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Speaker 2Hi everyone. We're back with another episode of fertility docs censored . I'm one of your hosts, Dr. Abby . Ablin from Nashville fertility center. And today I'm joined by my co-host and friends. Dr. Susan Hudson from Texas fertility center and Dr. Carrie beanie from the fertility center of Las Vegas. Hey, how are you guys doing? Good.
Speaker 3Doing good. Spring is around the
Speaker 2Corner. What I tell you ? I hope it gets here very, very safe . We were talking before the episode began about travels that we've been on. Cause I think we've all been so cooped up in our homes. We're ready to go somewhere fun. And our special guests today, Dr. Kristin van here to Ms here. And she was telling us about what of her adventures that she went on. Kristen , tell us a little bit about what you were talking about earlier.
Speaker 4Yeah. Hi everyone. So , um, one thing that my husband and I'll always, and I've always done together is travel together and , uh, we've been to Africa. I've been with him three times. He's been two additional times without me. We did, our honeymoon was in South Africa. We did a safari and like snorkeling camp. And then we went to Tanzania, the August before the pandemic and went and saw the great migration we've been to Morocco. Um, and then my husband actually climbed Kilimanjaro with his dad when he graduated from high school. Yeah . And then he did a safari with his mom , um , before that as well. So we've, we've been missing that for sure.
Speaker 3So what's like a normal, like you always see these things on TV and everything like that. So like if you're going to go on a safari, like what do you, what? What's like a normal.
Speaker 4Yeah, sure. So most of these camps, what they'll do is, you know, you'll get up in the morning, you'll have your coffee and you know, small breakfast and then where do you stay? Uh, so, okay. That's a great question. Let's get to the important
Speaker 3Thing . Do I have running water?
Speaker 4Oh yeah. So, I mean, there's all kinds of varying levels of, of luxury versus not. I am more of the glamping type then and the roughing it types . So we always have had showers and toilets and running water. Um, so, you know, for our honeymoon, the place where we stayed, it was one of these tented camp type things that it's a permanent structure, but it's surrounded by canvas and they would actually wake us up at five o'clock in the morning with coffee and tea and breakfast. And then we would get up before the sun even rose and go out on a morning drive, you know, the animals are just waking up then. So that was , was perfect. And then usually when it starts warming up, you go back to the camp, you lay by the pool, you eat something, you take a nap, whatever, and then you'll around sundown . You go out again for another ride. Um , and oftentimes they'll stop for, you know, what they call a sundowner, which is basically just a nice little drink out in the safari, out in the Bush. And then some camps, if it's a, like a private reserve, not a state run reserve, then they'll actually do nighttime drives, which is really, really cool. Oh, wow.
Speaker 2The best place to go. If you wanted to, if you've never been on a safari, where's the best place to go .
Speaker 4I think South Africa is a great place to try to start out. There's a Kruger is the main big camp there. And there's a lot of private reserves associated with it that are kind of open. They don't have any fences or anything, so the animals go in and out. Um, but I think the private experience is a lot more fun because you can go off the trail , the late night rides and then all that
Speaker 3We see stuff at night. Is it like lights on the cars and stuff that you can see them ?
Speaker 4Yeah. They have like one of those like red lights. So it doesn't bother the animals and you can take photos and stuff. So we tracked lions the one time we tracked hyenas, it was, it was wild. It was a lot of fun.
Speaker 2What was the coolest animal that you saw? I'm sure you saw lots of cool animals, but what was the , the coolest,
Speaker 4So we'll win in Tanzania. We saw a couple of cheetah, which that was, that was really, really cool. They weren't moving, they were laying there, but they were moving. We probably wouldn't have seen them. And then the other really cool thing we saw was a pack of wild dogs, which it doesn't sound that exotic, but it's actually unusual to see wild dogs. Um , we saw them take down an antelope, which was, it's unusual to see that, but it was wow. We didn't see the actual action of it happening. We saw them chasing and then we saw it after the fact, I think I probably would've cried if we actually saw them take it down.
Speaker 2So did you get sick or did you get many mosquito bites or snake bites or?
