Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, our docs take a deep dive into one of the most pivotal decisions in an IVF cycle: when and how to trigger for egg retrieval. They break down the thought process behind choosing between an HCG trigger and a Lupron trigger, explaining why the choice isn’t one-size-fits-all. One of the biggest advantages of a Lupron trigger is its ability to dramatically reduce the risk of ovarian hyperstimulation syndrome (OHSS), a key consideration for patients with a high response to medication. But Lupron doesn’t work for everyone. The docs explain why patients with hypothalamic amenorrhea must use HCG to ensure proper follicle release, and why a fresh embryo transfer also requires an HCG trigger for optimal luteal support. The docs also discuss the many clinical clues that guide trigger timing. These include a patient’s historical response to stimulation, whether they’re planning a fresh or frozen transfer, and crucial hormonal cues such as a drop in estrogen that can signal impending ovulation. They even share how sometimes they bring patients into the office for an ultrasound on retrieval day to confirm that spontaneous ovulation hasn’t occurred. Finally, they cover the selective use of combined HCG + LH triggers, and which patients benefit most from this approach.  This is a must-listen for anyone wanting a behind-the-scenes look at how reproductive endocrinologists make one of the most important calls in an IVF cycle. This podcast was sponsored by US Fertility.

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.

Carrie Bedient MD (00:22)

Hello everyone and welcome to another episode of Fertility Docs Uncensored. I am one of your hosts, Dr. Carrie Bedient from the Fertility Center of Las Vegas. And I am joined by my two absolutely beautiful, caring, dynamic, excellently fabulous co-hosts, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (00:41)

Hello! everyone.

Carrie Bedient MD (00:42)

and Dr. Abby Eblen from Nashville Fertility Center.

Abby Eblen MD (00:45)

Hi, how’s everybody doing?

Susan Hudson MD (00:47)

Doing good.

Carrie Bedient MD (00:47)

Good. What have you guys been up to?

Susan Hudson MD (00:53)

Working, working, we’re working.

Abby Eblen MD (00:56)

Busy busy.

Carrie Bedient MD (00:57)

I had lunch with friends the other day and in my family I’m known as very on top of all the work stuff. I’m very on top of all of the things that have to get done. But when you start introducing more extraneous things, that’s where, like, that’s kind of the conscious decision.

I’m not going to be on top of everything because I’m going to focus on the things that are good. I was supposed to meet friends for lunch and I’ve been listening to this podcast called Mobbed Up, which is all about the mafia history in Las Vegas.

Abby Eblen MD (01:26)

Well, if you live in Las Vegas, I think that’s legit. You probably want to know some of history where the dead bodies might be.

Carrie Bedient MD (01:30)

Oh, 100%, 100%. I’m listening to this and as I’m listening, I’m supposed to meet my girlfriends at the Pepper Club. And as they’re talking about this, and this is on my way into work before I go meet them, because it was a Saturday.

Abby Eblen MD (01:46)

What’s the Pepper Club? Okay.

Carrie Bedient MD (01:47)

You’ll find out. So I go to, I’m supposed to meet them at the Pepper Club. So I’m listening to my podcast as I go to work that morning and they’re talking all about Tony Spallatra and Frank Culotta, like big time gangsters in Vegas history and how they used to meet at The Pepper Mill and how they would do this and that and all those things. And it’s an old time Vegas gangster hangout, blah, blah. And so I go to work, I do my stuff, I get out, I program my GPS, so that I can get down there and head my way down to The Pepper Mill. I get there and I’m looking around and I don’t see them. The place is absolutely packed at 10.30 a.m., which anything packed at 10.30 a.m. in Vegas has gotta be good. I’m looking around, I’m like, where are you guys? And they said, oh, we’re to the left when you walk in. Oh, okay. So I go over to the left and I walk into the fireside lounge, which at 10.30 in the morning is dim, neon everywhere.

People dressed in all manner of clothing and in the middle of the room there’s this sunken, think old time 70s, 80s living room, sunken area with chairs and there’s a fire pit in the middle surrounded by water, surrounded by a table and everybody’s there drinking, talking, laughing, whatever and I’m like, where are you guys? No, no, they were at The Pepper Club. I was at the Pepper Mill. Yeah. So I got in my car and I drove to this very lovely old English hotel.

