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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