Rescripted S02E05_How To Prepare For An Embryo Transfer: Audio automatically transcribed by Sonix

Rescripted S02E05_How To Prepare For An Embryo Transfer: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi! I'm Kristyn Hodgdon, an IVF mom, current IVF patient, and co-founder of Rescripted.

Lucky Sekhon:
And I'm Dr. Lucky Sekhon, a board-certified reproductive endocrinologist at RMA of New York.

Kristyn Hodgdon:
Welcome to Dear Infertility, the first-ever podcast that doubles as an advice column for the millions of people globally who have trouble conceiving.

Lucky Sekhon:
We're here to answer real questions from real fertility patients about what to expect during each stage of the fertility journey and to provide you with the patient-centric advice and guidance you need to be your own advocate when trying becomes trying.

Kristyn Hodgdon:
Now, let's dive in and help you feel more empowered during this overwhelming process.

Kristyn Hodgdon:
Hi everyone, and welcome back to Dear Infertility. I'm your host, Kristyn, and I'm here with Dr. Lucky Sekhon. Hi, Lucky!

Lucky Sekhon:
Hi. How's it going?

Kristyn Hodgdon:
I'm doing well. How are you?

Lucky Sekhon:
I'm good, I'm good. I'm excited to be here.

Kristyn Hodgdon:
Thank you for being here. I am so excited about today's topic because I am in the thick of it myself. I actually have my embryo transfer tomorrow, so really excited to jump into how to prepare for an embryo transfer, what to expect during an embryo transfer, and all of that fun stuff. So we received a ton of community questions about this topic, obviously, because it affects so many people. And one thing a lot of people wanted to know is just what are the steps for transfer? I think it can often take a while for people even to make it to transfer, you know, if they have to do multiple retrievals, so it's a really exciting step. But, but what is it sort of entail? What goes into it?

Lucky Sekhon:
Yeah, I think it's often viewed correctly as the culmination of the treatments. And like you said, it could be a lot of hard work, and I think people get very tunnel vision and focused on the step that's immediately in front of them. And so I think it can be a little bit overwhelming, and it's good that we're breaking this down because it is really the crucial final stage to treatment, if you're going through the IVF process. Embryo transfer, by definition, is exactly what it sounds like, it's taking the embryo and transferring it to the top of the uterine cavity, and the steps to actually do the transfer itself, we can start there. The way that I like to do a transfer, and I think a good standard of care is to do it under ultrasound guidance. This is not a painful procedure. We actually want it to be smooth and non-painful, and not cause uterine contractions or disturb the environment in any way, so we're very, very delicate. And I think this is one of the places where the artistry of our training comes into play, because you really have to know how to navigate the curve of the cervix. And we use a long, thin, flexible catheter, and it's attached to a syringe, and basically the embryologist will place the embryo at the catheter tip and we're snaking it all the way to the top of the uterus, while an assistant is doing a transabdominal, meaning they're pushing on the abdomen. And we asked you to have a full bladder because we want a nice, what we call acoustic window. It makes it a nice view for us to be able to look at a side profile of the uterine cavity, and we can actually watch the catheter as it makes its way to the top of the uterus. And in our field, we think it's really important that this is done in an a-traumatic way. We're not blindly going up there and hitting the top of the uterus, that, we're really trying to disturb the lining as little as possible and very gently drop the embryo off. And if you think about the uterus as a collapsed cavity, it's not this open triangle, right? It's kind of like think about two surfaces, the lining of the uterus, just kind of opposing each other. And so when patients worry about, is the embryo going to fall out, when I get off of the table? I always explain to them it's actually nestled between these two layers that are thick and lush, and we've been building it up with the medications, which we're going to talk about, and then we're done. And none of this is done under anesthesia, so you can literally get up off of the table and go home. Oftentimes, clinics like where I work at, RMA of New York, will say, okay, let's have you wheeled back to the recovery room and we'll watch you for like 10 to 15 minutes and you'll just kind of get into that Zen place and have a moment for yourself. And then you can get up and get off of the bed and you can empty your bladder because you're definitely going to want to pee at that point. And it's totally fine, and you could go back to work, but if it makes you feel better to go home and rest, then that's what you should do. That day is your day, right? And 8 to 9 days after that, that's the earliest time that we would recommend doing a pregnancy test in the form of blood work. Blood work is much more sensitive than doing a home test. So that's why we do the blood work, because we want to be absolutely sure about whether this worked or not before deciding whether to continue the medications that are needed to support an early pregnancy. So that's kind of the steps of the actual transfer itself. But getting there, which we're going to talk about, really just depends on the type of transfer you're doing.

