Natural vs. Programmed Frozen Embryo Transfers (FETs): Why Fertility Doctors are Fighting

Dr. Amber Klimczak and Dr. Beverly Reed discuss the online controversy between 2 famous fertility doctors. They discuss the different types of protocols used for frozen embryo transfers and they weigh in on the pros and cons for each.

Watch this (Season 3, Episode 18) on Youtube or listen on your favorite podcast platform to Two Peaks in a Pod.

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

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Links are in @drhappyeggs IG bio.

#fertility #womenshealth #ivf #hormones #IVF #FET

Transcript

Speaker 2 0:06

Hi, I am Dr. Beverly Reed.

Speaker 0:07

And I'm Dr. Amber Klimczak.

Speaker 2 0:09

And we are...

Speaker 0:10

Two Peaks in a Pod.

Speaker 2 0:12

Pod. Hi, everybody. Welcome back. Okay, I have to tell you about my weekend.

Speaker 0:16

Ooh, tell me.

Speaker 2 0:18

Okay, I thought I was a dog person. I'm a cat mom now.

Speaker 0:24

You're a crazy

Speaker 2 0:24

cat lady? Actually, I'm a dog and, and a cat mom. Because I had two dogs-

Speaker 0:28

Hmm

Speaker 2 0:29

and then now I added three kittens to my

Speaker 0:33

family. Oh my gosh, disaster.

Speaker 2 0:35

Okay, and, like, this is a pretty crazy thing to do, but here's the thing. These little kittens were abandoned by their mom. Oh. Okay? There were four of them, and one person took one, and I was gonna take one, and somehow I ended up with three. Oh. But they're so cute- Aw and they're so sweet, and I didn't realize, 'cause I haven't had a cat, like, probably since, um, just a long time ago-

Speaker 0:55

Yeah

Speaker 2 0:55

um, when I was, like, a teenager or something. But, um, these little kittens, they... I mean, they think I'm their mom now.

Speaker 1:01

Aw.

Speaker 2 1:01

And it's so sweet. I love them. Every time they see me, they, like, come meow. And, uh, so I am a crazy cat lady now, so just so you know. But if you would like a kitten- No, thank you I do have extras, so.

Speaker 1:12

No, no. Steven would kill me if I brought home a kitten.

Speaker 2 1:16

Yes. And, okay, you know I love reality TV. One of the shows we talk about a lot is Vanderpump Rules- Oh, yes actually. And it's, one of the people in that show, her name's Scheana Shay.

Speaker 3 1:25

Mm-hmm.

Speaker 2 1:25

What's so crazy is I got my three kittens, the next day Scheana Shay got three kittens. She copied you. I'm like, she copied me. Exactly. Oh my gosh. Rude.

Speaker 1:34

Influencer.

Speaker 2 1:35

Yes, yes. Yeah. Um, okay, so I know you're not on social media that much, but there have been some social media fights going down- Oh between fertility doctors. Oh. Huh. And of course that always catches my attention. Yeah. So I wanted to kind of get your thoughts- Mm-hmm on this topic that's coming up. And so I'm not gonna name the fertility doctor names, 'cause I don't wanna call anybody out. But one fertility doctor kind of came out and made this very absolute statement that said, "When you're doing an embryo transfer, you have to be doing a natural cycle transfer, and if you're not, you're doing it wrong, basically." Right? That's a very absolute statement. Mm-hmm. And of course, that is really stressful for patients- Yeah to hear something like that, because if you did not do that type of cycle, you're thinking, "Oh my gosh, why? Why didn't I do this type of cycle?" Mm-hmm. "When..." And all the rest of it, right? So it's really stressful to make such absolute statements like that. And so other fertility doctors then kind of did a response to that where they said, "Look, you're really just trying to make a very complex topic into a sound bite." Mm-hmm. And there's lots of just, um, different recipes and lots of different reasons why we may recommend or offer certain options to certain people.

Speaker 3 2:49

Mm-hmm.

