Fertility

Choosing a path when you have DOR / IVF, Embryo Banking, IUI

There are many hard choices when you start with treatments. I’m hopeful this post will help with prospective as you decide which path is for you. In my groups, these choices seem to be some of the more confusing ones for people to sort out.

First, DOR – this can be defined so many ways. Someone with an amh of 0.9 and an AFC of 12 can be labeled DOR if they are 30 years old but they are clearly in a better spot than someone with amh 0.09 and AFC of 2 at 30 years old. And someone with amh of 0.9 and AFC of 12 who is 40 would not be in the same shoes as the 30 year old with the same numbers due to decreasing quality as we age. So, as you think through the path for you, you have to consider your individual situation.

photo of pathway surrounded by fir trees
Photo by James Wheeler on Pexels.com

IVF

Sometimes jumping into IVF makes the most sense. If you are hoping for more than child, are young, say under 35, and have OK numbers (AFC is decent, Amh is slightly low, FSH is normal), it is reasonable to hope for a pregnancy AND something left over for the next child. Just be aware that it isn’t the most likely outcome. I have seen stats show anywhere from 35-45% of cycles end with extra embryos to freeze, and this includes everyone, even those who make a lot of eggs.

Also, remember that only about 37% of all first time IVF cycles in women under 35 result in a live birth. Obviously stats change all of the time, but read up on it and go in with an open mind. All of this is to say, IVF is not a guarantee. IVF works by taking a group of eggs, fertilizing them and narrowing them down to the best ones to transfer. In some of us, because we retrieve so few eggs, and you generally lose some before transfer, there is no narrowing down.

So I would think through these questions and possibly discuss them with your doc:

  • At my age, about what % of eggs can we expect to be healthy?
  • With my lab values and AFC (and any previous response from any other cycles) what kind of response do you think I’d have?
  • How much will each try at IVF cost me (us)?
  • How many children do I (we) want to have?
  • Are there any values like FSH where you would refuse to do IVF with me?

Some of the downsides of IVF is that it is quite expensive and usually cost prohibitive to do enough cycles. If you do have success but have nothing left to freeze and want another child you will be ‘9 months of pregnancy + however long breastfeeding ‘ older when you start for another child. If you do get pregnant but have a miscarriage, you will be 8 or 12 weeks or longer out of the TTC game. PGS testing can help decrease the chance of a loss greatly, but it is, like everything else in this world, no guarantee.

Embryo Banking

Embryo banking is essentially doing several retrievals over a period of time, likely PGS testing anything that makes it to blast, and then transferring when you have banked your total number of desired embryos. Banking can be a really helpful tool for women with low response. Think of the normal woman who gets 15 eggs in one cycle, maybe 9 fertilize and then she ends up with 5 blasts. Now think of DOR and getting 3 eggs per cycle, doing 5 cycles, getting 9 to fertilize and 5 blasts. Banking has its downsides obviously. It’s physically hard on the body to cycle over and over and over. It’s emotionally trying – imagine doing cycles and having nothing go to blast or no blast pass PGS – that is likely to happen a cycle or two for all of us. It can be quite costly depending on where you do it and it can be hard to find clinics who have packages or pricing to make it work for you. It also is long. You may think 6 cycles equals 6 months, but don’t count on that. You can be benched a cycle for cysts, or your hormones are out of whack, or your cousins wedding happens to fall at the wrong time, etc… I would plan on double the time. If I was planning to do 6 cycles, I’d give myself a year to complete them.

However, if you can endure all of that, you can end up 1 year older with enough PGS embryos to build the family you desire. It’s awful to go through but I think of it like labor – you won’t remember all the pain once you are holding your precious baby.

Questions to discuss with your doctor about embryo banking may include:

  • Can I (we) afford multiple cycles, is there any sort of package?
  • How do I (we) determine the plan – how many cycles to do vs how many embryos do I need?
  • Am I (we) prepared for the emotional rollercoaster?
  • If I(we) happen to end up with more blasts than I need, what will be done with them?

IUI

Some people give IUI a bad rap. They talk about success rates vs IVF as if they are comparing apples to apples. The reality is in most cases, they are speaking of a cycle that consists of an oral med and trigger shot (based solely on follicle size) compared with a cycle consisting of some sort of priming, an agonist or antagonist, injectables or injectables and oral meds, trigger based on estradiol levels, lining thickness and follicle size.

