Ep 284: Try Try Again - Questions on When the Embryo Doesn't Stick

Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this listener Q&A episode, the docs take on an emotionally tough but important topic: what to do after a failed IVF cycle. They dive deep into strategies to improve egg numbers, enhance embryo quality, and increase the chances of implantation success in future cycles. The conversation includes how a hysteroscopy can help detect fibroids or polyps that might create inflammation in the uterus, the impact of bacterial inflammation, and diagnostic tools like the ReceptivaDx test, which checks for the inflammatory marker BCL-6. BCL-6 may be linked with inflammation from endometriosis. The docs also touch on evaluating sperm DNA fragmentation and exploring the uterine microbiome. For those with positive signs of inflammation, treatment options such as Lupron or even laparoscopy to remove endometriosis are discussed. And don’t miss the discussion on progesterone timing for frozen embryo transfer cycles—why the number of hours of exposure to progesterone can be critical for opening the window of implantation at just the right time. Tune in for a practical, science-based guide to navigating next steps after IVF doesn’t go as planned. This episode was sponsored by ReceptivaDx.

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.

Abby Eblen MD (00:50)

Hi everybody. Welcome back to another episode of Fertility Docs Uncensored. I'm one of your hosts, Dr. Abby Eblen from Nashville Fertility Center. And today I'm joined by my exciting and enjoyable co-host, Dr. Susan Hudson from Texas Fertility Center and Dr. Carrie Bedient from the Fertility Center of Las Vegas. Hey, how you guys doing?

Carrie Bedient MD (01:10)

How are you? What's new?

Abby Eblen MD (01:11)

Doing well.

What have you guys been up to lately?

Susan Hudson MD (01:13)

We met with somebody to talk about doing some remodeling in my house this weekend.

Abby Eblen MD (01:18)

That's fun.

Carrie Bedient MD (01:19)

So what are you doing and how is it going to happen?

Susan Hudson MD (01:23)

Well, we walked through the house and each room Our house is about 17 years old. So there's not one specific place. It's more what do we need to do to update and maintain and repair the things that you just don't do on a regular basis. It needs a little bit of a facelift. Some things are a little repainting or replacing ceiling fans, making them look updated and stuff like that. And then there's a couple of little wishlist things that will eventually happen, but probably not anytime soon, but they're on the list.

Carrie Bedient MD (01:51)

Is there anything big and dramatic or is it really mostly touch up paint, not necessarily any major changes, just a face lift.

Susan Hudson MD (01:58)

Yeah.

The biggest thing that I want, but it's far down on the list because I think there's other things that's more important. I'd like to do a dedicated wine closet, but it's going to be under our staircase and it's going to be clear and you'll be able to see the wines and then have them temperature controlled and stuff like that. There's a lot of great pictures on the internet.

It's a wish list thing and it'll be fantastic whenever it happens, but we're going to prioritize some practical things first.

Abby Eblen MD (02:30)

Carrie, if you had to redo your house, what room would you pick to redo?

Carrie Bedient MD (02:33)

If we're talking cosmetic or stylistic stuff, most of the walls in my house need a touch up. The carpet upstairs, my dog is very poorly behaved, but really loved an awful lot. So it's more get rid of the carpet, not get rid of the dog. ⁓ Although I think that will probably take several years before we're eligible for that. Once those big facelift things are done, I really want to do our downstairs powder room in some absolutely wild and crazy and ridiculous pattern. Our house is generally various shades of blue and I want to do either a peacock blue pattern with an actual peacock mural on there or…

Abby Eblen MD (03:12)

Yeah, they say in small spaces, that's the good place to kind of go wild in small spaces because if you don't like it, you can always change it later. It's not as big of a deal.

Carrie Bedient MD (03:17)

I hope.

Yeah, and I've gone down the different textures. There's this company where you can order slats. And so you can say, OK, I need mine to be nine and a half feet or eight feet or whatever it is. But they've got the slats are laser cut. You can get all of these different patterns there. And they've got things that look like very simple lines. But they've also got more elaborate patterns too. And then you can order them in different wood tones or you can paint them or whatever.

Abby Eblen MD (03:42)

I know.

Good.

Carrie Bedient MD (03:46)

I have spent a lot of time thinking about that, and I think we've talked about this before, figuring out what set of options to present to my husband so I get the one that I want. 

