Boz from RHOBH Opens Up: When is IVF the Right Step (and When isn't It?)

Dr. Amber Klimczak and Dr. Beverly Reed discuss how Boz from the Real Housewives of Beverly Hills has bravely shared her personal IVF journey. They discuss who actually needs IVF and who doesn't. They discuss alternatives to IVF and things you can factor in to make your decision.

Watch this (Season 3, Episode 14) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

https://www.youtube.com/@peakfertility

https://podcasts.apple.com/us/podcast/two-peaks-in-a-pod/id1694248202

Transcript

0:06

Hi, I am Dr. Beverly Reed. And I'm Dr. Amber k Clack. And we are two peaks. Two peaks in a pod. Pod. Well, hi everybody. Welcome back. How's your week going for you so far? I am doing well. I feel like everyone's under the weather right now. This is like, I'm just getting over a cold. I'm feeling so much better though. I was fascinated because my health ring. When I was sick told me I was sick. That is crazy. Like I woke up and I got this like red ominous alert from my ring and it was like major signs of strain on your body. And I was like, oh gosh. And indeed I got fevers and I was sick and you know, you just don't bounce back as quickly as you used to when you're older. It hung onto me. And you know what, today? My ring told me I'm better. Oh good. It said, oh my gosh, like you're showing all signs of recovery and I feel better too. And I'm like, oh, thank goodness. So it is funny how we've started to rely on them for our for, I'm like, did I sleep well? I don't know. I don't know how I feel. I need to check my sleep report. I know. Well, I'm just surprised that it was actually right though, because I didn't tell my ring anything. But it knew these things about me, and so I think that's. Kind of cool. That is very cool. Um, okay. But you should be having a great week because you're my hero. Okay. I need to tell you something. So I have a patient that you helped me with and I just found out today her result. Okay? So I did several IVF cycles on her each time she made an embryo, but it ended up being abnormal. And so we went to try again, and I sent her to you and you did PRP injections on her ovaries. You did two doses and then sent her back to me. I just got her embryo update Today. We have a total of 10 embryos. From this cycle, which is crazy. You are a hero. Well, you should tell our listeners how old this patient is too. She's 41 years old. Yeah, which is amazing. I also had, um, noticed her a MH level doubled in a month from you do doing the PRP. And so I'm just fascinated, um, by this and I don't know, maybe it's just some kind of crazy coincidence or something, but I now have. Probably like five more patients because I need you to do more miracles like that. You're amazing yourself. I think we're certainly needing to investigate more ovarian PRP injections more so in maybe a normal patient responder population. I think to date we've really studied it a lot in the low Ag reserve group of patients. Yeah. Um, but I think maybe there's some utility in other places. Yeah. I, yeah. So shocked. And so for our listeners, the concept with PRP is that you draw, we draw your blood. Unfortunately, it's a lot of blood. We have to draw. We concentrate down the platelets. Platelets have growth factors in them, so we essentially get these growth factors. And then under anesthesia, Dr. K can inject these growth factors into the ovaries and. We didn't really know kind of what response that my patient would have. And I said, look, this is considered experimental, but when you've tried everything else and your next step is using an egg donor, sometimes it might be worth exploring. And I'm just, honestly, I'm shocked and amazed and really excited. So I think we need to do some research on this and see if this is something that is repeatable and, and um, could be offered to women in a similar circumstance. Absolutely. But thank you for my hero. Yeah, absolutely. So excited for her. Um, but I did want to tell you, I'm kind of famous because, okay. You know what, we're big, we're both big on social media. Mm-hmm. We're social media influencers. Right. And I had shared, um, a story on my Instagram story about a reality star. Her name, her nickname is Bose. Okay. So I love the show. It's Real Housewives of Beverly Hills. Okay. This is a reality show. Is it Bose, like wearing a bow? Oh, no, no, no. Like, I think it's BOZ. Oh, BOS. Okay. Got it. Yeah. She's cool. Yes. Yes. Um, so Real Housewives of Beverly Hills, it's these like, very well to do. Um, you know, kind of dramatic women. Sure, sure. Yeah. They're usually just highly successful, beautiful, gorgeous, and everything. And one of the newer housewives overall is, her name is Bose gorgeous woman. Um, and she has NFL, which is our acronym for Newfound Love. So that means she's found a new partner kind