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Kristyn Hodgdon:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud fertility and women's health advocate, and co-founder of Rescripted. Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for all things fertility and women's health. This season, join me, along with Dr. Nicole Yoder, a fertility specialist at Spring Fertility in New York City, as we explore what to do when you're trying to conceive and feel like nothing is working. From when to seek the help of a fertility specialist, to what questions to ask when IVF fails, we'll address all things fertility troubleshooting so you can become your own best reproductive health advocate. Now let's dive in.

Kristyn Hodgdon:
Hi everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm here with Dr. Nicole Yoder of Spring Fertility in NYC. Hi, Dr. Yoder.

Nicole Yoder:
Hi, Kristyn.

Kristyn Hodgdon:
So we just came off a great episode all about IVF success rates. So piggybacking off of that, wanted to talk about IVF troubleshooting. So maybe your egg retrieval didn't go as well as you had hoped, or you didn't end up with any genetically normal embryos, or you found out there was an egg quality issue or whatever it may be, and what questions you can ask your doctor after that happens.

Nicole Yoder:
Yeah, it's a great tool to be able to have, sort of, some questions or some things to think about. So happy to talk about that troubleshooting aspect.

Kristyn Hodgdon:
Yeah. So first, what are some possible reasons for an unsuccessful egg retrieval?

Nicole Yoder:
Yeah. So if you have what we consider like an unsuccessful retrieval, it really can stem from several different aspects of the cycle. That can be part of the stimulation, it can be part of the retrieval itself, and it can be part of what happened after. So what happened in the lab? So when we maybe don't get the outcome that we're hoping for, or maybe we don't get the outcome that we were expecting, our job as doctors, as reproductive endocrinologists, is to really look back at that cycle and say, hey, where was the drop-off and where do we think we can do better? I'll start with just the protocol in general. There are tons of different protocols out there, and some are going to be better suited to different people. And the first step in any type of protocol sometimes has to do with priming medications. If you did a priming, maybe a good question to start with is is the appropriate protocol? Is there any different priming that we can do that might be better? Sometimes, we do priming, our goal is to get all, as many eggs as we can to grow together, but sometimes we overly suppress things. Or maybe it wasn't suppressed enough. So, type of protocol and priming, I'd say step one of, was that appropriate? Do we think we can make any changes there?

Kristyn Hodgdon:
And how often do you, would you say you change protocols?

Nicole Yoder:
If we have an unsuccessful cycle, I'd say it's pretty common. That's one of the first things that will change is just switching to a different way of getting into the cycle, or starting in a different time in the cycle, because sometimes eggs just respond, your body responds better to a different priming. So it's pretty common that we'll switch up the protocol if things don't go as we hope.

Kristyn Hodgdon:
And can you just elaborate on what priming is? For those who might not know, I actually didn't do that in my cycle.

Nicole Yoder:
Yeah, and that's not wrong either. You can just start a cycle with the beginning of your period, and that's what we'd say. No, no priming beforehand. You get your period, start medicine cycle day 2 or 3, and you can go. So priming is when we give you some type of medication or some sort of lead into your cycle, and the goal of priming really is to get all of those follicles that are going to be growing to be the same size and the same point on the starting line. So, hopefully, we get them to grow together and to not have a wide variety of sizes when they start to grow. So, examples of priming medications might be estrogen priming, which can be a patch pill, a type of progesterone, so maybe an ... pill, that type of thing. It can be a birth control pill. Lots of different types of priming medications, they are varying levels of suppressive, which can be good for some people, can be maybe overly suppressive, but really, priming is medication prior to starting those injectables with the goal of making all the follicles line up at that starting line at the same point.

Kristyn Hodgdon:
Got it. I did do birth control, but I didn't realize it was a primer.

Nicole Yoder:
Okay, yeah. And sometimes, we use birth control just to have a little more control over when you're starting, but it actually does work as a priming medication as well.

Kristyn Hodgdon:
Okay, great. And I just also want to know, I think a lot of people go into IVF thinking that it's going to work right off the bat, and they failed if it doesn't. And I just want to say that sometimes you need more than one cycle, and just because you may not have had a successful first egg retrieval doesn't mean that you're not going to have a successful next.

Nicole Yoder:
Absolutely. And if people take away anything from this episode, I would hope that it'd be that one failed cycle does not mean all failed cycles. And we learned a lot from that first cycle. We learned how your body works, we learn how you respond, and we learn what we can do better. So yeah, it doesn't necessarily mean if the first one doesn't go well that, you can't ultimately have success.

Kristyn Hodgdon:
Absolutely. So what kind of questions can patients ask after an unsuccessful egg retrieval to sort of give them the peace of mind that what they're doing next is? Because it's also such a financially driven decision sometimes too, and it's, you really want to get it right the next time.

