Journal club is one of those things that I don’t look forward to, but which afterward, I’m glad I went. About once a month, I carpool all the way from Orange County near Disneyland, to a restaurant just a block from the UCLA campus. A fellow RE, an embryologist and I battle the LA traffic and usually get there a bit late. Last night was no exception. We arrived to join a debate already in progress. In attendance, seated in a huge circle was an audience of 25 people, consisting mostly of RE’s, RE fellows, urologists and acupuncturists.
The first article concerned using new ultrasound technology to measure volumes of follicles instead of the way we do it now, which is to measure the diameters. There was a consensus lack of enthusiasm for this technology, although some postulated that follicle measurements could be automated and done by a tech or machine. We then debated the efficiency of letting techs do our ultrasounds despite the facts that the patients love it when the doctor does it. Should we go for efficiency or go for bedside manner?
Today’s second article concerned the proper obtainment of consent from egg donors regarding the potential use of their gametes in stem-cell research. When an egg donor agrees to donate, she is under the belief that her eggs will be used to generate embryos that will be transferred into another woman in the hopes of bearing babies. However, after the couples are successful, they sometimes end up with twins or are just happy to have one baby. So they then have excess embryos frozen for future disposition. If they are sure they have all the babies they want, they can opt that the remaining frozen embryos be adopted out or be used for research. The main debate was this: If we decide to do stem-cell research with the frozen embryos because they were donated by the couple, is it enough to get the couples permission? Or is it necessary to also track down the egg donor and tell her “Hey you remember those eggs you donated four years ago? We have some extra embryos leftover from them and want to use them for stem cell research. Is that OK with you?”
It can be fun to get a bunch of us opinionated doctors in a room and see how many different viewpoints there are. Some people believed that you should give informed consent encompassing not only all the known technology but on future technology as well. So, for example, someday if cloning is perfected, and you wanted to use the egg donors’ embryos to do cloning research, you would have to track her down and re-consent her. From the other extreme were people who pointed out that for years and years, sperm donors were never given a say in what is done with their sperm after they donated. This then evolved into a discussion of the future of our field. One person predicted the cost of IVF would drastically come down and down as we get more efficient. Another person made a bold prediction that I liked. She advanced that perhaps someday it would be routine for all women in their 20’s to go for an annual pap smear and be asked if she wanted a needle biopsy of her ovary to get some tissue to freeze and preserve for her future fertility. There was some anti-lawyer sentiment about how we aren’t even allowed to consent egg donors without paying a lawyer to represent her. We then moved on to the third paper.
The third paper concerned prepubescent boys diagnosed with cancer and undergoing chemotherapy. It’s common knowledge that adults who are about to undergo chemotherapy should be offered the option of freezing sperm beforehand in case the chemo drugs destroy their testicles. But what do you do if this occurs before boys can ejaculate. A children’s hospital in Pennsylvania did a project where prepubescent boys with cancer who were undergoing surgery anyway were given a choice to have a testicular biopsy done at the time of their main surgery. The big issue was that there’s no evidence that this testicular tissue will be of any use in the future, because right now we still wouldn’t be able to extract usable sperm out of frozen testicular tissue. As often happens, this evolved into an ethical discussion about whether 6-year-old boys could give consent to having their testicles biopsied or not. We then argued who should pay for this and whether or not it would turn commercial, comparing it to the way that companies which advertise cord-blood banking try to convince (scare?) parents into pay money to freeze the umbilical cord blood from newborns even though it is very unlikely to ever be of any use. I’m not sure how the conversation migrated, but we then started talking about different ethnicities and their obsession with fertility. Some of the West LA doctors recounted stories of Persian Jewish families who would insist on not marrying their daughter off until the future son-in-law had a documented normal semen analysis.
The final paper concerned endometrial receptivity and preovulatory progesterone levels. The paper was done by a very well-respected RE out of Nevada. Anyone who has been to a lot of journal clubs knows that with any experimental paper, the first thing journal club attendees do is to pick it apart and criticize the materials and methods, many times justifiably so. This time was no exception. Some of us were really critical of the paper author’s practice of altering someone’s IVF cycle if her preovulatory progesterone was over 1.0 ng/ml and then freezing all the embryos in preparation for transfer in a subsequent month on the theory that the prematurely luteinized lining was bad for implantation.
I worked 70 hours this week and spending time relaxing, learning and debating over dinner and wine is a nice break.