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Why We Say that IVF (In Vitro Fertilization) Is Therapeutic and Diagnostic…

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What on earth are those ladies talking about? Have they lost their minds? How can treatment tell you more about what the problem is than the diagnostic tests themselves? Isn’t the treatment supposed to treat the problem, not tell you what’s wrong? Yes and no and everything in between. Hold your questions for a moment, because we have answers.

A good chunk of couples today suffer from unexplained infertility. While much of that infertility is thought to be related to egg quality, often times unexplained infertility dodges our current diagnostic capabilities (the tests in our arsenal). No matter what tests we perform on you and your partner, we find nothing. Blood work, physical exams, ultrasounds, sperm checks, and the tube test: they all come back normal. This can be beyond frustrating, for both you and us! We want to give you answers just as much as you want answers. Unfortunately, despite our endless years of schooling, training, and post-training, we can’t.

In many cases, we can’t tell you about your reason for infertility until you go through treatment (a.k.a. IVF) and we take a magnifying glass to your gametes  and embryos.

Yes, ovarian reserve testing (FSH, AMH, AFC) tells us a whole lot. While these tests often help us diagnose the problem (diminished ovarian reserve-low egg quantity) and give us a good idea about how to treat the problem (and how much medication to treat it with), they don’t always tell the whole story. There are many women who have tons of follicles/eggs but have very poor egg quality. However, when their eggs come out and the resultant embryos don’t divide well, degenerate, and don’t make babies, we by the transitive property (woo-hoo, algebra) know a lot about the embryo quality. Furthermore, if such embryos make it to PGS (pre-implantation genetic screening = genetic testing for abnormal chromosome number), the abnormal-to-normal ratio can surprise us and provide even more answers to a previously unanswerable problem.

One of the most interesting parts of our job is to spend time in the IVF laboratory. Watching our skilled colleagues (embryologists) as they manipulate eggs, sperms, and embryos is fascinating. Through our time in their presence, we have learned a lot about infertility, fertility, and the grey in between. Eggs that degenerate, sperm that is abnormally shaped, and embryos that arrest, fragment, and break down provide us with a lot of answers (#diagnosis). If you get pregnant, then it is also treatment.

In many ways, we find answers in the smallest or tiniest members of our crew. It is for this reason that we say, nearly three times a day, that “IVF is both diagnostic and therapeutic.”

IVF is certainly not always the answer, for either diagnosis or treatment. It doesn’t always work and doesn’t always succeed in getting women pregnant. Even when the embryo quality is an A++++ in embryology labs that are not giving triple-A ratings just to get in good standings, IVF can fail over and over again.

We do not have tunnel vision, and we are not afraid to change directions or ask for directions. We want to do what’s best, and if that does not mean IVF or Western medicine or traditional treatments, we are open to trying new things. But just remember, when you hear “IVF” and think, “I will never do that,” and your doctor says, “IVF is not only diagnostic but also therapeutic,” that person has not lost his or her mind! The lab lets us in on a whole lot and in many cases leaves you pregnant!

Who Doesn’t Want Half and Half in Their Coffee? IVF Stimulation Medications

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Calories, shmalories… We like our half and half! In fact, the lighter the better (sweet is good, too!). Half and half gives coffee that creamy taste that is not replicated by any amount of whole or skim milk. The same can be said for ovarian stimulation medications—the ovaries of most women like half FSH and half LH. In many cases without this combo, the response is bland and lackluster.

But before we go any further, let’s take it back to the “beans” (a.k.a. the basics). While FSH and LH are hormonal medications used in IVF, they are also hormones produced naturally in the brain. It is the steady production of FSH and LH throughout the menstrual cycle that results in egg production and ovulation.

Because in a natural cycle you never see FSH without LH, many fertility doctors prefer to keep this dynamic duo intact when selecting IVF stimulation medications. As a result, combined protocols (as we call them in fertility medicine) are definitely leading in the fertility polls. Most of us have seen better ovarian response, better egg quality, and hence, better embryo development when the two are mixed. But taking it back to the beans (a.k.a. the basics), FSH and LH are two hormones that are normally made in the brain.

Great, now they want me to take two shots? Unfortunately, yes, we do. And while we would love to minimize the number of times you have to stick yourself, doubling up will likely do your ovaries wonders. When we stimulate ovaries for IVF, as unnatural as it feels, we are trying to mimic a natural cycle as much as possible. Nature happens for a reason! By giving both FSH and LH together, we are coming closer to what happens when we are not there. These two were paired together before we got there—it seems silly to separate them!

