[00:00:00] Speaker A: Hi, welcome to Fertility Cafe.
[00:00:02] Speaker B: I'm your host, Eloise Drain. When we think about our fertility, most of us wait for a reason to get tested. Maybe we're having trouble conceiving, or perhaps we've hit a certain age.
But understanding your fertility isn't just about solving problems. It's about being prepared and informed about your reproductive health.
Today's episode, when to test your key signs and best timing will help you understand not just when to get tested, but why timing is so important.
We'll look at why waiting for obvious signs isn't always the best approach and how being proactive about fertility testing can give you more options for your future.
I'm delighted to welcome our guest, Dr. Susannah Park, a fertility specialist from San Diego Fertility Center. Dr. Park is double board certified in obstetrics and gynecology and reproductive endocrinology and infertility.
She brings a unique global perspective to fertility care. With an impressive background that spans from Sol to Buenos Aires to New York City and now San Diego.
She's been recognized as a top fertility doctor by San Diego magazine five times, most recently in 2023.
Hi, Dr. Park. Thank you so much for joining me today.
[00:01:24] Speaker C: Good morning. Glad to be here.
[00:01:27] Speaker A: I'm just gonna jump right in, and my first question, of course, is going to be, what drew you to specialize in fertility medicine?
[00:01:35] Speaker C: So, you know, life truly is all about timing and mentors who you meet.
And I was doing my residency for obstetrics and gynecology with the full intention to be an OB gyn. I had tons of medical school loans to pay back, and I was really eager just to get into the workforce and start paying back my loans. And. And the chair of my department, Dr. Gerson Weiss, he and I had done research for a bit, and he came up to me and he said, have you ever considered becoming a reproductive endocrinology and infertility specialist? That's what we call our field. We call it REI for short. And I said, no. I said, what is that? And he talked to me about it, and I had not done my rotation yet, and I did my rotation and I really enjoyed it.
And that was really what set my path towards rei. And truly, had it not been for him and his encouragement, I would have been an OB gyn, which is fine, but I really feel that REI is my calling. So he nailed it, which is great.
[00:02:42] Speaker A: And I know that you also have a significant international experience that has also shaped your approach to fertility care. Would you share talking about that?
[00:02:53] Speaker C: Absolutely. So I was born in South Korea, and when I was nine months old, my family moved to Argentina in hopes of a better life. So Buenos Aires, Argentina.
And after being there for a few years, my parents realized it wasn't quite the life they had thought it would be economically. The country was struggling even back then, and so it took them years to get a visa to come to North America. And. And when I was six years old, my family landed in New York City.
And as many immigrants who come to the United States, it's a struggle when you come and you're just poor.
And so it was a lot of years of hard work just to pull ourselves out of poverty and those years of being in Argentina and being in Korea. But realizing that you're an immigrant to this country, you realize the value of hard work, but you also realize how great this country is. And in my current work, as you know, we have a lot of international clients, you really see the good and bad of every country, that there's not one country that's amazing. Every country has so many good things to offer.
Right. And so many things that maybe could be better. But having lived in Buenos Aires and Spanish became my first language, you really develop an appreciation for people who don't live in your own country and how
[00:04:16] Speaker A: different the reality is for so many people in different countries of even. Which I recently had on another episode talking about just the global perspective of fertility care. Not that it's the greatest in the US either, but just even across the board. I mean, even just the Pope coming out and talking about fertility or a surrogacy being a. Something that should be banned, and then Italy completely banning surrogacy altogether in their country, and it's just like, really.
[00:04:52] Speaker B: Do you really understand the. The magnitude of what you guys are doing?
[00:04:57] Speaker C: I know it's. It's so hard for people in our industry here in the United States to understand that. I just. It's hard for me to understand how if somebody wants to create a family and their heart is so full of love, I just don't understand why. Why do you make it so hard for them? It just boggles my mind. And many times when I travel internationally, I encounter patients who've struggled. Right? And they could be heterosexual patients. Seven miscarriages. And I just cannot understand.
I don't know the reason, but clearly she cannot carry. It's hard for me to understand why it's not. Not possible for them to have somebody else carry in their country. And thankfully, there are countries like the United States that offer this benefit. But it just breaks my heart to think the extremes people have to go to have a family.
[00:05:49] Speaker A: And the reason why I wanted to talk about this subject of, you know, when to test your fertility, because I think as a society we have not done a good job in educating our community about reproduction.
You know, they talk about sex education in school, but they don't really teach them about reproduction.
And for all of these people, not
[00:06:13] Speaker B: all, but for a lot of these
[00:06:14] Speaker A: people that are going through and having to do third party reproduction or having to have to do IVF later on in life or whatever.
[00:06:26] Speaker B: So many people that have come to me over the years would used to say, I wish somebody just would have told me, like, why didn't somebody just prepare me early on so I knew what to do so I could be prepared. So I'm not waiting now until I'm in my late 30s or in my 40s. And now just trying thinking that I have the time first. At what age should people start even thinking about fertility testing?
[00:06:51] Speaker C: For sure in their 20s. And life is a bit unfair. Men make new sperm all the time, whereas we women don't. We're born with our egg supply.
But having said that, even with men, I would say they should check a sperm test in their 20s or 30s, because even with men, especially once they hit their mid-40s, you start to see a decline in their sperm quantity and quality. For us women, our decline starts in our late 20s and it's gradual at first, but then it does become deeper.
So certainly I would encourage all young women out there in their twenties, go to your ob, GYN or your primary care doctor and just get some basic fertility tests done. There are three main ones, but I would just start with the simplest of them all, which is a blood test called anti mullerian hormone amh. This is a hormone made by the eggs in the supply. The eggs in the supply that you're born with are not visible to the naked eye. So there's no mri, no ultrasound that will tell you the number of eggs you have in your supply. The AMH is the hormone made by the eggs in the supply.