of later in life. And of course, like everybody does, she wants to have a baby. Mm-hmm. Um. But, uh, she's, she is older in, in our world. I hate to even say that'cause this is my age range, but I believe she's somewhere around like 48 or 49 some, something like that. And so, of course they wanna have a baby together and she is brave enough to share her journey on the reality show, which I so appreciate. But I think there's such a bias. Oftentimes when I'm seeing a journey shared, it's only when it's successful. Mm-hmm. And in her case, she showed how she did IVF and it was unsuccessful and it was so heartbreaking to watch you. And I know the statistics. Honestly, we don't even recommend trying IVF with your own eggs in that age group. Um, but I certainly understand why sometimes people may want to try. In most cases, we recommend using an egg donor. Um, but I thought it was really special that she shared her journey. So I shared it on my Instagram story. And guess who liked my story? Oh my God, that is so like that story so cool. Like the housewife. She liked it. That is really cool. I was like, oh my gosh. Chanel, I'm like, I'm famous. Did y'all dm? Like, because likes it, can't you like talk? Should inter Yeah. I mean, I feel like that's pretty cool. She might want you to do pr. Um, and, um, so anyways, I will continue following her journey. I think it's really special. Um, she has actually talked about and is considering using an egg donor, which I also think is very brave to be having these conversations, um, in public. I think it's really helpful for other patients in a similar situation to not feel alone. Oftentimes, it's more so presented after somebody. I got pregnant with twins at 50 or something. Mm-hmm. Like, oh, everything was great. And they don't really disclose that, oh, they did use an egg donor, or they had tried multiple cycles or something like that. Yeah, absolutely. So I love that. But, um, but what I kind of find interesting is I'm often bringing up these stories of IVF. Mm-hmm. But sometimes when we look for celebrities to talk about who did other types of treatment, like just fertility pills or IUI, it's hard to even find those stories. Yes. Um, and sometimes I feel like it makes. This impression of like the only fertility treatment available is IVF. Totally. Yeah. And how many times do you come and have a patient who comes to your office and they, that's the only thing they've ever even heard about. They think that's their only option, right? Right. Sometimes they've even been told by another doctor. Oh, you have to do IVF. Right, right. And so I figured maybe we should just kind of briefly touch on what are the kind of most common treatments that mm-hmm. We would see for patients and how do you know from a patient perspective, should you, and do you need IVF? Right. Yeah, I think it's a big disservice actually. To patients that are out there to think, okay, if I go to a fertility doctor mm-hmm. I have to have IVF. Yeah. Right. And sometimes I've had patients that put off going to a fertility doctor for years Yeah. Because of that. And I wish they would've come to see me sooner. Right. Yes. Because we had probably some more options. Yeah. And maybe by the time they see me, IVF is the only option. Yeah. But maybe not, you know, it just depends. Yeah. And so that is like such a good question, you know? Do you need IVF or not? So I think we should maybe run through some of the indications for this. Absolutely. Should be IVF. Yeah. Maybe this condition is something that we can consider treating with some of our lower level treatment options. Yeah. Well, and first, let me say too, because I know this seems pretty basic, but some patients don't even realize the difference between. IUI or IVF. Right. We have these acronyms that sound very familiar or, you know, very similar mm-hmm. To each other. And so how would you break it down for me if I were your patient and just wanting to understand maybe, you know, ovulation induction versus IUI versus IVF? Yeah. So I do this a lot for the partners too. Yay. You know, I, I try and I try and use words that they can understand. So I always say, okay, if we're gonna try. A medicated cycle or we're gonna try insemination, I need to rely on your own machinery to work for me. Right. So that means that everything that's gonna be taking place is gonna be taking place inside the woman's body, right? Yeah. So I need all of her machinery to work. I need. Her ovaries to be willing to release an egg. I need her fallopian tubes to be open. I need her uterus to be functioning and able to receive an embryo, right? So I'm relying on all of those things to work for me. I need sperm to be able to get up to the egg that's waiting in the fallopian tube and fertilize that egg. So I can't really do. Thing to manipulate that mm-hmm. With our lower level treatment