In this video, Aimee Raupp and Dr. Zaher Merhi answer all of your burning questions about fertility.

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Aimee:

Hello. How is everyone? I'm here to do a live Q&A. Ask us anything about fertility and alternative medicine, or fertility and reproductive medicine. I'm going to be joined by Dr. Merhi. So he's a reproductive endocrinologist. He is the founder of the Rejuvenating Fertility Center kind of everywhere. He's got offices in New York and Long Island and Westport, Connecticut, where I now have an office in his office, so phenomenal. I don't see him on yet. Request to join me live. Do you see him on yet, anybody? No.

Aimee:

Let me just see. Everybody's rolling on. You guys are psyched, aren't you? Me too. I love doing these with him. He's so bright and smart and a caring, compassionate physician, which is just wonderful to have and be. And so also, we're doing it in honor of National Infertility Awareness Week, which I would like to change that to National Fertility Challenges Awareness Week. I don't think any of you are infertile, or broken. There is something out there for everyone. We can figure it out and I'm wearing orange to honor that.

Aimee:

He's not here yet. We just texted. So let's see. He said for me to go live first, so let's give him… Hi, Carolyn. It's good to see you. I'm going to wave at you. Let's see. Where is this man? Okay. He's going to be coming on any minute. So yeah, we're excited to do another live and then this doesn't count towards our monthly lives. We're still going to be doing another one in a couple of weeks, together, in our regular pattern of… Hi, Robia. Of our monthly lives and yeah, let's see what unfolds today.

Aimee:

So I hope you guys came with questions. Remember he is a fertility doctor and has been around and knows a thing or two for certain about fertility and practices, some very cutting edge therapies to help women get the most out of their fertility treatments, or trying naturally. And I am a licensed acupuncturist and herbalist and the author of several books and one being Yes, You Can Get Pregnant. And I help women all over the world optimize their health and their fertility, so that they can get pregnant naturally, or have very successful fertility treatments.

Aimee:

And here he is. Let's see. I think you have to ask to join me live. There we go. Okay, here we go. He's coming on. Let's do this. We're waiting for him. [crosstalk 00:02:58].

Dr. Merhi:

Hi. I'm sorry. I'm so sorry.

Aimee:

You're still at the office? I thought you were going home.

Dr. Merhi:

I never go home. I'm always working. You know that.

Aimee:

Did you see the present I left for you on the desk?

Dr. Merhi:

Love it.

Aimee:

Okay, good.

Dr. Merhi:

Love it. Thank you.

Aimee:

I came in with James. He was looking for you, but you weren't there.

Dr. Merhi:

Thank you.

Aimee:

My son has a little obsession with Dr. Merhi. It's kind of cute. They haven't actually met, but he talks about him a lot. He's like, “Dr. Merhi. So can you ask him to get us a baby?” That's what he said.

Dr. Merhi:

That is so cute.

Aimee:

It's so sweet.

Dr. Merhi:

I can't.

Aimee:

Because the one day he said, “What does he do for a living?” I said, “He helps women make babies similar to what mommy does.” He was like, “Well, I think that's great. Let's get you a baby.”

Dr. Merhi:

Oh, that's so cute.

Aimee:

So no pressure.

Dr. Merhi:

That's really cute.

Aimee:

We'll figure it out. Don't worry.

Dr. Merhi:

No pressure. Yeah, Aimee. Thanks a lot. You tell me why I'm working all day long?

Aimee:

I know. I know.

Dr. Merhi:

So I can help people.

Aimee:

Sorry. Yeah, I know. It's a disease that you have. You want to help everybody. Oh, can I turn off my comments? Well then I can't see the questions, guys. Let's see. I don't even know how to turn off comments. Let's see.

Dr. Merhi:

I can do a [inaudible 00:04:07]. Someone wants to see my face? I'm not that cute, but here.

Aimee:

We can't see the doctor's face. I don't even know how to turn off comments. How about that. But [crosstalk 00:04:17] maybe if you know how to.

Dr. Merhi:

I don't think you can. Can you?

Aimee:

I don't know how to.

Dr. Merhi:

You can tap on the screen to minimize the comments.

Aimee:

Yeah. You can what?

Dr. Merhi:

Tap on the screen to minimize comments. I'm not sure.

Aimee:

Oh, I just did it. Okay. I've minimized them. Look at that.

Dr. Merhi:

Cool.

Aimee:

Now we can see your face. Okay, thank you for whoever gave us that pointer. Oh, no. Now they're back. Oh, I see. There we go. Okay, got it. So how are you? How was the day? Okay?

Dr. Merhi:

Very good. Still busy. Busy. I'm still working.

