Zoom with DrG

Author: John David Gordon MD

Good Morning!

As of last night Knox County is under a “Safer at Home Order.” As such we are moving all consultations to online consultations. Personally, I will be using Zoom to do my consults.

Growing up in Boston I loved watching the TV show Zoom which was produced by the local PBS station WGBH. I begged my Mom to let me apply to be on the show. Wisely, she realized that her beloved youngest son could not carry a tune, follow a beat or perform any other action that could be considered evidence of entertainment talent. Oh well.

Instead, I spent my energies and talent as part of Boy Scout Troop 3, Milton, MA and rose to the rank of Eagle Scout (as did both of my sons). Like all good Boy Scouts I strive to “Be Prepared.” Although I wish I had more hand sanitizer…

So please “Be Prepared” to “Zoom!” with Dr. Gordon for consults during this current situation.

Stay safe,

DrG

COVID-19 Update

Updated 6/10/20 at 10:30 AM

Dear Southeastern Fertility and NEDC Patients and Families,

It had been a while since we officially updated this blog post regarding Southeastern Fertility. The good news is that we timed our building construction just perfectly in terms of the global pandemic! The construction wrapped up and we hit our stride opening back up to restart fertility treatments.

Dr. Keenan is back in the Operating Room at UTMCK which restarted elective surgeries about a month ago. Dr. Gordon is back performing HSGs at Abercrombie Radiology each week on Tuesdays. All patients wishing to pursue IUIs or IVF or FETs are welcome to do so. We do provide an informed consent for those pursuing pregnancy, and certainly some patients are still not comfortable pursuing pregnancy at this time.

We are happy to continue to offer virtual consults for patients who did not need to be examined or undergo an ultrasound at the time of the consultation. Telemedicine is actually a convenient way to interact with many of our patients and is probably here to stay!

We place our hope in God above and we continue to ask patients to prayerfully consider their decisions to resume fertility evaluation and treatment.

Fear not, for I am with you; be not dismayed, for I am your God; I will strengthen you, I will help you, I will uphold you with my righteous right hand.

Isaiah 41:10 

Hope starts with a conversation and we look forward to seeing many of you real soon!

  • John David Gordon MD
  • Jeffrey A. Keenan MD HCLD

Updated 4/22/20 at 10:00 AM

Dear Southeastern Fertility and NEDC Patients and Families,

We hope that all of you have remained healthy and hopeful as we all continue to navigate the new normal here in our great nation.

The exciting news here at Southeastern Fertility is that our building construction is wrapping up… although we can barely hear ourselves think as the workers reattach the awnings with power drills. We have had an extended period of sunny skies and low humidity so Praise the Lord that we ended up right on schedule!

As previously planned, we will be back doing egg collections and embryo transfers the end of this week and those patients who had planned to undergo their FETs in April will not be delayed on our end! With the exception of scheduling surgery and HSGs (over which we have no control), we are continuing normal operations within certain limitations.

For example, we continue to follow our social distancing rules within the office at this time and are encouraging patients to continue to take advantage of telemedicine for visits that do not require an exam nor an ultrasound.

We continue to ask patients to prayerfully consider their decisions to resume fertility evaluation and treatment.

Remember that “Hope starts with a conversation…. ” and we are here to help in any way that we can.

Be strong and take heart, all you who hope in the Lord.

Psalm 31:24
  • John David Gordon MD
  • Jeffrey A. Keenan MD HCLD

Updated 4/3/20 at 10:00 AM

Dear Southeastern Fertility and NEDC Patients and Families,

Every day we are asked by patients: “What should I do?”

Although Dr. Keenan and I can certainly offer our professional perspective (and rest assured that we are continually discussing the decisions that we are making here at Southeastern Fertility), ultimately the decision will rest with you, our patients.

In such times, we are reminded that the concept that we are in control of our lives is an illusion. The situation is summed up by Pastor Alistair Begg who writes “In recent days, we’ve been reminded that the world can be a scary place. But whether we face a personal crisis or a worldwide pandemic, God remains our refuge.” There is an old adage that there are no atheists in foxholes during war. We are at war right now with an invisible enemy and it is indeed frightening to not be sure what to do.

