Can my endometrium be too thick?

Wow, what a terrible blogger I have been these past few weeks. No new posts for a while and no insightful hints for the 3 regular readers of this blog (sorry Mom, I promise to call this week!). I could make up some incredible story about how I have been performing 80 hours of community service a week or that I have been traveling to South America with certain public officials from South Carolina or that I have been sick for weeks with the Swine Flu. Clearly, this last excuse may engender some sympathy....but the truth is that I have just been pulled in too many directions. Sorry.

So let's discuss the endometrium here since I recently received a slew of questions on the INCIID site about the thickness of the endometrium and what is ideal for fertility. Abraham Lincoln was once asked "How long should a man's legs be?" He astutely answered "Long enough to reach the ground." The same could be said for the endometrium in that it needs to be thick enough to allow for implantation of the embryo. Most studies suggest that "long enough" is anything over 7-8 mm.

So a few years ago I had a patient that was trying to get ready to do an FET cycle and had not had a period for 6 months and had PCOS. On sonogram the lining was pretty darn thick at 22mm (usual is 7-12mm). Patients with PCOS are clearly at risk for endometrial hyperplasia and even endometrial cancer. So I gave her a couple of weeks of Provera to get the lining to shed. No significant bleeding and the lining was still at 22 mm. So I did an endometrial biopsy which was read by pathology as possible cancer. Yikes! I immediately sent her to one of our local Gyn Oncologists who did an office D&C that yielded only scant tissue.

When I repeated the sonogram the damn lining was still 22 mm. I really was getting concered here but too a step backwards and decided to do a water sonogram in the office. Guess what. There was a large polyp sitting right there in the cavity and since polyps can have an unusual appearance on pathology that would explain the initial concern about cancer. The patient underwent hysteroscopy and I was able to easily remove the polyp. Case closed.

So when patient inquire about endometrial thickness I usually respond that as long as it is a normal lining without a polyp or a fibroid or cancer then thick is fine.

Thin endometrial linings can be another matter. Some patients have a thin lining becasue of previous surgery or simply because that is the lining that they have been giving and nothing can really improve upon it. I have tried all the usual voo-doo for thin linings....vaginal estrogen, Viagra, terbutaline, nitroglycerine, animal sacrifice...you name it. Some seem to help, some don't...I honestly have no recipe that works for everyone. The thinest lining that I ever had that resulted in a healthy baby was 5 mm!

So good luck growing those endometriums but try not to panic if you have an 8 mm and not a 15 mm lining. Anything >7mm should be fine and if waiting an extra week gains you a mm or two then all the better.

Options Besides Donor Egg IVF

I made it back to DC from Boston, thanks for asking. However, the journey was not easy. I boarded my AirTran flight at 6:15pm and at 6:35 pm the pilot announced that the plane was grounded for mechanical problems. Not to worry, advised the gate agent....another plane would arrive and take us to Boston at 8:30pm. Having heard this story one time too many, I hopped on the internet (than you Verizon for my wireless modem) and saw that there was a JetBlue flight to Dulles leaving at 7:50PM. My wife and I discussed the options and decided that I would stick with AirTran....big mistake.

At 7:30 pm the gate agent announced that the plan that was supposed to take us to Dulles was grounded in Newport News and we would now hopefully depart around Midnight! I grabbed my laptop and ran for the JetBlue desk. They confirmed that there was a seat on the plane but that the plan was boarding as we spoke. The nice lady called the gate and they agreed to hold the plane while I ran through security. Mercifully, there was no line at the security checkpoint and I made it on board with 1 minute to spare. By 9:45pm I was home in Maryland! When I called AirTran they informed me that I was on board the earlier flight and could not figure out how I was calling them from the DC area! Still had to get my car at BWI, but no plan is perfect!

Sometimes the road to our destinations takes us places that we didn't anticipate or desire. Life is a journey that is filled with twists and turns. In many of our patients that path leads towards family building options that they had never really considered.

Clearly, most patients are not thrilled when their RE announces that the only option remaining is donor egg IVF or adoption. Such a recommendation represents the end of a dream for those patients who wished to be the genetic parents of a child. The good news is that clearly donor egg IVF is very successful for many patients. However, not all patients are willing to consider egg donation. PB was one such patient and her story is rather revealing.

PB had successfully conceived with IVF back in 2005 and delivered her daughter without complication. When she returned to her clinic in 2007 she anticipated a good chance of success as she was < 40 years old and had an IVF baby already. However, after 2 FET cycles failed she attempted another stimulated IVF. Unfortunately, her FSH was 20 and her stimulation was poor and the cycle failed. She was told that although she was 38 years old that donor egg IVF was her only option. A friend told her about Natural Cycle IVF and she came to see me to discuss her options.

