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 2Hi everyone. We're back with another episode of fertility dot said censored . I'm one of your hosts, Dr. Abby . Ebelin from Nashville fertility center. And today I'm joined by my cohost and friends , Dr. Susan Hanson from Texas fertility center and Dr. Carrie Mediant from the fertility center of Las Vegas. Hi, and today we're actually going to do a episode that was inspired by a patient I met with this week. And we're going to talk about what happens behind the scenes , um, at the time of an egg retrieval. But before we start with all that, what have you guys been up to this week?
Speaker 3I'm preparing to kill the plants. And I mean, that's not really what I'm preparing to do. I always have really high hopes and I have not killed everything that I've come in contact with, but I was so proud of myself cause I went to Lowe's and I've got my four big pots that I replant every spring. And this time I got , um, the, you know, how they always have a discount , like a couple of racks at any of the plant stores. And so I'm like, okay, if I buy these, then if I can't kill them, number one, I'm going to blame it on the fact that I got it from the discount rack. Number two, I'm not going to feel as bad about it, but , um, but I got them in a really beautiful flowers. And so they're , they're sitting out on my patio right now waiting to get dirtified.
Speaker 2So when do you, w what's the growing season in Las Vegas? Like when do you start planting stuff?
Speaker 3So I, if we hadn't had that cold snap, I probably would've started planting in a couple of weeks
Speaker 2Ago, rally . Wow.
Speaker 3I mean, it's it's I was hanging out yesterday in shorts and a t-shirt outside in the sun because it was just gorgeous and it was the perfect weather for that. So typically we try, we've got one growing season that's like late February, June, and then everything gets obliterated by the heat, except for the things that are really heat, tolerant. Like I've got some gorgeous yellow bells in my backyard that are six feet tall.
Speaker 2Wow.
Speaker 4My yellow bells that I planted last year, that completely destroyed and their snow storm .
Speaker 2Now what exactly are yellow bales ? We don't get the , we don't have those in Tennessee. They're like a
Speaker 4Bush that can get really huge. And they're the bright green brush. And then it has these yellow flowers, but look like bells. They're beautiful. Absolutely beautiful. But they can get Jain . Mungus
Speaker 3Bells cluster together. So it's really pretty. But Susan, I thought mine had all died when Vegas got that snow, we got snow last year. And then more importantly, we got a bigger snow two years ago and, and everything. I mean, they looked like horrible sticks, but they grew back and were bigger and prettier than ever.
Speaker 4So the entire thing looks brown. Like everything you can see is brown. So do I leave it alone?
Speaker 3Just leave it alone. Maybe the roots
Speaker 2Are still alive. Yeah. Maybe it'll grow up .
Speaker 3Yeah. I mean, I, that year I had to cut mine down, so it looked like a tiny little spiky troll head, like, you know, the troll , the hair that only instead of hair, they were just brown sticks, but it grew back and it's now I'll send you a picture later, but it's, I mean, they're huge. They're six feet now and I didn't have to do anything. I lost some of my land tan is that year. Um, which I thought didn't die for anything, but my yellow bells came back with a vengeance and they're gorgeous.
Speaker 4Okay. So you didn't , you did trim it back then
Speaker 3Though. I did trim it back.
Speaker 4Okay. Like to a step, like he deal with Lantana.
Speaker 3No, not to a stub . Like I would say there was probably maybe a foot. I mean, there were plenty of little branches. It's just, instead of the big spindly branches going everywhere was much more
Speaker 4Charlie brown Christmas tree.
Speaker 3I'm a little bit better than, yeah . I would say make a little stick brush ball. That's maybe a foot, a foot tall. Um, so rather than, you know, four feet of branches, you just have like a foot of branches down at the bottom. So it seems like teeny little thing. I bet they'll come give them a chance to come back at least
Speaker 4So sad, Texas, at least my part of Texas looks, so everything is brown and yellow. Like all, anybody who has any type of Palm plant, they're all destroyed. Like I'm hoping the like core, the trunk type of things are, are , have survived, but it's everything is I that's so sad. So Susan
Speaker 2Normally grow, could you grow like Carrie was talking about the , that in Las Vegas, they can grow lemons and peaches or peaches. I know we can grow peaches around here, but lemons and like tropical fruit, oranges, and grapefruits and
Speaker 4All that stuff. A little bit south of where we are, those things do well. There's some people who , um, very much baby there's here. Um, it's not quite the right temperature range, but like an hour south of us, those things do really well.
Speaker 3Our citrus here, like I'm really babying my little lemon tree to see if I can get anything out of it. It was more when I was growing up in Arizona, we had just in our backyard, we had a fake tree, a great lemon tree. Um , in the front yard we had four or five different, various hybrid trees where someone like it was kind of like somebody who just ate their citrus for the week, save the seeds and then dumped them a bunch of the seeds into various holes. Like we had one tree that grew both lemons and oranges out of it. I think you have to graph something in, but I don't actually know, like I can, somebody asked me if I could make a baby with blue eyes and I'm like, I can no more do that than I grow a comprehension .
