Fertility Docs Uncensored Today’s episode of 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, they are joined by guest Dr. Michael Homer of RSC Bay Area in Los Gatos and Menlo Park. The discussion focuses on natural conception success rates compared to IUI and IVF, with a strong emphasis on the impact of age. Patients under 35 have the highest chance of conceiving naturally, while success declines with age, making early evaluation important. Patients are considered to have infertility if they have tried to conceive after unprotected intercourse for one year. The doctors discuss when you should see a fertility doctor sooner. The group highlights earlier evaluation for patients over 36, those with endometriosis, prior pelvic surgery, irregular ovulation, or a partner with low sperm count. What are realistic success rates with IUI? IUI success is largely age-based and generally brings patients close to their natural baseline but does not exceed it. Who are the best candidates for IUI? Ideal candidates include those who ovulate or respond to oral medications, have open fallopian tubes, and have a partner with adequate sperm parameters. When is IVF a better option? IVF may be more effective for patients seeking a faster path to pregnancy or those with lower chances using less aggressive treatments. Younger patients may achieve multiple embryos from one retrieval, while older patients benefit from quicker feedback and the ability to repeat cycles if needed. IVF success rates for patients under 35 are often around 65%, though many patients underestimate their chances for success. This episode is sponsored by Reproductive Science Center.
Episode Transcript:
Susan Hudson (00:00)
Hello everyone, this is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I am here today with my fearless, feisty, and fantastic co-hosts, Dr. Carrie Bedient from Fertility Center of Las Vegas, and Dr. Abby Eblen from Nashville Fertility Center.
Carrie Bedient MD (00:14)
Hello
Abby Eblen MD (00:18)
Hey everybody.
Susan Hudson (00:20)
And we are so, so excited to be joined by Dr. Michael Homer, who is a REI physician at RSC Bay at Los Gatos and Menlo Park. How are you doing, Mike?
Michael Homer (00:33)
I’m doing really good today. Thanks for having me on.
Susan Hudson (00:36)
We are so excited to have you here!
Michael Homer (00:38)
Yeah, I’ve been listening for a while. It’s actually when I got the the call or the invite, it was a little palpitating, but really excited. You guys are super friendly. So I don’t feel like I’m gonna get skewered here. This is good.
Susan Hudson (00:51)
Well, we’re excited to have you. Before we got started, you have a little bit of a different ⁓ undergraduate experience than I would say the three of us have.
Abby Eblen MD (01:00)
Yeah, You went the easy route undergrad. right? ⁓
Michael Homer (01:05)
Yeah, exactly. So you know how there’s the thing that sometimes people just kind of do what their parents tell them and that sometimes in our field it’s the doctor, my parents want me. So in my world it was engineering. So I was a mechanical engineer. My whole family is like MIT engineers and I couldn’t quite get into that one, but I got to UC Berkeley. So I went to Berkeley for engineering and I worked for about two years before I’ll say saw the light and decided to try going into, going to a doctor. It was super not helpful in med school to do that because at Berkeley engineering, they don’t expect you to memorize stuff. It’s like, can you conceptualize so you can bring all your notes, all the books and med school was like, you have to memorize. Like there’s no, there’s nothing like.
Carrie Bedient MD (01:50)
no two ways around it. It’s a straight memorization.
Susan Hudson (01:53)
I do say though, after you got past that those basic science years, as my entire family that I have been married into are all engineers, I would think that knowing that thought process of being able to strategically look at all of the variables has actually probably benefited you, maybe not in the memorization part, but in the actual practice of medicine.
Michael Homer (02:19)
Yeah, 100,000 % the system process of how it all works. It’s all feedback loops, which is fun. I think I honestly like to, for the second half of the phase of creative, be very creative on things. How do we solve something, whether it’s like a clinical efficiency, which I’m very much into, or obviously, more specifically, most importantly, is the patients and how can we just tweak this or do this or take someone through that journey? It’s just nice to do this with humans and not with gears. So that’s kind of the primary thing.
Abby Eblen MD (02:47)
So my job, I’ve got the perfect thing you can do with your degree in engineering, because every time I have patients who are engineers, and I’ve done this for years and nobody’s taken me up on it, we need a drivable catheter in our field. And I keep going, could somebody help me make a prototype? I want a drivable catheter, and I can’t ever get anybody to do it. See, you could do great. You can make all kinds of tools and equipment with all your engineering background and the stuff you’ve learned in engineering.
Michael Homer (03:13)
I’ve contributed to a couple of things here and there. ⁓ But Always kind of coming up with like that latest and greatest. And the question is always who’s gonna pay for it? We’ll pay for it. been it’s been actually really
Susan Hudson (03:21)
On behalf of women everywhere, I would like a mechanical engineer to come up with a better speculum.
Michael Homer (03:26)
I actually looked when I was a fellow, I looked into different patents for that. And actually there are better solutions that are a little gentler, more, you can get away with smaller ones, because they have like a 360 kind of situation. But people own the patent on it. And then and then they just sits. So it’s actually really interesting. So yeah, 100 % agree
Abby Eblen MD (03:32)
Better hysteroscope with less stuff coming in and out everywhere.
Michael Homer (03:57)
You just hit nail on the head. That was another one that I went deep with UC San Diego where I was a fellow with. ⁓ But no one would pay for it because it wasn’t saving us. But yeah, but something to stop the water from coming back. was the whole thing. Yeah, no, these are not difficult We’re all like, we have them. The question is how you get it done, which is the key. Yeah, it was super exciting to think about all those ways to help anybody. It’s really fun.
