Inside the IVF Process: What Actually Happens?

In this episode, Dr. Kimberly Turner and Dr. Jerrine Morris discuss the complexities of assisted reproductive technology (ART), particularly focusing on in vitro fertilization (IVF). They explore the various procedures involved, the emotional and physical challenges faced by patients, the risks associated with IVF, and the implications of egg freezing. The conversation emphasizes the importance of understanding the risks and benefits of IVF and the need for proper counseling for prospective parents.

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Transcript

Introduction to Moms, Minds, & Medicine: Inside Maternal Health Research

SPEAKER_01 0:00

Hi, I'm Dr. Kimberly Turner, and welcome to Mom's, Minds, and Medicine inside Maternal Health Research. This podcast is your trusted companion on the pregnancy journey, where we break down the latest insights, answer the real questions, and empower you to make informed decisions every step of the way.

Welcome Dr. Jerrine Morris

SPEAKER_01 0:41

And today we have the pleasure of welcoming back Dr. Jereen Morris, who is a reproductive endocrinologist and infertility specialist. Welcome back, Dr. Morris.

SPEAKER_00 0:54

Hi, thank you again for having me for this talk.

SPEAKER_01 0:58

Yeah, so now we're getting to the part that I think is so fascinating and so hard to understand. So we're gonna try to make this as plain as possible. So let's just say that you have reached the point in the evaluation of a partnered or non-partnered person or couple where they are considering having what we call ART, assisted reproductive technology. Or sometimes we call it IBF in vitro fertilization. There's other procedures too that we as doctors talk about. There's one called ZIFT, GIFT. It's like alphabet suit. What are these procedures? And how do you know which one you need if you can do that sort of in an easy to understand way?

SPEAKER_00 1:44

Yeah, I think in terms of high-level uh GIFT or GIFT is basically where a gametes, so egg cells and sperm cells are placed in the fallopian tube, and you're hoping that, you know, fertilization occurs naturally and the embryo transitions into the uterus naturally.

unknown 2:02

Okay.

SPEAKER_00 2:03

Zift or zygote uh-based um uh treatment is where a fertilized egg is placed into the tube, and once again, hoping that the process of embryo development and transition into the uterus occurs naturally. We're not using either of these in clinical practice because IVF is where we take eggs from the body, take sperm from the body, we fertilize it in the lab, and then we actually grow the embryo to a stage by which it's more developed and there's a higher chance of pregnancy and live birth. This works a lot more efficiently and effectively. And so generally, we're not using gift or zift. Gift and zift, anytime you're putting something into the tube, you need a laparoscopy as well. It's a pelvic surgery where we place a camera into the uterus. And so it's a little bit more involved than the typical egg retrievals we do, which are vaginal procedures, hence they're better tolerated.

Understanding ART: IVF and Other Procedures

SPEAKER_01 3:08

Oh, great. So that's not as complicated as I thought. I love it. Trying to simplify it.

SPEAKER_00 3:13

Maybe a little overly simplified, but generally that's perfect. IVF and ART are what we're using.

SPEAKER_01 3:20

Okay. So we see a lot, you know, we're in information overload, as we've already talked about. We see a lot on TV, social media, print media, um, about how hard it is to have IVF. Is it hard because of emotions? Is it hard because of medications that you take? Why do why is their perception such a large perception that this is such a difficult time for women in particular and men as well?

SPEAKER_00 3:47

That's a great question, but I'm going to take a different spin on it. If you go to the physician and they tell you you need to take a pill every day, and then you need to come in to have a surgery, and then you need to undergo a vaginal exam and have something put into you, and that may not give you a 100% chance of what you're looking for. There's a lot of aspects of that that don't seem savory. So most people don't want to take pills and certainly don't want to take shots. Most patients don't want to undergo a surgery, and that's for anything. No one's excited about surgery. Anyone who's had a vaginal exam is usually not excited for a pelvic exam. And then to do a lot and then not have an outcome that you've so desperately wanted, irrespective of what that outcome is, is also hard. So there's a lot about IVF that depending on what aspect you're looking at, what lens you're looking at it from, it can be challenging. Why do I have to take medication? Why do I have to undergo a procedure that is not comfortable? Why do I have to subject myself to this? And why am I not getting pregnant? Then to take it a step further, IVF is not covered by every state. And so there can be a huge financial piece to basically obtaining what people are able to do for free. That is also challenging.

