Merry Christmas

I am wishing you all a very Merry Christmas now as I will be taking some vacation time over these next 10 days. I hope that Santa brings you lots of nice goodies and also hope that you can handle the emotional turmoil that can come with the holiday season. Well-meaning and no so well-meaning friends and relations often feel quite comfortable weighing in on fertility and family matters. All I can say is to hang in there and know that I am hoping and praying for all of you!

And just for grins here is the results of the "Who got photoshopped into the Dominion holiday card" puzzler!

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Photoshop and Other Holiday Traditions

Here at Dominion Fertility we gather each year around the Christmas tree to take a staff photo. Unfortunately, trying to get everyone together is a bit like herding cats so I end up having to photoshop in the missing staff members. Since this photo doctoring represents the only digital work that I do each year, I end up having to relearn Photoshop each December. So here is the result of my hard work. In a future post I plan to identify which staff members were added after the fact. You may ask "what does this have to do with infertility?" The answer is absolutely nothing but there is nothing wrong with a little change of pace....

Happy Holidays!

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Happy Thanksgiving!

Thanksgiving is one of my favorite holidays. It is a time for family togetherness and reflection upon our many blessings. Recently, the Wall Street Journal ran an article about how those individual who express gratitude are healthier, happier and wiser than those who spend a great deal of energy griping.

So as I am about to head home following a busy Thanksgiving morning at Dominion, I would like to take a moment to express my own gratitude before I stuff my face with turkey and all the other yummy food at home!

I am thankful for my wife and my family.
It is always a blessing to share every day with my wife and kids. Some days perhaps a little less so....It has been a stressful year as a member of the sandwich generation but all the Gordons are hanging in there pretty well at present. My Mom is doing just amazingly well and at 87 she is completely in control of her mental faculties. My Dad can now see the dashboard of his car after eye surgery which gives one pause to consider that he was zooming around Boston without reasonable visual acuity.


I am thankful for my career and for my patients.
Our former pastor at National Presbyterian Church, Craig Barnes, often preached on grace and the meaning of life. His message was that we are here to be a blessing to others and to give glory to God. I am blessed to have a job where every day I can go to work hopeful that I can be a blessing to others and make a difference in their lives. Hopefully, that difference will include success with fertility treatment but if not then I hope to be a source of comfort and support to those whose lives may take a different path than the one that they anticipated.

I am thankful for our country.
We live in an amazing nation, blessed with natural resources and with a system of government that allows for open discourse and free elections. Hard to imagine living under a different system or in a country with much more limited resources without acknowledging our gratitude for the United States. Last night at Union Station my 7 year old spontaneously started singing the Star Spangled Banner. Although her older sister was totally horrified and moved away, I could tell that many of the travelers surrounding us were moved by her small voice lifting up those well-known words motivated by nothing more than spontaneity.

Wishing you all the best on Turkey Day 2011!

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Natural Cycle IVF. Part 3: It Works

Although I anticipated posting this final part concerning NC-IVF two weeks ago, it took me longer than I had anticipated to pull all the data together and organize it into a coherent discussion of NC IVF. So after much effort here it is....

In December 2006, my partner here at Dominion, Dr. Michael DiMattina, attended the First World Congress on Natural and Minimal Stimulation IVF in London, England. Now, London is not the greatest place to visit in December but DrD came back completely convinced that Natural Cycle IVF was worth trying. The keynote speech was given by none other than Dr. Robert Edwards (Nobel Prize winner and one of the pioneers of IVF--see my previous Blog post). Only 2 Americans were present among the hundreds of fertility physicians from around the world. In January 2007 we launched our Natural Cycle IVF program and since that time Natural Cycle IVF has become an integral part of our fertility treatment options.

At the ASRM meeting in Denver we were peppered with questions from other physicians and nurses and embryologists about our experience with Natural Cycle IVF. Here are answers to the most commonly asked questions...

Question #1: How many other clinics offer Natural Cycle and how many cycles do they perform?

At the ASRM meeting in Denver last month I presented the national data on utilization of NC-IVF across all IVF clinics reporting their results to SART. As is evident from the table below, about 15% of IVF clinics in the US offer NC-IVF, but the average number of NC-IVF cycles performed at those clinics that offer NC-IVF is less than 10. In looking at NC-IVF in 2006 (the year before we started our program) it is evident that we now perform more NC-IVF than all the other clinics in the US combined. Clearly, we are in a unique situation to comment on the addition of NC-IVF to a busy fertility clinic offering comprehensive fertility care and treatments.
Question #2: How much Natural Cycle IVF do you do?

The quick answer is "quite a bit." In 2007, the year we launched the program, we initiated 66 cycles and this year we are on target to initiate about 500 cycles of Natural Cycle IVF. As a result, every year since 2007, the percentage of Natural Cycle IVF in our clinic has increased....from 20% that first year to almost 70% (predicted) for 2010. Question #3: Has the inclusion Natural Cycle IVF impacted your number of cycle of stimulated IVF?

In fact, we still perform a lot of stimulated cycle IVF. We strongly believe that there is a place for both Natural Cycle and Stimulated Cycle IVF within our practice. Our total number of stimulated IVF cycles has remained fairly stable over the past 4 years, which is very interesting given the economy and the higher costs associated with stimulated IVF.



Question #4: What are the pregnancy rates with Natural Cycle IVF?

There are many ways to answer this question. We can look at pregnancy rate per initiated cycle or per successful retrieval or per embryo transfer. Not every patient will make it to retrieval or transfer in Natural Cycle IVF which is different than stimulated IVF (as nearly all patients go to retrieval and transfer since there is more than just the one egg that is produced in a natural cycle).

Shown below then are the pregnancy rates for 416 completed cycles. In patients under 35 years old the pregnancy rate was 35.4% per embryo transfer and for patients 35-39 years old the chance of pregnancy was 41% per embryo transfer (which is not statistically different than the rate for the younger group).

2007-2009 Success Rates for Natural Cycle IVF

Question #5: How many patients who initiate a cycle make it to retrieval and transfer?

Natural Cycle IVF differs from stimulated IVF in many ways. As the cancellation rate is higher in Natural Cycle IVF we knew that patient expectations and the associated financial implications of canceling a cycle would be important to codify. Thus, we have a sliding scale that takes into account cycle cancellation before retrieval (LH surge or ovulation), after retrieval but before fertilization or after fertilization but before embryo transfer (arrested embryo development).

Here is our data for all patients younger than 40 years old (2007-2009):

Question #6: How does NC-IVF compare with stimulated IVF?

In answering this question I compared NC-IVF to the Society for Assisted Reproductive Technologies (SART) data for all IVF clinics reporting to SART for 2007. The implantation rate (pregnancy per ET) was outstanding for NC-IVF (over 35%). So if a patient made it to transfer the odds of pregnancy were excellent. Does that mean that NC-IVF produced better embryos or a better lining or both? It is hard to say, but the concept that Mother Nature may provide a better outcome is certainly intriguing.


