Happy New Year!

Happy New Year to all! Well 2012 is in the can and 2013 is full of promise. In looking back over nearly 6 years of blog posts I notice that I have rarely posted on January 1 so here's hoping that I can keep up the pace so that the 17 individuals who read this blog will not be disappointed with a paucity of posts by yours truly.

It is important to be careful what you wish for....Last week I was on vacation and laying in bed listening as freezing rain lashed the windows. We were on vacation with our expended family and my brother-in-law's sons had rarely had the opportunity to play in the snow. I was so disappointed that they were only getting freezing rain instead of snow. Ice storms they can get in North Carolina but snow would be something different entirely.

Suddenly quiet descended and I looked out the window and saw absolutely nothing....complete whiteout! The snow fell and fell and fell. By the end of the week I was pretty sick of shoveling the fluffy white stuff but the boys had a great time sledding and having snowball fights. I guess the lesson to remember here is: Be careful what you wish for...you may get that wish after all. I am constantly sharing this advice with patients who request twins. Twins can be a lot more overwhelming than shoveling snow 5 times a day...and this comes from a man who doesn't personally have twins!

So let me now put on my Jean Dixon hat and make some predictions for 2013!

Prediction #1: DrG will be starving
DrG will follow the Special K diet for about 4 months. Seriously. I tend to do this every year as a means to overcome the chocolate overload associated with the holidays. For months on end I defy the odds as drug reps tempt me with delicious lunches from Lebanese Traverna and California Tortilla Factory among others. Eventually, I cave and start cheating. But my waistline usually improves a bit.

Prediction #2: Natural Cycle IVF
More patients will continue to pursue Natural Cycle IVF. Given the state of the economy and increased visibility of those patients successful with NC IVF, I predict that this approach will continue to appeal to a wide range of patients.

Prediction #3: Increased Use of PGS
The use of Preimplantation Genetic Screening (PGS) will increase exponentially. For many patients the ability to transfer only genetically normal embryos will represent the most efficient way to achieve an ongoing pregnancy. Given that the cost of PGS is about the same as the cost of a Frozen Embryo Transfer (FET) it will make sound economic sense to screen embryos and thus reduce the rate of implantation failure and pregnancy loss. Remember that PGS will not improve the cumulative pregnancy rate but its use will reduce the number of embryos needed to be transferred in order to establish and ongoing pregnancy.

Prediction #4: Reduced Rate of Twins and Triplets
The increased use of NC IVF and PGS will assist us in maintaining our extremely low rate of IVF twins. Although some twin pregnancies are unavoidable (identical twins from single embryo transfer), the rate of non-identical multiples will continue to drop. Currently, Dominion Fertility has one of the lowest rates of embryos per transfer in the nation and therefore one of the lowest twin rates. Single embryo transfer is better for everyone.

Prediction #5: DrG Will Lose More Hair
Shocking but true. I will continue to be increasingly follicularily challenged. I wont dwell on this sad point but there is always Hair Club for Men....

So there you have them. My 5 predictions for 2013. I would post another 5 but I need to go eat a bowl of Special K...with Red Berries. Happy New Year!

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Chainsaws and Other Stress Relievers

I took this photo the other day on my way to the office and I think it is one of the more inspired decals that I have ever seen on a car's back window. As a fertility doctor I celebrate in the successes of our patients but that also means that I also share in their pain and frustration when it doesn't work out.

The holiday season can be tough on our patients. The daily mail brings holiday greetings from friends and family that report the happy news of a new pregnancy or a new birth. For those struggling with infertility or pregnancy loss these letters can make it seem like everyone is getting pregnant but them ("Guess what? We will be having a new bundle of joy next year! And we were using 3 methods of birth control and I can't even remember having sex!). Yup, just what our patients want to hear...

The proliferation of the individual family member decals that populate rear windows here in the Washington DC metro area also seems a bit over the top. Perhaps our patients can filter out these reminders of the frustration of infertility better than I think....perhaps not. Although infertility has not been one of our family's medical struggles, I think that I have some perspective into how emotionally distressing fertility problems can be for my patients.

As an Ob Gyn resident I took care of hundreds and thousands of patients. I handled deliveries that were happy events and some that were not...especially if it was a premature baby. When my son was born 6 weeks early I was surprised by how difficult it was for me as a parent. The same day that he was born one of the Labor and Delivery nurses popped out a 8.5 pound baby and was walking around showing that kid off to everyone. Meanwhile my son was in the NICU with an IV in his umbilicus and concern over apnea and bradycardia. I hated that nurse. Yes I know it was completely irrational. And I knew that my son would certainly have every expectation of quickly graduating from the NICU (actually it took over a week). But it didn't matter. I was still really upset that she was able to parade around with that newborn.

