We're so excited to be with Brianna today to talk about your fertility and if you decide you need to go further with fertility treatment, questions you have on that. But first, Brianna, why don't you tell us a little bit about yourself? You've mentioned that you've had some struggles with infertility and that you've worked in fertility clinics and started a fertility clinic.
I live in southern Indiana, just a few minutes away from Louisville, Kentucky. The bulk of my fertility experience personally and professionally has been in Louisville. I went to nursing school, got my Bachelor of Science in Nursing through Indiana University School of Nursing, and knew at a really young age that I was just infatuated with women's health; I really love that area. I was able to get into labor and delivery immediately after graduation, and that was an awesome learning experience for me. Through there, I started learning from my patients, all the different things that some of these people were having to deal with in order to get to that point, all the different treatments, and it struck my interest because early in my marriage, I knew that fertility was probably going to be somewhat in our path towards parenthood. It was very interesting to me, and I just thought how amazing would it be to be able to help women and that be my job?
I fell pretty quickly into a fertility center and became the IVF coordinator at the first clinic that I worked at, and that was really great. An IVF coordinator basically is the key holder to allowing people to go through IVF cycles.. So, I was able to make sure they had everything they needed before they did IVF. Then also coordinate their care through their IVF cycles. The team that I worked for, though, was really small. Uniquely, most fertility nurses only really deal with IVF, but because our team was so small, I was able to also work with patients who were doing more low tech options, like timed intercourse with ovulation induction, IUIs and that kind of thing. I was able to really carry patients from the very beginning to the very end, and all the different pathways that they took. That was really unique. Also, I've helped start up another fertility center in Louisville, Kentucky and get it up and running. I currently work as needed at a different fertility center, so I've had a lot of experience, and I helped with the surgical IVF procedures.
With my own experiences, about two years into doing IVF coordinating and working at that fertility center, I decided to go forward with my own fertility treatments. I had been trying for about four years, and I put it off a lot longer than I should. But for about four years, I was tracking my own cycles, doing LH kits, just trying to get pregnant on my own without any help, and then decided, after that, that I needed to go forward with more treatment. I started out with ovulation induction using Clomid with just timed intercourse, and then moved into IUI, which is intrauterine inseminations. Eventually, we were pretty much made aware that our best option -- and really almost the only option to achieve pregnancy at that point -- was IVF.
I eventually had my son through a frozen embryo transfer, and he's two now, and it was worth all the heartache and headache of it all. It was a really amazing experience to learn from the professional/medical side first, and then see it in my own personal walk and take it back to our team and use my experience to tweak the way we did things with patients. Some of the things that we didn't focus on were some things that I really struggled with going through fertility, and vice versa. So, we were able to tweak that. So, I have this really unique experience to know the inside of the fertility system and how it all works. And then also knowing how it feels as a patient to go through every stage of it.
Fantastic. Great, well, I think some of these questions relate to what you're talking about. So let's jump in. The first question is, when should you get an initial consultation to see if a fertility treatment is right for you?
So the rule of thumb is basically, if you are under 35, it's recommended that you give it a year to try achieving pregnancy naturally on your own. But also using amazing tools doesn't hurt anything. So using Premom and using ovulation predictor kits, and that kind of thing, would be ideal during that time period. And then if you don't get pregnant after that year, that's usually when it's suggested that you go ahead and seek treatment. But it's very common that sometimes it takes a year and a half, two years. . .It doesn't necessarily mean if it's been a year, and you've been tracking your LH surge and everything, and you haven't gotten pregnant that there was an issue, but it's usually just recommended that if you're really wanting to get pregnant, then that would be the point where you would go to the next step. Then, if you're 35 or older, you would really want to give it about a six month window. because as we age, our ovarian reserve diminishes, and so it can be a little trickier. And the longer you wait, the trickier it gets.
You mentioned in your introduction that you helped women prepare for IVF treatment, can you talk a little bit about that, like how they would need to prepare if they are going to that step?
