Rescripted S02E04_The IVF Process, From Stims To Egg Retrieval : Audio automatically transcribed by Sonix

Rescripted S02E04_The IVF Process, From Stims To Egg Retrieval : this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi! I'm Kristyn Hodgdon, an IVF mom, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi, everyone, and welcome back to Dear Infertility. I'm Kristyn, your host, and I'm here with Dr. Lucky Sekhon. Hi, Lucky!

Lucky Sekhon:
Hi. How's it going?

Kristyn Hodgdon:
I'm doing well. How are you?

Lucky Sekhon:
Good. I'm excited to be here and excited for the topic we're covering today.

Kristyn Hodgdon:
Yes. So, I mean, this is something that I see all the time in the Rescripted community. People just wondering what the IVF process looks like, because I think until you're kind of in it, it's hard to know what it entails and how to prepare yourself more so even mentally than physically, I think? You know, what's the timeline? What are the side effects for the meds? So I'm excited to chat about all of that today.

Lucky Sekhon:
Me too. I feel like this is something that overwhelms so many people because you hear little snippets maybe from social media or people tha you know, who have gone through it. So I think it's helpful, put it all in one place and just do a really broad overview so that people can put it into context.

Kristyn Hodgdon:
Absolutely. So we receive this question a lot. What are some of the key reasons to do IVF to begin with?

Lucky Sekhon:
Yeah, so I, you know, I think a common misconception for anyone who is about to go see a fertility doctor is that, you know, they might just enter the door of the clinic and then be told, okay, you're going to do IVF, but that can't be further from the truth. There are very specific reasons why we sometimes recommend IVF as a first step, but in the absence of those reasons, usually it's a stepping stone and it's on the more aggressive side of treatments. And we say aggressive not to mean it's more scary or, you know, in a negative way, but it's more so to reflect the fact that it tends to be a very efficient and effective treatment option, not across the board, it doesn't mean that IVF can't fail, but it tends to address a lot of the inefficiencies of reproduction that we talked about in prior episodes, and it does a good job of addressing them on an individual level at each different stage of the process. There can be really specific reasons why we would recommend it as a first step. For example, if someone has tubes that are blocked on either side, their fallopian tubes are damaged, or they've had them removed because of needing surgery for that, you know, IVF will help to directly bypass that blockage because what it involves is taking the eggs out of the ovaries, fertilizing them, turning them into embryos, and then placing the embryo through the vaginal canal and cervix at the top of the uterus. So you're able to bypass that blockage. Another common reason is when there are major sperm issues for male fertility issues. So if there's a low sperm concentration, that is going to make it harder to get pregnant on your own or even with IUI, if it's severe enough because the sperm really needs to outnumber the eggs. So if someone has a low concentration in their sperm count, then we can take each egg when it's outside of the body and individually inject one sperm cell into each egg that's called ICSI or intracytoplasmic sperm injection, and that can overcome a lot of that type of male infertility. So those are just examples. Another broader reason to do it is if you want to capitalize off of some of the benefits, like being able to genetically test embryos before you use them, that can be really beneficial in older women who have been suffering or are at risk of miscarriage because of the higher rates of genetic errors in embryos as we age and even just for family planning purposes, someone who's starting at an older age and knows that they want to have multiple children, one of the benefits to IVF is that you can have extra embryos frozen, and they can remain frozen indefinitely for future use. Your uterus doesn't age in the amount of time that they're frozen have no bearing on their reproductive potential. So those are some of the key reasons why I see patients who end up going straight to IVF.

Kristyn Hodgdon:
I think that that last point you made is so important because I think so many women and couples pursue IVF because they can't get pregnant. But when you are older, if you do know that you want a larger family, it could be almost like a preventative, you can, you can really you can do the genetic testing. You can have embryos hopefully left over for future children. Like it's a way of being proactive if you, if you have the means obviously to pursue IVF.

