Knocked Up Podcast - WE ANSWER YOUR QUESTIONS
We love receiving your questions, send them to podcast@womenshealthmelbourne.com.au
Thank you for your questions! In this episode we discuss:
Why do some IVF clinics genetically test embryos and some do not?
What can I do before FET to assist chances of success?
Going to try for a 2nd child. Should I still see the GP for pre-pregnancy bloods?
Why is the centre of most women’s health fertility and not quality of life?
What is the opinion for DQ alpha testing for recurrent loss?
3 failed transfers & and one ectopic, where to from here?
Can I TTC whilst breastfeeding?
How many babies do you make each year?
TRANSCRIPT
JORDI MORRISON: Hello, and welcome to Knocked Up, the podcast about fertility and women's health. You are joined, as always, by me, Jordi Morrison, and Dr. Raelia Lew, CREI Fertility Specialist. Welcome, Raelia.
DR. RAELIA LEW: Thanks, Jordi.
JORDI MORRISON: Raelia, time for our favorite episode of the year, audience Q&A. Ready for some quick questions?
DR. RAELIA LEW: Definitely.
JORDI MORRISON: Okay. So these are in no particular order, and they were gathered from Instagram. Thank you, listeners. Raelia. Why do some IVF clinics genetically test embryos and some do not?
DR. RAELIA LEW: I think I'm just going to challenge the premise of the question a little bit in that some doctors together with their patients will strategically incorporate PGT or genetic testing into their patients' treatment and some will not, even in clinics where PGT is available and offered. The reason that PGT in Australia is not offered universally is simply that it is not funded universally. And particularly PGTA or aneuploidy screening, so screening for chromosome errors. And we're talking here not about errors that are inherited and not to be present in the parent or sperm or egg provider, but errors that can happen randomly with the aging process. So problems like Down syndrome and other chromosome concerns that cause embryos to be abnormal and incapable of making a baby and potentially can be associated with an increased risk of miscarriage. Firstly, to do that test is very expensive and to provide the infrastructure to do that test is extremely expensive. And given that parameter, clinics that provide low-cost services just can't do it and patients who seek care in low-cost clinics generally can't pay for it. So that's why it's not offered by all units. It's generally offered by top tier units. And it does tend to be that the units that do offer PGT also do have higher success rates because they are able to invest in better technology. PGT is chosen for patients where we feel it's going to help them. And also it is a patient choice and would be considered in some circumstance as an IVF add-on for that reason. I can tell you an example of a patient that I did a pregnancy scan for just yesterday, which was beautiful. She was pregnant, happy outcome for her at 43. She'd had a lot of IVF elsewhere at another clinic under another doctor's care where she had had transfers of actually, I believe, 12 untested embryos. Can you believe it? And she, in that whole time of treatment, had one pregnancy that entered in miscarriage. She was someone who was able and capable to make multiple embryos. Now, many people at 43 are not in that circumstance. She wasn't challenged by ovarian reserve. She was challenged by age. And we did a cycle for her of IVF with PGT. And unsurprisingly, the vast majority of her embryos were abnormal and incapable of creating a pregnancy. But we found a normal embryo there. And on transfer of her... tested normal embryo, she actually conceived under my care with her first embryo transfer, which was amazing to her after the treatment burden that she'd been through.
JORDI MORRISON: Okay. You're back. You'd frozen. Okay. Great. All right. Okay. And what can I do before a frozen embryo transfer to assist chances of success?
DR. RAELIA LEW: So what we're talking about here is uterine factors and hormone factors. Embryo factors are important in success rates, but so are other factors. So what can we do to improve our chance of success in a frozen embryo transfer? We can optimize our general health. We can make sure that we've done everything we can to optimize our diet, optimize our lifestyle, make sure that we're a healthy weight, make sure that we are really the best version of ourselves that we can be. We've done all of our prepping with prenatal supplements to help us be replete in all the trace elements to have a healthy baby. We can make sure there's no inflammation inside the womb. And sometimes I pause IVF treatment to have a look inside the uterus with a camera and do what's called a hysteroscopy and take a biopsy of the lining of the womb, just to exclude factors like what we call chronic endometritis or acute endometritis, which is different to endometriosis. Anything itis means inflammation.