As people of faith, turning to God in such times should be our first instinct, but sometimes we get distracted by our desire to figure it all out on our own. That is a losing proposition.

So as you seek to reach difficult decisions we would suggest that you go to the Lord in prayer.

May the God of hope fill you with all joy and peace in believing, so that by the power of the Holy Spirit you may abound in hope.

Romans 15:13

Please remain hopeful and faithful.

  • John David Gordon MD
  • Jeffrey A. Keenan MD, HCLD

Updated 3/31/20 at 11:00 AM

Dear Southeastern Fertility and NEDC Patients and Families,

Seems like everyday we are making changes to how we live and work in these uncertain times. Currently, as a country we are engaged in social distancing to “flatten the curve” and lessen the potential impact on the healthcare system from a wave of very sick infected individuals. This concern has led many businesses including medical practices to limit patient contact by reducing services, changing scheduling slots or closing entirely for an uncertain length of time. In addition, some locales, including Knox County, have instituted restrictions governing non-essential business activity and recommended that residents “shelter in place.” Some states have imposed travel restrictions and recommended 14 days of quarantine for those arriving from certain “hot spots” within the United States.

So what should we do? At Southeastern Fertility we continue to remain open with appropriate modifications including patient screening, transitioning to virtual or phone consultations whenever possible and rescheduling certain non-essential visits. The response among fertility clinics has been varied as some are high volume centers in close proximity to where there is a cluster of cases and others (like Southeastern) are lower volume clinics in areas where there is currently a paucity of positive patients. Our plan has been to make changes as appropriate given the evolving situation.

At the present time all patients seeking to pursue fertility treatments are provided with a waiver that Dr. Keenan and I have written and amended as the situation evolves. All such patients are provided with the ASRM Recommendations and the update that was released on Monday March 30, 2020.

We are allowing patients to pursue IUI cycles after reviewing our recommendations. As I described in an earlier post, we had a scheduled prolonged shut-down of the IVF Program for March and most of April as we complete construction on the building.

Here at Southeastern Fertility we certainly agree with the concerns raised by the ASRM, but believe that community prevalence and patient choice must also play a role in the decision making process. We have advised all of our patients to consider deferring their upcoming treatments (including scheduled Frozen Embryo Transfers) but allow patients who are fully informed of the known consequences and willing to accept that there may be unknown consequences to continue their treatment for now.

Like any other woman who is considering pregnancy, a patient pursuing fertility treatments should consider the benefits and risks of that decision. At this time none of our professional organizations are advising potentially fertile women to avoid pregnancy.  IF such recommendations were made THEN all fertility providers would really need to consider ceasing all operations.

The recommendations of the ASRM are based on the efforts to minimize the risk to patients, staff and the general public. However, we agree with many fertility providers around the country that a “one-size fits all” approach may not make sense given geographic differences.

We have already instituted appropriate safety measures consistent with the guidelines of the CDC including providing sufficient minimal staffing, spacing in-clinic appointments throughout the workday to allow for 6-foot social distancing policies in shared spaces, enabling staff to work from home, and implementation of mandatory health screenings at our front door to patients who must be seen in person (temperature checks, recent history). Our staff members are wearing surgical masks, practice compulsory hand hygiene, and follow 6-foot social distancing policies in shared spaces. Patients remain in their cars until being brought into the clinic. We are blessed to be in a free-standing clinic with parking directly in front of the building. No one needs enter into the hospital or ride in a crowded elevator to reach us.

In addition, since we have a small staff the number of staff members that each patient would encounter is probably fewer than you would experience at the grocery store. At larger clinics this is not the case as one fertility specialist working in a such a program estimated that each patient would interact with over 35 different staff members during a treatment cycle. That is simply not the case here at Southeastern Fertility.

Fear without faith leads to panic. Let us all be faithful and not fearful.