Susan Hudson MD (03:01)

Pepper Club, not Pepper Mill.

Abby Eblen MD (03:03)

Hahaha!

Carrie Bedient MD (03:10)

And beautiful little courtyard garden, very much more a place where you would meet your girl friends for lunch than The Pepper Mill.

Abby Eblen MD (03:17)

So The Pepper Mill still exists then, so that’s cool that you went there.

Carrie Bedient MD (03:21)

very much so. Very much so. And it’s clearly a hopping place that supposedly has really good food, so it’s actually on my list. But now I have no idea when to go there because if they’re that busy at 1030 on a Saturday morning…

Abby Eblen MD (03:27)

Really? Mmm, more than food goes on there, I bet.

Carrie Bedient MD (03:38)

I have no doubt at this point. But Las Vegas is a lovely place to live. There’s never a dull moment. Mm-hmm. Mm-hmm. Yes.

Abby Eblen MD (03:40)

Hahaha! Lots of history, good and bad. ⁓

Susan Hudson MD (03:49)

I remember one time when Brook and I went to New York, it was a long time ago. Actually, it was right after 9/11 happened. Back in the day, whatever big cities, they would have these little brochures. They were booklets and they had all kinds of restaurants and things to go do. They were free. You got them at the hotel and stuff like this. And so we had one of those and we wanted to go eat Italian food. And this one particular restaurant wasn’t too far from where we were staying, I can’t remember the name of it, but what I do remember was it was endorsed by Regis Philbin. You remember like from Regis and Kathie Lee? Long time ago. And I was like, this is kind of cool. So we go there and it’s a gigantic restaurant. Huge, huge, huge. And needless to say, because it was right after 9/11, and I mean, right after 9/11, there weren’t many people there. I think…in the front part of the restaurant where my husband and I sat, there maybe were two or three other couples. But in the back of the restaurant, it wasn’t blocked off, but they had this long table. And I bet there were easily 30 people sitting at this table. And it was everything you possibly imagined from the Sopranos.

Abby Eblen MD (05:07)

Wow. ⁓

Susan Hudson MD (05:09)

I am not kidding. I was like, wow, that’s impressive. It was great people watching. What can I say?

Abby Eblen MD (05:16)

Hahaha

Carrie Bedient MD (05:16)

Amazing. I love that. Okay, so now everybody knows where to go if they go to New York or they go to Las Vegas and they need good people watching. But before then, what is our question of the week, Susan?

Susan Hudson MD (05:17)

Mm-hmm.

Our question of the week. I’m 29 and trying to conceive for the past 15 months. Tests are all normal, TSH is 3.08, but antibodies were negative. I ovulate on my own, husband semen analysis was all great except morphology was only slightly below the target. I am now my fourth IUI with Trigger and just had an IVF consult. We want four children, ideally wanted to conceive without IVF. I went to the consult pretty…ready to move forward, but the doctor made me feel like I’m rushing into IVF too fast. What would you recommend?

Abby Eblen MD (06:01)

I think the one key piece of information, she said right up front, I want four children. And so at 29, even if you want four children at 29, IVF is not a bad option because you are truly freezing your reproductive abilities. And so, if you make embryos with your partner and you know that you have a genetically normal embryo for every one of those, you have around a 65 % chance of an ongoing pregnancy. And so at age 29, there’s a really good chance that you could have three or four normal embryos and therefore may not have to do anything other than that one retrieval cycle.

Susan Hudson MD (06:37)

One thing you might want to think about, and this would be a caveat with an additional test, is statistically most people aren’t going to get more than three to four chromosomally normal embryos. There are the exceptions to the rules. We’ve all had people who had 10, 15 normals, but that’s not what we ever expect. And so if you end up with three or four normals and you’re wanting three or four children, what you may want to do is one, make sure that there’s not an additional sperm issue that could be determined by a test called Sperm QT. Sperm QT looks at genes within the sperm that can become what we call dysregulated or abnormally turned on or off. And if you have a high amount of dysregulation, then you really probably do need IVF for that sperm factor because essentially you could have millions of sperm, they get to the egg and they don’t know how to press the doorbell.