JORDI MORRISON: So dermatitis is inflamed skin. This is a good fact.
DR. RAELIA LEW: Yes. And endometritis is inflamed lining of the womb. That can happen for women who have endometriosis. It can just happen with a hormonal imbalance. And sometimes the stimulation hormones that we give in IVF cause fluxes in our bacteria that live in our body. And that in itself can... upset the balance and result in a transient bacterial endometritis. Infections like ureoplasma, mycoplasma can cause endometritis and that can happen as well and be missed in routine investigations. So checking inside the uterus with a camera and taking a sample of the lining to make sure that everything is calm and happy as it can be is something we sometimes do before an embryo transfer to improve the chance of success. That also makes the transfer easier for a different reason. It's because in order to fit the camera inside the womb, we dilate the cervix a little bit. And if you can fit a camera easily, then you can fit an embryo transfer catheter, which is much skinnier, very, very easily. And it just means that the transfer itself is more likely to be straightforward. So those are the kind of things that we can do to prepare for embryo transfer. And then there's a lot of things that are sometimes enjoyable for patients and they feel help them calm and balance like acupuncture and other pre-treatment preparations that some people choose to do before their transfer.
JORDI MORRISON: Going to try for a second child. Should I still see the GP for pre-pregnancy bloods?
DR. RAELIA LEW: Yes, definitely. It's a good idea. If you need help from a fertility doctor, let's say... I helped you get pregnant with IVF and you have frozen embryos and you want to come back and have an embryo transfer. Usually your referral letter to your specialist will have expired and you'll need a new referral and we will need to recheck all your pre-pregnancy bloods. Having had a baby, you may now be, for example, iron deficient or you might be, you know, kind of depleted in things like vitamin D. We want to fix those imbalances before conception. We want to check that your immunity is still strong for rubella and chickenpox and give you a booster vaccination if that immunity has waned. We need to do a repeat screening check for other infections. We often do a vaginal swab as well to check for any vaginal infections or imbalances that we can correct before a transfer. And I'll also ask you to do a pelvic ultrasound before your embryo transfer if you've given birth. You might have given birth by cesarean section, in which case I want to have a look at your caesar scar and make sure you don't have what we call an isthmus seal or a cesarean section scar defect that we may need to assess. I'd also like to just check anyone who's gone a few years after having a baby before I put an embryo back, just to make sure that there's no new issues like fibroids or polyps that are going to require management before we move forward with your embryo transfer to give you the best outcome with your frozen embryos. And so, yeah, basically it's going back to the starting line. If you don't have frozen embryos, we'll also need to reassess a male partner. If there is a male partner in the fertility equation as well, because things change. We all, unfortunately, as we get older, there's the aging process, there's new pathologies that can crop up. And we just need to make sure that everything, your hormones, infectious diseases screening, that, you know, there's nothing that's going to get in the way of your success. There are some tests that don't need to be repeated. So if you've done, for example, genetic testing before your first baby, and we know the answer to those questions, then they're not going to have change. So we don't need to repeat that type of testing.
JORDI MORRISON: So it's like what you said in the previous question. This is just about you being your best self before you start to conceive.
DR. RAELIA LEW: Exactly. You know, there are modifiable and non-modifiable factors always. And what we want to do is optimize the modifiable factors.
JORDI MORRISON: This one's a bit of a weird one. Why is the center of most women's health fertility and not quality of life? I feel like this is an interesting one for discussion.
DR. RAELIA LEW: I don't know. It sounds philosophical rather than medical.
JORDI MORRISON: Exactly.
