High Responder Blues

Being an overachiever can sometimes be harder than being an underachiever....at least when it comes to ovarian stimulation. I certainly don't want my kids to think that I want them to slack off in their academic and non-academic pursuits. Interestingly, my oldest son had to read the book the "Overachievers" for his AP English class. Man, that is like taking alcoholics on a field trip to a bar! The kids are already stressed out about working real hard and then they have to read a book on just that topic....yikes!

Well, being an overachiever in terms of fertility drugs is no fun either and is stressful for both patient, partner and physician. High responder patients are at risk for a wide range of suboptimal outcomes.

First of all there is OHSS. I really hate OHSS. Truly I do. The patient is miserable, the partner is often freaking out and the doctor is trying to navigate through dangerous waters. Patients with OHSS can end up in the hospital and may require draining the fluid that accumulates in the abdomen. Traditionally we have a radiologist drain this fluid but some RE's do it transvaginally as if doing an egg collection and that may make everyone's life a bit easier. Patients with OHSS can become dehydrated and are even at risk for stroke and blood clots in the leg or lungs. Fortunately, these complications are rare.

Secondly, they may end up with eggs that are not really all that good. The HCG may be given a bit early because of worries about the high estrogen levels so sometimes a lot of the eggs are immature. Also, egg quality may not be that great so eventhough there are a lot of eggs the yield is really poor.

Thirdly, you may end up with too many embryos for your confort level. If you start with 35 eggs and end up with 18 cryo'd blastocysts then you may be conflicted about what to do with the extra embryos. These are moral, ethical and religious issues that every couple needs to wrestle with as they pursue fertility treatment.

So the take home lesson here should be that "more is not necessarily better" when it comes to IVF stimulations.

Clinical Vignette: High Responder with ?PCOS

Here is a perspective from a patient who found herself in this situation. I have edited her husband's description of their journey but you get the idea....

Having tried unsuccessfully for years to get pregnant, my wife and I began researching fertility clinics in the DC area. Our doctor recommended Dominion Fertility (DF). We scheduled a consultation, met with Dr. Gordon and were pleased with our visit. As a result, we decided to pursue treatments at DF. My wife was diagnosed almost immediately with PCOS. Someone as slender as my wife wouldn’t normally fall into the PCOS category, yet Dr. G was adamant about his diagnosis. And thus we began our journey through fertility treatments.



As we explored our insurance options we discovered IVF would only be covered at certain clinics, and unfortunately DF was not one of them. Reluctantly, we researched clinics within our insurance network. We found another clinic scheduled an appointment with Dr. X. Our first impression of Dr. X was quite good, given his resume, certifications, awards, etc., and consequently we decided to go with that clinic. After Dr. X reviewed my wife’s file, he shared with us his strong opinion that in fact my wife did not suffer from PCOS. This was contradictory to the diagnosis offered by Dr. G and quite frankly we were relieved. Dr. X was convincing about the potential success with IVF.



As the IVF treatment progressed, my wife began showing signs of hyperstimulation. The doctors reassured us things were fine and to continue the medications. The retrieval date arrived and yet another unknown doctor performed the procedure retrieving 45 eggs from my wife. That’s right, 45 eggs (If you’re familiar with IVF, you know that’s way too many). As a sports fanatic, I thought a high number equated to great success and I wasn’t informed otherwise by the doctors so I was excited. Then I saw my wife in the operating room shaking, feverish, nauseous and bleeding. Something wasn’t right and it just didn’t add up, but again not knowing how these things work I figured this was normal. Everyone in the room appeared to be doing business as usual while my wife was crying and bleeding all over the bed sheets. After an hour recuperating time, I picked up my wife and walked her out of the clinic, hoping that this had all been worth the emotional and physical toll.



Due to hyperstimulation, the cycle was cancelled, meaning we were unable to move forward with a fresh transfer. Only 7 embryos were cryopreserved (not many for retrieving 45 eggs, but not surprising now that we understand how it works). We experienced 2 unsuccessful transfers using all of the cryopreserved embryos. It was disheartening to receive the news that we weren’t pregnant. Nearly a year had passed, and after enduring multiple fertility treatments at that clinic, without blinking an eye, Dr. X shared with us his medical opinion that my wife did in fact suffer from PCOS!



So, we returned to DF for IVF and this time we were well-informed and aware of each step and how my wife was responding. Finally, the day for the beta HCG (pregnancy) test arrived. Not knowing yet the outcome of the test, my wife thanked Dr. G for all he and his staff had done on our behalf. We were overwhelmed with gratitude since the experience was so different this time around. Dr. G. later recounted that he thought my wife had taken a home pregnancy test prior to that visit because she was so optimistic and thankful. Suffice it to say, the results were positive. We are now pregnant!


OK so why did I include this in today's post. Well, first of all I like for my Mom to proud of me and since she may see this post I thought I would include it. Secondly, the diagnosis of PCOS is a tricky one and I often have seen patients that seem to have some factors consistent with PCOS but not enough to make the diagnosis definitively. Thirdly, this case demonstrates the need to match IVF stimulation protocols to the patient. I originally had planned on using a protocol of 75 IU of FSH med and 75 IU of menopur. At the other clinic, she recieved a much bigger dose. When she returned to me I used 75 IU and 37.5 IU and she still ended up with 26 eggs which is a lot more than our average of 11 eggs! Of those 26 eggs, she ended up with 12 nice blastocysts (2 for ET and 10 for cryo). She did not get OHSS, but I was concerned about it given the # of eggs, her high estradiol levels and her probably diagnosis of PCOS. So a nice happy ending and I hope that the rest of her pregnancy goes well.

So that is my last (and first) post for November 2009. Sorry as usual for the long interval between posts. Now for faithful readers of this blog I want to enlist your help in an online popularity contest. Dr. Fred Lucciardi's blog has received about a gazillion votes for the Health Blogger Awards. This is incredibly unfair because not only ifs Fred a really great guy and an excellent RE but he is (presumably) a Yankee fan. So as a member of Bosox Nation it seems inappropriate for Fred's team to have won the World Series and for his blog to win the Health Blogger Award. So if you can find the time to vote for DrG, then please do so....just as in politics: Vote early and vote often! Just kidding...

Vote for DrG for Health Blogger Award
(http://www.wellsphere.com/voteBlogger.s?bloggerId=150461)

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Speaking the Truth with Love

I was not one of the cool kids in high school. Part of this was because I was, more or less, a "goody-two shoes" and gave my parents very little grief (unlike my older brother Steven). I am an Eagle Scout and actually wrote about service to others in my college essays. Although Hahvahd and Yale were unimpressed by my concept of helping others, Princeton lived up to its motto of "Princeton in the Nation's service and in the service of all nations" and I was accepted. So I must admit that it was pretty darn painful to watch my Tigers get slaughtered by the Crimson on a rainy day in Boston this past weekend. At National Presbyterian Church we have tried to emphasize the concept of "speaking the truth with love" when it comes to controversial or painful topics. So in regards to my Alma Mater....I can say with authority that the Princeton University Band remains undefeated.

In medicine giving bad news is never easy. In infertility therapy delivering bad news seems especially tough. Patients want their doctor to be enthusiastic and optimistic...but on the other hand we need to be realistic and try to offer a balanced view. I try to discuss all options with my patients and consider the economic, philosophic, emotional and physical costs of these various options. If a patient has coverage for IUI but no coverage for IVF and IUI is a medically reasonable option then I usually suggest that this is an appropriate approach. There are usually many possible options for most couples and one size does not fit all!