Susan Hudson (04:23)
That’s really sad to see patents getting in the way of progress.
Michael Homer (04:28)
Yeah, I mean, this was, right, it can be, I mean, I’m sure, I’m going on to the next phase and the next phase. So I think it is probably ways around some of those things.
Susan Hudson (04:37)
Well let’s do a question of the day. So our question is age 41, AMH between 0.15 and 0.4, did one stim cycle with estrogen priming, estradiol, Menopur, and follistim with Pregnyl trigger. Only three oocytes retrieved, two mature, and one day five blastocysts but low quality. It couldn’t have been tested.
Next stim is coming up soon. Doctor asked if I’m interested in Omnitrope growth hormone, studied in conclusive. They’ve had some good outcomes in patients with my age a bit expensive, but it improved number or eggs retrieved or quality. Why? Why not? Do you have any advice on HGH?
What are your thoughts? Sure, go for it!
Michael Homer (05:23)
And you want me to start or someone else?
Carrie Bedient MD (05:23)
What do you, yes, because we all know what each of the others of us think. So we love having somebody new walk in because we get to hear the new perspective of, what does somebody else think about the stuff that we rehashed a million times between the three of us over cocktails?
Michael Homer (05:38)
Well, oh, and I’m one of 10 at RSC for the docs. So we all kind of have this really collaborative way of working together to kind of like these type of questions. So I would say at RSC as a whole and for myself is that we would tend to recommend human growth hormone. You can definitely argue the live birth rates are not there in the data. But there’s OK studies showing at least the intermediate path you’re trying to get to can show maybe a little bit more maturity, maybe a little bit better on the blast growth rate. So we do tend to use that for sure in this case.
Susan Hudson (06:15)
Who do you use growth hormone on?
Carrie Bedient MD (06:18)
And when do you use it? Do you use it on a first cycle? Do you use it on a repeat?
Abby Eblen MD (06:21)
And when do you start it?
Michael Homer (06:24)
Yeah, yeah, pick pick it. But because there’s no there’s this is the this is like this sometimes I tell patients for trying to decide between IUI and IVF. The good and the bad news is that there’s no right answer. With human growth hormone, I do think that but I would say generally speaking to answer specific questions is that tends not to be for the first cycle, but I would tend to add it on to the second cycle. Every once in a while, I will see someone who’s 41 or 42 and I might start it from the bat. And a lot of times it’s more about the conversation with the patient. I don’t mind explaining things. I can add human growth hormone here. It’s going to cost a couple thousand dollars. I think it may help. It may not. If it we don’t do well in the first cycle. I may add it on the second. How do you feel about this? Because then some are like, why didn’t you tell me about this before the first one? And you’re like, well, cause the date is not there. I’ll go back and forth on those things. And how do we start it? Yeah. Primarily, we do it during stimulation for about six days, starting with roughly a 14 millimeter follicle. I think that’s the most commonly accepted way to go. We do use it for priming. So sometimes we will do like one half a vial two times a week. We’ll do that kind of in a couple of weeks coming up on it. and actually that started from me, but from a patient had a patient of ours. This is before COVID asking, Hey, HGH priming, and I was like, there’s really, I don’t know about that. And she’s like, can we just give it a go?
I’m listening to her, but then over time, some more docs are trying it. Now it’s a protocol RSC because of that one patient. It’s actually kind of neat.
Susan Hudson (08:00)
So you use it during priming and then you take a break until the follicles are about 14.
Michael Homer (08:06)
I would say specifically is that we keep the twice a week up until we start the stim, until we start the, so we call HGH priming, which is twice a week. And then it goes during, even when they start their gonadotropins. And then when they hit sort of that 14 mark, we go once a day for six doses total on the once a day. We don’t do a ton of priming, but the stim will definitely show up a lot more. And most of us are, not the first cycle. And some aren’t even the second cycle, but they might try it for the third cycle. But most of us are on the second cycle, if it seems appropriate, mostly age based or blastulation rate specific, how well do their embryos grow in the lab? We take that into account.
Susan Hudson (08:48)
Carrie, what do you do?
Carrie Bedient MD (08:50)
So we do a four to six week protocol total. It of incorporates priming into everybody. We just give low doses all the way throughout starting sometime after their period that’s going to proceed the period that they start. And we’ll do it roughly four to six weeks total from the time that they start until the time that they trigger.
Michael Homer (09:16)
Hmm. Yeah, I definitely seen that for sure.
Susan Hudson (09:16)
All right. And Abby.
Abby Eblen MD (09:19)
We kind of go either way. Sometimes we’ll do estrogen priming, but we do it daily. That’s kind of an interesting concept that you do twice weekly. Maybe that might be cheaper to do. But we do it sometimes for priming, and sometimes we just start with stimulation and continue it all the way through egg retrieval.
Carrie Bedient MD (09:34)
What do do, Susan?
Susan Hudson (09:36)
What I do is patient wise, I’ve started using it on 40 and up. I used to do 41 and up. I backed it down to 40 and up or anybody who has an elevated FSH and I will do once daily for the first 12 days of stim. And kind of anecdotally, I don’t think I tend to get more eggs, but I tend to get better quality eggs, better quality embryos, and I’m more likely to get chromosomally normal embryos. How that happens, I don’t know, but I’ve had a handful of people who were, or somebody who had a stimulation and we ended up with really not great looking embryos or they’re young and almost everything was chromosomally abnormal. I’ve had it work wonders on some of those people. We don’t know how it works, but it…doesn’t seem to be harmful. There’s a handful of people I don’t think it moves the needle on, but I think it moves the needle on more people when selected right, then it doesn’t do anything.
