tag:blogger.com,1999:blog-86853678631843414682024-03-13T13:18:47.344-07:00TRM's "Fertility, From the Inside Out"Observations, Ideas and Support from <a href="http://www.trmbaby.com">Tennessee Reproductive Medicine</a>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.comBlogger29125tag:blogger.com,1999:blog-8685367863184341468.post-11262775704121812982012-07-02T18:57:00.002-07:002012-07-03T13:19:18.641-07:00Timing is Everything - Lessons From CaddyshackReading <a href="http://www.trmbaby.com/TRM-infertility-webzine/current/TRM-patient-story-Allen.shtml">the Allen’s story</a>, I am reminded of many of the important lessons I learned during my medical education. <br />
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Some lessons I learned as a student, some as a resident, but one lesson I learned from Caddyshack. That’s right. Caddyshack. <br />
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Now, I realize that many women in my life collectively roll their eyes when I start quoting movies with my friends. It’s a guy thing. We can’t help it. The quotes make us laugh. They give us a bond. And yes, they can make us annoying….. <br />
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“Spalding, get your foot off the boat.” <br />
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“Oh, this is the worst-looking hat I ever saw. What, when you buy a hat like this I bet you get a free bowl of soup, huh? Oh, it looks good on you though.” <br />
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But sometimes there is great wisdom in the stupidity, and that is where I learned an important medical lesson…. <br />
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“We're about to tee off now so call the hospital and move my appointment with Mrs. Bellows back 90 minutes...Just snake a tube down her nose and I'll be there...in four or five hours” <br />
said Dr. Beeper.<br />
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Caddyshack Lesson from Dr. Beeper: Don’t be like Dr. Beeper. Take the time to do things right.<br />
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Flash forward now to 2002. The setting is a tour of a hospital that is recruiting doctors to train in the field of Reproductive Endocrinology. If this were a movie, I’d be the guy on the tour who was not impressed. In fact, I was disgusted. I told myself, these are people I will never work with. I was interviewing for fellowship training in Reproductive Endocrinology and Infertility. <br />
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I was with several other applicants taking a tour of a very well respected program when one of us asked the doctor leading the tour about doing fertility procedures on the weekends. The doctor told us, seemingly proudly, that they didn’t do much on weekends. He said they could always tweak a woman’s treatment to delay ovulation or to do it a little earlier than usual so that weekend treatments could be avoided. <br />
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The tour went on, but there was at least one less applicant for fellowship at that program. I don’t know if my face showed it, but I burned on the inside hearing this. Having been a fertility patient, it was very disappointing to hear a fertility doctor say that he was willing to sacrifice a patient’s chances of success just to make his life easier. <br />
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It is a common source of amazement to my friends and to patients that we see patients on weekends and even most holidays if they are bleeding in pregnancy, or in the middle of treatment cycles. But if you don’t do that, you may be decreasing a patient’s chance of success. It’s good to know that people appreciate the steps we take to maximize their chances of success. It is almost always interpreted as an act of kindness. Which I guess it is. <br />
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As the Dalai Lama says, “Be kind whenever possible. It is always possible.” <br />
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Big Hitter, the Lama.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-51771680364705137412012-03-09T05:14:00.007-08:002012-03-12T08:13:40.034-07:00Weight Loss QuizA) How many meals and/or snacks do you eat in a day?<br /><ol><li> 5<br /><li> 4<br /><li> 3<br /><li> 2<br /><li> 1<br /><li> Some days I don't eat at all</OL><br /><br />B) Do you count calories?<br /><ol><LI> Yes (I know exactly how many calories I eat because I weigh or measure my food and read food labels.)<br /><LI>Yes (but I estimate)<br /><LI>Sometimes<br /><LI>No…. and what is a calorie exactly?</OL><br /><br />C) When you eat at a restaurant, how to you pay for food?<br /><ol><li> Nearly always in cash<br /><li> Both cash and credit/debit card nearly equally<br /><li> Credit cards or debit card nearly always</Ol><br /><br />D) Which best describes the way you eat a meal?<br /><ol><li> I am painfully slow to the point that I annoy others.<br /><li> I have a leisurely pace to meals, because I enjoy the time at the table.<br /><li> I am a relatively fast eater.<br /><li> I eat with no wasted motion, and only put a utensil down to change to a different one.<br /><li> Very fast.<br /><li> Like I’m in a competition.</ol><br /><br />E) When you go to the movies, what describes your snack habit?<br /><ol><li> I don’t ever snack at the movies.<br /><li> I buy something small, with a low calorie content.<br /><li> I buy the value bucket and drink, but only have a few bites and leave the rest to my companion(s).<br /><li> I buy the value bucket and drink, even if I don’t finish it all.<br /><li> Love the value bucket and may get a refill.</OL><br /><br />F) When you go to the grocery store do you?<br /><ol><li> Nearly always pay with cash.<br /><li> Usually pay with a check.<br /><li> Usually use a debit or credit card.<br /><li> Nearly always pay with a debit or credit card.</OL><br /><br />G) When you go to the grocery store, which best describes your shopping habits?<br /><OL><li> I have a list and I’m sticking to it.<br /><li> I mostly stick to my list but usually see some things I forgot to list.<br /><li> I wing it.</OL><br /><br />H) How much television do you watch?<br /><ol><li> Less than 30 minutes a week<br /><li> 30 min to 1 hour a week<br /><li> 1-2 hours a week<br /><li> 2-3 hours a week<br /><li> More than 3 hours a week</OL><br /><br />I) Do you eat/snack in front of the TV?<br /><ol><li> No<br /><li> Rarely<br /><li> Usually. I fix a plate or bowl just for myself and don’t refill it.<br /><li> Usually. And I get seconds or refill when empty.<br /><li> Yes, and I bring the bag so I don’t have to make second trips to the kitchen.</OL><br /><br />J) When do you decide you are finished with a meal?<br /><OL><li> When I am no longer hungry.<br /><li> When I am satisfied, but not full.<br /><li> When I’m full.<br /><li> When I’m worried I might pop.</OL><br /><br />K) How many minutes of aerobic activity do you get per week?<br /><OL><li> More than 3 hours<br /><li> 2-3 hours<br /><li> 1-2 hours<br /><li> Less than 1 hour<br /><li> What’s aerobic activity, again?</OL><br /><br />L) How do you view a meal?<br /><ol><li> Food is fuel.<br /><li> Every meal must have balanced nutrition.<br /><li> Food is something I eat when I get hungry.<br /><li> Every meal should be a celebration.</ol><br /><br />M) If you were on a restrictive diet and lost 25 pounds, which of the following describes how you would most likely reward yourself?<br /><ol><li> I would sign up for a lesson with a personal trainer, yoga, or buy myself some exercise equipment.<br /><li> I would buy a new wardrobe.<br /><li> I would buy jewelry or an electronic gadget I’ve been wanting.<br /><li> I would go to my favorite restaurant and treat myself to my favorite meal.</ol><br /><br />N) Throughout the day, I drink mostly…<br /><ol><li> Tap or spring water<br /><li> Sparkling water<br /><li> Unsweetened tea (sugar substitute) or black coffee<br /><li> Diet sodas or coffee with artificial sweetener<br /><li> Regular sodas, sweet tea<br /><li> Alcohol (if this was your answer, you’ve got bigger problems than weight)</OL><br /><br /><br /><br />At the end of this quiz, tally the numbers corresponding to your answers. The higher your number, the worse your habits. Best practices or habits are listed first in the answers. Below, we discuss these topics, one by one.<br /><br /><br /><br /><br /><br /><br />Answers Explained: <br /><br />A ) For people trying to lose or maintain weight, it is generally considered better to eat small, frequent meals or snacks than one or two meals a day. Studies which look at body composition find that people who eat less frequently to diet, may lose the same amount of weight as people who eat more frequent meals, but the frequent eaters lost more fat and retained more muscle than those who eat infrequently. Also, if you go longer without food, your basal metabolism slows and you convert more of the calories you do eat into fat. Also, if you skip meals you may be hungrier by the time you do eat, and then you are more prone to over-eating. <br /><br />B) Weight loss is simple. If you consume more calories than you burn, you will gain weight. If you eat fewer calories than you burn, then you will lose weight. The speed of your weight gain or loss depends on how many more or how many fewer calories you consume during the day. If your metabolism is 1500 calories and you eat 2000 calories per day. You will gain a pound of fat in 7 days. It takes an excess of 3500 calories to gain a pound of fat. It takes a deficit of 3500 calories to lose a pound of fat. If you count calories and see that you are averaging 1500 calories a day and your weight is not budging, then it’s likely that your metabolism is right around 1500 calories per day. Counting calories can help you gauge your metabolism. <br /><br />C) There are data to show that people who pay with cash, are more likely to make healthy choices for their food. First, they are less likely to order the larger items (with more calories) on the menu. Instead, they are more likely to opt for smaller portions, and skip dessert, or a second glass of wine. People have a harder time parting with cash, and no one wants the embarrassment of running out of it. So, you generally eat smarter and/or less. <br /><br />D) Fast eaters tend to consume 200 more calories per meal than slow eaters. 200 extra calories per day translates into nearly 21 pounds in a year. Not everyone who is a fast eater will gain 20 pounds in a year, but they tend to fluctuate up and then have to work their way back. If you are a fast eater, put your fork down between bites. Take a sip of water between bites. You’ll eat less. Since it takes 5-15 minutes to feel full, you give extra time to have that sensation catch up with you. <br /><br />E) We don’t advise buying movie popcorn. In one study, people given small bags of popcorn vs large bags, estimated they at the same amount. However, the people who had the large bags actually ate significantly more without realizing it. In other words, the larger the bucket, the less accurately you are at judging how much you actually ate. <br /><br />F) Just like going to a restaurant, people who shop for food with cash, tend to make healthier choices. They are also less likely to make impulse purchases. Impulse purchases are rarely things like broccoli and more likely bugle horns or other tasty / fatty treats. <br /><br />G) This is the best way to eliminate impulse shopping. Impulse shopping tends to result in poor food choices. Make a healthy list and stick to it. <br /><br />H) The development of diabetes correlates to how much TV a person watches during the average day. The number one cause of diabetes is weight gain. Unless you’re watching on a stationary bike or treadmill….. TV is not good for the waistline.<br /><br />I) Data show that people who eat in front of the TV are more likely to consume more calories than if they at the same food at a table. Because you are distracted, if you eat from the bag, then you really have no idea of how much you actually ate. If you must eat before the TV, make a plate and don’t refill it. Count the calories. <br /><br />J) In Japan, the average answer to this question was “When I’m no longer hungry.” Japan does not have an obesity epidemic like that in the United States. If you eat until you are full, that’s at least 200 more calories than if you ate until you were no longer hungry. Again, that’s about 21 pounds a year. Another reason to slow down and stop before you’re full. <br /><br />K) Exercise is an effective weight loss tool, though not as good as diet alone. Exercise mainly helps people maintain their weight and maintain their weight loss. People who get more than 3 hours of aerobic activity such as running, brisk walking, swimming, have much lower rates of diabetes, hypertension and obesity. They also have less time for TV. They sleep better. They look better. (These are, of course, generalities, but they hold true for the average.)<br /> <br />L) “Live life to the fullest.” This seems to be the message from many food and drink commercials on TV or in print. We’ve come to expect that part of living life to the fullest is having a fabulous meal, with good company. Too often in our busy days, food is one of the only rewards we have time for. But if you are overweight and don’t feel good about your body, can you really say you’re living life to the fullest? Would you trade feeling better all day, for the small burst of fulfillment of a decadent meal? I think most of us would prefer to feel good all day, than to have a small burst of enjoyment followed by regret. <br /><br />M) Rewards that promote healthy lifestyles are better than rewarding yourself with the things that got you in the shape you didn’t want to be in. Also, if you make exercise a reward, you are more likely to do it than if you regard it as a chore. <br /><br />O) Drink 64 oz of water daily. Do it. You need it. It’s good for you. Carbonated beverages, even diet ones, can lead to weight gain because they cause your stomach to release a hormone that stimulates appetite. High sugar drinks are generally just empty calories.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-45114995188399563412012-02-16T09:46:00.006-08:002012-02-17T06:49:45.473-08:00Weighing in on hCG as a Weight Loss Tool<strong>Miracle Drug or Snake Oil?</strong><br /><br />Flipping through several women’s magazines and magazines which have had specials for women, I have been amazed to see that most weight loss clinics are promoting hCG as a weight loss tool.<br /><br />I don’t know if they really believe hCG is effective for weight loss, or if they are just responding to public demand for it.<br /><br />Currently, I have not seen any randomized controlled trial which shows that hCG augments weight loss, except in a subset of patients…. men with low testosterone.<br /><br />Proponents of hCG was a weight loss tool almost always say a variation of the same thing: <strong>hCG is the hormone of pregnancy and diverts mom’s calories to the baby. Some also say it curbs appetite.<br /><br /></strong>Let’s explore this for just a minute. Where is the data that supports these claims? If hCG is diverting colories to the baby, that would mean there needs to be a baby for hCG to work.<br /><br />Think about it this way. Think of calories as dishes on the countertop of your kitchen. You clean up your kitchen by putting the dishes into the cabinets.<br /><br />Now think of the dishes as calories and the cabinets as the baby and you as the hCG. How are you (hCG) going to put the dishes (calories) in the cabinet (baby) if you don’t have any cabinets (baby)?<br /><br />In other words, without a baby, hCG does not have a place to divert those calories to. So the main mechanism touted makes no sense.<br /><br />Now, I am not an expert in hCG, but I have spent years studying it, mainly as a hormone of pregnancy, as a fertility drug and as a way to boost testosterone. So let me tell you how hCG might work, if it works at all, as a weight loss enhancer.<br /><br />Before I go further, I must emphasize that hCG plus diet has not been shown to cause more weight loss than diet alone.<br /><br /><strong>Physiology:<br /></strong><br />hCG is a hormone secreted by pregnancy.<br /><ol><br /><li>In pregnant women hCG’s the only definitively known function is to increase the<br />amount of progesterone secreted by the ovary.<br /><li>Ovarian progesterone is what keeps a woman pregnant for the first 7 weeks of pregnancy.<br /><li>After that, the placenta makes enough progesterone to maintain the pregnancy.<br /><li>Other affects of hCG is that it may enhance a baby boy’s testosterone production to help it develop normally.<br /><li>hCG is also thought to cause nausea.</li></ol>How could these natural affects lead to weight loss? Well, if it induces low-grade nausea, some people might eat less. I have yet to hear a proponent of hCG say this is a feature of the treatment.<br /><br /><strong>Pharmacology:<br /><br /></strong>When used as a drug, hCG does have other purposes and this holds the key to how it is possible that hCG may one day be shown to be a weight loss enhancer. I emphasize might, because no one has shown that it’s effective.<br /><ol><br /><li>hCG is structurally similar to the hormone LH. In both men and women, LH increases testosterone production. <br /><li>Testosterone can have positive and negative effects. If it’s too high, women can get facial hair or balding. Men can accelerate balding. <br /><li>Testosterone is an anabolic steroid that promotes muscle mass.<br /><li>If muscle mass is created, a person would likely burn more calories due to a higher metabolism.<br /><li>hCG is commonly used in the fertility setting to promote ovulation. One potential side affect is cyst formation in women.</li></ol><br /><br />It is possible that hCG does augment diet. If it increases testosterone and therefore increases lean muscle, someone who loses 20 pounds may lose more fat but keep more muscle. Since muscle weighs more than fat, it is possible that that people who take hCG (while they weigh the same as those who don’t) are actually leaner.<br /><br />It is essential to point out that this is just a theory! No one has yet to show this in a study. It is quite probable that even if this could be true that it might take a high dose of hCG to accomplish this. Higher doses would much more likely be associated with unintended side effects such as increased facial hair and hair loss.<br /><br />With so many clinics now offering this therapy, I think it is time for one of them to actually do a well-designed double blinded study (in which neither the doctor or the patient knows if the patient is getting hCG) and see if weight or body composition is different. Only if hCG leads to more fat loss and preserves muscle, could we endorse this treatment.<br /><br />Until it's proven to work.... we will not recommend it, as many other diet plans have been shown to be safe and effective.<br /><br />One unintended consequence of the explosion of this diet's popularity is that it has driven up the price for hCG for fertility patients. We don't like that either, but if the diet ever is proven to work, we won't begrudge it.<br /><br /><br /><br /><br /><br /><br /><br /><p></p></li><br /><br /><br /><br /><ol></ol>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-30615769041807768882011-12-07T09:52:00.000-08:002011-12-07T10:09:10.260-08:00The Terrible Gift<p><strong>Terrible Gifts</strong><br />Sometimes we may have even given them, either on purpose… or worse, by accident. We’ve also received them on purpose… or worse, by accident.<br /><br />Several years ago, knowing my brother was very much an avid hiker and camper, I bought him a present which was both utilitarian and stylish. The gift was comfortable and when you put them on, you looked like you were ready to tackle Mount Everest without breaking a sweat. I knew he would love them. In fact, I was a bit reluctant to give them away.<br /><br />Yet, when my brother opened his present on Christmas Eve, for the first time, I saw the gift through his eyes… he didn’t view them as the thrilling gateways to adventure and exploration. All he saw was socks. Wool socks. Green, with red stripe.<br /><br />At that point, I could almost read his mind…. Is this a joke? What are you kidding? Thanks, brother. What’s next year’s gift, underwear?<br /><br />The fact that he later wore the socks, liked the socks, loved the socks, did not (and to this day does not) stop him from reminding me that this was possibly the lamest Christmas gift he ever received.<br /><br />Of course there are worse gifts (in the eye of the beholder), both accidentally and intentionally:<br /><br /><br /><br /><blockquote><br /><br /><li>Taco Rob once got neon red Argyle socks. (So, brother Benson, I don’t feel so badly.)<br /><br /><br /><li>Jeremy got a Tickle Me Gizmo (the Gremlin).<br /><br /><br /><li>For a full year, for all occasions, people saw fit to give me unicorns. I got two more today.<br /><br /><br /><li>My friend, Kip, received ladies underwear from his brother Danny.<br /><br /><br /><li>Kip’s brother Danny once received a Star Trek t-shirt. Too small to wear.<br /><br /><br /><li>My buddy, Doug, got a magenta (his word) hand-painted of Elvis.<br /><br /><br /><li>Our embryologist, Shan, got a Heineken indoor grill from a cousin who got freebies through his work at a distributor.<br /><br /><br /><li>Nicky, our andrologist, got Mariah Carey’s <a href="http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dpopular&field-keywords=rainbow#/ref=nb_sb_noss?url=search-alias%3Dpopular&field-keywords=mariah+carey+rainbow&rh=n%3A5174%2Ck%3Amariah+carey+rainbow">Rainbow</a>.<br /><br /><br /><li>My buddy Matt, laments receiving “The Audacity of Hope” – by Barack Obama (Knowing Matt, this was probably given intentionally).<br /><br /><br /><li>Jeff Scotchie (Jessica’s husband) got stuck with “<a href="http://www.amazon.com/Dont-Hassel-Hoff-David-Hasselhoff/dp/0312371292">Don’t Hassle the Hoff</a>” from Shan’s husband, Neal.<br /><br /><br /><li>My buddy Ted received a used Chinese wok.<br /><br /><br /><li>My friend Andrew got a $5 check from a great-great aunt with instructions to purchase a new “bonnet”.</li></blockquote><br /><br /><strong>So What’s the Point?</strong><br /><br />It was once said of James Michener, author of epic best-sellers like Hawaii, Alaska and Tales of the South Pacific, that it took him 50 pages just to say “hello”. If you’ve read my blogs before, you know I sometimes take a while before I get to the point.