Dive into the intricate world of fertility treatments in this episode of Taco Bout Fertility Tuesday with your host, Dr. Mark Amols. This week, we're zooming in on trigger shots—those crucial injections that help synchronize ovulation with reproductive procedures like IUI and IVF. But what are trigger shots exactly, and why are they so important? Dr. Amols will guide you through the different types of trigger shots, including hCG and Lupron, and explain how each one functions to optimize fertility treatment outcomes.
Discover why hCG is favored for its longer half-life and lower cost, and how it mimics natural hormones to kickstart ovulation. We'll also explore the strategic use of Lupron to reduce the risks of ovarian hyperstimulation syndrome, and why sometimes, a combination of both is used. Dr. Amols will shed light on the biological processes involved, from how trigger shots lead to the resumption of meiosis in eggs, to their role in ensuring egg maturation and readiness for fertilization.
Packed with scientific insights and peppered with Dr. Amols' straightforward explanations, this episode is not just for those undergoing fertility treatments, but anyone interested in the science of human reproduction. So, grab your taco and settle in for a detailed exploration of how timing truly is everything in the world of fertility medicine. Whether you're a patient, a healthcare provider, or a curious listener, this episode promises to enhance your understanding of one of the pivotal aspects of reproductive technology.
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.
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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.
>> Dr. Mark Amos:
Today we talk about trigger warning. No, seriously, we're actually going to be talking about triggers today. I'm Doctor Mark Amols, and this is taco. About fertility Tuesday. Whether you are doing iuis or IVF, you probably came across a topic of trigger shots. In today's episode, you're gonna have a deeper understanding of what trigger shots are, why there are different types of trigger shots, how they work, and why do doctors pick one trigger shot over another? So get the taco on your hand, and let's talk about trigger shots. So, whether you're doing IUI is also known. Artificial insemination timing, of course, cycles, or even IVF, at some point, you need the follicle that's growing to ovulate. And this is where trigger shots come into play. Trigger shots are a medication you take that makes you ovulate on the time we want. Technically, when you take a trigger shot, you're usually going to ovulate in approximately 36 hours. It's not exactly, but it's pretty close to that. So doing an IUI at 48 hours would be dangerous because it'd be too late. You have already ovulated. The same token, if you do the IUI at 12 hours, you're a little bit early. But that may not be harmful because the sperm can still be there waiting for the egg to be released. Some people use the term egg drop, meaning the ovary drops the egg, and this is the medication that causes it. Now, it doesn't mean you can't ovulate without a trigger shot. Matter of fact, if you take a med like Clomid or femara, eventually the follicles will get big enough. They'll just ovulate on their own. That's the same way it happens every month when someone has a menstrual cycle and they don't get pregnant. I've actually seen many people want a trigger shot thinking that if they don't take it, they won't ovulate, and that's just not true. If you get a follicle to grow, it will ovulate. The purpose of the trigger shot is to help with the timing. So if you're spending money on a trigger shot because you're doing time intercourse cycles, there's no reason to do that unless you just want to have intercourse only one time. Otherwise, just have intercourse because you don't need the trigger shot. Now, trigger shots come in multiple flavors, meaning there's different types out there. There's what are called hCG trigger shots, and then there's called a Lupron trigger shot. The hCG trigger shots usually come in the names Ovidril, Novaril, pregnyl, or just hCG, which stands for human chorionic gonadotropin. Lucran, on the other hand, is a little bit different. It's actually the gonadotropin releasing hormone that's released from the hypothalamus down to the pituitary. For the pituitary, then the release LH and Fsh. So, to explain these better, let's talk about what causes ovulation. Naturally. What causes ovulation is as the follicle gets bigger and bigger, eventually the estrogen levels hit a point where it knows it's ready to be released. And then your pituitary gland will release a large amount of LH hormone, luteinizing hormone, and that then will cause the process of ovulation, which we'll get into a little bit more of the embryology of that in a minute. As I've mentioned in prior podcasts, the size of the follicle isn't really the marker of making you ovulate. If you only have one follicle, it may get up to 24, 28 mm before your body makes the LH. But if you have multiple follicles growing, it could even be by 18 mm, you start ovulating, or even less, because it's