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January 19, 2022 by Ari Simon

The IVF timeline is mostly a two-step process now, changing the answer to the FAQ: When is the right time to try IVF?

I often get asked the same question (by patients, people at parties, moms of 30-somethings I see at the grocery), especially when they find out I’m a reproductive endocrinologist: when is the right time to do in vitro fertilization (IVF)?

Most people see IVF as a last resort. Why? Well, I guess because it’s reported to be arduous, painful, scary; it’s super expensive; and they may have heard that you might get twins or even triplets. There are a lot of unknowns and untrue rumors surrounding IVF.

How has the IVF timeline and process changed?

IVF has definitely changed in a number of ways over recent years, which has also affected the IVF timeline. This is what I tell people when they ask me to help them decide when is the right time to do IVF. Primarily, IVF is much more successful than it once was.

This also means the IVF procedure is much safer. You’re much more likely to have one baby at a time, and we know much more about the outcomes for both the mother and the child. We know they’re healthy, they’re developing well, and there’s no longer a stigma about being a test tube baby.

The IVF process has been split into two parts

There are simplified medicine regimes for the IVF process. For most patients, IVF is now split into two parts: part one is the egg retrieval, and part two is the embryo transfer. There are many variations on a theme – and this depends on your individual physician.

Once they take a careful history and physical exam your physician will determine the most successful option for you, depending on your family plan. For example, some people might choose to make embryos after the egg retrieval while others might just choose to freeze eggs for use in the future.

Part one: IVF medications and egg retrieval

The egg retrieval consists of approximately two weeks of hormone pills and two weeks of hormone shots. The hormone pills could be estrogen alone or oral contraceptives that serve the purpose of synchronizing your cycle so that more eggs can be developed.

The shots begin a few days after the oral medication is completed. This generally consists of two shots a night to grow multiple eggs, until the last five days when we add a third shot that keeps you from ovulating. Then there’s the final shot, called the trigger shot, which at RSC is most often a shot called Lupron.

Lupron helps the final maturation process of the eggs and also allows for the ovaries to shrink back down quickly to their normal size after egg retrieval. This prevents many of the discomforts that occurred in the past like bloating, weight gain, and a syndrome called OHSS (ovarian hyperstimulation syndrome.) Using the Lupron trigger shot, OHSS is almost unheard of. There are still some minimal risks to the procedure but they are below 1% and almost none are life-threatening.

After the eggs are retrieved, they can be combined with sperm to make embryos, and those embryos can undergo genetic testing to optimize the success rate and minimize the number of treatment cycles to have a healthy baby.

IVF part two: embryo transfer

For those patients who are ready to become pregnant, an embryo transfer is the second part of the IVF process. Physicians should work with patients and make every attempt to optimize their medical health before pregnancy. If there are medical contraindications to pregnancy, a gestational carrier can be used.

In general, there are two different protocols for use with the embryo transfer; one is a modification of the natural cycle where there is only one shot for the entire month of treatment.

The other is a programmed cycle, where estrogen is taken followed by the addition of progesterone in order to re-create a natural cycle. This type of protocol involves progesterone shots in the gluteal muscle, which is much more uncomfortable, but it’s also considered more successful in a number of studies.

The “perfect” IVF timeline is up to you

In summary, IVF has truly changed and should no longer be viewed as a “last resort.” Having good eggs and embryos allows you to have more options. The earlier you start IVF, the better the quality of eggs and the better your chance at success.

In the 1970s people viewed birth control as the ultimate development in women’s freedom. However, waiting too long to have a child can restrict your freedom to be able to have a family genetically. Being able to freeze eggs or embryos is the ultimate in reproductive freedom.

Related Fertile Edge Podcast: Elective Egg Freezing with Dr. Mary Hinckley

So, when is the right time to do IVF? In my opinion, it’s when you feel the desire – or perhaps the stress and pressure – to have a family but are unsure if the path you are on will provide the optimal timing for fertility.

This may be because you’re infertile and you’ve already tried the basics, or it may be because you want to preserve your fertility for the future. Both are valid reasons, and both are met with much greater success than in the past.

February 7, 2024 by Ari Simon

Understand the pros and cons of the medicated frozen embryo transfer and natural frozen embryo transfer protocols to prepare the endometrium to receive the IVF embryo.

If you are planning for a frozen embryo transfer (FET), you should know that the two types of treatment protocols utilize either a medicated cycle or a natural cycle. A cycle refers to one round of in vitro fertilization (IVF) treatment, and an embryo transfer cycle refers to one attempt at embryo transfer.

