Stim...retrieve...transfer....fail....repeat. NOT the Dominion Fertility approach to IVF.

Readers of this blog know that I have wide ranging taste in movies. On the one hand I loved Frozen and have been known to sing along with Broadway show tunes (much to the chagrin of my wife and kids). On the other hand, I am a lover of Sci Fi and zombie movies who surfs through the movie channels every night looking for giant monsters or giant robots or giant monsters fighting giant robots (Pacific Rim anyone?). In particular, I love movies that feature time travel such as Star Trek: First Contact, Looper, Source Code, X-Men: Days of Future Past, and now my current favorite chronologically confused film: Edge of Tomorrow.

What a great movie! What a great movie concept! Who would have ever thought of combining Groundhog Day (Bill Murray's best movie IMHO) with Starship Troopers (one of my all time favorite films but one with no redeeming social value)...what an inspired concept. In this movie, Tom Cruise actually does some excellent acting and Emily Blunt plays a hardened super-soldier which is playing against type to say the least. As you can probably guess from my description and the movie poster Tom Cruise ends up with the ability to relive his last 24 hours over and over again after being splattered with alien blood and gore on the battlefield. Like the Bill Murray character in Groundhog Day he grows as a person while becoming the soldier that he never thought he would nor wanted to be (he starts the movie and an unapologetic coward who is happy being a "talking head" for the military but completely uninterested in seeing war up close and personal). Tom Cruise doesn't draw the fans in as much as he once did so I convinced my daughters to accompany me to the multiplex last Sunday to catch the film before it was too late. My older daughter loves intense, kick-ass movies that feature the military fighting zombies, giant monsters, bad guys etc. She is seriously considering attending a service academy and her favorite new TV show is The Last Ship on TNT. However, after watching Edge of Tomorrow she definitely is leaning towards Navy and not West Point based upon how J Platoon fared in their hand to hand combat with the alien horde. My younger daughter took some convincing to see the movie and I kept an eye out for agents from Child Protective Services when purchasing our tickets (the movie is PG-13 but the Family Filmgoer described it as loud and intense but without blood and gore). They both loved the movie as did I so you need to go see this movie before it gets bumped out of the multiplex for Transformers.....Tell them DrG sent you.

So what does a 5'7" actor killing disgusting inter-galactic squid-like creatures have to do with infertility and IVF? I guess the point I want to make is regarding adapting and thinking outside of the box. To illustrate, let me share the stories of two patients pursuing fertility treatments.

L.P. is a 37 year old who came to see me after 3 failed stimulated IVF attempts at another IVF clinic. Her FSH was 14 IU/liter with an AMH < 0.16 ng/mL. Each of her 3 stimulated IVF cycles with had ended poorly without a single attempt at egg collection. In each case she had failed to meet the other clinic's minimal requirement of 3 large follicles needed to permit a patient to go to retrieval. Each stimulation essentially utilized the same protocol without much variation. Their recommendation was donor egg or adoption. When I met with L.P. she was uninterested in donor egg or adoption and thus only wanted to try Natural Cycle IVF. On the second attempt she was successful and delivered a full term healthy baby. She returned several years later and at the age of 41 was interested in another attempt at NC IVF. Amazingly enough, she was again successful on the second cycle and again delivered a healthy baby. Stim...fail to respond....repeat. Not a recipe for success. Kudos to her for hanging in there and believing that something so simple could be successful...twice!

