Kourtney Kardashian & IVF Attrition

Dr. Klimczak and Dr. Reed discuss Kourtney Kardashian's prior unsuccessful IVF cycles. They discuss why IVF cycles do not work at times. They start from the very beginning discussing the starting point with antral follicles and they walk you through every step of the way including egg retrieval, fertilization,  embryo development and beyond.

Transcript

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Hi, I am Dr. Beverly Reed. And I'm Dr. Amber Klimczak. And we are Two Peaks in a Pod. Well, hello everybody. Welcome back. We are now officially in Season 2. Oh my gosh, craziness. We did a whole season of podcasts. And, um, we didn't really give you guys much warning, but we decided to take the summer off because you and I were both gone quite a bit and busy. And hey, we need a little bit of a break, but now we are back. Um, how was your summer? It was great. It was great. We got some time away. We, um, escaped Texas's heat. Yes. So, but now it's back to reality. It's 105 here, so. Yes, yes. I know. So hot. I know. It's fall, but it does not feel like fall, right? No. Okay, good. Well, um, I don't think I've told you this yet, but I looked at our podcast numbers and since we're getting kind of geared back up and we've had over 5, 000 downloads of our podcast, which is so amazing. That is amazing. Yes. And it just makes me feel so good because here's the thing is, at this point, you and I are already so busy in clinic where you can only see so many patients per day. But you and I just have such a goal to educate people and to help people that even aren't our patients. And so I love that really all over the world, people are just getting to hear a different perspective, a different opinion. So even if you're not seeing us, it's sometimes helpful as you go through your journey, just to hear more detail and more education about what's going on with your body. But isn't that amazing? Oh yeah. No, I've had a lot of friends who also maybe aren't going through a fertility journey, but they're contemplating like, what's this going to be like for me in the future? So they love just having, you know, more valid education. Sometimes you can get some interesting information out there off of social media and TikTok. I know you love TikTok. They're happy to have somewhere that they can go and get some accurate information about fertility. So I have a lot of girlfriends, I guess, that are out there listening. So maybe they're part of the 5, 000. Yes. Well, speaking of fertility, I mean, of social media, actually, I wanted to bring up something that I see on social media quite a bit, which is, I'll see these random posts. I usually see at least one a day of somebody posting and saying, I only got 30 eggs when I did my egg retrieval. I'm devastated. And I just can't even take those posts because I'm like, what the average person who does IVF gets 10 eggs. So 30 eggs is amazing. Right. But also I just wish I could type up a whole big reply about numbers don't matter, it's about quality. That's a brag, what do they call it? That's like a brag. A whole brag. Yeah, a whole brag. Like that person just wants someone else to know that they got 30 eggs. I know. Rude. I never see anyone posting being like, I only got one egg. Like they, you know, so it's always the people, I, I do feel like sometimes it's kind of a brag. I mean, I did IVF in my 20s and I didn't even get that many eggs. That's so rude. Nobody should ever be upset about getting 30 eggs. Um, but, um, you know, in terms of the celebrity I wanted to bring up today, you know, one of my favorites, you know, I love the Kardashians and I had seen recently, and we talked a lot about Kourtney Kardashian. We talked about her IVF cycles that she had actually tried IVF five times and never worked for her. She ended up actually, um, what she says is got pregnant just on her own. And, um, and so I wanted to just have us talk about how can you go through five IVF cycles and, and not be able to get pregnant, um, from that. And I thought it would be good to kind of break it down to all the little steps along the way. And so I'd say, let's maybe start from the very beginning. So let's say you're doing a baseline sonogram and I'm sure patients even ask at that first one, Dr. K, how many eggs am I going to get? All the time. It's like they want to know the end outcome from the very first ultrasound. Yeah. So when we do your ultrasound, especially when you're first coming to see us, we're really just gathering information. We're trying to get a feel for what is your ovarian reserve look like. Ovarian reserve, fancy words for how many eggs do we have to work with? Approximately what sort of response might we get if we have to go through treatment? What are those numbers really turn into right? That's what we're trying to look at. So when we do your very first ultrasound, we're counting the number of resting follicles on your ovary that month. Follicles are simply the houses for the eggs. So we know that In theory, there's a little microscopic egg inside each follicle, but we can't see the egg. We only see the follicle on ultrasound and all we do is count. We're not doing anything magical, right? We just take our ultrasound and we count the number of follicles that are there and available for you to choose from to potentially just ovulate one each month. But the number that you have resting there is proportional really to the number of eggs you might have in storage. So in theory, you have more eggs remaining in storage. Your ovaries are going to be more generous, allow more follicles to come