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. In this episode, we are joined by Dr. Amy Harris, reproductive endocrinologist at Shady Grove Fertility in Colorado Springs, for a listener-question episode focused on the uterus and endometrium. In this episode, we tackle some of the most common and challenging questions surrounding the uterine lining and embryo transfer. Dr. Amy Harris joins us to discuss what she would do for a patient with fluid in the endometrial cavity, including possible causes, recommended evaluation, and treatment options. We review why fluid often resolves after progesterone exposure, when aspiration before embryo transfer may be considered, and how different stimulation protocols can impact outcomes. We discuss recurrent implantation failure after the transfer of multiple euploid embryos in the setting of a thin endometrium. We discuss potential causes of a thinning uterine lining, including hormonal abnormalities, hypothalamic amenorrhea, and Asherman syndrome. Strategies such as changing endometrial preparation protocols, reassessing thyroid and prolactin levels, and allowing the uterus time to recover without medication exposure. We review treatment options for uterine scar tissue and discuss whether programmed or modified natural frozen embryo transfer cycles may offer advantages in specific situations. Finally, we address the question of transferring two embryos at once after a prior cesarean delivery. We discuss the risks of twins and higher-order multiple pregnancies, including prematurity, neonatal intensive care admissions, pregnancy complications, and the emotional and financial impact on families. We also explore whether vaginal birth after cesarean (VBAC) may be an option for some patients planning future pregnancies. Can fluid in the uterus prevent embryo implantation? What causes a thin endometrial lining? How is Asherman syndrome treated? Should patients choose a programmed or modified natural transfer cycle? Is transferring two embryos ever worth the risk? Join us as we answer these important listener questions. 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.

Abby Eblen MD (00:23)

Hi everyone, we’re back with another episode of Fertility Docs Uncensored. I’m one of your hosts, Dr. Abby Eblen from Nashville Fertility. Today I’m joined by my co-host and friends, Dr. Susan Hudson from Texas Fertility Center.

Susan Hudson MD (00:35)

Hello everyone.

Abby Eblen MD (00:37)

And Dr. Carrie Bedient from the Fertility Center of Las Vegas. And we also have Amy Harris. She is a reproductive endocrinologist at Shady Grove, Colorado Springs. She’s gonna join us today as we answer listener questions. But Amy, you were mentioning to us earlier that you are a Disney fanatic, so tell me what that means.

Amy Harris (00:57)

So most people think about Disney and they think about their childhood or taking some kids to Disney, but there’s a whole another world of Disney adults where without attending with children we have an amazing time. A little bit nostalgic, but also a lot fresh and new that is all Disney themed.

Susan Hudson MD (01:18)

So how often do you go to Disney?

Amy Harris (01:21)

Well, so I guess it depends on how you define Disney. So Disney has a lot of different locations, both here and abroad. And then Disney also has cruise lines and resorts around the world. So I would say at least once a year, probably twice, I stepped foot in a Disney property, but it’s not usually the same one. So for instance, this past summer I went on a my first ever Disney cruise. and then this past April I was in Disney World. Before that Disneyland and all and kind of a mix of all of the locations.

Abby Eblen MD (01:54)

So you go as a group or do you go with local friends or is there like a big group of people that meet up and go to a certain property or?

Amy Harris (02:04)

So different things every time, because I’ve gone with lots of different people and I’ve indoctrinated a lot of people into the Disney adult world. So this actually started during my residency, where they split up what we called the three amigos. Well, we didn’t call ourselves that, but the med school class called us the three amigos who did everything together. one went to New York City, one went to Rochester, New York, and I went to Forces Naval Hospital. And we couldn’t get to anywhere, any of our each other’s locations easily. And but we found out that all of us had a non-stop in Disney World. And so actually that’s how it started accidentally as a meetup in Disney World. So that’s the original three of us. But now since that time we have lots of people who come and join us sometimes, not every time, friends and family of any of the three of us. And I’ve only gone one day solo and that’s because I was going to a conference for something else.

But I have aspirations of being one of the people that actually just goes completely solo and meets lots of new other Disney adults.

Carrie Bedient MD (03:04)

Do you have a Disney bucket list of things that you want to experience within that world?

Amy Harris (03:10)

Of course. And actually I’m just slowly chipping away at it. ⁓ Disney Hong Kong. Disney Dubai, which is supposed to join us in twenty thirty. I’m hoping to be one of the original guests. I’m a also a huge foodie, so Club thirty three at any of the locations is on my top of my list whenever I get get in there.