The second patient had traveled a different path to Dominion. K.F. is a 35 year old who had also undergone 3 cycles of stimulated IVF at another clinic. However, she had been an excellent responder to medication so she represented the opposite end of the spectrum from L.P. Each of her stimulated IVF cycles resulted in over 20 follicles and she had over 15 eggs retrieved each time. However, her embryo growth was disappointing with most embryos failing to develop well and no pregnancies and nothing to freeze in any cycle. We discussed the situation and I explained that we were dealing with one of three issues: 1) an intrinsic egg issue that we could not fix; 2) an intrinsic sperm issue that we could not fix or 3) a stimulation issue. The only way to prove that the issue is an intrinsic one with the egg and sperm would be to a) use donor egg/donor sperm, b) do PGS to see if they could produce any normal embryos or c) get pregnant. Option (a) was not acceptable and option (c) would have been nice but seemed unlikely without assistance leaving us with option (b). Although we could do PGS, we needed to consider changing her stimulation in order to get adequate embryos to blastocyst. I recommended reducing her stim dose aiming to get 8-12 eggs hoping that the concept of quality over quantity would hold true for her. Fortunately, her stimulation went very well and several embryos made it to blastocyst and were biopsied for PGS. Two genetically normal embryos were transferred but she failed to conceive. So we had demonstrated that as a couple they could generate genetically normal embryos but these had failed to implant. At this point we discussed performing an endometrial biopsy prior to additional IVF attempts, gestational carrier IVF or repeating an IVF cycle now that we seemed to have a better protocol for her and skipping the PGS since we had proved that they were able to produce genetically normal embryos. This time we hit the jackpot and they conceived with IVF.

I hope that these stories indicate the benefit of modifying future IVF based on past IVF cycles. Sometimes these changes are significant such as changing to Natural Cycle IVF whereas other times the changes can be subtle such as adjusting stimulation meds or doing an endometrial biopsy or convincing a bad-ass like Emily Blunt that you need to call off the planned battle with the Mimics and look for the Omega (which is hiding under the Louvre in Paris) in order to save the Earth...oops, wait that was a movie....I think.

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Avoid getting stung...advice from Dr G at Dominion Fertility

No good deed goes unpunished. I spend a fair amount of time traveling between our Fair Oaks and Arlington offices in order to do my best to do all the egg collections and embryo transfers on my own patients. So when my wife called to say that there was a lot of unanticipated activity in our neighbors backyard that seemed to involve significant tree work I thought that it would be helpful for me to pop in on my way back to Arlington for a quick look. Once at home I assured myself that the neighbor was not decimating trees on my side of the fence and thought that I could quickly knock some items off my project list and clear out a cedar dog house that our dog refuses to use. Bad idea. Did you know that bumblebees have small nests that usually are in the ground? I didn't. Did you know that bumblebees can make a nest in an old dog mat instead of in a hole in the ground? I didn't. Did you know that bumblebees are usually pretty docile and slow to anger and slow to sting a human....unless their nest is disturbed? I didn't. Did you know that angry bumblebees go for the eyes of any intruder who disturbs their nest? Well, I do now...

So as I ran screaming like a little girl away from the dog house, the angry bees followed and one of them managed to sting me on my eyelid. In short order my face started to swell on that side in spite of ice and benadryl. For some reason, this series of events elicits laughter from everyone who hears the story...my wife, the nurses, DrD.... I returned in time to see my afternoon patients. I wore my biggest set of glasses but did warn patients that indeed my face was swollen on one side. Of course, they could no longer look anywhere else and spent the consultations fascinated by my facial asymmetry.

So what does this have to do with Reproductive Medicine? Well, I guess the point I am trying to make is that you never know when you are going to get stung....in the eyelid. When counseling patients about a course of treatment one of my biggest concerns is that of multiple pregnancy. With twins (and worse) you just never know when you are going to end up in a tough situation. Twins have a markedly increased risk of preterm delivery compared with singletons and all the problems that go along with prematurity. Time Magazine recently had a cover story about preemies and how far we have come in handling our smallest patients. But the best treatment for prematurity is prevention. Electing to pursue IVF instead of superovulation and IUI will help. Preimpantation genetic screening to identify the normal embryos will help since if we transfer a single genetically proven normal embryo then the risk of twins will be incredibly low (although not zero because of the chance of identical twins). I spend a lot of my day trying to convince patients that twins are not a "buy-one get one free" type of deal. There is a cost involved....to the family, the children and to society. So try your best not to get stung....go with elective single euploid (genetically normal) embryo transfer and watch out for those damn bumblebees.

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Roller Coasters, Car Keys and the Use of the Matcher System at Dominion Fertility.

I am really not a roller coaster aficionado. In fact, I sometimes have a tough time with elevators that drop too fast....So when I recently found myself in line for Expedition Everest at Animal Kingdom in Disney World, I wasn't too thrilled. But I hung in there and through the magic of SmartPass I was able to negotiate the line without enough time to change my mind. I survived. Barely. Needless to say, I was not rushing over to one of the vendors after exiting the ride to purchase a roasted turkey leg (bleah).