forward, right? So that's our first number that we start with. That number has a name. It's called a called an antral follicle count. How many follicles are resting on your ovary? That's what's available to us to work with. So I like to use the number 10. What number do you use? Yeah. So I usually use 10 with my patients cause it's just like a nice round number. Right. So let's say we count and your antral follicle count is 10. That's all we're going to be able to stimulate. When we do treatment like IVF, we're giving you. extra hormones so that instead of just that one egg that you were going to ovulate, we're trying to get more of them. More of those follicles to grow and the egg inside to mature so we can take it out So if someone has 10 resting follicles, we're never gonna get 20 eggs, right? So this I get this question a lot too probably from these people who post and say, but I thought I could get 30 eggs Yeah, I'm like, but you have 10 resting follicles. So the first number we start with your antero follicle count That's what's available to us to even work with. Now, um, A couple of pitfalls too that I've seen is when a patient sees you for that very first baseline sonogram. And let's say you say 10, they get very attached to that number, but what they don't realize is that number is changing all the time. We know in more recent years, we as women are getting waves of follicles that are coming and going actually all throughout the month. So my best analogy is if you take an ant pile and you kick it and you count the ants. It's just an estimate because somebody can come right after you and count the ants and get a different number. So that's what's important to know about the antral follicles. Dr. K may scan you one day and say you have ten and then you might come see me the next day and I might say nine and then you might see her the day after that. I might be told. Those numbers are always shifting and moving. And that can be really hard as a patient because when you hear that first one, it kind of sticks in your brain and anything different from that feels wrong. But it's important to know this is a dynamic state that your ovaries are. Um, the second thing is I will say, I think it's a really important whenever you're doing that first antral follicle count to then kind of re counsel the patient as well to say, look, I know we were planning to do IVF, Let me now tell you if I think you're a good candidate for IBM based on what I see. If you have tons of follicles or an average number of follicles, then we kind of stick with what we had talked about before. But if, for some reason, I see way less follicles than we were, um, you know, planning on seeing, then sometimes we say, Hey, Let's just take this time to reevaluate. Are we sure we want to do IEF? If I'm only seeing, for example, two follicles, is this still going to be worth it for you to go through this whole process if we might, at max, only have a few chances at getting X? And so I think that's an important time to bring up that discussion. Um, and then finally, when you have that discussion, sometimes it's not of like, oh, we're going to cancel the IVF, but sometimes we say, is this the best month to do our IVF? So for example, I just told you follicles change numbers all the time. Now in a woman who has plenty of follicles, let's say she has 20 follicles. Well in one month she has 22 and one month she has 18 and one month she has 20. There's not a huge difference between that because we know she will likely get plenty of it. But in a woman who has two follicles. Is that the best time to start? What if next month she has four follicles? Okay, it's only a difference of two follicles, but when you're working with low numbers, every single follicle and egg counts. And so in those cases, sometimes I'll ask my patient, Hey, I'm only seeing two this month. Do you want to just come back again next month? And we'll see if it happens to look any better. Now, of course, if you're looking every month and it's always two, at some point, you just decide, Hey, do I just move forward? But I think it's nice to see, Hey, maybe nature will be treating you different next month. Maybe that might be a better month to try because really when you're looking at those follicles, that's usually the maximum number of eggs that you're going to be able to get. Yeah. So important. I kind of described to patients that it's sort of like a wave. So I say, okay, this is maybe what your average number of follicles each month is going to be. But each month you might have slightly lower, you know, in August and then slightly higher in September and then your average in October. So it kind of can go back and forth. So it is a little bit of a gamble if we say, let's come back next month, cause it could be even lower. We don't know if it's the best that you're going to perform or the worst. So I do always tell them, we just don't know. Absolutely. And sometimes it's helpful if they've had ultrasounds before, cause then you can go back and compare and you can say, well, we have two today, six, three months ago. We know it's possible for you to get higher numbers. And whereas in some people, if again, they've never gotten that high, then you'd sometimes you just have to, to be able to move forward. Um, but the next step then is we see the follicles and oftentimes you and I are doing some sort of preparation for the follicles. But when we start the stimulation injections, Do all the follicles grow? No. I think that is actually probably the hardest thing for my patients to wrap their minds around. Um, so I kind of mentioned this before, but