Speaker 2 2:50

And so I thought it would be good for us to really kind of break down the complexities. Because here's the thing, if you're going through Instagram or TikTok, this is a 15-second, you know, sound bite. Yeah. But we've got a whole podcast. Yeah. So let's get into the nitty-gritty. Let's get into the details. But first, I was gonna see, can you explain to the audience-

Speaker 3:09

Mm-hmm

Speaker 2 3:09

you know, why is this even an issue, right? We've been doing IVF for a long time, but I don't know if people really realize we've changed how we've done IVF, right?

Speaker 3:17

Yeah, absolutely.

Speaker 2 3:19

Yeah.

Speaker 3:19

Yeah. I think, um, just the whole- process and how we go about it. I think we've gotten a lot better at it and timing it, and we've gotten more creative with our cycles in general. But when you think about a traditional embryo transfer cycle, the most common way that we used to go about it is a programmed cycle. And programmed cycles basically mean we take control of your cycle, and we mimic your natural hormonal cycle for a transfer. We give you estrogen first, and then we give you progesterone. And so we kind of hijack everything. Everything's very controlled. Our levels are very specific. It's very well-studied. We know where those levels shill be- should be. So I think there's actually a lot of support act- out there for a programmed cycle. That's the most common way anyone's gonna do an embryo transfer, at least in the US And then, you know, more recently, I would say it's gotten really popular in the last five years, but definitely has, you know, been around for longer than that. There's, uh, now a newer way to go about embryo transfers called natural cycle transfers. And even amongst that, there's kind of subgroups of natural cycle transfers. The most natural transfer you could possibly do is where we just kind of let your body do its thing, right? You're gonna grow a follicle. That follicle's gonna release the estrogen, and it's gonna be the estrogen that makes your lining grow. It will ovulate, and it will shift to a progesterone environment, and that's what we use for the progesterone. I don't actually know of anyone that does, like, a true natural cycle. Most of us are doing a modified natural cycle where we actually control the time that you will trigger and actually ovulate so we know exactly when that's gonna happen with a lot of precision. Um, but these are newer takes on how we can do that, and I think there's pros and cons to both-

Speaker 2 5:09

Yeah

Speaker 5:09

for sure.

Speaker 2 5:10

Absolutely. Well, one thing that I think is really interesting, too, is we say it's new, but it's kind of old if you think about it. Yeah, yeah. Right? Because, okay, way back when, with IVF, the way you would do it is you would take your fertility injections to help your follicles to grow. You would do your egg retrieval, and then three or five days later, they would do your embryo transfer. We call this a fresh embryo transfer. That used to be what everybody did back then. But then, these days it really shifted for several reasons. The first is the freezing technology really improved vastly over the years. And so that made it a lot easier, um, to just freeze embryos to be able to use them later. You didn't have to be forced into a transfer when maybe those conditions weren't ideal. Um, but the second thing is most patients these days really choose to do PGT-A. That means genetic testing of the embryos. And the truth is, when you're testing, it takes time to get those results back, so you really can't do a fresh, um, transfer in those circumstances because you just don't have your results back yet. And so that's why in the vast majority of cycles, this is freeze all. You pull the eggs out, you make your embryos, you freeze them, and then you're working on doing a frozen embryo transfer later on. But if you think about it, the fresh embryo transfer concept is very similar to natural. Either way, your body is making the majority of the hormones that you're gonna need. And so when I think of it, I almost think of it like a circle. Mm. We're going in a circle.

Speaker 6:45

I know. I don't even think about fresh transfers anymore.

Speaker 2 6:48

Right. That's why- I know, right. Absolutely.

Speaker 6:50

It doesn't even cross my mind.

Speaker 2 6:51

Yes. Yeah, yeah. Um- But I thought it would be good for us to just kind of talk through maybe why somebody may be a good candidate or why somebody may not be a good candidate. So what are some of the factors that you think about when you're trying to decide if you should be offering this to your patient?

Speaker 7:08

Mm-hmm. Yeah. So I think the really lovely thing about our patients at Peak Fertility is we really get to know them.