Lucky Sekhon:
Yeah. And also it's important to keep in mind that there is what's ideal, and then there's what's being practical. I have some patients that choose to start with IVF because let's say they're 34, 35, and they would like to secure their ability to have a second child and not be worried at age 37 or 38 that it might be harder if they're already having some challenges to get there. And, you know, they might do a round and get two embryos, and then we have to think carefully. How much of the big picture do they want to focus on? Do they want to just move straight to transfer? Because their main reason for doing all this was to get pregnant now? Or do they want to take a second to say maybe we do a second cycle now because it would be ideal to have two or three embryos for the future, since we know not every embryo has 100% chance of implanting. So I think it's really about having a strategy-type approach with your fertility doctor and thinking about your overall goals as you make these decisions.

Kristyn Hodgdon:
Absolutely. I love that, we talked about that in an earlier episode, but so important that your doctor has those discussions with you, because some people just might not know that the first embryo might not take. And then if I have to use the second, you might have to do another retrieval down the road. And so having those chats upfront is, is crucial. So next question I received from the community is basically everything that goes into ovarian stimulation. How do you do it? What's sort of a typical IVF protocol? What does the schedule look like? Can you go into that a little bit?

Lucky Sekhon:
Yeah. So the first step to the IVF process, which is essentially fertilizing eggs outside of your body, is you have to be able to get to the eggs and retrieve them. And so that's what people tend to really fixate on. When you think about IVF, you think about the needles, right? And that is the first step. So what you're doing is essentially hijacking the system that you were born with. We have our ovaries that are stimulated by hormone signals coming from the pituitary gland in your brain, which is normally what selects that one egg that would ovulate naturally on its own. So when you take those injections of medication, if you're using those injections to give yourself that signal, but at an even higher level, in an effort to select every egg that has been recruited to the surface of the ovary, we want all of them to grow, we're greedy. Whatever's there, we want to take it, because remember, at the end of every wave of recruitment, regardless of whether you ovulate or not or you have eggs retrieved or not, those eggs are being thrown away, they're disintegrating, and can't be utilized. So we're essentially trying to salvage and take whatever we can that we have access to and mature it. The eggs are immature to start with, and they need, they need to be matured and pushed through different developmental stages. The final developmental stage, where we consider an egg to be mature, is what's capable of being fertilized successfully by sperm. So you're taking these injections, which are superficial injections with a very short, thin, small needle. You're pinching an area of fat on the lower abdomen and you're just depositing that needle and the medication under the skin superficially. And then it gets absorbed into your system. And hopefully, it will have the effect of getting as many of those eggs to grow and mature. And you're actually measuring and growing the follicle, which is a fluid-filled bubble where the egg is floating inside, and the egg is microscopic, so you can actually see that on the ultrasounds. And so we're bringing you in during the 8 to 10 days of shots that you're taking to monitor how the follicle is growing, we measure the diameter of each of these round follicles, and the size gives us a clue as to how mature the egg inside of each follicle could be. And we're also measuring your estrogen levels, so during the 8 to 10 days of shots, which in general will start on day two or day three of your period, because we want to start this process when all the eggs are on the same page and on a level playing field, or we'll start this like four days after coming off of birth control. During that 8 to 10 days of stimulation, you're maybe coming in for 5 to 6 visits on average, and of course, it's different for different people. But we're using those check-ins that happen usually at the beginning every 2 to 3 days, and then they become more frequent as you get closer to being ready, we're using those as check-ins to figure out if we want to add or cut back medication, if we need to bring you back in sooner for closer follow up, and ultimately, the main decision is when to trigger you for final maturation of those eggs. And that trigger shot is always timed 36 hours before the egg retrieval, which is the next step in the process. So our goal is to get as many mature eggs as possible. And I always tell patients that that phase of the process is two weeks starting from when you get your period or you come off of birth control, and then that, that part of the treatment ends with the actual egg retrieval itself.

Kristyn Hodgdon:
Mmhmm, I think a lot of people are surprised that the whole process is only about two weeks.