Kristyn Hodgdon:
Absolutely. And I just want to say, as a patient, like embryo transfer can be so magical in a way, like you're watching your em-baby be put into your uterus. Like I cried hysterically in my first transfer.

Lucky Sekhon:
It's very emotional.

Kristyn Hodgdon:
So, I mean, sometimes your husband's not even in the room, and you're getting pregnant, with COVID, with COVID regulations. But either way, it's like you get to witness the moment, and it's pretty, pretty awesome.

Lucky Sekhon:
And oftentimes, you'll even get a picture of the embryo, which I think is really nice to have for future. But yeah, I think it's important to talk about the prep because that's really the bulk of the work that goes into a transfer cycle. So maybe we should talk about that next.

Kristyn Hodgdon:
Yeah, I would love that.

Lucky Sekhon:
A lot of patients get confused because there's so many different ways to do an embryo transfer. The main categorization is a fresh transfer versus a frozen transfer.

Kristyn Hodgdon:
That was going to be my next question. I actually had a friend reach out to me the other day asking sort of what the benefits, first risks are, if you can go into that a little bit.

Lucky Sekhon:
Yeah, for sure. So a fresh transfer just means you go through the entire IVF process, starting with the ovarian stimulation and the egg retrieval, and then the growing of the eggs into the embryos, which we talked about in the last episode, so check that out if you missed it. And then basically a fresh transfer is in that same cycle a week after the eggs have been retrieved and fertilized. We're taking the best embryo, the fastest-growing embryo, the one that looks the best under the ultrasound, sorry, under the microscope, and we're placing that at the top of the uterus. So you're basically having the transfer a week after your retrieval and then 8 to 9 days after that, you'll know if it worked or not. That used to be the main way that embryo transfers were done. Now, I'd say the main way that embryo transfers are done is a freeze-all cycle where basically the, the eggs are turned into embryos, and then they're frozen as embryos either after they've been biopsied for genetic testing purposes or even just frozen without the biopsy for genetic testing. And then when your body has had a chance to kind of recover from the egg retrieval, and you get a subsequent period, so two weeks out from the egg retrieval, all your hormone levels fall, and your lining breaks down and you get a period. And then we start mimicking as if you were having a menstrual cycle, and we time the frozen embryo to be thawed and transferred at the top of your uterus when it is hormonally the right time for an embryo to be there. So usually, this involves mimicking the first three weeks of the menstrual cycle. So like two weeks of estrogen to just thicken up your lining as if you had a mature follicle, it also prevents you from actually recruiting and maturing an egg on your own so that you're not ovulating on your own. And we're completely controlling the most crucial aspect to the timing of an embryo transfer, which is making sure we know exactly when you're lining became exposed to the effects of progesterone. Progesterone is a pro-gestation, a pro-pregnancy, pregnancy support, right? You're basically, it's, you're trying to time it so that the embryo transfer is happening on the sixth day of progesterone. And obviously, that might be modified according to tests that your doctor has done and determine that you need more or less of a duration of progesterone. There are some experimental tests that can dictate that. But in general, you know, the, one of the main dogmas of my field is that there's this very narrow window of implantation that's dictated according to when you're exposed to progesterone. So we will prevent you from ovulating on your own, thicken your lining, once you're lining looks thick enough for the transfer, we'll say, okay, start progesterone. And on the sixth day of taking progesterone, in addition to the estrogen, we'll thaw out an embryo and place it at the top of the uterus. You'll continue those medications to support, hopefully, an early pregnancy. And we'll know 8 to 9 days after if it worked or not. If it worked, we're going to have you continue those medications for about the next three and a half to four weeks, because we need to support that pregnancy because you didn't ovulate on your own and we can taper and stop those medications completely once the placenta starts adequately producing progesterone, which happens between seven and ten weeks.

Kristyn Hodgdon:
Yeah, that's something, that's something I didn't realize before I got pregnant through IVF was that you, you stay on the medications until about eight weeks.