Susan Hudson MD (03:55)

I literally was about to say, do I feel a PowerPoint presentation for Mark coming on?

Carrie Bedient MD (04:01)

Oh, 100%, 100%. The only thing that's going to probably bump it is the backyard, which was the last PowerPoint presentation that I actually did for him that we talked about. And so, yes, the couple of things that I've shown him, he's not a fan. And part of that is because they're ridiculous. But also part of it is because I feel like he lacks that particular type of vision, which...he would be the first one to tell you that, so this is not a secret. So what about you, Abby? If you got to redesign anything, what would you do?

Abby Eblen MD (04:34)

Well, we just got finished during our kitchen and that was a huge undertaking. And fortunately, we had a contractor he and his wife had really good visions. And I think it turned out really nicely. They walked through the house and they're like, the fan, it's a three prong fan now, not a five prong fan. And there's wood shelves now and not built ins and the other thing too that we really didn't even think about was the lighting because our house was built in 1995. So it had canned lighting and he's like, in a few years you're not even gonna be able to buy the lights for that. So we redid it and redid LED lighting and things like that. Stuff like that makes a big difference and just makes your house look fresher and everything. So I'm glad we're done with it though.

So today, we are going to answer questions, and we're going to talk about reasons why an IVF cycle may fail. So all the questions that our listeners have sent in about IVF cycles, we're going to try and answer today, or least a lot of them anyway.

Susan Hudson MD (05:26)

All right, let's start with our first question. Hi ladies, thank you for all you do. Thank you for listening. My question is, I'm 36, partner is 38, trying to conceive for three years, already had a natural son who is five with the same partner, only fertility issues were low morphology, count and motility fine. I had a HyCoSy which was clear, and I have regular 28 day cycles with no concerns. AMH is 27.2 picomoles but on scan showed fewer eggs. My TSH is about 2.4. Our first round of IVF was 14 follicles, 10 eggs collected, nine mature, nine fertilized, and only two made it to day six blast. Both PGT tested, both normal. Two modified natural cycles, one with hCG trigger, both with only progesterone and pessaries, both failed to implant. Before doing another IVF cycle, what would you recommend?

So one thing I would mention to our listeners based on measurements and a couple of other things, I'm assuming this patient is probably not in the United States. So, ladies, what do you think you would target?

Abby Eblen MD (06:29)

What was her AMH?

Susan Hudson MD (06:30)

It was 27.2 picomoles.

Abby Eblen MD (06:35)

And what did she, did she talk about medicines for her IVF cycle at all?

Susan Hudson MD (06:38)

No, just how many eggs she got. 14 follicles, 10 eggs, 9 mature, 9 fertilized. Two blasts.

Abby Eblen MD (06:45)

So I think for any of us, if we have a patient that returns after they've done an IVF cycle, and it's not successful, one of the ways that we can help is to try and stimulate more eggs. And sometimes that works, and sometimes it doesn't. You actually had really good maturity, but sometimes we'll add in HMG if you didn't have that in before. It has both LH and FSH in it. Sometimes that can help with maturity. Sometimes it's just nice to throw it in there because it may be helpful. Sometimes we can add things like Omnitrope or growth hormone. There's not a lot of great data on that, but in some patients that will help, and it's one of those things you never quite know what's gonna be beneficial for a given patient. But you did great with those two embryos, getting two normal embryos, and so Carrie or Susan may wanna take it from there about what you might wanna do for failed FET, but the goal initially would be just to try and stimulate you more aggressively to see if we could get more eggs and more normal embryos to transfer.

Carrie Bedient MD (07:35)

So putting the picomoles conversion in for AMH, that's an AMH of about 3.7. So that's a really good AMH. So I would definitely be more aggressive in stimulating, which is something that, particularly if you are in another country, that doesn't happen nearly as often just because of all politics are local. Well, all medicine is local too. If you go to different parts of the world, they're people practice in a particular way. And so the aggressiveness of stimulation is one of those things that might be different. And that's true within the United States as well. I mean, there are some places where you go and you're gonna seem much more conservative, others much more aggressive. And so it's clinic by clinic as well as region by region. That's one thing that I would definitely consider. The other thing that I would consider and I will get on this soapbox forever, probably at least four more times during this episode today, is the progesterone.