Speaker 2It sounds like some CRISPR for plans, CRISPR procedure from plants or something. I was just telling Carrie that I'm kind of working on this garden at our school and I'm working with an older gentleman. Who's very, well-respected , he's a former teacher and he's retired now and he's a master gardener. And so we went over to his house and we literally took tomatoes from seeds and stuck them in the dirt. And like, he's got this whole system where it has a grow light for 12 hours that he keeps on and 12 hours off. And you know, he's, he's doing all the watering, but he, he ordered these seeds from this rare seed catalog. So like all these like unique varieties of tomatoes and heirloom tomatoes, they are, they are , they are actually air laymen in Cherokee . Purples are my favorite heirloom tomatoes. So he ordered some of those too. So anyway, so it'll be interesting to see if it'd be the first time I've ever participated in a successful Grove tomatoes. Probably I get like three tomatoes a year when I, when I try. So maybe with a master gardener, I can at least feel like I've somewhat participated in the growing of tomatoes. Tomatoes
Speaker 3Actually. Purple .
Speaker 2Yeah. They look really ugly. They're the ugliest looking things you've ever seen. The Amish around here , um , grow them a lot. And when I first, I got them at a farmer's market and I wouldn't get an embalmed , but the lady goes, oh, these are the best heirloom tomatoes I've ever eaten. And you look at them and they look like Bruce skin, they look purple on the top. Like somebody's bruised, like really got really bad bruise skin. And they are the best tomatoes. They're just, just great airline tomatoes. They're just got all kinds of juice and delicious flavor. And so those are my favorites. Very cool. So we'll move right along. Curious , got our question of the day. So Carrie field proceed on with that.
Speaker 3Okay. So let me find it again. Here we go. My husband and I have been trying to conceive for two years. Unsuccessfully, no miscarriages, just no positive tests. His firm's normal. My labs or hormones are all normal, except my AMH level, which is high. And nine periods are irregular 28 to 50 days, but I always get a positive LH. I was not diagnosed with PCOS, but I've been started on Letrozole. Curious if there's other auditory disorders that could be causing this since I don't have the hormonal changes typically seen with PCLs , but haven't been able to find any information on other types of ovulatory disorders. Okay. So Abby, what do you think?
Speaker 2Yeah. Tell patients that PCs is a condition where there's, there's a wide spectrum of people that have it. And we as physicians have tried to come up with a specific criteria and try to fit patients in this box and not everybody really fits in this box, in my opinion. And I was just telling a patient earlier , earlier this week that, you know, my feeling is whether we say you have POS or not. If you're not having periods about every 30 days apart or every 34 days apart or less, or somewhere 26 to 34 days, then bottom line is it tells me you're probably not offering ovulating consistently. And so whether you have PCLs or not, it's kind of a moot point, as long as you have a good egg number, which you do, your AMH is really good. Um, you know, I think somebody just needs to get you on some type of medicine, the same type of medicine we put people on that have PCOS to get you, to make an egg more consistently at a time where, you know, you're fertile. Um, and you know, it it'll make it easier for you to figure out kind of when to have intercourse and when to get pregnant. What do you think Susan?
Speaker 4Well, I think that you have to also remember that the diagnosis of PCLs is more than an FSH and LH Trey show. You know, that, that was kind of the way that it was diagnosed , um, back in the day. Uh, but you know, really you need to have two out of three criteria of having a race that appear polycystic on ultrasound, having irregular periods and, or having signs of hyperandrogenism or too much male type hormone, which can be both lab wise or things like increased hair growth, acne, those types of things. And just from what I hear, you know, I'm assuming the things that have been needed to be ruled out like a thyroid disorder or prolactin disorder have been ruled out that, you know, you have your regular periods and with an AMH of seven, I imagine you prop an AMH of nine , um,
Speaker 2Lots of
Speaker 4Bags there, there's a lot of eggs there. So I'm, you may not have the classic string of pearls, but I'm imagining you probably have more than 12 follicles on each ovary, which, or on a ovary, which is part of the diagnostic criteria. So it is possible that even though your Dr. May not have told you a label per se of that, you have PCs that you may in fact have PCOS
Speaker 3And there's other, there are some other anovulatory disorders as well. They start to get into the realm of the obscure of , um, of not having a response to LA because your receptors are damaged or , um , other screwball biochemical things that typically we don't really have a great way of diagnosing. And like, you can, you can suspect some of them, but as far as our routine diagnostic capabilities go, most people who come to see us are like, I want to be parking yesterday and they are not really down for all right, let's try this type of challenge test , and let's try this type of med and see if we get type separate response. Like really what we're doing is, is approaching it. How can we get you pregnant in the fastest way possible? And we're going to pick up whatever diagnostic , um , pearls we can along the way, if we give you X medicine and don't see a response, whatever we're going to change our approach. But , um, most of the time we're not going to really dive into those deep anovulatory disorder diagnoses because they're expensive. It's time-consuming and they may or may not change what we do to get you pregnant at all. And so , um, so it's kind of an unsatisfying answer from the academic perspective because all of us and really a good number of our patients want to know exactly why we're doing what we're doing and why they can't get pregnant, because that is very internally satisfying of, oh, I have X , Y , Z gene. That just didn't go. Right. And so that's why I'm having difficulties, but the reality of getting to those diagnoses is often so prohibitive that it's just not worth the time and the effort. And when you're looking to get pregnant, it's ultimately not going to change most of what we do. So, so yeah,
Speaker 2Well, I think that those are some great answers. So now we're going to switch gears and go to our topic of the day. And as I mentioned earlier, this was in patient inspired, and I think this was a great idea for a topic it's our topic is what happens behind the scenes in an egg retrieval. And so Susan, you want to start off and just kind of start out with what happens when you walk through the door on the day you're going to have your egg .
