Looks Can Be Deceiving…We Recommend a Double Take!

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At least once a day we get a call from a friend, a friend of a friend, or a friend of a friend of a friend (say that three times over) asking us to review their results and give them our advice. Inevitably, they are overwhelmed, frightened and often confused. “FS something, I’m not sure” and “mobility of sperm okay but appearance abnormal.” After we sort out some of the details, we are ready to break it down for them in the most basic of terms. Here are some of our tidbits from girls in the know.

  1. FSH means NOTHING without Estradiol. FSH and Estradiol are like Bert and Ernie or Bonnie and Clyde. You can’t test one without the other; they don’t make sense when analyzed alone. FSH is a hormone made in the brain (pituitary gland) that signals the ovaries to ovulate (and make estrogen measured as estradiol in your blood).  When FSH is measured early in your cycle, if elevated, it may indicate a decline in ovarian function (meaning your egg quality is declining, making pregnancy more difficult).
  2. FSH is falsely lowered by a high estradiol. A normal FSH level with a high estradiol level means that the FSH is NOT normal. Estrogen from the ovaries sends a signal back to the brain to make less FSH in the brain. When estrogen levels in the body are high, the brain makes less FSH. While abnormal levels don’t mean you’re down for the count in terms of baby making, it does make us question whether your ovaries are the cause of your fertility struggles.
  3. FSH and Estradiol MUST be sent to the lab on days 2-4 of your cycle. They are not accurate (in all cases except for women with very long, irregular cycles) if sent at other times. Don’t have the blood work done on the wrong day just to check it off your list; you will be re-writing it on your To Do list for the next month.
  4. The ranges on the lab report are not always right. Yes, we know that this may sound confusing and totally contradictory but levels need to be interpreted by a physician. Make sure that if you get your levels you speak to a licensed professional before shedding too many tears.  Don’t go straight to Dr. Google with your FSH level until you understand what it means for you specifically!
  5. The “dye test” (or the HSG, as we call it) must be done in the early part of your cycle. It cannot be done after you ovulate (you could be pregnant!)
  6. An HSG is not meant to be torture. While it can hurt, in most cases it’s pretty tolerable. Take some Ibuprofen before…You should be fine!
  7. A “luteal progesterone” test is not equivalent to a day 21 progesterone test. Luteal means “post-ovulation.”  Physicians often test a progesterone (blood test) on “day 21” to confirm an elevation, indicating ovulation.  A day 21 progesterone test is only appropriate for women who have (approximately) 28 day menstrual cycles. If your periods are 35 days, your progesterone on day 21 may be negative (low indicating no ovulation), but that doesn’t mean you won’t ovulate or didn’t JUST ovulate. It just means that it is  (approximately) 7 days too early to check the levels. Make sure to share how long your cycles are with your doctor before diving into the blood work.  If you have longer cycles, then going in after day 21 may be better to confirm whether or not you are ovulating.
  8. Not all fibroids are created equal. Fibroids can be a big deal. They can cause pretty bad bleeding, pretty significant pain and pretty real infertility. However, the caveat to the infertility issue is location, location, location. Whether or not a fibroid causes infertility depends on the location of the fibroid. Fibroids located within the uterine cavity are WAY more likely to cause infertility than those in the muscle. Make sure you have a road map of where your fibroid is before you undergo surgery.
  9. Motility (a.k.a. mobility in the words of many patients!) is how sperm swim. It is reported as a percentage (% of sperm moving in the sample). Old school normal was 50%. Now that number has been knocked down to 40% (and only 32% need to be moving forward). While no one wants to fail at anything, take it easy on your guy if his “mobility” is off—chances are if you use the newer guidelines things won’t be too bad.
  10. Sperm shape has really taken center stage recently. It has become one of the most debatable, doubtable and don’t-know-what-to-do-about-it issues. While it is still unclear as to what abnormal morphology means (impaired fertilization potential currently tops the list), the level of normal to abnormal has been reduced significantly. The new normal is 4% or above. Make sure that you are aware of the new numbers and are aware of what the information means before you start any treatment (some centers are still using the old reference values and therefore are calling anything <14% abnormal rather than <4%). Additionally, while low morphology does mean your partner needs more testing, it does not mean that he needs IVF (in vitro fertilization)!

There are a lot of myths circulating out there. Make sure to ask a reliable source before counting yourself out. While we may not be a friend of a friend of a friend, we are certainly your professional pals!

