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.

Read More

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....

Read More

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.

Read More

New Hope for Hyperstim...Curing the OHSS Woes (Part 1: Lupron Trigger).

I have been writing this blog for a couple of years now. Year in and year out the most popular post has been my discussion of OHSS (see the OHSS Woes). Hundreds of comments have been posted with some pretty scary stories of OHSS. Well, there will always be some risk of OHSS in patients who take fertility drugs but some recent advances may markedly reduce the risk. So here are some details about some new ways to manage OHSS that you may want to discuss with your RE....

#1. Lupron trigger
All egg collections must be timed so that the egg within the follicle is ready to ovulate but the procedure is scheduled before that occurs. Traditional timing of egg collection is 34-36 hours after an HCG injection. HCG is very similar to the LH hormone produced by the pituitary (master gland in the brain) and fools the follicle into thinking (if follicles could think) that it is time for the egg to pack its bags and get ready to pop out. The problem is that HCG hangs around for over a week whereas the LH that the brain releases is gone within hours. It is this prolonged HCG exposure that drives the OHSS bus. Similarly this explains why pregnancy makes OHSS so much worse...the developing placenta makes HCG constantly increasing the production from the ovary of the proteins that lead to OHSS symptoms.

So we need HCG in order to do the egg collection and actually get eggs out of the follicles but we really want the HCG to go away quicker to prevent OHSS. Some of us use 5000 IU of HCG to try and avoid OHSS, but the truth of the matter is that all my severe OHSS patients have gotten 5000 IU instead of 10,000 IU so clearly this is not all that effective...

However, some fertility clinics (including ours) are now using Lupron to trigger patients for egg collection. Lupron will cause the patient's pituitary glad to release the LH that is in storage and that LH is usually sufficient to get the eggs ready to be retrieved. The LH then drops precipitously and the risk of OHSS is very close to zero! Wow! What a great option....BUT...

Unfortunately, there is always a "but."

First of all, you can't use Lupron trigger in patients who have been on Lupron for their stim...no MDL flare patient, no Luteal Lupron protocol patients.

Secondly, the estrogen levels with Lupron trigger fall FAST. I mean really fast. This rapid drop in estrogen levels is good for OHSS prevention. It is not so good for implantation. DrD attended the Santa Barbara IVF meeting this summer and came back enthusiastic about Lupron trigger but he noted that although the rate of OHSS is nearly zero, the present recommendation is to freeze all the embryos and save them for an FET cycle because most REs believe that the implantation rate in a Lupron trigger fresh cycle is much lower than expected.

Thirdly, in patients with insurance coverage for IVF this may be problematic as the insurance could count this as 2 separate IVF attempts (one fresh and one FET...even though no fresh ET was ever planned)....Ugh. Nothing is ever simple.

So how do we like Lupron trigger? Well, I have had some very nice success rates with FET cycles with Lupron trigger but our experience seemed consistent with that of other clinics when it came to fresh ET with Lupron trigger. Some patients with really difficult stims (PCOS, AMH level off the wall, history of canceled cycles with estrogen levels >10,000 pg/mL) have made it through egg collection without an issue and their estrogen levels fall really fast and they have very little symptoms of OHSS. I believe this represents the future of IVF stimulations but there remain some unanswered questions....

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

Read More

Goodbye Summer...Hello Autumn!

Goodbye Summer…

Growing up in New England you get used to summer lasting only a few weeks. Of course, here in DC it seems like summer lasts a lot longer as temperatures can be in the 90s in April…. However, in Boston the weather in Spring may not be very Spring-like as I remember a snowstorm one year in June!

The end of summer is always sad to me. In June it seemed like there were an almost infinite number of possibilities for the coming season….then by September you are faced with all the fantastic activities that you failed to pursue. This summer was pretty good. There was the obligatory "honey-do" list which including clearing out closets of junk ("What do you mean I should throw out my high school soccer jacket?!?) but I did learn to wakeboard ("Wow Dad you look pretty good for a fat, hairy, balding, old guy!")…

The Bob Seger song "Night Moves" sums up my view of the end of summer:

I woke last night to the sound of thunder
How far off I sat and wondered
Started humming a song from 1962
Ain't it funny how the night moves
When you just don't seem to have as much to lose
Strange how the night moves
With autumn closing in

But as we say goodbye to the heat and humidity I guess that Fall has some positive aspects to it as well. Just gotta get over the things that we didn't get to this summer and move on.

I have spent a lot of time going through the 35 mm slides that I rescued from my parents' home following my Mom's death in May. My Dad really had no place to store them and I was appointed keeper of the family memorabilia. The amazing thing about those images is that there are slides of me and my brothers and parents that I have never seen before….In today's digital world where we have instant access to thousands of photos on our iPhones, it is hard to remember what it was like to have a box of slides that contained unknown images from the past. Opening each box of slides is like an archeological expedition. Some trigger sharp memories and other register complete blanks with me.

I love this photo of me and my best friend Karma. She was an excellent dog. Rescued by my Dad (after a lot of pleading) from Camp Cody in New Hampshire she was my buddy. This photo reminds me that Fall isn't so bad after all...