The cycle that you did with hCG, it's probably a lot more reasonable to get away with just progesterone pessaries. The modified natural cycle that you did without hCG. I'm assuming that that was done predictor kits helping the timing. Now I am so compulsive about progesterone timing, that, Susan and Abby are both laughing at me here. I can see you both.

Abby Eblen MD (08:51)

Now you've made me compulsive about progesterone timing. I'm the only one in my practice that is really compulsive because of you, Carrie, and I think rightfully so.

Carrie Bedient MD (08:58)

That just warms the cockles of my heart. I would probably try either progesterone and oil. I think the hCG is a reasonable way to go. When I do modified naturals, I will add in not only hCG, but I'll add progesterone and oil, at least for the first couple of days, because I want to make sure that that decidualization, which is the kick in the pants for the uterus to, say, get ready for implantation, I want to make sure that happens when we think it's going to happen and at adequate doses because even if your progesterone levels get up there to where they're supposed to be, we want them to get there as soon as possible so that that conversion starts to happen when it should and then you can always back off later. But that's my favorite soap box to dance on top of. What about you, Susan?

Susan Hudson MD (09:40)

So I also think that this is a reasonable time for you to look at some additional testing for why those embryos may not have implanted. We're really mainly thinking about a uterine factor of some sort. There's pretty good data to say that if you've had two failed embryo transfers, actually with or without PGT, that you need to have a hysteroscopy to look inside the uterus.

Even if you've had normal saline ultrasounds or HSGs to evaluate the lining of the uterus, about 30 % of people after two failed FETs have some sort of abnormality in the lining of the uterus that hasn't been picked up previously. So that's one thing. I think some sort of evaluation, whether it's your hysteroscopy or office endometrial biopsy to evaluate for chronic inflammation or what we call endometritis is reasonable.

And then there's two other tests. Some I think there's better support. Others I think that there's lesser, but maybe the right people for the right tests. So one test is called Receptiva. Receptiva is looking for a chemical called BCL6, which can be in the lining of the uterus. BCL6 has a relationship to endometriosis. Not everybody with BCL6 has endometriosis. Not everybody with endometriosis has BCL6. But if that BCL6 is present and not treated, either surgically or medically, it significantly decreases your chances of successful implantation. The other test is an ERA test or endometrial receptivity assay. There is some data to say that it might be helpful. There's some data to say that it is not helpful. Carrie and Abby aren't believers.

I am a believer that I think it helps in some people. I think there's a population for it. So, and it's something that's still out there. So plus or minus on the ERA, but I think we all kind of vote yea for hysteroscopy and Receptiva and chronic inflammation testing. So in addition to getting more embryos and maybe changing up your FET, doing a little more additional testing.

Another thing that I tend to do in this type of situation is also look for something called antiphospholipid antibody syndrome. APS is a condition that is an acquired blood clotting condition. We usually look at it in people who have recurrent pregnancy loss. But quite frankly, if I know I've put two chromosomally normal embryos in your uterus, I think that's a reasonable time to look for a blood clotting disorder that is present in a small amount of the population. And if that's present, then you may be a candidate for blood thinners. I think we're all pretty stingy with blood thinners. Blood thinners are not risk free and they can have some serious repercussions. So we want to make sure that people have real reasons to take blood thinners. But those people who do have the real reasons it can have a pretty big effect.

Abby Eblen MD (12:15)

Yeah, yeah.

Very good.

Susan Hudson (12:29)

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Abby Eblen MD (13:34)

All right. So another question for us Susan?

Susan Hudson MD (13:38)

Okay, our next one. Hi there. I'm 38, been trying to conceive for over five years, three years of IVF. I've had three egg retrievals, one at 34 and one at 35, eight transfers, four euploid, five untested.

One miscarriage at nearly seven weeks from a euploid embryo and seven failed implantations. All tests for both me and my partner, including karyotypes, came back normal.

I'm now being advised to consider either surrogacy or using an egg donor. I'm unsure which path to take. How can I know which one might work? How do I make this decision? Thank you. Whew, that's a big one.

Carrie Bedient MD (14:13)

That is a big one. There's a lot. There's so much discussion that has to happen in cases like those. It is very challenging, so not knowing your entire medical history. I would first dive into that. Start with the basics. What is your weight? What is your general health status? Are there things that you have that are not yet diagnosed or not treated?

