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Showing posts from 2011

Question 60. My reproductive endocrinologist has recommended a protocol that uses birth control pills. Why would birth control pills be used in IVF?

Last night I was speaking to a group of high school students that are interested in medicine as a career. I have spoken to such groups many times over the past 5 years and sometimes I feel like I am on the TV show "Kids Say the Darndest Things." Sometimes they get hung up on asking about transgendered individuals. Sometimes they ask about multiples like John and Kate plus Eight or the Octomom. Last night we got sidetracked into a discussion of the NuvaRing and oral contraceptives. These are high school kids I remind you....When I was in high school I spent most Saturday nights watching the Love Boat....I certainly was not wondering which girls were on forms of oral contraception. But amazingly enough I was able to eventually date, marry and reproduce...it gives me hope that geeks everywhere will be able to overcome social adversity...just look at Leonard on the Big Bang Theory as another success story!

Ok. So it's Friday afternoon and I am off this weekend so I am a bit p…

Question 59. What is natural cycle IVF? And why does my fertility clinic not offer this treatment?

As readers of this blog are well aware, we have a particular interest in Natural Cycle (unstimulated IVF). All I can say is that the past 4 years have been filled with outcomes that I would never have believed if these were not my own patients. Although it is not surprising that young healthy women with tubal factor infertility can conceive with Natural Cycle IVF, it is the patients that we thought were clearly long-shots that stick in your memory.

Once recent patient was B.W. (not her initials) who was a 41 year old whose husband had a vasectomy reversal 3 years earlier but had failed to conceive. Her evaluation revealed an FSH of 23 and an AMH that was < 0.16 (essentially zero!). We discussed donor egg and donor embryo and adoption. She was really not interested at this time in pursuing those options even though the success rates were clearly markedly superior to those with her own eggs.

So we elected to attempt NC IVF and during the treatment cycle her day 3 FSH came back at 40! I…

Happy Thanksgiving 2011

Happy Thanksgiving to all!

I usually post this on Turkey Day but honestly I was so busy at work this past week that I never got around to doing it. At my mother-in-law's house in North Carolina we always go around the room before saying Grace and ask everyone to say what they are thankful for this year. It never hurts to count your blessings. In face, several medical studies have indicated that those individuals who have a positive attitude about their life and situation are healthier than those who always see the glass as half-empty. On the other hand my Dad has always been a glass is half-empty guy and he is still hanging in there at 88 years of age.....

I am thankful for my family...they are a source of love, support and joy...even the teenagers.

I am thankful for my health...although I would like my hair loss to slow down.

I am thankful for my career...I remain stimulated and enthusiastic about my profession.

I am thankful for my partners and staff...Couldn't ask for a better p…

Question 58. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?

So last August I developed a wicked (note Bostonian roots given use of this adjective) toothache while on vacation at the Outer Banks. Naturally, I did what most physicians do...I started myself on antibiotics and ibuprofen and didn't call a dentist. By the next Monday I was not a happy camper and went to my general dentist only to be told I needed a root canal. Ugh. What a way to return from vacation. I took the recommendation of a local specialist and he did a fantastic job. Took 40 minutes and the next day I felt great! Last week it all started again and I went to my general dentist who said that I may need another root canal (different tooth). He proposed doing it himself without a referral to the specialist. I was in the chair already and it was 4:45 PM so I agreed to let him try. In retrospect, this was not a good decision. He found 2 of the 3 roots but ultimately quit the procedure at 6 PM and told me that I needed to see the specialist the next day anyway. I should have go…

Question 57. I was told I need assisted hatching. What is this, and why is it done?

Families are funny things. Some families are filled with artists and actors. Some are filled with athletes. Some are filled with engineers. Some are beyond simple description.

I grew up in a medical family and I am a 3rd generation physician. My nephew, Andrew, is currently a medical student at Tufts and he represents the first (maybe not the last) of the 4th generation Gordon to be a physician. My older brother Mike (on the far right in the photo) is a general surgeon in Sanford, NC. I don't think that he has gotten a full night's sleep in 25 years as he is regarded as the best surgeon at his hospital and is the most likely to be called when the ER needs a surgeon at 2 am!

