Decades have passed since Louise Joy Brown was the first baby born through in vitro fertilization (IVF). Though the technology’s advanced since that first IVF birth in 1978, understanding of who IVF can help and what it achieves has lagged behind.
Ovarian stimulation and egg retrieval may seem like the most labor-intensive processes of the IVF journey, but for many it is the transfer cycle that is the most nerve wracking.
Please watch as OC Fertility walks you through what a Frozen Embryo Transfer (FET) cycle is, the various protocols used and some of the important dos and don'ts.
Patients asked specific questions—all of them were great!
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Below is an auto-generated transcript of the webinar. Any mistakes are inadvertent. Thank you for your understanding.
Dr. Nidhee Sachdev: Hi, everybody! Thank you for joining us today as we talk about the frozen embryo transfer cycle.
We're going to go over the overall process of the frozen embryo transfer cycle some biology physiology about it and how the process works. Some key concepts we are going to talk about our how we make embryos, just a quick recap of that.
As we prep for your cycle, how we prepare the endometrium to optimize the situation for when the embryos placed in there it's ready for implementation. How we go about selecting the embryos and understanding your embryo transfer procedure.
The IVF process is what we call it like the high tech version as compared to the low tech version of treatment. Some of you guys have gone through, but just a quick recap, we stimulate the ovaries by taking injections for a course of about two weeks.
Over that course of time, we're slowly growing the eggs within the ovaries and we're measuring follicles. Once you're ready, we do a procedure to take them out once we take them out of the body there in the IDF lab when we fertilize them.
Let's burn eggs are fertilized and need to grow and divide to become embryos. The embryos which are more developed or called blastocyst, they typically become blastocyst around days, five through seven. These are the embryos that were then implanting. Now how do we prepare for your cycle and important process of planning and preparing for your frozen embryo transfer cycle is downloading and using the patient app that we have this allows you to access your private OC fertility patient portal. Can be on your phone, your tablet your computer, whatever you feel comfortable with. But we want you to get comfortable with this because this is how we will show you your calendar and it's a big way of how we safely and securely communicate with our patients. What's ideal is that you notify us via portal or you can still call in and tell us the approximate month that you want to start by giving us a notice at least three to four weeks. By doing that, we can then prepare and plan.
Now, if you're coming straight off your IVF cycle we already know that you want to do that as long as you're clear with us that, hey, once we have the embryos, we can move forward. Typically, we will share general instructions and orders in the portal under the documents section so you can download it and Apple store or Android store. It's this little orange icon called the AI NS patient app, there's a specific clinic ID. And here you can see there's buttons that should documents which is where we'll share information send messages to you. In the FET calendar. Now there's various different types of protocols that we use.
Here, you'll notice that we've highlighted FET protocol that's a frozen embryo transfer protocol. If you're somebody who's gone through many cycles and you're
Not sure which cycle, it is you can always ask your coordinator. But typically, you can see all of us on the bottom and you want to make sure you click and look in the right challenger for the one that pertains, so if you've done IDF before you can still have that calendar in there. You want to make sure you're looking at the FET cycle.
To get ready for your embryo transfer where we have to do the info gathering and again for many of you who are coming off a frozen embryo transfer cycle straight off of an IBM cycle. A lot of this has been done. But again, if you're taking a break between your IBM cycle and now you're frozen embryo transfer cycle. Or you've had a successful outcome had a baby you know you're coming back. We may have to repeat some of these labs. A lot of these labs are needed to be updated within one calendar year. So that means we want to make sure your immune to the different types of communicable infections like chicken pox rubella, measles and your infectious diseases like HIV, hepatitis and so on. We also need to make sure your uterine cavity is appropriate for embryo transfer
We do that via procedure called a... That's an office procedure in which we take a tiny telescope and we place it through the cervix into the uterus for us to evaluate to make sure there isn't anything in the uterus that could potentially impede an embryo from them planting, such as a fibroid that's impinging on the uterine cavity or a polyp which is a benign growth of uterine lining, or scarring. If you've had prior procedures or private miscarriages now a history has to be your, your ceiling and Sano is an important part of that process.
So you want to make sure that it's scheduled at the right time, typically a cycle day five through 11 of your menstrual cycle or if you're on the birth control pill. You can be done at any point in the cycle when you're not leaving, so typically, if you're getting a period calls on cycle, day one, you can use the portal or you can call leave a message when you do that, it's important that we have your pharmacy information on file so that way we can prescribe any medication that might be needed if you're still bleeding, we cannot perform the procedure, mainly because we can't see that well within the uterine cavity for still bleeding. So to optimize outcomes. We want to make sure you're no longer bleeding. Okay, here's Dr. M. She's going to go over a little bit more detail about the frozen embryo transfer cycle get after him.
Take it away Dr. M!
Dr. Sharon Moayeri: control pill and coordinate that way we will have you do some antibiotics proceeding, the procedure and then also we do encourage you to consider taking some ibuprofen or Tylenol, so that it helps with the cramping.
In terms of what the procedure is, this is what the history of the entail. It's an evaluation of the uterine cavity space. This is your uterus, the woman showing her uterine cavity.
Inside or uterus inside and then this is the camera that we pass through the speculum into the cervical channel to view inside the uterine cavity.
It's a skinny little telescope. It is the procedure we typically do in the office. You don't generally need anesthesia for it.
But it can be a little bit uncomfortable. It's probably comparable to the HST which many of you have done already.
We infuse some salt water and then look inside. And what are we looking for. Here's an example. This is
The doctors passing the camera into the uterine cavity. This is a monitor where we look inside the uterus basically like a telescope
And then here you see a picture of a very normal uterine cavity here you see an example of some problems polyps fibroid scar tissue.
So really, we want to make sure that that uterine space looks perfect. And sometimes on ultrasound. We're going to miss some of those details and so the history of it allows us to get a really clear view of inside the uterine cavity.
In addition to the history is copy will often follow it at the same time with what's called a sailing sonogram.