SPEAKER_01 5:20

Good point. Okay. Um does anything about the IVF process, aside from stress and what you've already talked about, cause risk to, and again, particularly to the mother, since we're talking about maternal health. Um, do these procedures the shots? Are they risky? And we know it's financially sometimes a drain. But are the medications risky? Do I need to worry when I'm 60 that I had IVF when I was

Challenges and Risks of IVF

SPEAKER_01 5:48

42?

SPEAKER_00 5:48

That's a great question. Um, generally, IVF is thought to be safe. In terms of outcomes, or I should say, risks and side effects from proceeding with IVF, the injections in itself are not thought to cause any major challenges. So obviously, a small risk for an allergic reaction, a small risk for bleeding at the injection site, but generally the uh medication in terms of the injections itself aren't thought to be harmful at that time or long term. Risps for the medication are typically dependent on one's response to the medication. These medications, by design, are supposed to stimulate the ovaries. And by stimulating the ovaries, patients will produce estrogen from the follicles in the ovaries that are being stimulated. The rise in the estrogen can cause potentially some conditions during the stimulation cycle and are what's concerning in terms of long-term exposure. So let's talk about that. With the medications and the rising in the estrogen and the response to the stimulation, patients are at risk for ovarian hyperstimulation syndrome. This is a condition by which fluid accumulates in the belly, the lung cavity. You can have changes in your electrolytes, and you're at risk for blood clots. This is usually seen in patients who have lots of eggs, not as concerning in patients who don't have as many eggs.

SPEAKER_01 7:24

Okay.

SPEAKER_00 7:25

There are a number of ways your doctor will try to prevent this, and we're fairly good at preventing this from occurring in someone who's at risk. Long term, it studies have been mixed in terms of really identifying whether the stimulation medication is linked to other comorbidities, namely cancer risk.

SPEAKER_01 7:48

Yes.

SPEAKER_00 7:49

With stimulation, you're increasing your estrogen levels. And so, yes, if you have a breast cancer that's indolent, so you don't know you have breast cancer, but it's present, that estrogen, if it's estrogen receptor positive, can impact its growth.

SPEAKER_01 8:06

Okay.

SPEAKER_00 8:06

Things to keep in mind. There the data is very mixed in terms of understanding is it the infertility someone has, so the fact that you haven't gotten pregnant, or is it the fact that you are undergoing infertility, which one of those is contributing to the risk of this condition? Furthermore, the amount of hormones that one is exposed to during an IVF cycle, it pales in comparison to that of pregnancy. So when I have patients who are concerned about their risks and concerned about breast cancer risk while doing IVF, I simply ask them, if the goal is conception, then we should have that same concern fourfold. Because your estrogen and progesterone are going to be much higher during a pregnancy than it will be during an IVF cycle. And during an IVF cycle, the risk is short term. That exposure is usually less than two weeks.

Pregnancy Risks Associated with IVF

SPEAKER_01 9:09

Excellent. So since we talked about the goal here being pregnancy of all of these treatments, is that pregnancy in and of itself more high risk? Is there a higher chance of more than one baby, which is high risk? Is there a chance of pre-eclampsia, which is high risk, and other high risk conditions in pregnancy?

SPEAKER_00 9:31

Great question. So generally, IVF pregnancies are higher risk than unassisted conceptions. We are placing tissue into the uterus, whether it's placental involvement, uh, the fact that you've taken stimulation medication, biopsy, embryos, hard to say. Presence of or absence of the corpus luteum sometimes can also or is also thought to impact risk. It's a corpus luteum for those that don't have to interrupt. So post-ovulation, you have the presence of a corpus luteum cysts on the ovary. That cyst has a function, it produces progesterone, and that progesterone is what maintains a developing pregnancy should you get pregnant post-ovulation or post-embryo transfer, as we see with natural cycles. There are a number of proposed mechanisms by which IVF pregnancies are thought to be riskier, but they are in fact riskier. Higher rates of high blood pressure in pregnancy, higher rates of preterm delivery, higher rates of diabetes in pregnancy, and these risks are certainly greater as someone is older. So that's usually what I reflect on. Main thing to keep in mind, however, is when we describe risks, we're looking at the relative risk oftentimes. When we say something is fourfold higher, something is fivefold higher, we're looking at the relative risk. So compared to someone who doesn't have that exposure, how much greater is the likelihood of this risk? The absolute risk for these conditions overall is still pretty low. And so if I say something is twice as high and it goes from one to two percent, two percent is still low. That is actually the increased risk for what's called monozygotic twinning. That's where an embryo splits into two at the time of an IVF cycle transfer. And it's a higher risk to see monozygotic uh twinning in someone who undergoes IVF. But 2% while higher than baseline is still very low.

