Ep 270: How an IVF Cycle Can Go Upside Down: The Unexpected Events in IVF Cycles

In this episode, Dr. Abby Eblen from Nashville Fertility Center, Dr. Susan Hudson from Texas Fertility Center, and Dr. Carrie Bedient from the Fertility Center of Las Vegas discuss potential challenges during an IVF cycle. We cover issues that may prevent you from starting, such as ovarian cysts or improperly suppressed hormones. We also discuss cycle cancellations due to a dominant follicle and when a cycle may still continue. Medication adjustments during IVF, possible ovulation before retrieval, and side effects from stimulation medications are explored. We break down complications that can arise during egg retrieval, including difficulties accessing the ovaries and why eating after midnight could lead to cancellation. Additionally, we discuss ovarian hyperstimulation syndrome (OHSS), a rare but serious condition, and what to watch for. Finally, we examine potential setbacks in embryo development, including cases where no embryos are available for genetic testing. IVF is a complex process, and while challenges can arise, understanding these possibilities can help you feel more prepared. Tune in to learn what to expect and how your fertility team works to navigate these obstacles.

This episode was brought to you from ReceptivaDx and IVF Florida.

Transcript

Susan Hudson (00:01)

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.

Susan Hudson MD (00:22)

This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test used to help detect inflammatory conditions on the uterine lining, most commonly associated with endometriosis and may be the cause of failed implantation or recurrent pregnancy loss. Take advantage by learning more about this condition at receptivadx.com and how you can get tested and treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx, because the journey is worth it.

Abby Eblen MD (00:54)

Hi everyone, we're back with another episode of Fertility Docs Uncensored. I'm one of your hosts, Dr. Abby Eblen from Nashville Fertility, and I'm joined today by my fun, fabulous, and feisty co-host, Dr. Carrie Bedient from Fertility Center of Las Vegas. and Dr. Susan Hudson from Texas Fertility Center. Hey, how you guys doing?

Susan Hudson MD (01:11)

Hello everyone.

We are good.

Carrie Bedient  MD (01:16)

Good.

Abby Eblen MD (01:17)

We were just talking before we got started about our trips that we've recently taken. I just got back from a really fun trip to Italy and Susan, actually, I didn't realize last year when you went on a cruise, you were also in Italy. So tell me where you went in Italy and what you did.

Susan Hudson MD (01:30)

So we kind of putzed around the coast and we went to Florence and we went to Pisa. We ended up in Rome. I remember we were along the French Riviera as well. We went to Marseille Yeah, exactly.

Abby Eblen MD (01:46)

Okay. That's in France.

Susan Hudson MD (01:52)

Yes, it is in France.

Abby Eblen MD (01:54)

So was your favorite part of all the stuff that you did?

Carrie Bedient  MD (01:57)

And more importantly, how much gelato did you eat?

Susan Hudson MD (01:57)

Wow.

Not enough because so when I've been to Italy in the past, gelato is what you do at 11 o'clock at night. And so we were we were on a ship and I have to say I love cruising, but I'm like a Caribbean cruiser. When I go to Europe, I want to stay in one place and dive into it. So I don't think I'm be doing that type of cruise again. But I have to say I think my favorite place was Pompeii because I had no concept of how big it was and how much had been excavated. And I really was in awe about how such a terrible, terrible event actually has brought something of beauty and of history to us in the future, because there are things that are preserved that look pretty much close to what they look like originally. I mean, there's, there's art that was on the walls that you can actually see and colors and how you can tell what type of storefront or business it was because the way the doors are and how they have reflective stones in their sidewalks to provide light at night. I was just, it almost brings me to tears thinking of something we would have no idea that they had something so absolutely amazing that many years ago if that terrible event hadn't happened.

Abby Eblen MD (03:33)

Well, the thing that made me, I didn't go to Pompeii on this trip, but the thing that amazed me about Pompeii when I did was how much they have left to excavate. I think they've only excavated, I don't know, like half of it at most, maybe. There's still a whole bunch more to excavate. And the other thing I don't remember, and you've been there more recently than I have, but I remember there was a symbol with like a penis and scrotum on a lot of different buildings, and I can't remember what that meant. What did that mean?

Carrie Bedient  MD (03:57)

Was that the brothels?

Susan Hudson MD (03:57)

Yes, there was there were markings for brothels. Yeah.

Carrie Bedient  MD (04:01)

I remember seeing that there and granted I was 18 when I went so clearly that's the historical yeah. But I remember there were pictures that you could point to of this is what I want in the brothels and very random. Yeah.

Susan Hudson MD (04:07)

What you remember?

Abby Eblen MD (04:15)

Yeah!

Wow, yeah. Well, you know, we're fertility doctors, so we remember things like that. All right, well, very good. Today, we're gonna talk about things that could, instead of going right, things that could go wrong with your IVF cycle and what you need to think about after those things happen. So, before we start, we have a question, don't we, Susan?