Michael Homer (10:37)
Do you ever take it off? Like, do you ever try it and then you like, I don’t think it was an effect. I’d say the third cycle that you don’t do it.
Susan Hudson (10:45)
Yeah. And it, on those people who it didn’t seem to do anything. If I end up coming back for a third cycle. I think there are just some people that whatever is the core of the problem, it’s not sensitive to the growth hormone that there’s, there’s some other mechanism other than what’s normally abnormal that, that I think is going on because there, there I’ve had a handful of people that I’m like, it just didn’t move anything. I’m like, that’s not the way it’s supposed to act. And it doesn’t seem to act that way in those people. But if it doesn’t seem to do anything, then the next cycle, I leave it off.
Michael Homer (11:23)
Yeah, it’s it’s it’s a very interesting way that you mentioned about the mechanism. I obviously don’t know what it would have been if I hadn’t used it. So what have been worse or better? We don’t necessarily know how much it helped. The idea that you’re sort of saying that is interesting way to look at it. Is it really moving that needle that much for you? So is it worth it? I just tend to think of things and so much like the probabilities and statistics of like Can I eke out that one more egg? Yeah, can I just get, it’s like, should be name of another podcast. Like one more egg. You’re just crossing your fingers and you’re holding your breath along with your patient. Cause you’re like every day is no whammy, no whammy, no whammy. Let’s go, let’s hit. I like that. I’m gonna try to remember that one about the idea that, maybe just mechanistically, the other issues we’re dealing with that this is probably not going to help that much
Susan Hudson (12:09)
I think, fortunately or unfortunately, that’s what keeps our jobs interesting is every couple is unique. Every IVF stimulation is unique. And there’s always something for us to learn through each stimulation.
Michael Homer (12:19)
Yes. And I think that to your listeners question. It’s like adding human growth hormone. Generally speaking, it sounds like we all are use it. So we probably would generally recommend, some version of how we do it. The good news is that, or the bad, again, there’s the amount that we use and how much we use and when we use it, there isn’t really great data about that. There’s just lots of papers that have been published.
Showing different ways of how much you give and when you give is harder to define But there does appear to be even in all those variations a little bit of benefit to it. I think that that’s what drives me to think that it’s gonna help a little bit But I think that that your listeners question is that the biggest change the biggest thing that she can do is if she can afford it emotionally and financially and everything is to roll the dice again She made that blast and it sounds at least, almost made that blast that was the call enough to be kind of frozen, but got a little further, first of all, three eggs, that’s pretty good. You’d imagine regression to the mean, you cross your fingers and hope that the next time that she would have maybe a little bit more of a higher number as well. So as you learn from the first cycle.
Carrie Bedient MD (13:32)
When you say regression to the mean, because we all talk about probabilities and statistics and all that with our patients all the time. And a lot of the times we’re thinking these things, but when you say that, what do mean by
Michael Homer (13:45)
We build a model of the patient in our mind a little bit. It’s like the age and body weight and AMH and some of these factors, how they had a child before their diagnosis. There’s a couple other things that FSH and follicle count. There’s a couple of things on there. And then we could just say like, hey, someone like you on average, we’re gonna get X number of eggs.
And then, but you’re not a program. You can have a, the grab bag of the ovary and how many eggs we get and what they’re going to be like, it’s all random. But if I can try to scoop as many of those raffle tickets as I can, that’s the, that’s why I my patients these eggs are raffle tickets. yeah. So I used to do lottery, but that’s like really low. So I do raffles.
Abby Eblen MD (14:19)
lottery tickets, that’s my term.
Michael Homer (14:27)
So I changed it to, but you’re right, raffle doesn’t hit as well. Lottery everyone knows, but I felt like that makes it, but I’m with you.
Carrie Bedient MD (14:35)
I would anticipate being in Silicon Valley with so many literal mathematicians, statisticians, all of that, that you can’t go with something that is not precisely what you mean, not just the gist of it, but you have to be very literal otherwise somebody’s gonna come back at you. Well, the odds of winning the lottery in the state of, and they’re gonna go on to a series of victories.
Michael Homer (14:54)
Yeah, I’ll say, but it’s the RSC lottery. There’s a better odds for that. I’m with you. When we talk about that, the regression to the mean anyways, is that you build the model of someone and you’re thinking, Hey, I think we’re to get on average, like six eggs. When someone gets like two or three eggs, it sounds like this listener was maybe sort of in that general category. I don’t know if that was a blip. I don’t know if that’s who you really are. And that’s what we’re going to get.
the only way to know that is to keep doing IVF cycles, which is not an unlimited, easy thing to do. That’s the hard part. You can’t just keep flipping the coin and get into your 50%. But that’s what I let them know. Over time, we should probably be getting this, like the average number and who does a second cycle? Those who didn’t do so well the first time. So, there’s a selection of, who were, who’s doing that second cycle.
I mean, people do it because they want to have tons of embryos and be hoarders. That’s cool. But generally speaking, you want people that want that success rate. So I do think that, and then the variable-ness of how the same person reacts to the same stim. We know that that’s the UCSF papers. I did the same protocol or I changed it and their outcomes are basically the same.
