by Joseph Martin, MD
“Twenty years ago, couples had about a 10% chance of getting pregnant from IVF but now more patients get pregnant from
an IVF cycle than not.”
For years my life in obstetrics and gynecology was tied to the nine months of gestation that tends to conclude, often dramatically, at unusual hours of the night and, equally as often, on weekends.
As I began some 20 years ago to focus my practice exclusively upon infertility, I became tied not to the conclusion of pregnancy, but to the initiation of it, with particular emphasis upon the ovarian cycle. Life is still unpredictable, as it seems that women tend to ovulate as often on weekends as they tend to initiate labor. Nonetheless, the quantum leaps in the various medications and technologies now available to treat infertility – both male and female – makes the seven-days-a-week routine both more successful than ever and, thus, extremely rewarding.
My day begins around 5:30 a.m. and, typically, I am seeing patients in our center by 7:30. Much of infertility therapy requires repeated visits by patients during their cycle, appointments that often consist of a blood draw, an ultrasound examination and/or a patient educational session. Since most of these people work, we try our hardest to get them in and out early, but arriving at the center each morning in the middle of this throng often gives the appearance that I have stepped into Grand Central Station. Today, for example, we will see 40 patients between 7 and 11:30 a.m. for some of the above needs, as well as for procedures and new consultations.
I see nine patients undergoing ovulation induction therapy either for in vitro fertilization or intrauterine insemination. For each of these, we evaluate ovarian ultrasound findings as well as serum hormone levels. At 8 a.m., we perform a trans-vaginal follicular aspiration under ultrasound guidance, obtaining six eggs on a 44-year old patient for IVF. We have two procedure rooms located adjacent to our embryology laboratory plus anesthesia support, making these cases easy to perform in the office setting.
I then see two patients, each having children from prior IVF attempts with us, who desire more children. My next patient is a 46-year old woman with no children seeking pregnancy for the first time. I discuss the decline in ovarian reserve in older women, the steep increase in chromosomal abnormalities of oocytes as maternal age increases, and how each contributes to the poor prognosis for IVF success in her age group. She elects to use donor eggs and we will initiate that process in the next cycle.
I consult with a new patient who is 28 years old and is four years infertile. She has an ovulatory problem so we schedule a work-up to include physical examination, pelvic ultrasound, initial hormone studies, a hysterosalpingogram, and a semen analysis of her husband. If these tests are normal, we will induce ovulation with Clomid and perform an intrauterine insemination at the appropriate time of her cycle.
Next, I perform an embryo transfer on a 30-year-old IVF patient suffering from infertility due to diminished ovarian reserve, as indicated by accompanying high follicle stimulating hormone levels. Two eight-cell embryos are transferred back into the patient and her remaining embryos are being cultured for another two days for possible cryopreservation. This will allow her to have an additional embryo transfer without another cycle of ovulation induction and egg retrieval if she does not conceive from this attempt or if desires more children in the future.
At noon I meet with Greg Neal, our other reproductive endocrinologist, and our staff of six nurses to review the current charts for the day. By this time, we have received the hormone results from the morning blood draws so we evaluate these and current ultrasound findings, and make any adjustments to drug regimens that might be indicated in patients undergoing ovulation induction for IVF and other procedures. It also gives us an opportunity to discuss new patients, surgical patients, or any problems that may have arisen today or yesterday evening. Today, we review 40 charts with the staff over the lunch hour.
I have time to see one more patient in the office before going to surgery. This patient is from out of town, has seen two other physicians before coming to our center, and presents with multiple ovarian cysts that are secondary to ovulation induction performed elsewhere. I place her on oral contraceptives and…
At 2 p.m., I go to the operating room and perform two dilation and curettages for fertility patients who miscarried, and then perform a laparoscopy on a patient with an ectopic pregnancy. Often, we can treat ectopics medically since we usually catch them quite early, but this patient lives out of town, so we opted for the more conservative approach of sur-gery. As it turns out, both Fallopian tubes are diseased so surgery was the appropriate action this particular time.
I returned to the office near 5 p.m., in time to review letters to referring doctors that arrived from the transcription service while I was away. Our nurses are finishing the phone calls they make to our patients on a near-daily basis and it is time to think about heading home.
The embryology lab has informed us of four positive pregnancy tests from the day – two from IVF cases and two from frozen embryo transfer cycles. It reminds me of how much this field has changed. Twenty years ago, couples had about a 10% chance of getting pregnant from IVF but now more patients get pregnant from an IVF cycle than not. The drive home has become decidedly easier with time.
Dr. Martin is the medical director and founder of Fertility Center of San Antonio.