I almost had that same look of terror on my face in our hotel room at midnight on our last night on vacation. It was at that time that I became convinced that I had somehow lost the keys to our minivan that was parked at the Charlotte airport back in North Carolina. At age 50, after countless vacations and business trips, this was a first. I never found the keys but fortunately my wife had brought a spare set and so disaster was averted. I have no idea where the keys went. I called Disney, both airports, the car service and no luck. Gone. Disapparated. Zip. Nadda. My best guess is that they ended up in the hotel room trash can. Oh well. Through the magic of the internet I was able to order a replacement key fob with remote for $60 and reprogram the thing myself using a YouTube video. Gotta love technology. Still, I wish I knew how I managed to do such a boneheaded thing as lose my car keys on vacation. You can bet that from now on I will be using that little key hook that is in the inside pocket of my suitcase....

Sometimes it takes a near miss to make you reevaluate something as simple as using the key keeper on you luggage, but it would be so much smarter to use the key keeper every time right from start. Here at Dominion Fertility we believe that an ounce of prevention is worth a pound of cure and that is why we are now the first clinic in the United States to use a patient identification system known as the Matcher System from IMT International. This system allows for precise patient identification and linking of eggs, sperm and embryos so as to prevent the possibility of error. We firmly believe that use of such a system is in everyone's best interest as a mix-up in eggs, sperm or embryos would have catastrophic implications for all involved. So all I can say is that I am glad that we are using the Matcher System and I sure as heck will now use that darn key hook on every trip in the future!

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Salon.com got it right. DrG at Dominion Fertility agrees.

Over a decade ago I received an odd email from the folks at Salon.com. They had seen my book: Obstetrics, Gynecology and Infertility: Handbook for Clinicians and were hoping that I would serve as the medical professional on a team of editors that was working on a book that Salon.com would publish. Seemed like a chance to make sure that the public got appropriate medical advice in terms of reproductive health so I tentatively agreed. "Just send me a list of the chapters so I can make my final decision," I requested.

Now I guess that at the time I was a bit naive about the interests of the target audience and basically thought that the book would just be about typical REI stuff....wrong. With chapters like "How to make sure that your sex toys don't transmit STDs" I realized immediately that I was way out of my little Presbyterian, Eagle Scout comfort zone. So I ended up begging off the project and handing it off to a recent graduate of the Ob Gyn residency program who was a little more up to speed on the whole subject of "marital aids"  and other topics that still make me blush.

Since that failed project I have honestly never been back to the Salon.com website...until recently. This week Dr. Reh shared with me a story circulated on social media concerning the recently released CDC ART Clinic Data (link to Salon.com blog). IMHO, the article is pretty on target . The story addresses the whole issue of patient selection by ART Clinics and the limitations that SART attempts to place on clinic advertising that are rarely followed (in our opinion).

In 2007 when we started the NC IVF program we realized that by offering NC IVF we would totally destroy our "rankings" based upon the CDC reporting requirements. But we believed that it was the right decision to offer NC IVF and now thousands of cycles later we stand by that decision. Our experiences with NC IVF have also markedly changed our view of the low responding or poor prognosis IVF patient.  So check out this blog on Salon.com and maybe you can even find answers to some of those questions that still make DrG blush....

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Managing DOR at Dominion Fertility

Here in Washington DC we love acronyms. The entire government is one big acronym....DHS, HHS, DOJ, IRS, etc, etc.

In medicine we are similarly guilty of using incomprehensible terminology. We say "ick-see" (ICSI) but spell out IVF. We throw around terms like IUI, DI, AI without a second thought.

Last week during a consult a patient confided in me that she had "door." I didn't want to sound like a dolt so I just rolled with it until she asked me again if I had a lot of patients with "door." Hmmm. Now this past week I was under the weather from some unknown cause and needless to say I was a bit slow on the uptake. Finally, the synapses clicked and I got it..."door" = "DOR"= diminished ovarian reserve.