Speaker 4Absolutely. Absolutely. And I would like to mention that things may vary from clinic to clinic, and we'll probably chime in on some different differences, you know, today in the light land of COVID-19. Unfortunately when you first come to our lit lab, there's a sign that says, please call this number so that we can come and screen you for COVID-19. Um, so once you make it through the front door , um, and you pass your COVID-19 questions , uh , generally you're probably going to go into some sort of intake or waiting room , um, where they may ask you for some form of initial identification. Obviously we want to make sure that whoever's coming in is who we expect to come in. Um, there's, there's lots of ID checking when it comes to , um, your egg retrieval and embryo transfer. And , um, so we generally will have some part of that process. And then they'll generally show you to your , um, your room, your , uh , at our office, each person has a, a private kind of pre-op post-op room. Ha how does that work for you guys carry an Abbey ? So
Speaker 3Us , we , um, before we get our new building, which will come up next year , um, we, we have people with a central changing area and then they each have their own little space , um, with a bed. And so when our people are coming in, I want to tell them like, okay, when you come in, you're going to get your own beautiful designer down and matching hat and booties. And then from there we get your IB started for the best cocktails you've ever had in your life. So just prepare order. Now, if you want Moses through the IB or bloody Mary's , whatever, we've got that all set up for you. So that's kind of how our , our clinic works. It's one central, it's a private changing area , um, that people go in and out of, and then they've got their own dedicated space while they're waiting and after. So
Speaker 4Are there curtains between the beds in your, in your location,
Speaker 3Current place and the next place is going to be walls and I'm expecting ,
Speaker 2Yeah, so same here. We have little rooms that patients go into and they're fairly small. They just fit in the necessary people and equipment. Um, and patients changing their , and then once they change, our nurse usually comes in and that's when she kind of goes through all the consents and explains to them kind of what they're going to expect when they go home. And, you know, just any kind of questions that they have and any kind of issues or any problems that , that we may need to talk about before they go back for the egg retrieval. And then once that happens, then basically at that point, once our embryologist are ready. So we , the nurse calls back, make sure that our lab is ready. Um, they are then rolled back to the room for their procedure.
Speaker 4Do you want to mention, is I would say most places before you get rolled back, you are going to see your doctor. So your reproductive endocrinologist, and you're going to meet with your anesthesiologists because that's probably a doctor you haven't met with before, and they're going to kind of go through all of your major health questions, make sure you don't have any heart problems, lung problems, any, anything that would make them concerned about you having more problems than the average person drank anesthesia. And so they're going to go through that and kind of explain the process of anesthesia during an egg retrieval,
Speaker 3Just to clarify the term rolled back. So in surgical terms, that typically means you're on your bed and they roll you to the operating room. Um, in our clinic, we actually it's right across the hallway. So people just walk right across the clinic. Um, but it, it does not mean that we like roll you up in a little ball and then play. Yeah, you're not doing somersaults. It's, it's rolling back on the bed. Um, and that's what that means. So once you get into the operating room , um, or the retrieval room, procedure, room, whatever your clinic happens to call it, would you want ,
Speaker 4You may not remember depending on when you get some of your medications.
Speaker 3Uh huh. Cause our , um, when I was telling my patients that anesthesiologists are the best bartenders you have ever encountered and that , um, they always win. And so you will, you will be asleep and comfortable, but we'll transition you over to the bed that you're gonna be on. And typically after you're asleep and comfy, you know, and you're fitted up with your oxygen mask that you're breathing. Um, I know for our clinic, we don't typically intimate people. It's just breathing on their own and they're using meds that are , um, they're closely monitored by the anesthesiologist or anesthetist and your oxygen levels are monitored throughout. But I know for us, most of our anesthesia is just sedation so that you are comfortable and you're asleep and you're happy. Um, and all of that makes you happy. And that also makes me happy because it also means you're not moving, which is key for what I need to .