My favorite park, right now has gotta be Hollywood Studios. I’m really into the Star Wars thing. So it’s so fun to get really, really into it and really enjoy it and you really feel you like you’re there and not that you’re in Disney World. So I think the emerging component of of ⁓ a Hollywood Studios is mine right now.

Susan Hudson MD (03:52)

What is the furthest that you have gone to a Disney property?

Amy Harris (03:57)

So we were I was on the Disney cruise that was out of Barcelona, Spain this past summer. which was phenomenal. Highly recommend the Disney Cruise line for any fellow Disney adults. Had great food, great experience, and just amazing service, and got to see a whole different side of Disney spoiling us.

I was supposed to go to Disneyland Paris, but the other thing you should know about me is I’m a ginormous klutz. So where some of my fellow infertility doctors are training for a marathon right now, I tripped over my dog in the kitchen and broke my foot, so I had to cancel my Disneyland Paris trip. So it’s back on the top of the list, so I can do that.

Susan Hudson MD (04:43)

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Abby Eblen MD (05:50)

Well, today we’re gonna answer some listener questions on the uterus and the endometrium. So we’re all gonna take a shot at it.

Susan Hudson MD (05:57)

Okay, so our first question is I am 44 and preparing for donor embryo transfer, PCOS, positive receptiva 3.2, and chronic endometritis treated with the antibiotics each FET cycle, two months suppression before first FET attempt, which was canceled due to fluid in the uterus after starting PIO.

Second FET on my own mosaic embryo was successful, but ended in missed miscarriage due to the genetic abnormality, followed by D&C hysteroscopy and two more months of suppression. Third FET attempt canceled due to fluid in the uterus again, again after starting PIO. RE now recommends surgery for possible hydrosalpinx to clear any remaining endo. I am worried about more delays and more uncertainty.

Previously had a clear HSG, but that was two years ago. What, if anything, does this pattern point to? What would you recommend?

What do you think, Amy?

Amy Harris (06:57)

So that’s a tough one. I think that a repeat fallopian tube evaluation of some sort is a good idea. So if it’s been two years since an HSG, either another HSG or if there’s other signs pointing at endo, potentially that laparoscopy. When you think of fluid in the uterus, we think of the causes and a a hydrosalpinx or fluid collection in the fallopian tube, rinsing back into the uterus could be absolutely one of the causes.

Other causes could be that also potentially the type of estrogen. If all the evaluation turns up normal would be potentially considering like either a natural cycle or more likely at forty-four a modified natural cycle to see if your body can produce its own endogenous estrogen. Some patients react more to the artificial estrogens and the either the patches or the estrace, mMore than their own bodies’ production.

Susan Hudson MD (07:48)

I think going to laparoscopy for presumed hydrosalpinx after having a normal HSG two years ago and not having anything, any infections or any concerns between here and there is a little bit of a stretch. I wouldn’t really be thinking of the fallopian tubes being a major source of this. I would more think of it being an estrogen source and I would really be curious when they’re saying after PIO is that that’s a little bit unusual as well, because a lot of times when it’s an estrogen source, you’re seeing it before we start the PIO. Cause I would say nine times out of ten, I’ll have somebody who maybe has fluid in the uterus. I’ll start the PIO and then I’ll do a scan the day before transfer. And like I said, most of the time people are like, I had this big episode of discharge and go and scan them and it’s gone. But I do think that how you get your estrogen, even whether you do a modified natural cycle, but even usually using different forms of estrogen, whether it’s vaginal estrogen, maybe a little bit lower dosages, patches, sometimes those things can have a different effect in kind of the architecture of that endometrium.

Abby Eblen MD (08:55)

Yeah.

What do you think Carrie?

Carrie Bedient MD (09:00)

One thing that they can possibly consider, especially once they rule out a lot of the other causes, if it’s just persistent regardless of type of estrogen and after surgery, you can aspirate that fluid immediately before transfer. And you go in, you take a transfer catheter and aspirate everything out and then switch out your catheters and use a fresh one for the embryo transfer. And there’s been good studies that have been done that have shown that that’s an effective way to go. Now, I would say if they see blood in there as the aspirate, then at that point it’s a cancel. But if it’s just serous fluid or mucousy type fluid, then…

That’s something that you can oftentimes just aspirate out and keep going.