Yes, there are certain women who do better with straight whole or skim milk or even black coffee. For example, women who suffer from hypothalamic amenorrhea (no periods due to low hormones from the brain) need LH. Their ovaries will sit on the runway all day without a blast of LH. On the flip side, women with the real deal PCOS do better with minimal LH in their stimulation. Their ovaries see LH all the time (been there, done that), so it’s better not to put fire on an already flammable situation.

The debate over whether to use FSH alone or FSH + LH has gone on longer than the Coke vs. Pepsi debate. There is evidence on both sides to support combo protocols vs. straight FSH or LH. While doctors may have a preference for one (and can certainly find evidence to support it), most large reviews have demonstrated that (like us) two are better than one. When sitting down with your doctor, before you start the shots, ask them what you are getting, why they are giving it to you, and why they like this for you. Asking questions will quell some of the confusion and anxiety that those bags of needles and boxes of medicines bring upon their arrival.

Your choice of cocktails is very personal. Trust us, we get it. While some of us are vodka soda fans, others like to mix with cranberry juice. And then we have the more elaborate amongst us who go for Cosmos, Long Island Iced Teas, and Mojitos. (Watch out the next day: sugar hangovers are the worst!) Whatever you like to mix with your alcohol, you probably have a reason for it. Same goes for your ovaries and us. Everything we do has a purpose. The difference is, we’re helping make babies, not Bellinis. Here’s to your success, your health, and your fertility. Cheers!

Cervical Mucus: A Marker for Ovulation and a Must for Pregnancy?

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For many of us, there is nothing more off-putting than the thought of tracking your cervical mucus day after day, month after month. It’s not easy knowing what you are looking at, why you are staring at your underwear, how long this exercise needs to go on, and what you will do with this information.

Egg white versus watery, creamy versus sticky. Are we baking a cake or making a baby? While in many ways, it’s sort of a little bit of both, tracking your cervical mucus is not a prerequisite for detecting ovulation or having a baby. The changes that occur over the course of those approximately 26 to 36 days can provide helpful hints on both if and when you are ovulating. However, while it is important and does serve as a reservoir for sperm, it is much lower on the fertility pecking order.

The cervix is the lower part of the uterus (a.k.a. the womb); it is the conduit between the uterus and the vagina. When not pregnant, the cervix measures about 2 to 3 cm. During pregnancy and particularly as its end is near, the cervix begins to shorten, thin out, and ultimately dilate. Think of the cervical mucus as the pond at the base of this conduit. It serves as a reservoir for sperm by providing it with nutrients and safety for several days (up to five, to be exact!). While the majority of sperm is in the tubes minutes after ejaculation, the pond holds on to the stragglers. Over the course of about three to five days, sperm is released into the uterus and the tubes, hoping to meet its mate and make an embryo.

Much like the variability in the uterine lining during the approximately one-month-long menstrual cycle, the cervix and its mucus also go through a host of changes. After bleeding has stopped, the cervical mucus is usually scant, cloudy, and sticky. This lasts for about 3–5 days. What comes next is the stuff that you are taught to look for.

In the three to four days leading up to and after ovulation, the mucus changes to clear, stretchy, and fairly abundant. Following ovulation, the cervix becomes somewhat quiet, and cervical discharge remains scant. The “stage hands” behind the curtain setting the scene for the changes observed in cervical mucus are estrogen and progesterone production. Altering levels of estrogen and progesterone results in major modifications in mucus content and production.

If the cervix falls short on producing and maintaining its reservoir (a.k.a. mucus), problems can arise. However, while cervical factor infertility used to be considered a serious and real problem, today the cervix and cervical mucus production are hardly ever the cause of infertility (only about 3% of infertility cases are due to the cervix). Because of this, tests to evaluate the cervix/mucus are no longer needed.

Traditionally, a postcoital test (nicknamed the PCT) was performed to seek out cervical dysfunction. Now, picture this: fertility doctors used to obtain a sample of cervical mucus before ovulation and after intercourse and check it out under the microscope. They were looking for the presence (or absence) of moving sperm. Although this is sometimes used in couples that cannot have a formal sperm check, it is otherwise one for the ages. The subjectivity, poor reproducibility, and very inconvenient aspect of it have eighty-sixed the PCT in the land of fertility medicine.