Susan Hudson MD (04:35)

Will we do that?

Carrie Bedient  MD (04:35)

Do we have a question first?

Susan Hudson MD (04:38)

We have a question.

Susan Hudson MD (04:39)

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Susan Hudson MD (05:11)

Okay. Here's our question. Hi, fertility docs uncensored. Thanks so much for your podcast. It's been an incredible source of information for me. My husband 42 and I 40 have been trying to conceive for two years. My AMH is about 0.8. Due to my age, moved to IVF after being unsuccessful on our own. I've had four egg retrievals, but we either get very few aneuploid embryos or none to test.

I've also had two spontaneous conceptions, one chemical, one missed miscarriage at eight and a half weeks due to triploidy from my egg. A karyotype test has shown that I have Turner syndrome, 45X monosomy. What are your thoughts on treating patients with mosaic Turner syndrome? I have normal menstrual cycles, but I sometimes wonder if having mosaic Turner syndrome is making things more difficult for me in addition to my age. Thank you.

I'm curious to how you guys handle this because I know we have policies in our clinic regarding this.

Carrie Bedient  MD (06:11)

Yeah.

Abby Eblen MD (06:11)

Well, she's just trying to stimulate right now, correct?

Susan Hudson MD (06:13)

Right, but I think we have two questions, stimulation and pregnancy.

Abby Eblen MD (06:17)

Yeah, so I think at 42, she's 42, right?

Carrie Bedient  MD (06:22)

No, she's 40. Husband's 42.

Abby Eblen MD (06:24)

She's 40. So I think at 40, it's a challenge for anybody to get pregnant because unfortunately as your eggs divide each time your egg grows, when it divides and kicks out the chromosomes it doesn't need, it only works, correctly, probably 20 % of the time in somebody your age and maybe even lower percentage than that. If you also have Turner syndrome or mosaic Turners, it's hard to know if that affects your eggs or not. And so, but, assuming it does affect your eggs and your ovaries, then I think yeah, I think it's going to be pretty unlikely for you to be able to make a normal egg genetically with Turner syndrome. I think the second part of the question is if you were to make a normal egg in carrying the pregnancy, I think that's what Susan's talking about too.

Susan Hudson MD (07:01)

Mm-hmm. So generally we don't even with the normal cardiac exam, we want Turner's mosaics to use a gestational carrier just because they're even with a normal cardiac exam, there is a significantly increased risk of having aortic rupture during pregnancy delivery and at this point. Yes. Yes.

Carrie Bedient  MD (07:10)

Which was very close to a synonym for death.

Abby Eblen MD (07:34)

Yeah.

Susan Hudson MD (07:35)

And we don't feel comfortable with that. And so in this situation, I would have no problem trying to create embryos with your eggs, but just as Abby said, I think that's definitely an uphill battle that perhaps thinking of things like donor eggs might be a good thing, but it's not your only option. But when it comes to carrying the pregnancy, we would be wanting you to use a gestational carrier.

Carrie Bedient  MD (08:04)

Mm-hmm. Yeah, we've got very, very similar, policies on avoiding that just because the risk is, I say the last time I looked, it was somewhere around 2 to 14 % of death for somebody who's got Turner's. And even if you do have normal cardiac results, for these, we counsel to high heaven for everything. And it's psychological counseling and it's genetic counseling for what we might get and how things go. I have had patients with mosaic Turners who have, there's one in particular where she came to me after several miscarriages and ended up conceiving on her own and ultimately had two babies on her own with no fertility intervention. We monitored early and were that extra support, but had maternal fetal medicine, which are the high-risk OB docs on from a very, very, very early point in it. But she, I mean, she was right around 38, 40, and she had two babies on her own. And she got extraordinarily lucky because she made it through both pregnancies without a hitch. And what's hard for a lot of patients to understand is like, well, 2 % is a really low percentage. And it's true, it is, but that's also typically an unacceptable risk.

Susan Hudson MD (09:15)

That's one out of 50%. 2% sounds a whole lot better than one out of 50.

Carrie Bedient  MD (09:19)

Yeah, yeah. And so everything we're doing is trying to make sure at the end of the day, healthy baby and healthy mom, and you need both. So that's approaching a gestational carrier in these cases is a safer approach, even though it's a lot of extra work and it's cumbersome and it's not particularly fun, but that's how we go about a lot of them.

Abby Eblen MD (09:40)

All right, so things that could go wrong in your IVF cycle. So Carrie, why don't you start, or actually Susan, why don't you start out with the stimulation. 

Susan Hudson MD (09:50)

Stimulation. So let's start at the beginning of the stimulation. You show up for your baseline ultrasound and blood test and you have a big old cyst on your ovary. Okay. So this is one of those things that it kind of depends on what the cyst is doing. So if we know that this is a cyst that's been there is stable, it's not been changing. It's been there for a while. Sometimes we'll just stimulate around it.

