You're listening to the fertility docs , uncensored podcast, featuring insight on all things, fertility from some of the top rated doctors around America, whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.
Speaker 2Hello everyone. This is Dr. Carrie median from the fertility center of Las Vegas, welcoming you to another marvelous episode of fertility docs censored . And I am joined here today by Dr. Evelyn from Nashville fertility center. Hey , everybody just thought she tried to give a thumbs up there.
Speaker 3It was a cross between a wave and a thumbs up
Speaker 2And Dr. Susan Hudson from Texas fertility center. Hello
Speaker 4Everyone . All right . So
Speaker 2Valentine's day is coming up. What are your best memories from Valentine's days in the
Speaker 4Past ?
Speaker 3I don't have a great when you probably have a better story than I do, but I really look forward to my dark chocolate heart box. Every Valentine's day, we had this, I think it's a chain called shock law. He goes, may have those two , but they had these molded heart Valentine boxes with dark chocolate. And then you get all these other chocolates inside. So I kind of looked forward to every year to Valentine's day. Cause I know that box is coming so my husband better not forget it. This year
Speaker 2Box itself has
Speaker 3Chocolate. The box itself has chocolate and you can, you can get either dark chocolate or milk chocolate.
Speaker 2That's my kind of environmental sustainability.
Speaker 3Yeah, absolutely. You know, you don't, you don't waste any packaging used to eat it, you know, that's very
Speaker 4Cool. That's very cool.
Speaker 3What about you, Susan? I think you must have an interesting memory, cause I think you came up with this topic. So,
Speaker 4So I actually got engaged on now . So when my husband and I were , um, seniors in college , um, we had been dating for two, two and a half years. And um, I, we went to Texas a and M Texas a and M um, in front of our academic building, which is one of the historic buildings. There's a tree called the century tree, which is obviously over a hundred years old. And um, my husband was in the Corps cadets and he sent me on this like , um, kind of scavenger hunt thinking that I was bringing one of our friends who we knew were getting engaged to the century tree. And it was actually her bringing me to the century tree, but I didn't know that it wasn't our psychology and we had the whole saver arts thing and things like that. And the neat thing was to saber arch. So like where the cadets have their source, like you walk under the swords and that kind of thing where you
Speaker 3Dress for the occasion. Did you have to be dressed
Speaker 4Up for that? Or I actually was, you know, funny thing you should mention that because I was like, I was dressed up for the occasion, but my Brooke, my husband then boyfriend was like, you know, dress nice, but you don't want to overdress Kelly and you know, things like this. And so, you know, you're, you're sitting there here, you know, twenty-something girl and you're like, okay, trying to get like the appropriate level of not overdressed , but not under dressed and set, but it ended up being beautiful and amazing. And neat thing was his parents actually got engaged on Valentine's day as well. And he had never told me that. And so it was pretty cool and our parents were all there and he had like arranged for our friends. And so it was, it was a neat thing. So it was just like during the middle of the day or at night, or, I mean, it sounds like it was like a whole big production. It was a whole big production. It actually happened Valentine's day. That year , um , happened on a weekend. And , um, it was actually funny cause I called my parents earlier in the day and we , uh , my parents live like two and a half hours away and I called them. This was back in the day before everybody had like a cell phone on them all the time. I called them as they were literally walking out of the house to drive from new Braunfels to college station. And so my mom was like trying to not like rush me as I was calling them to wish them happy Valentine's day, but like they're trying to leave and try not to be suspicious and everything like that. So it was , it was super safe and as a good memory, what about,