So we use ICSI where we inject the best looking sperm into each egg to bypass what the sperm don’t know how to do. Once they get into the egg, they can complete their thing. But if you ended up back to my original statement, if you ended up with three or four normal embryos, you had a normal Sperm QT afterwards. If you wanted to try a few more IUIs to get a child now and use those other embryos for backup, sometimes people choose to do that.

Or you can just transfer your embryos.

Carrie Bedient MD (07:55)

The key phrases in here is you, like Abby said, wanting four kids and you being a point where you’re saying, we didn’t really want to conceive by IVF, in which case you are absolutely not alone. Nobody wants to conceive with IVF. And that your doctor made you feel like you were rushing because that’s not really our decision to make as doctors.

We can of course offer advice and we should offer guidance based on data and experience and all those things. But there are patients who will walk into our office who say, I want to do IVF now, never do any IUIs. And that is absolutely the right decision for them. Even if it’s not medically indicated because they’ve got blocked tubes or very low sperm counts, there are some patients where they are just of a mindset, life goals, whatever it may be where going to IVF in that moment of time is the correct thing to do for them. And so I think at this point, you’ve done four IUIs, that is a very legitimate effort. That’s not like you looked at a prescription, a Clomid and said, okay, I’m good. You’ve put in the effort, you know that you’re ready to try and do the thing that you didn’t really do in the first place, which means you’re not rushing into it. And you do want four kids. And so, it makes all kinds of sense to go at that point. Think about it, make sure you truly aren’t rushing into anything. Maybe that doc picked up on something that we don’t know just from a written question, but I think, I think if you’re ready after four IUI’s that’s a legit decision. Yeah.

Abby Eblen MD (09:21)

Valid, yeah.

Susan Hudson MD (09:23)

Another thing to know, and your doctor may or may not have explained this to you, and this is great for our listeners to know, is that when you’re doing ovulation induction with IUI, and so also when you are saying you’ve done IUIs, we are all assuming that you used oral or oral plus injectable medications because IUIs on their own really have very minimal if any increased chances of success in somebody with a normal semen analysis. So it’s really using the combination of ovulation induction with IUI. Those two things married together is where we drive up our success rates. When you are looking at IUI success rates with ovulation induction or super ovulation, then we know that after three to four cycles, your odds plateau. And so it’s not that you can’t get pregnant, but we’re not having any major growing forward momentum. And so it was very reasonable for your doctor to discuss it. Again, final decision goes for you. I mean, we’ve all had people who are like, okay, you’ve talked to us about IUI. We really don’t want to do it. We’re going to do another two, three cycles. We’re going to sit down and talk about it again if we get past that and still not pregnant. But after three or four cycles, having that conversation is very appropriate.

Carrie Bedient MD (10:41)

Absolutely.

Susan Hudson MD (10:45)

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Carrie Bedient MD (12:07)

All right, so let’s talk about a question that is a, wait for it, trigger question of what kind of factors go into the decision of when to trigger someone, what to trigger them with, all of those types of things. Start with the basics as always. Susan, what is a trigger shot? When we say trigger shot, what are we talking?

Susan Hudson MD (12:31)

When your follicles are developing and they are getting bigger and bigger, different changes are happening within those follicles that we can’t see that are helping the egg develop into an egg that can possibly accept a sperm. Now, the final part of that process, it is dependent on trigger whether it comes from your brain or from an injection and that signal, signals to the ovary to help the egg finally mature and if you left it alone for the follicle to open up and you ovulate. Now in IVF we specifically time these things so that we can get maturity without that ovulation but those things go hand-in-hand.

Carrie Bedient MD (13:21)

Abby, in the body without any IUI IVF medications, anything like that, what actually is the trigger? What signals it and what is the trigger itself? Just like in the body, no meds.

Abby Eblen MD (13:36)