<br /><br />Well, here we are again at the Christmas season, possibly the worst time of year for most patients suffering from infertility. They face this season knowing that they won’t have the opportunity to buy a toy for a child and to see the happy expression that toy brings or even the disappointment a bad gift brings. They fear they never will have that chance.<br /><br /><strong>Last year, I wrote a blog about <a href="http://trmbaby.blogspot.com/search?updated-min=2010-01-01T00:00:00-08:00&updated-max=2011-01-01T00:00:00-08:00&max-results=5">how to cope with the holidays</a></strong>. Rather than rooting around in the cumbersome blogspot, I’ve provided a link here, if you’re interested in reading it.<br /><br />But this year, I want to focus on the terrible gift of infertility. It is terrible because it ushers so many opportunities for sadness and a sense of loss. It is the loss of a life that never was. It is terrible because the feelings it brings are often inescapable and frequently come without warning. It is terrible because it makes others frequently feel like they can’t speak to you about all the joys they experience with children and family – it can make friends censor themselves around you.<br /><br />But I want to remind you of just one thing. Though terrible, infertility is still a gift. Only people who have been through war together know what kind of bond that can bring. While the war may have been terrible, the bond is the gift. Infertility may or may not be what is intended for you for the rest of your life. But it is a gift for now. It is a gift because it is an opportunity to build a bond with your spouse, and to help you understand those who are suffering with greater clarity.<br /><br />I remember back when my wife and I had failed several IVF cycles. We could not get pregnant because of an issue with her fallopian tubes. I remember a time in my greatest sadness, thinking that if only, if only, if only…. If only I had married someone else, this curse would not have befallen me. I remember rolling that thought around in my mind, kneading it and shaping it until I finally realized that my love for my wife was so much greater than my need for a child. This terrible gift tested and strengthened my devotion to my wife.<br /><br />Though terrible, it is also a chance of you to deepen your understanding that we live in a broken world. While there is great joy, within the world and our own community and even amongst our friends there is often great suffering and tribulation. We all know the world is not fair, but we don’t live like we understand that. Really the best we can do is to make the best of the gifts we receive, no matter how terrible they are.<br /><br /><br /><br /><br /><blockquote></blockquote><br /><br /><ul></ul>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-74288957479661823012011-11-16T10:45:00.000-08:002011-11-17T07:50:22.512-08:00Don't Let Me Be Misunderstood!What do cheese-filled pizza crusts, The Mona Lisa, Valentine’s Day, being your high school’s most likely to succeed all have in common? They are all highly valued by some people and deemed overrated by others.<br /><br />This is not much unlike our friend Progesterone, or P4, if you prefer a chemically accurate rap name.<br /><br />P4, or Prog, as it is sometimes called, is one of the most measured and misunderstood, over and under estimated hormones that ever came into world of medicine.<br /><br />While it is true that progesterone is important (indeed essential) to maintain a pregnancy, what is not commonly known is how little progesterone is actually required. In our experience, too much emphasis is placed on progesterone.<br /><br />Part of this is our fault. By our fault, I mean the Reproductive Endocrinology Community (REI) as a whole. Years ago REI practitioners wrote papers and chapters in Ob/Gyn text books saying that a progesterone of 10 ng/ml was evidence of a high quality ovulation. This number was easy to remember and this factoid has been passed down through the ranks of Ob/Gyns in training and has essentially become “common knowledge.”<br /><br />But this common knowledge has mutated over time. It’s like the childhood game of telephone where someone whispers something in ear of the person next to them, and the information is propagated down the line until the last person in line says what they heard. The first person says corn flakes, and it gets ultimately gets changed to something like, “Monkey Diaper.”<br /><br />Well, that has happened with progesterone.<br /><br />Today, if a progesterone is <10, some people think ovulation has not occurred at all! This is not always true. Far from it. In fact, long ago, it was known that any progesterone greater than 3 was consistent with ovulation. In fact, after ovulation, progesterone levels can vary every 90-120 minutes from 2 ng/ml all the way up to 40 ng/ml. If you measured near the bottom, you may be told you didn’t ovulate! <strong>So Why Do Dr. Murray and Dr. Scotchie Measure Progesterone?</strong> <strong>And why do they give progesterone to some women?</strong> Why to measure progesterone:<br /><br />Reason Number One: Mainly we at TRM do it to confirm ovulation. Any level greater than 3 tells us that a woman did indeed ovulate. A low level (like 4) either means we caught it when it was just reaching a valley rather than a peak, or that the woman just ovulated, or that she’s just about to have a period. If she doesn’t have a period in 3-4 days, we can frequently check another level and often it’s at a high level.<br /><br />Why to measure progesterone: Reason Number Two: Sometimes progesterone can tell you about the viability (survivability) of a pregnancy. Assuming a woman is not taking progesterone supplements, in pregnancy a progesterone less than 5 ng/ml is nearly always abnormal. Conversely, a progesterone >23 ng/ml is almost always viable and in the uterus (not ectopic, or tubal). Unfortunately, in most early pregnancies, progesterone levels will be between these two values.<br /><br /><strong>When should progesterone be measured?</strong> Ideally progesterone should be measured at its peak. For most women, this occurs 7 after ovulation and around 7 days prior to menses. If a woman conceives, the hormone of pregnancy causes progesterone to rise throughout pregnancy. This is why high levels are frequently seen in pregnancy.<br /><br /><strong>Why do we give progesterone to some patients?<br /><br /></strong>IVF: We routinely give progesterone after in vitro fertilization (IVF). During IVF, we frequently give drugs which make it more difficult for the ovaries to make progesterone. Also, when we get the eggs out of a woman, we remove some of the cells that make progesterone. If we didn’t give progesterone to IVF patients, approximately 10% would lose a normal pregnancy.<br /><br />IUI: We routinely give progesterone after intrauterine insemination (IUI). There is some evidence that progesterone a few days after IUI may promote pregnancy. There are lots of reasons this may be true, but we don’t really know why this is the case.<br /><br /><strong>What about patients with recurrent pregnancy loss?</strong> Progesterone supplements have not been shown to decrease the chance of miscarriage, only to delay the diagnosis of miscarriage. In other words, a pregnancy can quit growing, but the progesterone we give can mask the miscarriage.<br /><br />That being said, just because studies have not shown that progesterone prevents loss, this does not mean that there is a woman who would not benefit. It may take giving progesterone to several hundred women to prevent one loss. Since progesterone has no known negative effects on pregnancy, and since it’s relatively cheap, I educate patients about the studies, but do prescribe it for those who want it. This way, the patient never has to wonder what might have happened if they had taken progesterone.<br /><br /><strong>In pregnancy, how long should my progesterone level be followed?</strong> In almost all cases, as soon as a heart-beat is seen, further progesterone measurements are not useful. The heartbeat can be seen as early as 5 weeks and 6 days. In natural pregnancies, at 7 weeks the placenta will make all the progesterone needed for a woman to stay pregnant. Even if you removed the ovaries and stopped all progesterone, the women won’t have an increased risk of miscarriage! How do we know this? A study was actually done that showed this!<br /><br />We routinely give our IVF patients progesterone until around 8 weeks of pregnancy, one week beyond this critical week. If a patient wants to stay on longer, fine. No harm should come from it, but it’s not needed.<br /><br />Measuring progesterone levels at this point are pointless. If the placenta can’t make enough at this point, then the placenta won’t be good enough to support the pregnancy and the patient would miscarry anyway.<br /><br />We would argue that progesterone levels measured after 7 weeks, especially if a woman is taking progesterone as a medicine, these levels are providing no real useful information.<br /><br />What if my doctor measures my progesterone and it is low… What should I do? This is a common situation patients face. The question is, what does “low” mean? If a woman is pregnant and progesterone is low… say 5 or less, giving progesterone supplements will not save the pregnancy. Progesterone is more likely a reflection of what’s going on and not a cause. It’s like looking at a car that has been in a wreck. You can see the dents in the body, but just by looking, you may not see that the engine has also been damaged.<br /><br />If the engine is damanged…. Or in pregnancy, if the embryo is abnormal…. Fixing the exterior of the car may make it look pretty, but it won’t make it run better….. Same with an embryo….. If the progesterone is low, this means the embryo is not doing well…. And you can’t fix and embryo with a hormone.<br /><br /><strong>As you can see….<br /></strong><br />There are many pitfalls to measuring progesterone and many ways to misinterpret the levels. Outside of IVF, there is no evidence that progesterone replacement is helpful.<br />In conclusion, Progesterone, P4, Prog is important. It is essential for pregnancy. We encourage any patient or doctor to contact us about questions regarding progesterone.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-43828037816248707512011-09-26T14:21:00.000-07:002011-09-29T07:07:33.747-07:00Does my thyroid matter? - By Dr. Jessica Scotchie<a href="http://www.trmbaby.com/common_conditions/common_conditions.shtml">There are many causes of infertility and recurrent pregnancy loss</a>. Often the <a href="http://www.trmbaby.com/fertility/fertility_testing.shtml">tests performed by Tennessee Reprodictive Medicine</a> are screening tests to guide further investigation or treatment. Thyroid dysfunction is one condition that may affect our patients.<br /><br />The thyroid gland is a small gland located in the neck, responsible for making thyroid hormones which help regulate metabolism. Thyroid dysfunction is very common, affecting up to 10% of the population at any given time. In general there are two forms of dysfunction: decreased thyroid hormone production (hypothyroidism) and increased thyroid hormone production (hyperthyroidism). Underactive disease, or hypothyroidism, affects 2-10% of individuals, and occurs 5-8 times as often in women than men. Overactive disease, or hyperthyroidism, is less common, affecting 1-5% of individuals. With both forms of thyroid disease, women are affected far more commonly than men (5-8x more often).<br /><br />The symptoms of thyroid disease are easily recognized, but are also commonly seen in other disease presentations and among healthy individuals. Hypothyroidism presents with weight gain, fatigue, cold intolerance, hair loss, constipation, muscle aches, and difficulty concentrating. Hyperthyroidism often presents with weight loss, tremors, hair loss, anxiety, irregular heart beat (palpitations), and sweating. Both underactive and overactive disease can result in menstrual irregularities in women.<br /><br />Most thyroid diseases are caused by autoantibodies against components of the thyroid gland. Antibodies are molecules made by our immune system to fight infection; in the case of auto-antibodies, our immune systems mistakenly make molecules to fight a part of our body that the immune system should recognize as a normal part of the body. The end result is organ damage, which either causes decreased thyroid hormone production (hypothyroidism) or increased hormone production (hyperthyroidism).<br /><br />How do we screen for thyroid disease? <a href="http://www.trmbaby.com/welcome/our_staff.shtml">Physicians</a> will generally start with a thyroid stimulating hormone level (TSH). The TSH hormone is made in the pituitary gland (in the brain) and is sent to the thyroid gland to tell it to make thyroid hormone (think of the accelerator in your car). The thyroid then makes thyroid hormones (T4 and T3) which circulate back to the pituitary gland; the pituitary gland then recognizes that there is sufficient circulating T4 and T3 and keeps the TSH in a normal range (think of a feedback loop). When there is too little thyroid hormone, the pituitary should respond by increasing the TSH level (as if stepping on the accelerator harder to make the car go faster), therefore underactive thyroid disease typically presents with an elevated TSH level. In contrast, if there is too much thyroid hormone, the TSH is usually suppressed, because the high levels of T4 and/or T3 have signaled back to the pituitary that there is no need for TSH to keep signaling for more T4 and T3 to be made (think of the accelerator being pushed as hard as possible, there would be no need for you to push harder to go faster). There are other conditions in which this relationship is not as straightforward as just described, and for this reason it is important to rely on your physician to correctly interpret hormone results.<br /><br /><a href="http://www.trmbaby.com/treatments/infertility_treatments.shtml">How do we treat thyroid disease?</a> For the two abnormalities described previously, the goal is to restore the thyroid hormone levels back to normal. For hypothyroid disease, we replete the patient with thyroid hormone. Usually after about 4 weeks of treatment the TSH level is rechecked and the dose adjusted until the TSH is in a normal range. For hyperthyroid disease, treatment options include medications to suppress thyroid production (propylthiouracil and methimazole), radioiodine ablation, and surgical removal of the thyroid. The optimal treatment can be decided with your physician. There are other causes of thyroid diseases (tumors, cancer, nodular goiter) that are treated differently and beyond the scope of this blog.<br /><br />You may be asking yourself, <a href="http://www.trmbaby.com/welcome/do_I_need_fertility.shtml">why does a fertility specialist care about the thyroid</a>? The answer is normal thyroid function is critical for normal menstrual function and for optimal pregnancy outcomes. Hypothyroidism has been associated with increased risks of miscarriage, pre-eclampsia (blood pressure disease in pregnancy), and low birth weight babies. Untreated hypothyroidism can also result in mental deficiencies in children, which in the most severe form is known as cretinism. Some women do not have overt hypothyroidism, but have mild lab abnormalities that we would call subclinical hypothyroidism (high TSH but normal thyroid hormone levels). Subclinical hypothyroidism has also been associated with higher rates of miscarriage.<br /><br />Hyperthyroidism is also associated with adverse outcomes, including pre-term delivery, pre-eclampsia, maternal heart failure, low birth weight babies, and miscarriage. Fetal hyperthyroidism can also occur as a result of maternal autoantibodies passing through the placenta, and causing fetal goiter (enlarged thyroid) which in severe cases can affect the mode of delivery.<br /><br />Clearly, avoiding these complications is critical and generally easy to do by closely monitoring a woman’s TSH level and adjusting thyroid medications to keep the TSH level in a low-normal range (ideally < 2.5 mIU/ml in pregnancy). Women with hypothyroidism typically require increased doses of levothyroxine in pregnancy due to the expanding plasma volume that occurs in pregnancy. Women with hyperthyroidism are usually treated with oral medications, as radioiodine cannot be used during pregnancy.<br /><br />The big central controversy with thyroid disesae at the present time is whether or not to screen all women who are trying to conceive or newly pregnant. We clearly know that overt over- and underactive thyroid disease is bad. We don’t have solid evidence that subclinical disease poses the same risk, or that treating women with subclinical disease improves these possible risks. There are two main professional societies that regularly review available medical evidence and make recommendations on practice guidelines for physicians. The American College of OBGYN currently does not recommend universal screening, on the basis that there is insufficient data to suggest that treating subclinical hypothyroidism improves obstetric outcomes. The Endocrine Society tends to lean more towards liberal screening, however they also do not recommend universal screening. They instead recommend screening any women with the following characteristics:<br /><br /><br /><blockquote>1. Infertility.<br />2. History of miscarriage or preterm delivery.<br />3. History of any thyroid dysfunction, or a family history of thyroid dysfunction<br />4. Presence of a goiter (enlarged thyroid).<br />5. Known thyroid antibodies.<br />6. Symptoms suggestive of disease as outlined above.<br />7. Type I diabetes.<br />8. Presence of other autoimmune diseases.<br />9. Prior head or neck radiation.</blockquote><br /><a href="http://www.trmbaby.com/">Most of the patients we see are infertility and recurrent pregnancy loss patients. </a>In our professional opinion, due to the fact that treatment for thyroid disease (especially hypothyroidism) is generally well tolerated and has few risks, we feel that the benefits of treatment outweight the risks of treatment, and therefore screen most of our patients trying to conceive with a TSH level.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-44751493776702669962011-09-20T06:30:00.000-07:002011-09-20T06:35:55.192-07:00Meet Shan<p>This is Shan Wilkinson, the embryologist at Tennessee Reproductive Medicine. I was picking on Dr. Murray the other day about how long it has been since his last blog post. He assured me he has done research about his next topic, but he’s still trying to wrap it all up in a nice little blog-package. He then suggested I write my own post to which I laughed, but then I thought I might have a few things to say.<br /><br />While trying to figure out how to format what I wanted to say, I thought about the weekly Monday Morning Quarterback article by Sports Illustrated writer Peter King. I am a football fan, especially the NFL and specifically the New Orleans Saints (you might remember, they won the Super Bowl) and I like the way King finishes his article with his “Ten Things I Think I Think” section. So, here we go:<br /><br />Ten Things I Think I Think<br /><br />1. I think handling 10,000+ cow embryos prepared me for culturing human embryos. It allowed me to learn quickly and to evaluate morphology to help choose the best embryo(s) for transfer.<br /><br />2. I think handling 10,000+ cow embryos did not prepare me for the emotional investment of “human IVF”. While I’ve been blessed to work in labs with above average pregnancy rates and while I celebrate each positive pregnancy, I think the negatives are difficult to overcome – you should see all my gray hairs! On my way to work one day I heard a verse on our local Christian radio station (J103) that sums up what we do. It is Romans 12:15 “Rejoice with those who rejoice; mourn with those who mourn.” There are many tears shed here for our patients, some of joy and some of sorrow.<br /><br />3. I think I work for really good doctors. They are both smart and compassionate and hold each other to the highest standards. Our patients have different reasons for choosing the doctor they want to see (male/female, etc.) and some just want the first available appointment, but I believe all patients are in the hands of personable physicians with high morals.<br /><br />4. I think it’s very difficult for me to make the leap from the ball of 8 to 150 cells in the dish to the baby that a patient brings in to visit after delivery. And if the embryo had been frozen it’s even harder for me to wrap my head around. I am blessed to do what I love to do in a place where I am appreciated. I hope to do it for a long time and I hope I will always make the right decisions to improve the laboratory to help our patients achieve their goals and realize their dreams.<br /><br />5. I think TRM is a great place to work. I’ve worked in both small and large clinics before and morale can be a problem in any size practice. We have a great group of employees who honestly care for one another without any gossip or jealousy. As all of our job duties become more involved and our work schedules grow, we have to look to each other for support and encouragement.<br /><br /><br /><blockquote>a. Our office manager works many hours to ensure things are running smoothly and always is available to employees.<br /><br />b. Our nurses see our patients more than they see their families and they always have a kind word and are ready to explain what this shot is for or what those initials mean. We use a LOT of initials around here!<br /><br />c. Our front desk/billing ladies are some of the best at what they do. They give patients a face behind the voice on their initial visit and their behind the scenes work helps the office run more efficiently.<br /><br />d. Our surgery scheduler is brave! After working for many years with the “elder” Dr. Murray, she now works a couple of days with his son, our Dr. Ringland Murray and his partner Dr. Jessica Scotchie. And despite the fact she spends most of her time talking to insurance companies (I think most people would rather have a root canal), she’s always smiling.