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Wednesday, July 2, 2014

Stim...retrieve...transfer....fail....repeat. NOT the Dominion Fertility approach to IVF.

Readers of this blog know that I have wide ranging taste in movies. On the one hand I loved Frozen and have been known to sing along with Broadway show tunes (much to the chagrin of my wife and kids). On the other hand, I am a lover of Sci Fi and zombie movies who surfs through the movie channels every night looking for giant monsters or giant robots or giant monsters fighting giant robots (Pacific Rim anyone?). In particular, I love movies that feature time travel such as Star Trek: First Contact, Looper, Source Code, X-Men: Days of Future Past, and now my current favorite chronologically confused film: Edge of Tomorrow.

What a great movie! What a great movie concept! Who would have ever thought of combining Groundhog Day (Bill Murray's best movie IMHO) with Starship Troopers (one of my all time favorite films but one with no redeeming social value)...what an inspired concept. In this movie, Tom Cruise actually does some excellent acting and Emily Blunt plays a hardened super-soldier which is playing against type to say the least. As you can probably guess from my description and the movie poster Tom Cruise ends up with the ability to relive his last 24 hours over and over again after being splattered with alien blood and gore on the battlefield. Like the Bill Murray character in Groundhog Day he grows as a person while becoming the soldier that he never thought he would nor wanted to be (he starts the movie and an unapologetic coward who is happy being a "talking head" for the military but completely uninterested in seeing war up close and personal). Tom Cruise doesn't draw the fans in as much as he once did so I convinced my daughters to accompany me to the multiplex last Sunday to catch the film before it was too late. My older daughter loves intense, kick-ass movies that feature the military fighting zombies, giant monsters, bad guys etc. She is seriously considering attending a service academy and her favorite new TV show is The Last Ship on TNT. However, after watching Edge of Tomorrow she definitely is leaning towards Navy and not West Point based upon how J Platoon fared in their hand to hand combat with the alien horde. My younger daughter took some convincing to see the movie and I kept an eye out for agents from Child Protective Services when purchasing our tickets (the movie is PG-13 but the Family Filmgoer described it as loud and intense but without blood and gore). They both loved the movie as did I so you need to go see this movie before it gets bumped out of the multiplex for Transformers.....Tell them DrG sent you.

So what does a 5'7" actor killing disgusting inter-galactic squid-like creatures have to do with infertility and IVF? I guess the point I want to make is regarding adapting and thinking outside of the box. To illustrate, let me share the stories of two patients pursuing fertility treatments.

L.P. is a 37 year old who came to see me after 3 failed stimulated IVF attempts at another IVF clinic. Her FSH was 14 IU/liter with an AMH < 0.16 ng/mL. Each of her 3 stimulated IVF cycles with had ended poorly without a single attempt at egg collection. In each case she had failed to meet the other clinic's minimal requirement of 3 large follicles needed to permit a patient to go to retrieval. Each stimulation essentially utilized the same protocol without much variation. Their recommendation was donor egg or adoption. When I met with L.P. she was uninterested in donor egg or adoption and thus only wanted to try Natural Cycle IVF. On the second attempt she was successful and delivered a full term healthy baby. She returned several years later and at the age of 41 was interested in another attempt at NC IVF. Amazingly enough, she was again successful on the second cycle and again delivered a healthy baby. Stim...fail to respond....repeat. Not a recipe for success. Kudos to her for hanging in there and believing that something so simple could be successful...twice!

The second patient had traveled a different path to Dominion. K.F. is a 35 year old who had also undergone 3 cycles of stimulated IVF at another clinic. However, she had been an excellent responder to medication so she represented the opposite end of the spectrum from L.P. Each of her stimulated IVF cycles resulted in over 20 follicles and she had over 15 eggs retrieved each time. However, her embryo growth was disappointing with most embryos failing to develop well and no pregnancies and nothing to freeze in any cycle. We discussed the situation and I explained that we were dealing with one of three issues: 1) an intrinsic egg issue that we could not fix; 2) an intrinsic sperm issue that we could not fix or 3) a stimulation issue. The only way to prove that the issue is an intrinsic one with the egg and sperm would be to a) use donor egg/donor sperm, b) do PGS to see if they could produce any normal embryos or c) get pregnant. Option (a) was not acceptable and option (c) would have been nice but seemed unlikely without assistance leaving us with option (b). Although we could do PGS, we needed to consider changing her stimulation in order to get adequate embryos to blastocyst. I recommended reducing her stim dose aiming to get 8-12 eggs hoping that the concept of quality over quantity would hold true for her. Fortunately, her stimulation went very well and several embryos made it to blastocyst and were biopsied for PGS. Two genetically normal embryos were transferred but she failed to conceive. So we had demonstrated that as a couple they could generate genetically normal embryos but these had failed to implant. At this point we discussed performing an endometrial biopsy prior to additional IVF attempts, gestational carrier IVF or repeating an IVF cycle now that we seemed to have a better protocol for her and skipping the PGS since we had proved that they were able to produce genetically normal embryos. This time we hit the jackpot and they conceived with IVF.

