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Sunday, June 21, 2015

Happy Father's Day!

Father's Day is one of those holidays that is tough for our patients. For many of them they wonder if they will ever be able to enjoy a holiday that celebrates the very goal that they are striving so hard to accomplish. My Dad was a huge influence on his 3 sons, all of whom pursued health related careers. But contributing half the DNA in that 1 cell embryo is really not the defining part of fatherhood. Fatherhood is really everything that comes once that child is born. Being a Dad is so much more and alternative pathways to parenthood such as the use of donor sperm or adoption provide many men the chance to be fathers. My parents had been told by Dr. Isidor Rubin, the most famous and well respected fertility expert in New York City, that they would never be able to conceive. As a General Surgeon trained in the 1940s, my Dad had a fairly low opinion of Ob Gyn physicians. They were, to quote my Dad, the guys too stupid to get into General Surgery residency programs. Needless to say, my decision to pursue a career in Reproductive Endocrinology (which requires a residency in Ob Gyn prior to a fellowship in Reproductive Endocrinology) was met with an unenthusiastic endorsement from my Dad.

Me: I am going to be a fertility specialist and need to do an Ob Gyn residency.
Dad: Why don't you apply for a residency in General Surgery?
Me: Because I want to be a fertility specialist.
Dad: Don't you think that you can match in General Surgery? I know people...
Me: Thanks Dad, but I want to be a fertility specialist...
Dad: Those Ob Gyn guys never sleep and never leave the hospital...
Me: I know Dad, I am going to do a fellowship after my residency in order to specialize in fertility medicine....
Dad: You know that your mother and I went to see Dr. Rubin in NYC. He told us we would never have children. I told him he was full of sh*t. Those guys don't know anything. And I was right. We had three wonderful boys. So how about General Surgery????

Life can be full of surprises and as my patients know, I always emphasize that unless a couple is truly sterile (no tubes, no sperm, no uterus) then there is always hope....I would hate to think that my patients would end up with the same opinion of me that my Dad had of Dr. Rubin!

Friday, June 12, 2015

Hope is not a 4 letter word at Dominion Fertility....

Over 10 years ago we remodeled our basement so that our kids would have a cool place to hang out and watch TV with their friends. At the time we installed a plasma TV with a conduit to carry the cords and wires behind the wall and out of sight. A few months ago I got it in my head that I should try to use this same conduit to hide the cords/wires from my daughter's XBox 360. At the time the game console was just sitting there on the floor instead of nestled safely on the shelves that flank the TV. My wife had pointed out that having the game console sitting on the floor was just begging for a disaster. So in spite of being forbidden from using power tools, I headed to Home Depot for some advice as to how I could fish the cords through the conduit. After much difficulty, I was able to successfully  explain the project and the sales associate sold me a 25 foot steel fish tape. Confident in my ability, I headed home to resolve this problem once and for all.... I carefully passed the fish tape through the conduit and attached it to the XBox cables. The problems started once I attempted to bring them through the conduit.  I got the fish tape (with the cables attached) about halfway through the conduit when it became firmly wedged. I was not happy. I yanked and pulled and started to completely panic that I would be caught by my wife or one of my kids with the cables jammed behind the drywall. Fortunately, with some careful manipulation and a lot of prayer I got the fish tape unstuck and completely abandoned the project. So the XBox remained on the floor.

Fast forward to this past Monday. As we were preparing to watch TV, a member of my family (not me) placed a glass of iced tea on the shelf above the game console. The glass tipped over and the iced tea splashed onto the XBox with some of it going right into the grill that covers the fan. Immediately the power light changed from the happy green power sign to the red ring of death (as seen above). I immediately unplugged the unit and did what most of my patients do....went to the internet. The news was not good. In fact, the prevailing opinion was that there was absolutely no hope for this game console and I should just toss it and go back to GameStop. I hated to give up that easily so I set the console in front of one of our industrial sized fans and cranked up the air flow. For over 24 hours I let the drowned console sit in front of the fan while I checked prices and delivery dates so that I could replace the XBox before my daughter returned from out of town.

On Wednesday I plugged the XBox back into the power adapter and......IT WORKED! Hard to believe but it somehow seemed to have suffered no ill effects. So what does this vignette have to do with infertility?

Well just last week a patient stopped by with her adorable baby. They had been trying for quite some time for another child but unfortunately had suffered several pregnancy losses. As she was in her early/mid-40s we discussed a range of options including the use of fertility drugs to recruit extra eggs for IUI or for IVF with preimplantation genetic testing. The latter was not of interest to them so they elected to go with the fertility drugs and defer the IVF. We were very happy when she conceived but at the time of her pregnancy ultrasound I was concerned about the findings. She was clearly pregnant but the heart rate was only 86 beats per minute at 6.5 weeks gestation. Given her age and pregnancy history the chances for a happy ending to the story seemed a lot less than 50/50. However, she remained cautiously optimistic and by the time she had another sonogram 2-3 weeks later everything looked great and she sailed through her pregnancy delivering a happy, healthy baby. Honestly, I stopped making bets with patients when it comes to pregnancy outcomes....there is simply too much variation when it comes to these early obstetrical sonograms. The key is to monitor each pregnancy sequentially so that if a patient fails to show appropriate growth and development with repeat sonograms then I can be much more definitive about whether or not there is hope for a good outcome.  Ultimately, you have to hope for the best and prepare for the worst...kinda like what I did when I plugged my drowned XBox back into that power adapter.

