Chainsaws and Other Stress Relievers

I took this photo the other day on my way to the office and I think it is one of the more inspired decals that I have ever seen on a car's back window. As a fertility doctor I celebrate in the successes of our patients but that also means that I also share in their pain and frustration when it doesn't work out.

The holiday season can be tough on our patients. The daily mail brings holiday greetings from friends and family that report the happy news of a new pregnancy or a new birth. For those struggling with infertility or pregnancy loss these letters can make it seem like everyone is getting pregnant but them ("Guess what? We will be having a new bundle of joy next year! And we were using 3 methods of birth control and I can't even remember having sex!). Yup, just what our patients want to hear...

The proliferation of the individual family member decals that populate rear windows here in the Washington DC metro area also seems a bit over the top. Perhaps our patients can filter out these reminders of the frustration of infertility better than I think....perhaps not. Although infertility has not been one of our family's medical struggles, I think that I have some perspective into how emotionally distressing fertility problems can be for my patients.

As an Ob Gyn resident I took care of hundreds and thousands of patients. I handled deliveries that were happy events and some that were not...especially if it was a premature baby. When my son was born 6 weeks early I was surprised by how difficult it was for me as a parent. The same day that he was born one of the Labor and Delivery nurses popped out a 8.5 pound baby and was walking around showing that kid off to everyone. Meanwhile my son was in the NICU with an IV in his umbilicus and concern over apnea and bradycardia. I hated that nurse. Yes I know it was completely irrational. And I knew that my son would certainly have every expectation of quickly graduating from the NICU (actually it took over a week). But it didn't matter. I was still really upset that she was able to parade around with that newborn.

If I had a chainsaw, then I would have chased her down the corridor....

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Christmas Lights and Other Frustrations.....

Last night I became inspired to get our Christmas lights hung up before the weather turned cold again when I would be risking frostbite to complete the job. So I got the bags of lights down from their perch in the unfinished part of my basement and began the job of sorting through which strings lit and which ones did not. Just as soon as one strand lit up it seemed that another winked out. Finally, I had enough to start the job and I managed to string up an assortment of white and colored lights in some semblance of symmetry. Just when I thought I had completed the task the corner outlet in my garage blew... Suddenly there was a cry from inside the house "what the %#&*$# happened to the Internet! I have to finish my homework! Dad!" So I moved to Plan B. Run an extension cord from the backyard to the garage. Hook up a surge protected power strip. Plug in the power to the internet box and voila...another crisis averted. But a new problem had arisen: the blown outlet. Ugh. An hour later I finally figured out how to reset the GFI and we were back in business. 

In reproductive medicine sometimes we fix one issue only to find ourselves confronted by another. Let's consider preimplantation  genetic screening (PGS) for IVF. Using PGS we can now determine within 18 hours following an embryo biopsy whether or not that embryo contains a normal number of chromosomes. Since many embryos are missing a whole chromosome (Monosomy 7) or have an extra chromosome (Trisomy 18) we can now elect to only transfer normal embryos. The use of PGS will not change the ultimate delivery rate (if there is a good embryo somewhere in the bunch then we will eventually find it) but it will decrease the rate of miscarriage since most pregnancy losses are genetic in etiology.

So if we only transfer genetically normal embryos then the pregnancy rate should be 100%...right? Except that it isn't. So just like my experience with hanging the lights, once one issue is resolved other issues may arise. For example, just because an embryo has the normal number of chromosomes doesn't mean that it is completely healthy. That embryo may have other problems including single genes that are failing to work correctly. In addition, besides the embryo there could be issues with the embryo transfer (glob of mucus on the catheter) or a difficult navigation of the cervical canal. Finally, the uterus itself may not be receptive to implantation. So even after eliminating genetic issues we still have to sort through other possible explanations for failure. But there is always hope for ultimate success, just sometimes it takes some creative electrical engineering to get everyone back online and sometimes it takes some creative thinking to get those embryos to stick!

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Goodbye to Twinkies

No more Twinkies. How is this possible? Yesterdays announcement by Hostess that the company is shutting down its bakeries has me completely stunned. In the movie Zombieland, the character played by Woody Harrelson is obsessed with finding Twinkies in the post-zombie apocalypse ravaged world. Now we have a world without Twinkies and no zombie apocalypse....go figure. I am on a bit of a post-apocalyptic bender at the present time....I am watching The Walking Dead while exercising and I am listening to the audiobook of the novel The Twelve by Justin Cronin ("...we made vampires. Seemed like a good idea at the time"). Then this past week I received a glossy 16 page publication from the American College of Obstetricians and Gynecologists (ACOG) all about social media. I was not a featured blogger. Oh well. Maybe next year the Academy will recognize my body of work and I will get an Oscar.

So I must admit that between the loss of Twinkies and my constant exposure to post-apocalyptic fiction I have not been a real laugh it up type of guy this week. Then my dog keeled over. Dollie is a 13 year old miniature schnauzer and she has developed vertigo and is having a really hard time walking and doing typical doggie activities. So now I face the difficult choice of deciding if and when to help my little friend cross over the Rainbow Bridge. Sigh.

Sometimes you just have to pick yourself up, dust yourself off and head into the future and not look back so much at the past. No Twinkies. No problem.

In medicine, especially reproductive medicine, we are always striving towards that elusive goal of achieving a healthy singleton term delivery as fast as possible. Change can come slowly or in staggering leaps forward. ICSI was a leap. The movement away from GIFT was a bit slower. GIFT involved a traditional trans-vaginal egg collection followed by a laparoscopy with a number of eggs and sperm mixed together and transferred into the fallopian tube. GIFT was helpful in cases of infertility in patients with normal tubes and normal sperm...and no significant endometriosis....so that really leaves you with unexplained infertility patients and Catholic patients who follow the specific admonition against combining eggs and sperm outside of the body. In any case, although GIFT here in Washington DC was pioneered by my partner at Dominion, Michael DiMattina, we have not done a case in years.  Sometimes there is a boomerang phenomenon. Such as Natural Cycle IVF. NC IVF was employed by Steptoe and Edwards culminating in the delivery of Louise Brown back in 1978. Now we are seeing a resurgence of interest in NC IVF as is clearly evidenced in our own practice where this year about 80% of our IVF will be performed in unstimulated cycles. Not what we would have predicted when we started the program in 2007.

So what's old is new again. Maybe Twinkies will be gone for a while but then return. But just in case I am headed out this morning to buy a bunch of boxes. With a shelf life measured in decades they will be just the thing to help me ride out the zombie apocalypse.

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Happy Halloween!

Good riddence to Hurricane Sandy! We are all happy to see the end of you... At Dominion Fertility we appreciate the dedication of our staff who braved falling trees and high water to make it to the office on Tuesday.

It is important to have an emergency back-up plan for your IVF lab and this past 6 months have been pretty rough here in the Mid-Atlantic. First we had the crazy July storm (Derecho - which means crazy thunderstorm that no weather forecaster managed to predict until the trees starting falling). Then we dealt with the huge weather event that was Hurricane Sandy.

We have a back-up natural gas powered generator that can run our embryo lab and several sonogram machines. This provides for a margin of safety when facing weather related crises and extended power outages. It also protects the office when a squirrel occasionally gets fried on the power lines outside our office which I have personally witnessed. Watching a furry little creature burst into flames is a fairly memorable event....

