Transcript
Speaker: No one expects not to succeed on the first try. You've got to at least show them that you've done everything possible. And just to say, well, she's done it before is not enough. If you've been a surrogate before, it's really easy to walk into another journey thinking, I know how this works. I've done this before.
Speaker: So what happens when a new fertility clinic asks you to do something completely different? and They have to justify the reasons for, you know, particularly when it's something that definitely falls outside of of the norm. And if she's putting stuff in her body, then she should have every right to know why we are invoking this protocol.
Speaker: Today, I'm talking with reproductive endocrinologist Dr. Armando Hernandez-Re about why fertility care can look different from one surrogacy journey to the next. We get into what your previous journeys can tell a medical team, why screening, medications, or transfer protocols might change, and what you can ask when a recommendation looks completely different from what you've done before. Because experience absolutely matters, but it doesn't necessarily mean the next journey will follow the same blueprint.
Speaker: Enjoy.
Speaker: to another journey as a surrogate kind of being like, hey, we know like what's going on. Like we know the blueprint. We know, you know, everything that's about to happen.
Speaker: But if they are with a new clinic or, you know, even with just this industry and this medicine being so ever evolving, so many things can change so quickly. And so from your perspective, like what could be behind some of those differences clinic to clinic and just time-wise and things like that? Well, that's an interesting concept. I think that's an interesting ah take and very nuanced.
Speaker: I think it's probably very relevant because I think a lot of surrogates and a lot of IPs probably have similar questions, particularly if they've worked with different clinics in the past. I think for the most part, we all follow a certain blueprint.
Speaker: yeah Now, candidly, i think the nuances are what separate the successful practices from the not so successful practices. Mm-hmm.
Speaker: Oftentimes when it's a very large practice, it becomes very robotic. And just because they've been a surrogate before, just because they've been pregnant before, oftentimes when we're using an egg donor, it becomes like just rinse and repeat, plug and play, don't need to look at the specifics,
Speaker: And you really, really need to look at the specifics. Everybody is different. Every case is different. you know Oftentimes are in in our practice, we're seeing so many surrogacy cases, but I would say a fair majority, I don't have a breakdown in terms of the percentages. There are women or couples who are using an egg donor and the guy is my age or older.
Speaker: And so without looking at the sperm and assuming that the sperm is going to be fine, you see poor quality embryos. If you have not looked at fragmentation testing on the sperm, if you haven't done anything, you know, if you haven't pre-gamed basically to try to improve sperm quality does the is he on testosterone is he on hypertensive medication is he obese is he just an older gentleman and of advanced paternal age you can have the best quality eggs but if you have poor quality sperm it doesn't matter you're not going to have the best possible embryos and you're spending quite a lot of money on surrogacy journey which is
Speaker: very emotionally charged and consumes a lot of not only emotional resources, but a lot of economic resources as well. So the difference is I can't speak for anybody other than myself. I can see that I can tell you that we've had patients and surrogates who've been and had other journeys who say, oh, we didn't do this.
Speaker: For example, we insist on ah on a mock transfer. Well, what value does that have? Well, you can have the best quality embryo, but if I screw up the transfer or I'm not aware of any subtle nuances in the cervical canal or she has a retroverted uterus or make perhaps a clinically relevant fibroid that nobody picked up on. sure
Speaker: i can alter the dynamics and the mechanics of the endometrium and the patient not get pregnant. The devil's in the taintail is what i'm what I'm trying to get at. So in terms of the differences, I know you said it's so it's so nuanced and the the mock transfer is such a great example. How much of a change can you see across the board just in terms of like those protocols and testings and things like that with all of those players? I mean, i think in medicine, particularly in in infertility,
Speaker: Yes. Changes are like, you know, telling a cruise ship to turn around 180 degrees. It takes forever. Sure. And there are things that we adopt immediately because they have such dramatic changes or or improvements in success rates that, you know, we turn on a dime. But those are very few and far between. For example, one example of that was the knowledge that vitrification when we were freezing eggs and embryos was that much better than the slow freeze protocol.