If I had a chainsaw, then I would have chased her down the corridor....

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Christmas Lights and Other Frustrations.....

Last night I became inspired to get our Christmas lights hung up before the weather turned cold again when I would be risking frostbite to complete the job. So I got the bags of lights down from their perch in the unfinished part of my basement and began the job of sorting through which strings lit and which ones did not. Just as soon as one strand lit up it seemed that another winked out. Finally, I had enough to start the job and I managed to string up an assortment of white and colored lights in some semblance of symmetry. Just when I thought I had completed the task the corner outlet in my garage blew... Suddenly there was a cry from inside the house "what the %#&*$# happened to the Internet! I have to finish my homework! Dad!" So I moved to Plan B. Run an extension cord from the backyard to the garage. Hook up a surge protected power strip. Plug in the power to the internet box and voila...another crisis averted. But a new problem had arisen: the blown outlet. Ugh. An hour later I finally figured out how to reset the GFI and we were back in business. 

In reproductive medicine sometimes we fix one issue only to find ourselves confronted by another. Let's consider preimplantation  genetic screening (PGS) for IVF. Using PGS we can now determine within 18 hours following an embryo biopsy whether or not that embryo contains a normal number of chromosomes. Since many embryos are missing a whole chromosome (Monosomy 7) or have an extra chromosome (Trisomy 18) we can now elect to only transfer normal embryos. The use of PGS will not change the ultimate delivery rate (if there is a good embryo somewhere in the bunch then we will eventually find it) but it will decrease the rate of miscarriage since most pregnancy losses are genetic in etiology.

So if we only transfer genetically normal embryos then the pregnancy rate should be 100%...right? Except that it isn't. So just like my experience with hanging the lights, once one issue is resolved other issues may arise. For example, just because an embryo has the normal number of chromosomes doesn't mean that it is completely healthy. That embryo may have other problems including single genes that are failing to work correctly. In addition, besides the embryo there could be issues with the embryo transfer (glob of mucus on the catheter) or a difficult navigation of the cervical canal. Finally, the uterus itself may not be receptive to implantation. So even after eliminating genetic issues we still have to sort through other possible explanations for failure. But there is always hope for ultimate success, just sometimes it takes some creative electrical engineering to get everyone back online and sometimes it takes some creative thinking to get those embryos to stick!

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Goodbye to Twinkies

No more Twinkies. How is this possible? Yesterdays announcement by Hostess that the company is shutting down its bakeries has me completely stunned. In the movie Zombieland, the character played by Woody Harrelson is obsessed with finding Twinkies in the post-zombie apocalypse ravaged world. Now we have a world without Twinkies and no zombie apocalypse....go figure. I am on a bit of a post-apocalyptic bender at the present time....I am watching The Walking Dead while exercising and I am listening to the audiobook of the novel The Twelve by Justin Cronin ("...we made vampires. Seemed like a good idea at the time"). Then this past week I received a glossy 16 page publication from the American College of Obstetricians and Gynecologists (ACOG) all about social media. I was not a featured blogger. Oh well. Maybe next year the Academy will recognize my body of work and I will get an Oscar.

So I must admit that between the loss of Twinkies and my constant exposure to post-apocalyptic fiction I have not been a real laugh it up type of guy this week. Then my dog keeled over. Dollie is a 13 year old miniature schnauzer and she has developed vertigo and is having a really hard time walking and doing typical doggie activities. So now I face the difficult choice of deciding if and when to help my little friend cross over the Rainbow Bridge. Sigh.

Sometimes you just have to pick yourself up, dust yourself off and head into the future and not look back so much at the past. No Twinkies. No problem.

In medicine, especially reproductive medicine, we are always striving towards that elusive goal of achieving a healthy singleton term delivery as fast as possible. Change can come slowly or in staggering leaps forward. ICSI was a leap. The movement away from GIFT was a bit slower. GIFT involved a traditional trans-vaginal egg collection followed by a laparoscopy with a number of eggs and sperm mixed together and transferred into the fallopian tube. GIFT was helpful in cases of infertility in patients with normal tubes and normal sperm...and no significant endometriosis....so that really leaves you with unexplained infertility patients and Catholic patients who follow the specific admonition against combining eggs and sperm outside of the body. In any case, although GIFT here in Washington DC was pioneered by my partner at Dominion, Michael DiMattina, we have not done a case in years.  Sometimes there is a boomerang phenomenon. Such as Natural Cycle IVF. NC IVF was employed by Steptoe and Edwards culminating in the delivery of Louise Brown back in 1978. Now we are seeing a resurgence of interest in NC IVF as is clearly evidenced in our own practice where this year about 80% of our IVF will be performed in unstimulated cycles. Not what we would have predicted when we started the program in 2007.