  • John David Gordon MD
  • Jeffrey A. Keenan MD, HCLD

Updated 3/24/20 at 9:00 AM

Dear Southeastern Fertility and NEDC Patients and Families,

I hope that all of you remain safe and healthy during these trying times. At midnight last night all of Knox County was placed under a “Safer at Home Order.” As a medical practice we are not in the non-essential business category, so therefore we are technically exempt from a mandatory shut-down. However, prudence dictates that we respect the spirit of the directive in terms of doing our part to “flatten the curve” by limiting face-to-face encounters.

As of this afternoon we will transition to performing all consultations via telephone, Skype or Zoom. Office visits will be limited to those patients with acute problems such as bleeding in early pregnancy or other Reproductive Endocrinology emergencies.

Patients who need blood work performed as part of their current cycles or to monitor their pregnancies will be able to have their blood drawn here in the office between 8-11 am daily. Semen analyses will be scheduled but samples will be received at the front door as no samples will be collected here at the office.

Current IUI cycles will be completed if desired by the couple but no new IUI cycles will be initiated at this time.

I will be providing additional details regarding Zoom in a separate blog post.

Our nonprofit partner, the National Embryo Donation Center, is maintaining business as usual. The NEDC team is still scheduling appointments, processing applications and addressing inquiries. Each member of the NEDC staff is working in isolation, from home, which may lead to some slight delays in these matters. We thank you for your patience and understanding.

Don’t be fearful…be faithful. We will come out the other side of this crisis with a new appreciation for all of our blessings.

John David Gordon MD

Updated 3/23/20 at 9:15 AM

Dear Southeastern Fertility and NEDC Patients and Families,

These past few days have seen such rapid changes in our lives that it is hard to contemplate. The near constant barrage of news from around the country and around the world affects all of us in different ways. Dr. Keenan and I have been discussing the situation on a daily basis. In addition, I have been in touch with my friends and colleagues around the country to see how they are handling the practice of reproductive medicine in such unusual times.

So where does that leave us here at Southeastern Fertility? First of all, I want to emphasize that Dr. Keenan and I are dedicated to the health and welfare of our patients, our combined staff, our clinic and the NEDC.

If all non-essential businesses here locally are asked to close then we will shut down.
If all travel is restricted then we will shut down.

At the present time we have elected to pursue the following approach.

We will encourage all patients who are just having a consultation appointment to schedule these as phone, Skype or Zoom consultations. Visits that require an ultrasound or a physical exam (including saline sonograms and trial transfers) will still be performed unless a patient asks to reschedule. We may move your date and time depending on staffing and the desire to limit the number of patients in the office at any given time.

All patients who have started fertility medications for IUI or timed intercourse cycles will be given the option to continue their cycles. New IUI or timed intercourse cycles using oral medications will be allowed, but if we have to close the office fully then these cycles will be cancelled in terms of further monitoring or doing an IUI. We have an information sheet/waiver for all patients pursuing fertility treatment cycles.

Months before the current situation, we had already scheduled a shut down of the IVF Program until late April in order to accomplish some building maintenance. We will assume at the present time that late April FETs will be performed, but any patient who wishes to reschedule to a later date can certainly do so.

The status of the Stimulated Cycle and Natural Cycle IVF starts will be determined over the next few weeks since we have less control over the precise timing of egg collections compared with FETs. However, all of these cycles were already pushed off until late April because of the construction project.

Other specific changes:

  • When you arrive at the office please call 865-777-0088 #1 and remain in your car until asked to come into the office.
  • You will be asked about symptoms of fever, cough, or shortness of breath. You will be asked if there is a family member or other close contact who is currently in quarantine. You will be asked about recent travel to a country with high prevalence of COVID-19 or travel to/from a US location with high prevalence of COVID 19.
  • Once inside the door we will check your temperature.
  • Please only enter with a maximum of one other family member/friend.
  • No children at this time please.
  • All staff members will be wearing surgical masks. We are taking this step as an added precaution even though our population is very low risk .
  • Please be patient as we work out the details of our revised patient flow through the office.