I always just tell them the biggest tool that they have, if they can afford it mentally and financially, is to try again, roll the dice again, and see where we get, there’s obviously limit to that for lots of reasons. But that’s why two or three IVF cycles is sort of like that number where you’re like, okay, now I really know who your ovaries are. Or embryo, sorry, sperm and egg together.
Susan Hudson (16:24)
All right, well, I think this is a great segue into our topic for today. And our topic today is talking about success rates with natural conception, with intrauterine insemination, and with IVF. And we’re gonna just stepwise go through what are expectations and what are things that affect those chances in an individual or couple. So we’re gonna start off with natural conception.
And just to kind of lay it out there, when we say natural conception, what are we meaning?
Carrie Bedient MD (16:58)
We being the REIs as opposed to the average patient who walks in who says, no, I’ve only been trying for seven months or six months. And then our very next question is always, well, when was the last time you used anything to contracept actively prevent pregnancy? At which point their answer is usually, I’ve never used anything like that.
Michael Homer (17:20)
Yeah, I mean, I think that, I mean, it’s, yeah, always to double check the things that you’re looking for. I actually in training, one time I presented a patient, I took the intake and I presented the patient and, and it was someone from a Hasidic Jewish background and faith. Over that year, they only complete intercourse correctly about three times at the timing because of the rules and some of the laws and religious observations they have to have around certain bleeding and things like that. So then when it got down to it, they had only had maybe two or three ovulations. You have to always just make sure that like, you having intercourse and how many times and all of that. Yeah.
Carrie Bedient MD (17:57)
So when you do have someone who’s actually been able to hit the marks that we’re looking for in the sense of they’ve been able to have an ovulatory cycle, time intercourse, have the appropriate intervals, all of those things that factor into making sure that the uterus, tubes, ovaries, sperm, everything is working together. How do you describe success rates to your patients?
When they are trying naturally. And this is at a point in time when they don’t have an infertility diagnosis. They’re just within that first year or so of trying. How do you describe that to your patients?
Michael Homer (18:35)
I let them know that time is what proves that there’s a problem and the hard part is that you can’t look to the future to know you can only look back at what the path was. We have all maybe not everyone listening to this has seen. There’s just there’s a curve. The highest chances of conceiving are about the first three months approximately But and then after that it starts to drop. It happens with the Clomid IUI’s What I had to tell the patients is not that your body’s getting resistant or used to something. It’s just that now we have more of a story to tell that this isn’t working. We’re taking our chance and we’re kind of flipping those coins. And then at some point you’re like, wait a second, where’s more of a problem. So the first two, three months have the best chance, but there’s still good chances after that. But for most couples who are healthy, you’re probably going to conceive We imagine that about 70 % of them will get pregnant in first six months. And then after that, so that’s 30 % left. And then of them, approximately half of them will get pregnant in the next six months. And that leads to 15 % that are not having conceived over that year. And it’s all age-based and things along those lines, of course.
Usually when I say to me, ASRM guideline less than 35 years old and these try for a year. And from a population medicine point of view, yes, but after about six months, if you’re feeling like you having the chance with a sperm to meet the egg pretty regularly, at that point, maybe trying to get a workup done during that time or start the process. Cause it’ll take a couple of months to meet someone like me. Maybe, it’s probably a good idea.
Abby Eblen MD (20:06)
And Mike, how does their age play into that? So if you have somebody that’s a 25 year old versus a 35 year old versus a 40 year old, how do you change what you say to them in terms of their chances for success within that first year or two?
Michael Homer (20:20)
Yeah, and age is by far the biggest predictor out of all of this, the age of the egg. So age, IVF, fertility, all of that is always like age categories. We kind of had this big old group that’s like less than 35, right? That’s considered to be the best years for childbearing. So ultimately would be about like 20, 25 % chance, per month of conceiving the fecundability; that’s the official term. Then around 34, 35 is when the egg has a harder time doing its division and splitting and helping to create an embryo that has all the right programming, To keep going. So it’s a little bit harder to do that around 34, 35 and that, and there’s a slope. It’s not a cliff.
But it is a slope. 35, 37 years old trying at home, it’s probably more like, know, 15, these are all kind of fungible numbers, but like 15 to 20%, I would say, And then it’s more sort of like, like 10 to 15%, around that 38, 40, and then around 40 plus, five to 10%, somewhere around there.
Different studies will show different levels, different populations, but I would say that it really is, less than 35, then after that, every couple of years does appear to make a difference.
Susan Hudson (21:39)
One thing I wanted to mention was I wanted to bring note of the fact that when you’re less than 35, you are only looking at about a 25 % chance of getting pregnant each month. So human reproduction is vastly inefficient. Even though we spend sometimes decades of our lives doing things to not get pregnant,
Michael Homer (21:50)
Yes, not a hundred.
Susan Hudson (22:05)
Realize that the odds are against a lot of people and if it’s going to happen, it’s generally going to happen relatively quickly and easily. And if it’s not happening quickly or easily, then seeking help sooner than later is a very reasonable thing to do.
Michael Homer (22:24)
You don’t have to do treatment. You can at least get the basic workup of is there sperm? What’s my ovarian reserve? It doesn’t even play a huge, role in natural fertility, but can give you some yellow flags or sort of give you a sense of timing for yourself and, future children, your family size. You really want to make sure. Bigger things that are less likely are like the fallopian tubes being blocked, not too often, but even the basic ultrasound. Is there a big old fibroid rock in the garden?