My brother Steve was never interested in being a doctor. He is an outstanding hospital sdministrator. We talk several times a week which is incredible to me considering how much we fought as kids (so parents don't give up hope that your kids will someday get along!). But when we fought it was epic. He te…

Question 56. What is the Sperm Chromatin Structure Assay (SCSA), and should my husband have it done?

The Holy Grail of Reproductive Endocrinology is the test that definitively tells us whether a patient has a good egg or a good sperm. This is not to be confused with the Holy Grail of Monty Python which is one of the finest films ever made and won the Oscar for "Best Movie Ever" the year after Highlander won that very same award. If you don't get these jokes then don't worry as it probably demonstrates that you are a lot more normal than me and explains why I spent every Saturday night in high school watching the Love Boat....

Back to fertility. So the million dollar question remains is there a good egg and a good sperm that can make a baby? The answer is we don't know until you actually deliver a healthy baby and then the answer is "yes" (obviously).

There have been tests proposed to answer this question. But do not be misguided into thinking that a woman's FSH, estradiol, AMH and antral follicle count answer that question...they do NOT.

Similarly, t…

Question 55. My husband and I were told by one RE that we needed ICSI, but another RE says that we don’t. What should we do?

So if you have read the survey results you are aware that most readers like the clinical vignettes that I post to illustrate points of interest. ICSI really is an amazing procedure. It really should not work and yet we have hundreds of thousands of babies born after IVF/ICSI and some clinics do only ICSI and never do just plain IVF....

This year I had a returning patient. She and her husband had been successful with Natural Cycle IVF with ICSI. We did ICSI because they had unexplained infertility and his sperm parameters were slightly abnormal. Since they delivered a healthy baby after the second NC IVF, we thought that this should be a no-brainer.

However, that is not how it worked out. We kept getting tripped up. Almost all possible outcomes were experienced from no fert to embryo arrest. But the couple had absolutely no desire to try regular IVF. They were uncomfortable with many aspects of stimulated IVF and only wanted to try NC IVF.

Finally, on the 6th NC IVF since delivering I sug…

Summer's Over Now Back to Work

Wow, no blogs in August 2011.....how did I manage to miss an entire month. I suppose I could blame it on the Earthquake that we had here in Northern Virginia....or Hurricane Irene...but the truth is that I was really enjoying summer and was just too tired and busy to post. Mea culpa.

Yesterday in the Wall Street Journal there was an entire article about the Post Labor Day Blues and apparently there is a recognized clinical syndrome called Post Vacation Syndrome. I know it well. Towards the end of my week at the beach on the Outer Banks I started to get a wicked toothache (note my clear Bostonian roots....just like seeing the movie The Town). I started myself on antibiotics and then on the Monday that I returned to work I found myself in the dentist chair in Arlington at 7 am. The news was not good...I needed an urgent root canal. Great. What a way to come back to work! So I got 2 recommendations from my general dentist and off I went at 11 am for my journey into the world of endodontic…

Question 54. Who needs ICSI, and how can my reproductive endocrinologist be certain that I need it?

So as you may recall from Question 53, ICSI is that crazy technique that involves taking a sperm and inserting it into the egg to induce fertilization.....hard to believe that it works but there you have it.

Sometimes it is not that easy to figure out who needs ICSI and who doesn't. I have a nice couple that first came to me a few years ago with mild male factor infertility as the apparent cause. Ultimately they decided to pursue Natural Cycle IVF and were successful on the 2nd attempt of Natural Cycle IVF with ICSI. We used ICSI as they had no previous pregnancies and there was some mild male factor. We have tended to err on the side of ICSI with Natural Cycle IVF as there is only 1 egg and if we don't get fertilization then the cycle is a bust....

In any case, following delivery of a healthy baby from that first NC IVF cycle they returned last year for another round of NC IVF. However, we just couldn't get them pregnant. Several cycles ended in failed fertilization in spit…

To Tweet or not to Tweet..that is the question...