DR. RAELIA LEW: I wouldn't say I'm an expert on philosophy, but I always do try and help my patients achieve their goals, whatever those goals are, with quality of life in mind. I often prescribe IVF medication in that way. I'm a big believer in splitting the cycle into achievable parts to make sure that my patients don't suffer unnecessarily. And quite often you can optimise their treatment outcome actually by similar schools of thought. So for example, I might often freeze first in creating embryos for my patients, so that I can use gentler medications with lower risks of complications like hyperstimulation syndrome. And so patients can have more oral medications and less injectable medications and just split their cycle up into more manageable parts. And then we'll quite often do a frozen embryo transfer in a natural cycle, which again has much less burden for a woman of side effects as well as a better success rate. So I actually think I personally... I'm very quality of life focused with my patients and I also try and minimise the number of IVF cycles they'll require in their lifetime by having conversations about embryo banking at a younger age where they're better prognosis patients, less likely to require multiple, multiple cycles so that later in life things are easier for them, and I'm very much into optimising general health and wellbeing which, you know, it's win-win for fertility. And also quality of life. So I don't know. I don't know that that's the case. Obviously, people who suffer infertility have a problem. They have a problem and they come to me for help in solving that problem. And that's extremely stressful for those patients. And I think most people come to see a doctor because they have a problem. They don't come to see a doctor for lifestyle advice or friendship advice or... know, to be their best selves or philosophy. They come because they've got an issue and they want help with that issue. And our job as medicos is problem solvers to help them, you know, use our knowledge and use our skill to overcome their medical concerns. So I suppose that's why we probably do have a problem solving focus and a problem centered focus. But that doesn't mean that when a woman thinks of her health, a woman who's not ill, that she shouldn't have a holistic viewpoint and a quality of life viewpoint. I think that's actually very important for us to have as individuals, even though it's not necessarily your specialist's perspective.
JORDI MORRISON: What is the opinion for DQ alpha testing for recurrent loss? I don't think we've covered this before.
DR. RAELIA LEW: Yeah, look, I think we have probably, but probably in like the myths busting sections of questions. It's something that doctors rarely order and patients often ask about, which is generally because of internet research rather than evidence-based medicine. So DQ-alpha gene testing, it's looking at basically our HLA, human leukocyte or white cell antigen profiles and looking at different partners. It's something that's done, for example, if you're trying to give a kidney or a bone marrow graft to somebody, you need them to be a match with the person that receives that graft so they don't reject that graft. And we all have an HLA pattern. So that's kind of what we're looking for, one of the things we're looking for as well as blood group and other parameters when you give someone a kidney or an organ transplant. Is controversy in consideration of DQ-alpha gene testing and reproductive issues because it's generally not a useful tool for any definitive diagnosis or as a sole guide for treatment. It was something that was raised probably about a decade ago as a possible hypothesis for recurring pregnancy loss or infertility. And subsequently, there's been a lot of conflictive research and lack of consensus in the medical community because we don't actually agree that it's a thing. There's no real consensus that it's actually useful in any way or that it's associated with recurrent miscarriage or implantation failure at all. And actually there are many people who are very fertile and have babies with no problems with the same pattern that is purported by some to be kind of problematic. So sometimes, I mean, the theory is that kind of that... maybe a mother's body might see the embryo as foreign if a certain pattern with her partner is present and that they may never have a child. But look, I don't really believe in it, to be honest. I don't test my patients for this. I've seen patients who've been told by other doctors that because they've got this DQ pattern with their partner that they'll never have a baby. I've helped them have babies without problems by genetically testing their embryos and putting back normal embryos for that same couple. So basically I don't talk about it with my patients unless they bring it up because I don't really believe in it.
JORDI MORRISON: Three failed transfers and one ectopic. Where to from here? This is from Ran O'Hanlon. Oh yeah, cut that out obviously.
