What IVF Protocol Did a Fertility Doctor Choose for Herself?

[00:00:00]Everyone always wants to know what my IVF protocols were. When it comes to IVF treatments and protocols, it is never a onesizefits-all.

[00:00:09]I have done two IVF cycles. I will go through that in a lot of detail. I did a dose of 275 units of Gonaleth in combination with 75 [music] units of Menipure. Anything that we can do that would maximize the [music] number of fertilized eggs and embryos that develop. I'm always game for. My entire stimulation duration was about 12 days until trigger. I was likely going to induce OSS [music] for myself, but because it was only one cycle that I got covered. I really wanted to [music] make it count. I knew I had a lot of follicles in a good range with a really good estrogen level. I wanted as many mature eggs as I could get. Of course, [music] we want what we want, but our bodies decide to do something different.

[00:00:57]Fast forward to [music] our second IVF cycle when I was 37.

[00:01:02]If this show has helped you, the best thing you can do is subscribe, rate, and review, and even share it with a friend.

[00:01:11]So many women deserve to have this information, but just haven't found it yet. So, help me get it to them. Welcome to Trying, [music] a podcast about women's health, hormones, and fertility.

[00:01:24]Welcome to another solo episode of Trying with Dr. Sasha Hackman. As always, we are looking at the comment section, seeing what you guys are asking for, and surprisingly, I don't know why I'm surprised by this. This was highly requested. Everyone always wants to know what my IVF protocols were. I'm not talking about the embryo transfer side because I did share that at length in multiple different episodes and even short YouTube videos. This is going to be purely about my IVF cycle and not embryo transfer cycles. What led me to get my embryos? I have done two IVF cycles. I will go through that in a lot of detail. I had to really rack my brain a little bit to remember what medication doses I had given myself looking back at text messages between my doctor back when I was 32 years old and I was in my fellowship training. But you asked for it and you're going to get it. What I want to preface before going into my IVF protocols that I did for myself and I will give you all the details of my AMH, my follicle count, etc. But I just want to remind you that when it comes to IVF treatments and protocols, it is never a onesizefits-all.

[00:02:40]Everybody's situation is unique and different. We have different diagnosis, different lab results, different follicle counts, different responsiveness. For those who do more than one IVF cycle, you have more data, and so you get to feed off of that data in order to sometimes hopefully get a better outcome. So, I'm going to share what I did and what my thought process was as I was navigating all the details of what we were going to do to create embryos.

[00:03:12]So when I was 32 years old, if you listen to the episode with my husband, you know that at 32, this was a purely elective IVF cycle in order to preserve embryos for the future because I knew that I wanted to have at least three children. Yeah, I'm pregnant with the third now. We are most likely done after this. I just don't see myself doing another pregnancy. I'm exhausted [clears throat] and it takes a lot of resources for every child. Um, and so I'm I'm just so grateful to be here. And um, it just was a lot of planning. At 32, I knew that we would not start trying until I was close to 35.

[00:03:54]Um, potentially, maybe sooner, but that when I did the math, I was like I'd be in my late 30s by the time we are trying to finish up our family, possibly even 40s, depending on how I feel and my readiness. And I did not want my age to be the variable that prevents us from creating the family that we desired. And so it was risky creating embryos with my husband at the time who we had been legally married, but we like were still doing long distance. We didn't plan on having kids anytime soon. And while I loved him dearly, obviously you always think your relationship is going to work out. it doesn't always. And so taking that chance to put all your eggs in one basket, so to speak, was definitely a risk. But because I was 32, I knew that if by 35 I was not pregnant or we weren't trying to have kids or there was some friction in the relationship, my plan would be to do multiple egg freezing cycles. And you I have my philosophy on why I would have done more than one. But I always personally think it's better to diversify, so to speak.

[00:05:07]And so you never know that batch of eggs that month, what that would represent.

[00:05:11]When you're freezing eggs, you have no data. The difference is when you're creating embryos, you do have data. You have way more prognostic information on what your future family may look like.

[00:05:22]So when at this point, I was actually in my second year of fellowship.

[00:05:29]And in my second year of fellowship, it's all bench research. It's not clinical and I had just finished my clinical year of reproductive endocrinology. So it afforded me a lot more flexibility in my schedule. I was living in Augusta, Georgia at the time doing my fellowship, but we didn't even get a discount, not even a little bit on any fertility evaluation or treatment.

