In this episode of Fertility Docs Uncensored, hosts Dr. Abby Eblen, Dr. Susan Hudson, and Dr. Carrie Bedient discuss various aspects of IVF, including listener questions about egg retrieval abroad, genetic considerations in IVF, and challenges faced during egg retrieval procedures, including the importance of patient safety, and the implications of ovarian positioning. The conversation emphasizes the importance of understanding the nuances of fertility treatments and the implications of genetic testing. They explore the concept of back-to-back egg retrievals, the role of PGT testing in improving outcomes, and how to manage cysts during IVF cycles. The conversation also addresses issues related to egg maturity and the significance of antral follicle count in predicting retrieval success. Join us for a fantabulous episode all about IVF! Have questions about infertility?  Visit FertilityDocsUncensored.com to ask our docs. Selected questions will be answered anonymously in future episodes.

Today’s episode is brought to you by Theralogix. 

Episode Transcript:

Abby Eblen MD (00:01.021)

Hi everyone, we’re back with another episode of Fertility Docs Uncensored. I’m one of your hosts, Dr. Abby Eblen from Nashville Fertility Center. And today I am joined by my exciting and entertaining co-host, Dr. Susan Hudson from Texas Fertility Center and Dr. Carrie Bedient from the Fertility Center of Las Vegas. How are you guys doing?

Carrie Bedient MD (00:21.432)

Hey. 

Susan Hudson MD (00:22.754)

Doing good, doing good. 

Abby Eblen MD (00:24.565)

What’s going on?

Carrie Bedient MD (00:27.48)

So earlier this weekend, I got a gift for my birthday that I was finally able to go schedule for. And it is to help me with my fashion sense, which it does kind of look like an angry raccoon has dressed me in the dark some days. I have gotten much better about it because I know the colors that I look good in. And so I just get the same things again and again because it’s hard to go wrong with it. But it was like getting colors done, so actually analyze some of the more subtle things about colors that look good. So the woman who did it had all of these scarves in different colors, all organized by spring, fall, autumn, summer, and went through some of the really subtle differences, which was cool.

Abby Eblen MD (01:15.223)

So does she categorize you, because a long time ago, you used to either be a spring or a summer or a fall. Do they still, is that sort of the same kind of thing? What season are you?

Carrie Bedient MD (01:24.556)

Yeah.

Susan Hudson MD (01:24.728)

So what colors do you look good? What was your thing? I think Abby is a spring.

Abby Eblen MD (01:31.211)

The spring with my bright neon bubblegum pink shirt today.

Carrie Bedient MD (01:36.12)

So I’m a winter.

Abby Eblen MD (01:38.645)

And so winter is like…

Carrie Bedient MD (01:41.058)

So Winter is the clear, vivid, high contrast type colors, like the icy colors. There’s very little blended colors. It’s a lot of really straight, bold primary. Not primary colors, but just really rich colors. 

Susan Hudson MD (01:50.168)

Yeah.

Susan Hudson MD (02:02.222)

I think that has to do with the fact that you have such dark hair and such fair skin. 

Abby Eblen MD (02:05.075)

And Susan’s probably is a fall. Yeah. Your hair is the color of autumn leaves, so.

Carrie Bedient MD (02:13.26)

Yeah.

Susan Hudson MD (02:15.854)

I have to say I love shopping this time of year.

Abby Eblen MD (02:21.715)

Wow, I love shopping anytime of year. Well that sounds cool, Carrie. I’m excited for you. Can send us some pictures? I think those would be good Instagram pictures of you like with different scarves around your neck and around your face.

Carrie Bedient MD (02:28.728)

Yeah. I will send you guys a couple because there’s one where I’ve got 12 different scarves of all of the Winter colors right next to me and she put it right next to one which was a summer color that was kind of a cream as opposed to a crisp white. And I never would have noticed those differences before but when you look at the pictures side by side you’re like, you kind of look sallow in the one and I look much brighter and…better, more glow, I don’t know what the words are, but looked better in the one versus the other. And to me it’s white.

