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Wednesday, April 2, 2014

Salon.com got it right. DrG at Dominion Fertility agrees.

Over a decade ago I received an odd email from the folks at Salon.com. They had seen my book: Obstetrics, Gynecology and Infertility: Handbook for Clinicians and were hoping that I would serve as the medical professional on a team of editors that was working on a book that Salon.com would publish. Seemed like a chance to make sure that the public got appropriate medical advice in terms of reproductive health so I tentatively agreed. "Just send me a list of the chapters so I can make my final decision," I requested.

Now I guess that at the time I was a bit naive about the interests of the target audience and basically thought that the book would just be about typical REI stuff....wrong. With chapters like "How to make sure that your sex toys don't transmit STDs" I realized immediately that I was way out of my little Presbyterian, Eagle Scout comfort zone. So I ended up begging off the project and handing it off to a recent graduate of the Ob Gyn residency program who was a little more up to speed on the whole subject of "marital aids"  and other topics that still make me blush.

Since that failed project I have honestly never been back to the Salon.com website...until recently. This week Dr. Reh shared with me a story circulated on social media concerning the recently released CDC ART Clinic Data (link to Salon.com blog). IMHO, the article is pretty on target . The story addresses the whole issue of patient selection by ART Clinics and the limitations that SART attempts to place on clinic advertising that are rarely followed (in our opinion).

In 2007 when we started the NC IVF program we realized that by offering NC IVF we would totally destroy our "rankings" based upon the CDC reporting requirements. But we believed that it was the right decision to offer NC IVF and now thousands of cycles later we stand by that decision. Our experiences with NC IVF have also markedly changed our view of the low responding or poor prognosis IVF patient.  So check out this blog on Salon.com and maybe you can even find answers to some of those questions that still make DrG blush....

Monday, March 31, 2014

Managing DOR at Dominion Fertility

Here in Washington DC we love acronyms. The entire government is one big acronym....DHS, HHS, DOJ, IRS, etc, etc.

In medicine we are similarly guilty of using incomprehensible terminology. We say "ick-see" (ICSI) but spell out IVF. We throw around terms like IUI, DI, AI without a second thought.

Last week during a consult a patient confided in me that she had "door." I didn't want to sound like a dolt so I just rolled with it until she asked me again if I had a lot of patients with "door." Hmmm. Now this past week I was under the weather from some unknown cause and needless to say I was a bit slow on the uptake. Finally, the synapses clicked and I got it..."door" = "DOR"= diminished ovarian reserve.

Diminished ovarian reserve refers to the clinical situation of a patient who has a limited number of follicles (usually for unexplained reasons) and therefore whose response to fertility drugs is usually very disappointing. Many patients with DOR fail to get egg collection in a stimulated IVF cycle and end up getting canceled after spending thousands of dollars on fertility medications that were ultimately of no benefit.

There have been numerous suggestions as to what drug protocol is best to use to stimulate such patients: microdose lupron flare, stop lupron, no lupron, clomid/gonadotropin combo, low dose stim, high dose stim, snake oil and pixie dust.... In addition, many adjuvant drugs have been used: DHEAS, growth hormone, thyroid hormone, MiracleGrow, etc.

There is no real harm in trying these protocols (except to one's bank account and also the emotional exhaustion that sets in when repeated cycles have failed to get off the ground). 

So at the end of the day patients who have repeatedly failed to get to egg collection are usually told that their only options are egg donor or adoption or quit trying. However, one benefit of having a well-established Natural Cycle IVF program is the profound satisfaction I get from receiving birth announcements (sometimes with yummy cookies attached) from patients who were previously told that their situation was hopeless. So although I totally agree that donor egg IVF or adoption are higher yield options in terms of success, these are not always viable choices for all patients. In addition, just the act of trying NC IVF represents an important bridge for some patients.

So I guess the take home lesson is that in our office is that if you have DOR that doesn't mean I am going to show you the DOOR. (ugh, terrible pun but couldn't resist).

Thursday, February 13, 2014

Happy Valentine's Day from Dominion Fertility

DrG wishing you all an early Happy Valentine's Day just in case I don't make it home in one piece given the "wicked" (Bostonian for very impressive) storm that blew through here last night and today....

My parents were married for 67 years. That is a very impressive accomplishment. Somehow they made it work although there was certainly a fair amount of yelling at times... How can you explain how to stay together for such a long time? In one sense it is unexplainable (certainly my wife will be hard pressed to suffer for 41 more years of Yoda impressions). But since it now hurts my vocal cords to say "Try not, do or do not. There is no try" we may not be headed to divorce court any time soon....

