Ep 291: Timing is Everything: How Docs Prepare You for Frozen Embryo Transfer

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 episode, your Fertility Docs unpack the different ways patients can be prepared for frozen embryo transfer (FET) cycles—because there’s more than one path to pregnancy. From fully programmed cycles to completely natural approaches and modified natural protocols, the docs explain how each option works, what medications may be used, and the pros and cons of each. In a programmed cycle, the endometrium is carefully prepared with estrogen and then progesterone, with timing of the progesterone being critical to ensure the embryo is transferred during the ideal window of implantation. Natural cycles allow the body to take the lead, using ultrasound or ovulation kits to pinpoint ovulation and then timing progesterone and transfer accordingly. Modified natural cycles use letrozole and a trigger shot to encourage follicular growth, followed by progesterone support. While the approaches differ, success rates are similar—and the key takeaway is that there isn’t a single “right” way to prepare for FET. The best choice depends on your body, your doctor, and your unique journey. This podcast was sponsored by Shady Grove Fertility.

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)

Hello everyone, this is Dr. Susan Hudson from Texas Fertility Center with another episode of Fertility Docs Uncensored. I am here with my radiant, reliable, and relatable co-host, Dr. Abby Eblen from National Fertility Center.

Abby Eblen MD (00:38)

Hey everybody.

Susan Hudson MD (00:40)

and Dr. Carrie Bedient from Fertility Center of Las Vegas.

Carrie Bedient MD (00:43)

Hey, I'm impressed that you used a letter from the end part of the alphabet, because we do not do that very often. We very heavily do alliteration from the first half of the alphabet.

Abby Eblen MD (00:51)

That's interesting. We're waking alert this morning, aren't we?

Susan Hudson MD (00:52)

I prepared today. I prepared.

We are! 

Carrie Bedient MD (00:59)

Speak for yourself.

Abby Eblen MD (01:01)

We all have lipstick on too, I noticed. We all look like we're quaffed and ready to go.

Carrie Bedient MD (01:06)

I would like to point out that 15 minutes ago I was still in my pajamas with eye crusties from having just woken up. And so you're welcome.

Abby Eblen MD (01:11)

Hahaha!

It is a little earlier at your way.

Carrie Bedient MD (01:19)

Just a little bit. So, Susan, you took a trip recently and sent us pictures and they were the best.

Susan Hudson MD (01:20)

Yeah.

Yes, so we recently got a new puppy and this puppy is for my oldest son. He is in college and he wanted a Portuguese water dog. And so I looked all over the place and found this amazing family in southern Kentucky, just north of where Abby lives. And

Abby Eblen MD (01:48)

I was so bummed. I was hoping you'd get to stay with me.

Susan Hudson MD (01:52)

I know, I know. You were taking off for your cruise. But it was a fun little 24-hour adventure, and she is just the cutest thing. However, she is a little velociraptor right now. But it's the dinosaurs that have the really sharp teeth that are in Jurassic Park.

Abby Eblen MD (02:07)

Velociraptor, is that a word?

Carrie Bedient MD (02:15)

They're the star of the original Jurassic Park movie.

Abby Eblen MD (02:15)

OK. Sorry, I missed that reference there.

Susan Hudson MD (02:19)

Yes.

So she is a sweetheart. She travels really well in planes and cars. When she is not trying to use you as a chew toy, she is the most amazing little puppy. And she's going to get big super fast. It's amazing.

Abby Eblen MD (02:39)

What does a Portuguese water dog look like?

Susan Hudson MD (02:42)

Like a golden doodle. Now they have two different types of coats. They have the curly coats that look more like golden doodles and then they have some that have a wavy coat and that's what she has. She has a wavy coat, but their body structure is approximately that of a golden doodle. They don't shed. They are very, very trainable.

Very sweet dogs. You just have to stay on top of them because they're the type of dog you have to keep on training because they get bored and if they get bored they get in trouble.

Abby Eblen MD (03:12)

Are they big dogs?

Susan Hudson MD (03:16)

She will be about 40 pounds. So a smallish medium sized dog.