Abby Eblen MD (09:42)

I would also wonder how high the estrogen level is, because sometimes I see in patients when their estrogen levels get really high on some form of estrogen, they tend to have more fluid in there. As far as a laparoscopy, I agree with Susan, for presumed hydro, I don’t think I would do a laparoscopy, but she did mention earlier that she had a positive BCL6. And so sometimes I found in some patients, particularly patients though that have had more obvious signs of endometriosis, patients with endometriomas, sometimes it is beneficial, I think, to go in and do laparoscopy and get rid of endometriosis because sometimes the treatment we typically use of two months of lupron kind of one size doesn’t fit all. It doesn’t, it’s not effective for everybody. So I probably in her case, I don’t think she needs to have laparoscopy, but I do think there may be a place for that in some patients that have these symptoms.

Susan Hudson MD (10:30)

Alright. Ready for our next one?

Hi, I’m hoping for some advice. I have unexplained infertility since 2021. I’ve done two egg retrievals, six euploid embryos each, and attempted nine embryo transfer cycles. Six completed, three canceled. One resulted in pregnancy, but I miscarried it ten weeks. All of my health markers are normal and my husband test husband’s tests are normal as well.

My concern is my uterine lining. It used to reach over 8 millimeters, but has steadily declined. My last cycle was canceled at 3.8 millimeters despite a stimulation protocol. Do you have recommendations for improving lining? Also, is estrogen fatigue real? Can the body become less responsive and can that be improved? Thanks.

Carrie Bedient MD (11:21)

That’s an awful lot of treatment. And she didn’t really tell us what timeframe that treatment was in, did she?

Susan Hudson MD (11:28)

No, just that it’s been over her fertility started in two thousand twenty one.

Carrie Bedient MD (11:32)

So, all right, Amy, what do you think?

Amy Harris (11:36)

I think we need to look at what causes unexplained infertility from the beginning. Frequently it’s either an egg function issue, a sperm function issue, or a uterine function issue. It’s not a numbers problem ’cause that’s what our testing is mostly geared at looking at. So something I would ask for is he they said that all the husbands testing was normal, but I will say that some of the newer literature and I don’t want to open a can of worms by mentioning DNA fragmentation index but sometimes elevated DFI on the sperm can lead to a disproportionate number of either miscarriagers or failed embryo transfers. So I’d be looking at that as one of the possible etiologies. And then congratulations making so many beautiful Euploid embryos.

But I also do wonder now about what’s going on in the uterus now that you mentioned that your lining is progressively getting thinner. Trying to look at what diagnostics we’ve done on the the uterus at this point. If it’s not been done, typically I either recommend either a diagnostic or office hysteroscopy with an endometral biopsy to see if there’s any inflammation or infection markers that are contributing to that.

That could either be done by the simple the kind of the classic CD138 staining, or I’d probably in this particular case consider maybe more of a specialized the genome testing for the actual bacteria where they look for one example is the Emma Alice test, and I know there’s competitors out there as well, looking for specifically if there is a overgrowth of a pathogenic bacteria in there that we could potentially be modifying before trying another transfer.

Susan Hudson MD (13:15)

I think another thing to consider is BCL6 testing just because you’ve had so many transfers and it hasn’t been successful. But when it comes to that lining getting thinner and thinner and thinner, that’s a little unusual. That’s a little unusual in the situation that you haven’t had repetitive surgeries, D&Cs, things like that, which I’m assuming you haven’t, otherwise you would have told us. I don’t know about a philosophy of estrogen fatigue. I mean, a woman’s body is supposed to experience estrogen on a monthly basis, pretty much from the age of, nine to twelve until you’re in your late forties. If anything, people tend to have too thick a lining from estrogen not getting more and more resistant. What what do you think about that?

Carrie Bedient MD (14:04)

I don’t know that I’ve ever seen estrogen fatigue. I’ve had one or two cases over the years where we just can’t thicken up the lining. And I do think it happens more often in people who’ve been going straight from one cycle into the next.

And so usually for those cases, we’ll do two months of a washout and no birth control pills, no progesterone and oil, no estrogen of any form. Just let, let the body do what it needs to do and see if that does reset. And that could be any number of etiologies. It could be receptor overwhelm. It could be, the type of meds that are being used maybe aren’t as targeted for that particular person, that particular uterus, but I would probably do a washout and give a little bit of time. would consider the BCL-6, I would consider the two months of Lupron just to shut everything down first before going again. But I think the first place you start is just give your body a little bit of a break. It’s been through a lot.

