Different Timing & Priming Recipes for Your IVF Cycle

Dr. Amber Klimczak and Dr. Beverly Reed discuss the different preparation recipes commonly used before starting IVF such as quick start, birth control pills, estrogen priming, and luteal phase stimulation. They also discuss a modern approach called Duostim. Finally, they discuss which recipes may be used to address specific patient issues.

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, hi everybody. Welcome back. Um, we've been having a fun day today. We just did a drone photo shoot. I had never done that before, but you have, right? Yes, It's not a normal thing, but my husband, it's a toy for my husband to play with. We have a drone and he just loves it. And so we do photo shoots of our girls with it. We have some interesting content from our girls running around. I think it's really fun. So you'll have to check out our social media if you want to see, you know, a good view of our building and us and everything, but that was a lot of fun. Um, okay. Well, I, you know, I'm in a lot of these social media, um, groups about fertility and everything. And one of the things I commonly see is you've got somebody who's about to start IVF or maybe is even in the preparation part for IVF and they're trying to kind of ask other people, what is the timeline going to be? What is, you know, what, what am I supposed to be doing right now? And everything. And I always know as soon as I see that, oh, that's such a hard question because every patient is different, every doctor is different, every clinic is different. And that preparation time leading up to when you're going to start your stimulation injections can be so different. Um, and so I thought it would be maybe a good podcast to kind of talk about the different times you can start for your IVF. the different protocols you can use and, and all of that so patients can learn more about them. Yes. I feel like we're about to arm you with some information that you may potentially use for your IVF cycles. So some of this is kind of behind the scenes knowledge. Um, I think what sometimes patients don't realize is there is so much behind the scenes work that happens for an IVF cycle. And we do have to make sure that all these preparations are made. So we need to make sure that the doctors are available, the nurses are available, the anesthesia doctors can be available. The embryologist is available. The anthrologist is available. They'll be able to not only be available, but for the whole next week after your retrieval to make sure they can be checking fertilization, making sure that the embryos are growing and to do genetic testing and everything. And so that's why these things have to be planned. so carefully. Um, but you and I share a pet peeve of one way of getting ready for an IVF cycle that we don't like. Do you want to share our biggest pet peeve that we see sometimes? Yes, that is a really long birth control pill hold. Okay. So I would say it's probably the easiest way to get someone set up and started for IVF because it gives you a lot of flexibility. Um, and you can really start at any time once you pull them off of birth control pills, but I really, really don't like for my patients to be on birth control pills. for more than just a few days. And I'm very straightforward with my patients. I tell them this, um, cause sometimes they come to see me after doing that. And I guess the idea that we worry about with birth control pills is that it can kind of suppress you a little bit. And then we don't get quite as robust of response once we start the injections as we would have without doing a long birth control pill hold. Yes, absolutely. And so do you want to share why then we would see. patients who are on birth control pills for so long. You know, what do you think the story is behind that? Yeah, I think there's kind of two reasons why this happens. First of all, this is something that affects our patients too, and that is insurance. So insurance is a huge barrier to care in general. I think a lot of people out there listening have fought with their insurance before, but IVF coverage for insurance is very complicated and you often have to ask special permission from the insurance company. It's called a prior authorization and get it approved and sign it off and say, yes, this person can start. And that can take a long time to acquire and a woman's body doesn't wait for a prior authorization. Right. And so sometimes your body is ready, but your insurance carrier is not. So I would say that's one reason. Why people may put you on a long hold because they're trying to get all their ducks in a row. Um, and it's a challenge for all of us out there. But I think the other common reason is that the embryology lab portion of an IVF center, it may not be actually up and running 365 days a year, right? There's one way that you can do IVF that's called batching or running in series. And that means where you kind of group all of the patients together to a certain time of the month and you. start them all at the same time to make it so that everyone's going through the embryology lab at the same time. And it's just a different way to practice. And that in turn, if your cycle is not lined up exactly with when that start is, you may be put on a birth control pill hold for quite some time. Yes, yes. And you know, the thing is, um, even though it's not what we prefer, it's sometimes you just have to do that, especially, you know, the