I hope that these stories indicate the benefit of modifying future IVF based on past IVF cycles. Sometimes these changes are significant such as changing to Natural Cycle IVF whereas other times the changes can be subtle such as adjusting stimulation meds or doing an endometrial biopsy or convincing a bad-ass like Emily Blunt that you need to call off the planned battle with the Mimics and look for the Omega (which is hiding under the Louvre in Paris) in order to save the Earth...oops, wait that was a movie....I think.


Thursday, June 5, 2014

Avoid getting stung...advice from Dr G at Dominion Fertility

No good deed goes unpunished. I spend a fair amount of time traveling between our Fair Oaks and Arlington offices in order to do my best to do all the egg collections and embryo transfers on my own patients. So when my wife called to say that there was a lot of unanticipated activity in our neighbors backyard that seemed to involve significant tree work I thought that it would be helpful for me to pop in on my way back to Arlington for a quick look. Once at home I assured myself that the neighbor was not decimating trees on my side of the fence and thought that I could quickly knock some items off my project list and clear out a cedar dog house that our dog refuses to use. Bad idea. Did you know that bumblebees have small nests that usually are in the ground? I didn't. Did you know that bumblebees can make a nest in an old dog mat instead of in a hole in the ground? I didn't. Did you know that bumblebees are usually pretty docile and slow to anger and slow to sting a human....unless their nest is disturbed? I didn't. Did you know that angry bumblebees go for the eyes of any intruder who disturbs their nest? Well, I do now...

So as I ran screaming like a little girl away from the dog house, the angry bees followed and one of them managed to sting me on my eyelid. In short order my face started to swell on that side in spite of ice and benadryl. For some reason, this series of events elicits laughter from everyone who hears the story...my wife, the nurses, DrD.... I returned in time to see my afternoon patients. I wore my biggest set of glasses but did warn patients that indeed my face was swollen on one side. Of course, they could no longer look anywhere else and spent the consultations fascinated by my facial asymmetry.

So what does this have to do with Reproductive Medicine? Well, I guess the point I am trying to make is that you never know when you are going to get stung....in the eyelid. When counseling patients about a course of treatment one of my biggest concerns is that of multiple pregnancy. With twins (and worse) you just never know when you are going to end up in a tough situation. Twins have a markedly increased risk of preterm delivery compared with singletons and all the problems that go along with prematurity. Time Magazine recently had a cover story about preemies and how far we have come in handling our smallest patients. But the best treatment for prematurity is prevention. Electing to pursue IVF instead of superovulation and IUI will help. Preimpantation genetic screening to identify the normal embryos will help since if we transfer a single genetically proven normal embryo then the risk of twins will be incredibly low (although not zero because of the chance of identical twins). I spend a lot of my day trying to convince patients that twins are not a "buy-one get one free" type of deal. There is a cost involved....to the family, the children and to society. So try your best not to get stung....go with elective single euploid (genetically normal) embryo transfer and watch out for those damn bumblebees.

Monday, May 5, 2014

Roller Coasters, Car Keys and the Use of the Matcher System at Dominion Fertility.

I am really not a roller coaster aficionado. In fact, I sometimes have a tough time with elevators that drop too fast....So when I recently found myself in line for Expedition Everest at Animal Kingdom in Disney World, I wasn't too thrilled. But I hung in there and through the magic of SmartPass I was able to negotiate the line without enough time to change my mind. I survived. Barely. Needless to say, I was not rushing over to one of the vendors after exiting the ride to purchase a roasted turkey leg (bleah).

I almost had that same look of terror on my face in our hotel room at midnight on our last night on vacation. It was at that time that I became convinced that I had somehow lost the keys to our minivan that was parked at the Charlotte airport back in North Carolina. At age 50, after countless vacations and business trips, this was a first. I never found the keys but fortunately my wife had brought a spare set and so disaster was averted. I have no idea where the keys went. I called Disney, both airports, the car service and no luck. Gone. Disapparated. Zip. Nadda. My best guess is that they ended up in the hotel room trash can. Oh well. Through the magic of the internet I was able to order a replacement key fob with remote for $60 and reprogram the thing myself using a YouTube video. Gotta love technology. Still, I wish I knew how I managed to do such a boneheaded thing as lose my car keys on vacation. You can bet that from now on I will be using that little key hook that is in the inside pocket of my suitcase....

Sometimes it takes a near miss to make you reevaluate something as simple as using the key keeper on you luggage, but it would be so much smarter to use the key keeper every time right from start. Here at Dominion Fertility we believe that an ounce of prevention is worth a pound of cure and that is why we are now the first clinic in the United States to use a patient identification system known as the Matcher System from IMT International. This system allows for precise patient identification and linking of eggs, sperm and embryos so as to prevent the possibility of error. We firmly believe that use of such a system is in everyone's best interest as a mix-up in eggs, sperm or embryos would have catastrophic implications for all involved. So all I can say is that I am glad that we are using the Matcher System and I sure as heck will now use that darn key hook on every trip in the future!

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).