Episode 29: Why Lala's IUI Worked and Yours Didn't: How to Troubleshoot Your IUI Cycle

Dr. Klimczak and Dr. Reed discuss how Lala from Vanderpump Rules got pregnant with her IUI treatment. They discuss IUI (intrauterine insemination) treatment in detail including how to troubleshoot your IUI cycle. They discuss common problems that come up and potential solutions to optimize chances for success.

Transcript

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I am Dr. Beverly Reed and I'm Dr. Amber Klinczak and we are Two Peaks in a Pod. Hi everybody. Welcome back. Hi Dr. Kaye. How are you doing today? Good. It's been a busy day. Yeah. I just did a nice transfer. Yay. Good. Okay. So you're going out of town next week. Where are you going? Gosh, I'm so excited. Costa Rica. Oh, so much fun. Yay. I was just, I was just telling Kennedy, my medical assistant, my husband and I really don't enjoy going on vacation because we're at that phase where we have little kids and so vacation is just like really hard work. But we're growing a family, my family, and I have older nieces and nephews so I'm very excited to pawn my children off with my nieces and nephews. Do you know what city you're going to? Um, I'm so bad. It's okay. It's okay. I'm just kidding. You know, I lived in Costa Rica. Oh my gosh. No, I did not know that. Well, just for five weeks. Okay. No, I know. I took medical Spanish there. Yeah. But obviously it didn't really take. No, I don't speak Spanish. That's hilarious. I, uh, I felt like I was really good at that time, um, but maybe that was paired with like And then I was like, Oh my gosh, it's just coming up. Are you guys going anywhere? We are going to Turks and Cato. Oh my gosh. The most beautiful beaches in the world. We're so excited. I've never been before. Um, and no, no one in my family has been. So we're really excited. So we're going to have a blast. Yeah. Your kids are a good age. Your kids are like, They are. I know. It's great. It's great. Yes. So for coming. Um, okay. Well, I don't know if you remember a couple months ago we did a podcast about Lala from Vandercump rules. She had announced that she was wanting to use a sperm donor to get pregnant and she's pregnant. Oh my gosh. Congratulations Lala. Okay. And of course, as a fertility doctor, I was so curious. How did she get pregnant? How did she do this? And I found a news article. And I actually was really excited to see, um, that she tried IUI insemination. And this really stood out to me because I always follow all the celebrity fertility stories, but the vast majority of them talk about, um, When they did IVF, our most aggressive fertility treatment, but I actually couldn't think of a single celebrity who had done IUI and at least had talked about it. Do you know of any? No, I'm just not trying to write right now. I don't think so. Yeah. And so, um, in this article, it said that Lala had friends who had tried IUI before attempting to get pregnant with IVF, and so, um, I guess she wanted to go that same route So I thought this could be a great time for us to talk about IUI, especially because I think it's really a topic that there's just not as much information about, right? Definitely. Yeah. And I feel like people, my patients, were always really interested to know more about it. You know, especially when they're first starting to get into their fertility workouts. Yeah. It is an important topic. I have a question about LALA. Okay. Yeah. LALA. Did she have fertility problems first, or was she just literally missing sperm component? She was missing sperm. She had a really bad problem with her ex husband. So, she has a baby with her ex husband, but they fight over custody and everything. So, it was really important to her when she had a baby that there was nobody to fight. With for custody. Got it. So she wanted to use a sperm donor this time. Got it. When she got pregnant. So as far as I know, I don't think she had any fertility issues or problems, so. Okay. Mm-Hmm. I understand. Yeah. Yeah. Um, okay. So I guess first couple things I wanted to talk about. What do we mean when I'm saying we're saying IUI, we're gonna talk all about I UIs today, why your I UIs maybe haven't been or didn't work. Um, and why we love IUI treatment. But I will say first when I'm talking about IUIs, really what I'm meaning is that you're taking fertility medication paired with an insemination. You're doing both of those. And so I think first, maybe the good thing to bring up is why are we talking about both of those paired together versus just trying insemination or just trying fertility medication. And this is a really common question that comes up for me a lot in consults. Do you hear this too, where people are like, well, why can't I just take Plymouth? Right. So what do you tell them? Depends on the couple. Yeah. Right. So specifically if the couple's interested in taking a medication called Clomid, Clomid is an oral medication. It helps you to develop more than one follicle. I say, it's, you know, kind of like playing the lotto, right? We're trying to buy a couple more tickets to get a couple more eggs to ovulate than just that one. And Clomid can have some side effects that can, make just timing intercourse, trying to get pregnant harder. And so when it's paired with an IUI, you have higher success rates. So, clomid can affect that cervical mucus, um, and make it more challenging for sperm to get through it and up to the egg. But of course, when we do an insemination, intrauterine insemination, we're actually taking that sperm, we're washing it, we're prepping it, and we're