Aimee:

Okay.

Dr. Merhi:

[crosstalk 00:04:52].

Aimee:

So we're doing this Q&A.

Dr. Merhi:

Well, we're doing this for National Infertility Awareness Week.

Aimee:

Yeah. I'm wearing my orange. You can't quite see it now, because I've been blocked out. But I have my orange on for National Infertility Awareness Week, although I would like to say that I don't like the word infertility. I'm in the boat of these are fertility challenges.

Dr. Merhi:

We discussed that.

Aimee:

We could do some fertility rejuvenation, which is so funny with your clinic name, because I said that in my book. I was like, “You're just in need of some fertility rejuvenation.” That's how I see it.

Dr. Merhi:

Before I even met you.

Aimee:

That's it. It was in the stars. It's more than [crosstalk 00:05:32].

Dr. Merhi:

So I want to do some comments about the word infertility and I agree with you 1,000,000,000%. Let me tell you, first of all, there was a period of time where all the fertility doctor were using the word subfertility, not infertility.

Aimee:

Yes, which is so much better.

Dr. Merhi:

It's better and more appropriate, because to me, infertile meaning you cannot.

Aimee:

It is, because that's what it is. Yeah.

Dr. Merhi:

But it's really not. Subfertile. It's similar to premature ovarian failure, or POF. It's not a failure. They call it now insufficiency and they changed the name to premature ovarian sufficiency.

Aimee:

Insufficiency. That's what it is. Yeah.

Dr. Merhi:

So to me, infertility should be replaced to subfertility. Mentally it's better on the person.

Aimee:

I agree. Because women just feel so broken. It's like, “Oh.” And I always say it's not an on-off switch. There's so many things we can do to help maximize. Yeah.

Dr. Merhi:

So I definitely agree with that term. But the national awareness week, we need to do a better job in my opinion. I was talking to Dr. Vidali today. We had a nice conversation.

Aimee:

Nice. I have to watch it. Yeah.

Dr. Merhi:

And we were talking about that the awareness should not just start with patients. Patients know about infertility, or subfertility.

Aimee:

Because they're going through it.

Dr. Merhi:

But we need to reach out to the regular public, who don't know about it, or who don't think about. I had a patient today telling me, “Oh, I always thought life would be easy. I'll just get married, have kids and bam. And look where I am, I'm sitting in front of you, struggling, because I didn't know infertility even existed.” So we need to reach out to those people, but also to the government and to all the lawmakers in every state, for them to understand that it's very common and one in eight couples do have infertility problems. And I compared that, sorry for the comparison again, to breast cancer incidents. One in eight women have breast cancer.

Aimee:

And we know all about it. We're doing everything prevention-wise.

Dr. Merhi:

Right. And we screen about it and mammogram and it's covered by insurance. But yeah, fertility is not covered by insurance the majority of the time, which to me, is not fair at all.

Aimee:

Not fair at all. I agree. And I always say to women too, it's you spend all this time and energy planning your wedding and prepping and spending all this money and like on this one event, what about preconception? No one's giving us these tips and tools about preconception care. And I think there's a lot of stuff we could manage to then prevent fertility challenges down the road, or at least be aware of. Even some of the testing and things like that, that women could do as well. But I agree, there's just not enough education around there.

Dr. Merhi:

But also, the OB-GYN doctor and primary care doctor, I really think we need to do a better job. A study that was published a couple of years ago, that it was basically surveying OB-GYN doctors to see how many of them, they talk about egg freezing to their patients, single patients. 23%, something like that. That was like, “Are you kidding?” So we really need to do a better job, I think and the education for even healthcare providers. I really do.

Aimee:

I agree. I agree. And just even all the other testing. None of them even really look at thyroid the way they should and understand how that could complicate things, or vitamin D levels. They're not checking things the way they should. That could be better support, than [crosstalk 00:08:59].

Dr. Merhi:

To maximize. I agree. I agree.

Aimee:

So [crosstalk 00:09:02].

Dr. Merhi:

Do you want to take some questions?

Aimee:

Let's see. So, “Hi, I'm 40 years old. Starting follicle testing with TSI and injecting Gonal-F and Ovidrel. Any tips to help with the process? Very scared. Timed sexual intercourse, that's TSI.” Okay. Yeah.