Some places might just do a thing in sonogram. But in our practice, we feel like it's easy to miss things on the sailing sonogram. And so the gold standard really for evaluating uterus is the historical
After we do the history of the p in case there's things
That we can't certain angles. We can't get into, like, for instance, if you have something blocking. We're not going to be able to see the details behind Will go ahead afterwards when there's fluid in there and insert the ultrasound and look at the interest again from a different angle. And that's essentially what a failing sonograms is having fluid inside the uterus and then looking at the uterus from a different angle with some contrast material and that contrast material is the salt water. The thing.
This is an example of just a routine ultrasound that you guys are probably very familiar with. That's what we do in the office all the time, but it's easy to miss things. One, the uterus.
Is collapse down like this. This is an example of a sailing sonogram that's normal. There's no defects. It's making moves on the borders and reflect spaces where the salt water is and then this year, last one is an example of there being a problem inside the US and these little blips right here are polyps that are in the human capital.
So we do both. Typically, we start with the history of up as a result of doing the history of fluid inside the US and so it's easy to roll by the entire team sonogram afterwards. That way, you kind of get the most thorough evaluation of the uterus and was much less likely to miss anything.
So that's the background of creating the embryos, getting the uterus in shape in terms of structure anatomic issues. The next step will be how do you get the uterine lining
To time with the age of the embryo. So if you have frozen embryos, we want to try to figure out, when's the best time to put those frozen embryos back in the uterus.
And to do that we try to basically replicate the menstrual cycle. So looks like actually discuss shift a little bit, but basically the menstrual cycle is just that the cycle.
We have estrogen and progesterone hormones that rise and fall at the beginning of the menstrual cycle.
You have a lot of estrogen around. And that's what this line this gray line here shows and the point of that estrogen is
To grow the lining. It's like the water for the belong. If you want to think of it that way. So you start out with your menstrual cycle, you're lining sends out that to people. You said you're lining. So now you've got the sin lining and then with the estrogen. We're building up the lining again. And as the estrogen goes up from an ocular Tori egg, you're building up the uterine lining once the lining reaches oscillation naturally
The aid is released and progesterone dominates the cycle. So the first part of the menstrual cycle before oscillation is dominated by estrogen.
The second part is dominated by progesterone and I'm sorry I think it looks flipped on this, but actually estrogen dominant in the first part that was your face.
Progesterone, the dominant and the second part, the luteal phase. And we really just want to try to replicate that with the medications that will give you so we're going to show you how we do that.
The point is the egg and the uterine lining want to be synchronized. And so, naturally, when we oscillate and the sperm meets the egg, most of that happening in the fallopian tube.
It takes about a week from that egg that's populated meeting a firm to make its way as an embryo into the uterine cavity.
So if this were all happening inside your body. We want to try to mimic that same timeline.
So that one week embryo, which you probably remember is called a blastocyst embryo. And so that's naturally in your body when the embryo would be entering uterus, and we want to replicate that in the cycle that we're doing.
This is what's happening in the laboratory, you get your bag and your sperm and then again a full week before it's what's called the blastocyst embryo.
And while remember you can freeze by up to your transfer it so a single cell egg a single cell from a full week later at the blastocyst embryo and this is the stage that it would naturally be entering the womb.
Sort of mimic that menstrual cycle. We're going to replace hormones and that's really what the embryo.
Frozen embryo transfer cycle is about. It's about mimicking the natural menstrual cycle but using medication to do so and so with hormone replacement. The two important hormones which I mentioned earlier, going to be estrogen.
And progesterone. Those are the hormones that build up the lining and prepare the line.
People use them in different forms and I'll kind of show you how we typically do it. There's not one right way to do it, but we have our protocols that went pretty well.
And then, in addition to your estrogen, progesterone. We're going to have some supportive medications and those might be things like steroids antibiotics.
Sometimes we'll use the medication called Lupron you don't always use it.
And then sometimes we'll do what's called a natural cycle. So these are different protocol types that we can use. But the most basic cycle is going to be a medicated hormone replacement cycle with estrogen, progesterone.
As well. Awesome supported medication if there's a reason for instance for some patients to do Lupron we might recommend that
It does take a little bit longer to July medicated cycle, but it might be indicated for some instances, and then the natural cycle will talk about also that it's kind of a less commonly used protocol. In our practice, it is a little more
And uncertain in terms of timing and that sometimes makes people makes it difficult for people to plan and one concern you have with a natural cycle for some people's
If you're having trouble getting pregnant, naturally, it's not clear that doing a natural cycle for implantation is going to be your best opportunity for success.
So what are some of the medications.
Go back estrogen. Okay, so I want you guys to be familiar with these medications and what they look like, you're going to get a whole bunch of meds and part to tease out what's what.
So just being familiar with what the pills look like and what you should expect is really helpful. There's always so many moving parts of these treatments that
We weren't, you know, especially if you're not otherwise taking any meds that can be hard to figure out which ones which medications like like the estrogen. I always going to have some side effects, but they're pretty minor with
Estrogen you might have some discharge or irritation of skin, especially if you're doing the patches or if you use the vaginal the pills bad generally
But most of these symptoms are rare and far and few between some people will complain of headaches anxiousness on palpitations allergic reactions are very rare, but they can happen more often with the patches.
So one of the forms of the estrogen I've shown you here are some examples of what the pills look like we typically will do estrogen pills to start your cycle.
That brand name is called X rays, and then the chemical name called Esther dial. So you might see these different names on the pill bottle, they're the same thing.
Okay, we can do anywhere from one to four pills per day. But we often will split that out so that you can tolerate it. And so the more even hormone replacement
It's funny. The thanks but we actually can do these pills either orally or vaginally and oftentimes you will see us recommending that you take these pills badge.
And it's really not a different pills, the same pill, you would take by mouth, but we have you inserted edge loops death, but this is what they look like. So when you get your prescriptions. This is a common... The other kind of estrogen that we use is the patches and the brand name is called vital, but oftentimes you can get the generic form and I've shown you here this is the brand name the purple box.