In cases where the cervix has been previously cut, burned, or frozen, a narrowing of the cervical canal can arise (medically called cervical stenosis). Cervical stenosis can make procedures that require access to the uterus difficult (picture trying to pass something through a really narrow hole—it doesn’t fit!). Therefore, prior to undergoing any fertility treatment, a cervical dilation (that is, a widening of the cervix) may be required. This allows your doctor to then put sperm or embryos back into the uterus.

However, while the narrowing can make infertility procedures somewhat more challenging, the width is not what’s causing the entire problem. Cervices that have been exposed to trauma like surgery can have difficulty producing mucus. No mucus equals not much of a place for the sperm to hang out (cue IUI or IVF).

While the cervix may not be playing the feature role in the fertility play, it does serve as an important role. In addition to providing a respite to sperm, it also helps maintain a pregnancy to term. When a cervix shortens or dilates before time’s up, it can lead to a snowball of negative events: preterm labor and preterm delivery, to name a few. Bottom line, it’s not only a reservoir but also a roadblock. Until that nine-month mark has passed, it should not let anything out that front door!

Think about your cervix and cervical mucus but don’t drive yourself nuts. Yes it is a way to confirm ovulation but no it’s not the only way. While we are advocates of knowing your body and being aware of what’s going on with your cycle, obsessing over what’s going on won’t change what’s coming out. We have ways to get the sperm to meet the egg even if the cervix isn’t cooperating!

5 + 5 = 2? The Difference between Follicle Count and Embryo Number

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Numbers are no strangers to fertility medicine; success rates, dosages, and egg/embryo counts are all things we count. And despite our tenuous personal relationship with math, over time, we have become quite comfortable with statistics, percentages, and probabilities (disclaimer—as they relate to IVF only)!

However, the number that often eludes us, and the question on so many patients’ minds, is the following: What is the follicle to egg to embryo to viable (able to make a baby) embryo conversion rate? Simply stated, if I have 10 follicles will I have 10 eggs, and if I have 10 eggs will I have 10 good embryos? The short answer, without any derivatives, formulas, or equations is no…You will very likely not. And here’s why.

Human reproduction is an incredibly inefficient process; think the DMV on a bad day! While we start with over a million eggs, a very small percentage of them actually have the potential of making a baby. So while a woman may ovulate every month, many of these months the egg that is released won’t put you on the path to pregnancy. Now, while in most natural un-medicated cycles only one egg is released per month, there are actually a group of eggs that are vying for the ovulation “trophy.”

Think of egg /ovulation selection as a horse race. At the beginning of the month, several horses (a.k.a. eggs) are racing to become the egg that will be ovulated. Ultimately, one breaks free, garners enough receptors to capitalize on the available hormones, and wins the ovulation race. When we are young, there may be 30 or 40 “horses” that enter this race. Although there will still only be one winner at the finish line, the race is more robust. As a result, there is a much higher chance that your winner will be fast, strong, and able to get the job done.

As we age, the number of “horses” lining up at the gate declines until we are left with only a few weaker, slower, scrawnier participants. There will still be a winner, but you may not get very many calls from interested breeders!

Let’s stay with the horse-racing metaphor for a moment. One of the primary goals of an IVF cycle is to ensure that all of the horses that start the race finish it; in this race, we don’t want a winner. As fertility doctors, we give hormones to ensure that there is enough juice to get every follicle/egg to go the distance and cross the finish line. We want all of the eggs in that month’s cohort to grow and develop at the same rate and ultimately achieve maturity.

However, even with the strongest of cocktails we are limited by the number of entrants. If five horses enter the race, we can have no more than five horses finish it. Think of the first ultrasound in an IVF cycle as the race check-in. If the doctor sees five follicles (remember, eggs are microscopic so we count follicles that hold the eggs) there are likely to be no more than five eggs extracted at the time of the retrieval.

Unfortunately, IVF is not as simple as horse racing, and the follicle number seen at the start does not always translate into the egg number you have at the end. There is a very large attrition rate as you move throughout an IVF cycle. The race is longer than a couple of laps around the track, and therefore, the numbers drop off quickly.

And the situation only becomes more complex as women age. As the years rise, the baseline follicle count falls, and you lose your cushion. With a diminished starting follicle count at the outset comes a decline in egg number at the conclusion. Fewer eggs equal fewer embryos. Fewer embryos mean fewer viable embryos.

