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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Two is not better than one....at Dominion Fertility!

Two are not better than one.....Two weeks ago I was zipping back to the Arlington office from the Fair Oaks location when suddenly there was a Virginia State Trooper on my tail with lights flashing. Ugh. I pulled over to the side on I-66 and dutifully awaited the officer's arrival. Honestly, I really had no idea what I had done. I was certainly not speeding. I wasn't weaving (heck, I can't even knit....that was from Robin Williams). I was using my hands free wired ear buds (to avoid brain cancer from my iPhone). What on Earth had I done wrong?

The answer came as swift justice. It is illegal to drive in the Commonwealth of Virginia with both ear buds in place. One is OK, two not so much. Seemed logical and yet I honestly never knew that this was actually illegal. Neither did my insurance agent. Neither did my wife or kids or anyone at my office. Go figure. You would think that in this day and age where every item contains instructions that are beyond simplistic that my ear buds would have a big sticker on them that read: "Hey MORON, don't drive with both ear buds in your ears!"

The same is true when it comes to deciding to transfer 1 vs. 2 embryos. 1 is safer and makes more sense. True you can get away with 2 most of the time. Some patients will have twins but most will not. But some patients with twins deliver extremely premature babies that don't survive or who struggle with lifelong health issues. One is better. Just like when driving along I-66 with your ear buds in place!

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Thanks to Those Who Serve - Happy Veteran's Day

I want to offer a heartfelt thanks to the brave men and women who serve or have served in our armed forces. My late father actually managed to serve in both the Navy (pictured here) and the Army. Growing up with extremely limited means in Charlestown, MA the V-12 Program supported my father's aspirations to attend college and medical school. My Dad loved to tell me stories that they were so poor that he had to eat lettuce sandwiches since they were too poor to afford meat to put in the sandwich. However, my Dad later confessed that he actually traded the sandwich meat for chocolate cake or other dessert items once at school....

Following the end of World War 2 (he graduated from Tufts Medical School in '47) Dad wanted to go to Europe to serve but as member of the Navy he was told that he would likely be assigned to Portsmouth Navy Hospital here in the US. Fortunately one of the former residents at the University of Minnesota was head of medical procurement for the armed services so in 1948 he and my Mom drove to Washington DC from Minneapolis to find out where he would end up. Turns out there was a spot in Trieste Italy and so Dad was made Chief of Surgical Services and off they went to Europe. Along the way he was quickly transferred from the Navy to the Army! Service to his country was very important to Dad. His two brothers had served as members of the medical corps assigned to the Big Red One and fought all across North Africa.

Although his military career was not long-lived, my parents had a deep love of country and respect for those who serve. Dad finished his career as a surgeon in the VA medical system. In July, he was laid to rest with full military honors including an honor guard. God bless all of you who serve or have served our great country both in peacetime and in war.

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Vote Early....Vote Often for My Patient.

One of my favorite patients is a finalist in the Ferring Pharmaceutical Heart to Heart contest (https://hearttoheartcontest.com). Although Gena does not name me or Dominion Fertility, I have her permission to share her story and encourage all of you to vote for her by going to the Ferring Website https://hearttoheartcontest.com/.

Gena is an amazing individual. I diagnosed her as having Hypothalamic Amenorrhea and all stimulations were done with Menopur only. Patients with HA sometimes have suboptimal endometrial linings. This was the situation with Gena and we began discussing the use of gestational carrier following the disappointment that she describes in the video.

Ultimately they had a wonderful experience with their gestational carrier who ended up carrying twice for them. 

I am so happy for the entire Marino family. They are wonderful people and hung in there with me through thick and thin. I once asked Gena if she had ever thought about jumping ship and switching clinics. She gave me that look and said "no way Dr. Gordon. You were not going to get rid of us!" Glad she hung in there and hope they win the $15,000 scholarship.

Daily voting is allowed. Polls close this weekend! Vote early. Vote often.