And this is the generic... they're the same thing. They just have the brand name versus the generic name. And our practice will use both form to give you consistent absorption. And so the side effects on as
A significant usually if you have different modes of administering the medication, it tends to minimize many of the side effects, you might experience.
There are practices that use estrogen and oil routinely. We don't use it routinely will use it in certain instances and circumstances.
The nice thing about the estrogen in oil is that it only has to be administered a couple times a week. Typically, but it is an Intra Muscular shot and there is some question about its absorption and consistency of absorption. So we tend to stick with the pills and patches.
The other important hormone replacement for the second phase of your prep for your lining is going to be progesterone.
So estrogen helps build up the lining and then the progesterone help prepare the line. So progesterone primarily we do in injectable form. And that's the shot that a lot of people complain about unfortunately
It can cause skin irritation, but we have a lot of tricks for that we'll talk about when they get to the instructions on how to do the progesterone.
So it comes in different solution sesame oil is the most common form, but it can also come in at the only eight or all of oil those forms may be less irritating for some people.
But they tend to be more costly as well. And the dosing is anywhere from half a milliliter to one no leader anywhere from one to two times per day. It's where we have to go higher than that.
And unfortunately, you will be on this project, not only for the duration, the latter duration of your frozen embryo cycle, but also for the first part of your pregnancy so you can expect to be on the progesterone shop for about two or three months.
And then the trend is another form of progesterone. It's a compounded. I mean, sorry. It's not compounded it's a bad news depository that is similar to a compounded national
Product that we used to prescribe often in the past few years. Now they have this FDA approved product which we prefer to use over the compound at one
Inch this gets inserted 123 times a day. But usually we don't use it in place of the press room shots. However, we could start you on the projects or shots and then transition into this depositories later on and pregnancy.
I promised you I'd show you how to shop work. I'm not going to go through too much detail, but I just wanted to simplify and give you some idea of what those shops look like they can seem very intimidating.
And basically the shops are given in the button muscle. And so there's actually two but muscles with me. There's one in the back. And there's one on the side. So you've got two large blue do muscle.
We even draw cross on your butt cheek and the upper quadrant would be where you would inject most often, especially if someone's getting you the shot.
If you have to do the shot yourself, it might be easier to use the anterior Luteal muscle, which is a little more lateral so if you took this
Post your location and kind of rotated around your hip, it would be more on the side of the hip. This is probably easier to do if you have to give it to yourself.
And I'm not going to go through all the details of how the shop done the team will go through this with you and we'll have these instructions available on your portal. But basically, you would inject the medication.
Perpendicular to tissue, there's a couple things I just want to review because a lot of times people don't get this right. You want to go perpendicular to your tissue.
And you don't want to track and, you know, a lot of times people angle this needle until it's going sideways and they might get into the fatty layer instead of into the muscle. The reason why we're doing the progesterone. Intra Muscular is because it can really irritate the surrounding tissue. And so if you're experiencing a lot of irritation. It could be because it's leaking into the surrounding tissue.
The other reason we do it intermittent is because you get better absorption. People ask, can we do this. That's cutaneous and unfortunately can't. And if you did you get a lot of skin irritation.
And fat tissue rotation. So it doesn't need to be done in the muscle and to do it properly.
You want to make sure that the needle 90 degrees. So you see perpendicular going into the skin and making sure that it goes all the way to the hub and the needle and into the muscle.
In fact, we often recommend pulling on the tissue. Sometimes people talk about pinching. We don't recommend pinching because when you create more risk for the tissue.
That the fluid to leak into those around the tissue you actually probably want to pull the tissue so there's less fat tissue between the needle and muscle and then that we might have lost the rotation.
You want to go and quickly inject the medication and then get out. We do recommend trying some ice to numb the area part of the injection and then maybe some heated massage afterwards to help absorb it.
If worse comes to worse. And you really feel like this is a difficult task we have, you know, nurses that can come to your home and give the injection. But honestly, it's very rare that we have patients who don't find a way to either have a family member or partner or friend Jeff for them.
Okay, stepping back. We talked about this one that luckily came out, right, the estrogen dominant phase of your menstrual cycle. And the progesterone dominant agent who menstrual cycle. And that's what we're trying to replicate with this whole HRT protocol hormonal replacement protocol.
nd that's essentially what we're doing with hormone replacement. So we're basically introducing hormones.
That replicate what your ovary would be doing if you were oscillating. And when we introduce those hormones that keeps your ovaries from inner from from articulating and interfering with the timing of the cycle. And so we basically take over the uterine lining responsiveness.
So in addition to your prenatal vitamin baby aspirin typically protocol involved starting estrogen and these are the little blue pill will be taking.
Typically to estrogen till starting with the second or third day of your period, you'll be on that for one week and the second week, you'd be out of your patches.
You'd be on the patches every other day for the second week
And then by the third week, you'd be adding your progesterone and that coincides with when we would expect a woman to be oscillating. Okay, so we're really just trying to emulate what the ovaries would be doing
And so in a woman's body her ovaries are going to be estrogen dominant and the beginning of the cycle and then progressed from dominant and a lot of part of the cycle. And that's what we're creating
So once you get to that third week you start your progesterone. The oil and we typically recommend two shots per day.
And you'll stay on that all the way up through embryo transfer your embryo transfer happens about a week after starting the progesterone.
Right in the middle part of that second phase of your menstrual cycle, called the luteal phase and then you'll stay on the estrogen, the
Pills estrogen patches and the progesterone shop, all the way until your pregnancy test. So estrogen till for a week.
Continue the estrogen pills. Add your patches for another week. Start your progesterone shots for about a week leading up to your embryo transfer
After your embryo transfer. We do recommend that rest for three days. I don't care if you're sitting or lying down, but we want you down. We don't want you on your feet. We don't want you exercising and then 10 days later you get your pregnancy test and hopefully you're pregnant. Okay.
