Today we tackle the question, what's the difference between IUI and ivf? What is diminished ovarian reserve? And we check the mailbag. I'm, Dr. Mark Amol, and this is Topo about Fertility Tuesday. You ever have one of those moments where you have an epiphany and you think, wow, I didn't know that. Well, I had that this week. I had a patient of mine who has gone through two IUIs, and unfortunately, they haven't worked. And she says to me, you know, what can
we do next? And we talk about some options. And one of the things I said is, we can try another iui. If, that doesn't work, we can go on to something like IVF or more testing. And then she says to me, well, if this next IUI doesn't work, we're probably going to stop, because if IUI didn't work, there's no reason to waste your time going on the IVF. And that shocked me, because IUIs and IVF are not the same thing. They don't even treat the
same things. I mean, it's clearly obvious if you have no sperm or low sperm, that you have to do things like ivf and, your tubes are blocked. You'd have to do some, like ivf. But it never dawned on me that a patient. We think if an IUI doesn't work, then IVF wouldn't work. And that's not true. I explained to her, if you went and ate a Junior Whopper and you liked it, then if you go on to the main Whopper, you'll probably like that, too.
Just like if you didn't like the Junior Whopper, you probably wouldn't like the big Whopper, because it's just kind of more of the same, right? But if you had a Junior Whopper and you didn't like it, and then someone said, hey, do you want to try, let's say a, taco? Well, you can't say you're notnna like the taco. The burger and the taco have nothing to do with each other. Who wouldn't like a taco? I mean, this is already crazy talk.
But the point is, what blew me away was to think that an IUI does the same thing as ivf. They're not just like a taco is not a burder. So I explained to her that an IUI is only done because they're low cost and they're easy. No one does IUIs because they think they work. Well, the only reason we do IUIs are because of the fact that they'low cost and that with multiple IUIs, approximately 50% of people would be pregnant. Now, I personally look at IUIS as a treatment choice. And not every patient
should do IUIs. For example, I put patients into four groups for IUIs. The first group are people that should absolutely do IUIs. These are the people with sperm issues, progressive motility issues, problems with motility, minor sperm issues, but the count still about 20 million or above that when we was the sperm. There'll be plan sperm and they should get pregnant. It would be crazy for them not to do IUIs.
The fourth group are, the people who are crazy who want to do IUIS and should not do IUIs. These are the people when their tubes are blocked and they still want to do IUIs. And I say, well, that's impossible. I mean, there's no reason to do that, or their sperm counts so severe, there's no way IUI is going to work. The two middle groups are really the groups for unexplained infertility. If your unexplained infertility is mild, meaning there's no endometriosis, there's no
other issues going on. All it is is just you've been trying for a year, you have been got pregnant and everything came back normal, and you have unexplained infertility. I think there's approximately a 50% chance after you do three artificial inseminations, which are IUIs, will lead to a pregnancy 50% of the time.
However, if you've been trying for three years, and during those three years you've been ovulating every month, or if you have any type of other medical issues such as endometriosis or multiple surgeries, any other complex history, the IUIs really don't work that well. It's definitely below 50% m in my experience, maybe 20, 25% of people get pregnant that. And so I generally tell people, if it's been three years and you've been ovuling every month,
why would an IUI really work? Because what an IUI is doing is you're just bypassing the cervix. The thought is that maybe there are sperm antibodies, maybe there's some reason the sperm is not getting in, but three years. 97% of people are usually pregnant by three years within the first three months of trying, not even really trying. I mean, just watching a little chocolatee movie or something and having a kid,
you have about a 50% chance. By the third month, by six months 70% of people are pregnant by one year, 85% by three years. 97% of people. If 97% of people are pregnant in three years, why would doing an IUI get you pregnant? I'm not saying it won't work, but in reality, if it does work, it probably would have worked with emine Ms. Anyways, because it probably is just a coincidence. Now, the point of all this was I explained to her that she has unexplained inf feertility. She has endometriosis.