Speaker 2 7:13

Yes.

Speaker 7:14

Right?

Speaker 2 7:14

Yeah. Yes.

Speaker 7:15

Um, and so I can almost predict-

Speaker 2 7:17

Yeah

Speaker 7:17

in general which patients I already think- Ooh not just medically- Yeah but just knowing them- Yes who I think a natural cycle will be. So here's the biggest medical considerations. First of all, if you don't get cycles on your own, you're not a candidate for a natural cycle, right? Mm-hmm. If you're a PCOS patient that does not ovulate on your own, you're really not a great candidate for a natural cycle. You can do maybe another subset of a modified natural cycle where we give you some medication to get you to grow a follicle. Mm-hmm. But you're not gonna grow a follicle on your own. Mm-hmm. So you have to have regular cycles.

Speaker 2 7:46

Mm-hmm.

Speaker 7:47

That's absolutely very important.

Speaker 2 7:49

Mm-hmm.

Speaker 7:50

Also, you might be someone who you're not very good at growing a follicle g- and growing lining in response to that follicle. Mm-hmm. Right? So you might be someone that kind of has lining issues in general, and you need higher doses of estrogen to make your lining grow, right? And we probably already know that about you if you already tend towards having some lining issues, right? We need to go about this a special way. Also not a good candidate.

Speaker 3 8:14

Mm-hmm.

Speaker 8:14

Um, interestingly, patients who are obese are also not great candidates for natural cycle transfers because there's some data to show you should actually use progesterone and oil still for those patients. And so with a modified or a natural cycle, we're typically not using progesterone and oil. We're using some supplemental vaginal progesterone, letting your body do most of the work itself. So I also, also don't really offer it for those patients. Here's the other kind of- personal side of things, right?

Speaker 2 8:42

Yeah. Mm-hmm.

Speaker 8:43

If you're someone that has a very busy lifestyle- Mm-hmm and really likes things to be planned out-

Speaker 2 8:50

Mm-hmm

Speaker 8:50

you're not a good candidate- Mm for a natural cycle transfer. They're extremely unpredictable. We don't know exactly when it's gonna fall. So that's not a, that's not a great person, right? If I was going through it as a fertility doctor where I'm working all the time- Yeah I need to know what day my transfer's gonna be on- Yeah with some certainty, right? Mm-hmm. In advance. Not a great candidate. Mm-hmm. If you're someone who's gonna be extremely disappointed in the moment if your transfer cycle gets completely canceled, you're not a good candidate for a natural cycle transfer. Mm-hmm. I counsel my patients, there's about a 10% risk- Mm with a natural cycle transfer that we're gonna cancel you. Because if you ovulate- Mm before I'm ready for you to, or your lining isn't getting thick enough before you're ready to ovulate, anything's off with the timing, we're not gonna put an embryo in when the circumstances are not perfect. Mm-hmm. You're gonna get canceled.

Speaker 2 9:41

Yeah.

Speaker 9:42

And I have some patients that that would crush them. That is-

Speaker 2 9:45

Absolutely.

Speaker 9:45

Yeah not a good match for them. Yeah. And we have a very candid conversation. They say, "No. That makes me- Yeah very nervous." Yeah. "I don't want to do that," you know?

Speaker 2 9:52

Yes. Yeah.

Speaker 9:53

So I can almost predict who is gonna be kind of open to it and-

Speaker 2 9:57

Yeah

Speaker 9:57

a- already, I think- Yeah previously, right?

Speaker 2 10:00

Yeah.