Lucky Sekhon:
Yes, yes. And even with a fresh transfer, even though your progesterone levels go up because you take the trigger shot, when you do the retrieval, you're changing, you're altering the environment in the ovaries. And so I don't know of any clinics or doctors that wouldn't recommend giving progesterone even for a fresh transfer just to give additional support because the ovaries may not behave as they normally would in an ovulation cycle, because you've gone and put a needle inside each follicle and drained the follicular fluid. So you're always going to be taking progesterone unless. Well, actually, I shouldn't say unless, no, you're always going to be taking progesterone. You might be able to get away with taking less progesterone if you do something called modified, you know, natural cycle, or a cryo-natural cycle, so that's another way to transfer a frozen embryo. But instead of actively trying to suppress your body from ovulating on its own, you might even harness the power of that ovulation. So we might track your body's natural ability to select an egg, make it ovulate, and then time the transfer to happen after a certain number of days of your natural ovulation. So those are kind of the two main categories I would say is fresh and frozen transfer. Within frozen, there's different ways to prep the lining. You can use a medicated way or you could use a cryo-natural way where you're harnessing the power of the ovulation. I think in any of those scenarios, though, you are going to be on some form or level of progesterone supplementation.

Kristyn Hodgdon:
Awesome. So I get asked this question a lot and I never know how to respond because I have twins from transferring two embryos, but I try not to have an opinion on it either way because, you know, I had a high-risk pregnancy and.

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
You know, I don't.

Lucky Sekhon:
... Early? Did you get delivered early?

Kristyn Hodgdon:
So I went into preterm labor at 26 weeks and was able to last until 37 on hospital.

Lucky Sekhon:
Wow!

Kristyn Hodgdon:
Hospital bedrest.

Lucky Sekhon:
Yeah.

Kristyn Hodgdon:
So I spent, the ..., after going through all of infertility IVF, I spent my entire third trimester in the hospital. My baby shower was canceled. So I'm always very, you know, obviously wouldn't change a thing, but I would just help people go into it knowing the risks of a multiple pregnancy and really be sort of mentally prepared. What would your advice as an RAB?

Lucky Sekhon:
Yeah. So I think when people think about IVF and the word aggressive because we say it's more aggressive as a treatment option because it tends to have higher success rates. But people often will think, oh, that means that they're going to put in multiple embryos, and I'm going to have a much higher risk of twins and triplets and whatnot. And I would say that at one point was true because we weren't good at freezing embryos to save them for the future. So it was kind of a shame if someone was going through the expense and effort of IVF to just put back only one and then not even be sure that we'd be able to freeze the other one as well.

Kristyn Hodgdon:
Oh, wow! I didn't know that!

Lucky Sekhon:
... Use what you have and I'm talking like 20, 30 years ago, right? Now, freezing has become, the technology is just so much better. Embryo-thaw survival rates are in the very high nineties, like 98% or more embryos will survive the thaw, at least where I work. And so I have no hesitation in recommending freezing all the embryos and only putting back one at a time, because it's not like I think it's putting a patient in a worse off position than trying to use as many embryos at one time as possible. The other thing that's really changed the game, and I think this is the biggest factor, is being able to do genetic testing of embryos and to know the quality of the embryos. The number one reason why embryos don't implant or will initially implant and later result in a miscarriage is because of chromosomal imbalances in the embryo. And if you can test for that in advance and know going into a transfer that you're transferring an embryo that has been detected to have all 46 chromosomes, it has a very high chance of implanting and resulting in a live birth, and the chance of a miscarriage really drops to much lower than what would happen naturally. Naturally, we say for all comers, at least one in four pregnancies ends in miscarriage. But this is a much lower rate when you know that the embryo is genetically tested and normal. So there really isn't a good justification to put back more than one genetically tested normal embryo because the chance of success is high, we know how to freeze them well. So you could always come back and utilize another embryo in the future if the first one or that particular transfer doesn't work. And the potential risk of putting back two embryos at a time or more is that you have a really high chance of twins, right? Because the success rate of each individual embryo that's normal and healthy is very high. And twins, while they are very cute, have very high rates of complications for baby and mom, a six times higher risk of preterm delivery or preterm labor. And that one hits home for me because my brother was actually born, he wasn't even a twin, but he was born at 25 weeks and he spent the first five years of his life in the hospital and had major medical issues. As a result, so many things can be affected by being born preterm, so that's a big one. And there are higher rates of things like diabetes and high blood pressure needing a C-section, hemorrhage at time of delivery, so twins are risk, risky pregnancies and we never want to set patients up where that's the aim on purpose. Some patients will come to me and say, I am here because I want, you know, I want twins, I want to be efficient. And then I have to explain all of this to them. And then I have yet to meet a patient that still wants to do it after I discuss all of the potential things that can happen.