Diminished ovarian reserve refers to the clinical situation of a patient who has a limited number of follicles (usually for unexplained reasons) and therefore whose response to fertility drugs is usually very disappointing. Many patients with DOR fail to get egg collection in a stimulated IVF cycle and end up getting canceled after spending thousands of dollars on fertility medications that were ultimately of no benefit.

There have been numerous suggestions as to what drug protocol is best to use to stimulate such patients: microdose lupron flare, stop lupron, no lupron, clomid/gonadotropin combo, low dose stim, high dose stim, snake oil and pixie dust.... In addition, many adjuvant drugs have been used: DHEAS, growth hormone, thyroid hormone, MiracleGrow, etc.

There is no real harm in trying these protocols (except to one's bank account and also the emotional exhaustion that sets in when repeated cycles have failed to get off the ground). 

So at the end of the day patients who have repeatedly failed to get to egg collection are usually told that their only options are egg donor or adoption or quit trying. However, one benefit of having a well-established Natural Cycle IVF program is the profound satisfaction I get from receiving birth announcements (sometimes with yummy cookies attached) from patients who were previously told that their situation was hopeless. So although I totally agree that donor egg IVF or adoption are higher yield options in terms of success, these are not always viable choices for all patients. In addition, just the act of trying NC IVF represents an important bridge for some patients.

So I guess the take home lesson is that in our office is that if you have DOR that doesn't mean I am going to show you the DOOR. (ugh, terrible pun but couldn't resist).

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Happy Valentine's Day from Dominion Fertility

DrG wishing you all an early Happy Valentine's Day just in case I don't make it home in one piece given the "wicked" (Bostonian for very impressive) storm that blew through here last night and today....

My parents were married for 67 years. That is a very impressive accomplishment. Somehow they made it work although there was certainly a fair amount of yelling at times... How can you explain how to stay together for such a long time? In one sense it is unexplainable (certainly my wife will be hard pressed to suffer for 41 more years of Yoda impressions). But since it now hurts my vocal cords to say "Try not, do or do not. There is no try" we may not be headed to divorce court any time soon....

Infertility can also be unexplained. That doesn't mean untreatable. Just got a nice birth announcement from a couple with unexplained infertility who had failed 3 rounds of clomid/IUI and came to see me back in December 2012. All testing had been fine: normal HSG, normal semen analysis, normal ovarian reserve testing.

Why does CC/IUI fail? Good question. Perhaps the tubes (although open) failed to capture the egg(s). Perhaps the sperm failed to find the egg (they get lost, they die, they don't ask directions). Perhaps the sperm and the egg didn't like each other (What no flowers or box of chocolates?). Perhaps the egg didn't fertilize normally. Perhaps the embryo didn't grow normally. Perhaps the embryo failed to make it to the uterus. Perhaps the embryo failed to implant. All we can say after a failed IUI is that it failed.

IVF offers a chance to gain some additional information. Even if IVF fails, we can at least see if the egg looked OK, if the egg fertilized, if the embryo grew... Success rates for IVF increase with each hurdle that is cleared: successful retrieval, successful fertilization, successful embryo development, successful embryo transfer....

Given all these issues, my patient elected to pursue Natural Cycle IVF. She had considered FSH/IUI and stimulated IVF. Given her age of 37 she would be unlikely to end up with a high order multiple pregnancy with FSH/IUI but she and her husband were frustrated with the lack of information gleamed from IUI cycles.  Stimulated IVF was an option but they elected to try NC IVF as a first step.

6 sonograms, 1 egg collection and 1 embryo transfer later they were pregnant and delivered a full term healthy baby recently. Score another victory for NC IVF. Remember that infertility may be unexplained but that doesn't mean untreatable.

Pray that I make it home to Maryland today. If you see a silver Murano in a ditch that could be me but I will channel my inner Boston driver and do my best to get home safely!

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Happy (Belated) New Year from Dominion Fertility!

It has been a very busy couple of months here at Dominion Fertility but I am slowly digging out from a number of time consuming projects ranging from writing a couple of research papers to updating all of our consent forms and everything in between. One of my favorite yearly holiday projects is trying to reply to all the Christmas/Hanukkah/Kwanza/Festivus/New Year's cards that I receive here at Dominion. Unfortunately, after 18 years in practice I tend to get a bunch of cards and it takes longer and longer each year to get all my replies out the door. (Note: If you sent a card and didn't get a reply from me, then it is probably because the card failed to get routed directly to me so don't take it personally....or it could be Sam's fault).