the estrogen that causes the process. This is one of the reasons you have to take other medications. When you're making multiple follicular equipment to prevent ovulation, you're trying to prevent your body from surging, releasing that LH hormone early. The problem is LH has a very short half life. LH has a very short half life, around 20 to 30 minutes, which means LH is quickly cleared from the body after it's released. Whereas hCG, human chorionic gonadropin, has a half life of 24 to 36 hours. So it takes a much longer time to get rid of it from the body. Now, I'm sure you're wondering, well, doesn't doctor Amos know that human chorionic gonadropin is not LH? The answer is, I do. The question then is, why do we use hCG instead of LH to cause trigger? It's because hCG mimics LH and because it's structurally similar to LH, it's able to cause the receptors, which are the LH receptors, to react to the hCG. And if you think about this, this kind of makes sense, because what does the baby do? The baby's placenta makes hCG to go to the corpus luteum to tell it to keep making progesterone. And so we already see in natural life where hCG is being used to mimic LH in the bloodstream for the baby to keep the corpus luteum around, which makes the progesterone until the placenta can take over completely. But theres also another reason, and its because LH would be very expensive to make, and it also has a very short half life, whereas hCG, because of the longer half life and being much lower cost, we tend to use hCG, it works better and again has a longer half life. Now, between the different brands of hCG, Ovidril is very unique. One of the benefits of, Ovidryl is just a subcutaneous shot, meaning it does not need to go in the muscle, it just has to go into the subcutaneous tissues. Very similar to the medication follistim and gonal f, which also go in the subcutaneous tissue. A lot of places will use Alvadril when they're doing artificial inseminations, and iuis because it's just easier to do and easier to teach. But when it comes to IVF, we tend to, as reproductive doctors, like to use hCG in its muscle injection form. And so that's where Novril and pregnyl and human chorionic gonadropin come in. The main reason for this is because it has a little bit of a stronger punched in the subcutaneous shot. Now there are clinics who will use the overgile shot, and I use it myself. I tend to add a second one to get the same strength. But there are some places who feel comfortable using one. That's their choice. There's nothing wrong with it, it's just a different way to do it. But in general, a lot of places use hCG and usually will use somewhere between 5010 thousand units. It's interesting, over the years everyone used 10,000 units and really no one knew why. It was just one of those things where, well, that's what's in the bottle, let's just use it all. And people used to get things called ovarian hyperstimulation at a higher incidence. And then they started wondering, do we really need 10,000 units? And so a lot of places now have switched to just using 5000 units. But there are times that we get a little bit concerned about ovulation and we'll still use the higher dose. Again, there's no wrong or right. That is the decision a doctor needs to make with you and your situation in mind. But Novaril comes in at 5000 units and pregnyl comes in at 10,000 units for the hCG that you purchase. But there's also another trigger called Lupron. And Lupron causes your pituitary to release lh. The thing we talked about that actually causes ovulation. And so you take this doses of Lupron, usually as one dose or as a dose, and then again 12 hours later, and that causes the initiation of ovulation without using hCG. Now, why would someone want to do that? Well, because it lowers your risk of ovarian hyperstimulation syndrome, because the Lubron releases LH and LH has a low half life, so it's going to be out of your body soon. Whereas the ECG sticks around and keeps causing the ovarian hyperstimulation syndrome to be worse. The problem is, is once in a while, Lupron doesnt work on some people. Its not that common. But there are times where they just dont respond to it. And in that situation, it would be a failed trigger. And so thats where some doctors will even add hCG with their lupron, but they use a much lower dose. Some of the studies show 1500 units is good enough. Some even use 1200 or 1000, and then some doctors even use a higher dose of 20, 500. But the point is that when you use Lupron, it can either be done by itself, solo, it can be done with hCG. And there are some doctors who even use Lupron with a full dose of hCG. In that situation, theyre usually looking at from the standpoint of maybe there was poor maturation of the eggs, and so they were trying to increase the maturity of the eggs by giving that higher dose of, both trigger shots. I've done that myself, and I have found it helps in people who keep having poor maturation. So let's go over those all again. There's hCG and then there's Lupron, and then there's Lupron with hCG. So for someone who is doing iuis, and you're not really worried about making every