What happens in the first half of the cycle is that egg starts to grow, it produces estrogen, and as the egg starts to get bigger and bigger and bigger, the brain is primarily producing the hormone FSH, or follicle-stimulating hormone, and that helps the egg to grow. As the egg grows and gets bigger, close to the time when the egg is mature, your brain starts to also secrete a second hormone called luteinizing hormone, and that’s the hormone that ultimately, over the course of somewhere between 24 to 48 hours, that starts to secrete in large quantities and it sends the signal to the ovary that it’s time to release the egg. So the egg sac, the follicle breaks open and the egg comes out. If we try and give you a trigger and say you forget to take it or you somehow don’t get the trigger, then a lot of times that egg will be stuck in the follicle and doesn’t come out very easily until your brain produces enough of that hormone. And so sometimes patients can secrete their…own hormone before the trigger, and we give you medicines to try and prevent that, but if that were to happen, sometimes you can actually ovulate before you go in for the egg retrieval. That’s really uncommon for that to happen, but that’s a possibility. And so it’s really important of the timing when we give it to you in an IVF cycle, because it helps the egg, as Susan said, go through the final maturation so that when we go in to try and retrieve the egg, it will come out, but we don’t want to do it at a time when you may have already, or you’re just about to ovulate, or may already have ovulated before we go in to do the actual egg retrieval.

Carrie Bedient MD (15:02)

Susan, let’s take a tiny little detour. Can you go through very briefly, what are the ways that we make sure someone doesn’t ovulate before we’re ready to give that trigger?

Susan Hudson MD (15:12)

There’s a couple of ways that we do this. There’s a couple of medications that we use. Historically, one of the oldest ways was for us to use a medicine called Lupron or leuprolide. And we would start that either a week before or right at the beginning of stimulation. It’s another injection. And essentially this Lupron helps suppress the brain from stimulating the natural LH surge, which would cause eventual maturation and ovulation. As technology and techniques have changed over the years, more and more people are using what we call antagonists, which is a different category of medicine from the Lupron. The Lupron is an agonist. A lot of us are now using antagonists.

And those are often started either when follicles get to somewhere between 12 to 14 millimeters or get to a certain estrogen level somewhere, I would say between 300 and 600. But there’s a lot of variability on where people make that call. So we do that. And now in people…who are going through cycles, are often using an oral medicine called Provera or medroxyprogesterone acetate, which for those of you who may not have regular periods, we sometimes give to you to make you have a period. But if you start that at the beginning of your stimulation cycle, it’s also very effective in helping prevent ovulation.

Carrie Bedient MD (16:52)

Abby, what is one medication we can give to trigger ovulation?

Abby Eblen MD (16:57)

We can give hCG to trigger ovulation because hCG, when you get that in the form of injection, it actually binds to the luteinizing hormone receptor. So your body sees it basically as the same hormone that you would normally secrete on your own from your brain if your egg was ready to be ovulated.

Carrie Bedient MD (17:13)

And, Susan, what’s another trigger med?

Susan Hudson MD (17:16)

Well, that wonderful Lupron that we were just talking about. And so it has multiple purposes. When you receive Lupron, initially you produce more hormone from your brain, especially that LH, and then it shuts down. And so if we use it in different dosages throughout different parts of your cycle, we can be very specific on what we want it to do, whether it’s to prevent ovulation or to make ovulation happen. Now, a very important thing to remember is if you’re using it to prevent ovulation, you cannot use it to cause ovulation. It doesn’t have that same effect. So a major reason why we have gotten away from using Lupron as an ovulation preventer is that a lot of times we use it to trigger that ovulation and thereby it helps down the road prevent a condition called ovarian hyperstimulation syndrome or OHSS.

Abby Eblen MD (18:22)

Yeah, and I would echo that that is a huge, huge, huge benefit because before we realized that you could use Lupron in that way, and it did shut down hyperstimulation syndrome, I mean, we would have several people a month that would come in with hyperstimulation syndrome and several people a year that would have to get admitted to the hospital. So giving a Lupron trigger works fabulously, particularly for young women who have really high estrogen levels, because as we start to grow the eggs, the eggs grow together and as they grow together, they start to make lots and lots of estrogen. So young women are really at big risk for hyperstimulation syndrome, particularly if they have high estrogen levels and that Lupron trigger does a fabulous job of shutting all that down and really minimizing the risk of hyperstimulation syndrome.

Susan Hudson MD (19:07)

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Susan Hudson MD (19:41)

For our listeners who are like, my goodness, I’m getting so confused on when you use Lupron when you use it in different types of situations, know that in our book, The IVF Blueprint, we have a whole chapter. What chapter, ladies, is it that we talk all about medications?

Abby Eblen MD (19:46)

Hahaha

Chapter three, Will the meds make me crazy?

Carrie Bedient MD (20:01)

There’s also the stimulation meds, which is chapter seven?

Abby Eblen MD (20:04)

Carrie is going to figure it out for us.