Playing the Lottery: Egg Count

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We’ve all been there before: lying in bed, listening to the local newscaster call out the Powerball numbers, hoping this may be your night! And while you may be a lottery regular, most of us hold out on playing until the pot is big. Really big. And if it gets super big, you might not only buy one ticket, but go in with your officemates for a bunch of them, because the more tickets you have, the better your chance of hitting the jackpot. The same can be said for egg number and good-quality embryos—the more eggs that are retrieved, the better your chance of having a baby!

Whether you’re an IVF newbie or have been through many retrievals, you know that numbers matter. Whether it’s from your fertility Facebook group or your fertility doctor, the numbers are a big deal in the land of fertility treatment. Not only does lower egg count reduce your chances, but also for many women, lower egg quantity is often linked to lower egg quality. For most women, both decline with age, and when low, make having a baby much harder.

Therefore, the more eggs that are produced during an IVF cycle (thank you, hormone shots!), the more embryos that can be created in the lab. The more embryos, the better the chance of having a baby. In many ways, it’s no more complicated than simple math. More leads to more leads to best leads to BABY!

And while the daily shots are no one’s idea of fun, they’re actually pretty essential to the process. The fertility medications serve as the “multiplier” in this mathematical equation—they take what’s already there and make them grow! Without this stimulus, it’s nearly impossible for the ovaries to produce multiple eggs.

So, although it’s fairly unlikely that any of us will even come close to winning the lottery, for many, it’s pretty likely that we’ll win the baby lottery. Because in the egg Powerball, even when you buy only a few tickets, with the right fertility clinic and fertility doctor, you have a serious chance of winning! And while we never encourage cheating, this is one place where a little help counting your cards (a.k.a. your doctor) is strongly recommended. Winning this game requires a strong and supportive team!

What Happens in the OR Stays in the OR!

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No matter how excited you are to get your eggs out (#retrievalday), the OR is no one’s idea of a good time. It’s cold, it’s sterile, and everyone is wearing a mask. To make matters worse, your backside is usually baring itself to a roomful of strangers (gotta love those hospital gowns)! And although you won’t remember a whole lot about what happens on that day (thank you, anesthesiologist!), here are the four things you can pretty much count on as you count yourself to sleep!

  1. Identification: We want to make sure you are who we think you are— repeatedly. When it comes to anything medical, particularly egg- or sperm-related, we’re super strict about identification. Plan on us asking you your name, your date of birth, your partner’s name, and their date of birth MANY, MANY times. This is one place that less is not more. Before you have any of the good stuff flowing through your veins, you want to make sure that you’ve been identified by the operating room team, the physician, and the embryologist. No shortcuts here! You want everyone to know who you are, why you’re there, and what you want done with your eggs.
  2. Recognition: You’ll see lots of familiar faces: The staff in the Operating Room generally includes a nurse, a surgical technician, an anesthesiologist, and a doctor (likely your doctor!). Given the amount of time you’ve spent getting your blood drawn and your ovaries checked, you’re probably on a first-name basis with almost everyone in the clinic. But if you’re not and these faces are somewhat foreign, they should introduce themselves. You should feel comfortable (although a bit cold) with the people around you!
  3. Reposition: While you’ll enjoy some Zzzs (again, thanks to your friend the anesthesiologist), we’ll ask you to do some exercise beforehand. And while we’re not talking about Soul Cycle, we do need to position your body so your bottom is aligned with the operating room table. Where you’re positioned on the operating room table will ensure that we can safely extract your eggs and that you can walk out of the office without any aches and pains.
  4. Relaxation: After the formalities have been exchanged (identification, recognition, and reposition) it’s time to go off to your “happy place” of choice. And whether you’re a beach or mountain girl, get ready to be there for the entire 15 minutes it takes your doctor to retrieve your eggs!

MDs love the operating room. It’s part of why we do what we do. But we get that, to most folks, it’s a scary place. And while we’re not likely to convert you into a surgery fan, we can help alleviate some of your anxiety surrounding the procedure by sharing some of our tips. So, take a deep breath, and know that most likely your doctor has done this MANY, MANY times. He or she has this covered. And don’t worry; whatever secrets you share are safe with us. What happens in the operating room stays in the operating room!