So though we can't see it, we know if your hormone level is good, then you know, all right, I must have eggs in my supply. And I think it's good to periodically check another blood test. But this is just a little bit more involved, is called f.
Sh. Follicle stimulating hormone. And you should do this along with an estradiol level. And this is just a little bit more involved because this is particular to your menstrual cycle. It should be done around cycles A, 2, 3, preferably sometimes 4.
Whereas the AMH can be done anytime in your cycle. So the FSH and the estradiol a little bit more involved. But again, it's just a blood test and you can, if you're smart, you can try to do all three the same day in the second or third day of your cycle. But again, the AMH can be done any time of your cycle. The third egg test, which I don't know that I would have a 20 something year old young woman go do it routinely. But that is an ultrasound, a vaginal ultrasound for something called antral follicle count. Afc and what happens is every month your body activates a group of follicles and you can see them on ultrasound. They look like these dark circles. And we know the more of these dark circles we see, then we know, ah, you must have a lot of eggs in your supply. But asking a 22 year old to do a transvaginal ultrasound I just think is a bit much. Not to mention the cost. Most ultrasounds, they charge a couple hundred dollars. So I think at least the AMH blood test alone or AMH with your day 3, FSH and estradiol are at least great starting places. Just to periodically screen your fertility status
[00:09:54] Speaker B: for these tests, what would be normal ranges?
So somebody goes and gets the test.
[00:09:59] Speaker A: What are they actually looking for?
[00:10:02] Speaker C: So for the amh, at least one, but it depends on your age. If I have a woman who's 40 and her AMH is one, wow, that is fantastic. But if I have a woman who's 25 and her AMH is 1.1, that's concerning because for somebody that young, you really wanted two or three, et cetera. So the higher the number, the better. Same with the antral follicle count. The higher the number, the better. So most women in their 20s, you'll see an antral follicle count of maybe 18 or 24 or 28. You'll see women in their 40s less than 10, and that's very age appropriate, which means that women in the 30s, which are the transition ages, are usually in the teens.
The FSH, you want a level less than 10, so that one's the opposite, the lower the better. An fsh level of 15 or 20 is quite concerning if you're in the
[00:11:06] Speaker B: process of figuring out how to build your family. Whether you're just starting IVF or already looking into options like egg donation, sperm donation or surrogacy. There's an event I want to make sure is on your radar. It's called the Family Blueprint and it's happening June 7th in Atlanta. It's a one day in person event hosted by fertility360 and is designed to support intended parents at every stage of the journey.
The day is thoughtfully curated. You'll hear from fertility doctors, legal experts, mental health professionals, and parents who've been through this themselves.
Every session is about breaking things down clearly and practically. So you leave with real answers, next steps, and a stronger sense of what's possible for your family.
If you've been trying to figure out what's next or even where to start, this is a space where you can get the clarity and support you need. You can learn more and grab your
[email protected] Atlanta so for AMH though, isn't
[00:12:12] Speaker A: it where the higher the number, you know, there's a pretty much a normal range. But if you really do start getting into the teens with amh, isn't there a potential that there could be other underlying issues?
[00:12:27] Speaker C: Great point. Yes. So there's a condition called polycystic ovarian syndrome, pcos.
So if your AMH level is incredibly high, then that tells you, oh my goodness, you have a lot of eggs in the supply.
But as with most things in life, nothing in extreme is great. Right. And so when you have an AMH level 15 or 13, it suggests that you may have this condition called PCOS. And PCOS is a bit of a double edged sword because it's great that you have a lot of eggs, you're born with this big quantity of eggs, but they're not necessarily the best quality eggs. In addition, PCOS is often associated with irregular cycles. So women with PCOS may have their own challenges getting pregnant because it may not necessarily be, hey, I'm running out of eggs. It may be, gosh, I can't even get myself to ovulate.
[00:13:25] Speaker A: Obviously then age does impact fertility for both men and women because I think you only hear about, you know, fertility is going to just affect women. It's not necessarily going to affect men. Like you said, men can reproduce sperm, you know, every few days. So it's really not going to be an issue. But I don't necessarily know if that's true.
[00:13:50] Speaker C: Correct. As men do get older, especially mid-40s or older. Absolutely. We see more abnormal chromosome issues in the embryos. So just like women, I would advise any men, if you know that you want to have a family and for whatever reason you're not ready at the present moment, freeze your sperm because frozen sperm, frozen eggs, frozen embryos, the quality does not degrade over time. And also I've noticed that there are men who take testosterone for bodybuilding, which is fine, but testosterone will kill your sperm production. So, yes. So men who want to get on testosterone, great, but try to freeze your sperm beforehand, because in most cases, when you stop the testosterone, you will start to regenerate, speed sperm again. And it takes about three months to make sperm. But I've had a number of cases where the sperm either does not bounce back at all, so he remains without sperm, or it bounces back, but it's not quite normal. Again, it's sort of very borderline values. So I encourage any men who want to get on testosterone to really try to freeze sperm before they do. So just in case the sperm doesn't bounce back. Back.
[00:15:11] Speaker A: So what are they looking for in sperm?
[00:15:13] Speaker C: So, a number of things. The volume, the color, the viscosity. But the main things are how much sperm is there, the concentration of sperm per milliliter of liquid, how modal are the sperm. It's great. You can have sperm, but if they're not really moving, it will make you less fertile. And then what is the shape of the sperm? So it is normal to have sperm that has a little bit of an abnormal shape. Maybe the head's too big, the head's too small, maybe the tail's too long, too short. Two tails, two heads. This is all normal. But you have to have at least 4% of normally shaped sperm, ideally 14, but at the bare minimum, 4. So again, we're not expecting all the sperm to be normally shaped. But why does this matter?