Ah. At this point, don't think of IUIs not working because you failed IUIs, but the IUIs aren't working because IUIs can't work for you. Because if there are things that are wrong that we can't test for, an IUI will never work. For example, just because your tubes are open does not mean that your tubes are functional. There are many women who have normal hysosy pingograms which are also HSGs, and their fallopian tubes don't work. They don't pull the eggs towards it, it doesn't
grab the egg. And in that situation, no IUI will ever work. Another issue is sperm penetration. We know there are some women and men, when you put the sperm and egg together, they don't fertilize. And then that, I mean, the sperm can literally look like Brad Pitt and it can't get in that egg. And that's just because sometimes some sperm can't get in. It's good looking as it this. And in that situation, no IUI is ever going to work.
So again, when an IUI doesn't work and it's unexplained infertility, the question isn't, oh, if this didn't work, my case must be so bad that IVF won't work. The question really needs to be is, hey, I'm, eating a Junior Whopper. And that, my friend, is a taco. And we know tacos are the best. And so IDVF is superior not just in the fact that the pregnancy rates are higher, but in the fact that we bypass most of the problems. There's nothing magical about ivf.
If you've got bad eggs and every single leg is bad, IVF won't work. If you have no sperm, IVF won't work. But what IVF does is, is it bypasses everything. It takes the eggs out of the body. So now we can stimulate you aggressively and not have to worry about multiples. We can then, pull the eggs out and look at the eggs, see if we see issues with them. We can then fertilize the eggs by injecting the spermum, getting rid of any type of fertilization disorder.
We then watch the embryos, grow them out a petri dish and can see any issues developing and then pick the best embryos and put them back. We can even take test them and put back only normal embryos. When we do the transfer, we can evaluate whether the transfer is the right timing. We can adjust the progesterone. We can adjust so much with the IVF that it's not magical, it's just we're controlling every parameter. They give it the highest assess
rate. Whereas with an iui, we're just praying and hoping that those little sperm can make it to that egg. Stay with us. We'll be right back. Levant po the Latin Minute is your new favorite byil lingual comedy podcast where two Latinos living in southwest Florida servru up some spicy takes, on the hottest celebrities, gossip, juicy cheeseme, and just a sprinkle of politics. With humor, culture and plenty of laughs, this podcast brings the best of both
worlds. So make sure to check out the Latin Minute. You can follow us On Apple Podcast, iHeart and Spotify. Also visit our Facebook page, the Latin Minute. We'll see you there. So, in summary, don't confuse a junior whopper for a taco. They aren't the same. I don't care what any would tell you. I don't care if they tell you it's a burger daco. It's not a burger. An IUI is not ivf. It is not a little bit better. It is a completely different
animal. And don't be worried if IUIs don't work that, now IVF has a lower chance. It does not. IVF is something completely different, just like a taco diminished ovarian reserve do. I find this is, a difficult subject for people because unlike a lot of things inf ferility that are very straightforward, diminish ovarian reserve is quite complex. And part of this complexity is because there really is not a good definition. The word diminished ovarian reserve, it's kind of like the word automobile.
An automobile could be a car, it could be a truck, could be a van. They're all automobiles. Well, din ovarian reserve is kind of the same way. You can have poor egg quality and be called diminished ovarian reserve. You can have a low ovarian reserve mean you don't have many eggs, and that's considered diminish ovarian reserve. You can even have poor egg recruitment where you just don't make a lot of eggs. And that also could be dimensional of arro reserve.
