What’s Your Recipe? The Various Ways to “Bake” an Embryo
Disclaimer: we are not cooks, chefs, bakers, or anyone who knows how to make much besides pasta, PB & J, and scrambled eggs. So while we don’t recommend seeking out our advice on the best ways to cook your Thanksgiving turkey or how to get your soufflé to rise, we are going to take a page out of our foodie friends’ recipe book to explain IVF protocols. We want you to think of the medications as the ingredients, the needles and syringes as the mixers and pans, and the eggs/embryos as the final project (a.k.a. the cake). And while you will likely never see either of us on the Food Network or competing on Top Chef, you will hear us use the cake baking reference frequently. It helps for visualization and in many ways is pretty spot on.
Think back to the last time you baked or, more likely, watched Paula Dean do it on TV! On almost all occasions, when setting out to bake a cake you need some core ingredients: sugar, flour, eggs, and butter. These basics are pretty standard. What varies is the amounts, the order in which they are added, and the “other” ingredients. Some recipes call for chocolate chips, some for oatmeal, and some for cinnamon and nutmeg. So pull out your rollers, put your apron on, and let’s get cooking.
Step 1: Think of the hormones and the needles as “your basics.” Every protocol requires injectable gonadotropins (FSH, LH) to stimulate the ovaries to produce multiple follicles/eggs. However, the dosages and the formulations can vary. If you have been through this process before or know a friend who has, you are probably pretty familiar with the likes of Follistim, Gonal-F, and Menopur (brand names of the hormonal medications). Just like Duncan Hines, Toll House and Betty Crocker, they are similar products produced by different companies. And although one may claim to be fluffier and the other moister, in many ways, just like the medications, those chocolate cakes taste pretty much the same!
Step 2: While some of us like to create our menu and set out our ingredients days before we get started, others of us get the ball rolling just moments before the party starts. Again, the same can be said for the medications. While some protocols call for “day 2 of your period’s start” others require you to begin the injections about a week before your period arrives. Some even have you take preparatory medications (patches or pills) for a full MONTH before you start.
Step 3: For most cakes, butter, eggs, sugar, and flour alone are not going to cut it. Yes, the batter will be tasty, but the cake will be somewhat bland. Similarly, you can’t just give FSH and LH (Gonal F, Follistim, Menopur) alone. While they will certainly provide needed motivation to make the follicles grow, they won’t prevent ovulation. High estrogen + big follicles = Impending ovulation. Therefore, to prevent this, we must add an extra ingredient to prevent ovulation from happening before it is time for the retrieval. It is with this “anti-ovulation” agent that we can spice our recipe up and give it some flair. By varying the “anti-ovulation” medication (examples include Lupron, “Micro-dose” Lupron, Ganirelix, Cetrotide), we tailor the recipe to your taste buds (a.k.a. ovaries!).
Step 4: It’s time to put your masterpiece in the oven, but how long do you set that timer and how high do you set that oven? Here, again, we see variability. While some chefs may like to turn that burner off when the browning process begins, some might prefer a more charred look. The same can be said for when the final trigger shot (a.k.a. ovidrel, hCG, or Lupron) is administered; while some doctors prefer a shorter stimulation course and smaller follicles, others like to let things go longer and push the size of the follicles.
The basics behind the various stimulation protocols are almost always the same—stimulate the ovaries to produce multiple high-quality mature eggs. And just like in the kitchen, we don’t always achieve perfection on the first attempt. We learn a lot from past trials and improve on future endeavors—add a little more cinnamon, add a little less sugar, cut down on the time in the oven…In the same vein, protocols change between cycles—add a little more FSH, add a little less LH, cut down on the length of stimulation. And although doctors and chefs make it look simple, neither baking nor achieving a perfect stimulation is just not “as easy as pie.”