thing is, it's expensive to hire embryologists. Some clinics may not be able to afford to have full time embryologist in house all the time. So sometimes they may just be flying in an embryologist for cases. Um, so, you know, sometimes they just have to do it. And I actually think it is okay if you have normal or high ovarian reserve to do that. I think you and I see actually a lot of patients with really low egg counts or maybe people who have had cycles that haven't worked before. And I think in that, um, kind of special population of patients, they are the ones that could really maybe suffer if you're having to do a batch cycle. Um, and so that's why I'm so appreciative for our embryologists. They work very hard because we're running cycles. Pretty much all the time. The only time we're shutting down is around the holidays, um, or if we need to close to clean the lab or something like that, but, but besides that, we're able to start, um, really at any time. And so I think that's just great that we have that benefit for some of those patients that really just would not be Yes, I have to share an anecdote about our embryologists because they truly are amazing and but we I had a patient We do try our very best to time IVF so that we don't just completely take over our embryologists live But our embryologists are really dedicated to our patients And so I had a patient that the timing of her IVF cycle worked out such that her eggs Needed to be checked at 3 o'clock in the morning and our embryologist came up here and At 3 o'clock in the morning, on a Friday going into Saturday morning, can you imagine? And it was just so kind, and that patient ended up making an embryo, which was really amazing. I mean, just truly, truly amazing, and I just, I know that not everyone out there would do that. So I am grateful that they're very flexible with us and they care about our patients as much as the rest of our team. Exactly. It's so true. They just have such a passion and they're cheering right along with us, um, for our patients. Um, I will say I do use birth control pills sometimes. I just don't like to use them longer. You say them a few days. I say four days. longer than a few weeks. So probably more than like two and a half weeks is when I've tended to see a lot of suppression. I really don't use birth control pills for people that have a low AMH, a low ovarian reserve, or you know, they don't have a lot of follicles or something like that. But if they have an average or higher amount of follicles, again, I think it's okay. But if for some reason it's going to go longer than two and a half weeks, then I usually say, Hey, let's just maybe cancel or something and try a different regimen. So, um, But there are some benefits to being on birth control pills, which are that it's really helpful for cyst prevention. Sometimes we have patients that just love to grow cysts, um, and a cyst can actually keep you from being able to start IVF. And so, um, sometimes if you have them on birth control pills beforehand, they are less likely to have a cyst right before. for you start. And then, um, another reason is some patients are at higher risk for having hyper stimulation syndrome where they over response to the medications and birth control pills have been shown to lower the chance of that happening. So there are certainly appropriate times to do it too. But I think it's really more about just customizing it according to your patient. Definitely. Um, so if we're not going to give birth control pills then, what are some other ways that you like to prepare your patients over each ride? Um, so I would say the most common way I called a straight start, but the most common way that I trained to start IBF, which was. I was a luxury to find out is when you start your period on day three of your period, we start medications. That's a straight start and that's just kind of like truly relying on your body, um, to do that. And so I think that's probably the most common way. And sometimes we achieve that by doing minor adjustments to your cycle, kind of leaning leading up to it. And so I would say probably the most common way that we're doing that is with estrogen priming or taking estrogen pills or patches. And we actually start that in the second half of your menstrual cycle, leading up to the cycle that we're going to start on. And it's just kind of exciting. extends that beginning part, and we're able to kind of start you when we need to around cycle day three. Yes, and so I love estrogen priming. That's definitely one of my favorite ways to get somebody ready for an IVF cycle. But you know what? I just remembered something else I wanted to bring up about birth control pills. Um, okay, so what a lot of people don't know if you're on birth control pills for a long period of time it actually lowers your body's natural growth rate. growth hormone. And I think this is really important because there's conflicting studies right now on whether growth hormone is helpful for an IVF cycle. But one of the things I think we have to logically say is, okay, but did we create a problem by giving somebody low growth hormone? And then later we have to give it back. And then we say that helps them. But it's also like, well, what if you just avoid a long course of birth control pills, then maybe those patients wouldn't have needed. So I think that's a factor that often doesn't get. discussed in that situation, but I love estrogen priming. So there are a couple