Carrie Bedient MD (03:21)

So, what's the status of all your shoes and furniture legs at home?

Abby Eblen MD (03:26)

Good question.

Susan Hudson MD (03:27)

Actually very good. We've been very on top of teaching her that shoes are a no-no. She loves strings and bows. So I have capri pants that have little bows near the ankles just like the little drawstring or shoelaces. It's the bow thing that she's attracted to. And so that's really the biggest thing we've had to watch her and we give her lots of good chew toys and all that kind of good stuff. So relatively speaking, she hasn't been too destructive.

Abby Eblen MD (03:55)

Super busy.

I lived with a Great Dane when I was in medical school. Actually, really two Great Danes, but Bo, the male dog, was six feet if he stood up on his hind legs, or really closer to six, two. And he consumed two dozen cookies that, at the time, I made for my boyfriend in one spell swoop. I was gone, came back, and the cookies were gone. And I thought somebody played a joke on me, but it turns out he'd eaten all of them.

Carrie Bedient MD (04:20)

Wow.

Susan Hudson MD (04:20)

You know, great danes are amazing. They're very sweet dogs, but oh my goodness, you would want to clean up that poop.

Carrie Bedient MD (04:27)

I feel like their poop is bigger than my dog.

Abby Eblen MD (04:30)

Hahaha!

Susan Hudson MD (04:30)

Yeah, I mean, it's like it's like shoveling cow patties. It's terrible.

Abby Eblen MD (04:34)

Yeah, it is.

Susan Hudson MD (04:36)

Well, let's do a question for today and then we'll get to our subject at hand. Okay, so our question for today is, I recently saw a video on social media where a doctor said during gynecologic surgeries, they tilt the table down like a seesaw. So the woman's head is down and her pelvis is in the air. She said it was called the Trendelenburg position.

Have I been tipped on my head during egg retrievals?

Abby Eblen MD (05:05)

You could have been. It's not really tipped on your head. It's really just tilted backwards. So it's and it's actually a very common thing that we do because sometimes the cervix is in a different position. So we put the speculum in. Sometimes if you put it right in the vagina, if the cervix tilts downward, you can't really see what you need to do. So you tilt the head backwards so that you just have a better view sometimes of what you're trying to do. And it's a common thing. I mean, it's not anything wrong; people do it all the time in gynecologic surgery.

Carrie Bedient MD (05:36)

I will say that for retrievals, I find that I don't tend to use Trendelenburg very often, mostly because it makes the ovaries move further away from us. And so if anything, I'm more likely to put the head of the bed up so that everything shifts down a little bit more because we want the ovaries as close to the vaginal wall as we can get because that makes it easier to grab them. And so I very rarely use Trendelenburg, but it is very common.

Abby Eblen MD (05:59)

You would use it for surgery though. I mean you use it for hysteroscopy. Yeah.

Carrie Bedient MD (06:02)

Yeah, yeah, laparoscopy,

Susan Hudson MD (06:02)

Laparoscopies, absolutely.

Carrie Bedient MD (06:05)

Some hysteroscopies, things like that, but not for egg retrievals in specific.

Abby Eblen MD (06:08)

I've used it sometimes for transfers too to see the cervix better.

Susan Hudson MD (06:12)

Yeah, but the thing is, it's safe. You are essentially buckled in, so you're not going to go sliding anywhere. And, you're being monitored by anesthesia to make sure all your vital signs and everything's doing well. And so it is a tool that we use, but it's not anything that's harmful to you.

Abby Eblen MD (06:20)

Yeah.

You're not tilted on your head. That's a little bit of an overstatement. You're just tilted backwards just a little bit.

Susan Hudson MD (06:37)

It's maybe like 10 or 20 degrees.

Abby Eblen MD (06:40)

Right, yeah.

Carrie Bedient MD (06:41)

I just want to make sure nobody is walking out of this with the impression that once they're asleep, we turn the table straight up and down 90 degrees vertical. Yeah, we don't have you suspended from the ceiling with us sitting on top between your legs trying to go in with that ultrasound to get the needles. That is not what happens. It is a very gentle tilt as though somebody took out the legs of the headboard of your bed.

