eating while pregnant

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mercredi 10 mars 2010

Question 2: What is Infertility?

Posted on 06:37 by Unknown
So how bad was the snow in Washington, DC? Let me tell you....it was epic! Seriously. I had not seen see snow that deep since the Blizzard of 1978 in Boston when I was only 12 years old (see photo below).

The roads were a complete disaster and just trying to get to work was near impossible. I remember a few years ago when we had a lesser storm that I arrived at the office to find myself the only employee who made it in. There were 18 patients waiting and no nurses, no medical assistants, no front desk. So until the rest of the crew made it in I was checking the patients in, rooming them, drawing the blood and doing the sonograms (my usual role)! So the hotel seemed a good option for this most recent storm (see other photo).

Of course, the bad weather was a perfect time for us to work on revising the book and trying to get it off to the publisher. I am pleased to say that we are doing well in terms of the timetable and I truly hope thatthe book will go to press way before I complete running through all these questions. I think that I need to talk with Jones and Bartlett about an iPad version so I have an excuse to give Steve Jobs more of my money.

2. What is infertility?

Approximately 80% to 85% of couples who are trying to become pregnant will successfully conceive within a year. Thus infertility is commonly defined as the inability to achieve a pregnancy within 12 months of unprotected intercourse. However, certain patients may have recognized factors that preclude normal conception; for them, the 12-month period of waiting makes little sense. Common examples of women with such problems include those who have extremely irregular periods, a history of severe endometriosis, a history of previous tubal pregnancies, or other anatomical factors that would clearly lead to diminished fertility. Since fertility declines significantly as a woman ages, couples are encouraged to seek evaluation for infertility after 6 months of no contraception if the woman is older than age 35.

Another problem related to reproduction is recurrent pregnancy loss. Many women can readily conceive, only to suffer repeated pregnancy losses. These women represent a special subset of those who are unable to successfully reproduce and should be evaluated by a medical professional.
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mardi 9 mars 2010

New Beginnings - Question 1: How does normal reproduction work?

Posted on 11:35 by Unknown
Well hard to believe that the 2nd week of March is here already. What an eventful month we all had in February as Washington DC was paralyzed by Snowmageddon. Dominion Fertility was open in spite of the terrible weather and several of us stayed for many nights with our friends at the Westin Arlington Gateway. The hotel was a Godsend to us...especially once the power failed at our home and we were reduced to living like small animals huddled together in a den.

But now it is time to buckle down and get back to the virtual world and the routine posting of fascinating information on the 100 Questions and Answers Blog! Dr. DiMattina and I have been hard at work revising the 100 Q&A book for a 2nd Edition. We anticipate outstanding sales and a possible movie adaptation staring Brad Pitt and Chris Pine. James Cameron will be directing and the special effects will be provided by ILM. Watch out for updates regarding open casting calls for this summer blockbuster.

Meanwhile back in the real universe I am planning on posting a Question of the Day every other day until we run out of questions. Do the math and that takes us into 2011...

So on with the show....or book....or blog....or whatever.

1. How does normal human reproduction work?

Norman human female reproduction depends on the correct functioning of four components of a woman’s body: the brain, the ovary, the fallopian tube, and the uterus. At the time of her birth, a woman’s ovary contains all of the eggs that she will ever have. These eggs are contained within fluid-filled sacs called follicles.

Every month, the brain sends out a signal from the pituitary gland (a gland located at the base of the brain) stimulating the follicles to grow. Not surprisingly, this hormone is called follicle-stimulating hormone (FSH). Under the influence of FSH, a group of follicles begins to grow, but by the fifth day of the reproductive cycle a single dominant follicle has already been selected. This dominant follicle may be either on the right ovary or the left ovary.

As it grows, the follicle produces an important steroid hormone called estrogen. Estrogen causes the lining of the uterus (endometrium) to thicken in anticipation of the eventual implantation of an embryo.

By mid-cycle, this follicle has grown to a diameter of 20 to 22 mm. At this time the brain releases a second hormone, called luteinizing hormone (LH), from the pituitary gland. LH is the trigger that induces ovulation.

Approximately 36 hours after the LH surge, the follicle releases the egg. It is the job of the fallopian tube to trap the egg. If the fallopian tube fails to catch the egg, then pregnancy cannot occur.

