Blog - Fertility Fact Checker

What to do other people do with left over embryos?

Before starting IVF, having numerous embryos ‘left over’ was my biggest fear. I mean obviously I was going to do one cycle, have my 1.8 children (1.8 being the average fertility rate in Australia) and then have all these embryos left over that I had created and didn’t need anymore.

It was why I wasted over a year doing several IUI’s despite being told I was not really the best candidate for it and also why I asked the laboratory to limit the amount of eggs they tried to fertilise on my first IVF cycle.

But to be fair, it also had a ‘protective factor’ in that it was also why I was never disappointed when I didn’t get the massive numbers of eggs retrieved and fertilised that women often hope for. It came as a relief in a way to get those small numbers because I wouldn’t have to make that decision.

For those who have read Eat Think Grow and know my story you would know that dozen’s of left over embryo’s wasn’t something that I needed to worry about, but none the less for a growing number of women it is.

As IVF increases in ‘popularity’ and accessibility, the industry matures and success rates increase, the issue of what to do with left over embryo’s is also going to increase. It also seems like a growing practice to do full cycles and ‘bank’ embryos while you are younger before doing transfers.

What to do with left over embryos is also an issue that is being discussed more frequently in mainstream podcasts (ie not just those for subfertiles), and in the numerous blog and news articles already written on the topic.

There are all sorts of reasons why women have embryos they won’t use. Relationships end, illness happens and now with PGS testing more embryos are likely to be found as mosaic or ‘abnormal’ meaning that, understandably, these embryos too will not be used (though if you read my article on PGS I think there is still reason to have some caution).

Generally, families have five main choices to choose from when they have completed their families (or can no longer use their embryos) and need to think about what to do with excess embryos.

Keep freezing

The problem with this is that, not only can it be expensive, but it is time limited to around 5 – 10 years depending on where you live. Again, depending on your location and surrounding circumstances, you can sometimes apply to have it extended for another 5 years, but that is generally only if you are still receiving IVF treatment, still want to extend your family or some other medical condition has temporarily stopped you from using them before now.

Image by Julio Pablo Vázquez from Pixabay

It isn’t an indefinite option, but it does buy you some time to make a decision that you can find peace with or at least access some counseling so that you can make a decision that you can live with.

Thaw and Dispose

This is also referred to as letting the embryos succumb, disposing of them or stopping cryopreservation. In this process they are taken out of the freezer and left at room temperature for a period of 24 hours, a process which destroys the cells and therefore the embryo.

In one piece of research done in Australia in 2006 (1; so it is over 13 years now and attitudes to IVF have changed a lot in that time) 30% of persons chose to dispose of their embryos when they had completed their family. Other studies have had this number as being higher.

There are many factors that influence what decision a couple (or person) makes for their embryos. Religion, psychosocial factors, values and beliefs and how they regard or think of the embryos all plays a role. Interestingly, in a recent study (2) it was found that couples who chose to ‘stop cryopreserving’, seemed to have had the most attachment to the embryos and thought of them as their ‘children-embryos’. The authors report that it could be that people who choose this option have invested a lot in the potential of their embryos and are too emotionally attached to them to donate them and know that they will have a future that they will never witness (2). They also report the most distress in needing to make the decision with 46% of respondents in a survey of 243 people reporting that it was a difficulty decision to make.

After the thaw

After the embryos have been thawed and destroyed there are several options. The laboratory can dispose of them for you, some people take them home for a ceremony to plant them under a tree for example and there is even the option of turning them into jewellery. In this process the embryo’s are cremated and then mixed with other substances so that they can be made into a ring, for example. Some women find comfort in knowing where their embryos are and having them close to their heart. Making the jewellery can also a symbol of not only what they have been through but also that the door has now closed. It probably wouldn’t be my first option, but I get it.

This is a pic of Baby Bee Hummingbird (BBH) jewellery from the Kidspot.com.au website.

Donate to another person or couple

I think this decision in itself takes a huge amount of bravery, strength and is perhaps the most altruistic thing a person could ever do. There are so many factors into what influence this decision but it does appear that those who have received donor sperm or eggs to make their embryos are more likely to donate them to a couple in need. As one articles puts its like they are continuing a Chain of Hope (2). I like it.

Approximately 16% of couples with excess embryos after completing their family choose to donate them to them to another person or couple (1).

But even if a couple does make the decision to donate their embryos, depending where you are in the world, there may be other reasons why your embryos wouldn’t be eligible to be donated (2). These can include the embryo coming from a couple where the man or woman is known to have a genetic anomaly, where a woman is over the age of 40, the quality of the embryo (for example if there is only one embryo of poor quality) and the parental status of the couple wanting to donate (it is sometimes a stipulation that the biological ‘parents’ of the embryo needs to have a child between them).

