Transcript for ""Low Fertility, Can I Get Pregnant?" Innovative DOR Treatments": Alright. Good morning, everyone. Oh my goodness. Here we are. We made it. It's the fertility and wellness summit. I'm so so excited. Before I begin, I just wanted to say thank you so much for that wonderful introduction, doctor Luke. I'm so glad to start off this wonderful session with Generation Next Fertility's director of third party reproduction, doctor Jesse Hade, and our lab director, doctor Alicia Broussard, who's really gonna dive into low fertility, can I get pregnant, innovative DOR treatments? So welcome, and good morning. Good morning. Thank you. Thank you. And as always, woah. Welcome. Welcome, everyone. Thank you so much, Destiny, for arranging this today. Really, amazing job. Yeah. Thank you so much. Happy to be here. Yeah. So as Destiny mentioned, I'm the good doctor Haight here today, and I have, doctor Alicia Broussard, who's our embryology senior embryologist lab director here at Generation X Fertility. And, we're gonna talk about strategies for improving outcome for women with low egg reserve or poor response. Just to give you a background, I'm, I've been practicing medicine clinically since, for almost 30 years now, and I've been at Generation X Fertility for the past 4 years. I'm the 3rd party director and not only do I specialize in, egg donation or couples who are looking to do egg donation as recipients or gestational carriers, as intended parents, we also do all sorts of fertility treatments and especially experimental cutting edge therapies specifically designed for people with either poor response or who have good ag reserve and are just having poor outcomes. And we'll go through a little of this today. And, doctor Broussard, please, I don't wanna hog up all the airtime. Thank you. Yeah. Thank you. I'm the laboratory director here. I've been in the field for about 21 years now. Started off as an embryologist for many years, and then, went back to school, got my PhD, became lab director. So, I'm very happy to be here. Always a pleasure to talk about share the stage with doctor Haydah anytime. Him and I certainly do a lot of work on a day to day basis, on these topics. So yeah. Terrific. So yes. No, please, doctor Haight, by all means. No. Yeah. Should should we start with the slides that I I think so because you know what? A lot of people have been asking us, and this is why we really thought this was the greatest, like, first topic to kick off the summit, is if I have low fertility, like, can I get pregnant? So if you could explain that for us, doctor Haight, that would be fantastic. Yeah. So let's jump on to the slide. So I always start off by telling every patient who sees me that your egg reserve does not predict outcome. They're independent factors. But when you're doing fertility treatment, someone with low egg reserve may require more treatments to get the same outcome as someone else who's undergoing the same therapy with a low reserve, or with a normal reserve. So when you're looking at egg reserve, in a normal menstrual cycle, everyone's only releasing 1 egg anyway. So that doesn't predict if you have only 3 follicles competing for ovulation or you have 35 follicles competing for ovulation in a month. It doesn't predict whether or not you'll be able to achieve pregnancy within the same time because everyone in a normal cycle is releasing one egg, so your time to pregnancy theoretically should be the same. Where reserve matters is only for couples who actually have an infertility issue, and that's really what we're emphasizing here. This is topics that we talk about that's related to couples who are seeking fertility treatments, and this is why we try to explain to them it's not predicting outcome, but it's just stating to manage expectations. How many therapies do you think we would require to get you the outcome for that beautiful child? Mhmm. Right? So Yeah. When we're looking at ovarian reserve, you could see that someone with a lot of follicle or an abundant follicles will have a high count versus someone with diminished reserve will have a low count. So what is DOR or diminished ovarian reserve versus what is poor ovarian response or POR? So the difference is is that lower diminished reserve just talks about the number of follicles and eggs competing in a month. So when you look at the average number of follicles that someone would have, it's based on age. So when you look at age, age matters because as a woman ages, the total number of follicles and eggs remaining in the ovaries is decreasing. But there are some women who have normal numbers of follicles, but when they undergo IVF, they actually don't respond appropriately to the injections and medications. So that's what we call poor ovarian response, where they're having very few eggs despite having fairly normal to robust numbers of follicles present on on ultrasound. So how do we do better? You know, doctor Broussard and I scratch our head all the time. We really look at this as if you think about IVF in general. I always tell most of the innovations that have come in IVF are through the lab and what doctor Broussard does. The laboratory the success rates from 1981 when the first IVF cycle was performed in the United States to 2024, the majority of these innovations and improvements and outcomes have been solely in the lab, better incubators. And I'll leave doctor Broussard to discuss why she thinks that may be. But, really, most of that innovation comes on her end. And that's why when you start to think about it and at Generation X Fertility, what we do differently is we say, what can we do as physicians to get you more follicles and maybe better quality eggs so that when we hand them off to doctor Broussard in the lab, how do we get that better chance of having that pregnancy and and live birth? Right? You agree so far? Yeah. Very well said. Yeah. Yeah. It sounds like I'm hogging up all the time here. No. No. Please. So when we talk about it, in reality, every almost everyone on this, in this forum today were were created in a cycle where only one egg was released for the most part. So remember, it only takes one egg to create a baby. Mhmm. But that's why by increasing that total number of egg yields per treatment can greatly improve the outcome specifically for women who have poor response or low reserve. And so we'll talk about some of these strategies, and we'll address it, such as luteal phase stimulation, platelet rich plasma therapy or PRP therapy, and additional medications such as human growth hormone or HGH. Mhmm. So when we talk about luteal phase stimulation, it's also referred to as duostim, meaning you're doing 2 treatments in 1 menstrual cycle. And, really, this is for women who have split cohorts. Because what's what's fascinating about