I'm on vacation. When I walked out of the clinic on Tuesday many people commented "don't think about this place," "relax - we'll take care of your patients," "don't do work while you are away." I never heed that advice. When I am on vacation I find it is the perfect time to relax and flip through research journals, catch up on emails and think about work, a lot. It's this break from the day-to-day concentration each patient sitting in front of you needs to getting to think bigger picture about practice, the future and how we can do better. I like this time.
We've been hammered a bit in on-line reviews lately so that's on my mind. How is it we can help over a thousand people each year reach their dream of a successful pregnancy yet we get (disproportionately?) negative reviews on line? Several of the reviews are non-sense, honestly. Someone called one of our nurses homophobic, which if you knew her personal situation you would see how silly that harsh accusation is. Some say we are all about the money. I think I'll blog on the economics of an IVF centre soon and that will reveal just why IVF is so expensive (spoiler: it's not us being greedy). Many comments are lovely and positive but I see the bias in on-line reports - those who are angry, post. Some of the negative reviews are accurate. We read them and we to our best to act - these reviews come to our risk management committee and our weekly Quality Management meetings so we can learn and get better. I'd rather people email me or call our operations director than post online as it is easier for us to manage their concerns directly.
Also on my mind is supplements. Recently, a patient had a nicer response to IVF drugs when she took an Acai supplement - is there evidence for this? I can't find any but like so many other antioxidants, like reservatrol (emerging evidence), coenzyme Q10 (for which there is good evidence), n-acetylcystine (no good human evidence yet), there is promise. We know very clearly that oxidative damage which occurs are eggs age is the main culprit for poor IVF outcomes in those over 40. I'm going to digger deeper into the supplement issue.
Fibroids are chronically on my mind. I am often consulted as a second opinion by surgeons asking "should I remove this fibroid to improve her fertility?" As time has gone on I have become more aggressive in recommending removal and this practice is supported by a study published this month in Fertility & Sterility that suggests fibroids in the wall of the uterus (called intramural or type 3) > 2cm should be removed before IVF. This is NEW information and will certainly effect my counselling of patients going forward.
Timing of orgalutran start in IVF is on my mind too. We decided to start everyone on orgalutran on cycle day 6 recently. This is a change - we used to decide on starting orgalutran based on estrogen levels on day 5. While there are some exceptions (we try to personalize each cycle), in general we are moving to starting everyone on day 6 as this has been what research has shown and yet another study this month in Fertilty & Sterility supports this shift in practice. I still like to see the day 6 blood because if the estrogen is really high or really low it might sway me away from a fresh embryo transfer.... so many factors we consider as IVF cycles proceed. I think patients sometimes feel like chicken in those old George Foreman commercials that we "set it and forget it" but that's really not the case - we tweak things and consider IVF cycle plans almost daily and certainly with each blood test, ultrasound and patient encounter.
So, lots on my mind while I am on vacation. If there is something on your mind: a concern, a blog idea, just something you've been wanting to ask go ahead and email me (firstname.lastname@example.org) and I'll do my best to help.