So my thoughts and prayers are with all fertility patients in NY, NJ and elswhere who were in the midst of a treatment cycle when this latest disaster struck. I wish you all the best of luck and remember that an IVF cycle is not worth risking your life so make sound decisions when dealing with downed trees and power lines.

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Scare Tactics

My brother Steve loved to scare the daylights out of me when I was a kid. He hid under my bed, in my closet, in the boiler room in our basement, in the hall closet or in the garage just waiting for me to pass by before jumping out and trying to give me a heart attack.

Just look at this picture of the two of us in the backyard of my house in Milton. Is there any way that I was not going to end up in therapy after being tormented incessantly? Actually, I have avoided therapy so far but interestingly enough many of my nightmares take place in the house where I grew up....I wonder why?

Sometimes it is the job of a physician to counsel patients about the scary things that can happen during fertility treatment or in pregnancy itself. Clearly there is a fine line between full disclosure and doing the healthcare equivalent of jumping out from under the bed with a latex mask covering your head causing your younger brother to scream like a little girl...

A few weeks ago there was a story in the news about a 61 year old who successfully carried a pregnancy for her daughter who was unable to be pregnant herself. Here is the link to the story for those who are interested. That week I received several phone calls from local news media asking if we had ever had a patient carry a baby who was that old and if we did could they please speak to someone who had a horrible complication of such a pregnancy such as death of the baby or the gestational carrier... Well, at least they didn't beat around the bush in regards to the story that they were after....

I am a very risk adverse physician. It gives me chest pain to contemplate someone over 60 years old carrying a pregnancy because the risk seems excessive to me. Of course, I am not the one carrying the pregnancy, nor a family member involved in the decision so the issue becomes one of informed consent and patient autonomy. Last year I was accused by a patient of being horribly insensitive when I recommended that she use a gestational carrier because of a profound uterine issue that I believed put her and her unborn child at excessive risk. She posted a very negative review of my handling of the situation and put me in the category of a fear monger (along with older brothers who wear latex masks and torture their angelic younger brothers). I felt terrible (unlike my Brother Steve) and reached out to her to clarify my position and apologize for how my advice was delivered. She thanked me for taking the time to discuss the issue with her and accepted my apology (but never revised her online rant..oh well). However, I remain convinced that my advice was sound. Ultimately, patients vote with their feet and at least here in Washington there is no shortage of REs to provide a 2nd or 3rd or 4th opinion. Walking that fine line between scare tactics and good advice is tricky.

As a 3rd generation physician I believe that medicine is a calling not just an occupation. So as a physician I need to look in the mirror every morning and believe that I have done my very best and that I am truly giving the best advice that I can to my patients...and I need to be sure that there is not an idiot in a latex mask hiding in my shower....

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New Hope for Hyperstim...Curing the OHSS Woes (Part 2: GnRH-antagonist Rescue).

So we have been using the Lupron trigger protocol in more patients and these patients cannot have been on a traditional LTL (long luteal lupron) or MDL (microdose Lupron flare) protocol. That means that the only patient eligible are those who are on a GnRH-antagonist protocol (one that uses Antagon or Centrotide) to eliminate the LH surge. Well, interestingly enough it turns out that adding GnRH-antagonists in the middle of a LTL or MDL flare protocol can really reduce the estrogen levels and seems to decrease the risk of OHSS in these patients who are in the midst of a stimulation that seems to be heading toward an excessive response.

As you can see below, our own Dr. Mark Payson was one of the authors of this intriguing study. Honestly, I never would have thought of adding Antagon or Centrotide during the middle of a stimulation that had started with Lupron....Go figure. Not sure exactly how or why this approach works but the study seems promising and gives us another way to deal with OHSS once we are in stimulation.

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New Hope for Hyperstim...Curing the OHSS Woes (Part 1: Lupron Trigger).

I have been writing this blog for a couple of years now. Year in and year out the most popular post has been my discussion of OHSS (see the OHSS Woes). Hundreds of comments have been posted with some pretty scary stories of OHSS. Well, there will always be some risk of OHSS in patients who take fertility drugs but some recent advances may markedly reduce the risk. So here are some details about some new ways to manage OHSS that you may want to discuss with your RE....

#1. Lupron trigger
All egg collections must be timed so that the egg within the follicle is ready to ovulate but the procedure is scheduled before that occurs. Traditional timing of egg collection is 34-36 hours after an HCG injection. HCG is very similar to the LH hormone produced by the pituitary (master gland in the brain) and fools the follicle into thinking (if follicles could think) that it is time for the egg to pack its bags and get ready to pop out. The problem is that HCG hangs around for over a week whereas the LH that the brain releases is gone within hours. It is this prolonged HCG exposure that drives the OHSS bus. Similarly this explains why pregnancy makes OHSS so much worse...the developing placenta makes HCG constantly increasing the production from the ovary of the proteins that lead to OHSS symptoms.

So we need HCG in order to do the egg collection and actually get eggs out of the follicles but we really want the HCG to go away quicker to prevent OHSS. Some of us use 5000 IU of HCG to try and avoid OHSS, but the truth of the matter is that all my severe OHSS patients have gotten 5000 IU instead of 10,000 IU so clearly this is not all that effective...

However, some fertility clinics (including ours) are now using Lupron to trigger patients for egg collection. Lupron will cause the patient's pituitary glad to release the LH that is in storage and that LH is usually sufficient to get the eggs ready to be retrieved. The LH then drops precipitously and the risk of OHSS is very close to zero! Wow! What a great option....BUT...

Unfortunately, there is always a "but."

First of all, you can't use Lupron trigger in patients who have been on Lupron for their stim...no MDL flare patient, no Luteal Lupron protocol patients.

Secondly, the estrogen levels with Lupron trigger fall FAST. I mean really fast. This rapid drop in estrogen levels is good for OHSS prevention. It is not so good for implantation. DrD attended the Santa Barbara IVF meeting this summer and came back enthusiastic about Lupron trigger but he noted that although the rate of OHSS is nearly zero, the present recommendation is to freeze all the embryos and save them for an FET cycle because most REs believe that the implantation rate in a Lupron trigger fresh cycle is much lower than expected.

Thirdly, in patients with insurance coverage for IVF this may be problematic as the insurance could count this as 2 separate IVF attempts (one fresh and one FET...even though no fresh ET was ever planned)....Ugh. Nothing is ever simple.

So how do we like Lupron trigger? Well, I have had some very nice success rates with FET cycles with Lupron trigger but our experience seemed consistent with that of other clinics when it came to fresh ET with Lupron trigger. Some patients with really difficult stims (PCOS, AMH level off the wall, history of canceled cycles with estrogen levels >10,000 pg/mL) have made it through egg collection without an issue and their estrogen levels fall really fast and they have very little symptoms of OHSS. I believe this represents the future of IVF stimulations but there remain some unanswered questions....

Next post: New Hope for Hyperstim...Curing the OHSS Woes (Part 2: GnRH-antagonist Rescue).

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Goodbye Summer...Hello Autumn!

Goodbye Summer…

Growing up in New England you get used to summer lasting only a few weeks. Of course, here in DC it seems like summer lasts a lot longer as temperatures can be in the 90s in April…. However, in Boston the weather in Spring may not be very Spring-like as I remember a snowstorm one year in June!