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Improving Implantation: The goal of SEET using PGS

The Holy Grail of IVF is having an IVF pregnancy rate that approaches 100% with a low rate of pregnancy loss...Now, I know that some clinics advertise pregnancy rates of 120% (just kidding....I hope) with a 100% money back guarantee and a free toaster in the color of your choice... All kidding aside, the goal is a laudable one and the Devil is in the details of how to achieve that goal.

Back in July I was in Santa Barbara for the Annual UCLA IVF meeting. This gathering of medical professionals is a truly excellent opportunity to interact with colleagues and learn about what constitutes the "State of the Art...in ART." A lot of programs are using stimulation protocols for IVF that rely upon Lupron (GnRH-agonist) to trigger for egg collection instead of HCG. We have been using this protocol for over a year now but quickly concluded that patients using this protocol may be best served by freezing all embryos and then performing an FET the following cycle. This protocol reduces the risk of OHSS to near zero but the benefit of that risk reduction also results in such a precipitous drop in hormone levels following egg collection that implantation rates also drop significantly. Hence the logic behind freezing all embryos after egg collection. Indeed, this year the theme at the meeting was almost uniformly "Freeze, baby, freeze."

However, the Holy Grail remains elusive. If we perform PGS on the blastocyst stage embryos then the implantation rates can be improved markedly and the miscarriage rate reduced as well. So if the implantation rate at age 38 is typically 12% and we can increase this to 65-70% with PGS.  So we are clearly making some real progress.

But why is the implantation rate not 100%? That is the $64,000 Question.... Data presented at the meeting indicated that performing the biopsy was not the culprit. Other possible explanations are single gene defects that are not currently detected, the embryo transfer procedure and the receptivity of the endometrium (hormonal or possibly immunologic).

So we are aggressively pursuing the concept of Single Euploid Embryo Transfer (SEET) which is a fancy way of describing the transfer of one genetically proven normal embryo.  Although an implantation rate of 65-70% isn't 100%, that may represent the best that we can do....but stay tuned.

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Edward T. Gordon MD, 1923-2013

Edward T. Gordon MD
1923-2013

Edward Theodore Gordon was born on March 4, 1923. He was one of four children of Mr. and Mrs. Samuel Gordon of Charlestown, Massachusetts. Edward was predeceased by his brothers, Nathan and David, and his sister, Celia. Edward graduated from Boston English High School. He attended Tufts College and Tufts University School of Medicine and graduated at the top of his class in 1944 and 1947 respectively. Following a rotating internship at Bellevue Hospital in New York City, Dr. Gordon pursued a residency in General Surgery at the University of Minnesota where he trained under Dr. Owen Wangensteen. In 1949, Dr. Gordon became the Chief of Surgical Services at the 7th Station Army Hospital in Trieste, Italy. Upon his return from Europe, Dr. Gordon completed his surgical training at the Beth Israel Hospital in Boston.

Dr. Gordon practiced at Quincy City Hospital and Milton Hospital for over three decades serving as Chief of Surgery and President of the Medical Staff. A lifelong supporter of Tufts University School of Medicine, he was active in the medical school alumni association founding the M Club dedicated to financial supporting his alma mater. Along with his wife, the late Claire Gordon, they supported several scholarships for deserving medical students.

Dr. Gordon met his wife, Claire Braverman of Quincy, when they were both in high school. They were married during Dr. Gordon's second year at Tufts University School of Medicine. During their nearly 67 years of marriage they lived in New York, Minnesota, and Trieste, Italy before returning to Quincy in 1950. The family ultimately moved to Milton in 1960 where they resided for the duration of their lives together.

Dr. Gordon's lifelong love of medicine influenced the career choices of his three sons, all of whom pursued careers in the medical field (clinical and administrative). He loved classical music and was an avid reader especially enjoying historical and political non-fiction books. He and Mrs. Gordon spent many happy summers at their vacation home in Chatham, Massachusetts where he enjoyed golf, tennis and boating.