Speaker 10:00

Um-

Speaker 2 10:01

Well, I think what is so challenging about the scheduling issue that you were bringing up too- Mm is, so when you do a program cycle, pretty much like you start your period, you come in for that baseline sonogram on the second or third day of your cycle, and we can already tell you, "Here's when you need to come in for your lining check," and what day do you wanna pick for your transfer, right? Mm-hmm. Yeah. You can even usually pick from, from some different options based on, of course, our availability too. Um, and so you have so much notice as well. Mm-hmm. With the natural cycle, that's what's so hard is as soon as you start your period, people are asking, "When's my transfer gonna be?" And I'm like, "You tell me. Ask your ovaries,"

Speaker 10:37

right? Yeah,

Speaker 2 10:38

yeah. Um, and so it does require a lot of appointments because they do usually bring you in on the earlier side before you are even likely to ovulate because they don't wanna miss it, right? So they kind of purposely- Mm-hmm, mm-hmm bring you in too early. But then sometimes it comes down to day by day, right? So imagine you're coming in for your appointment and I'm like, "Okay, well, you're not ready yet. Can you come in tomorrow?" And they're like, "Wait, I didn't have time to ask off of work," right? That's where you have more appointments, but also less time to even notify your work that you need to be gone, and that is really hard for our busy professionals. We see doctors, lawyers, and everything, and they already have stuff on their schedule, um, that really prevents them from being able to do that too. So it is nice to have different options to be able to talk through and, and offer your patients as well. Um, I will say maybe some other factors to consider is maybe your clinic. Can your clinic- Mm-hmm support a natural or a modified natural cycle, um, embryo transfer? And we are really lucky here. We do have the luxury- Mm where we're able to do transfers, um, any time of year, but some clinics have to batch, right? Mm. Can you kind of explain why a clinic would batch and, and, you know, just kind of explain too that it, it's okay, but then- Yeah you just have different options, you

Speaker 11:51

know? Yeah. Mm. And there's definitely clinics out there that will group all of their IVF starts maybe once a month, and that, that way they'll also time all of their embryo transfer starts to ar- all start at that same time so that perhaps that's the only time of the month that they'll have an embryologist available to come in and work at their clinic. Maybe if you're somewhere more rural where there's not a lot of, um, healthcare available, this is probably how an IVF clinic close to you is gonna work. Maybe it's a clinic that has multiple satellites. This is one of the satellites where they come in and they batch every once in a while, or smaller clinics maybe that just have one doctor will do batching a lot. And so if they're not up and running the entire month, there might just be one week that they're offering embryo transfers. And if you're dependent on your cycle actually and the timing of your ovulating, you're probably not gonna fall on that little week that they have available- Mm-hmm and so you're gonna do a program cycle.

Speaker 2 12:45

Yeah. Absolutely. And, you know, I think sometimes that can be frustrating on the patient side of things if you're at a clinic that batches, but oftentimes these clinics are working in underserved areas. And look, embryologist, it's very important you get good embryologist, right? But it costs a lot of money Mm-hmm to hire full-time embryologist, right? And so, um, again, although we're lucky to, to have that, we definitely understand that sometimes there may be areas where that can't be supported, and they're still trying to serve you and give you good fertility, um, care, but sometimes you just don't have all those available options. Um- Okay. I will say one of the best things about the natural cycle is no shots, right? Yeah, yeah. Because you know how for our IVF- Mm-hmm or kind of more of the egg retrieval part of it, we have this new device that a lot of our patients have been using with us. Um, we call it needleless IVF, where we put a little pump on the abdomen and they can just squirt their medication through the pump. So you don't even need to do those fertility injections anymore- Mm-hmm which is awesome. But imagine you've been doing that-

Speaker 13:47

Mm-hmm

Speaker 2 13:47

and then, uh, we say, "Surprise." Yeah. We've got some needles for you for the embryo transfer part. Yeah. And this feels frustrating, right? 'Cause my patient says, "Well, why can't I just use that pump again- Yeah for the progesterone?"

Speaker 13:59

Yeah.

Speaker 2 13:59

So-

Speaker 14:00

Progesterone in oil I think is a little brutal. Yeah. I

Speaker 2 14:02

definitely

Speaker 14:03

think it's the part of IVF... It's funny, like, patients who did IVF 8, 10 years ago-

Speaker 2 14:07

Mm-hmm

Speaker 14:07

all they remember-

Speaker 2 14:08

Mm-hmm.

Speaker 14:09

Yeah are the progesterone in oil injections.

Speaker 2 14:10

Yeah.