Meanwhile, our enthusiasm for Natural Cycle IVF remained very high and we made the decision in December 2008 to consider offering this option to older patients and/or those with a history of poor response to IVF stimulation meds. PB enthusiastically chose this option and underwent Natural Cycle IVF. She conceived on the 2nd attempt and is now >23 weeks pregnant. Needless to say, we were all thrilled for her and for the chance to offer another option to those patients who are not ready to pursue donor egg IVF.

We call this our IVF Hope Program to distinguish it from our standard Natural Cycle IVF Program (as we anticipate that the chance of success will be much lower in these patients who are looking to pursue a non-egg donor option). Interestingly, the use of Natural Cycle IVF in poor prognosis patients was the subject of a recent paper in Fertility and Sterility (see below). In this report, an Italian IVF clinic performed Natural Cycle IVF on those women who had failed to respond to fertility shots in THEIR OWN CLINIC! So clearly this was by any definition a group of low responder patients. Amazingly, their Natural Cycle IVF delivery rate was very good (all things considered) even in the older patients! At the Journal Club, Dr. DiMattina was placed in the position of defending Natural Cycle IVF while many of the other REs in attendance ridiculed the paper...even going so far as to physically rip the article into tiny shreds! Unfortunately, I was in Atlanta trying to convince my son to attend Georgia Tech and could not assist DrD in his defense of Natural Cycle IVF.

I think that patients should be allowed to make choices about their fertility treatment. Natural Cycle IVF is simply another choice. It does not work as well as stimulated IVF in good prognosis patients. It may be equally effective compared with stimulated IVF in poor responders...and may be the only ART option open to such patients who have failed to respond to stimulation previously. For those patients open to donor egg, donor embryo or adoption the role of Natural Cycle IVF is less clear as all those options work better so I would encourage patients to build their family through those means. However, some patients are not comfortable with Donor Egg/Embryo or adoption so for these patients a program such as the Hope IVF Program allows them to pursue another path.

Wanted: Egg Donor

So here I am sitting in Logan International Airport trying to kill some time before heading back to DC and hoping that I don’t catch Swine Flu. I was in Boston all day to attend a special ceremony honoring my father, Dr. Edward Gordon, who just retired from active clinical practice at the age of 86 and ending 60 years of continual practice as a general surgeon. All three of his sons were in attendance as he received several commendations for his contributions to medicine. Following these presentations, Dr. Pauline Chen gave a very emotional presentation including a reading from her NYTimes best-selling book Final Exam. I asked her for some hints as to how to get our book higher up the best-seller list but she was at a loss….Oh well.

What does all this have to do with infertility? Nothing. Just thought my patients may want to know where I was on a rainy Friday in Virginia. If you don’t care where I was then please accept my apologies but no one’s forcing you to read this blog anyway (although I pay my kids 5 cents per click to help my Google ranking).

This has been a week full of third-party reproduction questions. Egg donation, sperm donation, embryo donation, gestational carrier, gestational carrier with egg donation vs. embryo donation….etc, etc. If you can think of an usual way to have a child, chances are that someone has already tried that. Every year I get a couple of questions regarding daughter to mother egg donation. Adult daughter from first marriage wants to help mom have a baby with 2nd husband. If successful this makes husband #1 the grandfather of baby born to patient and husband #2. This is not as newsworthy as Octomom but most clinics will not perform this type of egg donation. The reason usually given (and I concur) is that children wish to please their parents and that makes Informed Consent without coercion impossible. Plus it just seems “yucky.”

So how do we even do egg donor IVF in the first place? This is the topic of today’s excerpt from 100 Questions and Answers about Infertility (which could use some more positive reviews on Amazon.com BTW!).

82. What are egg donors, and how is donor egg­ IVF performed?

Donor egg-IVF involves the use of healthy female egg donors who are usually in their twenties. Most donor arrangements are anonymous, although known donor egg IVF is possible. In the latter case, the known donors are usually family members or friends. In our experience, most of our patients prefer to use an anonymous egg donor to avoid family and interpersonal conflicts. Most medical practices recruit egg donors for their patients, but third-party agencies are also available that act as brokers. The American Society of Reproductive Medicine (ASRM) has developed a set of egg-donor screening guidelines, which most practices utilize for screening donors. The guidelines encompass comprehensive screening for infectious and genetic diseases, physical examination, and psychological testing.

