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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