Secrets of IVF Stimulation

If you’re a patient of mine, you’re going to get all my secrets. And in fact, one of my favorite patients dedicated a blog to her entire IVF cycle with me as her doctor. I think IVF Is Very Fun. I thought it was clever that she titled the website Is Very Fun. My patients actually benefit from her experience through her IVF cycle. But I realize that not everyone has access to the website, or to me, so I want to make sure that everyone can learn from my secrets in this article.

The first one shouldn’t be a secret if you’ve spent any time around me!

Get Your Levels Checked

I am always saying, “Get your levels checked, get your levels checked.”

-Did you just have a baby? Get your levels checked.

-Are you on birth control pills? Get your levels checked.

-Had an IUD placed? Get your levels checked.

-Just had a baby, thinking about another one? Get your levels checked.

Please get your levels checked. It’s a simple blood test you can do around your cycle. You don’t even have to be cycling to get an AMH level checked. You can track it over time so that you’re not surprised once you’re ready to have a baby, if your levels show that you are running out of eggs.

The Starting Line: What you need to know before starting IVF Stimulation

When you’re at the starting line of your IVF cycle, what you want to know is ‘Why am I here? How did I get here? Have I done all the tests possible or needed to understand what might happen?’

My patients ask me all the time ‘What might happen during my IVF cycle?’ or ‘What might go wrong?’. I don’t like talking in terms of what could go wrong, I like to discuss what we might learn. We might learn this isn’t the right protocol. You might not get as many eggs as we originally thought. You might not get as many embryos as originally thought, but whatever we learned, it’s going to help us get that much closer to our goal.

Your DNA may hold more answers than you think

There are a number of fertility gene tests that you can do now, for both men and women, that can potentially predict what might happen with your embryos. Let’s say you did a fertility gene test for the sperm, and you found out that you might have less blastocyst than originally expected. That might guide you to consider doing more than one cycle, or help you set your expectations so that you won’t be surprised or disappointed if you end up with fewer embryos.

The Secret Recipe

I’m actually the worst cook ever, so whenever I think of making embryos, I think of those amazing bakers who can add a little something to make their cookies chewy or make them a little salty. At the end of the day, it’s a cookie. When you’re seeing a fertility doctor, you really want to rely on their expertise. While I’m sharing my IVF secrets here, one of the many things I say is don’t believe everything you read. Just because you see it on a blog or on a YouTube show doesn’t mean that it’s true or applicable for you. Your fertility doctor knows your body the best, so be sure to ask them why. Why are they doing what they’re doing? Make sure you know everything about your sperm and egg before you are actually embarking on your cycle.

Some medications are necessary during IVF

Everyone wants to be as natural as possible, especially here in California! While the idea that less is more is true in certain cases, when it comes to starting stimulation, one thing that can confuse many people is why they need to take injections when doing IVF. Why can’t you just show up and have your eggs retrieved? The reason is that you have to basically grow, or as I say, ‘cook’ the eggs, meaning they must be mature. Only mature eggs can turn into an embryo. Once the eggs are retrieved, the mature egg is then either frozen, if you’re doing egg freezing, or turned into an embryo at the same time. And that’s what we call IVF.

Here I am on my lifeguard post (not really), sending out tiny little life vests to all of the eggs, because I consider myself an egg rescuer. I’m rescuing eggs from being lost, and they’re lost every day. Women have a finite supply, and going through a fertility treatment, even if it’s not IVF, is a way of saving eggs from something that naturally happens.

This leads to another reason you have to take medications when you’re doing IVF: your brain will only send enough of an FSH signal to your ovary to ovulate one egg per month. The hormones in the shots are higher doses of FSH than your brain is sending to your ovary, so that you ovulate more.

Birth Control can help start your cycle

When you’re trying to figure out your chances before heading into your cycle, you have to remember that you’re not a bunny. We’re just human beings and each egg is not a baby. Each egg is a chance for a baby, and that chance is basically determined by your age. At the start of your cycle, sometimes people need birth control pills, and the first thing people do is look at me like I’ve lost my mind. “Dr. Aimee I want to have a baby. Why are you prescribing birth control pills?” I want birth control pills to be rebranded when it comes to IVF. They really should be called IVF Readiness Pills, because we’re not trying to prevent you from getting pregnant, we’re trying to get your ovaries ready.

There are a lot of different ways of starting IVF. There’s a natural cycle start, birth control pill start, Estrace priming start, and you can even do testosterone priming. The way you start a cycle is determined by a number of things. We know that if a woman takes birth control pills, potentially she might get less eggs. If you’re older and you already have a lower number of eggs, it doesn’t make sense to start you on birth control pills.

However, some patients need the birth control pills, even if they have a lower number of eggs, and that is because they have a very set schedule. For example, they can only be available on certain days and have their retrieval fall on a certain day. Starting with birth control pills gives them the opportunity to plan their cycle even months in advance.

With a natural cycle start, you have to be very flexible. Once your period starts, you start meds on cycle day number two. This means you have to be available and ready to call me first thing in the morning and come in that day so that we can take a look at your ovaries, take a look at your hormone levels, and make sure that the plane is ready for takeoff. When you’re sitting on that tarmac you have to have everything checked to make sure everything is absolutely perfect before you start the plane. Well, that’s the same thing when it comes to starting an IVF cycle.

If Your Ovaries Are Working, I’m Working

The other thing is every center, every doctor is different. Some centers actually don’t have the flexibility to do natural cycle starts. But I’m a little bit different. If your ovaries are working, so am I. It doesn’t matter if it’s Sunday, if it’s Memorial day, if it’s Thanksgiving, if your ovaries are working, I’m going to be there too.