All these things that can affect that aren’t that hard to find. Those with ovaries women listening to this podcast, and they’ve done this, this, this and this, and there’s not a semen analysis, get on it. In my world, a lot of people have had it or already before the time they come in, OB-GYN’s are really great at ordering these things.
But still every once in a while I’m like, we can try it for a year. You’ve gotten all these things done, including HSG and there’s no semen analysis yet.
Abby Eblen MD (23:10)
I’ve even back in the day when we used to do laparoscopies a lot more readily. I mean, there was at least probably one or two people a year I would see that already had a laparoscopy because of infertility before they’d even had a semen analysis done. So good news when you find out after all that that there’s a low sperm count. So it’s really good to make sure that you cover your other bases too, just to make sure tubes are open, sperm count looks good. And there’s really not a ton of tests. I think people really think that there’s this whole bevy of things that we do and there are some tests, but I mean, they can be done easily within a month or two for sure.
Michael Homer (23:50)
Absolutely. It’s super important. And whenever we start talking about folks in the age of the egg, it just it takes two, like always just remember, it takes two. It’s not just all about the egg, but men’s age for sperm, is start is like round 45 ish, older, and the slopes gentler. We are focusing on the best outcomes here, which is the age of the egg of course.
Susan Hudson (24:11)
In people who are trying to conceive naturally, who are people who need to skip that? Who needs to go from, am thinking about trying to conceive to let’s go see a doctor now versus waiting six to 12 months?
Michael Homer (24:24)
Yeah, that’s a great question. I would say that anyone trying to conceive, you owe it to yourself for like two or three months. But higher probabilities of having problems is gonna be if you’ve had some history of certain conditions that can hurt your fertility. If you don’t ovulate regularly, and PCOS, oligo-ovulation, I mean, then there’s…
It doesn’t come out to play. Like that’s not fair. So like seeing someone. right. Yeah, thank you. Regular periods. If you have a diagnosis of endometriosis, which can hurt your ovarian fertility reserve and the quality of the eggs. If you’ve had any pelvic surgeries. Or that something like that, that could also hurt the quality of those eggs and the number of eggs as well.
Susan Hudson (24:46)
So if you don’t have regular periods, you should probably go see somebody sooner than later.
Michael Homer (25:06)
If you’re the male partner if there’s a testicular injuries, surgeries, developmental changes or challenges that happened before, or you were a gym bro and you were lifting and all testosterone and all the hormones. If you have something that you would generally know it affect your fertility. Then seeing someone on the faster side would be good and then all those other things being generally fine to me. 38 and older is where you’re like try for a couple of months, but sort of know the number of the call soon. It takes a little while get the appointment as well and you can be trying during that time
Carrie Bedient MD (25:42)
So how do you counsel your patients who come in saying, well, my mom had me when she was 43 and my grandmother had all my aunts and uncles when she was in her mid to late 40s. This is not an issue with my family. And especially for the patients who are looking to delay conception.
They’re on top of their game because they’re doing their fertility check early, but they come in and they say, yeah, my family has babies well into their forties. Even my great aunt Tilde had, uncle George when she was 50 years old or things like that. How do you deal with that type of family history where the mindset coming in is this is not a problem in my family.
Michael Homer (26:20)
Yes. Usually one of the questions I will ask gently is say, well, what number of baby was that for that particular person? So almost always is never number one. No, we’re talking like three, usually third, or a higher order, on those fronts. This is always a system that’s been tested and it’s pretty easy to be able to do. Again, it’s probabilities.
Abby Eblen MD (26:27)
Yeah, it’s usually never number one.
Michael Homer (26:43)
So the probability of this person conceiving was higher. And then yes, there’s a decline with age. There is one. They experienced that, but they had a higher probability and just this random lucky bounce that comes through. I tend to have the conversation with people like, look, you can absolutely be an except. Like I don’t have a crystal ball. I don’t know. But I just know from good studies and data.
My interest is to help you get to the family size that you’re looking for. All comers coming in, I’m going to say, if we’re talking to someone who’s 40 years older, like this is a 5 % chance per month at home. You can do that if you want to. But if we’re to move on to say, IUIs or into say an IVF world, to get to spend time at home to do that, you can try, but we’re crossing time and money. And excuse me, time and chances of success.
That’s where it’s like that zero sum game of that you’re spending time here is not time here. But again, not to say that we never tell you you can’t get pregnant. I actually do that very specifically with patients once I know what happened, there’s no, there is sperm and there is the tubes are open and I always tell them, I’ll never tell you you can’t get pregnant. Because I was at a kid’s birthday party like five years ago.
And this woman’s like, everyone else, I’m in San Jose’s Silicon Valley, everyone’s tech. And then kind of a brief conversation, oh, you do fertility. And then turns out one of the people there was a parent and then she just randomly came up to me you guys were wrong. And I was like, she wasn’t a patient RSC.
And basically they said that my doctor said that we would never be able to get pregnant.
Susan Hudson (28:22)
The rule is never say never, because we’ve seen never happen.
Michael Homer (28:26)
Yeah, two block tubes and low sperm I have I can think exactly that patient is and it just happened. It just just it happens all the time. But that’s why I always very because of that person, I specifically tell the patients just because I can never tell you you can’t get pregnant. But the odds of getting pregnant now per month are as far as I can tell, with based upon good data this high. So that’s the reality of where it is. so trying to gently turn that light bulb on for patients is something that I actually really do enjoy it because I really want to, it’s not good news, but trying to get someone in a compassionate way to tell them Hey, you can, but this is the reality that I think I see here, and getting them to sort of, again, my goal is to turn them into saying, Hey, I want the family, the size that I’m looking for. So.