Because in natural conception, only a normally shaped sperm can fertilize an egg. So let's say you only have 1% normally shaped sperm. That means 99% of your sperm cannot fertilize the egg because it's not normally shaped. So it just will take longer to get somebody pregnant naturally.
Now, ivf, of course, addresses all of this because it handles the sperm one by one.
But of course, you want to make sure your sperm is okay. So you don't have to do IVF to grow your family.
[00:16:36] Speaker A: If somebody is like, well, you know,
[00:16:38] Speaker B: yeah, I have sperm, every time I have intercourse, I ejaculate.
[00:16:42] Speaker A: And so there it is.
[00:16:44] Speaker C: Right, good point. So just because you see liquid does not mean there were sperm inside. So the saying is you're shooting blanks, right? You can be shooting all this liquid, but unless you see sperm inside, you don't really know it has sperm. Inside, and usually it will, but that's why you absolutely need to go get it tested. And then I hear the opposite all the time. That guys will provide a sperm specimen and they will say, oh my gosh, it was like hardly anything in there, like maybe this little. And I remind them you don't need a lot. Your sperm is so highly concentrated that what may seem like such little volume actually will contain a lot of sperm. And indeed that's the case.
[00:17:24] Speaker B: And can you see sperm with the naked eye?
[00:17:27] Speaker C: You need a microscope. Yeah.
[00:17:28] Speaker A: Now, I know we're talking about the testing, and you know that you should test, but is there such a thing as testing too early?
[00:17:35] Speaker C: Well, that's a great question. I wouldn't test a teenage aged child. I think that is kind of early, unless of course, they are diagnosed with childhood cancer and you have to have them undergo chemotherapy. But I think the 20s is really a good time just to sort of get a feel for where you stand.
I tell a lot of college graduates, right, who have graduated and they're ready to embark on their career and their life, and I advise a lot of them. For your graduation gift, you may want to ask people to fund your GoFundMe page, which should be your egg freeze page. Right, Your.
As we get older, our equality diminishes and egg freezing costs money. So rather than asking for things for graduation, start a GoFundMe page and ask your family and friends to fund that so that you have enough funds to eventually be able to freeze your eggs. Because the ideal age to freeze your eggs is your 20s. Not that you can't freeze it later, but the quality won't be the same.
[00:18:38] Speaker A: And the thing about it too, with age for women, our egg quality begins to diminish. At what age?
[00:18:43] Speaker C: Late 20s? Yep. But it's very gradual.
So I don't want a listener out there who's 31 to think, oh, my goodness, doom and gloom, the ship has sailed. Not necessarily, but you will. In women's ovarian physiology, you will notice that the egg quantity and quality starts to do a decline in your late twenties. And then just. It will get steeper the older you get.
[00:19:08] Speaker A: What specific signs or should prompt someone to seek fertility testing earlier than they may have planned?
[00:19:16] Speaker C: One of the cues is irregular cycles. So let's. I mean, if you've been irregular your whole life, that's different. But let's say you've been regular and then all of a sudden you're like, oh, this is kind of weird. I'm having these, like, these Erratic cycles.
Go check in with your OB GYN just to make sure, because you'd be surprised how many patients I've had in their 20s, and that was their initial presenting symptom was I went to my OB GYN and yeah, and they just checked my egg test. And I can't believe how low my AMH is.
The other thing is family history.
The age your mother was when she was menopausal is really important because if she was so most women in the United States are menopausal when we're 50, 51. But if your mom was 42 when she was menopausal, that's a red flag. So you should then get tested, certainly in your 20s, just to get an idea of where you stand scanned and really try to freeze your eggs sooner than later if you're not ready to have children.
So family history is pretty big. If you know that you unfortunately were diagnosed with breast cancer being the most common one we see, we encourage you and your oncologist, your cancer doctor, should be advising you, men or women, before you get chemotherapy, we want you to freeze your eggs or sperm, respectively, because some of these chemotherapy agents can really wreak havoc with your ovaries and your testicles. And then, of course, social reasons. Right. If you know that you're going to be pursuing this big career that requires extensive training, extensive schooling, long hours of work, or you just feel that, I know I want to be a parent, but I just haven't found a partner. And you're starting to personally feel that you're getting old, which is different age for every person. And I encourage you, go get your fertility testing done and try to do something about it.
[00:21:13] Speaker A: Talked about menstrual cycles. What is typically a normal menstrual cycle? Because I have heard numerous times of people will say, yeah, I was, you know, I normally have my period in
[00:21:27] Speaker B: the last 10, 12 days.
[00:21:29] Speaker A: Or it's so heavy that I can't go to school, I can't go to work, or, you know, I.
I bleed so much that, you know, I'm changing my pads every single hour.
[00:21:42] Speaker B: Like what is supposed to be normal?
[00:21:45] Speaker C: And again, there's a range for every woman. But in general, most women will bleed in terms of duration of bleeding, anywhere between three to seven days.
I have patients that tell me, my gosh, I go through a super tampon and a pad soaked in one hour.
That is concerning. If you're bleeding that heavily and you're going through that many hygiene products, you need to contact your OB GYN because The thought I'm having is, okay, there's something in the uterus, such as a fibroid or polyp in the cavity of the uterus that's causing you to bleed so much. And usually they will find something. I will say, sometimes I've had patients who've said, oh, my gosh, they've done every test and they just can't find anything. And in cases like that, there are medicines that your OB joint can put you on to try to slow down the amount of bleeding. Okay. In terms of interval, of how often you should get your menstrual cycles, I know most women say they get them 28 days apart, but there is a normal range, which is 21 to 35 days. So sometimes I'll have patients, they'll say, oh, no, I have some crazy cycles. I get my period every 24 days.