Speaker 14:11

You know? Totally. It's really that part, I think, that sticks with you.

Speaker 2 14:14

Yeah.

Speaker 14:14

The problem with progesterone is it has to be injected into the muscle.

Speaker 2 14:18

Mm-hmm.

Speaker 14:19

So it's a big needle- Mm-hmm it's a deep shot- Mm-hmm and it makes you really sore.

Speaker 2 14:22

Yes.

Speaker 14:23

I describe it as it feels like you did a really hard glute workout, but you don't have any benefits- Right. of doing the glute workout.

Speaker 2 14:28

Yes, yes. So

Speaker 14:30

for some patients, I mean, really, it's not tolerable to them. Mm-hmm. And it's the worst part of IVF. Mm-hmm. And luckily, when you do a natural t- transfer and you get 90% of the progesterone that you need from your own little follicle, you don't need PIO. Mm-hmm. You don't need the progesterone in oil injection. Mm-hmm. So it is a nice way to avoid. I will say, even some of my patients that do, like I said, modified or natural cycle transfers, I still think that they will benefit from progesterone in oil, so it depends on the patient.

Speaker 2 14:56

Yeah, yeah. Mm-hmm. Um, well, you and I have both done progesterone before. Mm-hmm. Progesterone injections. And I remember when I did them, I got what I call lumpy butt.

Speaker 15:05

Yes.

Speaker 2 15:05

Did you get lumpy butt?

Speaker 15:06

Yeah, you have it for, like, a year later.

Speaker 2 15:08

It takes a while to go away.

Speaker 15:10

Yeah,

Speaker 2 15:10

yeah. I thought it was so funny 'cause one of the partners the other day told his wife, "Don't worry, honey, I like your lumpy butt." So I thought that was sweet. Yeah. I'm like, "Okay, great." Um- It's there for a

Speaker 15:20

while

Speaker 2 15:20

but yeah. So I can definitely understand if you have the chance to avoid progesterone, um, injections, why not? Um, but I, I really do have other people who say, "I, I don't mind them," surprisingly.

Speaker 15:31

Yeah.

Speaker 2 15:31

Um, but what I'm jealous of is in Europe, they have subcutaneous progesterone- Mm-hmm that you can give in the abdomen. Mm-hmm. And I'm like, "Why don't we have that yet? I thought we're the best in the world."

Speaker 15:41

Yeah. Like,

Speaker 2 15:41

US medical care- Yeah best in the world, we don't have that. So I heard that they're working on studies, but I'm super hopeful that maybe that could be a great- Yeah option for us to add, you know?

Speaker 15:49

Yeah. I just hope the levels are as good.

Speaker 2 15:51

I know. That's the hard part with that. It's gotta, it's gotta keep the levels up. Mm-hmm. Yeah. Okay. I'm glad you brought up levels. Mm-hmm. Because, so some of my candidates- Mm-hmm for natural cycle FET say, "Dr. Reed-" I don't trust nature.

Speaker 16:04

Mm-hmm.

Speaker 2 16:04

I've been working with nature- Yeah for years, and it's failed me.

Speaker 16:08

Yeah.

Speaker 2 16:08

And I need medical intervention, and I don't trust my- Mm-hmm own hormones. Mm-hmm. And that's fair. So I get plenty of people who say, "Give me everything. You know- Mm-hmm give me all the hormones, give me the progesterone shots." And I have to admit to you, I also have trust issues with nature. Mm-hmm. I love nature. Mm-hmm. I usually like to go natural, but I have seen a kind of instances where the hormones are not as high as I want them to be. And so, and remember, guys, too, natural cycles are kind of something more we've just been doing in the last, what, six months to a year or so. And so I've been increasingly checking the hormones a lot more than I've needed to in a programmed cycle. Mm-hmm. When I check them in the programmed cycle, they're always so high. I'm like, "Okay, we're good." But in the natural cycle, sometimes they're great, and sometimes they tank on you. Mm-hmm. And then I'm like, "Oh my gosh, hurry up. Now we have to ha- add the progesterone shots," for example. Mm-hmm. And I always feel so bad 'cause I'm like, "Well gosh, this poor patient. She did the whole hard part- Mm-hmm of coming in for all these appointments- I know just to avoid these shots, and now I have to add the shots," you

Speaker 17:11

know? Yeah. Yeah, absolutely. Mm-hmm. I agree. Mm-hmm. I am pretty tedious with the levels.