bypassing the cervix. Placing all that sperm right at the top of the uterus. So you don't have to worry about anything with that cervical mucus. So it depends on the medication, right? If you're planning on using Clomid, I think, um, time to her first really isn't ideal. You really need to pair it with an IUI. Absolutely. I totally agree. And, and I think too, as she mentioned, it depends on your situation. So if we have a patient, for example, who never ovulates on her own, it could be that she only needs to do fertility medication, but in patients who are already ovulating every single month and you don't know why you're getting pregnant. They actually did a huge study to compare all these different groups. So they have one group that just kept trying on their own. They had a group that only did clomid, they had a group that only did insemination, and then they had a group that did clomid plus insemination. And the first three groups all had the same chances of getting pregnant. And it was only that last group with clomid and IUI that had triple the success rates of everybody else. And so as she was kind of mentioning, yeah, clomid is great for stimulating the ovaries, but sometimes it creates some other problems. which IUI can really overcome some of those issues. Um, and so, as we kind of go walk through this process, when I'm saying IUI, really I'm meaning fertility medication and IUI together. Yeah, definitely. I definitely have patients who, like you're saying, just don't ovulate me, but they're my PCOS patients. Their husband's sperm looks fantastic, which, by the way, is really annoying when Yeah, and they never ovulated maybe in a year, right? So I think it's reasonable for those patients to try a different medication called something like letrozole Which doesn't affect that cervical mucus and you can pair that with time different course and have nice success rates if the issue is really ovulation Right, we have good sperm. So kind of depends on the subset of patients. Yeah. Yeah Um, I also just wanted to touch on the fact that I you know I see lots of education from fertility doctors everywhere talking about So many of them are so focused on the idea. Um, and what I really wanted to do is try to get more information about the details of IUI. So what are the different protocols? What are different problems that can come up and how do we address them? And Dr. Kay and I both really feel like, honestly, some people are not putting enough attention into recognizing, um, maybe problems that are going wrong and overcoming them. Um, Because honestly, in the fertility world, a lot of times the thought is, okay, you try three IUIs and if it doesn't work, you do IDF. And when they say three IUIs, it may be the exact same protocol three months in a row. No changes, you know, nothing. In fact, sometimes these patients don't even get to be monitored by a doctor. Their cycles may be done and run by, you know, a nurse or somebody else. And I'm not saying there's anything wrong with that, but. Really, what I would want to know if I were a patient is, is my doctor paying attention to what's going on, and have we exhausted all measures before we're moving on to more aggressive treatment? Yeah, and I think it really goes off of what, like, all of us kind of took an oath to do, right? Like, what I tell my patients is, my role is your physician. Is to try and get you pregnant the least involved, least invasive, even least expensive way, right? Those should be our motivators and there really shouldn't be any other motivators. And when I was a patient, I wanted to get pregnant as close to natural as possible, right? Like every, I think every woman out there, every couple out there probably has that same thought. You're like, I really would just love to do something that is as close to getting pregnant on my own as possible. So, if there's a chance for something like IUI to work, you know, it's a good shot. Yeah, and I think sadly too, I need to mention, sometimes there is some bias towards things. Okay, so for example, for fertility doctors. Some of them are employed and honestly some of their pay may be based on how many IVF cycles they do every month or every year or things like that, right? And, um, hopefully most people do not let that affect their decisions. But if you as a patient have gone into an office for a consult and a doctor has told you you need IVF, Really, I think it's reasonable to say, are you sure I need IVF? Are there any other options that I could think about or consider? Um, and if it doesn't feel right, it's always okay to get a second opinion as well. I will say that is a huge number of the second opinions that I get. Or people have gone somewhere else, they were told they have to do IVF, and then they see me and I'm like, you don't have to do IVF. And look, it's not to knock IVF. IVF has higher chances of success with lower chances of miscarriage. We love IVF. But like you said, like as a woman, I kind of feel like I'd want to try a little bit more of the natural way. Something a little bit more convenient, less injections, less appointments, you know, definitely. And we're also not saying that there may be patients that we see too, and there are certain indications you have to go drug type. Yeah, for sure. That was just the one thing. That's the fact, right? Yeah, but not always. Yeah, there are some great areas and ways that we can really exhaust IUIs. Yeah Absolutely, and I think too like that's if if let's say a patient of yours said well, Dr K said I had to do IVF. I'm like if Dr. K said you have to do IVF for sure and