I know that sounds crazy, but that's still within normal.
[00:23:02] Speaker A: For someone that is having all of these issues, obviously going to their OB GYN and they find out that there are issues or there is concerns or whatever, or for somebody who is starting to, you know, think about their, eventually, I want to have a child or whatever, obviously they need to start doing some research.
What's the first step everyone should take to make sure that they're best prepared for family building?
[00:23:34] Speaker C: Making sure for a woman that her egg supply is fine and for a man that his sperm is okay. If a woman says, all right, you know what, I have great egg supply, and now, you know what? I'm ready. I'm ready to start having a family. I just want to make sure everything looks okay.
So there are four things you need to have a family. Eggs and sperm. And then for women, four fallopian tubes. The fallopian tube is what connects between the ovary and the uterus. So an egg leaves the ovary, jumps into the fallopian tube, and eggs sit there waiting for sperm. When a man ejaculates in a woman, the sperm is dropped off in the vagina. The sperm enters the uterus, goes into the fallopian tube in search of the egg.
And then that fertilized egg, we call that an embryo, goes back in the reverse direction and sticks in the uterus. So the fourth thing is uterus.
So there's a test out there called the hysterosalpingogram Long fancy name. We call it HSG for short. Or some people just call it the tube test. I will say it's not the most comfortable test. I've had it done before. And for me, it wasn't a problem, but I've had patients who told me it was like the worst thing in the world. But basically you lay down and it's usually in a radiology place and the radiologist puts a speculum in the vagina. Speculum is that same instrument that an obgyn uses to do a Pap smear. It's usually metal or plastic.
They put a speculum in the vagina to look at the cervix. The cervix is the entrance to the uterus. They then put a catheter into the cervix to go into the uterus. And there is a liquid in that catheter that lights up under the X ray machine. And as they push the catheter into the uterus, they're taking X rays. And you should see the liquid filling the uterus because if you have a huge fibroid in that uterus, you will see that the liquid fills the uterus, except for this big area there where there is this fibroid. And then they push more liquid in to fill both fallopian tubes. If your tube is blocked, they will see, oh, the liquid is not filling that tube. That's how they know the tube is blocked in the beginning or the tube could be blocked at the end. They'll see, oh, yeah, the liquid goes in, but, oh, it's not exiting because you want to see the liquid fill the tubes and exit.
So that hysterosalpingogram will check your tubes and the uterus at the same time time. So those are the main things. Eggs, sperm, tubes and uterus.
[00:26:11] Speaker A: And for someone that, you know has decided to get tested, what does that process actually look like? Like, what should they expect?
[00:26:21] Speaker C: So after the HSG and then they've done the egg test and the sperm test, so then you need to take all that data to. It could be your ob, GYN, or fertility specialist.
And I'm a big believer that if everything is fine, and let's say they haven't really started yet, reassurance, tell them, look, everything looks great. And I really encourage you guys to try on your own. So a big misconception about trying, you should not be having sex every single day.
Because what happens with guys is they're making sperm every day, every day. But that's sperm gets stored in their testicle in this little area called the epididymis. It stores the sperm and then when he ejaculates, what is released is the sperm and the epididymis. But if he's ejaculating every single day. Eventually the sperm that is stored there runs out and so he's still ejaculating liquid like you have mentioned before. But there's no sperm inside.
So it's good to give the guy some time to replenish the supply in that store. There are two ways of doing this. One is that if you know you have regular cycles, let's say you have 20 day cycle, then have sex every other day for a week around the time you're ovulating. Maybe cycles day 11, 13, 15 or 12, 14, 16. But it's always good to do a little before, a little after, just in case you were off.
Now, should it be that you guys cannot be together? Let's say somebody has a business trip. It's always better to have sex before than after because sperm, fresh sperm, can live inside a woman for up to four days.
So let's say she's ovulating cycle day 14, but one of you has to go on a business trip. Well, then have sex cycle day 11. Because maybe, just maybe, that sperm may still be fresh and living in the fallopian tube when she's ovulating three days later. Another way of doing this is let's say you check ovulation kids, which I think is fine, but just be careful because sometimes it really makes people a little nutty because you're just right, like just so obsessed with this. But if you check your ovulation kit and you know, yep, bam, it's right. Because what the kid is telling me is consistent with what I'm noticing in my body. Right? So when you're ovulating, you should usually notice cervical mucus, that egg white discharge coming out. And the ovulation kid is saying, yes, you're ovulating mid cycle. It's not like it's positive cycle day six, which makes no sense for a 20 day cycle. So if you think the ovulation kit is reliable, it's always good to have sex. Maybe cycle day 11, just kind of get that old sperm out. Optimal sperm is sperm that has been released every two to five days, preferably two to three days. Okay, so cycle day 11, get that old sperm out and then check your ovulation kit. And once it turns positive, have sex that night and the next night. Now, I know I just said two days in a row. When before I said not every day. But in this case it's just two very concentrated days. Okay, so that's another day if all the tests are normal to reassure the patients and just guide them a little bit on how to time their intercourse. And usually it will work, especially if they're young and all the test results are normal.
[00:29:38] Speaker A: But what if they've been trying for a while? Like, okay, I've been trying for six months, or I've been trying now for a year. I know that especially for insurance purposes, especially where they talk about, you know, infertility is if you've been trying for at least 12 months and you haven't gotten pregnant on your own.
[00:29:55] Speaker C: Correct. So, and that is indeed, you're right, the definition of infertility for women under 35, once you're 35 and older, the definition of infertility is trying for six months.