options. So that's like a medicated cycle or an insemination cycle. IVF or in vitro fertilization is actually where we take the eggs outta the body and we inseminate them with sperm in the lab. And so a lot of the machinery and everything that's happening is done in the lab. So when we have a missing ingredient, we can oftentimes help that in the lab setting. Right. So if we're missing. Seeing part of that machinery, then IVF right. Can come in and then we put an embryo back into the uterus after we create it for you. So that's kind of how I describe it so that partners can kind of visualize, because oftentimes they haven't even heard of an insemination. Mm-hmm. Right, right. Absolutely. Absolutely. And I think what's so nice about some of these other treatment options is when a patient comes in. They are immediately thinking, oh my gosh, I've heard about fertility doctors. I'm gonna have to do IVF, I'm gonna spend thousands and thousands of dollars. But one of the nice things is if you're a candidate for some of these other treatment cycles, they are very affordable, sometimes even covered by insurance and everything. And so sometimes even if they don't have as high of chances that's working, it's just nice to know what are all the options that could be considered as well. Yeah, for sure. Yeah. Um, okay. Let's maybe stop, uh, kind of. Start with the top three. Mm-hmm. We know that there are three major issues that cause fertility problems. In about 90% of people, we think about sperm problems, fallopian tube problems, and ovulation problems. And so maybe let's start with sperm. Yeah. Yeah. Um, okay. So let's say I am a guy and I just got the devastating news. My s my semen analysis is abnormal. So talk me through it. Like mm-hmm. What, what do I do? What? What's your recommendation? Yeah. So when we're talking about treatment options for male factor, there's something going on with the sperm. I like to sit down with them and talk about which category you fall into based off of your semen analysis results. So there will be a group of patients. That their sperm maybe has lower concentration or motility, which is the ability of the swim, the sperm, to swim and swim forward. But maybe it's not so low. Right? And you could be above a certain threshold that you'd be a good candidate for an insemination, intra and insemination or an IUI. And so we go through the calculation with them. I usually do a total modal count with them. So it's just a calculation we can do off of a regular semen analysis. And I let them know. Okay. Yes, I think your sperm is on the lower side, but this is a treatment option that the data shows us. It can help us to correct that and put you at good chances of getting pregnant. And then we kind of talk about there's a next group down, right? If your sperm counts are so low or your motility is so low and the sperm counts are solo, that perhaps you won't make it up to that IUI level, then that would be an indication for IVF. Even my guys who have really severe sperm counts, severely low sperm counts. I usually try and do a workup to investigate. Why is that? To see, can we boost you up in one way or another to get you to the IUI range? So I do think this is actually really important information to be armed with. If you're out there listening and you're. Male factor couple.'cause I have seen couples who maybe have lower sperm counts and concentrations. Mm-hmm. But they haven't tried some medications. Mm-hmm. Maybe that I think can improve because it's a huge barrier. Yeah. I think to get your sperm from, I was an IVF only candidate. Yeah. But I took a medication, I did some other things. Yeah. And I improved my counts enough to get to an IUI. I think that that's actually really important information. I love that about you because I have seen so many other fertility doctors where they see low sperm and they just say, okay, I-V-F-I-V-F. Right. And sometimes they've done IVF by the time they come see us and it didn't work. And, and I ask the question, well, why is your sperm low? And they say, well, nobody, I don't know. Nobody told me. And it's true, probably half the time we're not gonna know why. But has anyone at least tried to help you figure out why? Has anyone checked your hormones? Has anyone done a physical exam on you? Do you have a varicose seal? Is there some kind of blockage like. You know, um, for men who want that information, I think it's so valuable. I feel like I would want it. Yeah. If we were a guide, let's get to the root cause and if that root cause can be fixed, you may not even need us anymore. Right. That is the goal. We don't want you to have to do treatment. You don't need, and so often in these cases, I will offer to refer to a urology fertility specialist so that he can have a full assessment. But I give him the reassurance of like, Hey, if they can't get your sperm