Overcoming IVF Challenges: Personalized Solutions with Dr. Jennifer Kulp-Makarov, MD, FACOG, Board-Certified OB/GYN & REI Specialist

In this insightful episode of Fertility in Focus, Dr. Christina Burns sits down with Dr. Jennifer Kulp-Makarov, MD, FACOG, Board-Certified OB/GYN & REI Specialist, founder of Fleura Fertility. With over 16 years of experience and training at Johns Hopkins and Yale, Dr. Kulp-Makarov shares her patient-centered approach to IVF, individualized protocols, and cutting-edge fertility treatments. Discover how she is transforming the patient experience, optimizing egg quality, and supporting couples, women, and LGBTQIA+ families through a more personalized, stress-free, and effective IVF journey.

In This Episode, You’ll Learn:

• How a boutique, patient-focused approach improves IVF outcomes.
• The benefits of mini IVF and the Goldilocks method for women over 40 or with low AMH.
• Why individualized FSH monitoring matters for egg quality and success.
• The importance of considering sperm quality and male fertility in IVF.
• Advances in PRP and emerging treatments to enhance egg quality.
• How to set realistic expectations for IVF cycles, stress management, and long-term family planning.
• How to assess whether a center has a good lab
• The scoop on rapamycin
• Ins and outs of IVF for egg quality challenges
• Should you consider Ovarian PRP

Timestamps:

[00:01] Introduction: Meet Dr. Jennifer Kulp-Makarov and her patient-first philosophy.

[01:48] Moving from large IVF centers to a boutique practice: Why patient experience matters.

[03:17] The impact of stress, billing, and communication on IVF success.

[05:42] Mini IVF and the Goldilocks approach: Personalized, lower-dose protocols.

[14:50] Monitoring FSH levels: How adjusting doses improves egg quality.

[19:10] Optimizing outcomes for challenging cases: Sperm quality, egg quality, and individualized care.

[29:43] Experimental and promising treatments: Rapamycin, ovarian PRP, and future innovations.

[32:43] PRP procedures and how they enhance ovarian function.

[35:00] Supporting patients emotionally: The importance of a tailored, long-term IVF plan.

Connect with Dr. Jennifer Kulp-Makarov & Fleura Fertility:

Website: Fleura Fertility

Instagram: @FleuraFertility

Location: New York City, NY

About Dr. Christina Burns:

Dr. Christina Burns is the founder and Doctor of Chinese Medicine at the Naturna Institute. Committed, compassionate, and highly skilled in multiple disciplines, Dr. Burns has been in practice since 2004. She empowers both women and men to achieve their optimal life and health goals through natural medicine practices, integrative nutrition, lifestyle management, and personalized mind-body programs. Dr. Burns holds advanced certifications in acupuncture, herbs, nutrition, life coaching, and yoga therapy. She is also the best-selling author of "The Ultimate Fertility Guidebook."

Connect with Dr. Christina Burns:

Website: https://www.christinaburns.com/

Instagram: https://www.instagram.com/drchristinaburns/

Order the Ultimate Fertility Guidebook: https://a.co/d/hq0nFOo

Join the Eating for Optimal Fertility Course: https://naturna.mn.co/

Order Junk Juice: https://junkjuicemagic.com/

Follow along with the Naturna Institute:

Book an Appointment: https://naturna.janeapp.com/#/list

Instagram: https://www.instagram.com/naturna_life/

Transcript

SPEAKER_02 0:00

Hello and welcome. You are listening to the Fertility in Focus podcast. I'm your host, Christina Bruins, Doctor of Eastern Medicine and Holistic Fertility Expert. In these weekly sessions, I'll be bringing you the best of advice on nutrition, lifestyle, and natural medicine to optimize your fertility. Let's jump into today's episode. Welcome back, everyone, to an episode of Fertility in Focus. Today we have with us an amazing guest. Her name is Dr. Jennifer Kulp Makarov, and she is an REI. She's the founder of Flora Fertility, practicing for over 16 years, and trained at Johns Hopkins in Yale. She has now, at this point in her career, seen thousands of women couples in LGBTQ IA, helping them conceive, even despite very challenging cases. She's really great with individualized IVF protocols, trying to get away from these more set protocols at some of the other centers. We're going to talk more about that. Excellent at IVF over 40, which very few are good at. So I'm so excited to hear more about that. And for women with low AMH, issues with egg quality and poor response to conventional IVF protocols. Welcome to the show, Dr. Makarov.

SPEAKER_01 1:19

Thank you. Thank you, Christina. Thank you so much for having me today. And I'm really excited to talk about all these topics because I feel like they're not talked about enough. And it's really important to get this information out there.

SPEAKER_02 1:33

Absolutely. Wonderful. Well, let's jump right in. Okay. So you're leaving an established big center to start your own practice. What pushed you to make that leap at this stage in your career?