Embryo Glue: The 5 Secrets Everyone Should Know Post-Embryo Transfer

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There may be no more anxiety-ridden interval than the time between the embryo transfer and the first pregnancy test. Simply stated, it is sort of terrible. Those nine days can feel like nine years. Every symptom you feel (or don’t feel) can take your mind to places you didn’t think it was possible to go. However, while the rollercoaster of emotions is real, the good news is that you are not alone. Nearly every woman who has come before you and every woman who will come after you find the time between the transfer and the pregnancy test to be incredibly stressful. Here are five tips on how to best deal with your emotions during the transfer-to-test interval.

  1. Movement: Standing up after the embryo transfer is finished ranks up there on many women’s top 10 list of scariest activities while going through fertility treatment. The “if I move these embryos are going to fall out sensation” is super common, but it isn’t super credible. In fact, there is absolutely NO medical evidence to show that movement, be it in the form of a trip to the ladies room or a bumpy car ride home, will negatively impact your chances of pregnancy. Don’t sideline yourself just because you had an embryo transfer.  Movement won’t be the factor that makes or brakes the pregnancy.
  2. Diet: Food gets a lot of credit and a lot of flak when it comes to fertility. Pineapples will make your embryo stick, and hot dogs will make your embryos not stick. And although who doesn’t love a sweet pineapple in the middle of July, there is no evidence that food will improve or harm your chances of pregnancy. Bottom line, don’t lose sleep over what you have and have not taken in—your “intake” will not impact if your embryo takes up a permanent spot in your uterus.
  3. Exercise: There may be no more controversial words than exercise and fertility. These two engender A LOT of emotions. And while it may seem like it from what you hear and what you read, in reality exercise and fertility are by no means oil and water. Exercise—be it walking, running, cycling, or swimming—is not a no no post-transfer. While you may have to curtail your specific activity based on if you had a fresh or frozen embryo transfer, breaking a sweat won’t break your chances of pregnancy.  We do usually recommend a 48-hour period of relaxation after the transfer—but after that, most forms of exercise are okay. Just touch base with your doctor.   We will say, for those of you who will look back and blame yourself if the transfer does not work, we recommend you don’t engage in any activity that will make you think twice.  We can tell you there is no sound data to suggest moderate exercise after an embryo transfer will lower implantation rates, but we want you to have zero regrets!
  4. Coffee: Don’t say sayonara to Starbucks just because you had an embryo transfer. Coffee is not the culprit for your infertility and is cool (or hot!) post-transfer. While you should taper the amount of caffeine you ingest (<200mg/day), you can continue to indulge your caffeine kick.
  5. Stress: It’s nearly impossible not to count down the days from the transfer to the pregnancy test. The anxiety, anticipation, and stress mount as the time between these two events is minimized. These emotions are totally normal. Everyone has them. Engaging in activities that can help alleviate your stress is recommended but not mandatory  (although de-stressing will do your mind good, it won’t make a difference on the outcome of the transfer). On the flip side, if you can’t take your stress level below a 10 no matter what you do, don’t freak out. Stress post-transfer has not been demonstrated to decrease the chances of pregnancy.  

It’s important to always remember that whether you DO or DO NOT get pregnant, post-embryo transfer has to do with the quality of the embryo, the genetics of the embryo, and your uterine lining—not what you DID or DID NOT do. Unfortunately, you can live your best you and still not get pregnant. And while we don’t have all the answers for what makes some transfers work and others not, we promise to keep searching for that evasive “embryo glue”—and if we find it, we won’t keep it a secret!

The 5 Most Important Questions to Ask When Looking for a Fertility Clinic

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While fertility clinics aren’t as prevalent as Starbucks and Duane Reade in New York City, there are definitely many options to choose from. From uptown to downtown, the east side to the west side, you have a choice. And unless your BFF or your OB/GYN points you in a certain direction, deciding where to direct your care can be difficult. Whom you see and where you go can be the difference between walking away with a baby and walking away with nothing more than a big bill.

Here are the five questions you should ask before deciding where to do your thing!

