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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!

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.

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!

How to Properly Identify Sperm, Eggs, Embryos, and Everything in Between

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“License and registration” can be two of the worst words any driver hears: simply stated, you are so busted! No matter how loud the radio is playing and how good you feel driving on the open road, going 85 in a 60 is not a good thing. After the “Officer, I really wasn’t going any more than 10 miles an hour over the speed limit” and the half-hearted attempt to sweet talk your way out of the ticket without so much as a smile from the highway patrol guy or gal, you pretty much take your ticket and drive away.

And although you may vow to go to court and fight it, most of us pay our fine (ugh) and move on. And while no one likes to waste their hard-earned money, the downside of losing some cash is not so catastrophic (although points on your license can be a real bummer). However, errors in proper identification, particularly in a fertility office, can be disastrous.

In any medical practice, especially a fertility one, you want to be “pulled over” every time you set foot in that medical building. From the staff at the front desk to the chaperones who put you in the exam room to the medical assistants who draw your blood, asking to see identification is a good thing. In fact, the more people who ID you, the better (yes, we are looking at your age☺). When any gametes (eggs, sperms, or embryos) are being used, it should be even more in your face—in the changing room, in the embryo transfer room, and twice prior to the transfer. If you find yourself becoming annoyed, that means we have done our job correctly. While redundant, we want to be more sure than sure that we have who we think we have. Like the cop on I-95, we mean business!

Expect us to ask your name, your date of birth, your Social Security number, and your partner’s name and date of birth (here, we will give you a pass on the SSN). No need to call LifeLock. We’re not trying to commit identity theft; we’re just ensuring that we have the right players in this game of baby making. We ask repeatedly to eliminate the chance that any errors occur. We have systems set up to double check everything not only twice but also by two people. In fact, the most common words you will hear in an embryology lab are “Can I get a check?” No eggs, sperm, or embryos are ever moved without two sets of eyes—always.

When it comes to identification, we don’t mess around. We don’t even joke about it. So, if staff personnel don’t ask you these important questions and you feel uncomfortable, in the words of the NYPD, if you see something, say something. Voicing your concern does not make you annoying; it makes you on top of it. And if things don’t change, then maybe that is not the right fertility practice for you. In general, we are pretty good bouncers and know who should come into the club.

Trust us, even the best fake IDs don’t get past us.

Going Long: When the Finish Line May Be Further Than You Think

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For all of you runners, swimmers, and cyclists, you know what it takes to prepare for that long-distance jaunt. Aside from what you should eat (#carbLOAD) and what you should wear, how far your legs or arms need to take you is pretty important. Preparation, both physical and mental, is key to crossing that finish line.

The same can be said for individuals and couples going through fertility treatment. Knowing how many rounds or cycles it will take you to reach the finish line (#baby) will help you prepare for the journey. And while this is no straight-up calculation or predetermined training plan, information such as age, ovarian reserve, and fertility history can definitely help us estimate. Here’s how far you might need to go…

There are about 180,000 IVF cycles performed in the US each year. And from these cycles, about 65,000 babies are born. Over the years, the numbers have added up, and nowadays, nearly 2% of babies born each year are a result of IVF. Simply stated, more and more people are doing IVF, and more and more babies are born after IVF. However, the number that is less clear is how many cycles it took each person to get to her personal finish line (a.k.a. a baby).

And while this statistic may elude us, what is pretty evident is that those who hang in there longer (a.k.a. complete more IVF cycles) are more likely to conceive. In fact, a recent Swedish study demonstrated that women who did three IVF cycles had about a 65% chance of pregnancy. This was higher than women who stopped at one or two. And while we are certainly not advocating endless IVF cycles, we are recommending that you go the distance based on your doctor’s recommendations.

If your doctors think you have the potential to push on (you are still making a good number of eggs, you are having advanced embryos transferred, your embryos are passing the genetic screening test), then we recommend that you keep on keeping on. Just make sure that you know how far they think you should go, and in turn, make sure they know how far you want to go.

Going back to our original metaphor, think of it like this… If someone told you that you had to run five miles and then midway through told you it was actually 10 miles (oops!), you would be pretty peeved. You would probably doubt your ability to go the distance and maybe even decide to bow out before the race was over.

On the contrary, if you planned to do a 10 miler but midway through found out the race was only half that distance, you would feel pretty good. Energized and invigorated, you would kick that race’s butt and sprint to the finish line. Fertility treatment might make you go the distance. While we certainly hope the race is over shortly after it starts, if it goes longer we don’t want to leave you out there on the course without the appropriate gear.

Information, preparation, and participation (a.k.a. a doctor who consults with you after every IVF procedure) will guide you through this often-torturous race. But having a good idea about the course before you start will make each passing mile a bit easier.

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!