Speaker: We literally overnight changed those protocols immediately. immediately. And the only the only delay was in the delay in getting our embryologist trained in the technique itself. sure And then there are other things that you know are difficult to discern just what an an impact they'll have and in what patient population. And then we're all guided by evidence and that evidence is somehow sometimes very hard to come by and and really draw conclusions that are meaningful. So those are a little bit difficult. I think the the most important changes that we are seeing and will see in the future are the penetration of technology, particularly with artificial intelligence.
Speaker: um invoking a very significant dominance in embryo selection, me protocol design, in patient selection.
Speaker: Those I think are avenues where we'll see dramatic changes in in the not so distant future. In other ways that we'll see significant changes, i think dramatic changes will be in the way we culture embryos.
Speaker: and in the perhaps the stimulation protocols and then finally in genetics. And not only genetics about how to identify an embryo that's normal from an abnormal or you ploy from you any ploy, but An increase in the sensitivity and the ability to detect even more genetic material that is just as important to make an embryo implant and develop and lead to a healthy live birth.
Speaker: Right, right. when When we use the word protocol, how much of that is like a clinic's standard approach and how much of that is individualized to the circumstances of that particular journey? I know you kind of mentioned previously kind of robotic versus that individual care.
Speaker: Yeah. Well, that's a good question. I think um there is a degree of standardization that occurs, um but I think that particularly when you're looking back on a cycle that has not been successful, it cannot be standardized.
Speaker: You have to do the due diligence and the the work that it takes to draw meaningful conclusions from an unsuccessful cycle and not just chalk it up to a bad cycle or inter-cycle variability or I think you really need to look inward and and at least do put the time that it deserves to see if there are any changes, whether meaningful or not, or even subtle that can make a dramatic and ah difference in the the ultimate results.
Speaker: And we're talking beyond just surrogacy. We're talking about just, you know, transfer to the the patient's uterus. Sure, sure. can you can you take Can you dive into you know that a little bit more in terms of whenever there isn't whenever there is not a successful transfer? Because I know as a coordinator, there have been many times where, okay, transfer didn't work.
Speaker: that's not you know That's not something unusual. It happens more often than we you know we wish it was 100% science. It's not. um But then i think a lot of times you i will have intended parents ask me or surrogates ask me, okay, so what are we going to do differently this time? And a clinic will say, well, we won't.
Speaker: this is our This is our protocol. This is what we're going to do. We're just doing the same thing over again. Yeah, so that we get that question obviously all the time. In fact, today I probably had that same conversation three or four four times, with with and that's not hyperbolic. and And what patients don't realize is that we are actually doing something different by just either transferring a a new embryo hu or by stimulating and a different cohort of eggs.
Speaker: Now, with that said, there are changes that can be made that that are perhaps not so evident in the first cycle.
Speaker: But, you know, IVF is therapeutic, but it's also diagnostic as well. h I'll give you an example. I saw patient today. she's never been diagnosed with She's never been diagnosed with endometriosis. um she At 35, she froze so seven eggs.
Speaker: She tried to thaw them in New York, and they survived the thaw, but none fertilized. she She did one cycle here with us.
Speaker: She has a pretty normal ovarian reserve on paper, yet her response was abysmally poor. We got two eggs, and in one of the in the follicular fluid, we got a ton of endometriosis that she'd never been diagnosed before.
Speaker: ah wow Well, that that changes everything now. So that means she's got ovarian endometriosis that explains why she has not gotten pregnant. um And now we've got our work to do to figure out how we're going to stimulate differently or alter things, the the the mechanics and the dynamics of the ovary and what's happening in the phlic in the follicle to improve the egg quality. And whether that's supplementation or you know an anti-inflammatory diet or a combination of all of the above.
Speaker: We've got to figure it out because we need to get better eggs than the ones that we got. She had empty follicle syndrome. There was, she had a couple of follicles that were completely empty despite flushing with the, with the needle. So, you know, it's, it's, it's nuanced.
Speaker: It's very nuanced. And we would have never known had had we not gone through that first cycle and certainly was not revealed in the the cycle that she did up in New York, at least not to us anyway, or to her. Yeah.