Question #6: What about OHSS and multiples?

Well the incidence of OHSS with NC IVF is 0%. One can't have OHSS without fertility drugs so with Natural Cycle IVF there is essentially no risk of OHSS. Multiples are also very rare. The only twin pregnancy we have had so far was a case of identical twins. Interestingly that patient had a child from stimulated IVF with us but was a very low responder with only 3 eggs. She elected to give NC IVF a try and with her first cycle she had a beautiful blastocyst and ended up with identical twins. Go figure..... 3 eggs for thousands of dollars and one baby vs. one egg for a fraction of the cost and twins. Never a dull moment in reproductive medicine.

The reason for the lack of twins is simply the fact that there is almost always only a single follicle, a single egg retrieved and a single embryo available for transfer. Nationally, we still transfer too many embryos as seen below.


This phenomenon then directly influences the multiple pregnancy rate which is over 30% for patients younger than 30 years old and 24% for those patients between 35 and 39 years old. Elective single embryo transfer is attractive to consider but in reality not that many patients will elect to transfer only one embryo. Natural Cycle IVF solves that dilemma for the patient as there is almost always just a single embryo available.


The risk of twins is mainly that of prematurity. Although patients are often thrilled with twins, we are happier with singletons. The pregnancies are less complicated and the outcomes are better.

Concluding Thoughts:

As far as we are concerned, Natural Cycle IVF is here to stay. Our extensive experience has demonstrated that acceptable pregnancy rates can be achieved, especially if NC IVF is integrated into a fertility practice as a viable treatment option and not relegated to use only in extremely poor prognosis patients. In looking at our data from 2007-2009 we inform our patients that if they are younger than 40 years old then they can anticipate the following odds:I cannot emphasize enough how much patients appreciate having this option as a bridge. Many who have failed clomid/IUI or clomid/FSH/IUI are much happier trying NC IVF than full stimulated cycle IVF. Some patients who have known for years that they need IVF have been ecstatic that they have a new option. Some low responder patients with diminished ovarian reserve have pursued NC IVF as opposed to egg donor IVF or adoption. Although success rates in these patients are certainly lower than with donor egg IVF or adoption (we anticipate that 10-12% of these poor prognosis patients may still achieve a pregnancy with Natural Cycle IVF), many patients are not open to alternative pathways to parenting...at least not until they feel like they have exhausted all options.

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Natural Cycle IVF. Part 2: Patient Interest

So in the last post we discussed the development of stimulated IVF and how it made the entire process more efficient resulting in improvements every year in the IVF success rates. Yet patient interest in Natural Cycle IVF persisted. Why? Well I am not a patient so I offer these opinions based upon 14 years of practice and thousands of patients that I have had the privilege to treat for infertility.

Reason #1: Fear of fertility drugs
The drugs that we use for stimulated IVF have become much more "patient-friendly" over the years. Back in the dark ages, patients had to crack open little glass ampules of saline and then try to avoid slicing open their fingers as they mixed individual doses of fertility drugs. The injections had to be in the gluteus maximus (your backside) and the poor partners ended up having to dart their loved ones for over a week. Yikes. Eventually we moved to subcutaneous (under the skin) medications and now many patients use multi-dose pens. We are not to the level of the hypospray used by Dr. McCoy on Star Trek, but we are moving in the right direction.

However, some patients really have a great fear of injections and how they may feel on the drugs. It doesn't matter to them that the data suggests no increased risk of cancer for infertility patients that use these medications. They have no desire to go down that treatment path. Even if the drugs are free (with a co-pay), they really don't want to use them.

Reason #2: Fear of OHSS
Let's be honest here. OHSS is no fun. The patients feel terrible and as physicians we feel awful that they feel terrible. Although we can tap off the excess fluid and give the patients prompt relief, it is no fun to have OHSS. Of the nearly 200 blog posts that I have written, the one that gets the most hits is the OHSS Woes post that has nearly 80 comments attached to it. Although the risk of OHSS can be reduced by judicious drug dosing, the reality is that we can never eliminate this complication....we can manage it better perhaps but never reduce its incidence to zero...except with Natural Cycle IVF.

For the Hollywood version of OHSS, I refer you to the movie Malice which shows how OHSS can be used in a rather unique fashion....

Reason #3: Fear of multiples
So many patients come into our office asking for twins. I understand the mentality of "buy one baby, get one free" but the risks of twins are significant. Prematurity is a huge issue for babies and there can be life-long issues associated with preterm delivery. Although many patients are recommended to undergo elective single embryo transfer (eSET) in stimulated IVF the reality is that a minority of patients choose this option because the temptation to transfer 2 embryos simply becomes too great after going through the entire IVF cycle. In Natural Cycle IVF there is almost always only a single egg and therefore a single embryo. If you get twins in this situation then they must be identical twins which cannot be prevented!

Clearly, the extreme examples of fertility treatment gone wrong make the headlines much more frequently than do the news about twins. However, the NY Times did run a special series of articles last summer about complications associated with twin pregnancies. It was pretty scary stuff and yet most patients are still willing to roll the dice that their pregnancy will not run into such complications.

Reason #4: Fear of extra embryos
I really don't know when life begins. Clearly many embryos fail to grow, fail to implant and fail to develop into healthy pregnancies. However, the concept of extra embryos cryopreserved for future use is not always a welcome possibility to some couples. The decision to destroy the extra embryos is very difficult for many patients to handle...and yet if they are not interested in having more children and are not willing to donate their embryos to another couple then their options are limited. Some couples elect to undergo stimulated IVF but decline to freeze extra embryos for this reason. Others ask that only as many eggs get fertilized as they are interested in using. Freezing unfertilized eggs is becoming more effective, so that option may become more common in such cases. However, for many patients Natural Cycle IVF seems like a better way to handle their ambivalence.

Our Conclusions
None of these reasons are Natural Cycle IVF works better than stimulated IVF. For those patients who respond well to fertility drugs it is clear that stimulated IVF is more effective on a cycle by cycle analysis. However, I often use the analogy of driving to Leesburg from Arlington. You can take the Dulles Toll Road or you can take Route 7. Both will get you to Leesburg but usually the Toll Road is faster.

Opponents of Natural Cycle IVF seem to forget that patient preference does indeed matter. For some patients, stimulated IVF is just not an attractive option (usually for the reasons listed above). It really doesn't matter to these patients if they get seven cycles for the price of two....or a free toaster....or massage/aromatherapy....they really are not interested in stimulated IVF.

And we think that it is fine for patients to vote with their feet if they are interested in the Natural Cycle approach to IVF.