Both medicated and natural frozen embryo transfers involve providing your uterus with estrogen to thicken the endometrial lining and then adding progesterone for a fixed amount of time to induce changes in the endometrium to make it “receptive” to an embryo.

However, the medicated and natural cycles provide these two hormones in different ways. Fortunately, our data from the Reproductive Science Center of the San Francisco Bay Area shows that pregnancy rates are similar after both types of cycles. So, this article is aimed at explaining each protocol further, and helping you decide which protocol is right for you.

Medicated frozen embryo transfer cycles

In the medicated cycle, also called a controlled cycle or programmed cycle, your body relies entirely on estrogen and progesterone medications to prepare the uterus for embryo transfer. Estrogen, usually in the form of an oral pill but sometimes via patch or vaginal administration, is taken for approximately 2-3 weeks. Then, an ultrasound is done to ensure the endometrial lining is adequately thick and developed. If not, the estrogen dose is increased, and a repeat ultrasound is performed in a few days.

If the endometrial lining is adequate, progesterone medication is started, via daily vaginal suppositories and intramuscular injection, exactly 6 days before a scheduled frozen embryo transfer. Both estrogen and progesterone are continued for approximately 6-7 weeks after the embryo transfer.

Pros of the medicated frozen embryo transfer

Requires fewer visits for monitoring and bloodwork, typically just one visit for measurement of the endometrial lining.
Given that the administration of medications is controlled and scheduled, the date of an embryo transfer can be chosen around your work schedule/availability, or that of your doctor to ensure they perform your embryo transfer.
Because estrogen levels can be made higher than in a natural cycle, this is a good option for patients who have struggled with a thin lining in the past.

Cons of the medicated frozen embryo transfer

Requires more medications than a natural cycle, including daily intramuscular progesterone injections.

Natural frozen embryo transfer cycles

In a natural frozen embryo transfer cycle protocol, estrogen and progesterone are “naturally” produced by your body during the process of ovulation. Estrogen levels rise steadily in the first half of the cycle. Then, when ovulation occurs and a corpus luteum is created, progesterone starts to be produced and an embryo transfer is scheduled for 6 days later.

To ensure that the embryo transfer is scheduled relative to the time of ovulation as closely as possible, this protocol requires frequent (sometimes daily) monitoring after cycle days 9-10 to capture when ovulation will occur. Specifically, monitoring is aimed to assess for the luteinizing hormone (LH) “surge” that precedes ovulation by 24 hours.

Variations of a natural frozen embryo transfer cycle can add some predictability and convenience. An ovulation induction medication called letrozole can be taken for 5 days at the beginning of a cycle to almost reliably help your body ovulate 5-7 days after finishing the medication. Furthermore, rather than waiting for your body to ovulate naturally, in a “modified” natural cycle, an injection of the human chorionic gonadotropin (hCG) hormone is taken to enact ovulation approximately 36 hours later, and then an embryo transfer is timed accordingly. Both of these strategies can reduce the number of monitoring visits.

Though the progesterone produced by your body is likely sufficient to support implantation and a pregnancy, in any natural cycle we still recommend patients take a vaginal progesterone suppository starting after ovulation and continued for 5-6 weeks after the embryo transfer.

Pros of natural frozen embryo transfer

Utilizes fewer medications and injections compared to the medicated protocol and is therefore more “natural” and easier on the body.
Research studies show that pregnancies conceived after natural cycles have lower rates of hypertensive disorders including pre-eclampsia.

Cons of natural cycle frozen embryo transfer

Given this protocol relies on regular cycles, women with very irregular cycles or who are peri-/menopausal and no longer have a cycle are not eligible for this protocol.
Requires more frequent appointments for monitoring via ultrasound and bloodwork, especially around the time of ovulation. Furthermore, if the timing of ovulation is missed, then a cycle may have to be canceled.
Given that the day of embryo transfer is determined by the day of ovulation, it can be less reliably scheduled around your convenience and availability. Furthermore, this unpredictability increases the chance that your embryo transfer will be performed by a doctor different than your own.

October 22, 2009 by Ari Simon

Paternal age and obesity diminish fertility

SAN RAMON, CALIFORNIA – Infertility physicians at Reproductive Science Center of the Bay Area have found that their male patients follow the findings of a recent study that indicated sperm quality begins to deteriorate after age 35.