During intercourse, tens of millions of sperm are deposited in the woman’s vagina when her male partner reaches orgasm and ejaculates. While the egg is safely held within the fallopian tube, these sperm swim from the vagina, into the cervix, through the uterus, and up into the fallopian tube, where fertilization occurs. (See Figure 1.) Normally, the growing embryo travels through the fallopian tube for 5 days after fertilization, at which point it reaches the uterus. (An embryo that remains trapped within the fallopian tube is called a tubal pregnancy or ectopic pregnancy, and can be a life-threatening condition.) The embryo divides many times along the way, and by the time it reaches the uterus, it has grown to hundreds of cells and is called a blastocyst.

Once the egg is released from the ovary, the follicle (now called a corpus luteum) continues to produce estrogen and begins to produce a new hormone: progesterone. Progesterone induces changes in the estrogen-primed endometrium, allowing implantation of the embryo and thus permitting pregnancy to occur. In the absence of a pregnancy, the levels of estrogen and progesterone both fall 2 weeks after ovulation and a menstrual period ensues, shedding the lining of the uterus. Menstrual flow lasts approximately 3 to 5 days in most women.

Overall, human beings are not very fertile, with maximum pregnancy rates of only 20% to 25% per cycle during the years of peak fertility (the second and third decades of life).
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mercredi 27 janvier 2010

Happy New Year (belated)! Day 5 ET for Natural Cycle IVF.

Posted on 11:22 by Unknown
Well here we are at the end of January and somehow I managed to avoid posting any blogs for the past 2 months. I am not proud of this fact but I will apologize for my failure to stay on schedule. This past month has included a bout of food poisoning with salmonella and a weekend visit to Boston to visit my Mom who was in the hospital for a few days with some respiratory issues. Fortunately, Mom is now back home but her health is a bit tenuous and I don't think that she will be going on the computer for a while so that means one less reader for this blog. No one can have a better fan than your own mother and I hope that she feels well enough soon to go back online...

Meanwhile back at the ranch we have made some interesting changes here at Dominion. First and foremost we have decided to push all Natural Cycle IVF patients to Day 5 ET. We looked at our data for the past 18 months and it seemed to make sense given a number of patients who failed to conceive with a Day 3 NC IVF transfer but ultimately had success with a Day 5 ET.

But wait, you might say....aren't you the same DrG who years ago was not convinced that Day 5 ET made sense??? Guilty as charged. But some changes in the lab have led to my new postition. First of all, the commercially available culture media has made going to blast a much more reliable proposition. Secondly, in stimulated cycle IVF the excellent pregnancy rates following vitrification (ultra-rapid freezing) of blastocysts has allowed us to take patients to blast without the fear that the extra embryos of good quality were going to be wasted. Finally, the evidence from our Natural Cycle IVF patients suggests that there is improved synchronization between embryo and endometrium with a Day 5 ET. No way to prove this opinion but it sure seems to make sense. Finally, if the embryo arrests between day 3 and day 5 then it seems unlikely that it ever would have resulted in pregnancy, although no way to test this opinion. Interestingly, we had several cases of 4 and 5 cell day 3 embryos developing into beautiful blastocysts and successful pregnancies....so we feel confident that the good embryos will go to day 5 and the poor embryos will arrest.

So Happy New Year to all. I wish you all the best in 2010. May all your embryos implant and all your pregnancies be low-risk!

For a good laugh, I encourage all of you to visit Fertile Grounds (http://fertilegrounds.dominionfertility.com) and check out my video blogs. They are a work in progress and I am not ready to quit my day job and do stand-up....
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lundi 30 novembre 2009

High Responder Blues

Posted on 08:40 by Unknown
Being an overachiever can sometimes be harder than being an underachiever....at least when it comes to ovarian stimulation. I certainly don't want my kids to think that I want them to slack off in their academic and non-academic pursuits. Interestingly, my oldest son had to read the book the "Overachievers" for his AP English class. Man, that is like taking alcoholics on a field trip to a bar! The kids are already stressed out about working real hard and then they have to read a book on just that topic....yikes!

Well, being an overachiever in terms of fertility drugs is no fun either and is stressful for both patient, partner and physician. High responder patients are at risk for a wide range of suboptimal outcomes.