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Natural Cycle IVF. Part 1: History

Over the next series of blog posts I want to address several specific issues concerning Natural Cycle IVF. First I will cover the early history of IVF. Then I will describe why Natural Cycle IVF remained attractive in spite of lower success rates. Thirdly, I will review some pertinent research on Natural Cycle IVF. Finally, I will discuss our decision to offer Natural Cycle IVF and how our opinions differ from those of other clinics. This will include data about utilization of Natural Cycle IVF in the US and a survey of REs about Natural Cycle IVF. Finally, I will wrap it all up with a point by point discussion of the objections raised by some REs concerning Natural Cycle IVF.

Part 1: History

As I have previously described in an earlier blog post, this year has been a great one for those of us who practice in the field of reproductive medicine as Dr. Robert Edwards was awarded the Nobel Prize for the pioneering work that led to the world’s first IVF baby Louise Brown in 1978.

However, Dr. Edwards did not just wake up one morning and decide to do human IVF on the spur of the moment. His work represented years of careful research into egg/sperm/embryo physiology. In the early 1960s he began research on the development of the human egg and in 1965 worked with Howard and Georgiana Jones at Johns Hopkins in Baltimore. Howard Jones provided Dr. Edwards with slices of human ovary from patients with PCOS who were undergoing ovarian wedge resection as a fertility treatment. The immature eggs were isolated and matured in the laboratory but the process was inefficient and Dr. Edwards was not convinced that fertilization was occurring.

Meanwhile, Dr. Patrick Steptoe, an accomplished gynecologic surgeon, was making startling advances in minimally invasive laparoscopic surgery. Dr. Edwards realized that laparoscopy would enable a less invasive means to retrieve eggs...especially if fertility drugs were used to induce the growth of multiple follicles. You have to remember that this was before high tech ultrasound or rapid hormone assays or GnRH agonists (Lupron) or GnRH antagonists (Centrotide).
By 1971 they had grown fertilized embryos out to the blastocyst stage and decided to begin attempting to transfer the embryos back to the uterus with no success in nearly 100 attempts. Finally, in 1975 they had a positive pregnancy but it was an ectopic. Concerned that the use of fertility medications to induce multiple follicles was the problem, Dr. Edwards dramatically changed course and decided to attempt Natural Cycle IVF with Dr. Steptoe attempting retrieval of the single dominant follicle. Lesley Brown, who had no fallopian tubes as the result of previous surgeries, was the second patient to attempt Natural Cycle IVF. And the rest, as they say, is history....

Louise Brown’s imminent arrival was a worldwide phenomenon in the summer of 1978. I remember reading the Time magazine article about IVF and even remember the striking cover that graced the magazine’s July 30th issue. However, when I realized that the embryo was actually growing in Lesley Brown’s uterus, I was much less impressed. Heck, anyone who reads science fiction knew that IVF was anticipated for years or even decades...but an artificial womb...well that would have been pretty cool to my 13 year old way of thinking.

Natural Cycle IVF was technically more challenging that stimulated IVF and the tide soon turned towards the use of clomiphene or a combination of clomiphene and gonadotropin injections. The next IVF babies were born in Australia and India.

While Steptoe and Edwards were making advances in the mid 1970s, Howard and Georgiana Jones at Johns Hopkins were preparing for retirement. Hopkins had mandatory retirement at age 65 and allowed Howard to stay on for 2 years until his wife reached 65. One of their close friends and proteges was Dr. Mason Andrews, an obstetrician-gynecologist who lived in Norfolk, Virginia. He was able to launch a fledgling medical school (Eastern Virginia Medical School) in Norfolk but was having trouble recruiting faculty. He convinced both of the Jones to join his faculty upon their retirement from Hopkins.

Louise Brown was born the day that the Jones arrived in their new home in Norfolk. Sitting among the packing boxes a reported asked Howard Jones if IVF would be possible in the US. He replied that “all it would take would be money.” His comments were published in the local paper where one of their former patients saw the need and called the next day to pledge support. The Jones Institute was soon launched. Although they initially attempted Natural Cycle IVF they had failure after failure. Finally, they decided to try fertility injections and were successful with Judy Carr who had come to Norfolk from Massachusetts (where IVF was illegal). Dr. Howard Jones is now 100 years old and amazingly bright and energetic. He spoke at this year's ASRM and was amazingly erudite and witty. If only we could all be so lucky. Not bad for someone who "retired" 35 years ago!

So although IVF began with Natural Cycle IVF, the technical challenges of the time made the use of fertility drugs more attractive. Next up..Part 2: Why Natural Cycle IVF Remains Appealing to Patients.

If you are interested in reading more about the early history of IVF, then I recommend the following book by Robin Marantz Henig. Pandora’s baby: How the first test tube babies sparked the reproductive revolution. 2004. Houghton Mifflin Co. Boston, Massachusetts, USA. 256 pp. ISBN: 0-618-22415-7 (hardcover).

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Happy Belated Halloween

I must admit that I still enjoy Halloween. Nothing quite takes you back to your youth like walking around the neighborhood on a crisp fall evening while kids run from house to house extorting treats from the adults who stayed behind to dole out the candy. In particular I enjoy carving pumpkins and each year my kids seem to pick the hardest designs to test my ability. It takes a steady hand and a great deal of patience to carve those overgrown squashes into a jack-o-lantern.

Here are examples of this year's crop of designs with a Disney theme. I thought that Snow White came out pretty well....if I do say so myself.

So what does this discourse have to do with infertility? Honestly, absolutely nothing...but since I spent an entire afternoon scooping out pumpkin guts and carving little wedges out of my pumpkins, I thought somebody should see them besides the neighbors who were fixated on the Sour Patch Kids anyway.

But since we are on the topic of Halloween I wanted to address some fears that patients can have that do not involve Jason or Freddy or Dracula....I think that Dr. Gabe San Ramon covered some of these very nicely at the ASRM meeting.


Fear #1: Patients can be afraid that they need IVF.
Some patients look at IVF as an indication that their case is so hopeless that IVF must be used as a first line treatment. I understand that concern and certainly sympathize with their view. However, IVF is not the only option from which to choose and many patients find Natural Cycle IVF an option that is a bit less intimidating than traditional IVF. Some patients just want to try IUI or IUI and clomid or even just do diagnostic testing only. Walking into the office does not lead to getting hopped up on fertility drugs in a few days!


Fear #2: Patients can fear that they will never have children.
Clearly there are all different paths to parenthood. Some couples are more accepting of alternative pathways (such as adoption, donor egg, donor embryo or gestational carrier IVF) than others, but many will circle back to these options if success eludes them. In addition, unless a couple is truly sterile, spontaneous pregnancies can and do happen...you just can't predict it.


Fear #3: Patients are afraid of twins and triplets.
No argument from me on this front. Although I understand the attraction of twins for some ("buy one baby, get one free"), in truth twins are high-risk and can result in a huge cost to the couple, the babies and to society. If I never end up with another set of twins I would be ecstatic but the reality is that sometimes you just can't predict the outcome. If there are 2 follicles for a clomiphene/IUI then there can be twins....although rarely!