These are difficult times and in such times it is sometimes hard to remember our blessings which are so very great. We pray for the safety of those medical personnel working with sick patients, for the patients who are afflicted with any and all diseases and for all of us who are just doing our best to remain hopeful about the future.

For I know the plans I have for you,” declares the Lord, “plans to prosper you and not to harm you, plans to give you hope and a future.”

Jeremiah 29:11

Please check back soon for additional updates.

John David Gordon MD

Updated 3/17/20 at 3:45 PM

Dear Southeastern Fertility and NEDC Patients and Families,
 
At Southeastern Fertility, the health and well-being of our patients who are seeking to conceive or receive treatment for reproductive concerns is not only our first priority, but it is also our sole reason for being in business. For this reason we want to personally update you on our efforts to continue providing you and your family the superior level of care you have come to expect in the cleanest and safest environment available during these trying times.  As of this writing, there has only been one case of Covid-19 reported in Knox County, and the risk of infection in our community is still low. However, as we are expecting that number to increase, we are taking the following safeguards at Southeastern Fertility to ensure your protection:
 

  1. We have always endeavored to provide a clean office environment for our patients, which includes cleaning the exam rooms between each patient.  Currently, these efforts have been redoubled with an even more thorough cleaning between patients, and common surfaces in our entire office are being sanitized on a nightly basis to guard against disease transmission in our system.
  2.  If any member of the care team at Southeastern Fertility reports flu-like symptoms, that individual will not report to work until testing negative for Covid-19 and the resolution of symptoms. They will receive full paid time off during their absence.
  3.  If any patient has symptoms of fever, cough, or shortness of breath, we ask that you seek treatment and testing for these symptoms first, and reschedule appointments at Southeastern Fertility until cleared by primary care.
  4. If any patient has a family member or other close contact who is currently in quarantine, then that patient should contact us to reschedule their appointment.
  5.  For patients who have flu-like symptoms or who are concerned about attending a consultation appointment then we will be providing virtual telemedicine appointments online via FaceTime or Skype in the near future.  These must be scheduled through the office like any other appointment.
  6.  Although unlikely, there may be patients with Covid-19 or flu-like symptoms who have a gynecologic emergency or urgent problem that requires direct treatment regardless of other symptoms.  Such patients receive the care needed to assist them with such a gynecologic emergency.
     
    At Southeastern Fertility we are filled with hope about the future and in the ability of our great nation and community to pull-together to prevent the spread of disease.  We commit to doing our utmost to protect you and your family.  We look forward to seeing you soon.

Jeffrey Keenan MD HCLD
John David Gordon MD

Bless your little PCOS-loving heart, Dr. Gordon….

Author: John David Gordon MD

Last week Laurie Wood joined me on Talk Fertility, our Facebook Friday feature here at Southeastern Fertility. Laurie provided me some very helpful insight into the use of the idiom “Bless your little heart…” Now I am going to constantly wonder if I am being dissed by my staff when they utter these words…But I guess that is really up to me to figure out.

So after Laurie schooled me in various terms including “f-u-r” as in “my home is fur away from here,” I shared with her the correct Boston-based pronunciation of pharmacy (fahm-missy) and sent her on her way. This served as my transition into a discussion about Polycystic Ovarian Syndrome (PCOS). During my exposition I touched on the use of metformin or Glucophage and some patients were left wondering why they should take a medication for diabetes when they have a fertility issue. The answer lies in the data which suggests that PCOS is actually intimately related to insulin resistance.

The role of insulin resistance as the probable initiating factor in PCOS has important clinical implications. Because of the pioneering work done by Drs. John Nestler and Andrea Dunaif, the treatment of patients with PCOS has now shifted toward addressing the underlying issue of insulin resistance. Patients with PCOS are often treated with an insulin-sensitizing medication such as metformin (Glucophage). More than 20% of patients with PCOS and irregular cycles will experience a restoration of their normal cycles with metformin treatment. Because most patients who take metformin experience a diminished appetite, they may also benefit from weight loss with this therapy. Patients with PCOS also have increased rates of first-trimester miscarriage, and preliminary data suggest that there is a reduced rate of miscarriage in patients with PCOS who are treated with metformin.