SPEAKER_01 1:48

Yeah, so I spent more than a decade at a very high-volume IVF center managing very complex IVF cases. So that medical part of really challenging IVF cases, women who didn't have or couples who didn't have good experiences or success at other IVF centers would come to me. And I got very good at the medicine part of managing the cases. But it became increasingly clear to me over the years that the medical part and the protocols are a really important piece, but they're not the only piece. The other pieces of the patient experience are really important. And having it not feel like a factory for women as they're coming through. I think it's so hard to continue the treatment when you're feeling that way and not feeling really supported. And so I felt like it was so important for me to be able to help with that piece for the patients too. And so in establishing my own practice, I really want to create more of a boutique space where we can look at these individualized protocols and also improve all aspects of the patient's experience, whether that's billing supported, higher touch with their doctors and clinicians, more transparency on the billing side of things. So it's really a more supported experience overall, along with that clinical expertise. So really trying to move away from that factory model and get having a better patient experience overall was important for me and moving on from uh that type of center.

SPEAKER_02 3:17

Yeah, I totally agree. I I've always liked referring patients to you because I feel like, you know, you were always thoughtful in that respect and very patient with, you know, educating your patients and customizing the protocols and, you know, making sure as much as you could in a larger center that, you know, that some of the administrative experience was buttoned up, right? Because it's hard, you know, you know, billing and the admin is it can be sloppy. And I I feel personally that the psychological safety of the patient is huge and can potentially affect their outcome. So if they're being stressed out by, you know, something that's going on with the billing or not being able to get a hold of their doctor, not understanding what's happening, maybe some, you know, the protocol not being delivered appropriately by the nurse or whatever.

SPEAKER_01 4:06

Yeah. Yeah, I agree. That's gonna affect their stress and their, you know, when you're dealing with that, not able being not able to get pregnant or miscarriages, you know, you're already at a high high stress level for the for most women and couples. And you anything we can do as providers not to add to that or like these other pieces to have those stress-free is so important, I think. And really not only for the experience, but for the success of the treatment. Because if you're getting stressed by other aspects of it, you know, ultimately it maybe you're not able to stick with the treatment because of that. You know, that's the that's the thing I hate seeing the most is when a woman or a couple is not able to complete the family size that they want because of the stress of the IVF treatment or the experience of the fertility treatment. And that's like the saddest thing that I see. And that's something that I really seek to improve. Like everyone should be able to do treatment in a way that's comfortable for them and a lower stress, you know, supported environment. So that that is not a reason they're not growing their family to the size they want it to be. And I've heard those stories over the years, and that's something that's also something that's really motivating me to make this change. As that's never something I want, and I don't think it should ever be, you know, whether it's the super high dose medications, which are just not necessary, or or these other pieces of the experience that are creating an environment where women aren't able and couples aren't able to complete their family size. Like we really need to move away from that.

SPEAKER_02 5:35

Yeah, no, I I I totally agree with you because a lot of it is like the perseverance, right? Just like to keep going.

SPEAKER_01 5:42

And I think tough the IVF warrior and all these ideas that's true, it's tough.

SPEAKER_02 5:46

Oh, yeah, it's doggy dog.

SPEAKER_01 5:48

Yeah, but and I do but I know there are ways to make this easier, it doesn't have to be that. That's really what I strongly believe and want to change. It doesn't have to be that hard. You know, there's there's how IVF has grown up and fertility treatment has grown up in this country hasn't always made that experience easier. And I think there's an opportunity right now to change that experience of fertility treatment. It does not need to be that way. It does not need to be a factory, it does not need to be super, super high dose medications that make you feel awful. It's just there, there's no need for that. It's time for it to change. That's what I believe.

SPEAKER_02 6:20

I actually love I love that that's your view and that you believe that it can. I mean, I do see a lot of like I have a lot of people come that, you know, I feel like they could have been better prepared for what IBF was going to be like, you know. You know, there could have been a bit more counseling at the onset about particularly depending on their profile, you know, that that, you know, that this could be, you know, this could this might not be one cycle, this could be a number of cycles, and this is what to expect, and this is what you'll be going through kind of thing, just sort of being very clear about uh expectations, not that it won't work, but that you you might need to be playing the long game. You know, I'm sure there are a lot of considerations that could be voiced just to help women, couples, and LGBTQIA plus understand, you know, what they're getting into and and you know, and how to prepare themselves accordingly.