Abby Eblen MD (15:04)

Yeah, one thing I would think about is if she’s had all these transfers, she started in 2021. It’s been five years. What was a problem five years ago may not be a problem now and vice versa. So I think about things like are there hormonal things? Should we make sure her thyroids up to date? I also had a patient one time that had something similar. She ultimately had a macro adenoma. So she had elevated prolactin. We probably want to check that.

Day three labs, make sure her FSH is not going up, up, up. Worry about decreased ovarian reserve. I check her AMH. And then the other thing too, if she’s obese or has gained a lot of weight, that could be a cause if she has really high testosterone levels, hirsuitism, that sort of thing. So I think it might not be a bad idea to have somebody take a fresh look at everything. I mean, I don’t wanna disrupt your relationship with your physician, but maybe you go somewhere else and just let them sort of give you a second opinion about all the stuff that you’ve had done because sometimes fresh eyes can see things that that others can’t.

Susan Hudson MD (16:04)

So another thing to think about is on the opposite side, because I’d say most of my overweight PCOS patients, not all PCOS patients or PMOS patients, have obesity, but having thin linings generally doesn’t tend to be their problem. But if you happen to be an exercise fanatic or you’re restricting calories, you’re trying to get down to an ideal weight, runner, high level athlete, those individuals tend to have thinner linings, and that can also be a contributing factor. Making sure you don’t have any other health issues going on. If you have something else going on that you haven’t mentioned that isn’t maybe as well controlled as what it should be, the lining could be a reflection of maybe just overall your body isn’t at the right point that it needs to be to best support a pregnancy.

Abby Eblen MD (17:00)

And Amy, a question for you. Would you at what point would you say if this were your patient, gosh, maybe you need to think about a gestational carrier?

Amy Harris (17:09)

I love some of the ideas that everyone on this group put out there, refresh of the labs, refresh of a little bit of a break for the body. And I’d probably try one more time. trying with all the tools in my tool belt, and then if I can’t get to a line that’s impressive, I’d assess how many embryos she has. And then I’d have a discussion around now about when if a gestational carrier is a possibility for this family.

When that might be the the case because, at the end of the day, healthy baby is the goal. And yes, we most of most of us would love to carry our own, but at the same time, if we’re kind of running down our number of euploid embryos before we get to the bottom of it, using one if we have to on a gestational carrier at some point around now is probably when I would at least just start the discussion with the fan.

Carrie Bedient MD (17:55)

Would any of you get RPL labs on her looking at all the antiphospholipid antibodies for recurrent pregnancy loss, especially because it sounds like…

Susan Hudson MD (18:01)

I would have done that like three, four embryo transfers ago.

Carrie Bedient MD (18:06)

Yeah.

Susan Hudson MD (18:07)

I’m gonna say this because I think all of us have already thought this, but it it it’s one of those things that sometimes you assume people practice the way that you do. Is if your doctor hasn’t tried a different prep method, whether you’re doing modified natural cycles or you’re doing program cycles or you’re doing something in between, if you’ve done the same thing similarly six times, it’s time to change things up.

I think we all have assumed that she’s done different types of endometrial preps through all of these embryo transfer cycles, but that may not be the case. If you haven’t had some different perspective, this might be the time.

Susan Hudson MD (18:48)

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Carrie Bedient MD (19:26)

What’s our next question?

Susan Hudson MD (19:28)

All right. I was diagnosed with severe Asherman syndrome after C-section from my first child. I have had four surgical hysteroscopies and a handful more of in-office procedures. A spontaneous pregnancy but miscarried at seven weeks. I do have mosaic Turner syndrome after a high resolution karyotype. Partner sperm test came back normal. Nothing on carrier screening.

Fast forward, more hysteroscopies in four IVF cycles, no improvement to scar tissue after balloon, estrace, progesterone, vitamin E, and baby aspirin, along with daily heating pad and weekly acupuncture treatments. So far, 15 total embryos, no euploids from four rounds, AMH of 2.8, age 40. Supplements include prenatals, vitamin D, CoQ10, melatonin, and NAD plus.

Otherwise healthy. Thoughts on ashermans and on no euploids.

Carrie Bedient MD (20:26)

Is there anything she hasn’t tried that comes to mind for anybody? Because it sounds like she’s really gone through quite the list.