The point is, when patients hear the word diminish ovarian reserve, they assume they're in this category that is always bad, and it's not always bad. It depends on if it's theality or is it poor egg recruitment. I would rather get three eggs from someone with great quality than get 16 eggs from someone with poor egg quality. So because all clinics don't speak the same language, the problem that happens for patients is they compare themselves to other people with this category, diminished
ovarian reserve. Now, you can do that if you have pcos. You can do that if you have other diagnoses that can be compared. But to miss, ovarian reserve is so broad and so incorrectly understood that doctors use that term when they really should break it into what type of diminished ovarian reserve it is. And I think that would lead to less anxiety for patients if they realize that they're not the same diminishion ovarian reserve
as some other bad cases. In addition to the term being ambiguous, I think there's a lot of confusion with regards to the testing for ovarian reserve and then people thinking they have diminished ovarian reserve based off of numbers. Ovarian reserve testing is how we test egg quality, quantity, and the overall idea of how much time women have for their fertility. Now, there are essentially three tests
that you can test ovarian reserve. The first test is called an antral follicle count, sometimes abbreviated afc. And this is the amount of eggs that are seen on your ovaries at the beginning of each menstrual cycle. Think of this as the amount of eggs that month that you can maximum make. So when you're talking about things like IVF or IUIs, that is the absolute amount of eggs you can make per month. It doesn't matter if you have great egg quality. It doesn't matter if you have a low fsh,
you can't make more eggs. Then they're there at the beginning of the month. The second test is called an fsh, stands for follicle stimuli hormone. Think of this as the gasoline that pushes the engine to run. How much hormone the brain has to send down represents how hard it has to work to make an egg. If your body takes a lot of hormone to make one egg, then when I give it extra hormone, it won't respond as well. If the brain only has to send a little bit of hormonesh to the ovary
to still make one egg. Then I know if I give extra hormone, it will make more eggs. FSH is inversely related to estrogen. Therefore an FSH must be taken with an estrogen. This is because if the estrogen is elevated, it will make the FSH falsely lower. So any FSH must have an estrogen usually below 50 to be valid. I can make any woman'fsh look low if I give her enough hormones. And so always take an FSH parameter in consideration to the estrogen level. The last hormone is amh, which stands for
antiolarin hormone. Now, this hormone is made by the small follicular cells in the ovary. So the cells around the egg are making this hormone. And since they are making the hormone, that means it's directly related to the number of eggs you have. Now, the amount of eggs you can make per month is due to your antral follicle count. Because again, if you only have three follicles on your ovary, you can't make more than three that month. But the AMH represent
how much is there for the rest of your life. It kind of gives us an idea of, do you have a lot of time left? Now, one of the things when you look at these hormones and you look at these numbers is that you can misunderstand them sometimes because there are relationships. And so, for example, people will say, well, if the EMH is high, I must have good fertility. And that's actually not true. You can have a very high AMH and have poor fertility.
An example would be there are some women with polycystic ovarian syndrome who have very high AMH M levels but have a very difficult time getting pregnant. Now, technically, yes, their eggs are good, especially if they're young, but having a high AMH s doesn't guarantee they're going to get pregnant. A matter of fact, I find women with pcos do very poor in IVF when they have extremely high AMH levels. Because a lot of these women have high inflammation levels and that inflammation can
cause problems. However, I digress. My main point here is saying just because your FSH is high doesn't mean you can't get pregnant. Just because your AMH is low doesn't mean you can get pregnant and vice versa. If your FSH is low, it doesn't mean you're always going to be better. And, if your antal follicle count is high doesn't mean things are going to be better. But what I want to do is go over what each of these tests mean and how you can use them to determine how well you'll do in
treatment. I think it's very important to understand that IVF is not normal. No human was ever made to make this many eggs. God intended do to make one egg per month. So although it's frustrating when you're spending a lot of money to do IVF and you're only getting five eggs, keep in mind that really isn't abnormal. For example, I love basketball. I can't jump three to four feet in the air. Now, that doesn't mean I'm bad at basketball, doesn't mean I can't
play basketball. It just means like most humans, most of us can't jump three to four feet in the air. And that is why there are professionals. Well, when it comes to ivf, it's the same thing. I get women all the time who have had several kids and come in for family balancing and they don't make a lot of eggs. And they say to me, what's going wrong? I said, well, nothing. This is what God intended. They intended you to make one egg per month. We're asking you to do something that's not normal.