Speaker 2So my husband and I, the first couple of years when we were dating, when we were together , um, I had a really stellar reputation for trying to put together a wonderful romantic Valentine's day and daily and miserably. And so the first , um, the first Valentine's day that I can think of that we were together , we were med students at the time. So read no money, no anything. Um, and I was like, okay, I'm going to do this right. So I put them in my car and I said, okay, this is a surprise. You have to wear a blindfold. So put 'em in a , you know, put it on the blindfold, drove them all around. Our neighborhood, did lots of twists and turns. So he would have no idea cause this is the neighborhood close to where he grew up. So he was really familiar with it. And so had gone to get , um, had ordered some, some dinner, like a steak dinner and baked potatoes and all that stuff from a nice place and had it in talk to my car. So I went and grabbed that quickly, got him, drove him around blindfolded and then drove him back to his own apartment and said, okay, let me go, just check and see if everything is ready. And , and then my plan was, I'm going to take all this food upstairs, set it out on a picnic on his floor and lights and candles, and everything's going to be great. So I'm running at top speed across the gravel in the front of his apartment complex, the food goes online and the opposite potato managed to stay in their respective , uh , containers, but all the other stuff went flying. So I'm like, oh crap. So I like pick it up, throw it back into the box. And of course I have no money and no backup plan. Um, and so, you know, throw it back and run upstairs. Well, this took me longer than I anticipated. So when it's time I get downstairs and I open up and I'm like running and I think like, okay, this took me five minutes. I am so fast. I go to open the car, you know, was excited, threw it open. He's still blindfolded. Have you been sitting there in absolute silence for probably 15 minutes or so? I threw up in the door. He screamed as, as a person could scream because it was horror movie kind of quiet. And then we went upstairs and I gave him the , uh, the non [inaudible] , uh, dinner. And, and that Valentine's day was followed by many other Valentine's days where I set the smoke alarm off. I totally torched dinner. This is otherwise being really a pretty decent cook. Um, we have had many adventures over the years. It's kind of similar doubt, but our anniversaries are Valentine's day is birthdays. Like I pretty much all the romantic occasions I torched for the first, at least three years that we were together. So
Speaker 3Obviously your cooking, wasn't your only redeeming quality, I guess, carrier, right?
Speaker 2Yeah . It couldn't have been because and dinner . I, we still, we were talking the other night. This is now 16 years ago. We were talking about how those pork chops were irredeemable. So , so, okay. All right , Susan, what question do you have for us today?
Speaker 4Okay. So our question is dear doctors, the podcast has been a godsend during my two IVF cycles this year. I'm about to have my first FET in a peak in a couple of weeks and was wondering if there are different FET protocols and how you decide what to use for which patient. In other words, are they as customizable as IVF protocols? Thank you.
Speaker 2That's a really good question. All right , Abby, what do you think?
Speaker 3No, there are as many FET protocols probably as there are doctors that do this , um, you know, it amazes me, you know, in our group, we do certain things, certain ways, and there's different little different tweaks between different physicians and different go-to protocols. If a patient doesn't have a good lining. And , but I think as our group, we sort of stay fairly, fairly consistent. But, you know, it's interesting in talking to the other doctors, you know, like you guys and the other doctors in our big ovation group, it is so amazing how people can just, you know, they, they have different tweaks that they do that they think work. I think the challenging thing with a lot of things that we do and IVF and for FETs is if there's really no good randomized prospective studies. So it's really, truly hard to know if what you're doing makes a clinical difference or not. Now we, we can use things like endometrial lining as an end point. So the thicker, your lining the better, but to answer the question, there are all kinds of different protocols , um , that , that people can do. Um , when they're customizing treatment for an individual patient, what do you guys think?
