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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