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Speaker: All right, let's get back to the show. I was going to ask, you know particularly with with surrogates, when you're working with someone who has been a surrogate before, what from the previous journey is helpful for you to know as you're making decisions about your next steps when working with that surrogate? Well, in terms of the, let's let's say the stimulation Let's forget it's surrogate for one second. The stimulation that we've had unsuccessful cycles in the past is looking at all the data points that we can, whether, you know, what protocol did we use? What was the total dosing? How many follicles did we have at the time of egg retrieval?
Speaker: What were our estrogen levels? Did they, you know, did they double appropriately? Did they, how many eggs did we get? How many were mature? How many were fertilized? How many embryos did we get? What was the quality of the of the embryo morphology? What were the genetic testing? What was the PGT results? um How have they thawed out in the past?
Speaker: Did they freeze? Did they not survive the thaw? All of those things matter. And in terms of the surrogate, it's really how do they respond? you know a lot of times we will get a surrogate and she'll be sent us and she's had three journeys and they've all been successful.
Speaker: Oh, but in the last journey, she had a uterine apnea and required a very a DNC. They never mention aggressive DNC. They just say a DNC because she had bleeding.
Speaker: Well, now she comes to us in this purported fourth journey where she's had all of these successes, and now her lining is terrible. And she doesn't develop a ah thick lining or or or the characteristics of the lining are not trilaminar in the follicular phase or homogenous, homogeneous in the in the luteal phase.
Speaker: So, well, then she's now no longer us a a good surrogate because something has happened in that interval between the last successful pregnancy and now that has now...
Speaker: essentially eliminated her the possibility of her being a ah good surrogate. And those are things that you can't miss. Those are things that should be assessed and addressed um forget about that history, but it's particularly when they have that history, to as as as ah as a caretaker, as a practitioner, to look at before the couple, the intended parents undergo and pay all this money and put all this time and effort into hiring this the surrogate. It serves no one ah in the right way. Not not the intended parents, not the surrogate at all, and not the clinic either.
Speaker: Because you're we're potentially putting in time, unnecessary resources, and making this couple spend money where we know that probably, unlikely, this is going to resort or or turn out to be a successful pregnancy.
Speaker: Yeah. Well, and I know, I mean, i I, have been on the receiving end of, I had two successful journeys and then my third, um, you know, i my dear sweet intended parents, um, did extra testing for me and, you know, they even were looking at changing clinics and, you know, just, just all kinds of things. And at the end of the day, you know, after you some testing was done, it was deemed, we're This, you know, exactly that. I had had two successful journeys previously and due to a, you know, different medical circumstance, this is not, this is not going to work. And that is heartbreaking news to receive as a surrogate, especially whenever you have
Speaker: you know, gone through testing and gone through a lot of those steps just physically. And then you're looking at these sweet intended parents. And exactly like you said, they've spent those resources and, you know, you can't even get, you can't even get to the part where you're taking meds and, you know, and have hope or anything like that. It's just a straight no. And and then try to find another surrogate, which takes forever. oh yes. Yes. Surrogates do not grow on trees is what we always say around here. No, no, no. There was a time where you could find a surrogate fairly easily, but those days are long gone.
Speaker: Why do you think that is um Well, when I first got out of fellowship, you couldn't find a surrogate because nobody was doing surrogacy and it wasn't a thing.
Speaker: And then it started becoming a thin thing and gradually... you know, there was a surplus of surrogates and a dearth of intended parents. But then slowly but surely, that equilibrium went the other way.
Speaker: And now there is a dearth of surrogates because they're all on their own journeys. And there's a surplus of intended parents in need of surrogates. And it's just hard to come by.
Speaker: Yeah, yeah. Do you think that is because of more and more education around you know what a clinic is looking for, what a particular physician is looking for when you're trying to find an ideal candidate for surrogacy?
Speaker: I think it's a combination of everything. Yeah. I think it's a multitude of ah of factors, including the fact that there are more There's a more captive audience. There are more intended parents, people, parents that want to do surrogacy for a myriad of reasons, whether they're medical or personal.
Speaker: or not. and then And then there is that component of, yeah, maybe there's a um um a more rigorous selection process um because patients are more savvy and there no one expects no one expects not to succeed on the first try.