I'm sure you feel the same way about me because we know that we will personally exhaust every measure before We go there, but um also letting patients you know, got that guidance on that as well. Um, so, you know, today, um, I actually had a patient call this morning with a positive pregnancy test for their IUI. And it was actually so meaningful to me because she had tried two IUIs. They weren't working. She was like, so depressed and so sad about it. And she had kind of, you know, just let me know, I'm going to go ahead and stop my journey. We're going to close our journey. We're going to move on to adoption. And I looked back at her IUI cycles and we had made improvement from the second to the first, it wasn't perfect yet. Yeah. I knew I needed to get her lining better and I'm just like, have this gut feeling and I usually don't pressure or push patients. I'm like, Hey, I respect whatever, but I did. I pushed her a little bit and I said, You know, give me one more chance. I think I can do something that is going to make a difference and everything. And so she humored me. She said, okay, and we did it. And then I was so happy to get across her pregnancy test today. I'm like over the moon about it. Um, and so I think that's part of really what prompted me to, to want to talk about all these things that we could do. But before we get into it too, I should mention the realistic part of it is chances for success. are pretty low overall when we're looking at IUY cycles. So if you take the very youngest patients, we're talking about a 20 percent chance of success each time you try at most. Okay, and I always say, look, the thing is, you have to mentally prepare yourself for the fact that, hey, This may take multiple cycles to have a good chance of us reaching our goal. Um, and certainly again, IVF success rates would be much higher, but I think it's definitely a reasonable treatment where it's definitely higher chances than you trying on your own without having to go for a full on IVF. Yes. Yeah. I do a lot of counseling about. Okay, we're humans. Yeah, we're not bunnies. Yeah, it's like even if everything is perfect with humans We don't get that high of success rates per month I'm getting pregnant right and so IUIs can't improve your success that much because it's relying on your own Natural ability really for egg and sperm to get together And so we chat a lot about cumulative success rate like you're saying let's give this like 60% three months, you know, six months for my young good prognosis couples, you know, all the attitude that many rounds with them. Yeah. So Dr. K before you tell a patient, yes, we should do a UI treatment. I know you'd like to do some basic testing. So what are some of the basic tests that you would like your patient to have done before or maybe during your, Yeah, so we usually like to get a feel for how many eggs does our female patient really have to work with, right? What is your egg supply, ovarian reserve, lots of ways to talk about that. So it usually involves ultrasound, blood work, looking at your hormones. Which, by the way, can I just interrupt because we did our AMH contest on Instagram. So Dr. K and I had checked our own AMHs and we did a blind, live reveal of our AMHs and everything. And then, but before we released the video, we had everybody guess our AMHs and we did have two winners. But I have to say, thank y'all. Y'all got some really high numbers for me. I was like, everyone thought Dr. Reid had a really high A in each of them. I thought mine was really low. What am I saying? They really want to see my A. Well, I thought they had, certainly everybody had high, high guesses for you, I will say. But for me, I thought they would expect me to be low. And so I'm like, what a weird compliment. And I'm just like, oh, thanks guys. I think yours was good. I don't know. I would love that AMH. It was not good at all. And so only like two people were even eligible for my bid. Everybody else had bid like over one for my AMH. My AMH, 0. 7. Um, and so I just thought it was funny because I'm like, Oh, I love our audience. guys. Sorry to interrupt. Okay, so egg supply. You want to know about egg supply? Yeah, egg supply. In order to get pregnant off of an IUI, you have to have functioning fallopian tubes, right? Because we're relying on those tubes for egg and sperm to get together and fertilization to happen. So we do a test called an HSG, hysterosalpingogram, sometimes called the dye test, the tube test, right? Um, there's a couple different ways that we can check the tubes. This is the most common one. We got to do a test to make sure your fallopian tubes are open. And I often do this during the actual IUI process. Okay. You know, there's some thought that maybe it kind of flushes the tubes out a little bit if there's something there. So we got to make sure we have eggs. We got to make sure we have tubes functioning. Look at the semen analysis. We want to know what is the sperm like? How much sperm do we have to work with? What are the shapes of the sperm? Do we think that you're a good candidate for doing an IUI in the first place? Um, and then generally we do somewhat of an evaluation of the uterus, right, and this is the part that can deviate a little bit. We see your uterus a little bit on the HSG, we see it on the ultrasound. If we suspect something else might be going on with your uterus, we may do another test called the saline infusion sonogram. That's really all your parts. Yeah. Yeah. I'm sure working. Absolutely. Absolutely. Um, yeah, I, I think, you know, the HSG and we've talked about this test