In order to minimize the gastrointestinal side effects, the dose of metformin is increased gradually. Many physicians initially prescribe 500 mg a day of the extended-release preparation of metformin, to be taken at dinner. After 1 week, the dose is increased to 1000 mg; after another week, the dose is increased to the maximum of 1500 mg. Most patients can tolerate the medication, although severe gastrointestinal side effects (mainly diarrhea) arise in 10% to 15% of patients. Patients who fail to resume predictable cycles with metformin therapy alone will need to consider ovulation induction with fertility medications.

The use of metformin as a first-line medication in the treatment of ovulation problems in patients with PCOS is controversial. Some physicians believe that clomiphene or letrozole should be the first medication prescribed to women with PCOS who desire pregnancy and have irregular cycles. Our preference has been to start with metformin and then add letrozole or clomiphene if a women fails to resume regular menstrual cycles.

Deep Dive FAQ: Who needs ICSI, and how can I be certain that I need it?

Author: John David Gordon MD

For those of you following Southeastern Fertility on Facebook, you may have seen the DrG and Lynda show last week during which Lynda educated me on the correct East Tennessee pronunciation of certain words like “fur” and “hollow.” In return, I “learned her how to Tawk Boston” by having her pronounce “b-e-d-d-a-h” like a native Bostonian. Once the war of the accents had ended Lynda returned to work and I spent some time discussing Intracytoplasmic Sperm Injection or ICSI (ick-zee).

It seems like it shouldn’t work, but it does! When is ICSI right for IVF? Find out in this week’s Talk Fertility.

Posted by Southeastern Fertility-Admin on Friday, February 21, 2020

The most common indication for ICSI is male factor infertility associated with an abnormal semen analysis. Therefore, men with unproven fertility and a semen analysis demonstrating an abnormal sperm count, motility, or morphology are appropriate candidates for IVF with ICSI to improve the chances of successful fertilization. However, there can be differences of opinion between REI physicians and embryologists as to how abnormal a semen analysis needs to be for ICSI to be recommended over traditional IVF (putting 50,000 to 100,000 sperm in a droplet of fluid with each egg).

Some men may have a blockage in their reproductive tract that may keep sperm from getting out, perhaps as a result of a surgical procedure like a vasectomy or because of certain congenital abnormalities. In these and other cases, a specially trained urologist may retrieve sperm directly from the testicles or epididymis. Surgically retrieved sperm requires IVF with ICSI for fertilization, because typically such procedures rarely yield a sufficient number of sperm for IUI or standard IVF. Even though the sperm looks adequate, non-ejaculated sperm has not undergone the final maturation process and therefore ICSI should be utilized to fertilize eggs using any surgically retrieved sperm. ICSI may also be used for cases where traditional IVF has not resulted in fertilization (sometimes referred to as “fertilization failure”), regardless of whether the semen analysis is normal. ICSI is also used in any case with previously cryopreserved oocytes or in-vitro matured oocytes.

Learn How to Talk Boston…I mean Talk Fertility…Fridays on Facebook with DrG

Author: John David Gordon MD

Several years ago Dish Network ran an entire advertising campaign featuring Boston as a Second Language. It was wicked funny. Trying to learn another language can be challenging….whether that language is Boston or Fertility.

The language of fertility revolves around so many acronyms and medical terms that it can be overwhelming. So overwhelming that I think that it deserves its very own series of Facebook Live video spots to help explain some of the terms that get used by those of us in the fertility world everyday.

Please join me on Fridays at 12:30 PM for your chance to learn Fertility as a Second Language. It should be wicked helpful as you try to navigate the fertility diagnosis and treatment maze!