Speaker: I mean, they can say it, they they can tell you that they've had experiences that they've read on on on the internet, on TikTok and Instagram about all those cases.
Speaker: No one sits in my desk, in my in and my office, in front of me, and is really thinking, I'm going to be the one who doesn't who fails on that first try.
Speaker: good So you've got to at least show them that you've done everything possible, honestly. Yeah. And just to say, well, she's done it before is not enough.
Speaker: Mm-hmm. And that's the best you can do. I mean, you definitely, in this journey, in this in this job, you have many difficult conversations. I think the secret is just to be as truthful and compassionate as possible, but definitely be truthful and honest and open and and candid with the couple about their realistic chances. I saw a patient couple today from Brazil, um very wealthy couple. She's a very famous you know, person in, in, in Brazil, but she's 44 and has a very low AMH and they've done two cycles in in Brazil and they're, you know, they've had many friends of theirs who've been my patients who've been successful. And I was honest, I'm like, I don't know that I can do anything different that they did in Brazil, to be honest, but we can do consider egg donation.
Speaker: and you already have a child that's biologically both of yours. So why don't we consider the fact that you want to have ah give your child a sibling? Why don't we consider egg donation? Because that is more likely to be successful than any multiple attempts that I can try to offer you with your own eggs and IVF. yeah Difficult conversation, not something they want to hear.
Speaker: yeah They're hoping I have some secret sauce or some, you know, And you know, our our lab is amazing, you know, excellent top-notch pregnancy rates, but if we don't have an egg, it's not going happen.
Speaker: Sure, sure. When it comes to you know, patients and coming in with kind of this preconceived notion of how things are going to go or, you know, a surrogate having the experience and, you know, things like that.
Speaker: If a surrogate is being asked to do something differently than she did in a previous journey, what questions can she ask the medical team to kind of better understand the reasoning behind, you know, that choice beyond just simply like just this is our protocol? It would have to mean like, what what is the change? You know?
Speaker: Sure, sure. Let's say it's, um you know, again, you the the mock transfer is a really great example. Maybe it's a, you know, a bed rest protocol, or maybe it's a, you know, Hey, we have you on, um, six different medications, three steroids, or, you know, but versus maybe before she was only doing progesterone. I mean, they have to justify the reasons for, you know, particularly when it's something that,
Speaker: definitely falls outside of of the norm, for example. sure And if she's putting stuff in her body, then she should have every right to know why we are you know invoking this protocol. I'll give you one example where um we'll have a couple who comes in with their surrogate and they they had, let's say, one or two failed attempts.
Speaker: And so embryos look great. They've got like three or four more embryos. Like, hmm, that's interesting. Why is she why is she not pregnant? and and And I'm using this example because it happened not too long ago, so it's a top of mind. And so it turned out she had a retroverted uterus. And in one note, in the I believe the first transfer, the the the practitioner writes, difficult transfer.
Speaker: Hmm. a very difficult transfer, went through several catheters, and then the embryologist writes
Speaker: lots of blood or blood in the catheter. Oh, wow. There really isn't too much mention in the in the second transfer, but the patient neither neither time got pregnant. So she has a retroverted uterus, a severely retroverted retroflexed uterus.
Speaker: And so what we did was we i put a cervical stitch, for example. And the reason for the cervical stitch is that when the uterus when when the universe is antiverted, we always fill up the bladder so that the uterus straightens out and we have a fairly straight shot into the endometrial cavity. Mm-hmm.
Speaker: When the uterus is retroverted, but we don't have a bladder or we can't fill up the rectum, which is posterior to straighten out the uterus. Right. If you put a tenaculum on the uterus at the time of embryo transfer, the uterus is going to spasm.
Speaker: Mm. likely the patient won't get pregnant. So the reason for the cervical stitches, we put it in three or four days before the the plan transfer so that at the time of the embryo transfer, her uterus is really retroverted and retroflexed. We're able to pull gently on the uterus so that it straightens the angle so that we can then transfer an embryo.
Speaker: And This patient was just discharged today at the eight-week mark with a positive pregnancy test and it was the one embryo transfer. And so what I mean is not to like highlight like, oh my God, what an amazing doctor I am or anything like that. I'm just trying to make an example of the subtleties of taking the time to look at what's been done before to improve it. They could have easily happened to me first and i could those roles could have easily been reversed.