Abby Eblen MD (03:12.055)

Well, any time you’re a painter, you have colors that are cool colors and warm colors. For example, when I got married, I don’t look good in white, white, white. And so my wedding dress was a champagne. It was pinky and it looked so much different than  just the stark white. Even in a color like that, where there’s very subtle differences. It’s like white paint on your wall, too. There’s subtle differences if it’s a warm white or cool whit. So that sounds fun.

Carrie Bedient MD (03:37.09)

Mm-hmm. Iinteresting. When I think about my wedding dress, it was a super crisp, clear white. When I looked at the cream ones, it looked like it had fallen into a dirty puddle or something. Didn’t know how to do laundry. Washed something with a black or brown new piece of clothing that got everything a little, little off. Yeah, so.

Abby Eblen MD (03:54.193)

Hahaha! Well, very cool. Today we are going to talk a little bit about IVF, and we’re going to answer listener questions about IVF. So Susan, I’m guessing you have some questions for us.

Susan Hudson MD (04:15.894)

I have a lot of questions. Here’s our first one. Hello, I’m considering doing an egg retrieval abroad for many reasons. Have you worked with patients who might do diagnostics here and then begin stims overseas? Are there some things to look out for when choosing an overseas clinic?

Abby Eblen MD (04:34.753)

Carrie, you might be in the best position because you work with a lot more overseas practices, than I do for sure.

Carrie Bedient MD (04:39.81)

Yeah. There’s a couple. One is related to what you intend to do with those eggs or embryos later. There are some people who need to work with surrogates or egg donors or things like that. And for the U.S., as heinous as all of the regulatory stuff is that we have to go through, it’s all there for a reason. And it’s very clear where everything came from, who they were. The information is really clearly disclosed. And so that is all very helpful. But even when you’re doing it on your own body with your own intent to carry the pregnancy later with your own partner, where there’s not any of that third party donor surrogate stuff involved, protocols that occur in other countries are not necessarily the same as what we do here. If you look at particularly some of the European countries, they don’t push in the same way that we do and their success rates reflect that. And it’s not to say that they’re bad at what they do at all. It’s just that there is a different, there’s a different approach to it. And in part, it’s because of the healthcare systems they work within and that has an impact.

Abby Eblen MD (05:54.559)

And by push, you mean they don’t push somebody to stimulate as many eggs. Is that what you’re talking about?

Susan Hudson MD (05:59.886)

They’re not as aggressive. I mean, I can say in Texas, what we see most often are people going down to Mexico to do egg retrievals and that type of thing. And realize that you may not have the same quality lab and the lab matters. It’s not to say that you can’t get great care somewhere else, but make sure you’re really comparing apples to apples as much as you can.

Abby Eblen MD (06:02.196)

Right.

Susan Hudson MD (06:28.946)

And know the services that you’re gonna get. Are you going to have the option of ICSI if you need it? Are you going to have the option of PGT-A or chromosome testing on your embryos if you need it? Do they have good blast numbers? Or are they doing day three embryo transfers on 28 year olds because their lab is not great and that’s the only way they can compensate is to get it back inside of you as fast as possible. These are all things to think about. And then as Carrie was kind of alluding to, also know that if you have any intention of those embryos coming back into the United States, getting embryos through customs is not an easy feat. I know it is possible, but it’s not something that is easy and there’s a moderate chance that your embryos could end up stuck in customs longer than the liquid nitrogen that they’re stored in is guaranteed for.

Carrie Bedient MD (07:29.196)

I had embryos that were supposed to be sent to me from another country. And this clinic sent out two sets at the same time. I got embryos that were supposed to go to the country of Georgia. And the embryos that I was supposed to get went to Georgia instead. And so, both labs were great. They topped off the liquid nitrogen and they ended up in the right place. But, my God, everybody had chest pain with that one until we had what we needed because you’re never quite sure what are they going to go through at customs. How long are they going to be stuck there? Are they going to be exposed to x-rays or other things? What are the rules? There are some countries where you can’t even freeze embryos. That’s not allowed. And so knowing the rules of wherever you’re going, what their research is. like When you look at some of the research coming out of European, otherwise very scientifically developed countries, and you read those papers, you’re like, why are their success rates so bad? And they’re saying, these are amazing. If our lab put that out, we would be overhauling the lab to figure out what was going wrong.

