Dialing Down on IVF: The Critical Role of Down-Regulation

In this compelling episode of "Taco Bout Fertility Tuesday," join Dr. Mark Amols as we 'Dial Down' into one of the most crucial yet often overlooked aspects of IVF – Down-Regulation. Ever wondered what really goes on behind the scenes of your IVF journey? This episode shines a light on the significance of down-regulation, explaining how this vital step can make or break the success of your fertility treatment.

Dr. Amols expertly demystifies the science behind down-regulation, exploring why it's not just a procedural step, but a cornerstone in preparing your body for IVF. We delve into the hows and whys, the impact on egg quality, and the overall importance of this phase in synchronizing your cycle for optimal outcomes.

Packed with insightful anecdotes, expert knowledge, and a touch of humor, "Dialing Down on IVF" promises to not only educate but also engage. Whether you're in the midst of your fertility journey, considering IVF, or simply curious about reproductive medicine, this episode is an essential listen. Tune in and discover the intricate dance of hormones and healthcare that defines down-regulation, and why understanding it can be a game-changer for anyone embarking on IVF.

Thanks for tuning in to another episode of 'Taco Bout Fertility Tuesday' with Dr. Mark Amols. If you found this episode insightful, please share it with friends and family who might benefit from our discussion. Remember, your feedback is invaluable to us – leave us a review on Apple Podcasts, Spotify, or your preferred listening platform.

Stay connected with us for updates and fertility tips – follow us on Facebook. For more resources and information, visit our website at www.NewDirectionFertility.com.

Have a question or a topic you'd like us to cover? We'd love to hear from you! Reach out to us at TBFT@NewDirectionFertility.com.

Join us next Tuesday for more discussions on fertility, where we blend medical expertise with a touch of humor to make complex topics accessible and engaging. Until then, keep the conversation going and remember: understanding your fertility is a journey we're on together.