Speaker 2And one thing I was going to say too , I think patients get a little nervous when they roll back to the room because everybody sort of has the impression if I get to the, or, and I'm not a slowly , are they going to start operating on me before I'm asleep? Don't worry. We'll make sure you're sound asleep. And in fact, I always think it's so funny when the anesthesiologists are starting to put the medicine in and there'll be like, how are you feeling? And you know, patients will be talking away. And then all of a sudden speech will literally sound like a record player. That's gone. Whoa. And then people can sometimes mid-sentence will just absolutely stop talking. Um, you'll be able to breathe on your own. So you won't have a tube down your throat to breathe, but like Harry said, you'll be comfortable and not feel anything that's going on. And it's just amazing after we get done. Most of the time we wake patients that they're like, well, wait a minute, have I had my egg retrieval done yet? And it's over in a flash for them.
Speaker 4So one thing I do want to mention is that the anesthesia that we typically use during an egg retrieval is not the same type of anesthesia that you may have encountered previously. If you've had surgeries like a laparoscopy or a hysteroscopy , um, this is more like what somebody gets when they have like a colonoscopy, when we need to check out somebody's colon to make sure they don't have any precursors to colon cancer or something like that.
Speaker 3Not the colon prep. We will not make you poke your brains out prior to come Sienna . I just want to clarify that.
Speaker 4Yes, yes, but it's, it's a pretty gentle anesthesia and most people don't have, you know, even if you've had problems with nausea with the anesthesia before, but the type of anesthesia we use , um, is , is different from those others. And so it's , um, it's easier to wake up from and it's easy . It doesn't have as many lasting side effects.
Speaker 3The other thing to know is that as people are talking, going to sleep and then waking up, everybody worries about, oh my gosh, what am I going to say? What am I going to do in general? Nothing. Um, every so often we'll get somebody who is really, really funny because they'll, they'll come up with whatever is , is on their mind and that will come out. But that is very, very rare. Most of the time people just call me, go to sleep and calmly , wake back up without revealing your life secrets. So don't worry about that. It just, it doesn't happen very often.
Speaker 2So kind of going through the people in the room, and again, this may vary from center to center, but as a general rule, obviously your anesthesiologist is there watching you breathe and making sure your heart rate looks good during the procedure your doctor would be there. Um, and there's usually , um, uh, somebody who hands the instruments over the tubes over , um , so a scrub tech and there's usually a circulator who , um, you know, if we need something or if there's some issue or if they need stem , uh , some, sometimes she'll hand the tubes over to our embryologist and then the other person who's there is the embryologist. And if they're not physically in the room and in our case in Nashville, they're physically in the room. If they're not physically there, they're usually standing on other side of like a window or something so that we can very easily hand the little tubes to hopefully contain a lot of eggs over to them so that they can look at them. Um , what about you, Susan? Who's in your room.
Speaker 4That's exactly his in our room. We have an anesthesiologist, obviously I'm there. We have a circulator, a scrub tech and our embryologist is right on the other side of the wall. So , um, the circulators , the one who brings the tubes from the scrub tech to the
Speaker 2Embryologist ,
Speaker 3Um, other people who might float in and out of the room, depending on the practice. Um, if you've got trainees in the practice like residents or medical students, sometimes they will be in the room. It is very unusual for any fertility practice to have those people doing any retrievals, just because the specialized nature of what we do. And it , it doesn't really translate to skills that they need down the road. So , um, so in fertility docs, REI is, are pretty particular about that. There's no training participation in those things, unless
Speaker 4You're at a fellowship program,
Speaker 3Unless you are at a fellowship program, in which case, those are docs who have dedicated their entire lives to doing it, they're just earlier in their career. Um, and they always have an attending physician over their shoulder, watching them to make sure that everything is being done appropriately. But , um, but typically it's not, that is not something you ever have to worry about because they have, if anything, something to prove. And so they are going to go for every last egg and ,
Speaker 2And to be clear, the person who does your egg retrieval will have an MD after their name. And if, you know, if somebody is doing your egg retrieval, you'll, you will be taught to ahead of time. You'll know who's going to be in the room. If there's the only time we ever have anybody is occasionally we'll have a medical resident for example, but that medical resident really just observes. And we always ask our patients ahead of time to make sure they're okay with it. And if they're not, then the medical resident doesn't go in.
Speaker 3Yeah. Um, and that's really it. I can't think of anybody else who would be, who would ever be in the room there . Um,
Speaker 2So Carrie , start, start us off and tell us about the prep. What do you guys do for prep and how's the patient positioned and how does all that happen?
Speaker 3So, as you're asking that I can, I can hear my dictation in my head patient was brought into the room. Uh , consent was obtained. Anesthesia was induced without any complication. The patient was prepped and dorsal lithotomy position.