Abby Eblen MD (20:35)

Well, I have something that I don’t have a lot of experience with it and I’ve only used it on one patient so far. It’s a substance called Neoflow and it’s approved for use for many for corneal abrasions and for diabetic foot ulcers. They use it in wound healing and it’s placental tissue that’s been essentially sterilized. And some people actually will put it either infuse it in the uterine lining to help potentially get growth factors to develop. If you do it at the time of hysteroscopy, it comes in almost like a piece or like that you can actually put in the endometrium. There are people that do that. I just heard about it recently and don’t have a lot of experience with it, but certainly that’s something we’re sort of starting to look at in our practice and doing for patients like this that have really poor lining development.

Susan Hudson MD (21:21)

I think getting pregnant as somebody with mosaic Turner syndrome is a bit of an uphill battle. It’s a bit of an uphill battle just at baseline. I mean, I can say that in a lot of practices, they would not allow you even to carry a pregnancy because of the risk of heart issues and pregnancy and that type of thing. And the fact that we know that things are not as equal with all of the eggs you’re producing to create embryos. And this may be a time to consider, thinking about something like donor egg or donor embryo. It’s the right thing for some people, it’s not the right thing for others, but you’ve gone through four.

IVF cycles, 15 embryos, and we haven’t had a single eploid. And, I think things like omnitrope are great. I mean, it’s something I would do in a stimulation that I have had multiple aneuploid, chromosomally abnormal embryos, and we often get better outcomes. But I think when it comes to creation of embryos for you, it it’s it’s going to be innately harder because of that. And then adding on the situation of having, the Ashermans, it’s a really hard situation to be in.

Carrie Bedient MD (22:47)

Amy, how do you handle your Ashermans? Is there a particular protocol that you default to in those patients?

Amy Harris (22:54)

I think that we try to t take a customized approach. We’ve all gone to the operating room expecting maybe one or two bands of tiny Ashermans and ended up with a field of thick columns where better get is the opposite. But there’s a lot of ways to prevent adhesions that a lot of them aren’t super well driven by data.

If I find a lot of thick adhesions, I frequently place the inner uterine balloon and put them on estrogen and progesterone. But unfortunately the data on that is not that amazing. I know there’s some clinical trials undergoing with you know things like hyaluronic acid and ceprofilm and PRP after these type of procedures.

I can’t wait until some data for some of these things come out. But unfortunately I think some people are really good scar makers and some people are really good healers. And I think that’s the case for the C section scar patients where the same surgeon does one and you have keloids everywhere and unf the next patient has like barely a visible C section scar. I think the uterus is kind of the same way and unfortunately we haven’t found a one size fits all approach and so I try to take it by weighing the risk benefits of those interventions, depending on the degree of scarring I encounter during these cases.

Carrie Bedient MD (24:11)

I’m really intrigued by the fact that she was able to get pregnant spontaneously after four of these hysteroscopies because that to me says there’s something in there that is a useful place for an embryo to land.

Susan Hudson MD (24:25)

No, no, no, no. She had she got diagnosed with ashermans after her C section from her first child, and then she has since had those four surgical hysteroscopies.

Carrie Bedient MD (24:34)

Then she had an SAB at seven weeks. Knowing that she was able to get enough implantation to get to that far along is very promising. And sometimes what we see with Ashermans is that the entire uterus doesn’t go anywhere and there’s one little pocket that seems to be growing. And we just preferentially try and place an embryo in that pocket.

And that can lead to healthy pregnancies. Now, anytime with Asherman’s, you have to be very aware of abnormal placentation, meaning that placenta sticks way more than it should. And so when it comes time for it to release, it doesn’t. And that can lead to very heavy bleeding, transfusions, hysterectomy. It has the potential to be very, very serious. But I think knowing that she was able to get pregnant, that is hopeful that, maybe that SAB was because it was an affected Turner’s embryo that couldn’t keep growing and she might have more luck with donor egg or embryo of some sort.

Abby Eblen MD (25:37)

So she got pregnant in a natural cycle with her very first one, right? Is that what she said?

Susan Hudson MD (25:42)

It sounds like that. And then she has had a subsequent miscarriage from a spontaneous pregnancy.

Abby Eblen MD (25:49)

Good. There’s hope there.

Carrie Bedient MD (25:49)

Maybe some targeted work that can be done. Yeah.

All right.

Susan Hudson MD (25:56)

29-year-old, unexplained infertility. I have celiac, but it’s under control. Six embryos frozen and sent for PGTA. Four euploid, one mosaic. My RE said that generally they recommend a program transfer, but I can do a modified natural.

Trigger and progesterone suppositories if I want. When I asked about success, the doctor said they are comparable and then said if you look closer, program does a little better. I want to do a natural as my lining gets very thick on its own, but wondering if medicated is generally better, what is your protocol? Thank you.

