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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