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Hey, Hey, What Do You Say…What’s the Difference Between These “Ks”

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Historically, the final shot, or the “trigger” shot, in an IVF cycle was almost always a fixed amount. While there was variability in what medication was given (hCG/novarel vs. ovidrel), the dosage was pretty standard. Both medications when administered correctly were pretty good at achieving egg maturation. Their differences were in many ways limited to cost and prep time. (hCG must be mixed, and ovidrel is a pre-filled syringe). Who got what was frequently based on insurance coverage and cost. Nothing to shake your pom-poms about! Fast-forward to about 2008, and the game got more interesting with the introduction of a new player, a.k.a. Lupron (leuprolide).

It was discovered around this time that Lupron could not only achieve egg maturation but also eliminate the risk of the dreaded ovarian hyperstimulation syndrome (OHSS). Have we found ourselves both the rookie of the year as well as an MVP in one shot?

Yes and no. While Lupron is really good at avoiding OHSS for almost all, it falls short in achieving egg maturation for some. It requires the endogenous production of good amounts of LH (hormone made in the hypothalamus) to be effective. Without it, it really won’t work. Simply stated, it needs a teammate. Cue hCG or ovidrel. Giving two medications in combination (hCG + Lupron OR ovidrel + Lupron) is like drafting your dream team…dribble, shoot, score! Together, these medications (in the correct “K”) can achieve egg maturity without causing significant OHSS.

The tricky part about hCG, and where some of the confusion comes in (#most common on-call phone call for a fertility doctor!), is when we start to modify the dosage from the traditional 10,000 (a.k.a. 10K) down to 5K and then to 1K. In certain instances, we even modify it more to doses such as 2K or 3K. Why this can become so tricky is the mixing that the various “Ks” require. How you get from a 10K to a 1K dose is all about the water.

If you inject 1cc or mL of water (saline) into the powder and then give yourself a 1cc or mL injection, you have yourself a 10K shot of hCG. Not a problem if you are not cooking several dozen eggs. If you want a LOWER dose of hCG to reduce your risk of OHSS, you would increase the amount of water you inject into the powder to dilute the medication.

It would go something like this: 10 cc or mL of water into the same powder (rather than 1cc). However, you would ONLY give yourself a 1cc or mL injection of the water/powder solution. The more water = the more dilution = the less potent. Ovaries with a ton of potential that are being given Lupron alongside hCG don’t need so much oomph from the hCG. The combo is enough to get their system going without getting them sick.

While ovidrel is no slacker in terms of egg maturity, it is harder to play with the dose. Because the syringe is pre-filled it’s hard to manipulate the dosage. For this reason, many clinics have moved away from using ovidrel in exchange for hCG. It’s VERY important to discuss the trigger medication and what would be best for you and your ovaries before starting the cycle. It can be a huge bummer when you spent your hard-earned cash on a trigger medication that you can’t or don’t want to use. Also, make sure to get the playbook before you leave your doctor’s office on the morning of the planned trigger shot. Getting new instructions only a few hours before the big game can be incredibly overwhelming.

As physicians, we are here to be your cheerleaders and guide you in this “Hey, hey, what do you say?” chant as you throw the final pass. The trigger medication is the grand finale of a whole lot of plays. It’s important to get the medication and the dose right to ensure that your cycle ends on a touchdown and not on a fumble!

What Goes up Must Come Down: What to Expect AFTER an Egg Retrieval

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To all you cyclists, runners, rock-climbers, and challenge-takers, the hill can be a real beast on the way up. Pushing towards that summit can be exhausting and physically painful. However, once you peak and start the descent it’s a feeling like no other. You did it. Now, enjoy the reward of the downhill. Much the same can be said of the post-retrieval bloat, discomfort, and weight gain. After you reach the peak, it is smooth sailing.

Women are often shocked at how much worse they feel after the retrieval than before. While the swelling, heaviness, and blah feeling are definitely there before the retrieval, they’re about 10 times worse after! When we tell patients this, they’re often shocked. How can that be? You’re taking the eggs out; shouldn’t the symptoms get better? No, in fact, they get worse!

Let’s do a little Bio 101. Eggs are housed in fluid-filled follicles, and follicles live in the ovaries. Many follicles = big ovaries. Seems simple. During the egg retrieval, we drain the follicles of their fluid, and within that fluid comes the eggs. However, after the follicles are drained of fluid they fill with blood. They become corpus lutea (plural for corpus luteum—you learn something new every day!). The CLs (everyone needs a nickname) make a lot of hormones that can make you feel not so hot (#progesterone). Additionally, they often fill with blood. As a result, the ovary stays enlarged, and your belly stays big. This hormone soup keeps the ovaries large, the belly filled with fluid, and you feeling like a balloon at the Macy’s Thanksgiving Day Parade!

Okay, so I am going to feel awful…how long will this go on? The length of the post-retrieval to menses (a.k.a. period) varies based on the trigger shot you were given. Women that get straight HCG or ovidrel will feel the bloat for about 12–14 days. The HCG hormone in both of these formulations is like gas for the ovaries—they keep the ovaries charged and the hormones pumping. And although the symptoms will improve significantly after about seven days, you won’t be back in your skinny jeans until you get a period about 14 days later.

If you were given a Lupron or Lupron +HCG trigger, your period of pain will be protracted (that’s why we give it!). Most women will start to feel better about three to four days after the retrieval and get their period about seven days later. For the majority of women, the blah-blech feeling will steadily increase post-retrieval until you hit the peak about three-ish days later; the summit will be higher and the climb further if your trigger medication was straight-up HCG with no Lupron chaser.