According to the new study reported in the Aug. 1 issue of Obstetrics and Gynecology, sperm quality starts to go downhill after age 35 and indicates that paternal age is a significant risk factor for miscarriage. The study of almost 14,000 pregnancies, conducted by Dr. Karine Kleinhaus of Columbia University, showed that women with partners ages 35 or older had nearly a threefold increase in spontaneous abortions compared with women whose partners were younger than 25.

“Many of the male patients we treat were married later in life or in the course of their second or third marriages found they were unable to conceive–even if they had children from a previous marriage,” says Dr. Kirsten Ivani, IVF lab director of the Reproductive Science Center of the San Francisco Bay Area (RSC). “Sperm quality is clearly impacted as child-bearing is increasingly delayed – for both men and women. It is already well documented that fertility declines because of a limited number and quality of eggs for women as they get older, so this is research should alert men to similar issues.”

It may be that the clock ticks even faster for overweight men. New research from the National Institute of Environmental Health Sciences showed that men with increased body mass index (BMI) were significantly more likely to be infertile than normal-weight men. A 20-pound increase in men’s weight may increase the chance of infertility by about 10 percent. The majority of men who participated in the study were more than 30 years old. Obesity affects nearly one-third of the adult American population (approximately 60 million).

According to the American Obesity Association, the number of overweight and obese Americans has continued to increase since 1960, a trend that is not slowing down. The Columbia research found that the risk of miscarriage of a fetus conceived by a father over age 40 was 60 percent greater than if the father were 25 to 29, irrespective of other factors that have been linked with increased miscarriage risk, such as the mother’s age, maternal diabetes, poor maternal health and smoking during pregnancy. The increased risk of miscarriage does not just apply to fathers in their 40s, however. The miscarriage risk in a pregnancy involving a father aged 35 to 39 was three times higher than the risk if the father were under 25.

Data from the study showed that 1,500 of the women suffered miscarriages, while 12,000 carried their children to term. “This new study provides important information for people – of all ages – who are planning their families,” says Dr. Ivani. “It means that men should be sure to get the medical attention they need to uncover medical problems underlying infertility.”

In fact, the American Society for Reproductive Medicine (ASRM) has set an upper age limit of 40 years old for semen donors because of the increased risk of genetic abnormalities in the offspring of older fathers. According to the ASRM, infertility is a male problem 35 percent of the time; a female problem 35 percent of the time, a combined problem of the couple 20 percent of the time, and the final 10 percent is unexplained.

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October 21, 2009 by Ari Simon

“Fertile Awakenings” program one of a handful nationwide interlinking traditional western and alternative fertility care

SAN RAMON, CALIFORNIA – This month the Reproductive Science Center of the Bay Area, one of nation’s oldest IVF practices, launches “Fertile Awakenings,” one of the first programs to provide coordinated care by a team of traditional western fertility specialists and complementary and alternative medical practitioners.

Though the medical community is divided about complementary and alternative medical approaches to infertility, many patients have been using them successfully. However, it is rare for their care to be coordinated between all medical providers.

The program includes a panel of RSC physicians and the Fertile Awakenings team of alternative practitioners, who will review infertility treatment for patients on a case-by-case basis. When appropriate, they will recommend complementary treatment to be offered at RSC clinics as well as other locations, such as acupuncture at RSC’s Orinda clinic, mindfulness training and stress reduction courses at RSC’s San Ramon location, confidential phone coaching, and uterine massage and nutritional counseling at Harmony Acupuncture.

“It is becoming more common for infertility practices to offer a multidisciplinary approach, integrating western and eastern medicine, along with a Mind/Body program. There is some evidence that this combined approach may improve success for some couples,” said Louis Weckstein, M.D., IVF and Medical Director of RSC. “A collaborative program that addresses the stress as well as the medical aspects of infertility care more raises the bar for fertility care,” said Weckstein.

“Helping to manage the brutal stress and emotional rollercoaster of infertility can go a long way in supporting medical treatment for infertility,” he added.

More patients like Lidia Gutierrez, a 39-year-old San Ramon engineering consultant who is completely healthy but having difficulty getting pregnant, are using acupuncture while undergoing in vitro fertilization (IVF). “When Dr. Weckstein showed me the research on superior pregnancy rates for patients who used both methods, my husband and I agreed it was the best way to proceed,” she said. Gutierrez began acupuncture treatments in June in preparation for her first IVF cycle in August. Some studies show acupuncture increases the success of embryo implantation as well as improves relaxation and reduces stress.