SPEAKER_01 7:15

Yeah, I think so. You know, I always was so interested in the science behind that how the egg fertilizes and grows. Cause I was I'm still at this point in my career so amazed by how that works. But I think it's something that, you know, it's not like we're taught in school when we're younger. Oh, this is how fertility works and this is how egg and sperm work. So I think that's important. A lot of the education, even um, you know, I had part of what I had done is hire some younger women who were interested in going to medical school, and I have them work with me for a year and helping me with the patients. And I asked them recently, what's something that surprised you about all this? You know, like now you're coming in with fresh eyes into the fertility field and you've really worked in it for a year. What surprises you? And they said, Oh, like one thing they never knew is that when you collect a group of eggs, say you collect 10 eggs, that you don't end up with 10 embryos. And those embryos don't all grow into a pregnancy. Like there is, and there's nothing wrong. It's just this is how nature works with fertility is that those 10 eggs, they're not all gonna grow, they're not all gonna fertilize, and then they don't all grow to an embryo. And those embryos that can look really good and get greeted well by the embryo, just not all those have the potential to be viable. So it's just like setting the expectation for these things or educating because like who would know? No one would know coming in. You think, oh, I grew 10 eggs. That means like 10 embryo, 10 chances, and you know, 10 eggs is great, but it's just like knowing what that expectation is. Because I think if you don't know, it's another thing that adds to the stress, right? And you're like, oh, this went so terrible. Whereas I, as a fertility doctor, I'm thinking, okay, we got like a few potential embryos at the end. This is great. This is exactly what I wanted, you know.

SPEAKER_02 8:54

So they're interested almost as like a failure, like the the the ages of attrition, like, oh, I thought maybe more would grow, or I thought more would be retrieved. I thought sperm wise, like this is potentially a failure on my part.

SPEAKER_01 9:07

Yes. Everybody found something wrong with them or their egg quality, or it's actually like, you know, this is just a biology, like it's such a complex process when the egg and the sperm have to come together and then grow into an embryo, and it's just naturally prone to errors. So like you could do everything right, and this is just how the how the biology and the process works, you know.

SPEAKER_02 9:27

So that's a very uplifting viewpoint. So I know you had many years' experience in mini IBF protocols and have, you know, uh gone and and really tried to get away from set protocols and really focus on customizing. But since you know you have so much background in mini IVF, maybe we should get in a little bit to talking about the advantages and disadvantages of that and and how you have diverged into a more customized approach.

SPEAKER_01 9:52

Yeah. So I guess just speaking briefly about conventional IVF, because when most women or couples go into a fertility clinic in the United States, they're gonna be given what's called a conventional IVF protocol. So what this is is high dose, mainly injections and multiple injections a day. When IVF first started, it was that we want to shut down all the hormones your body's making, basically. Like shut them all down, and then we'll just replace them all with these injections or or hormone injections and pretty high dose hormone injections. Because this idea that every month you have a group of eggs that starts to grow, naturally your body will make these hormones to allow one egg to mature and ovulate. And with say fertility medications, you can get the whole group to grow. So that's the way IVF first started. And honestly, it's a way it's practiced in a lot of places across the country is this conventional, like, okay, it's easier or it's been done for so long, we just completely shut off the body's hormones and replace this with high dose injections. So then the idea with mini IVF is that okay, but the injections, what you're injecting in your body during IVF and all these protocols are hormones FSH, LH, or hormones that act like those in the body. But you know what, your body makes these hormones naturally. So why are we shutting them off? We should be using those natural hormones your body's making. And mini IVF came about, but you know, naturally your body, right, it's only gonna produce enough for one egg. And ideally, for some of this we're talking about with IVF, and if you if possible, it's not always possible, but if possible, if you can get a group of eggs, that's is the goal for some IVF cycles. So the idea of mini IVF is you can get pills. Some of these pills are like clomate or letrozole, and these will make your brain make more of your natural hormones, so it's gonna make more FSH and LH naturally or not in response to the pills, and that can get a group of eggs to grow. And then you really can move away from all these high dose injections, which are expensive, no one wants to do lots of injections, and you know, there's more than there's more side effects when you're taking massive doses of hormones. Plus, it's just like, you know, it's just I really feel like we really it's so important to move away from that because no matter what, I mean, this works really well for women with low AMH, but for any woman, you don't need to take massive doses of hormones to do IBF. And actually, sometimes it's just even especially for low for women over 40 or low AMH, it's like counterproductive. It's too much for the eggs. But at any age, that's sort of like I don't want to limit it to that group.

SPEAKER_02 12:23

No, no, I think you're right. Like I I definitely see the mini IBF be an option for women with PCOS so they don't hyperstimulate, right? They don't like potentially, you know, unwell from it. And then I and I definitely do see it for the women with with low AMH over 40, because what I see with them is if you use too many medications, oftentimes the ovaries just like arrest. It's like arrested development. You know that strike or the quality is bad because they were basically toxified by medications. The, you know, the patients can be traumatized just by how bad they feel or how bad bad the result is.