</blockquote><br /><br />6. I think most people I meet have never heard of an embryologist. When asked what I do I say I’m an embryologist. When they say “A what?!” or ask what that is I explain that I put eggs and sperm together in a dish and grow embryos which the doctors transfer and which hopefully become babies. Most people are fascinated and some think it’s a little weird, but almost everyone knows someone who has needed help getting pregnant.<br /><br />7. I think I cannot tell the difference between X and Y sperm. While I have been accused of choosing more Y sperm than X, there are no differences at the morphological level. If I could select X or Y sperm, we’d probably have a lot more patients and I’d probably make a lot more money.<br /><br />8. I think almost every male partner is nervous and/or embarrassed by what they are asked to do. It’s normal to be nervous, especially when Dr. Murray is the only other male in our office, but it really is commonplace to us. Humor helps.<br /><br />9. I think infertility sucks. I have friends and family members who have been affected by infertility and it is heart wrenching. And while some of them can get pregnant with the help of IVF (60 to 70% of women less than 35), it’s a fact that not everyone will get pregnant, including my friends and family members.<br /><br />10. I think these are my non-embryology thoughts of the blog:<br /><br /><br /><blockquote>a. My husband is a saint for following me around the country for the last 15 years. I hope the next 15 years (and the 15 after that) we stay a little more rooted.<br /><br />b. I love living in Chattanooga. We were walking downtown the other day after enjoying some popcorn and ice cream at a Lookouts game and I just really had a sense of feeling at home.<br /><br />c. I could eat ice cream every day if I had less willpower and more money. I crave ice cream at least once a day.<br /><br />d. I love my church. In a city with so many transplants, it’s nice to establish a church home where there are people you can count on to do life with you. www.christwaychurch.org<br /><br />e. I’m so glad Chattanooga finally got a Red Robin! We used to go to one after our trips to Hershey Park when we lived in Pennsylvania.<br /><br />f. Coffeenerdness: I don’t drink coffee. Although the Mocha Frappe’ at McDonald’s is really good, I don’t think it really counts as coffee more like dessert. I do, however, love a good hot chocolate. If I’m at home I’ll heat up milk on the stove and add either Christopher Elbow’s Cocoa Noir (www.elbowchocolates.com) or Valor Chocolate a la taza. If I’m at work, I make due to with hot water, Swiss Miss Dark Chocolate Sensation, and a couple of squares of Dove Dark chocolate melted in the cup.<br /><br />g. I’m from Slidell, Louisiana, and yes, my parents’ house did flood during Hurricane Katrina. I know a lot of people are tired of hearing about the storm and now that the 5 year anniversary is approaching they’re going to hear more about it. However, if you or anyone you know was affected by it, you know that time along the Gulf Coast has been divided between before Katrina and after Katrina.<br /><br />h. I spend a lot of time searching for the perfect dark chocolate truffle. One of my favorites is the Velvet Sin from Chocolate Fetish in Asheville, NC. Well, now Chattanooga is home to a very good chocolatier named Wendy Buckner, owner of The Hot Chocolatier. Her Oatmeal Stout truffle (made with Oatmeal Stout from the Terminal in downtown Chattanooga) rivals the Velvet Sin. She is awesome, her shop is great, and wait until you see her chocolate sculptures! www.thehotchocolatier.com</blockquote><br /><br /><p></p>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-84381682456867105902011-06-07T08:00:00.000-07:002011-06-07T08:00:09.925-07:00An REI’s Bad Language - The T Words, The Q WordThere are a lot of extreme words out there. Some words, or in some instances, are so extreme that they’re referred to only by their first letter. For example: the L word, is an example of a nice word (Love), as is the M word (Marriage). The D word (Divorce) is usually not so nice. Please don’t ask me to elaborate further on examples of the bad extreme words.<br /><br />In the world of REI, we have our own examples of this. The T word is one. (Really, we could have two T words.) We also have two Q words. Who knew we’d have an O word? Together, we can refer to them as the M words, or multiples.<br /><br />My first experience with a Q word was in residency. I had the great pleasure of taking care of a courageous and committed young lady who was about 26 weeks pregnant (full term is 40 weeks). She was hospitalized, on bed rest, with <em><strong>quadruplets - the lesser Q word.</strong></em> <a href="http://www.trmbaby.com/images/blog/triplet_stroller.jpg"><img style="FLOAT: right; MARGIN: 0px 0px 10px 10px; WIDTH: 239px; CURSOR: hand; HEIGHT: 204px" alt="" src="http://www.trmbaby.com/images/blog/triplet_stroller.jpg" border="0" /></a><br /><br />She was in the hospital in an effort to prevent preterm delivery at home. She had a short cervix and frequently had contractions. Her physicians had placed a cerclage (sewn her cervix shut) to help prevent preterm delivery. She had received steroid injections. Her day consisted of daily heparin injections (blood thinners), twice daily ultrasounds to look for heartbeats, and a laborious trip to the chair next to her bed maybe once or twice a day. She had to sit in the shower and spent most of her time on her computer, watching movies, reading books, but generally feeling miserable.<br /><br />She had worked so hard to get pregnant and had failed several attempts in the past leading her physicians to get progressively more aggressive with her treatment until she made up for lost time and cycles grouping 4 pregnancies into one. I don’t know who was more worried about her, me or her. I did not help her get pregnant, but felt very obligated to try to keep her pregnant as long as possible. I was usually the first person she saw in the morning and the last doctor to see her at night.<br /><br />I can’t tell you how many false alarms we had over the next few weeks. We were frequently rushing to her room to check on her or bringing her to labor and delivery to try to stop the contractions. She finally went into labor for real around 32 weeks. It was the fastest Cesarean section I think I ever did. Four babies in under two minutes. Each baby was taken to a different corner of the room and tended to by expert neonatal intensivists and nurses. We filled the nursery quickly that day.<br /><br />She would be in the hospital for 3 days after her delivery, but her children would remain for up to 8 weeks later, in the intensive care unit.<br /><br />She had a good outcome. Her babies were born healthy and progressed through infancy without many significant setbacks. The last time I saw her was about 6 months after delivery. She was pushing a ridiculously long stroller that was about 5 feet long and contained four seats, for four babies.<br /><br />At that point, she was not yet out of the woods. There was still time for lifelong problems to arise, even if she had escaped the immediate complications of preterm delivery.<br /><br />My next encounter with one of the M words was when I took my first job out of fellowship, in Memphis.<br /><br />On a hot summer day in 2006, I pulled up to the Memphis Children’s Museum with my wife and child in tow. We were parking when I first saw the sign at a parking spot near the entrance. At first I thought it was just a joke, then I saw the next sign and thought maybe it was an indictment.<br /><br />The first sign said, Triplet Parking. <a href="http://www.trmbaby.com/images/blog/tripletsonly.jpg"><img style="FLOAT: right; MARGIN: 0px 0px 10px 10px; WIDTH: 353px; CURSOR: hand; HEIGHT: 266px" alt="" src="http://www.trmbaby.com/images/blog/tripletsonly.jpg" border="0" /></a><br /><br />The second, Quadruplets Parking.<br /><br />Since I had just taken the job at Memphis’ only fertility clinic, I worried exactly what in the heck was going on in that city that would prompt a children’s museum to even need such signs.<br /><br />Did a lot of out-of-towners with triplets and quadruplets travel to Memphis to go to the children’s museum?<br /><br />Did the clinic where I had just taken a job have so many triplets and quads that it was actually altering parking practices at local businesses?<br /><br />Or was there a rogue doctor, shooting up fertile women with fertility drugs so that there would be an abundance of children?<br /><br />I was quickly reassured to learn that triplet pregnancies were very rare at the practice in Memphis and that there weren’t other doctors prescribing fertility shots to women…. So I settled on the idea that the museum was trying to be cute and serve a relatively rare need.<br /><br /><a href="http://www.trmbaby.com/images/blog/quadsonly.jpg"><img style="FLOAT: right; MARGIN: 0px 0px 10px 10px; WIDTH: 353px; CURSOR: hand; HEIGHT: 266px" alt="" src="http://www.trmbaby.com/images/blog/quadsonly.jpg" border="0" /></a> In truth, the triplets and quads parking are sort of like handicapped, expectant mother, or senior citizen parking seen at some businesses and churches. They give assistance to people who might need a little more time, or find it a little more onerous to get from the car to the front door.<br />So where am I going with this? I’m not sure…. I had the pictures and wanted to print them, but I really should talk about the perils of multiple gestation.<br /><br />I know, I know, most people reading this would never set out to try to have triplets, quadruplets, or octuplets. But the truth is, a high number of fertility patients actually want twins. Most people appreciate a bargain, and when they have to pay out of pocket for fertility treatments, two for the price of one sounds like a good deal.<br /><br />I have to remind my patients and myself that twins are a high risk pregnancy. With twins, the average duration of a pregnancy is only 36 weeks (four weeks short of term). This means a considerable number will deliver much earlier. The earlier the delivery, the more likely a child will experience life-long complications such as cerebral palsy or chronic lung, eye, or gastrointestinal problems.<br /><br />The rate of cerebral palsy is 0.1-0.2% in singleton pregnancies, but rises to 1.2-1.3% in twins and up to 4.5% in triplets.<br /><br />With triplets, average delivery occurs at 32 weeks with approximately 90% being preterm. And preterm delivery is not always the result of preterm labor. Many other complications can arise which might cause a doctor to have to deliver a baby before the baby is ready to be born. Due to competing space within the uterus, some babies may not get the blood flow required for growth and they can be small. If one of the babies becomes ill or if they stop growing in the womb, a woman has to decide if she needs to deliver all the babies to save the sick one.<br /><br />The higher rates of diabetes (high sugar), preeclampsia (high blood pressure), premature rupture of membranes (water breaks), placental abruption (separation of placenta from uterus) can all lead to the need to deliver these babies early.<br /><br />Babies born very prematurely frequently are hospitalized for weeks to months in an intensive care unit and face too many perils to be listed here. The earlier the birth, the more likely they are to suffer lifelong consequences. The immediate and long-term medical costs and time required for follow up can put a strain on relationships. Once in a grand rounds lecture, an authority gave the staggering statistic on triplets, saying that more than 80% of parents of triplets ultimately get divorced. I have not been able to find a credible reference with that high a number. Not all data shows that high of a rate, as reported <a href="http://www.mostonline.org/facts_divorcesurvey.htm">here</a>. While no study to date has looked at this adequately to say with complete authority what affect multiples have marriage, patients should realize that there can be considerable strain on a relationship.<br /><br />So how do we prevent multiples?<br /><br />Avoidance is the key.<br /><br />Many people think <a href="http://trmbaby.com/in_vitro/ivf_basics.shtml">IVF</a> (in vitro fertilization) poses the greatest risk for multiples. This is not true. While there are many things which influence the risk of multiples, using<a href="http://trmbaby.com/treatments/superovulation.shtml"> injectable gonadotropins</a> can cause a woman to release multiple eggs. The physician may have little control of how many of these eggs fertilize and result in pregnancy.<br /><br />Very rarely do we get more than twins with IVF. In IVF we can control how many embryos are placed in the uterus. ASRM has published guidelines on the number of embryos to transfer in IVF. Adherence to these guidelines will help practitioners avoid high order multiples (triplets or more) and minimize the risk of twins. To see ASRM guidelines, click <a href="http://trmbaby.com/in_vitro/getting_started.shtml">here</a>.<br /><br />One strategy employed to decrease the risk of multiples is to grow embryos out to the blastocyst stage. In the past, physicians routinely transferred embryos at the cleavage stage (three days after fertilization) when embryos are generally made up of around 8 cells. Top quality day 3 embryos have about a 30% chance of resulting in a pregnancy. Some day three embryos will stop growing after day 3. So if we wait two more days, frequently we can see which of the embryos has the greatest potential to make a baby. By waiting until day 5, we can place fewer embryos back into the uterus and theoretically reduce the risk of twins, triplets and more.<br /><br />At TRM, we encourage women with good quality blastocysts (day 5 embryos) to transfer a single embryo to maximize the chance of a singleton. The down side to blastocyst transfer is that it seems something in the culture system may increase the risk of identical twins! This is a slight increased risk, but not insignificant.<br /><br />If you want further proof that even elective single embryo (eSET) transfer can’t prevent multiples from occurring, consider the case of an Iowa woman who did IVF, had an eSET and was discovered to have 7 babies implant. Presumably, she conceived 1 through the embryo transfer, but due to the fertility medications and the fact that she had intercourse, she conceived multiple others on her own at the same time. The lessons learned from this case were: 1) don’t have intercourse during IVF if your tubes are open, 2) this lady probably didn’t need IVF in the first place.<br /><br />The bottom line is that it is very difficult to maximize the pregnancy rate and minimize the multiples rate at the same time. This can be especially true if we rush people into IVF.<br />Selective reduction, or elimination of embryos within the womb has been used by some patients to decrease the risks associated with high order multiples. Such a procedure requires placing a needle into the uterus and either stopping the fetal heart with potassium, or cutting the umbilical cord.<br /><br />Many patients would never consider selective reduction under any circumstances. Others thought they would be able to reduce, but after seeing a baby’s heartbeat, the reality of what they are doing sinks in and it is too much for them to do.<br /><br /><strong><em>It is my opinion, a patient’s stated willingness to undertake selective reduction should never influence the medical decision of how many embryos to place in the uterus or how to proceed with therapy.</em></strong> Because some patients are so desperate to achieve pregnancy, because some just don’t believe it can actually happen, some patients will want more embryos than recommended. If a physician decided to be more aggressive because a woman said she would consider selective reduction, then the patient may wind up in a situation that places her and her babies at risk.<br /><br />Finally, the nature of health insurance is to blame for some patients wanting to be aggressive and increasing their risks of multiples. Because of the expense of treatments, many patients cannot afford more than 1-2 treatment cycles of any kind. This causes them to want to maximize their chances of pregnancy with each treatment, especially in what they deem as their last treatment. These kinds of pressures can lead to bad decisions and pressures to be more aggressive than recommended.<br /><br /><strong>Concluding Thoughts</strong><br />Will we ever eliminate the increased risk of multiples in fertility treatment? It’s not likely.<br /><br />Until insurance pays for fertility care, economic forces will drive couples to aggressively pursue a positive pregnancy test and accept the risk of multiples. In fact, insurance companies should probably pay for IVF (where the number of embryos transferred can be controlled) more readily than they pay for injection-IUI (where the number of eggs released is not always controlled).<br /><br />Doctors have a fairly equal incentive to maximize their clinics pregnancy rates. Therefore they may risk pushing patients to IVF who don’t need it. They may also have incentives to place more embryos into the uterus to keep those rates high.<br />Singletons could be maximized by mandating single embryo transfers on day 3 (at the cleavage stage), but we must be willing to accept lower pregnancy rates.<br /><br />Alternatively, if we are able to improve blastocyst culture to reduce the risk of identical twins, an elective single embryo transfer on that day would increase pregnancy rate without increasing multiples. Embryo biopsy may in the near future maximize the chance of a viable singleton, but this procedure is not quite ready for prime time.<br /><br />The bottom line is: things need to change. And I think things can and will. Technology needs to change. Patients need to change and doctors need to change. I will do my best to educate patients on the risks and benefits of their choices, and I will still grant patients autonomy in the choices they make. Together, I believe we can minimize the extremes and get the Q words out of our vocabulary, and most of the T words, too.<br /><br />(Now that I've written this, hopefully, we don't have a patient turn up with high order multiples. I fear writing about this would be similar to working in the Emergency room and saying "everything is so slow tonight" and then the avalanche of patients hits.)Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-43133875058698456752011-05-30T08:00:00.000-07:002011-05-30T15:59:58.335-07:00There Is Always Something To Worry About - Part 3<p>How to Get Pregnant and Have a Healthy Pregnancy<br /><br />Step 3 – Getting Pregnant<br /><br />When I meet an infertility couple, the first things I want to know are the age of the woman, her past reproductive history and how long this couple has been having intercourse without contraception. I’m generally not as interested in how long they’ve been “trying” to get pregnant. The reason I say this is because if couple has been “trying” to get pregnant for 6 months but have not used any form of birth control in six years, then they have 6.5 years of infertility. Their prognosis is frequently much worse than another couple who quit birth control 12 months ago and is not pregnant.<br /><br />If you have not used birth control in 1-2 years and are not pregnant, call and make an appointment today to be seen by your provider or by us at 423-876-2229. If you are still truly in the early stages of trying to get pregnant, please continue to read.<br /><br /><strong>Areas of Concern<br /></strong>When we give talks about getting pregnant, we frequently discuss 6 areas of concern: duration of infertility, adequate intercourse, adequate ovulation, adequate sperm, anatomy and ovarian reserve.<br /><br />Of the six areas of concern, three are essential to conception and these are: a woman must produce an egg (ovulation), the man must have sperm, and the sperm and the egg must be able to meet (adequate anatomy.<br /><br /><strong><em>Adequate Intercourse<br /></em></strong>Many couples who are trying to conceive fixate on exact timing of intercourse, when in truth exact timing is not particularly important. What is essential is that a couple has intercourse on, or prior to, the day of ovulation. Sex on a single day of the month has virtually the same chance of pregnancy if the sex occurs on the day of ovulation, the day before ovulation or even the day before that. Sperm can live up to 5 or 6 days and still fertilize. This means, for most couples, intercourse every 2-3 days is adequate.<br /><br />Intercourse 24 hours after ovulation has a very low chance of pregnancy. After ovulation, the egg lives only about 12-24 hours. So make sure you have sex prior to ovulation if you want to conceive.<br /><br />Ideally, adequate intercourse would mean satisfactory intercourse for both partners. Unfortunately, for the purpose of getting pregnant, it really only has to be satisfactory for the male – as he must deposit sperm into his partner. Female orgasm has no significant role in fertility. I know, it’s not fair.<br /><br /><br /><strong><em>Adequate Ovulation<br /></em></strong>Ovulation (producing an egg) is essential to getting pregnant. Most women who have regular predictable menses are ovulating. Ovulation is even more likely in regularly cycling women who reliably predict their menses because of breast tenderness or bloating or mood changes that precede the menses by a few days. Ovulation can be confirmed various ways, with basal body temperatures, ovulation predictor kits, or even a blood test. Ovulation is generally deemed adequate when the luteal phase is 11 days or longer based on basal body temperature charts or 12 days or longer based on ovulation predictor kits. For more details, click <a href="http://www.trmbaby.com/fertility/testing_women_ovulation.shtml">Ovulation</a>.</p><br /><p>Normal menstrual cycles are between 24-35 days. Shorter cycles frequently mean a woman’s ovarian reserve is declining and should be evaluated. Longer cycles can mean a woman is not ovulating and also should be evaluated.<br /><br /><strong><em>Adequate Sperm<br /></em></strong>If a man has any sperm, it is possible to get pregnant; however, once sperm counts go below 15 million per ml, the chances of pregnancy can plummet significantly. Of course, we don’t recommend home sperm testing, because there are many facets of sperm which may affect fertility. Because it is a painless test, this should be the first test sought by a couple.