before too, it's kind of known as being one of the more uncomfortable tests, but Dr. Kane, I've worked really hard to just make it so such a comfortable experience for patients, um, by using, you know, laughing gas and they really don't feel much at all during the procedure and just using a really tiny little device to put the dye in and everything. Um, but I just love that. There are studies that show higher chances of getting pregnant the first couple of months after having had that test done and so that's what makes it really exciting is it's giving us information but it's also helping us have higher chances so, um, so I agree that that's a really great test to do as well. I really hope it's a great test because I'm radiating myself. So when we do an x ray we are an agency we are doing an x ray. And we track ourselves.'cause of course we're in there doing them, you know, all day apparently. And I'm the only person that's ever getting irradiated on my, my Dosimeter badge. I'll come to find out. Yes, yes. We're comparing numbers. That's a different kind of number. We compare one day I have cancer, I'm like these, all these, all these ages, but you've gotten a lot of people pregnant and um, it'll be worth it. Okay, good. So, um, so I agree before we do a medicated IUI cycle, we definitely want to make sure that we are either, or either have done the testing or in the process of doing the testing to make sure you're a good candidate for this type of treatment. Because, for example, if your tubes are blocked, if the sperm is really low, those are going to be the times you're going to hear from us of, Hey, IUI is not a good treatment for you. Let's, Sort of look into these other issues next to figure out what we need to to do next for you Um, but I will first just kind of talk about what a standard IUI cycle would look like and probably the most commonly used Medication is Clomid But I thought we should talk a little bit about why somebody would choose Clomid over Letrozole Those are kind of the two main medications that we would use. So do you have a preference on which one you use for your patients? Yes Depending on what their diagnosis is so pretty good studies to show Patients who don't ovulate, patients who have PCOS, we should probably use letrozole first line for their IUI cycles to help them to develop a follicle. Um, rates of ovulation, pregnancy rates tend to be higher. And then Clomid, I like to use Clomid for my patients who ovulate already on their own, um, and release a follicle, like one follicle, right, but I get a slightly higher dose of Clomid and try and push them maybe to release two or maybe even three follicles to increase our chances. Yeah. So that's generally how I go. I switch back and forth between them. My patients know this. I wash their lining. Clomid can often thin your lining. If I'm seeing that, I might try you on letrozole. So yeah, we tinker. I tell my patients I'm a tinker. Yeah, we mess with it a lot. So yeah, I love that. Yes. Yes. Okay. Same for me too. Um, and I will say, um, Clomid's kind of famous for having some side effects. Um, in fact, actually my last book, I had a really cute sign that said Clomid made me do it. Because, um, you know, although you can get side effects from Letrozole or Clomid, I would say the mood swings are definitely more prominent with Clomid. But I think Letrozole you just feel so bad on it because you basically feel menopausal on Letrozole. And I'm like, this is a preview of my life. It's going to be like, I mean, it's really miserable too, or I will say it's going to be rough. I hope I retire before Yes, yes, absolutely. So, I think that's kind of, you know, the first thing is just deciding which fertility medication to start off with. And then, which dose. And a lot of times when you're giving a patient medication for the first time, you don't know which dose they're going to respond to. So a lot of times you want to start off with either a low or medium dose. And for me to decide those things, I look at how old are they? How did their ovaries look? Have they tried medication before? And if so, what was the response to that medication before? So those are kind of some of the things that I look at. Oh, also may try to think about what, you know, do they have any factors such as they really want to try to avoid multiples, like having transcripts. Triplets or anything like that. If, if some of them are very scared of it. And so I'll intentionally go very low dose for them if that's their preference. Where as maybe, maybe an older patient, I might be more aggressive knowing that our chances overall, um, are lower. So we have to figure out what our dose is gonna be. Um, and then we have to figure out when to bring them back, which, um, you know, for most women, we're looking at bringing you back somewhere around cycle day 10 to 12 for an ultrasound to assess your response. But a lot of that can depend on when we think you're gonna ovulate. For some women, if you're having periods very close together, we may need to bring you back on the earlier side of things. Whereas some women who we know are going to be a little bit tougher to respond, we may even bring them back on the later side of things too. Is that what you do as well? Yes. Yeah. Okay. Yeah. Perfect. Um, so then when you come in for your followup ultrasound, this is just my favorite appointment because this is when I just start to get all the details and information that I really need. And you know, when I talk about medicated cycles, I really say, look, This is almost another fertility test for me because this is