Okay, but if we know it's a functional cyst, so it's producing hormones, you didn't have it a month ago, those types of things. In those types of situations, we're often going to pump the brakes a little bit and say, Hey, let's let the cyst go away for two different reasons. Number one, it could be causing it could cause a situation where hormonally, you're not going to get the best stimulation. And the second thing is it can create a space issue. We deal with a lot of real estate and fertility and real estate of the ovary can be an issue. And so I think the biggest thing is not wanting to have that abnormal hormonal environment. But those are kind of the two reasons why we may say, hey, if you're on birth control pills or something like that, we're going to keep you on those usually for a couple of weeks.

Usually these things go away on their own and then we can move on without a hitch. It's amazing how quickly some of these cysts can resolve. I had a new patient and I did a baseline ultrasound on her. She had a huge hemorrhagic cyst. It was five centimeters. It was big.

And she came in just during her routine testing for a saline ultrasound and I was like, I want to go check this out. I think it had been maybe two weeks since completely gone. The beauty of the human body. This is what I wanted to see. I wasn't necessarily expecting that, but I was just, it gave me like a warm and fuzzy Dr. Buzz.

Abby Eblen MD (11:40)

Wow.

Well, sometimes on the flip side of that, sometimes that will happen, but sometimes I've seen patients who have a on one side and then you bring it back a few weeks later and then they have a cyst on the other side and you're like, wait a minute, this is crazy. And sometimes that can happen too. So sometimes, and not for everybody, but we'll put people on birth control pills, not really to make the cyst go away that's there, but just to prevent your hormones from making potentially another cyst that could cause another problem when you come back in for your next suppression check.

Susan Hudson MD (12:18)

And sometimes I've even had people who keep on doing that on birth control pills. I'm like, okay, we're just going to stop. We're just going to look at what you do on your own. And sometimes that's the right thing. And so it takes a little patience. We know every one of you wants to be pregnant yesterday. And that's going to be a theme for this episode is we, we, we need a little patience and we know that you want to be pregnant yesterday, but we also want you to be number one, safe and number two, have the best outcomes we can get you.

And so sometimes it takes a little experimenting to figure out what's going to be the best thing for your body.

Abby Eblen MD (12:54)

Okay, so say you start your stim, all goes well, no cysts there. So, Carrie, what can happen with your stim that could go wrong if you're doing IVF?

Carrie Bedient  MD (13:03)

So many things.

So one thing that can happen is we realize your dosing is not adequate. And so most of us will do a check like four or five days into the stim just to see what your estrogen levels are doing. What are your FSH levels doing? A lot of us will check those, not everybody. How's your progesterone going? What's your LH levels? Like there's different layers of...who checks what and how in depth they go. But the overall goal of that check is to see how are you responding to the medication? And in some cases, you get really low levels, particularly of estrogen, just because you don't have very many eggs and that's expected. But sometimes you have really low levels in someone where like, wait a minute, this should be way higher than it is. And at that point, we have to consider number one, are you dosing your medication correctly? Do we need to increase the dose? Number two, are you giving yourself your medication correctly? Three, do we need to adjust the methods? So sometimes we'll start with sub-Q injections right under the skin and we realize, okay, for this patient, we need to do intramuscular injections because the absorption is gonna be better. They're a little bit more of a pain in the butt, which is why we don't always start with them, but sometimes that can have an impact.

I have had patients who have used medications that they didn't think about it. They left it in the car. It got really hot and their medication was no longer good. And so they had to buy new ones. I've had other people who are mixing.

Abby Eblen MD (14:30)

Now, we gotta remember you live in Las Vegas, so we're talking like really hot temperatures in the car.

Carrie Bedient  MD (14:35)

We're talking about really hot temperatures in the car. That's not a routine thing, but if your medication has sat on your porch for three, four days in the summer and like that in the the South.

Abby Eblen MD (14:45)

In Las Vegas, you're in trouble. And Texas, yeah, that's true.

Carrie Bedient  MD (14:55)

And missed and they put in the saline and they didn't put in the FSH and it's a lot harder to get a response when you're not taking the meds even though they were. So those are some of the early things that we can pick up and sometimes it's as simple as just repeating this is how you give your injections and medication teaching. Sometimes we have to go back and we have to start again because you're far enough in that a dominant follicle has emerged.

And that cuts off our ability to recruit all those other follicles, all those other eggs to grow. And so we have to say, okay, we're going to stop and reset so that next time we can do something differently and see if we can get more of these little guys to grow.

Abby Eblen MD (15:32)

So that leads to our next problem. So Susan, what do we do about a dominant follicle? What can we do?

Susan Hudson MD (15:37)

So what can we do? More times now than used to, we ignore it.

Abby Eblen MD (15:44)

I know, agree. That's exactly what I was thinking. Yeah, you used to be like, my god.