Speaker 2 17:16

Yeah.

Speaker 17:17

And I also agree with our patients because- Mm-hmm I do a lot of natural cycle monitoring- Yeah and I've seen patients' hormone levels just be really poor- Yeah especially in that luteal phase, and I think it can absolutely have an impact.

Speaker 2 17:29

Yeah.

Speaker 17:29

Um, but I will say to the patient that ends up having to do progesterone and oil- Yeah and did a natural cycle, there's also probably some other benefits- Mm-hmm to natural cycle transfers, right? So I, the way I explain this to my patients is when you ovulate, you have your little shell that's left behind called the corpus luteum, and we know for sure the corpus luteum's releasing progesterone, right? But it's also identifying a t- it's releasing a ton of other chemicals that we haven't even yet categorized. Mm-hmm. We don't even know everything that's releasing, but it's probably a lot of good stuff.

Speaker 2 18:01

Right.

Speaker 18:02

You know?

Speaker 2 18:02

Yeah.

Speaker 18:03

There's probably something related there, too, to controlling your blood pressure- Mm-hmm during your pregnancy. So there's some data to show that you're less likely to get hypersensitive diseases of pregnancy if you do a modified natural cycle, so, or a natural cycle transfer. So I think there's other benefits- Yeah even if you did end up having to do a little bit more supplementing of your hormones.

Speaker 2 18:22

Yeah. Yeah. And I do find that so fascinating to think, gosh, there's things that the ovary makes- Mm-hmm that we just don't even fully understand- Mm-hmm at this point. And I do love that overall concept of what if nature does do it better than- Mm-hmm what modern medicine can do. Yeah. So I do, I do really like that concept, too. But, um, but you know what? We didn't really talk about probably the most important thing, which works better-

Speaker 18:45

Yeah

Speaker 2 18:45

right? Yeah. No matter what, no matter what somebody's preferences are, they wanna know, "What gives me the highest chances- Yes of it working?" And I feel like we do have some reassuring-

Speaker 18:56

Yeah

Speaker 2 18:56

answers to that so far. Yeah. Right?

Speaker 18:58

Absolutely. So these are equivalent outcomes. They really are. There's not a substantial difference, especially if you're going for your first embryo transfer if you're gonna opt to do a natural cycle transfer or a programmed cycle transfer. There really is not a big difference. However, there are some crossover studies that we looked at w- back when I was in fellowship. I have some issues with crossover studies, but they looked at patients who failed their first transfer doing a programmed cycle embryo transfer- And then they crossed them over and tried a natural cycle, or they kept them in the programmed cycle track. And those women that crossed over and tried a natural cycle next had slightly higher success rates in that second embryo transfer. So I actually kind of agree with some of these other doctors that are arguing out there.

Speaker 2 19:42

Yeah.

Speaker 19:42

I kind of offer my patients the standard of care first. Yeah. Right? The fastest, most effective, tried and true, let's do a programmed cycle first for most- Mm-hmm patients- Mm-hmm unless there's really a reason not to. Mm-hmm. And then if we don't have success, then we can talk about doing natural cycle transfer, right? Mm-hmm. I, I think that it's an open conversation if they wanna do it right off the bat, but I don't think there's any reason that you need to feel like you're doing something wrong- Mm-mm by not doing a natural cycle first.

