome. The presence of uterine fibroids within or abutting the endometrial cavity has been proposed as a source of pregnancy loss (see Figure 7); the same is true of uterine polyps. Extensive intrauterine adhesions from a previous dilatation and curettage (D&C) procedure may also lead to reduced reproductive success. All of these abnormalities may be amenable to surgical correction, but the decision to pursue surgery requires a careful discussion with your physician.

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IVF Stimulation Protocols...cooking eggs with DrG

Many of the questions that I answer on the INCIID bulletin board revolve around issues of stimulation. High responders, low responders, unusual responders…you name it. Of course, making pronouncements on cycles that I have never seen, from clinics that I have never heard of and with REs that I personally have never met represents a difficult proposition.

IVF is really an art on some level and we need to carefully pick stimulation protocols and make trigger shot decisions after careful consideration of all the data. We sometimes really agonize over these decisions and that is why we prefer to do our own sonograms so we can get a real feel for whether the follicles are ready….and yet sometime it just doesn’t work out the way you thought that it would….

So after much delay, here is another question from the book that every fertility patient should buy or borrow or steal (OK, not steal) although we have yet to see a dime from our publisher…


62. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?

Although several drugs and protocols are available to stimulate the ovaries to produce extra eggs for IVF, most clinics The first method, called luteal suppression, involves suppression of the ovaries using a GnRH-analog (Lupron) during the luteal phase of the menstrual cycle preceding the planned IVF treatment cycle. Once the ovaries are suppressed, ovarian
stimulation is accomplished with daily injections of gonadotropins (e.g., Gonal-F, Follistim).



In the second method, called flare stimulation, the woman does not take any medications until the second day of her menstrual cycle. At that time, a microdose (most commonly) of Lupron is used to “flare” the pituitary gland and induce it to release its store of FSH and LH. Simultaneously, gonadotropins are started, producing a “one–two punch” in terms of ovarian stimulation. Premature ovulation of the eggs rarely occurs despite the low dose of GnRH agonist utilized in this protocol.

A third, more recent option is GnRH-antagonist stimulation, in which GnRH antagonists are added later in the stimulation to prevent premature ovulation. In this method, the gonadotropins are started on cycle day 2 of a normal menstrual period. Once the follicles have reached a specific size (usually 12 to 14 mm), the woman begins the GnRH-antagonist medication, which almost instantaneously prevents the pituitary gland from generating an LH surge.

Some reproductive endocrinologists prescribe oral contraceptive pills to their female patients prior to beginning the actual ovarian stimulation drugs, but this practice varies between patients and fertility clinics. We have found that the use of birth control pills often results in oversuppression of the ovaries and cycle cancellation except in those patients known to be high responders (women with PCOS, in particular).

The type of protocol selected for any patient (i.e., luteal suppression, flare stimulation or GnRH antagonist) depends on the individual patient and the philosophy of the fertility clinic. Factors that may influence the type of stimulation protocol selected include the patient’s age, her day 3 hormone levels, her follicle antral count as determined by ultrasound, and her previous responses to any other attempts at ovarian stimulation.

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Trust me, I'm a doctor...

Trust is at the heart of the doctor-patient relationship. You, the patient, put your trust in me to make the correct treatment recommendations, and I, the doctor, trust that you are being honest with me regarding your history, symptoms, insurance issues etc.

Patients will sometimes ask me to use non-fertility codes during their care in order to get their insurance to cover a particular visit or procedure. This request is known as insurance fraud and I explain that although I am sympathetic to their situation, I am not willing to go to the "big house" on their behalf.

The problem is that doctors may differ in their philosophy, approach and personality. There may be multiple acceptable options for each couple and it takes time to discuss all options as one works towards making a decision.

So how do you know that you can trust the advice that you are getting? First, consider the source. What is your physician's training background...how long has he/she been in practice...does he/she look as young as Doogie Howser (I used to get that a lot but not anymore)....and what services does your doctor offer (full range of fertility treatments; no IVF; only IVF; no Donor Egg etc etc).

Then when you can no longer figure out where to go you can always ask if your RE ever worked as a camp counselor at a Boy Scout Camp...


Have a great weekend!

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Egg Freezing

Clearly one of the biggest issues facing our patients is advancing age. We cannot turn back the biologic clock and it is not fair that Strom Thurman can become a father at age 84 and for women after age 35 fertility really starts to drop. If only we had a way to determine the number of health eggs remaining in a woman, then we could give accurate assessments of the chances for success. Unfortunately, there is no test for egg quality that is definitive.

So now that egg freezing seems to be working a bit better the use of this technology to preserve fertility has been debated. A few general issues need to be understood. First of all, although almost 5 MILLION babies have been born after traditional IVF, there have been perhaps around 500 babies born from frozen eggs. The problem is multi-factorial. Many eggs fail to freeze or thaw successfully and those that do need ICSI to endure fertilization. With the increasing adoption of vitrification (rapid freezing that instantly occurs) success rates are on the rise.