Kristyn Hodgdon:
Yeah.

Lucky Sekhon:
Obviously it's not avoidable. You can put back one embryo and the embryo can split. That can happen 2 to 3% of the time. And if that happens, we deal with it. And I've had that happen to patients and they do fine, but it's never our intention or goal. And particularly because an embryo can split, we're really pro single embryo transfer if it's in the best interests of the patient, right? If a patient doesn't do PGT or genetic testing of their embryos and they're, let's say, over the age of 38, it's actually backed by the American Society of Reproductive Medicine to put back two blastocyst stage embryos, because that's appropriately aggressive for someone who has a 50% rate of any embryo coming from their eggs being abnormal.

Kristyn Hodgdon:
Right.

Lucky Sekhon:
But if you can do the genetic testing or you do have that information in front of you and you know it's a normal embryo, it does not make sense to put back more than one no matter what your age is, because your age doesn't affect your uterus's ability to have an embryo implant, it just affects the likelihood of making a normal embryo.

Kristyn Hodgdon:
That's a great point. And embryo transfer is not 100%, obviously, I wish it was. But what are some of the factors that influence success? Are there anything, is there anything that you advise your patients to do, post transfer that can, that can help their chances of implantation, bed rest? What do you normally advise?

Lucky Sekhon:
So I think when you, when you want to transfer, when you want to maximize the chance of a transfer being successful, it's not, so, I think there's a lot of focus on the post, but I'm all about the pre. What are you doing in the lead up, right? I think if you had an HSG or an ultrasound at one point that showed your uterine cavity was normal, that's great, and that's a good starting point. But I think it is important to have a recent evaluation of your uterine cavity, and that's something that not everyone does across the board. But I think it's essential because things can change over time. You can grow a polyp, a small little fibroid that wasn't in the inner lining of the uterus and was kind of inside the wall of the uterus, it could have grown over time and changed, right?

Kristyn Hodgdon:
Do you mean a hysteroscopy?

Lucky Sekhon:
Not even, I mean, like a saline sonogram or an HSG. I think sometimes people have had it done and then they progress through various treatments, and a year later, now they hear they are ready to do their transfer. And I would urge them to advocate for themselves to get an updated look at their uterine cavity. And it doesn't have to be a surgery or anything invasive. I think just doing a simple saline sonogram, it's different than just a regular sonogram because a saline sonogram involves pushing fluid, water, into the uterine cavity and pushing those walls apart. Remember I said it's like a collapsed cavity? So you have to put something inside of it to actually get a good view of what the contour of the cavity is. And I have had patients where maybe they're even a little annoyed. They're like, oh, well, I already did that like a year ago, I did an HSG and I'm like, yes, I know you're back to do this transfer, but let's just take this moment to do this one test. And sometimes you find things that you're like, oh, that was hidden inside the lining, and I wouldn't have seen it unless I did the saline, like a polyp for example. And if it's in a location around where you'd be putting the embryo than it's worth removing and rectifying because you don't want anything that could be taking away surface area from where, where an embryo might be wanting to implant. And I also think that the added advantage is, it can act like a mock transfer.

Kristyn Hodgdon:
Yes.

