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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