Speaker 4Well , in , in Tanzania, yeah, South Africa, we were fine Tanzania. They have these tsetse flies, which they are. I mean, they will bite you through your pants. That was, yeah, that was rough.
Speaker 2Kathy sounds like a nasty name, but like they're little, but they sound big .
Speaker 4No, they're basically like big black flies and it's awful. And I did not follow the directions of getting your clothes treated with permethrin or whatever it is . I just got regular deep, which did not cover it at all. But otherwise, no, we were fine. Wow.
Speaker 3Maybe something for the agenda. Yeah .
Speaker 2That's very fun. Very fun. Well, Carrie, do you have our question of the day today?
Speaker 5Okay. So this question says, hi, I'm really enjoying your podcast. I have a question on missing a period. I've always kept track of my periods because I'm number four and a family of six girls and mom was terrific. It reminded us to do so in that line. I've never missed my period. They've just been later. My shortest cycle is 22 days and that , and the longest is 44 days. Is there a difference between missing a period and a late period? So really a solid question, Susan, what do you think?
Speaker 3Well, I would say first of all, I think we would get a lot of information by you getting your ovarian reserve checked. So, you know, when we, somebody who historically has longer period intervals, which I consider kind of greater than 34 days, so 35 plus, then we kind of think of somebody who may be go , I Villa to start thinking about somebody who may have PCs or polycystic ovarian syndrome. So not obsoleting on a regular basis. So not obviating, you know, kind of in that day 12 to 16 range that we would normally expect. Um, now sometimes people with PCOS can have short and long cycles because what happens is you end up having just dysfunctional bleeding that's happening at random times. But I, my kind of little spidey sense of worrying about diminished ovarian reserve or something like that gets a little more concerned when I hear short and long periods, because to me, that's telling me that the brain and the ovaries aren't talking quite effectively and part of what our job is, is to think about kind of worst case scenarios and, and diminished ovarian reserve is one of the harder things for us to treat. And it's definitely something we don't want to miss , um, and waste time , um, cause we want to get on things , um, relatively quickly. So I would say, you know , that that's something that I would highly recommend if you haven't had that done already. You know ,
Speaker 2Susan, I think the key thing is when somebody is trying to get pregnant, if you have irregular cycles, the problem is you don't know when your fertile window is and if you can't figure out when you're fertile, it's hard to know when to have sex and when to get pregnant. So I think our listener needs to see her doctor and do ovarian reserve testing to make sure there's not an issue there, but even if it is something like PTUs , she probably needs to go on some sort of medicine to make her cycles more regular so that she has a better idea of when her fertile window is actually occurring.
Speaker 5I think a lot of what the consideration is when you're thinking about missing a period versus a late period, it's all based on what's normal for you because typically in a system that's functioning, normally the pituitary in the brain that sends out all of these instructions and the ovaries should have some type of pattern. And so whether your pattern is every 24 days, 28 days, you know, 29 and three quarters, whatever it may be, that is your pattern versus yeah, I'm still within the window of time that I , I normally do. So that's maybe just a period rather than a fullness period. So context is everything in this point. And like Susan said , the ovarian reserve testing that you have is , is a good way to shed light on that historical patterns is a really good way to shed light on it. So it kind of depends on what's going on because women oftentimes have different types of regularity as they're going through their life. Teenager is different than their twenties and thirties is different than their forties. And it's really what is normal in context for you that helps us define missing versus late?
Speaker 3One thing I would like to mention is it is very normal and that's kind of in quotes for women to about 12 months or so have a little bit of an irregularity in there , period. So just because something happens once in a blue moon, that's not something to be super concerned about, but if things are all over the place, that's, that's definitely something that should be
Speaker 2Checked out. Alright , well, good, good discussion there. So I'm really pleased to introduce Kristin Ben here too , who is now a partner in my practice. I'm very happy to have her as a partner at Nashville fertility center. And she's going to talk to us a little bit today about depends on where you come from reciprocal IVF or shared maternity. So Kristen's going to take off from here and explain what we mean by those terms.
