Surgeon Interviews
INTERVIEW WITH DR. RICHARD LUCIDI - REPRODUCTIVE ENDOCRINOLOGY
TOPIC: TURNING A COUPLE INTO A FAMILY
Julie: So how does it feel when you have turned this couple into a family and you see them down the road?
Dr. Lucidi: Well, that’s why I do that. That is what makes this whole process worthwhile, especially when they come back later and they bring their children by to show them off, and also when they come back for their second pregnancy. I’ve had patients come from across the country back to see me in order to attempt conception again, so that definitely makes it all worthwhile.
Julie: Any humorous stories you want to share?
Dr. Lucidi: Hmmm... sure! My wife has told me on several occasions that she will be out at the grocery store or at the mall, and somebody says, "Are you Mrs. Lucidi?" and she says, "Yes". "Your husband got me pregnant!" And she says, "You too? Congratulations."
Julie: I am sure she is proud because I am sure she shares that joy with you, when you know you have had that next successful case.
Dr. Lucidi: I am sure she is.
TOPIC: MULTIPLE BIRTHS
Julie: There has been a lot of discussion and debate about multiple births through infertility treatments. Talk a little bit about that.
Dr. Lucidi: Sure. The treatment options we use most frequently are the oral medications. With those drugs, things like Clomiphene, there is a slightly increased risk of twins. With those drugs, triplets and higher are almost unheard of, that is, the “lower tech” treatments. It is the higher tech treatment options where we often get into the multiple births. With the injectable drugs, if we stimulate the ovaries and make a lot of eggs and then do something like have the couple have intercourse or do an insemination, then we have no control over how many of those eggs will fertilize and implant in her uterus. It is because of that that we keep a very close eye on her, when we are doing this type of stimulation, and if she has more than 3 or 4 follicles, 3 or 4 eggs in her ovaries, we will cancel the cycle at that point and tell her “Don’t even think about getting pregnant until your next menstrual period”. The other thing is that with in vitro fertilization we now have the embryos in our laboratory in the incubator and we can control how many embryos go back into her uterus. So most of the higher order multiples that you hear about in the news are not with in vitro fertilization and they are not with the conservative oral medications, they are with that “in between”, and it is that in between area that there is a lot of effort going on into being more conservative and reducing the risks of higher order of multiples.
Julie: I didn’t realize that. I thought they were IVF cases. How do you decide how many embryos to implant when you are in that IVF case? Does that depend on the case?
Dr. Lucidi: It depends on a number of different factors, including the woman’s age. The older she is, the lower her pregnancy rate is going to be. All of these factors are designed, or, all of these factors will determine the risk of multiple pregnancy and the chance of pregnancy, and our goal is to maximize the chance of pregnancy while still minimizing the risk of multiple pregnancy. So, the woman’s age is one factor we consider; so is the age of the embryo. If the embryo has been cultured for three days versus if the embryo has been cultured for five days-- a five day old embryo has a slightly better chance of causing a pregnancy. Also, how the embryo looks-- if the embryo is kind of falling apart, and doesn’t look like it is a very good quality embryo, it has a lower chance of causing a pregnancy than one that looks like it is ready to be put in a textbook as one of the photos. Other things to consider are her history, if she has done IVF multiple times before without success, we might get a little more extra aggressive with an extra embryo, but in general, somebody who is young, less than 35, with good quality day five embryos, we want to put in one embryo, a single embryo transfer. In somebody who is over 42, with poor quality embryos, who has failed IVF multiple times before, in that case we may put in 4 or 5, but in no case would we put in 8 and cause an "Octomom".
Julie: So really the goal is that one healthy embryo that implants. The goal isn’t ever for triplets or twins.
Dr. Lucidi: No, I tell my patients my goal is to get you as many babies as you want, one at a time.
TOPIC: THIRD PARTY REPRODUCTION
Julie: Couples have hope with third party reproduction, as it is called, right?
Dr. Lucidi: Correct.
Julie: Is that something that is growing here in our area? And what types of hope does that bring to couples?
Dr. Lucidi: Absolutely. There are multiple options as far as third party reproduction. Donor again means donor sperm and donor eggs as well as surrogate carriers for women who have had a prior hysterectomy or have a contraindication to themselves being pregnant. The simplest of those options is the donor sperm, and there are anonymous sperm banks where one can get donor sperm relatively inexpensively and easily. A little more involved is using donor eggs because the eggs are harder to get and it is more inconvenient for the female to donate her eggs, but certainly an option and available here in Richmond. And thirdly, the surrogate carrier, as I mentioned, for somebody who has a contraindication or a medical reason why she should not be pregnant or if she does not have a uterus and physically can’t be pregnant.