And when you don't respond, we don't think there's something wrong with you. We just say, okay, you can't jump three to four feet like most people can. I find this analogy helps people understand the test. So using those descriptions we talked about with the amh, the antral follicle count and FSH and estrogen, let's discuss analogy. So imagine in life, instead of having eggs, God gives you this big bowl and says you,
this is all the eggs you're ever going to have. But I'm not going to call them eggs. We're going to call them M&MS. Because we all like chocolate. And instead of being every color of them and M, they're going to be red and they're going to be green. And this bowl is going to have a lot of M and M. A matter of fact, it's going to have 2 million M&M'in it the day you're born. And what's interesting is this bowl, as you expect every month you take some of the M&M's out
and so that bowls getting smaller and smaller through your life. This is going to represent your egg count through your life. Now, interesting enough, that bull actually had 6 million M&Ms. In when you were 18 weeks in your mother's womb. So by the time you were born, you're down to 2 million eggs. And the reason for this is a lot of these eggs undergo a process called atresia, just a fancy word. She can't steal my job saying the eggs die off.
Now, from the day you're born, there are two types of M and Ms. In there, red and green. The green ones will represent every good egg you have. Now, when we say good, what do we mean? We're talking about eggs that don't have a chromosomal problem. That doesn't mean it can't have a genetic issue such as cysted fibrosis.
We're talking about chromosomal. This is things like down syndrome, tris to be 13, tries to be 18, Turner's syndrome, things that cause miscarriages, things that cause you not to get pregnant, or even things that cause things like Downs syndrome. Those will represent the red minem. The green ones will represent all of the eggs that don't have a chromosomal problem. Now, if you looked in that bowl when you were five years old, you wouldn't see redin m m'but not because they're not there. They are
definitely there. It's just there's so many more green to red. You don't see the red em thems. Fast forward now all the way to puberty. And now you look in that bowl and still see very few red mns because there's so many more green. But now you're down to 350,000m andms. That means more than 75% of your eggs have been used before you even started your period. Now, from this point, you're going to use about a 1000 MLMSS a month
over the rest of your life. It decreases here and there, but the point is about 1,000, by the time you get to 28, you look in that bowl, you start to see their M&MS. By the time you're 35, that boill ISS down to now 35,000 M&MS. And now about a third of them are red. But what's really interesting is your fertility rate didn't drop much. You would think if I lost 90% of my M&Ms, clearly my fertility rate would be much, much lower, but it's
actually not. It goes from about 20% near puberty down to 15% at 35. And when I say fertility rate, we're talking about the live birth rate, the chances of having a baby successfully. Now, why is that possible? How is it possible that you can lose so many and not have a big ah decrease in your fertility rate. Well, the reason is because it's not about the number, it's about the quality of the eggs. And so as long as you're getting that green M
and M, it's still fine. And there's still a lot more green M&M's. Now this keeps going down. By the time you're 38, the half of that bowl is red M and M'AND. By the time you're 42, the whole bowl is red M&Ms. Now you're searching and searching for the green M&MS. See, life likes the green M&MS. It eats those first and you're left them with the red ones. Now, if we take the testing we talked about and compare it to this analogy, it will help you
understand the testing. So AMH anti malarin hormone is the size of that bowl. So it doesn't represent how many green or red MMs are in it, it just represents the size of the bowl. However, people who have low AMHs probably have smaller bowls because it represents that. And those are usually older women. So people have become accustomed to seeing a low MH and meaning that your egg reserve must be low.
And that is true when you're older. If you're 42 and your AMH is low, then yes, the reason why your fertility is decreased is because of your age having more red M and Ms. S. And by the way, there's also this association that you have less eggs. But someone who's 21 years old who has a low MH, that doesn't mean that their bowl is full of red M&Ms. There's a good chance they have a lot of green M and Ms. Because of their age. But people will tell them that their chances are low when in
reality it's not. Their bowl is still good. They just have fewer eggs and so their time left is going to be lower because there are fewer eggs. Now remember, there are always exceptions to every rule, but in general that's how I would think, of about it. Now, the next thing is the antral follicle count, remember I mentioned that, is the amount of eggs you can remove each month.