Friday, May 15, 2015

Purple dresses and finding eggs....at Dominion Fertility.

We all have our weaknesses....one of mine is how much I hate losing stuff. I can't explain why I am so bothered by my inability to find a recently purchased pair of headphones or a missing glove or the lid to my stupid travel coffee mug. Then again I am comforted that my behavior is not a new phenomenon...Jesus told his disciples the parable of the lost sheep over 2000 years ago:

Luke 1:3-6.  Then Jesus told them this parable: “Suppose one of you has a hundred sheep and loses one of them. Doesn’t he leave the ninety-nine in the open country and go after the lost sheep until he finds it? And when he finds it, he joyfully puts it on his shoulders and goes home. Then he calls his friends and neighbors together and says, ‘Rejoice with me; I have found my lost sheep.’

My guess is that his disciples totally understood this story and were not left shaking their heads in disappointment thinking "we left our fishing business for this guy..."

So last Saturday after a full day in the office at Dominion Fertility I was sent to the Nordstrom store at Tyson's Corner Mall to complete a very important task. I was charged with matching a suit, shirt and tie combination with a purple dress that my daughters will be wearing in an upcoming family wedding. Amazingly enough, Anna helped me find an excellent match. As I was ushered back to the fitting rooms to meet with the tailor Anna assured me that it was fine to leave the dress by the register. I hesitated for a moment.....we had waited 4 months for this dress to arrive. The wedding is in 6 weeks. A responsible husband and father would have said "no thanks, let's take the dress with us because if it disappears then I will be in such deep poop that they will need Robert Ballard to come find me.." Yours truly said "ok, let's go."

The fitting took less than 10 minutes and then we emerged back into the men's department.  I headed to the register to get the dress. Which was gone. No dress. No one around had seen the dress. No one had any idea where it had gone. Anna called LP (loss prevention) to pull up the videos from the closed circuit cameras to see if they could tell us where the dress had gone. My knees were quivering a little bit and after about 3 minutes my ability to form a coherent sentence returned. Another salesperson thought that one of the women from upstairs had cruised through the men's department carrying a bunch of dresses....perhaps the dress was now with her. Anna and I headed up the escalator and into women's wear where we found a Nordstrom employee preparing to send the dress off the floor to the "unclaimed merchandise" section....located right next to Area 51 no doubt. With dress now in hand I exited the store and headed home rejoicing in my found dress.

So what does all this have to do with infertility? Readers of this blog and patients of our practice are aware that we do a lot of Natural Cycle IVF. In NC IVF we are working with a single follicle and trying to get that single egg that resides within that single follicle. We retrieve an egg in 85-90% of the egg collections performed for NC IVF. But to me that 10-15% is just like the lost sheep in the parable of Jesus. I am so disappointed. Plus I hate giving that news to my patients. Inevitably I am asked "where did the egg go?" I wish I knew. When we do a NC IVF egg collection we flush the follicle repeatedly and then hand off the tubes of fluid until the embryologist identifies the egg. We have found the egg on the 1st, 5th, 9th and even 13th flush (although most of the time we find it in the first 5 flushes). Still I wonder where does the egg go when we fail to find it? There are a couple of possibilities. First of all, the egg could have ovulated several hours prior to retrieval and we just didn't know. Secondly, as the needle enters the follicle and we then flush the follicle I think that the egg may squirt out around the needle. Finally, it is possible that there was not a healthy egg inside the follicle in the first place. This possibility has been referred to as "empty follicle syndrome." However, in our experience most patients will eventually have a successful retrieval even if no egg is found during an egg collection. Patience is a virtue and persistence can pay off in the end! Looking for the lost sheep or that tough to find egg just makes the finding of them all the more satisfying. So next time you see me in the office with a big smile on my face...it may be because I am remembering about having found that lost egg (or that lost purple dress)!