Since May 2005, the U.S. Food and Drug Administration (FDA) has mandated extensive infectious disease testing while screening all anonymous egg and sperm donors. The actual treatment cycle for donor-egg IVF essentially combines a fresh IVF cycle (the donor) and a medicated FET cycle (the recipient). The two treatment cycles are synchronized by using GnRH analogs. Usually, the recipient begins estrogen therapy 5 days prior to the start of the egg donor’s stimulation so as to provide an adequate time frame for the recipient’s endometrium to grow and thicken. After 10 to 14 days of stimulation, the donor receives an injection of HCG (Pregnyl, Profasi, Ovidrel) to mature her eggs. On the same day, the recipient starts progesterone therapy to create a receptive endometrium.

Because most egg donors are young, they tend to respond very well to the ovarian stimulation drugs, producing many high-quality eggs and embryos. Implantation rates with these embryos are also very high, so that usually only one or two embryos are transferred to the recipient. Pregnancy rates usually exceed 50% per initiated cycle, making donor-egg IVF the most successful therapy currently available for infertile couples. Usually, extra embryos that were not transferred can be frozen and stored for later transfer, with excellent pregnancy rates achieved in subsequent conception attempts.

Endometriosis Surgery Before IVF?

My wife really hates checking the mail. “There is never any good news in that mailbox,” she usually comments as I carry the heaps of LL Bean catalogs in from the street. Well, yesterday there was something good in the mailbox...my royalty check for sales of that famous book “100 Questions and Answers about Infertility.” As I eagerly opened the envelope dreams of a new car (mine has 119K miles on it) or a new TV (we still have one with a built-in VCR in one room) or even helping to pay for my son’s college tuition (yearly bill is too shocking to report here) danced in my head.

I ripped open that envelope and saw that I would receive the whopping amount of $347.34 for my portion of the royalties over this past year.

So clearly I need to act. There can be only one answer…I need to blog more and apply guilt more freely. My patients have usually figured out that I am an easy mark when it comes to applying guilt (nod if you agree). I blame this on being raised in Jewish household before I converted to Christianity. If I had become Catholic rather than Presbyterian the guilt issue would have worked out easier. So now I need to turn the tables on you…dear readers. Where are all those 5 star Amazon.com reviews? Why has Oprah not called me yet? Why is our book not a Book-of-the-month Club selection? Beats me but I need to sell a lot more books to get that new car.

But enough light-hearted banter, we need to get to work so you all have time to log on to Amazon.com and post those reviews that state that our book is much better than any of those in the "Twilight" series.

So let’s return to excerpts from that wonderfully informative book and address a question that arose in several of my patients this week…

39. Do I need endometriosis surgery if I am already planning to pursue IVF?


This is a somewhat controversial area of reproductive medicine. Most reproductive endocrinologists do not recommend surgery prior to IVF unless the woman has advanced endometriosis, such as an ovarian endometrioma. For women who have only mild to moderate endometriosis, IVF is associated with excellent pregnancy rates even without surgery. When advanced endometriosis is present, such as an ovarian endometrioma, its surgical removal prior to IVF may enhance the chances for a successful IVF outcome and may decrease infectious complications related to egg collection. Thus, in such cases, most reproductive endocrinologists routinely recommend the removal of advanced endometriosis prior to treatment using IVF.

However, severe endometriosis with endometriomas may lead to diminished ovarian responsiveness, and ovarian surgery may further compromise fertility in such cases. So the decision to perform extensive surgery for endometriosis must be weighed against the potential impact of that surgery on the ovary. Also, advanced endometriosis may increase the likelihood for an early pregnancy loss or spontaneous abortion. By first removing the endometriosis, the outcome of pregnancy is greatly improved.

Traveling After Fertility Treatment

A lot of patients ask for advice when trying to coordinate fertility treatments and vacation or business travel. In general, I ask them to consider a couple of factors when trying to decide what to do. First of all, if hoping on a plane were all you needed to do to prevent pregnancy then flight attendants would never experience unintended pregnancies! However, there are reasons to be careful about leaving town following fertility treatments (or during early pregnancy).


Clinical vignette A:

MS was a 34 year old patient who had never been pregnant. She was given 4 months of clomid by her Ob Gyn and told to just keep trying. No other testing had been performed. No sonogram, no sperm analysis, no HSG. During her 3rd Clomid cycle she was at a professional conference in Chicago when she experienced severe abdominal pains and was taken to the local ER. She spent the next day and a half in the hospital with bilaterally enlarged ovaries with large (6 cm) cysts that may have been either endometriomas (endometriosis cysts or chocolate cysts) or just Clomid induced cysts.