Speaker 4So I, I would agree . I would say that I kind of have a little bit of a step-wise approach. So I think of IVF protocols differently than the way I think of FET protocols. So IVF protocols, I more think of kind of age of patient status, ovarian reserve, what is the status of the sperm and those things kind of form, you know, how aggressive or not aggressive, how much medicine are we going to use? Um, you know, am I going to use antagonist or am I going to do an estrogen priming protocol, those types of things. Whereas for an fat protocol, things are stratified on a different method. So I kind of have my kind of normal protocol, but I do. Um, and I think this is what Abby is kind of saying. There's like a bajillion of those different protocols. How do you do this? You know, do you use oral estrogen? Do you use vaginal estrogen? Do you do use , um, some sort of stimulated protocol? Do you use transdermal, estrogen? Do you use injectable progesterone or combination of vaginal and injectable or just vaginal? You know, there's all kinds of permutations there. Um, and then, you know, I think about, you know, how many embryos somebody has and what their family goals are. You know, if I have somebody who has one or two embryos at the end of their IVF cycle, better chromosomally normal, and they're wanting to children, you know, that may be somebody that I choose to do an ERI cycle beforehand to kind of maximize that cycle. What's the New York cycle. So era , um, it stands for thank you, Abby , um , individual receptivity assay. And that is where essentially you do a practice embryo transfer cycle. And instead of the day of the embryo transfer, you're doing the embryo transfer. You do a little biopsy of the lining of the uterus in the, in the office , um, doesn't require any anesthesia or anything like that. And , um, receptivity of the lining of the uterus is opened and closed by progesterone exposure. And we know that most people, how much most people need, but , um, there's a certain percentage of people who about 20% that are going to need more or less than the average person and this era test. It helps us determine that. So sometimes we'll do that beforehand , um, to help us figure out if we need to adjust that progesterone exposure. And then we also have what we call our steroid protocol. It's a combination of steroids and some antibiotics in addition to the estrogen and progesterone that we do for people for a number of different reasons. Maybe they may have autoimmune disease, maybe we've done embryo transfers and they haven't been successful. And we're trying to, you know, add something into the mix. And so I would say the short answer is yes, there are lots of different protocols that can be tailored to your specific situation, but they're not necessarily the same thought process as what your IVF protocol is. What about you, Carrie ?
Speaker 2So I think that all of those things are true. Um, and , and probably the only thing that I would add is that I feel like it's a little bit easier to aim for perfection in a frozen embryo transfer cycle, because you've already got an embryo that's frozen and ready to go. So you don't have a time constraint. You've got the, I want to be pregnant yesterday constraint, but pretty much all of our patients have, but if you see something that's not working, you can bail on that with really relatively minimal costs. You know, it's the cost of whatever the meds are and the frustration of everybody involved, because want it to work right the first time. But if something doesn't look good, then you're really doesn't matter what protocol you use. Did you just say, all right, scrap it, we're going to go back and we're going to try something.
Speaker 3Well, and one thing too, I would want to emphasize is that there's no one size fits all. And if you take one physician , not everybody is going to do the same things exactly. As we, as an individual person does them. And so if your doctor doesn't do era bought or doesn't do injectable estrogen or something, it doesn't mean they're doing anything wrong. It just means that they do things differently. And so , um, so, you know , I think the key is we really want to make sure that endometrial lining looks good. That's sort of one of the major end points when we're trying to transfer an embryo and everything. I think that we do in that process is to try and enhance the endometrium and the endometrial lining and the implantation. Unfortunately, we just don't know a lot about implantation and what things have to be present in the uterus to make an embryo implant.
Speaker 4Well, it's not necessarily that we don't know what's involved it's that we don't have tests to determine what's happening in your specific body. So, you know, there there's, I always tell patients that if we wrote a book about everything we know about fertility, and we wrote a book about what we can actually test that second book is probably about half, two and a half to a quarter as long. Um, because you know, they're trying to test things. Noninvasively is one of the major challenges that we face as reproductive endocrinologists, because obviously the last thing we would want to do is interrupt something beautiful from happening.
Speaker 2All right. So some of that actually segues really nicely into our topic for today, which is looking at when do you get a second opinion? And I think we said, it said this on one of our prior podcasts, have you put three physicians in a room you're going to get four viewpoints. And so when, when should you as a patient go intentionally looking for one of those other viewpoints. And so what do you guys, what do you guys think when you have a patient who says, I want to go get a second opinion or you find out that they come back, having had a second opinion of, oh yeah. I talked to Dr . X , Y , Z
Speaker 3Across town. And they said, whatever it was, they said, what do you guys think about that?