After six months, you need to go see the OB, GYN, or fertility specialist, because time is of the essence now, right? Because you have a decrease in that quantity and quality. So indeed, if you've been trying for a while and all your tests are normal, it's so great your tests are normal. It's so frustrating that your tests are normal, right? Because now I don't know what to fix. I don't know what the is problem. Problem is I do encourage trying conservatively, especially if you're under 35. If you're above 35, you may want to become more aggressive sooner. But conservative options would be number one, because when you try on your own or ovulating one egg and the sperm is being dropped off in the vagina. So what if option one, I give you a simple pill to take, and that usually gets you to ovulate two, three or four eggs, and that pill is usually Clomid or Letrozole.
And then we monitor you, and then when we know you're ovulating, have sex. Okay, that's option one. The problem with option one is a lot of that sperm that lands in the uterus through sex never makes it up into the uterus. And I know all these women, right, lay there with their pelvis up, legs up, all of that, and that's fine, but it doesn't make a difference. But it is a waste of sperm. So here comes option two. Option two is what we call intra uterine insemination or iui, artificial insemination, same thing.
So in option two, you take the fertility drugs, we monitor you, and when we know you're ovulating, your partner brings sperm, we concentrate it, and a catheter is put into the uterus, and then the sperm is placed inside the uterus.
The problem with these two options is, is if you're taking that fertility Drug to ovulate multiple eggs. Be careful because that means you're ovulating multiple eggs. That means there's a possibility of multiple children.
So if you decide, oh, gosh, no, thank you. There's another way to do iui if you have regular cycles, forget the fertility drugs, right? Let's work with the rhythm of your body and you're ovulating your one egg and then you do the iui, so your chance of multiples is not increased at all. There's another way to do iui, which I'm not a big fan of, is I can use medicines even stronger than Clomid or Letrozole. They're actually the IVF medicines, but they're used for the intention of iui. I do it, but I'm not a fan because it will get you to ovulate, usually from four, five, six eggs. And then this is where we run into trouble with our triplets, etc.
Now, there is a type of patient that needs this IVF drugs IUI protocol, and that is the woman who has a condition called hypothalamic amenorrhea, which means she does not get regular cycles. She does not have pcos, but she does not get regular cycles because her body doesn't make enough FSH and lh.
So IVF drugs are FSH and lh. So for her, I can just give her the FSH and lh, get her body just to make her one natural egg, and then she can go home and have sex, or we can do the iui.
[00:33:26] Speaker B: What is a natural cycle?
[00:33:27] Speaker C: There are different natural cycles for different treatments. For, in this case, natural cycle. So we do different types. One is just an observational cycle where I give a woman nothing. I just do ultrasounds just to see what's happening and then tell her, yes, look. You look on the ultrasound, we could see you've got a big egg, beautiful lining. Yes. Go home and have sex. So we're just doing an observational cycle just to help guide her and confirmation objective evidence that indeed her body is working. Or you could do a natural cycle. Same thing, but the conclusion is different. The conclusions we do in iui. I also do a natural cycle in the IVF world, but it's usually for embryo transfers. When I'm transferring the embryo in, I'm a big believer of less is more. And there's some circumstances where I just really believe that she will not gain much from using the medications.
So if she has regular cycles, I let her body prep on its own again. I want her body to make that big follicle, that thick line of the uterus on its own. And I'm watching, I'm watching. And. And when the conditions are perfect, I have her take an ovulation medicine and then a week later, we're doing the transfer. I have done natural cycles ivf. I'm not a fan. That meaning that she makes that one egg on her own, and then we are going in to retrieve.
I'm not a fan because. And I'll do it if that's what a patient wants. It's just that the success rates are so low because we're going in knowing that we're just going to get one egg.
[00:34:58] Speaker A: So. And I know the third approach. We talked about CO Med and then iui.
Let's talk about ivf.
[00:35:06] Speaker C: So in ivf, your number of antral follicles, again, enter follicles is what your body activates every month is really key to your success because that tells us quantity. Let's say your body activates 20 antral follicles.
When you don't take IVF drugs, your body will look at the 20 antral follicles. It will naturally pick one to grow big and ovulate. But what happened with the other antri follicles that got activated? Well, they just die.
A lot of people have this very common misconception that, well, I just lose one egg a month, right? No, no, you ovulate one egg a month. But all those other antifollicles, you've lost them. So you actually lose many eggs every month. And this is why, even though we're born with about a million eggs, we run out of eggs by time we're 50. Because you're losing tons of eggs every single month. But what IVF does, it takes advantage of that by not letting them die off. So if you activated 20 antral follicles this month, you hope with IVF drugs to get 20 follicles to grow big for ovulation.
Your friend activated five antral follicles that month. Then I'm expecting five.
So a common misconception with IVF medications is just give me enough drugs. Can you get me to make, like, 25 eggs like my friend? It's like, I can't. Your body's going to tell me what your maximum potential is for that month. Another common misconception about IVF drugs is, great, okay, so I'm taking these IVF drugs. So now am I going to go through menopause earlier? Nope. Because remember, these follicles were going to die off.
Anyway, these IVF drugs are not tapping into your future egg supply. So the way you get these eggs to grow, the medicines for IVF are all injections. We call them subcutaneous, sub meaning below cutaneous skin. So you inject below the skin, in the fat layer under your skin, below your belly button.
So the needles are about 1cm short.
And it's scary at first if you've never done it, but after, I would say probably day three, you're like a pro at this, right? So you inject multiple drugs a day for about a week and a half.
And during that time, you need vaginal ultrasounds and blood tests about four or five times. So even though it's short, it is intense.
