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Doing the show is so special to me for so many reasons, but one of them is that I get to connect with amazing, brilliant doctors from all over the world. And many of them are my really close friends. So today, I’m super excited to have Dr. Jenna McCarthy joining me.
Dr. McCarthy went to Dartmouth for undergraduate degree, and she completed her medical training at University of Michigan, which is one of the top five women’s health programs in the US. She’s one of a handful of physicians selected by the American board of OBGYN to complete her training as a combined six year residency fellowship.
As a fellow, she was awarded grants from the Fibroid Foundation and NIH for her work on uterine muscle STEM cells. She’s published numerous articles and co-authored multiple book chapters on her major research interests, including uterine fibroids, ovarian reserve and fertility preservation. She has presented at multiple national and international meetings.
Dr. Aimee: We have known each other for fourteen years. Why don’t you tell our audience about yourself?
Dr. Jenna McCarthy: I’m a reproductive endocrinologist, and I work for IVF MD, which is in South Florida.
We have 12 doctors, and we have offices throughout South Florida from Miami, all the way to Vieira, and all the way out to the West coast of Florida in Naples. One of the things I love about our practice is that each of our offices is generally small with only a couple of doctors. Even though we’re a larger practice we maintain that small office feel where when you walk in the door. So that’s something that we take very seriously and pride ourselves in.
Dr. Aimee: Today we are talking all about how to avoid the most common IVF mistakes. How long have you been doing IVF, Jenna?
Dr. Jenna McCarthy: I’ve been in practice for 10 years, and as you can imagine, I have seen a fair number of mistakes.
Dr. Aimee: The reason why we’re tackling this topic is that we want people to avoid these mistakes, and hear that they’re common and they happen.
I just want to go through a whole bunch of scenarios for our audience. I think it would be really helpful for them to hear from an expert like you.
So here’s one mistake. Bending the needle, you have the needle, you’re going into the vial. What would you tell a patient?
Dr. Jenna McCarthy: This is something that can happen pretty easily because those needles are pretty flimsy. What I usually tell people in regard to any IVF mistake (including medications) is first off: don’t panic.
If it’s something that you can correct easily at home, go ahead and do it. If not, call your doctor or your practice. We are here to help you.
In this particular situation with a bent needle, see if you can extract the needle from the vial. If it’s not coming out easily, you can disconnect it from the syringe, which I would probably do. If you have a fair amount of medication in the syringe already, but just slide it out, put on a new needle and start over.
Dr. Aimee: Exactly. Don’t Google it. Don’t YouTube it. Call your doctor.
What about patients who run out of needles? Often patients think you have the “right” needle, and then all of a sudden you’re out of your 27 gauge half inch. What would you advise a patient in that scenario?
Dr. Jenna McCarthy: Fortunately pharmacies often have needles. If you contact your team, they can call in a prescription to a local pharmacy for you. Also, a lot of times we have these needles at the office. It’s not uncommon for either myself or a nurse to meet a patient at the office and provide them with something so that they can continue on.
Dr. Aimee: Worst case scenario, when it’s 10 o’clock at night, and that’s just not an option? You can always take an old needle that you used (and believe it or not) and wipe it with an alcohol swab. It was only in your skin, so it’s not contaminated. Put it back in. It’s something that I’ve told my patients to do.
What if someone has a needle, but it’s not the right size. Like you have the 22 gauge one and a half inch for mixing, but you don’t have the 27 gauge. What would you tell a patient?
Dr. Jenna McCarthy: You can always use needles interchangeably. Doctors pick the needles that we pick because they tend to be the most comfortable, but that doesn’t mean that you can’t use a larger needle, a longer needle or a thicker needle to inject the medication. It just tends to be a little bit more uncomfortable.
Dr. Aimee: What about if you’ve run out of a medication? You have enough menopur, but you’re out of gonal-F?
Dr. Jenna McCarthy: In those cases, you’re going to want to talk with your doctor. Some (but not all) medications are interchangeable to a certain degree. Your doctor may be able to help you out with medication you already have at home. Or they may offer to meet you at the office, if they have some samples that we can provide you.
Many doctors’ offices also know of a local emergency pharmacy that keep a little bit of fertility medication available. It’s unfortunately more expensive, but if it’s just one night kind of thing, it’s better than losing the whole cycle.
Dr. Aimee: Let’s move on to a question about the vial itself. What if a patient is putting the needle inside the vial and they keep pulling air out, with no liquid?
What would you tell a patient?
Dr. Jenna McCarthy: This happens a lot, and there are two common reasons.