Transcript

0:01

Today we talk about priming and down regulation in IVF. Is it really needed or is it. Just for the clinic's benefit? I'm Dr. Mark Amos, and this is taco. About fertility Tuesday, one thing I hear all the time is that patients think. That clinics put them on things like birth control for their own benefit. Meaning they don't want to be doing IVF all month. So by putting people on birth control, we can then get them to all line up so they start at the same time. And that way the doctor gets a. Great schedule, gets weekends off. A common term for that would be batching. And then right before you start the IVF process, you undergo a downregulation scan. Where you're going to make sure everything looks good before you go through IVF. And so today I want to talk about, is it really needed? Do you really need to do priming? is it just for the doctor? And the second part is with a. Down regulation scan, why do you need. To check right before going through? Is it just to make more money? We're going to talk about that today. So to be able to understand what a downregulation scan is, you need to understand what a downregulation scan is in. The process of IVF. So for someone who's just listening, the. First step in IVF, usually going on some type of priming agent, such as birth control, whether that is going to. Be a combined oral contraceptive, progesterone only. Estrogen only, that is a whole nother subject. But the point is you'd be put on something. Now where the word down regulation comes from is we truly used to down regulate people's hormones by putting them on Lupron. So in the past we used agonist. Cycles and everyone would start on birth control, then put on Lupron. And the reason why is because if you start Lupron without being on, Birth control, one of the things that. Will happen is you will then make a cyst, basically being a follicle. The reason that you had to downregulate. Someone because you didn't want their body. To produce any hormones, you wanted to control it with the IVF medications such as FSH, to get the eggs to grow. And so by downregulating, you would make. Sure the hormones were not going on. That has changed now because now we have antagonist cycles. And part of the reason we use Lupron in the past was it prevented ovulation. But now with antagonists, we can also prevent ovulation. So we don't need to use lupron anymore. Now, there still is some downregulation and. Upregulation that occurs, but we've kept the. Name a down regulation scan prior to starting the IVF process. So as I started, people are put on some type of priming agent, and. They'Re usually on that for about two to three weeks. And then they go into what's called the stimulation, and that is where you take injections to make the eggs grow. At which time you're coming in for. Ultrasounds, verifying that the eggs are growing. And make sure everything's going well. Prior to starting that, though, you'll do. What'S called a downregulation scan. And that's where a lot of our focus is going to be today, is. What is the importance of it? Why are we doing it, and is it really needed? From my perspective, it is absolutely needed. And, the reason why is because. I always get back to this topic about the stress of IVF and the fact that there is so much writing on it. And what I mean by that is. Saying if an IVF cycle fails, it's not just a failed IVF cycle, but that is hope that is lost in that patient. And so if you start off on. A bad foot and the chances are lower, it doesn't matter, the patient's still. Going to feel like they failed, their. Body failed, and it's going to hurt. Their hope and maybe their drive to keep continuing. So I feel like every IVF cycle should always be its best. And for that reason, the downregulation scan makes sure everything is good. Before you start, I always like to tell people it's kind of like the. Pit stop before the race. You're making sure that the oil is. All the way up. It's supposed to be. The tires look good. Everything's tuned up. Now, obviously, your body is not that, but the point is still the same. Make sure everything is okay. Now, the part we didn't talk about. Is we said you would stimulate the. Eggs after downregulation, which is true. And then eventually you retrieve the eggs, and then you do a transfer. And one of the parts in the. Down regulation is actually to even look at the endometrium. Now, this has fallen a little to the wayside now because most people are doing frozen embryo transfers. So what the lining looks like in the beginning doesn't matter because you're not going to be implanting into it. But before, when we were doing fresh transfers, this mattered. If your lining was abnormal, if it. Was thick and it didn't look like you shed your lining. That may affect a transfer because then they may not want to transfer the embryos into that lining because they're concerned about it. And so they may freeze your embryos in that context to make sure that you have a good lining before the transfer. Now, again, today most good clinics are. Doing frozen embryo transfers, and for that reason, that lining doesn't matter as much. And so that downregulation scan is as. Important to make sure the lining is. Thin and ready to build up. Now, if it's thick and it appears that it's not thin, I'm not going. To be too worried because I know eventually when I go to do the transfer, I can make sure it's okay then. So that's one of the first things we look at in the down regulation. The second thing we look at then is we look at the ovaries to determine are there any cyst on the ovaries. And that's because cysts can create problems. For example, if you're doing a fresh. Transfer and we see there's a progesterone producing cyst, that can create an issue because now that uterine lining will not. Be good to implant into. And so that would be a situation. Again, where you may not do a fresh transfer. If there is a cyst that's producing high estrogen, it doesn't always mean it's create a problem. You can keep proceeding forward with assist, and we do this all the time, like when patients have ovarian cancer or some type of cancer, need us to freeze their eggs, we will push past assist and we do just fine. But it doesn't mean it's ideal, right? Meaning, yes, you can do it, but. Is that really ideal? Now, someone who has cancer and has to undergo surgery with chemotherapy, eventually they need those eggs taken out. It doesn't matter. We'll just get what we