Welcome to this episode of Fertility Docs Uncensored, where your hosts Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Abby Eblen from Nashville Fertility Center, and Dr. Susan Hudson from Texas Fertility Center dive into what happens when you need to do a second IVF stimulation cycle.We’ll explore the valuable insights gained from a first IVF cycle and how they can shape the approach to a second one. From refining medication protocols and understanding how your body responds to stimulation to adjusting lab techniques and embryo transfer strategies, there’s so much we can learn to optimize outcomes.If you’re preparing for or considering a second IVF cycle, this episode will provide helpful guidance and considerations to make the process as effective and personalized as possible. Join us for an informative discussion filled with expert tips and advice to support your fertility journey. Have questions about infertility?  Visit FertilityDocsUncensored.com to ask our docs. Selected questions will be answered anonymously in future episodes.

Episode Transcript:

Susan Hudson (00:01)

You’re listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you’re struggling to conceive or just planning for your future family, we’re here to guide you every step of the way.

Susan Hudson (00:23)

Hello everyone, this is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I’m here with my amazing astonishing co-host Dr. Abby Eblen from Nashville Fertility Center and Dr. Carrie Bedient from Fertility Center of Las Vegas. Good, good.

Abby Eblen MD (00:36)

Hey everybody.

Carrie Bedient MD (00:41)

Hey, how’s it going?

Abby Eblen MD (00:45)

Just looking forward to spring.

Carrie Bedient MD (00:47)

Trying to get all of the stuff in my yard organized. Like, cleaning up from last year, redoing things. Now that all the holiday decorations have been definitively down, and not just taken out of the yard, but like, actually put away. Taking down in the yard is the easy part. It’s the organization in the garage that takes a while. There was definitely one year where we had like…eight months worth of Christmas decorations and Halloween decorations in the part of our garage that doesn’t get used as much. So yeah, so next step is to make the yard look pretty again.

Susan Hudson (01:18)

So are there certain flowers that you have a springtime affinity for?

Carrie Bedient MD (01:24)

Yes, the ones that I can keep alive.

Abby Eblen MD (01:25)

Which ones are those, Carrie?

Carrie Bedient MD (01:29)

I’ve got a pretty good track record with snapdragons. I’ve got a pretty good record with iceberg roses Mostly because they are harder in hell to kill.

Abby Eblen MD (01:31)

Snap dragons.

In your environment, I wouldn’t think roses would grow in Las Vegas. Really? Huh.

Carrie Bedient MD (01:41)

They thrive. The ones that are finnickier do harder, but like some of the knockout roses and the iceberg roses, like I’ve got, I don’t know, six or seven white rose bushes in my front yard that do well through a lot of benign neglect, really. I go through and I prune them and I try and lavish attention on them, but frankly, I don’t know what I’m doing.

I appreciate that they don’t seem to care that I don’t know what I’m doing and they just like attention now and then.

Abby Eblen MD (02:10)

Well, I love my hydrangeas and also my azaleas. guess those are my two favorites. I guess azaleas are really, when I see those, I know that spring is just around the corner and they’re so pretty because just, the room that I exercise in, they’re right outside the window. So when I’m exercising and they all, all the red flowers pop open, it’s just, it’s really pretty and it just makes me feel so happy because spring is around the corner. And then the hydrangeas are really beautiful too, and they change different colors depending on whether the soil is basic or acidic. And so they’re just really pretty flowers to be able to use and bring inside from the table and all that. They’re very decorative. You can use them in lots of different ways.

Carrie Bedient MD (02:48)

Do you play with your hydrangeas? Like do you put a little bit of vinegar or a little bit of oil or things like that to try to change?

Abby Eblen MD (02:56)

You know, in theory, I would like to do that. Maybe one of these days when I retire, I’ll have enough time to do those things. But right now, I’m just, I’m like you, I just want to keep them alive. I’m sure they’re watered.

Carrie Bedient MD (03:07)

What about you, Susan?

Susan Hudson (03:07)

I am not very good at planting things, however this spring I am wanting to try to create a little rose garden in my backyard. I have this area that we have had these trees and we recently cut the trees down because they unfortunately died and so I’m going to try my thumb at it and if not I will enjoy the wonderful Texas wildflowers.

