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Friday, May 15, 2015

Purple dresses and finding eggs....at Dominion Fertility.

We all have our weaknesses....one of mine is how much I hate losing stuff. I can't explain why I am so bothered by my inability to find a recently purchased pair of headphones or a missing glove or the lid to my stupid travel coffee mug. Then again I am comforted that my behavior is not a new phenomenon...Jesus told his disciples the parable of the lost sheep over 2000 years ago:

Luke 1:3-6.  Then Jesus told them this parable: “Suppose one of you has a hundred sheep and loses one of them. Doesn’t he leave the ninety-nine in the open country and go after the lost sheep until he finds it? And when he finds it, he joyfully puts it on his shoulders and goes home. Then he calls his friends and neighbors together and says, ‘Rejoice with me; I have found my lost sheep.’

My guess is that his disciples totally understood this story and were not left shaking their heads in disappointment thinking "we left our fishing business for this guy..."

So last Saturday after a full day in the office at Dominion Fertility I was sent to the Nordstrom store at Tyson's Corner Mall to complete a very important task. I was charged with matching a suit, shirt and tie combination with a purple dress that my daughters will be wearing in an upcoming family wedding. Amazingly enough, Anna helped me find an excellent match. As I was ushered back to the fitting rooms to meet with the tailor Anna assured me that it was fine to leave the dress by the register. I hesitated for a moment.....we had waited 4 months for this dress to arrive. The wedding is in 6 weeks. A responsible husband and father would have said "no thanks, let's take the dress with us because if it disappears then I will be in such deep poop that they will need Robert Ballard to come find me.." Yours truly said "ok, let's go."

The fitting took less than 10 minutes and then we emerged back into the men's department.  I headed to the register to get the dress. Which was gone. No dress. No one around had seen the dress. No one had any idea where it had gone. Anna called LP (loss prevention) to pull up the videos from the closed circuit cameras to see if they could tell us where the dress had gone. My knees were quivering a little bit and after about 3 minutes my ability to form a coherent sentence returned. Another salesperson thought that one of the women from upstairs had cruised through the men's department carrying a bunch of dresses....perhaps the dress was now with her. Anna and I headed up the escalator and into women's wear where we found a Nordstrom employee preparing to send the dress off the floor to the "unclaimed merchandise" section....located right next to Area 51 no doubt. With dress now in hand I exited the store and headed home rejoicing in my found dress.

So what does all this have to do with infertility? Readers of this blog and patients of our practice are aware that we do a lot of Natural Cycle IVF. In NC IVF we are working with a single follicle and trying to get that single egg that resides within that single follicle. We retrieve an egg in 85-90% of the egg collections performed for NC IVF. But to me that 10-15% is just like the lost sheep in the parable of Jesus. I am so disappointed. Plus I hate giving that news to my patients. Inevitably I am asked "where did the egg go?" I wish I knew. When we do a NC IVF egg collection we flush the follicle repeatedly and then hand off the tubes of fluid until the embryologist identifies the egg. We have found the egg on the 1st, 5th, 9th and even 13th flush (although most of the time we find it in the first 5 flushes). Still I wonder where does the egg go when we fail to find it? There are a couple of possibilities. First of all, the egg could have ovulated several hours prior to retrieval and we just didn't know. Secondly, as the needle enters the follicle and we then flush the follicle I think that the egg may squirt out around the needle. Finally, it is possible that there was not a healthy egg inside the follicle in the first place. This possibility has been referred to as "empty follicle syndrome." However, in our experience most patients will eventually have a successful retrieval even if no egg is found during an egg collection. Patience is a virtue and persistence can pay off in the end! Looking for the lost sheep or that tough to find egg just makes the finding of them all the more satisfying. So next time you see me in the office with a big smile on my face...it may be because I am remembering about having found that lost egg (or that lost purple dress)!

Friday, May 8, 2015

DrG is Outstanding in his field...or his garden....at Dominion Fertility

As a child I really had very little choice in terms of my chosen field. I am the grandson, son, nephew and brother of physicians. In fact, at family gatherings it was already assumed that I would be a doctor...the only question remained as to whether I would be a surgeon like my brother and father or whether I would specialize in some other field that really didn't pass muster...no pressure there. As many of you know, in order to become a fertility specialist, I had to first of all complete a residency in obstetrics and gynecology (4 years) followed by a fellowship in reproductive endocrinology and infertility (3 years). When I tried to explain this to my Dad he tried to be supportive but basically his perspective came down to his comment that "only the medical students too stupid to be surgeons ended up in ob/gyn." Oh well. My Mom was a bit more supportive having suffered multiple miscarriages before eventually having three healthy children (perhaps in spite of rather than because of the medical care that she received but that is another story). So naturally with Mother's Day just a few days away my thoughts have been on my Mom who was such a huge presence in my life.