Fear #4: Patients are afraid of fertility drugs.
Although Oprah may believe that fertility drugs cause cancer, medical professionals do not believe that the data supports her view. The reality is that birth control pills, tubal ligations and previous full term pregnancies reduce the incidence of ovarian cancer. Since most fertility patients do not have many of these risk reducing factors, their risk of ovarian cancer is increased compared with the fertile population. However, the real question is whether fertility drugs increase the risk of ovarian cancer over baseline in fertility patients. The answer is no.


Fear #5: Patients are afraid that no one cares about them.
I come to work everyday to a clinic with some outstanding nurses and other clinical staff that care a great deal about each and every patient. I imagine that most other fertility physicians feel the same way about their staff. Patients ultimately vote with their feet. Here in Washington DC there are many options so patients can choose a doctor/clinic/staff that meets their needs. We all work hard to earn the trust of our patients and give the best advice that we can because we know how tough this journey can be on everyone.

Back to familiar topics next post!

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ASRM Update #4: Natural Cycle IVF

I really hate roller coasters. But I hate the spinning tea cup ride even more. All of this dates back to my childhood when I tossed my cookies after playing on the spinning spaceship ride at the playground near my home in Milton, MA. The other children were quite amused by my barfing but what can you expect from 10 year olds.
Here is a classic photo of yours truly at age 10 with my Crazy Car in my driveway in Milton. Note the outstanding fashion sense evident in the checkered polyester pants. This was before I discovered LL Bean. I loved that Crazy Car but did not spin excessively....

Well, on Tuesday morning at the ASRM I awoke at 430 am with the room spinning like crazy. No I was not hung over. And no my friends from VLFC (Very Large Fertility Center) had not slipped me a "micky" the night before at the dinner presentation on IVF. What I had was Benign Positional Vertigo (BPV) which occurs when one of the little grains of sand in your inner ear gets stuck telling your brain that you are orientated in a certain way to vertical while your other ear sends a contradictory signal. The result is a Tea Cup Ride from Hell. I have had this before back when I was living and working on Long Island, so I jumped out of bed and tried to knock the grain of sand loose. The treatment of BPV is completely counter-intuitive....you have to keep tilting your head to elicit the gut-wrenching spinning sensation. With enough repetitions your brain decides to ignore the signal and the spinning stops....usually after you have tossed all your cookies....Well, dear readers, I actually didn't vomit but was able to extinguish the spins in time to get to the Convention Center for our presentations on Natural Cycle IVF.

During the ASRM meeting this year we presented 4 studies on Natural Cycle IVF. The first of these was our 3 year experience with NC-IVF detailing our success rates and number of procedures. The second study was an analysis of the embryology part of NC-IVF including the embryo quality and implantation rate. Finally, yours truly had 2 presentations on the attitudes of physicians about NC-IVF as well as an analysis of the use of NC-IVF nationally based upon the SART reports from 2006 and 2007 (the year we launched our NC-IVF program).

There was a lot of interest in Natural Cycle IVF from fellow physicians, laboratory personnel and from the media. Almost universally the first question asked was "What about your SART statistics?" Readers of this blog may recall my previous posts on this topic (The Politics of Natural Cycle IVF) and although SART Registry Committee is considering our position concerning reporting of NC-IVF separately from stimulated cycle IVF, I am not sure that anything will change in the near future.

We remain committed to Natural Cycle IVF as a viable fertility treatment. Over the next few weeks I will present some rebuttals to the published objections to Natural Cycle IVF. As we remain the largest provider of Natural Cycle IVF in the United States I think that we have a unique perspective on this option and how it fits into other fertility treatment options.

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ASRM Update #3: 3rd Party Reproduction

Greetings from the mile high city where I have yet to sleep past 5 am since I remain on East Coast time. All the zombies have left town and only the attendees of the ASRM remain...some of whom do ressemble zombies although better dressed.

Yesterday I attended a course on the role of mental health professionals in IVF and in particular in 3 rd party reproduction. Well it was certainly an eye-opener. Although I have had some unusual requests over the years (most commonly a woman who wants to use her adult daughter with husband #1 to be an egg donor for her and husband #2) these paled in comparison to some of the absolutely nutty cases that I was hearing about. The one that sticks in my mind was fhe couple in their 70s who wanted to use 2 gestational carriers simultaneously with multiple embryos transferred from egg donors to be able to have 4 children simultaneously! Honestly, you just couldn't make stuff like this up because no one would ever believe you....

This type of reproductive gymnastics can lead to the ultimate question of "just because you can do something doesn't mean that you should do it." We discussed whether gestational carrier on demand was reasonable to offer given that many ob gyns now will offer cesarean section on demand. One case involved a female professional who planned on using her niece as a gestational carrier because "I really like being a size 4." Good grief. Makes me glad that in general practicing in Virginia usually shields me from some of this nuttiness.

Well tomorrow we have 4 presentations on Natural Cycle IVF and then it will be off to the airport so I can wing my way home. I appreciate the understanding of my patients and my family for my absence over these past 5 days. Back to work soon enough!

TTFN

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ASRM Update #2: High FSH and Zombies

Yesterday at the Post Graduate Course that I attended there was a great deal of discussion about ovarian reserve testing (ORT) and what it really means. As I have indicated in several past blogs ORT predicts response to fertility drugs and age predicts egg quality. So ORT does not indicate if a woman has any good eggs left...the only proof of a good egg is of course the delivery of a healthy baby. The overall consensus was that ultrasound and antimullerian hormone (amh) were the best indicators of ovarian reserve and response to fertility drugs. Unfortunately we will probably never have a true test of egg health except repeated treatment failure which is a pretty expensive way to test for healthy eggs!

The following case was presented: 38 year old with no previous pregnancies and an FSH of 18. The question raised was what additional testing should be performed and what treatments offered. First of all the question we asked whether the patient was infertile. Many ObGyns check FSH levels on older patients even before they have tried to conceive. This leaves the patient with a seemingly bad prognosis but she hasn't even tried to conceive yet! So remember that patients with high FSH levels can conceive without assistance but if she tries IVF her response may be suboptimal with a high rate of cancellation.

I presented the following perspective....The data shows that patients with diminished ovarian reserve have a high rate of failing to make it to retrieval in spite of spending thousands of dollars on medications. On the other hand, if these patients do make it to transfer then pregnancy rates are acceptable. In a patient like the one presented it seemed likely that her response to medications will be suboptimal. If she is a one egg a month person, either with or without drugs, then I believe her options are to 1) try on her own if tubes and sperm are ok, 2) try IUI with no drugs or 3) try Natural Cycle IVF. The fact that NC-IVF is even an option has given these patients hope even if many other clinics have refused to attempt stimulated IVF. Last month I had a patient just like the one presented above and we had success on the first cycle.
There is nothing wrong with attempting stimulation in such a patient but the chance of success is clearly much reduced because of the high rate of cycle cancellation. NC IVF could still be looked at if the stimulation was really poor.