what I'm getting to learn. How did you respond to the medication? So we might see a couple of different things. Um, the very first thing you can see sometimes is what if you didn't respond at all? Yes, that's, that's frustrating, right? Yeah, there's no other way around it. It's just disappointing. Yes. Yes. So problem number one with an IUR cycle is you give the medication and nothing happened. Okay. And look, here's the thing. This happens, and we know what to do about it. So one of my favorite things, um, that we do is called a stair step protocol. Okay? The concept here is you start at a dose. You bring the patient back. If they didn't respond, You just do the next higher dose and you bring them back a week later. And then if they didn't respond you do the next higher dose and you bring them back a week later. And what's good about this is because you are immediately doing that higher dose and reassessing You are not wasting any time. There are other places that i've seen where They give you a dose and if it didn't work, they said okay call next month with your next period Like what? I just wasted a whole month on them? Yes. Actually, I think this is a really important point that Dr. Reid is making. A way that you can advocate for yourself if you're out there listening. Maybe you're just doing clomid with your OBGYN, right? You're just like, I'm not really thinking something's going on. She gave me clomid. I'm going to try this, right? Oftentimes, they'll just check like a progesterone to see, hey, did you ovulate, you know, afterwards? And then, like, it's like, You know, they don't do anything, right? It's a mistake, right? You check your progesterone and it's low. It's like, look, didn't work. Let's try again next time. So if you're planning on doing this cycle not monitored with an infertility specialist, maybe ask, how are you going to know if I responded, right? Ask for if they can get another lab, maybe an estrogen level earlier or do an ultrasound for you, because it can save you a lot of time. I mean, As an infertility patient, it's all about time. You're just going crazy waiting, right? So anything you can do to make, you know, take advantage of the month that you're trying. Um, and then, okay, so a common patient population that I would see not responding in is PCOS, polycystic ovary syndrome. This is a condition where you have tons of eggs, but sometimes they rest. They don't want to work for you, right? And so you have to give the fertility medication to get one or more of the follicles to grow. So stair stepping is best for these patients because some of them have very stubborn ovaries and I know I need to keep pushing the ovaries. Okay. But another important thing that I think we're willing to do is we're willing to be probably more aggressive than the average doctor. So for example, people say for letrozole, You have low, medium, high dose. Low is one pill a day. Medium is two pills a day. High is three pills a day. But guess what? If three pills a day doesn't work, you can actually go up to four pills a day. And if four pills doesn't work, you can actually go up to five pills a day. This is 12. 5 milligrams of letrozole per day. I actually remember when I first heard of this, and I was like, that sounds way too high and too scary, and, and all the rest of it. But you know what? You're only doing this on people who didn't respond to the lower doses. So I would never start at 12 and a half milligrams on a patient who's never tried medication before, but it is completely reasonable and warranted in somebody who's not responding to lower doses. And I have seen this save people from doing IVF. So for example, I've had patients who come to me and they said, well, I've already tried. I cannot respond to the medication. And I look and they never went above three pills a day. And I'm like, you know what? And this is based on studies too. Studies have shown people who don't respond to three pills a day, can respond to four and five at a time. So it is very rare that either of us have the patient that just ultimately will not respond after we've tried to write measures and you're seeing them for more kind of dangerous cycles too. What's the next step? It's really doing injectables, right? And those are much more likely to have multiples. And so if we can get you to respond with a pill and not an injection, we want to. Yeah. Um, another medication I do like to add on, especially for my patients with polycystic ovary syndrome is dexamethasone. So dexamethasone is actually a steroid medication and it actually can help your primary medication work more robustly. So let's say I have a patient who I'm not wanting to go up above a certain number, um, of pills per day. You know, let's say she did 7. 5 of the Letrozole, which is three pills a day. But let's say her lining was a little bit on the thin side. I do know one of the things that can happen is as you increase that medication, it can start to thin out the lining. And so sometimes instead of going up, I can add a second medication like dexamethasone to help her become more responsive as well. So really, I think that's point number one is if your problem is you're not responding, is your doctor trying hard enough? Have you ever had patients really like dexamethasone? Yes. Oh my gosh. Yes. Hi. Some of my patients are like, I have so much energy. I could work all week. Like, can I stay on it? And I'm like, yeah. Yeah. But I've also had some people really hate it too. In fact, I saw a patient today who was like, you're killing me after a kiss. You know why? She hasn't saw me