Speaker 2What's the dorsal lithotomy position. What's that
Speaker 3Dorsal lithotomy has pelvic exam position. Um, you know, we make sure that your legs are comfortable, that there's no extra pressure in weird places. We typically pad it. We then put , um, we clean off the vaginal area. And so for example, what we'll do is we'll clean out, clean off the outer component of it. And then we'll put a speculum in and clean off the inside of the vagina, different practices, do different things. Um, some use beta, Dyne some just use saline . Um , some use a practice like for us, it's typically a combination of both. And after I do the beta dine , I will flush with enough sailing. And until everything turns with yours , I know all of the diet has burn boat . Um, I've been in other practices like when I was in training where it was all saline and , and really either as reasonable, as long as the beta Dinah's out, it's fine. And, and that's something that is so it's so second nature because of disappoint. I mean, if you put together the number of times that Abby , Susan and I have prepped either like we're in this , uh, easily. Um, and so we just prep that, and then we do what's called draping, which is putting the blue drapes, which are the signals to everybody. This is sterile don't touch, unless you are also sterile, which seems odd to talk about in a fertility practice, because the goal is the goal is to avoid sterility in general, but
Speaker 2Different kind of sterile, sterile.
Speaker 3Um , we make sure that everybody's covered or the patient is totally covered in the blue drapes. And then we put in , um, uh , sterile ultrasound or an ultrasound probe, it's got a sterile cover on it. And I was taking a quick look around to, you know , spot my ovaries ahead of time and make sure there's nothing else that I need to approach. Do you guys do anything with your differently with your prepping and draping?
Speaker 4We use saline , we don't use beta dine . You know, the biggest thing is in probably coming up to where you are. Um, once you put the ultrasound in and you're taking that look, see, how does everything look? We always ask people to go to the bathroom right beforehand. Some people do, and some people , um, don't completely empty. I think it's nervous bladders , but sometimes we end up having to put in a little catheter to kind of finish draining the bladder, just so that we make sure that the bladder doesn't get injured while we're accessing those ovaries.
Speaker 3And it also moves the bladder. Cause if the bladder is super full, it's harder to see the ovaries.
Speaker 2So we just choose , um, basically, you know, sterile fluid to clean out the vagina, but also, and I'm sure you guys probably do this too ahead of time patients, or at least in our practice, we're given oral antibiotics and preparation, and they also get the antibiotics on the day of the egg retrieval because, you know, there is a small risk of infection because the vagina has germs and we're putting a needle literally through the wall of the Gianna , into the ovary. And so very, very rare for that to happen. But the cause of that risk, generally our patients get antibiotics to minimize the amount of bacterial flora and certainly in the preparation that helps as well.
Speaker 4We do IV antibiotics at the time of surgery. We don't usually do it beforehand, per se. If I have a patient who during the retrieval has an endometrioma, I'm more likely to prescribe some additional antibiotics afterwards
Speaker 2In the matryoshka Susan. So if ,
Speaker 4Um, you have a collection of endometriosis , um, in your ovary, which is where we're doing the egg retrieval. Um, so blood is a great , um, culture, culture, medium , um, a good place to grow bacteria. And so , um, just because there's a little bit of an increased risk in those situations that I tend to give a few extra days of antibiotics, but that's, that's pretty rare for me to even do that. So,
Speaker 2So once we start the egg retrieval, you know, our, our , um, CA or our transducers draped, so it's sterile. Um, as you guys mentioned where we look at the what's, the
Speaker 4Transducer Abbey
Speaker 2Transducer is that probe that we put in your vagina every single time that you've come in for monitoring, because you know, a lot of people before they see a fertility doctor, same that we do all, you know , female exams with ultrasound abdominally. And we don't, most of the time actually it's done vaginally. And the reason we do that is because it's the best way to see the uterus and the ovaries. And so as you go through the monitoring process, probably you'll see your ovaries once or twice on ultrasound. And that's exactly what we see at the time of equity travel . There's, there's no difference in terms of what we see. And unfortunately, I was tell patients, it would make my life so much easier if we could actually see the egg itself. But unfortunately we can't, all we can see is the fluid filled SAC that contains the egg . And based on the size of that, we have some, at least some ballpark idea of maybe how many eggs that will get never really know for sure until it's all over with, but we all, I think probably go in every single one of those fluid-filled sacks , because you just never know, you never know how quickly the eggs are going to grow and how mature they are going to be. You may end up getting several eggs that you didn't know that you were going to get. And so , um, that's kind of how the egg retrieval goes down and anything you guys do differently. Carrie , I have a critically important question for both of you. Okay. Critically important. What music do you listen to in the ,
Speaker 4I actually don't usually listen to music in the operating room, so I, I I'm, I'm relatively intense until I get my first seven eggs. I it's kinda like baseball players, like wearing the same stinky socks or something. Like, I am like super, super intense until I get seven eggs and my staff know this and it's like, once I get my seven, cause I have, I just have a good feeling that I'm usually going to get a baby out of sub at least one baby out of seven eggs. And once I get past seven, then we start having more conversations and I become much more real.