SPEAKER_01 12:59

And I see just as good, if not better, results with a more delicate approach to the Yeah, it's gonna be better, especially in women over age 40, because what I like to talk about is this Goldilocks approach. Because what happens when you're over 40 or with low AMH is your body's naturally put pumping out a lot of FSH. And so if you inject massive amounts more of FSH, you can see how it overwhelms the receptors on the eggs and the eggs, and they just kind of freeze and don't grow. So what eggs need, and this makes sense, right? What eggs need is this like Goldilocks level. They need this just right level of FSH. So something that's done with mini MVF in the more personalized IVF that I like to use now, because mini IVF sometimes can get a little stuck in like no injections at all. And listen, for some women, they do need a little bit of injections to get the eggs to grow. Almost never the high dose that's so common in this country, but some you know, there's a a good chunk of women who are gonna do best with a small dose injection along with pills. So that's where I really like to personalize the IV as not too stuck in a mini, which is more like pill-based. But that idea that like when you're over 40, your brain is making lots of FSH. So if you inject massive more amounts of FSH is not gonna work. The eggs are just like, oh, that's too much for them. So what you have to do is really check that natural FSH level through the cycle. So that's something that a lot of clinics don't do. They won't check, they'll check FSH once and then never check it again through the cycle. And really, that's not helping the eggs. The eggs really like a medium level of FSH. And so if you check it through the cycle and adjust your medication to just that right level of FSH, you're really gonna get the best results. And it's so much more patient-friendly, woman friendly, because you're not taking those heavy hormone injections.

SPEAKER_02 14:40

So this is so cool. So what would be like the you know, a a range of FSH that's a healthy range if you're checking it through the cycle.

SPEAKER_01 14:50

Yeah, a lot of times, you know, naturally what happens, and this shifts as you get over 40 or with lower AMH, that your then FSH will go up on the beginning of your cycle. But naturally the FSH should be pretty low. So something we do is start before you're even getting your period because we want to bring in bring you into your cycle with a lower FSH and then let it gradually rise. So, and what a good level of FSH for egg growth tends to be 15 up to 30. And that range is a really good range for the eggs to grow. Yeah, everyone's gonna have like listen, every month you have a new group of eggs there, and that number is gonna vary person to person a lot. That's called your antropolicle count. What we check on ultrasound when you come in to see your group of eggs, but month to month, that group is gonna vary. Person to person, that varies a lot. So, really, you need to also personalize the medication, the FSH levels for that group of eggs. You know, sometimes depending on factors like age, even BMI, you're gonna need different doses to get to that good level of FSH for your eggs.

SPEAKER_02 15:54

Wow, this is magical. I really love this. So again, because it's just, you know, it really is like highly customized. And not only are you checking, you're you're considering multiple factors, some of which you can continue to check throughout the cycle and adjust accordingly rather than just being like protocol, that's what it is.

SPEAKER_01 16:12

Yeah, that's a pro that's I think some yeah, that's a part of the issue that comes up with these protocols that are set. Like you're gonna do this conventional, you're gonna do this many. It's like, okay, but that's not how the body works. So I want like a set protocol and just go, you know?

SPEAKER_02 16:26

Well, that yeah, that's what I thought sort of like that in my you know system, because the you know, Eastern medicine is is all customized, right? So it's really feel it because it's all you know customized to the individual. And you know, I I my perception of you know Western medical practice is is a lot of it is bucketed protocols, right? And so, but I do think like you know, being specialized in fertility care, that I have seen patients get better results with an approach like yours, which is, you know, really thinking about the details and looking at this more critically. And what I think has happened with a lot of medical care is the factory model makes it so that doctors don't have time um to think or like critically or really give the time to that patient and they do okay with a certain subset of people, right? I think so.

SPEAKER_01 17:22

Yeah, I think that's right. Yeah.

SPEAKER_02 17:23

And then, and then, but like I think most people would benefit from there's a better way.

SPEAKER_01 17:30

You can feel better during IVF if you don't have to take such heavy, heavy injections, you know, yeah, because that's true, you know, for a subset of women, super high dose injections, they they will make the eggs grow, but there's a better way. You don't need to do that to get the eggs to grow, you know.

SPEAKER_02 17:45

You could still get good, you could still get just as good of a result, if not better. I guess that's just like it's you know, we in America, you know, I guess they're just leading with that, right? That's it. Because I know I know necessarily like that in other countries.

SPEAKER_01 17:56

Yeah, I think that's part of it. I mean, there's good and bad things that the pharmaceutical industry is, you know, can develop new medications, but they're also like very aggressive in the United States, which is different than other countries. So certainly in other countries, like you're saying, it's also not as common to use such heavy high-dose hormones. It's really the United States, I think, stands out around the world for using these type of IVF protocols.

SPEAKER_02 18:19

Well, if it's a culture of like more is better. Yes, yes, definitely. Definitely no gain. Right, exactly. It's just like highly capitalist, right? Yes, yes, which is good and bad. Definitely, definitely. Like I when I hear about protocols in say France or some of the European countries, definitely more delicate, right? Now, the advantage of doing your IBF in the United States is that you do have more options. Like you're not able to do the PGT testing there and what you know, there's like there can be long wait times in a lot of those countries.

SPEAKER_01 18:52

Yeah, absolutely.