The end of summer is always sad to me. In June it seemed like there were an almost infinite number of possibilities for the coming season….then by September you are faced with all the fantastic activities that you failed to pursue. This summer was pretty good. There was the obligatory "honey-do" list which including clearing out closets of junk ("What do you mean I should throw out my high school soccer jacket?!?) but I did learn to wakeboard ("Wow Dad you look pretty good for a fat, hairy, balding, old guy!")…

The Bob Seger song "Night Moves" sums up my view of the end of summer:

I woke last night to the sound of thunder
How far off I sat and wondered
Started humming a song from 1962
Ain't it funny how the night moves
When you just don't seem to have as much to lose
Strange how the night moves
With autumn closing in

But as we say goodbye to the heat and humidity I guess that Fall has some positive aspects to it as well. Just gotta get over the things that we didn't get to this summer and move on.

I have spent a lot of time going through the 35 mm slides that I rescued from my parents' home following my Mom's death in May. My Dad really had no place to store them and I was appointed keeper of the family memorabilia. The amazing thing about those images is that there are slides of me and my brothers and parents that I have never seen before….In today's digital world where we have instant access to thousands of photos on our iPhones, it is hard to remember what it was like to have a box of slides that contained unknown images from the past. Opening each box of slides is like an archeological expedition. Some trigger sharp memories and other register complete blanks with me.

I love this photo of me and my best friend Karma. She was an excellent dog. Rescued by my Dad (after a lot of pleading) from Camp Cody in New Hampshire she was my buddy. This photo reminds me that Fall isn't so bad after all...


What does any of this have to do with IVF and infertility? Well, not a lot I guess except that for many of our patients their view of their fertile years may be initially like my view of summer from the perspective of June. Then suddenly the years flash by and autumn seems to be closing in. But there can be good days in autumn….with or without your canine companion.

This past week I met up with a couple that had been through a lot including a tough mid trimester loss. We discussed issues of diminished ovarian reserve, and age-related aneuploidy (chromosome abnormalities). I spent some time discussing Natural Cycle IVF. Ultimately, they politely stopped me and told me that they were really more interested in hearing about donor egg IVF. They had moved beyond Summer and were prepared to embrace and love Fall. Patients are always a doctor's best teachers…

P.S. My Brother Steve is still kicking my butt in terms of Mom's Scholarship Fund.....

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Free Advice is Worth What You Pay for It....

Recently my older brother Steven and I were having a discussion about the Internet and this Blog in particular. He wondered why I spent so much time and effort responding to posts from patients all over the country and the world whom I would never meet face to face. In addition, we discussed the fact that I often referenced Mom and Dad in my posts and shared my grief over her final illness and passing at the end of May.

Honestly, the whole blog thing is out of character for me. In fact, I am a rather introverted person. I do not do well at cocktail parties and have a real problem putting names and faces together...although I pretty much have my kids down pat at this point...more or less. Yet my profession requires me to delve into the most intimate of details when working with a couple. Few issues are as difficult to discuss as those concerning reproduction and family building. Money is another one and as many of our treatments are not covered by insurance, money enters into the decision making as well!

As a 3rd generation physician I have an old-fashioned view of the doctor-patient relationship. I remember asking my Dad one time, as we drove past the Hollow restaurant on Adams Street in Quincy, MA, why we never ate there. He said that it was hard to go there because so many of his patients worked there, ate there or hung out there. I persisted and finally he agreed to take my Mom and me to dinner at the Hollow. It was like seeing the paparazzi descend on Leonardo DiCaprio! I think that he ate only about half of his meal because so many people came over to say "hi" and thank him for being such a great surgeon. That dinner made a real impression on me at the time. To this day my Dad views his identity as physician first and everything else second. Although I have attempted to develop a more balanced identity, I will admit that being a physician is very important as part of my worldview.

So why do I persist in answering post after post on this blog. And why do I drag myself over to Fairfax Hospital early in the morning to lecture to the students and residents. Well, I have always viewed teaching as being a big component of my job as a physician. As DrD states "I teach because someone taught me." As above, I lecture every week to the medical students and residents. I have served as a preceptor for Princeton pre-med students and every summer I have been a speaker at the National Youth Leadership Forum on Medicine (an organization that encourages high achieving high school students to explore medicine as a career). So I use this blog as means to teach and to educate the 12 people who read this blog regularly. Along the way I try to give some insight into how I think and practice. Sometimes I share some personal history as part of a quid pro quo...."Hi I am Dr. Gordon. How often do you two have sex?" Yikes. What a crazy way to make a living...

So back to my brother Steve. We are very competitive. So competitive that we rarely play one on one games anymore. Plus I hate to beat an old guy. In any case, he was very proud of all the contributions that had been made to the Tufts Medical School Scholarship Fund in memory of my Mom by his professional associates. In particular he said "so where are your internet buddies now?"

Dear Readers, I have never asked for anything from you...until now. If you have found any part of the hundreds of posts on this blog and my answers to questions helpful then please consider a nominal $5 gift to the Tufts Medical School Scholarship Fund in honor of my Mom (Claire Braverman Gordon). Contributions are totally voluntary and I will continue to answer all questions to the best of my ability..but I really hate to lose to my big brother...

Claire Braverman Gordon Memorial Scholarship Fund
Tufts University School of Medicine
Office of Development & Alumni Relations
136 Harrison Ave.
Boston, MA 02111

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It only takes one...

Although we strive for multiple embryos in stimulated IVF, sometimes we loose track of the concept that it really takes just a single embryo to make a baby. I have a current patient who went through IVF with PGS (preimplantation genetic screening) and had multiple grade AAA blastocysts for embryo biopsy on day 5. Interestingly, only a single embryo of all these normal looking blasts was genetically normal. We transferred that single embryo and now she has an ongoing pregnancy. Would we have found that single normal embryo eventually? Yes. Would the patient have become emotionally drained, frustrated and financially strapped by the repeated transfers... Possibly...

So as we revise our approach to stimulated IVF, PGS may become more and more common. In the end, it still just takes a single good embryo to make a baby. Does Natural Cycle IVF create a higher percentage of normal embryos compared with stimulated IVF? We don't really know but this could explain the higher implantation rate that we see in NC IVF....

Last weekend I was in Boston cleaning out my parent's home as my Dad prepared to move into an apartment. I ended up with a minivan full of thousands and thousands of slides. Many of these were photos of yours truly that I had never seen. (These photos would serve to undercut my brother Steve's assertion that I was found in the gutter one night and raised in my parents' home under the mistaken impression that I was actually a Gordon born and bred....).

The photo on the right is me with my dog Karma. Although not evident in the photo, Karma was actually missing her right front leg which was amputated after she was struck by a car early in her life. She lived to be about 13 years old and it never slowed her down. In her case it took only 3 legs to live a full and happy life and in your case remember it only takes a single good embryo!

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Crazy Twin Stories #2

Here is another one that leaves you scratching your head....

RL is a 32 year old fertility patient who had failed to conceive with less invasive therapies and elected to pursue stimulated IVF. At the time of egg collection we anticipated around 12 eggs but only got 4 eggs plus a couple of empty zona (egg shell only with no egg inside). From those 4 eggs we ended up with only a single embryo. However, it was a beautiful blastocyst and we had high hopes for success in spite of the relative inefficiency of the cycle...In fact, she did conceive and her betas were very high....really high.