[00:05:51]When I asked for a discount for a semen analysis, they looked at me like, who do you think you are to ask that? So there was no perk of the job type situation which is absurd to me. Um I have my thoughts and feelings about the university not providing any uh fertility preservation options especially for their fertility fellows but as a Canadian you get a covered cycle of IVF. And so I definitely have a lot more pull being Canadian and having friends and colleagues in the field that I was able to call on to help me get this done.

[00:06:29]So at the time at the age of 32 when I did an ultrasound at this point I had been on continuous oral hormonal contraceptive pills um combination of estrogen progesterone specifically Yasmin. I loved I've always loved Yasmin for me. I've tried a lot of birth control pills. This was by far my favorite. cleared my skin up with the acne because I have non-class congenital adrenal hyperplasia which is a partial adrenal enzyme deficiency and um that enzyme is 21 hydroxilase. that enzyme is responsible for converting progesterone into cortisol eventually. And if that enzyme is not working as properly, you have less cortisol and you have a buildup of of progesterone, which then will kind of go down a different path in the adrenal gland to make more androgens. So, a lot of the time the symptoms will be acne. Um, for a lot of women it will be herutism. I never experienced the heretism piece of things. However, uh, ovulatory dysfunction was definitely a big part of it for me. So, um, with the skin issues and the ovulatory dysfunction, Yasmin really was like a godsend for me. But as we know, continuous hormonal contraceptive pills can really quiet the ovaries and suppress the crap out of them. And many will say you should not just stop the pill and get started into an IVF cycle right away, uh, because you're just not going to get a good response. But when I checked my AMH, having been on continuous OCPS, it was 4 nanog per ml and my follicle count superseded 30 antrol follicles. So my ovarian reserve was very good. And at that point I felt really confident that when I get off the weight list for Ontario often times when you have a covered cycle there's a bit of a weight list. Once I got called to get off that weight list and I could get started, I, you know, immediately stopped birth control pills so that I got right into a cycle.

[00:08:41]Um, at this point, even though I had a doctor, I definitely took a little more control of the protocol because I was buying my own meds and I was living in the US doing it in Canada. So, because I had ovarian high ovarian reserve, it was a no-brainer that I would do an antagonist protocol. And I feel like I need to do a whole episode on the medication protocols to understand it.

[00:09:07]But with the medication protocols, the gist of it is you're getting uh gonadotropins. Gonadotropins are FSH and LH. The primary medication you're getting is FSH. There is the re combinant FSH which is a labmade form and it is incredibly effective and it is cheaper than sort of like the natural one which is human menopausal gonadotropen and it's called that because it's actually isolated from the urine of postmenopausal women and it's a combination of FSH and LH because when you're in menopause you have no ovarian activity but the brain doesn't like that and so it keeps sending out the signal for FSH and LH to try to recruit eggs if they exist.

[00:09:50]and ovulate them. And so that's part of why like menstrual cycles are so chaotic during pmenopause because the brain's just trying to get anything out there to ovulate and give you any chance of procreating if you know even if you don't desire it. So you're it comes out of the urine of menopausal women. You're able to extract that and essentially put that in an injection form. So that's HMG aka trade name Menipure in the US also in Europe uses Menipure too but Metapure is like sort of our go-to. Menipure is very expensive by the way more expensive than false gonol but it's all expensive anyway. So I did a dose of 275 units of gonolth. So that's the pen one which is re combinant FSH in combination with 75 units of menipure and an antagonist cycle means that at some point in the cycle you will receive a GNR antagonist. So in the brain you have the hypothalamus which is the control center of the brain controls all of your homeostasis in the body including your hormones. And when the brain gets positive feedback that estrogen is peaking, what the brain wants to do is it sends a specific signal to allow the release of an LH surge and then you ovulate. When you're doing IVF, you have so many follicles that are growing and your estrogen is rising so much more dramatically that the brain inevitably may want to ovulate those eggs before your egg retrieval. It doesn't know you're going through an egg retrieval. That's just what it wants to do. So, you need to have a form of blocking that signal. And a G&RH antagonist means that it binds to the G&H receptor. So, the gonadotropen releasing hormone receptor and it blocks the ability to have an LH surge. And usually you will start that everyone's protocol is a little bit different of when you start the antagonist which is either called ganorelics or cetride is the trade name in the US. I had cetride I think I purchased it in Canada actually to make it cheaper. And for how I do things in the clinic, if I see the largest follicle is 15 mm or that progesterone and or LH are starting to rise, we start the antagonist right away. A question I get a lot from patients who are trying to conceive is whether they should be worried about their tap water. And it's a it's an appropriate place to wonder because research has linked endocrine disrupting chemicals, things like PFAS and chlorine byproducts to hormone disruption and our tap water usually contains all of these things. Unfortunately, standard fridge or pitcher filters aren't built to catch most of them. And that's what led me to look into Aquatru when we had moved and we were looking for water filters. It's a countertop reverse osmosis purifier that's thirdparty certified to remove 84 contaminants including lead, chlorine, PFAS, microplastics that requires no plumbing or installation. It just sits on your counter. And reverse osmosis is genuinely one of the more rigorous filtration methods out there. So, if you're already thinking about ways to lower your everyday exposures, this is a reasonable place to start. So, head to aquatr.com and use code drasha for 20% off your purifier. That's aquat.com. a quu a t ru.com with code Dr. Sasha and it comes with a 30-day money back guarantee. So, there's really no real risk in trying it. I recently got rid of all my makeup in an effort to reduce my exposure to endocrine disrupting chemicals which are often found in beauty products. And as a fertility doctor, I think about endocrine disruptors a lot. And makeup is one of those places where we have a lot of daily exposure that we can control. This is how I come to find OG, which I am obsessed with. when I did my deep dive into clean beauty. It's NSF certified organic, which is really important since a lot of other beauty brands will claim that their product is clean, but it still contains ingredients that I'd never personally want to put on my skin.