Speaker 4Great. Thanks so much, Abby. Appreciate it. So yeah, we're going to talk about something that I've always referred to as reciprocal IVF. And I just learned today from Carrie that also shared maternity is another term for which, you know, we it's it's, we, we like it, but , um, either way basically , um, the concept is that in a same-sex female couple, this is a treatment modality that allows them to share the experience of , uh , bringing a child into the world. And so aside from the option of just doing donor inseminations in this circumstance, one woman has the opportunity to use her eggs, to create embryos, typically with donor sperm, for the other female partner, then to carry that pregnancy. And it's very nice to allow them to share that experience together.
Speaker 5When you say, you know , shared or reciprocal, it's not just sharing maternity in the sense that really all parents are sharing maternity, paternity, whatever, whatever the appropriate label is for your instance, really all couples are doing that, but this is more of a biological sharing and a sharing of the treatment process in terms of what you're actually going through.
Speaker 4Correct. Exactly. Yes. Usually these things are done, not necessarily in tandem, the , you know, the workup for them, which we can talk about that as well is kind of occurring in tandem. But typically in terms of the treatment what's happening is the partner that's choosing to use her eggs in the process, goes through the typical stimulations of IVF and create her embryos using donor sperm. And then once those embryos are created, then usually after that is when the second partner would go through the preparation for the embryo transfer.
Speaker 2How does all this start out? So say a couple's listening today and they're interested in this. How does it all start? What do you do first?
Speaker 4So, you know, they should come and seek care from someone like any of us, you know, fertility specialist , um , who then can talk to them about the different options. So, you know, options of donor insemination, like I mentioned, which is basically where just one partner is using her, her eggs, having an IUI or intrauterine insemination donor sperm to conceive . And then she carries that pregnancy or there's this option of , um , reciprocal IVF that we're discussing. And so a really big, important thing is to figure out what are their family building goals who wants to carry, you know, whose eggs do they want to use? Do they both , how involved do they both want to be and their comorbidities? So
Speaker 3You have a same-sex couple who comes into see you and they're like, we want to do this and say, one person does not strongly want to carry or give eggs. And they're asking your advice, which one should we use the eggs from? How do you get that advice?
Speaker 4Absolutely. So age trumps everything else. Unfortunately that's the biggest thing in fertility, especially for women. Um, the younger partner, if it's a significant age gap is typically going to have greater success using her eggs than the older partner. Um, now if they're both, you know, 26, 27, you know, that's not going to make a difference, but if one partner is 30 and the other one's 42, that certainly is going to have an impact on things. Similarly, if one of them has other medical problems that you're concerned about, you don't want them to carry, or if they can't safely, you know, go through any of these procedures, then that's going to have a big impact on which, which partner will do, which portion.
Speaker 2And can you explain how the FDA gets involved with all of this? Because the FDA gets involved with a lot of things that we do if we use third-party reproduction, but explain how it's a little bit different in this situation.
Speaker 4Sure. So the FDA is , is involved , um, in kind of the same capacity that they're involved in regular IVF, meaning we have to have documentation of the , um, sexually transmitted diseases for both partners and all that stuff, because this is a directed donation, essentially. It's not as stringent than when it's an anonymous donation. And so if there's something that comes up, then the recipient or the caring partner can kind of sign off and say, yeah, I'll waive that concern.
Speaker 2And certainly with donor sperm, I know the FDA is involved too. They have to do a lot of testing, but , uh , cause you know, that couple is truly a couple sexually active couple generally it's, it's really no different than if you had same sex, couple or heterosexual couples as do not BF except for the , the donors from part of it.
Speaker 3Is there any additional counseling or advice from other types of professionals that you , um, often direct? Um , these couples to talk to before starting a cycle like this?