Dr. Merhi:

Oh, timed. Okay. Okay. Oh. So typically, Gonal-F is expensive, even if it's covered by insurance. I'm not sure. And again, I'm not saying anything, the doctor must be great. I don't use injectables with timed intercourse, or IUIs. Not because I don't, because there was a big study that actually changed the practice of IUI and intercourse. And they found that giving pills with timed intercourse, or IUI, and then jumping to IVF is better than using injectable during IUI. More cost effective, same outcome and less drugs. So I don't use Gonal-F and timed intercourse cycles. I use clomid, letrozole, the trigger shot, to time things better. But at 40 years old, it's very important to kind of make sure not to waste too much, too many times, months, just doing timed intercourse. It's important to kind of have a plan. Three months of intercourse, three months IUI, I move on to [crosstalk 00:10:29].

Aimee:

Move on.

Dr. Merhi:

As much as we hate, but we need that baby. So we don't want to [crosstalk 00:10:36].

Aimee:

We don't want to waste time.

Dr. Merhi:

Exactly.

Aimee:

I love it. And so let's just see. Yeah, so I think try this, because she says she starting with this. So try this month, the way it is, but then bring up to your doctor about the idea of doing oral, like letrozole or clomid, instead of the Gonal-F and see if you get results and then not to spend time with it.

Dr. Merhi:

Right. But also remember, with Gonal-F, the chances of having triplets, twins and even triplets, is much, much higher than the pills. Absolutely. Because remember when you're [crosstalk 00:11:13], if you have three follicles, or four and you inject sperm, you can't control what the sperm is doing inside the body, so minimizing multiple pregnancies, but avoiding the injectable, is usually recommended. But again, I'm just saying in general, it might be [crosstalk 00:11:31].

Aimee:

One has their different approach. And I do think everybody does what they feel most comfortable with. So someone else says, “I snore every night. Can this affect fertility? I'm not sure if I suffer with apnea.” I can take this one from the holistic side of things too. Just I do think if you're not getting deep, restorative sleep, it will negatively impact your health and your resiliency and things of that nature, so it might be worth looking into. I would also look at dietary changes. I think taking dairy out a lot of times helps with snoring and inflammation, but I think it's a sign that you might not be getting… Especially if you wake up, not feeling rested in the morning. To me, that's something I would dive deeper into, because that's when your cells, everything in your body, rejuvenates itself, is when you're sleeping. So you really do need your restorative sleep.

Dr. Merhi:

I agree with you 100%. It's interesting though. Just I want to mention to this person who asked the question, is if she has PCOS, or polycystic ovary syndrome, there is a strong correlation with the sleep apnea. And when you get PCOS under control, the sleep apnea disappears.

Aimee:

What is the correlation? Can you explain it? Some kind of inflammatory response.

Dr. Merhi:

Nobody knows. But insulin resistance, plus usually they're a little bit overweight, all these where the insulin resistance do cause sleep apnea. So the guidelines by the Endocrine Society is to make sure three things for women with PCOs, diabetes, sleep apnea and endometrial cancer, because they don't get…

Aimee:

I never knew that. I never knew apnea. But it makes sense. So from a Chinese medicine perspective, it's the same thing of there's an accumulation. There's phlegm, the cyst are phlegmy to us. And that would translate to inflammation and typically, when you see the sinus congestion. And even to us too, we say that the nose and the vagina are very related. If there's mucus and congestion in the nose, there's typically mucus and congestion in the lower abdomen too. That's a correlation for us in Chinese medicine. So actually, that's very interesting. But yeah, that's the avenue I would go to, of like getting the mucus and the phlegminess under control. Okay. “I'm 38. I have stage III endo. Should I have full excision surgery before going back to IVF? I've had two fails. My AMH is 0.35. Not sure what to do. I can chime in on this too, because I feel like I know Vidali's brain so well.

Dr. Merhi:

Why don't you you tell us what Vidali would do?

Aimee:

But I would say absolutely, you should get surgery a hundred percent. Yes. Have a full autoimmune workup. I do always recommend reading the book, “Is My Body Baby-Friendly?” by Allen Beers. I think that's a good book to understand kind of what's going on. And the late Dr. Jeffrey Braverman would also say, “Absolutely, you should have the excision surgery.” And that endometriosis impacts egg quality, because it's an inflammatory condition. Until you get the endo under control, you might not improve the egg quality. And so Dr. Braverman wouldn't even actually use embryos that were collected, even if they were normals before endo surgery, because he felt like they would fail. Implantation failure. I didn't always see that clinically and I've said that to his face, so I'm not behind his back, even though he's not with us anymore.

Aimee:

But I didn't always see that, but he was that adamant about getting the endo out before, than going and doing another retrieval and/or a transfer. But I do see it with implantation failure and I'm sure you can say the same thing of if there's an inflammatory condition going on like endo, that you might not implant and you might not create the best quality eggs. So personally, I know it's a lot to go through a surgery. I would look into Dr. Andrea Vidali, because I think he's one of the best endo surgeons that is out there and I would do a consult with him and then move forward from there.