Lucky Sekhon:
The catheter we're using to do the saline sonogram, to put the fluid in the lining in the first place is very similar to the transfer catheter, and on occasion I will unexpectedly be unable to do the saline because there's a narrowing or there's a really tortuous path, and I and I realize I need special tools. On occasions, some patients need to have their cervix dilated in a separate procedure to ensure that the embryo transfer will be really smooth. And, you know, there are actual studies that show the amount of time that it required to do the transfer or the level of difficulty does correlate with chance of success because you want it to be a very gentle procedure that doesn't disturb the environment. And so you don't want to be doing anything harsh or violent to try to get the catheter in, and you want to be really aware of how to get to the top of the uterus. So I think it really serves two purposes, to make sure the cavity is smooth and make sure that the embryo transfer is going to be smooth. I also think making sure you're checking things like your thyroid function, your prolactin levels, being up to date on any health maintenance stuff because a healthier you is going to be a more fertile you. So in the lead up to transfer, those are the things that I recommend. Post transfer, there really isn't a lot that you can do to mess this up. I think we all want to feel like we have control and I think if there are things you can do for peace of mind, I always recommend it. So a lot of the restrictions that REs will put forth like don't have sex after the transfer until we know the results of the testing or until the first ultrasound. Don't do any strenuous workouts, there's no data to guide any of that, there's no studies. It's mainly because we know from treating women and the things that they're going through and how hard the two week wait is that if it doesn't work, you're going to look back at all those things and think that it may have been a contributing factor. And so it's almost better to kind of remove those types of things from the equation.

Kristyn Hodgdon:
Yeah.

Lucky Sekhon:
So that it just isn't going to be playing on your mind. But is there actual data that shows having sex in the week after a transfer or a specific type of workout is going to detract from your chances? No, I would say there are common sense things like I wouldn't do a hot yoga class, I wouldn't do hot tubs, anything that's extreme temperature wise, or it's going to not allow your body to be in a specific balance or state of homeostasis, like, don't do that. And I think obviously we want you to be pregnant and it makes sense to assume you are after a transfer. So avoiding alcohol, keeping caffeine intake to less than 200 to 300 milligrams per day.

Kristyn Hodgdon:
Yeah, I mean, I love working out and it's hard for me to sort of stop during the two week wait, but you will not find me doing anything other than a light walk because.

Lucky Sekhon:
Right!

Kristyn Hodgdon:
I'm so superstitious and I have beaten myself up in the past for doing a yoga, you know, a light yoga workout, even though I'm sure it had nothing to do with anything. But you do, there's a lot of superstition that goes into, yeah.

Lucky Sekhon:
Yeah. And I think it's hard, you know, that it's happening, right? Like you're aware that the embryo is sitting there. And is it implanting? Is it not implanting? I think just keeping it simple and not giving yourself reasons to doubt the things that you did in the lead up to that test is going to be better for your mental health.

Kristyn Hodgdon:
Mmhmm. So, we talked a little bit about what happens if you do get pregnant from an embryo transfer. But lastly, I do want to go into if you aren't pregnant after an embryo transfer, are there, is it your natural inclination as a fertility doctor to switch up the protocol the next time around or do any additional testing? Or do you, I mean, I know there's a lot of factors, like whether the embryos are tested and and whatnot.