Yeah, so there's just some requirements to make sure that IVF is the ideal option for them. There's some testing that you would initially do when you walk into a fertility center; you have a consult and that determines kind of what pathway you may want to go. But testing is really going to tell you what your options are. So there's some testing that's done for both the female partner and the male partner, if that's the scenario. And based off of those test results, it will tell you what avenue you need to go. Some things that we check is just to make sure that you have a good, nice environment in your uterus, there's no fibroids, nothing in there that could hinder uterine implantation. We make sure that bloodwork is good, that you're just a generally healthy individual, that there's no hormone variations that could prevent you from successfully getting pregnant. If you're going to go through all of the trouble of IVF and all of the money that it costs, and everything, we want to make sure that it's a really valuable option for you and you're going to get pregnant. We can't predict it, but that is the fastest, most predictable thing is that your chance of pregnancy increases quite a bit with IVF. But it still doesn't change the fact that it's very expensive, and it's not a for sure thing. So, there's going to be a lot of things that are done, just some typical testing things. They don't take very long; a lot of times clinics can fit it all in one day.
Another question we have: what is the average cost to get started with IVF?
That widely ranges between different fertility centers. You have private sectors, you have institutional sectors -- they're based off of a university-style hospital. Usually, the bigger the place is, a little bit cheaper it may be, but that's not a hard-pressed truth there. You really have to shop around. On average a cycle of IVF is about $15-20,000. That includes medications, which is a huge portion of that, and also all the testing that you have to do. But IVF coverage is becoming more and more common. With IVF coverage, that usually covers the cost of the testing and everything that you need done before you do IVF, and it also covers so many treatment cycles. IVF coverage for insurance is completely different. Some insurance companies cover only a certain number of IUIs before you can move to IVF and that sort of thing. It's very specific to the plan, but you just need to call your insurance company and then call the fertility centers that you're interested in, going in and asking questions. They're used to it. They have all the information at their fingertips, and they'll be able to help you make a better decision. But during your consultation at a fertility center, if you are interested in IVF, if that seems like a way to go, they will lay out all the costs for you at that time.
And as part of that, looking at different options -- I'm assuming, like IUI/IVF . . .?
Yeah, absolutely. Knowing your options and also knowing an idea of where you want to go. Some fertility centers really get a bad rap sometimes as far as trying to push you straight into IVF. But if you go to a good IVF clinic or fertility clinic, they're going to do that testing, and they're going to find out what options you really have. All the testing may look good to say, let's do ovulation induction a few months, let's do IUIs a few months before we move to IVF. You have the option to say "No, I want to go straight to IVF" or "No, I want to try these more, less aggressive, less expensive options first before moving forward." It just depends on your testing. There are situations, of course, where some testing suggests that really your best option is IVF. An example of that would be, they check to make sure that your fallopian tubes are open, so that you can release an egg and it can meet the sperm and create an embryo. And if you have blocked fallopian tubes, that's not going to happen. And so your your best option would be IVF.
Fantastic. Someone is asking: should I see a doctor after two times of miscarriage in early pregnancy?
Yeah, miscarriage, unfortunately, is very common -- especially early miscarriage -- a lot of times [it] happens probably more than we really know because you get a period. And we just assume it's a starting period. But really, you could have achieved a pregnancy and just had a very early chemical, which would be about the time that the embryo attaches to the uterus and starts to develop hCG, which is what turns a pregnancy test positive. That embryo stops developing, and miscarriages are very common.
Having two miscarriages doesn't necessarily mean that there's something wrong; it's our body's way of protecting us from having an abnormal pregnancy. The embryo that was created potentially could have been abnormal in some ways, which doesn't mean that anything's wrong with your body or your anatomy in any way, shape, or form. I would recommend just so that you don't have to go through this over and over again -- because miscarriages are hard and they can definitely take a toll on you -- just seeing your ob/gyn. You don't necessarily need to seek fertility treatments. There are some things that regular ob/gyns can check out for you and see if there's any cause, but a lot of times it's just from embryo abnormality, and -- like I said -- our body's way of protecting us from having an unhealthy pregnancy.
Wonderful. Okay, then we had a few questions about Clomid. The first was about Clomid and the success rate.
Clomid, clomiphene, is an ovulation induction medication. It helps to induce ovulation. If you're somebody who has PCOS and you don't ovulate regularly, Clomid is a great option, because it can help you to regulate that ovulation monthly so that you have a constant chance of getting pregnant every month. For patients who do still ovulate, it is helpful as well, in the fact that when we ovulate, our body usually naturally selects one follicle to be dominant, and inside the follicle will be the mature egg that gets released for ovulation. With clomiphene, it is common that there's usually one, two, or three dominant follicles. With ovulation induction -- and that would be with Clomid or letrozole, those are the two most common ones used -- it does increase your chances of pregnancy a little bit; it moves it up to about a 20% chance. So it is a good option for people who already ovulate or don't ovulate at all. It is a helpful tool, not necessarily what everybody needs. Also, the risk of multiples is a little bit higher, too.