Dr. Merhi:

Yeah. Look, it's a case by case basis. That's why Dr. Vidali and I will discuss common patients, because it's also important, with a low AMH, to get a good surgeon, because sometimes the surgeon can lower your AMH and you're beginning with less [crosstalk 00:15:46].

Aimee:

And I see, with Vidali, the opposite. The AMH tends to go up. I've seen that in cases. I've seen it not change. I haven't seen it go down, though, after surgery with him, I'll say that. I usually see it go up, which is kind of amazing and it makes sense to me. If it's a hormone secreted by the ovaries and the ovaries have endo around them. But if you do the surgery properly, where you're reducing the inflammatory situation in there, then wouldn't the ovaries start, I don't know, being happier, if you're making more AMH? Yeah.

Dr. Merhi:

Right.

Aimee:

You agree?

Dr. Merhi:

I agree. I can never disagree with you. I'm scared. If you're doing an acupuncture session, I don't disagree with you. Punch me with big needles and stuff. I don't want that.

Aimee:

Funny. Yeah, funny. But no, I also agree with what you said, if it's a case by case basis. But I think with the two fails and knowing you have stage III. If I were in your situation, I would go for the surgery, personally.

Dr. Merhi:

No, with two failed IVF cycles, Aimee, I always like to go back to the drawing board and see [crosstalk 00:16:48].

Aimee:

What are we missing? Yeah, I agree.

Dr. Merhi:

You need to kind of go back. They can look inside the uterus. Is there anything that was missed? Number one. Number two, go back to the sperm. We keep forgetting it.

Aimee:

100%. Yeah.

Dr. Merhi:

The latest recommendation and this is by the American Society for Reproductive Medicine. Very recent guidelines. If a couple has two failed IVF cycles, you should test sperm DNA fragmentation.

Aimee:

DNA fragmentation all the way. 100%.

Dr. Merhi:

And that has changed. I didn't believe in DNA fragment… Not because I didn't, because the guideline was it's still experimental. It doesn't change much. But with multiple failed IVF cycles, even if the sperm is good, good DNA fragmentation, if it's high, the urologist should go and do testicular aspiration from the epididymis to get the ones with the lower… And it makes a big difference. Now if your partner said, “No way I'm having a needle in my testicle for the [crosstalk 00:17:49]. Men. Trust me, if men were to carry babies, we won't have children. But then there's no purpose of spending time and money on DNA fragmentation.

Aimee:

But if the male sperm… If there's a male sperm. Could be same sex couple, I don't know. If the male sperm said, “I'm sure. I'll do anything.” Then it's worthwhile going back to that and [crosstalk 00:18:09].

Dr. Merhi:

Yeah. And looking.

Aimee:

Because we tend to always blame it on the egg. The sperm, even if it looks good with high DNA fragmentation, if the male partner smokes, take steroids, or take medication that could affect the DNA fragmentation, or overweight, or works in a gas station and getting toxins, all of that has to change. Also, just one little thing, antidepressants have been shown to increase, a little bit, sperm DNA fragmentation. So I'm not saying stop the antidepressant for your partner, but it's worthwhile.

Dr. Merhi:

But get onto an antioxidant support, right? Yeah.

Aimee:

Exactly.

Dr. Merhi:

100%.

Aimee:

Exactly.

Dr. Merhi:

Because that's when I watched Dr. Braverman, what he would do when he found DNA fragmentation, it was basically like powerful antioxidants that he would put the male patients on and it would decrease the fragmentation. And I have a YouTube video, recent one, on optimizing sperm health, but it's all about the current research and what you can do. There's so many things you can do. But I also heard too that if embryos arrest in their development, that a lot of times it's sperm-related. What do you think about that?

Dr. Merhi:

So that's an important question. So the embryo development between day one and day five, it varies from day to day. The first three days, it's 95% an issue.

Aimee:

That's what I thought. Yeah. And then the last two…

Dr. Merhi:

The DNA of the sperm kicks in on day four.

Aimee:

Wow.

Dr. Merhi:

Day four, day five. So if embryos are divesting, if they look perfect on day three and they starting to stop between day three and day five, and trust me, this is more common than you think,-

Aimee:

Yes. It's so common.

Dr. Merhi:

-it's important to start to think, “Okay, let me go back to that testicle and suck some sperm.”

Aimee:

Yeah. Wow. Yeah, because I've heard that too, of like the arresting embryo development, that a lot of times it could be sperm-related. And, “Oh, but the sperm's fine.” I'm like, “But you should get a DNA fragmentation test, or at the very least, let's get him on some supplements and change some things around.” Yeah.