At the first ultrasound visit I saw two sacs. At the next visit both sacs had embryos with heartbeats. I was very concerned about her ability to carry twins but she and her husband were ecstatic. She had an uneventful pregnancy and delivered at 38 weeks. Both babies were healthy and went home with Mom after delivery. So what, the informed reader may declare...another case of identical twins...ho hum. Yes indeed....except that the babies were a boy and a girl...clearly not identical.

So the explanation is that her fallopian tubes did catch at least one egg that we failed to retrieve and they had sex prior to retrieval and voila....bonus baby. This happened to me previously in a case where I froze all embryos because of OHSS and then the patient failed to get a period and was actually pregnant. She had been intimate with her husband 5 days prior to retrieval and I got 28 eggs in that case...but apparently I left one behind. That was a tough case to enter into our statistics....retrieval, no transfer but pregnancy and delivery...go figure.

Mark Hughes (smartest doctor I know) reported a case where he was comparing the results of PGD/PGS with pregnancy outcomes once the babies were delivered. In one patient, the baby was definitely the genetic child of the couple but did not match any of the embryos that were transferred. Another case of slipping one past the goalie I guess...

So the take home message is that if you have sex during stimulation then once in a great while you may see outcomes that defy the odds....

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Crazy Twin Stories #1

Here at Dominion Fertility we are really doing our best to reduce the number of twin pregnancies. Seriously. No, I really mean it. Recently we were commended by the CDC for our exceptionally high rate of single embryos transfers.

Usually we urge patients to pursue elective single embryo transfer (eSET) if it is their first cycle of stimulated IVF and they are < 35 years old and embryo quality is very good to excellent. However, as many patients/couples view twins as an acceptable and even desirable outcome it is hard to sell eSET to many of them.

In this case, the couple had been through a lot but was open to eSET. I was very happy when I saw the first beta level but figured it was just a really healthy singleton. Then came the first pregnancy sonogram and I saw a single gestational sac with two yolk sacs. Oh well. Follow-up sonograms demonstrated that the twins were not in a single sac which would have made the pregnancy a much higher risk endeavor. Still identical twins were not on our radar screen as the rate of identical twinning is usually only 1-2%.

So in spite of eSET, not all pregnancies will be singletons but as I really can't transfer less than one embryo we are stuck with a small risk of twins no matter what....

Still, as I tell my patients at the time of ET, I don't babysit and I don't change diapers anymore..

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Thanks from Dr G

I really want to thank all of my patients, friends and associates who have extended their heartfelt condolences on my loss. Your kindness is much appreciated. I apologize to any of my patients who were inconvenienced in my absence and also to those who have been trying to schedule appointments and have been unable to get in as quickly as usual to see me. Please understand that I am doing my best to accommodate everyone's schedule.

Thanks again,

DrG

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Claire Braverman Gordon (1923-2012)

My Mom passed away peacefully on Thursday May 31. She lived a full and wonderful life and will be missed by all of us who knew her.

http://www.legacy.com/obituaries/bostonglobe/obituary.aspx?n=claire-braverman-gordon&pid=157872029&fhid=5817

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Back to Boston....

Well I am on my way back to Boston to spend the day with my Mom. She is really going downhill fast and I really hope that she is awake enough to know that I am there with her. It is funny to think that back when I was born that a woman over than 35 years old was considered high-risk just because of her age. We are not talking about the risk of genetic issues...simply being pregnant at 35 was considered problematic! Now I consider a 35 year old to be pretty darn young considering my average patient is 38.5 years old.

My Mother conceived me when she was 40 years old. My Dad diagnosed her as being in menopause. That's what happens when General Surgeons provide RE opinions. She was a lot older than the most of my peers' mothers and yet I never felt that she was somehow less involved or moving slower. She was always there for me during those summers on Cape Cod and she frequently planned excursions to Mystic Seaport or the Boston Museum of Science and even a trip to Washington DC with a two of my classmates and their Moms.

Yet to even have any children was a miracle for her. She had a bicornuate uterus with a rudimentary horn. She and my Dad were told that it was hopeless and they needed to adopt. Clearly I am evidence to the contrary...as are my 2 older brothers!

Well, here's to mothers everywhere. We are heading down into Boston Logan. Wish me well...

Addendum 5/22/12: Back now in DC and I spent all day Monday with my Mom. She had moments of lucidity and at other times she had what my sister-in-law calls the "100 mile stare." Still she knew who I was and enjoyed watching the photos and videos that I streamed from my iPhone to her TV. We will just take it day by day. I appreciate all the support shown by my staff and by my patients. My mother has been one of my biggest supporters over the years. The natural order of life is for children to go on after their parents but that doesn't make it any easier. I am too open from an emotional standpoint to practice in a field of medicine where end of life issues are common....I am glad that I am blessed to practice in the field of Reproductive Medicine.

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Having a Back Up Plan

Yesterday my son Seth (see photo of him with his Grandparents before my Mom's recent turn for the worse health-wise) experienced the Mac equivalent of the "blue screen of death." His MacBook Pro started behaving unpredictably and then refused to boot up at all. Earlier I had made an appointment at the Genius Bar but Seth had reassured me that all was well and I didn't need to bring his laptop over to the Clarendon Apple Store (25 min from our home). Then the meconium hit the fan and at 7:40 pm he declared an emergency and I grabbed the defunct machine and hopped in the car to make the voyage back into Virginia. I called ahead and the gang at the Apple Store told me that my genius would wait for me….is that great customer service or what?

The laptop was apparently experiencing a "kernel panic" or is it "Colonel Panic" ?? Beats me. in any case the system folder was corrupted and the only solution was a clean reinstall of the OS following erasure of the hard drive. BUT he uses Time Machine and should be able to nearly completely resurrect his machine once he returns to college this PM to start exams. Crisis averted….I hope.

It always helps to have a back-up plan. In fertility treatment this back-up plan could be the use of donor sperm, donor egg, donor embryo, gestational carrier or adoption. Although we can never know who will achieve success, we can often give good advice to those patients who need to consider alternative paths to parenting.

The use of donor sperm is the most common issue that we face in these discussions. In certain cases of severe male factor I think that considering the use of anonymous donor sperm is appropriate. In stimulated IVF we often consider splitting the eggs between husband and donor in cases of severe male factor BUT this makes no sense to me unless the couple is accepting of the concept of parenting a child born from fertilization with donor sperm. Don't waste the eggs if you are uninterested in using those embryos.

I currently have a patient who is successfully pregnant after IVF using this concept of a back-up plan that fortunately was not needed. Previously her attempt at stimulated IVF had resulted in very poor quality embryos. We were uncertain if this was an egg issue, a stimulation protocol issue or a sperm issue. We adjusted the protocol, used donor sperm to fertilize some of the eggs and the cycle was much more successful with fertilization from both husband and donor . Ultimately we had a bunch of embryos from the sperm donor and even two nice blastocysts from the husband. We cryo'd the donor sperm embryos and used the two from the husband. We were all ecstatic to see cardiac activity on sonogram recently and they are off for obstetrical care...

Having a back-up plan can make all the difference.