Recently I had a patient at another clinic contact me to ask about options at 46 years old. She was unhappy with her care and frustrated that donor egg was her only option with her current RE. I discussed the range of options from FSH/IUI to Natural Cycle IVF to dinner/movie. My honest opinion was that she had been given good advice and that if she was open to donor egg IVF then I think that would be the best choice unless adoption was being considered. I am not sure why she seemed more satisfied with my answer than with her previous doctor's answer but that is the way it goes. I hope that most patients can get beyond the "kill the messenger" view.

So remember that all of us are human and a good doctor tries to give solid helpful advice when dealing with complex medical issues.

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IVF Nightmares

One of the benefits of working as a Reproductive Endocrinologist is that most patients end up with the outcome that they desired: a family. It may be accomplished with their own eggs and sperm, or donor eggs/sperm, or donor embryo or adoption or foster parenting or even on their own (GASP!). However, when a disaster occurs you can be sure that it will make all the papers and talk shows. By disasters I mean the usual parade of newsworthy events such as Octomom, lost embryos or transfer of the wrong embryos into the wrong patient.

There is no doubt that these events are too be avoided at all costs. The parents, the children, the doctors and the staff all wish to avoid this type of outcome. Octomom is the easiest to avoid. You simply follow reasonable guidelines when deciding how many embryos to transfer. There are very few individuals who believe that ET of 6 blastocysts into a single mother of six who is under 30 years old is a good idea. Case closed.

But what about the most recent IVF problems to hit the news that involve a different set of issues? There are few happy endings when the wrong embryo is transferred or cryopreserved embryos are lost or destroyed. But believe me, no doctor wants to find out after the fact that such an event has occurred. There is a level of trust that exists between RE and embryologist and when communication breaks down that is when mistakes can occur.

Working with eggs, sperm and embryos can be very stressful as there is so much riding on each treatment cycle. As a Fellow in REI, I would work weekends at the Kaiser clinic doing sonograms and IUIs. I was responsible for the whole 9 yards....prepping the sperm, doing the sonograms, doing the IUI etc. I was absolutely crazed about keeping the sperm samples separate. I labelled every tube and syringe to ensure that Mr. Johnson's sperm did not go on a little adventure into Mr. Chen's sample...and vice versa. When in doubt, I threw out the pipette and started again. You have to be meticulous or else a disaster could strike. At that time in my medical training, emergency C-sections were a piece of cake to me but keeping tabs on those sperm samples was a lot more stressful. These days neither really fazes me as I have tought one teenager how to drive so I pretty much feel that I can handle almost any stress!

So I asked our Chief Embryologist Awie Botes who has been working in Reproductive Physiology and IVF for over 30 years to give me a Top Ten list of how the laboratory staff here at Dominion (or anywhere really) ensure IVF nightmares do not come to pass.

1. Check identification of the patient
2. Never work with more than one sample at a time...one lab member per case
3. Use triple identification system for all eggs, sperm and embryos: color code, name code, number code
4. Personally identify patient for egg retrieval and embryo transfer (in case schedule has changed)
5. Team approach to fertilization as 2 members of lab team must concur before sperm and eggs are combined
6. Team approach to thawing of embryos so again 2 lab team members confirm plan to thaw embryos
7. Confirm with RE as ET transfer catheter is passed off
8. Management plan reviewed with RE in advance of treatment
9. Confirm treatment plan at time of egg collection
10. Adequate staffing to ensure a well rested team without fatigue!

Awie wanted to add providing all lab staff with new cars and a trip to Bermuda to ensure a happy lab crew....well 10/11 isn't too bad.

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The Internet....and other scary places...

The Internet is a wonderful tool. You can find answers to questions almost instantaneously. You can read articles from news sources a world away. You can watch videos of cats falling into fishtanks. What's not to like?

And yet, the Internet can allow faceless, nameless individuals to bully, confuse and intimidate vulnerable people who are just trying to get through this confusing maze of infertility treatments. The result is sometimes ugly and mean-spirited.

A few years ago several of our patients were posting to a bulletin board where the majority of patients were from another local clinic. Our patients were bullied and harassed in a really nasty way. One person accused one of my patients, who at that very moment was admitted to the High Risk Pregnancy Unit at Inova Fairfax Hospital, of being a liar who wasn't even pregnant! She actually had twins and pretty bad preterm labor.

So what to do? I think that one needs to consider Internet advice very carefully....including my own by the way! I often strongly urge patients that post to me to follow up with their RE. There is no substitute for speaking with your own doctor about your care. However, sometimes there can be some insight added by getting a fresh opinion. The knowledge that my replies may empower a patient to discuss difficult topics with their doctor is one reason that I continue to moderate Q&A sessions both on our own website and on the INCIID website.

Finally, I would advise patients to raise issues with their doctor....with their doctor. Seriously. The common practice of Anonymous posts complaining about issues really doesn't help at all, although it makes the one doing the posting feel better about venting. I have always encouraged patients to vent to me about issues that they may have with me or my practice. You cannot give good service without accurate feedback. A good physician always takes constructive criticism and makes adjustments. It is usually best to put these thoughts down on paper rather than rely upon memory when sitting in the office.

If your criticism is too personal, I can always have my Mother take care of the insensitive dolt who dared to knock her perfect (well near-perfect) son! Thanks Mom!

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Science Fiction or Science Fact

Nothing too helpful in today's blog...just some ruminations by DrG....

I don't have a very long commute to my office here in Arlington, VA on most days, but sometimes some idiot has crashed into a tree on Canal Road or has rear-ended the car in front of him while speaking on a cell phone and I end up in the car for quite some time.... A few years ago I joined Simply Audiobooks, which is like Netflix for books on CD. Over the years I have listened to a range of books from Jane Austen to Steven King and everything in between. I tend to gravitate to science fiction (much to my wife's chagrin) and recently I was listening to a novel by Isaac Asimov entitled "The Naked Sun" first published in 1957.

Much of Asimov's science fiction books involve sex, which would lead you to think of him as a "dirty, old man." In 1981, I actually met Isaac Asimov and had dinner with him. He was indeed a dirty, old man... but very charming and talented. In the "Naked Sun" there are several references to IVF, he called it something different, and the overall impression was that this approach to reproduction would be akin to a crime against nature.

Yet here we are in 2009 with IVF an accepted part of medical treatment and we have all become rather unimpressed with what is really an amazing process. The human egg, removed from the body, fertilized in the lab, sometimes even injected with a single sperm and then replaced into a uterus (usually that of the same woman, but not always in the case of gestational carrier IVF) with some embryos even stored in suspended animation in liquid nitrogen. It is sometimes just too fantastic to believe and yet most days I am too wrapped up in the details to step back and wonder in amazement that it ever works at all.

Today I spent a few minutes on the phone with a couple that were unsure about cryopreserving extra embryos. Ultimately, the biggest stumbling block was their feeling that this was just too weird to be safe. I tried to reassure them that the data is very reassuring and that in some countries like Finland, 40 % of the ART babies are from frozen embryos as there are strict limits enforcing single embryo transfer. But on some level I agree with them that it is incredibly weird to consider that a human embryo can stay in liquid nitrogen for a couple of years and then turn into a beautiful baby!

Asimov eat your heart out....my reality is weirder than your fiction. After all, who would have guessed back in 1981 that my daughter would tell her class at school "my Daddy puts babies in women's tummies."