SPEAKER_02 18:53

Yeah. So I I definitely think that you know, the night the right balance is finding somebody like country to do it this way. So, what are some other nuggets of wisdom or you know, nuances to your approach that help women with more challenging cases?

SPEAKER_01 19:10

Yeah, you know, I think it's really important to look at why the IVF didn't work. So if someone is coming where they didn't have an IVF work, you have to look. So eggs and egg quality is really important. So it's something I definitely focus on. But I think there's other things you can look at or that are important to look at too, besides the egg quality. So, you know, an egg is combining with a sperm. So I think sometimes in these conversations, because egg quality, listen, it's really important, but it's not the only thing. So I think looking at the whole picture is really important too. So some key things I see there are you need to look at the sperm quality. So that's something I've been talking about more too, because I really contribute. So that that's plays a role into making a quality embryo. And it's something where when we get too focused on the egg, we're missing that piece of the picture. So that's something that's really important to look at. And you know, listen, it's something that can really sometimes we can really make a big difference there because the biology is so different for men. They're making millions of sperm every day, and it's something that like sometimes it is easier to shift than egg quality. So that's a piece that I always look at.

SPEAKER_02 20:15

I love that because really what I hear a lot of doctors say is just like, oh, sperm's not ideal, but we have ixies, so don't worry about it.

SPEAKER_01 20:21

Yeah, yeah.

SPEAKER_02 20:23

Like, I'm like, uh, I don't really feel like because like you can't see everything when you can't see everything. Yeah.

SPEAKER_01 20:29

And there's like, you know, something that I've been talking about too is like, you know, when we're looking at like sometimes when we get embryos and that look really good and implant them, and then something like a miscarriage were to happen, we've looked at like what does sperm contribute to this at all? And it turns out there's more information that sperm contributes to that because they're playing a role in that. And there's, you know, you can look at the semen analysis and sometimes you'll see things there like the lower motility or morphology, but you can also look at sperm like DNA and look for damage to the sperm DNA. And when they've looked at that, they found that men with higher DNA fragmentation index that they are their partners are more likely to have miscarriages. So, you know, it plays a role.

SPEAKER_02 21:14

Thank you. Thank you for for involving the other half of the equation. When I see women, you know, when they're first case, I'm always like, you know, I know your your husband or your partner or sperm donor, whatever it is, yeah. So, you know, how is their sperm? Like, have has there been any attention on this?

SPEAKER_01 21:33

Right, right, right. It's important.

SPEAKER_02 21:34

Oh, they did like a basic sperm analysis, and you know, the maybe the morphology was off, maybe the motility was not so great, but the doctor said it was fine.

unknown 21:42

And I'm like, Okay.

SPEAKER_01 21:49

It's so important to optimize that. Yeah.

SPEAKER_02 21:51

Yeah. And and I don't have the tools to be able to do this extra additional testing. So I'm so glad that you do that and that you do focus on it. Cause I mean, when people are like, Well, why doesn't why don't They focus on the men ever. And I'm like, well, you know, I hate to be cynical, but like they don't really make money. They don't make money to focus on the men. And that's not all of what it's about. It's it's it's also about the fact that you know IBF centers are focused on um you know stimulating ovaries, right?

SPEAKER_01 22:16

Yeah, so a lot of REI, you know, all REI doctors really come from a background of women's health, and all they all do like training and OBGYN, and that's all women and women's health. So that's really their background too. So I think that's part of it. I mean, there are, you know, urology is really more what focuses on the men, and you'll see a few urologists that are focused on male fertility, and that's their background. But when you're going to a fertility clinic, those doctors have much their background is women's health. So I think that's part of it too. But I mean, that's that's changing because you can't just look at the eggs, I think. You know, you really have to look at that. That's definitely a key piece.

SPEAKER_02 22:50

Well, that's actually one of my questions. Like, you know, five years from now or 10 years from now, what do you think will have changed most dramatically in fertility treatment?

SPEAKER_01 22:58

Yeah, I think that's something that will change. You know, I think this, I think it's going, we're gonna have to move away from these protocols, from these set protocols and from these high high dose medication protocols. So I definitely think that will change. Oh, I hope anyway, I hope that will change. It really needs to change. So that's something. I think there's gonna be advances in embryo, how we can screen for embryos. You know, right now the tests that we do, the PGTA, it really doesn't screen for disease. It's really looking at like viability in the embryo, and it's not a perfect test. So I think there's gonna be advances in how we can screen embryos for viability and for disease. I think that will be coming up as well. And that will play a role into like the IVF lab, you know, it's always getting better and better, I feel like. And every five to ten years, there's advances that happen in the embryology lab that can improve these outcomes in IVF. So those are some simple things that I see improving.