Finally, she felt well enough to travel and returned to DC. She came to see me and on ultrasound had bilateral cysts which were hard to distinguish between clomid cysts and endometriomas. We waited a few cycles an they failed to resolve so she had a laparoscopy that demonstrated severe endometriosis.

Lesson learned: Don’t give clomid to patients that may already have a significant ovarian problem. This can easily be avoided by making the transvaginal sonogram part of the routine fertility evaluation. This week a couple was thinking about taking Clomid just before going to Europe for a fantastic vacation…I told them to have fun, get pregnant and wait on the Clomid until after they return!


Clinical vignette B:

TD was a 29 year old with unexplained infertility. She came in on a Friday afternoon for confirmation of pregnancy because she had tested positive on a home pregnancy test. However, her period had come that month or so she thought and was a bit concerned. The beta level was available on Saturday morning at 11:30 AM and it was over 1500 IU/L but not as high as it should have been given her usually regular periods and the fact that she was sure when she had conceived.

I called her and told her the news and suggested an ultrasound to evaluate whether this was an abnormal pregnancy in the uterus or even an ectopic pregnancy. When she answered her cell phone she was in line at the United baggage check to check her bags as she and her husband were on their way to France! I explained that an ectopic was possible and could rupture even in mid-flight on their way to France. On the other hand, it could be just an abnormal pregnancy destined to miscarry…My advice was to cancel the trip and come right on over to the office. They debated and called me back a couple of minutes later. They were going to France anyway. We discussed the risk of travel and the need for prompt assessment. They called me back an hour later. They canceled their trip.

On Sunday AM I performed an ultrasound that showed a 3 cm ectopic pregnancy. She underwent laparoscopy and was very grateful that she had not taken that flight.

Lessons learned: All pregnancies are potential ectopics. Sometimes you need to rain on someone’s parade in order to give them the best medical care.

Facebook

Well I guess I have now officially joined Web 2.0 with my own Dominion Fertility Facebook page. Although I am slightly worried that Facebook could prove as addictive as pinball was for me in college I am willing to test the waters and see how it goes.

So for all those readers of this blog (all 9 of you)...feel free to visit me on Facebook and become a fan (oh, gag me).

DrG

Fear of Flying

Usually I am a pretty calm traveler and with the exception of the months following 9/11, flying is usually not something that worries me. This past weekend I flew up to Boston for the day to celebrate the 86th birthday of Dr. Edward Gordon, my father and a recently (yes, recently) retired general surgeon. The flight to Boston on Sunday morning was fine. However, upon landing my brother Steve warned me that we may be staying for longer than just the day if the big storm brewing ended up slamming New England as predicted.

Well, the party was great and my parents enjoyed having two of their sons and a bunch of other relatives present. We headed off to the airport on Sunday afternoon and there were no standby seats available on the 5:30 pm flight to BWI. However, our 6:30 pm flight was scheduled for a 7 pm departure...still plenty of time to beat the storm to BWI. Then we heard the dreaded announcement : we had a plane and a pilot but no flight crew until 9 pm! So we watched helplessly as CNN described the monster storm bearing down on the I-95 corridor. Great.

We pulled away from the gate at 9:30 pm and had to wait for deicing to be completed. At 11 pm we were finally #2 for take off and just then all the lights came on in the cabin. The First Officer walked slowly back and forth. The Captain announced that this was just protocol to check for ice on the wings...not to worry. Heh, heh.

The sand trucks and snow plows made a nice path for us and we zipped down the runway. The plane lifted off and obviously made a safe landing at BWI 55 minutes later since here I am blogging about it. So what does this have to do with infertility? Not much but I actually do have a point. The checklist indicated that the First Officer needed to visually inspect the wings. He did so and we did fine. The flight that landed in the Hudson in New York came down safely because the crew followed protocols. In medicine, we need to follow protocols as well.

In fertility treatment we also need to follow a logical protocol. Check the tubes, check the sperm, check the hormones..etc etc. In the laboratory we check the patient's identity, double check the sperm donor's identity and confirm whose eggs go with whose sperm. These steps are crucial to a good program. Deviate from such procedures at you own peril. At Dominion each week we have a lab meeting to review past and upcoming patients in order to make sure that the plan makes sense for each patient. Your plan needs to reflect your needs. Make sure that you get a logical explanation of your plan...whether that means clomid/IUI or IVF. Remember that your RE is not trying to torture you by performing these tests, but just like the First Officer on Air Tran 800, he or she is just making sure that all bases are covered.

May all you flights be on time.