Susan Hudson MD (15:46)

This is kind of a change and it's part of the beauty of seeing science evolve and through all of our careers, we've definitely seen science evolve. 10 years ago, if we had a dominant follicle, we often just canceled the cycle. And a lot of that was because we were doing more fresh embryo transfers, that dominant follicle had the potential to really mess up the endometrium and some of the hormones related to the endometrium.

Now that we've broken away from doing that, and we're really focusing on the egg retrieval, and then we really focus on the frozen embryo transfer, that we can let that big follicle grow. And most of the time, that big follicle still isn't going to ovulate, which is kind of what we really don't want to happen. But we just let it grow until the main part of the cohort. Now, if you have a big follicle, you come in after three, four days of stim and you have a 20 and everything else is eight. Okay, that's a different ball game. But if we have one that's a 20 and everything else is a 15, 16, that's a chip shot nowadays. So it's neat to be able to see how our science has allowed us to make changes that are some of our changes are more patient friendly, which is great.

Abby Eblen MD (16:55)

Yeah.

Well, and to that end, just as a side note, in my career, we would trigger, if you had three follicles or three eggs or 18 millimeters or greater, you'd trigger the patient to go to egg retrieval. And a lot of times, there's a whole group of smaller follicles, and if you just push the person further, and Carrie's practice is responsible for a lot of this, if you just push the patient further, meaning go more days on medicine, a lot of times you get more eggs. You're really...

Now we kind of try and stimulate to the group of eggs rather than just one egg dictating when we're gonna trigger a patient. So I think that's really a good thing that we've learned over time. All right, so we stimulate the patient. We think there's a good number of eggs. It's the night of trigger. What could go wrong, Carrie?

Carrie Bedient  MD (17:51)

So sometimes we get to that point and we realize, oh crap, you ovulated early. And this doesn't happen very often, but it does happen. So we are giving medications throughout the stim cycle to prevent that. And there's a couple of different medications, injections, pills, things like that, a variety of ways to do this. But sometimes somebody just ovulates straight through that medication. And it can be because they missed an injection or two or missed a couple of doses. Sometimes it's because their own hormones are stronger than what we are doing. And we see this, especially in people who have really decreased ovarian reserve more often than anything, because their bodies are hell bent on doing whatever they want to do, not what we want them to do. And so sometimes that'll happen. And so if we see a big...drop in the estrogen levels, or if all of a sudden your ultrasound looks way different than it did a few days ago, then it's possible for someone to ovulate early. And we can see that sometimes by lab work, sometimes by ultrasounds. Sometimes we don't find it until we go in for the retrieval, and we're expecting to see a big full ovary, and it's not there, and there's a ton of fluid that's in the cavity.

And you just have maybe onesie twosies, small follicles, and everything else looks filled in. And so we don't discover that until really the last minute. So that's one thing that can happen right close to retrieval. Another thing that can happen as you're about ready to give your trigger shot is that you don't have it. And this is something, and it's on your neighbor's porch, it never got sent.

Abby Eblen MD (19:25)

It's on the neighbor's porch.

Susan Hudson MD (19:32)

You didn't order it?

Carrie Bedient  MD (19:34)

You didn't order it, which is really the biggest thing because everyone thinks, I got all my meds. I'm good. Trigger shots oftentimes come in a separate shipment because sometimes they are a little bit more time sensitive and they don't have the shelf life. And so you don't get it until you deliberately order it. And so that is always a bad feeling when we get a call in the clinic going, I don't have this injection. Or they realize, I accidentally used this earlier in my stim thinking it was some other med and so they've they had it but they used it. Sometimes that'll that'll screw up a cycle sometimes it won't actually particularly with hCG but but that's something or they give it at the wrong time they can't figure out how to draw it up and so a 10 pm injection happens at midnight. And and all of those are things where we need to know about it. If something didn't happen with your trigger the way that it should, we need to know about that right away because there are some circumstances where we can salvage that situation and there are others where we can't. But we for sure can't fix it if we don't know about it.

Susan Hudson MD (20:39)

And when Carrie says right away, this is one of those like, you need to let us know right away. Okay? I there aren't a whole, I mean, we have a few medical emergencies, okay? But this is truly one of those, the sooner you let us know, the more options we have to be able to salvage the situation. We might have to change the game plan. Sometimes we'll just have you take an additional dose of your regular medicines at night. Make sure you get your cetrotide or ganirelix or whatever you're using to prevent you from ovulation. We may push off your day of trigger for a day, okay? But the sooner you let somebody know about this particular situation, the more options we have available. If you don't let us know until you show up for your retrieval, there's a very good likelihood there's not gonna be much we can do.

Carrie Bedient  MD (21:32)

Mm-hmm.