get. But if you're doing in a controlled situation, you don't want to lower your chances. And so the question is, how does it lower your chances? Well, one of the first way it. Lowers your chances is it can affect the medications. Let's say you're using some type of. Med like femara as a coflare agonist. In this situation to help your eggs. Grow well, the high estrogen level will. Affect the femara from working as well. One thing I've noticed is when people have very large cysts, it tends to take more medication to get the same benefit. I don't know if it's just because of the way the meds are being distributed in the body when the cysts are there, but it seems to affect it. Other times, cysts can affect things because. With the high hormones, it makes it hard to evaluate how things are going. Because the estrogen levels are high even. If the follicles aren't growing much. And it's hard then to adjust because of those things. And so, in general, we are looking. For those cysts to figure out if there's problems. Now, cysts themselves does not mean you. Have to be canceled. There can be an endometrioma. That's not a reason to cancel. You probably knew it was there before you started. You can have a corpus luteal cyst. Again, not a reason to cancel as long as you're not planning on doing a fresh transfer. But there are certain cysts that get. To a certain size where it may impact whether you may move forward. An example I would usually use is. If I have a patient only has. Three follicles, and I look and she. Has a giant cyst on one ovary, and there's now only one follicle or two follicles. I may say, listen, it's not worth. Moving forward this cycle. You only have a few eggs here. Let's not start off on a bad foot. So I'd rather stop, regroup, and go the next month. Now, on the same token, if that. Same patient the next month had, let's. Say, nine eggs on their ovaries, and. I'm going, wow, this is amazing. I'd never see nine eggs. Well, I may then want to move. Forward regardless, because now we have an opportunity. Just like if someone had 20 eggs and had a system and say, listen, it's not really producing much hormones, and even if it is, you have plenty of eggs, I'm not worried. So you have to talk to your. Doctor and determine if it's a good situation or not. I usually tell my patients I'm either. Going to recommend them going forward, canceling. Or I'll give them the option where I say, it's not unreasonable to move. Forward, but it's not the perfect situation. And obviously finances come into that, right? If everything's free, you might not care, but if you're paying for out of pocket, you may say, I really want the best chances. I don't want to take that chance. So, I'm going to wait. One thing I do at my scans, and I can't say everyone does this. But I do my own down regulation, regulation scans when I can, and I make adjustments. So if I'm used to seeing someone. Let'S say, twelve follicles on their ovary. And then on the down regulation scan. I might only see eight. I may start off in a slightly higher dosage than I would have before, because now I'm worried that there may. Not be as many this month. Today I saw a patient and she. Had more follicles than she's ever had. But what was interesting is one follicle. Was a little bigger than the rest. And so for her, I'm going to. Bump the medications up a tiny bit, but I'm also going to bring her back early. And so one of the things a downregulation scan does is allow you to make those adjustments to make sure the cycle goes well versus if we never. Did it, I would have just brought. Her in the regular time. We bring everyone in after several days of medication, and I would have potentially missed early ovulation or potentially missed an opportunity to have a better cycle. Now, it's just not ultrasounds that we only do. We also look at your hormones as we look at estrogen, progesterone, and usually luteinizing hormone. And what those are looking at is. To make sure they're kind of low. We want that estrogen level, usually even less than 35. It's not unreasonable to be higher. There are many times it should be. Higher, but we usually want it low. And we also want your progesterone level low. Now, that doesn't mean you won't get. Canceled because they're elevated a little bit, but it depends the situation. So let's talk about a couple of those. If you're doing a luteal phase, start where you're stimulating after you ovulate, that progesterone level is going to be elevated. If you are on estradiol for a priming agent, where you are specifically trying to use a, weaker priming agent, then you'll see a higher estrogen level at that point. So there you would be looking at the lh to make sure that everything's suppressed, that your body is ready to get going, and the estrogen, you know, is going to be elevated because that. Was the priming agent, the same thing. You can use those hormones to figure. Out what's going on with those cyst. So, for example, if you see a. Cyst and all the hormones are flat. Well, then you know that cyst isn't really doing anything. It has no problems just hanging out there for some reason, like an uncle you don't want to have, over for your family. But you can flip that the other way and say, hey, everything looks good. This is the most beautiful looking over I've ever seen. Everything looks fantastic. And then you check the hormones, and. They'Re through the roof, and you're going, wait a second. Did I miss something? Matter of fact, I had this just. Recently where someone was just doing a. Scan with another ultrasonographer not at our clinic, and they came back and they. Said the ovary was really tiny and that it had very few follicles. And I said, that doesn't make any sense. Her amh is like five or seven, so there has to be more follicles than that. There's no way her ovaries, are that small. And so, clinically, what we do as physicians is we keep this stuff in. Mind, and things usually make sense. And so when we get these hormones and we get this scan, we ask. Ourselves, does this make sense? That way, when we leave the pit stop to go to the race, we. Know everything is good. And so with that patient, I knew something wasn't right. They redid a scan and came back the next day realizing they didn't actually see the ovaries. Now, it's always important to note this is the way we do things. There may be clinics that, only check hormones, and that's not unreasonable to do. I do think the hormones probably