Speaker 2 20:08

Yeah. I'm glad you brought this up- Mm because I'm gonna add another layer of complexity- Mm to it, which is sometimes we'll try an embryo transfer cycle and it doesn't work. And then, for whatever reason, we may suspect they have endometriosis- Mm-hmm or adenomyosis or something like that, and we say, "You know what? Before we try again, let's do some hormone suppression on you so that we can optimize your chances for success." This is all debatable, too, right? Mm-hmm. But this is a com- pretty common treatment we do. And imagine if you are suppressing the ovaries for two months. Your hormones are gonna be essentially zero. Your endometriosis and adenomyosis should shrink. But now imagine trying to do a natural cycle after that. That's hard to get the ovaries to wake back up, right?

Speaker 20:51

Yes.

Speaker 2 20:52

I mean, I wouldn't say it's impossible. I have done it. If I have a patient who really wants to do it, I will do it, but I'm like, "It's probably gonna be expensive," right? Mm-hmm. 'Cause really oftentimes you're having to give fertility meds again- Mm-hmm including, like, Follistim or Gonal-F or something like that to wake the ovaries back up.

Speaker 21:09

Yeah. And- I just don't think there's enough data to support it.

Speaker 2 21:12

Yeah.

Speaker 21:12

You know? Yeah. It's like a har- you're in a, operating in a weird space.

Speaker 2 21:15

Yeah. You know? Yeah,

Speaker 21:16

yeah.

Speaker 2 21:16

Yeah. And so, um, you know, so I think that's an instance where I often lean towards programmed over natural.

Speaker 21:23

Mm-hmm. Yeah.

Speaker 2 21:23

Now, let's say we did our two months of hormone suppression. We tried a programmed, it didn't work. Well, and then we're gonna try again. Then you can usually do a natural 'cause the suppression has worn off enough that your ovaries are gonna be able to, um, wake up a little bit more easily at that point. But, but I think that goes back to the whole point of, like, everybody's, um, kind of case is just a little bit different. Mm-hmm. And you never want to be just black and white in your recommendations and your conversations. It's, it's things to really kind of talk through together. Um, I also wanted to talk through a couple of things when I've looked at the studies that I've noticed. Um, first, I noticed that often the studies that have been coming out recently and hitting social media- It's always a headline, right? And I don't know that people are actually reading the study. Mm-hmm. But the headline usually will say pro- you know, program cycle and natural cycle are equal, or maybe even natural cycle's better than programmed or something. But when I go read the study, in almost all the circumstances, they're calling a program cycle estrogen followed by progesterone, but it's usually either vaginal or oral progesterone.

Speaker 22:28

Mm-hmm.

Speaker 2 22:29

Because many of these studies have taken place overseas where that is their standard of care. Mm-hmm.

Speaker 22:33

Mm-hmm.

Speaker 2 22:33

But you and I both know that is inferior to progesterone in oil. We have very good data to show vaginal progesterone, um, alone is not enough in a programmed cycle, and oral progesterone is not enough, um, in a cycle. So I'm honestly kind of even stumped why they do that overseas- Mm-hmm because here in the US we know if you're gonna do a programmed cycle, you have to have progesterone in oil. And so knowing that that is what gives you the highest live birth rate, I have yet to see a head-to-head of programmed cycle- Mm-hmm with progesterone in oil to natural cycle. That's what we really need to see, a prospective randomized controls, uh, trial comparing those two. And once that's done, if there's one better than the other, I think we're all gonna change to whatever it is, right? Yeah.

Speaker 23:17

Yeah, absolutely. You know? And- Yeah when we would review a lot of these, what I would notice is there's so much heterogeneity in what they're calling a natural cycle- Yeah. Same like I said. It was actually very hard for me to find papers- Yeah that do natural cycles like I do.

Speaker 2 23:30

Yeah.

Speaker 23:31

So.

Speaker 2 23:31

Right. Right. Yeah.

Speaker 23:32

Mm-hmm.

Speaker 2 23:33

Um, and then the other point, um, that I was gonna bring up is most of the studies, um, that I looked at where they compare programmed to, um, natural cycle are retrospective studies.

Speaker 23:43

Mm-hmm.