Diabetes is a big one here. Rheumatoid disease can also be a big thing. Lupus and that type of diagnosis. We want to make sure that that's all as optimized as possible. Are you an autoimmune type person where your thyroid and some ovarian antibodies and a little bit of this and a little bit of that all contribute? And so you may have some factors going on there. I think a lot of the things that we talked about with our prior discussion about optimizing the uterus and do you have adequate progesterone and all those things, that entire discussion applies here. The other thing that I would think about is what are the conditions in your lab like and what's the general ethos in that lab? And so, what are the things that they are looking for? Are they transferring absolutely every embryo or are they being more picky about it? There's neither one is right nor wrong. It's really just what is the style of that lab because there will be some that don't necessarily come down as hard on the embryos and they'll transfer everything. And there will be others that are very picky about it. And so they won't transfer as much. Both are very reasonable approaches, but it may be something where the last couple of embryos, especially that you were transferring were not of the same quality as the first one or two, especially where you got that miscarriage. And that's another discussion worth having, particularly as you consider going into another retrieval and the number of embryos you get may impact, do we use a surrogate, do we not, do we do both and try some into a surrogate and some into you, those types of questions. What do you guys think?

Abby Eblen MD (16:09)

What do you think, Susan?

Susan Hudson MD (16:10)

A lot of the testing we just talked about in our first question would be very helpful. The other reality is that sometimes you have to make a leap of faith when it comes to fertility that some of that is where your heart and your mind come together. Making the leap to a gestational carrier, I think is awesome.

But the reality of a gestational carrier cycle is that unless you have someone who you know as a friend or family member who's willing to carry your pregnancy, that usually comes with a pretty hefty price tag. And that price tag usually starts at about $150,000. You could do a lot of IVF cycles and transfer in your own uterus or looking at things like donor egg, that's the right thing for some people. It's not the right thing for others for the value of that gestational carrier. I don't think we have enough information to really specifically guide your decision-making process, but I do think that how much things cost and the real reality of that gestational carriers are actually very, very rarely needed. I mean, there are definitely some people who need a gestational carrier. Please don't get me wrong with that, but that is a very very very small part of the population.

Abby Eblen MD (17:28)

So I would just add, if you had four euploid embryos and had four individual transfers, again, Carrie and Susan have said there's lots of information we don't know here. But if I'm picking donor egg versus gestational carrier, it would suggest if you had four euploid embryos and didn't have implantation that maybe there's an issue with your uterus itself. And again, there's really no great test to really know that definitively. So it is a bit of a leap of faith before you go to donor egg versus gestational carrier, but looking at all things equal, not thinking about the cost, I would lean towards saying maybe a gestational carrier may be a better option.

Susan Hudson MD (18:03)

If you do another autologous cycle, so another cycle using your own eggs is when you go and test your embryos for chromosomes, which number one, I would recommend testing all of your embryos for chromosomes and not just a few of them. But also looking at doing advanced chromosome testing. A lot of the platforms nowadays have testing where if you have abnormal embryos, they're able to identify if the abnormality came from the egg, the sperm or the embryo itself. And though we don't have that information this minute, it could give you information for future cycles of hey, do we have an egg issue? Do we have a sperm issue? Or is it just fluky things that are happening with our embryo that if you end up with 10 embryos to be tested and you have half of them that are chromosomally normal and half of them are abnormal and every single one of them is derived from the egg, that's going to point you in a different direction than if they're a mix or male factor or whatever.

Carrie Bedient MD (19:12)

One thing to consider that we haven't really talked about yet is DNA fragmentation for the sperm. And that may be something that is useful to find out. Again, tracking down is this an egg issue, a sperm issue, a uterine issue. It's worth looking at that and also looking at your husband's health. Are there any things that can be adjusted there? Smoking, alcohol, marijuana use, particular health issues, weight, all of the typical things we talk about with lifestyle.

Those all apply to the sperm too. Can't forget our little swimming friends because they are half of the equation.

Susan Hudson MD (19:44)

And even though you have embryos, that doesn't mean you didn't have any male factor.

Carrie Bedient MD (19:49)

Right.

All right, what's next?

Susan Hudson MD (20:20)

Okay, love the pod and you ladies. Thank you again for listening.

