Happy Thanksgiving 2011

Happy Thanksgiving to all!

I usually post this on Turkey Day but honestly I was so busy at work this past week that I never got around to doing it. At my mother-in-law's house in North Carolina we always go around the room before saying Grace and ask everyone to say what they are thankful for this year. It never hurts to count your blessings. In face, several medical studies have indicated that those individuals who have a positive attitude about their life and situation are healthier than those who always see the glass as half-empty. On the other hand my Dad has always been a glass is half-empty guy and he is still hanging in there at 88 years of age.....

I am thankful for my family...they are a source of love, support and joy...even the teenagers.

I am thankful for my health...although I would like my hair loss to slow down.

I am thankful for my career...I remain stimulated and enthusiastic about my profession.

I am thankful for my partners and staff...Couldn't ask for a better partner than DrD (12 years and counting) and Dr Reh and Dr Payson and all the employees at Dominion.

I am thankful for my patients...They have always been my best teachers.

I am thankful for my church....2 years on the Senior Pastor Search Committee failed to dampen my support for the National Presbyterian Church (still there is no politics like church politics!).

I am thankful for God from whom all these blessings flow (just like in the song)!

So that's my list and I am sticking by it!

Hope everyone had a Happy Turkey Day! I will try to get to those recent posts....

DrG

Read More

Question 58. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?

So last August I developed a wicked (note Bostonian roots given use of this adjective) toothache while on vacation at the Outer Banks. Naturally, I did what most physicians do...I started myself on antibiotics and ibuprofen and didn't call a dentist. By the next Monday I was not a happy camper and went to my general dentist only to be told I needed a root canal. Ugh. What a way to return from vacation. I took the recommendation of a local specialist and he did a fantastic job. Took 40 minutes and the next day I felt great! Last week it all started again and I went to my general dentist who said that I may need another root canal (different tooth). He proposed doing it himself without a referral to the specialist. I was in the chair already and it was 4:45 PM so I agreed to let him try. In retrospect, this was not a good decision. He found 2 of the 3 roots but ultimately quit the procedure at 6 PM and told me that I needed to see the specialist the next day anyway. I should have gone there first and next time I will. Dr. DiMattina scolded me for not knowing better....

REs are the specialists in this story. Many generalists are truly excellent physicians but infertility work represents only a small percetage of most general Ob/Gyn practices. Your RE only treats infertility and as a result I think that the advice and approach is superior. Of course, I have a jaded view being a specialist but I should have gotten out of that chair and high-tailed it back to the root canal specialist...Think about this carefully before taking 6 months of clomid with your Ob/Gyn!

Not all patients are created equal. Some patients are destined to be high-responders and some are low responders. This past year I had a patient who had PCOS and I was planning on using a lower dose stimulation. She went to another clinic because of insurance and was hit very hard with stimulation meds and ultimately the cycle was a bust. When we tried stimulation again I had her on one of the lowest doses that I had ever used for IVF but it was successful and we were all much relieved that the OHSS did not materialize. More recently we have been using the GnRH-antagonist protocol with Lupron instead of HCG to trigger for retrieval. This approach is very reasonable in the PCOS patient at risk for OHSS but care must be taken to support the endometrium following retrieval as the estrogen levels tend to drop like a rock and that may affect inplantation.....yup, no such thing as a free lunch.

So here is today's Question of the Day...

58. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?

Although several drugs and protocols are available to stimulate the ovaries to produce extra eggs for IVF, most clinics utilize only a few of these stimulation protocols.

One of the more common IVF protocols is called luteal suppression (or long luteal or simply just long) and involves suppression of the ovaries using a GnRH-analog (Lupron) during the luteal phase of the menstrual cycle preceding the planned IVF treatment cycle. Once the ovaries are suppressed, ovarian stimulation is accomplished with daily injections of gonadotropins (e.g., Gonal-F, Follistim). Lupron is usually continued until the day of the hCG trigger shot. A common variation of this protocol is to stop Lupron at the time of starting stimulation. Not surprisingly, this protocol is called “stop Lupron.”

Another common protocol is called flare stimulation. In this case, the woman does not take any medications until the second day of her menstrual cycle. At that time, a microdose (most commonly) of Lupron is used to “flare” the pituitary gland and induce it to release its store of FSH and LH. Simultaneously, gonadotropins are started, producing a “one–two punch” in terms of ovarian stimulation. Premature ovulation of the eggs rarely occurs despite the low dose of GnRH agonist utilized in this protocol.