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Avoiding "cookie-cutter" Medicine

Medicine has been called an art and to some extent this is clearly true. Although statistics, protocols and algorithms exist to guide therapy a thoughtful physician must always take into account the particular needs of his patient. I know that this sounds incredibly obvious but the reality is that with the advent of the internet additional voices have been added to the patient-doctor relationship. I stress to my patients that they are unique and although others may voice their opinions as to the best course of action, the final decision should rest between doctor and patient.

Recently I had a patient with a strong history of depression whose insurance required a series of 3 IUI cycles before covering IVF. She had only a single good fallopian tube and as a couple they had no previous pregnancies. The semen analysis was a bit borderline as well. So given the situation I was proposing moving directly into IVF. Looking at the whole picture this seemed an appropriate plan and the couple was motivated. The insurance company was resolute in their requirement of 3 IUI cycles. I spoke with several employees and was finally told by the Medical Director that the requirements were non-negotiable. This is "cookie-cutter" medicine. No personalized care, one size fits all, don't tell me the facts just follow the algorithm medicine. Bleh.

So I followed the rules. 3 stimulated IUI cycles failed. No surprise. However, IVF was successful on the first try and the patient appreciated the effort that we made to "fight City Hall."

As a physician I learned early in my career that if all else fails "Listen to the patient." I view fertility treatment as a joint effort between the couple and the physician. However, as the physician I have the benefit of having treated patients with similar problems and can take the long-view of a treatment plan. This creative approach was instrumental in Dr. DiMattina and myself launching the Natural Cycle IVF program. One size does not fit all. Some patients are best served by a very proactive approach, moving into stimulated IVF as fast as possible, whereas others take a more step-wise tact with increasing complexity of treatments if unsuccessful. Talk with your RE to develop the plan that meets your needs. If you are a Diplomat going on assignment in 8 weeks then your needs are different than the patient with a pathological fear of needles...or multiples....or OHSS....or being pregnant during August in Washington, DC!

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Fluid in the Endometrium

As usual I find myself apologizing for the long delay between blog posts and as usual I have no real excuse except that I am just a bit tapped out....sigh. The summer has flown past and soon we will be back in the grind of school and work with the playtime of summer a distant memory. This Fall will be memorable as my oldest child will be off to college. Hard to imagine. You know, when I started practice I used to get the "you look too young to be my doctor...." but now not so much! I was thinking about looking into microscopic hair transplantation but my wife assures me that she loves me even as my bald spot and waistline seem to growing inexorably larger. But enough about me....

Everyday I answer posts on the INCIID.org website. I have done this for over 10 years and hope that some of you have found the feedback helpful. Dr. DiMattina and I have launched an online community for our practice (Fertile Grounds) that also provides opportunities for both patients (and non-patients) to post questions to us. We try to answer to the best of our ability and rest assured that posting a question on Fertile Grounds will not result in you being hounded to switch clinics and become a patient of Dominion Fertility....although we would welcome you with open arms and provide all qualifying individuals with a 2 week vacation to the French Riviera.

Recently I had another post on the INCIID.org website concerning fluid in the endometrium. This problem crops up a couple of times a year and is often a great source of distress to the patient who is informed that the lining does not look normal.

So where does this fluid come from? Initially just after a period ends there may be some residual fluid in the endometrial cavity. This fluid is usually old blood and as the follicle(s) begin to develop the lining thickens in response to the rise in estrogen and the fluid vanishes. This type of fluid is not an issue.

More concerning is fluid that appears during stimulation for IVF or for an FET. In general, the etiology of this fluid can be divided into anatomic and hormonal causes. Anatomic problems that lead to fluid accumulation are usually the result of previous damage to the endometrium during surgery. The most common surgical procedures that could damage the lining are removal of fibroids (by laparotomy or hysteroscopy) or a D&C performed for a retained placenta following delivery. Scarring that is present within the cavity is usually called Asherman's Syndrome (especially if it results in the absence of menstrual flow). The risk of adhesions after fibroid removal can be reduced by taking care during the surgery to ensure the lining is not damaged or by treating with estrogen after surgery to induce the rapid regrowth of the endometrium to cover any raw areas within the cavity.

Hormonal causes of fluid accumulation may relate to the high estrogen levels that can be seen in some patients undergoing IVF or FET. If the problem occurs during an FET then the cycle could be aborted. If seen during stimulation then a cryo all could be contemplated. However, in my experience the fluid will often reabsorb once HCG is given or progesterone is started. If, by the day of ET, the fluid persists then the embryos could be frozen or the fluid aspirated and the transfer performed if the lining otherwise looks normal.

Evaluation of the uterine cavity in such cases usually includes hysteroscopy or water sonogram (hysterosconogram). I have also found in helpful to monitor the lining during a spontaneous cycle and see if the endometrium looks normal. If it does, then a Natural Cycle FET may be the best treatment option. In cases of severely abnormal lining the use of a gestational carrier may be the best choice but this option may not to acceptable to all couples.

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It only takes one!

Now some of you that read my last post are thinking - "Sure it's easy for him to say that you only need one embryo but I KNOW that I need more than that..." But I remain steadfast in my view that measurement of ovarian reserve can only get you so far.

For example, here is another clinical vignette right out of our practice here at Dominion Fertility:

TM is a 37 year old with a history of slightly irregular periods who had been treated previously at another fertility clinic. She was successful in 2004 conceiving after a cycle of CC/FSH/IUI. In 2006 she returned to that clinic and underwent another treatment of CC/FSH/IUI but had a biochemical pregnancy. Later that year she had another cycle using the same medications and ended up with a quintuplet pregnancy. She ultimately delivered healthy twins but clearly wished to avoid that situation at all costs in the future.

When I initially saw her back in Oct 2008 her ovaries looked rather small with a low antral follicle count. Her AMH was 0.3 (low) and her FSH and E2 were 13.9 and <20. Considering her relatively recent quintuplet pregnancy, it seemed pretty surprising that her ovarian reserve was now problematic but so it goes.

So my thought was that we were looking at a one egg/month situation in a patient who wished to avoid multiples but had previous IUI success, and thus we elected to go ahead with IUI for a couple of cycles.....no luck after 3 attempts. At this point we discussed Natural Cycle IVF as an option.

Now, the advantage of Natural Cycle IVF over IUI in this setting remains unproven in radomized double blind clinical trials but anecdotally we have had success in such cases. The patient agreed and underwent a cycle of Natural Cycle IVF in May 2009. Although her betas rose initially they soon fell to <5. She went immediately into a 2nd Natural Cycle IVF and again conceived but this time all went well and her sonogram this AM showed a singleton pregnancy with good cardiac activity. Needless to say she was very pleased and agreed to let me tell her story on the website.

So what is interesting here..... Well a couple of points jump to mind. First of all, ovarian reserve can diminish rapidly in some patients. Here we went from hyperstim (quintuplets) to hypostim (low AMH, AFC and high FSH) in just 2-3 years. Secondly, IVF may be more successful than IUI even in patients with normal tubes, normal sperm and previous success. In this case, we were 0/3 on IUIs and 2/2 on Natural Cycle IVF. Go Figure! Thirdly, after a biochemical pregnancy the body is ready to go when you start cycling..no waiting necessary. Finally, it is a case of good things happening to nice patients. It would be hard to imaging a more pleasant and upbeat couple than these two and just remember that "you catch more flies with sugar than with salt." Not that we play favorites but always nice to deal with easy-going individuals.