Abby Eblen MD (06:48)

No, no. You're not doing a handstand.

Right.

Carrie Bedient MD (07:07)

And you're just slightly tilted a little.

Abby Eblen MD (07:09)

And you're strapped in like Susan said.

Carrie Bedient MD (07:11)

And you're strapped in.

Susan Hudson MD (07:13)

Safety first.

Susan Hudson (07:13)

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Susan Hudson MD (08:20)

All right. Well, on that note, we are going to talk about one of Carrie's favorite subjects in the whole wide world, frozen embryo transfers. And we're going to talk about programmed cycles versus natural-ish cycles. And we'll get into the details of the implications of those things.

Abby Eblen MD (08:32)

And the reason it's Carrie's favorite topic is because she was the primary author on that chapter in our IVF Blueprint book, Fresh versus Frozen, right Carrie? So you know all the details.

Carrie Bedient MD (08:54)

It is true.

That is a specialty within our practice and we are particularly crazy about it. Although I would like to point out this idea was not mine for a show. It was a listener who wrote in who said that she really wanted to know about this. Susan sent it to me. While I will admit, yes, this is absolutely my hobby horse. This was not my idea and I'm not fully responsible for this one.

Susan Hudson MD (09:17)

And we'd like to give a special shout out to Dr. Bruce Shapiro, because we're going to all channel our inner Bruce today and give you all kinds of good information about this. All right. So let's start out with the basics. What is a programmed embryo transfer cycle? What does that mean? What do those words mean?

Abby Eblen MD (09:38)

To me it just means that we're gonna control all the different factors in order to make sure that hopefully the lining grows appropriately. We give patients some form of estrogen, so we kind of programmed that. Tell them when they're gonna take it. Estrogen builds the lining of the endometrium. And then the other part of that is progesterone's really important. And we know from Bruce, and I've never forgotten this, exposure progesterone is important between 104 to 144 hours. So we generally choose intramuscular progesterone, we start it and we time the transfer usually somewhere in the middle of that window, the window of implantation, the time when you're most likely to get pregnant. And so we control all the different steps.

Susan Hudson MD (10:19)

Okay, and in comparison, there are versions of this, what's under the umbrella of a natural cycle?

Carrie Bedient MD (10:28)

So with a natural cycle, the idea is that the growing follicle in the ovary is producing estrogen, which is what it does on a normal basis, and that it is that estrogen that is stimulating the lining of the uterus to grow. Like Susan said, there's a bunch of different ways that you can spin this. There are some ways where we really and truly just do not do anything. We just monitor to see when that follicle is big. And then there are versions of it where we use other medications to help pinpoint some of those things where the natural course of events is the baseline of it, but we use those to time out certain things.

Susan Hudson MD (11:06)

Okay, so let's break these down because embryo transfer cycles, this is one of the things throughout reproductive endocrinology and infertility that there are a bajillion ways to do this. So there is no one right answer. That's probably the most important thing for you to take. 

Abby Eblen MD (11:23)

Yeah, I would agree with that. There's so many takes on this.

Susan Hudson MD (11:26)

Okay, so what we're going to talk about is what are some of the different variations for each of these and then we're going to talk about what makes one versus the other preferable to different physicians at different points in time. All right, so with a programmed cycle, so we're going to start off at the beginning. So we start off with sometimes people have a pre prep regimen.

What are some of the options of that pre prep regimen?

Abby Eblen MD (11:58)

Birth control pills is a common one that we use and that's really to suppress the ovaries so that when you come in to start your cycle, it doesn't look like you have a follicle or an egg that's really starting to grow that potentially would release hormones and change what we would have to do. So birth control pills would be probably the most common ones. Some people also will add subcutaneous lupron to that to keep a patient suppressed, again, for the same reason so that that patient won't release an egg or start producing progesterone at a time that we're not aware of.

Carrie Bedient MD (12:27)

And sometimes people will use longer Lupron cycles as well. And so there's two timeframes that you can use Lupron. One is like Abby said, where it's just just before leading into the cycle to suppress the brain's natural inclination to give instructions to the ovaries. But we can also use it for two months leading into the cycle.