Carrie Bedient MD (03:18)

Nice.

Abby Eblen MD (03:34)

Hahaha

Carrie Bedient MD (03:34)

That’s awesome. Do you guys have lots of ice plant there, Susan?

Susan Hudson (03:39)

Ice plant?

Carrie Bedient MD (03:40)

Mm-hmm. It’s a type of succulent that is nearly indestructible. I’ve got them around the base of some of my trees and like you put a couple of them in and then they just grow and they’re good ground cover. They spread and they’re green year round and they pop out these tiny little really pretty cute flowers. I’ve got a bunch of purple ones in my yard, but they’ve got white and they’ve got yellow and I think there’s an orangey red one.

They’re almost indestructible. And so that’s always an option for one of your projects.

Abby Eblen MD (04:12)

Okay, so what do the leaves of that ice plant look like? Are they little spiky kind of things? Okay.

Carrie Bedient MD (04:17)

No, they look like elongated jelly beans. Do you remember Mike and Ike’s? Yeah, they’re kind of like the slightly smaller Mike and Ike’s. Yeah. Classic succulents. Yes. Yeah!

Abby Eblen MD (04:22)

Okay, okay.

Yeah.

Okay, okay, and they have little flowers on them. they sound pretty.

Susan Hudson (04:30)

Interesting. I will have to look those up. For those of us who are not green gifted. all right. So we’re going to go for our question of the day today. Hello docs, your podcast is a godsend to soothe my worried mind with information. Thank you for listening. Following my IVF cycle in September of 2022, I had five chromosomally normal embryos present for girls and one boy.

Abby Eblen MD (04:35)

Hahaha

Susan Hudson (04:57)

We transferred the 5AA girl first with a natural cycle transfer and successfully implanted, but the seven-week ultrasound she was gone. Our second transfer of 5BB resulted in our beautiful baby girl, who is now eight months old. She was born via section due to being breech. OB’s suggested not getting pregnant again for at least 18 months to heal the uterus. We want to transfer our baby boy 6BB next. What advice can you give about FET after C-section, timing complications, et cetera? Also, what do you recommend about breastfeeding in the second FET?

Carrie Bedient MD (05:33)

Those are lots of good questions. So looking at some of the considerations for a transfer after a C-section, for the most part, the considerations are pretty much the same as what they were originally after the original FETs. The things you do want to pay a little attention, a little extra attention to, taking the 18 months prior to transfer, if your OB recommended that, is a good idea. There’s a couple reasons for those recommendations. Some of the…the data that’s come out more recently does recommend a slightly longer interval between pregnancies when you’ve had a C-section. Oftentimes when they go in, there’s something that they see as well. And on a first C-section, it’s unlikely that there was uterine wall thinning or a window or some of the things that make us worry about the uterus more, but you never know what they see. And sometimes it’s just the intuition that comes from experience of, you know, I think this one should heal a little bit longer before we do anything. And so if they say 18 months, I would go with 18 months and would definitely do a hysteroscopy, take a quick look inside, make sure that there’s no scar tissue, there’s no inflammation, nothing like that. But a lot of the rest of the considerations are pretty similar to what they would have been with your first FET.

Abby Eblen MD (06:45)

Yeah, and with breastfeeding, one of the things we generally say is we want you to completely stop breastfeeding before you try and get pregnant again. I’m sure you’ve had friends or know people that have gotten pregnant while they’re breastfeeding. That can certainly happen. But, it’s kind of like layers of an onion. We want to do everything we can to give you the best possible chance for successful conception. And so generally we want to make sure that you haven’t breastfed for a month or two until your milk has completely dried up. Usually if you breastfeed for a year, the episodes where you breastfeed your prolactin really just goes up sporadically, doesn’t stay up. But we think that elevated prolactin, particularly if it’s long-term, can cause issues with implantation, or at least that’s the theory. So in terms of timing, that’s the one thing that I would want to make sure that you finish before you plan to do your transfer again.

Susan Hudson (07:30)

A question for you ladies. In general, with somebody who does not have advice from their primary OB-GYN of waiting 18 months, do you normally wait 18 months or do you usually wait about 12?

Abby Eblen MD (07:43)

I usually wait about 12 is what I usually tell my patients.

