Click here for episode #1

RECAP: Cora and Anthony have been infertile for over seven years. The initial workup revealed potential tubal issues. Despite surgery and many IUI cycles, they failed to conceive. They eventually agreed to do IVF. Ten days ago, Cora received two embryos transferred into her uterus.

And today….she is pregnant!

The blood pregnancy tests that we do are quantitative. That means rather than a big YES or NO, we get even more detailed information in the form of a number. Cora’s hCG value was a 209, a very good level.

We typically repeat the hCG value in 2-3 days. The reason we do this is to detect the likelihood of abnormal pregnancies which will end up in miscarriage. When the values double in 48 hours, we are very optimistic. We are OK if they even just go up by 70%. However, when they rise more slowly than that, it is concerning. And when the values actually drop, the news is devastating.

Two days later, her value was 561, more than double!

Two weeks after that, her first ultrasound showed there to be two heartbeats. Cora eventually went on to deliver beautiful healthy twins, a boy and a girl.

To this day, they stand firm by their decision.
To quote Cora, "We don’t feel that our doing IVF is a sin that is in need of forgiveness. We sin in our daily lives all the time and God forgives us, but this is different. Our precious babies are a gift and blessing from God and we will continue to serve Him faithfully."

To this day, Cora and Anthony and the babies are active members of their church. While their DECISION to have these babies is not entirely accepted, they themselves are accepted. There are others who are not so lucky, such as this teacher who was fired for having her babies through IVF.

There are good pregnancies and bad pregnancies. We all know what the most common form of bad pregnancy is — miscarriage. However, there are pregnancies that are even worse than that — ectopic pregnancies. Ectopics are doubly sad because just as with miscarriages, you don’t end up with a baby. However, in addition to that, ectopics also put the mother’s life at risk. Most ectopics are in the Fallopian tube and can potentially grow so large as to rupture the tube, causing dangerous internal bleeding. 99.9% of ectopic pregnancies will either die on their own or be removed medically before they can develop. However, there is always that one in a million that grows to become a baby. Today, just such a case was reported in Australia

I try to visualize what would have happened had this occurred under my care. We would have detected a heartbeat in the ovary early on. Whenever, a heartbeat is detected in the tube or in the ovary, the risk of maternal death is so high, that instant intervention to remove the pregnancy is the clear choice. This woman was lucky that she survived. Furthermore, the baby was lucky that her mom didn’t have routine medical care initially, because then she would have surgery to remove the ectopic. So she actually wound up with a better outcome. Life is strange.

Click here for episode #1

The evening after your egg retrieval, things feel different from how they felt previously. Imagine this. For the past few weeks, you have been giving yourself injections, going in for ultrasounds and getting poked for blood tests every few days. Early this morning, it all culminated in you going under anesthesia and having a minor surgical procedure to harvest the eggs. Now the waiting begins. The toughest part physically is now over.

Cora was fortunate to get a great yield of 19 eggs. Not all IVF cycles are as good. As planned, we did ICSI on all the mature ones.

The typical progression for an IVF cycle is that we begin with a number of potential follicles seen on ultrasound. Some are "blanks" or "duds" and don’t have eggs, so the actual number retrieved might be less than that number. After retrieval, some eggs will be immature or abnormal, so only the good ones will undergo ICSI. Then, out of those, only some of them will have fertilized normally.

For example, Cora had about 25 follicles seen on ultrasound. She got 19 eggs. Of those, 17 were mature, and underwent ICSI. Of those that underwent ICSI, 14 became normal embryos. Of the 14 normally-fertilized embryos, 9 looked great on day 3. Up to this point, we were passively watching and waiting for information. Now, it was time to make some decisions.

Our first decision was whether to transfer the embryos today, on day 3, or to wait until day 5 to transfer them when they are at the blastocyst stage. What are the advantages and disadvantages of each option? Although this is controversial among RE’s, I agree with those who believe that a day 3 transfer is better in terms of survivability and a day 5 transfer is better in terms of information to aid selection. In the past, this used to be more agreed upon, but nowadays, with improved culture methods, there might not be all that much a drop in survivability when waiting to day 5.

