As I discussed before, the success rate of IVF depends on many factors including the status of the embryos, the status of the uterus and the nature of the transfer. Furthermore, the first component, the status of the embryos is determined by four factors: the patient’s characteristics, the embryology lab, some random factors and the stimulation protocol, which is the subject of today’s post.

Why is it helpful to stimulate the ovaries rather than just let the eggs develop naturally?
- For one thing, there actually are some IVF cycles in the world done without stimulation. This is called natural cycle IVF. I discussed this in detail in an earlier post. However, the overwhelming majority of IVF cycles are done in conjunction with some sort of ovarian stimulation. The main reason for this is markedly greater success rate and greater number of surplus embryos to freeze for the future. There are also some patients, who just don’t ovulate at all on their own and as such, absolutely require stimulation in order to grow eggs.

What does it mean to stimulate a follicle?
- Eggs remain in storage throughout a woman’s reproductive lifespan. They are encased in structures known as follicles. A follicle is an egg surrounded by a special layer of cells, called granulosa cells. The granulosa cells release estradiol.
- Stimulating an follicle causes it to fill up with fluid, making it visible on ultrasound. On the day of the egg retrieval, a needle is stuck into the follicle and the follicular fluid, along with the egg, are all sucked out into a container.

What is an IVF stimulation protocol?
A protocol is a combination of medications taken in a certain sequence. Think of it a recipe for making the eggs ready for removal.

What are the components of an IVF stimulation protocol?
There are five components.

1. Time-regulating component.
2. Stimulation component.
3. Ovulation prevention component.
4. Endometrial support.
5. Supplemental adjuncts.

What is the purpose of each component?
- The time-regulating component usually consists of birth control pills. Because IVF is not a one-day process, but rather a multi-week process, it is important to plan things out. Obviously patients have daily lives and must mesh the duties of doing and IVF cycle with their work and travel commitments. Having the patient take birth control pills allows the RE to better control when a patient will have a period and therefore, when an IVF cycle with start. There are other advantages of taking the birth control pills, including fewer cycles postponed because of cysts.
- The stimulation component is the bread-and-butter of an IVF cycle. It is what drives the follicles to grow. Although Clomid can be used, it rarely is, because of its relative low potency and because of deleterious effects on the endometrium. Therefore, the main stimulation medications used in most protocols are injectable medications, such as Gonal-F, Follistim and Bravelle. Dosage is very important. You want to use a high enough dosage to get a good number of follicles, but you also want to use as low a dose as possible because excessively high doses can compromise egg quality.
- The ovulation-prevention component is crucial. Before the standard usage of Lupron, Cetrotide or Antagon, IVF cycles were easily messed up if the patient happened to ovulate on her own before the eggs could be surgically removed. Nowadays, with the liberal use of Lupron, Cetrotide or Antagon, this rarely happens any more.
- Endometrial support usually consists of progesterone of some sort, whether by injection or by vaginal insertion. This is crucial in helping the lining be at its best. Some RE’s also add estrogen supplementation.
- Supplemental adjuncts include minor medications added to tweak the cycle into having a higher success rate. None of these medications are critical, but each RE has a favorite set of these extra ingredients that may or may not boost IVF success rates. In any case, the effect is minor, at best. It’s sort of like cooking something and adding a dash of MSG. Some examples of adjuncts include antibiotics, dexamethasone, baby aspirin or Viagara.

While this is outside my area of medicine, I’m impressed by the excellent detailed analysis of a recent unfortunate event in this blog post. This case has many implications for the state of medicine and lawsuits in the US and impacts your future medical care, so it might be in your interest to brush up on the facts before the next time you vote. Enjoy.

Today, in the United States, we celebrate Independence Day, the anniversary of our freedoms. I spent all morning cleaning the grill and trying to fix the patio umbrella in preparation for the fourteen or so friends who will be here shortly.

As I reflect on our freedoms, I am especially grateful for the opportunity to practice medicine here based on the wants of the patient and based on smart science rather than based on the frustrating arbitrary rules set by non-medical politicians. It’s easy to take this for granted, but what we are blessed to have here in the US is not something that is found in all other countries. The ironic thing is that while some countries are setting rules and regulations to try and force people to have fewer kids (China), other countries are setting rules and regulations to force people to have more kids.

