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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