yet. She's very energetic, but she can't go to sleep. So that's why I usually tell them to take it in the morning, and I say it's almost like your morning coffee. It'll put a little pep in your step for you. Um, but unfortunately it can cause some, uh, temporary, uh, insomnia. Um, okay, so we talked about what if you don't respond. Um, really kind of a similar concept is what if you only grow one follicle? Um, I, of course it depends on what your goal is here. If you have a patient who's not ovulating at all, your goal may be to help her grow one follicle. But if you have a patient who already grows one follicle on her own, well you want to do better for her than what she can do on her own. So my goal is usually to try to help them to grow two or three follicles at a time. So if I gave her fertility medication, I brought her back and I did an ultrasound and we only had one follicle and that cycle didn't work. Then that next month I'm thinking, okay, how can I get more aggressive? That's again, kind of similar concept increasing the dose or adding on a second medication. Definitely. Yeah. Carefully. Carefully. Exactly. Yes. Yeah. Um, you know, you mentioned injections. So I think maybe that would be a good time to talk about that. So, um, injections are actually similar injections that we would use for IVF, our most aggressive treatment. But of course, when you're doing IUI cycles, you have to be very careful because you don't want to overdo it on these doses. And so what I would typically do when I need to add injections for my patient is number one, I actually drop down the dose. of their primary medication. So let's say I tried 3 pills a day, the prior cycle. Um, I would actually drop her down to 5 milligrams, 2 pills a day, and then I add on these fertility injections. I just do 75 units every other day for a total of 4 doses. And the reason you do every other day is if you do every single day, sometimes you end up recruiting too many molecules. So, I don't know what your cutoff is, but if I have a patient that has four or more follicles that are 15 or above, I have to cancel the cycle. Do you, I, I, four is my threshold to proceed. So if like four and lower, I will still go. Okay. Yeah. Also depends on a lot about the patient. Yeah, that's true. And this patient is pretty young and we learn a lot about you along the way. Older patients who take care of this good enough. Yeah, right, right, yeah, right And I think it's a good point to also talk about too, the risk for this type of treatment is there can be risk in multiples If you're taking letrozole or plumid, there's about an 8 percent chance of twins and a 1 percent chance of twins chance of triplets or more. If we're adding on injections, that risk of multiples increases to about 15%. And the thing is, we would never do that on anybody or to anybody on purpose because we know that multiples are higher risk for mom, higher risk for the babies. But the thing is, we don't really get to pick either, but we try to do this as safely as we can to limit your risk as well. Right, and that is something that you should also ask your doctor about. Yeah, make sure you really understand that. What are the risks of this? What's my chances of having triplets? You don't want to have triplets. Most likely. Yes, exactly. Exactly. Yeah And so, you know if for some reason I have a patient who has four or more that are 15 or more then I cancel the cycle and I say I'm sorry. I'm so sorry. I overdid it. We're going to try again next month at a lower dose, you know, and so these are conversations that we have when we're troubleshooting and problem solving for, um, for ad recycles. Um, okay, so the next problem that sometimes we can see with IUI cycles is thin lining. Ugh, so you kind of mentioned some possible reasons why somebody might have a thin lining, right? Yep, so sometimes it can be from the medication itself, right? Clomid is pretty notorious for thinning out certain people's linings. Some people do beautifully with Clomid and just don't have that side effect. Mm hmm. Um, and basically it just means that Clomid is kind of working against the estrogen inside the lining of the uterus and preventing it from allowing it to grow. Um, blood vessels sometimes can do this too, but not nearly as much as Clomid. Clomid is probably the worst for this. Um, and then sometimes patients may have some intrinsic problems with their uterus and their lining just does not grow thick enough during their cycle. Absolutely. Yeah. And if I think it's something that's more from the patient side of things, sometimes we ask ourselves, do we need to assess if they have any scar tissue inside their lining that maybe we don't know about? Um, and that would typically show up on the testing Dr. K was talking about earlier. And then sometimes I'll see thin lining with my patients. that either need to gain a little bit of weight or patients that are doing a lot of cardio. Like my runners are kind of famous for having thin lining, um, and so those are kind of always things that I'm asking about if I'm seeing thin lining, but certainly it could be that we cause thin lining with our medication typically for both Klement and Luncher's oil. The higher that you go, the more it can thin out the lining just for different mechanisms of action. Um, but our solution to this kind of depends on which one you're taking. Um, With Clomid, the hard part is once you see that thin lining, there's not really much you can do about it at that point. You just have to like learn from that cycle and then just switch to something else in the future. And