OK so what about the zombies.....well as I was leaving the convention center there were thousands of people in the streets around the 16th. St Mall dressed up as zombies. The screaming and moaning was really disturbing. There was a zombie Santa and a zombie Elvis and a zombie spiderman just to name a few. Occcasionally, a human (designated with an x on his/her back) would be chased down and "eaten." Yup, it was quite a sight to say the least.

Apparently the Denver Zombie Crawl broke all previous records and just think I was here to see it,

http://www.examiner.com/zombie-in-denver/2010-denver-zombie-crawl-breaks-world-record

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ASRM update #1: Size does matter

Hello from Denver where the annual meeting of the ASRM is being held. American Society for Reproductive Medicine that it. Well it seems that this is the meeting where I will be unable to keep my big mouth shut. Yesterday at the Practice Retreat for the members of the Society for Reproductive Endocrinologists I spoke my piece about practice size. As a 3rd generation physician I feel strongly that the patient-doctor relationship must be at the center of all care. So that is why we try to do as many sonograms as possible on our own patients and ditto the egg collections and embryo transfers. That doesn't mean that practices where the RE rarely sees the patient don't have good success rates, but in speaking for myself I would not like to practice in such an environment when there is the opportunity to practice as I have at Dominion for the past 11 1/2 years. It seems that many of the practices represented are unable to offer that approach and I thank my lucky stars every day for my good fortune.

Obviously there are economies of scale and one physician from Boston indicated that he believed that 4 physicians is close to ideal. Well, let's see....Dr D, Dr G, Dr Reh and Dr Payson (for some weekend coverage)....I gotta agree.

Tune in for my next post and learn how DrG was surprised to find himself surrounded by thousands of zombies on 16th Street on Saturday PM.

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DrG on NBC

Clearly there was a lot of interest about IVF following the exciting announcement that Dr. Robert Edwards had been awarded the Nobel Prize. I was asked to speak about IVF on the Midday Show on the local NBC station here in Washington. I have been on TV a couple of times and I usually find it very painful to watch but this time I actually was pretty satisfied with how things went. The worst experience I had was on CNN when I was on a panel with Pete Singer and Arthur Caplan. Those two went after each other with a vengeance and I was left just sitting there looking stupid.

So for those who want to hear and see me on local TV check out the video below.... or go to http://gallery.me.com/johndavidgordon/100013.

See you in the movies!

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Robert Edwards Wins Nobel Prize for IVF

Earlier this week the Nobel Prize Committee announced that Robert Edwards had been awarded the Nobel Prize for Medicine in recognition of the groundbreaking work on IVF that led to the birth of Louise Brown in 1978. It is hard to remember a time when IVF was not part of our fertility treatment options and yet just 3 decades ago IVF was more science fiction than science fact.


Drs. Steptoe and Edwards ushered in a new era in reproductive medicine with their success in 1978. But public opinion concerning IVF was hardly united in this seemingly "Brave New World" approach to reproduction.

Time magazine had IVF as its cover story during the summer of 1978. The commentary below is from that article and I know that our current patients would find it hard to imagine the way in which all of us held our collective breaths as the birth of Louise Brown was announced.

"Some commentators heralded the coming birth as a miracle of modern medicine, comparable to the first kidney and heart transplants. Theologians—and more than a few prominent scientists—sounded warnings about its disturbing moral, ethical and social implications. Others, made wary by the recent cloning hoax, remained unconvinced that the child about to be born was indeed the world's first baby conceived in a test tube.....Yet on the eve of what may well be the most awaited birth in perhaps 2,000 years, there are also still many unanswered questions. For the Brown family, it is whether their test-tube child is healthy and can ever hope to have anything resembling a normal life. For the doctors, it is whether they have pushed medicine to a new frontier or set it dramatically back by creating a medical disaster. For the world at large, it is whether doctors should be free to continue such daring exploits or whether new restraints should be posted to keep them from poaching on nature's domain. There is a very large gathering in the waiting room for Baby Brown."

As we know, the story had a happy ending...not only for the Brown family (who had a 2nd daughter by IVF and now have grandchildren from both Louise and her sister [no IVF needed for that generation]) but also for the millions of couples that have used IVF to have their families. Well done, Dr. Edwards and congratulations on a Nobel Prize recognizing the debt that is owed to you and the late Dr. Steptoe for taking those first careful steps into IVF.

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Question 36. Do I need endometriosis surgery if I am already planning to pursue IVF?

I wish sometimes that medicine was more like engineering. In engineering there are lots of straight lines and right angles. You can usually describe any problem with specific equations and most of the time there is clearly one right answer. Unfortunately, medicine is not engineering. There are some questions that cannot so easily be answered with a definitive "yes or no." My wife is an engineering PhD, so I can easily understand why very intelligent people can just want to scream when faced with some of the uncertainty inherent in medicine...especially reproductive medicine. Obviously, the "right" decision is the one that results in a successful pregnancy. But since more than one option may result in pregnancy (including no treatment at all) the situation can often seem "as clear as mud."

The Question of the Day returns to the subject previously raised in Question 34 concerning fertility and surgery for endometriosis. However, today we are specifically dealing with the issue of surgery prior to IVF. In patients that have failed non-IVF treatments and are wondering if they should do a laparoscopy at this junction I offer them the following advice...

If I do a laparoscopy and see terrible endometriosis then I am going to recommend IVF.

If I do a laparoscopy and see some endometriosis then I am going to recommend IVF.

If I do a laparoscopy and see no endometriosis then I am going to recommend IVF.

So why the heck are we off to the operating room? Indeed. That is why surgical volume for fertility patients has fallen off a great deal. However, patients with a known/suspected endometrioma cyst represent a different group and call for a different approach...and that is the topic of today's Question of the Day!


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

The question of endometriosis surgery prior to IVF is a somewhat controversial area of reproductive medicine. Most reproductive endocrinologists do not recommend surgery prior to IVF unless the woman has advanced endometriosis, in particular, an ovarian endometrioma.

IVF is associated with excellent pregnancy rates (even without surgery) in women who have only mild to moderate endometriosis. 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 often 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 may be improved. Ultimately, the decision whether or not to remove perform surgery rests between doctor and patient. In general, we believe that the removal of a small 1-2 cm endometrioma is unlikely to impact IVF success but the removal of large endometriomas may be reasonable before attempting IVF. Some doctors advocate a threshold of 4 cm for endometrioma removal but the data supporting this contention warrant further study.

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Question 37. What is the difference (if any) between intrauterine insemination and artificial insemination?