As I regarded this photo (taken in my backyard in Milton, MA) several thoughts suddenly occurred to me. First of all, my Mom looks remarkably young to me... because in fact she is younger in this photo than I am today! Yikes.  Secondly, why am I sticking out my stomach? Who knows. Finally, I realized that I am standing in the flower garden. This fact is shocking. The flower garden was a place completely off limits and sacrosanct. In fact, for years I have regaled my youngest daughter with the story of how my brother Steve taught me how to ride a bike without training wheels by pushing me down the hill in our backyard. A story that ended with me crashing into this very garden and sending our Mom into orbit as she surveyed the damage I caused to her prized flowers. And yet, here I am standing in the garden...with my Mom...and she looks happy. How is this even possible? How could this photo have been altered before the invention of Photoshop? Of course, the truth is that the photo is real and untouched but that I simply have no memory of getting into that garden. So how does this relate to infertility?

Well, sometimes we find ourselves in places that we feared to go or places that we were told were not for us. There are many paths to parenthood. This past week I was happy to see a couple back for another baby after having success with modified natural cycle IVF. They had some concerns about the creation of extra embryos with traditional IVF and therefore they had not really considered IVF to be a valid option for them.

Considering the media firestorm about the fate of Sophia Vergara's frozen embryos I certainly understand why some couples are not enthusiastic about IVF. However, Natural Cycle IVF (NC-IVF) is performed using the single egg that is produced each month and therefore, the problems with multiple eggs/embryos are avoided. But Natural Cycle IVF is less efficient than stimulated IVF and some cycles result in no retrieval, no egg or no embryo to transfer.

The couple in question had ended up with a cancelled NC-IVF attempt because of an early LH surge and ovulation. We discussed options and they elected to attempt modified NC-IVF. In a modified NC-IVF cycle medications are used but the goal is NOT the development of multiple eggs. The goal of modified NC-IVF is to prevent the single egg from being released too early by using drugs typically associated with stimulated IVF. Using a slightly different protocol ensures the development of only a single follicle. So here a couple that had initially thought that all IVF would be off limits ended up with NC-IVF. But when NC-IVF proved problematic they now felt comfortable moving into modified NC-IVF instead of stimulated IVF.  Sometimes we end up in places that we never anticipated going. Sometimes we learn that standing in the garden may be just fine...you just need to take it one step at a time or have your Mom give you a lift....

Tuesday, April 21, 2015

Getting good grades...at Dominion Fertility.

Grades are important. There is just no way around this simple fact. On the other hand, a sense of fashion is not as important...which can explain how I got into and thrived at Princeton but was photographed looking like this in back of Nassau Hall. Raising kids in the Washington suburbs is an exercise in stress as everyone wants their kids to get all As and perfect SATs.....while taking 7 AP classes each semester...and playing several varsity sports...and starring in their high school's production of Chicago. Grades do matter in the college application process..no way around it. And yet, success in life clearly is determined by a whole lot more than your SAT scores or attending an Ivy League college. There are clearly other forces at work in the world and being reduced to a number, whether it is a GPA, SAT, MCAT, GRE usually fails to tell the whole story.

Given our predisposition to obsessing about grades here in the Metro DC area it is not surprising that our patients tend to become fixated on the grade of their embryos. In our laboratory we grade blastocysts with a 3-part score. Each part (inner cell mass, trophectoderm, blastocoele) is assigned a letter grade of A, B or C. Needless to say, everyone wants blastocysts with a grade of AAA. But those blastocysts with a lower grade can still turn into beautiful, healthy babies....similarly, AAA blasts can fail to implant or implant and miscarry. Although you would think that embryos graded AAA would always have normal chromosomes and those with lower grades would have abnormal chromosome counts, it just isn't true.

Case in point was a recent patient of mine who underwent donor egg IVF. She and her husband had chosen to defer PGS so we were relying on embryo grading alone to determine which embryos to transfer. Although I really was encouraging her to transfer a single embryo, they elected to transfer 2. Given her reproductive history I grudgingly agreed. The two embryos were graded BBB and BCC. Well, I am sitting here in my office admiring the birth announcement that shows an adorable photo of their son and daughter who were born at term following a relatively uneventful pregnancy. So keep in mind that grades cannot perfectly predict success in life or in IVF....nor can good grades guarantee any sense of fashion!

