Crazy Twin Stories #1

Here at Dominion Fertility we are really doing our best to reduce the number of twin pregnancies. Seriously. No, I really mean it. Recently we were commended by the CDC for our exceptionally high rate of single embryos transfers.

Usually we urge patients to pursue elective single embryo transfer (eSET) if it is their first cycle of stimulated IVF and they are < 35 years old and embryo quality is very good to excellent. However, as many patients/couples view twins as an acceptable and even desirable outcome it is hard to sell eSET to many of them.

In this case, the couple had been through a lot but was open to eSET. I was very happy when I saw the first beta level but figured it was just a really healthy singleton. Then came the first pregnancy sonogram and I saw a single gestational sac with two yolk sacs. Oh well. Follow-up sonograms demonstrated that the twins were not in a single sac which would have made the pregnancy a much higher risk endeavor. Still identical twins were not on our radar screen as the rate of identical twinning is usually only 1-2%.

So in spite of eSET, not all pregnancies will be singletons but as I really can't transfer less than one embryo we are stuck with a small risk of twins no matter what....

Still, as I tell my patients at the time of ET, I don't babysit and I don't change diapers anymore..

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Thanks from Dr G

I really want to thank all of my patients, friends and associates who have extended their heartfelt condolences on my loss. Your kindness is much appreciated. I apologize to any of my patients who were inconvenienced in my absence and also to those who have been trying to schedule appointments and have been unable to get in as quickly as usual to see me. Please understand that I am doing my best to accommodate everyone's schedule.

Thanks again,

DrG

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Claire Braverman Gordon (1923-2012)

My Mom passed away peacefully on Thursday May 31. She lived a full and wonderful life and will be missed by all of us who knew her.

http://www.legacy.com/obituaries/bostonglobe/obituary.aspx?n=claire-braverman-gordon&pid=157872029&fhid=5817

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Back to Boston....

Well I am on my way back to Boston to spend the day with my Mom. She is really going downhill fast and I really hope that she is awake enough to know that I am there with her. It is funny to think that back when I was born that a woman over than 35 years old was considered high-risk just because of her age. We are not talking about the risk of genetic issues...simply being pregnant at 35 was considered problematic! Now I consider a 35 year old to be pretty darn young considering my average patient is 38.5 years old.

My Mother conceived me when she was 40 years old. My Dad diagnosed her as being in menopause. That's what happens when General Surgeons provide RE opinions. She was a lot older than the most of my peers' mothers and yet I never felt that she was somehow less involved or moving slower. She was always there for me during those summers on Cape Cod and she frequently planned excursions to Mystic Seaport or the Boston Museum of Science and even a trip to Washington DC with a two of my classmates and their Moms.

Yet to even have any children was a miracle for her. She had a bicornuate uterus with a rudimentary horn. She and my Dad were told that it was hopeless and they needed to adopt. Clearly I am evidence to the contrary...as are my 2 older brothers!

Well, here's to mothers everywhere. We are heading down into Boston Logan. Wish me well...

Addendum 5/22/12: Back now in DC and I spent all day Monday with my Mom. She had moments of lucidity and at other times she had what my sister-in-law calls the "100 mile stare." Still she knew who I was and enjoyed watching the photos and videos that I streamed from my iPhone to her TV. We will just take it day by day. I appreciate all the support shown by my staff and by my patients. My mother has been one of my biggest supporters over the years. The natural order of life is for children to go on after their parents but that doesn't make it any easier. I am too open from an emotional standpoint to practice in a field of medicine where end of life issues are common....I am glad that I am blessed to practice in the field of Reproductive Medicine.