After you have had your BBQ meals and shared great companionship with your friends and family, you might want to unwind by reading this fascinating article.

I’ll offer a thought. Back when it was normal for people to prepare for old age by personally saving money and raising loving children who will someday help support us, the ideas of having children and living a great family life were something natural, to be treasured. Now that we have shifted more toward a nanny state where GOVERNMENT and not FAMILY are our providers, people seem less interested in having children. We shouldn’t need artificial incentives to get people to want to have children. Ridiculous.

I’m going to try my best to get my point across without whining. I’ll probably fail, but I’ll try. What I have to say is nothing earth-shattering, but here goes: The overall quality of life in this country would improve significantly if we could reduce the impact of frivolous lawsuits. It’s no secret where I stand on this issue and I’ve taken some criticism (via email) for being vocal about this issue when I myself have never been sued. That is such nonsense, like saying I can’t crusade against drunk drivers just because I’ve never personally been injured by one.

The harm that the overly litigious climate in America does to the people is seen in the higher prices we pay for everything — higher prices that go to subsidize legal fees, which essentially give no benefit to the people, other than for the small minority who get money as tort attorneys. It doesn’t really seem fair. The overly litigious climate also limits the options we have, as witnessed by the unavailability or lessened availability of certain high profile items, such as IUD’s, vaccines and yes, even breast implants. It even limits our access to very basic life privileges, such as the chance for children to play baseball.

For some items, such as life-saving childhood vaccines, more than half the cost of the vaccine goes towards this "lawsuit tax". We can’t fault lawyers for doing all they can to get away with it because, well, because they CAN get away with it. The trial lawyers legally spend millions lobbying our politicians to set laws that favor their ability to play their games. So what can we do? We need to increase our awareness. I’m going to do my part. Once more and more hard-working American people realize just how much we lose because of frivolous lawsuits, they would wake up and start voting for politicians who take action against this problem, no matter how much trial lawyers contribute to their campaign funds.

As I said before, I have yet to be sued in over 10 years of practice. However, that doesn’t mean my staff and I don’t waste a lot of time and energy towards playing the games we need to play to defend ourselves against frivolous lawsuits. I still pay close to $30,000 per year for liability insurance, despite having a totally clean track record. I still have to do things to the letter even to the detriment of our patients. For example, if I have expensive fertility drugs that are one day past the expiration date, I have to dispose of it, even though I could easily donate it to a patient.

So rather than just ranting, the question to ask is "What can we do about it?" There are many things we could do, but one logical one is to adopt a fair "Loser Pays" policy in our country with regards to frivolous lawsuits, and all lawsuits in general. There are others more eloquent than I who have laid out strong arguments supporting the wisdom of this and I will direct you to them here, here and here.

I don’t hate lawyers. I hate the unfair legal SYSTEM. You can’t blame lawyers for their political efforts that keep the system the way it is and you can’t blame them for using the system to their gain. If it were legal for you to walk into your neighbors’ homes and take things from them for yourself, wouldn’t YOU be tempted to do it? As a nation, we need to take action to make life better for all of us, and fixing the broken tort system is one way.

In a previous post, we discussed the general concept of TRUST. It might be helpful to read that before reading today’s piece. Now we’re ready to zero in on the specific topic of trusting doctors.

How do you come to trust your doctor?
Well, how do you come to trust ANYBODY? Simple. You take a tiny step, observe the other person’s actions and adjust accordingly.

So why is there the phrase "Trust me, I’m a doctor". Maybe there are some people who argue that there’s something inherently different about doctors. Some people might be falsely lulled into thinking that the rigorous selection processes of medical schools someone weeds out the less ethical people. Bah. Maybe some people think that the fact that we take an oath makes us more trustworthy. Even more ridiculous.

In reality, doctors should be treated as anybody else is. They SHOULD NOT BE, and ARE NOT, universally trusted any differently than those in any other profession. Just as it is not right to automatically MISTRUST people in certain professions such as used car salesmen, criminals or lawyers. We all have built-in biases based on two things - what we have personally experienced in the past and what we’ve been taught or told by friends, family or the media.