No matter how young or old you are, there will always be a noticeable decline in the follicle to embryo equation. It is a function of human reproduction. However, if you are going to fall, you hope that there is a cushion below you to break that fall.

What’s Your Recipe? The Various Ways to “Bake” an Embryo

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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.”

Oops, Shoot, Sh-t: What to Do When You Have a Medication Error

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No matter how you choose to say it, either PG or double-X rated, medication errors can make you nuts. Depending on when and where they happen in your cycle, they can cause major anxiety. The fear of knowing if you tanked your IVF cycle can be overwhelming, to say the least! And while some errors can be cycle ending, most are no more than a minor blip (and one that we can fix pretty easily). The best advice we can give you is to take a deep breath, gather your thoughts, WRITE down what you took and when you took it, and contact your doctor’s office. Going on the Internet to see how serious of a snafu it was or panicking is not going to solve any problems. Letting us know and letting us help you fix it will.

As fertility doctors, we give A LOT of medications—both oral and injectable. While the orals are pretty straightforward (most of us have been swallowing pills for the entirety of our adult lives), the injectable ones can get a bit dicey. Sure, you can miss a pill, and that can set you into a panic. But most of the time, we tell you to double up or simply skip what you missed. No harm; no foul. With the injectable ones, there is a little bit more to it. First, you have to learn how to not only inject but also mix medications. Problems on both ends can result in a medication error. Most fertility centers will have you sit through a class or take an online course to review the process. And while there are no grades and no pop quizzes, we recommend that you don’t snooze through this class. It will be important down the road. Often, when something seems to go awry or you are having a memory lapse, going to an online source, be it the fertility clinic site, YouTube, or a Facebook group, can be helpful. It can get you back on course. But again, take it from girls in the know…call your doctor!

Although we don’t want to raise your blood pressure, we don’t want to give you a preview into what might go wrong. Here are the six most common mistakes we have seen:

  1. I gave myself the wrong dose (too much or too little).
  2. I gave myself the wrong medication.
  3. I left my medication out on the counter overnight.
  4. I didn’t mix the medication correctly.
  5. I injected, but a lot of the water leaked out.
  6. I took my medication at the wrong time.

Again, we are not sharing them to stress you out (if you on the verge of doing IVF) but to bring you solace. You are not alone if you mess up—you are certainly not the first to have done it and definitely won’t be the last.

Although we likely won’t be the ones to pick up the phone when you do make that mistake, here is what we would say (in the order we wrote them above):

  1. Most over- or under-dosing (if caught quickly) can be remedied without so much as a hiccup. And while no one wants to be running at half-mast, the ones that make us cringe are the dangerous-, you-can-get-seriously-sick ones—women who have ovaries with tons of follicles are generally put on a low dose of hormones to prevent ovarian hyperstimulation syndrome (OHSS). If they accidentally triple their dose, they are seriously increasing their risk for OHSS.We can usually remedy the problem by reducing the dose, but it’s VERY important to call once you identify the mistake. Most of the times dosage errors happen when you didn’t get the right instructions or dialed up the pen incorrectly (for those formulations using a “pen” to administer). The best way to solve this is to write your instructions down in a SAFE place (not on your crumpled napkin from lunch) and to carefully set that dial. If you are getting an “I dunno type of feeling” when you are about to dial in the dose, phone a friend (a.k.a. your doctor) before you inject.
  2. Many of the medication names read like foreign languages. Most of us have never heard of Follistim or Gonal-F, let alone human chorionic gonadotropin (hCG). Swapping Follistim for Menopur or Gonal-F for Follistim is NO big deal (it’s like drinking Coke instead of Pepsi). However, giving yourself hCG instead of Ganarelix can be a big no-no. Our suggestion to ensure that this doesn’t happen is the following: become acquainted with all of your medications BEFORE the cycle starts. Open up those many boxes, and lay all of the contents out on your kitchen counter. While it may sound overwhelming, it will let you know what you have (and what you don’t have). Check it like you would a packing list with the list of instructions you got at the outset of the cycle. If something is missing, let your doctor know ASAP. Knowing what you have and what you are missing will not only let you prepare for the cycle in its entirety, but it will also make interpreting the daily medicine instructions a bit easier. It will be like hearing a foreign language a couple of times before traveling to that country!
  3. There are a lot of medications that come with an IVF cycle. They can turn your fridge into a pharmacy! Some medications need to be kept in a cold place. Make sure you are aware of which prefer the hotter climates and which like colder ones before you run out and leave all of the drugs on the counter. In reality, unless you are in the Deep South in the dead of summer, even if you left the “cold-blooded” ones out of the fridge for a night or two, you would be totally fine. However, prepping for what goes where will make the organizational aspect of things a whole lot simpler.
  4. Mixing can get people all mixed up! IMs, ccs, syringes, and needles; it’s like a baking experiment gone wrong. And unfortunately, more than one of the medications we use needs to be mixed. Our solution to this is practice—a test run before the big day. It will alleviate a lot of anxiety and clear up some of the confusion. If you are confused by what to mix with what and how much to pour where, make sure to ask before the oven timer goes off!
  5. The leakage effect is all in effect when it comes to shots. There will be water going in and going out after you administer a shot. The out part is usually what gets people freaked out and thinking that they must have done something wrong. Let the leaking go! It is highly unlikely that you lost a substantial amount of the medication in that trickle. Focus on what you did get in and how fierce you are to take shots two, sometimes three times, a day!
  6. Set an alarm clock. Set two alarm clocks. Set three if you need to! Timing for fertility medications is important, particularly for the last shot (a.k.a. the trigger shot). That final injection is timed to precede the retrieval by about 34–36 hours. While being off in the grand finale by minutes is nothing to lose sleep over, being off by hours can be pretty dramatic. Although we can usually match your time to ours, it’s best to be as in sync with our show time as possible.