Although I am not an early adopter of technology, I am not a Luddite either. I have written this blog for a couple of years now and I think that at least 3 other people (besides my Mother) read my posts. I have usually focused on questions from our book on infertility but have commented on a range of other topics ranging from Princeton's epic win over Hahvahd at Yale earlier this year that secured an NCAA invitation for the men's basketball team to the reasons that some clinics fail to offer Natural Cycle IVF and so on.

I am now trying to figure out where Twitter fits into my approach to helping patients. Honestly, I am not really sure what the answer is to that question. I certainly have no plans to end up with a Weinergate type situation and I have had the experience of hitting "reply all" instead of just "reply" on email so I am aware of how embarrassing these miscues can be....

So in order to best serve my loyal base of almost 10 readers, I am asking for …

Question 53: What is ICSI, and how does it differ from IVF?

In medical school at Duke I took a class in reproductive physiology taught by Dr. Patricia Saling. She was very engaging lecturer and the class was very interesting. During the class we had to memorize the sequence of events that included the fusing of the egg and sperm membranes, the release of the enzymes in the sperm acrosome and a bunch of other steps that I no longer remember. The possibility that you could get a baby from ramming a sperm into the middle of the egg with a micro-injector was just laughable....I would have flunked the class if I suggested it! So when the Belgium group reported on their experience with ICSI at the 1993 ASRM meeting in Boston no one could really believe it....seemed nutty. Yet here we are nearly 20 years later and ICSI seems totally banal! Hard to believe....

More on ICSI in the coming posts but here is today's Question of the Day from 100 Questions and Answers about Infertility, 2nd Edition.

53. What is ICSI, and how does it differ from IVF?

In rou…

Question 52. Are there age or other restrictions on who should do IVF?

You know, Dear Reader, when I started in practice over 15 years ago I used to get the "you're too young to be my doctor." Now, not so much. Growing older is a fact of life. I personally find it very disturbing that the medical students that I teach at GWU were born in the 80s or even in the 90s (some Doogie Howser types). Unfortunately, the aging process is difficult to fight against. Some patients are now considering freezing eggs for future use, but this process has limitations and usually the patients seeking to freeze eggs probably should have done it 10 years ago but at that time they didn't think that they would need to freeze eggs for future use....

Fertility treatment success rates are age dependent and stimulated cycle IVF pregnancies in patients over 43 years old are very uncommon and usually limited to those patients who are still excellent responders to stimulation in spite of being on the other side of 40... FSH/IUI can be considered in patients with pate…

Kindle Edition Arrives!

I really love June. It is my favorite month. The days are getting longer and school is out and the entire summer seems so full of promise. I would prefer to have a year with 3 Junes and no February or March and maybe a shorter November..... My love of the month of June and of early summer is my only excuse, dear readers, for the delay in posting to my blog. I have also been hard at work on a book chapter and some scientific papers but the honest truth is that I have been goofing off in the evenings....catching fireflies, throwing rocks at bats and trying not to be eaten by mosquitoes.

However, there have been some interesting developments with our 2nd Edition of 100 Questions and Answers about Infertility. No, there is no movie version or video game in the works. But there is now a Kindle ebook version available for purchase at Amazon.com! So as your friends and family get ready to head off to the beach tell them to download the Kindle ebook version of your favorite author's guide …

Question 51. How can you have an ectopic pregnancy after IVF?

Where does the time go? Here we are the last day of May and there are so many projects that I need to get to before June.....not looking so good here at 9:35 pm. Oh well, tomorrow is another day and I will just have to keep plugging away. Currently, DrD and I are working on several papers simultaneously including a chapter on Natural Cycle IVF for a textbook on infertility. I spent hours this past weekend slogging through paper after paper trying to extract the salient information as we reviewed the experiences with Natural Cycle IVF from clinics around the world (England, Japan, Slovenia, The Netherlands, Norway.....). All those places to visit and here I am unable to get away to New Jersey for the day because I am too busy. Traveling can be tough on anyone. But an embryo that travels out of the uterus following an embryo transfer after IVF can be heart-breaking. Although many patients are emotionally prepared for IVF to fail or for them to possibly suffer a miscarriage, the possibil…

Question 50. How do I decide how many embryos to transfer?