Abby Eblen MD (21:32)

And some clinics will have consignment medication so that even if, you I wouldn't count on that, but sometimes if you call the clinic, particularly if you called during regular business hours, you you've looked and you're supposed to take it tonight and you realize you don't have it. Sometimes we can get consignment medicines that the pharmacies will have kept that we'll keep in a refrigerator and you can actually pay for them come by the office and get the medicine that day. But yeah, like Susan said, the sooner we find out about it, the sooner we can start planning for what we're going to do.

Carrie Bedient  MD (22:00)

Yeah, sometimes we will have donated meds as well from people who've been through stim and they thought they were going to get a dual trigger, but only got Lupron or something like that. And so they just gave the unopened HCG back. Like that's something that's, that's also really helpful.

Susan Hudson MD (22:15)

So just thought of another trigger thing is sometimes the trigger medicine may not work with your physiology. And we didn't have enough information, evidence to make us suspicious of this ahead of time. Now this is most likely going to happen. It occasionally can happen with HCG and you may have some receptor defect, which is very rare, but we've all seen this happen.

Abby Eblen MD (22:28)

Evidence, yeah.

Yes, that's a great point.

Carrie Bedient  MD (22:42)

Mm-hmm.

Susan Hudson MD (22:42)

More likely to happen with a Lupron trigger. And it may be because of kind of the the interval that you've done Lupron triggers, it could be because of other health conditions like hypothalamic amenorrhea. It could be because of chronic medical illnesses. The last failed Lupron trigger person I had was somebody who actually she had always been on birth control pills because it would be life threatening for her to have gotten pregnant herself. We were creating embryos to be used in a gestational carrier. So I did not ever do FSH, estradiol, LH on her because those wouldn't be accurate on birth control pills. And so we did an AMH level and had no reason to think except for the fact that she had a chronic medical condition, but it was relatively well managed that she would fail a Lupron trigger.

Abby Eblen MD (23:25)

Okay.

Susan Hudson MD (23:38)

And she did, and it was, they're just, we didn't have the information because of the entire picture. It wasn't anything done wrong. It was just unfortunate and her safety had to come first. But that's something that occasionally occur.

Abby Eblen MD (23:50)

That's a good point and that's always disappointing for everybody, but the reason we do Lupron triggers and the reason we really like those is because they really decrease the risk significantly of severe hyperstimulation syndrome. And so, back before we did Lupron triggers, you know, in our practice, we would have people several times in the year that would be hospitalized and have to get IVs and were vomiting and we had to do paracenteses. So, it's a little bit of a calculated risk to do a Lupron trigger because like Susan said, every now and then you'll encounter somebody that you had no idea that they had this condition and you don't know until you trigger them. And a lot of times though, if you figure that out, if we check a luteinizing hormone level or have some way of checking that, we can give a rescue with Ovidrel. And a lot of times that will correct the problem. But yeah, sometimes that can happen. Nothing's ever 100 % in medicine, as I always say. But for most people, Lupron triggers are really good thing.

So, okay, so you've got your trigger. You're going to egg retrieval the next day. What can go wrong in egg retrieval, Carrie?

Carrie Bedient  MD (24:53)

So, my gosh, there's so many things.

Susan Hudson MD (24:54)

I've got one.

Abby Eblen MD (24:55)

Okay, Susan, you go.

Carrie Bedient  MD (24:57)

Okay, you go. And then…

Susan Hudson MD (24:58)

You decided to eat or drink after midnight.

Abby Eblen MD (25:01)

That's a problem. Because this is a surgery.

Carrie Bedient  MD (25:01)

Yeah.

Susan Hudson MD (25:04)

This is a surgery and your anesthesiologist is not going to be a happy camper. So in this situation, there are a variety of things can happen and us sitting here can talk about what are some possibilities, but realistically, a lot of this is going to come down to what you did and what your anesthesiologist will or will not do. So one, you might be canceled. There may be…

Abby Eblen MD (25:30)

Good chance you'll be canceled, because that's a safety issue.

Susan Hudson MD (25:31)

There may be no egg retrieval.

Okay, so that is a possibility. There's a possibility that you could do it awake with like a spinal anesthesia. There's a possibility that you could do it completely asleep and get intubated. So usually in egg retrievals, you have a little tube that's kind of keeping things open a little bit, but you're not fully intubated. Whereas sometimes they will fully put a tube down your throat. That's pretty darn rare in an egg retrieval. And that's...

Abby Eblen MD (26:02)

The other possibility, which is the two times that it's happened to me that I've done, is I've done it awake with local anesthetic.

Susan Hudson MD (26:09)

Yeah, that's not too bad if you only have a few follicles, but if you've got PCO or something like that and you have a lot of follicles, that is probably not going to be a fun situation.

Abby Eblen MD (26:20)

Yep. So don't eat or drink after midnight. All right, Carrie?

