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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Question of the Day: Diminished Ovarian Reserve

Yesterday I gave Grand Rounds at Inova Fairfax Hospital in Falls Church, VA. Fairfax is a very large hospital routinely performing over 10,000 deliveries annually. There are over 100 Ob/Gyn physicians on staff and I have the title of Division Director of Reproductive Endocrinology and Infertility. As Division Director, I am responsible for ensuring educational content at the weekly departmental meetings that have an educational purpose. These meetings are called "Grand Rounds" in order to distinguish them (I guess) from "Not-so-grand Rounds."

As a child growing up in a medical household I often heard my Dad and Brother speak of "Grand Rounds." But I though they were saying "Ground Round" which was this great chain of burger restaurants in New England that was famous for providing bowls of popcorn and peanuts to all diners as they sat down. Of course, we kids would stuff our faces full of popcorn leaving no room for the overpriced burgers which may explain why we rarely went to the Ground Round for meals!

So given that the topic of ovarian reserve has been on my mind, here is today's Question of the Day:

I have high FSH so my RE says I'm not a good candidate for regular IVF but I've done 3 rounds of meds and IUI with NO success. Would Natural Cycle IVF (NCIVF) be better?


DrG answers:

The short answer is "yes." The long answer is "yes, probably."

First of all, a high FSH suggests diminished ovarian reserve and a probably poor response to fertility medications. BUT a high FSH does not mean that there is not a good egg left in the ovary. The odds of having a good egg is very dependent upon age. The older the patient, the lower the odds of success. This patient didn't tell me her age. Younger is better. Less than 40 is better than over 40. Less than 44 is better than over 44 (although we had had a delivery in a 48 year old patient following NC IVF).

Secondly, I usually encourage patients with borderline elevated FSH levels to consider stimulated IVF as a first choice. If the patient fails to respond then you can do an IUI and then re-evaluate. I have seen many patients demonstrate decreasing responsiveness to FSH shots - 7 follicles then 4 follicles then 2 follicles. If at that point the patient switches to IVF she will likely get canceled prior to retrieval.

So what about the proven low responder to medications. Is NC IVF an option? Yes, we have had some amazing success with these patients. Are donor egg/embryo/adoption more likely to work? Yes, but those options may not be acceptable to all patients. That leaves NC IVF and I think that one can consider this a viable option for patients with diminished ovarian reserve.

I have a 41 year old patient who had FSH levels in the 18-26 IU/L range on several occasions. Her AMH was <0.16 and her antral follicle count was 2. Her husband had male factor (previous vasectomy and reversal). Her insurance company denied her IVF coverage because of the high FSH. She attempted NC IVF and her FSH level was 40 IU/L on day 3 of that cycle. Yet she conceived and is currently in her 3rd trimester with normal genetic testing and a healthy baby. Go figure.

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Looking and Not Seeing

For the past 12 years I have been giving lectures to the students and residents from The George Washington University (and more recently VCU). I usually give my lectures in a room that is located on the campus of Inova Fairfax Hospital and you can usually find me there every week at 7:15 am trying to keep the audience awake, entertained and educated. I usually hook up my MacBook Pro to the LCD projector that I keep in my car. After my lecture last week I noticed an LCD projector that was mounted on the ceiling of the room. Looking around I noted a VGA adapter on the wall and I plugged my laptop into the correct slot and voila....I now had a full-sized projection on the screen compared with the dinky little projection from my own LCD projector which I have usually placed closer to the screen.

My problem with all this is that it bothers me that I cannot recall how long that damn projector has been mounted on the ceiling of the room! Has it been there for days....weeks....years??? I really have no idea. Why did I suddenly just notice it last week? Why did none of the medical students or residents ever say "Hey, DrG why not use the ceiling mounted LCD projector instead of your ancient projector that barely casts a bright enough image to keep us awake?" Beats me.

In dealing with patients, I like to go over where we are, how we got there and why we chose the path that we chose. If you keep your head down and never take stock of where you are then you are sure to get lost. Hence, following a failed treatment or a series of failed treatments it seems absolutely crucial to reassess what we have learned and what options may now make sense. If the patient is doing IVF with ICSI but the sperm now are much improved then maybe we should consider IVF. If the stimulation was suboptimal then maybe we should consider a different protocol or Natural Cycle IVF. If nothing is going right then maybe it is time to consider adoption, embryo adoption, donor egg or donor sperm.

One has to keep looking but more importantly one has to keep seeing....

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Revisiting the Past

I just returned from Boston where I helped my Dad celebrate his 89th birthday. My Mom is doing amazingly well considering what she has been through this past year in terms of her health.
At the party, attended by many cousins that my kids never even knew that I had, my Dad relived his early years growing up in Charlestown, MA and how he went to Tufts and Tufts Medical School. He then was an Intern in Internal Medicine at Bellevue Hospital in NYC. Upon his arrival he was told that he had to work nights and sleep during the day...in NYC....in July...without air conditioning! My Mom promptly headed to New Hampshire where her parents had a lake house! My poor Dad lost 25 pounds in a month and thought about bailing out of medicine altogether. But he ultimately decided it was Bellevue that was the problem so he switched to General Surgery at University of Minnesota. Upon his arrival in Minneapolis he asked about time off....he was told that he would have from 1-5 pm off the last Sunday of every month. Otherwise he was expected to be available. Needless to say this is a far cry from the 80 hour workweek now mandated by law for medical trainees in the United States.....