Susan Hudson MD (08:32.846)

And what’s even more common, there are limited countries where you can only inseminate a certain number of eggs. But there’s a lot, if you’re considering Europe, there’s a lot of Europe that PGT-A is not legal. Whether you believe in PGT-A or not, and I think all three of us do, it makes a big difference in really diving into why are you doing your IVF. If you’re doing IVF for recurrent pregnancy loss or unexplained infertility, those are times that I think that PGT-A are especially warranted or if you’re over 35, especially if you’re in your 40s.

Abby Eblen MD (09:14.231)

Well, the other thing I think about when you travel, and it’s true when you travel in United States, but even more so to different countries, is, things go pretty well 98 % of the time, but there’s a few percentage of the time where things don’t go perfectly. Maybe you get hyperstimulated, or maybe you get pregnant and the hormone levels are not going up well, and they’re worried about a tubal pregnancy. So it’s, sometimes patients are in a bind because then they come back to this country everybody’s kind of like, well, you know, I don’t know what they did. So those are other things to think about too, there is splintered care, unless you’re going to stay put in that country for a while and make sure they manage any side effects or problems you may have from procedures that are done there.

Carrie Bedient MD (10:09.356)

The impact of your social situation… are you married? Are you not? Single? Same-sex couples? Any variation on male, female, heterosexual starts to run into a lot more problems internationally. Again, not guaranteed. There are places that are totally fine with it. But there is a big reason why the US attracts so many international patients is because it’s just it’s stuff they can’t get in their home countries.

Susan Hudson MD (10:41.562)

Let’s get to our next one. It was a good question. Hi, my husband and I found out we were carriers for the same fatal genetic condition. We are both 26 and have no known fertility issues. We are pursuing IVF to ensure we don’t pass on this disease to our children. Will our IVF experience differ than somebody who has a fertility diagnosis? I know a lot of information is about infertility, but I’m trying to understand the process for our situation.

Abby Eblen MD (10:43.332)

Good question. What do think, Carrie?

Carrie Bedient MD (11:12.29)

There’s a couple aspects of this. One is that there’s such a thing as unexplained infertility where all of your testing is stone cold normal, and you don’t know until you’re actually trying to get pregnant. We don’t really have a whole lot of information as to how this couple found out that they both carry this fatal disorder. I very much hope for their sake that they somebody did preventative testing and found it before they found out the really, really hard way. And so there’s always that aspect, but one of the biggest things that you will encounter is that even though you’re young and hopefully all of your testing is stone cold normal is a larger percentage of your embryos are going to be unusable, not just because of the normal aneuploid, incorrect number of chromosomes that develop, even a young person and that’s normal, but also because you’re going to lose a solid 25 % of your embryos because these two genes are going to combine and those are going to be the unusable embryos, which it’s good. You want to know that that’s a whole reason you’re doing it. But it does mean that you very well may have a far lower number of embryos at the end of one cycle than someone who’s got fertility treatment because they’re going through PCOS or have a low sperm count or some of these other reasons. And so you may not be able to as easily compare to one of your counterparts who’s the same age and going through IVF because of the additional testing that you’re doing. That’s normal, that’s why you’re doing it, but it makes those comparisons really a bad idea.

Susan Hudson MD (12:44.952)

I think there’s two differences. One, if you’re coming into this without a diagnosis of infertility you are coming into it more, maybe not in as negative a psychological point as a lot of our patients do. So you may be actually starting off on a good foot and have a little bit more resilience than what we sometimes see. It is stressful. It’s stressful no matter why you’re doing IVF. It is definitely a stressful process, but know that it is stressful. So have your community, however you like to release stress, make sure you have those things going on. And you’ll also need a little bit more lead time.