Carrie Bedient  MD (26:27)

Sometimes you can go in and you cannot find any follicles or not get any eggs. And so when we're doing these procedures, what we do is once you're asleep, we go in with a needle, drain that follicle, take the fluid, it goes straight into a test tube, and then it gets handed off to the embryologists. And the embryologists are looking in real time and giving us feedback about the egg numbers that we have. And so that helps us to shape what kind of...do we flush, do we not, how much time do we spend, things like that, because you're going to approach somebody who's got two follicles differently than someone who has 30. And so sometimes we can go in and everything can look perfectly normal. And we go in to the follicle, enter it with the needle, drain it, and we're just not getting anything. And it doesn't matter how many times you flush. It doesn't matter how simple and straightforward and easily accessible the ovaries are. You just don't get anything. And in the absence of something weird happening with your hormone levels, your trigger, the timing, sometimes this just happens. And sometimes this is an explanation of why you are here in our office that we might not have had up until that point where there's just empty follicles. Sometimes we can go in and we see everything and it looks normal, but the ovaries are out of our safe reach because for whatever reason, one or the other is riding high. And this can be because of prior surgery, this can be because of scar tissue, this can be an impact of what your weight is, this can be just simple dumb luck, but it's hard to access those ovaries. Now, we are all pretty adept at the maneuvers that you can do to help bring an ovary down. And a lot of times those will work.

But not every time and your safety is paramount. And so if I am faced with the decision of let's go through an iliac artery or the bowel or even a uterus. Yeah, yeah, like going through a uterus, fine, but those others are a really big deal. And so we're not gonna jeopardize your safety. Sometimes...

Abby Eblen MD (28:17)

Or even the uterus.

Susan Hudson MD (28:20)

Survey says, errrr.

Carrie Bedient  MD (28:31)

I see this more as a function of the weight of the patient and how their weight is distributed. Sometimes when you've got people who carry a lot of their weight around their midsection or right on their chest, when they are breathing after they're put asleep, the breathing isn't as smooth. And so what you end up seeing is that the abdomen is moving up and down and those ovaries are running away and then coming back.

Susan Hudson MD (28:37)

Mm-hmm.

Literally a moving target.

Carrie Bedient  MD (29:00)

They're literally moving target. And those are very scary retrievals to do because that ovary doesn't pin down, it means you're gonna have an uncapped open needle in the middle of the belly and that is not safe. And so we will approach that differently and be much less aggressive with that because again, your safety comes first. Sometimes we go in and we see those ovaries and they're empty and you can tell that the follicles have deflated and you've got a bunch of fluid that's rolling around the abdomen. And so in those cases, we will drain that fluid and try and recover as many eggs as we can from them. But that's, you you can maybe get a couple of eggs that way, but you're unlikely to get a full batch of them.

Abby Eblen MD (29:41)

Anything else?

Susan Hudson MD (29:42)

Well, with all surgeries, you always have the risk of bleeding, infection, damage to other organs. So damage to other organs is kind of what Carrie's talking about, that whole uncapped needle in the abdomen thing. Risk of infection is pretty low, okay? A lot of us give antibiotics for this type of procedure, okay? But realize that you are going to have some bleeding into your follicles.

Carrie Bedient  MD (29:53)

Thank you.

Susan Hudson MD (30:10)

If you have endometrioma, there's already blood in those follicles and if anybody remembers biology and how do you get things to grow like bacteria in a lab, you put them on plates of what's called blood agar and so it can create a place for infections to happen. In fact, infections are rare, but we don't expect it to happen. Bleeding.

There are some little bitty vessels that can cause some problems and there's some gigantic vessels that can cause some really big problems. And so that's why visualization is very important. That's the reason why a lot of us have BMI or kind of how your height and weight intersect limits for IVF. And it's because of safety issues regarding being able to see and also the breathing issues that Carrie just described.

Carrie Bedient  MD (30:50)

Mm-hmm.

Susan Hudson MD (31:03)

And so there's always a chance of bleeding issues. Big, bad bleeding issues are rare, knock on wood, but they do occasionally happen, unfortunately. So we have to think about those anytime you have surgery.

Carrie Bedient  MD (31:18)

Anesthesia issues are another thing, again, really rare because, for example, if you've had anything to eat or drink, you are far more likely to just flat out be canceled by your anesthesiologist because they will not take that risk because those risks are so big. Sometimes it's something that happens mid retrieval where a patient starts coughing or they're not getting air in for some reason or other.

And so again, your safety is paramount to anything. Theoretically it's the surgeon who's in charge in the midst of a case. In reality, if anesthesia says stop, we stop period, end of story. There is no argument there because if they can't keep you breathing, that's the end of the story. We get out and we do everything we can to take care of you. And so that is extraordinarily rare because of all of the work that's done in advance, but fluke things happen. That's part of the reason why if you get sick in the week or two leading up to your retrieval, we tend to cancel. And some of that is because eggs don't like fevers. And so if you're sick, it's not really a good retrieval to go through with anyway. But the other part of that is the anesthesia risk, where if you are far more likely to cough, sneeze, have mucus dripping down your throat, then we don't want to put you to sleep because we want you to have full control over your breathing capacity and putting you to sleep does not help with that.