And that's something called Depo Lupron that is oftentimes an IM injection, so into the muscle. And what that does is that is a much stronger dose that completely shuts everything down for a prolonged period of time. We do that for two months so that when we start to do the cycle, however we're doing it, that we're starting on an absolutely clean slate.

Susan Hudson MD (13:10)

Some other variations on that theme, when we're talking about people taking that long Lupron as Carrie mentioned, a lot of times that's because we're suspicious of endometriosis or there being a chemical called BCL6 in the lining of your uterus. And some other medications that can be used are something called Orilissa, which is a pill. Both the Lupron and the Orilissa essentially temporarily make you menopausal.

And the nice thing about the pill is it's not a shot and also if you need to stop it for some reason it's out of your system in a couple of days and sometimes we can even use letrozole. So letrozole is an oral medication that we often use in IUI or insemination cycles to help somebody recruit follicles or recruit more follicles but used in other ways it can actually help suppress the hormonal axis which is essentially how your brain and your ovaries talk together.

Carrie Bedient MD (14:09)

Sometimes when we do our baseline, let's say we haven't needed to do any treatment or we have done whatever pretreatment we need, sometimes when we get the baseline of the ultrasound, we find that that lining is really thick or someone's had a period and they've shed some of it off, but not enough of it. And so in those cases, we will oftentimes use some form of progesterone, aygestin or norethindrone or insert your favorite type of progesterone here or your doc's favorite as the case may be.

And we'll give that for five-ish days, sometimes seven, sometimes a little bit less, but we'll give it for a few days with the hopes that when we stop it, it triggers another bleed so that it thins down the lining of the uterus even more so that we really truly are starting with that nice thin lining and a good clean slate.

Susan Hudson MD (14:57)

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Susan Hudson MD (15:35)

Okay, so after we do the prep, we're gonna move into the estrogen phase. So what types of estrogen are available that can be used in this phase?

Abby Eblen MD (15:47)

There are many different ones. So patches can be used. They tend to keep your estrogen level a little bit more constant. And usually it's at increasing dosages. I mean really any form of estrogen that we use, we start out with a lower dose and generally increase it up, ramp it up to grow the endometrium. We can use oral pills. We can use vaginal pills. We can use estrogen shots twice a week.

Basically some form of estrogen and really there's different ways that you can give it. So it's really kind of dealer's choice. It depends on what your doctor's used to and what they like and what they've had success with.

Carrie Bedient MD (16:20)

In addition to the patches and the oral and the vaginal and the injections, you can also get the body to produce it. And this is where letrozole comes in a lot of the time. And so you give the pill for, you usually about five days at the beginning of the cycle.

Susan Hudson MD (16:35)

Let's keep that for our modified natural cycles. All right, so we have our estrogen and generally we give that estrogen for a couple of weeks to build up the lining of the uterus. And then often you'll go and get some blood work to make sure your hormones are where your doctors want them to be. And then when you get the all clear, we're going to start progesterone. Let's talk about progesterones and programmed cycles.

Carrie Bedient MD (17:03)

So progesterones and programmed cycles are, the reason they are so incredibly important is because they open up that window of implantation. And you want the signal to open up that window to be absolutely clear. You don't want some sort of half-assed approach to it where it starts to give it, but it is not a complete response. And so this is where the type of progesterone that you give matters quite a lot. And so right now we're talking about a completely programmed cycle. So there is no progesterone being given or being exposed at any point in the body besides what they are taking in the form of medications. And so in general, progesterone can come in oral, vaginal, or injectable forms. The injectable form of progesterone is an IM shot, so intramuscular right in the butt. It is one of the things where it is truly a pain in the butt part of process because it's in your backside. And so...