I’ve learned a lot over the years when I chose to go into business with a dentist, lawyer, accountant, hairstylist whatever. I try to slowly get to know them and give them a chance to prove themselves. If they do right by me, then I come to trust them more. If they do me wrong, then the trust erodes or even completely disappears. I’ll usually give people the benefit of a doubt at first, within the limits of what I have at risk. If I’m going to try some strange new restaurant, i don’t ponder it and research it. The risk of a unpleasant dining experience is a minimal loss. But if I’m going to entrust my entire retirement money to a certain investment, you can be sure that I’ll research it thoroughly.

Granted I realize that seeing a doctor is a much bigger investment than choosing a hairstylist, but my argument is that it’s not necessarily all THAT different. Some of my patients say they researched for weeks before deciding to make that first appointment with me. That is commendable, but not absolutely necessary. Is researching for 20+ hours really a smaller price to pay than a few hundred dollars consultation fee? I guess it’s different for everyone. My practice even offers a free meet-the-office session every month, where potential patients can come visit our office and meet us face-to-face. We don’t have many takers, but those who do end up visiting us eventually come see us as patients, almost universally.

Think of the way that trust develops. Trust is earned (or not earned) by people’s actions, not by their words alone. When deciding whether to enter into a business relationship with a lawyer, accountant, doctor, investment advisor, contractor, gardener, babysitter or whatever, we start out listening to their words, their promises. But it’s only one encounter at a time that we slowly begin to trust them.

I can speak best for my own field. When you are looking for an RE, all them will say on their website certain catch phrases such as “top expert” and “personalized care”. Some may even give objective data such as success rates, but those are often misleading or even outright lies. Words mean little in the end, because while the truly expert and truly caring practices will say that they are expert and caring, so will the poor-service places, and the average-care places. Everybody makes the same good-sounding claims.

This makes it tough for patients. You would think then that the only reliable way to know if you like a particular doctor is to try out his services, then to try out another doctor’s services and then to compare. This is not as difficult as it initially sounds and often times it is well worth the effort. I’ve had many patients come to me from other practices. I will hear from them what specifically dissatisfied them about the last doctor. When it goes the other direction and patient leave our practice to go elsewhere, I often try to find out what we could have done differently to keep their loyalty. Often, it’s something we can’t control, such as our being too expensive or too far in distance. But if it’s something that I can change, that I just didn’t think of, then it’s a positive thing because it helps guide us on how to further improve our practice. It’s especially satisfying when patients leave our practice to try another and then, end up coming back.

Our success these past years has depended a lot on word-of-mouth referrals. In this situation, we have gained the trust of person A because of the good care and good service we gave them. Then if there is a person B who trusts person A (either a friend or relative), then when person A gives their word of approval, person B comes to us already having some trust in us, sort of the Transitive Property of Trust. So this is the other way trust is earned, not by personal experience but by what someone whom we trust tells us.

Next time you do business with someone, whether it be your accountant, gardener or doctor, ask yourself whether or not your trust is being earned appropriately.
Do they things they say turn out to be true?
Do the promises they make turn out to be fulfilled?
Do you feel they have the appropriate balance of putting your best interests before theirs?

If not, then explore the options of seeing a different provider. You’ll be glad you did.

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.

Earlier this week, after a debate between me and my friends, I set out to settle the following question. What’s most important to people concerning marriage? Now, I’m not speaking of the truly important matters such as love, honesty, integrity, passion, trust. Instead, I am referring to just the more worldly matters. So, let me clarify. Out of the four big ticket MATERIAL items associated with marriage, namely the RING, the CEREMONY, the HONEYMOON or the HOUSE, which one would most women say takes priority in her heart? Obviously, not everybody will agree on the exact same answer, but is there a general consensus?

In a very unscientific study, I set up a poll inviting women’s input. The results, whether suprising to you or not, are certainly interesting. Here are the ongoing results so far. I would be grateful if you could also add your own answer and comments, either openly or anonymously.

As someone with great faith in the practical wisdom of today’s woman, I predicted ahead of time that most would choose HOUSE as the priority, at least those who were of a more mature age than let’s say… teenagers. I wasn’t so sure about those who were in their early 20’s. Perhaps they might be more romantic and choose the symbolic glittery ring as their primary focus.

