Ask an Expert: Your Fertility Questions Answered

We recently sat down with Dr. Dan Nayot, Chief Medical Advisor at Bird & Be to answer your fertility health questions. Here’s what he had to say.

Disclaimer: This article is sponsored by Bird&Be

Had a hysteroscopy that found polyps (HSG, SS, US didn't show). Chance of recurrence?

Polyps are benign growth of endometrial tissue found within the uterine cavity. Not all polyps have a negative impact on success rates. A quick guide for importance: 1. larger polyps (>1 cm); 2. those near the top of the cavity (fundal region is where the embryos implant), and 3. those having blood flow documented by ultrasound (“vascular”) are more likely to be detrimental and you should consider having it removed by hysteroscopy.

It’s very hard to predict the chance of recurrence, some studies have suggested that its quite low (<10%) while others have noted it to be quite high (30-40%) that eventually polyps will reappear. 

Ways to prep for a frozen transfer for unexplained infertility?

To maximize success rates you should focus on optimizing all variables ahead of time

-General Health → BMI, Diet, Lifestyle, Supplements

-Uterine structure → Make sure there are no fibroids, polyps or scar tissue that must be dealt with ahead of time

-Endometrial assessment → Make sure a complete work-up of the endometrium has been completed which might include ultrasound imaging to assess the endometrial thickness and pattern, and possible endometrial biopsy tests

-Personalize your FET protocol with your RE → This would included choosing between Natural  vs Medicated, as well as important considerations like progesterone support and adjuvant therapies 

-Know the details of your frozen embryo → Many FETs aren’t successful because of the embryo (development, grading, and chromosome analysis are all important variables to consider)

How can you prevent empty follicle syndrome? Could low dose trigger be a problem?

Empty Follicle Syndrome is an uncommon scenario where no eggs were retrieved during the extraction procedure. This is rarely because of an inherent problem (example a gene mutation in LH expression) and most of the time your personal response to the protocol. There are many options to consider next time including

-The size of the dominant follicle before triggering

-Triggering details → HCG or Dual trigger; Dose of HCG

-Time interval between triggering and egg extraction procedure

-Methods of the extraction procedure → Some REs attempt flushing each follicle several times before moving on to the next follicle

Go to protocol for DOR patients with AFC <5? Priming?

There isn’t a universally accepted best protocol for DOR patients, and it likely varies between clinics and REs

Some common approaches of RE:

-Priming with some form of testosterone therapy - Example DHEA or Androgel

-Estrogen priming to synchronize follicles

-Low dose stimulation

-Using Letrozole during the stimulation  

-DUO stimulation (back-to-back stimulation to take advantage of the 2nd wave of follicles in the luteal phase)

-Considering a fresh transfer without PGT-A (since there may not be many embryos to select from)

Is mini-IVF better than regular IVF? Who benefits?

Mini IVF is a term used to describe a lower stimulation which will result in less eggs per attempt. There is ongoing debate on the benefits of mini-IVF and for which patients. Its most commonly used for patients with DOR where any additional medications won’t produce more eggs (they have reached their limit). In this setting less medications are a cost saving measure.

In my opinion, less eggs don’t necessarily mean better quality eggs, otherwise we would be aiming for a natural IVF (1 egg at a time). The cumulative live birth rate is higher with more eggs, which means you will likely need less IVF attempts before succeeding. Some studies have highlighted that more eggs might have a lower euploid rate, but in terms of “cumulative” results, most patients would prefer 5 euploid from 20 eggs (5/20 = 25% euploid rate) than 3 euploid from 10 eggs (3 /10 = 30% euploid rate).

Is a period after egg retrieval more painful?

During the IVF process, patients take medications to stimulate the ovaries. Everyone may respond differently, but generally multiple follicles are stimulated which results in much higher-than-normal estrogen levels. The high estrogen levels thicken the endometrium. This is one of the main reasons that patients commonly describe a heavier period after the IVF process. Take into account other variables like enlarged ovaries, bloating, stress, etc and its logical to expect a more painful period, but that’s not always the case.

Tips to prevent ovarian hyperstimulation syndrome (OHSS)?

