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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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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