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.

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