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[00:14:41]So probably by stem day seven or eight is when I started the antagonist to suppress any possibility of a premature ovulation.

[00:14:52]I did not really change my dose for the first week in order to get that really strong initial recruitment and I had a very dramatic recruitment. Um there was probably about 50 follicles growing but at least 30 in the mature range and at by stem day uh seven or eight when I started the antagonist because my estradile levels were rising so dramatically and I knew I was at risk for ovarian hyper stimulation syndrome.

[00:15:19]We dropped my dose to 150 units of FSH with 75 units of Menipure.

[00:15:26]And um the details of that cycle are a little bit more blurry cuz it's been so long. I'm 39 in a couple weeks. I did this as soon as I turned 32. So it's been I can't believe I'm saying this.

[00:15:40]Almost 7 years since I did that IVF cycle. It's a long time ago. It feels like yesterday, but it was a long time ago. So, um, my entire stimulation duration was about 12 days until trigger, and my estradile level at trigger was 8,000. It was really high.

[00:15:59]Um, and of course, everyone was like, do not do hCG. Don't be crazy. And I thought, well, no, I need a little bit of hCG. I don't want poor maturity.

[00:16:10]Everyone's response is a little bit different to the triggers. There's two types of triggers you can get on an antagonist protocol. You can get something called a Lupron trigger, which is basically mimicking the L. It's allowing the internal storage of luteinizing hormone from the brain to be released and you have a natural LH surge or you can do an HCG trigger. Now, the hCG trigger, if you're like, why would you give the pregnancy hormone to trigger the follicles for egg retrieval? It's because hCG, your pregnancy hormone, fun fact, is identical to LH, the hormone responsible for ovulation. And why are you even giving this trigger in the first place? It is to help mature your eggs. It's not just for ovulation.

[00:17:01]Obviously, it has to be perfectly timed with your egg retrieval because you want enough time to mature your eggs, but not enough time to ovulate. However, with hCG, it lasts way longer in the body than Lupron. So, Lupron can when you're giving a dose, like a single dose, it will actually cause the surge of hormones from the brain to be released.

[00:17:26]If you take Lupron every single day, because when you hear about Lupron as like inducing medical menopause, that's when you take it every day, the brain gets desensitized and it shuts off that storage. But if you're taking one dose, you get that nice surge, but it may not be as strong for some women. You never know if you're going to be in that category or not until retrospectively you look back and see that it didn't work. So in many practices, people will give a double looper on trigger. So 12 hours apart, I do that or a co- trigger, a combination of Lupron with HCG. I also do that depending on the patient and the circumstances. And so in my case, I wanted to do both. So I took the Lupron trigger full dose. At the same time, I took 2500 units of HCG instead of the 5,000 in order to not have as robust of a response.