Most women couldn’t do IUI with the same protocols that are used for IVF because they would make too many follicles. It would put them at risk for high order multiples. When you are DOR, and only making a few follicles, there is no reason not to do a full, scientific protocol. When looking at success rates when IVF was canceled to IUI due to poor response, there isn’t a lot of difference between continuing IVF or doing IUI. If your tubes and sperm are good, you may benefit from being able to afford more cycles to allow you a greater chance to find the good egg. Let’s say egg #11 is the good egg, and you make 3 a cycle, then you’d be on cycle 4 when it finally appeared. Can you afford to do 4 cycles of IVF? Doing IUI with a full protocol is more expensive than just oral med and trigger, due to the medication cost, but still is a lot cheaper than IVF at most places.

Questions to discuss with your doc about IUI:

  • What protocol will you do with IUI? Is it the same as you would do for me with IVF? If not, why?
  • How much will the IUI cost? What’s the difference between IVF and IUI costs, monitoring, retrieval, transfer, PGS vs, sperm wash and insemination?
  • Do I(we) want more than one baby? If I get pregnant with one baby now, will I have time later to do this again?

Overall, the decision on how to proceed is a highly individualized and personal one. So much depends on how many kids you want, how much you can spend, and how old you are, not just for quality of eggs but also time to spend. I started with a doctor 4 years before I had my son. That’s a long time. We had several early losses. Each one cost me 8-12 weeks of TTC time. I had the one late loss which cost me overall 10 months of TTC time. It all adds up very quickly. If you are starting at 38 and want 2 or 3 kids, banking is likely the better route to be sure you have time. You can transfer a frozen embryo at 44 but making an embryo at 44 is a lot harder. If you are starting at 30, your eggs are good quality and you have more time so losing 12 weeks to miscarriage or breastfeeding for a year won’t make as much of an impact on your chance to have another.

Lastly, whatever you decide, try not to second guess yourself. Commit to it and move forward. Especially after I lost my twins, I regretted not having banked embryos and was so scared that I’d never have success, starting from nothing again. Then when I had my first, I regretted it even more as I was now months away from 40 and starting again, with nothing, except even worse labs and less, older eggs. I was beyond lucky to have a natural conception baby at 41, my second son. And now looking back, I hate that I suffered with blaming myself and saying I should have this or that. The regret and second guessing can really eat you alive. There is so much else in this process to get you down. There is no right answer or right choice, so trust yourself and know that at the end of the road, no matter how it turns out, you made the best decisions for yourself.

Fertility

The Donor Egg Conversation – my eggs were the butter knife

Photo by Daniel Reche on Pexels.com

Something I often see in fertility groups are feelings of anger and frustration over being offered donor eggs or the suggestion to go down that path by a fertility doctor. I was there at one point. My doc was very straightforward which is one of the many things I loved about her. I didn’t want sugar coating, and ethically she had to tell me what was likely to be the easiest and most cost effective path to my desired end, a baby. But it hurt. I cried a lot.

She suggested I think through what I needed to do to close the door on my own eggs. I think she meant, how many cycles am I willing to go through, how much money can I spend, etc. I took it a little further and researched like a mad woman and thought through which protocols I wanted to try and if response was good on X protocol, I will do it Y times, etc. I was going to do one more cycle with a lower dose protocol to see how I responded on less meds since that would stretch my money farther, take the summer off and start down the path of trying the protocols in the fall. I got incredibly lucky and got pregnant with my twins that first lower dose cycle. Overall I spent a good 6 weeks mulling over the donor egg conversation.

I have thought about those conversations a lot over the years. I think several things may play a part in how we come out of them feeling and I hope with this post to help someone gain some perspective that helps them not feel anger, disappointment or defeat.

First, let’s look at why they bring up donor eggs to start with. When I was processing the donor egg conversation, I was putting together a shoe rack. I needed tools like a Philips head screwdriver and rubber mallet or hammer. I was thinking, what if I had only a butter knife? It may be possible to get the job done with a butter knife, but it would take longer and would have made it ridiculously hard.

(We’ve all used a butter knife for a screwdriver, right?)