So What you’re doing is a process called PGT-M. We’re looking for a single gene that’s causing a disease. Whenever this happens, we have to have a probe, which is essentially kind of a device that will specifically look for your and your partner’s mutation. To develop this probe, we often need samples of either blood or saliva from other family members. Sometimes people are taken a little aback by that, but that’s part of the process. And it usually adds about four to eight weeks on onto the process. And so that’s something just to mentally prepare yourself because if maybe you got this testing done preemptively, through something outside of a fertility clinic and you’re like, okay, I have my new patient appointment next week. That doesn’t mean we’re getting started next week. You’re still going to need to go through a basic fertility evaluation, and you’re gonna have to have this probe created. It does take a little time. That’s just something to be forewarned about.

Abby Eblen MD (14:47.575)

I would just like to piggyback on what Carrie said about the funnel effect. I use her terminology because she started out with this. Any time somebody goes through IVF, no matter where you’re coming from in terms of your diagnosis, you start out with a certain number of eggs and at every step that egg number drops down. Quite frankly, the disadvantage that you have if you’re doing genetic testing for a specific condition is first your embryos have to go through the funnel effect to figure out which ones are normal and which ones are abnormal and it’s about a 50-50 proposition if you’re 26 years old. I think you’ll do well probably because you are 26 years old, so I think you’ll do as well as anybody but still I think you’ll be surprised by how much the embryo number drops and then ultimately once we do testing to make sure that the embryo is either a normal boy embryo or normal girl embryo, then your embryos, like Carrie was saying, go through one more filter and there’s one more layer they have to go through. And so it’s not unusual. Keep this in mind. It’s not unusual for patients to have to go through more than one IVF cycle sometimes to find a healthy embryo. And hopefully that won’t happen to you, but I would keep that in the back of your mind that that’s a possibility.

Susan Hudson MD (15:58.446)

All right, our next one. First of all, thank you for your podcast. Thank you for listening. I’ve done two egg retrievals and awaiting to do an FET. With ultrasound, the tech has always had trouble finding my right ovary. First ever doctor told me point blank, it’s because you’re too fat. My BMI is about 38. We changed clinics and since then I’ve been assured that they just sit high and that’s normal for ovaries to float around. My first round of stims they got full of follicles and dropped, making them easier to see. However, they couldn’t see my right ovary during egg retrieval and actually punctured my uterus trying to get eggs. They retrieved seven total and no embryos. Second round, they never could see it the day of egg retrieval and it was very visible and they got 13 eggs and five embryos. I never hear about this and wanted to know your thoughts. So the wandering ovary.

Carrie Bedient MD (16:52.024)

Ovaries running high definitely happens. And sometimes it can be for a whole bunch of reasons. Sometimes it’s just how you’re made. Sometimes you’ve got a particular ligament that’s a little bit shorter that holds it up higher. So it doesn’t have the capacity to drop to the same extent. Sometimes it’s a product of scar tissue. If you’ve had inflammatory processes go on in the abdomen, whether that is infections, whether that’s a surgery, particularly if was a complicated surgery of any type, anything with a lot of bleeding that myomectomies, all of those things are a little bit more prone to scar tissue. So bowel resections especially, yeah. All of those things can pull an ovary up and out of the way. Now, when you are asleep in a retrieval, we do have the capacity to push harder. And the things that you cannot do in an ultrasound while somebody is awake, you can do while they’re asleep because you can push on their belly and try and get it to come down. But sometimes those ovaries are up and out of the way. And going through the uterus to get to them is not necessarily a problem in the sense of the uterus is a very forgiving organ. I mean, it can take growing a watermelon seed to a full-size watermelon and evicting it multiple times over the course of your life and be perfectly happy with that. Whereas a lot of other organs, you so much look at them cross-eyed, they get pissed and they run away. The uterus can tolerate it, but it does make the procedure more difficult for us. The uterus is a very different organ to go through than just the vaginal sidewall.

Abby Eblen MD (18:22.709)

Well, it also is more risky because there’s a lot of blood vessels close around the uterus that sometimes we can see well and sometimes we can’t. So it’s a little unnerving and a little tricky to get around vessels in the uterus to get to a real high ovary sometimes.

Susan Hudson MD (18:39.638)

So it’s a very true thing that ovaries do not stay in the same position. They can go up and down. And sometimes we can see things better at egg retrieval. Like Carrie mentioned, we can apply more pressure because you’re asleep. But sometimes ovaries also just aren’t accessible. And unfortunately, that’s something that we do deal with.