One is that the needle is above the level of the fluids. To fix it, you need to gently pull the needle back till it’s in the fluid. That’s going to help draw the liquid up.
The other thing that can happen is that you either don’t have a full seal between the needle and the syringe, or you have a small crack in your syringe. To solve that, you can try putting the vial back down and starting over with a new needle on a new syringe.
Dr. Aimee: What if a patient comes in for her retrieval and she has had a sip of water? How often do you see that happening?
Dr. Jenna McCarthy: Not too much, because we really stress with patients not eating or drinking before a retrieval, it has happened. And, it’s not the end of the world. If it’s just a sip of water, we can generally go ahead with the retrieval using conscious sedation.
Now, if a patient forgets and has a full breakfast (and I’ve had that happen), then the procedure’s going to have to be done without conscious sedation, but it can be done.
And there are rare instances where a patient has had a full breakfast, completely freaks out, and doesn’t show up for the retrieval. They think that they’ve lost their whole cycle.
The good news is that there are things that we can do. So, don’t just not show up. Don’t ghost your practice, call them and tell them what happened. Let them advise you on what they can do to make things work.
Dr. Aimee: Exactly. Doctors take these situations personally, and very seriously. We want patients to succeed.
And what do you tell the partners (either a male partner or a female partner) as to what to eat or drink that morning? Because I’ve had the partner think the instructions are for them too, and they shouldn’t eat or drink as well.
Dr. Jenna McCarthy: Yeah, no, we want them to have breakfast. We want them to have their cup of coffee because we don’t want them passing out when their partner’s IV is put in. We encourage them to eat and drink as they normally would.
Dr. Aimee: What common mistakes have you heard about or seen regarding the trigger shot and the timing about that?
Dr. Jenna McCarthy: The most common mistake is forgetting to take your trigger shot at exactly the time that it was supposed to be taken. Doctors stress the importance of doing a trigger shot on time when you do your IVF consult or your injection class, depending on how your practice does it.
Sometimes life gets in the way, or something happens, and I’ve had frantic calls about a patient missing their trigger shot. For example: their trigger was supposed to be at 7:30pm. They left work with (what they thought was) plenty of time to get home in time to do it. And, now they’re stuck in Miami traffic and they can’t get home, and they don’t know what to do.
In this case, we moved the patient to the end of the retrievals on the day she was scheduled, and it worked out fine. There’s definitely things we can do. And that’s why talking with your practice is so important.
Dr. Aimee: Exactly. It’s also about pre-planning. If you think there might be a long drive home, you could bring your trigger shot to work with you that day.
One thing doctors don’t want to find out on the egg retrieval morning is that you were two hours off with your trigger shot. We’ll always be there to help you for sure, but we need to know ahead of time so we can create a plan for it.
And what about semen or sperm collection? What kind of mistakes have you seen associated with that?
Dr. Jenna McCarthy: We’ve been lucky. Our guys have been pretty good. Occasionally, someone will be nervous and they’re not able to do a sperm collection on the day of retrieval. That’s probably the most common. And I always want the guys to know that it happens. Please don’t feel like you’re the only one that this has happened to.
More commonly, we see that men have ejaculated too recently. They didn’t realize that they were supposed to be abstaining for a certain amount of time. We typically ask our partners to ejaculate on the day of trigger shot so that we can have as fresh of a sample as possible.
So they get a message, a reminder, to please hold off on ejaculating after the trigger shot, prior to the retrieval. But sometimes that happens, and that’s the big one.
We’ve been fortunate and not had a situation where a partner didn’t realize that he was supposed to be there. Although, I could see that happening, particularly if you have a partner who is out of town or out of the country.
Dr. Aimee: I had it happen once. He was out of state. And I was like, “Huh? Whose sperm are we supposed to get?” And it wasn’t frozen ahead of time. But, it all worked out. He was in a State close to California, so he flew back that day and we got the sperm right in time.
It’s situations like that that make me reinforce things a little bit more forcefully with my patients: retrieval time is the semen collection time. We need you there. If you’re not planning on being here, we’ll freeze the sample ahead of time. If you think there’s going to be a sperm emergency, and we’re going to freeze the sample ahead of time as well.
Have you ever had patients who use the wrong medication? So for example, they gave themselves the trigger shot (HCG) instead of the HGH? Or another medication instead of the trigger shot?
Dr. Jenna McCarthy:I have. The most common mistake I’ve seen happen is when we’re adjusting estrogen doses during the frozen transfer cycle. I’ve had quite a few patients accidentally take their vaginal progesterone orally. It doesn’t harm them physically, but unfortunately when the lining of the uterus is exposed to progesterone at the wrong time, it ruins the whole cycle. In that situation, we stop the cycle and we have to start over.