Speaker 4So I think, I think there's a lot of value in second opinions. And I kind of tear this kind of conversation, whether you're thinking about second opinion from your, because some of our listeners may be at the point where they're still working with their OB-GYN and then some of our listeners are working with the reproductive endocrinologist . So , um, you know, when you're working with your OB, Jen , I would say that, you know, if you've been doing something for three to six months and you haven't been successful, that's probably the time that going and seeking a second opinion from somebody who's a reproductive endocrinologist. So somebody who's specialty trained in fertility. So OB gens have four years of training before they go out into practice. Reproductive endocrinologists have done those same four years, but then they've gone through an additional three years specific and infertility. Um , so it's probably times to, you know, say kick it up a notch and , um, maybe get a little bit more evaluation than what you may have had with your general OB gen , um, and also just getting different perspectives. So , um, that, that's kind of the , the one tier I look at. And then when I think of , um, you know, somebody who's been going to a reproductive endocrinologist, and then not, that's, that's a whole, that's way more complicated. Um, cause there's not necessarily that easy timeframe. Um, but I think that second opinions can be very valuable. You may stick with your same doctor that you started with, you know, just because you go get a second opinion from somebody else don't ever think that your original doctor won't take you back or doesn't want to hear it. I mean, most of us like to hear other opinions and be like, oh, here's a new perspective. You know, that's definitely, and, and doctors may agree. They may not agree. And you know, it , it may be one of those situations where there's going to be a gray zone in the middle. And unfortunately for you, a lot of the time it's going to come to a gut decision as to which doctor feels like they're going to be able to deliver the best care to you. What do you think about ,
Speaker 3Well, I think sometimes if you've had some treatment, it hadn't worked, it's natural to be frustrated and to feel like, you know, maybe this person just doesn't know what they're doing. And I think sometimes when people leave and get a second opinion, I think they get a better perspective and feel more, hopefully more confident in their doctor. I think there's so many things that we do not know about infertility and in my past couple of decades and infertility , it amazes me how little we still know about implantation and pregnancy. And, you know, sometimes I'll get patients and all I've done kind of a workup on them. And then they'll try some things and they'll be like, well, okay, well now I'm ready. You can do those other tests on me. And I'll be like, well, there really are no other tests . We we've already done them all. And I think that's really frustrating to patients because I can't tell them sometimes why they're not getting pregnant. And I think that could be really frustrating. So I think if you find that you're frustrated, I think it's good to seek out a second opinion because I think symptoms , patients kind of just feel angry and they feel like there's something they're not telling, you know, someone's not telling them something. And I think you kind of get a better perspective and you realize that maybe, you know, hopefully that your doctor is doing the right treatment for you. I think sometimes too, I will have to admit. And I think you guys are probably in the same boat, you know, sometimes I'll know something that maybe I don't really feel comfortable professionally saying to a patient. Like if I know for example, Dr. X over there orders, million-dollar workups and gets a bunch of tests that I think in my opinion are not worthwhile tests. And, you know, you kind of wonder, is there some other incentive other than patient care? And so if you find that you're spending a lot of money at the practice or the doctors having you come back for a bunch of tests and you kind of wonder if they're really necessary, that's when I would seek out a second opinion and just make sure that you're really getting the care that you deserve to get.
Speaker 2I would say that your physician should be able to explain and should be pretty comfortable explaining why they're ordering what they're ordering, because, and be able to back it up with either data or be able to very clearly say, look, we don't have this data, or this is the data that exists, and this is why I trust it, or this is why I don't trust it.
Speaker 4Cause granted there's , there's a lot of tests that go into the basic fertility evaluation. So I don't want our listeners to think of, oh my goodness, we're doing a lot of tests. These aren't all necessary, but like Carrie's, Carrie's getting to that. They like there should be an explanation behind it and your doctor should be able to explain why we're doing this .
Speaker 3So, you know, for example, I was mentioning earlier that, you know, one time somebody called me and said, okay, my patients going through IVF, why are you ordering all these infectious disease tests? This doesn't make sense. Well, that's kind of the standard of care we have to know before we do IVF. First of all, that you and your husband are both healthy. And when we create embryos, if you or your husband has something like hepatitis, we need to know that cause those embryos need to be isolated in a different container away from the other embryos. So sometimes people don't really understand why we need to do infectious disease testing. And you know, that's a lot of different tests when you're talking about HIV and hepatitis and CMB and some other things that we do. Um, but you know, we should be able to tell you why we're ordering the tests that we are. Um, and I think too, the other thing that I meant to mention as well, it's always good. Even when you're seeing a doctor for the first time, I think it's great to do your own research on the internet, but just remember just like Amazon reviews, those reviews can be kind of all, you know, and so don't necessarily read a review online and think that the doctor that you're going to see is going to be really good or really bad because those reviews can be tweaked a lot. I think it's best. If you can find a physician that you trust to get their input. Um, and I think, you know, or word of mouth from another person, a friend of yours that seen that doctor because sometimes, you know, ads can be really glossy and really pretty and just make that person out to be, you know, the best thing since sliced bread. And in reality, they, you know, they may not live up to their hype. So I would try and go with word of mouth as much as you can, if you can, when you're getting universe where you see a doctor for the first time or even for the second time for that.