TOPIC: WHAT TO EXPECT
Julie: If a couple is hesitant to come into your office, what would they expect when they first meet you, and what are the first steps you take with a couple?
Dr. Lucidi: It is usually pretty straightforward, like coming to any physician. We start off by taking a history and doing a physical exam, just as any gynecologist would, since in order to get pregnant you need an egg, a sperm, and a path between them. I have an easy job because I only have to remember three things, but all of our evaluation is geared to those three things. So, we will assess whether she is ovulating with some lab tests, and we will also see what his sperm count is with a semen analysis, and we will check to see if her uterus is normal and her tubes are normal with one of several different tests including things like a hysterosalpingogram which is a test to see if the tubes are open.
Julie: And couples have hopes with third party reproduction as it is called, right?
Dr. Lucidi: Correct.
Julie: Is that something that is growing here in our area? And what types of hope does that bring to couples?
Dr. Lucidi: Absolutely. There are multiple options as far as third party reproduction. Donor again means donor sperm and donor eggs as well as surrogate carriers for women who have had a prior hysterectomy or have a contraindication to themselves being pregnant. The simplest of those options is the donor sperm, and there are anonymous sperm banks where one can get donor sperm relatively inexpensively and easily. A little more involved is using donor eggs because the eggs are harder to get and it is more inconvenient for the female to donate her eggs than males, but certainly an option and available here in Richmond. And thirdly, the surrogate carrier, as I mentioned, for somebody who has a contraindication or a medical reason that she should not be pregnant or if she does not have a uterus and physically can’t be pregnant.
TOPIC: WHAT'S NEXT WITH TECHNOLOGY?
Julie: Where is technology taking you now or how has it-obviously it has changed the way you do your job as you move forward-but what’s next, maybe? Is that a good question?
Dr. Lucidi: Sure. A lot of the technological advances that we have currently are aimed to make it more patient friendly-- the treatments. For example, in the old days in in vitro fertilization we would do the egg retrieval laparoscopically, so it was a surgical procedure where we put a camera into her belly and take the eggs out of her ovaries that way, which meant some down time for her and a lot of discomfort. Now we do it under ultrasound guidance with a very small needle that goes into the ovary. She still gets anesthesia but it is nowhere near as uncomfortable and nowhere near as much down time afterwards. Other advances are the way we give medications, for example, in the old days of in vitro fertilization, we would do intramuscular injections, now most of the injections are subcutaneously which are much less uncomfortable.
TOPIC: HOW SUCCESSFUL ARE THE TREATMENTS?
Julie: How successful are these treatments now these days? I mean, do couples have a lot of hope when they come to see you?
Dr. Lucidi: They do. The treatments are getting better. Every year the success rate with in vitro fertilization improves. It is, unfortunately, not 100%, and it depends on the age of the woman, which is the reason as I mentioned earlier that if she is over 35, we recommend coming in sooner than the one year mark. In general, nationwide the success rate with in vitro fertilization is about 40%, so unfortunately it is not 100%.
TOPIC: CAN YOU REVERSE PREVIOUS SURGERIES?
Julie: So if a woman has had a tubal ligation or if a man has had a vasectomy, can you always reverse that?
Dr. Lucidi: Not always. If she has had a surgical sterilization or if he has had a surgical sterilization, we have two options, one is to try to surgically correct the procedure and reverse it so that she is able to conceive naturally, and the second option is to bypass the obstruction and obtain conception with in vitro fertilization.
Julie: Let’s talk about in vitro fertilization, and the other tools in your toolbox. What are some of the most common things that you are doing now to help couples have the family they want?
Dr. Lucidi: Well we have a full range of treatment options, depending on what the etiology of the infertility or the etiology of the problem is. We can do everything from simple treatments like ovulation induction with oral medications, to ovulation induction with injectable medications, intrauterine inseminations, to in vitro fertilization, and what in vitro fertilization is, is where we stimulate the woman to make eggs and then we take those eggs out of her body into our Petri dish, so we that can fertilize them in the laboratory or in vitro. After we fertilize the eggs in vitro, we now have embryos, so it is those eggs we put back into the uterus, so you don’t need fallopian tubes, just a uterus and functioning ovaries for that to happen.