Abby Eblen MD (32:36)

And the other corollary that is if you're coughing and sneezing and a lot of times you're moving around, it's really hard for anesthesia to sedate you because they either give you too much and you stop breathing, which we don't want that to happen, or they don't give you enough and you're wiggling and moving. And like we talked about before, trying to chase the ovary around with a needle in your abdomen, it's a moving target. And particularly with something really sudden like a cough, I mean, it can really all of a sudden jiggle your needle into a different place. And so it can be really scary as a physician when you're like, okay, is she going to cough? And so a lot of times that's a reason that we would stop even if we haven't gotten all the eggs.

All right, so we're through the egg retrieval now. Let's talk a little bit about recovery and then we'll talk a little bit about what can happen with the embryos. So recovery Susan, what are some things that people need to think about or worry about potentially?

Susan Hudson MD (33:23)

So recovery, sometimes people have nausea. The nice thing about the type of anesthesia that we use for egg retrievals is most people tolerate it very well. It's like taking a great nap. And so most people don't have too much nausea from the anesthesia. Some people just take a little longer to wake up than others. So that's something to think about. When we're thinking of...real complications post-operatively. We worry about sometimes issues with your ovaries. That's really the big thing. So you can end up having sometimes bleeding in your abdomen. Sometimes ovaries can twist on themselves, those types of things. So if you ever have severe pain, most people are going to have some discomfort, but any severe pain, you need to let your doctors know.

Abby Eblen MD (34:10)

What about if you get like an Ovidrel trigger? What could be a result of that versus a Lupron trigger?

Susan Hudson MD (34:15)

Right. if you get an HCG trigger, then your risk of ovarian hyperstimulation syndrome or OHSS is going to be higher than if you just get a Lupron trigger. And so with OHSS, there are increased risks of you getting fluid in your lungs, fluid in your abdomen, blood clots, salt abnormalities. Sometimes people end up in the hospital.

Sometimes in very rare circumstances, people can even die from ovarian hypersimulation syndrome. So when your doctor's making certain decisions on which trigger shot is going to be the best for you, or if you're having maybe a dual trigger or something like that, that those are all things that are going into that decision making formula.

Abby Eblen MD (35:01)

So Carrie, tell me about what could happen in the lab. So everything's gone well, you've gotten through your retrieval, eggs have come out. What goes on in the lab and what could go wrong there?

Carrie Bedient  MD (35:10)

So one of the first things they're going to do is clean the eggs and identify which ones are mature. And then shortly after, they're going to fertilize. And so this is where the first set of stuff can happen. So sometimes they will find that your eggs are not mature or a disproportionately small percentage of your eggs are not mature. That's sometimes a function of your physiology. It's sometimes a function of how you responded to the trigger or the dose of the trigger that you got. Sometimes, again, it's just part of why you're here, like part of why you're in a fertility clinic. And we can only really use fully mature eggs to fertilize. Now, the ones that are almost mature, we will still fertilize them, but it's with a much lower expectation of getting anything useful in terms of embryos out of them. Sometimes we will take a look at the eggs and they're there and they're mature, but they just, they don't look good or they don't behave well. And that can be because there's internal structures that don't look good.

Abby Eblen MD (35:37)

Good luck.

Carrie Bedient  MD (36:04)

That can be because the elasticity of the membrane is just not there at all. Like you kind of want to push in and get a little pop sensation when the embryologists are doing it as opposed to just pushing and pushing and it never breaks and it just keeps stretching and stretching and stretching. And so sometimes we can see issues with the sperm where they have really abnormal morphology or appearance or there's nothing that's moving or the numbers are extraordinarily low.

Or if it's an extracted specimen, you don't get any good ones, you don't get any. Sometimes we'll get zero sperm, period, end of story, and there's just nothing to work with. And so those are some of the early things that can happen. Now, typically when these happen, we still keep moving forward and we just see what develops over the coming days because even if eggs look bad, we're still gonna put the sperm with them. We're still gonna give it a shot because I distinctly remember my lab director telling me these are the ugliest eggs that I have seen. And I have a beautiful baby picture to match those eggs. And so we're still gonna keep going, but those are things that can be unexpected, unfriendly surprises.

Susan Hudson MD (37:13)

And if you don't have sperm, say your partner comes in and he could not ejaculate that day, or if you're using donor sperm, the shipment didn't come in, you can freeze your eggs. There's always something we can do, okay? It's just not necessarily what we want to do.