SPEAKER_02 23:51

That's so interesting. What what would you say, you know, if we're thinking about, you know, a demographic that you seem to be very, very experienced with? These women who are having low AMH, lower ovarian reserve, or advanced paternal age that maybe are are like likely not to get a ton of eggs in a cycle. Um what would you say to a patient like that, you know, at the onset to just, you know, sort of hopefully make them not feel bad and make them feel like that it would, it's it's okay. The outcome's gonna be okay, even if you're not getting, you know, a ton of ton of eggs, you know, not to just from the approach entirely. Yeah.

SPEAKER_01 24:24

Yeah, no, I think that's something important because the bottom line, in the end, we just need one egg that can grow into a pregnancy. So it's important to know that. But I think with if you compare it to what you're seeing on social media or what your friend did, where they maybe did one IVF cycle and they were done, well, that when you have lower egg reserve or when you're over 40, I always say it doesn't mean we can't get there that you can't get pregnant, but it can take more work. And so it's important to know that that sometimes it can take, you know, we're not getting as many eggs in one egg retrieval, and that's okay. And I don't cancel egg retrievals because we're not getting a lot of eggs, you know, it's a person-by-person decision. But I have patients who come to me and say, Well, I didn't grow four eggs, so it's automatically canceled by the clinic. It's like, okay, but one of those eggs could have been the one that's so so we have to keep in mind we may not get a lot of eggs in one egg retrieval, but it doesn't mean you can't get there. You know, if we do three egg retrievals, then maybe you're gonna get there. So that's sometimes what it takes. It can take two or three egg retrievals because we need to we need more eggs to work with sometimes. Sometimes we get it the first time, but sometimes we need it takes more work to get there. Like maybe the journey is gonna be longer for you. It doesn't mean you can't do it, but the journey is gonna be different than your friends, and it may be longer, it may take more work in there. So I think that's important.

SPEAKER_02 25:39

Yeah, you definitely can't compare like a 30-year-old with a high ovarian reserve to let's say a 39, 40, 41 year old with like, you know, like a lower ovarian reserve.

SPEAKER_01 25:50

Yeah, they can both end up like they'll both end up pregnant through fertility treatments. They both will, but their journeys are gonna be very different. Their experience is gonna be very different as they're going through. And I think that's hard. I think that comparison can make you feel so bad too, you know. It adds to that stress. So, and a lot of times what you see on social media with your friends, you're gonna hear those stories where I did I I did one anger achievable, that was fine. I had a baby or two babies from that. You know, that's not everyone's experience. That's okay. You can still get pregnant through IDF, but your ex your journey's gonna be different.

SPEAKER_02 26:18

Yeah, you might be playing a bit more of a long game, like a marathon sprint so much, right?

SPEAKER_01 26:23

Yeah.

SPEAKER_02 26:24

Now, we were talking the other night about labs and how you know some of the centers are sort of like still riding on a reputation of this amazing lab that they had, you know, eons ago. And and you know, you were voicing that you know, lots of the labs are examples. And so how should patients, you know, like discern, you know, where they're going in terms of the lab? What what kind of questions should they ask beyond just you know recognition from the name from you know, a big name from 10 years ago kind of thing?

SPEAKER_01 26:56

Yeah, I think it was hard, you know, like 10, 15 years ago when IVF was there weren't as many IVF centers, the lab was something that was new, maybe it was harder to learn. A lot of those protocols in the lab have become standardized, and we don't see as large differences in the IVF labs as we used to. So I think it used to be maybe there were like one in the state that could really do IVF. Now it's like most labs can do IVF. That being so, there's not this huge difference in quality of the lab, you know. So some of those older labs, I would say I've seen a lot of maybe private centers that are really outperforming those large academic centers now. You know, they have like to really focus on quality to survive in this environment. And honestly, I see some of those smaller labs doing better than the big academic centers at this point. But it used to be the thought was only the big academic centers had the good labs, and that's where you had to go. And it's really just not true anymore. You know, again, I see some of these smaller labs doing better than there's huge academic centers. But some things you want to look at, I mean, there used to be this also this focus on the field only on like pregnancy rates and pregnancy rates and one egg retrieval, which again was like it doesn't make sense. That's not how it works for a lot of women. And what would happen is those centers, and we still see this a little bit, is those centers will say, like, oh, well, it's gonna take more work for your case, or maybe we won't be as successful with your case. So you're not like a candidate to do IVF with us here because we don't want to hurt those success rates per cycle. Everyone was so focused on that. But there are other things you can look at in the lab. So, you know, so you want to look at the volume of experience. So, you know, how long have they been operating? And things that you can look at and ask about in the lab that we that I look at as a physician is how are the eggs fertilizing? Because even when you're doing IXE, you're not the eggs a hundred percent are not fertilizing. And there is some skill in doing the ICSE, actually. So something you can ask about is what is the egg fertilization rate in the lab? What is the blastocyst rate development in the lab? So these are some factors that you could ask about and look at in the lab. I think you know, coming into IVF and focusing on the medications and all those high dose injections that most women have to take. And then, but we forget to ask about these pieces sometimes that are important too. So those are some simple questions you could ask to understand how the lab is working and how well it's working.