Speaker 2We usually, I usually listen to just the radio for retrievals. Now we have this Jim Brickman CD, which is very relaxing, but after you've heard it a million times every time I start to hear it for the embryo transfer, I think why did I not get , bring some other disc to listen to? But , um, but for the retrieval, it's just the radio. And you know, I'm like Susan, I mean , for the most part, once I get an egg or two, I feel like, okay, you know , everything's going to be fine. But if I go into a couple of different of those sacks and I don't get an egg out , when I think I'm going to, it does stress me a little bit. And so sometimes I'll even suck the fluid out, which is what we normally do and Cura where we kind of turn the needle to try and coax the egg out. But then a couple of times, if I , if I don't feel like I'm getting the eggs, I should, I'll put fluid back in and kind of blow the follicle up and try again , um, blow
Speaker 3It up because a balloon, not as in blow it up like a bomb,
Speaker 2That's correct. Blow it back out , just inflate it like a balloon again, so I can get another go at it. Um, and , and sometimes I tend to do that more when there's a really low egg number , because I just really want to do everything I can to try and get the egg to come out. How about you, Carrie ? Oh , go
Speaker 3Ahead .
Speaker 4I have a question I'm just dying to ask. So do you, okay. So when we collect the fluid, so the fluid can look a little bit different in different people. Okay . So it can vary from relatively clear to more yellowish to sometimes as kind of bloody. Okay. But do y'all watch for floaties? Oh yeah.
Speaker 2I used to, I don't so much anymore because when they hit it off, I can't really, I mean, it's , it's kind of orange, orange, pretty dark, and it's , it'd be really hard to sit and hold it up to the light and see if there's floating.
Speaker 4So when we're talking about floaties , we're actually not talking about something disgusting in your soda.
Speaker 2Good. Excellent. Granulosa
Speaker 4We're , we're seeing eggs and granulosis so even though we can't see things on ultrasound , um, when the fluid comes out, there's often little white particles that we can see floating in the, in the fluid that was in the full of killer fluid that we just collected. And so usually when we're seeing those little floaties, it's giving us reassurance that when that tube actually goes back to the embryologist, there there's, there's a good chance of being having,
Speaker 2But that was, that's what I was gonna say. More importantly, though, the person who gives the final call is the embryologist. So once that tube is handed off, very carefully handed off to the embryologist, the embryologist puts it in their little Petri dish, and then they look in the microscope to see if they can find the ag . And so, you know, sometimes we are waiting with bated breath waiting for what the embryologist has to say in terms of , of the eggs that they're saying . So Carrie , how about you?
Speaker 3And we're doing it now, granted, we do, we do a fair amount of research cause you y'all know we're nerds. Um , and we embrace our nerdiness. And so one of the research projects that we've been working on for a couple of years here in various forms has been, we track every single follicle. And so what is typical is that for most centers you go in and you collect the fluid and like Abby said, you may or may not flush, which is putting that extra media or the fluid that we store the eggs in , um, to keep them protected. You put that some extra of that fluid in and then suck it back out. So that way, just in case an egg is stuck to the wall or you didn't get it the first time you got a better shot at getting it well with the research projects that we're doing in order to really maintain separate eggs and clear the wine in between each time we ended up flushing every egg and we use separate tubes, whereas normal, you would just put them all in one tube and pass off as each two fills up and then just move on to the next, to move on to the next follicle. Well, so we separate for all of those. So it's actually alleviated some of my need to be super intense because I know as a matter of course, I'm going to do at least three flushes on every single follow-up . And oftentimes I'm doing more than that because I, what I have found and I have zero data for this particular thing, is that I feel like I need some wake-up flushes in the ovary for the first time I go in each side just to stir things up and let them know that they need, that they need to wake up and they need to come out. And so as a result, I'll do those flushes send off the, the tube. And then I oftentimes get a call back. And I know before I've ever left that egg, before I left that follicle, if I've gotten an egg or not. And so that allows me to judge my intensity going forward of can I sing or am I in my little pattern of, you know, flush one flush .
Speaker 2So I have a really important question as a flusher in the practice. So there's two of us that are flushers and there's three of us that are not flushers. So in symptoms, I kind of get criticized for flushing. I don't can do it to the extreme, but I just feel like if there's four or five follicles, I need to give it everything I can to get the egg out. So tell me what you guys have figured out when you have a follow-up call . Do you sometimes find that you with all your best efforts, you don't get it out with the first one and that you have to flush again? I mean, how many times do you get it out in the second or third flush or do you know that?
Speaker 4I would like to, first of all, comments, that when we're talking about flushing, so when, when you have your egg retrieval done, there are two different types of needles that could be used. You could have a single lumen needle be used, or you can have a double lumen needle. Generally speaking, when somebody talks about flushing, they're using a double lumen needle. So , um, but apparently that is not what Abby does.