<br /><br />If there is a history of frequent sauna or hot tubbing, significant testicular trauma, testicular surgery, undescended testicle, prior radiation or chemotherapy, low libido, erectile dysfunction or low volume ejaculations then a more immediate evaluation should be pursued.<br /><br /><strong><em>Adequate Anatomy<br /></em></strong>The fallopian tubes serve as a transit system for sperm and eggs. When a woman ovulates, the tube picks up the egg and holds it there for sperm to fertilize. For their part, the sperm are deposited in the vagina and have to swim through the cervical mucus, up through the uterus and out to the tube. Only 1 in a million sperm will eventually make it to the egg with intercourse.<br /><br />□ If the cervical opening is small or scarred due to prior surgery it may not produce the needed cervical mucus which assists in the transport of sperm.<br />□ If the tubes are blocked, the egg and the sperm cannot meet.<br />□ If sheets of adhesions (scar tissue) separate the ovary from the tubes, getting pregnant can be a real challenge.<br />□ If benign tumors such as fibroids are growing in the uterus, this may prevent a pregnancy from taking hold.<br /><br />Women with infertility for more than 1 year should have an x-ray called a hysterosalpingogram performed. For more details, click on <a href="http://www.trmbaby.com/fertility/testing_women_HSG.shtml">HSG</a>.<br /><br />Endometriosis, a condition in which uterine lining grows outside the uterus, can sometimes distort the anatomy. Even when it doesn’t distort the anatomy, endometriosis can make getting pregnant more difficult. If you are just starting to get pregnant and you have a history of endometriosis, ask your physician if yours is so severe that you should do something about it. We’ll talk more about endometriosis and fertility in a future post. For more information now, click <a href="http://www.trmbaby.com/common_conditions/endometriosis.shtml">Endometriosis</a>.<br /><br /><strong><em>Ovarian Reserve<br /></em></strong>This is the biologic clock. The best predictor of the biologic clock is a woman’s age. By age 35, nearly 30% of women will be sterile. By age 40, nearly 70% will be sterile. In a study of women who never used any birth control and stayed married their entire lives, the last average pregnancy occurred at age 42. Many of these pregnancies ended in miscarriage because the embryos have a higher rate of being abnormal the older women get.<br /><br />The biologic clock, or ovarian reserve, is determined by several factors: how many eggs a woman had at birth, how much damage has occurred to her ovary or eggs throughout her life, and how quickly she has lost her eggs.<br /><br />Smoking, ovarian surgery, radiation and chemotherapy can all lead to premature depletion of eggs. Genetics can also cause early loss of eggs. We find that many women with unexplained infertility and with endometriosis have findings consistent with diminished ovarian reserve.<br /><br />A sign that ovarian reserve is decreasing is a shortening of the menstrual cycle. Women who were regularly menstruating every 28 days, may find themselves having cycles every 24 days. This can be evidence of diminished ovarian reserve. The same goes for women who had PCOS and who never or rarely ovulated on their own who suddenly find themselves having normal menses.<br /><br />If you have any of the risk factors above, strongly consider having your physician, or us, evaluate your ovarian reserve.<br /><br />For more information click on <a href="http://www.trmbaby.com/common_conditions/diminished_ovarian_reserve.shtml">diminished ovarian reserve</a>. </p><br /><br /><br /><br /><p>If you have questions on any of the topics listed above, call us and make an appointment, visit our website: <a href="http://www.trmbaby.com/">http://www.trmbaby.com/</a>. </p>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com1tag:blogger.com,1999:blog-8685367863184341468.post-63179898860952765922011-05-18T10:09:00.000-07:002011-05-26T04:31:19.117-07:00There Is Always Something To Worry About - Part 2<strong>How to Get Pregnant and Have a Healthy Pregnancy</strong><br /><br /><strong>Step 2: </strong><a href="http://www.trmbaby.com/fertility/preconception_counseling.shtml"><strong>Preconception Counseling</strong></a><br /><br />Informing your obstetrician of your intention to get pregnant is advised. He or she can tell you what the risks of pregnancy are for you, given your past medical history. Prior to pregnancy, your pap smear and breast examination should be up to date.<br /><br />Vaccines: Chicken pox can be devastating to a baby and fatal to a pregnant woman. If you have no history of chicken pox and never received the vaccine, your doctor should test you to see if you are immune. Prior to pregnancy, the chicken pox vaccine can be administered and very effectively reduce the chances of infection during pregnancy.<br /><br />Rubella (which causes German Measles) can also harm a pregnancy. Just because you had a vaccine once (or twice) does not mean you are immune. Rubella testing can tell you if you are at increased risk for German Measles. If you are not immune, you may receive a two dose booster to induce immunity.<br /><br />Neither the chicken pox or Rubella vaccine should be given during pregnancy, therefore, testing and vaccination prior to conception are advised.<br /><br />Genetic testing: Your doctor should determine if your ethnicity or family history places you at increased risk for having a baby with a genetic disorder. If a known genetic disorder runs in your family, you may be at increased risk for having a baby with that disorder. Frequently, testing can be done to screen for that disorder in an individual patient.<br /><br /><strong>Groups at high risk for genetic disorders include:</strong><br />Women who are 35 years old when they deliver: While the risk of having a baby with Down Syndrome or other chromosomal abnormality is never zero, the risk does increase with age. At age 35, the risk of having a baby with a chromosomal abnormality is greater than the risk of losing a baby from amniocentesis (test for the abnormality), so counseling is advised.<br /><br />African Americans: approximately 1 in 12 carry the trait for sickle cell disease.<br /><br />Caucasians: approximately 1 in 25 carry the trait for Cystic Fibrosis.<br /><br />Ashkenazi Jewish: are at increased risk for multiple diseases including Tay Sachs, Canavan, Neimann-Pick, Blood Syndrome, Fanconi’s Anemia, Familial Dystautononemia, BRCA mutations and many other diseases and syndromes.<br /><br />Families with a history of Autism or mental retardation should consider testing for Fragile X Premutation.<br /><br />For more information preconception testing, see: <a href="http://www.trmbaby.com/fertility/preconception_counseling.shtml">http://www.trmbaby.com/fertility/preconception_counseling.shtml</a><br /><br />If you have questions on any of the topics listed above, call us and make an appointment, or visit our Facebook Page.<br /><br /><br /><br />Coming next: How to Get PregnantDr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-89999367098025102982011-05-18T10:07:00.000-07:002011-05-25T05:34:58.696-07:00There Is Always Something To Worry About - Part 1<strong>How to Get Pregnant and Have a Healthy Pregnancy<br /><br /></strong>For many people, how to NOT get pregnant is the most important question relating to <a href="http://www.trmbaby.com/">fertility</a>. Yet when the time comes to start a family, the anxiety can shift to the opposite camp and <a href="http://www.trmbaby.com/welcome/do_I_need_fertility.shtml">people begin to worry if they CAN get pregnant.</a><br /><br />If you are in the early stages of trying to get pregnant or are thinking about getting pregnant in the near future, there are some things that you can do to optimize your chances of getting pregnant and of having a healthy pregnancy. <a href="http://2.bp.blogspot.com/-GD2gQiS-Zlc/TdRx_DOf9eI/AAAAAAAAAFA/gbzytNg0lWA/s1600/IMG_0891.JPG"></a><br /><br /><strong><span style="font-size:130%;">Step 1:</span></strong> <strong><em>Optimizing your health before you get pregnant<br /></em></strong><br /><strong>Fitness:</strong> Women with a normal body weight prior to pregnancy have lower rates of pregnancy complications including diabetes, pre-term delivery and preeclampsia. Women who are physically fit also have lower rates of cesarean section. Three hours of aerobic exercise per week should be the minimum goal of any woman trying to get pregnant.<br /><br />If you are morbidly obese (BMI 40), you are at increased risk of many pregnancy complications including birth defects such as heart malformations and spina bifida. Alternatively, if you have been underweight and not ovulating or if you have been taking steroidal medications for a long time, you may be at increased risk of osteoporosis and of experiencing bone fractures during pregnancy.<br /><br /><em><strong>Nutrition:</strong></em> Women who are deficient in folic acid or other B vitamins have an increased risk of neural tube defects (or spina bifida). At a minimum, a woman should supplement her diet with 400 mcg, ideally 800 mcg daily.<br /><br />It is also becoming apparent that Vitamin D is important in many aspects of health and pregnancy. Vitamin D is also important for bone health. Fish and sunlight are good sources of Vitamin D. The daily recommended intake of Vit D is 600 IU daily, which means many people need to take a supplement.<br /><br />In general, a healthy diet will contain the RDA recommended nutrients and consist of 1200-1500 calories per day (depending on the weight of a woman).<br />> <a href="http://www.trmbaby.com/welcome/WebPearlsJan09weightloss.pdf">See more regarding weight and fertility</a><br /><br /><strong>Smoking:</strong> Smokers and women married to smokers have lower monthly pregnancy rates. Smokers more frequently have small for gestational age babies.<br /><br /><strong><em>Alcohol: </em></strong>Even modest alcohol consumption has been shown to decrease pregnancy rates and increase miscarriage. In the <a href="http://www.trmbaby.com/in_vitro/in_vitro_fertilization.shtml">IVF</a> setting, 1 drink per day has been associated with both lower pregnancy rates and higher miscarriage rates. In natural populations heavy alcocohol consumption is associated with high estrogen levels in women and this can impair egg growth and has been shown to cause a woman to stop ovulating.<br /><br /><br /><strong><em>Caffeine:</em></strong> More than 300 mg of caffeine per day has been associated with miscarriage. Next time you're at Starbucks check out the caffeine dose in a Grande coffee - 330 mg.<br /><br /><br /><br /><br /><p><strong><span style="font-size:130%;">Summary: </span></strong></p>A bad lifestyle is not birth control. So if you don't want to get pregnant, I wouldn't count on drugs, alcohol and cigarettes to save you. On the otherhand, if you are young and fit, a non-smoker, who doesn’t drink or have any medical problems then you’re off to a good start, but this does not mean you will be fertile. It doesn't even mean you are nutritionally ready to conceive. In our next post we will discuss preconception counseling and the labs that are advised prior to conception.<br /><br />If you have questions on any of the topics listed above, call us and make an appointment, or visit <a href="http://www.facebook.com/group.php?sid=b1829df0e3cc7c011672f677600da434&gid=110068611109&ref=search">Tennessee Reproductive Medicine's Facebook Page</a>.<br /><br />Coming Next: Preconception Counseling, then How to Get PregnantDr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-43913916009095877802011-05-18T08:11:00.000-07:002011-05-18T18:35:58.477-07:00Fertility Testing At Home - Ovarian Reserve TestsOvarian reserve is basically another phrase for the biologic clock.<br /><br />Younger women generally have more eggs and more of those eggs are normal, compared to older women. Women who have gone through menopause generally have no normal eggs remaining and they cease to ovulate. Between normal ovarian function and menopause, there is a state called diminished ovarian reserve.<br /><br />Women are born with 1 – 2 million eggs and every day of a woman’s life she is losing eggs. Some women are born with fewer eggs, some women lose them more quickly, and some women accumulate damage in their eggs more rapidly than others and they develop diminished ovarian reserve.<br /><br />Women with diminished ovarian reserve frequently have a more difficult time getting pregnant.<br /><br />Genetic predisposition is one cause of diminished ovarian reserve, so premature menopause in a relative should alert women to the possibility that this can occur in them. Other causes include smoking, ovarian surgery (such as the removal of a cyst).<br /><br />A sign that ovarian reserve can be decreasing is if a woman's menstrual cycle begins to shorten betweeen periods. If a woman has always menstruated every 28-30 days and starts to menstruate every 24-26 days, this can be a sign of diminished ovarian reserve and should be evaluated.<br /><br />Now women have the choice of testing ovarian reserve through their physician, or in the privacy of their own home through urine test kits that are used much like a home pregnancy test.<br /><br />The kits range in price from under $4 to nearly $100, and they test for a hormone called follicle stimulating hormone (FSH) on or around menstrual cycle day 3. FSH is what makes eggs grow. It’s like the gas pedal to the ovary. Like a well tuned car does not require someone to mash hard on the gas pedal to get up to speed, the normal ovary only requires a little FSH to ovulate. If the FSH is high, then the ovary is not working well and the woman has diminished ovarian reserve.<br /><br />The inexpensive kit costs around $4 per test and is available at <a href="http://www.early-pregnancy-tests.com/fsh-tests.html">http://www.early-pregnancy-tests.com/fsh-tests.html</a> . This kit detects the equivalent of an FSH of 25 mIU/ml, which is consistent with infertility and possible menopause. A normal test is when the FSH is below 25 mIU/ml. The problem is, women are generally infertile when FSH exceeds 17 mIU/ml.<br /><br />A more sensitive kit by Genosis Ltd, called Fertell, can detect FSH levels of 10 mIU/ml, which is consistent with diminished ovarian reserve. Fertell has recently become unavailable in the United States, but may be purchased on line. A normal test is when the FSH is below 10 mIU/ml<br /><br />The problem with both tests is that they only measure 1 hormone, FSH, which by itself can be meaningless. To know if the FSH is valid, an estrogen level must accompany it.<br /><br />If a woman has a normal test it can be falsely normal (because estrogen is elevated prematurely – as can be seen in women with diminished ovarian reserve. See Pitfalls of Day 3 FSH Testing at: <a href="http://www.trmbaby.com/welcome/WebPearlsDec08FSH.pdf">http://www.trmbaby.com/welcome/WebPearlsDec08FSH.pdf</a> .<br /><br />So a normal test does not mean the woman has normal ovarian reserve.<br /><br />An abnormal test can be falsely abnormal, too. During the midcycle, many women will bleed due to a temporary drop in estrogen associated with ovulation. If the woman thinks this is her period, she might measure FSH at an inappropriate time. If a woman measures her FSH during the midcycle, the FSH is normally high and might trigger a positive test.<br /><br />So either way, these tests need to be confirmed by a doctor. This is the best way to avoid false alarms and false reassurances.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-77979314383764940582011-05-11T07:56:00.000-07:002011-05-11T08:08:15.364-07:00Fertility Testing At Home: Home Sperm TestingOver the past few years more and more fertility tests have become available for home use. This month one of the leading journals in the fertility world, <em>Fertility and Sterility</em>, published a very nice review of many of these home tests. Coincidentally, I just gave a talk about many of these tests and thought I would share my thoughts about them.<br /><br />For the sake of time and space, I’ll tackle these one at a time. Today, we’ll talk about home sperm testing.<br /><br />Before we get there, let me give some background.<br /><br />The idea of home testing fits a definite need among consumers. It’s nice to be able to learn that you’re pregnant without making a doctor’s appointment. It’s also nice to identify problems early, if that leads to evaluation and effective treatment.<br /><br />The problem with a lot of tests on the market is that they can be falsely reassuring and may cause some people to delay proper evaluation. There is no good evidence that performing such tests actually improve a couple’s chance of conception. A patient without a history of <a href="http://www.trmbaby.com/common_conditions/common_conditions.shtml">infertility</a> is most likely wasting their money. On the other hand, if a couple has not conceived within 1-2 years of unprotected intercourse, I’m not sure that any home test is particularly reassuring.<a href="http://www.trmbaby.com/welcome/do_I_need_fertility.shtml"> A falsely reassured patient may delay treatment and therefore is at risk for not meeting their reproductive dreams.</a><br /><br />Several years ago after hearing a story about home fertility testing on NPR’s All Things Considered, <a href="http://www.npr.org/templates/story/story.php?storyId=10712488" target="_blank">http://www.npr.org/templates/story/story.php?storyId=10712488</a> I wrote a letter describing some of the pitfalls to such testing. <a href="http://www.npr.org/templates/story/story.php?storyId=10819112" target="_blank">http://www.npr.org/templates/story/story.php?storyId=10819112</a><br /><br />The two tests described where a semen test and a test to measure a woman’s FSH, marketed under the name Fertell (Genosis Ltd).<br /><br />The Fertell sperm test can determine if a man has 10 million total motile sperm and is sold for close to $100. The advantage of this test is that many men are embarrassed to have a formal semen analysis performed. Also, the test determines the motile concentration, which is fairly predictive of normal fertility. Recently, the World Health Organization (WHO) published findings showing that 95% of fertile men had a sperm concentration of 15 million sperm/ml and 32% were progressively motile and 5% or more had a normal shape. A reassuring Fertell tests should correlate well with 2 of those 3 parameters. If abnormal, the test should lead a man to have further testing performed.<br /><br />The drawback to the Fertell sperm test is that it does not test morphology, which can be very important. The cost is also a drawback. For an additional $50, <a href="http://www.trmbaby.com/male_infertility/male_infertility.shtml">a patient can have a full semen analysis at our clinic</a> and have it interpreted by a <a href="http://www.trmbaby.com/welcome/our_staff.shtml">physician</a> who can interpret the results in the context of the couple.<br /><br />Other home semen tests are also available. Embryotech has marketed several tests FertilMARQ, Start Male Infertility Test and PreConceive: A Male Fertility Sperm Test, all of which purport to evaluate sperm concentration. Because it tests only a single parameter (concentration), it tells nothing about motility or morphology. A man with few or no moving sperm may be falsely reassured. (As with the Fertell test, an abnormal result should be followed up with a visit to a physician’s office.)<br /><br />There are also small microscopes available: <a href="http://www.amazon.com/Micra-Sperm-Test-Count-Motility/dp/B000SLM504" target="_blank">http://www.amazon.com/Micra-Sperm-Test-Count-Motility/dp/B000SLM504</a>. The disadvantage of this test is that interpretation is left up to the patient. As with all home testing, the disadvantage to the home microscope is that there is no one with clinical experience to interpret the test in the context of the couple.<br /><br /><a href="http://www.trmbaby.com/welcome/our_facilities.shtml">One of the tenants of good medical practice is to treat the patient, not just the test</a>.<br /><br />As I said above, a normal test does not mean that all is well. A person without infertility may find this test reassuring; however, this person probably doesn’t need the test in the first place. A full semen analysis gives significantly more information than any of these tests. <a href="http://www.trmbaby.com/welcome/first_visit.shtml">A couple with infertility is probably better off having a medical evaluation by a knowledgeable physician</a>. However, if the only way to get a man to get tested is with at an at home test, I would pick Fertell since it gives the most information with the easiest interpretation.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-51566433522992962352011-05-06T09:29:00.000-07:002011-05-07T05:12:50.333-07:00It’s a Mother of a DayThis week some of our patients have had some good news about their pregnancies and this Mother’s Day may be like no other. For them, this will be a joyful occasion, a day many of them never expected to have.<br /><br />However, some of our patients and friends have had crushing news and are not yet pregnant, or are grappling with the possibility of never having a child. I know of others who have recently lost a child or a parent. I can’t imagine the sorrow a day like Mother’s Day may bring for them.<br /><br />I can count my blessings for now, as both my wife and I still have our parents and we have our children. We can still celebrate this day with all the people who have been a part of our lives.<br /><br />It is my hope and my prayer for all of those who are suffering a loss…either loss of what never or has not come to pass, or the loss of a parent or a child…can find a path to peace.<br /><br />I well remember those Mother’s Days, waking next to my wife, when we were childless. It is a certainty that I felt sadness and fear. But I can tell you this: the sadness I felt was shared. It seems strange to say, but sharing a burrowing sadness was somehow comforting to me. The fact that I shared it with the person whom I loved more than any other person on the planet somehow made the sorrow not only bearable, but good.<br /><br />My wife and I shared a sorrow. It was a sorrow wrapped, enveloped in a deep love…which in the end felt like a form of gratitude.