whatever you have resting there, those follicles, that's what's available for us to stimulate, but not every single one is going to grow. Um, so that really is challenging because I t right? We all want every have there to grow. Yes, So, you know, and here's when I said you're gettin Some of the follicles are coming up and some of those follicles are on their way out, but there's no way for any fertility doctor to know which one is which by seeing the follicle alone. So when we're giving you the stimulation medication, which binds to the receptors on those follicles, we are trying to recruit those follicles. To grow bigger and not go away, but it can be really frustrating because when patients come in, let's say they started with 10 and they come in for their first ultrasound to look and they say, well, why did only eight grow? Why did those other two not grow? And we don't really know, right? We just don't know the answer to that. Absolutely. And I really can't predict it. You know, I do have certain patient populations that I do warn, you know, more. So for example, the PCOS population, they have a lot of resting follicles. So actually they tend to be the ones that the percentage of follicles that they get to actually respond to medications can be rather low, but they have so many follicles that maybe it doesn't make as big of a difference. My patients that are real average on the number of follicles that they have available not so. super low, not super high, actually to see that they tend to recruit or get the, the higher percentage of their follicles to grow, you know, and then sometimes we have patients who have really low follicle counts, right? And you would expect, okay, at least half of these maybe should grow. Sometimes none of them respond to medication. So it can be a really challenging thing to predict as a physician. And so I do always try and give fair warning. Yeah. Yeah. Not all of them are going to respond. I just don't know how many are going to respond until you get going. Yeah. Yeah. And what's interesting too is, I'm sure you see this, sometimes somebody will respond more robustly on one ovary than the other. So I usually either call the left ovary the lucky left. or the lazy left, depending on which one it is, right? Yes. Um, and patients will often ask me why that is. They'll say, should I give my injections on the other side or something like that? And we know that doesn't really help, but I do think it's interesting that some people tend to have a good ovary and a bad ovary. Yes. It's the same thing. You know, sometimes people are like, Oh, I always ovulate from my left ovary. You know, it's, you know, we don't really know why one is the over performer, but it does tend to happen. Yes. Yes. Okay. Okay, so now we're, let's say we're taking our injections and we're, our follicles are ready and we're about to take our trigger injection to go to retrieval. And I know they probably always ask you, Dr. K, how many eggs am I going to get? I like to under promise. Okay. Okay. Yeah. So this number also has a lot of variability, right? Because it depends on what you mean when you say, how many eggs am I going to get? Okay. So. So what I explained to my patients is when you wake up from anesthesia, we're going to tell you a number of eggs that we retrieved. And for my patients, it's almost always inflated. Okay. Yeah. So that means the number of eggs that I actually take out doesn't mean that we're actually going to be able to work with all of those eggs. Right. Um, and because not all of them will be mature and only a mature, I can actually be fertilized. So In general, we would say, okay, I'm going to try and get an egg from 80 percent of the follicles. That's what I shoot for, right? We theorize that each follicle should have one egg in it, right? Most of the time I can promise 80 percent for my patients and we're one for one and we get an egg out of every follicle and my patients are really, really happy, right? But every once in a while we can have an egg that Maybe was too mature or old or was a cyst or just didn't really develop and mature appropriately. And so that could be an empty follicle, right? And so you have a follicle there that we can see on ultrasound, but it doesn't yield an egg. So I usually try and promise about 80%, but I'm really greedy. I tell my patients this all the time. I go after every single follicle on an egg retrieval. So the numbers tend to be a little bit higher than ultimately what we would get to use. Yes. Yes. And I think it's good to, to kind of think about what are some of the reasons somebody may have empty follicles. So I think that's probably the biggest issue that I'll see sometimes patients do on our own, on their own, where they're not communicating with me. So maybe they forgot to ask me for an egg estimate and I forgot to give them one ahead of time. And then after the retrieval, sometimes they can feel confused because they can say, well, you know, for example, Dr. Reid, I have 10 follicles. Why do I only have, let's say six eggs, you know, Well, here's the thing. I will usually measure all the follicles that I see, even if I know that they're so small that they're probably not going to give me an egg. So for example, usually a follicle that is 15 millimeters or bigger has a reasonable chance of giving you an egg. But I will still sometimes measure a follicle that's only 10 millimeters just for my own information to kind of see the spread that I had for follicles and everything. But when a patient gets those measurements on her calendar, she counts, you know, she counts, Oh, I'm going to get an