back to normal, that's okay. Come back. We can do IVF. We're gonna be able to help you still. But I at least like them to have the opportunity to see what the cause is and if it's reversible too. Yeah. Mm-hmm. Absolutely. Yeah. Okay, so let's move on next to fallopian tubes. Man, this is another really hard one. Mm-hmm. As a woman, there's no signs that your tube or tubes are blocked. Right? Yeah. And I just think of how many times where I was doing what we call the dye test, the HSG, we put the dye in, we take the x-ray. The tubes are totally blocked. It's very easy, it's very apparent, and the patient is shocked. Totally. Yeah. You know, it's pretty devastating. You made time for years. Mm-hmm. And had no idea, because oftentimes women, when they're tracking at home, it's very focused on tracking ovulation all the time. Mm-hmm. Right? They've got the apps, they're peeing on sticks and everything. There is no at home tool to see if your tubes are open. Right. And to hear that information is so shocking. But we know it causes about a third of fertility issues to have tubal a factor. Um, so we aren't necessarily shocked, but it is important that we kind of walk them through, okay, what do we do now? Yeah. So, um, so talk me through why is IVFA good option if you have blocked tubes? Yes. So the nice thing about IVF is we can completely bypass the fallopian tubes. Like I said, we're gonna do, you know, the procedure called the egg retrieval to take the eggs outta the body. And the purpose of the fallopian tubes in the body is for egg and sperm to get together and fertilization can occur, but we're gonna have that happen in the lab when we do IVF, so we don't need fallopian tubes. Yeah. And so that's the nice thing. We have a treatment option that's available that can completely bypass the fallopian tubes we fertilize in the lab and then we. Place the embryo back into the uterus so we don't need them. Um, I do think a common question I get about tubes is because tubes are complex, right? Mm-hmm. They can be blocked or damaged in all different sorts of ways. Yeah. So I do think it's important to ask your doctor too. What kind of blockage do I have? Right? Is it one tube? Is it both tubes? Where are they blocked? Are they blocked at the beginning? Are they blocked at the end? Because you might also be a candidate for some other treatment options depending on what your blockage looks like. And it's a lot to get into in detail, but I think you should ask. I think that that's important information to be armed with. Yeah. Yeah. Well, and maybe a couple things too. It may be reasonable to question the results of the test. What I mean by that is we do something called HSGA dye test here, but there are a lot of clinics who have switched to a different type of test that may not be as reliable too. So it's always reasonable to ask for a repeat test, um, depending on how sure they are about the findings. There are also sometimes false positives you can get, especially if you've got a tubal blockage. Close to where the tube meets the uterus. We call this proximal blockage. Those are oftentimes due to just a muscle spasm. And so oftentimes we'll talk patients through that of like, Hey, this could be a false positive. Do you wanna repeat this test in a different month to just confirm these findings? But I also wanna ask you,'cause sometimes I'll have a patient where. I'm very sure. I'm like, look, they're definitely blocked. And they say, okay, but can you just unblock'em? Yeah. Okay. Talk me through that. I know we get, um, asked this question a lot. Mm-hmm. Um, and so what I explain to my patients, especially with the type of blockage that Dr. Reed is talking about, that. You know, people used to, people used to go in and do surgery on the fallopian tubes and try and repair them. Mm-hmm. But unfortunately, what we realized over time and with the data accumulating, we were probably doing more damage than good. When you go in and try and do surgery on damaged fallopian tubes with modern obstruct. Obstetrics, really, one of the riskiest situations you can even be in anymore is a ruptured ectopic pregnancy. So anything that we're doing that's gonna increase your likelihood of having a pregnancy get stuck out in the fallopian tube and break open and bleed, that's a ruptured ectopic. It's pretty dicey. I mean, it's very risky. And so I explained to my patients that unlikely to have any real benefit from doing surgery to try and repair the fallopian tubes at this. Point, your best bet is to try and bypass them and for your safety too. Yeah. Yeah. And I, I really recommend the same thing To me, I really consider surgery to be a big deal. Mm-hmm. I consider it to be more invasive. You know, I always lean more towards the natural side and to me, IVF is less invasive and more natural than having to have surgery. But I will