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Question of the Day: Follicle Reduction

So as I was wasting precious time by goofing around on my blog I came across this post on another internet bulletin board. At the risk of getting flamed by posting on a patient board I have elected to reply here in the relative safety of my own blog/Facebook page! So here is the post.....

I was diagnosed with PCOS and am prone to overstimulating. Two of my IUI cycles were canceled due to too many follicles. I was googling and found Dr. Gordon's facebook page on follicle reduction. Just cautious whether someone here been through a follicle reduction procedure and what it is like. When I spoke to a nurse at my clinic, she told me they don't do follicle reduction. Instead I can choose selective reduction in the event of multiples or covert the cycle to IVF. Wonder why my clinic doesn't provide this procedure?

So first of all, a follicle reduction is performed the same day as an IUI (or coitus) and timing in terms of HCG is the same as for an IVF egg collection. Essentially, a follicle reduction is an egg collection but with 2 big differences. First of all, the eggs are discarded and not fertilized and secondly we leave 1-3 follicles untouched so that a pregnancy can occur once those eggs ovulate.

On this bulletin board some other individual opined "why not do IVF if you are going to do an egg collection anyway?" Yes, that is an option but usually I recommend follicle reduction in cases where the patient has maybe 6-8 follicles as opposed to the usual 10-15 that we like for IVF. Remember this is an IUI or coitus cycle that has resulted in an over-response. Usually the patient is not doing IVF for a reason......economic, religious, philosophic etc. In general, I have charged about $1000 for a follicle reduction on top of the charges for the whole cycle so it is not that expensive compared with converting to a full IVF which is $10-12,000 in most clinics.

I will say that the advice given by the nurse concerning selective reduction is a bit cavalier...Yes, fetal reductions (selective abortion) can be done but it is a Sophie's Choice situation and I really hate to ever put a patient into that difficult position. Better to cancel and walk away in my mind. When patients see 3-4 fetuses with cardiac activity it is really tough for them to undergo a selective reduction, although many do make that difficult choice.

Why don't all clinics offer this option. Beats me.

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Returning to Old Haunts

Over Spring Break I found myself back in Houston where I completed my first internship in Obstetrics and Gynecology at University of Texas Health Sciences Center, Houston at Hermann Hospital. As a medical student at Duke I had spent my 4th year doing electives that were not in Ob Gyn because the Chairman of Ob Gyn at Duke had encouraged me to rotate onto other specialties since I would be doing Ob Gyn for 4 full years....."But Dr Hammond," I inquired "won't that put me at a disadvantage come July 1st when I begin my intern year?" He reassured me that the first few months "might be a bit rough" but that I would quickly catch on....

Well those first few months were "a bit rough"in the same way that the maiden voyage of the Titanic was "a bit disappointing..." I was pretty much terrified by the responsibility thrust upon me on Labor and Delivery. But nearly all of my senior residents were supportive and dedicated to helping the newbies survive that first year. Dr. Hammond proved correct in that by the 6th month I was pretty much caught up in terms of my Ob Gyn knowledge base. But what a crazy year that was in Houston. I was sleep deprived and exhausted and the weather was pretty tough. In summer the heat and humidity were brutal and during the winter of 1989 there was a deep freeze and water pipes ruptured all over the Texas Medical Center. I still remember scrubbing for C-sections with nurses pouring bottles of sterile water over our hands!

In June we left Houston so my wife could take a faculty position at Stanford in the Department of Structural Engineering but there were no 2nd year residency spots so I had to repeat an internship year at Stanford in spite of my year of training in Houston. Believe me, that second internship year was a piece of cake compared with internship #1 in Houston!

So in any case, over break this month we traveled to Houston. We visited the townhome where we lived and walked around the streets of Rice Village in the West U neighborhood. I was amazed by the growth of the Texas Medical Center and was stunned to see light rail running down the middle of Fannin Avenue. Hobby Airport seemed much improved as well but my memory is a bit fuzzy....

Visiting old haunts is always bittersweet.....I think about the friends that I've lost touch with and the memories that I have trouble recalling. Every day for a year I drove from our rental to the hospital but suddenly I couldn't remember what route I took! Yikes. Sounds like my memory is going....

So how does this relate to fertility and fertility treatments? Well, I guess that it doesn't really, but one issue that often arises is what to do following a successful pregnancy that resulted from fertility treatment? Does one revisit old haunts or head off in a new direction.....smooth transition from personal ramblings to useful clinical advice, eh?

Good question. So here is my view. First of all, it is hard to argue with success. So although spontaneous pregnancies can and do occur following treatment derived pregnancies, I usually go with what worked before assuming that nothing else had changed. However, medical treatments can be dynamic and response to treatments can shift.

Currently I have a patient who is now pregnant with her second IVF baby but her journey was anything but a direct line. Theirs was a case of male factor and we started with Natural Cycle IVF (NC IVF). After several failed cycles we moved to stimulated IVF. She was a low responder but conceived and delivered a healthy baby. When they returned for baby #2 we decided to go back to stimulated IVF given that NC IVF had not worked. Unfortunately, stimulated IVF proved to be less than gratifying and after several failed cycles we decided to return to NC IVF....and voila, success with NC IVF!

Each cycle should be looked upon as an opportunity to learn about a couple's situation and hopefully make adjustments if the cycle failed to result in a pregnancy. IVF clearly provides more information than IUI. In an IUI cycle you never know if the tube caught an egg, or if the sperm swam and found the egg or if the sperm fertilized the egg or if the embryo formed or if the embryo made it to the uterus. All you learn is that the cycle ended with a negative pregnancy test. NC IVF and stimulated IVF at least provide insight into the cycle: was there an egg, did it fertilize, did it grow and how did it look. Not perfect but better than just wishful thinking...

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Question of the Day: Diminished Ovarian Reserve

Yesterday I gave Grand Rounds at Inova Fairfax Hospital in Falls Church, VA. Fairfax is a very large hospital routinely performing over 10,000 deliveries annually. There are over 100 Ob/Gyn physicians on staff and I have the title of Division Director of Reproductive Endocrinology and Infertility. As Division Director, I am responsible for ensuring educational content at the weekly departmental meetings that have an educational purpose. These meetings are called "Grand Rounds" in order to distinguish them (I guess) from "Not-so-grand Rounds."

As a child growing up in a medical household I often heard my Dad and Brother speak of "Grand Rounds." But I though they were saying "Ground Round" which was this great chain of burger restaurants in New England that was famous for providing bowls of popcorn and peanuts to all diners as they sat down. Of course, we kids would stuff our faces full of popcorn leaving no room for the overpriced burgers which may explain why we rarely went to the Ground Round for meals!

So given that the topic of ovarian reserve has been on my mind, here is today's Question of the Day:

I have high FSH so my RE says I'm not a good candidate for regular IVF but I've done 3 rounds of meds and IUI with NO success. Would Natural Cycle IVF (NCIVF) be better?


DrG answers:

The short answer is "yes." The long answer is "yes, probably."

First of all, a high FSH suggests diminished ovarian reserve and a probably poor response to fertility medications. BUT a high FSH does not mean that there is not a good egg left in the ovary. The odds of having a good egg is very dependent upon age. The older the patient, the lower the odds of success. This patient didn't tell me her age. Younger is better. Less than 40 is better than over 40. Less than 44 is better than over 44 (although we had had a delivery in a 48 year old patient following NC IVF).