Carrie Bedient MD (20:24)

Yay! We're POD people!

Abby Eblen MD (20:25)

The pod.

Susan Hudson MD (20:26)

We're pods!

If you had a 38 year old patient with BMI 37 PCOS positive Receptiva, three failed medicated FETs with euploid embryos day five, seven and transfer was primed with Lupron Depot for endo.

Would you recommend that patient take a break to lose weight with GLP-1s or try a modified natural FET first? My doc has presented both options after next retrieval. Should I be more worried about losing time and getting older or losing weight? Everything else seemingly normal, although going to test for autoimmune but don't have any indicators that that is an issue or other recommendations welcome. Thanks for all you do.

Carrie Bedient MD (21:08)

Susan, can you repeat? Is she asking about taking the break to lose weight before the retrieval or after the retrieval?

Abby Eblen MD (21:14)

Right. I think.

Okay, so she's gonna go straight into the retrieval regardless of what happens. It's whether or not, okay. Okay, that's.

Susan Hudson MD (21:20)

Yes. Should she just hop into a modified natural cycle or should she take some time to lose weight after we have more eggs and embryos?

Carrie Bedient MD (21:31)

I wonder what other medical issues are going on, if any. Let's pretend for a minute that there's a bunch of other stuff going on. In that case, get the blood sugar, get the high blood pressure, get whatever metabolic stuff. Go ahead and address that. I think that's definitely worrisome. If you are generally pretty healthy, because just having a BMI of 37 doesn't mean you're unhealthy, it might be be helpful either to do the GLPs or I just saw a bit of research and I pulled the original study yet of people whose all of their metabolic parameters improved once they got rid of a lot of added sugars. And so this is something that I'm, this is my current hobby horse to dive into and figure out what's going on. But they noticed a lot of improvement with metabolic parameters.

I think probably the bigger issue here is not only what will help you get pregnant, but also have a healthy pregnancy, which is likely to be going on the GLPs and losing weight. But that's, I would say that's a minimum of six months and functionally probably closer to a year that you're waiting. If you've already got those embryos and you have a good number of them, then that is something that's more worth doing. If you don't get very many embryos, and I think if there's anything on the table of we're gonna have to go back and do another retrieval if this doesn't work, that's when I think you may wanna consider not waiting quite as long. What do you girls think?

Abby Eblen MD (22:50)

Carrie, you bring up a great point in our book, The IVF Blueprint in chapter four, Susan did a great job covering all kinds of things medical wise that you need to get taken care of. Alot of times people kind of think, well, let me do this and then, when I'm pregnant, I'll take care of all these problems. But like you pointed out, if you have high blood pressure, diabetes, that sort of thing, it's really important to take care of those things ahead of time. And, hopefully that will help. One thing I was going to throw in, she mentioned that she did Depot Lupron a couple of months and that's really the recognized treatment that most people use if that inflammatory marker, that BCL6 is positive. And as we mentioned in an earlier question, we find that through the Receptiva assay and there is some link between endometriosis, we think, and this inflammatory marker. Just anecdotally, and I don't have any data to support this, but I've had a couple of patients, two or three patients actually now, that we did Depot Lupron for a couple of months. They did a transfer, still didn't work.

They came back and one patient even was just gonna have a polypectomy, but she said, really wanna have laparoscopy done to look for endometriosis. She had a bunch of endometriosis, had it ablated, she got pregnant. And I've had several patients that tend to have a bigger amount of endometriosis. My own, again, my own anecdotal feeling is that there's a certain group of people that may actually do better with laparoscopy. And laparoscopy traditionally is the way that we used to diagnose and treat endometriosis. So just something to think about.

Carrie Bedient MD (24:11)

Were those patients having a lot of pain with their periods? Were there any signs for them or was it just a straight?

Abby Eblen MD (24:16)

No, the one patient I was just like shocked because I was like, well, I don't really think you need laparoscopy. And she had it and she had pretty significant endometriosis.

Susan Hudson MD (24:24)

There's probably even if you use medical management there may be some people that need a little bit more maybe three months of treatment.

Abby Eblen MD (24:29)

Yeah, think so. Or maybe those people would have done well if they had had longer time on Lupron, maybe six months or something, who knows. But we just don't have that data yet, unfortunately.