Dr. Gordon was predeceased by his wife of nearly 67 years in May 2012. He is survived by his three sons, Dr. Michael Alan Gordon and wife Mary of Sanford, North Carolina, Steven Roger Gordon and wife Sharon of Brattleboro, Vermont, and Dr. John David Gordon and wife Dr. Allison Smith of Bethesda, Maryland. He is lovingly remembered by his nine grandchildren and celebrated the birth of his first great-grandchild last July.

Funeral services were held at Stanetsky Memorial Chapel, 475 Washington Street, Canton, on Friday, August 2 at 2:00pm.

Interment followed at Sharon Memorial Park, Sharon, MA.

In lieu of flowers, charitable contributions in Edward's memory may be made to the Dr. Edward T. and Claire Gordon Family Scholarship Fund, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111.

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And the winner is....Aauuuuugggghhh.....

Well, since the NHL season just ended 5 minutes ago with a crushing defeat for my hometown Boston Bruins I guess that winter is now officially over.....

So I guess I can still share my recent award from the folks at HealthTap. It is an interesting site and I have tried to provide balanced informative answers to questions all within a 400 character limit...kinda like Twitter but longer.

I am constantly amazed by some of the posts that patients put online. If I were in terrible pain or freaking out because of some other health issue, I doubt that I would rush to my computer and start typing....I would call my doctor.....

However, this behavior is not new as is clearly evident from this scene from one of Western Civilizations finest films....Monty Python and the Holy Grail.

ARTHUR:  There!  Look!
LAUNCELOT:  What does it say?
GALAHAD:  What language is that?
ARTHUR:  Brother Maynard!  You are a scholar.
MAYNARD:  It's Aramaic!
GALAHAD:  Of course!  Joseph of Arimathea!
LAUNCELOT:  'Course!
ARTHUR:  What does it say?
MAYNARD:  It reads, 'Here may be found the last words of Joseph of Arimathea.
    He who is valiant and pure of spirit may find the Holy Grail in the Castle
    of uuggggggh'.
ARTHUR:  What?
MAYNARD: '... the Castle of uuggggggh'.
BEDEVERE:  What is that?
MAYNARD:  He must have died while carving it.
LAUNCELOT:  Oh, come on!
MAYNARD:  Well, that's what it says.
ARTHUR:  Look, if he was dying, he wouldn't bother to carve 'aaggggh'.  He'd
    just say it!
MAYNARD:  Well, that's what's carved in the rock!
GALAHAD:  Perhaps he was dictating.
ARTHUR:  Oh, shut up.  Well, does it say anything else?
MAYNARD:  No.  Just, 'uuggggggh'.
LAUNCELOT:  Aauuggghhh.
ARTHUR:  Aaauggh.
BEDEVERE:  Do you suppose he meant the Camaaaaaargue?
GALAHAD:  Where's that?
BEDEVERE:  France, I think.
LAUNCELOT:  Isn't there a Saint Aauuuves in Cornwall?
ARTHUR:  No, that's Saint Ives.
LAUNCELOT:  Oh, yes.  Saint Iiiives.
KNIGHTS:  Iiiiives.
BEDEVERE:  Oooohoohohooo!
LAUNCELOT:  No, no.  'Aauuuuugh', at the back of the throat.  Aauuugh.
BEDEVERE:  N-- no.  No, no, no, no.  'Oooooooh', in surprise and alarm.
LAUNCELOT:  Oh, you mean sort of a 'aaaah'!
BEDEVERE:  Yes, but I-- aaaaaah!
ARTHUR:  Oooh!
GALAHAD:  My God!
    [dramatic chord]
    [roar]
MAYNARD:  It's the legendary Black Beast of Aaauugh!
    [Black Beast of Aaauugh eats BROTHER MAYNARD]
BEDEVERE:  That's it!  That's it!
ARTHUR:  Run away!
KNIGHTS:  Run away!
    [roar]
    Run away!  Run awaaay!  Run awaaaaay!
    [roar]
    Keep running!
    [boom]
    [roar]
    Shh!  Shh!  Shh!  Shh!  Shh!  Shh!  Shh!  Shh!...
BEDEVERE:  We've lost him.
    [roar]
KNIGHTS:  Aagh!