Once you decide to donate to another couple there is also the decision of whether to have an ‘open adoption’ or an anonymous donation. Although again, this is a decision that is going to have things to consider I’ve been listening to a great podcast recently called Half of Me. It is by a sperm donor conceived adult and covers issues around donor conception from all angles. Although there isn’t necessarily a one size fits all approach, there does seem to be reoccurring themes about how donor conceived adults found out about their genetics and generally speaking it seems that the earlier and more open you can be about your son or daughters genetic history the better.

A chain of Hope. Image by congerdesign from Pixabay

The good news is, that for those who chose to donate to another couple, 85% of people say that it was an easy decision to make and didn’t involve all the torment of some of the other decisions. When you know, you know I guess.

Donate to Research

This is traditionally where you would donate your embryos to science. One article has said that people that choose to donate to research tend to focus on the embryos being a bunch of cells and the biologic aspect of this as opposed to those couples that choose to donate and generally speaking tend to mentally represent embryos as being a potential child (2). Around 42% of couples who have left over embryo’s after completing their families choose to donate it to science (1).

I’ve read a few comments where people have been told that their laboratory couldn’t accept the embryos for research (and hence they needed to be thawed and disposed of instead) as there can be strict rules around needing to have proper research projects and ethics approvals and others being told they embryos will be used by lab staff to practice their techniques.

Couples who choose this option have reported that they also feel like they are contributing to the future happiness of fellow subfertiles by helping to contribute to the science and improve success rates, but couldn’t live knowing that a genetic sibling to their children or a genetic child is out there walking around.

Compassionate Transfer

This option doesn’t really get mentioned that much…but I do remember it being suggested to me by my Fertility Specialist when I couldn’t quite get my head into needing to do IVF for the reason of having loads of left over embryos. During a compassionate transfer, embryos are transferred into you, much like a normal fresh or frozen embryo transfer but at a time or location when pregnancy is going to be highly unlikely, for example transferring in the first week of your cycle or transferring into the vagina (over 26% of Reproductive Endocrinolgoists responding to a survey stated that they transfer embryo’s into the vagina when doing compassionate transfers; 3) . It is believed that you are still giving your embryos ‘a chance’ and their fate is a little less predetermined than if you, for example, donate to research.

It appears that not all doctors are willing to do a compassionate transfer though. Criticisms of it state that it is huge waste of resources and doctors time could be much better spent doing activities that was at least aiming to result in a positive outcome. They have a point. But in an industry that thrives on privatization surely if women are going to pay for it, as well as help support their long term mental health, than surely that is ok? According to the same survey costs for compassionate transfers range from $0 to the full $4500 frozen embryo transfer fee (3).

But is a compassionate transfer just trying to fool yourself? And I ask this from the perspective of someone who genuinely would have considered it as an option and thought about it with respect to my own circumstances. I say this because for all we know about reproductive cycles and anatomy we kind of know that transferring an embryo during week one of your cycle into the vagina (as opposed to where it should go in the endometrium a few days after ovulation) is kind of going to guarantee that the embryo is not going to implant. But then again there is such a wide variety in the reported timings and locations for transfers and after all three doctors in the above survey did report pregnancies after doing compassionate transfers. So in that respect, if you are doing a compassionate transfer to feel as if you are giving your embryo a chance than it might be an option for you.

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To sum it up

What to do with your surplus of embryos can be a massive and anguished decision. Other times the path of what to do with your left over embryos can either be that not big of a deal or it is obvious what path you are going to take. And often you can swing between the two as your thoughts and feelings change.

Typically, the longer you have experienced infertility the more troubling of a decision it may be. One study even point a time on it suggesting that those who have experienced infertility for three or more years have more trouble than those that have experienced less than three years. I guess experiencing infertility over that time allows a lot of time, money and emotion to go into creating those embryos. Also layered into that is that the thoughts you have on it now might also change by the time you have a child.

Nothing about infertility is easy. Above are the general options that you have to choose from, but remember you don’t necessarily need to make the perfect decision – because sometimes it doesn’t exist. But taking the time to know the details of what your options are and find the one that you can rest with is what is important.

References

Hammarberg, K. & Tinney, L. (2006) Deciding the fate of supernumerary frozen embryos: a survey of couples’ decisions and the factors influencing their choice. Fertility and Sterility 86 (1) 86 – 91.
Bruno, C., Dudkiewicz-Sibony, Co., Berthaut, I., Weil, E. Brunet, L., Fortier, C., Pfeffer, J., Ravel, C., Fauque, P, Mathieu, E., Antoine, J.M., Kotti, S. & Mandelbaum, J. (2016) Survey of 243 ART patients having made a final disposition decision about their surplus cryopreserved embryos: the crucial role of symbolic embryo representation. Human Reproduction 31 (7) 1508-14
Hairston, J. & Feinberg, E (2018). Compassionate Transfer: Provider Practices and Perspectives. Fertility and Sterility 110 (4) Supplement, Page e374

Is the keto diet good for IVF?