Speaker 2Yeah. And we definitely , um, really don't any, any doc who's good can understand the science and is willing to move forward with it is not going to be offended by you wanting to get a second opinion to say, okay, go for it. You know, they may, some of them may steer, you have , you know, I would recommend talking to this person or this person, you know , um, because , because I've seen how they practice them , I trust them. Um, and that's, that's one way to get a second opinion, you know, and, and granted, a lot of us are not willing to send you to the person, you know, that we think, oh, they're a total crackpot. Um , but if someone asks me and they say, okay, I really want to get a second opinion. Who do you recommend from lots ? How long who, who I would send them to Steve , because they're the people that I trust. And , and there's a layer of the patient just having to trust me and that I'm not a total fraud , but if they think I'm a total crook, they need to be going anyway. Um, because that's one thing that I tell everybody is that you, you got to trust me because if you don't trust me, then we don't have a good relationship. And if I call someone with bad news, if you're not pregnant, or you only have one embryo or whatever it may be, I need that trust for them to know that I have done absolutely everything that I can. And so sometimes second opinions are useful just because you walk into somebody else's office and you go, oh, I didn't realize, I didn't realize that I really did like it when I first was, or, or I didn't realize that this is what it could be. And this is a better suit
Speaker 4Kind of on that same layer of trust that Carrie was just talking about, you know, we, whether we're patients or doctors, there are going to be some people that we do mesh well better with some people than others. I mean, we're, we're all humans. And so, you know, for , I always say that fertility is a journey, okay. It is , is not a one-stop shop. Unfortunately it is, it is something that we're going to walk through together. And so if you don't have a good connection and that's gonna vary from person to person, some people need somebody who's really touchy, feely. Some people need somebody who's more transactional. And matter of fact, some people need somebody who can kind of coat things a little bit better. Some people like it to be, you know, given to them straight. Those are all things that quite honestly, until you're in with your doctor, you're not gonna necessarily know that sometimes you can get some of that information for reviews, but , um , not always. Um, but on that personal level, you know, you're going to know what you need and if who you're visiting with isn't matching those needs that maybe sometimes finding another clinic or another doctor, even within the same clinic , um, might make that journey better for you as well as for your, your team, because it is, it is a team sport
Speaker 2It's true. Very much true. Is there anything that you guys would say you should avoid when you're looking for a second opinion? Like if you, if you've gone to see your primary, you know, fertility specialist or , uh, or talking to your OB GYN and Susan, when you were saying OB-GYN, it made me think of when I was in residency, I switched from, from hearing, it's hearing it being called OB GYN, which is where I grew up to OB-GYN and now every time I think of OB-GYN I think like, oh, that's a great new cocktail. Um, OB GYN. I don't, I just say , I just spelled a little word letters out. I don't say either, I guess it's all where you trained, right? It is all , all, all medicine is local. It's like all politics are local, all medicines , local. Um, but, but what things do you need to look out for? Whether you're going from one REI to another, from an OB GYN to a specialist from, or, or just talking with your local fertility, Facebook group to, you know, do I need to go see, see somebody with medical letters behind their , their name? What are things to look at to avoid, to be kind of aware of
Speaker 4Bigger, fancy, glitzy, famous is not necessarily better. So, you know, when you're on the airplane and you're flipping through the, what used to be on airplanes and you see those, like the , those like doctors in the middle of the magazine and may look like they're like the world's end, you know , um, they've great photographers, you know, but that doesn't necessarily mean they have great qualifications and, you know, there are, you know, there are certain clinics out there that are renowned for being really good at blank. Um, my, in my experience , um, if it sounds too good to be true, it may be. And so take, take everything with a grain of salt. You know, there are, there are clinics that do cherry pick patients that don't allow certain patients with like diminished ovarian reserve or things like that to go through different protocols. And so they're not kind of in those fantastic numbers. Um, like I said , um, unfortunately, you know, and there's some clinics that maybe their start statistics or whatever may not look quite as good, but maybe they let patients come in who just want to have a chance. And there's a lot of people out there who just want to have that chance. Um, so that's kinda my,