Wicked Slippery

Author: John David Gordon MD

As many (? most…? all?) of my patients may realize, I grew up in Boston. My parents were lifelong Bostonians and both of them (especially my Mom) did have Boston accents. So where is mine? Dunno… Maybe just like Chris Evans (Captain America) and John Krasinski (Jim from the Office), all it took was moving “fahr awey from Hahvahd Yahd” to lose my accent…But as you can see from the amazingly funny Hyundai commercial that is currently on the air, you can take the boy out of Boston, but you may never really be able to take the Boston out of the boy…

Wicked is not an adjective that I hear very frequently here in Knoxville. Truth be told, I never heard it very often in Washington, DC either! But that is not the case in Boston, as is evident from the Hyundai ad and from the MassPort electronic bulletin board alerting drivers to the fact that the “Roads are wicked slippery!”

Wicked slippery is how I describe the fertility treatment process to some of my patients. You start out with a few months of infertility and then it becomes a few years. Then you see your Ob Gyn and then maybe you do some clomid. Then you end up in the office of the fertility specialist and before you know it you are shooting yourself up with Gonal-F in the bathroom at Longhorn Steakhouse… Once you start down the slippery slope it is hard to know how to stop….Should you do multiple stimulations? Should you fertilize as many eggs as you can? Should you do PGT-A (Preimplantation Genetic Testing) on all the embryos? And more and more until you find yourself at the bottom of that slippery slope looking up and wondering how did I get down here?

In my 23 years of fertility practice I have seen it over and over again. I think that there is a way to put some brakes on the rapid descent down that slope. I believe that IVF is an appropriate treatment option for our patients, but there needs to be consideration given to where the process can lead before ending up where you never wanted to be….especially finding yourself stuck with too many embryos on the one hand and a family that feels complete to you on the other.

The options of Natural Cycle IVF or Mini Stim IVF or Stim IVF with careful consideration of how many eggs to fertilize can all serve to mitigate the headlong plunge down the slippery slope. In particular, I love Natural Cycle IVF. One egg…one embryo…one baby. No fuss. No muss. Here at Southeastern Fertility, our Natural Cycle IVF is up and running. What can I say…I think that it’s wicked smaht!

Deep Dive FAQ: How many eggs should I fertilize?

Author: John David Gordon, MD

From time to time I will take one of the FAQs from our new website and use this blog to discuss the question in more depth…this is one of those times…so here we go…

Patients considering IVF often ask me how many eggs do I think that they will get and how many should they fertilize. Those are excellent questions and I believe that all patients need to carefully consider what to do before jumping onto the fertility treatment treadmill…

In the world of IVF we are facing an ever increasing crisis caused by our inability to address the huge number of frozen embryos being created by fertility clinics. In our efforts to help patients we are contributing to the moral and ethical dilemmas faced by the very patients that we are so desperate to help.

This issue was one of the reasons that ultimately led me to make the big move from Washington DC to Knoxville. There is no way that we are ever going to be able to get ahead of this problem if we don’t address the decision making process that has led to the fertilization of so many eggs in the first place. It is hard to get patients to consider the possibility that having extra embryos could ever be a bad thing and yet time and time again during my 23 years of treating infertility I have seen patients agonize over what to do with their extra embryos.

The difficulty in making a disposition decision is not limited to patients who are religious or Christian or conservative. Once patients have a child following IVF their perspective on how they regard these extra embryos that are stored in liquid nitrogen tanks at their fertility clinic often shifts dramatically. These embryos are no longer nondescript clumps of cells…They are something more. They are something special. They are something unique.

At Southeastern Fertility we carefully discuss with our patients how many eggs to fertilize before the IVF process even starts. We offer both Natural Cycle IVF and Mini-Stim IVF as options to avoid the temptation of fertilizing too many eggs. In our Stimulated IVF Program we limit the number of eggs fertilized but are happy to freeze the extra unfertilized eggs for future use. If clinics fail to counsel patients appropriately then the problem will only get worse. A recent segment on the Today Show (and another featuring yours truly on local TV) highlighted this very issue and suggested that if we do not take steps to address this issue, then it is only a matter of time before the government decides to address it for us.