I’ve been doing the ketogenic diet for a couple of weeks now and despite being seemingly the only person to do the ketogenic diet and not lose half their body weight in the first week*, I am loving it. Clear, defined guidelines around what is and is not ‘allowed’ is what I’m all about. My relationship with chocolate (and any source of refined sugar for that matter) was never about ‘moderation’. All or none is how we roll, and at the moment with the keto diet, it’s ‘none’. Plus, I love using the urine test analysis strips which tell you if you are in ketosis or not (is that TMI?). Clearly, it allows me to relive my days of being POAS obsessed and deriving my feelings of validation and success from the drying of urine on a test strip.

What I mean by a keto diet

I’m talking super low carbohydrates; less than 50gms per day (pretty much just incidental carbs you get from eating the non-starchy vegetables that generally grow above the ground like cabbage, broccoli, cauliflower, maybe a few berries and the like), a little bit of a protein and a whole lotta fat. The good fats though, not the nasty transfats that you get in fast and processed foods. I’m also crossing out calorie counting. It’s partly why I love keto (again, she says 2 weeks in).

By the way, did you know that the ‘keto diet’ has been around since the 1920’s and was initially developed as a way to reduce the symptoms of epilepsy in children? … Could Pete Evans actually be right and food is medicine?! (For the record, although I do believe that modification of nutrition and food intake can help improve our lifestyle risk factors that cause us to need medication in the first place I don’t believe food is actually medicine. Or that bone broth can replace baby formula. Or that anti-vaxxing should be a thing).

But what about for women doing IVF?

I know that quite a few women who are trying to conceive at least consider the keto diet. There are reported outcomes of weight loss, reducing insulin resistance and all round improvements including decreased bloating and increased energy levels after all.

I’ve done my PubMed search and like many of the big questions regarding IVF and lifestyle factors, there are very few peer reviewed articles looking directly at the ketogenic diet and its impact on the only outcome measure that really matters in an IVF cycle – the live birth rate. And even less indirect information around if you are not only looking at women labelled as obese or overweight.

There are though a few articles on the impact of ketosis and low carbohydrate diets on PCOS (a major reason why women ultimately need to use IVF) as well as on low carbohydrate diets and its impact on some IVF outcomes such as hormone levels².

Before getting started

If you see a fertility specialist, thinking about or are about to do an IVF cycle, 1000% speak to your fertility specialist first before starting keto. I’m sure that there are women who have done IVF and started keto the day before their meds started and got 50 Grade A Day 5 Blasts, but seriously, except under medical advice, the day before (or the weeks and longer before) starting an IVF cycle is NOT the time to make such radical changes to your diet. This is especially if you have thyroid issues, participate in regular hard exercise or a few other medical conditions. Again, run it by your doctor.

If you are in the lead up to an IVF cycle and want to make some dietary changes based in scientific research that will optimize your IVF cycle, make sure you have a look at Eat Think Grow. But again, still run it by your doctor and don’t make any huge changes in the short term lead up to IVF.

PCOS

According to the 2016 US Center for Disease Control’s National Summary Report which evaluates the success rates of IVF cycles, 16% of women doing IVF were diagnosed with ovulatory dysfunction – which is a ultimately why women with PCOS need to do IVF; for various reasons, normal ovulation fails to happen. So, by that thinking, if a ketogenic diet positively impacts PCOS symptoms and supports normal ovulation, than perhaps some women may not need to IVF at all?

The impact of the keto diet on PCOS was investigated back in 2005 by a small study (very small, only 11 participants, only 5 of whom actually stayed the six months to the end)¹. At the end of the study, what they found was significant (p<.05) decreases in body weight, percentage of free testosterone, insulin and LH/FSH ratios (testosterone and the LH/FSH ratio can often be higher in women with PCOS which throws the hormone cycle out and contributes to the lack of ovulation that women with PCOS experience). A reduction in all of these markers, as observed, are associated with an improvement in the ovulatory function of women with PCOS.

Although in this respect it seems tick, tick, tick for the keto diet in women with PCOS the authors themselves stated that they were unable to determine if these improvements were a result of weight loss in general (all the women started with BMI’s over 27, which is considered to be at least ‘overweight’) or the direct influence of the specific features related to the keto diet.

Low carbohydrate diet and general IVF outcomes

Melanie McGrice and her colleague, in 2011 examined how low carbohydrate diets can influence the outcomes of obese and overweight women doing fertility treatments, including IVF. A finding of their literature research appears to be that the consumption of low carbohydrate diets can reduce insulin and improve hormonal balance and ovulation function. These are factors which can also improve the quality of an IVF cycle.