Every December I have to relearn how to use Adobe Photoshop so I can add in employees who fail to make the group photo seen above. Next week I will provide an answer key for those interested in figuring out who was Photoshopped into this year's photo and who was actually there that day....Make sure you get your answers in ASAP.....

So a belated Happy New Year from DrG....

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Double Trouble at Dominion Fertility

Hey, DrG here in the frozen wasteland of our Nation's Capitol. Funny that when the weather turns nasty here in the Metro DC area the government shuts down, the schools close, the supermarkets run out of toilet paper and milk...but our patients make it to the office without any problem whatsoever....

This past week has been a week of identical twins for me....officially termed monozygotic twins (scientific talk meaning one egg/embryo). The best thing about MZ twins is that I can confidently look the patient in the eye and say categorically that this is not my fault. Apparently God or the universe or whatever you believe controls our fate wanted you to have twins because I cannot put back fewer than one embryo. I am even more innocent in cases where patients have MZ twins after an IUI as opposed to IVF as there is an increased rate of MZ twins in IVF compared with conceiving au naturel (yes, sometimes patients are rude and conceive without our help) or with IUI.

Twins that share a placenta can either be in their own little amniotic sac (diamniotic twins) or share a single sac with their sibling (monoamniotic twins). Identical twins do represent a higher risk pregnancy than fraternal (dizigotic) twins and can experience twin-twin transfusion syndrome which is life-threatening and can require advanced intervention prior to delivery (such as laser ablation of communicating blood vessels).

Last week one of my patients stopped by to visit with her beautiful identical twin girls that were from IVF. She told me that her doctor had said that the girls were probably identical but that no twins are really identical. Technically correct I suppose since twins have different fingerprints but at a genetic level they are identical since they came from a single embryo that split. Since these two were in a single sac (mono amniotic) there is no doubt that they were identical. The best news is that they were healthy and happy....plus I didn't have to do any babysitting!

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True Love Can Thaw a Frozen Heart (? and egg)....

I am a wuss. Seriously. My kids totally make fun of my sentimental nature. Years ago we had a pet hedgehog named Pocus. I had found Pocus wandering along our street in Long Island (long story) and adopted her. She moved with us to Maryland in 1999 and actually attended the closing on our house (a first at the Title Company). Pocus passed over the Rainbow Bridge a couple of years later and we buried her under a tree in our yard. At her memorial service I was the only one crying. This summer we lost our beloved Mini Schnauzer Dollie. As we laid her to rest under another tree in the backyard we read a number of appropriate selections including "Jesus Needed a Dog in Heaven." Guess who was unable to read the poems without breaking down...that's right, yours truly. Needless to say, these losses pale in comparison to losing both of my parents over these past 18 months. I still find myself trying to call home in the mornings on my way to the office nearly every day. I miss them both so terribly much that I find myself tearing up several times a week which I guess is pretty normal....

So when the kids decided that we needed to see the movie "Frozen" I was actually totally unprepared for the experience since I thought it was just a goofy Disney movie about a weird singing snowman. Wrong. The beauty of this movie is that it turns so many Disney Princess Movie conventions upside down (and believe me, I know a LOT about Disney Princess Movies since Daughter #2 is a princess aficionado!).

MOVIE SPOILER ALERT: If you have not seen the movie Frozen then skip below to: SAFE TO RESUME READING. Here is an edited version of the IMDB Synopsis: 

In the Kingdom of Arendelle, the King and Queen have two daughters: the elder named Elsa, and the younger, named Anna. Of the two, Elsa is special, as she was born with a power to create snow and ice. While Anna's life is rather normal, Elsa has to contend with her powers growing stronger as she matures. Her father cautions her to wear gloves to keep her powers in check, as well as conceal her feelings, which seem to cause her powers to manifest.