With these three types of progesterone, there's different ways that they get absorbed. In general, everybody agrees that the oral progesterone is not sufficient to get what you need. Very, very few people do oral progesterone, at least in this country, because what is available is not sufficient. Then there's the debate between vaginal and injectable progesterone. And this is where if you put four different REIs in a room, you're going to get at least seven or eight opinions. And so with vaginal progesterone, you place it once or twice or three times daily, whatever your doc's protocol is, compared to injectable progesterone where you can do it once, maybe twice daily. The doses are very different depending on your doc's favorite flavor. And there have been a ton of studies done about this. And I give a lecture every year where I go through this. And so I have, can see this slide in my brain of, it's probably about 10 different studies, and they use different types of progesterone. And when you look at just the raw information, it looks like, yeah, you can give either injectable or vaginal, and sometimes it works and sometimes it doesn't with the injectable, and sometimes it works and sometimes it doesn't with the vaginal. Well, what the difference is when you really tease through those studies is that the forms of injectable that didn't work were extraordinarily low doses, and the forms of vaginal that do work are much higher doses. And actually the alternative to injectable that this set of studies uses where it reliably shows that it's effective are, it's actually not injectable or vaginal, it's an oral form, but it's only available in Europe. And so it doesn't apply here. And none of us are familiar with it because it's not FDA approved.

When you really tease those studies out, the reason that some of them don't work is because they're an inadequate dose. When you give the really adequate dose of the injectables, it works because it's a very specific opening of that window.

Susan Hudson MD (19:54)

So another thing, sometimes people use combinations of those types of progesterone. So sometimes people use a combination of vaginal with injectables. There's all kinds of ways to literally skin this cat. But the important thing is that progesterone is absolutely essential to open and close the window of opportunity for implantation and to support the pregnancy

as the placenta is developing. Now eventually your placenta will produce so much more progesterone than we could ever give you. And so sometimes people are like, I don't want to take hormones. You need to understand that this estrogen and the progesterone that we're giving you is what your body naturally produces. And it's absolutely essential for an embryo to implant and continue to grow within your body.

Abby Eblen MD (20:51)

One thing I'd like to add too, now there's always exceptions to the rule, and I would say if you're a single woman and you can't give yourself intramuscular progesterone shots and you have to use vaginal progesterone, does that work? Absolutely. If you're allergic to all the different forms of oil in the progesterone and you can't do intramuscular, still vaginal progesterone works. So don't panic if you're using just vaginal progesterone, but generally, like Carrie said, your doc will probably put you on a pretty high dose of it, at least two or three times a day of medicine to make sure that your progesterone levels are adequate.

Carrie Bedient MD (21:23)

And as much as it's literally a pain in the butt to get those IM injections, the vaginal progesterone is a different kind of annoying because you have this squishy feeling a lot of the time and what goes up must come down. And so it is, it's not the same as the shots in the butt, but it is not necessarily a picnic either. Yeah. Yeah.

Abby Eblen MD (21:32)

Yeah. Yes.

Lots of discharge.

Susan Hudson MD (21:47)

Exactly. All All right. So to shift themes for a moment, let's talk about a purely natural cycle. And then what are things that could be what we call a modified natural cycle. So let's start off with a purely natural cycle, frozen embryo transfer.

Abby Eblen MD (22:08)

I would probably at least bring the patient in. So we would use her own ovulation, bring her in mid cycle to look at ultrasound, see that we see a follicle there. You could probably trigger with Ovidrel, but if it was purely natural, if that's my criteria, it would mean we would just wait until you had a positive surge with an ovulation predictor kit and time the transfer based on that.

Susan Hudson MD (22:27)

Are any other medications used in a purely natural cycle.

Carrie Bedient MD (22:31)

Typically, no. You just let it ride and you don't mess with anything. Now there are some requirements for a natural cycle. You have to be ovulating. If you do not ovulate for whatever reason, PCOS or menopause or whatever, then this will not work. If you can't pick up that ovulation, it won't work. So some people with PCOS will occasionally ovulate, but the way that their hormones are structured, they can't pick it up on an ovulation predictor kit. And so they might be ovulating, but we don't know when it is. And so we can't time out the way that we need to. And so that gets difficult as well. Some people ask, well, why can't you just follow labs to do that? And with a completely natural cycle, it is very impractical because the LH surge that triggers ovulation is pretty short-lived. And so...you don't exactly know when that's gonna happen and short of having someone come in minimum of every day, it's not reliable and it's not functional.