There are medication errors that matter and those that don’t mean all that much. You won’t know what’s yours is unless you ask. Take copious notes when you get your instructions, and if something is unclear, press pause and ask the person on the other end to repeat. It may save you a major error and some major anxiety. And even if you do make the error of all errors, it was an accident. We all make mistakes—how we handle them is what determines the outcome. Think of it this way: you certainly won’t make that same mistake again!

Do I Have to Put My Gym Membership on Hold While Doing Fertility Treatments? Exercise during IVF

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From Twitter to Instagram and Facebook to Google, we are constantly surrounded by other people’s thoughts, opinions, and advice (with the latter often being unsolicited). Do this; don’t do that. Eat this; don’t eat that. Wear this; don’t wear that. It’s overwhelming. One of the most hashtagged topics is what a woman should and should not do while she is either pregnant or trying to get pregnant. And while most advisors are well intentioned, their advice is often not well researched. This can not only be frustrating but also confusing; deciding whom to listen to can add to an already stressful process. Exercise and fitness top the list of hotly debated topics when it comes to preconception and pregnancy. But we are here to tell you to lace up, because your daily gym routine is unlikely to be the one to blame for your fertility struggles.

Exercise has taken quite the negative rap when it comes to preconception and conception. It has been blamed as the culprit for infertility, failed IVF cycles, miscarriage, early delivery, and everything in between. Keep your heart rate below 140. Don’t lift greater than X number of pounds. Don’t run more than three miles…the list goes on and on. But the science behind these data is weak, making them more fiction than fact. While there are times during fertility treatment where you may need to modify your regimen, it actually has less to do with the impending pregnancy and more to do with the size of your ovaries.

Fertility treatments, specifically IVF, cause the ovaries to grow in size. Bigger ovaries have a bigger chance of twisting (medical term = ovarian torsion); this is a medical emergency and requires surgery to correct. To reduce the chance of this happening, old-school fertility recommendations included a blanket recommendation: “Don’t exercise.” However, with more modern treatment protocols and a slew of exercise regimens, this is no longer the case. While you may not be able to run the New York City marathon three days before your IVF retrieval, you can certainly participate. The key is modification (and moderation!)—just as you would modify regimens and activities when pregnant, you can do the same while trying to get pregnant. But you don’t have to stop. It is likely what makes you feel good about you and what makes you sane. The medications can mess with you (both mentally and physically), and we want to help you maintain every aspect of what makes you YOU.

No one regimen, routine, or practice has been demonstrated to be the best. You should always share with your doctor what you are doing and let them referee your activity level. Additionally, if exercise is a big part of your life, then pick a doctor who gets it and your needs. Being avid exercisers ourselves, we get the yen for a good sweat. We have ways to alter your IVF treatment plan so that we can keep you moving throughout the entire process.  There will most certainly be a brief pause to any impact exercise at some point in the process, but the resume button can be hit pretty quickly!