<br /><br />So this weekend, this is my wish for all of us, in case anyone has forgotten…. May you all have peace in your hearts and be grateful for your shared sorrow, cherish the ones you love, whether they are here or not. Cherish the Mother you were, the Father you were, or the one you could have been.<br /><br />If you have lost a child or a parent, honor them by living a life which pays tribute to them.<br /><br />It’s the rarest elements in nature that are valued so dearly. The time we have together here on earth is so small, so fragile and so very precious. We never know exactly what we will be given, or how long we will have it. I think we should all be thankful for what we have been given, no matter how briefly. If we have been given less, or have suffered loss…it is my hope that we can all appreciate even the small gifts as what they are….precious and rare.<br /><br />This world contains enough sorrow that no one will ever go wanting for it. May we all recognize joy, too, and let it overflow from us and into others around us. If you know someone who is in the depth of sorrow and can’t find a way out, may you help to bring them peace.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-78158398343359387482011-05-02T08:17:00.000-07:002011-05-02T08:18:03.310-07:00True Love May Last Forever, But Fertility Does NotWhen it comes to fertility, we frequently find that our patients take their lead from celebrities. Too often, this has a negative impact on our patients. We see Hollywood starlets, senators’ wives, and TV personalities having children in their mid-to-late 40s or even early 50s, and we are left with the impression that fertility is lasts longer than it actually does. Sadly, as we have said before, many of these pregnancies are achieved through egg donation (using a younger woman’s egg to get pregnant), but the general public is not really aware of this.<br /><br />Lately, we’ve had a new couple to watch, a couple to remind us about the choices that face all of us who are lucky to find our true love. The couple is Prince William and his bride, Kate Middleton. The choice is: when to start a family.<br /><br />I came across a nice little article by Dr. Manny Alvarez, who had some advice for this couple. And by extension, it applies to many couples. <br /><br />(See the article here: <a href="http://www.foxnews.com/health/2011/04/27/kate-middletons-pregnancy-plan/">http://www.foxnews.com/health/2011/04/27/kate-middletons-pregnancy-plan/</a> )<br /><br />Dr. Alvarez correctly points out that Kate’s fertility will be on the decline from this point on. He advises her to try to conceive soon, rather than wait. Of course, from a medical perspective, he’s correct. <br /><br />But life is about balance and, for many of us, the trick is to know what decisions to make to maximize our chances of future happiness.<br /><br />Most of us dream about finding true love. We dream of all that comes with it. We will be secure. We will be complete. We will have children and we will watch them grow. We will be happy. <br /><br />But most newly married couples do not want to have children right away. They want to have time on their own to consolidate their married life together, to grow accustomed to the changes this brings. Adding a child immediately into the mix can place a couple under financial strain, time constraints and emotional fatigue that can interfere with the initial bonding between the couple. <br /><br />In the case of Prince William and Kate Middleton, I’m not sure we could concoct a more story-book modern day romance. Kate, the commoner (a term we don’t use in the US), marries a prince and becomes a princess. The presumption is that she will also become a mother and chances are good that she will reach this goal without any assistance from me or any other infertility specialist.<br /><br />I hope they do have a story book life.<br /><br />But if I were in Kate and William’s shoes, would I follow Dr. Alvarez’s advice and try to have children right away?<br /><br />That would depend on my goals, I guess. I frequently ask patients to project themselves into their early to mid 40s and picture themselves childless. From that vantage point I ask them to look back on their lives and reflect, to the best of their ability, what choices do they wish they had made when they were younger.<br /><br />If the life they spent growing together fuels their happiness, perhaps that is more important. If not having children is a devastating thought, perhaps they should begin just as soon as they are ready.<br /><br />Either way, this decision is to be considered carefully. Think about the pitfalls of each choice, about each direction. Think about how you will deal with those pitfalls ahead of time. Talk about them as a couple. Have a plan for what you will do if things don’t work out as planned. Agree with each other about how you will treat the other person if things don’t work out as planned. Agree to remain flexible as, sometimes, we can all change our minds.<br /><br />As for Will and Kate? It’s the same as I have for any couple. I wish them a storybook ending no matter whether it was the ending they planned, or not.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com1tag:blogger.com,1999:blog-8685367863184341468.post-63011375108606959802010-12-08T07:14:00.000-08:002010-12-08T07:21:32.091-08:00A Christmas Carol - The Other Ghost<p>It was just before Christmas about 9 years ago. I was at the Streets at Southpoint, an indoor-outdoor mall in Durham, NC. It was a pretty mall, with a pedestrian street that was lined with stores glittering like Rockefeller Center. The bounty of the season was everywhere. The aroma of hot cider from the kiosk and the carols swelling up from the speakers disguised as rocks along the path, enveloped the crowd, bundled like they were trekking on an expedition to the North Pole itself.<br /><br />I was trying to figure out what to get my mother, my father, my brothers, my sister, and my wife for Christmas. I confess that I rarely find things at the mall which make suitable gifts; however, I’ve always taken comfort in browsing and confirming my suspicion that this was not where I wanted to make my purchases. I guess this sort of made me an outsider, in a way. While I was glad to be surrounded by the holiday cheer, I did feel a bit disconnected. If I was honest with myself, I was actually a little sad and I couldn’t put an exact finger on the reason.<br /><br />Then, as I walked down the path past a Crate and Barrel, I saw The Children’s Store. Moms and dads were bustling into and out of the store. As I stood outside the store, peering in the display window at the reindeer jumpers, elf pajamas and angelic ball gowns for little girls, I could see my reflection in the glass. Looking through my own reflection at the warm holiday interior, I began felt like a ghost: empty, vacant, barely a whisper. I felt like the Ghost of the Christmas That Would Never Be.<br /><br />For people who have lost a loved one, for those separated from their families, for those without a family, with financial woes, with illness … we all know this is a tough time of year for some people. Watching other people, happy families apparently living the life of which you’ve been deprived can seem particularly unfair, or make you feel like a failure if you’ve not achieved these things.<br /><br />This time of year can be especially difficult for people suffering from infertility. All the hopeless feelings, all the lonely feelings of isolation that infertility brings are magnified by the merriment of the season, the energy and bustle, the long lines at toy stores, by the crowds of twittering kids waiting to sit on Santa’s knee. All the holiday cheer can seem to just mock the pain of childlessness.<br /><br />To make matters worse, if you feel like you’re on the outside of all of this Holiday fun and you see someone who is apparently blessed in ways that you are not, and you hear them complain about what seem to you trivial issues of the season… it can just make you mad.<br /><br />In the end, most of us really do want to be happy. The question is, how is a person to rescue themselves from the sadness the season besets upon them?<br /><br />Few solutions are perfect, but here are some things I have tried. Here are my suggestions, and I’m open to new ideas:<br /><br />Own your feelings. Acknowledge them for what they are and ask yourself if you want them. If so, embrace them. Sometimes we need to do this first, before we can move on. It may be a miserable December, but it may be the first step to healing. </p><ol><li><strong>If you do not want these feelings</strong>, you should recognize that you may not be able to completely shake them. You may go for hours or days without the negative feelings resurfacing; however, it doesn’t mean you’ve been defeated when they do. </li><li><strong>Focus on what the season is really about</strong>, for you. In my family’s tradition, Christmas, the season is a reminder of the gifts we have received – even though we were not worthy to have received them. Because of the gift already received, the season is about giving to others. (I know we all have different backgrounds and beliefs, but I do think the spirit of the holidays, Joy and Peace, can be enjoyed by all. When I was at my lowest, and thought I’d never have a child I would pray. I did pray that we would be given a child, but more than that I prayed that I could find peace in the event that we never did.</li><li><strong>If being around children is too much for you</strong>, some people say you should avoid areas that are likely to be filled with them. I find this to be an impractical solution for many people, but you should not feel guilty for protecting yourself. </li><li><strong>Consider devoting your time to someone else in need</strong>. This can be healing for you can for them. </li><li><strong>Get plenty of rest</strong>. (Fatigue makes nearly everything worse.) </li><li><strong>Get plenty of exercise</strong>. (This makes you feel vibrant and boosts your metabolism.) </li><li><strong>Surround yourself with supportive people</strong>.</li><li><div align="left"><strong>Seek counseling</strong>. If needed. If you’ve wondered if you should get counseling, then you probably should. I know a lot of wonderful people in the Chattanooga area and can make recommendations. </div></li></ol><p align="left">For some people this year, the Christmas season is going to be something to be survived, not enjoyed.<br /><br />If this is you, plan ahead. If you need to, give me a call…. do something to help reclaim your life. </p>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com2tag:blogger.com,1999:blog-8685367863184341468.post-9871377783778739962010-12-01T18:19:00.000-08:002011-05-11T08:02:59.902-07:00The Patient I Failed<strong>Part 1: The First Digression</strong><br /><br />We doctors don’t always take failure too well.<br /><br />I’ve talked with some colleagues about this and have heard lots of good theories as to why. The arguments go something like this: To get to medical school and through medical school, residency and then fellowship training, you have to negotiate a tough series of hurdles, and for most of your training and professional life you will successfully clear those obstacles. Bottom line, doctors aren’t accustomed to failure.<br /><br />Perhaps.<br /><br />On the other hand, I’ve talked to some friends outside of medicine and I think they are only half-joking when they say something akin to: Most doctors hate being reminded they are not God.<br /><br />Perhaps that’s true, too.<br /><br />Something tells me though, that it’s more than either of those two things. First, I don’t think the hating failure is unique to medicine. No one likes failure.<br /><br />I think that’s one thing that’s so frustrating for couples with infertility. What comes so easily for some couples is so elusive, that it frequently causes one or both partners to feel like a failure, like they have let their partner down. This brings me to a key point: I think most of us can handle small failures pretty well. It’s when those failures are tied to another person, that’s when they become difficult.<br /><br />For example, kids who play sports know someone has to lose. By and large it’s the kids who feel excessive pressure to win from their parents are the ones who are bothered the most by failure. They feel like they’ve let their parents down.<br /><br />It’s particularly painful when you didn’t just let yourself down, but another person as well. I think this is the hardest part about medical failures… someone was counting on you and you didn’t deliver.<br /><br /><strong>Part II: The Second Digression</strong><br /><br />When I first began the practice of infertility, I thought most patients were going to be like me and my wife – saddened by failure, but undaunted. We had our failures, but we kept trying, even after some people encouraged us to just stop.<br /><br />In some ways, we had an advantage over most patients. Since my wife had no fallopian tubes our choice was simple: do IVF or don’t have our own biologic child. This is in contrast to a lot of patients with unexplained infertility. In those cases there is nothing to say that they can’t get pregnant on their own. While my wife and I knew for a certainty that we needed help to get pregnant, many patients don’t have that certainty and it leads to uncertainty regarding if they should continue therapy.<br /><br />These patients are at risk for quitting treatment because, theoretically, they could get pregnant on their own. Sometimes these patients will take very long breaks from treatment. Sometimes they get pregnant. Sometimes they return years later only to find out their chances of pregnancy are actually much worse.<br /><br /><strong>Part III. The patient I failed.</strong><br /><br />A few years ago, I was treating two women with PCOS. Neither woman ovulated on her own or with oral medications, so both needed injections to conceive. Each of them completed one cycle of injections and IUI (intrauterine insemination) without success.<br /><br />Both women had an excellent chance of pregnancy if they had elected to continue on their current path, but both of them were extremely frustrated by their failure to conceive.<br /><br />The first patient told me that this failure was more than she could handle. The idea of doing another cycle was overwhelming her and she said she just could not handle the stress of doing another month of treatment. She quit treatment and I have not seen her again. The sad part is, she might decide to try again one day. When she does, she’ll be much older, and her chances of success will have decreased substantially.<br /><br />The second patient also told me she couldn’t do another cycle. She said she could not handle the waiting. She asked to do IVF. I tried to reassure her that she most likely didn’t need IVF, that she was good prognosis. She could not be swayed, she’d had enough. She was determined to do IVF. So, we did IVF. She conceived. Now she has a beautiful child.<br /><br />In some ways, I think I failed both of these patients…. but I think it’s pretty obvious which patient I failed the most… the first patient.<br /><br />I failed her because I assumed that most patients would be stubborn like me and my wife. I had failed to assess her emotional tolerance and fortitude prior to recommending treatment. If I had learned this about her, I would have warned her and perhaps have offered her the therapy that would have given her a very high chance of giving her a child.<br /><br /><strong>Part IV: The Aftermath<br /></strong><br />Every patient reacts to failure differently. There are patients even more stubborn than me and my wife. But many are not. For many, the burden of the infertility is so heavy, that one failure is just too much to bear.<br /><br />Realizing this has forever changed the way I counsel my patients. These days, I do my best to warn patients that any failure will strip some people of their will, of their hope, of their emotional reserve. I alert patients to this fact. I tell them that they need to be very honest with themselves and with their partner about how much emotional and physical energy they have in their tank.<br /><br />If they are running on fumes, they should start with the therapy that gives them their greatest chance of getting pregnant.<br /><br />Ultimately, I’m fine if a patient decides to walk away from treatment, especially if they have exhausted the options which they find acceptable choices for them.<br /><br />Walking away by choice, I’m fine with that.<br /><br />It’s when a patient can’t walk back… and they’ve left viable options on the table…<br /><br />That is hard to handle. Those are people I ache for.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com1tag:blogger.com,1999:blog-8685367863184341468.post-79833776177845797172010-11-16T06:14:00.000-08:002010-11-16T07:35:52.953-08:00New World Health Organization Semen ParametersFollowing a large multi-national investigation of sperm parameters in fertile men, the World Health Organization (WHO) has changed the reference ranges used in semen analyses.[1] The new normal values are based on men who took 12 months or less to help conceive a child. Parameters above the 5th percentile are considered normal. In other words, 95% of fertile men have parameters which exceed the new WHO values. We will reflect these changes on our future semen analysis reports.<br /><br />In all cases, the new normal reference values are lower than the previous WHO reference values. However, the new WHO criteria are actually more in line with how we at Tennessee Reproductive Medicine (TRM) and Tennessee Reproductive Laboratories (TRL) have already been interpreting semen parameters.[2] <br /><br />Below are the old reference ranges, our interpreted range and the new reference range: <br /><br /><a href="http://3.bp.blogspot.com/_sfoY73BvGhE/TOKkhcOJwbI/AAAAAAAAAEs/s7mZy3OJ4S8/s1600/sperm%2Bparams.jpg"><img style="cursor:pointer; cursor:hand;width: 400px; height: 102px;" src="http://3.bp.blogspot.com/_sfoY73BvGhE/TOKkhcOJwbI/AAAAAAAAAEs/s7mZy3OJ4S8/s400/sperm%2Bparams.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5540171386037322162" /></a><br /><br /><br />As you may have noticed, the biggest difference between the new WHO value and the TRM/TRL interpreted normal range is in strict morphology. Morphology is the most subjective variable within a semen analysis, and centers may calculate it slightly differently. <br /><br />At TRM/TRL, we have not used morphology to determine what therapy to offer patients. This study and the new reference ranges specifically support this practice. For example, we do not tell patients that a morphology of 4% means that they need IVF. Rather, they should consider a special technique for fertilization if they require IVF.<br /><br />In conclusion, these new WHO criteria will not dramatically alter how we interpret semen analyses. However, we believe these new reference ranges will help more labs generate a uniform recommendation. If you have any questions about the new parameters, or if you have questions about your previous analysis, please do not hesitate to call us. <br /><br /><br /><br />1. Cooper, T.G., et al., World Health Organization reference values for human semen characteristics. Hum Reprod Update, 2010. 16(3): p. 231-45.<br />2. Guzick, D.S., et al., Sperm morphology, motility, and concentration in fertile and infertile men. N Engl J Med, 2001. 345(19): p. 1388-93.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-84914194162129983262010-10-06T19:29:00.000-07:002010-10-07T21:04:10.120-07:00Tubal Reversal verus in vitro fertilization (IVF)<strong><span style="font-size:130%;color:#3366ff;">The Burning Question</span></strong>
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<br />One of the most common questions I get asked both by physicians and by patients around the Southeast is about tubal reversal surgery compared to in vitro fertilization (IVF).
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<br />It's easy to understand why there is so much interest. Millions of women have had their tubes tied. Inevitably, if millions of women are opting for "permanent" sterilization, many of them will later regret it.
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<br />I could spend a lot of time talking about who is likely to regret this decision. There is good data on that. But I'm not writing this blog entry for women who are trying to decide among different contraceptive options. I'm writing this for the women who find themselves in the unfortunate situation of wanting another child, but their tubes have been surgically blocked, cut, burned, clipped, tied, fried (and/or all of the above).
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<br />The bottom line is there are many people who regret their decision and they always ask me the same question: which is better, tubal reversal surgery (reanastamosis) or IVF?
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<br /><strong><span style="color:#3366ff;">The Universal Answer</span></strong>
<br />One of my mentors drove a lot of residents and fellows crazy when they approached him looking for a quick answer to what they thought was an easy question.
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<br />To almost every question, his answer was, "It depends."
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<br />Then he'd launch into a 5-10 minute lecture on the pro's and con's and nuances, caveats, hard and fast rules, exceptions to those rules and so on.
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<br />I'll try not to do that to you.
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<br />If you want the short answer to this question, I'll give it to you and I'll tell you why. Just scroll to the bottom of this blog and read: <strong>"The Short Answer."</strong> But be warned, you'll miss some good stuff in between.
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<br /><strong><span style="color:#3366ff;">Critical Questions I Must Know to Answer the Question for You...</span> </strong>
<br />For me to know to best advise a patient, there are some absolutely critical questions I need answered.
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<br />1) How were her tubes sterilized?
<br />2) How old is she?
<br />3) How many more children does she wish to have?
<br />4) Does her partner have adequate sperm?
<br />5) Does she or her partner have a history of previous infertility?
<br />6) Does she or her partner have any religious barriers to IVF?