Fortunately in these situations, the embryo is frozen. It doesn’t care or know the difference. Emotionally it’s difficult for the woman, but certainly better than going through an unsuccessful cycle.
I’ve seen fewer errors on the fresh cycle, likely because we speak with patients or see them either daily or every other day as they’re going through their cycles. They can ask their questions more easily, and literally bring in their medications to reference, and so we’ve had fewer of those problems.
Dr. Aimee: I just want to go back to you saying she took the vaginal progesterone orally. Are you talking about the Endometrin?
Dr. Jenna McCarthy: No, we use progesterone.
Dr. Aimee: That’s a big tablet. I actually had a patient place that rectally because she read something online about it and thought that she could do that. And I’m like, “whoever wrote that online hates people and they’re just messing with you. You don’t put vaginal progesterone, rectally.”
Dr. Jenna McCarthy: No, that would not be comfortable.
Dr. Aimee: Another story: I actually had a patient take birth control pills during her frozen embryo transfer cycle, because she wanted to keep having sex and not get pregnant.
These are the kinds of things you need to talk to your doctor about upfront.
She told me she was taking birth control bills at the time of the embryo transfer.
I was literally about to put an embryo in and she’s like, “Oh, I’m going to stop taking the birth control pill now.”
I’m like, “What?”
I’m so glad we caught it. Because, obviously, the transfer probably wouldn’t have worked, but it’s just so important to just talk to us. Tell us what you’re doing, tell us what you’ve done. There’s a reason why we’ve given you instructions.
Have you run into situations where you give a patient clear instructions for something, but the pharmacy will put different instructions on the bottle?
Dr. Jenna McCarthy: Yes. Especially around taking estrogen and progesterone together. Sometimes the pharmacist doubles down, and tells a patient, “Oh no, this is going to cause birth defects.”
And that’s when we get a very concerned patient calling us and we just have to reassure them that in this particular situation, the pharmacist is giving you bad advice. Estrogen and progesterone are normal pregnancy related hormones. If you take them at the wrong time in your cycle, they’re a contraceptive, but it is safe. We wouldn’t prescribe something that’s not safe for women to take during pregnancy.
Dr. Aimee: Exactly. What about taking expired medications? In some other areas of medicine, expired medication could be okay. What about in fertility medicine?
Dr. Jenna McCarthy: I recommend against it. Cycles cost anywhere from 10 to $20,000, depending on what type of cycle you’re doing, and what type of add-ons you have chosen for your cycle, genetic testing, HGH, that sort of thing.
Why would you want to take the risk with expired medications to save a little bit of money? You want to make sure that this cycle has the greatest chance of being successful. And so for me, that means using medications that haven’t expired.
Dr. Aimee: How about if you’re a patient and you don’t get a followup call on your blood work? You’re doing IVF and you’re going in for your monitoring ultrasound. What kind of steps does your clinic take to make sure a patient knows what to do that night?
Dr. Jenna McCarthy: Unfortunately, that can happen. We’re all human, and even though the nurses and doctors are trying to do everything perfectly, mistakes can happen
So we have a couple of things. First of all, every patient who goes through an IVF or stimulation cycle with us has a personalized voicemail that’s set up within our system. It’s a private voicemail with a password. This is where we leave information for patients. It’s helpful because it removes the issues around misdialing a number, or reaching a patient when they are busy or can’t really engage in the conversation. You never know where you might catch someone when you call them: maybe she’s at a gas pump? She might be standing in front of her boss and she doesn’t want to say anything that reveals what she’s talking to you about, but she can’t really tell you that either. This private voicemail set up has been really helpful because patients can call in at times that are convenient for them.
Additionally we always have someone on call. We have a nurse on call till midnight, and we have doctors on call 24 seven. So if someone doesn’t get a message on their voicemail, they can simply call and the on call doctor or nurse will look in their chart and say, “Oh, I see you were supposed to take this much medication tonight and come back tomorrow” or whatever the current protocol is going to be.
Dr. Aimee: That sounds great. Have you ever had a trigger failure where you’ve told a patient to take a trigger shot and she actually didn’t take it? And, you find out the hard way — have ever had that happen before?
Dr. Jenna McCarthy: I’ve had trigger failures, but never because the patient didn’t take the shot. Unfortunately in that situation the post trigger shot labs looked really good, but when we went in to do the retrieval, we weren’t able to get any eggs. In situations like that (after a discussion with the patient), we’ve tried re-triggering using a different type of trigger shot to see how things go. We also offer the patients the option of canceling the cycle and starting over.