Speaker 3Yeah . To follow up on that, Susan, our clinic in your right . Some people will say, unless you're less than 35 and you have a certain AMH, we're not going to let you go through IVF and that's well and good, cause it makes your stats look really good, but we have the philosophy that everybody deserves a chance to try and get pregnant because every now and then you'll predict that somebody won't do very well and they do great and they get pregnant and they would have been patients that probably most, a lot of clinics would not have let go through. And so I had a patient, I don't know , it was probably six months ago. So when you know Dr. Eben , Eloctate your start numbers. And they looked really good, but why don't you have so many cycle cancellations? And I said, well, because we allow everybody to go through. And some people within a few days of stimulation just don't make it. And we have to cancel their cycle if their egg numbers really low, but we still give them the opportunity to go through and do IVF. And so you have to be careful, like Susan said, too , when you look specifically at statistics, cause there's can be, there can be lots of things that are hidden in those statistics that you may not quite understand. And there's sometimes there's a reason why, if the statistics look too good to be true, they might be, what
Speaker 4Are , what are your , um, kind of red flags Carey ?
Speaker 2Um, I mean, I, I worry about the people push their success rates a ton because it's like you said, those statistics are really easy to manipulate and things that apply really on a great level when you've got an, a star football stadium worth of people don't apply when you're talking about one human being, because for one human being that outcome is 0% or a hundred percent, there's no such thing as being 62.5% pregnant, you are , or you are not. Um, and, and paying attention to , to the bigger picture, really knowing what you're looking for, like the patients who come in to our practice when they're talking to our schedulers and they, and part of this is our schedulers are , are good at looking for this, but able to kind of figure out, okay, who needs the cold, hard numbers person who needs the doc, who's going to hold their hand, who needs whatever. And so when, when you can identify what your needs are, like, if you have a really screwball case, you may want someone who is totally different than who you were at before and whatever direction that goes. And so kind of be open-minded of all right . You know, let's, let's see, see what happens next. Well , what makes the most sense?
Speaker 3One last thing, Carrie , that I was thinking of as you're speaking , um, you know, I think the other thing, and it's not always that, you know, not all clinics that haven't been around for very long are bad, but I think if you go to a clinic that's been there for a long time. And I think too , if you sort of look at the employees and you see them over and over again, and employees who've been there for a long time, that kind of tells you something about the practice. If, you know, if you know, practices were doing things that were maybe not ethically on the up and up, or, you know, a lot of people would probably feel uncomfortable with that and wouldn't want to stay with that practice. But if there's a
Speaker 2Lot of longevity in the employees, I think that's another sign that it's a good place to work. And then everybody's kind of on the same team. And that probably will be a good place for patients excellence as a practice and in something that you, if you make the effort to be on point every single day, and you've been around for 10, 20, 30 years , um , you're unlikely to just drop that Willy nilly. You know, everybody makes six and that's fine. But if , if it is a random one here, one there than in you are otherwise in a practice that's been around for a good long time, you know, it's, it's a , another helpful way to say, all right. You know, maybe these guys are all worth getting the next opinion for so
Speaker 4Absolutely get staff. All right .
Speaker 2So to our audience, thank you so much for listening. Be sure to tune in next week for more and be sure to subscribe and leave us a review on iTunes. We would absolutely love to hear from you.
Speaker 4You can also visit fertility docs on syncer.com to schedule an appointment with any of us or submits this specific questions. I always mess up that word. We know you may have about infertility. All questions will be answered on the podcast anonymously for , I asked the doc segment. So don't hold back in the more embarrassing, the better. All right , we'll talk to you soon. Bye everybody. Bye everyone.