Infertility can also be unexplained. That doesn't mean untreatable. Just got a nice birth announcement from a couple with unexplained infertility who had failed 3 rounds of clomid/IUI and came to see me back in December 2012. All testing had been fine: normal HSG, normal semen analysis, normal ovarian reserve testing.

Why does CC/IUI fail? Good question. Perhaps the tubes (although open) failed to capture the egg(s). Perhaps the sperm failed to find the egg (they get lost, they die, they don't ask directions). Perhaps the sperm and the egg didn't like each other (What no flowers or box of chocolates?). Perhaps the egg didn't fertilize normally. Perhaps the embryo didn't grow normally. Perhaps the embryo failed to make it to the uterus. Perhaps the embryo failed to implant. All we can say after a failed IUI is that it failed.

IVF offers a chance to gain some additional information. Even if IVF fails, we can at least see if the egg looked OK, if the egg fertilized, if the embryo grew... Success rates for IVF increase with each hurdle that is cleared: successful retrieval, successful fertilization, successful embryo development, successful embryo transfer....

Given all these issues, my patient elected to pursue Natural Cycle IVF. She had considered FSH/IUI and stimulated IVF. Given her age of 37 she would be unlikely to end up with a high order multiple pregnancy with FSH/IUI but she and her husband were frustrated with the lack of information gleamed from IUI cycles.  Stimulated IVF was an option but they elected to try NC IVF as a first step.

6 sonograms, 1 egg collection and 1 embryo transfer later they were pregnant and delivered a full term healthy baby recently. Score another victory for NC IVF. Remember that infertility may be unexplained but that doesn't mean untreatable.

Pray that I make it home to Maryland today. If you see a silver Murano in a ditch that could be me but I will channel my inner Boston driver and do my best to get home safely!

Friday, February 7, 2014

Happy (Belated) New Year from Dominion Fertility!

It has been a very busy couple of months here at Dominion Fertility but I am slowly digging out from a number of time consuming projects ranging from writing a couple of research papers to updating all of our consent forms and everything in between. One of my favorite yearly holiday projects is trying to reply to all the Christmas/Hanukkah/Kwanza/Festivus/New Year's cards that I receive here at Dominion. Unfortunately, after 18 years in practice I tend to get a bunch of cards and it takes longer and longer each year to get all my replies out the door. (Note: If you sent a card and didn't get a reply from me, then it is probably because the card failed to get routed directly to me so don't take it personally....or it could be Sam's fault).

Every December I have to relearn how to use Adobe Photoshop so I can add in employees who fail to make the group photo seen above. Next week I will provide an answer key for those interested in figuring out who was Photoshopped into this year's photo and who was actually there that day....Make sure you get your answers in ASAP.....

So a belated Happy New Year from DrG....

Wednesday, January 22, 2014

Double Trouble at Dominion Fertility

Hey, DrG here in the frozen wasteland of our Nation's Capitol. Funny that when the weather turns nasty here in the Metro DC area the government shuts down, the schools close, the supermarkets run out of toilet paper and milk...but our patients make it to the office without any problem whatsoever....

This past week has been a week of identical twins for me....officially termed monozygotic twins (scientific talk meaning one egg/embryo). The best thing about MZ twins is that I can confidently look the patient in the eye and say categorically that this is not my fault. Apparently God or the universe or whatever you believe controls our fate wanted you to have twins because I cannot put back fewer than one embryo. I am even more innocent in cases where patients have MZ twins after an IUI as opposed to IVF as there is an increased rate of MZ twins in IVF compared with conceiving au naturel (yes, sometimes patients are rude and conceive without our help) or with IUI.

Twins that share a placenta can either be in their own little amniotic sac (diamniotic twins) or share a single sac with their sibling (monoamniotic twins). Identical twins do represent a higher risk pregnancy than fraternal (dizigotic) twins and can experience twin-twin transfusion syndrome which is life-threatening and can require advanced intervention prior to delivery (such as laser ablation of communicating blood vessels).

Last week one of my patients stopped by to visit with her beautiful identical twin girls that were from IVF. She told me that her doctor had said that the girls were probably identical but that no twins are really identical. Technically correct I suppose since twins have different fingerprints but at a genetic level they are identical since they came from a single embryo that split. Since these two were in a single sac (mono amniotic) there is no doubt that they were identical. The best news is that they were healthy and happy....plus I didn't have to do any babysitting!