  1. Success Rates:
    Fertility medicine is moving fast. To quote our friend Ferris Bueller, “Life moves pretty fast…if you don’t stop and look around once in a while you could miss it.” The same goes for fertility treatment! As a result, you need to make sure wherever you go for treatment not only knows this but also practices fertility medicine on their toes. Being up to date with the newest techniques and latest procedures translates into success. Furthermore, you want to check the success rates of the clinic you are visiting and what they are doing to get those success rates—say, are they putting in multiple embryos to get a pregnancy, or can they achieve those success rates with a single embryo transfer? Although your goal may be to have a brood one healthy baby at a time is the safest way to go.
  2. Practice Styles:
    While we all went to medical school followed by a residency and fellowship to become board-certified Reproductive Endocrinologists, the way physicians practice medicine can be very different. Some are talkers, and some are quiet. Some like to chat on the phone, and some prefer to email. Some move fast, and some move slow. Make sure that whom you select as a doctor matches your needs and personality. These partnerships can be lengthy; you want to make sure you find someone who has the “death do us part”-type of feel. While you can certainly get a divorce if things get rocky, starting over puts you back at square one (minus some valuable time).
  3. Take a number; we’ll see you in an hour:
    Unfortunately, many fertility clinics have started to resemble factories. Patients are shuttled in and out like cattle going down an assembly line. Waiting rooms are littered with patients, and you can go an entire IVF cycle without seeing a physician who knows you by name. Before you commit to a specific center, ask around about how the clinic functions and what previous patients who have been treated there have experienced. While it may not change your decision about where you decide to be treated, it will prepare you for what lies ahead.
  4. Availability:
    We all have busy lives and schedules. Trying to squeeze in time to chat with your mom can be a challenge. Therefore, it’s important that you know when both your doctor and fertility clinic will be available not only to speak to you but also to see you. Just like personalities, you want to make sure that your schedule can effectively merge with their schedule.
  5. Honesty is key:
    Sugarcoating the situation when it comes to your ability to have a child can become a “sour” situation. You need to make sure that the physician you are seeing is honest with your prognosis, the chance of the treatment being successful, and the clinic’s ability to help you achieve your goal of having a baby.

     

The 10 Questions Everyone Should Ask When a Fertility Cycle Fails

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A negative pregnancy test can be hard for anyone to bear, particularly individuals and couples who are going through fertility treatment. It’s like studying for weeks and weeks for an exam, thinking you know the material, and then getting an F. “Disappointing” doesn’t even begin to describe how you feel. And while the first place you usually go is your significant other’s shoulders for a good cry (and for a glass of wine and a bite of unpasteurized cheese), the second should be to your fertility doctor to break down why this cycle didn’t = baby.

Here are our suggestions on what should be on your list:

  1. Why didn’t it work?

Hands down, this is the most frequently asked question when a fertility cycle is not successful. And while it is a good place to start, in order to get concrete answers, it’s better to break it down into little pieces (a.k.a. your reproductive parts). When you chat with your doctor, make sure to be specific in your line of questioning; the narrower the question, the more useful the answer. And bring a pen and paper!

  1. Did I make a bad egg?

While we are never fans of finger pointing, in many cases the culprit is an abnormal egg, which resulted in an abnormal embryo, which = no pregnancy (especially if this was an IVF cycle where the embryo did not undergo genetic screening). Unfortunately, barring genetic testing of the embryo, there is not much that we can do to predict if the egg you ovulated or we extracted was normal. While we use hormonal assays (think FSH and AMH) and female age to help guide our treatment plans and analysis of the outcome, they are limited in their abilities to predict the future. This is why we are huge advocates of embryo screening. While it can’t tell us if the extra chromosomes came from the egg or the sperm, it gives us a lot of data about where the “damage” may have started. And while it is nearly impossible to change egg quality, by analyzing the embryos that are produced by those eggs, we can find the good egg (s).

  1. Was my partner’s sperm only so so?

Although men are often sperm-making machines for years longer than we are egg-making machines, as time ticks away, so does sperm quality and quantity. Furthermore, certain medical conditions or recreational habits can hamper your other half’s sperm production. Make sure that your partner has had a semen analysis, and if the results were only so so, your fertility doctor should refer your partner to a urologist. There are procedures, techniques, and medications that can help improve sperm quantity and quality.

  1. Are things not flowing freely through my tubes?

Think of the tubes like any major New York City tunnel—they can get blocked up anytime and for any reason. And while there are certain things in one’s medical and gynecologic history that would predict a tubal closure (a.k.a. a history of pelvic inflammatory disease or multiple abdominal surgeries), in many cases they are just closed for no clear reason. Therefore, before any fertility treatment is initiated, it’s a good idea to have your “tunnels” checked. If there is a problem, you will need to take an alternate route to achieve a pregnancy—and learning this before you set out on your fertility journey will save you a lot of time!