In terms of what's happening with the lining. That's what we're looking at when you come in for the monitoring ultrasounds.
The beginning of your cycle when you come in for your baseline the lining of sense. So this is the uterus and this here is the lining of the uterus to nice them line.
After you've been on the estrogen pills for about two weeks. This is what the line should look like. It looks like the nice
Three stripes and call that try lamanna so you can see now the lining one on one single stripe to three sites. This is all a result of the estrogen.
Helping the wind grow after you start your progesterone. The lining becomes more fallen and appearance and that's the progesterone preparing the lining
For the embryo, because the embryo has progesterone receptors on it. Okay, so thin lining cry laminar right before progesterone start and then during the time that you're doing the transfer, you're going to see what's up a solid sick lining
In addition to your HRT hormone replacement the estrogen and progesterone. We've already reviewed, we're going to have you on prenatal vitamins. We're going to have you on baby aspirin and we think that baby aspirin x by reducing inflammation, improving blood flow.
We're also going to have you sometimes start the cycle with birth control pills. They Justin or Lupron
This helps control the ovarian activity in case we're worried that you might all be late through or for worried about you have the end of the trio. So there's different reasons why we might proceed the cycle of antibiotics or routine. And then, in certain cases, if you have a patient who has underlying medical MS or who's had prior failed cycles, we might do some add ons as well. And that might include other types of protocols such as Lovenox or heparin again those are only for certain individuals.
So natural cycle protocols prior to starting your hormones with birth control pills Olympians. These are all variations of the basic protocol just reviewed with you.
And there's different reasons why we would choose those protocols over the dominant protocol that we already reviewed. Sometimes we have add on, and I had briefly mentioned the reasons for that might be medical conditions sales cycle, etc.
So how do you choose your Ambrose. Well, the ones that make it are generally going to be better than the ones that don't. And so just making it to the end game is going to be important.
The appearance of the embryos, the stage of the embryos and then testing. So if you remember from your fertility funnel that lots of eggs and sperm, resulting in fewer embryos. And so the question is, you know, how do we choose at this stage which embryos to put back
I'm going to talk about first kind of the concept that age is a very important predictor of viable versus... non-viable eggs. So in our 20s. If we had, say 10 eggs, we'd expect about nine of them to be healthy. Okay, so you're only going to see maybe one out of 10 not viable.
When we get to be 40 that golden egg is much harder to find. And so the question comes, how do we figure out from the embryos which of those eggs were healthy and not
So here's your culture dish in the laboratory. This is what we see and we'll try to make decisions you've got all these embryos and you're trying to make decisions. And this really comes down to
How do you choose the best embryo. Statistically speaking, we don't know if you land if you're here. If we don't do more testing of the embryo.
If you're here or if you're here. Generally, we know that as you get older, you're going to have fewer healthy unreal. So you might actually have a lot of unhealthy embryos.
Or if you're younger, you might be here, but we certainly have young patients and the cause of their infertility is that they have higher than expected unhealthy embryos.
And so even though we expect based on their age for them to be here. They may actually be here. And so we're only relying on survival or the appearance of the embryo. We may not be choosing the best and
So this comes down to what else can you look at. So other than survival. What else can we look at to determine if these embryos your Bible.
Or likely templates. There is what's called stage and grade stage to describe kind of how expanded and develop that embryo is
Generally, one and two are not good. We don't you wanted two embryos.
Today, just three through six are generally the embryos that we were placed back into this and there's a whole algorithm that goes into it. It's not as straightforward as
You know, it's not a unilateral or linear decision based on many features. But generally speaking, stage one and two are not viable stages three to six are viable and this just described how expanded the embryo is... are the cells. Nice and separated or they still only impactful and haven't really developed to the stage that they could implant into the uterine wall.
Stage five and six. You can see is starting to what we call hatch out and it's kind of looking for the uterus and motive implants.
Whereas, if you look at these one into the cells are still really merged together. They haven't separated so three to six is generally why we're going to landing
The second thing we look at as an embryo is the grade for the grade described more of the parents of the embryo.
And there's two things we look at the cells on the inside of the embryo and the cells on the outside of the real
The cells on the inside of the embryo or the cells definitely become the baby and the cells on the outside of the cells definitely become a placenta. These are called the blastocyst cells are perfect in terms of the processes.
So A's are going to be better than seed and part of that you can see here, it's very well defined, you get down to see it's not very well defined. So generally, a great embryo is going to be better than great
So we talked about survival staging grade. And then the next thing would be embryo testing. So what are the pros and cons of doing embryo testing.
And the embryo testing would be the biopsy of the cell and then screening for the genetic of the chromosomes inside the cell.
The Pro. You can select which embryo better than just looking at them are seeing if they made it or not. But if you only have a few embryos to begin with. You might not be gaining much because that's all he's got
You're going to have more information preconception
Then waiting till you're pregnant and that's important for some people, but it does have an error rate of about 3% so you have to be aware of that. So it's not a replacement for testing and pregnancy.
Healthy embryos do survive the biopsy, but there's always the concern that the biopsy itself may damage the embryo again that risk is probably less than 99%
And as we discussed with our patients. Anything you do in medicine is going to have a risk and benefit you gotta decide where you land on that there is some evidence that it might be more efficient. You might save some down
Because you will be avoiding unnecessary. In some instances, but it is costly up front. And that might be prohibitive for some patients.
It is useful for patients who want to bank for the future because they know what you're thinking, and know that they're valuable.
But it made her life and getting pregnant because you got to wait for the results of the biopsy before you can do the transfer for people who want to put back one embryo and avoid multiple gestation. It gives you a lot of confidence and knowing that you've chosen the best embryo.
But it may not be needed to succeed. Some people are going to have a plethora of healthy embryos and so we wouldn't have needed it to select out the best deal and then for other people it's important to know gender or they may have some other chromosome issues that they want to be able to identify and so doing the testing is going to be very
Important for the outcome. But on the flip side, some people aren't comfortable with all that genetic detail me feel like that mother nature too much so it can be good for some people that way and other people can be an ethical dilemma.