So for those who say that Natural Cycle IVF doesn't work, I restate my premise that it only takes one good embryo to make a baby!

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What is AMH?

Clearly the issue of ovarian reserve strikes many doctors and patients as "clear as mud!" Remember from our past discussions that ovarian reserve relates to the number of eggs that a patient has and the reproductive potential of those eggs. Ovarian reserve is not truly a test of egg quality as a woman's age is the final arbitrator of egg quality. As I am currently unable to make any patient younger, although I could retire if I could, we need to keep the difference between egg quantity (ovarian reserve) and egg quality (age) segregated in our mind.

So in trying to determine how a woman might respond to fertility drugs we use a variety of tests to predict her response. Day 3 FSH and estradiol, antral follicle count on sonogram and the clomid challenge test (CCCT) have been the methods used most recently. However, for the past 2 years we have also been measuring anti-mullerian hormone (AMH). This protein is made in the cells that line the follicles (the fluid filled cysts that contain a woman's eggs - 1 egg per follicle). The more follicles, the higher the AMH and the better the response to fertility drugs which resue the extra eggs that were doomed to run out of gas during the menstrual cycle.

Apparently AMH is getting some attention in periodicals outside of the medical literature as you can see in this link to the Wall Street Journal. We still rely on Day 3 FSH, estradiol and sonogram to get a complete sense of how a patient will respond to fertility drugs, BUT the AMH has proven helpful in many patients as we try to pick a stimulation protocol.

However, in doing Natural Cycle IVF, all tests of ovarian reserve may fail to predict success since by its very nature...natural cycle IVF is unstimulated. So if a patient is doing Natural Cycle IVF, whether or not they would respond to fertility shots is a moot point! What has been amazing to us is the ability of patients with high FSH, low antral follicle counts and low AMH to generate a beautiful embryo in Natural Cycle IVF. What matters is pregnancy and delivery but we have many patients whose ovarian reserve testing is poor and yet they have had success with Natural Cycle IVF. "It only takes one good embryo" as many patients are fond of saying!

So should you have an AMH level done. Yes, as long as you are working with a doctor who can interpret the results for you given the "big" picture and not lose sight of the forest for the trees.

Good luck

DrG

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Gestational Carrier IVF

Fertility doctors are pretty popular at cocktail parties (or so I hear since I really don’t get out much). Between OctoMom and the latest Hollywood star announcing that they are pregnant with twins using a surrogate, there is always some interesting aspect of reproductive gymnastics to be discussed.

In the past month I have discussed the use of a gestational carrier with a wide range of patients. Some have had previous uterine surgery that has made pregnancy problematic. Another has a history of severe medical problems that make her a risk for pregnancy and yet she and her husband do not want to consider adoption. Finally, another patient has experienced multiple unexplained pregnancy losses in the mid-trimester. All of these are valid reasons to consider this alternative pathway to family-building.

When a couple chooses to use a gestational carrier I ask them to arrange for me to interview her as one of the first steps. A few years ago, a couple found a gestational carrier through an agency and asked me to meet her. She lived in the Mid-West so I asked her to fax me a patient questionnaire. She never did (first red flag). One afternoon she appeared in person for an appointment. I asked her about her previous pregnancies. She looked away but said that everything ended up fine by the end (second red flag). Upon further discussion, it turned out that she was incredibly sick every pregnancy with hyperemesis (killer morning sickness) and required multiple hospital admissions and even intravenous feedings at home! Yikes! She didn’t (or wouldn’t) understand that the risk to her was real in terms of pregnancy complications and that the cost of any hospital admissions may be the responsibility of my patients. She called me several times that day on the way back to the airport but I remained steadfast that she should not be a gestational carrier.

So here is one of the few remaining questions from our book 100 Questions and Answers about Infertility…

85. What is a gestational carrier, and when should you consider using one?

Fertility doctors sometimes recommend the use of a third- party gestational carrier if the infertile couple wants to have their own biological child. Many medical conditions necessitate the use of a gestational carrier, including the absence of a uterus in the would-be mother, either because of a congenital (at birth) condition or when a disease necessitated its surgical removal. A gestational carrier may also be the best option when a woman has a systemic disease that may affect either her own or her baby’s health, such as advanced heart disease, severe diabetes, or multiple sclerosis. Likewise, a woman with a history of poor pregnancy outcome—including repetitive pregnancy losses, preterm labor, incompetent cervix, or severe preeclampsia—may be a good candidate for IVF using a gestational carrier.

Prior to the IVF treatment, thorough screening of the gestational carrier is routinely performed using ASRM guidelines. Gestational carriers are usually well known to the couple and may be relatives or friends. In addition, agencies exist that introduce gestational carriers to prospective patients. In such arrangements, the gestational carrier is usually compensated for her time and energy (especially if the pregnancy proves successful).

When using a gestational carrier, IVF is performed by combining the infertile couple’s sperm and eggs to produce their own genetic embryos. However, unlike in standard IVF, these embryos are then transferred into the uterus of the gestational carrier. This process resembles donor-egg IVF in that the process requires synchronization of two patients: the egg donor (genetic parent) and the recipient (gestational carrier). Pregnancy proceeds normally just as if the gestational carrier had become spontaneously pregnant. The major factor in determining the success rate is the age of the woman whose eggs are donated. The ideal gestational carrier is a woman who has had a previous uncomplicated pregnancy and delivery.

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Can my endometrium be too thick?

Wow, what a terrible blogger I have been these past few weeks. No new posts for a while and no insightful hints for the 3 regular readers of this blog (sorry Mom, I promise to call this week!). I could make up some incredible story about how I have been performing 80 hours of community service a week or that I have been traveling to South America with certain public officials from South Carolina or that I have been sick for weeks with the Swine Flu. Clearly, this last excuse may engender some sympathy....but the truth is that I have just been pulled in too many directions. Sorry.

So let's discuss the endometrium here since I recently received a slew of questions on the INCIID site about the thickness of the endometrium and what is ideal for fertility. Abraham Lincoln was once asked "How long should a man's legs be?" He astutely answered "Long enough to reach the ground." The same could be said for the endometrium in that it needs to be thick enough to allow for implantation of the embryo. Most studies suggest that "long enough" is anything over 7-8 mm.

So a few years ago I had a patient that was trying to get ready to do an FET cycle and had not had a period for 6 months and had PCOS. On sonogram the lining was pretty darn thick at 22mm (usual is 7-12mm). Patients with PCOS are clearly at risk for endometrial hyperplasia and even endometrial cancer. So I gave her a couple of weeks of Provera to get the lining to shed. No significant bleeding and the lining was still at 22 mm. So I did an endometrial biopsy which was read by pathology as possible cancer. Yikes! I immediately sent her to one of our local Gyn Oncologists who did an office D&C that yielded only scant tissue.

When I repeated the sonogram the damn lining was still 22 mm. I really was getting concered here but too a step backwards and decided to do a water sonogram in the office. Guess what. There was a large polyp sitting right there in the cavity and since polyps can have an unusual appearance on pathology that would explain the initial concern about cancer. The patient underwent hysteroscopy and I was able to easily remove the polyp. Case closed.

So when patient inquire about endometrial thickness I usually respond that as long as it is a normal lining without a polyp or a fibroid or cancer then thick is fine.

Thin endometrial linings can be another matter. Some patients have a thin lining becasue of previous surgery or simply because that is the lining that they have been giving and nothing can really improve upon it. I have tried all the usual voo-doo for thin linings....vaginal estrogen, Viagra, terbutaline, nitroglycerine, animal sacrifice...you name it. Some seem to help, some don't...I honestly have no recipe that works for everyone. The thinest lining that I ever had that resulted in a healthy baby was 5 mm!