Most fertility experts agree that reducing stress is key for many of their patients. Stress signals the pituitary gland that the body is in trouble, which can slow the release of the luteinizing hormone, which in turn triggers ovulation. Even if ovulation occurs, a shortage of the luteinizing hormone could mean a lower level of progesterone, a hormone necessary to nourish and sustain an embryo’s implantation.

Infertility patients who have endured many months or years of frustration may have low emotional reserves and benefit from the emotional support of a professional coach. Research showed that couples who participated in group counseling sessions were more likely to get pregnant than couples who did not. The Fertile Awakenings coaching program also helps patients navigate the stress of decision-making regarding complex treatment options, such as determining which assisted reproductive techniques are appropriate, when to consider use of a donated egg or sperm, a gestational carrier, or cease treatment and consider other choices.

Separate German and Chinese studies of 160 women combined who used assisted reproductive techniques, as reported in the April 2002 issue of Fertility and Sterility, found that 42.5 percent who included acupuncture with their treatment achieved pregnancy compared to 26.3 percent who did not use acupuncture. Other studies have shown that sperm quality benefits from acupuncture treatment as well.

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Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is caused by infrequent or absent ovulation — the body’s process of producing and releasing eggs from the ovary.

Essentially, people with PCOS have an inappropriate production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that results in limited egg development and an increase in testosterone and other typically male hormones (androgens). People with PCOS also have abnormal insulin metabolism, which worsens with anovulation (no ovulation), increases androgens, and leads to obesity.

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What is PCOS?

PCOS stands for Polycystic Ovary Syndrome. It is a hormonal disorder that results in small cysts growing on the ovaries. These cysts may disrupt the function of the ovaries, resulting in symptoms such as:

Irregular menstrual periods
Irregular ovulation
Heightened levels of male hormones, which result in excess facial and body hair and/or acne

What causes PCOS?

The cause of PCOS is not completely understood. It is clear that there is a genetic basis to the condition, as a person is more likely to develop the condition if their immediate family member has it. It is also known that disrupted signaling from the brain to the ovary affects ovarian hormone production, which further exacerbates, or worsens, the condition.

Symptoms of PCOS

The hormonal imbalances experienced by people with PCOS can cause the following symptoms:

Irregular menstrual cycles, specifically those that are 3 to 5 days shorter or longer than a typical cycle (a normal cycle ranges between 21 and 35 days).
Heavy or absent periods — some women with PCOS only menstruate one to two times a year.
Acne.
Excess facial and body hair.

How PCOS affects fertility

PCOS is a leading cause of female infertility, yet many women with the condition go on to conceive and have healthy pregnancies. The impact of PCOS on fertility can include:

Irregular or absent ovulation.
Hormonal imbalances affecting egg development.
Difficulty with implantation or early pregnancy loss.

Unlike other fertility concerns, women with PCOS often benefit from early evaluation and management. Consulting a fertility specialist can provide personalized treatment options to support your reproductive goals.

Diagnosing PCOS

Your medical history and a pelvic exam are necessary for diagnosing PCOS. However, your physician may need other tests to confirm the diagnosis such as:

Blood hormone levels: Blood tests that reveal the levels of certain hormones in your blood, such as FSH, LH, estrogen (estradiol), and androgens.
Ultrasound: A scan that uses high-frequency sound waves to identify cysts in the ovaries.
Endometrial biopsy: A procedure in which your physician obtains a sample of your endometrial tissue to help explain why your periods are irregular.

Fertility treatment options for PCOS

Your treatment will depend on your specific needs. Obesity may make the condition worse, so losing weight may help improve the hormonal imbalance. If your goal is to become pregnant, then your doctor may prescribe a medication to stimulate ovulation. Common fertility treatments include oral medications to help with ovulation such as clomiphene citrate (Clomid, Serophene) and letrozole. Your doctor may prescribe a second oral medicine, such as metformin, a diabetes drug, which can help make the body more sensitive to insulin and lead to more regular ovulation.

Historically, Clomid has been the first line of treatment for PCOS. However, letrozole use has been increasing due to a possible increase in pregnancy rates. It’s important to note that if you haven’t conceived after three to four cycles of Clomid, you should consider a different course of treatment, such as intrauterine insemination (IUI) or in vitro fertilization (IVF).

Take control of your fertility journey

PCOS doesn’t have to stand in the way of your dreams of parenthood. At RSC, we’re committed to helping you understand your condition, explore your options, and take confident steps forward.

More about PCOS

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