Susan Hudson MD (23:36)

And I would say in the United States, probably less than 5 % of embryo transfers are pure. Nothing else is going on, correct?

Carrie Bedient MD (23:46)

Yeah, there are a couple of centers that really focus on it, but for the most part.

Abby Eblen MD (23:49)

I would venture to say there's not too many people that just do pure natural cycles. Although, as we talk about this, I had a patient last year that really wanted to do a natural cycle. We did it, and she got pregnant. So it does work, but it wasn't my choice because I was joking, saying I like to control as many things as I can, and you can't really control anything when you're doing a natural cycle.

Carrie Bedient MD (24:10)

Is that a joke or is that just a statement of fact?

Abby Eblen MD (24:13)

I guess maybe a statement of fact.

Carrie Bedient MD (24:15)

I gonna say, in my world, that's not funny, that's just true. 

Susan Hudson MD (24:20)

So let's talk about modified natural cycles for frozen embryo transfers. And then we'll lead into a little bit in case somebody is doing a fresh embryo transfer. What does that look like?

Carrie Bedient MD (24:34)

So a modified natural cycle for a frozen embryo transfer means that you are getting your eggs to grow in some way, shape, form, usually with the help of medication. Most often, this medication is letrozole. And you take it in the same way you would for an insemination cycle, usually for about five days. You watch the follicle grow throughout. So you usually do an ultrasound before to make sure you don't have a follicle that's growing and your lining is thin. You do an ultrasound after to make sure that the follicle is growing and the lining is thickening up.

Letrozole is most commonly used for this. Technically, you could use Clomid. Very, very, very rarely does that happen because Clomid can potentially have a negative impact on the lining. And so most of us just don't go there. You could also do a modified natural cycle using FSH or gonadotropins. That's probably more relevant in talking about the fresh to transfer pathway. So I'll kind of pause on that there.

Most often a modified natural cycle is using letrozole. Now, there are some modified natural cycles that will let somebody just develop that follicle on their own and the way that the cycle is modified is with a trigger shot or with progesterone injections.

Susan Hudson MD (25:44)

Do you want to talk a little bit how we would use a trigger shot versus progesterone injections in a modified natural cycle?

Abby Eblen MD (25:51)

So there's two different ways to do that. One would be to say, okay, if a patient comes in and we see a follicle, the fluid filled cycle around the egg that suggests that the egg inside is mature, one of two things, either you would not trigger them and start intramuscular progesterone, which is the way I typically do it, and then you time their transfer based on that. I know in my same group, there's physicians that don't do that. What they do is the opposite. They trigger with Ovidrel then they start intramuscular progesterone at a time after that. And so there's really no right or wrong way, and we have pregnancies from both, but those are really the two major ways to determine when to do the transfer.

Carrie Bedient MD (26:29)

Looking at which one of those is right or wrong, because sometimes patients will get really set on one way or the other, depending on what their doctor is doing, you really can do them interchangeably. there are more and more studies that are coming out that show that whether or not that follicle ovulates doesn't actually make a difference. And it's more the presence of the estrogen to thicken up the lining that makes a difference and that the ovulation of that follicle may impact some stuff that happens later in pregnancy. There's studies going on right now to figure that out, but it doesn't seem to impact the success rates one way or the other. So truly, whatever the flavor of your office happens to be, giving the HCG and then progesterone, giving the progesterone and then the HCG, doing just one but not the other, there's good support for all of those.

Pregnancies happen with all of those, so it's just what makes the most sense given that particular practices and docs preferences.

Susan Hudson MD (27:28)

Now for those people who are wanting to do a fresh embryo transfer, how do we prepare the lining for that?

Abby Eblen MD (27:36)

It's called IVF. So basically that's really not something we do very often now, but for the first probably two thirds of my career almost, that's what we did. I mean, that was normal. You would stimulate somebody with an egg retrieval. You take the eggs out. You put the egg and the sperm together. And three to five days later, we would do an embryo transfer in those patients.

By fresh, it means that the embryos are never frozen. We do them before they get frozen. But the challenge we have, is we can't genetically test those embryos, and it's harder to figure out which one of those embryos is gonna be a better embryo to transfer.