Friday, March 6, 2015

Snowblowers and other dangerous devices...

Yesterday we declared a "snow day" for Dominion Fertility. We had a team come in for monitoring and procedures but all regular patients were rescheduled. I was not the doctor yesterday so I got the chance to stay home and hang out with my family. By late afternoon we had at least 8 inches on the ground and I decided it was time to get out my trusted Toro electric snow blower. Let me tell you that this snow blower is really wimpy compared with the one that my Dad owned. However, living in Boston demands the use of extreme measures (especially given a winter like the one they are experiencing this year).

As I used my dinky little electric snow blower my thoughts were on my Dad. Wednesday would have been his 92nd birthday. Year after year I would zip up to Boston on or around March 4th to celebrate his birthday. Several trips included weather drama including one year when my return flight to BWI was the last plane out of Logan International Airport and we literally followed the plow down the runway in order to get off the ground....

In any case, as I was slowly clearing the driveway, I started to chuckle remembering one of many stories relating to my Dad and his routine use of his hulking Ariens gas powered behemoth of a snow blower no matter how bad the weather. On this particular occasion, my Dad and Mom were trapped at our home in Milton following about 10-12 inches of snow. As usual, Dad announced that he needed to clear the entire driveway even though they absolutely had no plans to go anywhere. Mom suggested that Dad take Chester, their miniature schnauzer, outside to keep him company. Dad put Chester's coat on and off they went to do battle with the driveway. Chester was a rather unusual animal, but Dad loved him. Unlike many Gordon family dogs, Chester was non-violent and had never trapped my Mom in the kitchen nor bitten any family members. So in the pantheon of Gordon dogs one has to rank him pretty high on the list in spite of his rather diffident attitude to all humans except my Dad and occasionally my Mom. 

So on this fateful morning Dad took Chester outside and hooked him to the corner of the garage using the vinyl coated chain that would keep him safe from wandering away. As Dad carefully cleared the driveway he failed to realize that the chain attached to Chester actually looped out into the driveway and then back again to the corner of the garage. He failed to realize this because the chain was under nearly a foot of freshly fallen snow.

As my Dad approached the corner of the garage, Chester slunk back towards his dog house to get away from the noisy gas powered monster that was chewing through the snow and hurling it off to the side of the driveway. Suddenly, Dad passed over the dog's chain which was instantly sucked into the maw of the snow blower. My Dad released the drive lever but the rotating blades of death kept spinning. Chester was yanked out of the garage and dragged towards the front end of the now stationary snow blower. My Dad was frozen in horror as Chester yelped in terror. The blades finally stopped rotating when Chester was only inches from recreating the famous wood chipper scene from the movie "Fargo."

My Dad gathered up the traumatized animal and retreated into the house. It took several days for dog and owner to recover. In fact, Dad told me that he even had nightmares about the entire surrealistic episode, but his nightmares did not have a happy ending.

So what does all this have to do with infertility? Well, it's funny how you sometimes get an idea from a totally unpredictable source. I had a patient recently who had failed to conceive in spite of several embryo transfers of genetically normal embryos following IVF with PGS. She had a normal appearing uterine cavity with a perfect triple line endometrium on ultrasound. The embryos looked perfect following thawing and I had even performed an endometrial biopsy following the first failed ET because I was so surprised at her failure to conceive. However, the one issue that concerned me   was that she always reported a sharp cramp just as the embryo transfer catheter passed through the top of her cervical canal and into the uterine cavity. Most patients have no sensation at the time of the embryo transfer. In fact, if it wasn't for the fact that they see the catheter on sonogram at the time of transfer and/or conceive following transfer, I think that many of them would doubt that we had even done the procedure in the first place.

But in this situation it seemed that every time the catheter passed a specific point she really felt it. I could also feel a little hitch as the catheter passed this spot. So I made an adjustment and this past cycle I did not use our traditional afterload technique but rather took the whole catheter from the embryologist and navigated through the cervix with the embryo already loaded in the catheter. Voila! Pregnant with a normal looking gestational sac on ultrasound. But that little hitch reminded me of the little hitch that my Dad might have felt as the snow blower passed over Chester's chain and almost sucked the hapless animal to a grisly demise. Fortunately, both of these stories had a happy ending as Chester did live several more years, keeping my Dad company for the rest of my father's life and my patient was ecstatic that she conceived.