FAQ 24.  How many eggs should I fertilize?

Our recommendation to all patients is that they consider fertilizing only as many eggs as embryos that they are willing to transfer either now or in a future FET cycle. Since we are very comfortable with freezing unfertilized eggs we recommend that patients carefully consider this decision so as to avoid the difficulties inherent in deciding what to do with frozen embryos once a couple no longer wishes to use them to have additional children. Although the National Embryo Donation Center (NEDC) has matched thousands of donated embryos with recipients, there are estimated to be over 1 million frozen embryos stored in IVF clinics across the United States. At Southeastern Fertility we are committed to helping resolve the problem inherent in storing these embryos indefinitely by avoiding the creation of too many surplus embryos.

Trigger Shot or No Trigger Shot…That is the Question..

Author: Ciera Roberts, MSN, APN, WHNP-BC

One of the questions that patients often ask us in the office here at Southeastern Fertility is whether or not to use an HCG trigger shot for the timing of an intrauterine insemination (IUI). So is it better to use a trigger shot than to use an at-home ovulation predictor kit? The answer is (drum roll please): There isn’t one correct answer.

We aim to do an IUI at the optimal time in a treatment cycle. The optimal timing of an IUI is at the time ovulation occurs; therefore, it is important to be able to accurately predict that time frame. Ovulation is triggered by a surge in luteinizing hormone (LH), which is released by the pituitary gland, when the ovarian follicle or follicles become mature. The egg is released from the follicle about 36 hours after the LH surge.

When we plan to use an HCG trigger shot, the patient is monitored via transvaginal ultrasound and hormone blood tests at intervals until the ovarian follicle or follicles are determined to be mature. Once we estimate that the follicle is ready (usually when it measures 18-22 mm in average diameter), an injection of HCG is administered. HCG is very similar to LH and thus the trigger shot serves as the LH surge, and IUI is scheduled accordingly anticipating that the egg(s) will be released about 36-42 hours following the HCG injection.

How does this compare to using an at-home ovulation predictor kit (OPK)? Well, in most patients the LH surge will be detectable in the urine after the surge is noted in a blood test. Usually the egg is released the day following a positive OPK. So, an IUI is ideally performed the morning after a positive OPK. Patients will typically begin testing on cycle day 12 and test every day until the test is positive.

Current research indicates no significant difference in either clinical pregnancy rates or live birth rates when comparing home monitoring of ovulation with OPKs to ultrasound monitoring and HCG triggering. Therefore, the choice is patient specific.

If your schedule doesn’t allow the time commitment for multiple ultrasound visits and lab draws, and you are confident in your ability to do in-home monitoring, then OPKs may be the best option for you. However, if you have had difficulty interpreting OPK results in past cycles, or you’re simply afraid that you might miss the positive result, then ultrasound monitoring and HCG trigger shot may reduce your anxiety and uncertainty. Using a trigger shot also takes some of the guesswork out of the timing of an IUI, and may be beneficial if there are potential scheduling conflicts near ovulation (such as you or your spouse leaving town on a business trip).

The bottom line is that there is no right or wrong answer, and you should talk to your doctor about what is going to be most beneficial for you.

Stepping out in Faith

Author: John David Gordon, MD

Anyone who has been in my office can readily guess that I am a dog person and not a cat person. If you are a cat person, then you have my sympathies…Dogs have families and cats have servants. Making the decision to move to Knoxville was clearly a case of stepping out in faith. I am someone who is loathe to change toothpaste brands and who, much to my wife’s chagrin, always orders the exact same menu items whenever and wherever we go out for Indian food. So the decision to move was not insignificant. But sometimes making a leap is the right call (like moving to Knoxville) and sometimes making a leap can end up with you getting a bit of a surprise…

A few summers ago we adopted a second four-legged friend from a high kill shelter in South Carolina. Lucky was heartworm positive and his life had taken a turn for the worse since he had been abandoned by his former owners. Fortunately, he responded very well to medical treatment and was declared healthy prior to making the journey up to join our family.

