Fertility

Simple Breakdown of Fertility Meds

I hope to break down the different meds and their uses in a way that helps you understand why you are taking what you are taking at the different times in their cycles.

A very simplified explanation of how the body works – during your period, your ovaries ideally have a lot of tiny follicles all vying to be the one that gets to ovulate. Your body releases FSH, follicle stimulating hormone, to tell the ovary to grow the follicle. As it grows, it releases estradiol, which in turn tells the body to slow the release of FSH. One follicle (usually) is selected as the winner and grows to maturity while the rest die off. The mature follicle releases enough estradiol to tell your body it is ready for it’s big debut which triggers your body to flood your system with LH, luteinizing hormone, which will perform the final polishing on the follicle and then launch the egg out for it’s big shot at fertilization.

When you do medicated cycles, you are typically trying to get around that natural process and get your ovaries to go into overdrive and make more follicles. You also have to be careful you don’t ovulate those prior to their maturity or your IVF retrieval, IUI, etc. All of this is accomplished with various drugs given in various ways. As I said, there are so many different ways to do a cycle. It is called ART, as in assisted reproductive technology, but creating the best med protocol for you is truly a work of art!

Stims:

Stimulation meds are meds used to push the ovary to grow more than one follicle per cycle. They can be oral meds, like clomid or letrazole. Clomid blocks estrogen receptors and letrazole stunts the production of estrogen, so when on either of these, your body is likely to be releasing more and more of your own FSH, looking for that estradiol message back to let it know a follicle is growing. Because it releases more FSH than normal, you are likely to have more than your normal 1 follicle growing.

Gonal-F and Follistim (in the US) are injectable FSH. Just like you imagine, they work the same way your own FSH works, stimulating the ovary to grow more follicles. Menopur is an injectable that contains both FSH and LH.

LH blockers:

Stimulation meds are used in the follicular phase and typically given for 5 to 12 days, with the sole purpose of helping to grow follicles.

Imagine you have multiple follicles growing and your estradiol is getting nice and high. Your body would normally see the high estradiol and start the ovulation process, which you want to avoid, so you need something to block your own LH surge. There are two types of drugs used to do this, an agonist like Lupron or an antagonist like ganirilex or cetrotide.

Lupron may be started before your cycle and continued throughout. This is typically called the long Lupron or down regulation protocol and most of us women with DOR never even see that one, as it can be suppressive. Lupron can also be given in a smaller dose in a “flare” protocol. The flare is referring to the action of the Lupron to first cause a huge flood of your own FSH and LH, which helps get follicles growing, then a few days in, the Lupron starts suppressing.

Antagonists are typically given when your biggest follicle is around 14mm. The key here is to start it before your LH is creeping up too much, but it is usually started mid to late follicular phase. Typically you take an antagonist only 5 days or less, leading up to your trigger shot

Triggers:

Triggers are used to finish the maturation of the follicle and then either force ovulation in the case of IUI or timed intercourse, or time egg retrieval. Triggers are generally usually HCG, the pregnancy hormones, common names are Pregnyl or Ovidrel. You can also be triggered with Lupron. Lupron when given as a trigger will cause your own LH to release. A little less common is a nasal spray that can be used as a trigger, Synarel. It also causes a release of your own LH.

So if you are following, we have stim meds and LH blockers taken during the follicular phase to grow as many follicles as we can but not ovulate them before we are ready. Then we have a trigger med to cause the ovulation or time the retrieval.

Luteal Phase:

Post IUI, or retrieval we have the luteal phase. Generally when you ovulate your follicle that the egg ruptured from forms a corpus luteum cyst which produces progesterone. Progesterone is needed to support a pregnancy. If by day 10 or 12, there is no pregnancy, the lining of the endometrium begins to breakdown to shed, progesterone drops and your period starts. If there is a pregnancy, the hcg released by the embryo will “rescue” the corpus luteum and let it know to stay put and continue to release the progesterone.

In IVF, retrieving the follicles disrupts this natural process and may result in no or inadequate corpus luteum, so for the luteal phase, most are put on some sort of progesterone treatment. It may be an injection or vaginal gel like Crinone or suppository like Endometrin. Many times women who do IUI or TI are also put on prog for good measure. And luteal support may also include estrogen in the form of patches or pills.