But if you have a patient who didn’t do the trigger shot, and she tells you that morning or if the labs reveal that she thought she drew up her HCG, but she really drew the water and didn’t actually mix it with a powder or something like that?
Sometimes we can look at the rest of the hormones. There’s an old fashioned process called “coasting” where women actually go a day without hormones to let their estrogen levels drop prior to trigger. We can give that a try. It used to be done when we were seeing a lot of ovarian hyperstimulation syndrome. So, it may not be the end of their cycle.
It’s definitely a situation where you’re going to want to talk with your doctor and your nurse about what can be done potentially to remedy and salvage the cycle.
Dr. Aimee: I think one of the biggest mistakes when it comes to IVF is not having the right set of expectations going in. This process is taxing on our hearts and our souls, as well as financially. I I think that the biggest risk is of the emotional toll that this whole process takes on a patient. And it can be harder if the patient doesn’t have the right set of expectations.
If you go in with the right mindset, then no matter what happens, you’re prepared for it. What do you do for your patients to prepare them for their IVF cycles, so that they have expectations around what success looks like?
Dr. Jenna McCarthy: That’s a great point. All my patients sit down with me starting an IVF cycle, and we do an “IVF chat.” We review the risks and benefits of IVF. That’s the official purpose of it.
It’s also important to set expectations. As the doctor, I might consider a cycle to have been a success. But if I don’t tell my patient that I’m expecting to get four or five eggs from the cycle, and she’s read online that someone else got 20 eggs, she might feel very disappointed or feel that the cycle wasn’t successful.
One of the very first risks that we talk about is the idea that IVF might not work.
I also talk about what I think each patient’s cycle will look like based on their history, age, and labs. So I’ll say to them, “Your antral follicle count is five, which means if this is an ideal cycle, I’m going to get for example, four to five eggs.”
We review the average fertilization rate is with IVF, conventional insemination, and with ICSI. And I share the blast formation rate for our labs, so that they have an idea of how many embryos they can expect from any given number of eggs that we retrieve, and about how many embryos I anticipate they are going to have to freeze or biopsy.
For context, nationally, we’re looking at about only one out of every three mature eggs is going to make a blastocyst. If you have someone who starts at their cycle with 15 eggs and ends up with five blastocysts, I’m doing my happy dance! That’s great news.
I don’t want a patient to be disappointed because she was thinking that each of those 15 eggs were also going to become a viable embryo.
I want to make sure we don’t run into that disconnect, and give each patient the context for what success looks like, and what a great outcome looks like.
Dr. Aimee: I wish more doctors did this because I’m sure you and I both get so many second and third opinion consults. Patients are hearing this kind of information for the first time when they speak to us.
Now you know what questions to ask your doctor ahead of time.
- What do you expect from my cycle?
- What would be considered a great cycle for me?
- And how many cycles should I consider doing for the goals that I have for myself?
Don’t you think?
Dr. Jenna McCarthy: Absolutely. There are some women who need to come in with the mindset that they are going to do a couple of IVF cycles, and there are other women where it’s very reasonable to anticipate that they’ll be able to achieve what they’re looking for in terms of the size of their family with a single cycle.
Dr. Aimee: Yes. Jenna, thank you so much for being on our show. Thank you for answering these questions about common IVF mistakes. I just want you to know I went to your website and I saw this beautiful quote and the quote was, hold the vision, trust the process. Can you tell us what that means for you?
Dr. Jenna McCarthy: I love that quote. Basically what it means is that there are detours and potholes as you’re going through the whole IVF process. But if you really keep your eye on what you’re looking to get out of this, which is a healthy baby, the process can be okay. And, you just need to reach out to the people who are there to support you. And that includes your team. That’s what we’re here for. Just hold onto that final end goal that you’re looking for, and you’ll be successful.
Dr. Aimee: I love it. You have so much passion about what you do. What made you go into medicine, and more specifically, fertility medicine?
Dr. Jenna McCarthy: I couldn’t think of anything else that I would rather be doing than getting up every morning and helping someone to have a baby. I mean, honestly, can you think of anything that’s better?
Dr. Aimee: Oh, absolutely not. The patients ask me all the time, “When are you going to go on a vacation?”
I’m like, “I’m sorry, why do I need one? I’m doing what I love every single day.”
Dr. Jenna McCarthy: It’s pretty awesome. These women trust us with so much, it’s really a privilege to do it.My office is in Jupiter, Florida, and our website is https://www.ivfmd.com/.
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