Unfortunately, the girls' lives are turned upside-down, when their parents are lost at sea. Of the two, Anna is the only one to attend the funeral, and goes to Elsa's door, pleading for console from her only other family member, but Elsa (sadly) refuses to communicate to Anna.

3 years after the death of their parents, Elsa has come of age, and the castle is in preparations to crown her as the Kingdom's Queen. Elsa is nervous about opening the doors to the castle and receiving the many guests to the kingdom, while Anna is eager to get out of the castle. When Elsa gives the order to open the castle doors, Anna eagerly rushes out into the city, and encounters a handsome prince named Hans. As the two talk further, they both find that they seem to have so much in common. This revelation soon leads to Hans proposing to Anna, and her eagerly agreeing.

Returning to the ballroom, they both ask Elsa to approve of the marriage, but Elsa grows emotional, and claims she will not grant this blessing on her sister. Elsa then requests that the guests leave, setting Anna off on a tirade at her sister. Unable to contain her emotions, Elsa makes a violent sweep with her arm, causing a barrier of sharp icicles to appear. Shocked at the room's reaction to her powers, Elsa rushes from the room, and across the waters of the kingdom, her feet causing ice to form, allowing her to flee into the far mountains.

Arriving at the Ice Palace in the mountains, Anna enters but Elsa retreats to the upper portion of the palace, and Anna follows her, explaining about the "eternal winter" plaguing the kingdom. Elsa grows so upset at what she has caused, that she unleashes an icy chill, of which a portion strikes Anna in her heart. Kristoff suddenly notices that Anna's hair has started to turn white. Fearful that she may be injured, Kristoff takes her to his family...who happen to be a group of rock trolls.  The trolls determine that being struck by her sister's powers, has caused Elsa's heart to begin to freeze. As he cannot save her, Pabbie (head troll) tells them that "an act of true love, can melt a frozen heart." Anna's condition grows worse, a chill coursing through her, and more of her hair has turned white.  Eventually, Anna is brought to Hans, and tells him that he has to kiss her in order to save her.

Hans places Anna in a chair...but then reveals that he doesn't really love her. As Anna shockingly looks at him, Hans explains how being the youngest of 13 brothers, he feels he would have no chance at claiming his family's throne, and so went looking for a Kingdom he could marry into. Elsa would have been suitable, but no one seemed able to win her over. However, upon finding out about Anna's naivete, he played her along, intending to marry her, before causing some form of "accident" with her and Elsa, thereby taking the throne.

However, with Anna's current condition, he plans to simply have her frozen heart overcome her, then kill Elsa, ending the eternal winter. Anna tries to stop Hans, but he extinguishes the fire in the nearby fireplace, before locking her in the room. It is then that Anna collapses, her hair now completely white. Meanwhile, Hans has found Elsa wandering the ice of the fjord. Thinking he's come for her, Elsa tells him to leave her alone, and take care of Anna, only for Hans to lie, and say that Anna was killed by Elsa's magic. The pain of this causes Elsa to collapse, the snow in the air suddenly hanging in stillness.

The sudden stopping of the whiteout, causes Kristoff to see Anna, and he quickly runs to her, but as Anna looks around, she sees Hans about to stab Elsa. Even with her own life at stake, Anna rushes in front of Hans, blocking the knife. As she does so, her frozen heart finally consumes her, turning her into a statue of ice, and shattering Hans' blade.

This causes Elsa to turn around, and upon seeing her sister turned to ice, she breaks down in tears, hugging her sister, saddened that she has lost Anna. No one is sure what to say, when suddenly, Anna's icy form begins to dissipate, and she returns to normal! Apparently, Anna broke her own spell, with saving her sister (an act of true love).

It is then that Elsa realizes what can end the winter: love. And with this realization, she dissipates the ice and snow, and summer returns to the kingdom.

What great plot twists. Princess Anna falls in love in one day and her older sister totally shuts her down when Anna suggests that she and Hans are going to marry that same day (or very soon)! SHAZAM! Then turns out Elsa is vindicated when Hans turns out to be completely evil scumbag. SHAZAM AGAIN! Finally, as Anna is about to have her frozen heart thawed by her "true love" (of 2 additional days), Kristoff, she decides to turn away from his kiss in order to rush and try to save her sister. And guess what, her true love is for her sister and not for cute, blond, reindeer loving Kristoff.  GAME, SET, MATCH. Man, what a great movie.