Lucky Sekhon:
Yeah, and I think it's because when IVF was first invented, we really only had one protocol or way of doing this. I should mention, in addition to stimulating the eggs, there has to be a way to prevent you from ovulating. And the first protocol that was ever invented used Lupron in the preceding cycle so that you could suppress the ovaries and prevent them from wanting to ovulate, in the subsequent cycle when you actually started stimulating the eggs. Now we have more modern protocols, where we can during the course of that 8 to 10 days of shots, at a certain point we can add in a medication known as an antagonist. This could be things like ... or ..., it really just depends on the pharmacy or the type of drug you're using. But it's basically added in at a certain point when we see a large follicle or a certain estrogen level to say to your body, okay, don't ovulate. It basically prevents that process from happening where your pituitary gland would send out additional signals to make these eggs be released. We don't want them to be released, we want your body to think that it's about to release them. So they're primed for the retrieval. But then we want to go in and actually take them out during the egg retrieval procedure. So to answer your question, the first part, ovarian stimulation involves stimulating the eggs and maturing them, but also using a mechanism to prevent the body from ovulating, which can be added in during the course of the stimulation. There's also types of protocols where you're utilizing microdoses of Lupron throughout the stimulation and those start at the same time as the stimulation shots and you know, eventually, they will also have that effect. The Lupron will also prevent your body from sending out additional signals that would make you release the egg. So there's always those two components, it's like a push and a pull. And then the third and final component is that trigger shot, which I think stresses a lot of people out because it is time-sensitive. A lot of people think that each of these shots is time-sensitive. And yes, we want you to take them with some level of consistency and your doctor will instruct you whether it's twice a day, morning and night, or you can do everything at night sometimes, but the trigger shot there really is not that much wiggle room, because once you give yourself the trigger shot, that usually means within an average of 40 to 42 hours you would actually release the eggs. So we timed the retrieval to happen usually around 36 hours after. That's the one thing that I would say is truly time-sensitive about these shots.

Kristyn Hodgdon:
I'll never forget, during my first IVF cycle, they said that the trigger shot was time-sensitive, and I said, do you mean if I'm on the Long Island Railroad, on my way home from work, I have to go into the bathroom and do it. And they're like, pretty much, yeah.

Lucky Sekhon:
Yeah! I feel like people have all different kinds of stories, including myself, because I've gone through multiple cycles and yeah, I've definitely given this to myself in a bathroom of a restaurant. So if anyone is listening and they've had a similar situation, you're not alone.

Kristyn Hodgdon:
Absolutely. So let's talk about the actual egg retrieval procedure, because it can be daunting. But, but overall, you're under anesthesia, and it's largely painless, correct?

Lucky Sekhon:
Correct. Yeah. So the anesthesia is not the same type of anesthesia that you would have for a major surgery. Obviously, each clinic might have their own way of doing things, but the standard tends to be a light sedation where you're given sedating medications through an IV, and I strongly recommend that this be done with the expertise of a board-certified anesthesiologist who's watching you the entire time. And that's their only job is to monitor your vitals, and the whole procedure itself usually takes anywhere from 5 to 15 minutes. So you're not under for a very long time, but we want to give you anesthesia because we want you to be totally relaxed, comfortable and not moving around and obviously not feeling anything. You're not going to feel or remember anything about the procedure and the reason why it's such a short procedure and what we consider a very minor surgery as far as surgeries go, it's because if you think about where the ovaries sit, they sit very low down in the pelvis. Forget any health class or any textbook diagram you've seen of the female reproductive tract because a lot of them show the ovaries to be really, really far from the vaginal canal, but they actually sit really low down on either side. And as they get bigger, when you're going through the stimulation process, they start to really kind of hug the outside of the vaginal canal and there's very little space or intervening structures between the vaginal wall and the actual ovaries, so they're easy to access. So we do everything vaginally, there are no incisions and we're using an ultrasound probe just like the ultrasounds, the vaginal scans that you've had during the course of your monitoring, during the ovarian stimulation, except it has a long, thin needle mounted on top of it. So under ultrasound guidance, meaning we're watching where the needle is at all times. We're passing the long, thin needle through the vaginal wall directly into the adjacent ovary. And we're just draining each of those bubbles of fluid and watching them collapse. And we're handing the tubes of fluid that are extracted to the lab next door where there are embryologists looking at them under the microscope and then sorting through the cells and counting the eggs and giving us updates as we go along. You'll be taken to the recovery room as soon as we're done. You wake up almost immediately and you'll be shocked to find that the procedure has already been done and it's over. You'll be given an update on how many eggs were retrieved, and that's all you'll really get in terms of information at that stage. And the main purpose of being in the recovery room is to just watch you and make sure you're feeling comfortable, you might have cramping, you may have a little bit of spotting, which is normal, but they're going to monitor all of those things and make sure that you're stable to be discharged. You should be picked up by someone that day because of the anesthesia, you might feel groggy and just kind of not so steady on your feet. So it's always important to have someone be a chaperone and take you home and you're going to want to sleep for like 3 or 4 hours, maybe even longer, you're just going to feel groggy and tired and out of it. Expect to continue to feel bloated, a lot of people think that the ovaries are going to deflate and all of those symptoms will go away immediately. But they're still going to be swollen, maybe even for a few days. And I would say you can expect all of the symptoms or side effects that go along with ovarian stimulation to fully go away within a week to two weeks after the egg retrieval, but in terms of time needed off of work, usually I only tell my patients to take the day off that they're having the retrieval. Maybe if they have, we're anticipating they're going to have a lot of eggs retrieved, maybe they'll have more symptoms or side effects than the average patient, I might say. You know what? Maybe take an extra day, but most people are back on their feet and feeling pretty okay by the next day, except for that residual bloating and just feeling fullness in your pelvis.