Abby Eblen MD (19:04.735)

Yeah, and just like everything, safety is our primary concern. Nobody wants to go in and not get both ovaries. We’re disappointed, patient’s disappointed, but the number one priority is your health. We certainly want to get as many eggs as we can, but we don’t want to injure organs in the process. I will say in our office, sometimes we’ll actually do bowel preps on patients because really the things that are down in your lower abdomen are, your ovaries, your uterus and your bowel. And so sometimes if we can get the bowel decompressed and get it out of the way, sometimes we have a better shot at getting the ovary. If someone hasn’t tried that on you and you’re going to do another egg retrieval, I would mention that and think about doing a bowel prep. And sometimes we’ll even have patients do a clear liquid diet the day before just to really decompress the bowel as much as we can to give us more room to get to that ovary.

Carrie Bedient MD (19:51.338)

One of the ways that the weight plays in specifically is that it depends on where you carry your weight. Some women carry their weight in their middle and in their chest. When they’re breathing during a retrieval, their chest wall is going up and down. And that has the downstream effect of pulling the ovary up and down every time they take a deep breath in, and they can’t control it in the same way. Cause of course they’re asleep so that we can safely do the procedure. And so that means that we are chasing an ovary every time you take a deep breath in and out and you can’t necessarily aspirate all the fluid to get it out, to get the egg that fast. And so it’s very scary to have this long needle in and have the ovary move up and out of it. You suddenly have this uncapped needle in the middle of the abdomen. And that does become more of a challenge when someone is carrying extra weight in part because of where they carry their weight and also in part because of how long the needles are. We deal with really long needles. That’s typically not the issue. It’s just there is a length to what you can safely control and that plays a part as well.

Susan Hudson MD (20:58.851)

And always remember that when we’re trying to help you during this journey, your safety is our number one priority. So if it comes between potentially causing harm to you and getting an egg, you win every time.

Carrie Bedient MD (21:14.072)

Yes.

Susan Hudson MD (21:15.784)

Hello. I’m a 40 year old woman turning 41. AFC 14, AMH around three when we checked it last year. Have had one chemical pregnancy, tried through three IUIs for insurance purposes. My husband and I have done two egg retrievals, but have had issues with maturity or not fertilizing and only have one euploid embryo. We’re about to go through another retrieval and have budget to do a fourth and final round. We were hoping to do back-to-back retrievals to get it in before the end of the year lab closures, which would put us in January or later, which I worry about with my age. Any downsides to doing back-to-back retrievals? What about DuoStim for someone my age? I have read some things online that it’s possible to get good results with this. Thanks.

Abby Eblen MD (22:06.313)

So our practice will do some DuoStims. I’m not a huge fan of the DuoStim. I just talked to somebody the other day about this. Essentially that’s where you go through a typical IVF cycle that takes 12 to 14 days. And then really right as your hormone levels are coming down and you start a period, or even before that sometimes we’ll even start you in the cycle. The problem with the DuoStim, in my opinion, is you end up having to use so much more medicine in that second cycle and it takes a lot of days. It takes much longer to get somebody stimulated and really you really don’t end up better off and sometimes we don’t get as many eggs with the DuoStim. So it can be done, but I’m not a huge fan of it. I think the difference between, doing a cycle, waiting a month in between and then maybe starting another cycle in January, if it were me, I would do that as opposed to do a DuoStim just because I don’t think we get nearly as many eggs with the second stimulation.

Carrie Bedient MD (23:02.922)

I don’t think anybody’s shown that they are definitively better or worse. I think that there’s enough variation that you do have leeway. But I would agree, I think, especially when you’ve got a ton of eggs, DuoStims were made for people who only have a couple of eggs, because that way you get the first set of, a handful of eggs, and then there’s just not as much that has to recover before you do the second one. For somebody who’s got a ton of eggs, I don’t really like the idea of going in immediately because you’re going into an ovary that hasn’t fully healed yet. I think some of this is based on individual circumstances. And with an egg count of 14 and an AMH of three, I don’t know that you’re really very well served by a DuoStim other than just getting it done with so that you can mentally move on to the next stage, whatever that may be. I’m inclined to say just wait a little bit longer. Take the month, have a breather and then let your body recover and go into the next stim if you need it.

