"What Do You Mean We Got ZERO Embryos?!"

After learning I have Asherman Syndrome and low ovarian reserve, Matt and I decided with our doctor to move forward with IVF.

We were stunned at first — we never expected we would end up here. At the same time, we were eager to get started and optimistic about our chances.

My doctor walked me through what would happen next: we discussed the necessary medications, the cadence of appointments, the potential timeline of my retrieval. I have a hazy memory of her mentioning there is, on average, a 5% chance of an IVF cycle yielding no fertilized eggs. But what we didn’t discuss, and I didn’t think to ask, was what my expected outcome was given my diagnoses.

In fact, I remember sheepishly confiding that we were really hoping to only have to undergo one cycle — we don’t have IVF insurance coverage and the budget was going to be a stretch. She said, “OK”.

My antral follicle count (AFC) at the start of the cycle was 8 — low for my age at the time, but not devastatingly so. But as the cycle went on, my ultrasounds showed disappointing results. Only 3 follicles were growing as expected, the others trailed far behind. My retrieval date was incrementally, painstakingly, pushed out a day at a time in hopes of coaxing more follicles to grow (which is to say, daily appointments and a nightmare of a work schedule).

In the end, we retrieved 4 eggs.

I felt a confusing mix of disappointment and hope. I was crushed we didn’t retrieve more and knew this likely meant a longer road ahead. But I was glad we had something.

Then came (what I now know as) the gauntlet of the fertilization process. Initially, 3 of the 4 eggs showed signs of fertilization. A couple of days later, we got word that all 3 had stopped growing.

None of them developed into blastocysts.

We had pushed through the retrieval cycle, shelled out more money than we ever expected to spend, and had zero embryos to show for it. I hung up the call with the clinic and sobbed on the bathroom floor, the weight of it absolutely flattening me.

Anyone that has done IVF knows it’s a numbers game (IVF Hunger Games, anyone?).

Arming yourself with the data — though it won’t necessarily soften the blow of any setbacks — allows you to begin the IVF process with eyes wide open, aware of all potential outcomes.

I know now that when my doctor didn’t push back when I said I, a patient with low ovarian reserve, only wanted to do one IVF cycle to meet our family goals, I wasn’t given the resources to be as well-prepared as possible. What I should have understood at the outset was that it would almost certainly take us several cycles to obtain the number of embryos we needed.

The IVF Funnel

IVF is all about attrition. At every stage of the retrieval and embryo development process, you lose numbers. That’s simply the imperfect nature of human reproduction.

I like this resource about the “IVF Funnel” that approximates the expected rate of attrition at each step. It’s important to note that outcomes are strongly influenced by one’s age, diagnoses, protocols, and more.

While I wish I had seen this before I embarked on the IVF process, seeing examples that illustrate this phenomenon were incredibly informative during our unsuccessful retrieval round.

Family Planning & Goal Setting

Most reproductive endocrinologists will advise that a couple should bank 2-3 embryos for each live birth that you hope for. You’ll hear this because each euploid (genetically normal as determined by PGT-A testing) embryo has a 65-70% chance of resulting in a live birth. Genetic normalcy isn’t a guarantee of viability — there are other factors that can cause an embryo to fail to implant or to miscarry.

What I didn’t realize before we began IVF was that you need to get really clear on what your goals for your family are for your lifetime, not just for this first pregnancy. And if your doctor doesn’t ask (they should), you should tell them.

We knew we wanted multiple children and that our fertility timeline was limited due to my low ovarian reserve diagnosis. So we knew our goal was to bank enough embryos for several live births— for all the children we hoped to have. I just didn’t realize how many rounds that could take.

Since we want up to 3 kids, the realization that we would need several rounds of egg retrievals to bank enough embryos to meet our goals — 6 to 9 — hit me like a ton of bricks. I realized how poorly my expectations had been managed, and how much that impacted my mental health as we navigated the process.

Before my first retrieval, I called a friend who froze her eggs over several cycles to ask for any perspective she could share from her own experience. One thing she shared that I wish I took to heart significantly more than I did is that many doctors see the first round of IVF as diagnostic.

In your first cycle, your doctor doesn’t know how you’re going to respond to the meds. All they can do is prescribe you a basic protocol, hopefully customized around your unique diagnosis, then hope for the best. It is only once you complete that cycle that you and your doctor have valuable insight into your body’s unique response to stimulation, which medications work best for you, etc.

While physically we had nothing to show for our first retrieval, what we did have was data and perspective.

Managing your expectations based on your family goals is what will make it possible to keep going. Once I understood how many embryos we would need, and how many rounds it might take to get there, I mentally buckled up for the long road ahead.

I understood that this was going to be a marathon, not a sprint, and that I should prepare myself accordingly, body and mind (more on that in a future post).

I had to say goodbye to yet another pregnancy timeline. “I’ll probably be pregnant by March” turned into “…Maybe next year?”. So I knew I needed to care for myself in the meantime.

There were several questions I wish I had thought to ask my doctor prior to starting that first retrieval cycle that would have helped me manage my expectations.

What would you add to this list?

• How many eggs can we expect from this cycle [based on my unique situation]?

• Walk me through the expected embryo attrition rate [based on my situation].

• We want to have ### kids.

  • How many embryos do you recommend we bank?

  • How many rounds do you anticipate we will need to get there?

• How are cycle updates communicated?

  • This can help you know what different types of contact might mean and can prevent surprises. E.g. does the doctor, not a nurse, only call if the news is good or bad?

• How many successes have you had with cases like mine? What worked and what didn’t?

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