of things with estrogen priming. First, if you're going to do it, you have to start the estrogen after ovulation has occurred. The reason for that is if you try to start it before you have a dominant follicle, Your body may not grow a dominant follicle. You may get in this weird situation where you're like, My period's not coming, and all the rest of it. So, usually I'll have a patient either check their own ovulation, or I'll check their ovulation with a blood test, um, to make sure they had ovulated for that cycle, and once that cycle is over, the case. Then I start, um, estrogen patches is what I do. Um, and leading up to, um, when we're going to start the injections and I do it for a couple reasons. Um, one, a lot of my patients when they do have low egg counts, their FSH level from their brain tends to be elevated. And when you give estrogen that lowers the FSH, that's important. That way your follicles stay more synchronized. When we are starting injections, our ideal situation is that all those follicles are lined up at the same size, like little soldiers ready to go. If you have one or two follicles that have already started growing bigger, then when you start the injections, they're all going to be growing at different sizes. So you'll have some follicles that are ready before others. And so that's why I really like to do some estrogen. And then also estrogen priming has been shown to upregulate the receptors on the follicles so that those follicles will then be more sensitive to the injections that we're going to be getting as well. Um, so I think because a lot of my patients that I see are low egg count patients, I, I really love, um, estrogen priming. That's definitely one of, um, one of my favorites. However, It's not perfect. And so sometimes I've tried estrogen priming a patient and I think this is so important right before I'm about to start injections. I always bring them in for a sonogram to say, did we achieve our goal with whatever type of preparation we're using? We're looking at the follicles and if they don't look well synchronized or if there's not enough of them or something, then Then sometimes I'll just cancel the whole preparation and say, look this preparation didn't seem to work well for you. Let's not force it because this=is the time we had planned to start. Maybe let's try, um, something different. And so sometimes I'll do a, um, lupron priming. Do you ever do lupron? Not often. Not on my stems. I would say that's probably the most rare type of start that I do. I pull out some other tricks, I think, if I'm worried about synchrony of the vocals. Yeah, yeah. So what I'll do loop on with is, um, well, we know that estrogen will lower the FSH, but the LH level can still be high. Okay. And, and that's probably fine in the average person, but in some women, if both their FSH and their LH is high, Then sometimes I need to use a medication called Lupron. And again, you start it after ovulation, but sometimes I'll, I'll be able to use this to better sync up with those follicles if my estrogen priming was not enough to sync them up. But the thing is, you do have to be careful because Lupron can be suppressive. Okay. So one of the old protocols was called a long Lupron protocol. He would be on Lupron for months, um, leading up to the egg retrieval. And that is not good. It's too suppressive. So this is just maybe a little short little course of Lupron, um, right before starting. And so, um, sometimes I've found that to be helpful too. Yeah. So for the luteal down regulation that Dr. Reed's a hormone LH being high. And so a lot of the research for these protocols has been done on PCOS patients, actually, not even patients. who necessarily have low egg reserve, but that's another patient population where you can have a kind of wide variety of follicles that are just resting there that are available to stimulate. And so you can have a lot of problems with maturity when you do PCOS and maybe stemming from asynchrony of the follicles or the follicles not kind of being lined up. So a lot of people will do that luteal, um, Lupron lead in for a PCOS patient. Also shuts down that LH, which we think is way too high in PCOS. And so that protocol has been used a lot for PCOS patients. Yes. Yes. Because I don't use a lot of birth control pills. Um, one of my most common situations that comes up is patients feel confused because I may not be starting their injections on the third day of their cycle. They may have seen with other people who were on birth control pills. So as Dr. K mentioned, if you're on birth control pills, you can stop the birth control pills and predict that the period will come at a certain time and then plan to start injections on that third day. Okay. But if you're not using birth control pills, then it's not going to be as reliable or predictable. And so there's many times where I'm not starting on the third day of the cycle. But what's really interesting is that that is really based on old school ideas. With modern IVF, it doesn't really matter when you start. And do you want to kind of explain to them why that happened over time? It used to matter a lot. Probably the biggest push for this is that we basically dissociated your IVF stimulation, where we're giving new injections and creating the embryos for from the actual embryo transfer. So nowadays we freeze the embryo and then in the next menstrual cycle, or sometime in the future, we actually transfer the embryos. So whatever is