Susan Hudson MD (24:09.998)

I agree. Our next one. I had an AMH of 0.7 with vitamin D deficiency. After supplementing, my AMH went up to 1. AFC all over the place, 8, 10, 17, 10, ended up being 5 at baseline for my first retrieval, got two eggs, both mature, both blasts, both genetically normal with PGT. Husband’s sperm, low motility 31%, total motile 11 million. 3% morphology, both of them are 34. Question is halfway through the second cycle, 14 follicles, yay, wondering if we should plan to do PGT testing if we have any blasts to test. Also is low ovarian reserve a good diagnosis for me given me my up and down AFC? Thanks so much, love the podcast. Thank you for listening.

Carrie Bedient MD (25:00.63)

Yay. What do you think, Abby?

Abby Eblen MD (25:03.127)

I would say congratulations that you did fabulous for an AMH with a 0.7 to have two eggs and have two blasts and both be normal. That’s incredible. That’s amazing. That’s wonderful. You don’t make many eggs, but you do a really good job of it. I think that your diagnosis probably is decreased ovarian reserve, and the question was, should she go back into another cycle? That the question?

Susan Hudson MD (25:32.014)

No, should she do PGT testing if she has any more blasts to test since she has two chromosomal normal embryos?

Abby Eblen MD (25:38.997)

I’m a big fan of PGT testing because I think it just helps really narrow down, if it’s good a good embryo because if you go through another cycle and you have two blasts again, they may be two abnormal blasts, and you don’t know that. It depends a little bit on money, obviously, because it’s expensive. If you have insurance coverage for it, I would absolutely do it. If you don’t, you’ve got those two normals. So you could go ahead and potentially have two babies and maybe think about testing those later if you wanted to or just gamble based on the results that you got from this cycle.

Susan Hudson MD (26:12.514)

You might even think about transferring untested embryos before transferring your tested embryos later on. I’m guessing you’re wanting to have more than one child. Otherwise you would have already gone forward with an embryo transfer. So if I’m hedging my bets, I’d rather transfer my untested embryos, understanding 50 50 chance they were abnormal. And then if I’m pregnant with one of those great, if not, then move on to your chromosomally tested ones. Another way to like think about it. I also would encourage you to consider PGT testing them. But if you chose not to, I would almost think about transferring those untested embryos first.

Abby Eblen MD (26:55.755)

Yeah, particularly if you’re not gonna go through one more time. Because if you transfer the untested and if worst case scenario or bad scenario, you got pregnant, had a miscarriage, it’s gonna take you out of the loop for a few months before you would be able to get back into cycle again too. So that’s something else to consider.

Carrie Bedient MD (27:12.396)

And a lot of times the financial works out such that doing PGT is kind of the cost of one embryo transfer. And if you identify that there’s a couple of abnormals in here, you probably cut even on the financial part of it, plus save yourself some heartache as well. Because if you can avoid around a progesterone shots or a negative pregnancy test or a miscarriage, so much the better.

Susan Hudson MD (27:35.24)

Exactly. Our next one is, went in for my suppression check before starting stims and they found a cyst on my ovary that was producing hormones. My REI said they could do a trigger shot that day and still begin stims in two days with the gonal F dose being higher. Is this a common approach you would take? Could this ruin my outcomes for egg retrieval? He did also give me the option of cancel the cycle and wait for the cyst to resolve.

