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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.

Monday, January 12, 2015

Going a little batty at Dominion Fertility.....

Last month I turned 51. I guess that turning 51 "beats the alternative" as my Nana used to say but the passage of time can certainly give one pause. On my birthday we decided to take a nice hike at one of the local Maryland State Parks and I guess that my anxiety about aging got the better of me.... As my kids would say, "Dad totally lost it." Once I was done venting at my kids for being disrespectful and unappreciative we headed back home with a dark cloud hanging over the family. A little bit later in the afternoon my wife yelled out for me to come help her in the bedroom as there was a bird flying around. Well, she didn't have her glasses on and what she thought was a bird was actually a member of the flying rodent family...a bat. Now, all of us germaphobes know that bats carry lots of bacteria and viruses. In addition to rabies, bats also carry viruses that cause people to turn into mindless flesh-eating zombies....oh wait, that may have been in The Passage and may not actually be scientifically accurate. In any case, bats give me the creeps and now there was one flying around my bedroom.

Being the manly guy that I am, I got my wife safely out of the room and then suggested that we call a real man. But since this was over Christmas break it was decided that I would have to deal with the problem as my wife pointed out that waiting for our handyman Todd to drive over would take an hour and during that time we would have effectively abandoned the bedroom to the bat and its bat guano producing activities. So I returned to the bedroom armed with a rolled up shower curtain and opened the door leading from the bedroom to the patio in order to give the furry little disease carrying beastie a way to exit. Meanwhile I took up a defensive position by the door leading back to the main part of the house and waited to see if he would make his escape. Suddenly the little flying vermin came right at me just like a scene from the Three Stooges. I "screamed like a little girl" and slammed backwards into the door which was slightly ajar because my wife was reaching into the room to try and close the sliding door into the closet. The bedroom door slammed into something hard (her skull) and my wife staggered back into the hall with a bruise immediately forming just above her eyebrow.

Once the kids saw my wife take the blow to the head they made a break for the basement and immediately started playing video games. The bat, its mission accomplished, flew out the window and headed for the woods. My wife lay back down with an ice pack on her head to help the swelling. Meanwhile I sat down with a beer and tried to figure out a way to spin this story to make it seem like I was more of a hero and less of a wife-beater who also can "scream like a little girl".....still working on that by the way.

So what does this little vignette have to do with infertility? Well, dealing with the unanticipated is pretty common in our business. Although it makes sense to plan for any contingency, sometimes we have to make a "game-day" decision and change course. For example, most IVF centers are really enthusiastic about Preimplantation Genetic Screening (PGS) of embryos. By allowing us to identify which embryos are genetically normal, we can transfer fewer embryos and yet still maintain an excellent pregnancy rate. At Dominion, we perform the trophectoderm biopsy on day 5 or 6 and then immediately freeze the embryos awaiting the results of the genetic testing. As we are already planning to freeze the embryos and not perform a fresh embryo transfer we usually use Lupron (leuprolide) to trigger for egg collection. Using Lupron to trigger almost completely eliminates the risk of ovarian hyperstimulation syndrome (OHSS) and that is a very good thing. However, the rapid drop in estrogen levels is problematic for patients trying for a fresh embryo transfer so we freeze all embryos (biopsied or not) if Lupron is used to trigger.

So last month I had a patient whose stimulation went fine but it looked like we would only end up with 6 or so eggs. Given fertilization rates of 80% and blastocyst formation rates of 50% of fertilized eggs I predicted that we would have only 1 or maybe 2 top quality embryos. So we made a rapid course change. We ditched the Lupron trigger and went back to HCG trigger allowing the option of a fresh ET if no PGS was done. After retrieval and 5 days of culture we had a single beautiful blast and went for ET deferring PGS. She conceived and had now been referred out for OB care. The low response to meds was a bit unexpected but by remaining flexible and having a thoughtful conversation about options we were able to secure a good outcome. This story illustrates why I think it is so important to have the ability to easily communicate with one's doctor during an IVF cycle. You never know when you may end up with an unanticipated stimulation result.....or a bat flying around the bedroom...

Monday, January 5, 2015

Best Wishes for a Happy and Healthy 2015 from the Staff of Dominion Fertility

Somewhere along the line seemed to have misplaced the month of December 2014. My apologies for not posting the Dominion Fertility holiday photo earlier but life interrupts sometimes....

I lost a bet with the young daughter of one of my patients over this photo. I bet her that she couldn't identify all the staff members that I had Photoshopped into the picture because they were out of the office on the day we took the photo....should have known better. She gleefully took my money. No more bets with kids...

Happy New Year!


Tuesday, November 11, 2014

Wishing all those who serve a safe journey home....

In 1951 my parents returned from Trieste, Italy where my Dad had served as Chief of Surgery at the Army hospital located far from Charlestown, MA where he was born and raised.

Their time in Europe was a defining part of their lives and I still have literally hundreds of 35 mm slides and many notebooks filled with my Mom's beautiful handwriting as she dutifully studied Italian.

When they finally began their journey back to the United States they were not returning empty handed as can be seen in this photo. They were bringing back their infant son who had been born at the Italian hospital in Trieste. Mom went into preterm labor and was unable to be airlifted to the American hospital in Rome before my brother Michael was born.

Their journey to parenthood was not easy as my Mom had been informed by one of the leading fertility specialists in the country (Dr. Rubin in NYC) that she would never have any children. Dad, always the General Surgeon, told me that he never liked that doctor and thought that he was an ass. Well, Dad proved correct in the end as my brother Steve and I followed over the next 12 years. Every time I perform an HSG using a Rubin-type cannula, I think about how wrong Dr. Rubin was about my Mom. Although my parents had headed off to Europe completely prepared to adopt a war orphan, they were not yet ready to give up all hope of biologically becoming parents. Obviously, I am glad that they kept trying...although my Dad did diagnose my Mom as being in menopause when she became pregnant with me (hey, you can't be right all of the time...). 

So on this Veteran's Day 2014, I salute all those who serve in our military and wish them Godspeed and safe passage home from wherever they are currently stationed. God bless all of you who serve or have served our great country both in peacetime and in war.