Secondly, I usually encourage patients with borderline elevated FSH levels to consider stimulated IVF as a first choice. If the patient fails to respond then you can do an IUI and then re-evaluate. I have seen many patients demonstrate decreasing responsiveness to FSH shots - 7 follicles then 4 follicles then 2 follicles. If at that point the patient switches to IVF she will likely get canceled prior to retrieval.

So what about the proven low responder to medications. Is NC IVF an option? Yes, we have had some amazing success with these patients. Are donor egg/embryo/adoption more likely to work? Yes, but those options may not be acceptable to all patients. That leaves NC IVF and I think that one can consider this a viable option for patients with diminished ovarian reserve.

I have a 41 year old patient who had FSH levels in the 18-26 IU/L range on several occasions. Her AMH was <0.16 and her antral follicle count was 2. Her husband had male factor (previous vasectomy and reversal). Her insurance company denied her IVF coverage because of the high FSH. She attempted NC IVF and her FSH level was 40 IU/L on day 3 of that cycle. Yet she conceived and is currently in her 3rd trimester with normal genetic testing and a healthy baby. Go figure.

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Looking and Not Seeing

For the past 12 years I have been giving lectures to the students and residents from The George Washington University (and more recently VCU). I usually give my lectures in a room that is located on the campus of Inova Fairfax Hospital and you can usually find me there every week at 7:15 am trying to keep the audience awake, entertained and educated. I usually hook up my MacBook Pro to the LCD projector that I keep in my car. After my lecture last week I noticed an LCD projector that was mounted on the ceiling of the room. Looking around I noted a VGA adapter on the wall and I plugged my laptop into the correct slot and voila....I now had a full-sized projection on the screen compared with the dinky little projection from my own LCD projector which I have usually placed closer to the screen.

My problem with all this is that it bothers me that I cannot recall how long that damn projector has been mounted on the ceiling of the room! Has it been there for days....weeks....years??? I really have no idea. Why did I suddenly just notice it last week? Why did none of the medical students or residents ever say "Hey, DrG why not use the ceiling mounted LCD projector instead of your ancient projector that barely casts a bright enough image to keep us awake?" Beats me.

In dealing with patients, I like to go over where we are, how we got there and why we chose the path that we chose. If you keep your head down and never take stock of where you are then you are sure to get lost. Hence, following a failed treatment or a series of failed treatments it seems absolutely crucial to reassess what we have learned and what options may now make sense. If the patient is doing IVF with ICSI but the sperm now are much improved then maybe we should consider IVF. If the stimulation was suboptimal then maybe we should consider a different protocol or Natural Cycle IVF. If nothing is going right then maybe it is time to consider adoption, embryo adoption, donor egg or donor sperm.

One has to keep looking but more importantly one has to keep seeing....

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Revisiting the Past

I just returned from Boston where I helped my Dad celebrate his 89th birthday. My Mom is doing amazingly well considering what she has been through this past year in terms of her health.
At the party, attended by many cousins that my kids never even knew that I had, my Dad relived his early years growing up in Charlestown, MA and how he went to Tufts and Tufts Medical School. He then was an Intern in Internal Medicine at Bellevue Hospital in NYC. Upon his arrival he was told that he had to work nights and sleep during the day...in NYC....in July...without air conditioning! My Mom promptly headed to New Hampshire where her parents had a lake house! My poor Dad lost 25 pounds in a month and thought about bailing out of medicine altogether. But he ultimately decided it was Bellevue that was the problem so he switched to General Surgery at University of Minnesota. Upon his arrival in Minneapolis he asked about time off....he was told that he would have from 1-5 pm off the last Sunday of every month. Otherwise he was expected to be available. Needless to say this is a far cry from the 80 hour workweek now mandated by law for medical trainees in the United States.....

My Dad has loved being a physician and could never imagine any other profession. I guess that I am the same way. Perhaps I lack the imagination to see myself in another job, but I don't think so. I appreciate the trust that patients (usually) place in me and of course, I love celebrating their triumphs and am saddened by our failures. Earlier this week I had several patients with unfortunate outcomes but then today a patient came by to introduce me to her 8 month old daughter (who I last saw as a blastocyst) and another patient emailed me happy news right from her LDR room in the hospital! As my son contemplates a career in medicine I have emphasized to him that he needs to carefully consider his choice. I think that the best physicians regard medicine as a calling rather than a career. Perhaps that is why my Dad always emphasizes that he is "Doctor Gordon" ....because that title is at the heart of his identity and the focus of his reminiscences when he revisits the past...

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Question of the Day: Failed FETs, what to do next?

Question of the Day:

Hello Dr,
I had egg retrieval in sept 2011 5 blastocyst and 6 third day embryo.I ended having OHSS and transfer was cancelled. I had my FET done with one five day embryo in october 2011 which did not work.
I had one more FET done with two embryos from third day. Today is 12th day and I got -ve on HPT.I also gave my blood this morning will have results tomorrow.I am afraid that result may be -ve.
At this I do not know what to do for IVF to work.I have followed all the instructions religiously.

What would you suggest if I was your patient. Or what you do different in my next FET cycle.
Thanks.


DrG answers:

Clearly a very frustrating situation. Here a patient had a great response to IVF medications…so great that she had to freeze all the embryos. The embryo development sounds pretty good as 5 blastocysts and 6 D3 cleavage stage embryos were frozen. Following 2 FET attempts nothing has worked.

However, I don't have all the details. Why were there both D3 and D5 embryos frozen? Why did the second FET involve the transfer of D3 embryos instead of D5 embryos? How experienced is the clinic with D5 freezing?

A few years ago we changed to ultra rapid freezing or vitrification of our blastocysts. Slow freezing is not as good an option when dealing with more developed embryos. We usually see a 95% survival rate with D5 embryos and the implantation rates are identical for fresh vs. frozen embryos. However, not all clinics have as good a track record so these questions needs to be asked in order to better understand why there has been no success in spite of the cryo-all…

However, let's assume that this is my patient and I have a great confidence in my FET program. I think that if the actual embryo transfers have been easy then one has to consider there may be a uterine factor. Patients in this situation may benefit from a hysteroscopy and an endometrial biopsy to further investigate the failure to initiate a pregnancy. Interestingly, performing an endometrial biopsy may improve implantation in the following FET cycles. The mechanism of action may involve reparative changes in the lining following the biopsy but no one really knows…. Finally, I assume that assisted hatching (AH) has been used in the prior FETs but if not then clearly AH should be used...

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Question of the Day: Blocked Tubes and IVF

Question of the Day:

My doctor said she will remove my left blocked tube to help IVF without mentioning whether I have a hydrosalpinx. Is it possible that my tube doesn't have this condition? Do they have to remove a blocked tube no matter whether it has a hydrosalpinx? I am frustrated because they don't tell you enough and I cannot ask suitable questions as obviously I don't know enough as a patient.

DrG answers:

So first of all we need to define "hydrosalpinx." This term literally means a water/fluid filled tube as "hydro" is latin for water and "saplinx" means tube. So a hydrosalpinx is a fallopian tube that has become blocked at the end that is furthest from where the tube attaches to the uterus. The far end of the tube has the fimbria which are delicate finger-like projections that allow the tube to capture the egg as it is released from the ovary. Unfortunately, if the fimbria become damaged by infection or trauma (surgery) or inflammation (endometriosis) then they can clump together effective sealing off the end of the tube. Since the tube produces fluid from the cells lining the inside, this fluid begins to accumulate once the end becomes sealed and a hydrosalpinx is formed.

