All about IVF

Hi everyone and welcome to another post. I hope you're enjoying my blog. Make sure you tell a friend. Dr. Carolina Sueldo, super easy to find, super easy to subscribe. The goal of this section is education. I want to make sure that patients have access to the information and that they're able to go into their visits empowered and with the information they need to ask specific questions for their individual case.

So if you've been following along, we started with what’s a normal menstrual cycle, the new patient visit, we moved into testing (Ovarian Reserve Testing, the HSG, and the Semen Analysis) and had a whole series of posts about testing, and now we're talking about treatment. I always start with talking about the three-armed approach. We talk about lifestyle, we talk about supplements, and then we talk about the medical therapy, the treatment you'll actually be doing in the office with the physician provider.

When we talk about fertility treatment, it gets divided up into three buckets. We talk about timed intercourse, with or without medication. We talk about IUI, which we covered last week, intrauterine insemination, also known as artificial insemination, that is typically done with fertility therapy medication. That medication can be either oral or injectable, also covered last week.

And today we're going to be talking about all things IVF. And IVF is that big, scary three-letter word that most fertility patients hope to never hear. But I'm here to demystify, and I really wanna try and break it down so that if you need to go through the IVF procedure, you feel like you have the information you need. And I'll just put a little asterisk here saying that IVF can be done in many different ways, shapes, and forms. It's definitely not a one-size-fits-all. And so I may in the future do shorter posts talking about genetic testing, talking about minimal stimulation IVF, talking about the different protocols. So we can kind of go over that in the future. But today, I really want to cover the basics. This is really going to be IVF 101.

And a second asterisk is really talking about stress management. The reproductive psychology literature shows that going through IVF can be as stressful as going through cancer therapy. So knowing that, acknowledging that, and then being proactive about taking steps to address that is gonna be hugely important as you go through your IVF process. You wanna make sure that whatever that stress management looks like for you, again, in a previous episode, we talked about acupuncture, meditation, super helpful, super important, counseling, whether that's individual or couples counseling, group therapy, online or in person. There's so many different ways to to do stress management, but you really want to make sure that you're being proactive about it.

Okay, so now let's start talking about IVF. Generally speaking, from a logistical standpoint, there are two big parts to the IVF process. So the first one is going to be the preparation stage. Most fertility clinics will make sure that you have all the paperwork signed, you know, all the consents, what happens to the embryos if one of you dies, if you divorce, what's the disposition if you complete your family? So there's a lot of things that go into that paperwork. You want to make sure you take your time, you read through it, and that you have a thoughtful discussion with your partner, if there is a partner present, to talk through what this might look like for you guys.

The next thing they're going to look through is sort of a checklist. Is your pap smear up to date? If you're over 40, they may ask for a mammogram, and then the CDC does require some infectious disease screening for both partners. We want to make sure that that's up to date so going through that checklist and crossing things off as they go through. And then the last piece will be ordering medications. The medication order will depend on what your physician has recommended as far as your treatment protocol. And sitting down with the nurses to talk through the medication piece. Now, the last one, if you are not in a mandated state or if you do not have insurance coverage, is you want to have a clear understanding of the costs involved.

Most people understand that IVF is a very costly procedure. It depends on the geographic location, depends on the clinic, but it also depends on the treatment that you are specifically doing. So you want to make sure that if you don't have insurance coverage and you'll be paying out of pocket, you have a clear breakdown of what's included, what's not included, what additional costs may be coming down the pipeline as you go through the procedure to try and avoid any major surprises.

So going back to the IVF process, we're still in that preparation phase. So we talked about paperwork, including consents. We talked about that checklist going through pap smear, infectious disease. And then we talked about medication ordering as well as cost sheet or cost breakdown.

Now, once you get into the treatment stage, there are basically three different parts to the treatment itself.

The first step is ovarian stimulation. The goal is to stimulate the ovaries to produce as many eggs as possible. That stimulation is typically done with injectable medications. Remember we talked about Follistim, we talked about Gonal-F, we talked about Menopur, also Bravelle might be out there. So those are the different stimulating medications typically given in doses to optimize recruitment and stimulate the recruitment of as many eggs as possible. Now, if you think about what happens in a natural cycle, estrogen kind of peaks around 200 to 250 picograms per ml, and that's what triggers the LH surge of ovulation. But here, we're not stimulating one egg to grow, we're stimulating lots of eggs to grow. So your estrogen levels are gonna be significantly higher than what they would be in a natural cycle. So if we just did the stimulation meds alone, then the brain would trigger that LH surge of ovulation and release all those eggs into the pelvis before we could get to them with the egg retrieval. We have to add in an additional medication to prevent that premature LH surge or that premature hormone of ovulation from releasing. And there are two types of medication to do that:

1) The traditional medication, the one that's been around the longest and just the one we've used longer, is known as GnRH agonist, also known as Lupron. Some people may have heard Depot-Lupron, others may have heard Mini-Lupron or microdose Lupron, but basically Lupron is an agonist to the GnRH receptor. All that means is it binds to the receptor, stimulates it, so it induces the release of FSH and LH, and then once it's done stimulating, it stays turned on and the brain can never replenish its supply. So ultimately that stimulant becomes a suppressor. It prevents that premature LH surge of ovulation. It's a little bit of a complex way of thinking about it, but really, it's helpful for us because either the lupron is started while you're on birth control pills or around cycle day 21. So it’s started before your stimulation. And the idea with that is to minimize that flare effect from the initial stimulant effect that it has. So by the time you start your injectables, it's having that suppressor effect on the brain.