Carrie Bedient MD (20:06)

Chapter three and chapter seven are gonna be the two big ones. And then we also talk about the medications we use for transfer in 13, and that’s got some Lupron stuff in it too. So it’s scattered all throughout the book because it’s all throughout the book, which is part of the reason why it’s confusing, but a delightful, helpful med. And not everyone may think that it’s delightful because it can cause hot flashes and mood swings, and it doesn’t necessarily make you feel amazing.

Abby Eblen MD (20:19)

Hahaha!

Carrie Bedient MD (20:33)

But when it’s a baby you want, what we’re going for, it is a very valuable medication.

Susan Hudson MD (20:39)

Absolutely.

Carrie Bedient MD (20:39)

So what of these two medications if we’re talking about an IUI trigger? Which one of these are you going to use for an IUI trigger?

Susan Hudson MD (20:48)

We’re going to use an hCG trigger when we’re doing IUIs because if you use the Lupron, it can change the endometrium and make it not hospitable for implantation or a little embryo to nestle into the lining of the uterus. So that’s what we would use with an IUI trigger. And that’s what we would do if we’re doing a fresh transfer, although a lot of people are doing fewer and fewer fresh transfers out there and hCG trigger is generally what’s recommended. There’s a few doctors out there who will do a Lupron trigger and try to do some rescue medications, but I don’t know how effective that is.

Carrie Bedient MD (21:29)

So Abby, sticking with IUIs for the moment, when would you give a trigger in the setting of an IUI cycle?

Abby Eblen MD (21:37)

So generally in IUI cycle, we bring patients in to look and make sure that the fluid filled sac around the egg, the follicle, looks like that the egg contained inside is mature. So we measure the size of the follicle. Generally if it’s 17, 18, 19 millimeters, somewhere in that range or higher, we would go ahead and have the patient take the trigger shot. And then ultimately in our practice, we have patients come in around 24 to 36 hours later for the actual IUI procedure.

Carrie Bedient MD (22:02)

Okay, and that can definitely vary from practice to practice. Like in ours, we tend to go a little bit later on that one. Like we’ll give more hours between the trigger, usually somewhere prior to 40-ish, give or take a little bit. Susan, if you’re giving a trigger for an IVF cycle, how do you know when to give that trigger?

Susan Hudson MD (22:20)

The major determination is going to be based on the size of the follicles, just like we talked about with IUIs. Based on knowledge out of Fertility Center of Las Vegas and some of their great papers, we also know that back in the day, we used to trigger around 18. And we tend not to do that. We tend to let follicles get bigger, 22, 24, 26, even sometimes close to 30 because we’re looking at the entirety of the cohort and the bigger we can get them and there’s a sweet spot and everybody’s gonna be different and some of it depends on how quickly your follicles are growing. If you are older or have diminished ovarian reserve, your ovaries tend to be a little less predictable and things can go from 20 to 28 overnight sometimes.

When they have ovulation, if you’re younger, have great ovarian reserve, we tend to have a little bit more leeway. And so that’s generally what we’re going to do. We’re going to base it again on the size of the follicles, but we’re going to let those follicles get bigger than necessarily with IUI because not only are we looking at the leads, but we’re looking where is the majority of your cohort of follicles to give us the best chance of getting more mature eggs without getting into that ovulation period.

Abby Eblen MD (23:41)

I think sometimes patients will go, well, wait a minute, I only had three eggs. Why did you trigger when I only had three eggs? Because I had five other ones. Well, if the five other ones are really small, like less than 10 millimeters, and the three are maybe 18, 20, 25 or something like that, then we know that if we push you further, we run the risk of you losing all three of the big follicles. And the small follicles may be so small that we know that they’re not going to grow enough to ever make a mature egg.

Sometimes when I see patients and they come in, they’re like, I just don’t understand, I had eight eggs and you only are saying I’m gonna get two or three and that’s why, because the size of the eggs really matters in terms of trigger and in terms of having a mature egg at the time of retrieval.

Carrie Bedient MD (24:24)

So what are the differences in the instructions that we give in trigger between an IUI and an IVF cycle? Like what’s kind of a characteristic set of instructions for an IUI versus a characteristic set of instructions for an IVF trigger?