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Learning to Swim - Natural Cycle IVF and Stimulated Cycle IVF

I love summer. I really do. In fact, I love June most of all because summer has just begun and there seems almost limitless possibilities for fun in the sun....at least there were when I was a kid.

When I was about 6 years old my parents decided to send me off to Day Camp somewhere south of Boston. I am not sure exactly where this camp was located but my Mom assured me in later years that it was an outstanding camp. I don't remember a lot about that camp but I do remember two very specific aspects of being a camper there.....First of all, we ate a lot of hot dogs. I can still remember the smell of those burned cylinders of artificial fillings and how the odor mingled with the smell of all the fresh pine needles at the camp. Secondly, I remember the pool....

Now I was not afraid of water. In fact, I spend hours and hours in my backyard swimming in a little plastic kiddie pool that we bought at Child World. The best thing about the pool was that it was warm and shallow. I loved making a whirlpool by swimming around and around the edge of pool and then rolling over on my back and letting the moving water continue pushing me along. Boy, life was sure easy...

But then I was sent to Day Camp and I found myself way outside of my comfort zone. First of all, the pool was 25 feet deep. Not really but it seemed that way. Secondly, the water was ice cold. How cold was it? Well every morning the cooks broke off chunks of ice from the shallow end to add to the Kool-Aid to keep the drinks cool all day. Finally, the method of choice to encourage us to become comfortable in the pool was to have us hold hands and play "Ring Around the Rosie." Of course, I always ended up holding hands with a kid whose lung capacity allowed him to remain submerged for half the morning. That meant that every game represented a "near-drowning" opportunity. Needless to say, I didn't swim a lot that summer. To my Mother's credit she silently noted every day that my bathing suit was completely dry and never ridiculed me for my pool phobia.

The following summer we rented a house in West Dennis on Cape Cod and an amazing thing happened...I learned how to swim on my own. The gently sloping beach allowed me to gradually overcome my fear of deeper water and by the end of that summer I was a real little fish. Years later I served as the Assistant Waterfront Director at Storer Scout Reservation...a far cry from the scared 6 year old who wouldn't go swimming.

So what does this little vignette have to do with IVF? Well, sometimes you have to wade before you can swim. Natural Cycle IVF offers some patients a much less threatening introduction to ART than stimulated cycle IVF. Although some physicians roll their eyes and basically tell patients to just get over their fears and jump into the deep end of the fertility treatment pool, not everyone is comfortable with that approach. Patients who fail to succeed with NC IVF will often consider stimulated IVF following this less imposing introduction.....sometimes surprising themselves in the process. So when patients come in and tell me that they are not mentally and emotionally ready for stimulated cycle IVF, I remember how I felt sitting on the edge of that pool in 90 degree weather watching those kids dodge icebergs and laughing with joy and am really glad that I can offer them a chance to get their feet wet gradually...

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Improving Implantation: The Endometrial Tickle

Sometimes you learn things about your friends, co-workers and mentors that you really would prefer not to know. Years ago when I was a Stanford Ob Gyn resident we were sitting around the lounge on Labor and Delivery and chatting about my decision to specialize in Reproductive Endocrinology. The discussion turned to the subject of the endometrium and implantation (yup, we were a totally out of control group of docs...just like on Gray's Anatomy..). One of the faculty members volunteered that she had conceived with an "endometrial tickle." I did a double take. What in the world was an "endometrial tickle" and did I seriously want to find out. Clearly we were traveling into the TMI zone here....