also acknowledge my bias in that I'm an IVF doctor, right? So if you ask an IVF doctor, what's better IVF or surgery, I'm probably gonna say IVF. And if you ask a surgeon, what's better IVF or surgery? They're probably gonna say surgery, right? So there might be some controversy there. It's nice to have multiple different options. Sometimes it's about shared decision making. Sometimes I'll have a patient who's not a good candidate for IVF, in which I say, Hey. Maybe in your case surgery would be, um, a better option. Um, but these are all things that could be talked about or considered. But in most cases, if you have a clear blockage, IVF is gonna be the recommendation. There is one subgroup of patients who need both, right? Yeah. Mm-hmm. Surgery and IVF, and this is an important, um, distinction. So some patients can have blocked tubes. Other patients can have dilated tubes. That mean it's called a hydrocele. Pinks. That means the fallopian tube is stretched and filled with fluid. And even if you do IVF, that can actually disrupt implantation or increase risk for miscarriage. And so in a patient that has hydrocele pinks, we actually recommend removal of the affected tube or tubes. Um, and so you do IVF, you get the hydro cell pigs or hydro cellies removed, and then we do the implantation. Yeah, yeah. Very important. And that I've had a lot of those recently, so. Mm-hmm. Mm-hmm. Um, okay, so we did, we're talking about the big three. The third one was ovulation. Now when we have patients with ovulation issues, lots of times we can just get them to ovulate with fertility pills. Um, so I would say, um, certainly if you're not ovulating, you could go to IVF, but in most cases you wanna probably have tried. Just regular pills first, right? Mm-hmm. Yeah, absolutely. Mm-hmm. So that would be a couple that you might wanna try. Medicated time, intercourse cycles. Mm-hmm. At least I would say for three. Sometimes there's data for longer, um, treatment plans for you before moving forward with IVF. Now, if you've gone through many of those and you're still not having success, then maybe IVF would be indicated for you at that, at that point. Yeah, and when I think about those patients, there's probably two subsets that I end up having to do IVF on one is. That we're pretty aggressive mm-hmm. With our dosing and everything. Um, but sometimes you can give somebody the highest dose and they still don't growly eggs. And in those cases you have to switch to IVF because what happens is you end up having to give them such a high dose that you can't just get a few to grow at one time. It's kind of like an all or none, right? Mm-hmm. And if you have too many eggs growing at one time, you've just gotta do IVF so that you have the control over how. And you put back just one back. The second subset that is there are women that have something called hypothalamic amenorrhea, and that means that your hormones from your brain are not functioning properly in order to communicate with the ovaries. And for fertility pills don't work in those kind of patients. And because that communication link is broken. And so in cases like that. It's kind of frustrating because what they really need is probably to have the hormones to work, uh, properly. And in other countries they have a little pump actually mm-hmm. That you can use. Um, but we don't have that available in the us and so. Um, in the fertility clinic, it's a problem for us because the only medication that patient will respond to are injections. But if you're just giving injections, it's a very high risk for higher order multiples, meaning, you know, quadruplets contemplates and things like that. And so in those cases, it's IVF is recommended just to make sure that you only have one healthy baby at a time. Mm-hmm. For sure. Yeah. Um, okay. What about genetics? Can you tell me a little bit about how, um, IVF may be helpful for patients that know that they have genetic problems? Yeah, absolutely. So I would say this is a couple that might come directly to us mm-hmm. From day one and say, Hey, I'm here for IVF and they might already know that, but. Don't completely understand where you go from there. Yeah. Um, so I, I would see this a lot. Maybe couples have one child that's affected by a genetic condition. They get testing and realize that, and they want to have another child and avoid having a child that's affected with that condition. Or maybe you've done some genetic testing or carrier screening and found out that both of you carry a gene and you're at risk for having a child that's affected by a genetic condition. And so when we do IVF, we can utilize something called PGT and. Specifically PGTM, it just stands for monogenic testing, meaning we're looking for a specific gene. When we biopsy or take a small sample of cells from the embryo and send it off for testing, we can actually