Nicole Yoder:
And I totally appreciate that part of it. You want to be as efficient as you can. So if you have a cycle that doesn't go as well as you hope, it's good to ask your doctor, like, okay, where do you think we could do better, and what part of the whole process do you feel like wasn't optimal? So we're just talking about it could be the priming, could be the protocol, could be the way the eggs were growing. Did they grow together? Were there a whole variety of sizes? Were they really spread out? Another question to ask, was there any challenge with the retrieval itself? So sometimes you just can't retrieve all the eggs, or maybe some of the follicles were empty. Was that a scenario that happened? So that's another question to ask. And then maturity, where there as many mature eggs as you were expecting to get? Maturity is another point that we can sometimes make improvements on. And then, finally, the lab component. So maybe everything up to that point went great, the eggs grew nicely, the retrieval was beautiful, maturity was great, but then, in the lab, things didn't go quite as well. And if that's the case, do we think it's because of egg issues? Sperm issues? Maybe both, maybe neither. And are there any lab parameters that can be changed to hopefully improve the outcomes on that end?

Kristyn Hodgdon:
Actually, speaking of sperm, I want to talk a little bit about ICSI, is that, can you explain what that is, and do you do it across the board, or only in the case where you suspect there may be a sperm issue?

Nicole Yoder:
So ICSI is when is a way to fertilize eggs, and there's really two options. We can do conventional insemination, where we have one egg, put a whole bunch of sperm on it, the sperm that fertilizes wins. Or we can take one sperm, this is what ICSI is, where you take one sperm and directly inject it into that egg. As you already said, male factor, infertility, or sperm quality issues is definitely indication for doing ICSI. Now, I would say that these days, there has been a trend to move more toward, more people are doing ICSI than they were before, probably not indicated in all cases, but whether or not you do ICSI is going to depend on a few parameters. So how many eggs we're expecting? If you have really low egg counts, we're probably going to do that. Have you had poor fertilization in the past? Probably going to do it. Are you testing for a specific genetic disease? Then we're going to use ICSI, or sometimes it's just the lab's routine parameters. The lab routinely does ICSI, and that's the reason for doing it, but definitely some hard indications, and then some providers just prefer it.

Kristyn Hodgdon:
Okay. Yeah. No, that's something that can be modified, though potentially if they didn't do it the first time around, right? And then.

Nicole Yoder:
Yeah, absolutely. If we see that the issue might have been, fertilization was not what we were thinking it would be, and you didn't do ICSI that first time, sometimes we'll say, maybe we should switch to ICSI for the next round just to hopefully get that fertilization up.

Kristyn Hodgdon:
Yeah, that makes total sense. What's the typical time frame between egg retrieval? So you might maybe you did one, and you didn't get the results that you had hoped for. Do you typically have patients go take CoQ10 for three months and come back, or is it just let's go back to back, or is it just a personal preference?

Nicole Yoder:
It's ... either, it's a short answer. So some people say, you know what, I want to jump right back in. And for the most part, unless we suspect that there is like major lifestyle issues that need to be addressed before moving forward, most of the time, we're comfortable having people move towards the next cycle fairly quickly, so you can really jump into the next cycle, probably within about a two week period of time if you are motivated to do, and you're ready to go. But some people say, you know what, I did that, I need a break, I need a breather, or maybe I'm going to work on my diet, my exercise for a little bit, and depending on the whole clinical scenario, that's not an incorrect approach either. So really personal decision, but you can move towards another cycle, I'd say, within a two-week period of time. If you feel that you just want to keep going, get it over with, like move on to the next.

Kristyn Hodgdon:
Okay, and if someone did decide that they wanted to take some time off and possibly work to improve egg quality, are there any things that you recommend? What are your what's your take on acupuncture and CoQ10, like I mentioned?

Nicole Yoder:
Yeah. So I'd say CoQ10 is definitely, I'd say, the one supplement that most reproductive endocrinologists will all get behind just as a general antioxidant, again, good for your cardiovascular health, good for your reproductive health. Anything up to about three months, beyond that, I think you've reached max benefit. Beyond that, there's no point in really like delaying a cycle longer than that, but CoQ10 certainly can be an improvement. Acupuncture can be a great way to think, recenter, focus on yourself, focus on your health. Really, I feel like a lot of people really benefit from doing acupuncture, both prior to a cycle. Again, ideally, if you're going to do that prior to a cycle, they want to see you a couple months of doing that before starting and then throughout the cycle as well, and then focusing on your health again with cleaning up your diet, getting some exercise, getting some movement going. But really, most benefits that we see when you're working on yourself and optimizing your body, three months in most things are going to be good to go, longer than that isn't really necessary, I would say, unless it makes you feel better, and then, if that's the case, by all means.