egg from that 10 millimeter and this and that. Right. So. And in her mind, she got very attached to, there's going to be an egg in that follicle. So I think that's hard. I do try to make sure I remember to tell people, Hey, don't count the ones that are less than 15 millimeters. Really you're looking at the ones 15 millimeters or above that are more likely. And then, um, and so the way I get my estimate is I count the follicles that are 15 or greater. And just like you said, I take 80 percent of that number. And the way I got 80 percent is there's a huge study that looked at this and they said, out of these thousands of women, How can you estimate? And that was the best way to estimate. And I would say most of the time are right, or might be a little bit higher, but sometimes you will see way lower. And if that's the case, it is such an important piece of information. So let's say somebody had 10 follicles, 15 or greater. And you got two eggs. Whoa. That's a problem. Why was where those follicles not getting eggs. And that is usually a moment where you can go back and sometimes these are patients who've had unexplained infertility. Everything had always been looking so good, but they weren't getting pregnant when they were trying, for example, IUI cycles. And once you have that information, you can go back and look and say, well, now I know why your IUI cycles weren't working. On an IUI cycle, we do an ultrasound. We're assuming there's eggs in your big follicles and maybe there were months where you were shooting blanks and there were no eggs in there, you know. And so I think that can be a really valuable piece of information in terms of being able to help the patient understand what the issue is as well. Definitely. Um, and then the other thing I would say with empty follicles of just another theory as to why they may happen is remember how I said there's some follicles that are coming up and some follicles that are going away, and we're trying to recruit those. If you recruit a follicle that's coming up, it should have an egg in it. Great. But if you recruit a follicle that's going away. It's essentially a cyst, right? The egg inside of it has degenerated, but sometimes those follicles that were going away are still sensitive enough to respond to the stimulation. And so that is another theory as to why some women may get, um, empty follicles too. And typically I'll see some risk factors for getting a higher proportion of empty follicles, usually age over 40, Low AMH or low egg count level and very thin patients are ones that I've typically seen. Okay, so after we've got our eggs out, then we hear from Dr. Yang. And Dr. Yang, the very first piece of information she tells us is egg maturity. You want to talk about that? Yeah, so you get your number, you wake up from anesthesia, you, let's say we got eight eggs, right? Because you Did really well with your stimulation and now we're trying to figure out how many of them are mature So the process that the embryologist actually does is we hand them over to the embryologist They look at them under the microscope and they actually take a little cellular layer off so that they can look at them and tell If they're mature mature means they went through this process basically of cell division and replication replication. It's complicated, but they look at it and they have a particular appearance to them. And that is a mature egg. And that's what we can work with to actually fertilize or put the sperm into the egg. And the number of the maturity number can be wildly different between patients, between physicians. It's very, very interesting because this is actually hard to predict. And so you kind of have to know what your pattern is so that you can counsel patients. So for example, I told you my patients numbers are often inflated, right? Because I, even if you might have small follicles, maybe there's thirteens, right? I still will try and get an egg out of them if I can. And that might lead to a lot of immature eggs, right? So I might be getting out some eggs, but I just don't know what's going to be mature or immature. So you can actually have a pretty high percentage of your eggs be immature. And it doesn't mean necessarily something is wrong with you or that's an error, or sometimes it does. There are certain conditions. PCOS is one of these where you tend to have your eggs kind of widely spread across maturity. So you can have some that are not mature that were retrieved if you have PCOS. So you start with this number of eight, but only a smaller proportion of them are going to be mature. Rarely, all of them are mature. And I'm sorry, so happy when patients have really good maturity because it really helps bulk up the numbers, but you definitely can expect to have a drop from the initial number that you're told when you wake up from anesthesia. Yes. And then what about, um, Dr. K, eggs? So let's say, and I think you may have had a case like this before, let's say most of the eggs are immature. Does that mean the cycle can't work for the patient? No, not necessarily. So it depends. First of all, if you have any mature egg, one mature egg, like I absolutely hold out hope for those patients. Um, because I've definitely seen one egg make it all the way through it. Cause we're going to talk about the rest of this attrition as we go down the line. So. So having one mature egg, do not lose hope. Just let's see what that egg does. But very rarely people can actually have maturation disorders, maturation defects, right? With their follicles, um, probably receptors that aren't functioning properly, or maybe not responding