I thought of the tools my doctor had to get me pregnant – eggs, sperm, medications, procedures. If I take away those tools from her, how is she supposed to build a baby? In this case, the more eggs you have, the easier it is to find a good one and get pregnant. I thought of my pitiful response to meds and my 2-3 eggs per cycle and I realized that my eggs were the butter knife. They may work, but it is going to be a lot harder. This isn’t my doctors fault. She offered me the Philips screwdriver. She explained that the screwdriver would increase the chances of building a baby, would likely decrease the time it takes to build and would very possibly lessen the cost to build the baby by doing less treatments overall. I had to make the choice between taking the screwdriver and the butter knife and she was doing me a great service by explaining that choice.

As much as I call my doctor a magician, she truly isn’t magical. Doctors only have so many tricks up their sleeves, and each trick requires tools. Offering donor eggs is compassionate and ethical. The doctor has to look at the patient and make the call on when not mentioning donor eggs would be unethical. If the patient is 25 and has low amh and poor response, because their egg quality at that age is still likely good, maybe not offering donor eggs right out of the gate is ok. If the patient is 40 with low amh and poor response, it would be completely unethical to cycle her over and over and never offer the donor alternative. In many cases, offering the screwdriver while agreeing to work with the butter knife is the right thing to do.

Now lets think about the conversation with the doctor.

Did you hear what they said? For me it was like what I imagine being told you have cancer is like. It was a shock and I felt a little like I was having an out of my body experience. I knew she was still talking but I wasn’t able to hear what she was saying, let alone focus on the words. Sometimes people walk away feeling like the doctor said there was no chance of them having a baby with their own eggs, period.

I would be shocked if any reproductive endocrinologist said to anyone that their chance of conceiving with their own eggs is 0, since no one actually knows that. There are natural surprise pregnancies every single day, even in women who thought they were well into menopause. Doctors by training know not to talk in the definitive. They may say you have a UTI, but then follow it with, “this antibiotic should kill it.” What they are probably quoting when they give you a chance of getting pregnant is a statistical chance of pregnancy using all the tricks up their sleeve. They may base this on their own practice data or maybe some published study, something likely based on age and the # of eggs you historically retrieved or are likely to retrieve. They aren’t saying this to discourage you. They are saying this so you can make an informed decision. They tell you this so you can factor that in when you are choosing how to spend the funds you have available.

Sometimes people say that the doctor won’t allow them to try with their own eggs. They believe the doctors are more concerned with their success rates than giving each person a chance. That may be true of a few doctors. What I believe is more often the case, is that if they truly don’t want to try cycles with someone it is because they feel sure they don’t have the tools to build the baby. Maybe their general population are PCOS or male factor and they have little experience with DOR. Maybe their clinic is in a location where they struggle to get embryology staff year round so have to batch patients, which basically is like when the butter knife bends – the tool you do have is even more ineffective. Maybe they are part of a health system or not in control of their prices, so feel you would be better served at a place that does mini cycles and banking packages where your money will stretch farther. It’s better to know how equipped the doctor is to handle your care before sinking time, heartache and money into it.

Some people react to the conversation about donor eggs as if it is no big deal. They love that they have that option, are not upset about the genetics and choose that path right away. Some choose it but mourn the loss of their own egg baby. For them, maybe the emotional toll of many failed cycles is just not worth it, but choosing that path is still a loss. Some women have seen negative test after negative test at home already and just want to be pregnant already. The doctor has no way of knowing whether you are going to be happy to move forward with donor right out of the gate or really want to try with your own until they have that conversation.

I believe most doctors who choose infertility for their specialty do so because they genuinely want to help people build their families. They go to school for hundreds of years to end up working long hours, weekends, holidays. They review lab results or call patients with directions while most are sitting down to dinner. They are busy and dedicated. They experience the pain of each failure right along with their patients and they feel genuine joy when they can celebrate a success. They look at us and want to solve our problem and it is a really hard thing for them to have to tell us that they don’t have a trick big enough to solve depleted egg reserves. The conversation is not just hard for you.

Fertility, High FSH

Q & A with Dr. Jerome Check – Treating patients no matter their numbers

When I first consulted an RE, I was under the impression that most who took the insurance I was so lucky to have would make me pay up front and file claims myself so I chose my clinic based on how they approached billing. I didn’t know I had DOR. I had never heard of AMH or FSH, so I didn’t stop to think that I may need a specialized clinic. I don’t think I am alone in this. Many women just starting this journey have no idea how to choose the right doctor. Eventually we figure out if we are in the right hands and hopefully find the right fit if we are not.