First of all there is OHSS. I really hate OHSS. Truly I do. The patient is miserable, the partner is often freaking out and the doctor is trying to navigate through dangerous waters. Patients with OHSS can end up in the hospital and may require draining the fluid that accumulates in the abdomen. Traditionally we have a radiologist drain this fluid but some RE's do it transvaginally as if doing an egg collection and that may make everyone's life a bit easier. Patients with OHSS can become dehydrated and are even at risk for stroke and blood clots in the leg or lungs. Fortunately, these complications are rare.

Secondly, they may end up with eggs that are not really all that good. The HCG may be given a bit early because of worries about the high estrogen levels so sometimes a lot of the eggs are immature. Also, egg quality may not be that great so eventhough there are a lot of eggs the yield is really poor.

Thirdly, you may end up with too many embryos for your confort level. If you start with 35 eggs and end up with 18 cryo'd blastocysts then you may be conflicted about what to do with the extra embryos. These are moral, ethical and religious issues that every couple needs to wrestle with as they pursue fertility treatment.

So the take home lesson here should be that "more is not necessarily better" when it comes to IVF stimulations.

Clinical Vignette: High Responder with ?PCOS

Here is a perspective from a patient who found herself in this situation. I have edited her husband's description of their journey but you get the idea....

Having tried unsuccessfully for years to get pregnant, my wife and I began researching fertility clinics in the DC area. Our doctor recommended Dominion Fertility (DF). We scheduled a consultation, met with Dr. Gordon and were pleased with our visit. As a result, we decided to pursue treatments at DF. My wife was diagnosed almost immediately with PCOS. Someone as slender as my wife wouldn’t normally fall into the PCOS category, yet Dr. G was adamant about his diagnosis. And thus we began our journey through fertility treatments.



As we explored our insurance options we discovered IVF would only be covered at certain clinics, and unfortunately DF was not one of them. Reluctantly, we researched clinics within our insurance network. We found another clinic scheduled an appointment with Dr. X. Our first impression of Dr. X was quite good, given his resume, certifications, awards, etc., and consequently we decided to go with that clinic. After Dr. X reviewed my wife’s file, he shared with us his strong opinion that in fact my wife did not suffer from PCOS. This was contradictory to the diagnosis offered by Dr. G and quite frankly we were relieved. Dr. X was convincing about the potential success with IVF.



As the IVF treatment progressed, my wife began showing signs of hyperstimulation. The doctors reassured us things were fine and to continue the medications. The retrieval date arrived and yet another unknown doctor performed the procedure retrieving 45 eggs from my wife. That’s right, 45 eggs (If you’re familiar with IVF, you know that’s way too many). As a sports fanatic, I thought a high number equated to great success and I wasn’t informed otherwise by the doctors so I was excited. Then I saw my wife in the operating room shaking, feverish, nauseous and bleeding. Something wasn’t right and it just didn’t add up, but again not knowing how these things work I figured this was normal. Everyone in the room appeared to be doing business as usual while my wife was crying and bleeding all over the bed sheets. After an hour recuperating time, I picked up my wife and walked her out of the clinic, hoping that this had all been worth the emotional and physical toll.



Due to hyperstimulation, the cycle was cancelled, meaning we were unable to move forward with a fresh transfer. Only 7 embryos were cryopreserved (not many for retrieving 45 eggs, but not surprising now that we understand how it works). We experienced 2 unsuccessful transfers using all of the cryopreserved embryos. It was disheartening to receive the news that we weren’t pregnant. Nearly a year had passed, and after enduring multiple fertility treatments at that clinic, without blinking an eye, Dr. X shared with us his medical opinion that my wife did in fact suffer from PCOS!



So, we returned to DF for IVF and this time we were well-informed and aware of each step and how my wife was responding. Finally, the day for the beta HCG (pregnancy) test arrived. Not knowing yet the outcome of the test, my wife thanked Dr. G for all he and his staff had done on our behalf. We were overwhelmed with gratitude since the experience was so different this time around. Dr. G. later recounted that he thought my wife had taken a home pregnancy test prior to that visit because she was so optimistic and thankful. Suffice it to say, the results were positive. We are now pregnant!