SAFE TO RESUME READING:
So what the heck does all this have to do with frozen eggs?  Well, a couple of years back we started our Life After Cancer Program.

The Dominion Fertility “Life After Cancer” Program provides young women with the option to preserve their eggs, free of charge, prior to undergoing cancer treatments that threaten their fertility. While men have been able to freeze sperm prior to cancer treatment for many years, women have not had this option until recent advancements in egg freezing techniques. Egg freezing is not covered by medical insurance, and would normally cost a patient approximately $10-12,000 for one cycle. This service is complimentary to qualifying patients as part of Dominion Fertility’s commitment to providing exceptional patient care. Dominion Fertility is one of few fertility centers in the country to offer such a charitable program.

When reviewing whether or not a patient is an appropriate candidate for egg freezing prior to chemotherapy I take several factors into consideration.

First of all, what type of cancer does the patient have and what is the time frame for starting chemotherapy?

Secondly, will the change in hormone levels during ovarian stimulation possibly adversely affect the patients chance for long-term cure? This question is extremely difficult to answer with any certainty and some Oncologists are more open to their patients undergoing ovarian stimulation than others. Protocols using Letrozole, GnRH-antagonists like ganirelix and GnRH-a trigger (Lupron) can result in excellent numbers of eggs with shocking low estrogen levels.

Thirdly, what are the chances that the patient will respond well to stimulation making any delay in starting chemotherapy worth the effort? In general, it is estimated that it takes 6-8 frozen eggs to have a good chance of pregnancy and delivery (also depending upon the age of the patient, of course).

Finally, is egg cryopreservation consistent with the needs/desires of the patient and are other options more appropriate (embryo cryo) or even no fertility preservation treatment (if patient's life expectancy is sadly very limited).

Infertility can cause the loss of a dream of being a genetic or biologic parent but not loss of life. Not true in Oncology. And yet, as cancer cure rates have soared the need to consider cancer patients future fertility has become more and more important. Egg freezing offers some additional hope for genetic parenting after chemotherapy. Other interventions include the use of Depot Lupron to protect eggs from chemotherapy. Not all studies have shown Lupron to be effective but the risk/benefit ratio favors treatment in my opinion.

The point of the Life After Cancer Program was to remove financial worries from the equation. But why do it? Why offer free treatment in this setting? I know why I do it....because I love my job and I love my patients and it breaks my heart to hear about patients unable to explore egg cryopreservation prior to chemotherapy for financial reasons. So if love can thaw a frozen heart, like in the movie Frozen, then maybe love is the right reason to freeze an egg...

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Over the Edge....Taking it one step at a time.

I am not a very good skier. When renting skis I am never tempted to describe myself as a Type III skier. I am more comfortable cruising along on greens and blues rather than attacking black diamonds. Part of this could relate to my memory of fracturing my collar bone while on a college ski trip to Mount Snow in Vermont. Sadly enough, that injury occurred on the first day of skiing and while on a trip that I had worked hard to organize. Oh well. Meconium happens. So fast forward to this past weekend when I found myself staring into the abyss of black diamond slopes while skiing with son #2. Good grief! The damn trail just dropped off into the ether...How was I going to get down this slope and not have to change my underwear? The answer was one step at a time. Suddenly I was actually doing it and actually enjoying myself. What a shock!

Going down that black diamond was not as different from some of those blue trails as I had feared. So it is with Natural Cycle and Stimulated Cycle IVF. At first Stimulated IVF just seems totally overwhelming to some of our patient. But really it isn't such a huge leap from NC IVF.... There are ultrasounds and blood tests and an egg collection and usually an embryo transfer (but sometimes in the month after the egg collection). The fertility drugs are the difference and these days the drugs are a lot easier to handle. Using GnRH-a (Lupron) to trigger instead of HCG has nearly completely eliminated OHSS but does necessitate freezing all the embryos (in our opinion). So going down those black diamonds is a lot less intimidating after getting experience on the blues and doing NC IVF prior to stimulated IVF may help patients ease the transition as they look over the edge...

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