Friday, February 6, 2015

Working at Dominion Fertility is better than getting a root canal.

Sometimes you just feel like crying.....Two weeks ago I got a call from my general dentist that was pretty much the last straw for that day....as feared, I needed yet another root canal. Now, I must admit that getting a root canal is certainly small potatoes compared with thousands of other potential medical issues faced by individuals a lot less blessed than yours truly. But still, another root canal....really?  For dramatic purposes I have recreated that phone call for readers of this blog. In carefully examining the accompanying photo I would like to point out two additional details. First of all, I may have to reconsider contacting Hairclub for Men. My kids have been documenting the increasing size of my bald spot with the gleeful enthusiasm with which Global Warming believers track the shrinking size of the Arctic ice shelf...or the increasing size of the hole in the ozone layer (take your pick). Secondly, fans of my blog post detailing my successful efforts to master loping a horse while at Rainbow Trout Ranch may appreciate the photos on the wall behind me. These were taken at Rainbow Trout Ranch with an iPhone 6 (believe it or not) and then I had the canvas prints made through art.com....not bad but I must admit that I did take hundreds of photos of which only a few made the cut. So as I hung my head in disgust at the prospect of another root canal I contemplated what I should do about the news from my general dentist....

Several years ago I needed 2 root canal procedures (on different teeth) in a relatively short period of time. Foolishly I let a general dentist who was covering for my regular dentist convince me to let him perform the root canal. Who knew? He seemed very competent, compassionate and well trained. However, he is not an endodontist.  Unfortunately, I was a bit uneducated in terms of endodontists and halfway through the root canal the general dentist had to abandon the procedure and ship me off to a local endodontist.

The difference was profound. Dr. Richard Pollock was confident, skilled and lightning fast. I was in and out and on my way before I knew what had happened. The key difference between Dr. Pollock and the general dentist was quite simply Dr. Pollock's level of experience with endodontics and his ability to rely on his extensive personal professional experience in handling my slightly aberrant anatomy.

So here I was facing the decision about another root canal. My general dentist offered to do it for me but to his credit he didn't even blink when I suggested that I would prefer to return to Dr. Pollock's care. Yesterday afternoon I was back in Dr.P's office and fortunately I again had an excellent experience. I was drooling a bit when I returned to the Dominion Fertility office but nobody seemed to notice...which leads me to wonder if I drool routinely...

What does any of this have to do with infertility? Well, I often see patients with infertility who have spent months and months of valuable time with their general Ob Gyn doc doing month after month of clomid or progesterone or estrogen or BBTs.  Sometimes these poor patients have not even had a complete evaluation and I am left to explain to them why clomid would never work since their tubes are blocked or their partner's sperm are barely moving.... Just as in dentistry, there is a place for generalists and a place for specialists. The key point is knowing when to go to one over the other.

Three years ago I had a patient who came to me at age 36. She had undergone an appropriate evaluation by her Ob Gyn with an HSG, semen analysis, blood tests and ultrasound. All the tests were normal and her Ob Gyn elected to prescribe empiric clomiphene (presumably in hopes of recruiting additional follicles since she had regular periods and was not anovulatory). I saw her after 6 months of clomid and she had never conceived. We discussed options and she elected to try Natural Cycle IVF. She conceived on the second cycle and delivered a healthy baby. At her yearly exam when her baby was a year old, she confided in her Ob Gyn that she had never resumed contraception because she wanted another child. So what would be the next logical step?

Check an HSG to ensure the tubes were open?
Perform some lab tests to  ensure that the patient was not slipping into diminished ovarian reserve? Get a basic sonogram to look for endometrioma cysts or fibroids or whaever?

Nope. None of the above. Here's a prescription for clomiphene and see you in 6 months! I don't know why the patient went along with that plan. Perhaps she was like me receiving the news of needing yet another root canal.... The good news is that after the 6 months of clomiphene she returned to Dominion and we picked up right where we left off and following a slightly more involved course of treatment she conceived again and had a successful pregnancy.

I accept that no one really wants to come see a fertility specialist. It is an admission that things are not working out and that there could be the possibility of giving up on the dream of having a child. The good news is that most patients ultimately achieve their goal of becoming parents. It may not be through the path that you had expected and may involve such alternative means such as donor egg, donor sperm or adoption...but in the end there is the chance to be a parent. So speak up and make sure that you get the opportunity to speak with a specialist when suffering from infertility. And if you need a root canal, make sure that you seek our Dr. Richard Pollock...tell him DrG sent you.