OK so why did I include this in today's post. Well, first of all I like for my Mom to proud of me and since she may see this post I thought I would include it. Secondly, the diagnosis of PCOS is a tricky one and I often have seen patients that seem to have some factors consistent with PCOS but not enough to make the diagnosis definitively. Thirdly, this case demonstrates the need to match IVF stimulation protocols to the patient. I originally had planned on using a protocol of 75 IU of FSH med and 75 IU of menopur. At the other clinic, she recieved a much bigger dose. When she returned to me I used 75 IU and 37.5 IU and she still ended up with 26 eggs which is a lot more than our average of 11 eggs! Of those 26 eggs, she ended up with 12 nice blastocysts (2 for ET and 10 for cryo). She did not get OHSS, but I was concerned about it given the # of eggs, her high estradiol levels and her probably diagnosis of PCOS. So a nice happy ending and I hope that the rest of her pregnancy goes well.

So that is my last (and first) post for November 2009. Sorry as usual for the long interval between posts. Now for faithful readers of this blog I want to enlist your help in an online popularity contest. Dr. Fred Lucciardi's blog has received about a gazillion votes for the Health Blogger Awards. This is incredibly unfair because not only ifs Fred a really great guy and an excellent RE but he is (presumably) a Yankee fan. So as a member of Bosox Nation it seems inappropriate for Fred's team to have won the World Series and for his blog to win the Health Blogger Award. So if you can find the time to vote for DrG, then please do so....just as in politics: Vote early and vote often! Just kidding...

Vote for DrG for Health Blogger Award
(http://www.wellsphere.com/voteBlogger.s?bloggerId=150461)
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mardi 27 octobre 2009

Speaking the Truth with Love

Posted on 06:01 by Unknown
I was not one of the cool kids in high school. Part of this was because I was, more or less, a "goody-two shoes" and gave my parents very little grief (unlike my older brother Steven). I am an Eagle Scout and actually wrote about service to others in my college essays. Although Hahvahd and Yale were unimpressed by my concept of helping others, Princeton lived up to its motto of "Princeton in the Nation's service and in the service of all nations" and I was accepted. So I must admit that it was pretty darn painful to watch my Tigers get slaughtered by the Crimson on a rainy day in Boston this past weekend. At National Presbyterian Church we have tried to emphasize the concept of "speaking the truth with love" when it comes to controversial or painful topics. So in regards to my Alma Mater....I can say with authority that the Princeton University Band remains undefeated.

In medicine giving bad news is never easy. In infertility therapy delivering bad news seems especially tough. Patients want their doctor to be enthusiastic and optimistic...but on the other hand we need to be realistic and try to offer a balanced view. I try to discuss all options with my patients and consider the economic, philosophic, emotional and physical costs of these various options. If a patient has coverage for IUI but no coverage for IVF and IUI is a medically reasonable option then I usually suggest that this is an appropriate approach. There are usually many possible options for most couples and one size does not fit all!

Recently I had a patient at another clinic contact me to ask about options at 46 years old. She was unhappy with her care and frustrated that donor egg was her only option with her current RE. I discussed the range of options from FSH/IUI to Natural Cycle IVF to dinner/movie. My honest opinion was that she had been given good advice and that if she was open to donor egg IVF then I think that would be the best choice unless adoption was being considered. I am not sure why she seemed more satisfied with my answer than with her previous doctor's answer but that is the way it goes. I hope that most patients can get beyond the "kill the messenger" view.

So remember that all of us are human and a good doctor tries to give solid helpful advice when dealing with complex medical issues.
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mardi 6 octobre 2009

IVF Nightmares

Posted on 08:12 by Unknown
One of the benefits of working as a Reproductive Endocrinologist is that most patients end up with the outcome that they desired: a family. It may be accomplished with their own eggs and sperm, or donor eggs/sperm, or donor embryo or adoption or foster parenting or even on their own (GASP!). However, when a disaster occurs you can be sure that it will make all the papers and talk shows. By disasters I mean the usual parade of newsworthy events such as Octomom, lost embryos or transfer of the wrong embryos into the wrong patient.