So now we covered a full cycle sort of… What about pre-cycle? You can start a fertility on your period, whenever it comes. We call that a natural start. But most are timed or primed.

Priming:

You may take birth control pills pre-cycle. They are helpful to time the cycle, they quiet the ovaries and many believe help the body respond to the stimulation meds more. Women with DOR may find the opposite is true for them and BCP are too suppressive. You may do estrogen priming pre-cycle. It can also help with timing and is thought to help the follicles grow closer in size instead of having a lead follicle, as well as to create a better environment in which the follicles can grow.

There are other priming protocols, including using estrogen with antagonist, using testosterone or even using human growth hormone.

I hope this very generalized explanation is helpful as you look through your box of meds or try to make sense of a protocol or calendar. There is no right way to do this, and unfortunately it is trial and error. Your doctor will hopefully create a personalized plan for you based on all available data then tweak it after each try as they are collecting more data about how you respond.

Fertility

Fertility cycles are like fishing.

An analogy.

Imagine your ovaries are a pond. The pond is full of fish, little useless guppies and nice big bass. When you are young you have tons of fish and most of them are bass, say 90%. As we fish (age), the total number of fish depletes as well as the ratio of guppies to bass. By the time you are 45, you have way less fish and most of the fish are guppies.

If the goal every time we do a fertility cycle is to catch a bass (a good egg), then it makes sense that the chances of catching a bass is going to be higher the younger you are and with the most fish you can catch.

What makes conceiving so hard when you have DOR, High FSH, low AMH, or just unexplained poor response to meds, is that each month when you go fishing, you only catch a few fish. If you are 25 and catching 3 fish, there’s a great chance 1, 2 or even all 3 of those fish will be bass, as your pond is still full of them. If you are 40, you may need to catch 15 or 25 fish to find a bass, and it may take you five fishing trips to catch 15 fish.

Low AMH, High FSH, and low AFC are all indicators that you probably won’t catch many fish each fishing trip. Some with great hormone levels still don’t catch many fish, and I have seen women with low AMH catch a good amount of fish (have a good response). Point is, they are just an indicator of response. They don’t tell you what your guppy to bass ratio is, etc.

Some women luck out and catch a bass on their first fishing trip, regardless of only catching one or two fish. Some women may go fishing 10 times, catch 30 fish and still not catch a bass! Sadly, in spite of all the medical advances out there, catching a bass is still largely based on luck.

When you consider all the things that go into a fishing trip – finances, emotional toll, relationship strain – sometimes we just can’t go fishing over and over and over in the hopes of finding a bass. Sometimes it may make more sense for you to move on to other options, like donor eggs, adoption, etc. This is something that only you and your partner can really know.

Bottom line, there is no lab test to tell you if you can get pregnant with your eggs. There is no magic number on a lab report that says you have all guppies. There is no way of knowing when you have a bass that is growing for ovulation. I believe all we can do is try to make our pond the healthiest environment possible; eat clean, take a good supplement regimen, exercise, get rest and hydration and try to manage stress, and hope that we find a bass OR we find our path to peace, whatever that is.

Fertility

Good Read – It Starts with the Egg

A book that many of you may have heard of already is It Starts with the Egg. I remember reading this book on my kindle over a vacation after having a few early miscarriages. I was super intrigued and also a little upset that no doctor at my first clinic had ever mentioned anything about diet or supplements or anything that I could control in this process that is wildly out of your control. In fact, this was a pivotal part of my decision to seek a second opinion and find the wonderful doctor who helped me have success.

The book is exceptional in that it lays out all the current data. Important to note that Rebecca Fett also updated it recently, so even though I read it several years ago, if you purchase it today, it will be an updated version referencing more recent available data. She lays out the studies and explains what they mean in easy to follow dialog. She explains what you really need to understand about egg quality, goes through the dangers of BPA and other toxins that are present in our environment, and lays out general obstacles to pregnancy.

Next she helps her readers understand what supplements are available and what data there is and isn’t to support them. She goes into diet suggestions, sperm quality and creating an action plan for how to get in the best possible shape to find a good egg.

I took the book for what it is, a fantastic resource to help me make informed decisions. I used it as a springboard to my own research. That being said, you wouldn’t have to, you could if you are not the research and study reading type, just follow the suggestions and already be well on your way to being in optimal shape to give yourself the best chance at finding a good egg.