[00:18:17]But what the data says is that if you are going to hyper stimulate and you give hCG at any dose, you have now started the process of ovarian hyper stimulation syndrome. So it doesn't matter if you give a lower dose or a higher dose cuz if you're going to give it, you might as well just give the full dose honestly because um you are probably going to get OSS anyways. So, I was taking the hCG knowing that I was likely going to induce OSS for myself, but because it was only one cycle that I got covered. I really wanted to make it count. I knew I had a lot of follicles in a good range with a really good estrogen level, I wanted as many mature eggs as I could get. So, and then, you know, of course, we want what we want, but our bodies decide to do something different. So, I took the trigger. I go in for the retrieval and they got 26 eggs. Of the 26, 11 were mature. And I was so disappointed. I thought, gosh, I am going through all this hell now. And I ended up with OSS, ovarian hyper stimulation syndrome. My belly was full of fluid. It was really hard to breathe for many days. I could barely walk. I was in so much pain. I looked like I was in the second trimester of pregnancy. Um, and it took probably 5 to 6 days before I felt like I was really starting to recover. So, it was rough. Um, I probably should have gone in for evaluation and to get tapped, but I was a little stubborn with it where I thought, you know what, I'm just going to pull. I can suck it up. I'm going to push through. I can do this. I don't want to be stuck waiting in the ER, waiting to get admitted to, you know, whatever is going on. Um, and my husband's an ER doctor. He was in his residency at the time. And so, he actually got IV supplies and just gave me IV fluids, like gentle IV hydration at home. So, it was a fun little perk to have him take care of me in that sense and give me whatever medications I needed for the nausea and the vomiting.

[00:20:25]Um, but it was a really rough recovery, especially knowing that I pushed my body so hard only to get 11 mature eggs. But this is part of that roller coaster. Out of the 11 mature eggs, we had um nine fertilized and then seven blastois develop, which is way above average. Keep in mind, I'm 32. My husband's sperm is honestly just fantastic. Very, very, very high concentrations. His total modal sperm on average supersedes 350 million. Sorry, Eric, for giving out your private personal uh health information here, but yeah, he's got great great sperm. When we check, anytime I've checked DNA fragmentation, it's almost non-existent, which is so crazy to me because he literally does nothing in his lifestyle to try to improve his sperm quality. I mean, he he overall lives a good lifestyle because he lives with me, but it's not like he he he doesn't exercise hardly at all, like really. And I mean, he eats well because we cook at home. He doesn't smoke. He doesn't do drugs, but he does drink alcohol often. But somehow this doesn't seem to affect his sperm quality. So, we did have really good embryo development. The average grade for all of the embryos at the time were 4 AAAS. Our lowest graded embryo was a 4BB. So, we have beautiful blastes.

[00:22:02]However, we opted not to do PGT testing at the time because a this was elective for fertility preservation. And then B, we honestly just couldn't afford it.

[00:22:15]Like I I was in fellowship, he was in residency, we weren't making a lot of money. We were long distance. And so all of my money was spent on flights to see him every couple weeks to make up for the long distance. And doing genetic testing of embryos, knowing the data at age 32, just didn't feel like it was in my favor. So it felt like it would be sort of wasteful. Looking back, I do wish that we just did it.

[00:22:42]Actually, yes and no. And I'll say why in a second. In Canada, if you do PGTA, you cannot know gender of the embryos and therefore you cannot sort of have that control of planning your family, which I know some people feel very strongly about how like they find that unethical. I personally totally disagree with that. I think that if you're already making the embryos, you might as well just know and then it's just a matter of prioritizing. No one's saying to discard embryos because of a particular gender. And I mean, honestly, somebody chooses to do that, that's their prerogative. But, you know, for me, I just wish I knew that information, but you can't get that information as a Canadian if you're creating embryos in Canada. Um, and honestly, the majority of other countries in the world, the US is pretty much the exception. um thanks to the American Society of Reproductive Medicine that feels strongly about patient autonomy and choice. So I love that we have that in this country so that if you have let's say two boys and you really want a girl, you get to choose that. So that was sort of the outcome of that first IVF cycle. In terms of the lab details, weirdly enough, they would not give that to me. I kept asking to see my chart. I really wanted to have a little bit more transparency on what was happening behind the scenes. Very different vibe.

[00:23:59]I was just not getting that information.

[00:24:02]But I had to fight pretty hard to get to find out like are you guys even doing conventional versus uh Ixie and they did do Ixie and they do do assisted hatching. So that's become pretty standard for the majority of labs, but it's not necessarily standard for every single IVF lab. And that's why I want to kind of go into those details, especially with my second IVF cycle since at this point I had been in private practice for 4 years. I controlled my entire cycle from start to finish. Um, and I was like in the lab watching it all happen for my tissue.

[00:24:36]And so it was a very different experience being the doctor who controlled my own IVF cycle. It was great.

[00:24:44]Okay. So in wellness, the word mitochondria gets thrown out a lot. So let me as a physician explain what mitochondria actually do. They're part of your cells that produce energy. And like most things in the body, that function naturally slows down with age.