Kristyn Hodgdon:
Gotcha, that's really helpful. So something that I think is important to talk about when we, about the IVF process is what happens after the egg retrieval, because I think a lot of people during their first IVF cycle are surprised about how many eggs they retrieve versus how many actually fertilized and then how many actually make it to embryo or blastocyst stage. Can you talk a little bit about that?

Lucky Sekhon:
Yes, I think mental preparation for that part of things is essential. And I always go back to the basics when you think about what it takes to get pregnant. You know, not every egg fertilizes, not every fertilized egg grows into an embryo, not every embryo is going to be normal. All that inefficiency of human reproduction is still there. Doing IVF doesn't mean that you've completely circumvented that, it's just better and efficient as a treatment option because instead of working with one egg, you're hopefully retrieving multiple. And that's why IVF is a numbers game, because it's really an advantage when you have multiple eggs to work with. All of that attrition will still play out in the lab, but when you're starting out with a larger cohort, at least you're still ending up with something or maximizing your chance of ending up with something useful, like a healthy embryo. So in general, you're going to start off with a certain number of eggs retrieved. The next day we'll know, and actually by the end of the day, the lab will be able to understand whether those eggs are mature. If you're doing ICSI, you have to strip each egg of its surrounding cells. And that's actually the only way to know that an egg is mature because you have to be able to see certain structures on the outer part of the egg. So there are certain forms of IVF where we're not going to know about egg maturity, but in the case of where you're stripping the eggs of its cells because you're going to inject sperm directly into each one, that's called ICSI, we first assess the eggs for maturity and if 80 to 90% of eggs are mature, that to me, that's my personal threshold, in my mind of that was a great stimulation. I don't expect 100% of eggs to be mature because we're draining every single follicle, even the smaller ones that we know might not have a mature egg. So if the majority are mature, that will be great. But even at that early stage, there's some drop off. We'll fertilize the eggs either by dumping like 50,000 sperm onto each egg cell that's called conventional insemination, or we will do ICSI where we inject one sperm directly into each egg. Regardless, our average fertilization rates tend to be pretty high, like 70 to 80% of eggs fertilized successfully. But don't expect 100%. It's great if you get 100%, but you might lose a few in that early step of the process. And then the biggest drop off is really going from fertilized egg to embryo. And when we say embryo, what I'm referring to is something called a blastocyst stage embryo, it's, by definition when the embryo has separated out into two cell types and you can clearly see those two cell types under the microscope, the cells that become the baby and the cells that become the placenta, that line the periphery. And it takes a lot for an embryo to get to that stage. There's a lot happening during that 5 to 7 day process from the time that the eggs are fertilized. So if 60% make it, that's kind of in line with the average statistics. And we see age related influence here for sure. I mean, I think for women who are older and we know are probably going to have some egg quality and resulting embryo quality issues, it could be harder to grow fertilized eggs into a blastocyst stage embryo on day five, six or seven.