Susan Hudson (29:16)
All right, so to kick it up a notch, say you have somebody who is a reasonable candidate for IUI. So first of all, who are generally good candidates for intrauterine insemination?
Michael Homer (29:31)
Patients who ovulate, patients who have open fallopian tubes, and patients where we have enough sperm to make an IUI worth it, I think would be the primary ways to go. The most common patient.
Susan Hudson (29:42)
And if they don’t ovulate, we can give them medicine to help that happen.
Michael Homer (29:47)
Yeah, specifically in there. Yeah. And then obviously, of course, in the IUI canidates also, as I mentioned, there has to be enough sperm, but ultimately, we’re looking for certain sperm levels. So we’re looking for the total motile count on that sperm. And that’s what the studies are based on. And that’s your volume times the concentration times the percent moving. So that product ultimately is the total number of millions of moving sperm in the ejaculate. And there’s just levels that we’re looking for. intercourse about 30 million, plus or minus 10 million or so or greater, we’re generally going to have a good chance to intercourse at home. But once you about like for IUIs, post wash, I love to have about four or 5 million or more or greater. So ultimately, 10, less than 30 million, but say 10 to 8 to 30 million moving sperm. That’s IUI territory, because I can really help boost the chances for the sperm.
And then generally less than that or smaller, you gotta use IVF. So I think ultimately again, unexplained patients, male factor patients are the primary ones I think of for IUI.
Susan Hudson (30:50)
When you think about success rates for IUI, the way I generally discuss it is that what we’re trying to do is get you close to what your natural fecundity or chances of getting pregnant each month would have been if you did not have a diagnosis of infertility. So once you have a diagnosis of infertility, having unprotected intercourse for six months or a year, depending on what your age is, your chances generally go down to about one to 2 % per month without help. I generally say that doing insemination gets us close, not necessarily to, but close to those general chances. Is that kind of what you advise your patients or how do you counsel your patients?
Michael Homer (31:35)
Yeah, I agree. Close, but not at. Cause we’ve already proven there’s a little bit of a problem here. And again, maybe the system doesn’t work so well. Without a GoPro, I have no idea. Is the sperm, is the sperm in the egg? Are they, my neighbor might work for GoPro, but did sperm go through? Do we have the sperm? Does it meet the egg?
Are they high quality enough to continue to grow? Can you come down the fallopian tube correctly? Can the implant the rest of it? So if you’re already proven out that there’s a bit of a problem there. When you get them back, Hey, I got the sperm kind of fixed. But we’re still using the same system that wasn’t really working so easily from before. So I agree with you that it’s just, it’s just, it’s getting there. But that back to your original point of like, remember 20, 25 % per month.
Don’t compare yourself to 100%. So I can say, hey, this is a 15 % chance, you’re comparing that to 22. It’s still not a great number to hear, of course, but the ceiling is not 100%.
Abby Eblen MD (32:23)
So if you decide that you’re gonna talk about IVF or if the patient comes in wanting to talk about IVF, what do you talk about in terms of success? Because I think patients overestimate, like you said, what the chances are with IUI. And when you tell them eight to 10%, they kind of look at you like you’re kidding me. And then when you talk to them about IVF, what kind of success rate do you give them for that?
Susan Hudson (32:56)
Before we hop to that real quick, I have one more IUI question. When you’re advising people to do IUI, how many cycles should you do? I know sometimes I get people who have transferred from different clinics who may have been doing lots of cycles, like six, 10, 12 cycles. What do we all do in our practices?
Carrie Bedient MD (33:18)
Here’s like what’s your cut point when you say, all right, we’re done with this now.
Michael Homer (33:23)
Three is that the pretty normal standard advice and my, way that I frame it is saying that the chances of success are about the same for the first like two, just start to drop probably on the third one. But at that point after that, the ship is sinking. So you can get pregnant on the fourth or fifth one. We’ve all had patients who like, I’m not doing IVF yet or something along those lines. So it’s okay not to do IVF from there.
but just know that what you’re spending your time and your effort and your emotion and your money on is not as successful as it was last month or two, because we have the history to look back at it. So I usually let my patients know that we’ll do two, three of them fairly automatically. We’ll optimize as much as we can, Clomid versus Letrozole, estrogen, something like that, but ultimately giving it the shot and rolling the dice two or three times is…usually recommend it, but I always let them know that there’s no rule or law here. So some people skip go skip IUIs because they’re like, Hey, 15 % like no that I’m already spent all the emotional time here. I just really don’t want to look at another negative pregnancy test, which you still can in IVF, but there’s better chances with IVF. Two to three, I would say, and then kind of automatically like our clinic, generally speaking, we make sure it’s structured so that we have a visit during the third IUI. No one wants to lose that time. No one wants to lose that month. And we work in the state, in the area where there’s lot of insurance coverage, we want to make sure we kind of keep things rolling, get our authorization.
Abby Eblen MD (34:52)
So on that same note, I work in a state where there’s not a lot of insurance coverage, and I have people that want to do the opposite. They’re like, well, you tell me the odds, but I’m not ready for IVF. I can’t afford IVF. How many cycles would you let them continue to do if that were the case?