[00:24:59]And it's nothing to be concerned about.

[00:25:00]This is normal biology. But one of the ways that your body maintains this function is through a process called mphagy, where damaged mitochondria are cleared out and replaced with healthier ones. But there's a compound shown to support that process called uroliththn.

[00:25:14]It's a postbiotic your gut bacteria can make from foods like pomegranates and walnuts. But you would have to consume a lot of both consistently to get any meaningful amounts and most people don't. That's the gap my appear is built around. It's timeline's patented form of uroliththna studied over 18 years and across 12 human clinical trials. I've personally been taking it for a while now and honestly my energy levels have dramatically improved especially because I need it and the gummies are a delicious treat. But I will keep the claims honest here. This is not a muscle building supplement. It won't replace sleep or training, but what the research does show is it can support cellular renewal and energy at the mitochondrial level. And in fact, in one trial, there was a 12% increase in hamstring strength after 4 months in sedentary middle-aged adults with an average BMI of 29.5. If you're curious about the more evidence-based side of healthy aging, this is a reasonable place to start.

[00:26:10]Head to timeline.com/sasha for 20% off Metapure gummies. Again, that's timeline.comsasha.

[00:26:19]Fast forward to our second IVF cycle when I was 37. Now, at this point, we have two children. Remy was IVF for an an embryo transfer in Canada and then Rocky was a natural pregnancy. And at this point, we really really wanted to have a girl. and we were undecided on and just sort of unsure on what the path to having a third child would look like.

[00:26:47]And we were really not agreeable on the timeline of things. And so I didn't want to wait for us to figure it out to then look back and say, "Oh, I wish I did another IVF cycle." Perk of the job. And I am very very well aware of my privilege in having this type of coverage that you know because I do this for a living. Part of the perk and this is actually all of our staff that works in a fertility practice usually after you work for a certain period of time like in my past practice it was after a year you got a full IVF cycle covered for free. Some will give even more than that like unlimited treatments whatever but um yeah that's Essentially what we chose to do, we chose to do another IVF cycle. I was 37 years old. When at this point I had been pregnant, postpartum while breastfeeding for 7 months, pregnant again, 9 months postpartum, and then breastfed for 7 months again, and then went on birth control pills.

[00:27:52]So, my ovaries had been suppressed for a really, really long time, but my ovaries have always been suppressed through medication or some sort of avenue. And my AMH came back this time at 37 as two.

[00:28:06]So, it dropped in half. I mean, the year before when I had checked it and they were suppressed cuz I was pregnant, it was still at four and then it dropped to two the next year. So, there was a big difference there. There was a big drop in my AMH. And so I was like, okay, all the more reason to just make some more embryos and then we figure out what our lives are going to look like, you know, in the next year or two or even after that. So at this point, I actually decided to switch up my medication protocol for two reasons. The antagonist protocol was fine, but obviously I had very low maturity at such a young age. And even though we had amazing embryo development, there's something off there. At the time, I had thought that I had POS for so many years. And so I said, you know, with POS, it is very typical to have low maturity. That is a thing. Um, and we didn't even test the embryos. And so we don't even actually know like the act the you know chromosomal makeup of these embryos. We would just throw them in and see what happens kind of situation. So, let's switch up the protocol because my egg reserve has dropped. I'm hoping to get more mature eggs because now I'm 37 and I don't know what the uplate status is going to look like. And so, I did a long Clomid protocol. The other reason to do that was frankly I just like the idea of only having two medications and one injection. And so, while I have IVF cycles covered, I do not have medication coverage. So the medications I do have to pay for and so it was a much cheaper protocol compared to an antagonist cycle and so I kind of like that. So I took 100 mg of Clomid every single day throughout the entire stimulation as well as folim only at 325 units daily. I pretty much kept the dose every single day the same. I did not drop it. I was responding well. I saw my estrogen was rising appropriately.

[00:30:12]Everything was looking good. And I probably could have gotten away with dropping the dose a little, but I just decided to keep it as is knowing that I could risk once again ovarian hyper stimulation syndrome, but I was okay taking that risk. Uh I'm a little reckless with my own body. I will say that. But my recovery was actually so much easier this this second time. Um and that also goes with the fact that I was older and my AMH is lower. So, we did this long Clomid protocol. I'm taking two pills a day. I'm doing one shot a day. It felt so easy on my body.