Microdose lupron it's completely different; it’s started either with or just before your injectable medications with the goal of exponentiating stimulation so you're not only getting the external medication that we prescribed, but you're also getting that flare effect from internal FSH and LH to hopefully boost that stimulation internally. So the idea behind the agonist is that initial stimulant or flare effect followed by a suppressor effect. Again, the goal, prevent the LH surge of ovulation prematurely.

2) The second medication is going to be a GnRH antagonist. So we have agonist and we have antagonist. The antagonist is now more commonly used than the agonist, which was around first. The antagonist is a daily dosing. It binds to the receptor and essentially blocks it from acknowledging circulating estrogen levels. So you have two medications out there, typically Ganirelix or Cetrotide. Both of them, they're just different companies, but same medication. It's a GnRH antagonist. The nice thing about the antagonist is that it does not deplete the internal supply. So if the patient has a very robust response, a very high response to medication, we can tweak things around to try and minimize her risk of ovarian hyperstimulation syndrome. But I'm getting ahead of myself, so let's go back to the stimulation. Typically you would do the injectable medications for 8-10 days (on average). Somewhere in there, we're going to incorporate either the GnRH agonist, think Lupron, mini lupron etc or we're going to have the GnRH antagonist typically started about halfway through your stimulation, remember that's going to be Ganirelix or Cetrotide.

And throughout all of this, you are having regular monitoring with your physician or your clinic to make sure that the number of eggs growing are appropriate and the size of the eggs are appropriate. And again, every physician, every clinic has slightly different trigger criteria. Typically that is dependent on what they have seen in their lab. And so when the follicles are ready, they'll give you a trigger shot. Remember the post from last week, that trigger shot is to mimic the LH surge of ovulation. And based on the timing of that trigger shot, they would plan out the egg retrieval. Now, classically, the trigger shot that has been used is something called HCG. And I mentioned Ovidrel, one of the commercial names. You can also use Pregnyl. There's Novarel. There's several. Compounded HCG now also exists. So there's several different formulations, but the HCG is acting as a stimulant or as a mimic to the natural LH surge of ovulation.

What's interesting is that if you are using an antagonist and if the patient had a very robust response, your clinician may decide to switch out that HCG for another medication, Lupron. Lupron, which is that GnRH agonist we talked about, may be used as a trigger shot if and only if the antagonist was used to block that surge of ovulation. Why? Because it replaces or it displaces, I should say, it displaces the antagonist, binds to the receptor, and provokes your own internal release of LH.

And because LH has such a short half-life in the body, the ovarian stimulation decreases rapidly. So once the egg maturation process has occurred and (meiosis) reinitiated, and we've done what we've needed to do, it goes away, the ovaries shrink, and the risk of hyperstimulation is essentially eliminated. I wouldn't say it's completely zero, but the risk of hyperstimulation is very, very, very, very low.

Now you'll have the egg retrieval. The egg retrieval is typically done with a little bit of sedation. The eggs will then be combined with sperm, embryos will be formed, and then those embryos will be put back into the uterus known as an embryo transfer procedure. For the embryo transfer, you are typically awake. It is typically done in a room that is connected to the IVF laboratory. And you're watching the whole thing happen.

In terms of what you feel, it's very different from the egg retrieval. It feels very much like a pap smear or an IUI procedure. But obviously there's a lot more involved and it's a lot more delicate.

So that my friends, in a nutshell, is IVF. So ovarian stimulation, trigger shot, egg retrieval, embryo culture, embryo transfer, pregnancy test. Now those are the broad strokes. There's a lot more to it than that, but I really wanted to focus on the stimulation piece and understanding the why we use each of the medications. If you understand the why, that'll help you navigate your journey with your physician.

Please understand that every physician and every clinic has a little bit of a different tailored approach. So you really want to make sure you're talking to your physician about what approach they're going to recommend for you based on their clinical experience, based on their lab, based on their protocols, but also based on your diagnosis.

I hope this has been helpful. If you have not already, please be sure to subscribe to my YouTube Channel and I'll see you next week. Bye-bye now.

*This content is intended solely for educational purposes and is not to be construed as medical advice. For personalized recommendations concerning your specific healthcare needs, kindly consult with your healthcare provider.
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Focusing on Fertility Meds & IUI