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<br />Tackling these questions one at a time:
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<br /><strong><span style="font-size:85%;"><blockquote><em><span style="color:#3366ff;"><strong><span style="font-size:85%;">1) How were her tubes sterilized?</span></strong>
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<br /><blockquote><p>In general, the less damage to the tube, the easier the repair. Some methods,
<br />such as the Filshie Clip, or the Fallope Ring create very little damage and
<br />reconnecting these is a lot easier than if the tubes were burned in multiple
<br />locations, or if large segments of the tube were resected. It can be
<br />important for a physician to see the operative report from the tubal
<br />ligation. If a lot of damaged tube has to be removed and there is not much
<br />to put back together, the chances of success are much lower. In general, a
<br />minimum of 4 cm of tube is required at the conclusion of the reanastomosis
<br />to have a legitimate shot at getting pregnant. </span></strong></em></p></blockquote></blockquote><blockquote></blockquote><em><blockquote><p><strong><span style="font-size:85%;color:#3366ff;">2) How old is she?</span></strong></p></blockquote><blockquote><em><blockquote><em><p>Older women, especially in their forties, have less time to conceive and
<br />their monthly pregnancy rates are much lower than younger women. After age 37, monthly fertility rates begin to drop rapidly. There are women at age 37 who get their tubes reversed, but if they have not had a baby in one year, then their chances of conceiving at age 38 are significantly lower. Each 6 months to a year, fertility wanes. For good prognosis patients, a single cycle of IVF is generally as successful as trying to conceive for one year on your own. In other words, you can pack a year's worth of treatment into two months.</em></p><span style="color:#009900;">Even for young women, ovarian reserve testing should be considered. This testing can tell you if your eggs are behaving their age, or
<br />like a much older woman. </span>
<br /></blockquote><p></em></em></p></blockquote><em><span style="color:#3366ff;"><span style="font-size:85%;"><strong><blockquote><em><span style="color:#3366ff;"><span style="font-size:85%;"><strong>3) How many more children does she wish to have?</strong></span> </span></em></blockquote></strong></span></span></em><span style="color:#333399;"><span style="color:#cc66cc;"><blockquote><span style="color:#333399;"><span style="color:#cc66cc;"><blockquote><p><em><span style="color:#333399;"><span style="color:#cc66cc;">A young woman who wants to have several more children spaced out over several years may be the best candidate for tubal ligation reversal.</span> </span><span style="color:#000000;">When she's not trying to get pregnant, she'll need to use some kind of birth control, but this can stop when she's ready to try again. </span></em></p><p><em><span style="color:#993399;"><span style="color:#cc66cc;">On the other hand, a woman who wants only one child, or the older woman who wants more than one child may be a better candidate for IVF.</span> </span><span style="color:#000000;">If she only want one child, we can limit the number of embryos we place in the uterus. In some cases, we only place one embryo in the uterus. Once she delivers her baby, she still has her sterilization in place.</span> </em></p><p><em><span style="color:#cc66cc;">Finally, the older woman who wants more than one child may do best with IVF.</span> </em><span style="color:#000000;"><em>In her case, we can be a little more aggressive about the number of embryos we place in the uterus, assuming she is willing chance the pregnancy will be twins. Also, if she gets pregnant and
<br />delivers a single child, she may have embryos that we were able to
<br />freeze. Months later, after birth, after she finishes breast feeding and
<br />gets through the sleep deprivation of having a newborn, she can return
<br />to clinic and use the embryos that are in storage. She will have
<br />virtually the same chance of conceiving as she did when she was a
<br />younger age.</em></span></p></blockquote><p></span></span><em>
<br /></em></p></blockquote></span></span><strong><span style="font-size:85%;color:#3366ff;"><blockquote><strong><span style="font-size:85%;color:#3366ff;"></span></strong></blockquote><blockquote></blockquote><blockquote><strong><span style="font-size:85%;color:#3366ff;"><p><em><span style="color:#3366ff;">4) Does her partner have adequate sperm?</span></em></span></strong></p><blockquote><p><span style="color:#000000;"><em>A lot of centers which specialize in tubal ligation reversals do not require a
<br />semen analysis of the male partner. I will acknowledge that in most cases, the male partner will have adequate sperm, but on numerous occasions, shortly before tubal surgery, I have found that the male partner's sample was wholly inadequate. Surgery would have put those women at unnecessary risk, with little hope of achieving pregnancy.</em></span><span style="color:#333333;"> </span><span style="color:#000000;">If a physician does not offer or recommend a semen analysis be performed, I would be suspicious that he or she was not acting in my best interest. </span></p></blockquote><p></span></strong></p></blockquote><span style="color:#3366ff;"><em><strong><span style="font-size:85%;"><blockquote><span style="color:#3366ff;"><em><strong><span style="font-size:85%;">5) Does either partner have a prior history of infertility?</span></strong></em></span></blockquote></span></strong></em></span><em><blockquote><em><blockquote><em>If so, I would carefully consider your choice. In these cases spontaneous
<br />pregnancy is much less likely and IVF would be favored.
<br /></em></blockquote></em></blockquote></em><em><span style="color:#3366ff;"><span style="font-size:85%;"><strong><blockquote><em><span style="color:#3366ff;"><span style="font-size:85%;"><strong></strong></span></span></em></blockquote><blockquote>6) Does she have religious barriers to IVF?</strong></span> </blockquote</span></span></em><em><blockquote><em><blockquote><p><em>If so, tubal ligation should be preferred. </em></p><p></em></em></p></blockquote></blockquote><p><span style="font-size:130%;color:#3366ff;"><strong>So who should you seek for advice?</strong></span></p><p>The best people to talk to are physicians who perform both procedures. They are less likely to sway you toward one over the other. They will also try to put the statistics into real clinical context to help you understand what you're getting for your time, effort and money. </p><p><strong>From them, you should get truthful statistics about real results. </strong>If you looked at a graph of how many pregnancies occur after tubal ligation reversal compared to IVF, you would probably run straight to surgery and have your tubes reversed - because in every age group, far more pregnancies are achieved per reversal than per IVF cycle (according to nationwide IVF statistics). </p><p><strong>But not so fast!</strong> If you look a little closer, you'll notice the <strong>live birth rate</strong> only barely favors tubal reversal over the average national IVF success rate. </p><p>First, what happened to all of those extra pregnancies? <strong>Many of these tubal reversal pregnancies are located in the tube.</strong></p><p>Another reason live birth rates are similar between tubal reversal and IVF is this: the statistical deck is stacked in favor of tubal reversal. That's because many tubal reversal clinics compare their success rates to "average national IVF success rates."</p><p>This is NOT a fair comparison. </p><p>Tubal reversal patients are the best prognosis patients for conception. To compare these patients to ALL IVF patients is like comparing apples to Orangutans. </p><p>Most IVF patients do not have proven fertility and voluntary sterility like tubal reversal patients do; most have multiple other more-serious fertility problems. </p><p>If you randomised these best prognosis patients to tubal reversal versus IVF, you would almost certainly see significantly higher live birth rates from IVF, with a much lower risk of tubal pregnancy. </p><strong><span style="color:#3366ff;"></span></strong>
<br /><span style="font-size:130%;"><strong><span style="color:#3366ff;">The Short Answer</span></strong>
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<br />Ok, I promised you a short answer. If you've read this far, you're probably going to think I'm just going to recommend IVF, but I'm not going to do that. See which category you are in, and this is generally what I would advise.
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<br />1) Money is scarce and you can find a cheap tubal reversal and you're willing to sacrifice some chance of success - go with tubal reversal.
<br />2) If you have religious conflicts with IVF - go with tubal reversal.
<br />3) If you are a young woman who wants several more children spread out over a number of years - go with tubal reversal.
<br />4) If you want to get pregnant but don't want to have to use future contraception - go with IVF.
<br />5) If you want just one child - go with IVF.
<br />6) If you're older and want several more children - go with IVF.
<br />7) If you want the highest chance of pregnancy, period - go with IVF.
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<br /><span style="font-size:130%;color:#3366ff;"><strong>Conclusion</strong></span>
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<br />I hope this was simple enough. There are some details, some pros and cons of each choice that I have left out of this blog post. For any individual patient, there may be additional testing I'd recommend. I didn't discuss all the risks associated with each procedure, either.
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<br />If you have questions regarding which treatment is right for you, come see us. Dr. Scotchie and I will try to help you find it.
<br />Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com2tag:blogger.com,1999:blog-8685367863184341468.post-10848298000439997102010-10-01T06:46:00.001-07:002010-10-06T19:28:58.545-07:00Second Opinions<span id="SPELLING_ERROR_0" class="blsp-spelling-error">Ok</span>, last time I posted here, I promised I'd write about how to get the most out of a second opinion. To do this, I did something a little novel - and so it took me longer than I expected. While I have pretty strong opinions on how to get the most out of a second opinion, I <span id="SPELLING_ERROR_1" class="blsp-spelling-corrected">queried</span> a lot of doctors from around the country to see what they would advise.<br /><br /><br />I have to say, overall, I was a little <span id="SPELLING_ERROR_2" class="blsp-spelling-corrected">disappointed</span>. Most of the responses were some variation of "send the patient to me."<br /><br /><br />Most advice was also not very helpful. A lot of the advise was almost opposite from the advise of other physicians.<br /><br /><br />To be fair, not all the people who responded were reproductive endocrinologists, so they may be quite in tune with the issues infertility couples face.<br /><br /><br />However, of the people I polled, there were some excellent points and issues to consider.<br /><br /><br /><strong>Why Get a Second Opinion?<br /></strong>There are many reason patients consider a second opinion. Frequently, in our field of medicine, it’s because a person did not have success with their previous provider, because they were given difficult news with few acceptable options, or simply because they did not mesh with their first provider. Sometimes, it seems some people get a second opinion because it’s just what they do… they like more than one opinion.<br /><br /><br /><strong>How to prepare for a second opinion:<br /></strong>1) First identify why you are seeking a second opinion (be aware of your agenda).<br />2) Be aware that your first and your second doctor may have an agenda, too.<br />3) Gather your records and get them to the physician ahead of time if possible.<br /><br /><br /><span style="font-size:130%;"><strong>Agendas are critical.</strong> </span><br /><br />Agendas may completely alter the advice you receive.<br /><br />First, <em><strong>the patient’s agenda</strong></em>: Almost every patient has a reason for getting a second opinion. Nearly every doctor I polled said that patients should know why they want a second opinion. If it’s because they just <span id="SPELLING_ERROR_3" class="blsp-spelling-error">didn</span>’t get the answer they were looking for from the first doctor, the patient needs to recognize this and keep this in mind when seeking a second opinion.<br /><br /><br />It has been said that the very poor and the very wealthy are at greatest risk for receiving the worst medical care. The poor have no access. The very rich can doctor shop until they find physicians who will do whatever the patient wants. Michael Jackson could always find yet another surgeon to carve him up or help him sleep. If you're just looking for someone to tell you what you want to hear, you should be aware that this can lead to sub-optimal treatment.<br /><br />My advice to patients is, to the best of your ability, don’t tell the doctor your agenda until he or she gives his opinion.<br /><br />Here is why.<br /><br />There have been many times when patients come to my office for a second opinion and it is very apparent that they simply did not like what they heard from their first physician.<br /><br />If I realize that the patient is very unhappy with the first doctor because of the opinion, I have a tremendous advantage compared to the first doctor. I already know what information, or what type of information that a patient does not like to hear. Simply agreeing with a patient’s preexisting biases may strongly influence the way the patient feels about my advice.<br /><br />I would like to think this knowledge does not influence my opinion or how I relay information to a patient. I hope that’s not wishful thinking.<br /><br />If I don’t know a patient’s agenda, then there is no opportunity for me to be influenced by this.<br /><br />Knowing which advice is the best is not always easy. These are not fool-proof clues to which advice is best, but here are my suggestions:<br /><br />*Did each doctor support their opinion, with evidence from the medical literature?<br />*Did each doctor explain the diagnosis to your understanding?<br />*Were you given a full range of options and the likelihood of each being successful?<br />*Does the doctor’s advice make sense?<br /><br /><strong>The Doctors’ Agendas<br /></strong>Dr. Deane <span id="SPELLING_ERROR_4" class="blsp-spelling-error">Waldman</span>, of the University of New Mexico Health Science Center said that physicians providing a second opinion would ideally just be providing an opinion and not be gaining financially from such an opinion.<br /><br />I frequently tell patients this, too. If a physician has nothing to gain from giving the opinion, he or she, is less likely to be influenced by his or her own gain. This kind of opinion is least likely to be biased.<br /><br />So how does the patient learn if the doctor has an agenda?<br /><br />In general, physicians in our field of medicine should really be providing you with information to help you make the very best choices. If their advice is good, they should not be threatened by the thought of you getting a second opinion.<br /><br /><br /><strong>Red Flags</strong><br />There are certain circumstances when a first or a second opinion should cause you concern. (Preston Parry, an <span id="SPELLING_ERROR_5" class="blsp-spelling-error">REI</span> at the University of Wisconsin pointed out some of what follows below.)<br /><br /><br />1) False choices: I have encountered patients who have been told they either need donor sperm or in <span id="SPELLING_ERROR_6" class="blsp-spelling-error">vitro</span> fertilization. One couple had actually had two previous pregnancies over the past two years. In this case, the recommendation was made on the strength of a minimally abnormal semen analysis. (Clue 1: this advise didn't make sense, based on the patient history. Clue 2: a minimally abnormal result, even a moderately abnormal does not always mean extreme measures need to be taken.)<br /><br /><br />2) <em>Only the positives are discussed.</em> Every treatment has advantages and disadvantages. If you are offered only one treatment and the physician does not volunteer the disadvantages and advantages of all the options, then be wary. This is not to say the doctor is incorrect. But unless you really understand the upsides and downsides to all treatments, how can you make an informed choice?<br /><br /><br />3) <em>It's Natural:</em> the doctor suggests an array of supplements/holistic medicines. (Trying to prove that their practice is more thorough; the reality is if these things had a dramatic effect, everyone would be using them.)<br /><br />4) <em>It's what we do:</em> the doctor suggests protocol modifications, but can’t say why it is appropriate through evidence-based medicine. (“We do it that way for everyone,” is not science, it’s opinion.)<br /><br />5) <em>Only We Syndrome</em>: the doctor claims that he or his group has a unique procedure that only he can perform.<br /><br /><br />6) <em>Cherry picking:</em> This is a common concern among <span id="SPELLING_ERROR_7" class="blsp-spelling-error">REIs (reproductive endocrinology and infertility specialists)</span>. There are some clinics which report extremely high success rates by age group. There is a suspicion among some <span id="SPELLING_ERROR_8" class="blsp-spelling-error">REIs</span> that some of these clinics are only treating good prognosis patients and trying to funnel poor prognosis patients toward egg donation. Without naming them, I will say this: I have referred some young, fairly poor prognosis patients to certain clinics for a second opinion and they have been told things like, "We wouldn't do a better job than your local docs." This is code for "we don't want you to hurt our statistics." Even if you are poor prognosis, a good clinic will give you realistic odds and should still let you proceed with care as long as you understand the chances and the treatment is not overly dangerous for you.<br /><br /><br /><br /><strong><span style="font-size:130%;">Conclusion:</span></strong><br /><br />Second opinions can be tricky. Ultimately it will come down to a matter of trust. If you get a second opinion, be sure that the physician fully explains why a recommendation is being made. If he or she can't explain it to you so that you understand it, then it likely is not the best choice for you.<br /><br />If an alternative treatment is suggested, the relative advantages AND disadvantages should have been discussed with you.<br /><br /><br />You can ask your referring provider what their experience has been with the doctor. Ask your friends. Watch for red flags. And, ultimately, if all else fails, you should trust your instinct.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-36058316480871249132009-12-08T06:35:00.000-08:002009-12-08T06:52:10.449-08:00How Does Anyone Have a Baby?If you are having difficulty getting or staying pregnant, you are not alone. At some point, infertility affects 15% of all couples. Recurrent pregnancy loss affects another 3% of couples. <br /><br />If you are one of these couples, you may feel isolated and depressed. You will get all sorts of helpful and unhelpful advice from people (including yourself) who really do care. Perhaps one of the worst things someone can tell you is to “relax” or “quit trying so hard.” This advice generally has two effects:<br /><br />To make you even more tense.<br /><br />To make you think it’s all your fault. <br /><br />At <a href="http://www.trmbaby.com/">Tennessee Reproductive Medicine</a>, we understand the stress that <a href="http://www.trmbaby.com/fertility/fertility_testing.shtml">infertility and pregnancy loss</a> causes. While it is true that in extreme cases stress can cause a woman to stop ovulating, very rarely is stress a cause of <a href="http://www.trmbaby.com/common_conditions/common_conditions.shtml">infertility</a>. If stress isn’t causing the infertility, as so many people commonly think, let’s consider what is normal and abnormal in the world of conception so you can take charge of your fertility. <br /><br /><strong>Normal Conception Rates</strong><br />After one year of adequate unprotected intercourse, 85% of couples ages 20-40 will be pregnant. Of the 15% who aren’t pregnant, half of those will be pregnant within the second year. The monthly chance of conceiving among couples in which the woman is less than 32 years old is approximately 20-25%. This illustrates that human reproduction is very INEFFICIENT! It may take some couples many months to conceive and this is within the range of normal. After age 32, monthly conception rates start to decrease slightly, then more significantly after age 35 to about 10-15% chance per month. <br /><br /><strong>When Should I Seek Help Conceiving?</strong><br />Infertility is considered the lack of conception after 12 months of unprotected regular intercourse (timed adequately during the suspected time of ovulation). <a href="http://www.trmbaby.com/fertility/fertility_testing.shtml">All couples who have not conceived after 12 months warrant a full evaluation.</a> While some couples will spontaneously conceive after 12 months of attempts, most will need <a href="http://www.trmbaby.com/treatments/infertility_treatments.shtml">some form of fertility therapy </a>and further attempts at natural conception may be wasting precious time. <br /><br />Furthermore, many couples warrant a sooner evaluation if there is a history suggestive of:<br /><br />-ovulation disorders<br />-tubal disorders<br />-male reproduction disorders<br />-female greater than 35 years old<br />-endometriosis<br />-female with prior radiation or chemotherapy treatments<br /><br /><strong>Do I need a fertility specialist?</strong><br /><a href="http://www.trmbaby.com/welcome/do_I_need_fertility.shtml">Sometimes this is an easy question to answer, sometimes it's difficult.