I never saw Dr. Check but over time in groups and reading research I learned of him. I have suggested him to those that have very high FSH and those that are in the PA and NJ area. He is known for taking tough cases and for an individualized approach for trying to get follicles to grow in women whose ovaries have struggled or failed. In the questions below he touches on many important points, from how his protocols work to the what supplements he believes in and the business of fertility.

Dealing with women who have a small likelihood of responding to meds very much limits the tricks in the bag of any RE. Some may refuse these patients because they don’t know how to help, or because they are worried about their stats, or because they feel ethically challenged for taking money for cycle after cycle with a poor prognosis. I don’t fault any RE who treats DOR primarily with donor eggs, but I do deeply appreciate REs that will give everyone a chance at their own. I have seen a lot of hope from women in groups who go to Dr. Check and I know he works tirelessly to help those in even the worse shape.

Dr. Check is at the Cooper Institute for Reproductive Hormonal Disorders and has offices in NJ and PA. https://ccivf.com/ His nurses run a great facebook group found here https://www.facebook.com/groups/DrCheckInfertilitySupportGroup/?ref=group_header You an also like their facebook page at  https://www.facebook.com/cooperinstituteforreproductive/?rf=1708524172727649

Dr. Jerome Check

In Facebook groups people discuss their experiences and report what they are told by nurses and doctors. Often they get it right, but sometimes they don’t fully understand what was said in an appointment, especially when emotions run so high. I know it is easy when you hear something like donor egg to leave that appointment not fully recalling everything else that was said and hearing donor egg over and over in your head. So since I never consulted with Dr. Check and had actually sent many women to him, and gotten some mixed information about his approach, I reached out to the clinic to see if he would explain it for me to print here.

I think its important to follow your own path with your doctor. Everyone has an opinion and your care is best managed by the person monitoring you. For example, Dr. Check details below why he doesn’t want people taking DHEA with his protocol, but your doctor may prescribe it to you based on your labs and/or your protocol. I am hopeful for those of you that are not able to see Dr. Check but are interested in his approach, this will help you formulate questions for your own RE. The good news is that Dr. Check will take patients from all over, and remote monitoring is possible.

1. Can you describe your protocol with ethinyl estradiol?  Why do you use that form of estradiol?  How does it work?

First, I am going to also send you some articles that will deal with this in more detail. I am going to send you first article #632 entitled “The Multiple Uses of Ethinyl Estradiol for Treating Infertility.”  We use ethinyl estradiol to lower FSH, but the reason that we use that as opposed to standard estradiol preparations is because it does not measure in the assay for 17-betaestradiol in the blood test. So we can evaluate people by the bloods because even if you see a follicle on ultrasound, it does not necessarily mean it is mature enough, or it may even be what we call an airhead.  Sometimes it looks like a follicle but it is not making estrogen, so it is not a follicle.  So it lowers the FSH, but it is not that we use it for everybody.

2. Do you feel that ethinyl estradiol is the right path for all women who have elevated FSH or would you reserve that for women whose levels are above a certain threshold? 

We do not reserve it for women above a certain threshold but, for example, if we have a woman who is actually in premature ovarian failure where they have high FSH, low AMH but have an estradiol level that is less than 20 that does not rise, then they probably have down-regulation of their FSH receptor by the high serum FSH level. If you lower the FSH, you can have receptor restoration and then they can even respond to their own endogenous gonadotropins, or they can respond to a little boost of FSH at that point.  

We also use ethinyl estradiol for women who have diminished ovarian reserve who wind up having short cycles related to a short follicular phase.  I am actually going to enclose an interesting article, article #97 entitled “Successful Pregnancy in a Forty-Five-Year-Old Woman with Elevated Day 3 FSH and a Short Follicular Phase.”  You need a certain number of days of estrogen exposure to develop progesterone receptors and although some people can conceive with a short follicular phase, it is much better to have a little bit of a length to it, even if you eventually get to an estradiol above 200.  A lot of times we will use it to hold back the follicular development and then let it go and let the person respond to their own endogenous FSH or sometimes we will give them a tiny boost of FSH.  We tend to give the boost when the FSH is closer to the normal range.  If it is elevated, we do not want to add more FSH because that will shut down the receptors by raising the serum FSH level.

 3. One thing I have noticed anecdotally is that some of us whose FSH is 50 or below tend to be able to get it down to a better level with supplements, diet, acupuncture, etc.  When it has succeeded in doing this with a better FSH and a normal estradiol with baseline, they tend to respond better in stimulated cycles.  Do you feel there is a place for trying to reduce FSH naturally?