So what about your embryo transfer procedure. This is a question that people ask a lot about. And it's way easier than you retrieval, that's for sure.
You don't go under anesthesia. So just to put it in perspective, I think it's really important to think about how small that embryo it, so the egg. Egg human egg and me are about the same size about 100 microns. So if you think about that and the concept and the context of what we know.
This is what a grain of table salt would look like. And you can see where the egg embryo would land in terms of its relative side to a grain of table salt.
So the embryo and our aid which happened to be about the same size.
Are right on the verge of what we can see with our naked eye. Most of the time we're looking at the microscope. Can you can't see much of it if you can see it at all with your naked eye, and I certainly can't see with my naked eyes because they're too old. But in any case, the
The embryo is at that stage where usually need to look under a microscope to see it.
So we can't see it, and we have to really figure out how to get this
Particle that we can't see into the right spot and uterus, and so we use a lot of tools to help us identify one place it. So stepping back to your anatomy. This is your uterus inside your pelvis.
And our goal is to get the embryo inside the kind of right in the middle towards the top. This is a side view of your uterus.
And basically we take that embryo. This is the blastocyst embryo. We put it inside a catheter. And here's some pictures of some common catheters, that we may use these catheter is a few millimeters in size.
We load up the embryo inside that catheter and we can't see it. The embryologist loaded up under the microscope.
And then he'll flank, he or she should be careful. He or she will link it with some bubble air bubble that are actually visible on ultrasound imaging and our practice, we do ultrasound vaginally to identify while placement of the embryo some practices will do abdominal ultrasounds, but we feel as we get better visualization that I generally and so at the same time that we're passing this catheter through the service.
We have a vaginal probe to identify wearing the uterus replacing it. And this is what it looks like. This is that catheter coming into the uterine cavity.
And this is the air bubble that will displaced inside the uterus.
And the placement of the air bubble tells us the placement of the embryo. So even though we can't see the employee. Oh, it's too small. The air bubble is linked to the embryo in the catheter and the identification of it, your bubble. Once this know where the placement of the embryo occurred. And it's that simple. It's kind of like a pap smear in terms of what you go through. So you're not asleep for this procedure, you're awake and it won't feel too uncomfortable, but it will be on the level of what happened.
So then important question is, well, what are the chances of getting pregnant. Well, again, this depends on whether or not you have a viable and real, so finding a viable embryos awesome going to be your biggest hurdle. And if you have a viable embryo.
You have a very high chance of getting pregnant, but the odds of finding a healthy viable embryo go down to the age
So on this chart. You can see the odds based on your age, and especially as you get into your late 30s, early 40s that rate goes down precipitously.
So in your early 30s AND MID 30s, you've got about a 5050 chance or so finding a healthy embryo as you're going into your late 30s AND EARLY 40s. You can see you've got between 10 and 20% chance of finding a healthy embryo.
But once you have a healthy embryo, your chances of pregnancy are about seven to 10
So if you put in a healthy viable embryo seven out of 10 times you're likely to be pregnant, but that's not 100% and that's the thing we all want to tell people that there's no 100% and I feel
There could be other factors other than the viability of the embryo that affected plantation partly related to the woman, but also partly related to the embryo as well.
So what are some of those things you can do for women who don't get pregnant, you can do more testing you can step back and do the history philosophy is it's been some time.
And then sometimes we do some further testing while bloodwork to look for other underlying conditions and in the mom.
So briefly, I'm going to go over to test a lot of people talk about era and a mutual receptivity of say
This is an important test we think for identifying the optimal window, then plantation.
It's not clear if you should be doing this on all patients are not personally I think that it's really only indicated in certain cases it's costly. It's time consuming.
And it's not needed for most of our patients to get pregnant, but certainlyFor women who don't have many embryos to begin with, or for women who failed implantation, at least twice. I think this is a very reasonable.
Procedure to step back and do basically what it does is it evaluates the uterine lining receptivity to the embryo by assessing is progesterone receptivity, and if you remember, earlier we did talk about how the latter part of the cycle when the embryo ready to be implanted focuses on progesterone receptivity
We take to buy up. We basically go through a whole mock embryo transfer cycle and then take to biopsy two days part to figure out when that timing would be optimal for replacing the embryo.
It could be that we have the timing right and we just confirm that, or could be that we were either too early or too late and putting back the embryo relative to the number of days wrong progesterone.
And so 70% of the time we might uncover a problem. But again, this is for people who have already failed treatments. There's not a lot of data, looking at women who've never done a transfer and what the odds are finding a mismatch. So it's mostly for those who've already failed transfers.
And other tests that we often will talk about as we stepped into this is a test. It's been around. It's kind of really packaged over the past few years, but it's been around for a long time.
And it's looking for endometriosis primary and inflammation in the lining of the uterus.
It's for people who have unexplained infertility unexplained failures for transfer all the current pregnancy wall.
It's not a perfect test. Some people think surgery might be equally informative. So looking for endometriosis laparoscopy, for instance, that sometimes that helps you decide if it's even worth doing surgery or not. It's pretty accurate but
A lot of people don't want to take the time or the money to do the test. If you do find out that it's positive, then the treatment generally is going on for months, depression,
Before your own real trances so doing things like Lupron or other forms of hormone suppression like birth control pills for about two to three months before doing your embryo transfer. So for some women who fail. This will be useful.
And then if we still, you know, want to rule out other causes. We kind of go down this additional. This is on the PS hug testing and this additional indicated might include things like climbing disorders autoimmune conditions, etc. And most of those are going to be blood test.
So we talked about basically kind of step by step. But to give you an overview month one is often going through your egg retrieval preparing for retrieval and creating the embryos month to could be preparing your uterus for an embryo transfer and then hopefully months 334 would be actually a pregnancy, you stay on your hormone replacement. This is the question we often get, starting with your embryo transfer and then all the way through to your first trimester of pregnancy, we start to wean off the hormone replacement. And the second part of your first trimester usually started around week nine and then we graduate you at week 12 usually during this time you start to see your OB/OYN you're generally the Julian that we do see you all the way through to the 12 week on these visits, we're seeing weekly monitoring for field development and assessing hormone replacement need during that first part of your pregnancy.
