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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Seeking but not finding...

Gordon men are known to lose all sense of perspective when it comes to our dogs. I am not sure why this is true. My Dad is so attached to his miniature Schnauzer that he actually called the kennel to check on the dog while he was being boarded a few weeks ago. Chester was unable to take the call as he was too busy playing with the other dogs at the time. Since we are all products of our environment then it should come as little surprise that I became a man on a mission when looking for a comfy dog bed for my two 4 legged friends. I had found a great bed at a Walmart several months ago but only bought one bed at the time. Since that purchase I looked and looked for a similar bed at all the local Walmarts and Lowes and Petsmart and Petco.....No luck. Amazingly enough I found one at a local small pet boutique in Arlington. I was totally psyched! Finally, my search was at an end. I bought that item and then went online to buy another one on Amazon. These beds are washable and that made all the difference to me since I have been known to leave the beds outside in bad weather. I was happy that my search was at an end. I brought home my trophy and placed Indy, my miniature goldendoodle, on the bed. Indy was also very excited. Really excited. So unbelievably excited that she promptly peed on the bed! Great. So now after 5 min it was time to wash the bed. I went on Amazon and to my dismay review after review said something like this: "Great bed. Dog loved it. I washed it once and then the thing totally fell apart"....or "Washed this bed and all the stuffing clumped together and I threw it out." Needless to say, I was not a happy consumer. But as an Eagle Scout I followed the Boy Scout motto and I was prepared. I washed the bed and then dried it with a couple of tennis balls (a trick I learned when drying sleeping bags after rainy campouts). Miracle of miracles the bed came out good as new...which it was since I had used it for only 5 min!

So does this have anything to do with fertility treatment? I guess I would consider the distressing information that I found on the internet prior to washing the dog bed insightful. Clearly these people were posting their experiences with the dog bed in an attempt to be helpful. However, it totally freaked me out that the washable bed was not really washable in a meaningful way. Same is true for patients who post information about clinics and treatments online. I have no doubt that these individuals are accurately describing their own experiences. But one size does not fill all in this case. Make sure that you don't become overwhelmed by the internet "experts." Your RE should be your best source of information. By all means, ask questions. Just remember that not all questions can be answered when it comes to infertility. We know a lot but some of it remains a mystery to all of us.

So here's the post script to my little dog bed search. Last week I was in Giant getting groceries and some dog bones. I look up and there on the top shelf in the pet care aisle are 4 of my sought after dog beds....at a better price than on Amazon. I almost sat down and cried. 

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Working With What You Have

I was actually able to get away this past weekend and made it on the slopes to ski for a day. The weather was spectacular and the snow pretty darn good for the Mid-Atlantic. I am not an aggressive skier which is mainly the result of breaking my collarbone on a ski trip back in college.

That tumble was on the first day on the slopes and apparently my fall was pretty impressive. As I lay on the ground stunned from my fall a well-meaning fellow skier rushed over and said "Man, that was an amazing wipe-out!" "I can't move my arm," was my reply. "That's OK, Dude. It's probably just dislocated. Wanna have me pop it back in?" I declined his offer and skied down to the first aid station. I ended up with an x-ray from a machine that looked like surplus from Dr. Frankenstein's laboratory. I survived the trip from Vermont back to Boston in an 8 seated prop plane and eventually healed up by the time Spring Break rolled around. Not sure how I ended up on that tangent but could be part of the aging process I suppose. In any case, the point I wanted to make has to do with the lovely self-portrait seen here. If you look closely you may notice that I am wearing a fetching pair of turtle shell sunglasses that my wife purchased from Brighton.

To say that this choice of eye-wear was embarrassing to my children would perhaps be an understatement. However, since I had given my sunglasses to one of my kids to protect from the blinding sun on the snow I was forced into sporting the Dame Edna look. Ultimately, the day was a success and the comments that I received on my sunglasses were minimal...at least to my face. But the lesson here is that you work with what you have. In terms of IVF that means not giving up and remaining hopeful in the face of odds that sometimes seem overwhelming.

Time and time again I have seem success with the final embryo that remained in the cryo tank. Over and over patients turn up pregnant when treatments have failed. If you have high FSH, low AMH and diminished ovarian reserve then all we can truly say is that you a one egg a month person. Other than that we really can't know if you have that one good egg left....until you walk in with your baby and then the answer is definitively "YES!"

So if you are a one egg a month person don't despair...there are options. Plus, be happy that your significant other wears more appropriate eye-wear out in public! 

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Wicked Slippery

Another Friday afternoon in the center of the known universe (Washington, DC) and the town is shutting down under threat of snow. Yes, that is correct....threat of snow. No snow has actually fallen from the sky but all local school systems have shut down and all after-school events are cancelled. The only thing missing from today's Snowpocolypse is.....("wait for it")...snow.

The sign in the photo is actually from a state which does get winter weather and miraculously enough continues to function in a near normal fashion in spite of the cold, white stuff.

I have taken it upon myself to catch up on many comments that I failed to respond to since November. For this lack of responsiveness I am very sorry. However, I fully understand the desire of patients to receive prompt and accurate answers to pressing questions. So I have attached the Health Tap widget to this blog. I have been responding to posts on the Health Tap website for a couple of months. Seems like a pretty interesting concept. Doctors respond to patient questions but both are limited in the character counts..kinda like Twitter but with a medical slant. The answers are provided by physicians who have passed some sort of screening process ("Convicted? No, never convicted.") and other physicians can agree or disagree with your answers. An interesting concept by itself.

In any case, please feel free to head over to Health Tap (www.healthtap.com) and don't forget to do your best to support your favorite RE physician...but if he/she is not on Health Tap then feel free to throw a little love my way so my DocScore increases...not that it's a competition or anything. Plus, you can check out all my witty and pithy answers to the questions I have chosen to answer on the site.

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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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