Yes, the higher the FSH, the less tendency a woman has of making a mature follicle.  We do not have a hard fast rule on that.  If someone has regular cycles and they have an estradiol level of 45, if they are making a mature follicle I am not looking to suppress their FSH and then give them stimulation, I am looking at their own endogenous FSH to stimulate their follicle.  If they are nowhere close to a mature follicle, then many times we will use the ethinyl estradiol, bring down the FSH, stay on it but then give a small boost of FSH to push the follicle to the right point. I am not so sure though that there is enough estrogen in supplements like wheatgrass or soy to lower FSH and I have no experience to say yes or no that acupuncture can help lower it or not.

4. Some doctors say you are good as your highest FSH, yet they will cycle a woman when her FSH drops.  Do you feel that statement is false?

Absolutely it is false if I am reading it right.  The highest FSH we ever had a pregnancy in is 185.  We have had pregnancies at 163 and many people above 140.  To me, there is no absolute level of FSH where a person cannot get pregnant.  In fact, a woman who had a 185 actually is a woman who failed, I think, four cycles to get pregnant with donor eggs and she got pregnant with her own egg.  Article #103 is entitled “Successful Pregnancy with Spontaneous Ovulation in a Woman with Apparent Premature Ovarian Failure Who Failed to Conceive Despite Four Transfers of Embryos Derived from Donated Oocytes.”  We published that in 2006. Later she told me that when she was in California her level had been as high as 185 but I have it lower in the article.

5. Some doctors say that having high FSH is a sign of having bad egg quality.  It seems from the experience of my group that egg quality is largely based on age, not lab values.  Do you feel high FSH is a sign of bad egg quality?

No, not necessarily.  I think you are right on point with that.  I am enclosing article #702 which is entitled “The Younger the Patients, the Less Adverse Effect of Diminished Oocyte Reserve on Outcome Following IVF as Long as the Proper Ovarian Stimulation Protocol is Used.”  If you look at the data and the table on that, you will find that women when they are 35 and under, when the proper low-dose stimulation was used, they had 80% as likely chance of getting pregnant as a woman 35 and under who has normal egg reserve.  In the group that was 36 to 39, they were 70% as good.  In the women who were 40 to 42, they were 50% as good.  Interestingly, if you look at the data, it looks like the women who were 35 and under who have diminished egg reserve behaved the same way with pregnancy rates and live delivered pregnancy rates as women 36 to 39 with normal egg reserve and women 36 to 39 with diminished egg reserve seemed to do just as well as women 40 to 42 with normal egg reserve.  Although we have written some papers on women 45 and 46 getting pregnant, there is no question age is a much more important determinant than the FSH, but the FSH becomes more important the older you are as far as the elevation is concerned.  Eighty percent does not mean as much when you are  young and a little more important but not tremendously important when you are 36 to 39, but you are only half as good when you are 40 to 42, so some of that answer is right and some of it is a little bit…There is some effect, but age is definitely much more important. 

6. Often I see women with low AMH being pointed to IVF right away when they have unexplained infertility.  Do you feel that is the best course of action for DOR? Why or why not?
            Indeed, many people will fail IVF and then get pregnant on natural cycles.  The drugs have an adverse effect.  I am also enclosing summary articles #706  and #690 about using the proper stimulation protocol.  There is no one right answer to that question.  IVF if done the right way will give a person a two and a half fold higher pregnancy rate per cycle than non-IVF, both in women with normal ovulation, normal fertile women and women with DOR.  If you have a 35-year-old woman who has a 50/50 chance of being pregnant in three cycles with just good, old-fashioned sex if everything is normal, if she did IVF she would have a 50/50 chance of getting pregnant in one cycle.  Obviously, for that woman it is not a lot greater benefit than having sex. 

            The way that most doctors will do IVF is using too high of a dose of FSH drugs, it is probably more detrimental than helpful.  Done the right way, if a woman’s husband had borderline low sperm but not really enough that she really needs IVF or let’s say a morphology issue where morphology does not really matter much,  but we can get the insurance company to pay for it, do you think there would be any advantage to doing IVF? The answer would be yes.  We can’t guarantee that if we use drugs to make a few more eggs that they are all going to release, but at least with IVF we can go in and get them.  The key is that it has to be done the right way. 

