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mardi 27 mars 2012

Question of the Day: Diminished Ovarian Reserve

Posted on 06:31 by Unknown
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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mercredi 14 mars 2012

Looking and Not Seeing

Posted on 14:46 by Unknown
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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jeudi 8 mars 2012

Revisiting the Past

Posted on 14:05 by Unknown
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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