There have previously been studies done investigating very low calorie diets (less than 2000kj/day) which have found that women doing IVF and on these diets had high attrition rates and low fertilization rates. Clearly, this is not what any woman doing IVF wants. As McGrice explains, the authors hypothesized that it may be the impact of ketogenesis causing this result. When the authors³ went and did another study, this time ensuring higher protein and less severe calorie restriction (around 5000kJ/day in the 2 months prior to IVF) this same negative impact was not reported. But the subjects were also consuming around 130gms of carbs a day and 23gms of fibre, so is generally not a low carbohydrate diet and ketosis was unlikely. So maybe there is something in that ketosis may have a negative impact on the egg quality?

Conversely and although not directly IVF related, there is early evidence that suggests the ketogenic diet may increase mitochondrial function. Mitochondria is often considered to be the ‘power house’ of a cell and its dysfunction is associated with cell death. Improved mitochondrial function, which is also associated with weight loss, also may result in improved ‘egg quality’⁴.

Low energy diet and IVF birth rates

Another study looked at the impact of very low energy diet on IVF success rates⁵. Sim and colleagues conducted a study where over a 12 week period, women classified as ‘obese’ were divided into two groups – the experimental group who were subjected to (or benefited from) the full changes to diet and lifestyle that researchers wanted to test and the control group, those that did not experience all these changes. Being overseen by a dietitian, for six weeks the experimental group consumed a very low energy diet. This was then increased to a ‘normal’ intake over the next six weeks in the lead up to their IVF cycles. Additionally, the experimental group had the added experience of attending a weekly support group where they were provided with dietary, psychological and exercise advice. Plus they had the added benefit of being in a group and having the opportunity to connect with other women experiencing infertility and IVF, a process which cannot be underestimated. Those in the control group were simply advised to go see their GP for weight loss advice and provided the same printed literature as the experimental group.

It was found that those women in the experimental group not only lost more weight but also had higher pregnancy rates (48% versus 14%) and higher live birth rates (44% versus 14%) plus the added benefit of only needing to do two cycles to get there take home baby, as opposed to four cycles in the control group.

In this case, participating in a fully guided meal plan and getting the right emotional support certainly appeared to contribute significantly higher pregnancy and birth rates.

Transfats

There is the concern, that in order to continue eating foods that are ‘keto’ some women may be inadvertently eating higher amounts of trans-fats – the bad one, for pretty much everything, including fertility. Transfats are found in a lot of prepared and prepackaged foods as well as some animal fats and in small amounts red meat. Speaking of the impact of eating red meat on IVF success rates, this was discussed in Eat Think Grow were it was reported that the consumption of red meat was associated with poorer embryo development and pregnancy rates⁶. Again in the quest to eat ‘keto’ it becomes a temptation to start eating more and more meat for the ease of it. I’m not saying eat more meat is necessary a bad thing for your keto diet (though some would) , but you need to be mindful of your other goals and what the evidence says there impact is on IVF success rates, not just being in ketosis.

Saying that, I would like to think by and large though, most people doing keto have enough ‘food literacy’ to know that you don’t eat prepackaged foods (cause a lot of the time they aren’t actually keto anyway) and to try and consume fats in healthier and alternative way than just having steaks 3 times a day.

To sum it up

As it stands, there is insufficient data to recommend the ketogenic diet to women doing IVF. The studies done primarily are only looking at women with PCOS and those that are labelled ‘obese’. Also, these studies are not all necessary looking only at the ‘keto diet’ as we know it. If you fall into the one of the categories of ‘obese’ or having PCOS and you have, say, six months to go before you do your IVF cycle and some significant weight loss to achieve than it would certainly be worth a go.

But the benefits you experience might be from weight loss as opposed to specifically the keto diet.

If you are three months or less before your IVF cycle, I would certainly be seeking professional advice before making such radical changes – although the data is far from water tight, in my opinion there is just enough doubt to think twice, or at least have a good discussion with your treating team and make sure that whatever changes you are making are optimized for your individual medical condition and cycle.