A third, more recent option is GnRH-antagonist stimulation, in which GnRH antagonists are added later in the stimulation to prevent premature ovulation. In this method, the gonadotropins are started on cycle day 2 of a normal menstrual period. Once the follicles have reached a specific size (usually 12 to 14 mm), the woman begins the GnRH-antagonist medication, which almost instantaneously prevents the pituitary gland from generating an LH surge.

Some reproductive endocrinologists prescribe oral contraceptive pills to their female patients prior to beginning the actual ovarian stimulation drugs, but this practice varies between patients and fertility clinics. We have found that the use of birth control pills often results in oversuppression of the ovaries and cycle cancellation except in those patients known to be high responders (women with PCOS, in particular).

The type of protocol selected for any patient (i.e., luteal suppression, flare stimulation or GnRH antagonist) depends on the individual patient and the philosophy of the fertility clinic. Factors that may influence the type of stimulation protocol selected include the patient’s age, her day 3 hormone levels, her follicle antral count as determined by ultrasound, and her previous responses to any other attempts at ovarian stimulation.

Read More

Question 57. I was told I need assisted hatching. What is this, and why is it done?

Families are funny things. Some families are filled with artists and actors. Some are filled with athletes. Some are filled with engineers. Some are beyond simple description.

I grew up in a medical family and I am a 3rd generation physician. My nephew, Andrew, is currently a medical student at Tufts and he represents the first (maybe not the last) of the 4th generation Gordon to be a physician. My older brother Mike (on the far right in the photo) is a general surgeon in Sanford, NC. I don't think that he has gotten a full night's sleep in 25 years as he is regarded as the best surgeon at his hospital and is the most likely to be called when the ER needs a surgeon at 2 am!

My brother Steve was never interested in being a doctor. He is an outstanding hospital sdministrator. We talk several times a week which is incredible to me considering how much we fought as kids (so parents don't give up hope that your kids will someday get along!). But when we fought it was epic. He teased. He tortured. He told me I had been hatched!

But as you will see from today's Question of the Day, we actually all really do hatch! Steve just didn't realize it at the time....In IVF we sometimes recommend Assisted Hatching and let's take a look at what that means and who needs it..




57. I was told I need assisted hatching. What is this, and why is it done?

Dr. Gordon’s older brother Steven used to tease him by claiming that he was hatched and not born, but actually all of us do “hatch” in early embryonic life. The human embryo hatches out of the eggshell (zona pellucida) at the blastocyst stage of development. Assisted hatching involves weakening the zona to facilitate the emergence of the embryo following its transfer into the uterus after IVF. Proponents of assisted hatching suggest that it increases implantation and pregnancy rates.

Assisted hatching can be performed chemically or more recently using a laser. In the chemical technique, a dilute acid solution is used to dissolve the external eggshell. Some clinics still perform mechanical hatching, in which a slit is made in the eggshell. Along with many other clinics, we have moved to laser-assisted hatching, in which a laser is used to thin the zona sparing the embryo from any exposure to the chemicals used in hatching. (See Figure 5).

There is some controversy regarding which patients benefit most from assisted hatching, and the indications for assisted hatching remain somewhat unclear. Most clinics recommend this procedure in cases where the female partner is older than age 37, has diminished ovarian reserve with increased levels of FSH, or is undergoing a frozen embryo transfer (FET) with previously cryopreserved embryos. Patients who have previously failed IVF following replacement of good-quality embryos may also benefit from assisted embryo hatching.

The risks of assisted hatching are believed to be quite low. There have been reports of increased rates of identical twinning following mechanical hatching (but not after chemical or laser assisted hatching). There is no evidence that assisted hatching harms the embryo or causes any increased rate of birth defects in children.

Carol comments:
After my first IVF attempt failed for no obvious reason, the RE suggested that we utilize assisted hatching during our second attempt. We immediately moved into a second fresh cycle and employed assisted hatching. From my perspective, there was no difference. The procedure happened after the egg retrieval, so I was not involved. I did get pregnant during the second cycle, and in theory, the assisted hatching was the primary variable that was different.

Read More