What does any of this have to do with IVF and infertility? Well, not a lot I guess except that for many of our patients their view of their fertile years may be initially like my view of summer from the perspective of June. Then suddenly the years flash by and autumn seems to be closing in. But there can be good days in autumn….with or without your canine companion.

This past week I met up with a couple that had been through a lot including a tough mid trimester loss. We discussed issues of diminished ovarian reserve, and age-related aneuploidy (chromosome abnormalities). I spent some time discussing Natural Cycle IVF. Ultimately, they politely stopped me and told me that they were really more interested in hearing about donor egg IVF. They had moved beyond Summer and were prepared to embrace and love Fall. Patients are always a doctor's best teachers…

P.S. My Brother Steve is still kicking my butt in terms of Mom's Scholarship Fund.....

Read More

Free Advice is Worth What You Pay for It....

Recently my older brother Steven and I were having a discussion about the Internet and this Blog in particular. He wondered why I spent so much time and effort responding to posts from patients all over the country and the world whom I would never meet face to face. In addition, we discussed the fact that I often referenced Mom and Dad in my posts and shared my grief over her final illness and passing at the end of May.

Honestly, the whole blog thing is out of character for me. In fact, I am a rather introverted person. I do not do well at cocktail parties and have a real problem putting names and faces together...although I pretty much have my kids down pat at this point...more or less. Yet my profession requires me to delve into the most intimate of details when working with a couple. Few issues are as difficult to discuss as those concerning reproduction and family building. Money is another one and as many of our treatments are not covered by insurance, money enters into the decision making as well!

As a 3rd generation physician I have an old-fashioned view of the doctor-patient relationship. I remember asking my Dad one time, as we drove past the Hollow restaurant on Adams Street in Quincy, MA, why we never ate there. He said that it was hard to go there because so many of his patients worked there, ate there or hung out there. I persisted and finally he agreed to take my Mom and me to dinner at the Hollow. It was like seeing the paparazzi descend on Leonardo DiCaprio! I think that he ate only about half of his meal because so many people came over to say "hi" and thank him for being such a great surgeon. That dinner made a real impression on me at the time. To this day my Dad views his identity as physician first and everything else second. Although I have attempted to develop a more balanced identity, I will admit that being a physician is very important as part of my worldview.

So why do I persist in answering post after post on this blog. And why do I drag myself over to Fairfax Hospital early in the morning to lecture to the students and residents. Well, I have always viewed teaching as being a big component of my job as a physician. As DrD states "I teach because someone taught me." As above, I lecture every week to the medical students and residents. I have served as a preceptor for Princeton pre-med students and every summer I have been a speaker at the National Youth Leadership Forum on Medicine (an organization that encourages high achieving high school students to explore medicine as a career). So I use this blog as means to teach and to educate the 12 people who read this blog regularly. Along the way I try to give some insight into how I think and practice. Sometimes I share some personal history as part of a quid pro quo...."Hi I am Dr. Gordon. How often do you two have sex?" Yikes. What a crazy way to make a living...

So back to my brother Steve. We are very competitive. So competitive that we rarely play one on one games anymore. Plus I hate to beat an old guy. In any case, he was very proud of all the contributions that had been made to the Tufts Medical School Scholarship Fund in memory of my Mom by his professional associates. In particular he said "so where are your internet buddies now?"

Dear Readers, I have never asked for anything from you...until now. If you have found any part of the hundreds of posts on this blog and my answers to questions helpful then please consider a nominal $5 gift to the Tufts Medical School Scholarship Fund in honor of my Mom (Claire Braverman Gordon). Contributions are totally voluntary and I will continue to answer all questions to the best of my ability..but I really hate to lose to my big brother...

Claire Braverman Gordon Memorial Scholarship Fund
Tufts University School of Medicine
Office of Development & Alumni Relations
136 Harrison Ave.
Boston, MA 02111

Read More

It only takes one...

Although we strive for multiple embryos in stimulated IVF, sometimes we loose track of the concept that it really takes just a single embryo to make a baby. I have a current patient who went through IVF with PGS (preimplantation genetic screening) and had multiple grade AAA blastocysts for embryo biopsy on day 5. Interestingly, only a single embryo of all these normal looking blasts was genetically normal. We transferred that single embryo and now she has an ongoing pregnancy. Would we have found that single normal embryo eventually? Yes. Would the patient have become emotionally drained, frustrated and financially strapped by the repeated transfers... Possibly...

So as we revise our approach to stimulated IVF, PGS may become more and more common. In the end, it still just takes a single good embryo to make a baby. Does Natural Cycle IVF create a higher percentage of normal embryos compared with stimulated IVF? We don't really know but this could explain the higher implantation rate that we see in NC IVF....

Last weekend I was in Boston cleaning out my parent's home as my Dad prepared to move into an apartment. I ended up with a minivan full of thousands and thousands of slides. Many of these were photos of yours truly that I had never seen. (These photos would serve to undercut my brother Steve's assertion that I was found in the gutter one night and raised in my parents' home under the mistaken impression that I was actually a Gordon born and bred....).

The photo on the right is me with my dog Karma. Although not evident in the photo, Karma was actually missing her right front leg which was amputated after she was struck by a car early in her life. She lived to be about 13 years old and it never slowed her down. In her case it took only 3 legs to live a full and happy life and in your case remember it only takes a single good embryo!

Read More