1. Mavropoulos, J., Yancy, W., Hepburn, J. & Westman, E. (2005). The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot study. Nutritional Metabolism 2: 35 doi: 10.1186/1743-7075-2-35

2. McGrice, M. & Porter, J. (2017). The Effect of Low Carbohydrate Diets on Fertility Hormones and Outcomes in Overweight and Obese Women: A Systematic Review. Nutrients 9(3), 204; https://doi.org/10.3390/nu9030204

3. Moran, L., Tsagareli, V., Norman, R. & Noakes, M. (2011). Diet and IVF Pilot Study: Short term weight loss improves pregnancy rates in overweight/ obese women undertaking IVF. Australian and New Zealand Journal of Obstetrics and Gynecology 51 455 – 459

4. Kulak, D. & Polotsky, A. (2013). Should the ketogenic diet be considered for enhancing fertility? Maturitas 74 p10 – 13

5. Sim, K., Dezarnaulds, G., Denyer, G., Skilton, M. and Caterson, I. (2014). Weight loss improves reproductive outcomes in obese women undergoing fertility treatment: a randomized controlled trial. Clinical Obesity 4 61 – 68

6. Braga, D., Halpern, G., Setti, A., Figueira, R., Iaconelli Jr, A. and Borges Jr, E. (2015). The impact of food intake and social habits on embryo quality and the likelihood of blastocyst formation. Reproductive BioMedicine Online 31 30–38.

*That’s a joke by the way… obviously I wouldn’t want to lose half my body weight in the first week, or at all!

7 must knows for an IVF first timer

You’ve chosen your fertility clinic, got a grasp on the type of cycle you’re doing and you’ve got an action plan for administering those needles.

There is just a few more things you need to know…

1. It all takes so much longer than what you anticipate.

I don’t mean to start all negative here, but it really does and you are either going to develop your patience skills to equal that of Mr Miyagi in the Karate Kid, or go a little cray-cray. I’m sure it will be the first of those two options, but if it’s the second, take a breath and remember you’ve got this. And if you haven’t got this, seek counseling or see a doctor that knows you well. You definitely won’t be the first.

But back to the waiting. Whether its waiting to get into a specialist for an initial appointment, waiting for day 1, waiting to get the money together to buy your medications, waiting to get bloods done in the morning, waiting for the afternoon results to come in, waiting for your what-went-wrong appointment (otherwise knows as the WTF appointment) after an unsuccessful cycle or even waiting during the dreaded two week wait for that pregnancy result there is waiting behind every twist and turn.

And while I hope you are one of the lucky ones that get pregnant and get that take home baby on the first go, unfortunately, statistics indicate that most women will need to have more than one cycle.

Hoping for the best but preparing for the worst has never been more appropriate than when starting out the IVF journey.

2. You need to be kind to yourself.

And protect yourself. There may be days when you just can’t go to another baby shower. When the thought of going to your best friends babies first birthday is just that step too far. That’s ok. A good friend will understand and one that doesn’t perhaps wasn’t really a good friend to begin with.

Sometimes you know when you need to have a break and hold onto those emotional reserves for when you really need it.

3. Most of it – out of your control.

There are very few things that you can control in this whole crazy process. People who do everything absolutely ‘right’ may fail a cycle and those that do everything ‘wrong’ have success first go. Kind of put that in the ‘ignore bucket’ like hearing about unwanted teenage pregnancies… it really doesn’t help to try and find the fairness in the situation and it doesn’t make sense.

Similarly, ‘bad’ blood tests one day may quickly turn into ‘good’ news the next day at the ultrasound. It really is a rollercoaster and you can be thinking you are ‘kicking fertility goals’ one goals one day and ready to throw in the towel the next.

The quicker you learn that so much of it is out of your control, the easier it is.

4. Get fertility fit.

Not forgetting that you really can’t control a lot of what happens during an IVF cycle, there are just a few things you can control. This includes what you eat, drink and to an extent other toxins that your body comes into contact with.

I know now, before your first cycle your thinking all you really need is a few drugs to get you ovulating or a bit of ICSI to get the sperm to meet the egg and bam! The magic is all going to happen. And hopefully it will! But if it doesn’t, chances are in a cycle or two you are going to look for alternative ways to try and improve the success of your cycle and you’ll quickly read that there are some real changes YOU can make to try and improve the egg quality, lining and implantation rates BUT ideally you’ll be starting these changes three months before your cycle for them to have full impact.

I know many women have read the well-known book about increasing egg quality . This is a great book chock full of research and ideas. But for some women, this can also be a bit intense. An alternative read is ‘Eat Think Grow’ it also has research but in a lighter format as well as practical strategies (including 4 week eating plan and mindfulness strategies) on how to implement it and get going .

5. Be your best advocate.

I’ve said it before, but no one really cares as much as you if you get this take home baby or not. Except maybe your partner that is. Doctor’s are people too and you are paying them a lot of money to help you bring this little baby into existence. If you have a question about a medication, or aren’t sure why you are doing the same protocol for the 5^th cycle in a row, ask! This is happening to your body, so make sure you understand (more or less!) why you are injecting those drugs!

Similarly, if you have done several cycles and don’t feel you are getting anywhere, or that your concerns aren’t being heard or if it is just your gut instinct, it can’t hurt to get a second opinion. Well, it might hurt the back pocket, but nowhere as near as much as extra IVF cycles does. Sometimes just putting a fresh set of eyes on your situation can come up with a new (and more successful!) plan.