SPEAKER_02 29:20

That's incredibly useful. Thank you so much. Yeah. I I had a patient question yesterday about some claims around rapamites. I mentioned that I was gonna maybe bring this up. What is this drug? That what can like have you used it? Does it show promise in a in for the short term in helping with egg and embryo quality and cycle outcomes?

SPEAKER_01 29:43

Yeah. So rapamycin is a drug that was used for transplant patients, and then it was picked up by sort of clinicians in the longevity space. And there was a small study that came out that looked at using rapamycin in women to improve egg quality and prevent depletion of the egg supply. So it really shows a lot of promise. There, I think, you know, it's much more common. I had a patient come to me the other day where she was interested in it, but said, I haven't yet prescribed it because it's so brand new in the fertility space, you know, and it's a transplant medication. So the first thing is you don't want to do harm by getting this like heavy medication. But listen, it does show a lot of promise. So I had a patient come to me and said, Well, I just went online a televisit with a longevity doctor, and they gave it to me. So I'm taking it fertility. I got it for fertility, I got it from a longevity doctor. I said, Okay, well, let's see how it does. You know, I I am very interested in it. It's showing a lot of promise. I'm excited about it, but it's really brand new. So we just want to make sure what are the side effects that would come with it from it if you're using it for fertility, just to make sure we're safe. But it's really exciting, I would say. It's really it's you know, it shows a lot of promise there. It's such a hard thing to fix, this egg quality issue, you know, because the woman, as as you know, you know, you're losing your egg quality with HH. We haven't had any way to stop or slow that meaningfully. So these this is the medication that maybe can do some of that. So it's really exciting, but it's like I've barely seen it be used in infertility just starting. So yeah.

SPEAKER_02 31:15

Yeah, and it's like, and and I totally am with you on the like do no harm, right? Because you know, a lot of the things I recommend oftentimes they do help with cycle outcomes, and I'm generally confident that they will do no harm, right? When when we get into like newer drugs or drugs that haven't been used in this part of the field, it's you know, who are gonna be the people to test this out, right? And and you know, and bring and the brave, amazing patients that are willing to maybe they've had uh, you know, really not good results so far and are willing to at that point try something new, even even though it might be considered a bit more experimental or avant-garde, right?

SPEAKER_01 31:50

Yeah, yeah.

SPEAKER_02 31:51

I love how I love how open you are and that you're excited about, you know, the sense I really want to follow the development.

SPEAKER_01 31:58

And once like I'm c confident that it's not gonna hurt, what's the like some side effects? And absolutely, you know, I think there are some newer things for egg quality that have more evidence right now, you know, like something I've used a lot is ovarian PRP, which I I have seen a really meaningful difference for women with the egg quality issue. So, you know, I have a lot of experience with that and have seen that really shift where women, you know, I've had women come to me where we cannot get a blast as our embryo, it has some viability. And after PRP, it makes that shift that's so hard to make where we're getting embryos with viability. So that is something that I use at this point to shift egg quality.

SPEAKER_02 32:38

That's amazing. How how much do you have to do the PRP? Like I think it's done in different sessions, right?

SPEAKER_01 32:43

Well, so there's PRP. So PRP can actually help in the you can infuse it into the uterus and it can help for implantation. So that's one way to use it, which is probably not easy enough, in my uh opinion. So that's something to consider. But for the ovary, so for the ovary, we have to put it that's best used to put it directly into the ovary. There are a few centers where I've seen where they just like say they like kind of drop it over the ovary, but that I think it's better to put it right into the ovary where the eggs are. So it does require a procedure to do that, but it's you know, it's similar to an egg retrieval, but less, I would say, because you're not like the ovaries aren't getting enlarged with multiple eggs, but you are going vaginally into the ovary in a few spots to put the PRP. And the PRP is a blood draw from your own blood that's spun down with lots of natural hormones and growth factors. And then that's put into the ovary, into each ovary in a few spots. Now the PRP will take a few weeks to work, so it takes two to four weeks to really get that optimal effect. Once you're getting that optimal effect, I've seen that last depending on the patient for three months, you know, give or take a month there. So some women who are doing it for fertility treatment will do it and then try to optimize their fertility treatment for those few months where we really see it working. And then oftentimes that's enough, honestly. But I have had there is some evidence that if you repeat it two or three times, you can kind of get booster effects with the PRP. So after three or four months, do a second dose if you haven't gotten the results you needed in a first three months. So there is that option. Sometimes we don't need that though, because you know it's working in that first few months where it's really making that shift in quality.

SPEAKER_02 34:19

Goodness, I love all of what you've been doing and and just like really, you know, su such a focus on getting better results and knowing that it's possible and knowing that there's a way if you just, you know, if you just you know keep on the path and and this is so cool.