Susan Hudson MD (24:38)

Yeah, absolutely. Very good. All right, our next one. Hi, thank you for all you do. I am 35. My husband is transgender, so we are using donor sperm. I have diminished ovarian reserve. AMH has ranged from 0.9 to 1.4. We did five retrievals and were able to bank five embryos but have had two failed FETs. We really want two kids if possible.

Our embryos are all PGT tested. First transfer did not implant. After that, we did hysteroscopy and found some polyps plus a mock cycle with ERA and Receptiva. Found I needed 24 more hours of progesterone and negative for BCL6. Our second transfer included embryo glue and antihistamine protocol plus extra day of progesterone, but it ended in a chemical pregnancy. What would you look...into next or just move to another transfer and hope for the best. Thank you so much.

Carrie Bedient MD (25:31)

She didn't say if she had other embryos that were not euploid. She just said she got five euploid out of those five retrievals, right?

Susan Hudson MD (25:42)

Correct. I am assuming she has euploids.

Carrie Bedient MD (25:45)

So I wonder if they use the same sperm donor all the way through. And I wonder if this is one of those cases where particularly because with five retrievals, there's a decent chance that they've got several embryos that are abnormal in there. This might be one that's worth going back and testing those embryos for the origin of the abnormality to see what's going on. Because for someone who's only 35, who's done five retrievals and only gotten five euploids, even with a lower AMH of 0.9, I would still guess that you would get more than that. And so it makes me wonder what else is going on. And if you...

Abby Eblen MD (26:23)

So are you thinking there might be a sperm issue is what you're kind of alluding to or?

Carrie Bedient MD (26:26)

Well, one to nail it down because changing sperm donor is a relatively easy thing to do. The other thing is if there truly is an egg issue, this might open up the conversation that has previously been closed about her partner having his eggs removed ⁓ or stimulated. And that's something that there's more and more data coming out about that. Molly Moravec out of Michigan, I think almost every paper has her name on it somewhere. And so, they're finding more and data about this of how to do these stims. And so it's something that we typically don't approach unless there's a very good reason for it. And it may be completely off the table for this couple for a variety of reasons, either surgical or mental, physical, emotional, however it comes down. But that might be something where it's worth having that discussion because the importance of having a family and how that works out with this family. Like that may shift that. I've certainly had trans men go through egg retrievals before and no, they don't particularly like it. But it's a different layer of disliking than every other patient doesn't like it. But there's a lot of things that human beings will go through for their children. 

Abby Eblen MD (27:24)

Yeah, well, think we know too, if you've been exposed to testosterone, it's still okay. You still can do quite well with a retrieval if you're a transgender man. So it's the emotional layers if you are able to do that.

Carrie Bedient MD (27:41)

Mm-hmm.

Yeah.

Susan Hudson MD (27:47)

Sounds good. All right, our next one. Hi, I'm 33. I've been trying for 1.5 years, have never gotten pregnant. My blood tests and HSG results are all good. Husband's sperm results are average too. We did IUI and IVF, both failed. During IVF, 21 eggs collected, 15 mature, 12 fertilized, five reach blastocyst stage. We transferred one but later on the four blastocysts remaining couldn't develop past seven days. So she did a fresh embryo transfer of the one and she had four remaining that did not survive. What could possibly be the reason for failed IVF? We are thinking of giving IVF a second try.

Carrie Bedient MD (28:29)

Do we think this was a fresh transfer and those other four blasts were just being watched to see if they.

Abby Eblen MD (28:33)

It didn't make it.

Susan Hudson MD (28:36)

Yeah, I mean this looks like a fresh they it was like a fresh going into a frozen type of situation where they did a fresh transfer and then the four.

Abby Eblen MD (28:42)

Yeah, I wonder if that was planned on the front end or if they started to develop and they looked like they weren't doing great and then they changed gears and decided to do a fresh transfer just because it might do better as a fresh as opposed to frozen. It's kind of hard to know.