Speaker 4So in our practice, anytime we have anybody using donor egg, donor sperm, gestational carrier, any form of third party , uh , we have them consult with a psychologist really just for implications counseling, make sure this is, do you understand? You know, this is really what this means. How do you talk to your child about it, how you talk to your family about it. Um, and so just the fact that they are using donor sperm, they're meeting the criteria to , to meet with that person. And they also will talk with about the entire process of, of reciprocal IVF as well. And I think it's just helpful anytime. You're kind of doing something that goes out of the typical societal norm. Certainly I think it's wonderful, but not everybody will. So it's easier to have some tools that ahead of time. Now you guys have
Speaker 3Obviously in Tennessee, how do the laws work pertaining to, I mean, obviously same-sex marriage is protected in Texas parentage among same-sex couples is a whole different ball game. Is that the same in Tennessee? Yeah. So
Speaker 4It is all state dependent. And in Tennessee it is if the couple is married, then they both have parentage rights. If they are not married, it's a lot more muddied. And so I think that even can depend on the county. So it's always important to consult with a, an attorney, if there's any concerns or questions
Speaker 5Rebirth, the orders can be really helpful in those kinds of instances where you go in. And they know that we do a lot of that in Nevada, the lawyers that we work with do where they'll just automatically put the second parent's name on the birth certificate before, and they will do that and start that process so that it's just automatic and understood as soon as the kid comes out, the stage has already been set. And so I would think that in some counties and some, some states that's a helpful process to know about. You can do it all ahead of time because goodness knows when you've got a newborn. That's
Speaker 3The last thing you want.
Speaker 4You don't want to go to court. Yeah, exactly. So
Speaker 5Two women and assuming that they're both, let's say under the age of 35, so kind of our model group , without me particular risk factors where it's a same sex female couple, which, you know, the other way to think about it, medically in the infertility realm is just permanent lack of male factor. Do you, do you automatically assume or do your patients automatically assume, oh, this is going to be a slam dunk where two women we're young, we're never going to have any problems with that. Do you find that that is the case in reality?
Speaker 4I feel like that's how most patients come to me, to be honest, especially if they're wanting to do IVF or say, they're wanting to do IVF for some genetic condition or family balancing or anything like that. Most people don't realize how inefficient human reproduction is. And, you know, especially if it's a , you know , same-sex female couple that neither one of them has been pregnant before or attempted to conceive before. You know , they have unproven fertility at that point. And I always tell all my patients, whenever they're going to go through any kind of IVF process, we don't know how you're going to respond until we actually do this. And all we can do is make our best assessment based on your testing.
Speaker 5Unexplained, infertility can certainly kick in, in an unfriendly way is , um, I don't know if you guys have found this, but I find that most of my female couples, they're just there . They're wonderful. They're optimistic. They go through the testing and just do it and they have a fabulous outflow, but sometimes it's a little bit different when things aren't working self to remember 15% of heterosexual couples can come in with unexplained infertility where all their testing is totally normal and women in same-sex relationships are still subject to that. It's just, they have less ability to know that ahead of time. So sometimes you find out the hard way going through treatment that, Hey, there's, there's an issue here. And we don't know exactly what that ,
Speaker 2So Kristin walk us through once the FDA testing has been done once the partner who's going to stimulate to been chosen, kind of how does it, how does it break down from there?
Speaker 4Sure. So , um, as I kind of alluded to my recommendation is to get your embryos first, it's always a little bit more challenging to try and do a fresh transfer scenario where you have the , um, recipient getting ready at the same time. It's just too many moving parts. Um, so I recommend , um, that your person who's going to use their eggs. She has her ovarian reserve testing performed to kind of see what protocol and how successful do you think that she will be in terms of going through this stimulation and get your sperm donor chosen. And that involves , um , also doing genetic carrier screening that I highly recommend on the women whose exits you're going to be using that way. You know, she has a choice in who's in what sperm she use . And so if she's a carrier for say cystic fibrosis or something like that, then she should choose someone who's been a donor who's been screened for that and screen negative to kind of alleviate the risk of passing that onto a child. And then once she's kind of done with all those things, and she'll go through the typical IVF process of coming in, either with her period or being on birth control pills for a little while and starting her injections of stimulation medications, it's usually about a week and a half long process of doing the injections and coming in for monitoring. And then she'll do her egg retrieval, which is performed vaginally. And then once the eggs are retrieved, the eggs are inseminated using the donor sperm. And typically we recommend using ECC or intracytoplasmic sperm injection because it is frozen sperm. So we just think it's going to have a greater chance of fertilization with that procedure. And then the embryos are frozen after they reached the blastocyst age around day five, six or seven.