My Dad has loved being a physician and could never imagine any other profession. I guess that I am the same way. Perhaps I lack the imagination to see myself in another job, but I don't think so. I appreciate the trust that patients (usually) place in me and of course, I love celebrating their triumphs and am saddened by our failures. Earlier this week I had several patients with unfortunate outcomes but then today a patient came by to introduce me to her 8 month old daughter (who I last saw as a blastocyst) and another patient emailed me happy news right from her LDR room in the hospital! As my son contemplates a career in medicine I have emphasized to him that he needs to carefully consider his choice. I think that the best physicians regard medicine as a calling rather than a career. Perhaps that is why my Dad always emphasizes that he is "Doctor Gordon" ....because that title is at the heart of his identity and the focus of his reminiscences when he revisits the past...

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Question of the Day: Failed FETs, what to do next?

Question of the Day:

Hello Dr,
I had egg retrieval in sept 2011 5 blastocyst and 6 third day embryo.I ended having OHSS and transfer was cancelled. I had my FET done with one five day embryo in october 2011 which did not work.
I had one more FET done with two embryos from third day. Today is 12th day and I got -ve on HPT.I also gave my blood this morning will have results tomorrow.I am afraid that result may be -ve.
At this I do not know what to do for IVF to work.I have followed all the instructions religiously.

What would you suggest if I was your patient. Or what you do different in my next FET cycle.
Thanks.


DrG answers:

Clearly a very frustrating situation. Here a patient had a great response to IVF medications…so great that she had to freeze all the embryos. The embryo development sounds pretty good as 5 blastocysts and 6 D3 cleavage stage embryos were frozen. Following 2 FET attempts nothing has worked.

However, I don't have all the details. Why were there both D3 and D5 embryos frozen? Why did the second FET involve the transfer of D3 embryos instead of D5 embryos? How experienced is the clinic with D5 freezing?

A few years ago we changed to ultra rapid freezing or vitrification of our blastocysts. Slow freezing is not as good an option when dealing with more developed embryos. We usually see a 95% survival rate with D5 embryos and the implantation rates are identical for fresh vs. frozen embryos. However, not all clinics have as good a track record so these questions needs to be asked in order to better understand why there has been no success in spite of the cryo-all…

However, let's assume that this is my patient and I have a great confidence in my FET program. I think that if the actual embryo transfers have been easy then one has to consider there may be a uterine factor. Patients in this situation may benefit from a hysteroscopy and an endometrial biopsy to further investigate the failure to initiate a pregnancy. Interestingly, performing an endometrial biopsy may improve implantation in the following FET cycles. The mechanism of action may involve reparative changes in the lining following the biopsy but no one really knows…. Finally, I assume that assisted hatching (AH) has been used in the prior FETs but if not then clearly AH should be used...

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Question of the Day: Blocked Tubes and IVF

Question of the Day:

My doctor said she will remove my left blocked tube to help IVF without mentioning whether I have a hydrosalpinx. Is it possible that my tube doesn't have this condition? Do they have to remove a blocked tube no matter whether it has a hydrosalpinx? I am frustrated because they don't tell you enough and I cannot ask suitable questions as obviously I don't know enough as a patient.

DrG answers:

So first of all we need to define "hydrosalpinx." This term literally means a water/fluid filled tube as "hydro" is latin for water and "saplinx" means tube. So a hydrosalpinx is a fallopian tube that has become blocked at the end that is furthest from where the tube attaches to the uterus. The far end of the tube has the fimbria which are delicate finger-like projections that allow the tube to capture the egg as it is released from the ovary. Unfortunately, if the fimbria become damaged by infection or trauma (surgery) or inflammation (endometriosis) then they can clump together effective sealing off the end of the tube. Since the tube produces fluid from the cells lining the inside, this fluid begins to accumulate once the end becomes sealed and a hydrosalpinx is formed.

The fluid within a hydrosalpinx contains inflammatorty proteins that apparently decrease implantation rates both in spontaneous conceptions (if the other tube is normal) or in IVF when embryos are transferred into the uterus. So most REs recommend that patients undergo a surgery to prevent the fluid from backing up into the uterus. This procedure may be removal of the tube or performing a tubal ligation to simply divide/block the tube. Less commonly, patients undergo a hysteroscopic procedure to occlude the tube as it exits the uterus (Essure). Patients must wait several months after an Essure procedure and have a follow-up hysterosalpingogram to confirm occlusion of the tube.

Tubes that are open but abnormal may not need to be removed but doing so may further decrease the possibility of an ectopic (tubal) pregnancy occurring after IVF. Tubes that are very abnormal may progress to a hydrosalpinx so again removal may be justified depending on the laparoscopic findings. Tubes that look normal but have proximal occlusion with no dye entering the tube do not need removal in my opinion.

The final comment of the post is particularly disturbing to me.There is no reason that patients should feel that they cannot ask their doctor appropriate questions. How very sad….My patients certainly don't appear shy at asking my opinion...

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