The fluid within a hydrosalpinx contains inflammatorty proteins that apparently decrease implantation rates both in spontaneous conceptions (if the other tube is normal) or in IVF when embryos are transferred into the uterus. So most REs recommend that patients undergo a surgery to prevent the fluid from backing up into the uterus. This procedure may be removal of the tube or performing a tubal ligation to simply divide/block the tube. Less commonly, patients undergo a hysteroscopic procedure to occlude the tube as it exits the uterus (Essure). Patients must wait several months after an Essure procedure and have a follow-up hysterosalpingogram to confirm occlusion of the tube.

Tubes that are open but abnormal may not need to be removed but doing so may further decrease the possibility of an ectopic (tubal) pregnancy occurring after IVF. Tubes that are very abnormal may progress to a hydrosalpinx so again removal may be justified depending on the laparoscopic findings. Tubes that look normal but have proximal occlusion with no dye entering the tube do not need removal in my opinion.

The final comment of the post is particularly disturbing to me.There is no reason that patients should feel that they cannot ask their doctor appropriate questions. How very sad….My patients certainly don't appear shy at asking my opinion...

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Natural Cycle IVF Success After Essure

This has been a busy month for patients with prior tubal ligations. Although some patients with a prior tubal ligation will opt for a surgery to reverse their tubal ligation, most will pursue IVF. The data seems to favor IVF over tubal reversal if the patient is over age 37. Of course, other factors also come into play when making this decision. The presence of male factor infertility, the ovarian reserve of the patient, the desire for additional children etc…

More recently those patients seeking sterilization have undergone hysteroscopic sterilization with Essure. Essure is a procedure in which silicone-free inserts made of a polyester fiber, nickel-titanium and stainless steel alloy titanium coils are placed into the fallopian tubes from the uterus during hysteroscopy. The resulting inflammation causes the fallopian tubes to become blocked as they exit the uterus (proximal occlusion). Patients like Essure because the procedure is done hysteroscopically and is therefore less invasive than a traditional tubal ligation performed laparoscopically.

Although there have been a few reports of pregnancies using IVF in patients with Essure inserts in place, none have been in Natural Cycle IVF to my knowledge…until now that is. I have been concerned that the presence of the inserts could decrease implantation rates. Our patient had inserts that were clearly visible on sonogram. She and her husband did not desire stimulated IVF and were much happier with the NC IVF option since no extra embryos would be created. She conceived on her 2nd NC IVF attempt and everything looks great so far on sonogram.

Essure has also been suggested as an option for patients with hydrosalpinges who need surgery to block off the tubes prior to IVF. Although several studies have looked at this option, again the numbers are pretty small but reassuring. I may consider suggesting this option in the future but would still like to see some additional published series that address this question.

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DrG on NBC

This morning one of my favorite patients, Kaet Ruffner, joined me on the Midday Show on NBC channel 4 here in Washington, DC. The topic was the comments that Mr. Gingrich had made concerning oversight of IVF and specifically concern about extra embryos. Of course, there are no extra embryos in Natural Cycle IVF ....one egg, one embryo, one baby. So off we went to NBC to talk about NC-IVF....

View more videos at: http://nbcwashington.com.

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Endometriosis and NC IVF

One thing is true in medicine and that is that you never want to be an interesting patient! Seriously. You should aim to have the condition that your doctor sees all the time and knows exactly what to do. As soon as you start getting a lot of "hmmms" and "wow, that is unusual'" then you may feel free to panic a little bit. Not a lot. Just a little. Because being an interesting patient doesn't preclude a happy outcome! It just means that when you are successful then the medical team feels like they deserve a victory lap. So here is a headline for today's blog about an interesting patient....

NC IVF results in only 2nd pregnancy ever reported in a patient with endometriosis hemorrhagic ascites undergoing IVF!

Ascites is a medical condition in which excess fluid accumulates in the abdomen. Usually we see this in young patients with OHSS. Oncologists see it in patients with cancer. This past year I saw a patient that had recurrent ascites resulting from severe endometriosis. How rare is this condition? Well there have only been 63 reported cases worldwide since 1954 ! That's pretty darn rare.

The patient had first noticed the problem in 2009 and had undergone several procedures to drain the blood fluid that accumulated slowly every day. Lupron dried up the fluid but she came to see me because she wanted to conceive.

We performed a laparoscopy in April 2011 and I was shocked to see how severe the endometriosis was at that time. I thought that it was actually ovarian cancer but the pathology proved it to be endometriosis.

Her options for fertility treatment were limited since we were concerned that the use of fertility drugs could make the whole process a lot worse. Her tubes were very damaged by the endometriosis that was everywhere so she needed IVF…..

Natural Cycle IVF to the rescue! She underwent one cycle of NC IVF. Egg collection was a bit unusual as the ovary was literally floating around in her abdominal fluid but we got a healthy egg, a beautiful embryo and a positive pregnancy test. She is currently almost 12 weeks pregnant and doing great! Another first for NC IVF and Dominion Fertility!

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Question 61. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?

We often have drug reps in the office at lunchtime. As there are only really 4 companies that make pharmaceuticals that are used in fertility we get to know the reps pretty well. This past week we were speaking with a couple of reps about vaginal progesterone in lieu of PIO. The data is very good regarding success with vaginal progesterone but honestly some patients just prefer the shots because the suppositories are so messy.

Both Endometrin and Crinone may prove less annoying to patients who want a shot-free 2ww but these products are also more expensive. I advise the husbands that they do NOT have a vote in this decision unless they are willing to take IM injections themselves. Just because I am driving a new car with the vanity plates CR1NONE should not be taken as evidence that my support of a product is based on anything except a careful review of the medical literature. But seriously, I really do not believe that most doctors are swayed to prescribe a drug just because they got a free pen or because the drug rep is a former cheerleader (although in fact, most drug companies do advertise in Cheerleader magazine according to this NY Times article).

So as we head into a beautiful weekend here in Washington DC here is the latest excerpt from 100 Questions and Answers about Infertility....

61. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?

Following follicle aspiration, most clinics place patients on progesterone supplementation. The rationale behind the supplemental progesterone is that following egg collection, ovarian hormone production may be impaired because many of the hormone-producing cells are removed at the time of follicle aspiration. In addition, the use of GnRH agonists such as Lupron may diminish ovarian steroid production following egg collection. Progesterone supplementation has evolved over the years to include patients undergoing both stimulated IUI cycles and IVF.

Although many clinics tend to use progesterone-in-oil injections, equivalent pregnancy rates have been reported in patients using only vaginal progesterone supplementation. Allergic reactions to progesterone are infrequent, but switching patients to vaginal progesterone usually resolves the problem.

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Can NC IVF work following a failed stimulated cycle IVF?

When a stimulated cycle IVF fails it is devastating to say the least....all that money, all those shots, all those morning visits, the bloating, the cramping, the PIO shots....yikes, it's a wonder we can convince anyone to try it again. Thank goodness the husbands don't have to go through all that or our business would fold overnight!