Okay. So I think we've gone through all the basics of the embryo transfer cycle. And if anyone has any questions. I think now would be the time to ask them.
And if you guys need to reach us. I put up here, some information about our website, our social media phone office phone and email address.
So please, I'm going to introduce GG who's going to be helping me moderate today she's going to be taking some your questions and I'll try to answer them as best they can be
Gigi, OC Fertility: A doctor. And so we had a question early on, where you talked about using Lupron were indicated and the person asked what would be a reason for using...
Dr. Sharon Moayeri: So a lot of times we do Lupron for patients that we suspect have endometriosis.
So something in their history might make a suspicious of that or if we know they have an end materials that we would use it.
Sometimes we'll do it for patients who operate through the other protocols will worry that they're not going to be suppressed enough on just estrogen alone so those can be some indications some practices, you move on and everybody.
So you know we don't use the University on everybody, but we do quite a bit.
Gigi, OC Fertility: Excellent. So we have another question. If you want to proceed with fit as soon as possible after egg retrieval. What does that timeline look like
Dr. Sharon Moayeri: So basically we went over that last slide, if I can get back there and it'll be basically you're one month to create the embryos two weeks of injection leading up to the retrieval. Two weeks after your retrieval, you'd be getting a period. So that's four weeks right there.
With that second period, you could start prepping for the embryo transfer depending on which protocol we use if it's a medicated versus the Lupron you could be doing your transfers, or eight weeks into your initial starting with any fertility treatments.
So, about seven to eight weeks from starting new retrieval, for instance.
Gigi, OC Fertility: Fantastic. Now, this slide might also answer this question, but it's a it's a good one for preparing and you know setting expectations. And the question is, how often our appointments during the embryo transfer cycle and this we also got a question on this during our IDs journey webinar. And maybe you can address. You know who they meet with more who they would be talking with at during their appointments at OC fertility. So did they see you today, see Dr. So maybe maybe eliminate a little bit more than just the appointments for who they're with all so.
Dr. Sharon Moayeri: Yeah, absolutely. So we pretty much scan most days and then we make ourselves available to our patients who travels and transfer. So anytime we have procedures. That's our priority.
The doctors are the only ones doing ultrasounds. In our practice, we don't have ultrasound texts or mid level practitioners
Basically you're coming in. Anytime there's a change in one line. So you start your estrogen. We're seeing we see a week later to start the Bible, we see a week later to start the progesterone. So we're seeing, at least, you know, three to five times your annual frozen embryos cycle.
Generally weekly depending on your progress and the protocol, your own, you can anticipate. At least, I would say three to four cycles three to four appointments minimal up to six.
Appointments depending on what protocol you own or there's any issues with how your lines developing and so after the appointment. You'll see one of either myself or Dr. Fetch Deb, we give patients as much opportunity to see their own physician if that's important to them. But there are some time some appointment conflicts, if we stop surgery. But truthfully, a lot of the information we're getting is pretty routine. It's nothing. You know nothing. Terribly unique about it. We do make our own decisions about our own patient so that if it's my patient. I'm the one deciding final results of what to do if it's darker sensitive patient. She's the one who decides the next step.
Gigi, OC Fertility: Fantastic. We have a question. Hello, I started my in vitro treatment. Three days ago, when do I take the medication to prepare the lining...
Dr. Sharon Moayeri: I need more information because I don't know what that means. So meaning in vitro retrieval. Was it clear.
Gigi, OC Fertility: Maybe it's not clear, so maybe that person will give us some more information. But in the meantime, we'll use the time to go on to the next question.
We have one on social media. A friend told me that a frozen cycle is less stressful than fresh. Do you think that's true. Our success rates are fresh. The frozen comparable. Yeah.
Dr. Sharon Moayeri: So that's a really good question. So when I first started practicing using a lot of restaurants and then as things evolve. There's some information that I think is real. That shows that all that hormone stimulation from the egg retrieval might make the uterine lining less receptive to the embryo.
And so we shifted away from doing the fresh transfers, partly because of that. But the truth is, that question really depends on the lab and the experience of the lab because if your lab can demonstrate very high success with freezing and thawing embryos, it's probably true that you're better off during your frozen cycle been a stretch.
But if your lab did not demonstrate great survival of spying embryos, then you might be better off doing the fresh so that questions, hard to answer universally, it really depends on the individual location.
And what their outcomes on with buying embryos and making sure that they have a good vitrification system. So we have a 99% survival of our embryos and so it's very unlikely that you would lose an embryo by freezing and thawing it and the detriment and pregnancy rates from a stimulated fresh transfer probably outweighs the benefit.
Of doing a fresh transfer. So most of our patients. I think 99% or more are doing frozen transfers, whether or not they're testing and we have some patients don't choose a 97% of our patients embryos that even if they decide not to just embryos are usually freezing them.
And I do think it's less stressful because you're giving your body a chance to cool off from all that and hormone injection
You're always a time to heal and that bloating tends to go away by the time your next period starts. And then from there, you're building up and prepping for the transfer and it gives you time to do it without your body been under so much pressure and stress.
Gigi, OC Fertility: Great. For the most so let's say you're saying, for the most part, it's probably less stressful.
Dr. Sharon Moayeri: Yeah, I think that like I mean that's been my experience with my patients. And I think the outcomes are actually better than me to at least in our product.
Gigi, OC Fertility: Got it. Next question is, why does someone going through IBM need to take progesterone for the first two to three months of pregnancy how time ties to specific are the progesterone shot. Yeah. Like time of day at...
Dr. Sharon Moayeri: Yeah, so if we do a medicated cycle. We have blocked your ovaries from producing the hormones support the pregnancy in the first trimester. So
In your body, your ovaries and your uterus are synchronized and whatever is going on in the ovaries, it's helping support the uterus.