So good luck growing those endometriums but try not to panic if you have an 8 mm and not a 15 mm lining. Anything >7mm should be fine and if waiting an extra week gains you a mm or two then all the better.

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Options Besides Donor Egg IVF

I made it back to DC from Boston, thanks for asking. However, the journey was not easy. I boarded my AirTran flight at 6:15pm and at 6:35 pm the pilot announced that the plane was grounded for mechanical problems. Not to worry, advised the gate agent....another plane would arrive and take us to Boston at 8:30pm. Having heard this story one time too many, I hopped on the internet (than you Verizon for my wireless modem) and saw that there was a JetBlue flight to Dulles leaving at 7:50PM. My wife and I discussed the options and decided that I would stick with AirTran....big mistake.

At 7:30 pm the gate agent announced that the plan that was supposed to take us to Dulles was grounded in Newport News and we would now hopefully depart around Midnight! I grabbed my laptop and ran for the JetBlue desk. They confirmed that there was a seat on the plane but that the plan was boarding as we spoke. The nice lady called the gate and they agreed to hold the plane while I ran through security. Mercifully, there was no line at the security checkpoint and I made it on board with 1 minute to spare. By 9:45pm I was home in Maryland! When I called AirTran they informed me that I was on board the earlier flight and could not figure out how I was calling them from the DC area! Still had to get my car at BWI, but no plan is perfect!

Sometimes the road to our destinations takes us places that we didn't anticipate or desire. Life is a journey that is filled with twists and turns. In many of our patients that path leads towards family building options that they had never really considered.

Clearly, most patients are not thrilled when their RE announces that the only option remaining is donor egg IVF or adoption. Such a recommendation represents the end of a dream for those patients who wished to be the genetic parents of a child. The good news is that clearly donor egg IVF is very successful for many patients. However, not all patients are willing to consider egg donation. PB was one such patient and her story is rather revealing.

PB had successfully conceived with IVF back in 2005 and delivered her daughter without complication. When she returned to her clinic in 2007 she anticipated a good chance of success as she was < 40 years old and had an IVF baby already. However, after 2 FET cycles failed she attempted another stimulated IVF. Unfortunately, her FSH was 20 and her stimulation was poor and the cycle failed. She was told that although she was 38 years old that donor egg IVF was her only option. A friend told her about Natural Cycle IVF and she came to see me to discuss her options.

Meanwhile, our enthusiasm for Natural Cycle IVF remained very high and we made the decision in December 2008 to consider offering this option to older patients and/or those with a history of poor response to IVF stimulation meds. PB enthusiastically chose this option and underwent Natural Cycle IVF. She conceived on the 2nd attempt and is now >23 weeks pregnant. Needless to say, we were all thrilled for her and for the chance to offer another option to those patients who are not ready to pursue donor egg IVF.

We call this our IVF Hope Program to distinguish it from our standard Natural Cycle IVF Program (as we anticipate that the chance of success will be much lower in these patients who are looking to pursue a non-egg donor option). Interestingly, the use of Natural Cycle IVF in poor prognosis patients was the subject of a recent paper in Fertility and Sterility (see below). In this report, an Italian IVF clinic performed Natural Cycle IVF on those women who had failed to respond to fertility shots in THEIR OWN CLINIC! So clearly this was by any definition a group of low responder patients. Amazingly, their Natural Cycle IVF delivery rate was very good (all things considered) even in the older patients! At the Journal Club, Dr. DiMattina was placed in the position of defending Natural Cycle IVF while many of the other REs in attendance ridiculed the paper...even going so far as to physically rip the article into tiny shreds! Unfortunately, I was in Atlanta trying to convince my son to attend Georgia Tech and could not assist DrD in his defense of Natural Cycle IVF.

I think that patients should be allowed to make choices about their fertility treatment. Natural Cycle IVF is simply another choice. It does not work as well as stimulated IVF in good prognosis patients. It may be equally effective compared with stimulated IVF in poor responders...and may be the only ART option open to such patients who have failed to respond to stimulation previously. For those patients open to donor egg, donor embryo or adoption the role of Natural Cycle IVF is less clear as all those options work better so I would encourage patients to build their family through those means. However, some patients are not comfortable with Donor Egg/Embryo or adoption so for these patients a program such as the Hope IVF Program allows them to pursue another path.

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Wanted: Egg Donor

So here I am sitting in Logan International Airport trying to kill some time before heading back to DC and hoping that I don’t catch Swine Flu. I was in Boston all day to attend a special ceremony honoring my father, Dr. Edward Gordon, who just retired from active clinical practice at the age of 86 and ending 60 years of continual practice as a general surgeon. All three of his sons were in attendance as he received several commendations for his contributions to medicine. Following these presentations, Dr. Pauline Chen gave a very emotional presentation including a reading from her NYTimes best-selling book Final Exam. I asked her for some hints as to how to get our book higher up the best-seller list but she was at a loss….Oh well.

What does all this have to do with infertility? Nothing. Just thought my patients may want to know where I was on a rainy Friday in Virginia. If you don’t care where I was then please accept my apologies but no one’s forcing you to read this blog anyway (although I pay my kids 5 cents per click to help my Google ranking).

This has been a week full of third-party reproduction questions. Egg donation, sperm donation, embryo donation, gestational carrier, gestational carrier with egg donation vs. embryo donation….etc, etc. If you can think of an usual way to have a child, chances are that someone has already tried that. Every year I get a couple of questions regarding daughter to mother egg donation. Adult daughter from first marriage wants to help mom have a baby with 2nd husband. If successful this makes husband #1 the grandfather of baby born to patient and husband #2. This is not as newsworthy as Octomom but most clinics will not perform this type of egg donation. The reason usually given (and I concur) is that children wish to please their parents and that makes Informed Consent without coercion impossible. Plus it just seems “yucky.”

So how do we even do egg donor IVF in the first place? This is the topic of today’s excerpt from 100 Questions and Answers about Infertility (which could use some more positive reviews on Amazon.com BTW!).

82. What are egg donors, and how is donor egg­ IVF performed?

Donor egg-IVF involves the use of healthy female egg donors who are usually in their twenties. Most donor arrangements are anonymous, although known donor egg IVF is possible. In the latter case, the known donors are usually family members or friends. In our experience, most of our patients prefer to use an anonymous egg donor to avoid family and interpersonal conflicts. Most medical practices recruit egg donors for their patients, but third-party agencies are also available that act as brokers. The American Society of Reproductive Medicine (ASRM) has developed a set of egg-donor screening guidelines, which most practices utilize for screening donors. The guidelines encompass comprehensive screening for infectious and genetic diseases, physical examination, and psychological testing.

Since May 2005, the U.S. Food and Drug Administration (FDA) has mandated extensive infectious disease testing while screening all anonymous egg and sperm donors. The actual treatment cycle for donor-egg IVF essentially combines a fresh IVF cycle (the donor) and a medicated FET cycle (the recipient). The two treatment cycles are synchronized by using GnRH analogs. Usually, the recipient begins estrogen therapy 5 days prior to the start of the egg donor’s stimulation so as to provide an adequate time frame for the recipient’s endometrium to grow and thicken. After 10 to 14 days of stimulation, the donor receives an injection of HCG (Pregnyl, Profasi, Ovidrel) to mature her eggs. On the same day, the recipient starts progesterone therapy to create a receptive endometrium.