Susan Hudson MD (24:40)

Generally with trigger with IUI, we encourage you to have intercourse. And for IVF, we really don’t want you to because we don’t want you to accidentally get pregnant with a plethora of babies. And so that’s going to be one of the biggest differences between the two.

Abby Eblen MD (24:56)

I think another big difference is we’re very, very, very specific when you’re doing IVF about when you get the trigger shot and when you come in for your egg retrieval. Whereas with IUI, like Carrie said, it can vary a little bit. We know sperm can survive in the female reproductive tract for one study many years ago showed even up to five days. Now the average person, the sperm survives on the reproductive tract for two to three days. And so we’re not as…adamant about you have to come in in this particular hour in order to have your IUI because we know the egg can still be surviving in your reproductive tract. But with IVF, we want to optimize the shot in that we know that you’re still going to have eggs there, meaning you’re not going to have lost the eggs or ovulated the eggs. But we also want to do it at a time where you’ve had the benefit of that medicine to mature the eggs to make it easier for the eggs to come out when we do the egg retrieval.

Susan Hudson MD (25:50)

Another thing when you do your trigger for IVF, you are more likely to be asked to do some sort of post trigger monitoring, whether that’s peeing on a stick, whether it be an ovulation predictor stick or a pregnancy test or going in for lab work. And this is one of those things that this is going to vary widely. I know this varies widely even among our three practices. If for IVF, if we do an hCG trigger, we don’t generally do labs, but if we do a Lupron trigger, we always do labs. I would say most people don’t do post trigger labs for IUIs, though I’m sure there’s some places that do, but I would say that’s much less common than when you’re doing your trigger for IVF.

Carrie Bedient MD (26:35)

And it’s pretty rare that these triggers don’t work. Most of the time when we’re giving an hCG trigger or a Lupron trigger, even if we were to not do any kind of check afterwards, the vast majority of the times are going to work. What we are really looking here to do is to prevent those cases where you know you have an under response. Like there will be a very small grouping of people, usually less than a handful, a year where we give them a Lupron trigger and the level just doesn’t increase. And it’s a surprise. There are some patients where we know we can’t give those, but there will be a few patients where we give it, we expect a response and we don’t see one. And in those cases, you’ve got a couple of options of what to do. Sometimes the practice will just completely re-trigger and they will give either another Lupron or they’ll give Lupron and hCG. Sometimes they’ll give hCG alone.

Sometimes they’ll decide to cancel the cycle. A lot of it depends on what those levels look like, how many eggs were going to be there, what the clinical situation is. Is this somebody who is highly likely to hyperstim if you give them an hCG trigger versus someone where you’ve got that wiggle room and you can titrate a dose. But it’s a pretty rare situation, but when it does happen, there’s a lot of thought that goes into what’s the right thing to do for this patient.

Do you give another trigger? Do you cancel? Do you keep monitoring? How do you go about that? The other thing that we look at when we’re getting those labs is what are the actual levels? And every practice has their own standard of what they want to see. Like Susan was saying, some are going to have you pee on a stick. Others are going to look at actual lab levels. Others are going to say, great, we’ll see you in the morning, tomorrow for retrieval. And they’re not going to check anything. But your center will have an idea of what their thresholds are for what they want to see in that trigger to say, yes, this is very reasonable to go ahead versus, I’m a little bit more worried about what’s going to happen next.

Abby Eblen MD (28:31)

Yeah, and there’s a couple of things too that would make me want to give a trigger sooner rather than later. So for example, if you’re somebody that comes in and your estrogen level plateaus, meaning it kind of is about the same number two days in a row, or if it drops a little bit, I would say it’s like a roller coaster and the roller coaster has gotten to the top and it’s starting to go downward. Typically at that point, we make the call to trigger you.

In some situations, if there’s a really large drop, that’s the situation like Carrie was saying, sometimes your doctor may decide to cancel your cycle because they’re so worried that you’ve ovulated. In our practice, a lot of times we’ll bring patients in earlier, an hour or so early before their egg retrieval and just look, make sure that has not happened because that’s never a happy conversation to have with anybody, particularly after you’ve already been put to sleep and we realized that after that it already happened. So we always like to check that ahead of time.