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Having a Back Up Plan

Yesterday my son Seth (see photo of him with his Grandparents before my Mom's recent turn for the worse health-wise) experienced the Mac equivalent of the "blue screen of death." His MacBook Pro started behaving unpredictably and then refused to boot up at all. Earlier I had made an appointment at the Genius Bar but Seth had reassured me that all was well and I didn't need to bring his laptop over to the Clarendon Apple Store (25 min from our home). Then the meconium hit the fan and at 7:40 pm he declared an emergency and I grabbed the defunct machine and hopped in the car to make the voyage back into Virginia. I called ahead and the gang at the Apple Store told me that my genius would wait for me….is that great customer service or what?

The laptop was apparently experiencing a "kernel panic" or is it "Colonel Panic" ?? Beats me. in any case the system folder was corrupted and the only solution was a clean reinstall of the OS following erasure of the hard drive. BUT he uses Time Machine and should be able to nearly completely resurrect his machine once he returns to college this PM to start exams. Crisis averted….I hope.

It always helps to have a back-up plan. In fertility treatment this back-up plan could be the use of donor sperm, donor egg, donor embryo, gestational carrier or adoption. Although we can never know who will achieve success, we can often give good advice to those patients who need to consider alternative paths to parenting.

The use of donor sperm is the most common issue that we face in these discussions. In certain cases of severe male factor I think that considering the use of anonymous donor sperm is appropriate. In stimulated IVF we often consider splitting the eggs between husband and donor in cases of severe male factor BUT this makes no sense to me unless the couple is accepting of the concept of parenting a child born from fertilization with donor sperm. Don't waste the eggs if you are uninterested in using those embryos.

I currently have a patient who is successfully pregnant after IVF using this concept of a back-up plan that fortunately was not needed. Previously her attempt at stimulated IVF had resulted in very poor quality embryos. We were uncertain if this was an egg issue, a stimulation protocol issue or a sperm issue. We adjusted the protocol, used donor sperm to fertilize some of the eggs and the cycle was much more successful with fertilization from both husband and donor . Ultimately we had a bunch of embryos from the sperm donor and even two nice blastocysts from the husband. We cryo'd the donor sperm embryos and used the two from the husband. We were all ecstatic to see cardiac activity on sonogram recently and they are off for obstetrical care...

Having a back-up plan can make all the difference.

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Question of the Day: Follicle Reduction

So as I was wasting precious time by goofing around on my blog I came across this post on another internet bulletin board. At the risk of getting flamed by posting on a patient board I have elected to reply here in the relative safety of my own blog/Facebook page! So here is the post.....

I was diagnosed with PCOS and am prone to overstimulating. Two of my IUI cycles were canceled due to too many follicles. I was googling and found Dr. Gordon's facebook page on follicle reduction. Just cautious whether someone here been through a follicle reduction procedure and what it is like. When I spoke to a nurse at my clinic, she told me they don't do follicle reduction. Instead I can choose selective reduction in the event of multiples or covert the cycle to IVF. Wonder why my clinic doesn't provide this procedure?

So first of all, a follicle reduction is performed the same day as an IUI (or coitus) and timing in terms of HCG is the same as for an IVF egg collection. Essentially, a follicle reduction is an egg collection but with 2 big differences. First of all, the eggs are discarded and not fertilized and secondly we leave 1-3 follicles untouched so that a pregnancy can occur once those eggs ovulate.

On this bulletin board some other individual opined "why not do IVF if you are going to do an egg collection anyway?" Yes, that is an option but usually I recommend follicle reduction in cases where the patient has maybe 6-8 follicles as opposed to the usual 10-15 that we like for IVF. Remember this is an IUI or coitus cycle that has resulted in an over-response. Usually the patient is not doing IVF for a reason......economic, religious, philosophic etc. In general, I have charged about $1000 for a follicle reduction on top of the charges for the whole cycle so it is not that expensive compared with converting to a full IVF which is $10-12,000 in most clinics.

I will say that the advice given by the nurse concerning selective reduction is a bit cavalier...Yes, fetal reductions (selective abortion) can be done but it is a Sophie's Choice situation and I really hate to ever put a patient into that difficult position. Better to cancel and walk away in my mind. When patients see 3-4 fetuses with cardiac activity it is really tough for them to undergo a selective reduction, although many do make that difficult choice.