SPEAKER_01 34:36

And so I think sometimes a different approach isn't is important too, because I think when you go to one clinic and rightly so, you're kind of attached to that clinic, but you're doing IVF cycles and they're not working, it's time to you you it's important to change something. You know, you need to change, you need a different approach with protocol, a different lab, a different technique like PRP. Like if it's not working, you don't want to just stay keep doing the same thing.

SPEAKER_02 34:59

So I think that's that's you also have to be brave and creative enough as a doctor, right? Because so some of the larger centers, the larger academic centers, not all, but most of them have like a bureaucracy. Like this is like the head guy says these are the protocols we do, and and that's what it is, right? Like, don't color outside the lines, it's not scientific enough, it's not, you know, there's not enough research to support it. And so, you know, when you're getting into these areas with a little bit less research, you know, as of yet, but you know it's safe, you know, and then you start trying to yourself and you've seen it, you know, have some positive effect, you just have to keep on the path because we're gonna see in five, 10 years that, you know, this has been something that maybe could have been practiced by by others. So you're really at the forefront of improving IVF and the outcomes for these patients that traditionally were having much rougher times.

SPEAKER_01 35:47

So before we before we sign off, um I just want to add one point about that, which I think is important because it's something I've seen coming up a lot in IVF, and maybe women and patients aren't that aware of it. I do think it's important. You know, I'm in a unique position where I have that lots and lots of experience doing thousands of IVF cycles, and I have been able to personalize it and choose alternative methods. But I think all doctors tend to want to do the best for their patients. But what we see in the fertility world right now, and especially like in New York City and other places, is that most of these fertility clinics are owned by private equity. So they're owned by these big businesses. And, you know, ultimately in the end, they want to standardize protocol so they can maximize profits. It is, it's true. I think it needs to be said, you know, so women are aware of this. Those doctors have no flexibility. I mean, I I, you know, had spoken to one recently because there was a big, it was a big fertility group and you know, looking maybe to work with them, but they were like, well, you can't really treat many women over 40 because we only have one protocol that works. We need to standardize it across our whole network. And it doesn't work for us if you're treating women with low AMH or all that. That's just like you can't do that. And I that's like, okay, this is nothing.

SPEAKER_02 37:03

Working with you. No, we talked about all yeah, because I never thought this would happen. Acupuncture in New York has gone private equity, where like, you know, it's just like, you know, you can hire sort of anybody, like a McDonald's, you put them into the system, you teach them, you teach them the system, the protocol, and and it's kind of takes away the magic of the medicine and what's possible for people again, like anybody who's like a little bit outside the box, because that standard conventional protocol only works well for a certain subset.

SPEAKER_01 37:32

Yeah.

SPEAKER_02 37:33

So when they're looking to maximize their their profits in the end.

SPEAKER_01 37:36

So they're not gonna like personalize or yeah.

SPEAKER_02 37:40

No, not venture capital. It's definitely difficult. Like this is a profit system. Like it's not a it's not a help the little guy system. And so, you know, for you, what other nuggets of wisdom would you want to leave our listeners with as they're embarking on their journey?

SPEAKER_01 37:56

I would just say I think it's really important to know that fertility treatment isn't one size fit all. And it's really important that you're comfortable with the journey. And so you're partnering with whether it's a doctor or a clinic who can give you IVF or fertility treatment in a way that works for you. Because at this point and where we are with fertility treatment, it can really be personalized and it should be something that you're comfortable with because you don't want to stop your fertility journey just because you feel it's too much or there's not options. There are options for different ways to do fertility treatment that don't again involve super high injections. And I think that's important to find that right place where you're comfortable with the treatment plan and just know that there are other ways that work as well, if not better, that do not involve heavy, heavy injections. It's just not how women need to be doing IVF anymore.

SPEAKER_02 38:45

That is so well said. Thank you so much for bringing all your wisdom. Dr. Makarov, where can our listeners find you?

SPEAKER_01 38:51

Yeah, so I am on social media, Dr. Jen Fertility Friend. So what? On Instagram or TikTok, YouTube. So I have all those channels where I do a lot of education. I'm posting multiple videos a week. So you can easily find me there and florafertility.com as well. I offer virtual consults across the country as well.

SPEAKER_02 39:11

Oh my gosh, amazing. Thank you again for being here. Thank you for all your wisdom. This was an amazing conversation. I'll be definitely asking you to come back again. How good. I would love to. I'm really happy you've tuned in and joined the community. And I'm so excited to bring you more helpful content with each episode. In order to make this podcast as helpful as possible, I want to hear your input on what questions you need answered to get you feeling empowered on your fertility journey. You can DM me on Instagram at Naturna underscore life to share your most important fertility-related questions. And if you're enjoying this podcast, please follow and share with friends. My mission is to help as many women and couples as possible. And for that, I need your help. Yours as always, in love and light, Dr. Christina.