Susan Hudson MD (29:00)

There's some clinics who do that routinely as they like to do a fresh transfer. Looking at things from my perspective, I would say if you did another IVF cycle, I would probably add Omnitrope or growth hormone to your stimulation. In my experience, I don't necessarily tend to get more eggs, but I tend to get better quality embryos and more chromosomally normal embryos, for whatever reason. I think that you do have a chance that you might end up with the same results, but there's also a reasonable chance that you could end up with a better result and a pregnancy out of it. So I wouldn't say the door is closed. But I think it's something that I would definitely want to change things up, make sure you're taking some CoQ10 to help with egg and potentially embryo health down the road. Making sure we don't have any DNA fragmentation in the sperm. I've seen situations like this before where that's an issue as well.

Abby Eblen MD (30:01)

Yeah, and would tell the listener too that I can count a lot of patients that have gone through IVF. You think they're going to do great. They get a lot of eggs and then they just have either nothing that's normal or nothing that develops. And then I've had patients that have done that, gone to another one and it's been like night and day difference. You just never know. It's really, until you do another retrieval, we won't really know if there's some problem with the egg or the sperm or if it's just bad luck. And sometimes I've just seen bad luck happen and the next retrieval does fine.

Carrie Bedient MD (30:30)

I mean, if you've seen one retrieval, you've seen one retrieval.

Abby Eblen MD (30:33)

Right.

Carrie Bedient MD (30:34)

Crap I had something really deep and wonderful and insightful it's gone. Probably. ⁓

Abby Eblen MD (30:38)

I'm sure you'll think of it before too long. You'll come. All right, we want to do one more. Oh, OK.

Carrie Bedient MD (30:44)

Wait, I know.

It's with if you're a fresh into frozen cycle where you're doing a fresh transfer, go back and be very meticulous about thinking about all the parameters that were going on. This is this is less related to the embryo itself and the egg quality. This is more related to the ability of that particular embryo to implant. Were there things like your progesterone rising before your trigger? Did you get a lupron trigger? What is the hormonal environment? Were your estrogen levels crazy high?

All of those things are helpful to look at because there are some fresh cycles that go into transfers that really are ideal for transfers and they're great, but there's an awful lot of things that can throw a wrench into it. And so that may be something that's worth looking at too. See, deep and insightful. Got it.

Abby Eblen MD (31:24)

Yeah. Good point. That was a good point. All right.

One more.

Susan Hudson MD (31:31)

Okay, hi, I'm going through IVF and my first egg retrieval resulted in a fairly big shock. Only four of 15 eggs retrieved were mature despite follicle sizes between 13 to 20 at trigger with 10 over 15 millimeters at trigger and five from 13 to 15. I'm trying to understand what may have caused this as well as future protocol adjustments to try to boost the number of mature eggs. Do you have any suggestions? More details about my protocol and history.

Unexplained infertility. 34 year old female, partner 34 year old male. One miscarriage last year from a natural conception. AMH 2.2, AFC 18 to 20, RPL testing negative, karyotype test for both is normal, sperm tests times 2 normal, protocol for last retrieval was luteal protocol with 225 of Follistim, 75 of Menopur with dual lupron 40 IU hCG 5k trigger.

Ganerilix. Ooh, we got a lot of suggestions for that one.

Carrie Bedient MD (32:32)

Yeah.

Abby Eblen MD (32:33)

What was her estrogen level, did she say?

Susan Hudson MD (32:34)

She did not.

Carrie Bedient MD (32:35)

So for me, the really low hanging fruit here, push longer, get those little babies bigger, get those follicles way bigger. The 13s to 15s, there's no expectation for those. We don't assume that those are gonna be mature. You very reasonably get eggs from them, but they're unlikely to be mature. And between 15 and 20, you've got a ton of room to get bigger and get those smaller ones bigger. And so go longer, stim harder.

Abby Eblen MD (32:46)

Uh-uh.

Well, that's the reason I ask about her estrogen, because I wonder if she was somebody that had an estrogen level of 15,000 or something. When you have a really high estrogen level, that's really, really high. But sometimes if you have a high level, everybody gets nervous about pushing you too far and they want to trigger you a little bit earlier. And that's the point that Carrie was making. If your estrogen level wasn't sky high, and even if it was in this day and age when we use Lupron triggers, it's really unlikely to get hyperstimulated. But in the past, we always worried about pushing somebody, particularly a PCOS patient, have really high estrogen, we worry about pushing them further because it would potentially increase your risk of hyperstimulation syndrome. But I agree, you need to go longer.