Why don't all clinics offer this option. Beats me.

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Returning to Old Haunts

Over Spring Break I found myself back in Houston where I completed my first internship in Obstetrics and Gynecology at University of Texas Health Sciences Center, Houston at Hermann Hospital. As a medical student at Duke I had spent my 4th year doing electives that were not in Ob Gyn because the Chairman of Ob Gyn at Duke had encouraged me to rotate onto other specialties since I would be doing Ob Gyn for 4 full years....."But Dr Hammond," I inquired "won't that put me at a disadvantage come July 1st when I begin my intern year?" He reassured me that the first few months "might be a bit rough" but that I would quickly catch on....

Well those first few months were "a bit rough"in the same way that the maiden voyage of the Titanic was "a bit disappointing..." I was pretty much terrified by the responsibility thrust upon me on Labor and Delivery. But nearly all of my senior residents were supportive and dedicated to helping the newbies survive that first year. Dr. Hammond proved correct in that by the 6th month I was pretty much caught up in terms of my Ob Gyn knowledge base. But what a crazy year that was in Houston. I was sleep deprived and exhausted and the weather was pretty tough. In summer the heat and humidity were brutal and during the winter of 1989 there was a deep freeze and water pipes ruptured all over the Texas Medical Center. I still remember scrubbing for C-sections with nurses pouring bottles of sterile water over our hands!

In June we left Houston so my wife could take a faculty position at Stanford in the Department of Structural Engineering but there were no 2nd year residency spots so I had to repeat an internship year at Stanford in spite of my year of training in Houston. Believe me, that second internship year was a piece of cake compared with internship #1 in Houston!

So in any case, over break this month we traveled to Houston. We visited the townhome where we lived and walked around the streets of Rice Village in the West U neighborhood. I was amazed by the growth of the Texas Medical Center and was stunned to see light rail running down the middle of Fannin Avenue. Hobby Airport seemed much improved as well but my memory is a bit fuzzy....

Visiting old haunts is always bittersweet.....I think about the friends that I've lost touch with and the memories that I have trouble recalling. Every day for a year I drove from our rental to the hospital but suddenly I couldn't remember what route I took! Yikes. Sounds like my memory is going....

So how does this relate to fertility and fertility treatments? Well, I guess that it doesn't really, but one issue that often arises is what to do following a successful pregnancy that resulted from fertility treatment? Does one revisit old haunts or head off in a new direction.....smooth transition from personal ramblings to useful clinical advice, eh?

Good question. So here is my view. First of all, it is hard to argue with success. So although spontaneous pregnancies can and do occur following treatment derived pregnancies, I usually go with what worked before assuming that nothing else had changed. However, medical treatments can be dynamic and response to treatments can shift.

Currently I have a patient who is now pregnant with her second IVF baby but her journey was anything but a direct line. Theirs was a case of male factor and we started with Natural Cycle IVF (NC IVF). After several failed cycles we moved to stimulated IVF. She was a low responder but conceived and delivered a healthy baby. When they returned for baby #2 we decided to go back to stimulated IVF given that NC IVF had not worked. Unfortunately, stimulated IVF proved to be less than gratifying and after several failed cycles we decided to return to NC IVF....and voila, success with NC IVF!

Each cycle should be looked upon as an opportunity to learn about a couple's situation and hopefully make adjustments if the cycle failed to result in a pregnancy. IVF clearly provides more information than IUI. In an IUI cycle you never know if the tube caught an egg, or if the sperm swam and found the egg or if the sperm fertilized the egg or if the embryo formed or if the embryo made it to the uterus. All you learn is that the cycle ended with a negative pregnancy test. NC IVF and stimulated IVF at least provide insight into the cycle: was there an egg, did it fertilize, did it grow and how did it look. Not perfect but better than just wishful thinking...

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