I didn’t follow her recommendations completely. For example, I did take Royal Jelly, as I knew I wasn’t allergic and I read anecdotal stories of it helping. I put it into the category of “may help, won’t hurt.” I also took L-Arginine, though in doses smaller than the studies I read and I agree with her completely that there isn’t enough data to really know if it does help. I also didn’t cut out all of my products. I was living in New York City and in the summer I really couldn’t depend on natural deodorants. You get it, right? I did however take a good look at the products I put on and in my body daily and made good effort to lessen my exposure to phthalates. I stopped using canned food and drinking from water bottles.

Basically, I considered the possibility that I wouldn’t have success and thought about what I would blame myself for should that happen. I felt confident enough that if I chose to wear my favorite nail polish for a big night out and then never had a baby, I wouldn’t hate myself and blame the nail polish. Would I feel bad if I never tried supplements that have medical data to back them up and then didn’t have success, absolutely. I think that is truly the best way to think about it. We have to live. I needed a balance between doing everything possible to get pregnant and feeling like a living, pretty, healthy, normal person.

One last point, Rebecca Fett has a Facebook group. That’s a nice touch. You can find it here: https://www.facebook.com/groups/2217875998431371/

You can buy the book at Amazon:

It Starts with the Egg: How the Science of Egg Quality Can Help You Get Pregnant Naturally, Prevent Miscarriage, and Improve Your Odds in IVF

Pregnancy

Pregnant over 40

Have you ever woken up and asked someone when did you turn 40?! And have them answer, “3 years ago”. Does this happen to anyone else?! I didn’t mean to get this old, but I guess it’s better than the alternative!

Because first off, I didn’t want to have kids too young. Married at 28, just a baby I thought, and to an exciting man who loved to travel and live life to the fullest, and with both of us being career focused, it just seemed silly to rush into kids. Then because when it seemed just the right time to have baby #1, you know like 33.8 years old on the nose, (cause you think it’s gonna just happen right away) it wasn’t easy, I woke up one day pretty old and still childless.

I had my first bring home baby, sweet son #1 in May 2016, exactly 4 years after my first RE appointment, at 39 years old. I had my second baby, the sweetest little man ever, in October 2018, and celebrated my 42nd birthday the day after he was born. Did I mention he was naturally conceived? Oh the irony.

Where I live, just north of NYC, bordering the Bronx, if we see a young girl with a stroller we assume she is the au pair. I am not an anomaly at all. A very unscientific Facebook poll in a local mom’s group concluded that 37 was the average age for first baby around me.

When pregnant I felt tired. I was never very sick. I felt pregnancy brain and some strains and pains here and there, but ultimately never felt what I imagined it to be. It didn’t hurt that I work from home and can essentially wear pajamas all day if I need.

I don’t have anything to compare to, being pregnant over a certain age vs being pregnant in my 20s, but I spoke to some women in my groups to get their take.

Vic G. had 3 pregnacies, at 28, 31 and 43. At 28, it never crossed her mind that anything could go wrong and she told everyone early on. By her last pregnancy, she held it in till 23 weeks due to a string of 10 miscarriages. I can relate to that so much. After our twin loss, I wouldn’t even use the P word (pregnancy) till we made it to viability. As we age our chances for miscarriage go up and up, and the heartbreak of 10 is unimaginable.

Surprisingly, Vic G. also found her last pregnancy to be the easiest. She was fit and healthy and in better shape than before. But recovery from birth was more of a challenge, easiest she reports, at 31. This makes total sense to me too. I don’t bounce back from cold as well as I used to, let alone hours of labor!

Interestingly, with advanced age sometimes comes a specialist. In my area you must meet a couple of criteria to qualify (though there may be a certain age when you just qualify). The criteria are above 35, used fertility treatments, carrying multiples, diabetic, etc. The specialist, a maternal fetal specialist or perinatologist is essentially the baby’s doctor while they are in your womb.

Having an MFM in addition to an OB is golden. It means more visits, more scans, a bigger team looking out for you. I was thrilled to have the extra set of specialized eyes. Should anything come up that you need to be prepared for, you want an MFM you trust coordinating the care of your baby.

My last point about advanced maternal age is to focus on attitude and appearances. I know I am lucky to be in the community I am where I fit in with the other moms trying to cover our greys and schedule our Botox before daycare pickup, but in many parts of the country, that isn’t the case. Being a mom that is in any way not the norm in your area can be isolating.