And so for women who are working, it's a little bit hard to juggle going to the fertility clinic and trying to let work know, hey, I've got to leave early today. Oh, hey, I'm going to be a little late for work today. It is challenging. After the week and a half, the eggs should be ready to be removed. It's done in an outpatient setting. Most fertility centers have an operating room. You are put to sleep. To some point. We put our patients to sleep completely by an anesthesia doctor. But I do have some colleagues who use, they call it twilight. They just use sedation through your iv. But regardless, you should not be feeling the pain of the retrieval because the way the eggs are removed, there's no cut in your abdomen. It's all removed through the vagina. And the duration of it depends how many eggs. For women from whom I'm getting 20 something eggs, about 30 minutes. But when I have a patient from whom I'm expecting about five eggs, I'm done in five, 10 minutes, usually 30 minutes max or less.
[00:38:34] Speaker A: Is that the same process that an egg donor goes through? And then what about what the process is for a gestational carrier that everybody still calls it ivf, but we're not using her eggs.
[00:38:46] Speaker C: Correct. For gestational carrier, it's very different. But this is the same process. Correct. That an egg donor would use or a woman who's freezing her eggs? The exact same thing. The only difference is the day I take the eggs out, I'm just freezing the eggs versus a person who's continuing with the IVF process. The day I take the eggs out is I need that sperm. So if it's a donor, then we already have the sperm sources. Sperm. Could it be fresh or frozen? If it's frozen, we defrost it. But the sperm and the egg comes together the day the eggs are removed,
[00:39:20] Speaker A: now and then for the gestational carrier. Because I know we use the word IVF all the time. So. So, you know, and trying to explain people technically, IVF is kind of a two step process.
[00:39:35] Speaker C: That's right. So once you fertilize the eggs with the sperm, you make these embryos. Embryos are fertilized eggs, right? They're frozen. Then you can prepare the gestational carrier. So there are different protocols for the gestational carrier, but most people do more or less the same protocol. So it's a combination of. You start off with estrogen.
So there are different forms of estrogen. You can use estrogen in the form of an oral tablet, vaginal estrogen, estrogen patches, estrogen injections, big needles in the butt. We call that intramuscular. So many different forms of estrogen. The purpose of estrogen is to tell her body, hold on, do not make an egg. Because we want to take control. And all we want to do is get the lining of the uterus to grow through thick.
And usually about week and a half to two weeks of estrogen, you'll hit that thick lining. Now, every clinic has a different minimal criteria, which is usually 7 millimeters thick, 8 millimeters thick, or 9 millimeters thick. And then there's a certain pattern, we call it triple layer pattern, three white lines. And you'll usually achieve that with the estrogen. So you need thickness and pattern. Once you have that, then you start progesterone. I will say most clinics in the United States do progesterone intramuscular injections, meaning in the butt. So because we don't really want our surrogates to do estrogen injections and progesterone injections, though sometimes we will.
Generally we will do estrogen orally and progesterone injections. Some centers also add progesterone suppositories in the vagina, which is fine. We generally don't do oral progesterone because it tends to have more side effects, though some centers do. So that's the protocol most centers use. But as you alluded to earlier, we also do an unmedicated, where they don't use any of the estrogen their body prepares itself naturally. But I still do like to use progesterone for the natural, which is the unmedicated, just because I don't know, sometimes I just am a little worried that they're not making enough progesterone. So I do give progesterone, maybe not as Much as a medicated, I usually use half the dose, but I do use a little bit of progesterone. There are some pros and cons of each for the clinic as well as for the surrogate. So I would say most fertility centers would agree that the success success rates are pretty similar. I know there are some centers that find they have better success rates with the unmedicated. And I've talk to other centers where they feel that they have better success rates with the medicated. At our center, we notice the success rates are the same, but the medicated, at least from the perspective of a center, it gives us more control.
So by me controlling when you start the medicines and how long you're on it, I can control the timing of the transfer. And for me, for somebody who travels for work, that's important because I hate, hate, hate missing somebody's transfer.
So by me controlling when you start and stop your hormones, I can ensure that I will be back and available for that embryo transfer. Whereas for an unmedicated, I'm at the mercy of her cycle. I don't, I don't know when her cycle begins. I mean, I know approximately when it will begin, but I don't know the exact date.
And then also I'm. Even though she has regular cycles, sometimes it takes a little longer or it's faster and she's ready. I'm like, oh no, I'm not going to be here for the transfer. So that's something that we inform intended parents that if she's doing an unmedicated, I may or may not be there for the transfer. If I happen to be traveling for work on the weekends, if I'm around, I'll come in for the transfer. It's not a big deal. But if I'm physically not available, the medicated also allows for that calendar and surrogates love that. Right? Because many surrogates have children who are still of great age. Right. They still need to find who's going to take care of my kids, who's going to take them to this activity, that activity, okay, I need to rely on my partner, I need to rely on my family, need to rely on friends. I can't do that with an unmedicated. With the unmedicated, you get one week notice when your transfer is. Whereas with a medicated, you have a month and a half notice when your transfer is going to be. So just for planning purposes, a lot of surrogates like to understandably make sure their family is well taken care of as they come here for Their transfer. The other thing is for a medicated, I can pretty much tell you when your ultrasounds are going to be. So for work, the surrogate can say, okay, on this day, I'm going to be a little late for work. On this day, I may have to leave work a little early.
For an unmedicated, it's a little bit like the wild, wild west. Because I may have her go in on cycle day 11 and I may say, oh, you're not quite ready yet. Can you go back in two days? She's like, two days? Oh my gosh. Okay, I have to give work notice. And let's say she goes back in two days. And I say, ugh, you're there, but not quite. Can you go back tomorrow? Right. And she's like, what? You need to have a bit of a flexible schedule to do the unmedication.
The other thing is, and this is for me, it makes me very nervous is we always tell our surrogates, right? No sex during preparation for an embryo transfer. Who knows what they do at home.