That’s why I can offer natural cycle starts to my patients because I don’t batch cycles. That’s something that a lot of even excellent centers do for a number of reasons. Before you start your IVF cycle, remember I said ask why, why, why, and then why and why? Why am I on this protocol? Why did you choose this protocol for me? And if you start off with that, then you’re going to be more informed and know why things are happening the way they’re happening. You can be a part of the process rather than feel like it’s something that is happening to you.

Let’s say you want to do IVF. In order to plan the stimulation, you have to make a calendar. I will make a calendar for you. We can do it in person or over video or a phone call, and I will actually mock up exactly how your life will look. It’ll start with a baseline ultrasound. Baseline just means the starting scan, and I like to do it maybe a couple of days before your period will start, especially if it might start on a weekend. If your period starts on a Saturday and you need to start taking medications Sunday night, well, it’s very hard to get medications to someone on a Sunday night. I want to make sure that you’re never feeling overwhelmed or rushed and that everything can go very smoothly.

Your first appointment will last about an hour to an hour and a half, and you’re going to meet with me or one of my assistants to teach you how to mix the medication. I find that patients waste a lot of money with medication errors.

IVF injections aren’t scary

When people think of IVF medications, they usually think of those big hypodermic needles, but the reality is the needle is actually much, much smaller and it goes in the skin of your tummy. It doesn’t matter where specifically, but you have fewer sensory nerves in the lower part so it hurts less. Most patients say, “I cannot give myself the shot.” But, it actually hurts less if you are giving yourself the shot than if someone else does it for you.

Each shot will take about 15 minutes or so for you to prepare. We teach you how to mix your medications, and if you ever have any questions at all, you call me. Don’t go to Google, don’t go to YouTube, and don’t phone a friend. You call me because your medications and making sure they’re right is actually the most important thing to me. There’s only one time I get annoyed and that’s when people don’t ask a question because they think they’re going to bother me.

Let’s Look at an Actual IVF Calendar

Remember the calendar I introduced earlier? Once your period does start and we are doing a natural cycle start, we would then make another calendar for you that tells you exactly what to do every single day. Your baseline appointment will start with an ultrasound to make your diagnosis and do a blood draw.

Step two is a meeting to review the protocol, and that protocol kind of depends on your follicle count that day. If your follicle count is over 15 I would consider a lower dose of medications, and if your follicle count is under five, I might consider a hybrid cycle using fertility pills with injections.

On the calendar above, you’ll see that I use a medication called Letrozole, which is also known as Femara. It’s used for breast cancer prevention, and unlike Clomid which requires an exorcism (I promise you, it does) it has less side effects. It only stays in your system two days, and unlike a lot of meds that cause hot flashes, mood changes, nausea, vomiting, for the most part, Femara doesn’t have those side effects. But I would say that there are maybe one out of 10 patients that will actually have lower leg cramps.

I combine the fertility pills for five nights with fertility shots. You come into my office a lot. It’s not just “Start your meds. See you in seven days.” I see some people after just two nights of meds, after three nights of meds, after five nights of meds, and the decision when to come back in is really determined by what’s going on with you. What have we learned from your prior cycles? Are you someone that makes a follicle really, really fast? Well, I want to see you earlier so that we can start the antagonist, which on the calendar above is the Cetrotide which would actually slow the follicle growth.

Going down the list, you have:

Femara, a fertility pill

Menopur, the F S H and L H hormone. (Remember, we have to give patients a higher signal of these hormones than their brains send their ovary so they ovulate more than one egg).

Estradiol blood tests, something that we do at each visit to track the follicle growth, and we expect approximately a doubling every visit.

Ultrasound, which guides us about the sizes and when to start the “antagonist” also known as Cetrotide. There are a number of brands to these medications, but basically the antagonist refers to a medication to slow down the growth and prevent the egg from actually leaving the ovary.

Human Growth Hormone, which I offer to any patient who has lower egg quality. Another name for it is Omnitrope. That’s the generic version, and the brand name is Saison.

I want to show you another example of other protocols, because I do have patients that are on much higher doses of medication. They’re taking straight FSH hormone and the brand names for that is Follistim and Gonal-F. Those are the different brands for straight FSH with Menopur at night. I sometimes have patients do twice daily dosing, but for the most part with me, it’s one shot at night every night for approximately 10 nights, a total of five visits from start to end.

Here’s another example of a straight Menopur protocol, and this is one shot a night. While you might be taking up to three, maybe even four different injectable forms of medication, we actually teach you how to mix them all together in one shot, so you never have to give yourself more than one shot or feel like a human pin cushion.

When I say I want a patient to take HGH, everyone thinks they’re going to get taller, or get more muscular. But, basically it’s an anti aging supplement, so the thought is that it might help with egg quality. It might help a woman get one extra egg. It doesn’t seem to hurt, it just hurts your pocketbook because it’s rather expensive and most insurance companies will not cover it, even if you have IVF covered. I offer HGH automatically to every woman over 40, or any woman, regardless of age, with an elevated F S H level, and anyone who might have lower egg quality, for example, someone with a history of endometriosis.

When it comes to the secrets of IVF stimulation, I think the most important thing is to ask questions, ask more questions, and ask why. Why am I doing IVF? If you don’t know the answer to that question, you should know. Is there anything that I can do to make my chances better or higher? Why am I taking the meds that I’m taking? Why did you pick this protocol for me? My patients know the answers to those questions. When I see patients who come from all over and say they’ve done multiple IVF cycles, and I ask them, “Why did you have to do IVF in the first place?” And they say, “I don’t know.” I think it’s important to know because ideally I like to set up each patient so that they have the best chance for getting pregnant without my help. If I can give people an idea as to what they can do on their own to give themselves the best chance, whether it’s losing weight, making sure the triglyceride level is low, then perhaps the egg quality is going to be even better, even if we end up doing IVF.