So what's old is new again. Maybe Twinkies will be gone for a while but then return. But just in case I am headed out this morning to buy a bunch of boxes. With a shelf life measured in decades they will be just the thing to help me ride out the zombie apocalypse.

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Happy Halloween!

Good riddence to Hurricane Sandy! We are all happy to see the end of you... At Dominion Fertility we appreciate the dedication of our staff who braved falling trees and high water to make it to the office on Tuesday.

It is important to have an emergency back-up plan for your IVF lab and this past 6 months have been pretty rough here in the Mid-Atlantic. First we had the crazy July storm (Derecho - which means crazy thunderstorm that no weather forecaster managed to predict until the trees starting falling). Then we dealt with the huge weather event that was Hurricane Sandy.

We have a back-up natural gas powered generator that can run our embryo lab and several sonogram machines. This provides for a margin of safety when facing weather related crises and extended power outages. It also protects the office when a squirrel occasionally gets fried on the power lines outside our office which I have personally witnessed. Watching a furry little creature burst into flames is a fairly memorable event....

So my thoughts and prayers are with all fertility patients in NY, NJ and elswhere who were in the midst of a treatment cycle when this latest disaster struck. I wish you all the best of luck and remember that an IVF cycle is not worth risking your life so make sound decisions when dealing with downed trees and power lines.

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Scare Tactics

My brother Steve loved to scare the daylights out of me when I was a kid. He hid under my bed, in my closet, in the boiler room in our basement, in the hall closet or in the garage just waiting for me to pass by before jumping out and trying to give me a heart attack.

Just look at this picture of the two of us in the backyard of my house in Milton. Is there any way that I was not going to end up in therapy after being tormented incessantly? Actually, I have avoided therapy so far but interestingly enough many of my nightmares take place in the house where I grew up....I wonder why?

Sometimes it is the job of a physician to counsel patients about the scary things that can happen during fertility treatment or in pregnancy itself. Clearly there is a fine line between full disclosure and doing the healthcare equivalent of jumping out from under the bed with a latex mask covering your head causing your younger brother to scream like a little girl...

A few weeks ago there was a story in the news about a 61 year old who successfully carried a pregnancy for her daughter who was unable to be pregnant herself. Here is the link to the story for those who are interested. That week I received several phone calls from local news media asking if we had ever had a patient carry a baby who was that old and if we did could they please speak to someone who had a horrible complication of such a pregnancy such as death of the baby or the gestational carrier... Well, at least they didn't beat around the bush in regards to the story that they were after....

I am a very risk adverse physician. It gives me chest pain to contemplate someone over 60 years old carrying a pregnancy because the risk seems excessive to me. Of course, I am not the one carrying the pregnancy, nor a family member involved in the decision so the issue becomes one of informed consent and patient autonomy. Last year I was accused by a patient of being horribly insensitive when I recommended that she use a gestational carrier because of a profound uterine issue that I believed put her and her unborn child at excessive risk. She posted a very negative review of my handling of the situation and put me in the category of a fear monger (along with older brothers who wear latex masks and torture their angelic younger brothers). I felt terrible (unlike my Brother Steve) and reached out to her to clarify my position and apologize for how my advice was delivered. She thanked me for taking the time to discuss the issue with her and accepted my apology (but never revised her online rant..oh well). However, I remain convinced that my advice was sound. Ultimately, patients vote with their feet and at least here in Washington there is no shortage of REs to provide a 2nd or 3rd or 4th opinion. Walking that fine line between scare tactics and good advice is tricky.

As a 3rd generation physician I believe that medicine is a calling not just an occupation. So as a physician I need to look in the mirror every morning and believe that I have done my very best and that I am truly giving the best advice that I can to my patients...and I need to be sure that there is not an idiot in a latex mask hiding in my shower....

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New Hope for Hyperstim...Curing the OHSS Woes (Part 2: GnRH-antagonist Rescue).

So we have been using the Lupron trigger protocol in more patients and these patients cannot have been on a traditional LTL (long luteal lupron) or MDL (microdose Lupron flare) protocol. That means that the only patient eligible are those who are on a GnRH-antagonist protocol (one that uses Antagon or Centrotide) to eliminate the LH surge. Well, interestingly enough it turns out that adding GnRH-antagonists in the middle of a LTL or MDL flare protocol can really reduce the estrogen levels and seems to decrease the risk of OHSS in these patients who are in the midst of a stimulation that seems to be heading toward an excessive response.

As you can see below, our own Dr. Mark Payson was one of the authors of this intriguing study. Honestly, I never would have thought of adding Antagon or Centrotide during the middle of a stimulation that had started with Lupron....Go figure. Not sure exactly how or why this approach works but the study seems promising and gives us another way to deal with OHSS once we are in stimulation.

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