Carrie Bedient MD (28:13)

The other big challenge that we have with those cycles is that with a fresh transfer, you are trying to optimize both getting the embryos and transferring the embryos. And those are two very different hormonal environments. The setup for a really good stim, especially in someone who's got a bunch of eggs, is hormonally very, very different than when we do a frozen embryo transfer, when you would figure just a single egg ovulates and has the potential to create a natural pregnancy.

One of the concerns is that progesterone levels start to rise prematurely and you throw off that exposure time that's so very important and you have to either compromise your transfer or compromise getting the embryos to get there. They absolutely can work. They did for many, many years. This is not to say that they don't work at all. It's just where we are trying to take advantage of every last percentage point to get success. This is one of the ways to optimize that.

Abby Eblen MD (29:06)

And the other really big challenge medically for those patients, and we ran into this more times than we liked, usually a few times a month, if the estrogen level roughly is over 3 to 4,000, when we do an embryo transfer, we would have patients that would truly get ovarian hyperstimulation syndrome. And that's really uncommon now because we don't do a fresh transfer and also because we do the trigger with Lupron. And that's another talk that we can have someday, but essentially that also prevents people from getting severely hyperstimulated where we have to remove fluid from their abdomen a few days after their transfer or retrieval. We have to hospitalize them. It can be really a serious condition. That alone, aside from all the other stuff is really impactful for the health and wellbeing of our patients now.

Susan Hudson MD (29:51)

So one thing Carrie was mentioning was those rising progesterone levels. And we actually see that almost at the two extremes. So as she mentioned, if somebody has lots and lots of follicles, sometimes we can have a natural rise of progesterone just because there's so many of those follicles that each one producing a teeny bit of progesterone added all up together ends up being a higher quantity. The other extreme is those people with diminished ovarian reserve tend to have higher progesterone levels earlier in their IVF stimulation. And so that again can adversely affect a fresh embryo transfer success. All right, so let's talk about, just because we've been talking about fresh embryo transfers, what are contraindications for fresh embryo transfers? Abby already mentioned one, and that's you want...genetic testing of some sort. Either PGT-A looking at chromosomes or PGT-M looking at specific genes or even PGT-P looking at certain health risks for that future child. What are other contraindications?

Abby Eblen MD (31:00)

When I said to significant risk for hyperstimulation syndrome. If your estrogen levels above three or four thousand, I would not want to do a fresh transfer because that can reinvigorate your ovaries and the factors that cause hyperstimulation get revved up if you get pregnant.

Susan Hudson MD (31:14)

Carrie, what about the effect of Lupron as a trigger shot for a healthy endometrium for a fresh embryo transfer?

Carrie Bedient MD (31:23)

Definitely less ideal. We certainly see lower pregnancy rates when someone has used a Lupron trigger with the intent to go into fresh transfer. So Lupron trigger, if you know you're doing frozen, totally fine and beneficial in many ways. But for a fresh transfer, that Lupron will not have a good effect on the endometrium for that cycle. And so we typically don't use that, which is part of the reason why there's such a risk for hyperstim, because we have to use the HCG and we can't use the Lupron, which is protective and some of the other measures that we use like cabergoline and things like that to prevent hyperstim, people think twice about when doing a fresh transfer. Not necessarily that can't, it's just multiple things start to play into there that we get worried about.

Susan Hudson MD (32:06)

All right, now when we're talking about modified natural cycles versus programmed cycles. First of all, know that a lot of those individual types of cycles are very interchangeable. There are practices where everybody does a modified natural cycle in some way, or form, and there's other programs that do all programmed cycles, and then there's clinics that do a mixture of those things.

What are some of the things you think about that would be great for a modified natural cycle?

Abby Eblen MD (32:40)

It's a quicker cycle and you don't need as much medicine.

Carrie Bedient MD (32:42)

I don't know that it's necessarily quicker unless you're using Lupron in your programmed cycles. I think it takes about the same time, at least the way that we do ours.

Abby Eblen MD (32:50)

Well, let me rephrase, if you don't use birth control pills ahead of time, if you just go in and you give them letrozole and you trigger them, it can be done fast.