Carrie Bedient MD (07:47)

I do a minimum of 12. Some of the things that I consider pushing longer, if there were any complications with their surgery, if they’re particularly anemic, that is something that pregnant women tend towards anemia anyway. If you had a C-section, you tend towards anemia. If you are breastfeeding, a lot of your nutrients are going to baby. And so I do want to make sure you’re not anemic going into it. And sometimes that can take a little bit longer along with replenishing vitamin D and just overall nutrition. Keep taking your prenatal vitamins forever, essentially, until you’re done having babies, just keep taking those little suckers. But most of the time, it’s a minimum of 12 months. But after C-section, I do find there’s a little bit higher likelihood of endometritis and some of that inflammation. So sometimes it just kicks out longer anyway, because we’re fixing issues before we get started.

Abby Eblen MD (08:17)

Yeah.

Susan Hudson (08:35)

Very good.

Carrie Bedient MD (08:37)

Also, if they’re coming back for a repeat, they have a small human being at home and their life is not nearly as regimented perhaps as what it once was the first time around. So a lot of people end up delaying anyway because children.

Susan Hudson (08:50)

All right. Well, kind of on the note of second time around, today we are going to talk about a second IVF stimulation cycle and what are some things that we should consider? What are some things that we learn from that first IVF cycle that can have implications if you’re needing to do a second IVF stimulation? So let’s first of all, talk about why would anyone want to do a second IVF stimulation? There are multiple reasons.

Abby Eblen MD (09:24)

Yeah, I would say the biggest reason would be if unfortunately you only had one normal embryo from your last cycle, you transferred it, you had a baby, and now you want to have a second little human being, in Carrie’s words. That would be a reason to go back through again to make more embryos basically.

Carrie Bedient MD (09:40)

I think it’s because people like our offices so much. They just want to hang out with us because we are such cool people. Another really common reason to do a second IVF cycle is because you need more embryos for whatever reason. And that can be because your first cycle did not yield any. It can be because you did get embryos, but they were all genetically abnormal.

Whatever that may mean, whether it’s abnormal PGT-A, abnormal PGT-M, whatever abnormality, they’re not usable. You don’t have any left from transferring them. Your family planning, this is a big one that we’re starting to see more and more. So for example, I’ve got a patient who she knows that she wants a big family and she came to me right at 35. And so we have worked really hard and have done several cycles in order to get enough embryos for the size family she wants while also considering that her egg quality is pretty poor. We were gonna have to do IVF anyway, but we have done quite a bit more because she knows that she wants as many small human beings as she can possibly get. And that’s taken quite a bit of work.

Abby Eblen MD (10:42)

And a side note about that, and it seems like some of the insurance companies have changed a little bit. So if you have coverage, just really make sure if you want to do egg banking, make sure that you have coverage for that. So just check with your insurer and make sure that before you start into that cycle that you know you have coverage for it.

Carrie Bedient MD (10:58)

To add onto that, it is important if you are thinking about banking and you are so fortunate as to have coverage, that you know what the rules are. Because many insurance companies, regardless of the company, will say, once you hit X number of eggs or X number of embryos, they will not cover anything else until you transfer. So for example, I’ve got a cancer patient where we know exactly what the rules are and so we’re using them to maximize what we can get for her because that will be her option and nothing further. And it also takes into consideration, we’re gonna get embryos on her where we originally planned on getting eggs because that allows her to maximize her benefit. And it also works within the pattern of her life. It was just making sure she knew hey, this is how you maximize this benefit versus doing this.

Susan Hudson (11:47)

So going into a second IVF stimulation, I would have to say we do have a strategic advantage because when we’re doing your initial stimulation, we’re having to base all of our decisions on your testing and our experience. And in our second stimulation, we get to add a very important caveat and that is your first stimulation. So what are some things that we learn during a first stimulation. We’ll focus on the stimulation part first. We’ll go to embryology later. What are some things in the stimulation that we may tweak in a second stimulation?

Abby Eblen MD (12:32)

I think when we do a stimulation, we look at the average person that’s your age and the average person that has your egg number and the average person that has an antral follicle count like you do. But what we don’t really know, like Susan said, is how you are going to respond. I would say we hit it correctly 85, 90 % of the time, but there’s probably five to 10 % of the time where we start to stimulate a patient with the dose of medicine and the kind of medicine that we think is going to be helpful for them.