This is just an informal poll, not a scientific investigation. The study design could be easily picked apart. First of all, there is great selection bias in that the answers are obtained only from women who are internet-savvy and have the energy and passion to visit a website and render their opinion. I also chose not to moderate, censor nor hide the comments, making it very likely that a respondent will read all the previous answers and allow the crowd mentality to potentially sway her own response. But I’m not rying to get this published in a journal, get a government grant or obtain FDA approval for anything. I merely wanted to generate some fun discussion and stimulating thought. And from the feedback of friends who have read the responses, that has certainly been achieved.

How does this have any practical value regarding fertility? For me, it serves as a reminder about how well or how poorly women (or people, in general, as I believe it’s just as true of men as well) know what they want. And even if they do know what they want NOW, they certainly don’t always know what they want in the FUTURE.

For example, the respondents who are on their second marriage show that their views on the priorities NOW (house is #1) differ greatly from their views when much younger (ring is #1). I see this often in patients who pour their hearts out to me saying , "Doctor, it’s so ironic. When I was 25, I would have sworn on a stack of Bibles that I never ever wanted kids. I was so sure of it that I would have signed a contract attesting to it. And here I am (at age 37) struggling with infertility and seeking expensive treatment. And now I can’t bear the thought of never having kids of my own."

Just a gentle reminder to those of you in your youth who are so sure that you don’t want children. Be proactive and reexamine your priorities from time to time. Be open-minded about your potential to change your mind and maybe you’ll be able to get a start on motherhood early enough so as not to need the services of an RE. But even if you don’t realize it early enough to do it on your own, we’ll still be here to help.

Thanks again for your participation in this poll.

I’ve heard of an orthopedic surgeon naming his dog Bones. I’ve heard of an ophthalmologist not naming his dog Spot, but instead naming it Macula, which is a "spot" on the retina.

One of my dogs is named Ixie, after ICSI, the procedure by which a sperm is injected into the egg as part of IVF.

Here is a video of my yorkie, Ixie, fighting with Brandy, my german shepherd.

There are some in this world who claim that what I do is vile and despicable. No, I’m not manufacturing toxic waste that will decimate our environment and I’m not selling crack to destroy the lives of countless addicts. Instead, I’m responsible for helping bring something into this world that is much much worse —- CHILDREN!

Today, an article in the Washington Post describes how some people view parents with families of more than two children as being "showoffs". How have we gone from the normal traditional view that family and children are a good thing to this type of crazy thinking? I’ve certainly helped many patients have more than one child (often two at one time) and a lot of these families come back to discuss having even MORE children. I will have a thorough discussion with them regarding this big decision, making sure they look at the pros and cons. Then, I embrace their right to have a 3rd, 4th or even a 5th child if that is their choice. I also wholeheartedly embrace their right to stop at two. In fact, I strongly embrace the right for people who refuse to have any children at all. While I’m certainly generous with my embraces for people’s freedom to choose, I have no hugs to give to those who butt into other people’s lives with their own judgmental criticisms, or worse yet, who take actions to restrict other people’s freedoms.

Worshippers of the Immaculate Church of Dr. Al Gore don’t look at children as being human beings, but rather as vermin attacking the planet earth. They don’t care as much about the cute little footprints of babies’ feet as much as they care about the carbon footprint, whatever that means. Fine, they can rant all they want, as long as they don’t try to seize more and more power in controlling what other people do. In fact, I am actually quite enthusiastic about saving energy and about not being wasteful. My family is actively involved with the environment and we have started a worldwide recycling and waste disposal company. However, we do these by choice.

Then you have the Voluntary Human Extinction Movement that believes…well perhaps you should read for yourself. I know they claim to be just joking, but still.

Again, the beauty of our country, or at least, our country the way our founding fathers established it, is that everyone is entitled to their opinions as long as it does not infringe on the right of others. So we will just let them spout their views all they want.

Meanwhile, my patients, staff and I will continue to work together very hard, expending our blood, sweat and tears towards bringing babies into the world and delivering them into the arms of loving parents. We will just offer a polite smile to those who scream of the environmental atrocity that this represents as long as all they do is talk and scream.

However, if the crazies ever start taking ACTION to oppose us, such as China’s one-baby policy or laws banning IVF or regulations to restrict our reproductive options, then we will be ready to fight for our rights! It hasn’t happened yet in this country, but in Europe, patients are restricted in how many embryos they can transfer and what types of fertility options they can choose (such as bans on egg donation). A few determined European couples are coming to the US for fertility treatment to pursue their dreams of having a family, but if our own government seizes more power in this area, then we won’t be able to help them, let alone help ourselves.