the reason for that is with Clomid, you're essentially blocking receptors. So you can try to give estrogen at that point, but it's not really going to help. Um, Letrozole is a little bit different because with Letrozole, once you see medication. You do have the opportunity to add on some estrogen later on. So right towards the end. So you could always add an estrogen patch or vaginal estrogen pill or oral estrogen pill and still have the opportunity to help the lining out a little bit at the end. Um, but if that cycle doesn't work, then for the next cycle, oftentimes I'm trying to do intervention. to help the lining out, which may be adding on injections. I've found that IVF injections seem to thicken up the lining a little bit better sometimes. Um, and so again, this is where we're learning about your body to try and help you do better for the next cycle if we need to try again. Yeah. I've seen cases too, where Every time we put the ultrasound probe into someone, they get a little contraction. The lining looks really thin. And sometimes people are just impatient with skinning. I used to work at a really busy practice, and there would be someone, Oh, thin lining, thin lining, thin lining. And then if you just take a minute, Relax, you know, go back to it and look at it. The uterus expands back out and they have like nice length. So you have to also make sure that your doctor's not rushing through, you know. Yes, yes, absolutely. Well, I think that's another good point too. Every time we're scanning, I call it dynamic ultrasound testing. Instead of just like seeing images, when Dr. K and I are doing your ultrasounds, we're noticing and thinking about all these things. thing. If I move the probe over and you say, Ouch, that's a tender spot. I'm like, Oh, she has some tenderness there. Okay. Maybe could she have endometriosis, right? Could she have some scar tissue over there? Or if I'm noticing the position of their ovaries and every single time they're in the exact same spot and they never move. I'm like, Oh, I do have scar tissue. That's putting your ovaries down there. You know, we're always trying to pay attention to all these little hints and everything along the way, trying to figure out how can we do better for your treatment. And for future treatments, too. It's really important information. Yeah, yeah. Um, okay, what about if Your follicles aren't popping like they're supposed to. Do you want to talk? Because you had a patient recently that's been popping. Do you want to tell us about that? Yeah, so we sort of assume, right, for most patients that if you grow a nice big follicle, we monitor it on the ultrasound. Often we give you an injection to make you ovulate, right? And then you get a period two weeks later. We're assuming that that follicle is popping, like starting once they rupture, right? It's breaking open and releasing the egg so that it can go be swept up by that bloating tube and be fertilized by the sperm. Well, in some cases, this is pretty rare, right, a patient's follicle may not rupture and release the egg and that makes it pretty tough, right, for egg and sperm to get together and for you to get pregnant. Um, sometimes we can be very suspicious of this. In my patient, what was happening is, We were trying to do IUI cycles, and I would give her Clomid, and then on that side that she would have the follicles every time I'd bring her in for the next month, she'd still have these big follicles. I'm like, why are your follicles always there, right? So then all we had to do to kind of discover this was the ultrasound after we did the trigger shot that supposedly is making you ovulate to an ultrasound a few days later, where you should see Nice collapsed follicle, kind of starts to fill with blood, it's pretty clear, there's fluid in the pelvis. We didn't see any of that, so she wasn't really actually releasing her egg. Mm hmm. And imagine, your egg's trapped in that follicle, it doesn't even have a chance, you know? And so, that gives us the opportunity to give you some answers as to why your eye cycles may not work, and then also some possible, um, solutions. solutions as well. We kind of talked about, could you consider doing a higher dose, um, trigger injection or maybe different types of trigger injections, but ultimately some of these patients, um, do end up needing to do IDF where you just put a needle in there and you get, um, and then, okay, finally I went to talk about, well, actually there's two more I want to talk about. So, um, cervical stenosis, have you ever, um, been trying to put the little catheter in and I always call, I say it's like you're knocking on the door and nobody wants to let you in. Yes, I have a patient that I'm actually doing an IUI that is like this tomorrow and we usually recognize it because we do your HSG first and that's the first time that we're kind of trying to get into your cervix and it becomes very apparent that we're going to struggle. And so the cervix is just the opening into your uterus. Um, and so sperm has to swim up through that cervix to get to the fallopian tube in the egg. We have to get our catheter through there. And so sometimes it can be. Scarred off, narrowed, um, sometimes this can be from prior procedures that maybe you've had, if you've ever had an abnormal pap smear and then had to get something done for it, like freezing or a leap or other procedures to your cervix, it can actually cause a little bit of scarring to the cervix and it makes it closed off and very difficult for us to get the catheter through. Yeah. So if I'm really having issues getting, um, getting