Carrie Bedient MD (28:05.474)

Some of this depends on how old she is because someone who’s 30 years old, you’re maybe a little bit more inclined to say, eh, just wait a month or two and let’s do this when you’re 30 and a half years old. For someone who’s 40, 41 years old, there’s a little less tolerance for waiting. That said, some of this depends on is that cyst there normally? Do you normally have other cysts? Are you someone where your FSH is high enough such that you kind of routinely make cysts going into a cycle where it doesn’t matter if we wait and do it another month, this is likely to happen again with another cyst. And so you might as well just bite the bullet and go ahead and do it now versus this is a more random thing, or this is the very first time you’re doing it. And so it makes more sense to wait because on the one hand, you don’t want to charge into a cycle that’s not ideal, but on the other hand, you don’t want to waste time and effort and money and emotional reserves… waiting, waiting, waiting for something that you’re gonna have to trigger or drain in order to get into cycle. Some of this depends on circumstances that we don’t necessarily know about what your case is. Given the option, especially the first time, my preference tends to be let’s wait, let’s put you on a longer suppression, let’s trigger it, let’s go into a luteal start. That happens to be my MO, because it’s an equally as easy way to optimize what’s going on. But there are some patients where they just have cysts all the freaking time, and you have to work around that. And we know how to do that too.

Susan Hudson MD (29:42.178)

Yeah, I think there’s a lot more to the story that we may not have knowledge of. I tend to, if I’m going to trigger somebody like this, I usually go into kind of an estrogen priming protocol. I don’t go straight into a stimulation, but that’s just kind of the way I typically do things. This is definitely the art of medicine where there’s a lot of ways to handle this.

Abby Eblen MD (30:08.247)

Yeah, and I would say it’s probably not optimal to trigger. I wouldn’t typically do that. I think for cancer patients sometimes we do that if we’re trying to get into a cycle really quickly. But I think it, like Carrie said, if this was your first cycle, I probably wouldn’t trigger you. I think It would be more optimal if you would wait until your next cycle to get started.

Susan Hudson MD (30:30.35)

Our next question is, hi, Docs. Thank you for your amazing podcast. Again, thank you for listening. My husband and I are both 36 and dealing with secondary infertility. We have DOR and male factor, AMH 0.6, AFC 10, FSH 10. Only sperm issue is 2 % morphology. Just did two back-to-back antagonist rounds of IVF. Letrozole, 300 of Follistim, 20 units low dose HCG, dual trigger. My first round was eight eggs retrieved, six mature, five fertilized, four blasts. That’s awesome. Second round only difference was that it was back to back in eight days versus 10 days of stim and added Omnitrope. I had five eggs retrieved, but only one mature.

Abby Eblen MD (31:06.165)

Wow, that’s great.

Susan Hudson MD (31:17.038)

What do you think the maturity issue was from? Does back to back ever cause issues or were the stims too short? My retrieval was also an hour earlier at 34.5 hours versus 35.5 hours. There’s a lot of information in that one.

Abby Eblen MD (31:33.623)

So this was kind of a DuoStim then basically, right? Yeah. It’s unique to each individual. As we were talking about earlier, DuoStims sometimes don’t go quite as well as waiting. Who knows if that’s what it was? Certainly we’ve had patients that have done everything absolutely perfectly timing wise and still end up with some immature eggs. Did she have HMG added at all to her stim? She did. Yeah. So, if I were planning your stim again, if you were doing it again, I probably wouldn’t do a DuoStim and I probably would give you HMG, which is a little bit more powerful than giving you HCG. We do that often. We do HCG every other day or daily. But I feel like if I see patients that have immaturity or maturity issues, I would add an HMG in addition to what you’ve been doing.

Susan Hudson MD (32:29.902)

I’d also be a little concerned that you did dual trigger back to back on a DuoStim just because with your initial trigger, your internal hormones probably responded more aggressively than they did having another Lupron trigger two weeks later. And so that’s a very, very short interval. On most dual triggers, you use a little bit lower dose of your HCG trigger. And so, if you have to do DuoStims for whatever reason, doing a full HCG trigger, I think would be reasonable or spreading it out more. I do think as much as we just talked about, the DuoStims probably don’t cause much harm. It may not have been an ideal circumstance for you.

Carrie Bedient MD (34:31.416)

Yeah, I think length of stim and potentially length of trigger time to retrieval as a function of those things working together. I think If you had 34 versus 35 hours with a longer stim, I don’t think that’s going to make a difference, but it may be something that in this particular setting leaned a little bit more one way or the other. Doing retrievals 34 to 38 hours is normal within the standard.