Look at it this way. On day 3 (3 days after retrieval), Cora has 14 embryos. Nine of these are excellent looking. You might recall, that we judge the appearance of embryos based on cell number and degree of fragmentation. We presume that of these nine, some are genetically perfect and will become babies when implanted. Some won’t. I might make a guess that 30% of them will become babies. If I’m correct, the next problem becomes guessing which of these 9 are the good ones and which are the bad ones. They all look about the same. What can we do?

One option is to wait two more days. In two days, it’s likely that these nine won’t look so similar any more. Some will become great looking blastocysts and some will be so-so blastocysts and others won’t even make it to the blast stage at all. Information from those additional two days now makes it easier to choose which to transfer.

Because of the abundance of great-looking embryos, I suggested waiting the two days. After discussing all the pros and cons, they reluctantly agreed. (I’ll go over the cons shortly and you’ll understand their reluctance).

After another 2 days of waiting, we opened the incubator on day #5 and saw 6 blastocysts. The other three had stopped developing. Now, instead of choosing from all nine, we got the chance to choose from just the six best. This time, I estimated that they had a 45% chance per embryo. Our first decision had been a good ones. Had we come back today only to discover that all 9 embryos failed to develop, then we could have potentially regretted our choice to wait until day 5. Even that is controversial, because there are some who argue that if the embryos don’t make it to day 5, then even had you put them into the uterus on day 3, they wouldn’t have resulted in a baby nor even survived it to day 5 inside the uterus. There are others who argue that the uterus is a better environment than the laboratory and that there is a small chance that some embryos that don’t grow to blast in the lab environment, could have become a baby had they been transferred on day 3. The great fear of this was what really tempted Anthony and Cora to go for a D3 transfer. As it was, they trusted my judgment and now it paid off (this time, at least).

Our next decision was on how many to transfer. I first made it clear that my estimate of 45% chance pregnancy per embryo was just that an educated guess. So any interpretation of calculations must take that into account. i then told them that their choice now was to transfer 1, 2 or 3 with the following estimated outcomes.

TRANSFER ONE: Fail = 55%. Single baby = 45%.

TRANSFER TWO: Fail = 30%. Single baby = 50%. Twins = 20%

TRANSFER THREE: Fail = 17%. Single baby = 41%. Twins = 33%. Triplets = 9%

Just for comparison, I gave them my calculated estimates for transferring four, even though we wouldn’t remotely consider it.

TRANSFER FOUR: Fail = 9%. Single baby = 30%. Twins = 37%. Triplets = 20%. Quads = 4%

In a future post, I’ll discuss these types of calculations and the limitations in using them. But for the most part, having these numbers in ones head when making decisions is better than total wild guessing, as long as we take them with a grain of salt as not being absolutely guaranteed to be accurate.

I was pleased, when they decided to have me just transfer two.

I did a very smooth transvaginal-ultrasound-guided transfer and we waited for the pregnancy results, remembering that with blasts, the wait is only 10 days instead of 12.

Click her for episode 10

This question was posed by a future medical student:

I’m entering med school this fall, and women’s health and REI is a great interest of mine due to personal and familial reasons. Once you completed your Ob gyn residency, how difficult was it to enter into the REI fellowship? How long was the fellowship? I’ve also considered Perinatology– what are your thoughts on that field?

When I made the decision to go into OB/Gyn, I did not know I would end up in REI. I didn’t even consider it initially, mostly because I didn’t know much about it. As my residency progressed, I found a great mentor in one of my faculty who was once president of the American Board of OB/Gyn. His field was Gynecolgical Oncology and he encouraged me to go into that field. I was initially greatly drawn to Gyn/Onc because it involved a wide range of very skilled surgery, including GI surgery and urological surgery in addition to medical knowledge of chemotherapy. However, when I discovered REI, it became my new love. When my mentor learned of this, rather than being upset, he was fully supportive and did all he could to help me enter a fellowship at UCLA. Each person’s situation is different, so if I were to answer your question of "how difficult was it to enter into the REI fellowship", it was very difficult only in the sense that I had to go to the right med school and the right residency and earn the respect of the right people. Other than that, it was easy.