Susan Hudson MD (32:59)

We often do that with our programmed cycles. We just start with the period.

Carrie Bedient MD (33:02)

Yeah, I was going to say I don't use birth control pills very often just because, so many patients don't want to be on a birth control pill just mentally because they're trying to get pregnant. and even though...

Abby Eblen MD (33:10)

So I'm comparing it to two months of a programmed cycle. If you do birth control pills for three weeks and then you do patches for three or four weeks, if you compare that to a modified natural shorter, that's what I'm saying.

Carrie Bedient MD (33:21)

Yeah, yeah, no, that's definitely true. If you're doing a programmed cycle that just goes into it using the period, they're pretty equivalent.

Susan Hudson MD (33:29)

When I think about the two different cycles, the things I think that may be negative for the modified natural are if you're having to travel quite a bit and you're needing to plan things ahead of time, travel, busy work schedules, things that are not super flexible. A lot of times when people have gone through their egg retrieval, they're like, well, at least we got to the embryo transfer where we can actually plan for certain things to happen at certain times.

I think that kind of adds a kink to it. And then sometimes if you're thinking about using things like gestational carriers, just because it can be a little more complicated getting all the people who want to be there at a specific time and not knowing exactly until just a few days beforehand.

Abby Eblen MD (34:18)

Well, the other thing too, if your own physician, like I generally do almost all of my own transfers, if you want your physician to do the transfer, a lot of times if you do a modified natural, that doesn't really work very well because that would mean your doctor would have to be available seven days a week. And so a lot of times in bigger practices, which is the case in our practice, we cover each other. So generally I can't guarantee a patient that I would be able to do their transfer if it's a modified natural cycle.

Carrie Bedient MD (34:43)

There's also embryology lab components here because embryologists, there are some practices where there's embryologists around all day, every day, and they're a little bit better situated to do anything whenever they need to. But there are other practices where that's not necessarily the case, especially practices that batch that put everybody together in this. So things happen in the same general timeframe because that's when the embryologists are available. The other thing is even if you've got an embryologist available all the time, It's nice to be able to plan things so that they can make the best of their workflow. You don't really want embryologists doing all of the things all of the time on the same day. You want them to have time. You want them to have space, and we try and be kind to our staff as well and not haul them in every day all day because they are they are humans too and there's some of the realities of just what we do and how personnel intensive it is because a Sunday embryo transfer brings in more than just the doc and the patient. It brings in embryology, front desk, the assistants, the phlebotomists, it brings in quite a lot of people. And so we try and be respectful of our staff as well, because we ask quite a lot of them all the time. And if this is an area where we can give people a little grace, we do.

Abby Eblen MD (35:45)

That's right.

Susan Hudson MD (35:58)

Other thoughts on different types of cycles?

Carrie Bedient MD (36:01)

I think we've covered an awful lot of it.

Abby Eblen MD (36:03)

I think we have.

Carrie Bedient MD (36:04)

I like it.

Susan Hudson MD (36:05)

And if you want more information, absolutely go check out our new book, the IVF Blueprint. It's available on Amazon, Barnes and Noble, all your independent booksellers. And you can learn more than we could ever cover in a 30 minute episode of our podcast with all kinds of nitty gritty details.

Carrie Bedient MD (36:25)

We wrote two chapters on it, specifically one that talks about Fresh versus Frozen and one that talks about the cycle protocols themselves. And so, feel free to make your heart happy by reading those. It made my heart happy to write them.

Susan Hudson MD (36:37)

Good stuff, good stuff. Well, to our audience, thank you so much for listening and subscribe to Apple Podcasts 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 help as many people as possible.

Abby Eblen MD (36:54)

Also, you can visit fertilitydocsuncensored.com to submit specific questions and sign up for our email list. Keep an eye out for our book, the IVF Blueprint. Check out our Instagram and our TikTok for quick hits of fertility, tips between episodes. See you later.

Carrie Bedient MD (37:10)

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, hit the like, hit the follow buttons, and we will talk to you soon. Bye.

Susan Hudson MD (37:22)

Bye.