Because most egg donors are young, they tend to respond very well to the ovarian stimulation drugs, producing many high-quality eggs and embryos. Implantation rates with these embryos are also very high, so that usually only one or two embryos are transferred to the recipient. Pregnancy rates usually exceed 50% per initiated cycle, making donor-egg IVF the most successful therapy currently available for infertile couples. Usually, extra embryos that were not transferred can be frozen and stored for later transfer, with excellent pregnancy rates achieved in subsequent conception attempts.

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Endometriosis Surgery Before IVF?

My wife really hates checking the mail. “There is never any good news in that mailbox,” she usually comments as I carry the heaps of LL Bean catalogs in from the street. Well, yesterday there was something good in the mailbox...my royalty check for sales of that famous book “100 Questions and Answers about Infertility.” As I eagerly opened the envelope dreams of a new car (mine has 119K miles on it) or a new TV (we still have one with a built-in VCR in one room) or even helping to pay for my son’s college tuition (yearly bill is too shocking to report here) danced in my head.

I ripped open that envelope and saw that I would receive the whopping amount of $347.34 for my portion of the royalties over this past year.

So clearly I need to act. There can be only one answer…I need to blog more and apply guilt more freely. My patients have usually figured out that I am an easy mark when it comes to applying guilt (nod if you agree). I blame this on being raised in Jewish household before I converted to Christianity. If I had become Catholic rather than Presbyterian the guilt issue would have worked out easier. So now I need to turn the tables on you…dear readers. Where are all those 5 star Amazon.com reviews? Why has Oprah not called me yet? Why is our book not a Book-of-the-month Club selection? Beats me but I need to sell a lot more books to get that new car.

But enough light-hearted banter, we need to get to work so you all have time to log on to Amazon.com and post those reviews that state that our book is much better than any of those in the "Twilight" series.

So let’s return to excerpts from that wonderfully informative book and address a question that arose in several of my patients this week…

39. Do I need endometriosis surgery if I am already planning to pursue IVF?


This is a somewhat controversial area of reproductive medicine. Most reproductive endocrinologists do not recommend surgery prior to IVF unless the woman has advanced endometriosis, such as an ovarian endometrioma. For women who have only mild to moderate endometriosis, IVF is associated with excellent pregnancy rates even without surgery. When advanced endometriosis is present, such as an ovarian endometrioma, its surgical removal prior to IVF may enhance the chances for a successful IVF outcome and may decrease infectious complications related to egg collection. Thus, in such cases, most reproductive endocrinologists routinely recommend the removal of advanced endometriosis prior to treatment using IVF.

However, severe endometriosis with endometriomas may lead to diminished ovarian responsiveness, and ovarian surgery may further compromise fertility in such cases. So the decision to perform extensive surgery for endometriosis must be weighed against the potential impact of that surgery on the ovary. Also, advanced endometriosis may increase the likelihood for an early pregnancy loss or spontaneous abortion. By first removing the endometriosis, the outcome of pregnancy is greatly improved.

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Traveling After Fertility Treatment

A lot of patients ask for advice when trying to coordinate fertility treatments and vacation or business travel. In general, I ask them to consider a couple of factors when trying to decide what to do. First of all, if hoping on a plane were all you needed to do to prevent pregnancy then flight attendants would never experience unintended pregnancies! However, there are reasons to be careful about leaving town following fertility treatments (or during early pregnancy).


Clinical vignette A:

MS was a 34 year old patient who had never been pregnant. She was given 4 months of clomid by her Ob Gyn and told to just keep trying. No other testing had been performed. No sonogram, no sperm analysis, no HSG. During her 3rd Clomid cycle she was at a professional conference in Chicago when she experienced severe abdominal pains and was taken to the local ER. She spent the next day and a half in the hospital with bilaterally enlarged ovaries with large (6 cm) cysts that may have been either endometriomas (endometriosis cysts or chocolate cysts) or just Clomid induced cysts.

Finally, she felt well enough to travel and returned to DC. She came to see me and on ultrasound had bilateral cysts which were hard to distinguish between clomid cysts and endometriomas. We waited a few cycles an they failed to resolve so she had a laparoscopy that demonstrated severe endometriosis.

Lesson learned: Don’t give clomid to patients that may already have a significant ovarian problem. This can easily be avoided by making the transvaginal sonogram part of the routine fertility evaluation. This week a couple was thinking about taking Clomid just before going to Europe for a fantastic vacation…I told them to have fun, get pregnant and wait on the Clomid until after they return!


Clinical vignette B:

TD was a 29 year old with unexplained infertility. She came in on a Friday afternoon for confirmation of pregnancy because she had tested positive on a home pregnancy test. However, her period had come that month or so she thought and was a bit concerned. The beta level was available on Saturday morning at 11:30 AM and it was over 1500 IU/L but not as high as it should have been given her usually regular periods and the fact that she was sure when she had conceived.

I called her and told her the news and suggested an ultrasound to evaluate whether this was an abnormal pregnancy in the uterus or even an ectopic pregnancy. When she answered her cell phone she was in line at the United baggage check to check her bags as she and her husband were on their way to France! I explained that an ectopic was possible and could rupture even in mid-flight on their way to France. On the other hand, it could be just an abnormal pregnancy destined to miscarry…My advice was to cancel the trip and come right on over to the office. They debated and called me back a couple of minutes later. They were going to France anyway. We discussed the risk of travel and the need for prompt assessment. They called me back an hour later. They canceled their trip.

On Sunday AM I performed an ultrasound that showed a 3 cm ectopic pregnancy. She underwent laparoscopy and was very grateful that she had not taken that flight.

Lessons learned: All pregnancies are potential ectopics. Sometimes you need to rain on someone’s parade in order to give them the best medical care.

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Facebook

Well I guess I have now officially joined Web 2.0 with my own Dominion Fertility Facebook page. Although I am slightly worried that Facebook could prove as addictive as pinball was for me in college I am willing to test the waters and see how it goes.

So for all those readers of this blog (all 9 of you)...feel free to visit me on Facebook and become a fan (oh, gag me).

DrG

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Fear of Flying

Usually I am a pretty calm traveler and with the exception of the months following 9/11, flying is usually not something that worries me. This past weekend I flew up to Boston for the day to celebrate the 86th birthday of Dr. Edward Gordon, my father and a recently (yes, recently) retired general surgeon. The flight to Boston on Sunday morning was fine. However, upon landing my brother Steve warned me that we may be staying for longer than just the day if the big storm brewing ended up slamming New England as predicted.

Well, the party was great and my parents enjoyed having two of their sons and a bunch of other relatives present. We headed off to the airport on Sunday afternoon and there were no standby seats available on the 5:30 pm flight to BWI. However, our 6:30 pm flight was scheduled for a 7 pm departure...still plenty of time to beat the storm to BWI. Then we heard the dreaded announcement : we had a plane and a pilot but no flight crew until 9 pm! So we watched helplessly as CNN described the monster storm bearing down on the I-95 corridor. Great.

We pulled away from the gate at 9:30 pm and had to wait for deicing to be completed. At 11 pm we were finally #2 for take off and just then all the lights came on in the cabin. The First Officer walked slowly back and forth. The Captain announced that this was just protocol to check for ice on the wings...not to worry. Heh, heh.