[00:30:49]Um, and especially when you have two babies and a full-time job and you're super busy and as you all know, I have this podcast and I have my social media and all of that is time, right? So time is not on my side and therefore I don't want to ever feel like I'm in a position of needing to recover or feeling really just bogged down by medical things. I wanted this to feel as easy as I possibly can. And thankfully this protocol felt so easy for me. It doesn't feel like this for all of my patients. I will say most of them do really well with this protocol but some of them will really hyper resppond and then they don't feel great.

[00:31:29]Uh, and even if you get a good outcome, you still want the experience to be relatively okay. But that was my medication protocol. I went in for a baseline on cycle day two. Everything looked good. Um, my ovaries were, you know, I did hadn't started recruiting, which was perfect. I started both meds that day and um, by cycle day, I think it was 11 or 12 once again, uh, is when I decided to trigger. And I triggered with 5,000 units of HCG and 80 units of Lupron. So I did a code trigger with a higher dose of HCG this time. And um this is where we got 25 eggs. So very similar to when I was 32. So not much had changed there. And this time 16 mature. So overall much better in terms of mature egg yield compared to when I was 32. And out of the 16, we had 11 that fertilized. So the fertilization rate was a little bit lower this time, but still within normal range. And then of the fertilized eggs, sorry, 12 out of 16 were fertilized. And out of the fertilized eggs, six made it to blastois. So it's perfectly on par with statistical averages nationally speaking. So from there um with the six blast we did a biopsy to send out for PGA test PGTA testing. What I want to go through is once we got the eggs they did immediate stripping of the cells. In my past practice that is what they routinely do.

[00:33:13]They immediately strip the cells. Um, in my current practice, we actually delay stripping of the cells. So, what does that mean? When you get the eggs out during a retrieval, they are surrounded by what's called the cumulus complex.

[00:33:28]The cumulus complex. And the cumulus has all these cells surrounding the eggs.

[00:33:33]That is what's producing hormones like estrogen to nourish the egg, to help grow the egg, to help mature the egg.

[00:33:41]When you get the eggs in the lab, you can't tell which ones are mature or immature until you strip those cells off. And you have to strip them off if you are going to do Ixie, intracytoplasmic sperm injection. And a common question I get is, do you do Ixie or do you not do Ixie? And I kind of went back and forth a little bit because I see that Eric's sperm is amazing and we got pregnant naturally before our first embryo transfer for baby number one worked. And so even though we've had to go through fertility treatments and we didn't have the easiest journey and I had prior to my embryo transfer with Remy so many failed cycles of ovulation induction with IUI, with triggers, etc. I still felt like I had a really good fertility outcome when I go to more advanced treatment. So, I kind of went back and forth like should we do conventional IVF where you don't strip the eggs at all from their cells and you just put the eggs that you retrieve in a dish with the sperm and let them naturally fertilize.

[00:34:47]And I really strongly considered that when you go to strip them right away, if the eggs are still immature, you have essentially largely removed the chance that these eggs are going to mature and do anything useful after that. This is why I like doing a delayed stripping so that those cells can still work to nourish the egg for a few hours so that if it's really close to having that meotic division, splitting of the chromosomes to mature and probably normally fertilize, it gives it that chance. And so they immediately stripped, they did Ixie and we had that fertilization rate. It is possible that if we did conventional, we would have higher fertilization rate because and I know this from my fellowship training for instance, we would do very we would actually split it for all patients so that if anyone ever needed to do another IVF cycle, we could get gather that information on them to see which fertilizes better. The fertilization rate was normal. So what ultimately made me decide to do Ixie was I mean ultimately the indication for Ixie is severe male factor infertility that was not us previously frozen and thawed eggs that was not us PGTM.

[00:36:02]So, if you're specifically doing uh genetic testing for monogenic diseases or if you're doing PGTG or PGTP, which if you haven't listened to that episode with Juniper Genomics, it is a really great one to learn all about the types of genetic testing and how that's done.

[00:36:19]And um I would assume for PGT something like PGTG you would really need to do AXC because what happens is in natural fertilization all of the sperm stick to the outside of the egg to try to penetrate it only hopefully one will to fertilize it while the rest of the sperm are kind of stuck on the outside. But if you go to do the biopsy then you may end up touching those cells in the other sperm and you have DNA contamination in theory. Now, that hasn't been shown to actually be true for PGTA, but it is true for PGTM looking for specific diseases. And then I would presume that it is probably true for whole genome sequencing as well. There probably may be some contamination, although that's not likely going to be researched really because most IVF labs have made Ixie sort of the standard. And so when we do Ixie, what we're doing is we're looking under the microscope at the sperm. We put them in a solution called PVP to slow it down. You knock the tail. You take a good look at it. Is the head normal? Does the midpiece look good? The tail was working great, which is why you had to immobilize it. This looks like a good sperm. You suck it into the pipet. And then you inject it into the cytoplasm of the egg. And if you see pictures of the egg, you see that it's got a shell that's called the zona palucida. And then it's got sort of a little bit of a space before you have that dark round circle in the middle.