Friday, May 8, 2015

DrG is Outstanding in his field...or his garden....at Dominion Fertility

As a child I really had very little choice in terms of my chosen field. I am the grandson, son, nephew and brother of physicians. In fact, at family gatherings it was already assumed that I would be a doctor...the only question remained as to whether I would be a surgeon like my brother and father or whether I would specialize in some other field that really didn't pass muster...no pressure there. As many of you know, in order to become a fertility specialist, I had to first of all complete a residency in obstetrics and gynecology (4 years) followed by a fellowship in reproductive endocrinology and infertility (3 years). When I tried to explain this to my Dad he tried to be supportive but basically his perspective came down to his comment that "only the medical students too stupid to be surgeons ended up in ob/gyn." Oh well. My Mom was a bit more supportive having suffered multiple miscarriages before eventually having three healthy children (perhaps in spite of rather than because of the medical care that she received but that is another story). So naturally with Mother's Day just a few days away my thoughts have been on my Mom who was such a huge presence in my life.

As I regarded this photo (taken in my backyard in Milton, MA) several thoughts suddenly occurred to me. First of all, my Mom looks remarkably young to me... because in fact she is younger in this photo than I am today! Yikes.  Secondly, why am I sticking out my stomach? Who knows. Finally, I realized that I am standing in the flower garden. This fact is shocking. The flower garden was a place completely off limits and sacrosanct. In fact, for years I have regaled my youngest daughter with the story of how my brother Steve taught me how to ride a bike without training wheels by pushing me down the hill in our backyard. A story that ended with me crashing into this very garden and sending our Mom into orbit as she surveyed the damage I caused to her prized flowers. And yet, here I am standing in the garden...with my Mom...and she looks happy. How is this even possible? How could this photo have been altered before the invention of Photoshop? Of course, the truth is that the photo is real and untouched but that I simply have no memory of getting into that garden. So how does this relate to infertility?

Well, sometimes we find ourselves in places that we feared to go or places that we were told were not for us. There are many paths to parenthood. This past week I was happy to see a couple back for another baby after having success with modified natural cycle IVF. They had some concerns about the creation of extra embryos with traditional IVF and therefore they had not really considered IVF to be a valid option for them.

Considering the media firestorm about the fate of Sophia Vergara's frozen embryos I certainly understand why some couples are not enthusiastic about IVF. However, Natural Cycle IVF (NC-IVF) is performed using the single egg that is produced each month and therefore, the problems with multiple eggs/embryos are avoided. But Natural Cycle IVF is less efficient than stimulated IVF and some cycles result in no retrieval, no egg or no embryo to transfer.

The couple in question had ended up with a cancelled NC-IVF attempt because of an early LH surge and ovulation. We discussed options and they elected to attempt modified NC-IVF. In a modified NC-IVF cycle medications are used but the goal is NOT the development of multiple eggs. The goal of modified NC-IVF is to prevent the single egg from being released too early by using drugs typically associated with stimulated IVF. Using a slightly different protocol ensures the development of only a single follicle. So here a couple that had initially thought that all IVF would be off limits ended up with NC-IVF. But when NC-IVF proved problematic they now felt comfortable moving into modified NC-IVF instead of stimulated IVF.  Sometimes we end up in places that we never anticipated going. Sometimes we learn that standing in the garden may be just fine...you just need to take it one step at a time or have your Mom give you a lift....

Tuesday, April 21, 2015

Getting good grades...at Dominion Fertility.

Grades are important. There is just no way around this simple fact. On the other hand, a sense of fashion is not as important...which can explain how I got into and thrived at Princeton but was photographed looking like this in back of Nassau Hall. Raising kids in the Washington suburbs is an exercise in stress as everyone wants their kids to get all As and perfect SATs.....while taking 7 AP classes each semester...and playing several varsity sports...and starring in their high school's production of Chicago. Grades do matter in the college application process..no way around it. And yet, success in life clearly is determined by a whole lot more than your SAT scores or attending an Ivy League college. There are clearly other forces at work in the world and being reduced to a number, whether it is a GPA, SAT, MCAT, GRE usually fails to tell the whole story.

Given our predisposition to obsessing about grades here in the Metro DC area it is not surprising that our patients tend to become fixated on the grade of their embryos. In our laboratory we grade blastocysts with a 3-part score. Each part (inner cell mass, trophectoderm, blastocoele) is assigned a letter grade of A, B or C. Needless to say, everyone wants blastocysts with a grade of AAA. But those blastocysts with a lower grade can still turn into beautiful, healthy babies....similarly, AAA blasts can fail to implant or implant and miscarry. Although you would think that embryos graded AAA would always have normal chromosomes and those with lower grades would have abnormal chromosome counts, it just isn't true.

Case in point was a recent patient of mine who underwent donor egg IVF. She and her husband had chosen to defer PGS so we were relying on embryo grading alone to determine which embryos to transfer. Although I really was encouraging her to transfer a single embryo, they elected to transfer 2. Given her reproductive history I grudgingly agreed. The two embryos were graded BBB and BCC. Well, I am sitting here in my office admiring the birth announcement that shows an adorable photo of their son and daughter who were born at term following a relatively uneventful pregnancy. So keep in mind that grades cannot perfectly predict success in life or in IVF....nor can good grades guarantee any sense of fashion!