SPEAKER_01 11:49

Interesting.

SPEAKER_00 11:50

Yeah.

Egg Cryopreservation: A Modern Solution

SPEAKER_00 11:51

Last question that you you posed was regarding twins, and that is a question that I often get in my practice. Um we do not usually intentionally cause twins. And in fact, for IVF pregnancies, twins are quite rare, and that's because the ASRM, as I defined previously, really advocates for a single embryo transfer. So that's transferring one embryo.

SPEAKER_01 12:20

Got it.

SPEAKER_00 12:21

There is sometimes that we will transfer more than one. Certainly that's not common, and that is not mainstream, and that's not something that we consider with the goal of tr of trying to obtain twins. We will only transfer more than one embryo when we're trying to increase the likelihood of a singleton gestation in some rare cases.

SPEAKER_01 12:47

Interesting. I think that's probably a misconception that most people um I know it's a misconception that people desire twins and don't understand that that's a riskier pregnancy, but also that the intent sometimes is to have twins, which you just said is not the intent. Not the intent. Correct. Good to know. And finally, in this discussion, I wanted to bring to light what's called egg cryopreservation or freezing your eggs. So many of my old patients had never heard of this, they were shocked, they didn't know anything about insurance coverage. What is the indication to freeze your eggs? And what should we be counseling patients on in terms of age and cost and things like that?

SPEAKER_00 13:34

Oh my, that's a loaded question. It could be a consult, but say this. If you are someone who is unpartnered, you desire to have genetic offspring, you should consider egg freezing. If you are 30 to 34, it's reasonable to consider. If you're 35 to 37, you should absolutely think of it as an investment. And if you're 38 and above, we should be talking about conception now. Egg freezing is the process by which you undergo an IVF cycle, but instead of fertilizing the eggs, we freeze mature eggs for a later date. Egg freezing allows opportunity, but there is no guarantee. And so ideally, you would freeze as many eggs as your doctor that you consult with recommends based on your age. Understanding that if and when you need to come back to use them, there's a higher chance of pregnancy, usually with those eggs than the eggs you currently have based on age. But that chance is not 100%.

SPEAKER_01 14:46

Talk a little bit about the cost. We didn't talk about IVF costs and all of that. But the freezing of the eggs, is it covered most of the time? Is that 50%?

Cost Considerations in IVF and Egg Freezing

SPEAKER_00 14:57

Great question. So high-level IVF, when it's for infertility, is more likely to be covered by many state mandates or different insurance policies. Egg freezing, on the other hand, is usually unlikely to be covered by many state mandates. There are a few insurance carriers that will cover egg freezing. And that's something that generally, when you're looking for a job, that's an advertisement. That is something that they usually will lead with. We have X carrier and they cover egg freezing for you or your spouse. When it's not covered, it can be several thousand dollars, not including the cost of medication, not including the cost of storage. And so I look at it as an investment. The reason why it is something to consider is if you end up having infertility at a later age, then treatment tends to be more costly, even if you do have insurance coverage. So that's why it's sometimes reasonable to freeze when you're younger. And yes, it may be costly and you may not need those eggs, but it may down the line save you a lot of money. I always recommend patients before they consider going down that path, discuss it with a clinician because there are a lot of situations and scenarios by which I would encourage someone to freeze or I would discourage someone to freeze.

SPEAKER_01 16:31

Okay. Okay. All right. Well, we're sort of out of time. I know that you have other things to do today. Um, and I just would like to have you give maybe one take-home message about IVF and risk.

Final Thoughts on IVF and Maternal Health

SPEAKER_00 16:48

Absolutely. So IVF is has been out for some time. This is not a new medication treatment. This is not a new way to help you family build. It is thought to be generally safe. A lot of patients use it to family build. However, there are distinct risks associated with an IVF cycle, whether it's the medication that you take, the procedure that you undergo, or the pregnancy that you hopefully will have. As long as you're counseled on these risks from your infertility doctor, and then you speak to either your OBGYN or high-risk maternal fetal medicine specialists about these risks, and you understand what they are prior to proceeding. Most patients go on to have very healthy, full-term deliveries for a child.

SPEAKER_01 17:40

Excellent. That was a great way to put it and a great way to think about it. So we thank you again for your time. I know how busy you are and your willingness to spend your lunch hour with us.

SPEAKER_00 17:53

And until next time. Absolutely. Thank you all so much for having me. This is something that I'm very passionate about. I love what I do. I love taking care of patients, and I love being what I was called to do, which was an educator first when it comes to medicine. So thank you.