  1. Was my uterus not ready for a guest?

Although the uterus is infrequently the primary or solo cause of infertility or a failed fertility cycle, it should be looked at from a few angles. Routine ultrasounds depict the uterus in two dimensions. And while it can look good in this mirror, it’s important to have a 3D study or a test (HSG or hysteroscopy) that shows the inside of the uterus. Unwanted guests (e.g., fibroids, polyps, or scar tissue) that can interfere with implantation can be lurking!

  1. Should I repeat the same treatment, and if I do, what is the chance it will work?

Yes and no and maybe. (Well, that was helpful advice!) But all kidding aside, the reality is that most fertility treatments doesn’t work the first time you try them. You often must try a few attempts before you see success. However, you should 1,000% speak with your doctor between every attempt and ensure he or she breaks down what happened and how he or she can make things happen next time. Additionally, make sure you have an end point. While this road can be long, it shouldn’t be endless. Make sure there is a stop and you know where and when that will be.

  1. When is it time to move on to the next step?

Unfortunately, this one doesn’t have an easy answer. However, we added it to the list to make sure you ask it. And to ensure that you know that there are options, both in what you do and where you do it. You aren’t tied to one type of treatment or one treatment center. Ask, look, and listen. There are many good resources out there with lots of information (#trulyMD).

  1. Do you have paper and pen?

Write things down! Whether it be the questions you want to ask or the questions that you had answered, remembering everything can be hard. Jotting down what you want to say and what has been said will serve you well in the future.

  1. Can I have my records?

You are your best advocate (and your best record keeper). Asking for your records and speaking up on your behalf does not make you annoying. It makes you smart. And while you don’t need to become a bookkeeper, keep track of what goes into and out of your body. It can ensure that you stay balanced!

  1. What’s next?

We love plans. Just check out our calendars! But we especially love plans when it comes to our patients. Knowing what you are going to do if your day 1, that is, your period, comes can make dealing with D day somewhat easier. Simply stated, plan for the worst (#period), but hope for the best. That way, you won’t waste any time.

Getting pregnant and having a baby are not easy. Contrary to what we thought in college, you don’t get pregnant every time you have sex! Although people use the word “fails” liberally, remember that you are so not a failure. Doing fertility treatment is hard: emotionally, physically, and financially. Staying in the game when things get hard makes you a success—no matter what that pregnancy test shows.

If Your Friend Jumped off a Bridge, Would You Do It, Too? Altering your lifestyle for fertility.

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How many times do you remember telling your parents, “I did it because Susie did it”? And how many times do you remember your parents saying, “If Susie jumped off of a bridge, would you do it, too”? This usually was met with a muffled “no” and a trip to your room. Bottom line, the “because my friend did it” response never got you anything more than a grounding. And while our moms may no longer discipline us, our doctors do. And telling us that you have picked up bad habits because Susie has them is not going to go over well.

Saying that habits are hard to break might be the understatement of the century. They become a part of us, our routines, our cultures, and the essence of who we are. Whether it be smoking, drinking, drugging, or doing lots and lots of exercise, they become a part of who we are and how we see ourselves. Because of the latter, it makes them really hard to taper or totally take out. Even the best of habits (exercise, eating healthfully, or engaging in some sort of activity) can become excessive, and while they may not need to be eliminated, they may need to be reduced.

Substituting is a great concept and often works well. For cardio junkies who can’t turn up the torque during IVF stimulation, we recommend a long stroll in the park or an inclined walk on the treadmill. You don’t have to lie on the couch and eat bon bons (although it is nice to give yourself a break!); you can still do something that will build a sweat.

While some habits can be halved or quartered, smoking and drug use need to be out out completely. There is no healthy amount of smoking or toking; it’s got to go. It’s not good for your ovaries or any of your vital organs, so take this as an opportunity to go cold turkey.

When it comes to alcohol, we are definitely more lenient. I think someone said a glass a day will keep the doctor away. Although this is probably more wishful thinking than reality, a glass of wine from time to time (it even rhymes!) is nothing to stress about. You don’t have to cork the bottle when you’re trying to get pregnant.

Food is a fairly big issue when it comes to fertility. Although nothing has been proven definitively, there is a lot out there on the internet and blogs, as well as in friendly conversations, about what is best to eat. Should I can the carbs, should I forget about fat, should I say goodbye to gluten? We say no, no, and no, not unless you have been diagnosed with celiac disease (true gluten intolerance) or have been directed to follow an anti-inflammatory diet.