Yeah, we did have a question about using Clomid or letrozole to get pregnant faster if you're already ovulating by yourself.
It doesn't necessarily get you pregnant faster, because there's no guarantees ever. There's no guarantees with whatever you do. Whether it's IVF or ovulation induction with timed intercourse, it does increase your chance of pregnancy per cycle. So, relatively speaking, it could actually make you get pregnant faster, but not necessarily. You typically develop more than one dominant follicle. The goal is usually about two; we don't want a lot of follicles because again, we don't want multiple pregnancies, because that puts the mom and the baby at risk. So, it does give your body a better chance at getting pregnant, but it doesn't necessarily make you get pregnant faster.
What's the next step after unsuccessful rounds of Clomid?
I would need to know a little bit more about what unsuccessful means. Unsuccessful, I'm thinking that person is probably meaning they just didn't get pregnant. But I would want to know, did the Clomid actually result in developing a dominant follicle, and you actually ovulated? If you did ovulate, you had a period afterwards -- you just didn't get pregnant -- then the Clomid is working. You just haven't gotten pregnant yet. We usually recommend about at least three cycles to give it a really good try, but for some women we recommend usually three to six even, to really give that all it's got. If you are really interested in trying to get pregnant aggressively, then I would recommend going to potentially IUIs. If the Clomid is working, you're ovulating, but just not getting pregnant, then IUIs would be the next best step. But if the Clomid is not working, and you're not actually ovulating, then there's other medications you can try, like letrozole. Sometimes Clomid doesn't work for you, and letrozole would be the next best option.
Alright, switching gears a little bit. We had a question about getting a positive progesterone test and getting your period on the same day.
Yeah, so progesterone tests are great. They help us to confirm that you are indeed ovulating. What happens in your natural cycle is that when you do ovulate, you get that LH surge before you ovulate, you ovulate, and then after you ovulate, your progesterone increases. The test that tests that, it's just testing to see that you actually got a positive progesterone level. Your progesterone levels elevated, and that means that you ovulated. It doesn't mean that you're getting pregnant necessarily, it just means your body's doing what it needs to do to give you the chance to get pregnant. When you do ovulate, that progesterone level increases. Eventually your body decides: Hey, I'm pregnant -- or not. If it's pregnant, then the progesterone level stays elevated, and that's what helps to support the pregnancy up until about 8 to 10 weeks gestation, once the placenta is formed. If you are not pregnant, then the progesterone level drops very quickly, it plummets very quickly. That's what causes you to have a period. That drop in progesterone level causes you to shed the lining of your uterus. So it's very possible to get that positive progesterone level and then start your period on the same day. And again, that doesn't mean that anything's wrong. It's actually eliminating a possible problem. Now you know, that you ovulated, and you have a great chance of getting pregnant; you just didn't get pregnant that month. And that's okay -- just means you’ve got to keep tracking.
This person wanted to know about suggestions for foods to eat at different parts of the cycle, what they help with. For example, they said they were told to eat Greek Yogurt from CD 1 to help with cervical mucus -- do you have any thoughts on that?
Yeah, well related to the example of the Greek yogurt and cervical mucus, there are some things like omega-3 rich foods that are supposed to help with hormone balance that helps with cervical mucus. But really, if your body is doing what it needs to do, cervical mucus is created from your hormones. So, as long as everything is hormonally working right in your reproductive cycle, foods aren't necessary for certain parts of the cycle necessarily. What is more important to me, this is my own personal opinion, would be just to be overall a generally healthy person. That's what's going to be more important for you. Making sure that you're eating healthy, exercise, no smoking, minimal alcohol consumption, taking a prenatal vitamin and folic acid about three months prior to trying to get pregnant and continuing. I know women are really bad -- I, myself included -- about staying consistent on that, especially when they're not pregnant. It's just another reminder that we're not pregnant yet. I know it can be frustrating, but really thinking about just being a generally healthy individual is what's going to make your body function appropriately. If you think about it, your body is working harder in a certain area, then your reproductive system can't focus on what it needs to do. So just overall -- I know it's a very general answer to that question -- but just being a healthy individual is what's going to be more important.