Janet spoke to me about her experience. She is in a community of predominantly young families and often feels left out. At a birthday party for a classmate of her 5 year old, she was asked if she was the grandmother then left out of all the small talk. Her advice to others in her shoes is to keep trying. She kept her head up and eventually found her people. Though still 10+ years younger, they get her and make her feel welcome. They bond over playdates and yoga classes and have become a small tribe.

Have you got a story about being an older mom? Please share the good, bad and ugly!

Fertility, Low AMH

Protocols for DOR

When I first started trying, of course I knew nothing about stimulation meds or how different drugs are used at different times. I went on a research frenzy, reading studies, slide shares, forum posts and Q&As from various doctors. It was all very helpful.

During the process we tried many different protocols and both high (very high) and low dose stims. I managed to squeeze out 3 eggs max regardless of how hard we pushed. Ultimately my success for my oldest son and for the twin daughters I lost was with a femara antagonist cycle.

shared from IVFmd.net with their permission

My cycle looked very much like the picture above. I was almost always doing back to back cycles and needed both progesterone and estrogen to have a good luteal phase so also was almost always estrogen primed. I did do both natural start and primed and my response was the same. But after the estrogen my 3 follilces seemed to be more closely matched in size. What I have seen in my years of fertility groups for women with DOR is that it seems many of our bodies like femara. We do well with a little flood of our own FSH and LH then supplement that with just a little injectable of those and response as well, and often better, than we just shoot a high dose from the start. It seems counterintuitive, but it truly seems like too much drug shuts down a poorly or not optimally functioning ovary and it is better to coax out a few follicles rather than push for a bunch.

I love too that the femara antagonist protocol is a short and relatively simple protocol. Very straightforward. And since you are depending on a cheap oral med to stimulate your own FSH, with only some Injectables, it can be a lot more bang for your buck. It amazed me that I made the same number of eggs on like $1000 worth of meds that I did on $9000. That’s a lot less money per egg! And again, many people actually get more eggs with less meds.

For more great info on protocols, check out https://www.ivfmd.net/services/aggressive-ivf-protocols.

I truly appreciated this site so much when first learning and point people there all the time. They explain the different options in easy to understand wording. They are located around the Dallas area and I am in NY so I never consulted there, but based on their webpage they seem to know what they are doing when it comes to dealing with the special ovaries that belong to us DOR women. Other options like Microdose Lupron with birth control or estrogen priming, which many do well with also, are detailed nicely too. If you live near Dallas, would be a clinic worth consulting. (Super nice when I asked to use their materials on my blog too. )

Fertility

Favorite Products for TTC

Here are some of my favorite products for TTC

I must have used over a thousand tests, both ovulation and pregnancy tests. I tried every brand out there and I found over time I preferred Wondfo. They are simple, straightforward and accurate. They are also a great price. There are some copycat versions out there but you want the genuine thing. You can get the real ones at the link below:

Some people prefer the digital ovulation and pregnancy tests. The ovulation tests make it super clear whether or not you are at peak, there is no evaluating color. The general instructions on how to do OPKs is a little different with some digital ones as they measure both estradiol and LH, so instead of testing once or twice in the afternoon, you test only one time a day in the morning. Pay attention to the instructions. The pregnancy tests are also very straightforward but they do require higher levels of HCG to get a positive so keep that in mind you early testers! Below are links to my favorites in the digital category.

Let’s talk lube. You may not need any, but there are some that claim they help sperm swim. If you have any issues with not enough cervical mucus, it doesn’t hurt to try one of the following. Remember, many lubes kill sperm. I know some people have used regular egg whites or coconut oil. That sounds messy to me. I would buy the stuff in a tube with an applicator.

I will disclose that as an Amazon Associate I earn from qualifying purchases. I am not recommending these for that reason, rather these items were my favorites, and I used a ton, during my 8 year TTC journey. If only I had a dime for every pregnancy test I took!

Mommyhood

Plagiocephaly

When my first son was born, the first thing I heard before I saw him was the nurse asking “was this baby breech?” When you have a C section you expect the perfect little round head over the cone shape you often get with vaginal births. Well, didn’t happen here. My baby’s head was squished under my ribs forever. They had to twist and turn to get him out! I could feel it. His little head was crooked. His lips didn’t even line up when he closed his mouth. They told me in the hospital it would get better.

