We asked one of San Diego’s top reproductive endocrinologists, Dr. Alexandar Quass of Shady Grove Fertility, some of the most common questions we get from patients. Read on to get your questions answered.
Plus! Stay tuned for our June event, Fertility, Unfiltered: Ask Us Anything (Seriously, Anything) — Too shy to ask your doctor? Googled it at 2am? Bring that question. We’re spilling the fertility tea—no filters, no judgment. Submit your questions anonymously and get real, unfiltered answers from a team of San Diego’s Leading Reproductive Endocrinologists and Board Certified Fertility Acupuncturists. It’s the convo you wish happened in the treatment room… but way more fun.
1. How many rounds of IVF is too many?
There is no set number of IVF cycles that is considered too many for everyone- it is an individual consideration. Whenever I talk to a couple (or an individual patient such as a “single parent by choice”) about doing another treatment attempt, I review the following: the treatment cycle is an investment on a physical, emotional and financial level. The “return of investment” is a chance of success (usually regarding the outcome of live birth) which is never 100%. I encourage my patients to check their reserves in these areas and review a realistic success rate with them. The decision whether to do another round of treatment can be based on this. If, for example, after 3 unsuccessful cycles, a couple has not reached their emotional, physical and financial limits, and there is a realistic chance of success, they are welcome to proceed with another cycle.
2. Is there ever a right time to take a break from fertility treatment?
If a patient feels exhausted on an emotional, physical, or financial level (or a combination of them) then it is necessary and advisable to take a break. From a strictly medical point of view, a break from treatment is not needed. But mental wellbeing, for example, is crucial for success, and in the case of a couple doing treatment, for the health of the relationship. So I recommend that patients are honest with themselves with regards to their reserves, and make decisions about treatment timing accordingly.
3. Are success rates just marketing or should I be choosing my clinic based on them?
Success rates reported on the CDC / SART website are not just marketing. They do provide useful information regarding a clinic. For example, if a clinic does not report their success rates to SART as recommended, that is a “red flag”. Most clinics do fulfill their duty of reporting success rates to SART. And patients can look up age-specific success rates to get an idea of the quality of the clinic. But this should not be the only factor when choosing a clinic. It is very helpful to speak to other people that have done treatment at a clinic, ask local Ob/Gyn providers, or look up reviews on the internet and on social media platforms to get an idea about the different clinics. The outcome of treatment is of course very important, but the journey to get there matters as well. So, when choosing a clinic, patients should not only factor in success rates, but also the treatment experience.
4. Why do some embryos look great but still not stick? What gives?
There are various ways to assess embryos. Traditionally, the morphology of the embryo, in other words the appearance as rated by an embryologist, has been used to predict success rates. But an embryo that looks great may not be genetically normal. Therefore, over the past few years, pre-implantation genetic assessment of the chromosomes of the embryo (PGT-A) has been added to our embryo assessment toolbox. Unfortunately, even an embryo with perfect morphology and the correct number of chromosomes by PGT-A (a euploid embryo) is not guaranteed to implant. We can make predictions regarding the likelihood of live birth based on morphology and PGT-A.
However, we do not have a test or a set of tests that can predict live birth with a 100% sensitivity and specificity, and there are factors we cannot measure and test for yet that are likely involved. We also need to remember that the uterus and the receptivity of its lining (endometrial receptivity) also play a big role. But most of the time we can optimiz endometrial receptivity to a point where the main responsibility for a successful outcome lies with the embryo.
5. What’s the difference between IUI and IVF—and how do I know which one is right for me?
IUI (Intrauterine insemination) is a procedure where washed and prepared sperm is placed in the uterus at the time of ovulation, often after stimulation of the ovaries with oral medications. IUI is “in vivo fertilization”, as the process of fertilization and embryo development happens inside the female body. IUI can be helpful in the treatment of unexplained infertility, mild male infertility, or when donor sperm is used. The success rate of IUI is usually lower than the success rate of in vitro fertilization (IVF), a treatment where we retrieve eggs after ovarian stimulation, and fertilize them in our lab with the goal of creating embryos for transfer. In some instances, such as when the tubes are blocked or when there is a severe male factor, IVF is the only option.