Speaker 2And then the question always comes, how long can the embryos be frozen
Speaker 4As long as you keep paying your storage fees
Speaker 5Really far beyond that. Cause nobody's gonna , even if you're not paying the fees, people are very, very hesitant about this guardian embryo .
Speaker 4Yes, yes, absolutely. That is for sure. True,
Speaker 2Got these frozen embryos and then what happens after that?
Speaker 4Sure. So then, you know, likely the recipient will have gone through her testing beforehand. So all the FDA testing that we talked about, make sure her thyroid is under control, kind of all that good stuff. Um, and then some kind of uterine cavity evaluations, usually a Celine ultrasound or a hysterosalpingogram to make sure that the uterine cavity is normal. There's no scar tissue or polyps or fibroids or anything like that. Um, and then she will start a medication plan usually involving, you know, birth control pills, possibly Lupron and estrogen of some form to get the uterine lining thickened and ready to receive the embryo. Um, and then usually she'll receive , um, injections of progesterone leading up to the embryo transfer. And then the embryo transfer is done. That Ember is thawed is placed into her uterus under ultrasound guidance. And then it's the eight to 10 day waiting game of seeing if the pregnancy is there,
Speaker 3It's a very exciting process, but it's a lot to go through, isn't it?
Speaker 4It is for sure, but it's a nice opportunity for same-sex couples. And I've actually also had , um, couples where one of them is a trans man and that's still Fords him the opportunity to have a biological child without having to carry the pregnancy. Um, which can be very important to some , some of these , uh , men who have chosen to kind of forgo their , their other reproductive options
Speaker 2And down the road, if the partner who you retrieved them X from, wants to carry a pregnancy, the other advantages she can carry a biologic sibling. Correct.
Speaker 4That's right. That's absolutely correct. And then, I don't know , um , caring Susan, if you guys use this, this isn't something that we use, but there's , uh , something called invo cell where the sperm and the eggs are put together into a small device, which is essentially an incubator that's placed into the vagina that some people feel that's another way for kind of shared carrying of the pregnancy, that the one partner carries that incubator in the vagina as the embryos develop. It's not something that we've chosen to use in our lab, but it's , it is something that's out there
Speaker 2It'd be clear. It's just an, essentially an incubator where he put the eggs and the sperm and then fertilization takes place in the info sale . And then what happens after that, with the infidel it's removed and
Speaker 4Removed usually day five or day six, and the embryology team takes a look and sees, okay, what do they have in terms of embryo development? And then, you know, either frozen or transferred or whatever I do .
Speaker 3I think that the success rates for in the style compared to what I would consider kind of a standard IVF process that we all do in our labs is , is significantly different. It is .
Speaker 2Yes. And it's interesting. I think emo cell has been around for a long time and sort of has made a resurgence. I've seen more about it lately , but it's something that's been around for a really long time. I think really before labs were as good as they are right now. And really didn't have the ability to grow embryos as well as they do right now. The way Susan was alluding to,
Speaker 4It seems to have a better place in , in places that have limited resources in terms of embryologist and lab equipment. Well, very
Speaker 2Good. Any closing comments you have Christian ?
Speaker 4No, I think, you know, the, the best thing to do is if you have questions, you know, go see a reproductive endocrinologist and talk about your options and
Speaker 3Realize that there's a lot of ways to do this. Very good well to our audience. Thanks for listening and tune in next week for more, be sure to subscribe and leave us a review in iTunes. We'd really love to hear from you. You can also visit fertility@accentsensor.com to schedule an appointment with any of us or submit specific questions you have about infertility. All questions will be answered on the podcast anonymously for ask the doc segment. Don't hold back. We love to hear your questions. All right . Y'all we'll talk to y'all soon. Bye bye.