Dietary variety is a good thing. We need proteins, fats, and those carbs (we have such a love-hate relationship with the lattermost). While everything in moderation is the right way to go and no one ever overdosed on fruits and veggies, eliminating foods to boost your fertility probably isn’t the best idea.

What works best for you and your body may be very different than what worked best for your BFF or your pseudo BFF. As much as we may think our bodies are the same, they are not. Yes, we all have bones, brains, and muscles, but after the basics, there is a lot of variety. So while Sally had to cut out sugar and Georgia had to remove gluten, you don’t necessarily need to follow their menu plan.

Despite what you hear, fertility treatments do NOT mean you have just seen the finale of your favorite things; telephone is a dangerous game! Exercise, caffeine, and alcohol plus are okay when trying to conceive. While we may ask you to tone it down, we will infrequently ever ask you to turn it off completely. Although your friends and those who have made the fertility journey before you are a good source of information, they do not have the final word. Just because they were told to do something or had to change something doesn’t mean the same applies to you.

Leader of the Pack, Take It on Back!

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For all of you runners, cyclists, and swimmers out there, you know how good it feels to exercise in the pack. There’s definitely comfort in numbers—the energy and the spirit can pull you through even the steepest of hills or the roughest of currents. Drafting off the guy or girl in front of you is also pretty nice! Follicles (a.k.a. eggs) also like the group mentality. Growing in concert or an evenly sized cohort is ideal. It increases the chances that many, if not most, will achieve maturity simultaneously. Mature eggs are the ones that get fertilized, and fertilized eggs = usable embryos!

When a follicle takes the lead, we’re not standing on the sidelines applauding and screaming, “Go, follicle, go!” We’re actually pretty bummed and do everything we can to hold it back and let the others catch up. No, we’re not believers in the “Everyone gets a trophy no matter what place you come in” phenomenon, but lead follicles can negatively affect the outcome of an IVF cycle. They can force you into scheduling the retrieval a bit early to avoid compromising the bigger ones. This can result in a bunch of eggs that are uneven in development and therefore uneven in maturity.

Additionally, if one follicle is putting the pedal to the metal while the others are strolling in the pack, there is dis-synchrony in the hormones secreted. The leader has enough juice to get him or her across the finish line. However, the fumes the leader is releasing can be toxic to the smaller follicles. Hence, it can impair their growth, development, and quality.

When an egg retrieval is performed, there will always be something of a Goldilocks story. Some eggs will be post-mature (too hot), some will be immature (too cold), and some will be mature (just right)! It’s very hard to complete 100% maturity (and probably not normal). When a lead follicle pops up, it can throw the balance off even more. To avoid the leader of the pack, we have many tricks up our sleeve, a.k.a. the birth control pill, estrogen patches, and luteal antagonists, to name a few. The purpose of pre-stimulation medications is to level the playing field and make sure everyone starts the race when the gun goes off (and not a minute before).

If a dominant should arise, we can either chose to cancel the cycle or ignore it. By ignoring it, you can recruit what’s called the secondary cohort. While this can work, it can also compromise the quality of the follicles on the B team. In this case, it becomes a pluses and minuses and pros and cons-type of situation that you and your physician need to have.

Synchrony’s a big deal in ovarian stimulation. It’s what we strive for, what we train for, and what we aim for. We know when it isn’t happening and know how to try and make it happen. When we can’t get it to happen, no matter what we pull out of our hats, it’s a sign of poor egg quality.

Follicles, just like females, like to travel in groups. We can chat, we can bond, and we can share experiences. Going out on your own can throw off the balance of everything else, and it can be lonely! If your follicles appear to be growing unevenly, have a sidebar with your doctor and talk about calling a time out. Even if you do it again and have a lower number that’s more even, that’s probably a better race to run. Think about how much you and your friends can cover if you do it together!

“Judgey” Eyes: What Are Embryologists Really Looking At?

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How do I look in this dress? What do you think of these shoes? Is red a good color for me? Let’s face it: even the most down-to-earth among us has an inner diva. Who doesn’t want to look good and turn some heads? Furthermore, how we look on the outside can impact the way we feel on the inside. While we’re certainly not saying that looks matter, we are saying that how you think you look often impacts the way you feel. The same can be said for your embryos. How they look to the embryologist in the lab can tell us a lot about their health, their genetics, and their ability to make a baby.

While different labs use different grading systems, most that perform day 5 or 6 embryo transfers use the Gardner and Schoolcraft embryo scoring system. This dynamic duo introduced their scoring system in 1999 to determine blastocyst (day 5 or 6 embryo) quality.