The sand trucks and snow plows made a nice path for us and we zipped down the runway. The plane lifted off and obviously made a safe landing at BWI 55 minutes later since here I am blogging about it. So what does this have to do with infertility? Not much but I actually do have a point. The checklist indicated that the First Officer needed to visually inspect the wings. He did so and we did fine. The flight that landed in the Hudson in New York came down safely because the crew followed protocols. In medicine, we need to follow protocols as well.

In fertility treatment we also need to follow a logical protocol. Check the tubes, check the sperm, check the hormones..etc etc. In the laboratory we check the patient's identity, double check the sperm donor's identity and confirm whose eggs go with whose sperm. These steps are crucial to a good program. Deviate from such procedures at you own peril. At Dominion each week we have a lab meeting to review past and upcoming patients in order to make sure that the plan makes sense for each patient. Your plan needs to reflect your needs. Make sure that you get a logical explanation of your plan...whether that means clomid/IUI or IVF. Remember that your RE is not trying to torture you by performing these tests, but just like the First Officer on Air Tran 800, he or she is just making sure that all bases are covered.

May all you flights be on time.

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Eight is Too Much

I am a child of the '80s. I still listen to Fleetwood Mac (yeah I know they really are a '70s band) and Supertramp. I like the Back to the Future movies and I still remember how I felt when Darth told Luke he was his father...whoa! I never really liked the TV show "Eight is Enough" and clearly the recent events on the Left Coast have those of us who practice reproductive medicine scratching our heads.

My patients know that I am not a big fan of twins. The problem with twins is the risk of preterm labor, preterm delivery and prematurity. Although many patients brought the recent NY Times article about birth defects and IVF to my attention, nearly all of them went on to state how wonderful twins would be...."two for one deal....buy one get one free..." This line of thinking ignores the forest for the trees as the biggest risks facing IVF babies are not those from birth defects but the risks from prematurity... and almost all of the prematurity is from multiple gestations. Of course, it follows that the multiples come from replacing >1 embryo in an effort to improve the pregnancy rate.

As one would expect, there are now cries calling for more regulation of the IVF "industry." We are already extremely regulated. Clinics have to undergo inspections, the FDA is involved in donor egg, donor sperm, donor embryo and all gestational carrier cases and our own professional associations publish clear practice guidelines. However, this does not mean that certain individuals cannot practice in ways that are beyond the norm.

Ultimately, a physician should aim to follow the dictum of Sir William Osler of "First do no harm." Whenever I go into the room to perform an embryo transfer I ask the couple how they feel about twins. If twins are not desired then they get a single embryo back. The possible situation where the government legislates the number of embryos to be replaced eliminates any consideration of an individual patient's clinical history. However, I agree that if the government agrees to pay for all IVF cycles then they can determine the number of embryos to transfer. Until that time, we should not make sweeping changes in the practice of reproductive medicine because of the events in Beverly Hills.

Remember that you can always ask for a single embryo transfer or consider Natural Cycle IVF where there is only one available for transfer. If you get twins with a single embryo back...well, I can't be blamed for those twins as no one has yet been able to transfer <1 embryo!

So how do all of you feel about the octuplets....freak show or medical miracle? You know where I stand.

DrG

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Natural Cycle IVF - Vote Early, Vote Often

Readers of this blog know that we believe in Natural Cycle IVF. Although some of our colleagues think that this is akin to believing in the Easter Bunny, Santa Claus, Alien Abduction and in the recently passed Economic Stimulus Package.....we really do practice what we preach.

We receive calls from all over the US asking about Natural Cycle IVF and I usually encourage patients to ask their local RE to see if they can do it rather than traveling to VA. Usually they are told that it is not an option and no one does it here in the US. They are wrong and we are trying to change attitudes about Natural Cycle IVF.

Last week a survey was sent to all IVF clinics in the US asking REs to weigh in on Unstimulated IVF. For those interested here is the survey. I hope that the results help us to change how Unstimulated IVF is reported as I view this as a real stumbling block to getting more clinics to pursue Natural Cycle IVF. The other factor is you, dear readers. "If you build it, they will come." So if you are interested in Natural Cycle IVF, then make calls, send letters, call in to talk shows, get us on Oprah...This is the antidote to the octuplet disaster! (Almost certainly not IVF by the way).



SO can Natural Cycle IVF really work?? Yes indeed and here is a real patient's story to show it!

Clinical Vignette#4: Natural Cycle IVF Works!

RT is a 24 year old who initially came in for consultation over the summer. She and her husband had been trying to conceive for over 2.5 years without success. All of her testing had been totally normal but his semen analysis was extremely abnormal with a perm count of 1 million/mL and very poor morphology and motility. He had undergone genetic testing (normal) and a urology evaluation (normal). The couple had been informed (correctly) that IVF with ICSI was the best option unless they were interested in using a sperm donor (which they didn’t).

However, financially IVF was a reach for them and they looked at a variety of options. They traveled to NJ where a clinic was doing a research study on IVF but they did not want to participate and RT was concerned as well about using fertility drugs. They learned about Natural Cycle IVF on the internet and drove 2.5 hours to have a consultation with me.

We discussed Natural Cycle IVF vs. regular stimulated cycle IVF and the couple was really excited about trying natural cycle IVF. Every day of monitoring they drove 5 hours round trip to come to Arlington and on day 10 she had a 17x14 mm follicle with an E2 of 141. We gave her HCG, did the retrieval and got a mature egg. It fertilized with ICSI and she underwent ET with a beautiful compacting 8 cell grade I/early morula on day 3. Her first beta was 1422 and was sent off to her Ob after fetal cardiac activity was seen on sonogram.

In a lovely letter she thanked us for providing Natural Cycle IVF stating that it was an answer to their prayers for a treatment option that was ideal for them.

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Persistence Can Pay Off

The sun is out and DrG's fingers have defrosted enough to allow me to add a new post to the blog. Camping is great but it was about 7 ° F on early Saturday AM. I have not ever been quite so cold as I was at 2 am, huddled like an animal inside 2 sleeping bags. My son was quite warm but he had the winter weight sleeping bag and a new fleece liner while I had the light-weight bag with a fleece liner...When we woke up it was snowing INSIDE our tent as the moisture from our breath had frozen on the inside of the tent!

My son announced to his mother that I would probably come home early. I had thought about leaving by making up some excuse until another parent (a woman on her first campout) announced what a great time she was having and how fun it was to camp out! Well, this Eagle Scout was not going to wimp out so I hung in there and drew upon my pioneer ancestors to get me through to the end of the campout. Ultimately, my persistence paid off as we had a great time and my son appreciated the time we got to spend together.

Sometimes persistence can pay off in terms of fertility treatment as well. Here is such a case.


Clinical Vignette #3: Persistence can pay off (patient PH)

The age related decline in fertility is a factor in many of our patients. Although it is inequitable, a woman’s age matters more than a man’s age when considering fertility treatment and success. Over the age of 35, a woman’s fertility begins to decline and the rate of pregnancy loss increases leading to lower odds of success. Unfortunately, there is no test that can predict what percentage of a woman’s eggs are healthy (able to produce a healthy child). However, persistence can pay off in such cases and in this light let us review the case of PH.

PH was about to turn 41 when she and her husband of 6 months came to see me as a new patient. After routine testing revealed no clear etiology to their infertility except PH’s age of 41 the couple elected to pursue an aggressive path of treatment with IVF.

IVF #1 resulted in 10 eggs and 5 perfect day 3 embryos were transferred and 3 cryopreserved. The pregnancy test was negative.