Dr. Merhi:

Zinc, vitamin E, all these are anti-allergenic and good for the sperm.

Aimee:

L-arginine. Yeah. Good fish oil. Okay. So, “Irregular cycles and PMs throughout the month and cystic nodules on the thyroid. Any tips?” I would make sure you have a complete thyroid panel. TSH, free T3, free T4, thyroid antibodies. You have to make sure you don't have Hashimoto's and make sure your TSH is in range. It should be below a 2.5, right?

Dr. Merhi:

Absolutely. The TSH should be less than 2.5. That's also recommended. So even though that normal range for TSH for the thyroid is between 2.5 and 5, but if your number is a 4, even though it's normal for women who are not trying to get pregnant, it's not good for [crosstalk 00:21:09].

Aimee:

Not normal for fertility.

Dr. Merhi:

And by the way, you caught one person and I remember the doctor said, “No,” and then you said yes and you were right, so I put her on it.

Aimee:

I was right.

Dr. Merhi:

So it's important to have it between 0.5 and 2.5. Very, very important. It's correlated with miscarriages and failed implantation, if the TSH is not well controlled,-

Aimee:

That's it.

Dr. Merhi:

-so yeah.

Aimee:

And I would also think some of the other cycles like irregular… Oh my God, there's so many questions now. We're going to have to cut this off at some point, because this man has to go home. But irregular cycles… Wow. Where… Oh my God, I lost our question. Okay, here we are. So Sophie, so irregular cycles, I would definitely look at diet and lifestyle and supplements. All those things I talk about in my book too, but really look at that TSH. Make sure you have a complete panel. “34 with hypothalamic amenorrhea. Lean PCOS. All six embryos went to blast. Any success with poor and fair embryos?” So you didn't test them. I'm assuming. If they just went to blast, so they're frozen at blast? What about success with [crosstalk 00:22:17]?

Dr. Merhi:

So wait, so hypothalamic amenorrhea and lean PCOS. This is very tricky, okay? It's very, very important to differentiate the problem, because I'm assuming this person doesn't have a regular period.

Aimee:

No. Right.

Dr. Merhi:

If you don't have a regular period and you're skipping, it could be from the ovary or from the brain. But she gave us two problems and the same. PCOs and hypothalamic amenorrhea. It can happen. There are some data around it, but we need to make sure that it's not one or the other. What I'm trying to say is that it's very rare to have both at the same time.

Aimee:

Got you. Right.

Dr. Merhi:

Okay.

Aimee:

Because one's coming from the ovary versus one coming from the brain. If you have hypothalamic amenorrhea, you are not ovulating, right? Is that correct?

Dr. Merhi:

Correct. But then you need something like Menopur.

Aimee:

To help [crosstalk 00:23:09] PCOS.

Dr. Merhi:

We need Menopur, which is FSH and LH, in order to work as if there's a gland, in order to cause the ovaries to [crosstalk 00:23:19].

Aimee:

To ovulate.

Dr. Merhi:

The good news [crosstalk 00:23:22].

Aimee:

You've got six Embryos.

Dr. Merhi:

Yeah, they get pregnant very easily.

Aimee:

Yeah. And once you figure it out. So I guess her question, any success with poor and fair embryos? If you haven't tested them, you transfer untested embryos, right?

Dr. Merhi:

I do. And honestly, the grading is very subjective.

Aimee:

Yeah, I agree.

Dr. Merhi:

If you give an embryo to three embryologists, one will give you A, one will give you B and give you C+, so it depends on how you're looking at the embryo. But having said that, it's unfortunate that the genetic testing does not correlate with the grading. And I can tell you from experience,-

Aimee:

Yeah, I know. It doesn't.

Dr. Merhi:

-I've had embryo's that are AA. Beautiful, Aimee. Beautiful. You test them, they're down syndrome. And then you have a C embryo-

Aimee:

Yeah and it's healthy.

Dr. Merhi:

-and then the [inaudible 00:24:09] gives a beautiful, perfect baby. To me, I always say if you're doing genetic testing, the grading doesn't really matter much.

Aimee:

Yeah. Right. But does the grading matter then? Either way just transfer and see if it sticks.

Dr. Merhi:

If we not, then we have to go by the grading. That's the only thing we have to work with.