So when you go through IVF, if your antral follical count is 12, I know I should be able to get about 12 xggs, whereas if your antral follicle count is 3 like my wife was, you're not going to get as many eggs. So think of this from the analogy. This is how big your hand is going into that bowl and pulling out the M&Ms. If you'got a big giant hand, you got a high antropocle count because you can get a lot of
eggs. But if you got a little trump hand right, you're not going to get as many eggs because that hand is too small. They can't get a lot of that those eggs. And so you get less than them in handful. Now when you associate that with diminish ovarian reserve, it kind of makes sense. It women get older, they usually have lower antral follicle counts and that's why low antero follicle counts are associated with decreased
ovarian reserve. But there are some people, like my wife when we were young at 28, who make very few eggs but still have great ovarian reserve because the bowl of M and Ms. Are still green. So we can get away with getting less. Now, when it comes to the FSH and estrogen levels, this is how well the body responds the medication. So this would be equivalent to when you take a handful of Those M&Ms, how well your hand can grasp with them in
them. So if you've got that big giant hand we were talking about which has the potential, they get a big handful of M ms, but that hand has arthritis, which would be equivalent to having a very high fsh, it won't be able to grasp all those M&Ms, and so then it might only get three M&Ms, even though the hand should be able to get 10. And that smaller hand which should only get three M&Ms, can get all three of those M&Ms, so in the end
they're equal. And so someone with a high afc, with a high fsh, may get fewer eggs even though their potential is higher. And the person who has a low AFC with a small hand in that M emine M jar but has a good response, which is a normal fsh, can get all three with their hand. This is exactly what happened with my wife and I. We could not get a lot of eggs, but the eggs we got were good eggs. So
what does this mean for you? If you're a patient coming through and you have either high fsh, low AMH or low antralonical count. The thing you need to look at is what's your situation and what's your problem. Age always represents egg quality. Doesn't mean you can't get pregnant at 45. It just means you're always going to have a higher percentage of red M and ms, the green M and ms,
the same thing. If you have a high FSH it's always going to be harder because it's going to be hard for your body to make the eggs when you have a high fsh. It's not that you can't get pregnant. The problem is as a doctor, it's hard for us to help you. One of the issues when you have a high FSH is that as a doctor we can't make more eggs because your body won't respond. So if you have an FSH of let's say 30, that means your body has to requires a high level of FSH just to
make one egg. So if we give you more hormones, we can't get those hormones high enough to make another egg. So it's not that we don't want to help you, it's just that unfortunately we can't. So I get asked a lot of times, how many IVF cycles should I do, when should I quit? And this is asked to me a lot by people with diminish ovarian reserve. And I think you have to take this all into account.
If you are 42 and you only make one or two eggs per month, it is going to be very difficult to get pregnant because how are you going to get enough eggs to make this work? It's going to take somewhere around five to eight eggs to even have a small chance of having a normal egg. And so I remind people that you can try, but the chances are lower. However, when you're younger and you're making one or two eggs, I feel you can keep going ahead because of the fact that most of your eggs are
good. So only getting 12 eggs at a time obviously has a small chance compared to your peers, but still much higher than someone who's at 42 trying the same thing. Additionally, I think you can't look at IVF as ah cycles when you're trying to determine if you should do another cycle. If you're only getting one or two EGs per month, then six cycles really isn't that much when you're talking about egg number.