What's in a name? Sometimes not much I guess and certainly we throw around medical jargon quite freely in our practice sometimes forgetting that all this can be quite confusing to patients. I recently had a patient that came in requesting IUI with ICSI. She was very frustrated when I explained that you really cannot do ICSI unless you do IVF. However, she was adamant that she didn't want IVF with ICSI she wanted IUI with ICSI. I just was unable to make her understand the difference between IUI, IVF and ICSI. Oh well, she probably posted on some website that I am an insensitive physician who was unwilling to help her....

Of course, I know that all of you would easily be able to explain the difference between these because you have read this blog (along with my Mother) and have purchased our book.

So for those a bit unclear on some basic terminology here is today's Question of the Day from the soon-to-published 2nd Edition of 100 Questions and Answers about Infertility.


37. What is the difference (if any) between intrauterine insemination and artificial insemination?

Artificial insemination (AI) is a historical term that encompasses any technique involving the introduction of sperm into the female reproductive tract without sexual intercourse. Semen can be placed into the vagina (intravaginal insemination) or into the cervix (intracervical insemination) without any special preparation of the specimen. However, if unprepared semen is placed directly into the uterus [intrauterine insemination (IUI)], then severe spasmodic uterine cramping can occur. Thus, when performing an IUI, the sperm must first be washed and prepared prior to placement inside the uterus. Washing the sperm removes prostaglandins, the hormones that cause the violent uterine contractions. Washing also eliminates substances that might lower the sperm quality and activates the sperm, thereby leading to improved sperm motility. Generally, the IUI specimen is prepared in the doctor’s office just prior to insemination.

The actual IUI is a painless, simple, in-office procedure that is often performed by a nurse. It usually takes just a minute to perform. Physicians typically ask patients to come in with a full bladder so that the angle between the uterus and cervix is altered, which allows for easy passage of the catheter into the uterine cavity.

Today, it is rare for patients to undergo other forms of insemination besides IUI because the pregnancy rates with IUI are better than those obtained by intravaginal insemination or intracervical insemination.

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Question 35. Are there medical treatments for endometriosis?

Occasionally I am asked to see a patient with endometriosis who is not interested in fertility. Although I can certainly manage these patients, I honestly think that they are better served by going to a non-fertility clinic RE. Our practice is pretty much 100% geared to the needs of fertility patients and I wonder if those patients who are not seeking pregnancy ultimately feel like a fish out of water in our waiting room....

Fortunately there are some effective medical treatments for endometriosis. Unfortunately, all of these treatments shut down reproduction so they are not appropriate for the endometriosis patient seeking pregnancy.

Meanwhile I wanted to share the exciting news that the 2nd Edition of 100 Questions and Answers about Infertility is at the printers! Let the presses roll!

35. Are there medical treatments for endometriosis?

Several medications are used to treat endometriosis. All of these medications suppress ovulation and cause a hypoestrogenic state. Understandably, suppressing ovulation also prevents pregnancy from occurring so medical therapy is not appropriate in patients actively seeking fertility. In patients who are not trying to conceive, medical treatment of endometriosis can be very beneficial and relieve symptoms of dysmenorrhea and pelvic pain.

One common medical treatment is to prescribe the combination oral contraceptive pill. Although each of these daily pills contains estrogen, the progestin (progesterone-like component) in the pill overrides the estrogen effect, resulting in suppression of endometriotic lesions. Oral contraceptive pills are effective in 30% to 60% of patients with endometriosis-related pain.

Many physicians prescribe gonadotropin-releasing hormone (GnRH) analogs (such as Lupron), which reduce estrogen levels to postmenopausal levels for their patients with endometriosis. These medications suppress estrogen production, prevent ovulation, and cause atrophy of the endometriosis in 70% to 90% patients. Unfortunately, GnRH analogs are expensive and must be given as injections either once a month or every 3 months. GnRH agonists can cause side effects including headaches, hot flashes, moodiness, insomnia, and vaginal dryness. To counteract these side effects experienced by many patients treated with GnRH agonists, physicians often prescribe oral contraceptive pills or supplemental progestin therapy (such as norethindrone) along with the GnRH analogs. This combined therapy ay allow for improved treatment acceptance through the alleviation of the many side effects associated with the use of the GnRH analogs as single therapy. Patients tolerate this combination very well and achieve maximal benefits in suppressing the disease and its symptoms.

As noted previously, medical therapy is not indicated for patients with endometriosis who are actively trying to conceive, since all of these treatments will suppress ovulation. Instead, for these patients, the goal should be to promptly establish pregnancy before the endometriosis causes any further damage to the reproductive organs. Generally, these women should seek treatment from a fertility expert to maximize their chances for successful pregnancy.

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Question 34. Does surgery for endometriosis improve pregnancy rates?

Where does all the time go? Seems like just yesterday that I was writing the last post before I went on vacation and now I realize that a whole month has passed. You may have wondered "where is Dr. Gordon?" "Why hasn't he posted a new blog that will make our day a little brighter and put a little more zip in our step?" "Why do the 6 of us keep reading this blog if he doesn't care enough about us to spend just a few minutes posting his words of wisdom?" "Why didn't I buy Apple stock at $25?" Wait that last question is the one that I keep asking myself. Not to be a name dropper but my son was in preschool in California with Steve Job's son Reed. Man, if only they had become best buddies.....unfortunately, my son thought that Reed was weird and wouldn't play with him. Apparently, when you are 3 years old it doesn't matter when some kid's father is worth 6 Billion dollars. But I digress....

So in a couple of weeks we are having a CME (doctor's continuing education) course at Fairfax Hospital. One of the questions concerns surgery for endometriosis. Guess what? No one is really sure of what to do in some of these cases. Overall, we seem to be moving away from surgery for the infertile patient, and yet, there are still occasional patients that would benefit from a laparoscopy. The problem is figuring out who would benefit from surgery and who will not. In starting to address that issue I will present today's Question of the Day from the 2nd Edition of 100 Q&A about Infertility (which is currently being printed!):

34. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small implants of endometriosis can improve fertility by as much as 50%. In a large Canadian study, the monthly pregnancy rate following surgical treatment of minimal endometriosis rose from 3% to 4.5%. Although this finding represented a 50% improvement in the patients’ monthly chance of pregnancy, it does not compare very favorably with IVF pregnancy rates, which average above 30% for a single treatment cycle. Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most surgeons will do their best to destroy endometriosis at the time of laparoscopy by using either laser or coagulation techniques. In addition to improving fertility, surgery may often eliminate or improve symptoms of dysmenorrhea and pelvic pain.

Ovarian cysts that contain endometriotic tissue may grow quite large. They are often called “chocolate cysts” because of the dark brown fluid found within them, although endometriosis cysts are more correctly referred to as endometriomas. If left untreated, these growths may destroy part or all of the normal ovarian tissue, including the eggs. Endometriomas must be surgically removed, usually via laparoscopy, as medical therapy is ineffective in the treatment of endometriomas. The ultimate choice of whether to perform a laparoscopy or laparotomy depends on the operative findings and the skill and experience of the surgeon.