Michael Homer (35:08)
So it is age dependent on this factor and some of the other things, but I would say in general that once you’re hitting about like, I mean, like five or six, and I would say no, if they’re older about 38, three, four, maybe four, I’d be strongly advising them not to do any more Clomid IUIs for sure. Obviously patient autonomy, patient reproductive right and choices, as long they lay it out for you, we can do this, but definitely strongly, especially at 38 or older, couple of IUI cycles and kind of move.
Susan Hudson (35:37)
One thing that I know that all four of us have access through because we’re all part of the US Fertility Ovation Network is we have access to something called Pathway to Parenthood, which is a fertility AI program where we can put in patients de-identified information and get an idea of what are your individual chances of being able to conceive using IUI. And I’ve really appreciated this resource because if I have somebody who over three cycles has like a seven, eight, nine percent chance of getting pregnant on IUI versus someone who has a 10, 15, 30 percent chance over three cycles of getting pregnant with IUI, I think that also can play into hopeful counseling without a better term. ⁓
Michael Homer (36:32)
Expectations, that’s the key. Everyone has sort of in life, if they work somewhere, they work with a colleague, like anything in life, like children set of expectations, just be like, Hey, if this may or may not work, here’s the chances. Doctors are humans. Sometimes in conversations, you’re sort of saying, hey, I think this will work. the chances are kind of low, but we can try it. I’ve tried to tell them, I think 12%, I’m not that accurate, but this is just the chances that we have. I think having that pathway to parenthood is a fantastic tool because you can come back to the patient.
And again, time, effort, money, emotion, and chance of success. And all of that will guide out which path that you want to take. I think it’s super important to know that. So I really do like that tool.
Carrie Bedient MD (37:19)
How do you find your patients adjust mentally to the success rates that you show them? Because I imagine, given where you live and the type of patient population you see, if you feed all of those numbers in, because this tool looks at a patient’s specific numbers and put their numbers in. And then once you start playing with the ages, because many people are going to ask, well, do I have one year? And I’d really rather wait three years because that’s more convenient because of X, Y, and Z. How do you see that those success rates change based on the ages that you’re putting in, especially for IVF, when you’ve already got the data, you’ve already got the numbers, and how do patients take that information in and react to it?
Michael Homer (38:03)
I try to emphasize very strongly again that age is the largest predictor of success in what we’re doing. And it’s just a biological no matter how healthy you are, obviously being healthy, taking care of yourself will kind of, keep your number above, say someone who’s the average person who is your age, that will always be benefits to always keep doing that. But there’s just how it works, just the biology and the reality of all that that does play a role.
Round 34, 35 is when things are going to get start to get harder. And I’d say that, essentially about three years, I think for the most part, three, four year, 38, 39, you’re gonna pretty like not almost half your chances. And then when you hit about 40 or more, we’re in there sort of like 25, 30 % of what those chances were at that time.
And we can’t predict the slope. Some people, and again, when it comes to IVF, there’s the chances per egg, which is based upon age and some other factors, but the number of raffle tickets that you can get is also playing a role in going down. The AMH, the follicle count, that plays a huge role in success secondary to the age. That slope is nefariously difficult to predict.
We try to do our best. I tried to our best to model it out. So IUI versus IVF now. How many kids do you want to have? I really want to have two. I have in my head. yeah. Great. Excellent. So you’re 36 years old right now. Here’s your IUI chances now, but also here’s your IUI chances three years from now when you want to try for their second child or your IVF chances in three years from now, if you want, if you need to do IVF. It’s just always to come back to the idea that younger is always better. And hopefully you never have to use them if you’re saving them for the future. But if you want the best chance of having this family size that you want, especially around 35 or older, and you want more than one child, that’s where the embryo cryopreservation power of IVF really comes into play.
Abby Eblen MD (39:58)
I think one bad thing is IUI and IVF sound so much alike if you really don’t know what they are. And they’re like, now what’s the difference between this IUI thing and IVF? And when you talk to them about the details like we just did about IUI, they kind of look at you like, oh my gosh, I didn’t realize my chances were so very low. And they kind of look at you like, are you really telling the truth? Then when you talk to them about IVF, what…What numbers do you give them for IVF? Why do we think that that’s so much better in terms of success rates?
Michael Homer (40:26)
We have studies that show that it is better chances per person. So the to parenthood is so powerful because I really shudder when someone says, what’s the average, what’s the success rate at my age? the scope is massive. The bar on that is massive. And so I’m always very specific to tell them, but it’s good to be an informational mark.
Hey, greater than 50 % chance probably if you’re less than 35 years old. Somewhere like less than 40 % chance that goes all the way down if you’re 40 or greater. And then it kind of like runs all the way through, you’re 35 to 40. And the reason why, let them know specifically why I think it’s going to be a better choice is that you’re going to get multiple, hopefully, many eggs all at the same time, which you were going to throw away anyway. So we’re not stealing them from your future. So it was important thing to know. Kind of like, I love that. I pause and wait for applause when I say that one, because I’m like, this is going to be good. It’s just like, sorry, but we have variables that we’re going to take out of it. Does the sperm meet the egg in the body? Well, it does in the lab because we make them. Did they make it through the fallopian tube? This is a fallopian tube bypass.
Abby Eblen MD (41:15)
Yeah. They always ask that question. Yeah. Yeah.