If someone goes through IVF and gets 22 eggs and out of those 22 eggs only one makes it to a blastocys and the other person who's getting one or two eggs makes the blastys every time, I would say the person going six times making one to two eggs has more justification to keep moving forward because at least when they go through things go well, they can't help it that they make fewer
eggs. Whereas the person who is making 20 something eggs and still only getting one embryo, their chances are actually lower because it's not going as well. So, in summary, if someone ever told you you have diminished ovarian reserve, take a look at the numbers, take it all and whole. And remember, diminish ovarian reserve is like saying automobile. You cannot compare yourself to everyone else. So if you hear that someone did something, they got pregnant, keep in mind that may not
be you. And just because you have the same word diminished ovarian reserve doesn't mean you have the same thing, just like automobile doesn't mean the same thing in every situation. If you are young, regardless of your FSH and regardless of your amh, you have the best chance of overcoming it. Now, clearly there are examples that are severe, such as ovarian insufficiency, that can make it
very difficult to get pregnant. On the same token, if you are more mature and your FSH levels are good and AMH is good, your chances are higher of having success, even though you have dimish OARI reserve based off of age, because you make enough eggs to get a big enough handful to get that green M and M. Today we check in the mailbag. Today's question comes from Lauren. Her question is, what are my thoughts on transferring two embryos over one? Lauren is aware that there are
risks with having twins. This is a great question because I would have answered this question different in the past than I would now. As everyone, or, most people know, I have two sets of twins, and both times I put back two embryos in ivf. I have never been against putting back two embryos, and to this day, I still am not against putting back two embryos. I know there is a lot of push to go to single embryo
transfer. However, if you have never been infertile, I don't believe you can understand the mindset of an infertility patient. When it comes to twint, it's not just a financial decision. Although getting 2 for 1 is quite nice when the cost is exortbantt. But even the fact of having two children, you would then know that, you never have to worry about having another child and you won't only have a single child. So I have never been against putting
back two embryos. And when I first started, honestly, I think I would tell people put back two embryos because they would give them their best chance. And that's still true. No one can ever tell you that putting back two embryos will not give you a better chance than putting back one embryo. That's just mathematically always true. And anyone who Says otherwise is honestly not understanding it or is lying. However, where I differ now is that the rate of success is so high when you do PGS.
PGS pre genetic screening, also called PGD A, is 60% per embryo and slightly higher at some clinics. When you take that into account, two embryos without testing have approximately a 60 to 70% chance of pregnancy. So one embryo with testing has almost the same pregnancy rate as two embryos untested. And so I think this is part of what should play in someone's decision. If you have PGS tested embryos, I think you can feel comfortable pulling back one embryo without the
risk of, twins. Now, your twin risk would only be 1 in 240, whereas if you put back two embryos, your twin risk would be 60% with testing. If you put back two embryos without testing, your chances are 60, 70% and about a, 40% chance of twins. Keep in mind, these statistics is at our clinic. However, what I take into consideration now is how many embryos you have. If you only have two embryos and you want the best chance at becoming pregnant, you actually have a higher chance
putting one embryo back at a time. Now, I know this seems weird because I just got done saying two embryos always gives you a better chance than one. And that is still true. But if you only have two embryos and anything happens at the transfer, you lose both your embryos. So your chances per transfer are always higher with two embryos, but the cumulative pregnancy rate between individual transfers is actually higher
than putting two back at the same time. So for example, if you put back two embryos and let's say during the transfer you started moving or coughing or whatever reason something went wrong, that's it, you're done. Even if the transfer was off for timing purposes, or whatever reason, you're done. But if you are doing individual transfers, each transfer might have a lower chance than that
one transfer with two embryos. But because you're getting two chances, if anything goes wrong, you still have another chance, increasing your then cumulative pregnancy rate. So how would I summarize things? I think there's a couple things to take into consideration when choosing how many embryos to put back. Now, I think I should point out that your clinic may have guidelines, and I recommend you following your clinic's guidelines, since each clinic has their own
guidelines. However, at my clinic, or if yours has a choice, I first would look into how many embryos you have. If you have multiple embryos, then if you want the risk of twins, I think it's fine to put back too because of the fact that you have multiple chances. Now there are risks with twins. ###br it can split. You can get triplet. However that is something you should discuss with your doctor and not every person is safe to have
twins. If you don't have a lot of embryos such as only having two or if it's very difficult to get embryos for you, then I would recommend putting one back at a time because that will give you the highest chance at success from a cumulative pregnancy rate. Remember there is no wrong or right. This is a personal choice that needs to be made between you and your doctor. To keep this episode from getting too long, I created the second part to diminish ovarian reserve. Would you would like to hear
that? I've created a second podcast that you can listen to. Have a great week and I'll see you next week for Talkaco about fertility Tuesdays.