Please excuse me now. I must get ready to unleash some more future polluters and resource consumers into this world.

Click here for episode 1

RECAP: Aimee and Boyd have been infertile for three years. They’ve finished basic testing under the care of their regular OB. They’ve also been tried unsuccessfully on six cycles of Clomid. Their only significant findings include minimal endometriosis and periods that are just a tiny bit longer than average.

What additional testing would you do?

Before we answer that, let’s think about the basic principles of medical testing. This applies to infertility testing as well as to ANY general medical testing. Here are the factors to consider before deciding on whether or not to get particular test.

USEFULNESS: This is defined by whether or not the test results will affect your decisions. Some tests fall in the category of "gee, that’s nice to know", but since it does not change management, there is little reason to do it.
LIKELIHOOD OF POSITIVE FINDING: How likely is it that the test result will come back abnormal? For example, if there is some tropical parasite that is the cause of infertility in one out of a million couples, is it really worth testing?
COST: How much will doing the test cost you in terms of $$$, as well as inconvenience and/or suffering and/or danger? If we want to get really fancy, we can even factor in the cost of following up a false positive. This is a huge issue in general medicine. The only way for doctors to safely defend against frivolous lawsuits in this country today, is to do a lot of testing, much of it unnecessary from a medical point of view, but crucial to do from a medico-legal point of view. Sometimes, the testing will falsely end up showing something that is not really a problem, sort of a false alarm (better known as a false positive). However, once you have that positive result in front of you, you are forced to address it, even if it means sometimes putting the patient through unneeded invasive surgery. This is not a big problem in infertility, but my heart goes out to my fellow physicians in other specialties who have to deal with this on a regular basis.

There are hundreds of possible tests that I can order, but for Aimee and Boyd, AT THIS TIME BASED ON WHAT WE KNOW NOW, there is no pressing reason to order anything else. This might change in the future as the situation evolves and we learn more things, but for now, it’s better to focus our energy and resources on treatment rather than testing.

Often, patients come to my office with an article printed out from the internet asking me to order this test that they read about. Most of the time, I will explain the rationale behind NOT doing it. Other times, I will explain the pros and cons and leave it to the patient to individually decide if she wants it or not.

I’ll give an example. There is a common blood test used to get a general idea of a woman’s ovarian reserve (to sort of get an idea of how old her ovaries are). This test is called a day #3 FSH. For reasons I won’t go into here, it is only accurate if done in conjunction with a day #3 estradiol (E2). So we abbreviate this combination of tests as a D3 FSH/E2.

So should we do this test on Aimee? Wouldn’t it be nice to get a better idea of her ovarian age?
Let’s analyze the logic using the principles mentioned above.

COST: This is a pretty cheap test, easily done for under $200. It consists of one poke to get the blood. It’s non-invasive and has virtually no risk associated with doing it, unless perhaps you pass out while getting your blood drawn and bonk your head. So cost isn’t much of a factor.
LIKELIHOOD OF ABNORMALITY: At Aimee’s age, it is highly unlikely she is menopausal or even near menopause, especially since she has regular periods, has positive ovulation testing, does not get hot flashes and has ovaries which are normal-sized. This fact alone makes me very unexcited about ordering this test on her.
USEFULNESS: If her FSH comes back sky-high (indicating she is menopausal), that would be a shock and would not make sense. But still, would it change our management? Do you think that if a test claimed she was menopausal, we would all just nod our heads sadly and agree to give up, or to move on to using an egg donor, all on the basis of a blood test? Of course not. Most likely, Aimee would not believe it and would still like to try with her own eggs anyway.

Therefore, if someone comes to me waiving a printout and screaming, "This website says all infertile women should have their FSH checked. When are you going to check my FSH?", next time I can just give them a printout of this article for them to read first.

In summary, there is no absolute MUST-DO testing to perform for Aimee. I will concede that anyone can try and make an argument for this test or that test, but it will fail to be overwhelmingly convincing if you consider the balance of cost, usefulness and likelihood of a positive. Again, this strongly applies to where we are NOW.  That may change, so that we might get some more tests on Aimee in the future, as things unfold. But I wouldn’t get anything just yet, which brings us to the next issue, that of choice of treatment options…

Click here for episode 3