6. Quality over quantity.

Like every day of the week. Try not to get down when your fertility friend has 18 eggs harvested come collection day and you are feeling like a dried up hen with your two. Although, your friends eggs might be all the highest quality, chances are they may not be. Personally, I’d take a low number of eggs with a higher quality than a large number of maybe immature and lower quality eggs any day of the week.

7. Think about what you will do with any left over embryos – if you should be so lucky.

Ok, so not really a ‘must know’ but definitely something to think about…You don’t need to set the decision in stone and situations and feelings on the issue can change in a heartbeat (literally!). But being mindful of what you might want to happen with ‘left over’ embryos now might make it a little easier in the future if you are one of the lucky ones who manage to complete their family with embryos to spare.

Good luck as you go about your first IVF cycle. Hopefully doing everything you can now to prepare your body for it and setting your mindset to roll with the punches (and the victories!) will make the rollercoaster just that little bit smoother

Which is better: fresh or frozen IVF cycles?

While it seems the trend is building for fertility clinics to do ‘freeze alls’ as standard in an IVF or ICSI cycle, the scientific evidence is a little more shaky.

A typical IVF cycle can go something like this:

Girl takes medications to stimulate those ovaries into egg producing machines, eggs are harvested, eggs meets sperm and lots and lots of embryos are made. Ok, well hopefully, at least more than one embryo is made. Traditionally, the finest of these embryos are then transferred on either day three or five, this being the fresh transfer, and the rest are frozen, ready to do frozen embryo transfers should girl not be lucky enough to have success from the first fresh cycle.

If you are about to do an IVF cycle and are looking for evidence based ways to increase your success rates, make sure you check out Eat Think Grow.

More and more though, the step of doing that first fresh transfer is being skipped in favor of freezing all the embryos instead. That is, there is no transfer on the first cycle where the eggs are collected; only doing frozen embryo transfers on subsequent cycles when there hasn’t been large amounts of medications injected to stimulate those ovaries into over drive.

The theory why

The underlying theory of doing freeze all cycles is that the medication that is taken to stimulate the ovaries is also responsible for reducing the endometrial receptivity for the implanting embryo (1). That is, it is an unwanted ‘side effect’ of ovarian stimulation that the lining isn’t as welcoming to the implantation of an embryo as what it perhaps should or could be.

It is thought that transfer of only embryos that have first been frozen and then thawed during a later cycle would therefore sidestep the possible negative effect that the medications used to stimulate the ovaries has on the lining and as a result, increase live birth rates – which to be honest, is pretty much the only outcome measure most women doing IVF are interested in (myself included).

The additional benefit to doing a freeze all cycle is that it is also believed to reduce the risk of ovarian hyperstimulation syndrome, or OHSS. When a woman has done a complete IVF cycle, using the medications to stimulate the ovaries and then becomes pregnant in the same cycle, there is an increased risk of OHSS. Therefore avoiding pregnancy in the same cycle that ovarian stimulation has occurred would reduce the risk of OHSS (1).

So does it work?

That depends. On a lot of things.

Firstly, it depends on if you are looking at the success rates per cycle (the cumulative rate using up all available embryos formed from each egg collection) or per transfer – and even then it still depends. A recent Cochrane review (1), which is generally considered to be the gold standard when it comes to research, combined studies to look at the cycles of 1892 women who were doing IVF or ICSI and found that when you look at the cumulative success rate there is no significant difference in the live birth rates depending on if there was that first fresh transfer or was a freeze all cycle.

One of the reasons they highlight that this is the case is because, even if the first fresh transfer doesn’t work, over the course of a cycle it all evens out. It may even by hypothesised that the ‘time to pregnancy’ may even be longer because you need to wait for a whole other cycle before any chance of pregnancy, that being a transfer, happens. Are you with me?

While that makes sense, what it doesn’t really account for is the agony of going through a two week wait for a cycle that may or may not work and although it says that the cumulative rate is the same, what about those women who only have one embryo to transfer? Would their individual success rates be the same as well?

They did also find that the incidence of OHSS was lower in the freeze all group, as well as the incidence of miscarriage, though there was an increase in pregnancy complications, presumably gestational pre-eclampsia which is mentioned in other studies.

So the general consensus of the cumulative success rates of fresh transfer versus freeze all transfers is that there is no merit in waiting to do only frozen embryo transfers. So what about per transfer success rates?

Success rates per transfer

Earlier this month, a metaanalysis was published which combined the findings of 11 studies and included 5739 women doing IVF or ICSI (2). On the surface of it, it did look like doing a freeze-all cycle was associated with a significant increase in pregnancy per transfer (those women doing freeze-all cycles were seemingly 12% more likely to have a live birth than those that did not).