Kristyn Hodgdon:
Okay, I mean, this is so helpful for someone who sort of is just looking at the IVF process for the first time. I think this really kind of lets them know what to expect. So one last question, our company name is Rescripted, what would you rescript about how people think about IVF?

Lucky Sekhon:
I would say there are a couple of things that need to be rescripted. One is, it's not as scary, I would say, as is what it's often made out to be, because I think people hear IVF and they think invasive, needles, you know, a procedure, aka surgery, you know, and a lot of people are surprised to find out how we actually retrieve the eggs and how little downtime is required. So I think it's not as scary, it is a lot, I don't want to minimize that. It's a lot more intense than some of the other treatment options we've talked about, like IUI, and it is.

Kristyn Hodgdon:
But I always say that, I always say that coming off of many failed IUIs, IVF makes you feel a little bit more in control?

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
For my personality type was a positive. Like, you know, you're kind of, you know, every stage of the process is somewhat more controlled.

Lucky Sekhon:
Yeah, exactly. And you're getting a lot of information, too. I think sometimes people feel like if they are in a position where they do have to do a second cycle for whatever reason, either because they didn't get embryos or they didn't get enough embryos that they wanted to, don't think about it as a failure. It's obviously not where you wanted to end up, but I really mean it when I say that nothing is a waste. We get so much diagnostic information, especially from that first cycle, because you're getting insight into your biology and how your body behaves in response to these hormonal signals, how your eggs behave in the lab and interact with the sperm, it's really a lot of information gathering. The other major thing that needs to be rescripted when it comes to IVF is also on the other side of things, not to sound negative, but sometimes people will move on from treatments like IUI, where you've been programmed to think this is not likely to work. You know, it's kind of a crapshoot. The success rates are low, let's just keep going and then you switch to IVF. And I think sometimes it's easy to think, all right, now I'm going to do IVF and get pregnant. While I hope that for everyone, it is not a guarantee, IVF is not a guarantee and there is major attrition going from egg to embryo, none of that changes, it's just that you're starting out with a higher number. So I think that's obviously something that is a source of anxiety for people, but it's just important to be realistic and mentally prepared.

Kristyn Hodgdon:
Yeah, I think, I love when celebrities talk about IVF because it kind of destigmatizes the topic, but also.

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
I think it can give people the illusion that IVF works every time.

Lucky Sekhon:
Right.

Kristyn Hodgdon:
So I love like people like Amy Schumer who are coming out and saying like it didn't, it didn't work for me and no one wants that outcome, but, but I remember being completely blindsided when my, when I had a really successful retrieval and fertilization and got a good amount of embryos, and then my first transfer failed. I was like, What do you mean it failed?

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
I was completely blindsided. So, so, yeah, I think knowing all of this going and being able to be optimistic, but also kind of being able to balance that with, with being realistic is important.

Lucky Sekhon:
And I also think you can say be mentally prepared all you want. I mean, I tell my patients, I try to mentally prepare them, but it's one thing to intellectualize things and have the stats in front of you. And then it's a totally different ballgame to be going through it. I'm someone that.

Kristyn Hodgdon:
Absolutely.

Lucky Sekhon:
Like I said, has done multiple retrievals and I've had a retrieval where only two mature eggs were retrieved and, you know, they both fertilized, but I knew it was a long shot. And having all of the expertise and training still wasn't enough for me to be crushed and devastated when nothing turned into an embryo, right?

Kristyn Hodgdon:
Oh, yeah!

Lucky Sekhon:
So, it's hard and I think it's okay, whatever feelings that people go through and emotions that they have, and disappointments that they have, they're, to some level is no way to completely prepare yourself for that. And I think watching the attrition happen is always hard, even though, you know, it's a normal part of biology.

Kristyn Hodgdon:
Yeah, 100%. This is so helpful, Dr. Sekhon. I think a lot of people are going to benefit from this episode and we appreciate your time, until next time!

Lucky Sekhon:
Thanks for having me!

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Restripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe. To find this episode, show notes, resources and more, head to Rescripted.com and be sure to join our free fertility support community while you're there.

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