search to figure out which embryos carry that bad gene or two copies of the bad gene to avoid having a child that's affected with that condition. So I've seen couples that have an affected child, couples that share a similar gene, or even maybe you yourself have a genetic condition that you've inherited and you know about and you know that it's a particular single gene disorder that we can test for. It's a little complex'cause I do see couples every once in a while that they know they have a really strong family history. Something genetic and they want to come and do IVF for it. But I would say we can't do IVF with PGT for every type of genetic condition that's out there. Mm-hmm.'cause things can be, uh, complex in their inheritance. And so certain ones, we absolutely can, but there's also diseases that are multifactorial. We know they have a genetic component, but maybe there's some other things that can affect whether or not your child's gonna have it. So you, it's a conversation for a geneticist and your IVF doctor. Okay. Um, probably the other one to think about is maybe somebody who's having recurrent miscarriages and you find out mm-hmm. That either parent has a rearrangement in the way their chromosomes are put together that may put them at higher risk of having, um, either implantation failure or a miscarriage or even a child affected with an issue or problem. And so that can be another way in which IVF may be helpful, um, as well. Um, okay. I want to talk about, and these two things may go hand in hand, although not always, age and egg count levels. Mm-hmm. So very reserved. Mm-hmm. Mm-hmm. Mm-hmm. So a common scenario will be I have a patient come in and she says, well, I'm 40. I'm here for a second opinion. You know, I walked in the door and my doctor pressured me to do IVF or. A patient comes in and she says, I had my A MH level checked and it's 0.5. And even if she's young, let's say she's 25, and she said, my doctor said I have to do IVF. Okay. So I'm curious if a patient comes to see you for a second opinion and they say, do I have to do IVF? What, how do you counsel them in those circumstances? Yeah, so I almost never, in those two circumstances mm-hmm. Tell ever tell someone you have to do IVF. Mm-hmm. But I do think this is something that you and I differ on. Mm-hmm. Because I think something that really drives me, mm-hmm. To encourage my patients to consider IVF is often. Age. Mm-hmm. Um, even more so than egg supply. Mm-hmm. Numbers, right? Mm-hmm. Yeah. So, and I think that this maybe is a difference too between, more so like you getting some general testing with like your primary care doctor or OB gyn. Mm-hmm. They might see some of these low numbers in a younger patient and think, oh my gosh, you need to do IVF, right? Yeah. You come see me and I'm actually kind of on the opposite. Yeah. Camp for those patients. If you're a younger patient with lower eggs. Supply or a lower egg reserve, I'm probably not gonna encourage you to do IVF. Mm-hmm. But if you're an older patient and you have normal egg reserve, I'm probably gonna encourage you to do IVF because I think your success rates are gonna be higher moving directly forward with IVF and time is kind of not on our side. Mm-hmm. So I actually use age more so as a biomarker for success rates for different treatment options. Yeah. Um, oftentimes more than even ag supply numbers in those. Patients. Yeah, I think you could absolutely have an argument for. Either doing IVF or lower level treatment options when someone presents with just low egg supply numbers. Mm-hmm. I mean, I could, we could probably debate it all day. Yeah. And I could probably sit on both sides of the table. Right? Sure. Yeah. Um, I think, and so that's why it's important to kind of individualize treatment for that patient. Mm-hmm. Something that's so important that I think you should ask your doctor if this applies to you and talk to your doctor about is what's your desired family size? You know, definitely How many children do you want? Yeah. Um, it's our role as your physician to guide you into treatment options that make sense for you and for future you. Yes. And so that's an important question for someone. Maybe you're a young person. Mm-hmm. And I tell you it's okay that you have a low A MH, but then you say, well, I want five children. Yeah. Then I might say, okay, well then maybe we need to talk about IVF. Yeah. And I think that's such a good point too, right? It's not always. That you have to choose one or the other. Mm-hmm. Sometimes you do both. So I'll give you an example of, let's say I have a patient who is 38 and she says, well, I wanna have three kids. Mm-hmm. And then I say, well, we're probably running outta time for that. So why don't we do embryo banking? So that means we do an egg retrieval, we pull the eggs out, we add the sperm, we test the