When we do a frozen embryo transfer we're usually separating those processes and so your ovary ovarian activity is shut down unless you're doing a natural cycle to briefly alluded to, but again there's some conflict, whether that's always going to be a good choice.
So when we introduce the hormone. We're not just supplementing your body's hormones. At that point, we're replacing them. So, your body's not releasing estrogen and progesterone.
You're only getting the estrogen and progesterone that we're giving you and the pregnancy relies on that hormone and the first few weeks until the placenta is able to do it for your body. And so naturally the ovary would have that function until about seven to 10 weeks.
But since we shut your ovaries down in order to prepare your uterus. It's up to those medications to keep the pregnancy going and then one placenta for scoring between seven and 1212 weeks the placenta will be releasing estrogen, progesterone to support the pregnancy and you don't need to be on those hormones anymore.
This is a menopausal woman. So a lot of people don't know if you're menopausal. We can we can prep your uterus to carry a baby. And once you're pregnant, the fetus, the fetus is placenta will keep you pregnant so you don't even have to have over an activity in order to carry a baby.
And then into timing of the progesterone, you do want to be pretty you know it's not like some of the medications we do for the retrieval where it has to be within a few minutes. But you do want to be within an hour. So on each side because you do want to keep those hormones steady state.
Gigi, OC Fertility: Excellent. So next question is, do you still recommend acupuncture.
Dr. Sharon Moayeri: Yeah, that's a hard question. I mean, I think that acupuncture can be very helpful. I think we've covered. We've taken a pause and kind of been a little more cautious about pushing acupuncture.
But I think if you can find an acupuncturist that you feel you're confident with the environment. Then we still think it's generally beneficial. The data shows either neutrality or benefit to doing acupuncture. I think for the most part, it can be a positive thing. But again, I would just be really cautious in the area code.
You do spend a lot of time with the acupuncturist and closed room and see will make sure that they're practicing good preventive measures in your mouth, their mouth and you keep your distance as much as possible.
Gigi, OC Fertility: Excellent. Do you provide value prior to transfer, if so, what is the reason...
Dr. Sharon Moayeri: Yeah, we do. I like giving my patients value for a couple reasons. One, it helps them relax, which is always helpful, but there's also some clinical benefit.
Too relaxing the smooth muscle of the uterus that I think can help improve implantation. Right. So I do recommend volume for transfers. It's not mandatory, but we do encourage it one to just help them relax and keep the smooth muscle from contracting while we're doing that transfer and during the next few hours of one the embryo kind of burn its way into the moment...
Gigi, OC Fertility: Is there more than one healthy embryo for him if there is more than one healthy embryo for implant. Do you still only recommend implanting one versus two, I suppose, or more
Dr. Sharon Moayeri: Yeah, so I'm generally a one one embryo one baby wreck person doctors there are circumstances that we would recommend more than one, but I always want to have patients think about it that you know, every embryo has a, you know, a change of them planting at about 70% and if you put into you don't double your pregnancy weight. You really don't change your pregnancy rates much but you introduce a very high chance of plan.
When pregnancies are generally less successful than singleton pregnancies and so you do introduce potential harm. And I always say our job as doctors. First and foremost, do no harm.
The second thing to think about is you kind of want to spread your risk and so like anything if you only have a couple embryos and their high quality embryos.
You probably don't want to put all your embryos and one uterus. At the same time, you want to take the opportunity to separate the chances of them taking you probably going to get a better cumulative pregnancy rates by not putting them into gifs.
Gigi, OC Fertility: Great. At what point in the process. Do you know the stage grade of the embryos.
Dr. Sharon Moayeri: So the embryologist will get that When they freeze the embryos and so at the end of your lab.
Development of the embryos as their biopsy the embryologist will give us a stage in a grade they actually don't report it to us until the end.
But when they go to follow the embryo. They'll restage and great it because the embryo might change is staging. And grading from the time was frozen to the time that was thought. So that might be updated with the time to transfer as well.
Gigi, OC Fertility: Another question with reference to your Pros, cons genetic testing slide. I don't know if maybe you want to go back there. So you can address it.
Dr. Sharon Moayeri: Sure.
Gigi, OC Fertility: The question is how does genetic testing of embryos delay the transfer
Dr. Sharon Moayeri: Oh, so we freeze all our embryos that are getting tested so you don't have to. You don't have to freeze just for that reason, we already talked about other reasons why you might want to freeze embryos.
But we intentionally will freeze if we're doing a biopsy some practices will biopsy and try to transfer the next day in a fresh cycle.
I haven't done that for a long time because I felt like the pregnancy rates are lower and that contact and to you don't get all the embryos to the finish line in that cycle until they seven which is too late to be transferring and refresh cycle. So I like to make sure that we get the
Biggest cohort of the biggest group of embryos to the finish line. And if you're going to test we freeze the embryos, let the body cool off. It gives us a chance to let them all grow.
So that we're optimizing every opportunity to capture every unreal for that that
Gigi, OC Fertility: Let's say we have looks like the person asked about acupuncture has also asked, anything else you would suggest that helps the transfer work any
Anything that you, you know, particularly in the era of code can think of that would help with stress or or maybe not to do that. Could, could you know effective success rate.
Dr. Sharon Moayeri: Yeah, well I guess now everyone one. One thing I don't recommend it seems like a lot of people are drinking these days because they're grouped up at home. So you don't want to be drinking a lot, so I would say you want to limit your alcohol and you want to limit caffeine. So if you're cooped up at home. You want to find healthy ways of dealing with the stress and so meditation can be helpful for some people.
You know, eating whole foods, plant-based middle my package minimally processed food.
Limiting, like I said, alcohol, caffeine and then exercising, but in moderation. So you don't want to be a couch potato, but you also don't want to be able to doing it when I have that moderate
A low impact low intensity regimen for exercise. I think that can be very helpful because it lowers inflammation in the body.
