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!

Read More

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...

Read More

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....

Read More

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.

Read More

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....

Read More

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. 

Read More

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! 

Read More