embryos, and we bank embryos. The general guideline is you want to bank at least two to three genetically normal. Highly graded embryos for each future child you wanna have. And so I'd say, let's bank as many embryos as you want for your dream family. And once you have that, hey, if you wanna try a more basic fertility treatment at that point, you can, you have the luxury of doing that, right? Because you've got your embryo saved for later. So sometimes you can even sort of take the best of both worlds, um, when you're kind of making your decisions as a whole, um, as well. Mm-hmm. But I think fertility preservation is the big key there because. If you do, let's say, an insemination treatment, let's say you're 40, you do your insemination treatment and you're pregnant, that means you're not gonna be able to try again, realistically until probably two years later, and then you're 42. And so I do feel like I made this mistake when I was a younger doctor because I did have patients who would tell me. We would just be so blessed if we had one. And so I'd get them pregnant with one and then they would come back in two years. Mm-hmm. And they'd be like, okay, we're ready for our next one. Yeah. And I'm like, wait, we talked about this before. Like, yeah, but you know, and that's okay. They didn't know any better. Right. But now that I knew better, I really say, look. Not, not just what can you get by with, but what is your dream? What can we do to try to give you your best chances at building your dream family? Mm-hmm. So, yeah. Absolutely. Yeah. Um, okay. Another reason is sometimes. You've been trying treatments, right? Mm-hmm. Let's say you're trying fertility pills, you're trying, and I UIs these more basic treatments and they're just not working. It gets so frustrating. Um, my patients will say, why is this not working? What's wrong with me? And everything? So I'm just curious, do you have a number in mind of how many cycles your patient would do before you start kind of suggesting, Hey, should we consider moving on to some other type of treatment? Yeah. And I think that this is also an important conversation to have on the upfront when, when you're sitting down with your, um, doctor and just about expectations. I have this conversation with all my patients, but sometimes I feel like their memories erase once they start going through treatment. Right. It's a lot to remember. And then I Exactly. They end up saying, what's wrong with me? And I say, we talked about this, right? Mm-hmm. So I think the challenging thing is when you're trying a lower level treatment option, probably a medicated IUI cycle. That each time you do it, the chances of it working are probably pretty low. Mm-hmm. But you don't always hear that or process that, I think when you're initially talking about it. Mm-hmm. Um, and so what I usually counsel, most of my patients, depending on your age, usually medicated. I UIs. I really like to try it on my. 38 in younger patients, 38 years old and younger, your cycle success rate per cycle is probably about 15% each time you do it. Mm-hmm. And then I tell them, if we're gonna go down this route, I want you to give it the good college try. I don't want you to say after one, okay, it didn't work. I wanna give up. Right. Because that's not our goal. When I'm giving you your treatment options, do you wanna do IUI or IVF? If we're gonna go down the IUI route. I really want you to commit to at least doing three I UIs, and there's a good reason why there's data to support it. Cumulative SU success rates for medicated IUI cycles are about 30 to 40% when you try at least three cycles, sometimes four in some of the studies. And so it's hard when you drop out of treatment after just one. I don't feel like you really gave it the good shot for you to fall into a reasonable success rate. I actually think. 30 to 40% is a pretty good number. Yeah. You know, in terms of getting pregnant. Um, even though my patients wish that it was, you know, 70 to 80, but, and we wish too. Totally. Yeah. Um, but you have to remember, just because that first one or even that second one, second one didn't work, it doesn't mean you shouldn't try a third one because you, you still have pretty good chances. Yeah. Yeah. Um, I think a good statistic that I saw is if IUI is gonna work for you. For 90% of people. Mm-hmm. It's gonna happen within that first three. Mm-hmm. So I think that is when you'll start hearing from me too. Hey, I don't know that we're gonna have much benefit by continuing to try past three IUI cycles. You don't wanna get, just get stuck in this loop where you're trying the same thing over and over. Now, always shared decision making. Do I sometimes have patients who say, I don't wanna do IVF, I wanna keep trying. IUI. Absolutely. Have I ever seen people get pregnant on the sixth? IUI? Yes. I even had one just