And we find out pretty quickly that, wow, we need a lot more medicine. Like they go for four or five days and they come back in for a monitoring visit and all of a sudden we see their estrogen level may be really low and maybe we need to really jack up the dose of medicine or maybe the opposite. Maybe you come in, you come in really fast, hot and fast. And it turns out that, that you come in really with a real high estrogen level and we were like, wow, her ovaries are going crazy. Let’s tweak it down a little bit. So we really just get a better sense of how you as a person respond and not the average person like you responds basically.

Carrie Bedient MD (13:30)

We look at, medication absorption and see there are things that we’re tending to look at that in the first cycle as well, but there’s a difference between having to react to information received versus be proactive on that information. So like Abby was saying, we may find out from the first cycle, you you’re really coming in hot or really slow and we need to adjust. The other thing is sometimes we’ll know, all right, do we think a pretreatment would make a difference where otherwise we maybe didn’t or a different type of pretreatment? Not everybody needs pretreatment. It’s not like painting a house where you have to pretreat otherwise you’re going to get terrible results. There are some patients where you don’t need to prime everything ahead of time. So we learn that information. We also learn how long you are likely to go.

And if that needs adjustment, medication levels either up or down. And we learn what kind of a response to a trigger you have. And that’s a big one because there’s a couple different types of triggers. There’s the HCG trigger, there’s a Lupron trigger. And knowing what your levels are, knowing how you respond, knowing what the correlation is between the number of follicles that you had growing with the number of eggs we got out with the number of mature eggs that came from that is really helpful because if we’ve got someone with a particularly high follicle count who got very few mature eggs, they may have had a stim that looked very pretty and very textbook, but that low mature number of eggs means we’re gonna make adjustments based off of that, just looking at the straight numbers from the stim we’re like yeah this is fine but once you actually know some of those details you you have a better capacity to adjust.

Susan Hudson (15:18)

Good. Now that’s a great segue going into things that you might change at egg retrieval. So what are some things that we could learn during an initial egg retrieval that you might change for a second egg retrieval?

Abby Eblen MD (15:32)

Well, like Carrie said, you might want to have a patient on a medicine called HMG that has both luteinizing hormone and also has FSH and it helps with the maturity of the eggs. The maturity eggs can be really important and the same thing goes for the trigger. So when we trigger patients, a lot of times we use Lupron to trigger patients because it really decreases the risk of things like hyperstimulation syndrome. In other patients, if they have poor maturity and say their egg count doesn’t get very high or their estrogen level doesn’t get very high, then we may want to trigger them with something like Ovidrel because Ovidrel sometimes will help with the maturity of the eggs.

Carrie Bedient MD (16:05)

One thing that we can learn at egg retrieval is, is there any barrier in getting those eggs? So sometimes you’ve got someone who’s got a very active bowel pattern and it’s really hard to get to the eggs or the ovaries are up high or what I find is probably the most valuable piece of information is let’s say I’ve got a set of ovaries that look perfectly clear, but I go in and I get endometrioma material back out because there are some cases where you don’t get any advanced warning that there’s endometriosis going into retrieval. And when you get that fluid back out, all of a sudden, everything clicks into place of why she’s having difficulties getting pregnant, why I’m not getting as many eggs as I feel like I should, why the eggs that I am getting are not quite as good quality. It can really click a lot of things into place and will help us inform what we do with the next retrieval and medication cycle of, maybe we need to push even harder with her than we otherwise think we would to overcome that.

Susan Hudson (17:06)

Two additional things that I think about is number of hours of trigger. Now there is a relatively wide amount of time that we have in leeway, usually between 34 to 38 hours are well accepted ranges of trigger times. And the thing is, is that some people are going to fall outside of that norm. There are some people who may prematurely ovulate and they may release eggs sooner than we would expect. There’s other people who we go in and we may have lots of follicles and we may have trouble getting eggs out or when we do get them out they may be less mature and so it may have been they haven’t had quite enough time to do the thing that they would normally do in a shorter amount of time and those are things that we don’t know until we’re going into that stimulation.

I do think that there is something to be said about the actual texture of an ovary.

Abby Eblen MD (18:03)

A knife and butter, that’s good.