Michael Homer (41:33)
There’s so many variables that we take out of the equation. When we do IVF, it’s not guaranteed to work, but a lot of the steps that we just have no idea that also like for the key to fit the lock, they all have to go right. In IVF, we’re going to how to cheat a little bit and at least really kind of skip to the important parts. And not have a random, stumble on some other thing that the egg and sperm were great, but they just couldn’t meet that time.
IVF takes that out of the equation. So to me, that’s the primary benefit of how IVF helps you for IUI. In addition to obviously as many raffle tickets as we can probably hopefully get and then the fertility preservation, freezing, they’re good for 20 plus years. There’s no freezer burn. That’s all these extra benefits that really help for IVF.
Susan Hudson (42:19)
Another thing is even when we’re saying they’re talking about success rates with IVF, the biggest hurdle to overcome if you’re willing to do PGT-A, which is pre-implantation genetic testing for aneuploidy looking for chromosomally normal embryos, whether you’re 28 or 43, if we have a chromosomally normal embryo, we have some pretty kick ass statistics.
You are at a high likelihood of being able to achieve pregnancy. It’s never going to be 100%. Honestly, it’s probably not going to be 80%. But depending on certain factors, we can get some pretty high success rates regardless of age if we have chromosomally normal embryos. That is the biggest hurdle to overcome. If we’re able to get that, you have a whole new pathway and opportunity.
Michael Homer (43:18)
Yes. Yeah. And I think to that end actually is also to Abby’s question. When you give those average numbers. That takes an account people who come out with diminished ovarian reserve and have had major surgeries in the age of 25 years old. They lost an ovary due to a tumor or something. That skews it. If you’re coming in and you’re
33 years old, you have an AMH of two, which is like a generally normal over there. Your chance of having a baby with a single IVF stim is closer to 75, 80 % in general. And unfortunately there is, we remember the one in five that don’t. So we’re like, oh, it can’t be, it’s not, but really if you look at the data and we have, you we keep track of us, all that data that path of parenthood keeps track of all this data. Like the success rate is really high.
I have, patients, who have PCOS or maybe not PCOS, but you’re PCOS-ish. And you have a fall AMH of three or four. And I’m like, Hey, your IUI chances, I know you’re scared of IVF, but your IVF IUI chances are not helped by that. They’re still at that 15%. But your IVF is, I mean, pretty close to two standard deviations above 85%.
Michael Homer (44:28)
82%. Sorry. But then like, then you’re hitting the, but really it’s more about 85. When you compare those, I know, I know, sorry, I want to be accurate. But when you compare though, you guys make me nervous, but when you compare them, you really, it’s like, what’s the question here? Obviously it’s time and the effort and scary and all the other factors that come with it. But I’m just, we’re just so used to it. It’s like, yeah, do IVF. What’s wrong with that? It’s fine. It’s easy. It’s not, I know it’s not. Yeah.
Abby Eblen MD (44:31)
the mechanical engineer talking there, I think.
Susan Hudson (44:53)
But it’s time well spent. It’s time well spent and if you have it within you and it’s within your means, it can provide you excellent chances. But if it’s not something that’s the right thing for you, what we want to do is the right thing for you. So that may be IUI. That may be just supporting you as you try naturally.
Michael Homer (45:08)
But not to get too lost in the woods. You just really have to, I hear you. And the emotional part too, I think it makes it important. I always kind of let them know that IVF is more intense, it’s more expensive, it’s more invasive. It is all of those things, but it is concentrated down to about two weeks of the real strong roller coaster ride. And the first two weeks trip is just those, 12 days of injections, which is a lot, but not a ton of time and you get the feedback. A Clomid IUI cycle trying on your own, it doesn’t work. I have no idea why. I can’t tell you why, but doing so much more work for that negative pregnancy test hits hard. That’s why I want people to know like your emotional cushion’s gone. you’ve been on this ride for a year plus and I’m gonna put you on a way faster roller coaster right now.
We’ve all have seen patients who burn out on the IUIs. And either money’s spent there, and there’s studies about how after a certain number of times, it’s a better cost per child to go into IVF at some point, that’s there. But emotionally, if they’re wrapped and then they go to IVF, which may not work, but is more likely to.
it’s really hard to kind of build that cushion back up and really give them that sense of I can do this. So getting them to that finish line is a lot harder. So I would just let patients know we can do Clomid IUIs, but if you start to feel, if you feel really burnt from that, just know that you’re spending emotional capital on something that has less chance. So let’s think about spending on something that has a better chance for you, because that’s not an unlimited resource.
Susan Hudson (46:55)
Alright, well I think we have covered so much today. Mike, thank you so much for joining us. This has been fantastic.
Michael Homer (47:01)
Yeah, it’s been a lot of fun.
Carrie Bedient MD (47:03)
Thank you.
Susan Hudson (47:04)
All right.
This is Dr. Michael Homer at RSC Bay in Los Gatos and Menlo Park. And to our audience, thank you so much for listening today and subscribe to Apple Podcast to have next Tuesday’s episode pop up automatically for you. Also, be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.
Carrie Bedient MD (47:27)
Visit fertilitydocsunsensored.com to submit questions and sign up for our email list. Pick up your copy of the IVF Blueprint today at Barnes & Noble, Amazon, or your favorite bookstore. And check out our Instagram and TikTok for quick hits of fertility tips between weekly episodes.
Abby Eblen MD (47:42)
And as always, this podcast is intended for entertainment. It’s not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we’ll talk to you soon. Bye.