You may not be a world-class athlete or make the next Olympic team, but if exercise is important to you, then you should not have to stop. Motivating yourself to move can be hard. We commend you for wanting to keep “moving it,” no matter what the season, the occasion, or the situation. Although you may have to move slower or lift lower, we can find something that you can do to keep that blood moving and the endorphins flowing, even when you might be growing!

Are We Doing Leftovers Tonight…What’s in the Freezer?

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Nothing tastes better the day after, the week after, or certainly after it’s been sitting in the freezer for a while (except maybe Haagen Dazs coffee ice cream!). With this being said (and true), it’s hard to believe that frozen embryos are as good as, if not better, than fresh embryos. Explaining this to patients can be incredibly confusing—and rightfully so. Who wouldn’t think that fresh chicken is better than the stuff you defrosted last night?

Given our perception of food and what happens after a stint in the fridge or freezer, it can take a while to convince patients to take a pass on the fresh embryo transfer and opt for a frozen one. However, embryo freezing has come “a long way, baby” since the first baby was born in Australia in 1984. Currently, nearly half of IVF transfers in this country are frozen embryo transfers. So why the shift? Changes in the freezing process and techniques have resulted in frozen embryo transfer success rates that in some cases top those of fresh cycles. Data from our OB friends have shown that babies born after frozen cycles do better in utero and as infants than babies born after fresh cycles! Large studies have shown lower rates of preterm delivery, low birth weight, growth restriction, and mortality after frozen embryo transfers—pretty impressive stuff.

Furthermore, the congenital anomalies/malformations that arise after frozen embryo transfers are no different than after fresh transfers. Your next question is likely…why? What could possibly be better about something that was frozen and then thawed rather than something that was hot (or fresh) off the press? Here’s the deal.

Researchers believe that it has something to do with the uterus and the endometrium’s ability to receive the embryo after a fresh vs. a frozen embryo transfer. The thought is that maybe the high estrogen levels seen in many fresh IVF cycles, while beneficial to the ovaries, may be detrimental to the uterus. An “unhappy uterus” means “unlikely to have implantation.” And if you take it one step further, maybe the high estrogen levels not only decrease the chance of implantation but also the ability of a good placenta to form.

Poor placental development will ultimately translate into poor fetal growth (hence, the higher incidence of growth restriction and low birth weight after fresh embryo transfer cycles). Whatever it is, the data are fairly impressive. And while we are all rah-rah-go frozen embryo transfers for the above reasons, there are also two more important reasons to raise the pom-poms:

  1. When embryos are not transferred back into the uterus during the fresh cycle, it gives your body a chance to go back to baseline. Deep breath in, deep breath out! The pause allows your body and, in many ways, your mind to reset. Without a pregnancy in the uterus to provide the juice to keep the ovaries revved up and enlarged, you will get a period about 7–14 days after the retrieval. And this breather is more than just getting your pants to button again (although it does feel good!). It allows your body to return to baseline and prepare for pregnancy with a more normal hormonal environment.Additionally, for those of us who are exercise fanatics, once you get a period you can resume your normal activities (#run #spin #yoga). While we know that exercise is not the most important thing in the world, it and any activity you do to keep you sane are pretty important. If we can help you maintain some normalcy in the midst of shots, vaginal ultrasounds, and never-ending blood draws, we most certainly want to do that.
  2. Recently, embryo freezing has taken on a whole new meaning; it now is a major player in the genetic testing of embryos game. Call it what you want: PGS, CCS, TE biopsy. Embryo testing has become all the rage. It provides patients with important information, significantly increases success rates, and majorly reduces the twin rate. It’s the triple threat! However, in order to get an accurate read on all of your embryo’s genetic material it takes time. In a fresh embryo transfer cycle, time is of the essence. But if you freeze the embryos, time is also frozen. With the embryos on ice, you have time for chromosomes to be checked and your chances increased.

Bottom line, fertility treatment can be a cold place if you don’t have up-to-date information on what’s going on in the field of reproductive medicine. Be fluid; don’t be “frozen” in your thinking patterns or your plans. Medicine changes faster than ice melts in the summer. Ask your fertility doctor about what’s hot and what’s cold. You might be surprised at what’s hiding behind the frost!

It’s All in the Sauce: Why the IVF Laboratory Matters So Much

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How many chefs do you know that will hand over the ingredients to their famous, to-die-for, take-seconds, -thirds, and even -fourths “sauce”? Not many. What makes their dish unique is usually kept under lock and key and shared with only their closest confidants. The same can be said for the conditions in an IVF laboratory. “Secret ingredients” (a.k.a. laboratory culture conditions, temperature settings, and embryologist technique) are in many ways what distinguishes one IVF center from the next.