Now if they are on a medicated cycle, 99% of the time they are not making an egg because that estrogen prevents you from selecting an egg and ovulating. And that usually works. Or for an unmedicated, I want them to make an egg to ovulate.
And so we tell all the surrogates, no sex during the preparation. But the reality is with the medicated cycle, even if she had sex, she probably won't get pregnant because there was no egg to ovulate. For an unmedicated, she can get pregnant.
And that makes me very nervous. Right. So we emphasize, we're telling you you cannot, cannot, cannot have sex because there was a chance you're going to get pregnant. Like, we really drive that point home.
So at least makes me a little nervous. Yeah.
[00:45:56] Speaker A: Unfortunately, we've had a couple of situations where surrogates in the middle of a process, not in the middle of medications, but prior to, you know, getting pregnant on their own. And it, unfortunately, it happens often. More often than, you know, you hope. So I'm gonna switch gears and actually ask a question. I know we've been talking about women and all of that, but how do
[00:46:17] Speaker B: you approach testing for same sex couples? Male, male coup, or sometimes even for women too?
[00:46:24] Speaker C: So I'll start with the women because it's less complicated for the women. I do ovarian testing on both of them. And many times women couples will say to me, we want to do. We call it reciprocal ivf, where they both have their own group of embryos, but then they want to carry each other's embryos, which I think is so sweet, right, because everybody's just involved in the creation of every child.
And that's super easy. Each woman does her own IVF cycles. We keep their embryos separate.
And then usually they'll have the same sperm donor. And either it's a donor from a sperm bank or a friend. And then so once everybody has their embryos, it's frozen, then it's quite simple. Then each of them does their own cycle to prepare for transfer, but we're just putting the other person's embryo in her body. So it's pretty simple. You know, one of the things, and this is with any couple is especially when you have women, women couples, though, just be prepared that sometimes one woman's egg results are better than the other. And if there's a big difference in age, it's not surprising. But when their ages are quite similar, you know, it makes for just a very. Talk about having just to realize, oh my gosh, like I thought I was fertile and I'm not. They're not trying to get pregnant, right? Because they're the same sex female relationship. And sometimes it's just hard, you know, I just feel, I feel for them when I have to explain to them, your tests are great and your tests are, are not that great. So let's talk about it, right? That's hard for the male. Male couples, not all, but most of them have pretty decent sperm. And even if they didn't, right. In the world of ivf, it's so forgiving with sperm because IVF handles sperm one by one that even if I don't have perfection, we can still make embryos, even if a guy doesn't have great sperm. Very different for women.
So in male, male couples, they will do their own semen analysis. And they do this in their hometown. So whether it's in the United States or whether what country they live in, they do the semen analysis in their hometown. And we also have them do infectious disease testing in their hometown just to make sure if anything's abnormal, let's just deal with it and get it tested. Then they have to do this again, but this time it's the real sperm we use for the treatment. And the blood test has to be at a lab that's approved by the fda. The FDA is a Food and Drug Administration. So in the United States, when we are creating embryos with the intention to put that embryo in a gestational carrier, the FDA says that the egg source, that is the egg donor and the sperm source both need to have these FDA tests done at the time we're getting the egg and the sperm. The FDA test consists of blood test, urine test, a full physical examination and a questionnaire. And because we have so many intended parents throughout the world, we actually have these labs throughout the world.
So these male males, of course they're welcome to come to San Diego, right? It's a great place to travel to and have a holiday.
But many times they're like, I'm too busy and it's too far. Right. So we send them to our locations throughout Europe, throughout Asia, where they can get this done. And then the sperm is frozen and then shipped to our center. And then the blood, urine, all of that will then get processed at a FDA approved lab. Well, once that sperm is at our center and frozen, just keep it frozen and the quality does not change. We keep it frozen until the day we're taking the egg donor's eggs out from her body. And that is the day when we defrost the sperm. And also DNA mutation compatibility, right? And this is, be it with lesbian couples using a sperm donor or male, male couples using an egg donor, we need to make sure the egg source and the sperm source do not have the same DNA mutations.
Because if they do, and if it is for a disease that's pretty lethal, then there's a chance that they will both give it at the same time. That embryo will have two copies, one from the egg, one from the sperm, and then that embryo, that child will actually be sick with the disease.
Now, sometimes we have people who use like a family member or friend, and if they truly, truly, truly, truly want to stole, you make an embryo with that family member and that egg and sperm source do have the same DNA mutation.
Depending on the disease, we can create a probe and then the probe can detect which embryos have double copies. And then those embryos we will throw out, because embryos with one copy is fine. It's only the embryos with double copies that will be affected by the disease.
So we can do that. But keep in mind that that means that you're losing some embryos, because some embryos with the double copies I will throw out, but also increasing cost and time to the whole process.
But if that's important, it's doable.
[00:51:28] Speaker A: Yeah. And that brings me to my next question about technology. Because obviously the advances in technology over the years, over the 20 years that you've been in this space and I've been In this space now, 24 years has changed drastically. What developments have you seen in your practice that are like making a real difference?
[00:51:51] Speaker C: Gosh, yes. I remember, Eloise, when I started this in 2004, right, we were doing day three transfers because we were growing embryos to day five at that time, we didn't know how. And I remember day three transfers. We never put in one embryo ever, right. It was always, how many embryos are there? Four. Let's throw all four in, right? Of just hoping, hoping something would stick. I mean, that's how bad IVF success, success rates were at that time, Right. It's amazing, right, isn't it, when you see how much our field has changed, right? So, number one, growing to day five, day six, we call that the blastocyst stage. And the studies are so clear that day five, day six embryo transfers are superior to day three embryo transfers. Two, because they're superior, we don't have to throw in four or five embryos anymore. And that the trend now is transfer of one.