So following a failed stimulated IVF it is typical to ask what other options do I have. In cases of poor responders who may have not even made it to retrieval the answer has been "not much." Some of these patients will still conceive on their own, others will try a new protocol (or add DHEAs or human growth hormone or snake oil or miracle grow..). Donor egg or adoption are great options but not every couple will consider these as viable choices. So can NC IVF work in such a setting? "Certainly not," the critics of NC IVF would opine! After all, this approach to IVF is a terrible choice for any patient and how could this approach work in cases where our best treatment has already failed.

Sound logic. However, it just happens to be disproven on a near weekly basis by our patients who pursue NC IVF. Last year I asked what readers wanted from this blog and the majority stated they wanted patient stories so here are 2 vignettes that illustrate the use of NC IVF in patients over 35 with diminished ovarian reserve and failed stimulated cycle IVF!


Patient #1: Bonus baby with NC IVF after being told FSH levels precluded another IVF attempt!


Just received a wonderful email from a lovely couple who traveled all the way from Georgia to do NC IVF here at Dominion. Having had a previous IVF/ICSI baby in 2006 they had returned to their RE for another attempt at IVF. Previously the response to medications had been poor and this time the response was even worse with no retrieval even attempted. Her FSH was 18.9 and they were told that essentially no good options existed in terms of IVF. Fortunately, they had heard about NC IVF and we had a phone consult in April with an IVF attempt in June. Her AMH was <0.16 consistent with diminished ovarian reserve.

Her NC IVF cycle was picture perfect and they ended up with a beautiful early blast for transfer then headed back home. I received the good news that the blood pregnancy test was positive and rising fast. Then came the first shock...it was a twin pregnancy. Yup identical twins. Then came the second shock...the twins were sharing the same sac (in medical terminology they were mono-amniotic, mono-chorionic twins). Then the final shock...there was possibly a third sac.....Fortunately, this last shock turned was not true...there was just a probable blood clot that ultimately went away.

Pregnancy went amazingly well and the girls were delivered at 32 and a half weeks. They spent 2 days in the Intensive Care Nursery and should be home soon. What a great outcome to such a surprising story...one egg, one embryo, TWO healthy babies!


Patient #2: Ongoing pregnancy with NC IVF at 40 with FSH of 17 and AMH of <0.1


Back in 2009 I met DM who was turning 38 and been referred to me by one of my patients who had succeeded with NC IVF after being told donor egg was her only option. We discussed NC IVF versus stimulated IVF and elected to try stimulated IVF. On a MDL flare protocol we got 3 follicles but only one egg and she failed to conceive with transfer of that embryo. I suggested we consider NC IVF rather than pursue additional medicated cycles.

Her first NC IVF cycle resulted in a pregnancy but unfortunately she had a miscarriage. The second NC IVF cycle resulted in a healthy full term baby. She returned this Fall to try again. On day 3 of that third NC IVF attempt her FSH was 17. But we got a nice egg, a beautiful embryo and she conceived again. That makes her 3 for 3 using NC IVF. Currently she had an ongoing pregnancy and here's hoping for another successful outcome.

Again this demonstrates the limitation of ovarian reserve testing when applied to NC IVF. When one eliminates the use of fertility drugs all bets are off when it comes to ovarian reserve. Makes our job difficult since patients assume that diminished ovarian reserve = poor egg quality and the relationship just isn't that simple!

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IUI vs IVF...The FASTT Trial

Frequently I am asked about IUI compared to IVF and specifically about NC IVF compared with IUI. Although IUI can be successful, there are clear limitations to an IUI. First of all, unless pregnancy occurs an IUI does little to explain why a couple has failed to conceive.

Could the tube have failed to catch an egg(s)?
Could the sperm have failed to find an egg(s)?
Could the sperm have failed to fertilize an egg(s)?
Could the fertilized egg(s) have failed to grow?
Could the embryo(s) have failed to make it to the uterus and failed to implant?

The answer to all of these questions following a failed IUI is "we don't know."

This is the reason that IVF is a powerful diagnostic as well as therapeutic tool. It is so difficult to counsel a patient undergoing a stimulated IUI cycle with multiple dominant follicles. On the one hand you have to say "well, there are 6 good follicles so we could end up with 0-6 babies..." Then when it fails (which is more often than it succeeds) you have to say "well, we really have no idea why it didn't work." Very frustrating indeed.

The FASTT Trial aimed to look at the impact of omitting FSH/IUI for patients with unexplained infertility who were <40 years old. Its results clearly demonstrated the superiority of IVF first compared with FSH/IUI then IVF if FSH/IUI were unsuccessful. I think that NC IVF is also superior to IUI. Perhaps the comparable option would be CC/IUI but I think that NC IVF is likely superior to even FSH/IUI in cases where a couple has no previous pregnancies or there is possible male factor or possible tubal factor or endometriosis. Since many patients do not have a laparoscopy these days, it could be that many of them have an element of tubal disease or endometriosis and clearly IVF would be superior in these patients.


So for those wanting to conceive FAST.....think about the results of the FASTT trial and give strong consideration to IVF. It is not the only option but it may be the best option...whether it is NC IVF or stimulated cycle IVF.

Good luck.

DrG

A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril. 2010 Aug;94(3):888-99. Reindollar et al.

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Here comes 2012!!

Happy New Year! (belated)

Good grief, somehow I have failed to post for nearly 6 weeks….How is this possible? Beats me but I am hoping to make up for it in 2012. This past year was full of ups and downs. I am hopeful that 2012 will be a little bit less of a roller coaster ride for the world economy. Last weekend I was camping (yes, in a tent) with the Boy Scouts at the USNA Jambo at Annapolis. It was pretty chilly at night and I may indeed be getting too old to sleep outside in a tent when all standing water freezes solid…Be that as it may, I was so impressed by the young men and women at the Naval Academy. What a great education and what outstanding young people…it gives me hope for the future that I rarely feel when reading about 20 somethings living in their parents' basement playing X Box 15 hours a day and transforming slowly into Jabba the Hut. So last weekend I was too busy to work on the blog.

I did get a week off as well just after Christmas and then there was an avalanche of charts to deal with upon my return. Still not sure where all my time went. I have no recollection of being abducted by space aliens so who knows how i managed to neglect the blog so long but there you have it.

There are still numerous chapters left to cover from our book. There are some very interesting cases from our clinic to share (with no identifying info) and there are some clinical questions that I really want to discuss.

As we start this New Year of 2012 I would also like to address those who wish to post a question or comment.

First of all, when you post a comment it goes to my Inbox before it gets posted to the site. Thus, don't fret if you fail to see your well constructed post appear with a single mouse click. I was getting so many posts about Viagra that I had to change my settings with Google so all posts had to be approved by me before they are posted to the blog.

Secondly, it would be nice for those who post comments to enter some sort of screen name. I get tired of replying to Anonymous #1, #2, #3 etc etc. No salesman will call. No email spam will be sent. I just think that if you are asking for an opinion then you can at least share some sort of name with me…even if it is totally unrelated to your real name.

Finally, if you are dying to read my opinion on a particular issue then please post it as a comment to this post and I will try to cover it this year. Medical issues are preferred but I can certainly weigh in on my favorite DC Pizza restaurant or why my wife hatesd Tom Brady and the New England Patriots and other matters of critical importance….

Happy New Year to all!

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