Aimee:

Yeah. Right. But yeah, I remember that with PGS testing in the beginning that the naked embryologist eye, in comparison to the PGS testing, was actually not accurate. You would have a beautiful embryo and it could still be abnormal. You would have an ugly, fragmented embryo and it was… Yeah. Okay. Let's see. Oh, so Carista, was that your question? Did I miss Carista's question? “41.” Okay. “I'm currently in it right now. Love it.” Okay. “Just in my fourth retrieval, 18 eggs, five blast tested.” Okay. Amazing. So she's talking about… Okay. “My FSH has been consistently…” That's amazing news, Carista. “My FSH has been consistently in the 20's and I'm supposed to start IVF, but then this cycle, all of a sudden, cycle day three, my FSH shot up at 56.3. How could this happen in one month? The cycle is so different now.” I want you to take that.

Dr. Merhi:

Yeah. The answer is yes, it does. The FSH varies tremendously. A lot of things can shoot the FSH. The issue is not with the FSH. A lot of people panic. I have patients who have FSH over 100.

Aimee:

Well, I panicked. It was two months ago.

Dr. Merhi:

But I have patients who are FSH over 100 and they have babies now. I'm not lying to you.

Aimee:

I've seen it too. I've seen 60s, 70s and then two months later, it's a 12, but they make babies. I agree. Yeah. It doesn't correlate to egg quality.

Dr. Merhi:

But if she's starting IVF, she has to be extremely careful. Now I always tell patients if your FSH is high, your body is stimulating itself. You don't need more stimulation.

Aimee:

You don't need stims. Right.

Dr. Merhi:

You need suppression and this is how, when we use estradiol, or birth control pills,-

Aimee:

Birth control pill.

Dr. Merhi:

-to shut it down before you start anything. But be gentle. Try to do natural IVF, rather than a stimulated IVF cycle.

Aimee:

Yeah, well, you don't need the FSH, because yours is already high. That's exactly what you're saying.

Dr. Merhi:

But the injections are FSH, that you spend $1000 on. The FSH, made in the lab.

Aimee:

“When should I expect to get my period after an early miscarriage, when we six to seven weeks? This was my first time getting pregnant after IUI.” Well, sending you lots of love, Maggie. That sucks.

Dr. Merhi:

Oh, I'm so sorry. I hate miscarriages. Ugh.

Aimee:

I think if you miscarry naturally, it usually resumes four to five weeks. If you have a D&C, it could be six to eight weeks. Everybody's different. I recommend acupuncture, Chinese herbs, like castor oil packs. Those things will really help kind of bring it on. And then I don't know about this. “That this just my first time getting pregnant after an IUI. Is my risk of future miscarriage higher?” I don't necessarily think so, but I want to hear what you have to say about that.

Dr. Merhi:

The answer is every miscarriage is independent than the other. We have a couple who have a down syndrome baby and then normal baby or vice versa. Every egg is different. So not necessarily, you might have a higher miscarriage, but with IUI, because we're putting the sperm and we can't test the embryo and the egg, it's hard to know what's going to happen.

Aimee:

Got you. You kind of force the [crosstalk 00:27:35]'s hand a little bit. Yeah.

Dr. Merhi:

Right.

Aimee:

Yeah.

Dr. Merhi:

As far as the miscarriage, I agree with you, Aimee, that everybody's different, because the hCG, the hormone pregnancy level, you need to wait for it to be cleared out of your system, but everybody clears things differently based on their kidney function and everything. So some people in two weeks, everything's bam. I'm like, “What?” Because she dropped from 5,000 to 5 in two weeks.

Aimee:

They're ovulating in two weeks. It's crazy. Yeah.

Dr. Merhi:

And some people last forever, so everybody's different.

Aimee:

Yeah. Yeah. And I would think too, one thing that I learned a lot from working with the Vidali and Braverman group is in the recurrent miscarriage category, if you have any other seemingly autoimmune type conditions, maybe you go to a hematologist and get a clotting factor panel, or ask your practitioner, the doctor who did the IUI, to do a miscarriage panel on you, just so you could rule out if there's a clotting factor issue that may be caused the miscarriage. Make sure to check your thyroid, that kind of stuff. I always say to girls too, if you want to go into the next pregnancy armed, feeling like you checked the boxes, that you did things differently, even though miscarriages happen 20% of the time and it can be as random… So it's kind of where your head's at, but it doesn't mean that your likelihood of having another one.

Dr. Merhi:

Also testing the tissue. If she did D&C,-

Aimee:

Yeah. If you did the D&C. Yeah.

Dr. Merhi:

-testing the tissue for chromosomes,-

Aimee:

So helpful.

Dr. Merhi:

-I think would be helpful. If it's genetically abnormal, we know what the answer is. If it's genetically normal, then you need to get immune recover stuff.