to trigger meds that we might use standardly. And so you can have really, really, really low numbers of mature eggs. But it doesn't mean that ultimately you can't have success. There's interestingly something that a lot of research is going on with called in vitro maturation. And so that actually is an embryologist takes out an immature egg and you mature it in culture. Um, and so there are definitely have been case reports of pregnancies from eggs that have come from in vitro maturation. So it's something that you might, if you know, if you're out there and you've had this happen to you, it might be something that you want to ask about. Um, you can ask if the embryology lab does it. Not everyone is willing to do it. Um, certainly a more rare situation that you could be in, but if you have a high number of inmatures, you might want to ask about it. Yes. All right. So, okay. So we've got our mature eggs. Now we're going to add the sperm. The next day we get to know how many of the eggs fertilized normally. And so this is another hurdle to overcome. And this is where there tends to be another drop off. Um, I would say overall, the average number you might hear is that about 75 percent of mature eggs should be fertilized. fertilized normally. I have to brag about our embryologist here. I would, we've looked at our own data. It's in the eighties, um, for their fertilization rate in the eighties. Um, but that still means that you may be losing maybe, you know, 20 percent of the eggs at that point. And that can be really frustrating. But again, this is an opportunity to learn more about your body and about your eggs. So one thing that's interesting is if you have an egg that didn't fertilize normally, I think it's great to dig into the details. You say, well, if it didn't fertilize normally, what do you mean by that? Did it not fertilize at all? Okay. If something didn't fertilize at all, it seems that there might be some sort of issue with the oocyte activation versus Did the, did the oocyte fertilize abnormally? That means it didn't divide properly. And if that's the case, I will say a lot of times that is due to egg quality issues. So let's say we have a patient and let's say she has 10 mature eggs. And we add the sperm and the next day only two of them fertilized normally and the rest were all abnormal fertilization. I can usually say with that, hey, this is really telling us that we're having egg quality issues. And although we would never want somebody to have to deal with that, it's really helpful to have that knowledge so that if the patient needs to cycle again, we can really target all the things possibly that we can do to try to improve egg quality for next time. Yeah. You know, I find this really annoying actually. Oh, why? Because being a fertility patient, a woman fertility patient, sometimes I just really like to blame things on the male. It just feels really good. We're coming up to that next. Yeah. My husband knows this. Like, I really like for things that go poorly to be Stephen's fault. And it, it's very frustrating that even fertilization, right? Something that you would think depends. Mainly on the sperm should not be the eggs fault. And I have to explain this to my patients all the time, you know? And they're like, what? Yeah. I have bad fertilization and it's my egg quality. Right, right. Well, and I will say too, it's probably a little bit different for Dr. K and I, because we are almost always doing. ICSI, where we inject the sperm directly into the egg. Okay. And so in those cases, if you're seeing abnormal fertilization, it is oftentimes an egg issue. However, if you are doing IVF, which means you're just putting a drop of the sperm nearby the egg, then oftentimes that it, that does factor more into the sperm. So let's say you have a case of somebody who has 10 eggs, you do IVF, meaning you just put a drop of the sperm near the eggs and none of them fertilized. Honestly, that can be a sperm issue too. But I think in our circumstance, because we almost always do exceed anyways, it does tend to end up being more of an egg issue. But I will say our next step is when we can start to blame the guys a little bit. Um, okay. So after an egg has fertilized normally, then. We need to actually leave it alone a little bit so it can grow and flourish. And this is time to brag about our lab a little bit. So when reproduction happens in the body, a fertilized egg actually starts in the fallopian tube, which has very different. It has a very different environment when compared to being in the uterus, which is where an embryo goes when it's at its later stage. Okay. So in our lab, we actually have it designed to mimic your natural body conditions. And so we have a set of incubators that are set to mimic the conditions of your fallopian tubes. So really there are mechanical fallopian tubes. So that is where we keep embryos for the first three days. And then just like how they would move in your body from the fallopian tube to the uterus, then we move them from the mechanical fallopian tube to the mechanical uterus in the lab with a whole new set of conditions. Because again, we feel like mother nature knows best. We're trying to mimic that. Yeah. And so not only do we have incubators, but we have media that we change to. So the different components of what the embryo was going to use really change after that day three time period. And so we have a swap in media that we use to really mimic that natural environment. Um, there's a lot of debate about this, you know, in what's, in what's, Um, but really where we stole this from the, the lab that has the