I can also help answer your question by presenting last year’s statistics:

Match Results Statistics
Obstetrics/Gynecology (OB/GYN) Fellowship

Match Day October 31, 2007
Appointment Year 2008

STATISTICS BY SPECIALTY

Updated 11/09/2007

As you can see, in Gyn-Onc, there were 49 positions available, of which 45 filled. In perinatology, also known as MFM (Maternal-Fetal Medicine), there were 77 positions available, all of which filled. In REI, there were 38 positions available, all of which filled. The newest subspecialty is Pelvic Surgery, of which 27 of 29 positions filled. There wasn’t a breakdown of the different subspecialites with regards to number of applicants, but overall for all the fellowships, there were 343 total applicants. Of those, 55% matched somewhere and 45% failed to match anywhere. I would estimate there are just over 1000 graduating OB/Gyn residents nationwide. There are also some foreign applicants adding to the pool. These data also don’t include applicants who were accepted outside of the match system.

When I counsel medical students regarding a career in REI, one recurring theme is the need to be happy doing general OB/Gyn as there is a very real scenario of OB residents failing to get into a REI fellowship and ending up practicing OB. A minority of students give up on the idea of going into REI because they don’t feel that they would be happy doing OB. As many students will attest, OB seems to be a polarizing rotation in the 3rd year with a greater % of students feeling the extremes of really loving it or really hating it.

I know many RE’s and many doctors in other specialties. There are happy RE’s and disgruntled RE’s. There are happy FP’s and disgruntled FP’s. I will offer an opinion that from my observations, RE’s tend to lean towards being more satisfied with their work than being less satisfied. As for myself, I’m an extreme when it comes to that question, being very very happy with my choice of specialty. Bear in mind that about 1 out of every 700 doctors is a RE, so we are very much a minority.

Finally, in answer to your question on my opinion on perinatology, I love the perinatologists with whom I work. They save us when we end up with triplets or more. I’ve witnessed some incredible work by the MFM miracle workers who rescue those of our IVF babies who happen to be born prematurely. When you ask a perinatologist what they think of RE’s, they might give a mixed answer of dreading the occasional sets of triplets and quads they get from us, but also acknowledging that we definitely keep them in business.

I recently completed an interview for a medical student website, after which I asked them not to use my real name in keeping with how I don’t have my real name on this blog. My reason for the anonymity, as many of you know, is a minor one. I do have another website for my practice which is a pure marketing tool, intended to help patients decide to come see me. I wanted to distance this site that you are currently reading from being a marketing tool. Many more readers come to this site than they do to my regular site. What they want is authentic information and opinions, not a sales pitch to increase my patient volume. Granted it’s a minor thing, as many of my colleagues, patients and those who first visit my main site will know who I am by the time they come HERE.

The interesting thing is after I requested my name be withheld, the author of this interview decided to make up a fake name for me without informing me. So you can call me Dr. Lawrence Terra. i believe they are sending me a whole dossier including passport, fake ID and biographical cover story so I can begin doing undercover assignments for the CIA.

UPDATE: December 1, 2008. I give up on being anonymous on this blog, as people are using google to easily figure out who I am.

Click here for episode #1

When I saw their names on my morning schedule, I smiled at the surprise. Six years ago, when they left our practice, I had said a silent prayer for this sweet couple. Now, six years later, Anthony and Cora were back. It’s not unusual for patients to come back after several years. Often, it’s because they are back for a second or third baby. It’s usually very fun to catch up on what they’ve been up to, how the new kids are doing and what type of cute baby stories they have to share. Unfortunately, Anthony and Cora did not have a baby yet. They both looked great. The years had not packed any extra weight on them. If anything, Anthony looked lighter and Cora was the same. I was eager to catch up with what had been going on.