Aimee:

Then we look deeper. 100%. And I missed that. You're right. And I also would say, after my miscarriage, that was such peace of mind when I got the testing results. I can't describe it. It really was healing for me. “I've been on very low dose of Menopur 75 and Gonal-F 75. It's been 16 days of stimulation and the follicle is growing, but slowly. Can so many days of stimulation harm the egg? There's only one.”

Dr. Merhi:

Look, the reality is first I want to know the age of the patient. If the patient is over 38, the answer is yes, it could. Why? Because as we get older, things become more fragile and more sensitive. So when I was a teenager, I would fall on the floor, I would bounce back. But now if I fall down, you're calling 911 in a minute. But all jokes aside, egg is the same thing. They become more susceptible to the drugs as we get older. But also, if you're taking 75 and 75 and you're not developing anything, all I can tell you, if you don't take anything, you might develop one follicle. So it's better not to take anything, than taking medications.

Aimee:

I [crosstalk 00:30:05] so much. That's one of the reasons I love you. I agree with that so much. Why do all those meds to just get one or two, if that's what you're going to normally produce anyway? Yeah. And talking about the age thing too, what I say is even as we get older, the pipes get clogged more easily. We just can't detox the same way we did and so we're more sensitive to the meds and I do think they harm. Okay, I think we're going to take a few more questions, because then this man's going to go home and rest.

Aimee:

“Just turned 40 years old. Once a year consultation for IVF to be single mom. They found quite a big ovarian cyst and a polyp, so it's suggested to go under surgery before the IVF process. I'm very concerned.” I think I know what you would say. If the cyst isn't secreting estrogen, maybe we don't care so much about it, but the polyp could impact implantation, so we should get it out.

Dr. Merhi:

This needs to be taken out.

Aimee:

Yeah. Yeah. “Thoughts on priming with Omnitrope, Estrace and Prometrium for 30 to 60 days prior to doing mini IVF? I'm 45, attempting IVF for the fifth time, but this is my first time priming prior to a cycle.”

Dr. Merhi:

So the answer is I'm not sure why the Prometrium, but all I can tell you is the only true operations of human growth hormone, there are data showing that if you take it for at least two weeks, you need sometimes up to a month, or more, to prepare with that, might. I'm saying might improve egg quality, because I can tell you with my experience and I've done a lot of Omnitropes, a lot of people it's not doing anything and they spent, every 10 days, $1,000. So we're talking $3,000 just for Omnitrope-

Aimee:

Maybe.

Dr. Merhi:

-for a month.

Aimee:

For a maybe. Yeah.

Dr. Merhi:

And then for a maybe. Again, I'm not saying this because I want to promote PRP, but if you think about the PRP, platelet-rich plasma, I'm taking your own blood, your own growth hormone, your own other factors and putting them directly inside the ovary. Directly. So to me that's more aggressive and actually more cost effective, if you think about.

Aimee:

It's much more cost effective. Yeah.

Dr. Merhi:

Because when you also take Omnitrope, usually we'd command to take seven units per day. A patient injects herself seven units. Not all of it get absorbed. Let's say five out of seven get absorbed and they go onto the blood, half of it get metabolized, three units reach the ovary. Out of the three units, maybe one or two units will reach the egg. But with the PRP, I'm going and putting it-

Aimee:

Right in there.

Dr. Merhi:

-directly at a much higher concentration. But some people in Cypris, they do put both at the same time.

Aimee:

Wow.

Dr. Merhi:

PRP and prepare with…

Aimee:

That's that guy in [inaudible 00:32:51] that does the…

Dr. Merhi:

Correct.

Aimee:

Yeah.

Dr. Merhi:

Now as far as the Estrace, I like Estrace. Varies from person to person. But Prometrium, I'm not sure why would someone do that. Unless for three months, you have to have some Prometrium, otherwise they'll increase the risk of endometrial cancer without anything like that.

Aimee:

Okay. Interesting. Okay. So how do you feel about one more and then we'll let you go?

Dr. Merhi:

Yes.

Aimee:

Okay. Okay. “Can egg quality be improved with low AMH at age 35?” So I'm going to tell you to go watch the video him and I did last week. Okay, here's a good one. “I have low AMH, 0.35, but normal FSH. I'm 33, hoping to have multiple children. Would you recommend embryo freezing?”

Dr. Merhi:

So one out of five women will have discrepancy between AMH and FSH.

Aimee:

AMH and FSH. How many? One out of what? One of five?

Dr. Merhi:

One in five.

Aimee:

And antral follicle count. That's got to matter the most, right?

Dr. Merhi:

The study that I'm aware of has compared to AMH to FSH. I'm not aware of studies comparing antral follicle [crosstalk 00:34:11].