Well, we are halfway done with the 2nd Edition of 100 Questions and Answers about Infertility. I am still waiting for my invitation to go on Oprah and the book is not on the NY Times bestseller list. I am thinking about having Audible produce an audiobook version but my attorney has warned me that I could be legally responsible for those listeners that nod off while playing the book in the car and then end up off the road in a car wreck. Oh well. Guess I will need to keep coming to work.

Deciding how many embryos to transfer is not an easy decision and raises many questions. Some patients are not comfortable with the concept of embryo freezing and thus elect to transfer all viable embryos. Obviously, the RE needs to be aware of this plan and such patients may need to restrict how many eggs are fertilized in order to avoid becoming the next Jon and Kate plus Eight.... Usually, 50-75% of the eggs will fertilize and half of these will develop into embryos that are good enough to transfer …

Question 49. Are the children born after IVF normal?

The goal of all of our patients is to have a normal, healthy child. However, there are risks in life that none of us can eliminate and unfortunately any child can be born with a birth defect. So the real question is whether IVF derived pregnancies result in more complications and birth defects than non-IVF pregnancies. But here's the problem...patients who undergo IVF have a problem....INFERTILITY.

So really what we need to compare are the outcomes of pregnancies in infertile couples that conceived on their own and those that conceived with IVF...otherwise we are truly comparing apples and oranges. One very revealing study looked at pregnancies in gestational carriers (who have proven fertility which is why they were chosen to be gestational carriers in the first place!) and compared these to IVF pregnancies where patients carried themselves. Guess what? All the issues of bleeding, prematurity, low birth weight etc completely went away! So since most infertile patients do not use …

Question 48. How successful is IVF?

Different physicians have different styles. I have always attempted to involve my patient's in the decision making process so that they look upon the treatment plan as their plan not my plan. Not all patients want this responsibility. Some look to the physician to run the show with little to no input. I always try to make my recommendation clear but I think that there are often alternative pathways.

For the past 4 years we have been promoting Natural Cycle IVF as an alternative pathway to traditional IVF. I believe that many clinics are unable to offer this approach effectively because of cost limitations and volume concerns. However, it certainly represents more of a finesse approach than that of stimulated cycle IVF. On the other hand, no arguing that stimulated cycle IVF has a higher pregnancy rate per initiated cycle and a low cancellation rate. On the other other hand, some patients are willing to trade off the cancellation rate in order to avoid taking fertility drugs....and …

Question 47. How do I know if I need IVF?

Although there are many paths to reproductive success, IVF is usually the fastest road to success. However, not all patients are thrilled about taking that road as the use of stimulation drugs can be intimidating to say the least. Our extensive experience in Natural Cycle IVF has been so encouraging that it makes one reassess how to counsel patients who are considering other options such as clomid/IUI or gonadotropin/IUI treatment cycles. Although our initial inclination was to encourage Natural Cycle IVF mainly in patients < 35 years old with well-defined fertility issues, our results suggest that success can be obtained in older patients and in those with unexplained infertility. Clearly pregnancy rates will be higher in patients < 40 years old but our current record holder was 47 years old with 4 failed stimulated cycle IVF attempts prior to achieving an ongoing pregnancy with Natural Cycle IVF. Go figure.

I spent over an hour on the phone with a reporter from NPR recently. S…

Question 46: What is IVF, and how is it performed?

Sometimes the first step is really the hardest in the entire journey. There is no doubt that IVF can be a roller coaster ride...physically, emotionally and psychologically. As physicians the best we can do is try to educate our patients so they can handle the ups and downs. Personally, I am really wimpy when it comes to riding roller coasters. At Universal Islands of Adventure my knees went weak at the site of the Hulk roller coaster and you can just forget any of the other big kid coasters. The best I can do is the little kid roller coaster as seen in this video. Those little girls thought it was so funny that I looked petrified but it's not my fault....it's my parents' fault for never taking me to Paragon Park in Nantasket Beach back in my formative years....



So as you consider the potential roller coaster ride of infertility treatment here is an overview of the IVF process from 100 Questions and Answers about Infertility, 2nd Edition.


46. What is IVF, and how is it perfor…

Question 45. How would I know when to pursue more advanced fertility treatments?