The other thing I always look at is if you’ve done an IVF cycle before because there’s no better control than you yourself. So to look and see how you did when your estrogen level was a certain amount in the previous cycle gives me guidance as to whether or not I think, gosh, we shouldn’t go another day or maybe we should go another day because maybe her eggs that were normal size just didn’t do great. They weren’t very mature. So maybe she would benefit from an additional day of medication. So there’s always those little nuances that can make your doctor decide one way or another in terms of the trigger.

Carrie Bedient MD (29:52)

So we’ve talked a little bit about who should not get certain triggers and hCG really the big indicator is if there’s any risk of hyper stimulation, especially if you’re going to do a fresh transfer, those types of things, you want to really avoid hCG and someone who might hyper stimulate. When would you want to avoid Lupron?

Susan Hudson MD (30:11)

You would want to avoid Lupron in somebody that you would not expect it to be successful. So if you have somebody who has what we call hypothalamic amenorrhea, they often, these are people who are marathon runners, people who have had eating disorders, are people who sometimes that axis doesn’t work. People who have severe chronic diseases. I’ve been burned by that one. That have been on birth control pills essentially their entire reproductive life. And it’s not because they’re on the birth control pills. It’s because I couldn’t do the testing to show me what their LH is doing naturally. And so that’s another big one. People who have midline defects. So if you have had a history of cleft lip, cleft palate, and it’s along the midline. Those are other people who we most often are not going to have a successful Lupron trigger. And so because of that, in those people, you are probably going to be stimulated more gently. And it’s not because we don’t want you to have lots of eggs, it’s because we want to be safe. Safety is always number one, pregnancy is always number two. And we want things to turn out the way we want them to.

Abby Eblen MD (31:30)

And I think what you’re saying is a lot of times those young patients have lots of eggs and if we give them hCG, they really have high estrogen levels and they’re much higher risk for hyperstimulation. But unfortunately, like you said, those kinds of patients, that’s the only option we have. We have to do an hCG trigger.

Carrie Bedient MD (31:48)

One other group of patients where it’s really helpful to give an hCG trigger is if they’ve had any sort of pituitary or brain radiation before. So brain cancer patients, any kind of major pituitary surgery, there are certain other defects, particularly regarding the eyes, that can be a tip off of the pituitary is not working the way that it should. That’s another big group where we don’t expect that Lupron trigger to work. When you give these triggers, what do you guys think about doses?

Are these for Lupron and hCG, are they one size fit all doses or are they person to person?

Susan Hudson MD (32:21)

For hCG, it’s way more variable than your Lupron trigger. Lupron triggers, there’s some variability in what people use, but I don’t think that’s nearly as technically savvy as what you can do with an hCG trigger. With an hCG trigger, sometimes we can give you more of a whiff of hCG if we’re concerned about.

And there’s some people that need a whopping big dose of hCG. Some of that’s going to depend on your weight. If you are a much larger individual, you’re somebody who’s probably going to need more hCG. But some of this is really an art to the science of what we’re doing.

Carrie Bedient MD (33:03)

Do you guys tend to use double triggers at all?

Abby Eblen MD (33:06)

Yes, I do. So in older patients, a lot of times if the estrogen level is not very high and it’s a patient that’s late 30s, early 40s, then yeah, I do think Ovidrel triggers. I do think they help the maturity of the eggs more. So I do tend to give those in patients that I think don’t have many eggs and that may benefit from that. But for younger patients, I try not to give double triggers in young patients with high estrogen levels ever.

Susan Hudson MD (33:32)

I tend to do dual triggers more in second IVF cycles that I have evidence that I may have had maturity issues the first time around. About 40 % of my patients live three hours away from me. So the risk of somebody getting sick a long distance away from me trumps me potentially wanting to take that risk of giving an hCG trigger at the same time as a Lupron trigger unless I have evidence that I think it might actually help.

Carrie Bedient MD (34:02)

And I realized right as that question was coming out of my mouth that there’s two meanings of double trigger. There’s dual trigger, which is giving hCG and Lupron at the same time. And then there’s also what I think of as a double trigger, but somebody else might call something different where you give two doses at different times. So for example, if Lupron, let’s say 34 to 36 hours in advance, and then you give a second dose 12 hours later. And so I realized as that question was coming out of my mouth…there’s multiple questions within that question. And the way that we handle that is we give an awful lot of dual triggers where we will do both hCG and Lupron. We titrate the hCG and we’ve got our own algorithms of how much we give based on a whole bunch of different factors. And so sometimes we will give just a bare whiff of it along with a little bit of Lupron. But then every so often I will give, and this is usually applicable to the Lupron triggers, we’ll give a second dose of Lupron, it’s pretty rare. It’s only when there’s something that’s happened usually in a prior cycle or a response that I see when I know I can’t give hCG, those types of things. But that’s kind of how we handle it.