When the data was further analysed though it was found that higher live birth rates for freeze all cycles were actually only higher for those doing preimplantation genetic screening and those that would typically be considered as ‘hyper-responders’ or with PCOS, that is, those women that get pretty big numbers of eggs and developing follicles grow. These ladies were 16% more likely to have a live birth if they did a frozen transfer than those ladies that did a fresh transfer (2).

Interestingly, there was actually no differences observed in ‘normo-responders’ and those without PCOS. In other words those women that would have egg and follicle growth as expected did not benefit from waiting for another cycle in order to do a frozen embryo transfer as opposed to transferring the fresh one straight away. Additionally, the cumulative success rate was not different either depending on whether you did fresh or frozen transfer (2).

As predicted, the risk of moderate or severe OHSS was significantly lower in those women that did freeze all cycles than with fresh embryo transfer, though at the risk of pre-eclampsia which increased.

So to sum it up

Ultimately researchers concluded that there was not enough clinical data to support clinics doing blanket recommendations for a freeze all cycles when doing IVF or ICSI – as seems to be the trend more and more.

While it seems like it might be a good strategy for women at higher risk of OHSS or those that hyper respond to medications, have PCOS or are doing preimplantation genetic screening and generally would freeze all their embryos anyway, it isn’t necessarily a practice that is going to improve the success rates for all women doing IVF. In fact, it may even increase the cost of treatment (as an extra cycle is needed to do a frozen transfer), requires extra handling of embryos when they are being frozen and thawed and may even increase the time it takes to come to a live birth.

This is only one article though and although it has considered the results of previous studies completed testing the superiority of frozen or fresh transfers, the question of whether or not a fresh or freeze all cycle is better has more shades of gray than definite black and white conclusions. Ultimately though, it is a decision that needs to be made by your doctors and treating fertility team with your unique situation, medical history and IVF history in mind.

Reference

Wong KM, van Wely M, Mol F, Repping S, Mastenbroek S. Fresh versus frozen embryo transfers in assisted reproduction.Cochrane Database of Systematic Reviews. 2017, Issue 3. Art. No.: CD011184. doi: 10.1002/14651858.CD011184.pub2.

Roque M, Haahr T, Geber S, Esteves S, Humaidan P. Fresh versus elective frozen embryo transfer in IVF/ICSI cycles: a systematic review and meta-analysis of reproductive outcomes. Human Reproduction Update. 2018 pp. 1–13 doi:10.1093/humupd/dmy033

Possible benefits of mindfulness when doing IVF (including increased DHEA and melatonin)

When I learnt at a seminar I attended this week that mindfulness can increase DHEA and melatonin levels in our blood, I was intrigued.

As you may remember from the free book, ’19 ways you can contribute to increasing your chances of IVF success’, optimized melatonin levels can be associated with higher numbers and quality of eggs come IVF egg pick up day (1).

Similarly DHEA, or dehydroepiandrosterone, is a bit of a controversial IVF supplement which is believed to increase egg quality, especially for those with diminished ovarian reserve or who have been poor responders to IVF treatment. There needs to be more larger studies supporting and evaluating its use but from the preliminary evidence there is, it seems like DHEA could be beneficial to increasing the live birth rates for some women doing IVF.

For example, in a very small study with only 33 patients (2) they found that the live birth rates for women who had DHEA supplementation were 23% where as those women who did not take the supplementation had live birth rates of around 4% (remember, it was only a very small study and although an increased birth rate of 19% for taking a tablet seems great, it is ‘only’ an extra 5 births… but it is certainly a start and a step in the right direction). You absolutely need to check with your treating fertility specialist to check that DHEA would be suitable in your situation (so no off-grid, unapproved supplementation) but maybe if we can support levels naturally through mindfulness that can only be a good thing?

What about mindfulness

At the seminar, led by mindfulness expert and international best selling author, David Michie, a study which found that when people meditate for five years or more the DHEA in their blood stream is the equivalent to someone twelve years younger was discussed. DHEA depletes as we age and if we can have the DHEA of someone twelve years younger, could that lead us to the path of having eggs twelve years younger? It seems unlikely that such a direct correlation exists, but while looking for evidence to support this theory, I found other remarkable statistics linking DHEA to mindfulness. For example, did you know people who meditate have upto 44% more DHEA than those who don’t? (3)

Whilst looking for the ‘smoking gun’ linking DHEA, mindfulness and IVF, I found that the studies linking mindfulness to increasing DHEA were sometimes just only looking at male populations, sometimes it only looked as far as it impacted cardiovascular health… unfortunately I could not find any evidence that examined directly, or even indirectly, of how mindfulness impacts DHEA in women, women with fertility problems or women doing IVF.