And that's always good. And so does a good diet. A good diet and exercise does there's lots of evidence that lowers inflammation in the body, which is not as good for fertility. It's just good for overall wellness. And that's going to be good for your pregnancy weight.
Gigi, OC Fertility: Sometimes when people hear, you know, lowering inflammation, etc. It can trigger the idea of supplements you know like turmeric, or whatever it might be. What's your general feeling about supplements with regard to fit cycle.
Dr. Sharon Moayeri: Yeah, so we have we share with our patients list of some supplements.
But I'm always really cautious with supplements, because there's so much out there and it's really hard to know what's safe and what's not safe and supplements are medicine and no matter how you look at it, their
Products that are designed to have specific effect on our bodies. And so I'm really careful to push supplements, but we do create a list that I'm comfortable with patients want to try and not necessarily advocating for a transfer that they use the supplements. I think getting your nutrients and supplements through your food is the better way to go.
But if you find it difficult to do, or if you know that you're depleted also on Vitamin D, for instance, they do believe that it's important to supplement. If you can't
If your body's not getting enough of those things. But I'd be cautious about veering off of what we've outlined in our own literature or the practice.
Gigi, OC Fertility: Following up on that just a little bit with regard to supplement people might have heard could be good for their immune health because of Kobe's. Is there anything specific that you for, you know, since we've we know what some of the more common ones are that you know has been talked about in popular culture and, you know, sort of the People magazine type coverage out there that isn't necessarily as scientific as as obviously what you're reading. Is there anything that you would definitely recommend someone be more or less cautious about are definitely talk to their doctor before considering that might be, you know, considered immune-boosting...
Dr. Sharon Moayeri: Yeah, so I think vitamin C is a common one that people are using it's probable okay and reasonable quantities dosing and see any harm in trying. That I wouldn't be doing blackwill necessarily unless you have a medical indication for it. And so I think some supplements like vitamin D, not necessary for code but vitamin C for coded Zinc, I think, is another one that they're talking about we do you think and recommend things for fertility purposes. Well, we also do baby aspirin, which is an anti inflammatory. I think there's some evidence that that might be helpful for code as well. If you were infected buttons, not a few.
But I guess if you're an asymptomatic carrier that can be helpful on that seems to be beneficial and are transparent least not harmful for transparency we do you do prescribe the baby aspirin.
Gigi, OC Fertility: Fantastic. We have just one more question. And we're at seven o'clock, so hopefully you don't mind. Take actually we have a couple more. Are you okay to take a couple more questions. But even though we're over time.
I am great. So how many days in advance. Well, we know our transfer date.
Dr. Sharon Moayeri: That's a tough one. Yeah. So we always do eggs before transfers in terms of scheduling and so we will give you your day of your transfer assuming that you respond as you're supposed to but we won't have a time until usually a day or two before.
So we'll narrow down on your calendar, the date and if your body's reacting and responding appropriately, then that dates going to be pretty fixed, but we won't have a time until one or two days before because we have to get the egg on first before we...
Gigi, OC Fertility: Got it. Another we've got two final questions, and I encourage anybody that that still has questions to connect with us on social media. We love to put out educational material. We have another webinar coming up.
But to get to the last two questions I've been told that I don't have good a quality and I'm 41 do you think IVF might work for me.
Dr. Sharon Moayeri: It's hard to know without knowing more information. I'll be on that 41 we're not surprised if you don't have good quality. That's pretty common already. But it doesn't mean you wouldn't be able to find a healthy and that's really what you're asking.
So you know how many cycles, would it take for you to find a healthy egg. I wouldn't be able to answer until I had someone mentioned about your specific case.
It could be one. It could be, you know, for could be more it's impossible to really know but certainly there are patients in your age group.
Who are succeeding and generally speaking, as we get into our 40s. We have portray calls. So I don't think that that's unique to necessarily an indigent visual at 41 that's that's kind of the story at 41 so when you use that as a reason to deter you from, you know, seeing what you're going to die within because...
Gigi, OC Fertility: Just to follow up on that one a little bit. I know you're you've been doing tele health more robustly since... or someone like that person that wrote that question and you could cheat. Start with a tele health consultation, so she wouldn't have to necessarily come in.
To get things started, and find out you know for to actually start the conversation or would that really require coming in for a physical exam.
Dr. Sharon Moayeri: No, I think. I mean, it depends if she's had any testing done or not. And if we have any other history on her, but I would say, you know, fertility is definitely agent history, first and foremost, and so I would want to know a little bit more about her background pregnancy.
Know pregnancies, how long she's been in a relationship without protection and those kinds of things to help guide think but 41, you know, is a pretty typical for our age group, and many 41 year old don't have read a quality, that's not uncommon. So I wouldn't say that that would be a reason why treatment wasn't working. And what's more important is kind of her workup and water testing show
Gigi, OC Fertility: So maybe she could connect with connect with us and then find out based on what testing. She's had done whether or not. Maybe she could just do a tele health appointment to get more insight as to what's going on.
Dr. Sharon Moayeri: Yeah, absolutely. And if she had records has if she's already done testing and that's where they came up with that advice on them. And she heard this from another doctor or from where this where that idea came from them that would also give us a lot of insight and we could review that until houses it without saying
Gigi, OC Fertility: Yeah, I think there's a lot of confusion with popular culture and you know celebrities that have babies later. And it seems so easy that it may be from any of those places, right.
I'll get to our last question, which is, well, prepping for FET, is it okay to get your hair and nails done.
Dr. Sharon Moayeri: Oh yeah, I mean, so I would say do it before we transfer. That's what I recommend. Because you're not gonna be able to do in the first trimester. Some good allow your system nailed you can do in your first trimester. But here you gotta wait to a 10 week mark to your here.
Gigi, OC Fertility: Fantastic. That was our last question for the evening. Thank you so much.
Dr. Sharon Moayeri: Bye.
Gigi, OC Fertility: So we should let people know that we have another webinar coming up on fertility preservation, they
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