When trying to figure out what doctor you should go to and where you should do your fertility treatment, it is important to have some stats about their lab. Think of a pitcher or a hitter. Would you draft a pitcher without knowing their ERA or a hitter without knowing their batting average? Probably not—especially not if you want to win! Think of pregnancy as the win. If the IVF laboratory the doctor works with has poor stats, no matter how much you like the player (a.k.a. the doctor), you should probably draft someone else.

Where you get these “player’s stats” can be tricky. Some sites and resources are not so reliable. We suggest you check out the CDC and SART websites. They are reputable and well researched. They give data to you straight and perform due diligence in getting accurate information from individual clinics before sharing it. Use their information to become informed. Checking them out before you draft your team might make you re-think your roster.

The old saying goes, “Behind every great man is a great woman.” Nowadays, you could say, “Behind every great woman is a great man” or “Behind every great woman is a great woman” or “Behind every great man is great man.” Whichever combination is specific to you and where you are standing, you can be sure whoever is standing behind you is the key to your success. The same goes for us fertility doctors and our IVF laboratory staff. Without the men and women who sit behind us, we are powerless. We can tell you what’s not working and figure out how to fix it, but only with the skill of our embryology colleagues.

In line with the overarching theme of Truly, MD (honesty and transparency), we are going to give it to you straight. The lab is where it’s really at. No matter how many accolades one physician receives, that person cannot do it alone. So while we can’t share the secret to each center’s sauce, we can recommend that you do some serious taste tasting before settling on your choice—it can make the difference between success and failure.

The Five Best Ways to Prepare for the Embryo Transfer

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The big day is finally here! After days and likely months of planning, you are ready to walk down that aisle—with your embryo. You are probably anxious, excited, scared, nervous, and overwhelmed all at the same time. This ball of emotions can become a snowball of negative energy if you don’t know how best to prepare for the main event. Here are five tips to prepare for the embryo transfer.

  1. Hydrate.
    The bladder and the uterus are very tight. They run in the same circles at all times. We ask you to fill your bladder because it not only allows us to see the uterus with more clarity but also can change the angle of the cervix and uterus (# make the transfer easier!). And while we, too, are type A perfectionists who err on the side of doing more rather than less, we recommend underfilling rather than overfilling your bladder. Overfilled bladders can be uncomfortable and cause your muscles to contract, making the transfer more difficult. And one last word of bladder advice: if you do lose it and let some urine out on the table, don’t worry. You aren’t the first and certainly won’t be the last!
  2. Hear, but don’t listen to the doctor doing the transfer.
    No, we did not write that backwards. We want you to hear the information we give you about the embryo quality, but limit how much you take in. Patients often want to know every detail about embryo grade, embryo quality, embryo survival, and everything else in between. While you should be educated and you should know what’s up, obsessing over your grades in this classroom won’t help. You couldn’t have studied anymore. At this point, it is what it is. There will always be time with the “teacher” in the future to break down the cycle if it doesn’t work!
  3. Valium is a very good thing.
    Valium is not a villain. If you are a ball of nerves or the speculum is Public Enemy #1, taking something to calm you down before the transfer is a good idea. It won’t hurt your chances and might even help.
  4. Keep your eyes on the prize.
    You will be asked to identify your name, your partner’s name, and even your embryo before the transfer is performed. Make sure that the doctor, the nursing staff, and the embryologist identify you. While the endless checkpoints will feel like O’Hare on a bad day, they are not set up to be annoying but to be extra cautious.
  5. Make sure your plus one is one with positive energy.
    There is no rule as to whom you have to bring with you on transfer day. In fact, given that you don’t get anesthesia, you don’t need an escort home. Most women like to bring someone along with them. Whoever you pick, whether it is your plus one, your parent, or your pal you want to make sure they are exuding lots of positive energy. You don’t need any Nelly Negatives around on this day.

No matter how hard you try, you can’t control what happens over the next 48 hours; after a transfer, embryo (s) will bounce around for about 48 hours before it/they implant. Those guys and/or gals are either going to find some good real estate and set up shop or not. If they don’t, try to remember that it was nothing that you did or didn’t do, nothing that you said or didn’t say, and nothing that you ate or didn’t eat. You covered all of your bases. If you don’t hit it out of the park this time, you can take another swing soon.