For an infertile couple who were still childless, they were just bubbling with positive energy as they eagerly got me caught up on the past six years. Cora had done 5 more IUI cycles with her HMO. She had also attempted to have laparoscopy to fix the endometriosis and open up the tubes more. Obviously, there had been no success at all. That was the medical part. On a personal level, they were doing great. They had a huge house, many friends and a fulfilling mix of charitable projects to keep them busy. Anthony’s career was very successful. Cora recently decided to quit working and stay at home in preparation for having a baby. They acted like a couple who were still very much in love. Then Cora said, "I bet you can guess why we’re here".  I had almost expected to say that they had broken away from the Catholic church, but instead, it was the opposite. From their descriptions, they had given even more of their time, resources and money to support their church. And that, ironically, is how they came to the decision that they wanted to proceed with IVF. Huh? I didn’t quite understand, so I asked for clarification. Apparently, they began taking on more of a leadership role and started counseling other married couples. In the course of doing this, they encountered many fellow parishioners who were now parents via IVF. They shared that, at first, many of the couples didn’t want to "confess" how they had gotten pregnant, but when Anthony and Cora shared their sadness at not being able to have kids, many couples felt the burden to share their own IVF stories in the hope that it could help Anthony and Cora come to terms with their decision. Cora always faithfully supported Anthony’s hard stance against IVF. Anthony, on the other hand, could no longer stand to see his devoted wife so sad. They prayed diligently for a sign and they said they clearly got one and that’s why they declared their intention to have a baby with IVF. They apologized to me that part of the deal with God was that they wouldn’t share the details of "the sign" with anyone, not even me. I didn’t mind at all. I was just thrilled they were here. We discussed certain restrictions, such as avoiding left-over embryos and avoiding the possibility of fetal reduction. They had done their homework. I acknowledged their wishes.

After making sure this was their final decision, we started the cycle. I made a protocol schedule and started Cora on birth control pills. (Since we were using the BCP’s for cycle-regulation and not for birth control, it was OK with the Vatican). Towards the second half of her cycle, I did an uneventful trial transfer and checked her ovaries for cysts. Immediately, Cora started on Lupron. When her period came, she got another ultrasound prior to starting stimulation. No cysts. We were good to go. She was started on Gonal-F 225 IU and Menopur 150 IU daily, beginning on cycle day #3. We were being relatively aggressive. They promised that they would eventually transfer any frozen embryos, leaving nothing to discard. They were prepared to do this, even if it meant eventually having ten kids.

After four days of stimulation, this is what we saw:

Cycle Day #7. (Stimulation day #5)
RIGHT OVARY: (9×9) (8×8) (8×8) (8×8) (6×6)
LEFT OVARY: (9×9) (9×9) (9×9) (9×9) (9×8) (7×7) (6×6)
Estradiol level = 588 pg/ml

This was an excellent start! I lowered her dose to Gonal-F 150 IU + Menopur 150 IU and told her to come back in two more days.

Cycle day #9. (Stim day #7)
RIGHT OVARY: (14×14) (13×13) (13×13) (13×13) (11×11) (12×11) (12×12)
LEFT OVARY: (13×13) (13×13) (11×11) (11×11) (9×9) (8×8)
Estradiol level = 1251 pg/ml.  Progesterone = 0.5 ng/ml

Still going great, yet not out of control either. The low progesterone value reassured us that the eggs were not in any immediate danger of getting prematurely "stale", or post-mature, as we say. I lowered her dose to Gonal-F 75 IU + Menopur 150 IU for the next day. And then I dropped it to just Menopur 150 alone for the next day after that.

Cycle day #12. (Stim day #10)
RIGHT OVARY: (19×19) (19×18) (22×20) (19×19) (18×18) (18×18) (17×17) (16×16) (16×16) + 5 smaller ones
LEFT OVARY: (20×19) (19×19) (18×18) (18×13) (17×17) (16×16) (15×15) + 4 smaller ones
Lining = 9mm triple layer
Estradiol level = 4122 pg/ml. Progesterone = 0.8 ng/ml

This was the perfect day to launch her ovulation. She was given 5000 IU of hCG to launch the follicles and her egg retrieval was scheduled to occur in two days.

Two days later, I was able to retrieve 19 eggs. Because of the unproven status of Anthony’s sperm, we had planned all along to do ICSI. Since we had many eggs, we had the option of doing ICSI on some, and not doing ICSI on the others, but we decided not to play around with that idea. This month’s yield was enough to make us completely discount Cora’s previous understimulated cycle six years ago. Her ovaries were great! Anthony reminded me about the field goal story I told him way back. "Hey, doc, thanks for the 19 footballs. Take care of them, OK?"