At 12 weeks we had a lactation consultant come in to check for ties. She mentioned torticollis to me. That took us down a path of twice weekly PT for about 9 months. At first I wasn’t super worried about his head shape. At about 5 months old or so, the PT asked if I had considered a helmet. I hadn’t really, I still expected it to get better as he started moving and sitting up. Still I ended up making an appointment at one of the big cranial helmet companies.

As I was in the waiting room, I heard the entire consult with another family in a room right beside me, through the closed door. The man was telling them how the back to sleep campaign has caused so many bad shaped heads and that they should have done more tummy time, etc. It was close to blaming the baby’s head shape on the family. Then he went on to talk about how they don’t have to worry because he can fix what they have done. It didn’t sit well with me. When it was our turn, as soon as he came in, he started giving me the same speech. I interrupted at one point to tell him about how the baby was breech and his head had improved a ton and he gets tons of tummy time, but he wasn’t having it. He just continued on implying it was my fault. Before he left the room, he mentioned my neighborhood and how it is expensive but a helmet is not that much money for my child’s entire life.

I was so turned off I wanted to vomit. They measured him at 16mm asymmetry, severe in their opinion. They loaded me down with tons of documents and quoted one study that said heads don’t improve on their own. I left there feeling almost taken advantage of. I only want what is best for my kid, I love him with all of my heart, and I felt like they were playing off that. I went home and did a ton of research. I found the study they mentioned and I don’t recall specifics but it was a super small study. I couldn’t find a lot to support their claim that he would have jaw problems and ear infections and helmets would never fit him right. But I also couldn’t find any posts from parents who chose not to helmet or a lot of data to show what happens if you don’t.

I went to the pediatrician to get an opinion. The caveat is that my pediatrician had left that practice and for other reasons related to where he went, I wasn’t going to go with him. The person I saw that day seemed confused about why I was there and basically said, if they think you need a helmet, get a helmet. I asked for a referral to a neurosurgeon or someone who can provide an opinion. They literally looked at me like I was crazy, rolling their eyes between two of them and gave me a brochure for the same helmet place I had just been to. I went home steaming mad (and btw went back to my original pediatrician who I love to this day).

As soon as I got home I started researching. I live in the NYC area, and it turns out, there are neurosurgeons who have plagiocephally clinics! I wasn’t so damn crazy afterall. I went to Cornell’s plagiocephally clinic, ran by their chief of pediatric neurosurgery, and saw a wonderful female doctor. She checked out my son, explained that heads grow like a deflated basketball when you add air back, filling out one area then another. She wasn’t wishy washy at all, said absolutely No you don’t need a helmet. My son is now almost 4 and looks great. I will add pictures to this post eventually to show the difference.

To be clear, I have nothing against helmets and I think everyone needs to make the best choice for them. I chose not to helmet for my son. I joined some Facebook groups and saw that many babies have rashes, dry skin patches and other complications from the helmet. Some don’t adjust well. You must go often to get it adjusted, and remember we were already doing PT 2 times a week. I just didn’t want to put him through all of that. He may have had to wear it 8 months, maybe 12 months. It was a lot. Also, I saw so many moms who were unhappy with the helmet’s result. Maybe they went from 16mm to 12mm and that wasn’t enough for them. I didn’t want to put him through all of that for a result that is that slight. Also there was a lot of data suggesting that helmeting exacerbates torticollis, which I knew had to be the focus of treatment.

The icing for me was the obsession. I saw so many moms who were not satisfied when they went from 16mm to 3mm. They were chasing absolute perfection and always being let down. I saw some take their second child for a helmet as a given, even when that child measured only 8mm off at 3 months. I didn’t want to become obsessive about the head shape. I wanted to enjoy my son and I trusted the doctor at Cornell, though to be honest, it was hard. It was very hard to let it go and have faith that it would be Ok. That is because we all want the best for our kids and making a decision is scary – it is either the right or wrong choice every single time.

If you are in the situation where you are deciding whether to helmet or not, I feel for you. It’s a hard choice. I really believe it will be OK no matter what choice you make. Some kids do great in helmets, don’t even mind them and their results are fantastic. Some kids helmet with little result but by age 3 look fantastic. And some kids don’t get the helmet and also look fantastic by age 3.

What I learned was overall it wasn’t worth the stress and agonizing I did over the decision.