best success rates in the world. So we figure if they're doing great with it, we're going to copy them. Yeah. And there is, there is actually the summit trial out there. There's a randomized control trial to show a. Especially women who are going to make a very low number of embryos that this type of media setup is, is superior to the other. So we're always looking out for those patients that really are depending on their one embryo to grow. Right? So those low numbers of IVF, you know, outcomes, those are the ones where it really counts. Yeah. And I think what we found over time is we are the type of clinic that people come to if they're really struggling with their other clinic. We call ourselves the clinic you go to when you're mad at your first month, um, but because of that, a lot of times our patients have already tried IVF, it didn't work. They've already tried transfers and they didn't work and we really want to take on and help those patients. But in order for us to do that, we know we have to have a really good lab. And so we really look at all these details as we go along. Um, okay. So now where we get to blame the guys. Um, so, so what's interesting is yes, fertilization is highly dependent on egg quality, but when you go from a day three embryo to a day five, six or seven embryo, That is when the embryo becomes reliant on the energy from the sperm actually too. And so if you're in a scenario where you see, for example, perfect fertilization, and then all of a sudden between day three and day five, six, seven, you see a huge drop off in the embryo. It's always something to kind of think about. Could there be some kind of sperm issue or contributor here that is causing that issue? Now, granted And quality can also impact that part of the process too, but it is a time of that attrition kind of rate where it is more. Yeah. And this transition is sometimes called the maternal to zygotic transformation. So it's going from solely relying on that maternal genome into the part where actually more so the combination of genetics, right? The zygote or that early, early embryos genome is being relied upon. So that's certainly a mixing of both egg and sperm. So yeah, Yes, I think they're, sperm is playing a part, but unfortunately I think it's both parties at that point too. So, so this can be a really hard hurdle for people because this is one of the biggest drop drop offs you can get. So when you look at Um, eggs that fertilize normally, you can usually expect only about 30 to 50 percent of them to turn into blastocyst embryos. And in other words, into mature embryos. Okay. And so usually we would give our update to our patients on day five, six, and seven. Most embryos tend to be ready around day six. Sometimes you get some that are ready earlier. Sometimes you get, um, embryos that are ready later, but this tends to be a really stressful time for patients too, because again, you would go essentially a week without knowing from your whole IDF cycle, do I even have any embryos to work with? Absolutely. Yeah. And I cite my patients that same way. same number, right? You're going to at least drop by half of the number that we have that fertilize. And that's a huge drop. Um, certainly, and it really is hard to predict. And so I always tell my patients, you're not going to hear from me for a week because it's hard to kind of give an update along the way. Cause we're really hedging. If we give you an update or along the way, things can really change at the end. So, okay. So at this point, I know both you and I have a lot of patients that opt to do. PGTA. So this is genetic testing of the embryos. And so this is where the embryologist takes a very small sample of the cells that would ultimately become the baby's placenta. And we can send them off for genetic testing to determine does each embryo have the proper number of chromosomes. And I will kind of bring up something that I love about our embryologists. Um, lately is that, you know, we're not an idea factory. It's not like we just say, do genetic testing. And she just does it without thinking or anything like that. She really looks at each embryo very carefully to determine, is this an embryo that is a good candidate for genetic testing? What I mean by that is, look, if you have highly graded embryos, aas or BBS or something like that, sure, they can tolerate the genetic testing, but there are some embryos that maybe are lower graded in particular if they have a C in them where maybe they just don't have as many cells available to make the placenta. And although this may be controversial too, I will say some people don't even give those embryos a chance at all. If they have a C in them, we, we don't believe in that. We like to give every embryo a chance. If it looks like it, it could be viable. Um, but, but the question is. If it already looks to be a bit fragile, should we take those cells when maybe that could potentially harm the embryo? And so, you know, whether somebody decides to test the embryo in that case or not can be an individual decision, but I do love that our embryologist at least brings it to our attention. It gives us the opportunity to talk to the patient about it too, to just make sure we're using shared decision making with our patient. with any of the next steps that we do totally. And we should be really clear that for like the majority of patients and there's data to prove this, right. That genetically testing your embryo is not harming the embryo. If you have a full grown embryo, right. An embryo, that's. grown all the way in the lab to day five, six or seven. So really, I get this question a lot. If I biopsy my embryo, is it going to harm it? No, there's good studies to show that we're talking about the very rare embryo that maybe other labs wouldn't have even dealt with. Right. So this is a rare circumstance, but it is really nice that we can individualize this for our patients. Yeah. But then this brings us to another hurdle. We send them off for genetic testing and then the results come back. And you tend to get a drop off there, but this drop off is highly dependent on age. So for example, let's be extreme here. Let's say I did IVF right now. I'm 45 years old. I feel confident. Dr. Kay could do IVF on me. She could get eggs, maybe not a lot, but she could get some. And I would make embryos. Okay. But here's the thing. 