Mindfulness Benefits for IVF

This then lead me to think, that if you want to increase your DHEA or melatonin levels, by all means giving mindfulness a go is definitely worth it for this reason alone. But ultimately, to achieve the results that you want in the quickest time possible (forget yesterday, who doesn’t want that baby, like, 3 years ago?!) with a more evidence based approach, you are best speaking to your fertility specialist to see if supplementation might be right for you.

But mindfulness has so much more to offer than just its influence on hormone levels.

For many women doing IVF, the process can become EVERYTHING. Everything you eat, everything you touch, everything you do, the plans you make, the plans you don’t make, it all becomes linked as to how it’s going to possibly increase or decrease your chances of a take home baby this cycle. It’s mentally exhausting. Practicing mindfulness gives you the opportunity to have that weight taken off your shoulders even for the shortest time while you are doing it.

We focus so much on eating right and taking the medications at the exact time in the exact way that we forget to take care of our mental health. But as David Michie highlights, when we look at our physical health, the absence of disease does not equate to health. We can be incredibly unhealthy physically, not at all ‘fit’ and still not have an actual disease process going on. Similarly, we may not have a mental health condition, such as anxiety, depression or otherwise, but that still is not to say we are actually mentally healthy either. Mindfulness is what helps you achieve a better state of mental wellbeing as exercise helps you achieve a better state of physical wellbeing.

Other benefits of mindfulness

When we are in our one thought IVF tracked mind it is hard to open up to other things and experiences. It is, understandably, easy to get resentful with the world – especially the 25 year old you share an office with who ‘boom!’ accidentally got pregnant. Giving yourself the head space to get out of that mindset even if it is just for a short period of time at first lets you feel less stressed, develop better coping strategies, become more accepting, innovative, creative and taking one more step towards living your most vivid life.

How to practice mindfulness

I’ve written about the benefits of mindfulness to IVF success rates in previous posts and also given some practical exercises for you to get started on. Although you can get benefits from day one, overall for the best results you need to practice mindfulness on a daily basis. As David Michie points out, you don’t go to the gym just the one time and then wonder why you haven’t got abs of steel. Similarly, don’t just practice mindfulness the one time before deciding it’s not for you. Like going to the gym, it seems there is direct correlation between the hours you put in and the impact it has.

But if you want a time frame to aim for, David Michie guarantees if you practice mindfulness five times a week for six weeks you’ll definitely see these rewards.

I write a lot about mindfulness in Eat Think Grow. In fact, there are mindfulness or mindset suggestions for every day of your cycle and it is specifically tailored for women doing IVF. It focuses on helping you through every step of your IVF cycle and is written from the perspective of someone who has been there and knows how you might be feeling.

There are also other mindfulness resources around, including apps such as ‘Insight Timer’ and ‘Smiling Mind’ and books such as ‘Why Mindfulness is Better than Chocolate’.

Like so many practices that will ultimately influence your quality of eggs and overall health, the key is just to start. If you are not ready to take the plunge into a more detailed mindfulness program, such as Eat Think Grow, for now just start the day taking three deep breaths. Breathing in for about 3 seconds and out for around six, focus on nothing but these breaths. Pay attention to the temperature of the air, the sound your breath makes, the rise of you abdomen as you breathe in and lowering as you breathe out. Let your thoughts only focus on these three breaths… It will certainly be a start in clearing away some of the unwanted and often negative thoughts that may be swirling around your mind.

To sum it up

Although it seems that there is still so much that is unknown about the mind-body connection, there is still so much information that supports that the way we think and feel can have a direct relation to our physical health. Already they have linked serotonin, cortisol and other steroids (which all potentially impact our IVF health) and here we have mentioned DHEA and melatonin.

While it is likely that by practicing mindfulness you will see an improvement in these hormone levels in a natural way (which is theoretically a great thing for egg health during IVF) the other benefits of mindfulness on your ability to cope and get through what for many women may be some of the most challenging times of their life, is equally, if not more so, important.

PS If you have any worrying thoughts that turn towards harming yourself, those around you, or you feel have gone on just a bit too long, make sure you speak to a health professional that knows you. There are many treatments out there – and some of which will be suitable for women doing IVF or, hopefully, about to be, pregnant.

Reference

Fernando, S. & Rombauts, L. (2014) Melatonin: shedding light on infertility? – a review of the recent literature. Journal of Ovarian Research 7 98
Wiser, A., Gonen, O., Ghetler, Y., Shavit, T., Berkovitz, A and Shulman, A. (2010). Addition of dehydroepiandrosterone (DHEA) for poor-responder patients before and during IVF treatment improves the pregnancy rate: A randomized prospective study. Human Reproduction, 25 (10) 2496–2500
https://eocinstitute.org/meditation/immune-brain-chemicals-how-meditation-boosts-dhea-melatonin-gh/)