Speaker 2That's not what I've done that in the past many years ago, but now we just use the same single woman natal.
Speaker 4If I have somebody who does not have a whole lot of eggs, I will use a double lumen so that I can flush more easily. And if I have somebody who has a lot of follicles, I'll use a single lumen needle. Now, if I'm flushing, it varies from PIR . So back to Abby's question, it varies from person to person. Now I have a theory that people who are more anxious, tend to require more flushes
Speaker 3The doctor or
Speaker 4The patient is exceptionally anxious. It seems like
Speaker 2A research project
Speaker 4Season. It does sound like a research project. So Carrie , since y'all do all this data, you need to eat it , make some note of like some sort of anxiety scale, because it really seems like people who are more uptight tend to hold onto their eggs a little bit more. Um, and sometimes they come out really easy and, but people, I tend to think that people kind of end up being a certain number of flushes. Like if it takes three flushes to get an egg out, the next follicle is probably going to take about the same. If there doesn't seem to be a lot of variability from follicle to follicle, if, if you're actually flushing. So that's my non-scientific opinion right there.
Speaker 3That's really funny. And we could probably spend the next hour on confounding , um , components of that theory and how you would tease each one out. Uh, cause I'm pretty sure we have to control for the number of eggs and follicles seen and the age,
Speaker 2Age, and the diagnosis
Speaker 3And diagnosis and all those things. But , um, but that's interesting. Okay.
Speaker 2Okay. So have you figured out how many flushes it takes to get the average egg out or do you get more eggs in some people with second, third flush or
Speaker 3Usually by the time you hit three flushes it's out there, there is a subset of patients where I have found that I pick them up on four or five and six. And in part of the way I know that is there when we first started doing this study in order to make sure that we had no hold over from one follicle to the next, we were doing like 6, 9, 12 flushes. Um, and it is very rare that I pick up an egg after flush number six.
Speaker 2So what you said about three flushes, that's usually what I tell patients with a low egg number. I usually say I'm going to flush your follicles three times and I found out over the years, if it doesn't come out in three, it's probably not going to come out. So that's, that's kinda what I do. If it doesn't come out in three, then I move on. So yeah . Well, good to know. All right , well, sorry, we digressed a little bit, sorry for
Speaker 3What are the conditions of your, your operating rooms that are perhaps different than a standard or , or a standard clinic room ? That's
Speaker 2A great question. You go ahead.
Speaker 4Um, the rim is generally dark because we have the ultrasound on and so there are some lights on in the room and so it's not like pitch dark. We can all see what we're doing, but it does let us have good visualization there. There's usually like a spotlight type thing that we use to kind of look while we're placing the speculum and make making sure everything's there. Um, the rooms are generally not decorated in any way, so that's very different from a clinic room , um, at our, at our clinic. I want you to feel as homey as possible and it be very comfortable , um, in an operating room that there generally is no , um , decor. Um, and so there's, there's a lot of equipment. We have a full anesthesia cart, which is kind of this big cream color box thing that is, has all these kinds of bells and whistles that lets the anesthesiologists do their thing. I think those are kind of the big things that you would notice.
Speaker 2We also have a positive pressure environment too. So you can almost feel suction when you walk in and walk out. Because as Susan alluded to embryos, don't like light very much. They don't like particles floating in the air. And so kind of the ideas you want to want them in an environment that they thrive in. They also don't like you to wear perfume. So don't wear a perfume on the day of the egg retrieval. We all try not to wear perfume. They don't like to odors. They don't like set . And so , um, we all do
Speaker 3Based . So even though there's no,
Speaker 2We don't have any kind of odor good or bad week , we hope on the de facto retrieval . So , um, so that's, I think that's different than other environments, some , some other ORs . And so once the eggs come out, so we've done the egg retrieval, what happens next Carey ?
Speaker 3So once the AICS come out, they get handed off. I mean immediately once they come out in that tube is full , uh, full, they get handed off to the embryologist. The embryologist is typically working in an environment with a really specific oxygen tension or ratio between oxygen, nitrogen and CO2, because eggs are really particular about that. And so your embryologist is going to identify the egg and set them aside. And what happens from there is a whole other episode. Um, but once all of the eggs are out of the woman, we then take all of our instruments out. Um, you know, I usually clear off sometimes some people bleed, some people don't, you know, I always go in and check and make sure that there's no little bleeders that I need to either stitch or just pinch to , to close off. Um, I always do one final look with the ultrasound to make sure there's no internal bleeding. You know, there's always , uh , uh, usually I would say about a hundred CCS of fluid in there, whether it's serious fluid from the follicle being ruptured, or if it's just blood that is normal and nothing to worry about. Um, and then once I've done that final check, I take all of my instruments out. I clean off anything that needs to be clean and take all the draping down and take the patient out of lithotomy or pelvic exam position. Once we have her out of position, then the anesthesiologist is typically waking her up at that point. So I'm cutting off the good cocktails. They're washing her air supply, making sure that levels are all good. And then she starts to pick up usually , uh, she starts to perk up within, I would say 10, 15 minutes. Like it's, it's a really quick , pretty fast, and sometimes it's even faster than that.