Susan Hudson (18:05)

Exactly, if we put in the little needle and it slides right in versus if we have to kind of puncture at the ovary and to get into the different follicles, those can be signs of ovarian aging that we don’t have any other way and it’s one of those things that we’ve learned through experience. Now when we’re looking at what happens in the lab, so in the embryology lab between day zero, the day of retrieval, day one, the day of fertilization, day five, six, and seven, the days that you may have embryos biopsied, you may have embryos cryopreserved, or you may have a fresh embryo transfer, what are some things that we learn during those seven days that can have an important impact on a future cycle?

Abby Eblen MD (18:55)

So within the first 24 hours, what we can learn first of all, after we get the eggs out, as Carrie always says, it’s like a funnel effect. So not every egg is gonna continue to grow and fertilize. And so the very first thing that sort of decreases your overall usable number of eggs is how many are mature. And so it’s not too awfully uncommon that you can get somebody that looks like they have lots and lots of eggs and we get a good number of eggs out.

But sometimes they have a small number that are mature and a lot of them are immature, meaning they just haven’t really kicked out the right number of chromosomes in order for the sperm to fertilize. And unfortunately, people have worked on this for years to try and find ways to mature the eggs in the lab and nobody really has done it effectively. So unfortunately, a lot of those eggs that are immature, we won’t be able to use if they don’t mature over the right amount of time in our lab. And so…We find out that, and I do think there’s certain groups of patients, like some people would say PCOS patients tend to have less mature eggs. And so going back to what we were talking about just a minute ago, those are the kind of patients that once you find that out, you’re like next time around, you’re like, we need to really try and push her if we can a day longer with more medicines to see if we can get those eggs to mature. Even though the follicle, the fluid filled sac looked like it was the right size, the eggs that we got out, we know are just under ripe, not mature. And so that’s something you can learn. The other thing that you can learn, is how well fertilization goes. And so we put the egg and the sperm together that day and then about 18 hours after fertilization, we know how many of those eggs have fertilized. And we do expect about 30 % drop off there. We expect about 70 % fertilization for most people. And if you have a significantly lower percent that fertilize, then that kind of makes us want to look, is it an egg issue or is it a sperm issue?

Carrie Bedient MD (20:37)

I think PGT-A + can be really helpful in knowing whether or not it was, originating in the sperm or the egg. If you’ve got aneuploidies where you’ve got too many, too few chromosomes. It’s always really interesting to see what do the eggs look like? What do the sperm look like? Because going in, we’ve got your FSH and your follicle count and your AMH, but that’s kind of it. And then we know, all right, well, how’s she responding to the medications to grow the eggs? Once we actually get the eggs out, we get actual feedback on what do they look like? And some of that feedback is interesting, but doesn’t necessarily translate to anything, meaning you have grainy eggs, or there’s lots of vacuoles, or there’s increased space. Multinucleated, there’s increased space between the outer barrier and the inner good stuff. And then there are other things that really do tell us more information of, let’s say they go to do ICSI to put the sperm in, and there’s just no elasticity in the membrane or it just starts to degenerate immediately. Those things let us know more directly about egg quality. Same with sperm quality. When we get a semen analysis, especially if it’s coming from a commercial lab, not our individual labs, we know what those numbers are, but we’re poking and prodding and working with that sperm to push it just a little bit more. And so, for example, you may have absolutely beautiful numbers on a commercial lab semen analysis, but when it when the sperm gets to our lab and we’re separating it out, we may see, okay, yes, technically you do have 50 % of your sperm moving, but there’s really maybe 1 % of Olympic swimmers in there as opposed to the 20 plus percent that we would expect to see in any other sample. And so it gives us a little bit more information from the people who do this day in and day out of yes, this is behaving normally or no, it’s not.

Susan Hudson (22:27)

So it’s just an important piece of the people who know the next field of the behavior is, they see what’s the end product. Because you put all the things that you want to put there, and them in there. So that’s the end product. And I don’t know if going to to ask you a question, but want to know just how do the items look in there? And how do you answer that? I just want to know.