But how could I not ask? Well turns out that the endometrial tickle was not as disturbing a concept as I feared. On the day of an LH surge she had popped into the clinic where an RE doc had basically done a mock IUI/cervical check/mock ET with an empty catheter. In mice you can apparently generate a false pregnancy by doing something similar and the thought was that by scratching the endometrium the odds of implantation following a bit of romance would be enhanced even though she was not a rodent. Yikes. Talk about learning a bit too much about friends and faculty.

Fast forward to 2013. Amazingly enough this concept of the endometrial tickle has resurfaced in the form of enhancing implantation in IVF cycles by performing an endometrial biopsy in the cycle prior to an IVF attempt. The mechanism by which doing an endometrial biopsy weeks prior to embryo transfer and with an intervening menstrual cycle is elusive to say the least. We don't know the ideal timing, the mechanism, the duration of the effect or the degree of improvement in implantation. But besides that, we totally believe that it works.... Actually, I really don't know how to interpret the studies that have looked at this issue. So in general, if one of my patients fails to conceive after one or two ETs with good embryos then I usually suggest we consider performing an endometrial biopsy. Anyone who as had an endometrial biopsy knows that I would risk being beaten to death by my patients if I dared to call that procedure an "endometrial tickle" but still makes me wonder if the concept is similar....

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A Face for Radio

 My brother Steve used to tell me that I had a good face for radio....nice. Well, I guess that is what big brothers are for...torturing their younger siblings.

This week both DrD and yours truly were out testing out our radio faces in honor of National Infertility Awareness Week.

First of all, we were both delighted to meet Jack Diamond and spent some time getting to know him. The interview is available on our Fertile Grounds website and does address typical concerns of our patients.

Next I was able to visit the "glass-enclosed nerve center" of WTOP. And believe it or not...there actually is a "glass-enclosed nerve center" at the studio. And they say that the media is not truthful....

I was incredibly impressed by the team at WTOP and was amazed at how they don't miss a beat from spot to spot as they go about their business. Always a pleasure to see true professionals in action! Here is the link to that interview (look for 12:20 pm) or you can also listen on Fertile Grounds.

Hope that you enjoy these spots and apologies as usual for the delay in getting back to the blog....sometimes life interrupts.

Next topic: Implantation: the Endometrial Tickle.

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Improving Implantation: Embryo Transfer

There are few outcomes more frustrating than calling a patient who has failed to conceive in spite of the transfer of top quality embryos. I usually break down the factors into: 1) transfer technique, 2) endometrial receptivity and 3) embryo issues.

Embryo Transfer:
The goal of all transfers is to perform the transfer in an atraumatic fashion and to get out of the room without the patient peeing on you. In 16 years I have yet to have a patient urinate on me during an embryo transfer, but this is not to say that some of them did not fantasize about getting some payback.

We perform all embryo transfers under ultrasound guidance. For 16 years I have performed all embryo transfers to the accompaniment of Sam Cooke's classic ballad "You Send Me."

The reason for this choice is a story for another time but I am reminded of the line that John Candy uttered in the 1984 movie hit "Splash": "Hey, when something works, I stick with it..."

However, I have had some patients who have rarely requested a different soundtrack to their procedure and so I guess that I need to come up with a backup plan. Recently, I was presented with a request to go with the antithesis of Sam Cooke. I sat there and pondered for a moment while I scrolled through my iPhone 4. Another Sam Cooke ballad would be too similar.

I needed something appropriate to reproductive medicine...and with a driving beat and preferably a song from the 70s or 80s....So I chose.... "Love Shack" by the B-52s. Although we argued about the actual lyrics in this MTV favorite, it ultimately seemed like a good choice since the patient did conceive. For the record, I thought that the lyric in question was not "Tin roof....rusted," since I was sure that I had seen an interview with the band stating that the original lyric was total gibberish and made up on the spot without any consideration given to making it fit the song. Perhaps, I am totally confused on this point.

So ultimately the key is to play music that has the embryos best interest at heart. These two songs work for me. If you are not having any luck, then consider asking your RE to play one of these songs at ET...just don't tell him/her it was my idea....

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