Speaker 2So then she rolls back to her room. Um, and what happens when she gets to her room, Susan
Speaker 4Generally , um, you're going to have a nurse with you watching you kind of wake up until you're able to kind of have somewhat of a conversation usually around then if you have your partner there with you , um, they'll bring them back into the room to kind of keep you company and then they're there to help you with any pain control if you're having issues with pain control. Um , generally they'll start you off with some ice chips to make sure you're tolerating that, and then kind of progress you to usually to a little something to drink and maybe some crackers or something, and most people after recovering for about an hour or so, they're going to be ready to go home.
Speaker 2And one important bodily function that we try and make sure that you can do is go to the bathroom before you go home, because every now and then there's a patient who just can't go to the bathroom. And sometimes that's just a , a response that people have to pain. Um, and it just prevents them from going to the bathroom. And it's , it's really rare that a patient absolutely can't go, but sometimes we might have to coach your bladder a little bit, turn on a little water. You know, sometimes you may just be dehydrated and we have to have you drink more fluids. Um, but easily we'd like to make sure that you can urinate before you leave. Um, and then generally, as far as pain management and we were all talking about this earlier, most of us for the most part provide or tell you essentially to take ibuprofen and Tylenol, when you go home , um, occasionally we'll give patients narcotics in certain situations, but for the most part, it's just things that you can buy over the counter in terms of pain relief. And then before you leave in our practice and I'd be interested, interested to see if it happens that way in your practice, but before you leave to go home, our embryologist will come in after they've done the final count. So they've looked through all of the tubes of fluid initially have initial count, and then they go back through all of it again, just to make sure that they didn't miss any embryos or I'm sorry, any eggs. And so they'll tell you how many eggs that you have before you go home. Is that how you guys do it, Susan ?
Speaker 4Yeah , that's what we do. Essentially. When I come back, I usually let the partner know that , um, how many eggs they had at the time that I left the operating room, but that the embryologist will give them the final account before they leave. So I know you two are pretty close in location to where you, you see your clinic patients and where you do their retrievals. I've got 45 minutes away. So usually I , yeah, so I usually am doing retrievals and I have to drive 45 minutes to get back to my clinic. So I don't usually hang around too long unless there's been any complications. But I also have my partner who actually has a clinic right down the hall, in case if anything's needed, she she's available to come down if there were emergency or anything.
Speaker 3Yeah . We typically do the same, same thing as you Abby , where we'll , uh, it's usually the doctor who lets them know, but , um, but before they go, we let them know how many eggs were, were there finally. And then the day after they get an email of this is how many eggs we got confirmed, how many were mature and then how many fertilized? So, and the patient goes home. We typically have them come back about four or five days later just to make sure that everything is resolving as it should. Um, but that's, that's not as necessary. And part of that we're doing just because we're control freaks. And there's a lot of research component that we get out of it. So , um,
Speaker 2One of the things I want to mention having gone through the egg retrieval myself is, you know, I was really surprised when I went through my own egg retrieval at how much discomfort I had , um, the next day. And it really, I said earlier, it felt like I did about a thousand sit-ups in one day. It just, it didn't really hurt, but it just felt really sore. And also one important point to know is that once the egg retrievals done, I would say, you know , it takes you a couple of weeks for your ovaries to get big and full of eggs. And it's probably gonna take you about a couple of weeks for your Everest to kind of get back down to normal again. So there's sort of the immediate acute pain probably last year, maybe 24 hours after the egg retrieval. And then it really dissipates and really kind of the lasting discomfort that you have has really just from your, every still being enlarged. And again, it takes about two weeks for that to kind of go away. Um, so I think that's kind of yet Susan, anything, Carrie , anything you want to add about equity travels that we forgot to mention?
Speaker 4I think those are all the big things. I think it's a pretty nice, relatively detailed overview of what to expect. And a lot of what you're wondering about that you're not going to remember as you're asleep. So it gives you a good idea of, you know, what you're going to be doing and what you have done , um, during that time period.
Speaker 2All right, well to our audience, thanks for listening and tune in next week for more, be sure to subscribe and leave a review on iTunes. We'd love to hear from you. You can also visit
Speaker 3The docs on sensor.com to schedule an appointment with any of us or submit any specific questions you have about infertility. And all questions will be answered in the podcast anonymously for ask the docs segment. So don't hold back. Um, the more embarrassing, the better, the more that we can tell you about,
Speaker 4All right, we'll see you all soon. Bye guys.