I will say, as an aside, I am still one of the few fertility doctors left who transferred two embryos day five, day six. It's not for everybody and it's not without its risks. But indeed, if you want to minimize risk, maximize health, transfer of one day five, day six embryo is the answer. But also PGT testing, my pre implantation genetic testing, which is where we would biopsy the embryos. It used to be we would biopsy a day three embryo which only had 6, 7, 8 cells.
Now, of course, we don't do that. We biopsy a day five, day six embryo which has over 100 cells, and we only take out four, five, six cells. I mean, gosh, what a big change over the years.
And then of course, all the advanced genetic testing that we're able to do. I remember back then we would test people genetics based on their ethnicity. And it was like a handful of tests, just a few.
And now look at these DNA mutation panels of like 300, 500 diseases. It's like, wow, it's significant.
[00:53:57] Speaker A: I mean, you know, I've been a gestational carrier three times, but the first embryo transfer was three embryos. The second one was four embryos, the second one, and the third one was two embryos. And that was from my first journey. So, yes, I, I was there during those times. I can absolutely relate. How does somebody go about when they're looking for a fertility specialist?
[00:54:25] Speaker B: What should they be looking for?
[00:54:27] Speaker A: What's the credentials that they should be considering?
[00:54:30] Speaker C: Yeah, and I think this is tough, right? Because in the world now, where we do so many zoom calls, you're not really having these meetings face to face in person. I mean, sometimes you are, right. But most of the consultations I have, just because we have such intended parents from all over the country and all over the world, they're by Zoom. And I think it's really hard to gauge a connection with the physician. So in the United States, board certification is challenging to get board certified in the United States because it's not only a written test, it's a three hour oral exam. It's hard. Keep in mind that if you have a physician who's fairly new out of training, they are not board certified yet, just because they haven't, you have to accrue enough cases to be board certified. Okay. So I think that looking at where your physician trained, how many years of experience they have, which I'm sure all patients would do this right? That's a given. I know many people will look at reviews online, and I mean, I do as well when I look at physician, but I would take it with a grain of salt because I feel that the people who write reviews are one of two extremes. Either your super happy patients or your super angry patients. Right? Like the people in the middle, like, don't really write reviews. So I would take that with a grain of salt. I think reference from somebody maybe who's gone to that physician, friends or family members also carries a lot of weight. But honestly, at the end of the day, like, you've got to do either in person or zoom call with this physician. And I would do a zoom as opposed to just a phone call. And I think that at the end of the consultation, you may just sort of get a sense of what this person is like. And again, I know it's hard, but you got to just go with your gut. And also keep in mind that it's not just the physician, it's also the team.
Right? And ask them, okay, but I understand it's you, but. So how does the protocol work at your clinic? Who, who do I. Who's my go to? Who do I talk to? Who's on my team? For us? Because we do. I mean, in a year, we do over 1200 cycles, but over 600 of that are surrogacy cycles. We have a pretty streamlined process, right? So we have a team, a whole system that makes this work so efficiently. And we're not perfect by any means, but we have an infrastructure in place. And I think that for some people, especially if they're new to the process, they may want perhaps a smaller clinic which is completely fine. But for some people, they want that well oiled machine. And I think that's important to ask your physician. What is your clinic like?
[00:57:01] Speaker A: Absolutely. So for last question, what's the best piece of advice for someone considering testing or, you know, like, I'm just getting started, I'm thinking about this process. I just don't really know where to go, what to do.
[00:57:20] Speaker C: Yep, yep. I would definitely say if you are a woman, contact your, I would say ob gyn, probably the primary care doctor because an ob GYN is probably more well versed in the egg test that they need to do. I would contact your ob GYN and share with him or her that, you know, you're just looking to get an assessment, you're not concerned, et cetera. And then for men, your primary care doctor probably is able to order your semen analysis. And if and for either of them, because I've had some men who are like, my primary care doctor doesn't know where to send me, then for both of them, contact a local fertility clinic. They are more than happy just to do initial assessment. And I would say that no matter the results, and of course I hope that they are okay, but that no matter the results, especially if they're not great, there are so many resources out there. Get yourself educated. Get yourself educated because you can't change your current status, but what you can control is how you will respond to it. Right. Your reaction to it and what you're going to do about it. So you gotta get yourself educated and hopefully you're at an age where you can just take things into your own hands and just try to make the most of it.
[00:58:34] Speaker A: Yeah, definitely.
[00:58:36] Speaker B: So before we wrap up, where can
[00:58:38] Speaker A: listeners learn about you and SDFC?
[00:58:42] Speaker C: Great. So our website is SD for San Diego, SD fertility.com so they're welcome to go on the website and take a look and make any appointments, look at the services we offer and you know, and hopefully that we can build a partnership with our clients as we do with you and to grow families. Because like, and I know you agree with this, like, love has no boundaries. Right. So we both are very strong believers that if you want to have a family, we will make it happen.
[00:59:16] Speaker A: Absolutely.
[00:59:17] Speaker B: Thank you so much, Dr. Park, for joining me.
[00:59:19] Speaker A: I really appreciate it.
[00:59:20] Speaker C: This is great. Eloise, great talking to you.
Thank you.
[00:59:25] Speaker B: To our listeners, remember that understanding your fertility is a crucial step in your family building journey. Regardless of your background or circumstances. If you'd like to learn more about fertility testing or connect with Dr. Park, visit our website at thefertilitycafe.com where you'll have links to resources mentioned in today's episode. You can also watch the full video version of this interview or on our YouTube channel. Remember, love has no limits. Neither should parenthood. Thank you for joining us at the Fertility Cafe. If you found value in today's episode, please subscribe, leave a review and share with someone who might benefit from this information.
You can find, show notes and resources from this episode in the description, or visit thefertilitycafe.com for more information.