recently. So it can happen. Um, but really we're just trying to give you the best advice based on the statistics that we have. Um, I don't feel like I'm as strict as making them go all the way up to three. Mm-hmm. I think I'm often patient led. Mm-hmm. And also maybe perhaps by how the cycle's going. You know, do I feel like they had a good chance? Did they grow multiple eggs? Yeah. With good lining and has all the testing been done and all the rest of it. So if I had a patient who wanted to, you know, switch to IVF after the first or second, sure. Like, I'm definitely open to those things. And in fact, sometimes I have patients who don't ever, they don't wanna try IUI. Mm-hmm. And that's an important point too. A big part of this is patient preference, right? Yes. Yeah. And I think that, yes, I tend to lean more natural, but at the end of the day, I show my patients a graph and I say, no matter what your diagnosis is. And no matter what your age is, IVF will always give you the highest chances of having a baby with the lowest chances of miscarriage. Not even debatable. Um, however, why do I have so many patients who opt for more natural treatment? Well, it's less appointments, it's less injections. It's way cheaper. And I think that's where maybe sometimes my patients and I drift from kind of what people commonly recommend, especially in the population that's maybe like 43, 44, 45. If you look at the stats, the difference between IUI and IVF working is very similar. You might be talking about 5% versus 8% success rate in that age. And so I say, well, if the 5% is.$1,100 and the 8% is$20,000. I don't think it's totally unreasonable to try IUI for somebody who's 43, 44, 45. Now, either way, unfortunately they have low chances of it working, but sometimes people just wanna be given a chance before they consider other options like using, um, an egg donor or something like that. Mm-hmm. But I think the biggest thing you have to acknowledge in women who are older, who are trying IUI is. Okay. It's not just do you get pregnant, but do you have a baby? Right. Because the miscarriage rate is so high when we're 40 and above, sometimes as high as 50%. And with IVF in most cases, the miscarriage rate is so much lower because we're able to, um, exclude the number one cause of miscarriage with doing genetic testing with IVF. Mm-hmm. Yeah. And that is another I. Like basically indication mm-hmm. For IVF that you should talk about. This one I will say is debated in the world of fertility. Mm-hmm. But I do counsel my recurrent pregnancy loss patients as well. Yeah. About IVF with PGTA or testing, uh, your embryos for genetics because we are able to identify a normal genetic embryo. Prior to putting into the uterus, I will say my RPL patients are the least likely to consider mm-hmm. IVF as an option. Yes. Even though I really work with them and explain to them like why I actually think that IVF is a very good treatment option. Mm-hmm. I just think it's so hard mm-hmm. When you get pregnant. Yeah. So easily yes. To consider IVF as a treatment option for you. Um, but it is a really rewarding patient population to treat with IVF. I, in my experience, it works beautifully. Yeah. To do IVF with PGTA for the recurrent pregnancy loss population. Right. Yeah, absolutely. And I think that almost just brings me maybe to, the last amazing reason with IVF is you get so much information. Mm-hmm. Right? When you've had recurrent miscarriage, of course you wanna know why. Mm am I miscarrying? Right. Even just getting your genetic testing results back on your embryos and seeing what proportion of embryos are eulo versus an point, meaning normal versus abnormal and everything, even just getting that information is so helpful. Even if you were to put a normal embryo in a miscarry, of course that's devastating, but then that tells us there is something else going on. Very informative. Yeah. Um. So with IVF, you get this higher level of detail every step of the way. So sometimes when I have patients, for example, who are trying, I UIs and they're so frustrated'cause they're like, why is this not working? I say, look, here's the things we don't know. Are there eggs in your follicles? Are they mature? Do they fertilize normally? Do they go into embryos? Are they normal? Do they implant? These are all things we can tell you with IVF. Whether your IVF works for you or not, that's never a guarantee, but I can guarantee you, you will know more after you've done IVF mm-hmm. Than you knew before IVF about your own body and your fertility. Yeah, absolutely. Yep. Okay. Should we wrap it up? Yeah. Okay, good. Well, thank you guys for listening. Um, if you enjoyed our podcast, we would love if you left us a positive review on either the podcast platform or on YouTube, or even on our peak fertility practice page, and we will see y'all next week. Bye bye.