And while it’s certainly not the Miss USA competition, embryologists are grading the embryos in three ways: development and morphology (don’t worry; we can count). Morphology is assessed for both inner cell mass and the trophectoderm, bringing the total to three!

Embryologists are looking for things like embryo expansion, cell compaction/tightness, and cohesiveness. Years of experience and tons of training have trained their eyes to be really judge-y and label these areas with letters and numbers. We don’t give an overall number; it’s more of a general impression! The cumulative score determines which embryos have the potential to wear the crown. The scoring system not only helps embryologists and fertility doctors decide which embryos to transfer but also how many embryos to transfer. Those with straight As should have a limited number of embryos transferred to avoid an octo-mom situation.

Remember, just like undergrad universities, some grade inflation may go on. An A at Harvard may be a B at Yale—grading is subjective. (Just sayin’. And no, neither of us went to Harvard or Yale). Therefore, while a patient may make all A+ embryos in lab #1, when they come to lab #2, the report card can be totally different. Usually, this is not because your eggs or your partner’s sperm went over the cliff, but because the scoring was skewed. Skewed scoring doesn’t decrease one’s chances; it just messes with one’s expectations. If you have an A+ embryo, you’ll think this is a slam dunk. If it’s really a C, you won’t expect to win the science prize.

Unfortunately, even those with the “judgiest” of eyes can’t discern a trisomy 21 from a 46XY. Visually, they look pretty much the same. Aneuploid (genetically abnormal embryos) clean up well; they can look just as handsome when it’s time for their big date. Cue modern day PGS (pre-genetic screening). PGS has allowed us to distinguish between those who have natural beauty and those who are caking on the makeup. By subjecting the embryo to genetic screening, we can take embryo selection and success rates to the next level. We know a lot more about their abilities to make a healthy baby and the reasons why IVF cycles work or don’t work.

For the type As among us (we’re both raising our hands, so you’re not alone!) we lived and died by our grades. We burned the midnight oil to get the coveted A in Chemistry and logged many sleepless nights for the Honors on our English paper. However, grades don’t mean everything. In the same regard, there are several modest-quality embryos that make the most beautiful, smartest, and kick-butt kids.

So, while we totally get your hangup with the grade, don’t obsess. It won’t change the outcome and will only increase your anxiety. You’ve studied as hard as you can; the rest is in our hands!

Where Everybody Knows Your Name

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While most of you, particularly those above the age of 35, are now picturing a couple of bar stools, Sam, Cliff, Norm, Woody, and Frasier, our minds are far from a local bar in Boston. Our minds are on the waiting room of your local fertility clinic. The place where “everybody should know your name” (but should not scream it loudly for everyone else there to hear!) but never does. The place we are referring to is the waiting room of your fertility clinic.

Contrary to popular belief, the waiting room should not resemble the subway platform during rush hour! Patients are not cattle, and your lady parts are not pieces on a factory assembly line. And while we, too, are fans of a morning sweat session, it should not be achieved by racing your fellow patients to the front of the ultrasound line.  It adds anxiety to an already stressful process. Fertility treatment is not easy. The process of getting there, getting in, and getting out should not make this process even harder. Simply said, if your blood pressure rises several degrees when you walk through the door, it might be time to walk out.

The desire to have a child can be overwhelming. It can drive even the sanest of us to do crazy things. And although we can’t promise that pineapple core, vitamin supplements, and a gluten-free diet will do the trick, we can promise you that they won’t hurt you. However, allowing yourself to be treated as a number and not as a person can be hurtful. In fact, it can compromise the quality of your care and your chances of conceiving; if nobody really “knows your name,” how can they appropriately treat your infertility?

Let’s face it. You don’t need everyone in the fertility office to be your best friend, but the individual doing your ultrasound should know your name, know why you are there, and know what you might be doing next (and should give you more than 30 seconds of their time!). If you are getting the boot out of the door the moment your bottom hits the exam table, it’s probably about time to find yourself another fertility clinic.

Fertility treatment is often a journey. For some, it can take years. The relationship you form with your doctor and your doctor’s office staff should be a good one. And while you may never find yourself in a bar in Boston talking about baseball, it is important that you feel comfortable with those sitting on the stool in front of you. The fertility clinic should be a place “where everybody knows your name.” You owe it to yourself. Cheers!