However, should this still be considered experimental?? Probably. Should patients have to pay for an experimental procedure? I guess...although this seems inappropriate to me personally (but since we don't offer fertility preservation from egg freezing -- yet, I guess my view is biased).

So this remains controversial. Here is a PDF file of the most recent position statement by the ASRM about egg freezing. It is comprehensive and pretty informative...I think.

Of course, if you want to debate egg freezing with us in person, be sure to drop by the Clarendon Barnes and Noble bookstore on Saturday January 26th from 12 noon until 2 PM. You don't even need to buy a book...

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Birth Control Pills and IVF Protocols

Many of the questions that I answer on the INCIID (www.INCIID.org) bulletin board revolve around medication protocols especially the use of oral contraceptives. Personally, I have had poor results with the use of oral contraceptives except in known high responding patients. I know that many clinics use pills in protocols without any problems but my own experience has not been very positive.

So here is today’s “Question of the Day” from the book that really needs some more reviews on Amazon.com…100 Questions and Answers About Infertility. As the snow starts to fall here in Washington paralyzing the government, I want to invite all local readers of this blog (and their friends and family) to the Barnes and Noble Bookstore in Clarendon, VA for a book signing of this book on Saturday January 26th from Noon until 2 PM.



64. My reproductive endocrinologist has recommended a protocol that uses birth control pills. Why would birth control pills be used in IVF?
Birth control pills or, more correctly, oral contraceptive pills (OCPs) can be used as a part of the IVF stimulation protocol in several different settings. First, in patients who are known or suspected to be high responders, OCPs may help mitigate the risk of ovarian hyperstimulation syndrome (OHSS; see Question 67).

Second, in patients without predictable regular menstrual cycles, OCPs can be used in combination with Lupron to initiate an IVF cycle. In our practice, we usually start OCPs in such cases after confirming with a blood test that the woman has not recently ovulated. Then, after 1 week, we add Lupron. After 1 more week, we stop the Lupron and wait for withdrawal bleeding. Once a patient has bled, we begin the gonadotropin stimulation.

Third, some clinics use OCPs for microdose Lupron (MDL) flare, traditional flare, or patients who are taking Antagon in the hope that pretreatment with OCPs will prevent one follicle from growing faster than the other follicles once the stimulation has begun. We have not routinely use OCPs with our MDL flare patients, as we have rarely had problems with the emergence of a single dominant follicle compared with the more common problem of oversuppression and a cancelled cycle. Given that prolonged OCP use can lead to oversuppression in low responders, we use these medications very carefully.

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The Politics of Natural Cycle IVF

Yesterday we discussed two major issues facing patients and their doctors: How do we completely avoid the temptation to transfer more than one embryo and also avoid the risk of OHSS completely? One answer was to use Natural Cycle IVF.

Why then would all clinics not offer Natural Cycle IVF? The procedure is already proven and familiar. We all do egg collections. We can use ICSI to ensure fertilization occurs if there is any concern. We all culture embryos. So where’s the problem?

Here’s the situation as I see it. According to the Wyden Law every fertility clinic in the US must submit its statistics to the CDC so that they can be made available to the general public. The CDC emphatically states that consumers should not use these tables to compare clinics because practice patterns can vary between clinics and physicians…yadda, yadda.

Of course, the reality is that most patients use these statistics to directly compare clinics eventhough the old adage of “there are lies, damn lies and statistics” always holds true. Honestly, if you really want to compare clinics and eliminate the influence of patient selection then look at their donor egg IVF pregnancy rates (ours is 127%) since donor egg IVF would represent a “level playing field.”

So back to Natural Cycle IVF….we believe that the best candidates for Natural Cycle IVF are patients <35 years old with a well defined fertility problem (tubal blockage, male factor, endometriosis). In these patients Natural Cycle IVF can be successful with very good pregnancy rates (although the per cycle pregnancy rates will be about 1/3 of the stimulated cycle pregnancy rates). But guess what? This patient population also represents the best candidates for stimulated cycle IVF.

Now every year I am asked to submit my statistics for my IVF program to the CDC. On each patient’s data entry form the CDC asks if this is a stimulated or unstimulated (Natural Cycle) IVF cycle. Then they ignore this piece of information and lump all the IVF cycles together to yield the tables that patients then look at when choosing clinics.

So if I am an RE trying to make a practice decision concerning Natural Cycle IVF, then I need to think carefully about the implications of this decision. I can offer Natural Cycle IVF, which is less expensive and more patient friendly, BUT as a result I will siphon off some of my best stimulated cycle IVF prospective patients into a program that will also yield lower per cycle pregnancy rates. The end result is that I will be shooting myself in the foot in terms of my CDC IVF stats that patients love to use to compare clinics….Hmmm let me give that a great deal of thought. Guess what most clinics in the US decide…

However, I do have a solution that would determine if my assessment is correct. What I have suggested to the CDC is the following: since they already ask us to delineate between stimulated and unstimulated IVF cycles, why not publish the stimulated cycle IVF pregnancy rates and unstimulated IVF pregnancy rates as separate sets of tables? 

