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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.

Wednesday, November 5, 2014

Tell me a story.....about Dominion Fertility.

I love audiobooks. I have been known to sit in my car in the driveway or in the garage at work just waiting for the end of a chapter. I know I am really engaged in a great listen when I see the beltway looking like a parking lot and silently rejoice that I will have the chance to listen to even more of my book. I have a pretty wide range of taste in terms of audiobooks: from science fiction to non-fiction and everything in between. However, one book that really grabbed hold of me since I first listened to it over 3 years ago was "The Thirteenth Tale" by Diane Setterfield. This Gothic tale is all about telling stories and telling the truth, although sometimes it is unclear what is the truth and what is fiction. Plus, it's a story about twins...so its clearly right up the alley of a Reproductive Endocrinologist.

Relating stories is an important part of being a physician. I believe that patients often feel so alone in thinking that their problems are so unusual that we physicians have no idea of what to make of the situation. Of course, that is usually not the case. In a recent, NY Times blog, this issue of using clinical vignettes to enlighten both colleagues and patients alike was thoughtfully presented. When patients hear stories that resonate with their own situation, I think that it provides more reassurance than reviewing a multitude of randomized controlled trials...although some of our patients do love to share their latest internet research....

So since we are talking about telling stories, let me share a story (with her permission) about a patient that just gave me some very happy news.....

I first met VW and her husband back in 2010.  She was almost 35 years old and they had been trying for over a year to conceive. At first we thought that their biggest issue was one of timing since as busy Washington DC professionals they were like ships passing in the night for months at a time. Her ovarian reserve was concerning with an AMH of 0.3 ng/ml (normal is 1.5-2.5 ng/ml) and we talked about stimulated IVF as an aggressive first step. They elected to go with a very low tech approach and pursued Natural Cycle IUI. Happily, they conceived on the second IUI and delivered a healthy full term daughter 9 months later. As a wise man once said, if all else fails listen to the patient. Perhaps this really was just a timing issue.

They returned a year later to try for baby #2. However, her ovarian reserve was much lower now with an AMH of <0 .16="" 14="" 30="" 3="" a="" additional="" after="" again="" an="" and="" antral="" be="" chance="" chose="" conceived="" could="" count="" cycle="" cycles.="" cycles="" diminished="" dinner="" discuss="" do="" egg="" elected="" estrogen="" failed="" fertility="" follicle="" fsh="" gal="" given="" going="" had="" her="" however="" i="" if="" iu="" iui="" ivf.="" latter.="" level="" low="" medications="" met="" ml.="" ml="" month="" movie="" natural="" ng="" of="" on="" one="" options.="" or="" our="" ovarian="" p="" pg="" pretty="" previously="" reserve="" responding="" results.="" she="" since="" so="" sonogram.="" that="" the="" then="" they="" thought="" to="" type="" undergo="" was="" we="" well="" with="">
NC IVF cycle #1 went to retrieval but no egg. NC IVF #2 went to retrieval and ET but negative beta. NC IVF #3 went to retrieval and she got an egg but no fertilization. NC IVF #4 went to retrieval and ET and resulted in a positive beta but it ended up as a biochemical pregnancy. They were encouraged and went for NC IVF #5. We got an egg, an embryo and a positive beta. She was sent off to her Ob Gyn with a normal looking pregnancy and in spite of some scary first trimester bleeding she went full term and delivered another healthy baby girl weighing over 8 and a half pounds!

In "The Thirteenth Tale" the reclusive author Vida Winter is exhorted by another character to "tell me the truth." So here is the truth about NC IVF. It really does work. It really can result in good outcomes for patients with diminished ovarian reserve, and persistence can be rewarded with eventual success. But even if you have no interest in NC IVF, do yourself a favor the next time you are stuck in beltway traffic and listen to a ripping good audiobook like the Thirteenth Tale.

Tuesday, September 23, 2014

8 years, 3 successful pregnancies, 4 babies (3 is for quitters)....at Dominion Fertility.

This is my 16th year at Dominion Fertility and for 8 of those years SH (not her initials) and her husband have been my patients. Although I cannot remember what I bought my wife for Christmas last year, I still remember speaking with her parents following a laparoscopy back in 2006....

Could I guarantee that she would be successful with IVF?

Would I swear to do my best to help her become pregnant?

I told them that although I could not guarantee success, I believed that she had an excellent probability of success and I would absolutely do my best to help their daughter. In looking at the options for IVF they elected to enroll in our Financial Guarantee Program and on her first IVF attempt she conceived following a fresh ET and had an uneventful pregnancy.

When they returned for follow-up their son was almost a year old. No problem we all thought...this should be easy. But after another stimulated IVF followed by 2 FETs they had come up empty. We moved onto another stimulated IVF but that fresh transfer and one additional FET also failed. An endometrial biopsy had been normal and for the final FET cycle I decided to take a dramatically different approach by using low dose stimulation to prepare the lining for the final FET from her stimulated/freeze all cycle. Not a typical approach but we were all getting a bit frustrated (complete understatement) and her only pregnancy to date had been on a fresh ET. Shazzaam! Pregnant on the FET and after an uneventful pregnancy their second son joined their family.

But they were not sure that their family was complete so when son#2 was almost 18 months old they returned to discuss options. Stimulated IVF was not an option that they wanted to pursue so they opted for NC IVF.

NC IVF #1 resulted in no fertilization. Needless to say they were very surprised since in their stimulated cycles they had always had excellent fertilization.

NC IVF #2 resulted in a transfer and a pregnancy...but then a miscarriage after 10 weeks. Pregnancy loss is so devastating and in this situation it was totally unexpected given how good things had looked early in the pregnancy.

18 months passed and they finally decided that one more try was in order. Sink or swim....this would be the final hurrah. No pressure, Dr. G....

NC IVF #3 went perfectly and she underwent ET of a nice looking early blastocyst. Success! Her betas rose appropriately and we all very excited when she came in for her Ob sonogram. At first I wasn't sure if I could trust my eyes, but I was pretty sure that I was seeing 2 fetal poles and 2 yolk sacs and 2 heartbeats! Although I can certainly understand how an expanded blastocyst can split like a soap bubble into identical twins, I must admit that I was not expecting this turn of fate since we had transferred an early blastocyst.

Well, last week I received an email with the happy news that Mom and their 2 new DAUGHTERS were doing just great. Talk about instant family balancing....

SH agreed to let me share her story and all the ups and downs that these 8 years have represented. The joys and the sorrows. the good times and the bad.... After 19 total years in practice she has claimed my top spot with delivery of babies #3 and #4. I have several couple who have had 3 babies from our efforts but I think that this is a first for me.

On the Disney Channel Show "Good Luck Charlie" Teddy (the oldest daughter) asked the Mom (Amy) why on Earth they had decided to have a 4th child.....Amy's reply: "Because 3 was too easy. 3 is for quitters!"

Congrats to SH and her whole family who never quit and allowed me to be such an intimate part of their lives!