7. Do you believe in supplements to enhance egg quality like CoQ10, DHEA, melatonin and others?  Why or why not?

I see no harm in CoQ10.  I see no harm in melatonin.  I do not really know if it works or not, but I do not stop people.  On the other hand, for a follicle to be a dominant follicle, what happens in normal ovulation is you have to convert these antral follicles into a dominant follicle and to do that, these antral follicles are androgen dominant and the follicle that can be converted to an estrogen-dominant follicle, that follicle is now controlling its own destiny. Once it does that, there are all kinds of interactions that occur that allow that follicle to reach complete maturation.  The way some people treat, DHEA supplementation could help them because DHEA is converted to estradiol and the estradiol can lower the FSH and they may be benefitted.  When you do it the right way, however, it is actually harmful because the DHEA will make the follicular fluid more androgenic and it is less likely to form a good dominant follicle. 

We tried that and we looked at serum DHEA levels and it is article #661 called “No Evidence to Support the Concept that Low Serum DHEA Sulfate Levels are Associated with Less Oocyte Production or Lower Pregnancy Rates.”  The original article came out of a Dr. Casson from Tennessee.  Actually, it is interesting.  His group were poor responders who did not have elevated FSH but had low DHEA levels and he found in some cases giving them DHEA made them make more follicles.  Norbert Gleicher was a naysayer in the beginning, then became a follower when one woman apparently went from like three follicles to eighteen, but that is extremely rare.  So the thought was if you have low DHEA levels, you should have less egg production and have a lower pregnancy rate.  Though we did not see a statistical difference, there was a definite trend toward a higher number of eggs produced in an IVF cycle with low DHEA levels and also higher pregnancy rates.  I forget what New York group did it because they all blend together, I think it was NYU, but a year later they looked at it better than we did.  They looked at the follicular fluid level of DHEA to see whether or not…again them thinking that the higher the DHEA, the better the number of eggs and the better the pregnancy rate.  There they found a significant difference in lower pregnancy rates and less egg production the higher the DHEA.  So we say nay to using DHEA.

Wheatgrass has some estrogen in it, but it is like dumping a glass of water in a big lake.  It does not really contribute much to the total estrogen production.

 8. For those readers in other parts of the country and world, what advice would you give them to finding an RE that is willing to work with them?

That is a tough one because as you may or may not know, a lot of people do not want to be bothered with it because they like to do a type of cookie cutter shotgun approach because it is easier. Everybody gets put on the same regimen and it is too many different phone calls and nuances and it also takes an understanding of the concept because it is not one protocol for everybody because the protocols vary from person to person.  It depends if the woman has adequate egg reserve, at least five to six follicles but her FSH is only 13 or if she had not had a period in four months or has not had a period in two years.  It all changes.  Some people need a boost and some people can take 150 IU FSH earlier.  I have them all listed.  In fact, I have another article that we wrote that talks about women who only had a single embryo transfer depending on their egg quality, but it talks about some of the protocols.  That is article #105 that I am sending.  

Also, from a business standpoint, people worry about the fact that the CDC publishes their statistics, and if they wind up taking people with diminished egg reserve, and even I admit done the right way that women 35 and under will have only 80% as good of a chance of getting pregnant and women 36 to 39 only 70% as good and women 40 to 42 only 50% as good. If you have a lot of those patients, they are going to lower your success rate and other people who have normal reserve are going to spend their money with the other center that seems to have higher live delivered pregnancy rates.  The IVF center is getting paid for 1 IVF cycle but losing 10 other “customers”.  If you can get them into a donor egg cycle, that is win-win.  Do not lower your pregnancy rate and at the same time even make more money from a donor egg cycle than you do from a regular IVF cycle.  So not too many people are that interested.  

We are willing to take cases from around the world. I am a little short right now with associates.  I had been doing it right now while we are down, but from a survival standpoint, I may not be able to do as many long-distance phone consults for survival to get enough people locally that I have enough work for my staff to see.  I do them.  I am happy to help them that way.  I am adding another associate in January, but at the moment I am a little short.  I lost one and one is on sabbatical.

9. Is there anything else you would like to share?

We have to face the reality of life that medicine is a business and that difficult problems take too much time and they do not pay more money.  They are not going to get a large number of REI’s interested in this.  There are some of us who care, like I do.  It is part of what I do.  In fact, MY WHOLE STAFF REALLY CARES. I would be happy to help out as best I can.