Susan Hudson MD (33:39)

I'd say you need to go longer and when Carrie saying bigger, let your follicles get to 24-26 millimeters easily.

Carrie Bedient MD (33:48)

And there's a couple that can go bigger than that if it's worth it to get some of the little guys into a bigger range where they're going to be juicier and more likely to be mature.

Susan Hudson MD (33:56)

Exactly. You probably don't need a dual trigger. No offense, but that's your doctor being nervous about, ew... we might have immatures and you had matures, you probably needed more Lupron. Let your brain totally take over that. And we usually, often use 80 of Lupron, not 40 of Lupron.

Abby Eblen MD (34:15)

Yeah.

Susan Hudson MD (34:17)

There's a lot that could happen in there that could have a big, big impact.

Abby Eblen MD (34:23)

Yeah, and I would caution too. I didn't hear the part about the dual trigger until you just said that. I think they were worried about hyperstimulation because they gave you that dual trigger. They triggered you earlier than what they would have wanted to do, but then they turned around and gave you a dual trigger to help with the maturity. I would have probably, and everybody's different, everybody has their own ways that they do things, but I probably would have pushed you further and done just a Lupron trigger to really decrease your chances of having severe hyperstimulation syndrome.

Susan Hudson MD (34:47)

Agreed. And I also tend to do more split dosing than what you experienced. You did 225 of Follistim, 75 of Menopur. I would start you out at 150, 150. It's the same total amount, but I would give you more Menopur in that antagonist cycle. And sometimes that can improve egg and embryo issues as well.

Abby Eblen MD (35:10)

But I will say, it's like a crystal ball. We don't have a crystal ball, your doctor didn't have a crystal ball, there's no way that they would have known this, and it's easy for us to look and go, I would done this, I would have done that, knowing the results. It's one of those things we all learn on every cycle that we do, and I'm sure these are things that your doctor has already thought about and is probably thinking about changing potentially when the time comes. But, certainly good for you to know these things and discuss it further.

Carrie Bedient MD (35:33)

We all have cases like this where you go back and look at it and go, man, I really wish I had done the other thing. And there's just as many cases where you're like, no, I would have done the exact same thing again. And one of the advantages of having a second set of eyes on it is just to say, hey, did you think about X, Y, and Z and maybe make those changes?

Susan Hudson MD (35:53)

Very rarely do we go back after a failed cycle that any of us have run and do the exact same thing. Very, very rarely, unless it's one of those that we essentially did the Hail Mary, everything in the bucket of tricks because of poor prognosis. Most people, there's something we can change. And so just because we're wanting to change something doesn't mean something was done wrong. It's that IVF is not only therapeutic and that we're helping you try to achieve pregnancy, but it's also diagnostic. There's just some things we don't know until you're going through your stimulation and we see your eggs and sperm in a dish to see how they are going to interact.

Abby Eblen MD (36:29)

And there's a lot of great things in our upcoming book where we talk about all these different medications. And so if you want to know more about them, because it's hard to know the ins and outs by just looking at the internet, there's a really great chapter on all the different medications that your doctor may consider using.

Carrie Bedient MD (36:41)

And one way in the normal world to think about this when we're talking about tinkering is for those of you who like to cook, there are some people who will find a recipe and they will follow that exact same recipe from here until the end of the world and never ever make any adjustments. For the most part, fertility docs aren't like that. We're going to adjust a little bit each time based on what we see and based on the ingredients we have. Even if you've got the same recipe, even if you have all the ingredients in front of you, as you're going there, you may look and say, those tomatoes aren't quite what I thought I was gonna get. Let me adjust here, here, and here so that it balances out. And that's exactly what happens in every IVF cycle. So there's always some tinkering that we can do, because most of us, frankly, cannot help ourselves. We're always looking to make it better.

Abby Eblen MD (37:12)

haha

That's right. ⁓

This was a great episode. So 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 to help as many people as possible.

Carrie Bedient MD (37:42)

Visit fertilitydocsuncensored.com to submit questions and sign up for our email list. Keep an eye out for our book being released on September 23rd. Hint, hint, you can pre-order now. Hint, hint. And check out our Instagram and TikTok for quick hits of fertility tricks between our weekly episodes.

Susan Hudson MD (37:57)

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!

Abby Eblen MD (38:06)

Bye.

Carrie Bedient  MD (38:07)

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