Carrie Bedient MD (26:30)

All right, Amy, kick us off. What is your favorite protocol?

Amy Harris (26:32)

So this is a hot topic right now because although I would agree with the physician, again I don’t know everything about this patient’s case, I would agree with the physician that the outcomes are comparable. I think you’re comparing a couple different commodities. I think the pregnancy rates are very comparable, but our goal is a full term live birth healthy delivery. And there’s some surmounting data that there’s less hypertensive disorders and more full term normal weight babies in patients who do natural cycles. Right now my favorite protocol is a modified natural. I typically use five days of letrozole and then trigger based on the patient’s dominant follicle and then do the transfer.

Susan Hudson MD (27:15)

What are your thoughts, Carrie?

Carrie Bedient MD (27:16)

I agree with everything there. I think that which protocol you use is totally dependent on what works best in your hands. And I don’t think we really know, is it the corpus luteum that is making that environment better for the entire pregnancy? And that’s the space that is left that remains when the egg releases.

Or if it’s that there’s lower estrogen levels and there’s lots of debate going back and forth in the literature of what it’s related to. And if you get four doctors in a room, there’s a very reasonable chance you’re going to get seven and a half opinions. And so I know that I personally tend to prefer the program cycles because I’m a control freak, admittedly, and like that level of control. But also I do, I would say at least half my cycles are modified natural.

I do my modified natural a little bit differently, which is do the letrazole, and then I typically start progesterone, and then after that, I give the HCG because again, Control Freak, I wanna know exactly when that progesterone window opened, but there’s a bunch of different ways to do any of these protocols. So I would say it’s about 50-50 either way through. You just have to know with a natural or modified natural, there’s more ability for the universe to take over and an egg to ovulate early or a lining to misbehave or whatever it may be. That’s part of the reason why I do programmed when given the opportunity, but that’s probably more of my pathology than the patient’s pathology.

Amy Harris (28:48)

I will piggyback that I do give the asterisks when I do this, that I do talk about patients making sure their lifestyle fits it because not everybody can with five days notice run to our surgery center to have their transfer. And also even in a patient who’s ovulatory with beautiful linings, every time I’ve checked it, they could still have that particular month have a thin lining and I’m not thawing a beautiful embryo if the lining doesn’t match said embryo. I do counsel highly that there’s a more chance of a canceled cycle if I do do an natural cycle.

Carrie Bedient MD (29:24)

What’s your favorite cycle, Susan?

Susan Hudson MD (29:26)

I do mostly program cycles, but forty percent of my patients are driving about three hours to our IVF center for their embryo transfers. And the those that aren’t driving three hours are driving an hour. Really it’s mainly for logistics and I have some really amazing success rates doing what I do. And so I often say, if you have a pull to do one thing or another because of something specific to your situation, finding a clinic or a physician that matches that is important because I can do modified natural cycles. It’s not what I do a lot of and I do them reasonably well, but it’s not the same as when I’m doing a program cycle, just because I do so much more of the program.

Abby Eblen MD (30:09)

So I’m kind of right down the middle. I’m for many, many, many years I did program cycles because that’s what we did. We didn’t do modified natural cycles and really that’s kind of a new thing, sort of in the whole scheme of things. But now my younger partners who mostly do modified natural cycle FETs have convinced me that patients love it from a patient perspective because it’s usually quicker. Like if they have a failed cycle, they can get right back in and do it, or if they have fluid in their lining.

Then worst case scenario, you just stop and a couple weeks later you’re back into another cycle. A program cycle takes a long, long time. And I also am a control freak and I like that control, but patients really don’t, at least the patients that I see. I would say now for me, and this is just a change in the past year, year and a half, I probably do about half and half. As far as success rates, there really is no difference in our practice. Trust me, our IVF people are looking at it all the time, like which one’s the best.

Basically the outcomes are pretty much the same. And I think it’d be really hard to design a randomized perspective study to figure that out. And that’s one of the many things in our field that we’ll probably never have a great answer for, probably.

Amy Harris (31:14)

I think the best thing to say is whichever one works for you and your team is the best one. I think I had a physician who had a lot of guilt that just she just couldn’t make a natural cycle work. And I’m like, We’ve been making babies beautifully for a long time using programmed. If that’s what works, that’s what I want you to show up for. I think it’s nice to now hopefully make it customized to the patient in front of you and not a one size fits all. Everybody has to have PIO. Everybody has to have the exact same thing, but looking at the patient in front of you and trying to customize it to what their needs are.