And speaking to cervical mucus actually, cervical mucus -- for anybody who doesn't know -- that is the tool that helps the sperm get to the egg. It's a healthy fluid that basically helps the sperm travel. Using certain lubrication during intercourse can be a hindrance to the sperm, as well, it can actually hurt it. There are some safe lubricants that you can use that do not hurt the sperm, that are healthy for the sperm when you're trying to conceive. You can also use just mineral oil, that's always good. But some of the more common lubricants are not helpful to the sperm. And a lot of people don't know that. Cervical mucus is great and, like I said: if your body is functioning the way that it should, you should be developing healthy, appropriate cervical mucus, but also making sure that you're doing your part to not hinder anything else as well, as far as like lubricants and that kind of thing.
We have one more question. This last question is a little bit more particular. Whoever this person was, I recommend if you want to go deeper, be sure to consult with Brianna. They said "I'm on a third round of letrozole and not getting a positive LH this round." She's a good way through the cycle. She had a chemical last cycle, which she said can happen. And she's wondering about the potential of still getting pregnant this cycle. Thoughts on that generally?
So letrozole can do a number of things to our cycles. For PCOS patients, it can obviously regulate it better, but it doesn't necessarily keep you ovulating at the same time. She said she's on her third round so that makes me think that if she's kind of far into her cycle... did she say what cycle she's on?
She said third round of letrozole and she mentioned, I think, that she's on CD 15
Okay, perfect. So letrozole can sometimes make you ovulate at different times in your cycle. Let's say you ovulated the past two cycles on cycle day 12. That doesn't necessarily mean that this round you're going to ovulate or get a positive LH surge on cycle day 12 this month, it could take a lot longer. Also, as you stay on these medications a couple of months in a row, sometimes they do take longer to work. It doesn't mean that they're not any less efficient, but they do sometimes take longer. We see that very often. So we usually don't give up on the cycle or give up on getting a positive until you're about cycle day 20-22, actually. I would definitely keep testing, because like I said, as you're on these medications for month after month, it can take longer and longer for your body to respond, and that's perfectly normal.
The other thing is having a chemical pregnancy -- I would want to confirm that really was cycle day one of your period and that you just weren't having irregular bleeding. Because with a chemical, it can sometimes take a month to get back to normal. If you don't start these letrozole medications right at the beginning of your cycle - typically it's between cycle days three and five -- if you don't start them right at the appropriate time, then it's not going to do what it needs to do. It's not going to encourage follicular development the way that it should, if you started too late. So, if you're not sure that really was your period, too, that could also cause this to not work.
But I would recommend, definitely keep testing. Wait for your period to come. If your period does come, then you probably did ovulate; you just might have missed it because it might have even been earlier than you expected it to. That's very possible. It's recommended to make sure that we get a negative pregnancy test or a negative hCG level through blood, before going forward, after you've had a chemical. Because if you still do have hCG in your system, these medications aren't going to work the way that you want them to.
Well, thank you! Are there any final thoughts you'd like to leave our audience with?
I just really enjoy what I do and I'm thankful to Premom for giving me an opportunity to work so flexibly for myself and the users. I worked really hard through seven years of infertility to get my son, and so I never want to stop being someone to help these patients, these people, to help them, encourage them. But I also want to be there for my son, and Premom gives me a perfect opportunity to do that. I'm really excited about it. Premom is a great app. I’ve had lots of patients through the years come to me with Premom, you know the little screenshots of all of their LH tests and that kind of thing. It's helped me, and it's helped us stay on the same page as the patient and the nurse. It's been great, and they have great products, and I'm excited to stand behind them and help them.
I want to speak to any users out there: if you're getting frustrated, if you're feeling like you want to give up, first of all, don't. You got this! But I want to be there for those types of people. So, if there's anybody out there that is feeling like they're just confused, frustrated, there are some simple teachings that we can go through to help you gain control of your care, and knowledge is power. I want to give you the knowledge that you need to overcome this battle, gain motherhood, and all of that, if anybody is watching that is getting frustrated, feeling like giving up, this is just too complicated for them. So many women have been there, been through it. And that's why we have these amazing providers available to be able to help you walk through it and answer just some simple things that are going to make the difference in your care.
Fantastic. Thank you for joining us today, Brianna.
Thank you for having me. I'm so excited!
You can find Brianna right in your Premom app! If you go to Schedule a Consultation, you can find her -- she's a registered nurse. You can learn more about her and show her your charts, your ovulation cycle, your BBT if you're taking that. All of it's right there in Premom that you can share with her and get some personalized insight.