Currently only a few clinics offer unstimulated IVF. I predict that number would rise dramatically if the disincentive to offer Natural Cycle IVF was removed. I may be wrong on this point but I don’t think that I am…

So if you are interested in encouraging the CDC to change their approach just let me know and I will tell you who to send a letter to….hey, if we could save Star Trek in 1966, certainly we can get Natural Cycle IVF into the mainstream.

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Natural Cycle IVF, OHSS and Multiples

Happy New Year to all those wonderful people out in cyberspace who read this blog. Mom, check your mail for the family calendar that I sent you and tell Dad to stop shoveling the snow himself unless he wants to keel over from a heart attack this winter.

January is the time for New Year’s Resolutions and one of mine is to resume this blog with the regularity that I was able to maintain prior to Tatiana’s sudden death (see last post). Part of healing is moving forward without losing your connection to the past and it is in this spirit that I am taking up pen and paper to continue the work set before me of correcting all of the misinformation provided to patients by all of those REs that do not agree with my opinions (just kidding…sort of..).

So for the coming year from a clinical perspective I would love to see no twins and no cases of ovarian hyperstimulation syndrome (OHSS). These are laudable goals. As readers of this blog are aware I am not favorable inclined towards twins. Yes they make cute Christmas cards and occasionally can generate income for families by appearing on TV and in print advertising but you can’t count on that revenue stream. The problem with twins rests in the risk of prematurity. Some twins will deliver in the midtrimester and die. Some twins will deliver early and survive with significant medical problems and some twins will go full-term and end up on Christmas cards the week after delivery. We never know which outcome a patient will have….

However, unless we limit patients to transfer of a single embryo, the chance for non-identical (fraternal) twins is always present. Interestingly, a study showed that even when patients were informed of the risk of transfer of 2 vs. 1 embryo, they chose ET of 2 if putting back a single embryo dropped the overall success rate by as little as 5%.

OHSS is also a tough problem. Although the ideal number of eggs to me is 8-12 we sometimes overshoot the runway and end up with too many growing follicles. Options include cycle cancellation or retrieval of eggs and subsequent freezing of embryos without a fresh ET but this is frustrating to patients…eventhough it is often the best choice.

So how do we completely avoid the temptation to transfer more than one embryo and also avoid the risk of OHSS completely? Well there is a way to do that and it is called Natural Cycle IVF. Today’s “Question of the Day” reflects this important issue and here at Dominion the issue of Natural Cycle IVF is close to our hearts as we launched our Natural Cycle IVF program last January.

Tomorrow I want to address why the Natural Cycle IVF Bandwagon has yet to stop in your town…



63. What is natural cycle IVF? And why does my fertility clinic not offer this treatment?


The use of natural-cycle IVF (NC-IVF) has been proposed as a means of reducing the risk of multiple pregnancies, eliminating the costs and risks associated with fertility drugs, and reducing the stress and time commitment needed for traditional stimulated IVF. This approach has been espoused by a number of leaders in the field of IVF, including Dr. Robert Edwards, whose pioneering work along with Dr. Patrick Steptoe’s led to the birth of the world’s first IVF baby, Louise Brown, in 1978.

NC-IVF avoids the use of ovarian stimulation drugs, which cost about $4000 per treatment cycle. With NC-IVF the risks of ovarian hyperstimulation, multiple pregnancy, and the issues of cryopreserved extra embryos are avoided as only one embryo is produced. Total costs are about 20% to 25% of the total cost of conventional IVF.

However, NC-IVF has its own set of disadvantages. For example, by not using fertility drugs, unexpected premature “LH surging” or ovulation can occur, leading to cancellation of the planned egg retrieval. This occurs in about 20% to 30% of treatment cycles. In such cases, if the fallopian tubes are open, the doctor may recommend converting the treatment to an intrauterine insemination (IUI) to try to produce a pregnancy. Furthermore, because only one egg and one embryo are produced, the chances for pregnancy are less than with conventional IVF where two or more embryos are typically replaced.

Proponents of NC-IVF expect the “cumulative” pregnancy rate for NC-IVF to be similar to a single cycle of conventional IVF within one to four treatment cycles of NC-IVF. The best candidates for NC-IVF are patients with regular menstrual cycles who are less than 36 years old and have a normal day three FSH level. Patients with tubal-factor infertility or male factor infertility may be good candidates for NC-IVF before resorting to conventional IVF. Patients with poor ovarian reserve or unexplained infertility will probably experience poorer outcomes with NC-IVF compared with those patients with male factor or tubal factor infertility.

Many European fertility centers routinely use NC-IVF with good success rates. For a variety of reasons, the availability of NC-IVF in the United States has been limited. We believe that NC-IVF will soon become increasingly available as patients will demand less stressful and less costly fertility treatments that utilize little to no fertility drugs with good pregnancy rates.

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