Abby Eblen MD (31:47)

And it’s funny, every now and then you have that one patient who’s like, I don’t want to do the PIO. I just wanna I wanna check a predictor kit and I’ve had a couple of people over the years that they’ve done that and they’ve gotten pregnant, they’ve done fine. I’m like, Okay, maybe we don’t need to do all this stuff. But so there’s lots of different things that can work for sure.

Amy Harris (32:05)

In the wise in the wise words of Carrie’s partner Leah Kay, trust the corpus luteum.

Carrie Bedient MD (32:12)

Yes, we do hear that frequently.

All right, should we do one more?

Susan Hudson MD (32:16)

All right, so here’s a good one. Hi, I’ve been listening to your podcast for a year now and love it. Thank you so much for listening. My husband and I are wanting to transfer here soon, but we’re considering doing a double embryo transfer. I have to have C-sections and I’ve already had one with my son in 2023.

We want to use all of our embryos. We have six. My OBGYN said I can only have three to four C sections total. I was wondering what are your thoughts on double embryo transfer when it comes to having a C-section max. Risks of double embryo transfer versus risks of potentially seven C-sections.

Carrie Bedient MD (32:56)

What are the odds of her needing seven C-sections?

Abby Eblen MD (32:57)

What are you thinking?

Susan Hudson MD (33:01)

Not likely.

So with a chromosomally normal embryo, we expect probably about sixty to seventy percent of those to result as a pregnancy that’ll go on to a live birth. If you have six to seven C sections, that would be a highly unlikely situation, statistically in my opinion.

Carrie Bedient MD (33:22)

What would you do here, Amy?

Amy Harris (33:24)

I like to make decisions with my patients and I try to weigh the risks and benefits of all the opportunities in front of us. Did she mention if she did PGTA testing on the embryos?

Susan Hudson MD (33:34)

She did not.

Amy Harris (33:36)

Okay. But so I kind of go through the likelihood of success at her age that she made the embryo if she did not do the PGTA testing versus the 60 to 70 that I typically quote to for the euploid embryo. And then I also talked to them about the risks of a double embryo transfer. When patients have two embryos transfer, there’s a higher likelihood that they could end up with a twin pregnancy. A twin pregnancy could be a previable pregnancy.

Resulting in unfortunately the loss of the pregnancy prior to the age where the fetuses can survive outside the uterus and then that a double embryo transfer typically ends up with a lower live birth potential and so I would encourage her to do a single embryo transfer, at least for now. And again, as she a accumulates hopefully her whole family size, try to make sure it matches her needs, but I would not rush to a double with just one prior sounds like successful embryo transfer.

Carrie Bedient MD (34:35)

I think there’s a variety of ways that embryos can fall off throughout this process. Sometimes it is that they don’t survive the thaw. Sometimes it’s that they survive it, but it’s just barely, and maybe we transfer, but it’s with the discussion of, we don’t think that this one is as likely to stick, but we don’t want to put another one in there because we don’t want two to go in and the one that we think is a higher likelihood for a miscarriage, we don’t want it to take the good one with it, which it is not required to do, but it happens often enough. And certainly you’ve worked hard enough for this pregnancy that we don’t want to jeopardize anything that happens. And then beyond just the embryo surviving and the embryo implanting, there’s still a fair amount that has to happen in early pregnancy to continue on. I agree, I would not go to a double embryo transfer anytime soon.

Whether you’ve done PGT or not does make an impact, but we tend to see that when people are doing double embryo transfers, it’s not that it doubles the success rate. It increases it by maybe 10-ish percent. But the thing that it more than doubles is the cost, because if you end up having twins, especially if they are high medical need babies, the cost of that, the NICU stay alone can be $100,000.

And that doesn’t even count all the rest of it. And so we tend to lean on the side of single for me too.

Abby Eblen MD (36:00)

How old is she? Did she say?

Susan Hudson MD (36:03)

She did not say that.