single egg mature, because you're not trying to make the patient octomomy. Ovidrol is a great source. And if you're doing IVF, there's nothing wrong using Ovidril, but sometimes people use two doses. Don't be surprised by that. Now an IVF, again, most people are going to use regular hCG, pregnyl or novaril. And in that situation, it's going to be somewhere usually between about 5010 thousand units. That's going to be an intramuscular shot. And what they usually will do is also verify that the shot was taken, well, by checking the hCG the next day so they can verify that the shot worked. Now, for patients im worried about, with ovarian hyperstimulation syndrome, im going to use a Lupron trigger. And if Im really concerned about ovarian hyperstimulation syndrome because their estrogen levels are really high, but they have so many aches, I didnt anticipate ill use lupron only. But if im a little bit concerned, what ill do is ill add lupron. With a low dose of acG, I use 1500. But again, its not abnormal to use less or even use a little bit more. And then in that last situation we talked about, theres the patient that we are concerned about, the maturation of the eggs. In that situation, well do a dual trigger lupron and the full dose of acG. That way, were throwing everything at that egg to make sure that it matures. I have had several patients where they just were not getting very good egg maturation. And so what I did was a full dose of lupron, a full dose of acg, and it was better. They still had some of the problems, but it was still better. So if youre one of those patients that keeps getting poor maturation, but they still let the follicles get to the right size, it might be something to bring up with your doctor and ask them, hey, could we do this dual trigger idea? But remember earlier I said, why dont I explain to you what is ovulation? Because in the end of the day, we just think its releasing the egg, but it's actually not. Ovulation is a very important step in the egg. This is the reason why eggs that are not mature cannot fertilize, because eggs are stuck, suspended in time in prophase. One of meiosis. So I've talked about before in this podcast, there's, mitosis and meiosis. Mitosis is your cells dividing and duplicating. Meiosis is your cells duplicating from a progenitor cell. But then they halved the amount of DNA they have, so they can then combine with another cell to make a baby, which is the sperm and the egg. Sperm divides and then makes four sperms. But eggs divide unequally. As they divide, they make these things called polar bodies, and eventually they have a single egg with two polar bodies. Now, for an egg to become mature, you're going to see one egg with one division and one polar body. But let's talk about this a little bit more in detail. The eggs are stuck in what's called meiosis of prophase one. So in the different stages of meiosis, it's in the prophase stage. Then for the egg to go from meiosis one prophase to meiosis two metaphase, it needs to undergo this ovulation process because it's at that metaphase two stage in meiosis two, where the sperm then combines with the egg and it undergoes its last transformation. At that point, it divides again, and at that point it will then send the other polar body. You'll have two polter bodies showing fertilization. What the hCG does and the LH does is it restarts that suspended prophase one meiosis egg to resume the mitotic spindle formation, to allow the egg to undergo the process of meiosis, to allow it then to get to meiosis two in the metaphase stage. So, as an overview, meiosis one prophase is where all eggs sit at from the day you're born. And then the LH surge, whether it's hCG or LH, then reinitiates the process to stimulate resumption meiosis. And so that way you end up getting two meiosis, two menophase, where the egg then sits there and waits for the sperm. Then once the sperm attaches, it finalizes meiosis two, where it releases the second polar body, and then you have a fertilized egg, which is now an embryo. Im sure, I probably went into more than you need to know, but I find science really cool, and I think its pretty awesome how this stuff works. The goal of this podcast was to make sure you understand why youre taking that trigger shot, what's the purpose of it, and why is it important. So, as you see, if you don't take it, you won't have mature eggs because they won't undergo that process of that suspended meiosis one prophase egg all the way to meiosis two menophase. Hopefully this was helpful for you, and hopefully it can maybe help a friend if they're going through this. As I always mentioned, a lot of the stuff I talk about is the way we do things, and your doctor may do it different, and that doesn't make it wrong. Just talk to them and say, hey, I heard about this, and they might be interested in trying it. As always, I appreciate you coming back and listening to this. And if you like us, as I always say, tell your friends about us. Give us a five star review on your favorite medium. But most important, always come back. I look forward to seeing you again next week on talk about fertility Tuesday.