Kristyn Hodgdon:
Yeah. No, absolutely. And what about male factor? Because I think sperm is on like a 90-day cycle, right?

Nicole Yoder:
Yeah.

Kristyn Hodgdon:
So, do you ever recommend men take a beat and clean up their lifestyle, and that?

Nicole Yoder:
Yeah, absolutely. Yes. It takes two to tango. The sperm quality is the other parameter. And sperm is regenerated about every three months. So sometimes we say, you know what, we think there's some sperm quality issues. We're going to work on the lifestyle of the male partner, and that typically again falls about a three-month trajectory.

Kristyn Hodgdon:
What else? What are, do you have any stats on, that can help provide some hope for someone who may have had an unsuccessful egg retrieval for like, how many people end up going on to have a healthy pregnancy or go on to have an improved cycle? Do you see it often?

Nicole Yoder:
Often, mostly because we learn so much from that first cycle. So even if the first cycle isn't great, there is a lot of potential for changes, tweaks, protocol to medications to the lab parameters, especially after that first cycle. Now, if you're on your like fifth or sixth cycle, maybe you've tried a lot of things, and maybe that's a different scenario. But after one cycle, there's so many things that we can change or modify that I really encourage people not to be discouraged by one bum cycle, because there's lots of things that we can modify in different ways, that we can try to get you a successful cycle.

Kristyn Hodgdon:
Absolutely. So lastly, you finished with the egg retrieval process, you have, hopefully, on your, after an unsuccessful egg retrieval, you have a more successful cycle, and you have your embryos, and you're ready for a transfer. What does that typical timeline look like?

Nicole Yoder:
In order to do a transfer, we're definitely going to want to do an evaluation of your uterus, which if you haven't done that, by the time you have your embryos, it's time to look at the uterus. Make sure that there aren't any issues there, that will include doing a saline sonogram, usually just to make sure cavity looks good, making sure you're up to date on all of your other routine, testing your thyroid levels, make sure that's well under control. No other concerns for actively being pregnant, but once you have your uterine evaluation, you've had your preconception checklist done, you can move towards a transfer, which is exciting part. The whole transfer cycle is usually about a month-long, but most people are able to go into that transfer pretty quickly after you get your normal embryos.

Kristyn Hodgdon:
Amazing. How many normal embryos, just curious, do you hope to have before moving into a transfer?

Nicole Yoder:
So we usually like to have two normal embryos for every baby desired, mostly because each normal has about a 65% chance of a live birth. So most people are going to do pretty well with two as a backup plan. If you want to be a little more on the conservative side, maybe you have three for every baby desired, but two is our general like standard of what we recommend for people having stored before moving towards transfer.

Kristyn Hodgdon:
Okay, so in some cases, you'll recommend the quote-unquote embryo banking for those who may want a larger family prior to.

Nicole Yoder:
Now, if you only want one baby, you can do a transfer as soon as you have a good embryo. But if you do want babies in the future from that same cycle, usually, we're looking at two normals per every baby desired.

Kristyn Hodgdon:
And because age matters so much, you don't know when you might necessarily go back to do another cycle later on, so you might want to front-load those embryos.

Nicole Yoder:
Correct, correct. Because, say you do get pregnant. Great. Yay! You're pregnant, you have your baby, maybe you're breastfeeding, by the time you're ready to jump into another cycle. Usually, somewhere 18 months to two years has passed, and then your ovaries and eggs are two years older, and the outcomes are that much, they decline two years' worth over that period of time.

Kristyn Hodgdon:
Yeah. No, it's so important to talk to your doctor about how many kids you want to have and how many embryos they think you should bank before moving forward because you won't have any regrets. I wish I'd banked more embryos.

Nicole Yoder:
Yeah, yeah. No, that is never a fun position to be in and be like, shoot, I wish I'd just done one more cycle two years ago, so always good to keep that in mind.

Kristyn Hodgdon:
Absolutely. I love that we kept this episode on such a hopeful note, because an unsuccessful cycle does not necessarily mean that you won't have IVF success. Thanks for explaining all that to us. All right, we'll chat next time. Thanks, Dr. Yoder.

Nicole Yoder:
That sounds great. Looking forward to it.

Kristyn Hodgdon:
If this podcast means something to you, be sure to hit follow or subscribe. This helps you because you'll never miss an episode, and it helps us because you'll never miss an episode. For everything you need to know about fertility and women's health, head to Rescripted.com or follow us on social at @HelloRescripted.

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