Abby Eblen MD (36:05)

So ASRM for many years, even before we did genetic testing, would say that if you’re 35 years of age and younger, they would not recommend to transfer more than one embryo. And our clinic and many clinics follow those rules. For at least the first half of my career, we couldn’t do genetic testing. So sometimes we’d have patients over 35 and by about the third transfer, and these patients were pretty much mostly pain out of pocket, they’d be a little Like, look, doc, I’m paying a lot of money and I haven’t gotten pregnant. I want you to transfer two. ASRM would say if they’re untested embryos between 35 and 37, it’s reasonable to do that. We did that. And probably in our practice, 400 cycles a year, we’d have maybe five people that would have triplets from a two embryo transfer. So I’m not just worried about your twins that you could have. I’m worried about your triplets that you could have. We certainly don’t want to take a low risk pregnancy, one baby that hopefully is much bigger and healthier if it’s delivered preterm, to then have potentially two or three babies that are much smaller. And even if they deliver at that same gestational age, they’re at much higher risk for lots of other complications. And Carrie mentioned the cost, and that’s a huge deal, the cost and the emotional cost of babies in the ICU for months and months and months. I’m a little more black and white on this one. I think it’s the easy answer is I would not transfer more than one embryo ever if it’s a genetically normal embryo. I mean it’s a rare rare situation that I would.

Susan Hudson MD (37:33)

If they’re if they’re untested embryos, I do think that there’s more wiggle room. But this is almost kind of when you sit in there and you’re saying, okay, what if these are untested embryos and you really wanted to do multiple embryos? I would almost suggest transferring your poorer quality untested embryos as multiple embryo transfers than your best quality embryos. Because if you’re going in for an embryo transfer, aAnd you have untested embryos, the only thing we can gauge it on is the grade of the embryo. And granted, grade of embryo has no relationship. It has no relationship to chromosomal normality, but grade of embryo does have some impact, depending on where you are, because different labs are different, on potentially success rate. And if you had, two day seven embryos that were fair, fair quality and they’re untested, that that might be something you might want to do, but I wouldn’t do that for your next embryo transfer.

Abby Eblen MD (38:34)

No, absolutely so.

Amy Harris (38:34)

I would also say that the number of C sections the patient can have is really patient specific. We talked about the uterus healing earlier when we talked about Asherman’s. She’s only had one C section. If she does a single embryo transfer is successful and has a beautiful, hopefully full term singleton baby, and her uterus is healing really well, the doctor might be again, I don’t know, it’s in that conversation, might be a little bit more willing to have I think most OBs would rather patients be on their fifth than have preterm twins in there or triplets in there, God forbid. Although that’s old guidance I would say that that patients have a finite number of C sections, I think we put the whole picture together as it evolves over the several children that hopefully I’ll be able to successfully have and maybe not jump the gun and try to put two in at the same time just yet.

Abby Eblen MD (39:16)

That’s true.

Amy Harris (39:23)

And maybe only get there if we really get there. And again, the goal of a double embryo transfer is for a singleton healthy live birth. We only usually do that when there’s a reason that we think that two would make it more likely.

Carrie Bedient MD (39:37)

There’s an argument, especially in a case like this where you know that this couple wants a big family and they’re going to be trying multiple times in the future. There’s an argument to try for a VBAC, a vaginal birth after cesarean in this woman. And it depends on what the reason was. If she had a breech baby that just had the nerve to come down butt first instead of head first, then that’s a pretty good prognosis for trying for a VBAC and being successful. Now, if she had a five pound baby that couldn’t come out and needed a C-section because it was just too big for the birth canal, that’s a very different story. So it’s worth the conversation with your OB and knowing what kind of hospitals are in your area and if your OB is willing, how far you are from the hospital, if your OB is willing to do a VBAC if there’s the setup for it. So that might be a consideration as well because if you can have a vaginal delivery, great.

Abby Eblen MD (40:16)

That’s a great point, Carrie, ’cause I think people are a little bit more open to doing that. The pendulum kinda swings back and forth in terms of what we do, but I that would be if she could have a vaginal delivery successfully, that would change the whole conversation really.

Susan Hudson MD (40:41)

It would.

Carrie Bedient MD (40:42)

Yeah.

Amy Harris (40:42)

But I would say that twins typically are double trouble and so if you do a double embryo transfer, God forbid they’re triplets, but they’re more likely that one is malpresented and would need a C section. And so a singleton is gonna improve your odds of a vaginal delivery after cesarean. A singleton, especially next, I think would be definitely in your best interest.

Susan Hudson MD (41:02)

Amen to that one.

Abby Eblen MD (41:04)

To our audience, thanks for listening and subscribe to Apple Podcasts to have next Tuesday’s episode pop up automatically for you. Also be sure to subscribe to YouTube. That really helps us spread reliable information to help as many people as possible.

Carrie Bedient MD (41:18)

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Susan Hudson MD (41:32)

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!

Carrie Bedient MD (41:42)

Bye.