in, I think there's a couple of things that sometimes can help if the patient has what we call an anteverted uterus, where it's kind of standing straight up. Sometimes you can try it again or in the future with a full bladder because as the bladder folds, it straightens it out. It makes it easier for us to get the tube in. So that's one possibility. Um, another thing that sometimes I'll do if I'm really struggling is we'll just do a quick ultrasound and I'll say, okay, let me just map out the exact angle. of where your cervix is maybe kinked or bent, and so I'll take measurements with the ultrasound and then compare it to my measurements on my IUI catheter, and then usually that is also really helpful for being able to get in on those ones that are really tough. The vast majority of them are super easy, but when you get a tough one, they can be a little bit challenging, but I say in those cases, you know what, these are probably the ones where it helps the most. Maybe if you're having trouble getting through that really tight cervix and we're able to get past it. This might be our ticket here. Yes, I put Kennedy to work last time for this. You did? I made her scan, do the ultrasound. Great, that's great. She's like, we're in, we're in. That's great, that's great. Okay, and then one other one that has come up. Really? I kind of feel like I made this up in the last year, um, which is, um, estrogen priming. Okay. So estrogen priming is a strategy. We all all fertility doctors use or hopefully most use it, um, as a strategy to prepare patients for IVF, um, particularly ones that maybe have low egg counts. And the concept here is that estrogen lowers FSH, which is the hormone that comes from your brain. Um, women, as we're starting to run lower in our eggs, sometimes our FSH level is too high. And when it's too high, it's causing a woman's follicles to grow too fast. So let's say a woman tells me I'm ovulating on cycle day seven or something. I'm like, I know this is a problem. You're going to have a hard time trying to get pregnant So if we estrogen prime, meaning we give estrogen before she even starts her period, before we even start that fertility medication, a lot of times that helps the follicles have a better starting point, a better set point there for us to be able to start our medication and help her to have an ovulation that's more of a normal ovulation date, maybe, you know, cycle day 13, 14, somewhere around there. So I think you've tried a little bit on some of your patients, too, right? Yeah. And I think So helpful. Yeah. A lot of my diminish ovarian reserve patients, like those low response patients like Dr. Reed saying Yeah. To kind of normalize the cycle a little bit. Yeah. Provide with some progesterone in the phase. Yeah. And I haven't ever seen anyone else do this, and I think that it's logical, it makes sense, but I think honestly, some people are just like, oh, it's just an IUI cycle. Don't put the effort into it, but I'm like, no, let's put all the effort into it. Yeah. Yeah. You know, back to kind of what you were saying. It's almost like, um, when it comes to IVF, you know there's that saying, the best doctors use the least medicine, right? And I guess, we're humble doctors, we want to say we're the best doctors, right? But, I think our approach is, let's go more natural if we can, and to me that's another way of sort of hacking your body, to be able to go more natural, and, okay, we went over a lot of good stuff. Oh, I guess the final thing, what, what if we're trying, IUIs are not working? Yeah. Yeah. Unfortunately, that usually means we need advanced treatment. Yeah. Yeah. So, the stepping stone, there's not really a good in between between IUIs and IVFs, so typically it means that, IVF, but I will say for Dr. Reed and my patients, we've learned so much about you from your IUI cycles that normally our IVF patients do pretty well, because we are prepared. We're not kind of like shooting in the dark with making your IVF protocol. We know what your body responds like, um, and we know a lot about you at that point instead of just going straight to IVF. Yeah, it's been so helpful for me, like dosing. I think sometimes I'll say, look, I didn't think I'd need to use this high of a dose for your IUI cycle. That tells me when I do your IVF cycle, I need to be more aggressive on the dosing. So I think it helps us provide better IVF cycles when we've gone through that with our patients. But here's the thing, too. It's also where you get to learn more because patients sometimes, you know, let's say we've tried three IUIs. They were perfect cycles. Everything went great. We did all the testing. The patient says, why didn't I get pregnant? And I say, you know what? Here's the thing. It's most likely on a microscopic level because I've looked for everything I can see with my eyes or on ultrasound. But what are things I can't see? So did the egg and the sperm find each other? Actually, was there even an egg in your follicles? We make the assumption there's an egg in every follicle, but some women can be shooting blanks a large amount of the time, right? When you do IVF, we're putting a needle into each one, each follicle and saying, is there an egg in there? Is it a mature egg? Does it fertilize normally? Does it grow into an embryo? Is that a normal embryo? Does that embryo stay? So it's not that there's not a reason for what's going on. It's that we've ruled out all those other things. And now we need to chase down what that microscopic reason is. All right, well, let's wrap it up for the week. All right. guys. Bye.