Susan Hudson MD (35:10)

I haven’t done that before.

Carrie Bedient MD (35:11)

It has saved me not very often, once or twice, but there have been a couple cases where it doesn’t hurt because it’s another dose of Lupron and so the body doesn’t care, the patient doesn’t care at that point because there’s nothing more that that Lupron’s gonna do that they haven’t already gotten from the first shot. But there have been a couple times where I’ve seen a better response having given that second dose.

Abby Eblen MD (35:33)

Carrie, what’s the worst case scenario, say you give one shot of Lupron or two or whatever, and the patient doesn’t respond to Lupron, what happens when that occurs if you go in to do the egg retrieval?

Carrie Bedient MD (35:44)

If we go on to do the egg retrieval and usually with those patients, we’ve got an advanced idea that something is going to be off. And we’ll go in and we’ll do usually one side and see what we get. And if we get absolutely nothing at that point, we stop and weigh the full situation out and say, okay, is this something where it’s worth triggering again with different medication usually it’s that’s a case where we’ve given a Lupron and we’re thinking about do we have to titrate hCG or is it better to just cancel at that point. That’s very very dependent on the individual patient and what their characteristics are. If you’ve got someone who’s got a ton of follicles you just call it and In those cases a lot of time we will go through and we will still aspirate all the fluid out of them because you want to minimize their risk of hyper simulation I think it also minimizes some of their discomfort when you get some of that fluid out and you get rid of the hormonal factors that are play there. But these are, to our audience, these are really rare situations. These are the things where REIs tend to geek out over them of what would you do if, because they’re the things that none of us see terribly often, thankfully. 

Abby Eblen MD (36:41)

Yeah, very rare.

There’s no evidence-based therapy or evidence-based literature that tells us what to do in those kind of situations. That’s the art of medicine right there. like, well, let’s think about the risk and the benefits. What should we do?

Carrie Bedient MD (37:02)

Exactly, those are the times when you pull back on your training and you go, okay, if I do this, this is what can possibly happen based on the physiology and how these receptors work and what the timing is and what do we do? And there’s almost always phone a friend involved in one or two ways, whether it’s you’re calling partners, you’re calling your co-fellows back from training. But this is where it’s a very nice thing with the fertility community.

Among the docs is pretty tight because you always have somebody to call to say, hey, have you seen this? And you never know what little tidbit of information someone’s going to give you of, yeah, I saw this and I did this and it worked. All right. Anything we missed about triggers? I know one. Before you get to your trigger, double check your medication box to make sure you actually have it, because on places that send the trigger separate from the big box because of the timing involved. So cross-check that you’ve got the medication before you’re going to need it. That’s probably the most important thing any of us might say today is make sure you have the shot in your possession.

Susan Hudson MD (38:10)

If you get to the night of your trigger and you don’t have it, there is a very good likelihood you are not going to be triggering. Because this is not a medicine that you can go to your local Walgreens and get.

Abby Eblen MD (38:23)

And I will say the medicine can, particularly Lupron triggers can be kind of confusing to draw up and to inject and make sure you know those instructions by heart before the night comes where you’re gonna have to give the trigger. Because it can be a little confusing sometimes when you give that particular shot.

Carrie Bedient MD (38:39)

hCG as well, especially if we’re titrating the shot, like I know for a lot of our patients, if we’re giving a weirder dose, we will mix it in our clinic for you or give you very specific instructions about exactly how much to take because we don’t want you to accidentally overdose yourself.

All right, so thank you so much to all of our listeners. Please subscribe to Apple Podcasts and have next Tuesday’s episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information to as many people as possible.

Abby Eblen MD (39:10)

And visit fertilitydocsuncensored.com to submit specific questions you have and to sign up for our email list. Check out our new book, the IVF Blueprint at all major book sellers.

Susan Hudson MD (39:19)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye!

Abby Eblen MD (39:29)

Bye.