IVF also allows for the genetic analysis of embryos, and for the freezing of extra embryos. Advantages of IUI are that it is cheaper and “more natural”. However, in addition to being more successful, IVF is nowadays associated with a lower risk of multiple pregnancy including twins and triplets, as the transfer of only a single embryo has become the standard of care. When deciding which treatment is best for you, it is important to talk to a fertility specialist that listens to your individual situation. I tell my patients every day that it is not my job to make treatment decisions for them, but rather to give them all the information possible to empower them to make excellent decisions for themselves.
6. Can you explain attrition?
In IVF, after the eggs have been retrieved, the goal is to create embryos with these eggs. Generally speaking, not all eggs are mature, not all mature eggs fertilize, not all fertilize eggs grow to the cleavage stage (around Day 3) and not all cleavage stage embryos make it to the blastocyst stage (Day 5-7). Lastly, not all blastocysts are euploid, meaning that they have the correct number of chromosomes.
7. How do I improve egg quality before IVF?
The main predictor of egg quality is the age of the patient, and unfortunately it is not possible to dramatically change the age-related decline in egg quality. It is certainly useful and recommended to have a healthy lifestyle, minimizing toxic exposures such as tobacco products, alcohol etc, and maintaining a healthy diet, with regular exercise and adequate sleep. Supplements such as antioxidants / CoEnzyme Q10 etc. may also play a role. But sadly, there is not (yet) a magic “fix” to the age-related decline in egg quality.
8. Can you explain what PGT-A testing is and whether I should do it? What is your opinion of the new research and controversy coming out surrounding this testing?
There is an ongoing debate regarding the usefulness of PGT-A testing, and this is a very complex topic that I recommend discussing with your fertility provider. In summary, it should not be done for every IVF cycle, but there are subsets of patients that benefit from this screening test, such as women over 38, especially those with an above average quantitative ovarian reserve. As mentioned, it is a screening test and not a treatment, so it cannot make embryos better, but rather help with selection, and therefore with reducing the time to pregnancy. In addition to the question of who should choose to do PGT-A testing, controversy surrounding PGT-A also exists with regards to its accuracy, the question whether the technique may harm the embryo, claims that it may lead to the wrongful discarding of embryos with live birth potential, and the topic of mosaicism. The best course of action for patients is to choose a fertility specialist who considers each individual clinical situation carefully and discusses the pros and cons of PGT-A in the particular IVF scenario.
9. How long should I wait between IVF cycles?
There is no need to wait to start another cycle when one cycle has been completed for medical reasons. However, it is perfectly appropriate to take a short amount of time off
between cycles for other reasons, such as emotional well-being (see question 2)
10. What can I do to feel more in control of this process?
Learning about your clinical situation as well as understanding the biology and the treatment process as much as possible can be helpful for some people. A lot of my
patients became experts in reproductive biology at the end of the process. However, I tell patients every day that it is impossible to have complete control, as biology is not
entirely predictable, at least not with the tools we currently have. Therefore, it can also be useful to work on ways of finding peace and acceptance regarding the lack of complete control. Mental health professionals and experts in complementary medicine can be very helpful in this process.
11. Do any/all of the IVF hormones affect my long-term health?
The short answer is no. There is no clear indication that the medicines we use for IVF have consequences for long-term health. The overall body of evidence suggests that
the IVF process, including the medications used, does not increase the risk of cancer or affect future fertility. Women with estrogen-sensitive tumors are an exception to the
statement regarding cancer risk, and special considerations apply. In these special circumstances, women should seek expert advice when considering treatment.
12. What’s one thing you wish more patients understood about IVF before they start?
The single most important thing when going into an IVF cycle is to have realistic expectations regarding the chance of success. Every day, I try to do my best to create realistic expectations, by reviewing individual chances of live birth using AI-based predictor models and other tools. I am a very positive and optimistic person but try to be extremely realistic during the counseling phase, when deciding whether to move forward with treatment. For example, I review that a 20% chance of live birth means that sadly 4 out of 5 patients in the same situation will be unsuccessful. After someone has decided to proceed, I do not see much of a point of being negative or pessimistic, and I am “in it to win it” with the patient or couple. But as difficult as it may be, I tell patients to mentally prepare themselves for the undesired outcome of a negative pregnancy test, and not to take a successful outcome for granted.
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