going on with your cycle during the stimulation, where you're taking injections and having an egg retrieval, it's Doesn't really matter because your uterus doesn't have to be lined up, your uterus doesn't have to be ready to receive this embryo because we're going to do that later. All we really care about is, okay, can we get a good number and good quality of eggs and make it to an embryo from that first half of IVF? Yeah. And I think it's so hard when something has been done the same way for a very long time. Back in the olden days, everybody was doing fresh embryo transfers. So it was so important that you started those injections on cycle day three, so that by the time you have your retrieval, Your lining is going to be ready to go to accept an embryo. And it used to be that they used to do it on day three and a day three embryo transfer. But now, since those things that she's saying are just not even connected at all, it doesn't actually matter. You can actually start IVF. Um, and we actually first learned about this from cancer patients. So unfortunately some women will be diagnosed with cancer and when they are, they are typically counseled that they need to consider emergency fertility preservation prior to undergoing chemotherapy. And I think in the olden days they used to try to say, Oh, well we need to wait for your period. But then they said, no, let's not wait, let's get started right away. And what they found out is it didn't affect outcome at all. by starting at any given point during the cycle. So I think it's not about the period, but it's more about us just judging, looking at the ovaries and saying, do we have a good number of follicles? Are they synchronized? Is this a good time for us to start? Especially for like egg freezing and embryo freezing, things that are For fertility preservation. I had a funny conversation with one of my friends that was trying to do egg freezing, and we're going to talk about this, but one of the parts of the cycle that you can start people on is the luteal phase, which is that second half of the menstrual cycle. I love doing luteal phase stimulations. I think they work beautifully. And she was like, Oh, I have a big follicle. I'm about to ovulate it. I can't start my egg freezing. I'm like, why? I'm like, you can start. Start your medications in a couple of days. You're about to be luteal. And she's like, what? And she messaged her doctor and the doctor said, luteal stems don't go well. And I was like, and I was texting her. I was like, agree to disagree. I don't know. You know, I think that that person maybe has different mindset about when you can start IVF cycles, but it just kind of made me laugh because I'm like so many of my, I love luteal phase stimulations. My patients know that. And now with our peak fertility practice, that's probably actually my most common start time here. Yeah. Yeah, absolutely. Um, okay. Can you talk to me a little bit about duo STEM? Okay. I, this, I kind of feel like you're already talking about blue deals. Maybe you should bring up duo STEM. So when, if somebody is wanting to do sort of back to back IVF cycles, can you share with us about an efficient way? Yeah, so let's clarify kind of what this means because a lot of people out there track their menstrual cycles So I think women are much more understanding of what their monthly cycle does But remember you have two parts to your menstrual cycle. You have the beginning part which lasts about two weeks or so It's called the follicular phase. That's where you're going your follicle. Then you ovulate and you have the luteal phase. That's the second part So So we used to think, well, you grow follicles in the follicular phase, right? So that's when we should try and grow follicles for IVF. But what we realized is that your brain actually recruits. another little group of follicles in the luteal phase. And so you actually have two chances, right? At really recruiting a big wave of eggs that are up and coming in the same menstrual cycle. So that potential led to a duo stem where we can actually start you on injections, traditionally kind of at the beginning of your menstrual cycle, do a retrieval, and then your luteal. And you actually start Start back up on your medications just a few days later, and then you have another egg retrieval 10 days after taking those injections. So you kind of get two in the timing of one menstrual cycle and they work really nicely. Yes, yes, absolutely. And it's just such a nice thing because then you're just not having to wait and wait for your next IV Fs cycle. to start. Um, not everybody is a candidate for it, especially if you had a really robust response from your first retrieval. Um, number one, you may not need to do a second cycle, but number two, you just may not be feeling up to it. I think it's ideally used for women who just aren't getting a very high, number of eggs with each retrieval. So let's say we've got somebody, she only gets two or three eggs each time. Um, she may, um, perhaps be a good candidate for it, but again, it's something we have to do an ultrasound and look to see, you know, at the time of retrieval, do you have any small little follicles that look like they would be available to stimulate, um, for a duostem? But I just love that we have kind of all these options again, which are based on that you can really start anytime. Um, absolutely. Okay, good. All right, should we wrap it up? Yeah, y'all have a good week. Bye everybody.