Speaker 2 23:44

And you have to understand when you're doing a retrospective study, that means you're looking backwards to see, okay, well, these people did natural and these people do programmed, so let's compare. But you have to understand the biggest confounder there is that people who did programmed were probably people who weren't candidates for a natural cycle. And so what are people like that? Well, maybe, like you mentioned, the obese patients or the patients with, um, polycystic ovary syndrome, and we know these are patients that are already at higher risk of high blood pressure and preeclampsia and everything too. So whenever I've seen some of those, "Oh, well, natural cycle has lower rates of this," Mm-hmm And I'm like, but does it really? And, and I'm curious. It's a good point. Yeah. I, I do wanna know, because it could just be that you're studying two very different populations without really accounting for that as well.

Speaker 24:32

Mm-hmm. Absolutely.

Speaker 2 24:33

Yeah. Um, so then, uh, the other thought I had because of my trust issues, right? Mm-hmm. Is what if we kind of combined the two?

Speaker 24:40

Mm-hmm.

Speaker 2 24:41

Right? I was thinking, you know, and of course they're not gonna have the study yet either, what if you could get the benefit of a natural cycle where you let your follicle grow, you have a corpus luteum making all those important, um, hormones and substances, but what if we also added progesterone oil, right? Mm-hmm. Because I do think that that can be really important for people. Um, of course, it's still a shot, which I don't want for patients, but I do think you could use a lower dose. Mm-hmm Because instead of replacing, you're just supplementing. Yeah. Right? Mm-hmm. So I think you could probably, um, get away with a much lower volume, less lumps.

Speaker 25:20

Yeah, yeah.

Speaker 2 25:20

Um, and could maybe even spread 'em out too, right?

Speaker 25:23

Yeah, absolutely. Mm-hmm. And I do think it's such a pref- like, a personal preference. Yeah. I have patients that hate the vaginal progesterone.

Speaker 2 25:30

Oh, yes. Yeah. I

Speaker 25:31

think I'm one of those patients too.

Speaker 2 25:32

Yeah.

Speaker 25:32

It's just so messy.

Speaker 2 25:34

Uh-huh.

Speaker 25:34

And sometimes it can be itchy.

Speaker 2 25:36

Yeah. And

Speaker 25:36

some, in some ways the progesterone oil is cleaner.

Speaker 2 25:39

Yeah. Great. Like,

Speaker 25:40

you do feel, like, a little bit more tidy.

Speaker 2 25:42

Yes. Ti- Yeah tidy. I love that word.

Speaker 25:46

Yeah. Just in my own experience. Yes. Yeah. So I can understand, like, someone maybe- Yeah being like, "No."

Speaker 2 25:51

Mm-hmm. "I'll

Speaker 25:51

definitely do the PIO. I do not-"

Speaker 2 25:52

Yeah "want

Speaker 25:53

to do vaginal." I'm like, "Okay."

Speaker 2 25:54

Yeah, yeah, yeah. Perfect. Well, I guess what I would say is at the end of the day, it really amazes me science and technology have advanced so much, but we're not there yet. You know? Mm-hmm. When, and this is, I... It still always stands out to me how I was showing a patient, I say, "Okay, my current per embryo transfer rate is 76%," and I kind of say that proudly. And they were like, "That's a C." And I'm like, "What? You made a C on your test," and I'm like, "Oh, that's a good point," 'cause here I'm comparing it to, like, many years ago- Yeah when pregnancy rates were probably, like, 20% or something. Mm-hmm. And here, and you know, we need to be making A+ on our tests, right? Yeah. I need to be making 100%. Yeah. And I think you and I are always in pursuit of perfection, right? Yeah. So how can we make it better, not only in terms of success rates, but lowering pregnancy complications and just making the journey as easy as possible for our patients as well. So we have lots of work to do still.

Speaker 26:47

Yeah, absolutely.

Speaker 2 26:48

Perfect. Okay, we'll go ahead and wrap it up for the week, and we hope you guys have a great week. If you would be so kind, we would greatly appreciate if you would leave us a review on our podcast page, our YouTube page, and/or our Peak Fertility practice page. Bye.

Speaker 27:02

Bye.