</a> Consider your situation and conditions by taking this TRM Quiz at <a href="http://www.trmbaby.com/welcome/do_I_need_fertility.shtml">http://www.trmbaby.com/welcome/do_I_need_fertility.shtml</a>. If the total number of points equals or exceeds 15 points, and you wish to conceive, strong consideration should be given to seeing a <a href="http://www.trmbaby.com/welcome/our_staff.shtml">fertility specialist</a>, specifically a reproductive endocrinologist.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-40955712968355519382009-11-18T20:20:00.000-08:002009-12-08T06:53:29.996-08:00Interpret With Caution!It’s been a while since I’<span id="SPELLING_ERROR_0" class="blsp-spelling-error">ve</span> written anything here. Quite frankly, I’<span id="SPELLING_ERROR_1" class="blsp-spelling-error">ve</span> been a bit busy, and no topic seemed particularly inspiring. Until yesterday.<br /><br /><a href="http://www.wrcbtv.com/Global/story.asp?S=11519358">I was asked to make a comment for a local television station, <span id="SPELLING_ERROR_2" class="blsp-spelling-error">WRCB</span> TV3 Eyewitness News, which was running a story on a New York fertility doctor </a>(Dr. <span id="SPELLING_ERROR_3" class="blsp-spelling-error">Sami</span> David) who says that too many couple use <span id="SPELLING_ERROR_4" class="blsp-spelling-error"><a href="http://www.trmbaby.com/in_vitro/ivf_basics.shtml">IVF</a></span> to get pregnant and that many of those couples should try alternate methods first. He notes that his favorite fertility drug is antibiotics.<br /><br />What I am about to write may at first sound like a <span id="SPELLING_ERROR_5" class="blsp-spelling-error">pre</span>amble to denouncing this doctor’s claims, or like a build up to a defense of <span id="SPELLING_ERROR_6" class="blsp-spelling-error">IVF</span>.<br /><br />It really is neither.<br /><br /><strong><span style="font-size:130%;">The "Caution" Part...</span></strong><br /><br />I am saying there is a lot said about <a href="http://www.trmbaby.com/treatments/infertility_treatments.shtml">fertility and infertility treatments</a> which should be interpreted with caution. In this post I’m going to elaborate on some of the ways any news story you might encounter can be misinterpreted.<br /><br />This post is also an expansion of what I would have like to have said if the news station actually had the time to air it. My response to the news story was limited to about 8 seconds and the reporter was only able to highlight a couple of sentences of my response. Such is the nature of broadcast journalism. I am very grateful to Channel 3, the NBC affiliate, that they gave me what time they could spare to my point of view. <a href="http://www.wrcbtv.com/Global/story.asp?S=11519358">I am also very happy that they put my entire response on their website</a>.<br /><br />It appears that the story was filmed by a New York affiliate station and sent to local NBC affiliates from the network. Local affiliates could interview local physicians as time permitted. In case the link above does not work, I’ll give you the skinny on the news story:<br /><br />Dr. <span id="SPELLING_ERROR_7" class="blsp-spelling-error">Sami</span> David performed the first <span id="SPELLING_ERROR_8" class="blsp-spelling-error">IVF</span> procedure in New York and he has not done one since that time. He says that <span id="SPELLING_ERROR_9" class="blsp-spelling-error">IVF</span> has a high failure rate and that many people who resort to <span id="SPELLING_ERROR_10" class="blsp-spelling-error">IVF</span> could get pregnant without it. He said doctors need to pay more attention to treating the man and looking for not-so-obvious causes of <a href="http://www.trmbaby.com/fertility/fertility_testing.shtml">infertility</a> and treat those causes. The story illustrates the proof of this concept by interviewing a woman who went through three <span id="SPELLING_ERROR_11" class="blsp-spelling-error">IVF</span> cycles but miscarried all three times. She then saw Dr. David, conceived and now, happily, has a child. Dr. David has now written a book explaining much of this. It is called Making Babies.<br /><br /><span style="font-size:130%;"><strong>Unavoidable Bias<br /></strong></span><br />There are several inherent and hard to avoid biases in stories like this. For example, simply by saying Dr. David is offering an alternative, this does not mean many people in our field <span id="SPELLING_ERROR_12" class="blsp-spelling-error">aren</span>’t also incorporating some of the <a href="http://www.trmbaby.com/common_conditions/common_conditions.shtml">same treatments</a>. Much of what Dr. David promotes and what your typical fertility would promote will be similar. The implication is that most fertility doctors push a lot of people to <span id="SPELLING_ERROR_13" class="blsp-spelling-error">IVF</span>.<br /><br />As a matter of fact, fewer than 10% of our patients ever require <span id="SPELLING_ERROR_14" class="blsp-spelling-error">IVF</span>. <a href="http://www.trmbaby.com/welcome/first_visit.shtml">Dr. <span id="SPELLING_ERROR_15" class="blsp-spelling-error">Scotchie</span> and I try very hard to use <span id="SPELLING_ERROR_16" class="blsp-spelling-error">IVF</span> as a last resort</a>.<br /><br />Another unavoidable bias is that simply by reporting this story, makes the information seem like its new. Just because this story is in the news, this does not make it new. The reason Dr. David is in the news is not because of remarkable success rates. The reason he is in the news is because he has written a book. He is promoting the book and he seems to be doing a good job with that. By saying this, I’m not trying to imply that Dr. David wrote this only to promote his practice and to make money. I have not read the book, but until I see proof otherwise, I’ll assume that he wrote it to get the word out that for some people, there are alternatives to <span id="SPELLING_ERROR_17" class="blsp-spelling-error">IVF</span>. Quite frankly, if I were a reporter, I’d be inclined to write a story about it, because there people who would be interested in it.<br /><br /><strong><span style="font-size:130%;">My First Thought</span></strong><br /><br />My first thought upon hearing what Dr. <span id="SPELLING_ERROR_18" class="blsp-spelling-error">Sami</span> has to say is: I agree that some people get thrust into <span id="SPELLING_ERROR_19" class="blsp-spelling-error">IVF</span> too quickly. I think some doctors don’t do enough investigation to find out if there is a treatable cause. This is especially true of <a href="http://www.trmbaby.com/male_infertility/male_infertility.shtml">male factor infertility</a>. I know this because I get to review a lot of medical records as a second opinion, and not just from Tennessee or the surrounding areas. Friends from all over the country refer their friends to me to give them my assessment.<br /><br />Doctors are partly to blame, and there are various reasons for this. High tech treatments do generate more income for the practice than low tech treatments. Also, high tech treatments are generally far more likely to be successful than low tech treatments. <a href="http://www.trmbaby.com/welcome/testimonials.shtml">A pregnant patient is usually a very satisfied patient</a>. It makes the patient feel good. It makes the doctor feel good.<br /><br />It can be difficult for patients to know if a doctor is pushing you too quickly into <span id="SPELLING_ERROR_20" class="blsp-spelling-error">IVF</span>. Second opinions can be valuable here. However… CAUTION must be exercised when getting a second opinion. (I promise to write about this VERY soon. But this is too big a topic to tackle here.)<br /><br />Sometimes the doctors push for <span id="SPELLING_ERROR_21" class="blsp-spelling-error">IVF</span> too quickly and, truthfully, sometimes the patients push themselves into <span id="SPELLING_ERROR_22" class="blsp-spelling-error">IVF</span> before they’<span id="SPELLING_ERROR_23" class="blsp-spelling-error">ve</span> tried all other reasonable options.<br /><br /><span style="font-size:130%;"><strong>My Biggest Fear</strong><br /></span><br />My biggest fear about this story is that there would be people who would interpret Dr. David’s message in a way that would cause them to delay seeking the advice of a fertility specialist.<br /><br />I worry especially about women approaching their mid- to late-30s who spend several years trying on their own, or using herbal or homeopathic remedies. By the time they reach my office, they have significantly decreased chances of conceiving due to age, or due to the limited number of remaining reproductive years with which to attempt pregnancy.<br /><br />Despite treatment, it can take some couples years to conceive. I should know. <a href="http://www.trmbaby.com/welcome/rink_murray.shtml">My wife and I were one of those couples. </a><br /><br /><strong><span style="font-size:130%;">Dangers of Interpreting Success</span><br /></strong><br />It is sometimes hard for doctors to know if it was treatment or time which cured a patient.<br /><br />I am careful to counsel my patients that I may not know if it was our treatment which helped them conceive. In some cases, all we can say is that we increased the odds of conception in a given month.<br /><br />It is a happy reality of my practice that some patients will conceive spontaneously before, between or after an infertility treatment.<br /><br />In cases when patients get pregnant between treatments, patients usually understand that they did not conceive due to treatment. I will know it, too.<br /><br />Some practitioners have a difficult time in knowing if a patient got pregnant because of treatment or simply because it was a patient’s time to conceive. For example: Suppose I am a doctor who gives everyone an antibiotic or an herbal remedy. A portion of my patients would have conceived anyway. But since all of my patients are “under treatment” at all times, I would be likely to think that the therapy was what made the difference. The patient would think so, too.<br /><br />Under a lot of alternative regimens, patients are always technically in treatment. In these cases, it can be very difficult to know what actually caused the pregnancy. In my experience, the assumption of the practitioner and the patient is to give credit to the treatment.<br /><br />In certain situations, I downplay my role to patients. Still, when they get pregnant, they give me the credit, even when it’s more likely that I was <strong><em>not</em></strong> the difference maker.<br /><br /><em>Example:<br /><br />If I do surgery on 12 infertility patients and remove low-grade <span id="SPELLING_ERROR_24" class="blsp-spelling-error"><a href="http://www.trmbaby.com/common_conditions/endometriosis.shtml">endometriosis</a></span> and then do no other treatments, studies have shown that 3 of them will get pregnant within the next 12 months. All three who conceive say “the surgery worked” and that’s why they got pregnant. All three give me the credit.<br /><br />The truth is, if I had not done surgery, 2 of the 12 would have conceived on their own.<br /><br />This means, I must do 12 surgeries to get one additional pregnancy than doing nothing. This is called number needed to treat, <span id="SPELLING_ERROR_25" class="blsp-spelling-error">NNT</span>, to get 1 different outcome.<br /><br />I tell patients this beforehand. Still, EVERY single patient who has gotten pregnant after surgery remarks something like, “The surgery worked!”<br /><br />I usually say something like, “Maybe, there’s a 33% chance that it did.”<br /></em><br />This example illustrates the point that doctors and patients can be very likely to give or accept credit more often than deserved.<br /><br />Even when it is more probable that my intervention had something to do with the pregnancy, I am careful to counsel patients that the only thing we did was increase the chance.<br /><br /><em>For Example:</em><br /><em></em><br /><em>If I do an intrauterine insemination (IUI) on a patient and the patient gets pregnant, I cannot always say that the pregnancy was due to the procedure or due to intercourse that she and her partner had a few days earlier. All I know is that the IUI increased their chances of conception that month. </em><br /><br />The news story used an example of a patient to represent Dr. David's success. In this example, the patient had failed to have a baby after three IVF attempts. She was then treated by Dr. David, and after an unspecified amount of time, she got pregnant. Did Dr. David's treatment get her pregnant? Or was it just her time to succeed? Clearly both the doctor and the patient have given him the credit. In all honesty, neither of them could possibly know.<br /><br />I am wary when anecdotes are used as evidence that a treatment is successful. It does not mean I don’t try some of those same treatments myself, but both the patient and I must still be wary about interpreting the results.<br /><br /><strong><span style="font-size:130%;">My Final Thought</span><br /></strong><br />I’m sure there is a lot more I could write. But my wife is cleaning the house for family members of mine that are arriving from out of town, and it seems somehow wrong that she is doing all of the work, so I’ll leave it at this.<br /><br />I have not read Dr. David’s book, yet. My suspicion is that I will agree much more than disagree with it. I do think it is very sensible to not turn your back on any practical ways to improve your ability to conceive.<br /><br />There are many recommendations out there for stress reduction, optimal supplements, exercise, sexual positions. I’ll try to address some of these issues in future blogs.<br /><br />I think I’ll write about the pitfalls of second opinions next.<br /><br />But first, I have to mop.Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com0tag:blogger.com,1999:blog-8685367863184341468.post-37542951849057618942009-08-11T07:21:00.000-07:002009-09-04T12:31:22.373-07:00What to expect when you're not expecting - or, the slow erosion.<a href="http://www.trmbaby.com/welcome/having_a_baby.shtml">Infertility can make you crazy</a>.<br /><br />In some previous posts, I discussed how the advice from others can contribute to a sense of anxiety. What we in the world of medicine must also acknowledge is that the infertility investigation and treatment can also be maddening.<br /><br />Couples embarking down this path need to be prepared for the emotional landmines that can occur. <a href="http://www.trmbaby.com/common_conditions/common_conditions.shtml">While many couples have very different causes of infertility </a>or may get different <a href="http://www.trmbaby.com/treatments/infertility_treatments.shtml">treatments</a>, they do share many of the same frustrations.<br /><br /><strong>How it begins:</strong><br />The first maddening aspect of infertility is that getting pregnant should not be difficult. After all, some people get pregnant with a single act of intercourse. Teenagers get pregnant…. some more than once. Women on the pill get pregnant. We hear women say, “He’d just walk by me and I’d get pregnant.”<br /><br />So it’s frustrating to have difficulty in an area that seems to be easy for most people. This frustration can turn into guilt, hopelessness, a sense of inadequacy, a sense of injustice, sorrow or anger… or all of them at once.<br /><br /><strong>How it perpetuates:</strong><br />To get control of the situation, many women start monitoring their menstrual cycles. She and her husband have sex when the calendar tells them to. (Fun at first…. but this can lead to a loss of intimacy.)<br /><br />Other couples seek the advice of physicians. For many couples, the problem resolves here… problem is found and fixed… medicine is taken… pregnancy happens. But if you’re not one of those fortunate couples, the sense of inadequacy grows, as does a sense of anxiety.<br /><br />I’ve been on both sides of the desk on this. When my wife and I started seeing doctors to try to get pregnant, it seems every time we had an appointment, we received more bad news.:<br /><br />“You’re not ovulating…”<br />“You did not ovulate with the medicine”<br />“Your tubes are damaged.”<br />“We tried to fix your tubes, but they’re damaged beyond repair.”<br />“You need IVF.”<br />“We got 25 eggs. Half fertilized. Only 5 are still growing.”<br />“You’re not pregnant.”<br /><br />Repeat.<br /><br />Then there those times when the news it at first good, but then turns bad.<br /><br />Early on, before each IVF cycle, we were told that we were <strong><em>excellent</em></strong> prognosis, but with each attempt, we had the same outcome - failure.<br /><br />Then there was the time we finally got pregnant. My wife's hormone levels were rising wonderfully. I will never forget the serenity that took over me and my wife at this point. I remember going to the driving range and hitting golf balls while she read “What to Expect While You’re Expecting.” We had 2 weeks of unbridled bliss.<br /><br />Then, my wife started to experience pain. A friend performed an ultrasound, and where we should have seen an embryo, there was just the smallest amount of fluid in the uterus. Over the next few days, the pain escalated and finally she saw her doctor. She was still in pain, but that didn’t matter. Her emotions soared as he performed her ultrasound. He saw the baby. He showed it to her. It looked normal. It had a robust heart beat and little arm buds. He was saying everything looked good when his assistant tapped him on the shoulder and whispered something. Suddenly the doctor stopped talking and looked closer at the screen. He scanned for a moment, and then looked at my wife.<br /><br />The other shoe dropped.<br /><br />It seemed that this perfectly formed baby, with a robust heart beat was not in the uterus, but in the fallopian tube.<br /><br />Within 3 weeks, we had been taken from the heights of happiness to a breathless sorrow. It was so cruel to be given hope, only to have it taken away. In our hearts, we knew there was nothing wrong with that baby. It was a victim of geography.<br /><br /><br /><strong>The loss of that child has changed me forever.</strong> Whenever my wife and I talk of that time, we are crushed. And when I see someone else who is losing a pregnancy or a child, I am swept back in time and feel a rent in my soul.<br /><br />This is how life was for us. We were given hope. Then hope was dashed.<br /><br />Still, by some accounts, my wife and I had it easy. There are couples who don’t have infertility at all, but suffer <a href="http://www.asrm.org/Patients/FactSheets/recurrent_preg_loss.pdf">repetitive pregnancy losses</a>. There are couple’s who have identified problems, but lack the financial means to undertake treatment. Then there are those 10% of couples in whom we can find nothing wrong. This can be especially frustrating for them.<br /><br />There are many roads to the madhouse. Many infertility patients will find themselves on that road. For some, it can ruin a marriage, or enjoyment in life. For some people, the trauma suffered from infertility is not completely healed by getting pregnant or even having a baby.<br /><br />Infertility patients are likely to be more worried about things going wrong in pregnancy than someone who never had trouble conceiving. I see this in patients, and it was true for me and my wife. If you've gone through a lot to get pregnant, if you've suffered many disappointments, you just simply feel like the pregnancy is high risk. You keep waiting for the other shoe to drop. You've been trained to know that it will. <a href="http://4.bp.blogspot.com/_sfoY73BvGhE/SoNch0az5oI/AAAAAAAAADk/B8OzqWl3RjY/s1600-h/DSCF0861.JPG"><img style="MARGIN: 0px 0px 10px 10px; WIDTH: 320px; FLOAT: right; HEIGHT: 241px; CURSOR: hand" id="BLOGGER_PHOTO_ID_5369236916832298626" border="0" alt="" src="http://4.bp.blogspot.com/_sfoY73BvGhE/SoNch0az5oI/AAAAAAAAADk/B8OzqWl3RjY/s320/DSCF0861.JPG" /></a><br /><br />In my final year of Ob/Gyn residency, when my wife were at what we thought was the end of our IVF journey (we were going to try one last cycle), we got pregnant. At the time a woman misses her menses, the average hCG level is supposed to be around 90mIU/ml. My wife's was 53. We were told that this was okay in an <a href="http://www.trmbaby.com/in_vitro/ivf_basics.shtml">IVF cycle</a>, but we were still deeply concerned. In two days, the hormone did rise as it was supposed to. Two days later, it doubled again.<br /><br />It was an agonising 2 weeks until our first ultrasound. We were trying to be cautiously optimistic (which, as an aside, never actually worked for us.) I'll never forget how scared both of us were, waiting for our physician to enter the room to perform the ultrasound. Finally, once the scan began, the doctor was quiet what seemed like an eternity. I was looking closely at the monitor, but couldn't see very well from my vantage point.<br /><br />She withdrew the transducer and put it aside and told us: the embryo was only half the size it should be and it didn't have a heart beat. She recommended returning after the weekend to confirm that the pregnancy was not viable. She said it wasn't hopeless, that sometimes embryos play "catch up," but the truth was all over her face. She was clearly in pain when she said this to us.<br /><br />I will say without shame that my wife and I broke down. I tried to go back to work, but seeing the condition I was in, my friends volunteered to cover my shift on labor and delivery. I went home. I was badly shaken and felt absolutely abandoned. There was so little hope. Every time I had grasped at hope, I had come up empty.<br /><br />Fortunately, friends around us had not given up. It's almost like they willed our outcome to be different. When I returned home, Robert Strauss (a mentor and friend at UNC Hospitals) called me and said that he just didn't believe that we didn't have a heartbeat. He said that he would be on call tomorrow and that he wanted me and my wife to come back in and get an ultrasound on the high resolution machine then.<br /><br />The next morning, we got the scan with Dr. Strauss. The embryo was normal size. There was a heartbeat. A Niagara of relief and thankfulness crashed upon us.<br /><br />Within days, we once again had been taken on an emotional roller coaster, and now we were on the uphill again.<br /><br />Of course none of this made me less nervous. It seemed that the very earth beneath our dreams was so fragile. After that, about 3 times per week, my wife came to the hospital where I would do an ultrasound on her. We were almost paralyzed with fear before each scan.