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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