IVF #2 resulted in 15 eggs and 5 high quality day 3 embryos were transferred. The 3 cryopreserved embryos were thawed but none were of sufficient quality to transfer. The pregnancy test was negative.

IVF #3 resulted in 18 eggs, 8 excellent quality embryos were transferred on day 3 and 8 were cryopreserved. The pregnancy test was positive. Initially there were 3 gestational sacs but 2 were empty with no fetal pole inside. PH delivered a healthy 8lb 15 oz girl at full term.

But the story doesn’t end there…last year PH returned at age 44 for a frozen embryo transfer (FET) of her remaining embryos. These had been frozen on day 3 so we elected to thaw all of them and transfer the viable embryos on day 5. PH had 5 blastocysts and one morula transferred and again the pregnancy test was positive. Although initially there were 2 sacs, only one contained a fetus with a heartbeat and she was sent off to her OB Gyn for pregnancy care! Just last week I got a wonderful card with photos of her new baby.

This story clearly demonstrates the impact of age upon fertility. It took 33 eggs to find one good one for PH’s first pregnancy. However, it is amazing that the 3rd IVF cycle went so well including the fact that the frozen embryos yielded a dividend a few years later. Sometimes good things happen to nice people and PH was an excellent patient, asking appropriate questions but understanding her options clearly.

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Freezing, OHSS and PCOS

Given that it is a brisk 19 degrees here in the Nation's Capitol, I thought that it would be appropriate to share a patient story that had some freezing in it...The use of cryopreservation has really helped us to reduce the risk of multiples and improve the overall long-term success rates with ART. More recently, vitrification, an ultra-fast freezing technique, has been used by our clinic and others to markedly improve the success rates with blastocyst stage embryos. The previously used slow-freezing approach was OK for day 3 embryos (as seen in this story) but not very good for day 5 embryos.

This story also points out how tricky stimulated IVF can be in patients with PCOS and why I always ask patients to get copies of their previous IVF cycles so I can review the pattern of response to meds.

FYI, this weekend I will be camping with the Boy Scouts out by the Naval Academy....so if I don't post next week, it could be because my fingers are still frozen. I plan on running by Dick's Sporting Good later today for some battery powered socks! Think of me when you are all warm and cozy in your beds on Friday and Saturday nights!

Clinical Vignette #2: Fertility Treatment Is Dynamic (patient BE)

Medicine is a dynamic discipline and all patients respond differently and even the same patient may demonstrate different responses to the same treatment. It is important to individualize care to each patient and not practice “cookie-cutter” medicine. The case of BE is an example of how a patient may need a flexible approach to her treatment plan.

BE presented as a new patient at age 30 with over a year of infertility. She had been diagnosed with PCOS by her Ob Gyn but had failed to conceive with 5 cycles of Clomid at doses of 50 and 100 mg. We began treatment with metformin (Glucophage) and she conceived within 4 weeks. Her pregnancy was uneventful and she delivered a healthy 6lb 11 oz baby.

She returned 2.5 years later desiring another baby. She had restarted metformin 6 months earlier and had again failed to conceive with 6 months of clomid with her Ob Gyn. She and her husband elected to undergo ovulation induction with Gonal F. After 3 excellent cycles yielding a single mature follicle she had failed to conceive.

The couple then elected to pursue IVF. We started stimulation at a low dose of 75 IU of Gonal F and 75 IU of Menopur. Her response was excessive and after 24 eggs were retrieved we elected to freeze all of the embryos to avoid severe OHSS. 9 embryos were frozen and she underwent an FET of 2 embryos that resulted in a twin pregnancy. One of the sacs contained no fetal pole but she eventually delivered a healthy boy weighing 7 lb 8 oz.

One year after delivery she underwent another FET but failed to conceive. In spite of their concerns about OHSS the couple elected to pursue another IVF cycle. This time I cut her dose in half to 37.5 IU of both Gonal F and Menopur. The stimulation was perfect with 8 eggs retrieved and 2 blastocysts transferred. She had no symptoms of OHSS. She conceived and just delivered her second son who weighed a hefty 8 lb 11 oz.

This case demonstrates the dynamic nature of our branch of medicine. Here a patient conceived and delivered 3 healthy children through 3 different approaches. This case also reveals the need to consider past response to fertility meds when planning future cycles. There are few patients that will respond so well to fertility shots at age 36 that you can prescribe such a low dose. However, this is where the art of medicine comes into play as the patient relies upon the experience and judgment of her physician to make the best decision possible on her behalf.

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Happy New Year!

Well, here we are at the start of another new year and I have a bucketful of New Year's Resolutions that are unlikely to last until the Spring but you never know....2 years ago I did the Special K diet for an entire year. Dr. D would make fun of me every day as he enjoyed delicious lunches and I had my little bowl of Special K. Of course, by dinner time I was so darn hungry that I would wolf down an excessive amount of food thus defeating the purpose of the Special K diet.

This year I also resolve to blog more frequently. Ha! We'll see how long that lasts but I still have to catch up with work here at the practice since we did an extensive remodel with new wallpaper and carpets. All former patients who wish to view the changes are more than welcome to visit.

I thought that it may be informative to profile some interesting patients. I will omit the names and identifying details but there may be some interesting aspects to these cases for those 7 people who read this blog. Of course, I will still comment on fascinating developments in the world of fertility and readers are always welcome to post questions to me on the INCIID bulletin board at this INCIID forum.

Clinical Vignette #1: Secondary Infertility Can Be Tough to Treat

Although many of our patients have never been pregnant there are a significant proportion who suffer from secondary infertility. To illustrate just how unpredictable fertility treatment can be here is the story of SG.

When SG initially presented for discussion of fertility treatment, none of us thought that her case would be very difficult. She was 30 years old and she and her husband had 2 previous pregnancies (one resulted in the birth of her son and the other was an early pregnancy loss). However, she and her husband had failed to conceive after a year and were getting frustrated.

Initially the thought was that this was a timing issue but when she failed to conceive after 3 clomid/IUI cycles in spite of all the tests (HSG, semen analysis, hormones) being normal it was time to up the ante and consider IVF.

She elected to enroll in the financial guarantee program (FGP) and I felt very confident that we would soon see success. Her first IVF went well but the stimulation (luteal lupron with 125 Follistim and 75 Menopur) was failrly mild and 7 eggs resulted in 3 embryos. Interestingly, sperm attachment to the eggs appeared poor suggesting that perhaps their issue was inefficient fertilization. Unfortunately, she failed to conceive and very soon afterwards attempted IVF again.

The 2nd IVF cycle was better both in terms of eggs and embryos. We switched to microdose lupron flare and the cycle yielded 14 eggs and ultimately 4 excellent blastocysts. We transferred 2 but again the pregnancy test was negative. Finally, we did a natural cycle FET and she conceived. She delivered a full-term healthy girl earlier this year.

So what lessons can we learn from this story? First of all, it is tough to predict what treatment will yield success. If you had told me after initial testing that this couple would require MDL flare IVF with ICSI to have another child, then I would have shaken my head in disbelief. Yet, that is exactly what we needed to do to gain success.

Secondly, the benefit of the FGP approach can be seen here as the couple clearly received more treatment than they paid for initially with 2 fresh IVF cycles and an FET.

Finally, their story demonstrates that physicians need to look at each couple with fresh eyes when treatment is not yielding the desired results. Additionally, I did tell this couple to use birth control if they didn’t want any more children as I have seen spontaneous pregnancies in such cases.

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