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

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.