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Question 33. What is endometriosis and how is it diagnosed?

You know I should have really been an Orthopedic Surgeon. I have spent so much time in their offices recently that I could have been much more useful to my family if I had specialized in something more practical. Of course, then we probably would have had fertility problems instead.....

On the other hand, endometriosis is a problem that I know something about.....But that being said, our understanding of the link between endometriosis and infertility remains less than clear cut. It was not unusual to diagnose endometriosis in a patient undergoing a laparoscopic tubal ligation in a woman with several children so the impact on fertility may be difficult to predict on a case-by-case basis.

So today's Question of the Day concerns some basics about endometriosis....

33. What is endometriosis and how is it diagnosed?

Endometriosis is a chronic disease characterized by the growth of endometrial-like tissue beyond the normal confines of the uterine cavity, Endometriosis is usually diagnosed at the time of laparoscopic gynecologic surgery although endometriosis cysts (endometriomas) may be presumptively diagnosed on ultrasound. Endometriosis is the presence of endometrial-like tissue located outside of the uterine cavity. Most commonly, it is located on the ovaries, but it can also be found on any of the organs inside the pelvic–abdominal cavities.

Although there are several theories about formation of endometriosis, it seems likely that retrograde menstruation (the passage of menstrual debris out of the ends of the fallopian tubes and into the pelvis) plays a major role. Some women may be unable to effectively remove this tissue allowing lesions to form and grown with continued hormonal stimulation. Since the endometrium sheds through menstrual bleeding every month during menstruation, the endometrial tissue that comprises the endometriosis implants will also respond in kind. This phenomenon leads to inflammation of the pelvic reproductive organs, causing pelvic pain, painful periods (dysmenorrhea), and infertility. Pelvic adhesions or scar tissue may also develop. However, since endometriosis has been described in areas outside of the pelvis (eye, lung, brain, etc.), the retrograde menstruation theory cannot account for all cases of endometriosis.

Endometriosis may be suspected when patients complain of increasingly severe dysmenorrhea, pelvic pain, or infertility, but remember that it can be definitively diagnosed only via surgery. Most often, a diagnostic laparoscopy—a simple outpatient surgical procedure—is used to diagnose endometriosis. Other nonsurgical techniques such as ultrasonography, CT scan, or MRI can occasionally be helpful in their abilities to detect endometriosis.

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Question 32. Should I consider using a sperm donor to conceive?

So first we had Snowmaggedon and the Gordon family was without power for six days and now we have experienced Summerggedon! Sunday afternoon an intense thunderstorm ripped through the Washington DC area and did widespread damage. Over 300,000 taxpayers were without power and that included yours truly. Fortunately the power was restored last night after more than 48 hours of pioneer living. Needless to say we were very happy to rejoin the 21st century. On the other hand, the simplicity of going to sleep soon after sundown and waking up early in the morning fully refreshed should not be underrated. Simple can = good.

This concept can also apply to cases of severe male factor infertility. Not all couples are prepared to go the distance in terms of IVF/ICSI with testicular sperm in cases of azoospermia. A few years ago I had a couple that came to me following a talk that I gave regarding donor egg. She was relatively young and he had extremely low sperm counts. They had already spent almost $100,000 on fertility treatments and were now considering donor egg IVF using his sperm. Apparently no one had discussed the use of donor sperm with them. They quickly decided that this approach made more sense and 3 weeks later she had an IUI with donor sperm in a natural cycle (not even clomid). She delivered a full-term healthy baby 9 months later. Total cost....about $2200. Not a bad deal!

So should you consider using donor sperm or as Lois (our former beloved front-desk manager) used to call it - "man in a can"? Well that is the topic of today's Question of the Day from 100 Questions and Answers about Infertility.

32. Should I consider using a sperm donor to conceive?

Couples who desire a child but in whom the male partner has a very low sperm count (oligospermia) or no sperm at all (azoospermia) often consider using third-party sperm donation and artificial insemination. Donor sperm can also be used by single women or lesbian couples. Many high-quality, reputable commercial sperm banks exist. They recruit and thoroughly test the donors and provide a listing of their available donors and their characteristics from which the couple can then choose. The donated sperm is obtained from the donor, tested, and quarantined for at least 6 months at the sperm bank. The donors are then retested to ensure that they are still free from any sexually transmitted diseases.

The specimen is released for use only after the tests results confirm the donor is free from any infection. The frozen sperm is then shipped to the physician’s office, and artificial insemination is performed around the time of the woman’s ovulation. Placement of the sperm inside the uterus (IUI) results in better pregnancy rates than placement of the sperm in the vagina or cervix. Frozen donor sperm can also be used for more advanced fertility procedures such as gonadotropin/IUI or IVF with or without ICSI. If a woman wishes to use sperm from a known donor with whom she does not have a physical relationship, then the sperm may need to be quarantined for at least 6 months and the donor retested for infectious diseases before the specimen can be used for fertility treatments.

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Setting the Record Straight About NC-IVF

I am posting this recent blog by Dr. DiMattina which addresses some recent inaccurate information about Natural Cycle IVF that is circulating out in cyberspace.

DrG


Hello Everyone!

Recently, there have been many mistruths appearing on-line about our NC-IVF program. So, I am writing to set the record straight and provide you with honest information about our experience with NCIVF. As you well know, the internet provides a platform which all too often provides only one side of a "story" and unfortunately, far from reality too.

By way of background, because of our high success we experienced with our stimulated IVF program, in January, 2007, we decided to add a NCIVF program for our patients as most of our patients achieving pregnancy in our stimulated IVF program had only one or two embryos transferred. Thus, we believed that many of our patients did not require ovarian stimulation drugs and the high costs associated with stimulated IVF.

Six weeks ago, we submitted 4 papers describing our experience with NCIVF to the American Society of Reproductive Medicine(ASRM) annual meeting in October, 2010. All 4 abstracts were accepted by ASRM. First, let me say that after 3 and a half years of performing NCIVF, we remain most enthusiastic about the success of our program and especially so for 2010.

So, here are some of the facts about our NCIVF program from 2007 to 2009 as presented to the ASRM: First, on-line there are individuals claiming that most of our patients never made it to an egg collection and instead they underwent an IUI rather than the intended egg collection. The FACT is: 86% of our patients who started our NCIVF program went to egg collection and an egg was retrieved in 88% of these patients. So, the vast majority of our patients not only made it to an egg collection but also had a successful egg retrieval. IUI occurred in less than 15% of our patients! And successful embryo transfer occurred in 56% of the patients who had an egg obtained. Overall, 35.3% achieved a clinical pregnancy per embryo transfer. In my opinion, not bad for only one egg and one embryo! Cumulatively, of course, with more embryo transfers, the total pregnancy rate is even higher. In fact, our very first patient to deliver from our NCIVF program, delivered again last year from a repeat NCIVF treatment.