Speaker: m And so had I not looked at the embryology report at the, you know, the little notes in the corner that says difficult embryo transfer, and then that prompted me to look at the embryology report to see if there's anything about blood in the catheter, which there was, and then there wasn't anything in the second transfer.
Speaker: So we had nothing to go on. And they could have probably had a very easy transfer the second one, I have no idea. Although now that I'm remembering the the surrogate did say um that she had cramping after the second transfer when mentioned to her about putting the the cervical stitch.
Speaker: maybe that cervical stitch did make a difference. and Maybe it did instead of the catheter, you know, hitting budding the back of the uterus because we had no way of flipping it there.
Speaker: Maybe that did make a little a subtle difference that made all the all a subtle difference in the in the transfer that made all the difference in the world in terms of the results. Right, absolutely. Well, again, I feel like it just goes back to you know what you said at the beginning of the differences in this is such a nuanced medicine, but it can become so robotic and you're just looking at you know only cer okay surrogate, embryo, transfer, here you go.
Speaker: Yeah, exactly. Yeah. After working in this field for as long as you have, what do you wish more people understood about why fertility care doesn't always look the same from one clinic or even one journey to the next?
Speaker: Oh, that's a loaded question. But I mean, in terms of one journey to the next, it's because women are very complex. You know, you you look at ah at the pelvis of a man, it's empty.
Speaker: You look at the pelvis. It's true, you really do. yeah You look at the pelvis of a man, there's nothing there. You look at the pelvis of a woman and there is, you know it's it's full of organs and primarily the ovary and the uterus, which are very complex and work and you know mutually inclusive and mutually exclusive of each other. and And then when you're talking about eggs, you're you're recruiting a a different cohort of eggs every single month.
Speaker: Right. And so you may stimulate every single month the same way and you may get totally different disparate results ultimately. And the older she is, the older we are likely for that to happen as opposed to, you know, a 21 year old donor egg donor, we're more likely we're going to do the same simulation and with, ah you know, varying degrees of differences in the total number of eggs we get, we're going to get the pretty much the same number of eggs.
Speaker: and um and And then everybody's different depends on where they train depends on you know, what part of the country, even the way we call things or, you know, name name things, the nomenclature could be potentially a little bit different.
Speaker: You know, yeah if you trained on the West Coast versus you train in in the East Coast, just so many variables. and And the goal is for sure, some level of standardization that I 100% agree with. And then there's that little subtlety that that nuanced approach that goes beyond just the the basic standardization to something that could make a ah profound difference in the end result beyond what standardization can accomplish.
Speaker: Well, thank you again so much. I think, I mean, it really is so helpful because i think it is really easy for people to fall into the trap of, oh, I've done this before.
Speaker: you know, i know how this is going to go. you There is. It is so nuanced. It has changed. it Your body has changed. all you know The medicine has changed. um And so I really, really appreciate just you giving giving us your time and your expertise. I have one last question for you, but it's a fun one. So for anyone who knows me, they know that I will always have a coffee cup in hand and I consume way too much coffee than probably what is healthy. But I always love to ask the question, what has filled your cup today?
Speaker: Honestly, that sounds so cheesy, but like today dropping off my daughter at school with her goofy costume because it's freshman initiation week at her our at our at our high school. and i love it. getting her so excited getting Seeing her so excited for ah her third day of freshman initiation week and getting a little haze and a little love from the upperclassmen and her yeah the her her uh upperclassmen sister i guess is what the term is so that's that you know that's makes makes my day puts a smile oh yeah oh 100 and good for you i have a freshman and this is a theme week too and she won't dress up i'm like bummer no no she will she has to she has no choice
Speaker: I love it. I love it. That's amazing. Well, I just want to thank you for inviting me on the show. It's been awesome. You are wonderful and your questions are really, really very informative and and the way you asked them and it's just been a pleasure to be on the show with you.
Speaker: Thank you. Thank you. I really appreciate that. And again, I really do just appreciate your your expertise and your time. So thank you for just everything that you do and are doing. So really appreciate
