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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.

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.