Second, misstatements were made concerning our costs and profit motives. We currently charge $4,400 for a completed NCIVF treatment and it is prorated. If a patient does not make it to an egg retrieval, then the cost is prorated to $1,400 and the rest either refunded to the patient or credited towards another treatment. In our NCIVF program, we routinely perform ICSI without an added charge since there is only one egg. Compare these costs to a stimulated IVF cycle where the drugs alone cost about $5,000, the treatment cycle itself about $9,500 and another $1,500 to $2,000 for ICSI. Thus, the total costs for a stimulated IVF cycle can be $15,000 or more. In my opinion, DF is not only cost conscious for our patients, but the most cost conscious fertility center in town since we were the first and perhaps still the only IVF center in the Washington DC area to offer and produce babies using NCIVF. Interesting to me that NCIVF is routinely performed in over 50 countries around the world but not so in the US.

Critics of NCIVF say that it may take many treatments before one achieves pregnancy. The FACT is: 64% of the pregnancies that occurred in our NCIVF program were achieved in the FIRST treatment cycle and 21% in the second. So, we usually only recommend one to three treatments of NCIVF to our patients.

So, here is the truth about our experience with our NCIVF program and we are most proud of our accomplishments and success. NCIVF is not a "cure-all" for infertile couples, rather another option for many. I wish all of you the very best in obtaining your fertility goals.

-Dr. Michael DiMattina

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Question 31. What can cause my husband to have no sperm at all and can we still have children together?

Summer is in full swing here in Washington DC and we are really getting cooked these past few weeks. I have been trying to be a real handyman this past week and have been granted a special dispensation by my wife in regards to the use of power tools. My project has been to strip off the paint and rust of an old patio set by using my power drill and a steel brush. Actually it has been very gratifying to see years of rust submit to my efforts. Does this have anything to do with infertility and IVF? Probably not, except that being a man is more than doing projects around the house and it is more than being able to father children. Being a father or a mother has everything to do with what happens after delivery or adoption.

We understand the desire to be genetic parents and will make every effort to accomplish that goal. However, every couple must decide what being a parent means for them. For some, the use of donor sperm or donor egg or both or adoption are all acceptable choices. For others, these are not options....or at least not options until the others have been fully explored.

Today the Question of the Day concerns men with no sperm at all on semen analysis. It is a true miracle of medicine that some of these men can become genetic parents through IVF and ICSI. So keep the AC cranked and read on. Plus, if anyone can explain why my hands get blue paint on them when I touch my repainted patio set even after it has dried I would really appreciate it....I must not be a real man after all...

31. What can cause my husband to have no sperm at all and can we still have children together?

Assuming that there was not a problem in collecting the specimen, the absence of sperm on a semen analysis—a condition known as azoospermia—requires thorough evaluation. Azoospermia can be divided into two major categories: obstructive and nonobstructive.

Obstructive azoospermia occurs when the duct carrying the sperm from the testicle to the urethra becomes blocked. This blockage may be the result of previous surgery on the scrotum or testicle, or even follow repair of an inguinal hernia. During hernia surgery, the vas deferens may be inadvertently damaged or even cut. Scar tissue that blocks the vas deferens can form either postoperatively or as the result of an infection (most commonly gonorrhea, though other infectious diseases may also cause blockage of the sperm duct).

Congenital bilateral absence of the vas deferens (CBAVD) leads to some men being born without a vas deferens on either side and is associated with the gene for cystic fibrosis. CBAVD is a rather unusual presentation of cystic fibrosis as it occurs in the absence of any chronic lung disease. For this reason, any man with azoospermia associated with congenital absence of the vas deferens should undergo genetic testing to determine whether he carries the gene that causes cystic fibrosis.

Nonobstructive azoospermia results from dysfunctional sperm production as opposed to an anatomic issue and can represent a more problematic situation. The failure of sperm production in an otherwise normal testis may be the result of either a testicular issue or a pituitary or hypothalamus issue. If a hormonal evaluation reveals normal levels of prolactin and thyroid hormone, then testicular sperm production may have failed. If this finding is associated with an elevated FSH level, then the chance of finding any sperm production in the testis is quite unlikely. A testicular biopsy is often performed to assess whether any sperm are present within the testis. Even very low levels of sperm production may allow for attempts at IVF using ICSI. Genetic testing to rule out a chromosomal problem is often suggested in cases of very low or absent sperm production. We suggest that men undergoing a testicular biopsy arrange for cryopreservation (freezing) of viable sperm in order to avoid having to undergo a second biopsy procedure.

The use of IVF with ICSI can allow couples to successfully achieve pregnancy even in cases of obstructive or nonobstructive azoospermia. Sperm that is removed from the epididymis or the testicle may look excellent but is incapable of fertilizing an egg since it has not undergone the final changes that result in fully capacitated sperm. The introduction of ICSI in 1993 revolutionized the treatment of male factor infertility. To obtain sperm for use in IVF/ICSI, a needle aspiration of the testis or epididymis can be performed under local anesthesia in cases of obstructive azoospermia. If the male partner has nonobstructive azoospermia, a urologist usually performs a testicular biopsy in the hospital while the patient is under general anesthesia as sperm production may be severely impaired necessitating the removal of more testicular tissue in order to have an adequate sample. In either case, the testicular tissue or the sperm aspirate can be frozen in liquid nitrogen and maintained relatively indefinitely. If a testicular biopsy reveals no mature sperm, then the only option is to use donor sperm or to pursue adoption.

Occasionally, the sperm retrieved through a testicular biopsy or needle aspiration is of exceedingly poor quality. In such cases, a repeat testicular biopsy on the day of egg collection for IVF or even use of a cryopreserved specimen from an anonymous sperm donor may be considered as a backup plan.

Rarely, men with diabetes or those taking certain antihypertensive medications may suffer from retrograde ejaculation. In this condition, there is no emission of fluid with male orgasm because all of the fluids travel backward into the bladder instead of out through the urethra. Retrograde ejaculation can easily be diagnosed by checking the post-ejaculation voided urine for sperm. Sperm present in the man’s urine can be washed and used for either insemination or IVF. Pretreatment with bicarbonate the night before sperm collection may improve sperm quality by increasing the pH of the urine.

One final (and interesting) cause of azoospermia is anabolic steroid abuse. Some men with azoospermia may have used testosterone or other steroids as part of their strength and conditioning training. High doses of these steroids can suppress sperm production. Sperm production can be reinitiated in such patients by stopping the steroids and starting gonadotropin therapy (analogous to ovulation induction therapy in women). Although clomiphene citrate has been used to improve sperm quality in men, most studies reveal it to have little to no benefit.

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