[00:37:45]That's that periolin space. And then the circle in the middle, that is your cytoplasm. And so the pipet has to inject and break through the membrane into the cytoplasm and then uh push the sperm into it. And what we do know from large bodies of research is that it does increase the fertilization rate. It reduces the chance of fertilization failure. It also reduces the chance of not having an embryo to transfer. And so when you're going through so much, you're just sort of like, I don't want to wait to find out that I'm the person who needed to do Ixie. Just let's go ahead and do the Ixie. If I have one or two fewer embryos as a result, which is rare but possible, I'm okay with that risk because the benefit probably outweighs the risk for Ixie. So, we decided to go through with Ixie on all of the eggs that are mature. And um so out of those, you know, what was it? The the 15 or 16 eggs that were mature, 12 fertilized.

[00:38:51]And then from there we recheck 5 days later to see how many developed into blastois and um for me most of them developed on day five some the rest developed on day six. So I had day five and six embryos and luckily for me at that point this is where you have to do something called assisted hatching. So before I get into that I want to talk about assisted hatching. The shell of the egg remains until it becomes a blastoyst until it's time for implantation. It has to hatch out of its shell. Now, when you're freezing and thawing embryos, sometimes that shell gets really hardened and it becomes harder for the embryo to hatch out of it. And technically indications for assisted hatching um are primarily if you are doing PGT. So what you have to do is you basically laser a hole in that shell so that you're able to access the outer portion of the embryo so you could biopsy five to 10 cells to send out for genetic testing. So you have assisted hatching and then you have the biopsy and then that gets sent out and that was on day five and six for me for a total of six blastoysts. And that's when a week later you get the report back showing which ones are uploid and which ones are anoid. And so like I said we had three uploids. One was male, two females, and those were all day five.

[00:40:14]And then we had um three analoids. I think two of them were day six. I can't remember those exact details. I just sort of forget about the analoids cuz I'm like, well, I'm not using them anyway. So, who cares what they are, what days, what grades, because they're anoid. They're chromosomeally abnormal.

[00:40:30]I'm never going to transfer these. I'm not even going to take that chance personally. Um, and so that is where, you know, we had the embryos frozen by the time we got the report back and that was the cycle outcome. In terms of medication add-ons or IVF lab add-ons, I made the decision given my personal fertility history to add nothing. I kept it very basic. I've always kept my own treatments very basic. Even with my failed embryo transfer, I really didn't do any additional testing. Um, I did change up my medication protocol as you would know from that episode, but I really wanted to keep it evidence-based for myself because I think it would be different if I had suffered so many failed IVF cycles where I just could not develop embryos.

[00:41:20]At that point, I would probably try anything. But um the only thing like adding on that I concurrently did a little bit of was acupuncture appointments here and there. It's always really hard for me to get in because of my schedule and I don't necessarily prioritize it as I should. But that's also because I sort of really keep my energy for the high yield things that are really important dayto-day which is my nutritional habits, my exercise habits, my sleep habits. Um, and so that is like a big part of the controllable aspect of my reproductive health that I have always taken care of for years and years and years and years because all of that compounds, right? So, um, that is essentially my IVF cycle in a nutshell. It's a little bit of a shorter episode because we really didn't do too much. The protocols were really straightforward.

[00:42:18]They were fairly easy. I would still do Ixie again because at the end of the day, anything that we can do that would maximize the number of fertilized eggs and embryos that develop, I'm always game for. And um with assisted hatching, what's really interesting about my prior practice is that they do assisted hatching twice.

[00:42:44]They do it before the biopsy and then again at thaw to create an even bigger space from the zona. Um but it I think it's just like a personal embryologic practice because not every place does this and at the end of the day there are risks and benefits. So obviously the benefit is in theory you are increasing the chance that the embryo is going to come out of its shell and implant and attach to the uterine lining but you can theoretically cause some damage by doing assisted hatching. Obviously if you have a really skilled embryologist that chance is extremely low. Um, but there also is an increased risk of monozygotic twinning. And the data on that is a little spotty and controversial, but what that means is you're increasing the risk that that embryo is going to split and you have identical twins, which I know a lot of people get really excited about that idea, but monozygotic twins are a lot higher risk than dygotic twins, which are your fraternal twins.