We awaited the next day’s fertilization report, very happy with today’s retrieval.

Click here for episode 9

I bet if you ask most people if they believe everything the media tells them, they will answer NO. However, what they may not realize is that they still do believe a lot of stuff that is misleading or outright false. I confess I used to be pretty naive. There was a time in my youth when I sheepishly believed what the newspapers, magazines and TV news fed me regarding the world. But over time, I’ve realize the error of being too trusting of the media.

For example, when the headlines scream "Unemployment on the rise!", you read the fine print and see that it really rose just from October to November, which is something that it tends to do every winter, just based on seasonal changes. So things aren’t really bad at all.

Sometimes, the news will report something truthful, but report it with a misleading slant. For example a headline that reads "Millions wasted on building more prisons, despite lower crime rates ever" could just as easily read "Crime rates drop to lowest ever as more criminals are kept behind bars".

There is a tendency for everything to be presented in a negative viewpoint. When home prices dropped, the headline was, of course, "Homeowners suffer worst drop in house value ever". However back a few years ago, when home prices soared, the headline was "Shortage of affordable homes worse than ever".

By the way, just because the media distorts and lies is not necessarily a grave sin in itself, as long as we, the readers, take caution to assess things intelligently and critically and as long as we are diligent in reading from a variety of different sources and synthesizing our own views. The worst thing is when people mindlessly accept everything at face value. Of course, everything I write is slanted from my own viewpoint. So make sure you to pursue reading opposing viewpoints from mine before making up your own mind.

I came across an article today that provides abundant examples of how being critical in our thinking can help us from falling into the trap of becoming media lemmings.

Let’s start with the headline. The wording implies that prior to this news, women somehow were not given the "right" to have children without fathers. In the US, for example, single women and lesbian couples are free to pursue motherhood without fathers. The same is actually true of the UK from where this article hailed. The only difference is now the government will pay for it. It’s not a simple matter of gaining the right. There was always the right. The difference is that now, it can be demanded and have the NHS foot the bill.

This article mixes together some different topics besides the issue of fertility treatment without the need for fathers. It also talks about a ruling on abortion. In the splash photo, the caption mentions the 24-week abortion limit. In actually, it is showing a picture of an embryo that is less than 9 weeks. If a true 24-week pregnancy was pictured, you would be looking at something that appeared very much like a baby and not an embryonic organism. Very misleading.

Later in the article there is a quote that "children without fathers were more likely to have problems at school and with drink and drugs". This is misleading in the context of this particular article, because while it’s true that traditionally, fatherless children do have more behavioral issues, these are children of divorce or of involuntarily unwed moms. There is data that intelligent, financially stable, productive single mothers by choice have children who are as stable or more so than average.

I personally disagree with this policy change of not taking into account the need for a stable family unit when deciding on who gets free fertility care in the UK. Whereas in the US, there is a safety system in place that only financially stable women could afford to be single mothers by choice, thereby predicting a more stable future for the child. Now, in the UK, they will have the socialist policy that any single woman, even those on the dole, can have kids. The government will pay for the treatment. And the government will pay for the child’s upbringing. One can only guess what that will do to family and society there. Is it a surprise that marriage rates in the UK are the way they are?

It’s a quiet day at work and I got a good laugh out of this unbelievable story that a friend sent me. On a personal note, this crazy lady is now teaching at my undergrad alma mater, Northwestern University.

Click here for episode #1

When patients come in for their pregnancy test and they look happy and excited, many times, it’s because they already did a home urine pregnancy test. That was our first guess when Cora arrived to get her pregnancy test drawn. However, when we asked, she denied testing. She just felt nauseous and her breasts were tender. My staff member cautioned her that we really need to wait for the results. Still smiling, she acknowledged this and told us to call her cell. This time, she said we could call her directly with the news, either way, positive or negative.

An hour later, we had a sad call to make. The results were negative. Cora took the news well, considering. Anthony and Cora scheduled to come in three days later to have a talk.