When embryos are transferred back into the uterus during the stimulation cycle and you get pregnant, it’s like you are racing the Tour De France rather than your local 10-miler. The pregnancy will make HCG, and the HCG will make that hill way longer. You won’t recover for several weeks into the pregnancy. It is for this reason, along with new data on the OB benefits of fresh cycles, that we push you to press pause and freeze the embryos. Trust us. Your body, your ovaries, and your brain will thank us.

They say life is about the journey and not the destination. And we mostly agree with that. However, in terms of ovarian stimulation and the aftereffects it’s all about the destination. The climb up will likely not be fun. Keep your eye on the top, and take one step at a time. We’re right there beside you, cheering you on!

The Retrieval: The “Eggs” Are Cooked!

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After multiple days and nights of shots, several early morning ultrasounds, and endless blood draws, D Day has arrived: it’s time for the retrieval! Your doctor has used the information from these early AM get-togethers to time the procedure perfectly. While the goal is to obtain the highest number of mature eggs (remember, only mature eggs can be fertilized!), we don’t want to risk quality. Therefore, while the shots could go on and on (don’t look so excited!), we stop them when we feel we have hit the sweet spot—the highest number of mature high-quality eggs.

The retrieval (a.k.a. the egg extraction) will occur approximately 35 hours after the trigger/final shot (hCG, ovidrel). The finale of shots and the retrieval are timed so that the eggs have reached their “finale” in maturation when they make their curtain call in the embryology lab!

In nearly all cases, the egg retrieval will take place in an operating room adjacent to the embryology lab. And while it may be cold in there (brrrr, blankets please!), there will be many people ready to make the experience less frigid and less frightening. In addition to the physician, the nursing staff, and the operating room staff, there will most likely be an anesthesiologist present who will administer pain medication to you during the procedure. This will alleviate almost all of the discomfort and erase most of your memory of the procedure. However, because anesthesia will be given, we ask you not to eat or drink anything after midnight on the night of the procedure (a small price to pay for a pain-free experience!).

The egg retrieval is a vaginal procedure; with the help of a vaginal ultrasound, physicians watch themselves as they pass a needle through the vagina into the ovary and ultimately into the follicle. The needle is attached to a suction system which, when activated via a foot pedal, allows the follicular fluid and egg to drain into a tube.

The tube filled with follicular fluid and hopefully an egg is walked from the operating room into the IVF laboratory; an embryologist will be anxiously awaiting its arrival (let the egg hunt begin!). In most cases, the retrieval is pretty short and straightforward and takes no longer than 20 minutes (timing can vary based on how many follicles you have to drain). You will wake up in the recovery room with little memory of the event, asking us when it is going to start!

In many ways, although the egg retrieval feels like the finish line, your journey is only just beginning. And while the stomach/thigh shots will come to a halt as well as the early AM rendezvous, the waiting game has just begun. Much of the real information about egg, sperm, and embryo quality will come over the next several days.

Although the waiting game is the worst, a lot of information will be gleaned during this time period. One word of advice: be aware of the dropoff that will inevitably occur over the course of the next few days. Follicle number does not equal egg number, egg number does not equal embryo number, and embryo number does not equal baby. (LINK: 5 + 5 = 2? The Difference between Follicle Count and Embryo Number) If you are prepared for this dropoff, the loss will be easier. Remember—don’t count your chickens before they hatch!

5 Pointers for a Peaceful, Productive, and Plentiful Egg Retrieval

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  1. It’s go time!
    The big day is here. You are filled with anticipation, angst, and probably some fear. To minimize some of the negative thoughts running through your hormone-infused head, we have a suggestion. Before you walk into the operating room, make sure you have spoken with your doctor and have an idea about what to expect. What will the procedure be like, how many eggs do they think you will get, and how many embryos will you ultimately have? Managing expectations (particularly when it comes to the number side of things) will make both walking in to and out of the operating room a whole lot easier.
  2. Pain is not a part of the process.
    No pain, no gain does not apply to the retrieval. We want to minimize the physical (and mental) discomfort you feel in every way possible. There will be an anesthesiologist present during your retrieval whose job is to focus on you, your comfort, and your overall well-being. Their cocktail will ensure that you neither feel pain nor remember a thing (without the calories or the hangover!).
  3. Don’t be tardy for this party.
    We are pretty punctual when it comes to retrieval time (no airport delays here!). The time of the trigger medication and the retrieval are more coordinated than the worst bridezilla’s bridal party’s attire; while clinics vary in how many hours separate the trigger medication and the retrieval (some do 34, some 35, and some 36), what doesn’t vary is their commitment to staying on time. When things run behind schedule, what’s at stake is not your connecting flight but our ability to retrieve those eggs (ovulation can occur). So give yourself plenty of time to face the morning rush hour and the inevitable street closures—you don’t need another thing to stress about.
  4. All in all, the process is pretty quick.
    Retrieving eggs is a fairly simple and fast procedure. In fact, most egg retrievals are no longer than a power nap and take no more than 15–20 minutes. Before you know it, you will be recovering in the recovery room, drinking apple juice, and eating graham crackers!
  5. Relax—we’ve got you covered!
    Most fertility doctors are more comfortable doing retrievals than tying their shoes. As medical procedures go, this is our “bread and butter.” Think of something that you do every day (with ease and with grace): that is how we feel about extracting eggs. So while fear and anxiety are totally normal emotions, take solace in our experience. Close your eyes, enjoy the relaxing medications, and dream of something good. We will see you on the other side.