Fertility

Medical Concierge France & IVF Abroad

With our current healthcare system here in the US, IVF is often out of pocket and very expensive.  Also in my groups I see people who don’t have access to doctors in their country or who are denied treatment for one reason or another.  I thought about trying to cycle out of the country but the idea seemed overwhelming to me, when fertility treatments can already be overwhelming as is.   There are services out there that make it easier.  Ever heard of a medical concierge? I hadn’t.  

I reached out to Oana Gharbi, co-founder of Medical Concierge France to understand more about what these services can do for those seeking treatments away from home.

What are the reasons someone may travel out of their country for IVF?

Depending on where you are coming from, the reasons differ.  
Americans choose to do IVF abroad most often for financial reasons. Stats say up to 70% of American infertile couples have to pay for IVF out of pocket.  British women travel abroad for IVF because the NHS can have a long waiting list, it covers IVF only if you have never had any kids, and many other sorts of requirements. Private clinics in the UK have very high prices.  Here in France, women benefit from 4 covered IVF and 6 covered IUI, but things like age limits, marriage requirements, being in a same sex relationship or requiring or desiring PGS testing may mean they need to go outside of the country. French women are the luckiest: they benefit from 4 IVF and 6 IUI cycles completely free, meds included, up to the age of 43, no waiting list. Unless they are unmarried, or in a same sex relationship, or they require PGS testing. 

What is the benefit for using a medical concierge?

 Infertility is strenuous as it is. Having to deal with the logistics of organising a trip abroad to do IVF doesn’t take any of the stress away, On the contrary! A medical  concierge service takes care of all the little details that help to make your trip as uneventful as possible and helps you focus on what matters most: your cycle, your body, your future pregnancy.  

What services does the medical concierge provide?

From looking up the best transport options, to offering you special rates to partner (3, 4 or 5*) hotels, translating your medical records and picking you up from the airport, a medical concierge takes care of everything for you. The services are customized and aimed to provide you with a stress-free medical experience. We accompany you to your medical appointments and we keep in touch with the medical staff on your behalf if you wish. We provide tips for spending your free time, arrange bookings at restaurants, spas, beauty saloons, shopping. 


Can the medical concierge handle bookings for lodging?

Yes, we have contracts with hotels offering us special rates and upgrades, and with short term rental agencies so we can find the best accommodation for you.


How much does it cost and how do the fees work?

Our standard rate is 10% of your total medical bill. For an example, an IVF cycle at the American Hospital in Paris, meds included, would be around 7000 Euros assuming you are a medium to high med protocol, and our fee would then be 700 Euros. Translation services and chauffeured drives though are to be payed separately, priced by request.

IVF can be unpredictable, what happens if my cycle is canceled or I need to stay longer than planned?

There are various options.  You may decide to do the monitoring at home in the US and come only for retrieval and transfer, in which case you will have to make a short trip overseas before starting your cycle so that you can come pick up your meds (prescription meds cannot be shipped to US and yes, the cost savings is substantial even with a plane ticket.  One 900ui Gonal F pen costs a little over 300 euros in France versus up to 900 USD out of pocket in US. You may need to use up to 7 pens in one cycle, depending on the kind of protocol you choose to do. 
If you decide to spend 3 weeks in Europe for an IVF cycle and make a vacation out of it, should your cycle be cancelled you may decide to go back home earlier. We always advise our patients to make sure their plane tickets can be exchanged. As for the lodging, we assist you with the bookings and make sure cancellation options are very clear before you sign the contract. Again, you only pay us the agency fee. All the other payments go directly to third parties we put you in contact with.

What other types of medical services does your service help with?

We facilitate access to affordable healthcare in top notch facilities. We guarantee 48 hour appointments for every specialty. We have several fixed priced packages, including our Second Medical Opinion package. For 450 euros, we make an appointment for you at a top specialist, we present your case, we skype during the consultation to assist you with asking the questions you need answered, with us acting as translators and mediators. We provide you with a complete medical report with the doctor’s opinion and recommendations. All this from the comfort of your home, no traveling, no hassle.

To speak directly to Oana, you can find her at https://www.medicalconciergefrance.com/

So there you have it.  We know that IVF works first time for only 35% or so of couples so thinking outside of the box to find affordable options can be key.  Travel isn’t so daunting when you have a personalized translator and assistant walking you through the process.  My cycling days are over, but thanks to my kids I may need to use this service for some sprucing up of the body!

Have you cycled out of the country? Would love to hear experiences and recommendations in the comments.

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

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!