[00:43:52]So, for me personally, looking to have our third child, I really really don't want to have twins, but knowing that it's only a 1% chance isn't too bad. Um, it's still not low, but in practice, personally, I've only ever had one patient where that that happened in the last like six or seven years. And so, it's it's pretty rare. You don't you just don't see it a lot. And so I was also okay with that risk with the assisted hatching.

[00:44:24]But and the other thing about it is that even though the research on assisted hatching isn't fantastic, there are 39 randomized control trials showing that there's a slightly increased pregnancy rate. So once again, anything we can do to slightly increase the pregnancy rate, but people often ask me about things like hyaluronic acid or embryoglue. And it's one of those things where I'm like, you can do with or without it. it probably doesn't matter or make a difference. It's more of like an extra cost thing, but if you feel better about trying everything, why not go for it?

[00:44:57]Like for the IVF protocol, I did not do growth hormone. I did not do any other supplementation outside of like burden B CoQ10 type situation. Um, so I kept it really simple and straightforward because at the end of the day for the large majority of people, the protocol probably does not matter that much for many, many women. I'm not saying all this is very individualized and nuanced. But for many, your ovaries, if they're very responsive, if they just get FSH, they're going to do their thing. And often times they even go into autopilot. So whether you're doing an antagonist protocol or a micro dos lupon protocol or a long clomid protocol or if you're adding let you're adding clomid it probably isn't going to make a huge difference. Now for there are many women with diminished ovarian reserve or history of poor response and you have that data. This is where optimizing the protocol will really really really matter. Um, and there's a lot of nuance to what personally I do in practice to deal with that, which in my case in LA is actually the large majority of my practice now, but I mean, this is just what worked for me. So, I always want you to take these things with a grain of salt. It is what worked for me.

[00:46:18]I also have the massive advantage that if it doesn't work, if I keep it really simple and it doesn't work out and I do the same thing again and it still doesn't work out, I have the luxury and it really is a luxury of doing this repeatedly without the financial strain that a lot of people deal with. And so there's a lot less pressure and patients who have really good insurance coverage have that same ability of feeling a lot less pressure of like the details of the protocol because they know that okay, we're always going to gather more data.

[00:46:55]Um, and we can always troubleshoot later if need be because we have more cycles covered.

[00:47:01]But at the end of the day, if you have a really good cohort of follicles and eggs, usually they will respond better.

[00:47:06]I'm really hoping in the in the next few years we're going to gather more information on the genetics of how somebody is going to respond to a specific protocol so that it becomes a lot more personalized like I already know you are the type of person who is going to respond better to an antagonist protocol. So this is the protocol we're going to do for you because genetically speaking you are predisposed to responding better to this type of protocol. We are still very far away from that, but there are people working on these types of tests to gather that information to optimize IVF.

[00:47:38]Um, so I'll leave it at that. And if you have any other questions about the IVF protocol that I did in order to build my family, um, then I would be happy to answer it. Uh, just as an update, I am now 23 weeks pregnant and, um, everything is going well. I'm scheduled for an echo cardiogram for the baby, which is pretty standard if it's an IVF pregnancy. After an anatomy scan, you also do an echo to make sure that the baby's heart is okay. This is just based on some old school historic studies that there's a slightly higher chance of congenital heart defects, but the baseline population risk is 3 to 4% of the population will have these congenital heart defects. And although it's probably overkill, I will never say no to more ultrasounds to gather anatomic information about my unborn child so that we can ensure that she's got the best chance so that if god forbid they were to find anything, we can potentially do something about it early on rather than being reactive. So, that's where I'm at with the pregnancy.

[00:48:48]And um things are just a little bit tough this time around. I'm not going to lie.

[00:48:55]Like, physically, I'm just really admitous and swollen and um uncomfortable and it just feels really different this time. But I'm grateful to be here. I can't believe how quickly it's flying by. Even though I'm uncomfortable, it still feels like it's really flying by.

[00:49:14]and in hopefully three and a half months I get to welcome a baby. And so I'm really really looking forward to that.

[00:49:21]Um but yeah, we'll end it there. If you have any questions about IVF protocols, what works, what doesn't, um please make sure to leave that in the comment section and I will try my best to always answer. Thanks for listening to [music] this episode of Trying with Dr. Sasha Hackman. Don't forget to subscribe and if there is anything in particular you want to hear about, leave [music] it in the comments section.