Abby Eblen MD (37:31)

Well, and that's a really good point, but one correlated to that that we learned the hard way last year, we had a patient in our clinic, it wasn't my patient specifically, but she had a third party payer that paid for her IVF cycle, paid for her all the steps, except they don't pay for egg freezing. So what happened was her partner came in, couldn't collect, and then she was stuck literally on the day of her egg retrieval, having to come up with several thousand dollars to pay for the egg retrieval because the third party payer wouldn't pay for it.

So I always warn people about that and always say, hey, if there's any chance that you think you can't collect on the day of egg retrieval or won't be around, it's always good to freeze sperm for backup because that way, particularly in that particular situation, you wouldn't have to worry about paying for it since the third party payer will pay to create embryos but not pay to freeze eggs.

So one last thing I was thinking about is genetic testing. So Susan, if somebody's gonna do genetic testing, tell me what could go wrong there.

Susan Hudson MD (38:28)

So number one, you have to have embryos that get to the right stage and quality to be tested. So these embryos have to survive until day five, six or seven. They have to become what's called an expanded blastocyst where we can tell what part's going to become the baby and what part's going to become the placenta. And again, as I mentioned, they have to be a high enough quality that we think they're actually going to result in a baby.

And so when those samples are taken, there's always a small chance that something adversely could affect the sample, but that's pretty small, okay, when it comes to the actual biopsy. The little embryos are then cryopreserved and then those samples are sent off to a lab. Now, when they're sent off to a lab, there's various things that can happen there. So things that we would hope not to happen.

One, you get no results for a variety of reasons. A lot of times we'll get reports that just say no results. Other times it says no amplification. Sometimes it's because there weren't enough cells or the cells were not of good enough quality to run the test. Sometimes you get results that show us that we have all abnormal embryos or all embryos that aren't exactly normal. So maybe like mosaic embryos where there's information that shows that some cells say one thing, some cells show another. There's a lot of caveats in those things. And the best thing you can do in those situations is sit down with your reproductive endocrinologist and really talk about your specific situation. Because there's, there's so many things that can feed into those outcomes that it's really hard to say you should do this because there's no cut and dry answer to that. But there's, what we're hoping for is as many chromosomally normal embryos as possible. But unfortunately, that's not always what we get. Also realize that with PGT tested embryos or pre-implantation genetic testing, that those test results are right 98 plus percent of the time. So there's a one point something percent chance that the results that we think we are getting is not actually what it is. Now, the most likely situation for that is when we are looking at the sex chromosomes. Those are the chromosomes that are most likely to not give us an accurate result. Meaning, if you think you have a chromosomally normal blank boy or girl, it may be the opposite. Again, 98 plus percent of the time it's right, but there's a one point something that it may not be exactly what you thought.

Abby Eblen MD (41:12)

Very good. Well, I think we've covered a lot of topics. Anything else that we left out that you guys think we should mention?

Susan Hudson MD (41:21)

I just like to say that remember that as you go through the IVF process, IVF is not only therapeutic in that we're helping you get pregnant, but it's also diagnostic. And so there are things that every reproductive endocrinologist is gonna learn through a stimulation. And, that's gonna help them figure out what to do next. And so there's just...There's limited testing to show us what exactly is happening with eggs and sperm. We've got good testing, but it's not complete. And that's the strive of science and medicine to get as much information as we can so that we can ideally predict the future. But unfortunately, all of our crystal balls are a little hazy every now and then.

Carrie Bedient  MD (42:05)

Mm hmm. One other thing to consider, and we don't see this very often, but we do see it, is when interpersonal relationships take a sudden change in the midst of the cycle right before, right after, things like that. And all of a sudden, a couple decides, hey, we may not be together. When that happens, it's very much a case by case situation of what do we do?

It doesn't happen often, but when it does, it's very important to realize that whatever comes out of that in terms of eggs or embryos, you need to consider who will have to give permission to use them in the future. It is not just a guarantee that, we've got embryos, therefore he can use them, she can use them, he cannot, she cannot, whatever. Anything we do with those embryos has to be a joint decision by everybody involved. And so sometimes it is much better to not create those embryos, even though it's a hard decision to say we've started this and we're going to stop midway through. But sometimes that is the right decision because we can also go back and try it again later. But that doesn't happen often, but when it does, it's very traumatic trying to decide what do we do and how do we approach this for this really emotional process that we have embarked on.

Abby Eblen MD (43:15)

Very good. To our audience, thanks for listening and subscribe to Apple Podcast to have next Tuesday's episode pop up automatically for you. Also be sure to subscribe to YouTube. That really helps us spread reliable information and helps us get in touch with as many people as possible.

Susan Hudson MD (43:31)

Visit fertilitydocsuncensensored.com to submit specific questions you have and sign up for our email list.

Carrie Bedient  MD (43:38)

And as always, this podcast is intended for entertainment and is not a substitute for medical advice from your own physician. Subscribe, sign up for emails, and we'll talk to you soon. Bye!

Carrie Bedient  MD (43:48)

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