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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