Lucky Sekhon:
Yeah, I think that we don't talk about that enough, and that's really important to mentally prepare for, even in the best circumstance, when you have a genetically tested embryo in a clinic with a great lab and the grades of the embryo, which we didn't even talk about, but we can assign a score or a grade according to how an embryo looks under the microscope. And there are different parts of the grading that pertain to specific parts of the embryo and, for instance, the inner cell mass or the part of the embryo that becomes the baby, that grading is really important, more so than the grades assigned to the cell that becomes the placenta. So I think talking through, even pre-transfer, what the grades of your embryos are and understanding their relative chances of implanting based on that clinic's experience an the data that's out there, it's also how fast the embryo developed, if you had it biopsied and frozen, was it ready for that on day five or did it have to be grown out to day seven, which is a significant difference, right? In terms of the chance of it implanting. Slower embryos aren't as healthy. So I think when you go into this knowing that in the best circumstances, the maximum chance of success of a live birth is like 60 to 70%, in the best case scenario. And so, you know, one third of even genetically normal embryos may not implant, and there's a variety of reasons for that. And you're not always going to be able to get to the bottom of why, but it's not something that's a rare outcome. So what happens if you get a negative test? Well, first off, this is a negative test that should be done in the setting of the clinic with a blood test. Sometimes people will test early and the threshold for something to be called a positive test is different. If you're peeing on a stick at home, some of those tests won't call it a positive beta unless it's like 25 or 50, whereas blood tests will be very sensitive. So don't make any decisions to continue or stop your medications without the guidance of a doctor or based on home testing, especially if the home testing is done early. But let's say you do the blood test and it's definitive and it's not, it didn't work. You know, obviously, you should talk to your doctor. They're going to have you stop the medications that you were taking because there's no need to be on them anymore. And once you stop the estrogen and progesterone, if that's the regimen you've been doing, you're going to get a withdrawal bleed. So you can expect that to happen within a week or so, might happen even within a four or five day period. And I think it's nice if you can talk to your doctor before that happens, just so you kind of have a game plan, are you going to get on birth control to try to save time and be efficient because birth control will hold you at day three of your cycle hormonally, which is where you need to be for any next step, whether it be doing another egg retrieval to make more embryos or starting the prep process. So you may want to kind of give yourself a little bit of time to come up with next steps by just starting the birth control pill. Or you might say, I need a break and I'm just going to wait till my next period, which might for you be in a month if you have regular cycles. And, you know, we could definitely think about tests that you would want to do. You know, you may want to reevaluate your uterine cavity if the last time it was looked at was like two or three months ago, maybe for peace of mind, we want to do another reevaluation. If you've never looked at your fallopian tubes because there was never a reason to, you went straight to IVF, maybe we would choose an HSG because at least then we can look at your uterine cavity again and for peace of mind, look at your fallopian tubes, because there can be instances where there's a dilation of a fallopian tube that suggestive of maybe some inflammatory fluid or something in there. And we know that if that exists, it can relate back to what's happening in the uterine cavity because it's all connected and it could lower the chance of implantation. There's actual data that suggests having dilated inflammatory fluid inside a dilated fallopian tube could also lead to an increased risk of miscarriage. So it's not something that is a high likelihood, but it's definitely worth looking into in cases of implantation failure, where you're wondering what could have happened if the embryo looked beautiful. We've looked at everything else that might be one stone to turn over that just has been has been looked at before. I think looking at the whole picture and re-evaluating with your doctor what embryos you have left, and if you should take a moment to pivot your approach and think about having more embryos, if this is not the first failed transfer, thinking about the overall big picture approach and what the next steps down the line might look like. If you're someone that has known uterine factor issues like scarring and you haven't been able to have a positive test with multiple transfers and you have a limited supply of embryos, is it time to start thinking about alternative options, even things like a gestational carrier? So I think a constant re-evaluation of the big picture, thinking about what you have left in terms of embryos and then really critically examining what other stones should you be turning over and and thinking about.

Kristyn Hodgdon:
Absolutely. I do want to end on a note of hope, though. I know that there's a statistic and I'm sure you can help me exactify it, but is it that after three embryo transfers with a normal embryo, what is the percent of a successful pregnancy?

Lucky Sekhon:
Yeah, I think anyone can have a first failed transfer. There are, it's still possible to have two that don't work if you're thinking about a normal tested, high quality embryo. But I think it's it becomes increasingly rare to get past three. And so IVF works, it's a really high efficacy, high efficiency approach to helping you get pregnant and get around barriers that could be standing in your way. It doesn't work for every single patient, but there could be different specific reasons for that. But for the average patient that comes through our doors, if they have, if they're able to make normal, healthy embryos, then their chance of getting there is very high. And I think that our success rates have just come such a long way. I'm so grateful to be practicing in this day and age where I can say that majority of my patients are successful, don't always know how long it's going to take, you know, the measures that we might have to use to get there, but I really do feel like most people end up being successful if they're open to the different options that they end up needing. And that is really encouraging and an amazing place to be as a field.

Kristyn Hodgdon:
Absolutely. Well, that gives me a lot of hope. Thank you again, Doctor Sekhon, this is great and we'll chat with you next time.

Lucky Sekhon:
Thank you for having me. This was such an important topic and I hope this was helpful to whoever's listening.

Kristyn Hodgdon:
Thank you for tuning into this episode of Dear Infertility. We hope it helps you feel more empowered to be your own advocate on your fertility journey. Whatever you're currently struggling with, Rescripted is here to hold your hand every step of the way. If you like today's episode and want to stay up to date on our podcast, don't forget to click Subscribe. To find this episode, show notes, resources, and more, head to Rescripted.com and be sure to join our free fertility support community while you're there.

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