95 percent of my embryos would be abnormal. Okay. Because my egg quality is not good because I'm old. Okay. Now the good thing is most of our patients are not 45 like me. They're much younger. And so let's say if we go on the other end of the spectrum, let's take a 30 year old and say she tests her embryos. Yes. She's gonna have many more chromosomally normal embryos when compared to me. But even so at age 30, we can expect about 30 percent of the embryos to be chromosomally abnormal. So you can still expect a drop off even when you're really young. And so again, I think it's helpful to just have that mental preparation as you go through every process to know, Hey, this is normal to have this drop off. And really just hoping that we've got some good embryos to work with. Right. And I think, um, you had mentioned sometimes, you know, IVF, the citrician can really tell us what was happening previously. Yes. I've certainly had some younger women who I would have really expected to get pregnant off of some of our less involved treatment options, like inseminations, and then we take them to IVF, and a really high percentage of their embryos have an abnormal set of genetics. And it's very clear then, okay, this This was the issue, but now we're not doing anything magical with IVF, right? But now we have the ability to sort through your 10 that you potentially could ovulate. We got down to maybe the one embryo that has a normal set of genetics, right? So that's very, very difficult to do when we're just doing IUIs. Yes. IVF is just so much more efficient when it comes down to getting to that rate. Yeah. Yeah. Um, so what I usually tell my patients when I'm talking to them about IVF is we kind of walk through every step of the process here and I do warn them that IVF is extremely stressful because of each steps that I talked about. It's really months of me always giving my patient bad news. That's the hard part, right? And I really put a lot of thought work into how can I make this better for my patients so they don't feel so stressed as they go through the process. And the hard part for my patients is I have not figured out the answer yet, except I do think it's helpful to know that the drop off is coming. And it's really helpful if you have a good support system around you. So when that drop off comes, comes, you can say, look, I knew this was going to happen, but maybe I'm just struggling with anxiety about it. Really what your brain tries to tell you is, Oh my gosh, you have this drop off. IVF is not going to work for you, right? That's what your brain's trying to tell you. And ultimately what it comes down to is we don't know either. We just have to wait and see. And it's not about numbers. It's truly the most important thing is quality. And I have two real life examples. I have a patient who did IVF and she gave me one egg. That is it, but it fertilized normally. It grew into an embryo. We tested it. It was normal. We put it in. She got pregnant and she had a baby because, but then I can contrast that to a patient I've had who got 30 eggs. She was one of those people who had 30 eggs. She only got one embryo and it didn't even stick because her egg quality was not good. Okay. And so really, what does that show everybody? None of these numbers matter at all. Right? So why do we obsess about them? It's just because it's all we have. And so it is okay to obsess about them, but you just have to keep reminding yourself. It's quality. It's quality. And let's just have a curious mind about it. As you go through, let's just learn about your body as we go through it together so that we make it less stressful. And we get little tidbits that are actionable in terms of our next steps for our treatment. Absolutely. It's so helpful to see where the drop is along the way for us. Um, and you know, Sometimes I have to remind myself as the physician that ultimately the goal with IVF with a round is really to get you pregnant with one baby. Sometimes I really get ahead of myself and I want my patients to only have to do one round of IVF to fund their whole family for the future, you know. So I get disappointed when the numbers drop too because I'm like, I know this couple wants two babies, you know. So, um, keep in mind the goal at the end, no matter what you start with is still one normal embryo. That's it. that sticks and makes a life healthy baby and we can do that really with a wide range of starting numbers. Yep. As long as we get one. One egg, we can do it. Okay. Good. Should we wrap it up for the week? Yeah. Okay. Good. Thanks for listening. everybody for listening. If you have time, we would love it if you would just leave us a review, um, either on our two Peaks on a Pod, um, podcast on Apple or on our YouTube channel, or even on our Peak Fertility, um, Google page. And we hope you take care and have a great week. Bye. Have fun. Bye