matter even more than the scan. But for me, the scan plays a. Part in it because it allows me to make those early adjustments. But I always think it's important to. Understand different isn't wrong. So then that takes us to the priming. What was the purpose of priming to this downregulation scan? Well, like we said in the beginning. The original purpose was put someone on. Lupron, and that shut everything down. If your estrogen was even a little bit elevated, we knew something was wrong because the Lupron should have shut everything down. The way Lupron works is it basically. Is the hormone called GnRH, ganatropin releasing hormone. And when giving in large amounts, it. Actually causes you to not release gonatotropins like FSH and LH. So it eventually has an effect of shutting down your pituitary. When you no longer release FSh and Lh, then everything suppresses. You don't make estrogen, you don't make. Testosterone and so forth. Now, currently, we don't use that as much. So the downregulation scan is being used slightly different, but the priming still has some of the same purpose. The purpose of priming is to keep. Your body from making cyst. So when you're getting ready for ivF. It also causes upregulation of receptors. So if you shut down the brain. From making lots of hormone, eventually the. Ovaries and the fogles around them start making more receptors, looking for that hormone. They're, like, basically going, hey, I haven't seen the ice cream man in a while. Like, where's the ice cream man? And who doesn't love a good ice cream truck, right? So now you're like, well, listen, maybe I'm missing it. Maybe I'm just in the bathroom every time it comes by. So you start going, okay, I need to know when this ice cream man's coming, because there's nothing better than a chocolate covered banana. So then you start putting up receptors everywhere. You're putting out, like cams out there. You have, a sound thing that looks for that crazy music that the ice cream truck makes. And now you know you're going to be ready. So as soon as that ice cream truck comes around, you're going to have more ability to recognize it. Well, that's exactly what your body's doing. By making more receptors. It's going to have a better chance to find it because it doesn't understand why it's not there. It's used to seeing the ice cream man all the time. And so it's like, where's my fsh? Where's my lh? And so it has to upregulate, those receptors. But then when all those receptors are there, all of a sudden the hormones. Are released, and now the body reacts even better because there's more receptors. Just like if I have those receptors out for the ice cream man, now. My whole family knows about instead of. Just me getting my ice cream, all six of us get our ice cream. Now, you probably heard me talk about how sometimes some people may use different types of priming agents for some patients because they make so few eggs. We don't want to be as aggressive. And I definitely want to do another podcast on that because I feel like sometimes some m people misunderstand that and think they shouldn't be on priming agents. Priming agents do have a benefit, as. We talked about, upregulates receptors, which gets a better response, but it also synchronizes the eggs. So when they grow, they grow as a group. That way, there's a zone of where. The eggs are mature between approximately 15 and 20 mm. So if you make 20 eggs but only four fall in that zone, you really only have four good eggs. But if you make ten eggs and all ten eggs go in that zone, even if you make less eggs, you have more mature eggs. That is one of the other benefits of priming. So to answer the question, do doctors. Put people on that so they can have a better schedule? The simple answer is no, we do. It because it benefits the patient. Even if my clinic was open all. The time, I would still do priming. Now, there are clinics that don't, again. Doesn'T make it wrong, but I can assure you one thing that is true. When I see those patients, it's one of the first things I look at is see the spread of the follicles and know how it affects it. And usually we'll add some type of priming. Again, there's some very weak priming agents. You can use so you don't get. Over suppression for those people. And again, very small subgroup that don't need to be over suppressed. Now, does that mean people don't appreciate the effects of priming? Well, I sure do appreciate, I like to see my family every once in. A while, but that is definitely not the reason we do it. Now, that being said, yes, you can be over suppressed. And so one of the things your doctor should be doing is looking at if you're the type of person who shouldn't be on for a long period of time. So if you got pcos, you can. Probably be on for nine months and. It won't have an effect. Whether you have demetriovarium reserve, it's very. Important not to be on for too long because it can oversuppress and you need to have some type of break. While you're on the birth control. I even have patients who are on birth control for a year or two. Stop it first, take a month off before we do IVF and start priming, because I know they're going to be too oversuppressed by having been on the birth control for a year in the end. Now, when you go in for your. Ivf cycle and you go for the downregulation scan, you realize, okay, now I. Know why I've been on this birth. Control the whole time. Now I know why they're looking at this. The purpose is for you. We want to make sure you have. The best IVF cycle possible, and now we can make those small adjustments that are needed for things that we didn't. Know were there at prior appointments. It's literally the last check before you start. You don't want to find this stuff. Out three days later after you start the medication, you want to know it before you start. Now that we wrapped that up, maybe we should all get some ice cream, because I've been talking about for a little bit here and think even I want some. Hopefully this was a helpful episode for everyone. And if you enjoyed it, as I always say, please tell us about us. Tell us that you enjoyed it. You can send a message to TBFT at new directionfertility.com and let us know that you like the show. And if there's anything you want us to talk about, tell your friends about us. Give us a five star review on your favorite medium. But always, the most important thing is come back again next week on taco belt fertility Tuesday.