The main key methods to prevent or minimize OHSS:

-Don’t over stimulate → Your RE should use your ovarian reserve tests to choose a medication dose that will stimulate the ovaries, but not excessively. You should be monitored closely (the number of follicles growing, estrogen levels, etc.) through the stimulation and adjust the medications accordingly (eg decreasing the dose)

-Don’t trigger with HCG → HCG hormones are the gasoline for the OHSS fire. In this case we trigger with “agonist only” and avoid the HCG trigger

-Freeze all → Don’t transfer an embryo. If that embryo implants, then HCG is released and OHSS symptoms are greatly worsened

What to do if doctor isn't a good fit?

Only you can decide if your RE is a good fit or not. You can always request to transfer to another RE at the same practice - this will be a faster approach, and they should have all your investigations to date. Or alternatively, in some cities there are several fertility clinics to choose from.

Is progesterone in oil (PIO) better than suppositories? 

The consensus is not out on this one and continues to be debated.

The thought is that PIO is more potent (but also more painful / inconvenient), but the suppositories are more localized to the endometrium (“uterine pass effect”)

Recall that in a natural or modified natural FET your ovaries are producing progesterone so you might not need any further exogenous progesterone like PIO or suppositories, or very little

In medicated FET protocols, this is very clinic and RE dependent. Based on some recent studies, the PIO seems to be more popular among REs these days, or at least alternating between PIO and suppositories every other day 

When is it safe to resume treatment after testing positive for Covid?

I would recommend following your updated local COVID guidelines. Many fertility clinics have their own policies when it’s safe to return to the clinic. But if you’re feeling well, and COVID is behind you, there’s no reason to delay treatment.

Is there a way to test to find out why IVF cycles failed?

There is a lot of information you can gather from a review appointment. In the very least you should review both the embryo (development, grading, and post-thawing survival) and the endometrium (peak thickness and pattern on ultrasound). Although you might not know exactly the cause, you likely rule out some variables and be able to focus more on others. For example, if the embryo transferred was a slow growing, low graded and only partially survived the thawing process, then it's very likely the reason it didn't work.

What can someone do with leftover IVF meds? Donate?

Most IVF medications have an expiration date. Almost all fertility clinics won't be able to accept these medications once it’s removed from the clinic (for safety and regulatory reasons). Most clinics do have a medication donation program to help others in their journey.

Can weight gain prevent IVF success?

It's very difficult to measure the specific effect weight has on overall success. Most studies are consistent that a higher BMI does negatively impact IVF success. It remains unclear if this is related to egg quality (and downstream embryo quality) or more about the implantation / early miscarriage component? 

We generally advise to optimize all variables that you can control prior to IVF which includes immunizations up to date, thyroid well controlled, a healthy weight, etc.

Fertility osteopath discovered tilted uterus to the left. During IVF right side only manages to make a few eggs and never the left. Anything I can do to increase chances? 

A tilted uterus is quite common and by itself not considered a negative predictor. Recall that sperm is microscopic and can make their way to the ends of the fallopian tubes. But if there’s also one ovary that’s not responding to stimulation medications, then it makes sense to investigate further (e.g., MRI of the pelvis). An unresponsive ovary and a tilted uterus make me wonder about a previous surgery to one ovary and perhaps scaring after surgery that is keeping the uterus in a certain position. Of course, there can be several other reasons…

Dr. Dan Nayot Chief Medical Advisor at Bird&Be

One of North America’s top reproductive endocrinologists and infertility specialists, Dr. Dan Nayot is committed to providing his patients with individualized evidence-based care. He’s a strong believer in empowering patients to make educated decisions, whether by appraising the latest research studies or facilitating a holistic team approach to infertility.

 Dan is passionate about innovation and medical research. He’s co-founder and medical director of Future Fertility, an innovative med-tech startup that applies artificial intelligence to reproductive medicine, as well as the co-founder of HaloHealth, which is like the AngelList for MDs. He’s also the medical director of The Fertility Partners, a network of clinics that seeks to improve access to reproductive care for all Canadians.

Medical Disclaimer:

The information provided in this blog is intended for general informational purposes only and should not be considered as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your healthcare provider or qualified medical professional with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this blog.