Carrie Bedient MD (22:29)

Just as importantly, these are the people who not only see what the behavior is, they see what the end product is. Because the embryologists are working with the egg and the sperm and they’re putting them together. so, for example, I always ask my embryologists, how do the eggs look in the middle of the table? And they always give me an answer, usually of, don’t really like them or yep, they look good. And every last one of them is like,

Carrie Bedient MD (22:53)

You know we’re just telling you this and it has absolutely no bearing on anything, right? And I always say yes, but I’m asking anyway, just because it’s the information we can get. But a lot of that information is useful, but a lot of that information is just information.

Abby Eblen MD (23:08)

It’s nice to ask the embryologist because I think the grade, and we talked about this before too, is a little bit antiquated in the sense that back in the day before we had anything other than just seeing how pretty it was on the outside, there was no other way to grade to pick the embryo that you were gonna transfer. Now we know what’s on the inside and the outside, which is helpful.

But it’s also helpful to have that human part of it too, where the person who’s done this for years and years and years looks at it and goes, no, just, their sixth sense tells them this is not as good of an embryo as this other one, even though it has nothing to do with the grading or with the genetic part of it.

Susan Hudson (23:41)

I think it’s great whenever our embryologists are able to give us comments about the eggs because we do our testing. We do our ovarian reserve testing, the antral follicle counts, anti-Mullerian hormone or AMH levels, the FSH or follicle stimulating hormone levels. But there’s something to be said about looking at all of those characteristics that you mentioned. And that helps me if I know in a future cycle, maybe I should pre-treat with things like CoQ10, maybe we should look at using things like growth hormone or Omnitrope to improve egg quality. We know that our hands are somewhat tied when it comes to egg quality, but there are a few things in our armamentarium. And the nice thing is to know that some of these things take a few months to take effect. Just like when we’re looking at improving sperm function and we’re giving all those great antioxidants, it takes, two to three months to have an impact for that, of the supplements and additives that we add on to the stimulation, we need to have time to prepare for that. And so sometimes when you’re going through that second stimulation, you may mentally be like, okay, I’m ready to go right now. And your doc may say, I know you’re ready. And that’s great. We really want that kind of forward driving power, but we need to take a little bit of time to actually have an impact in what we’re going to do this next time.

Carrie Bedient MD (25:09)

Absolutely.

Susan Hudson (25:09)

All right, so what are some other things that you can think of that we may learn from a first stimulation that gives us a strategic advantage in a second stimulation?

Abby Eblen MD (25:20)

From a patient perspective, I think when somebody’s done IVF a first time versus a second time as a general rule, I think they’re a lot more calmer, a lot more laid back. I mean, anytime you’ve done something, and it’s scary to do IVF, I’ve done it too, and it’s scary because you don’t, I sort of knew what to expect, but you don’t really know personally how it’s gonna make you feel, and I think people get really nervous about that.

I find that when I see a patient a second time, almost universally, everybody is much more laid back, much more relaxed. They know what to expect and they know it may be a little uncomfortable for day or two, but it’s just, there’s less of the fear of the unknown the second time around. So I think for most patients, it’s a much easier process the second time around.

Carrie Bedient MD (25:59)

I would absolutely agree with that because they know there’s not the same fear of the needles, of the medications, of the timing, of the procedure, of how they’re gonna get information and when they’re gonna get information. And so that knowledge and expectation, no matter how well we counsel upfront, knowing that because you’ve been through it the second time makes people a lot calmer. Also times like…think that they’re a lot more receptive when we say, hey, maybe you go find a counselor, a therapist, somebody who can give you an extra hand during this because they realize, this is not the sprint I thought it was gonna be. This is a marathon. Having an extra coach in there might not be a bad idea. And so it helps them to pull in some additional resources because they’re a little more open to, okay.

You you may have mentioned that before, but now I see a little bit more why you said that. And so, okay, let’s do, let’s try this this time.

Susan Hudson (26:53)

All right, good stuff. Well, I think we covered a lot of great information today. And to our audience, thank you so much for listening and subscribe to Apple Podcasts to have next Tuesday’s episode pop up automatically for you. Also be sure to subscribe to YouTube.

Carrie Bedient MD (27:08)

Visit fertilitydocsunsensored.com to submit questions and sign up for our email list too.

Abby Eblen MD (27:14)

And as always, this podcast is intended for entertainment and it’s not substitution for medical advice from your own physician. So subscribe, sign up for emails, and we’ll talk to you soon.