Abby Eblen MD (35:00.171)

Well, the huge positive is you proved in that first cycle, you did great. You had eight eggs and four made it to blastocyst. That’s great. It can be done and sometimes it’s just a one-off. It just doesn’t go well. And hopefully, your doctor will be able to build on what you did in the first cycle medicine-wise and hopefully get a better result if you do it again.

Susan Hudson MD (35:19.342)

Yep. Y’all wanna do one more? Hi, docs. First off, thank you for all the work you do to make the science of fertility so accessible, but at the same time, not holding back on the detail and nuance. Thank you so much for listening. You’re an invaluable resource. I have undergone two egg retrievals in freeze-all embryo cycles. My question is, my AFC both times was around 14, but we were only able to retrieve seven eggs each time. We did not change the protocol, Follistim and Menopur with estrogen priming from the first to the second cycle, except starting a slightly higher dose the second time. My question is, is it normal for the actual number of eggs to retrieve to be so much lower than the AFC at baseline? Would it make sense to try to change the protocol if we were doing a third cycle? Thank you.

Abby Eblen MD (36:08.929)

So anything can happen. You never know what’s gonna happen. You never know which eggs are gonna stimulate which aren’t. The AFC is a place that we start at, but when we start to give you the FSH medicine, it’s hard to truly know what happens in your ovaries. But I suspect that some are better equipped to respond to the FSH. And so the FSH as they bond to some of the eggs, some of them just grow faster and rich get rich and the poor get poorer. And so you have a group that come and grow quickly but a group that just don’t respond at all. And I think that’s unique to the patient, unique based on your age and on the quality of your eggs. It’s always disappointing when you see a good AFC count, but you don’t really have eggs that stimulate and grow in the way that you would expect. So the answer is, yeah, it does happen. And as far as changing the protocol, I think they did go up on your dose in the second time. Other things to consider might be a microdose lupron flare. I didn’t see what your AMH was, but if your AMH is a little bit lower, that sometimes can also work to your benefit. It gives you a little bit more boost because your own FSH is released in addition to the FSH that they give you. That might be something to consider for another stim.

Carrie Bedient MD (37:22.486)

I have questions. I want to know what your trigger was. I want to know what they found at retrieval because sometimes you can go into those follicles and find out, we’re getting endometrioma fluid and that plays a part in it. Sometimes I would want, what was that? Meaning there’s no egg there and there never was gonna be. I’d be interested in knowing what your FSH level was to figure out, do you need a higher dose or are you at a plenty high dose and it’s just your body that’s not responding because that has an impact as well. There are other protocols you can try like the microdose flare that that Abby was mentioning, but I have questions. I want to know what else is going on to figure out what makes the sense versus to tweak versus not to tweak.

Susan Hudson MD (38:11.438)

Yeah, when I’m working with my patients, I don’t usually emphasize an antral follicle count at the beginning of the stimulation. When you’re getting triggered, that number and how big your follicles are is way more predictive of how many eggs we’re potentially going to get. Sitting there being like, I have an antral follicle count of 14 and I think I’m going to get 14 eggs. I honestly would never promise that to somebody. And the other thing to remember also is this might be a component of your fertility challenge. So we always say that IVF is not only therapeutic and that we’re helping you get pregnant, but it’s also diagnostic. And so this may be part of the big picture of what has led you to ending up needing IVF to begin with.

Abby Eblen MD (39:08.823)

Well, great episode and so to our audience thanks for listening and tune in next week for more. Also be sure to subscribe and leave a review in iTunes. We’d love to hear from you. You can follow us on Instagram or Facebook and please leave a hop on and leave us a like or a comment.

Carrie Bedient MD (39:23.798)

You can also visit fertilitydocsuncensored.com to submit specific questions you have about infertility. All questions will be answered on the podcast anonymously for our Ask the Docs segments so don’t hold back. We love episode ideas, so let us know what you’re thinking and what you want to hear.

Susan Hudson MD (39:38.264)

As always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. All right. We’ll talk to you soon. Bye.

Carrie Bedient MD (39:46.648)

Bye!