Aimee:

I guess I was just asking you from a clinical perspective though too, but yeah.

Dr. Merhi:

From clinical perspective, you need to be careful with the antral follicle and AMH. A lot of things lower AMH. If this person is on anything, for example, birth control pills lowers AMH. If you stop the AMH birth control pill for a month.. You should stop it for a month, then measure AMH, because it's shut it down. Mirena IUDs. All type of hormonal contraception over a long period of time lowers AMH.

Aimee:

Will lower AMH.

Dr. Merhi:

Vitamin D deficiency are related with low AMH. Replace vitamin D, bam, it goes up. There's tons of studies on this. Smoking, being overweight. Losing weight improves the AMH. So the fact that the FSH is good is great, but with the AMH, if the antral follicle count is low, I would definitely bank, because if you get pregnant today and you don't have anything in the freezer and you're 33 years, average of 0.35. You need nine months of pregnancy, then you deliver a baby, then postpartum. Try again, that's two years from today. Your AMH might be 0.1. Much harder if we don't have anything in the freezer to do anything, to get pregnant again. So I'd rather be on the safe side. Listen, I've never heard someone saying, “I wish I didn't freeze my eggs, or my embryos.” I really didn't. I always hear the opposite. So to me, why live through this anxiety? Just freeze embryos.

Aimee:

Yeah, just do it. The other side too is I've seen AMH go up with age. I'm sure you've seen that in cases, where it's appalling sometimes, where you're like, “How did your AMH go up that much?” But is it because of radical lifestyle changes? That if they were doing certain things that were suppressing it and then they removed those things. Yeah.

Dr. Merhi:

The answer is yes, but also, Aimee, one important thing is different labs have different standards for AMH.

Aimee:

Ah, okay.

Dr. Merhi:

So if I take your blood and send it to two lab, I might get 1 or 1.5. Which is a big difference.

Aimee:

Big difference.

Dr. Merhi:

And also, the lower the AMH, less than 1, the more likely the variation between tests. So you might get 0.4 For today, 0.7 in two days, just because it could be… I'm not saying the diet and all that doesn't help, but also you need to see what the lab and who did it, because if you see how they do the test, mistakes can happen. [crosstalk 00:36:45] when they do the test. I say yeah.

Aimee:

Okay. I know. “What is DNA fragmentation? What should it be at?” someone's asking. Is there a percentage?

Dr. Merhi:

So there is multiple tests. This all depends on the test. I do believe the most common used one recommend less than 25% fragmentation, but I could be wrong. Please don't take this number. It depends on the lab. And the normal AMH at age 40 is usually 1.

Aimee:

Yeah.

Dr. Merhi:

1.

Aimee:

1. Okay. All right. We're going to let him go home and he's tired. Okay, wait. This girl. “44. Worth going into retrieval on no stim? Only BCP. Possibly one egg. Or do I do an IUI, or skip and try to start oral stims?” I'm a little confused. “44. Going into retrieval on no stims, only birth control pill. Possibly one egg. Or do I do an IUI, or skip and try to start oral and stims?”

Dr. Merhi:

I wouldn't do IUI. Let me tell you why. Because if God forbid, it's abnormal egg and it sticks and then we get pregnant,-

Aimee:

Miscarriage and we lose time.

Dr. Merhi:

-get miscarriaged, then do a D&C, then wait till it's over. We lost a lot of time. Again, case by case basis, but I'm just trying to do a devil's advocate here. Yeah.

Aimee:

Yeah, but you just want to [crosstalk 00:38:14]. You'd rather go in, fertilize, see if it grows a blast, test it. You would do all that?

Dr. Merhi:

Or I would bank. Not just test it, bank,-

Aimee:

Yeah, bank.

Dr. Merhi:

-before you end up in a miscarriage and waste nine months of your life and then you could have banked multiple other embryos.

Aimee:

Yeah, I agree. [crosstalk 00:38:30] time lost.

Dr. Merhi:

You don't have to always test, but bank.

Aimee:

I lost almost a year, I feel, from my miscarriages, [inaudible 00:38:33]. Yeah. Okay. Okay. This is where we're going to wrap it up. We're going to let this man go home. He's tired. He's had a long day. But thank you for being so dedicated to this community.

Dr. Merhi:

Thank you, Aimee.

Aimee:

And yeah, I'll talk to you later, okay?

Dr. Merhi:

Thank you for my gift.

Aimee:

Bye.

Dr. Merhi:

Bye, guys.

Aimee:

Thank you so much.

Dr. Merhi:

Okay. Bye-bye.

END OF TRANSCRIPT.

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