DR. RAELIA LEW: Of course. In IVF, you know, we say that most of our patients will have a chance of about one in three of each embryo making a baby if it's an untested embryo. And if it's a tested embryo, about one in two chance of that embryo making a baby. Unfortunately, we'll have patients who are undertaking IVF who do take multiple cycles to get pregnant. And that is actually, while disappointing to patients, patients would love there to be a 100% success rate in IVF. Doctors would love there to be 100% success rate in IVF, but there isn't. And the reason that there isn't is that not every embryo, once it goes back in the body, does the right thing. An ectopic pregnancy is when a pregnancy happens in a fallopian tube or somewhere else that it shouldn't be. That's unfortunate. We actually do know that genetically abnormal embryos are more likely to implant in the wrong spot. That's something interesting that has come up in research. So sometimes it's that the embryo had funny gene experiments and it made it make the wrong choices as to where implantation happened. When someone's had multiple failed transfers, the options that we consider are to have another look inside the uterus with a camera. We spoke earlier about hysteroscopy, check the lining, make sure there's nothing hostile going on inside the womb. So we can test the mother. We can test the embryos and check that we're only putting back normal embryos because that does reduce the risk of failed transfers and it reduces the risk of miscarriage and it reduces the risk that IVF will take a long time until it works. At the end of the day, sometimes what we need to do differently is frustratingly just use a different embryo because that different embryo may have a different prognosis and may through chance elements do the right thing. And I always say to my patients, you know, when you think that embryos have to go from a little ball of cells that is a thousand times smaller than a poppy seed to make the complex human body, all our organ systems, our placenta, and navigate the immune mechanisms between the mother and the baby. It's not surprising that it doesn't always go right. In fact, it's somewhat a miracle every time it does. The other thing to say is that couples who require IVF to conceive and women who require IVF to conceive, it's not because they have perfect fertility. They have concerns and problems. So we're helping people against the odds to achieve hopefully a normal pregnancy. And sometimes it is for them the exceptional rather than the average embryo that can make a baby. And it's the exceptional set of circumstances aligning that will succeed because they themselves in their situation have a poor prognosis compared to the average person, may be for a myriad of intertwining factors, including male factors. So what can we do differently? Again, going back to the basics, optimize general health of both partners, optimize the circumstances for embryo cancer and persistence, because persistence is what's going to get us there in the end. And I always say IVF is a marathon, not a sprint. And sometimes the same people who have challenges and struggles will eventually get where they're going, if they persevere.
JORDI MORRISON: Can I try to conceive whilst breastfeeding?
DR. RAELIA LEW: Yes, you can, but breastfeeding is nature's contraception. So breastfeeding can completely stop your periods if you're breastfeeding fully and that will be different person to person and it will depend on your resources and your, I guess, nutrition and just how much breastfeeding takes out of you. So women who have smaller breasts will have to expend more energy making the same amount of milk. So we're all a bit different. But as well as lactational amenorrhea, nature's contraception to help us space children, prolactin can have to some degree a negative effect on the endometrium. And that again is a relative rather than absolute contraceptive issue. So look, some people can fall pregnant when they're breastfeeding and some people can't. Some people ovulate while they're breastfeeding and some people don't. And some people's lining can be receptive while others can be affected. So I usually say to patients that unless there are exceptional circumstances, it's best to finish feeding one baby before trying to conceive another. But in exceptional circumstances, we can work with you. But it is possible. And if you don't want to get pregnant, use contraception.
JORDI MORRISON: Well, that's right. If you do not want to be pregnant yet, then you should use contraception if you're having periods. Somebody, if they are relatively fertile, they could get pregnant actually before they even have a period if they ovulate, if they get pregnant with their first ovulation. And that's happened actually. I've seen a patient come to have an IUD fitted in a gynae clinic when I was a registrar and she'd had a baby and she hadn't had a period. And as we do for all patients in that circumstance, we did a pregnancy test and she came back positive and then we did an ultrasound and she was about 12 weeks pregnant and she didn't realise.
DR. RAELIA LEW: So it can happen.
JORDI MORRISON: I love this question, Raelia, but I don't know if we have the answer. How many babies do you make each year?
DR. RAELIA LEW: Oh, a lot. Usually at least a thousand, me personally. I don't actually count. It's pregnancies. Yeah, at least because it's IVF cycles that I help patients go through and frozen embryo transfers. And I have a lot of patients that I've been helping for decades now who come back for a frozen embryo transfer. It's not just egg collections that we do, or they might have frozen eggs and we're warming eggs to transfer embryos. We're doing that more and more. In fact, this year I've made the most frozen egg babies of my career compared to other years. So I think the number of women coming back to use their eggs is increasing significantly, which is great. So yeah, it's all the babies I make from fresh IVF cycles for patients that I'm treating. It's all the babies I make from frozen embryo transfers, both for patients that I'm actively treating for the first time and also patients that are coming back who have helped have babies in the past, and all the babies that I help make through IUI and ovulation induction and all the babies I help make through frozen eggs.
JORDI MORRISON: So that's a lot of babies.
DR. RAELIA LEW: It's a lot of babies.
JORDI MORRISON: Thank you, Raelia.
DR. RAELIA LEW: Thanks, Jordi.
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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