In the Kenny Rogers song the gambler there is a very famous line "you gotta know when to hold them, know when to fold them, know when to walk away, know when to run...." Sometimes I think about that line when counseling patients, but fortunately for them I never break out into song during a consultation. Deciding when to move onto more advanced treatments is a common concern among most fertility patients. Even those that start with IVF have to consider moving to donor egg/embryo if success is eluding us. I wish that I had that crystal ball to provide a glimpse into the future. That way I could advise patients "Don't worry, I know the 3rd IUI will work or the second clomid cycle or the first IVF or the FET or whatever.....But I don't have that ability...and if I did I would have used it to play the Powerball lottery and then it would be "see-ya later."

In general, most successful treatments will occur in the first 3-4 cycles of whatever treatment has bee…

Princeton Beats Hahvahd (WARNING: This Post Has NOTHING to do with Infertility

I know that world events have been so depressing lately.....from the unrest in the Middle East to the terrible earthquake and tsunami in Japan. It is hard to find something to cheer about and for a moment forget all the troubles and suffering that confront us on a daily basis. And then something completely meaningless (in the cosmic sense) and really quite silly can lift your spirits and make you grin from ear to ear.

Last Saturday afternoon I had just such an experience as I watched the Princeton Men's Basketball team battle Hahvahd in a one-game playoff to determine which team would go to the NCAA Tournament. Princeton battled back from a half-time deficit to finally pull even in the last few minutes. The teams traded baskets and then Princeton had the ball with 2.8 seconds on the clock under the Hahvahd basket but trailing by 1 point.

Here is the YouTube video of what happened next.


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Question 44. What complications can occur after IUI?

Years ago in Long Island I had a patient experience an allergic reactions to an IUI. She got very bad hives and even began to have a bit of laryngospasm (throat tightening). She was taken to the ER and did fine with a dose of epinephrine and some steroids. Such reactions are really really rare but it was so surprising given the number of IUIs that I have done over years without any weird reactions. Clearly the more concerning complications after IUI are those of multiple pregnancy and OHSS. Both have plagued our specialty for years. However, the risk of both can be somewhat mitigated (but not eliminated) through judicious use of fertility medications.

First of all, no one ends up with a litter without seeing it coming. A patient does not have one follicle on Monday and 14 on Tuesday. Secondly, if there are more than 2 follicles > 15-16 mm at trigger then there can be more than 2 babies. It may be too risky to try an IUI when so many follicles can ovulate so often we discuss 3 major …

Question 43. My doctor wants to use Lupron or Antagon during my IUI cycle. What are these drugs, and why do I need them? I thought they were only for

The blue screen of death....or in the world of Mac computers...the gray screen of death with the question mark folder. These two phenomenon are terrifying for those of us dependent upon computers on a daily basis. Last week my college-aged son called us with the news that his MacBook Pro was giving him this problem. So naturally we all jumped into the mini-van and raced up Route 95 to his rescue! In our computer based world we are all on that razor's edge between happy computing and disaster!

In Natural Cycle IVF we are always on the razor's edge between wanting the follicle big enough to have a mature egg but not so big that there is an LH surge and the cycle gets canceled. In stimulated cycle IUI, an early LH surge is not such a big deal unless the follicles really were too small and the eggs immature. So what can one do about premature LH surge...well that is the topic of today's Question of the Day from 100 Questions and Answers about Infertility.

43. My doctor wants to …

Question 42. Can we have sex during a treatment cycle?

Sometimes medical advice makes sense and sometimes it doesn't. Historically, fertility patients have been told to contracept during the month that they plan to start luteal lupron in order to avoid conceiving while on lupron. Actually, the registry of patients that have, in fact, conceived on lupron suggest no risk of birth defects in the children born after this little oops. Years ago in Long Island I had a patient that had 8 years of infertility. She and her husband finally got up the nerve to do IVF and boom, she conceived on lupron. Then 2 years later she wanted to have another baby and voila, she conceived on lupron again! Go figure.

So this recommendation against sex during a luteal lupron cycle has morphed into no sex during any treatment cycle which makes little sense except in a few cases as detailed below. Now if a woman is really bloated and unconfortable while on fertility drugs then that is a totally different issue. In that case we send the partner off to take care of…