I summarized their situation. They have been infertile for close to three years. Their testing came back normal for sperm and normal for ovulation and abnormal for tubes. So while the tubes were open, the scarring and endometriosis were suspected to make proper egg pickup a difficult task. They have failed three IUI cycles with a total of about 14 mature follicles and still nothing has taken so far! When you are worried about triplets and end up with nothing, that’s a clue that it’s time to consider something different. When you have a lot of follicles on IUI’s and there’s no pregnancy, it could mean that the eggs are not getting picked up by the tubes (most likely in this case), it could mean that the sperm is not fertilizing the eggs or it could mean that bad embryos are being made. In any case, IVF would be the way to go. I told them so. I would do another IUI if they insisted, but I wouldn’t recommend it.

Anthony came right out and said "We can’t do IVF".

There are different reasons why patients choose not to do IVF. The most common one is financial. Not everybody has the financial resources to afford it. Another reason patients choose not to do IVF is because they don’t really understand what it is. Some people don’t want to do IVF because they feel they don’t need it. It turned out none of these were the reasons. Anthony and Cora had a clear understanding of the procedure, a clear understanding that they needed it and they were financially successful. They never said they didn’t want to do it. They said they COULDN’T do it. This was the clarification.

They had met with their parish priest, who had made it very clear that the Catholic church does not allow IVF. Anthony and his entire family had been very involved in the Catholic church for many generations. He had been an altar boy and was in training for the honored position of serving communion. In the short time that they had been in California, he had become very well known in their church, almost as much as his family had been back home near Chicago.

This was not the first time I’ve encountered this dilemma. Many Muslim patients and Catholic patients have asked about their faith’s view of doing In-Vitro. I referred them to speak with their priests or imams. Many chose not to speak with their religious leaders, but went forward with the IVF. I can think of at least 10 Catholic couples of mine who had babies through IVF. Protestant Christians don’t usually bring up any objections to IVF as long as fetal reduction is out of the question and as long as all frozen embryos will eventually be given a chance at implantation. I’ve had patients who were themselves pastors and pastor’s wives of Protestant Christian churches and they went forward with IVF without hesitation. I once heard another RE say that she tells her patients that God does not reject the concept of IVF babies even though the Pope does.

In any case, I approached this sensitive issue the way I usually do. I confirmed that they had spoken sufficiently with their religious leaders. There was one time when a Muslim couple spoke with their imam and then went ahead with the IVF, saying they were hesitatingly given the green light. But for Anthony and Cora, the answer was a clear no. There was zero chance that they would consider IVF. I sensed that Cora wanted to go forward with it, but Anthony was adamant. Once this was 100% established, I discussed all other options, including adopting. The other way would be to keep trying on their own, or to do some more IUI cycles. This couple had been seeing me outside of their insurance and it was costing them more to do their IUI cycles with me than if they would do it within their network. So one option to save money would be to do any future IUI cycles elsewhere. They were welcome to do more cycles with me if they chose to, but I expressed that it wouldn’t be the wisest use of their finances at this point.

Cora was tearful. She thanked me profusely for everything. They left my office, saying that they would pray for guidance. Although we gave them our prayers and best wishes, one of my staff members, who had particularly bonded with Cora, took it extra hard. I noticed that she would mention Cora from time to time, and it took her about three years before she stopped bringing up her name.

Click here for episode 8

According to this article, the five mistakes women make are:

1. Women don’t question doctors
I think a lot of this is determined by the doctor. Some doctors get angry when they are questioned. I take the opposite approach. My staff and I welcome questions, actively solicit patients for any questions and do not take offense if a patient wishes to go elsewhere for a second opinion. More than half the time, after seeking a second opinion, patients come back to us, confident and ready to proceed with our treatment plan.
2. Women tend to over-research
Ha ha. In the field of infertility, I would definitely agree with this. Despite a lot of misinformation out there on the net, I’m open-minded enough to look at the printouts patients bring me, knowing that it’s always possible that they could teach me something.
3. Women don’t recognize gender bias
This is not an issue with RE’s and OB’s because ALL our patients are women. This applies to women who go to doctors who see both men and women and who might not recognize the potential medical differences between their male and female patients.
4. Women interpret their own symptoms
Very true, but so do men. I know I do.
5. The mother of all mistakes: Women don’t trust their intuition
I disagree. Some do. Some don’t.