<br /><br />Despite now having a pregnancy on its way, my wife could not give up her progesterone shots and I could not let go of my sense of dread.<br /><a href="http://4.bp.blogspot.com/_sfoY73BvGhE/SoNf3rD0RVI/AAAAAAAAAEE/XWXLhysSUK0/s1600-h/Peanut.jpg"><img style="MARGIN: 0px 0px 10px 10px; WIDTH: 320px; FLOAT: right; HEIGHT: 234px; CURSOR: hand" id="BLOGGER_PHOTO_ID_5369240590811940178" border="0" alt="" src="http://4.bp.blogspot.com/_sfoY73BvGhE/SoNf3rD0RVI/AAAAAAAAAEE/XWXLhysSUK0/s320/Peanut.jpg" /></a><br />I could not give it up until the day I called Jenifer Behrins, a friend of mine who had 4 children but had suffered severely in each pregnancy from intractable nausea and vomiting and multiple hospital admissions. I confided my fears to her. I told her how worried I was, despite how well everything was going. She listened while I spoke, then paused. Then she gave me some of the best advice I've ever received. I share her advice with nearly all my newly pregnant patients who I imagine feel much like I did about our pregnancy.<br /><br /><br /><br /><br />Jenifer said, "You need to enjoy this. You never know what's going to happen. You need to enjoy every moment of your pregnancy. You need to enjoy every moment of that child's life. Don't worry if he's doing everything he should be, what stage he's at, if he's advanced, or if he's slow.... just enjoy it. Enjoy every stage for what it is, because you never know for sure that you'll get another stage. You never know what the future holds."<br /><br /><br /><div>To someone else, her advice may have seemed someone dark and pessimistic. To me, it was liberating. She gave me permission to celebrate the here and now. I realized that if I didn't enjoy the small blessings, I might not ever enjoy the big ones. It was my first step out of the madhouse.<br /><br /><strong></strong></div><br /><div><strong>Epilogue:</strong><br />I know not all patients enter this madhouse I allude to. Some people weather this much better than I did. I envy them. I don't know if this experience makes me a better doctor, but I'd like to think it does. <a href="http://www.trmbaby.com/welcome/rink_murray.shtml">I do know that it feels very personal to me when a patient does not get pregnant or has a loss.</a> Those old emotions are like live wires, hidden just below the surface. </div><br /><div>I know my experience affects some things that I do. When I do an ultrasound for a heartbeat, I look for the heartbeat and tell the patient as soon as I see it. With that out of the way, I go about my measurements.<br /><br />I've also realized that infertility doctors can make you feel very high risk, especially if we bring you back for ultrasounds every week of the first trimester. It's a double edge sword. On the one hand, seeing an embryo grow everyweek is reassuring. On the other hand, if I bring patients back every week, it can make them feel like things are more in perile than they actually are.<br /><br />The truth of the matter is this: as long as things are going well and there is no bleeding or history of recurrent pregnancy loss, once you see a normal heartbeat, the miscarriage rate drops dramatically. For most women under 35 years old, once you see a heartbeat, the miscarriage rate is about 4-7%.<br /><br />The sad truth for me is that the sooner I get a patient back to her doctor, the more likely she is to feel like a normally pregnant woman. For sure, it can be hard for me to let go. It can be hard for her to let go, too. In the end, it's what we all must do, and we're all better off for it.<br /><br /></div>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com3tag:blogger.com,1999:blog-8685367863184341468.post-24090046070845546662009-07-01T11:06:00.001-07:002009-09-04T12:19:39.239-07:00Playing God - Part 2 and Part 3<p>The Pope and I are having a disagreement. Not a full-fledged brawl. But it’s a fight. And quite frankly, I’m a bit peeved at him. He is opposed to not only what I do for a living, but to how I conceived my children. He says I’ve violated their rights.<br /><br />You read correctly. Pope Benedict XVI says my wife and I have violated my children’s rights by conceiving them the way we did.<br /><br />I know this from his writings that are available through the Vatican Web site. This would probably bother me a lot, if I were Catholic. As a Presbyterian, I can be a bit more, well, philosophical.<br /><br />Before he became the Pope, in 1987 Cardinal Joesph Ratzinger was the principle author of the Catholic Church’s position statement on treatments for infertility. I wanted to see how the Church justified its opposition to IVF, so I read it. The paper is titled, “Respect for Human Life” and is also known as the “Donum Vitae.” Translated literally, the Donum Vitae means the “gift of life.”<br /><br />I was shocked by what I read. It wasn’t the conclusions that surprised me, but the rational and the basis for the rationale. At a minimum, I expected a scripturally-based argument. But it was (and is) not.<br /><br />All told there are 64 references in this paper. Of these 64 references, only three are biblical passages. The remaining references are Papal and other Vatican writings.<br /><br />The first quoted scripture noted that man should have dominion over earth. (I thought this sounded like an argument for IVF.) The other two scriptures said we should value life:<br /><br /><em>God created man in his own image and likeness: "male and female he created them, entrusting to them the task of "having dominion over the earth" (Gn. 1:27-28).<br /><br />In the light of the truth about the gift of human life and in the light of the moral principles which flow from that truth, everyone is invited to act in the area of responsibility proper to each and, like the good Samaritan, to recognize as a neighbor even the littlest among the children of men (cf. Lk. 10:29-37). Here Christ's words find a new and particular echo: "What you do to one of the least of my brethren, you do unto me" (Mt. 25:40).<br /></em><br />If that were all there was to the Donum Vitae, we would not really have an argument.<br /><br />I agree that man, scripturally and by default, does have dominion over the earth. I also think we should value human life.<br /><br />So exactly what is my beef with the Donum Vitae?<br /><br />First let’s look at some of the declarations made by the Donum Vitae, then we’ll discuss them. I’ve paraphrased some of what comes below, because much of what the Church declares is obfuscated in ornate language (like this sentence.). The Donum Vitae says:<br /><br /></p><blockquote></blockquote><blockquote></blockquote><ol><br /><li><em>The child has the right to be conceived, carried in the womb, brought into the world and brought up within marriage and from marriage. </em></li><br /><li><em>Donor insemination is immoral because it violates the rights of the child; it deprives him of his filial relationships with his parental origins and can hinder the maturing of his personal identity. Donor insemination is also wrong because it violates the child’s right to be conceived and brought into the world in marriage and from marriage. </em></li><br /><li><em>Donor eggs are immoral for the same reasons as donor sperm. </em></li><br /><li><em>Masturbation to achieve sperm is immoral. </em></li><br /><li><em>Artificial insemination is permissible only when the procedure is not a substitute for the sexual act but instead facilitates the sexual act to have a child. </em></li><br /><li><em>Fertilization achieved outside the body is immoral. </em></li><br /><li><em>The freezing of embryos is immoral because an embryo may not survive and it deprives them temporarily “of maternal shelter and gestation, thus placing them in a situation in which further offenses and manipulation are possible.” </em></li><br /><li><em>Life begins at conception.</em></li></ol><p>Of course there is much more in the Donum Vitae about genetic testing and scientific research. I’m not going to focus on those issues during this entry, mainly because it would take too long, and only a small fraction of patients ever opt for these treatments. </p><p><strong>Life Begins at Conception</strong></p><p>The overriding issue addressed by the Donum Vitae is <em>respect for human life</em>. A key question is when does life begin? A reasonable position <em><strong>is</strong></em> the Church's position: life begins at conception. After all, an embryo is human; an embryo is alive. This is a reasonable assumption. </p><p>Others might argue that life begins in the sperm and the egg <em><strong>before</strong></em> fertilization. After all, the sperm and egg are both human, and both alive. Of course, we could argue that neither is a complete being. </p><p>So is an embryo a complete being? It usually has the genetic material to become one. But clearly an embryo is vastly different from a fetus, which is vastly different than a child, which is different from an adult. All are human. All are alive. </p><p>At what point does an embryo become a human life? </p><p>I would contend that if life is a gift from God then no matter the level of intervention, man cannot create life. </p><p>For example: in the lab, we cannot force a sperm to fertilize and egg. We cannot force the embryo to grow. We cannot force the embryo to implant in the uterus and to prosper. If we could do these things, our success rate would be 100%. As a specialty, we fall woefully short of this. All we can do in the lab is to create situations where fertilization is more likely, statistically. We can nuture embryos to the best of our abilities. But we cannot create a baby. Way too much is out of our control. This is at once humbling and reassuring to me. </p><p>It’s conceptually easy to believe that the human soul enters the embryo at the time of conception. After all, an embryo is alive. An embryo is human. Of course, these two points don’t make it a human being, no more than a fetus is a child, or a child is an adult. These are all points on a continuum and we don’t have the real ability to say when someone leaves childhood and becomes an adult. All we have are conventions. One convention says we become an adult at age 16, when we can drive. Another says 18, when we can vote. Another 21, when we can drink. Another 24, when we can rent an RV (at some rental shops in Colorado.) </p><p>I say all of this to show that it is convention to say that life begins at conception. Quite frankly that is how I have always, and continue to look at it. </p><p>But what if I’m wrong. If God is the giver of life, then when does He give an embryo a soul? Does this happen at the moment of conception? If so, then why are 50% of naturally achieved pregnancies lost prior to the onset of menses and the woman never knows she was pregnant? What would be the purpose of this? The truth is, we cannot know. The best we can do is to make our own assumptions. I look at it this way: an embryo is alive and it is human, but I know it’s not a child – yet. It is a potential child. For this reason, I would not elect to destroy my embryos. <strong></strong></p><p><strong>This brings us to statement number 7,</strong> <strong>that Egg Freezing is immoral</strong>. The Church’s argument against egg freezing is that it places the embryo at risk and deprives it of maternal shelter. My response to this is that twin, triplet and quadruplet pregnancies can all do the same thing. High order gestations can create an environment that is unsuitable to sustain a pregnancy or might cause harm to the unborn child. </p><p>If I am creating embryos with IVF and not all of the embryos will be used, some of them might die if I freeze and thaw them. I am not trying to dispose of them. Rather, I am giving them a chance at life that they didn’t otherwise have. I am also maximizing their chance of having a safe pregnancy. </p><p>New freezing techniques are not perfect, but very few embryos are lost. Those that are lost, the intent is not to kill them, it is to save them so that they can be used. Yes, we place embryos at risk. How is this much different from a woman who is high risk for pregnancy who decides to conceive naturally? These pregnancies can be lost, too. Did she do something wrong? According to the Donum Vitae, this woman should not use contraception either. </p><p><strong>Statement 6,</strong> <strong>saying that fertilization is immoral if it occurs outside the body</strong>. I don’t quite know what to say here, except, “According to whom?” Obviously, this is not in the Bible, so it is difficult to make a scripturally based argument against this. I think suitable scriptures to argue against the Church would be: “Man shall have dominion over the earth” and “Be fruitful and multiply.” </p><p><strong>Statement 5,</strong> <strong>limiting the use of artificial insemination</strong>. Though the Donum Vitae doesn’t say this implicitly, this implies you can use a condom that has a small hole in it to allow some sperm to escape during sex, but you can then recover much of the sperm from the condom and use it for artificial insemination. </p><p>I at once welcome this exception, and yet I see the hypocrisy in it. The Donum Vitae is very clear that a child should be born of sexual relations between a man and wife. If the purpose of the sex is really to get sperm for IUI, rather than the IUI assisting the sex, it’s more likely that the sex act is assisting the IUI. </p><p><strong>Statement 4,</strong> <strong>masturbation is immoral</strong> because the Church says so. No scripture is quoted to support this claim. I have looked for Biblical references on this. There is a lot about lust. Masterbation is not mentioned. So if lust is removed, then I see little to say this is wrong, espeically if it is being done to "be fruitful and multiply."</p><p>The story of Onan is commonly used to promote the idea that masterbation is wrong. However, as noted below, Onan's sin was not "spilling his seed" per se, but disobeying his father by refusing to help his dead brother's wife conceive a child. </p><p>Admittedly, we can get sperm from a Catholic-Safe Condom (one with holes in it); however, the results are less reliable. </p><p><strong>Statements 2 & 3,</strong> <strong>donor egg and sperm are immoral</strong> because they deprive the child of its right to be conceived in the womb and of and from marriage. The reasons given by the Church have no basis in Biblical teaching. I hope I don’t go to Hell for what I am about to say, but even Jesus was conceived out of wedlock with 3rd party reproduction. Mary had the ultimate donor! </p><p>There is also reference to donor sperm, in Genesis. Onan was commanded to impregnate his dead brother’s wife, so that the brother’s clan line could be continued. When he refused to complete the act of sex and spilled his seed upon the ground, he was killed.<br /><br />Onan was killed for disobeying the command to partake in the Biblical era's version of artificial insemination. He disobeyed his father and was killed for it. </p><p>One area where the Catholic Church and I can agree is that there is danger to this sort of reproduction. One of the ethical concerns with 3rd party reproduction is that children may grow up with a sense of loss if they do not know their genetic parents. This can be especially frustrating if it is thought that the parent is still alive and does not know. </p><p>It is in our nature to blame our anxiety on our circumstance in life. For example, if I were a minority and got bad service at a restaurant, I might wonder if it was the color of my skin. Or if I were a woman passed over for promotion so that a slightly less qualified man could be hired, then I might assume race or gender discrimination was a factor. Similarly, if a child is born from donor egg and sperm, he or she is also at risk for blaming the troubles in life on the fact that the biologic parent is unknown.</p><p>This is a very legitimate concern and while not all offspring suffer this, it is important to be aware of this potential problem prior to using donor eggs and sperm. </p><p><strong>Statement 1, a child has the right to be conceived within the womb and born of and from marriage. </strong>I do not see this written anywhere that this is a child’s right. However, this has been frowned upon in the scriptures and through the ages. Jesus was sometimes referred to by Jews who opposed him as, “The Son of Mary,” meaning he was born out of wedlock. </p><p>I do believe that the best environment in which to be raised is in a loving home. I want there to be a mother and father in the house because this was how I was raised. </p><p><em>Final thoughts....</em></p><p><em>I think much of the debate around the Donum Vitae surrounds what is "natural." God's laws and natural laws are often seen as the same. But to say that an IVF baby was conceived unnaturally is to say that we are above God's laws, above nature. As a human, I am part of nature. Everything I do is part of nature. Kevlar is a natural product if man made it. </em></p><p><em>It is the hieght of vanity to assume that what man has made is above or outside of nature. </em></p><p><em>To an automobile is unatural is to say an anthill is unatural. The anthill was constructed. It's primitive, but constructed. </em></p><p><em>So my children, conceived with IVF were not conceived outside of nature. They were and are the product of a loving, committed relationship.</em></p><p><em>So, I did not violate my children's rights through their conception with IVF. The Pope owes me, and them, an apology.</em></p><p><em>I won't hold my breath waiting. </em></p>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com3tag:blogger.com,1999:blog-8685367863184341468.post-9129056905110351392009-06-25T12:15:00.000-07:002009-09-04T12:16:06.987-07:00Playing God - Part 1<em>A few weeks ago, before an <a href="http://www.trmbaby.com/in_vitro/blastocyst_transfer.shtml">embryo transfer</a>, my embryologist recited a Bible verse to me that she had given to my patient. The patient, had written down this verse on a scrap of paper and was taking it into the room to get her embryo transfer. </em><br /><br /><em>When Shan recited this verse and told me that the patient was carrying it, I felt a lump in my throat, a lump that is usually associated with great sorrow, or overwhelming joy and relief. </em><br /><em></em><br /><em>"That's strange," I thought and wondered why it made me feel so unexpectedly emotional. </em><br /><br /><em>It was like an aroma that transports you back in time, to a specific place, by-passing the normal circuits of memory. I was at once filled with specific and vague memories and feelings </em><em>of joy, despair, love, shame and remorse. It was a tidal wave of regret and gratitude. </em><br /><br /><em>It reminded me of how small we are compared to the forces at work in the universe. </em><br /><em></em><br /><em>Despite my religious upbringing, I honestly could not recall ever seeing that verse. More likely, I hadn't been prepared to see it before. </em><br /><em></em><br /><em>It's humbling to realize that this was there all along, and it sums up something that took me years to understand. </em><br /><br /><em>So what was the verse? </em><br /><br /><em>1st Corinthians 2:9, "No eye has seen, no ear has heard, no mind has conceived what God has prepared for those who love him."</em><br /><br /><p><em>With that, let me get to the actual blog entry.<br /></em><br /><em>What I am about to write is not something just for people with a religious inclination. I think even an atheist will fall prey to some of the thinking that I talk about in this entry.</em> <em>If nothing else, perhaps it will help somebody else understand how another person feels (and fears).</em> <em>So hopefully, this entry will be of benefit to everybody. </em></p><p align="center">******</p><p>When I was an Ob/Gyn resident, I told a nurse that I wanted to be a Reproductive Endocrinologist. As she looked back at me, a look of disgust spread across her face. “Why would you want to do THAT?” she asked. “It’s so immoral. It’s playing God.”<br /><br />She proceeded to lecture me along these lines for several minutes before finally concluding that if people weren’t meant to have kids, then they should not have them and they had no right to be parents.<br /><br />I asked her if she thought that my wife and I should not be allowed to have children.<br /><br />“I didn’t say that,” she said.<br /><br />“Yes, you did,” I told her.<br /><br />This exchange allowed us to have what is sometimes called a teachable moment. Probably for the first time in her life, she saw what she said in context of an actual human being rather than a person on paper or in her imagination.<br /><br />I told her that I didn’t know what God intended for my life. Despite using all the technology available to us, my wife and I had not conceived. Was this punishment for trying to play God? I had no way of knowing. But I did know this, no matter what I did, if God did not want me to have children this way, then my wife and I would be childless.<br /><br />I think her mind changed that night. What changed it was not an argument, but a realization.<br /><br />As my wife and I struggled with <a href="http://www.trmbaby.com/welcome/having_a_baby.shtml">infertility</a>, we wished there were clear signs telling us what we were supposed to do. Were we supposed to just stop? Or were we supposed to take advantage of all the treatment that God put before us? Was <a href="http://www.trmbaby.com/in_vitro/in_vitro_fertilization.shtml">IVF</a> a path to the garden? Or was it the forbidden fruit?<br /><br />With each failure, in the midst of each great sorrow, we asked the same questions again… what were we supposed to do? Were we being sinful, or prideful wanting to have children that were biologically related to us? Were we following God’s commandment? Or were we pushing our wishes ahead of God’s will?<br /><br />In the absence of signs, we persevered. We knew only one thing for sure: if we did not try, we would not conceive we would regret our decision later.<br /><br />I personally have not met any patients who I thought were trying to play God. <a href="http://www.trmbaby.com/welcome/testimonials.shtml">I’ve met people suffering from infertility</a>, people like me and my wife, struggling to understand the plan, if any, for our lives. </p>Dr. Ringland (Rink) Murray and Dr. Jessica Scotchiehttp://www.blogger.com/profile/07233371327486494259noreply@blogger.com1