There is no doubt that these events are too be avoided at all costs. The parents, the children, the doctors and the staff all wish to avoid this type of outcome. Octomom is the easiest to avoid. You simply follow reasonable guidelines when deciding how many embryos to transfer. There are very few individuals who believe that ET of 6 blastocysts into a single mother of six who is under 30 years old is a good idea. Case closed.

But what about the most recent IVF problems to hit the news that involve a different set of issues? There are few happy endings when the wrong embryo is transferred or cryopreserved embryos are lost or destroyed. But believe me, no doctor wants to find out after the fact that such an event has occurred. There is a level of trust that exists between RE and embryologist and when communication breaks down that is when mistakes can occur.

Working with eggs, sperm and embryos can be very stressful as there is so much riding on each treatment cycle. As a Fellow in REI, I would work weekends at the Kaiser clinic doing sonograms and IUIs. I was responsible for the whole 9 yards....prepping the sperm, doing the sonograms, doing the IUI etc. I was absolutely crazed about keeping the sperm samples separate. I labelled every tube and syringe to ensure that Mr. Johnson's sperm did not go on a little adventure into Mr. Chen's sample...and vice versa. When in doubt, I threw out the pipette and started again. You have to be meticulous or else a disaster could strike. At that time in my medical training, emergency C-sections were a piece of cake to me but keeping tabs on those sperm samples was a lot more stressful. These days neither really fazes me as I have tought one teenager how to drive so I pretty much feel that I can handle almost any stress!

So I asked our Chief Embryologist Awie Botes who has been working in Reproductive Physiology and IVF for over 30 years to give me a Top Ten list of how the laboratory staff here at Dominion (or anywhere really) ensure IVF nightmares do not come to pass.

1. Check identification of the patient
2. Never work with more than one sample at a time...one lab member per case
3. Use triple identification system for all eggs, sperm and embryos: color code, name code, number code
4. Personally identify patient for egg retrieval and embryo transfer (in case schedule has changed)
5. Team approach to fertilization as 2 members of lab team must concur before sperm and eggs are combined
6. Team approach to thawing of embryos so again 2 lab team members confirm plan to thaw embryos
7. Confirm with RE as ET transfer catheter is passed off
8. Management plan reviewed with RE in advance of treatment
9. Confirm treatment plan at time of egg collection
10. Adequate staffing to ensure a well rested team without fatigue!

Awie wanted to add providing all lab staff with new cars and a trip to Bermuda to ensure a happy lab crew....well 10/11 isn't too bad.
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lundi 28 septembre 2009

The Internet....and other scary places...

Posted on 09:59 by Unknown
The Internet is a wonderful tool. You can find answers to questions almost instantaneously. You can read articles from news sources a world away. You can watch videos of cats falling into fishtanks. What's not to like?

And yet, the Internet can allow faceless, nameless individuals to bully, confuse and intimidate vulnerable people who are just trying to get through this confusing maze of infertility treatments. The result is sometimes ugly and mean-spirited.

A few years ago several of our patients were posting to a bulletin board where the majority of patients were from another local clinic. Our patients were bullied and harassed in a really nasty way. One person accused one of my patients, who at that very moment was admitted to the High Risk Pregnancy Unit at Inova Fairfax Hospital, of being a liar who wasn't even pregnant! She actually had twins and pretty bad preterm labor.

So what to do? I think that one needs to consider Internet advice very carefully....including my own by the way! I often strongly urge patients that post to me to follow up with their RE. There is no substitute for speaking with your own doctor about your care. However, sometimes there can be some insight added by getting a fresh opinion. The knowledge that my replies may empower a patient to discuss difficult topics with their doctor is one reason that I continue to moderate Q&A sessions both on our own website and on the INCIID website.

Finally, I would advise patients to raise issues with their doctor....with their doctor. Seriously. The common practice of Anonymous posts complaining about issues really doesn't help at all, although it makes the one doing the posting feel better about venting. I have always encouraged patients to vent to me about issues that they may have with me or my practice. You cannot give good service without accurate feedback. A good physician always takes constructive criticism and makes adjustments. It is usually best to put these thoughts down on paper rather than rely upon memory when sitting in the office.

If your criticism is too personal, I can always have my Mother take care of the insensitive dolt who dared to knock her perfect (well near-perfect) son! Thanks Mom!
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