Although we think that he may be a Goldendoodle, we really have no idea about his doggie DNA. He has shown absolutely no interest in swimming and after getting a bath to get whatever that black deer musk is off of him he now refuses to go anywhere near a bathroom!

But one thing that he absolutely loves is riding in the car. He sometimes sits in the minivan while it is in the garage in hopes that one of us will decide to take him for a spin. Since a boat is kind of like a car with no roof he quickly decided that tooling around on our boat was pretty awesome.

One summer day we were out on the lake and pulled up to the dock at the market to grab a snack. Lucky was happy to get back on land for a few moments to use the doggie facilities (nearest tree). Suddenly he realized that just 20 yards away there were a bunch of Canadian Geese. However, they were not on land. They were happily gliding around the end of the docks seemingly oblivious to Lucky. As we walked back to the boat he decided to check out the geese from a different vantage point. I walked with him to the end of the dock and we stood for a few moments watching the geese mill around about 10-15 yards away from us.

Then Lucky launched himself into the air and off the end of the dock. I have no idea what he was thinking… He hit the cold water and immediately turned back toward the dock…all hope of catching a goose quickly forgotten. As I helped him clamber up on the dock he seemed a bit embarrassed by the whole affair. However, his happy personality soon returned and he dried out quickly in the heat of the day.  He now clearly regards swimming as a near-death experience.

So what does this shaggy dog tale have to do with infertility? Well, on some level pursuing fertility treatment is a leap of faith. Our patients are making the assumption that there is a good egg, a good sperm and a uterus capable of carrying a pregnancy. We really wish that we had definitive tests to figure out if these assumptions are correct, but we do not.

AMH, FSH/estradiol and antral follicle count will predict responsiveness to fertility medications for stimulated IUI or stimulated IVF cycles. However, these tests will not predict who will conceive either with or without treatment.

Recently I had this discussion with a patient who was over 40 years old but with poor ovarian reserve as evidenced by her AMH, antral follicle count, FSH levels and previous response to fertility medications. I explained that the further use of medications was unlikely to improve her odds of success and that NC IVF probably made the most sense in her situation unless she was interested in Embryo Adoption or traditional adoption. I explained that NC IVF pregnancy rates per embryo transfer depend upon her age (which I cannot change) and are NOT dependent upon ovarian reserve.

Making that leap of faith is difficult. Sometimes you come up short…just like Lucky in his attempt to secure a tasty lunch of Canadian Goose….BUT sometimes the leap is successful. The only way to find out is to take a deep breath and take the plunge.

Dr. G says “Hello Knoxville!”

Author: John David Gordon, MD

It is with mixed feelings that I ended my nearly 20 years at Dominion Fertility a little over 6 months ago. I am so proud of the wonderful staff at Dominion and so thankful to the patients who trusted me to be their fertility specialist. I rejoiced in their successful pregnancies and mourned along with them in the failed treatments.

When I arrived here in Knoxville back in July, it was like coming home without realizing that I had ever been away…The amazing staff at Southeastern Fertility and the wonderful people who make up the National Embryo Donation Center have been so welcoming to me….a Bostonian by birth no less! We have quickly found a wonderful church and have begun making friends.

It is a real pleasure to work alongside Dr. Jeffrey Keenan, and with our combined 50 years of fertility practice, we have had some very interesting discussions about the care and treatment of the infertile couple.

Slowly I am learning how to pronounce the names of local towns without the staff bursting into laughter, and I have been introduced to all sorts of new cuisine, including Petro’s Chili and Chips…

Over the coming days, weeks and months I will be blogging here on the brand new Southeastern Fertility website and covering a wide range of medical questions. This blog will also keep everyone updated on practice events including our Trying 2 Conceive Tuesday (T2-CT)…[It’s not my fault… I’m a Star Wars fan and if we can have R2-D2, C-3PO and BB-8, then why not T2-CT?]. Well, if anyone has a better name for our upcoming in-office information sessions then feel free to email me…

Fondly,

DrG