when you're doing infertility treatments is that you can't just keep stimulating and get follicles to grow and decide at any specific day, I'm gonna trigger on a Tuesday because that's convenient for me and the patient. Unfortunately, it doesn't work that way. You really have to go by what the follicle is telling us is the right and specific time. So when patients are coming in and when we're doing monitoring, really the whole goal is to look at when you're starting at the beginning of the cycle, what these small little antral follicles look like. Those are follicles between 2 9 millimeters. And through the process of giving medications, what the medications are doing is to allow multiple follicles to grow to maturity. So mature follicle is considered a follicle somewhere between 15 23 millimeters. And in reality, that varies from individual to individual. And we're also drawing blood work to assess different hormones produced by these follicles to say how much estrogen are they making, are you taking the appropriate amount of FSH to stimulate the total amount, and that's why we sometimes do FSH levels. LH levels to make sure there's no premature surge, that you're gonna prematurely ovulate. And progesterone is the follicle starting to produce. Progesterone meaning it's transitioning from a, a follicle to a corpus luteum. So these are the things that we're we're measuring in the blood work. And really what you're trying to assess by all this data is when do you think the follicle is gonna have enough receptors so that when a trigger shot is administered, that that egg will actually respond to the trigger shot and detach from the follicle wall and undergo the maturation so that when, an egg retrieval is performed, that egg will actually come out in during the aspiration procedure. So in some women, and it's not uncommon at all, you'll have a whole you'll have some follicles that are just growing very quickly, and you'll have some follicles that are growing very slowly. So if you're trying to get most of these follicles too big, what's gonna happen is think of it like a roller coaster, and you're trying to go up and then some is starting to go down in the cart. So if you're in the last cart, you're still going up while the front of the cart is going down. Right. So it's the same principle there that you're just trying to say, okay. I'm trying to manage to get most of them on the downward side so that their most of them will respond. And sometimes when you push those limits, you actually make things worse as an outcome. With do with the luteal phase stim, what we do is we capture the first cohort that are growing very quickly. We trigger those and take those follicles out and keep stimulating those small ones because the smaller they are, believe it or not, those follicles will not respond to a trigger shot. That's the amazing thing, and that's where timing matters. That's why the whole field is critical based on timing. And so then what you can do is for the next 7 to 10 days, keep stimulating following the egg retrieval, and then do a second trigger shot, and then extract those follicles. So you've captured now, instead of only a fraction of the cohort, you've captured the majority of the cohort, and you're just trying to increase the number of mature eggs that I can give doctor Broussard. Because if I don't give her mature eggs, she gets upset with me. Right? Yeah. And, doctor Haid, I think you should also mention at this point too, that what that means for the patient as far as stimulation medications and what they're able to achieve as far as the number of oocytes yielded from one cycle and the amount of medication that they've actually had to to purchase and to use. Sure. So when you look at the data, the first half of the cycle before ovulation, there's a multitude of medications that are required. You need both FSH, LH, in the form of either the Menopur low dose HCG, and you need something to block, you from prematurely ovulating, like cetrotide or ganarol, some type of GnRH antagonist. And when so there's multiple shots in a day that's required when you're doing the first half of the cycle. But postovulation, those follicles are making progesterone, so we don't need a lot of these medications. And you already have the the h HCG or LH in the form of HCG from the trigger shot. So number 1, the cost, as I think doctor Broussard was alluding to, the cost of the medications and the amount of medications is significantly reduced. At Generation X Fertility, the price that we charge for a luteal phase stim following a follicular phase is nearly, 50% lower. May even be 60% lower in most so the amount of savings that you can get is significant. Not only that, but the number of eggs that you can get is more than double. So when we and doctor Brassard, you'll address this after in the study that we looked at. You get on average 5.3 eggs total in a follicular and luteal phase 2 versus 2.3 in just a follicular phase or the first phase of the cycle. So you have lower cost, more eggs retrieved, and the quality of these eggs, maturity of these eggs, embryos form, chromosomal normalcy of embryos is the exact same as in the follicular phase. So it's really an amazing improvement that you get with using this strategy. And I think, doctor doctor Yeh, we should mention too, I think anecdotally, we've had some patients that have had poor embryo development in their their follicular phase, in multiple cycles. And then when we add in the LPS factor, they're we're finding that they have really good quality embryos from those luteal phase o sites that we retrieved much better than we ever did. And that that's only for some patients, but, still, you know, we've seen some really amazing results on some patients that they couldn't achieve with just traditional stimulation. Right. And then that's oh, I'm sorry. No. I definitely say, I said that's really incredible. And I think we actually have a few questions that I just wanted to highlight while we're talking about LPS. Questions that I just wanted to highlight while we're talking about LPS. And and one of the questions actually from Grace says, during Duo SIM, is it actually 2 retrievals? So I just wanted to clear that up a little bit so we can get to our audience. Yes. So the answer is yes. There are 2 egg retrievals Mhmm. That are occurring, but they're roughly about 7 to 10 days, 7 to 12 days apart on average, what you're doing, because you have to keep growing these smaller follicles. Mhmm. Mhmm. And especially for women of advanced age, 44, 45, 46, 47, we see some women who are older than the general, population of people undergoing IVF in the United States. And as a result, time is of the essence. So I've had some people who there is about 30% of people who have 3 cohorts of follicles and eggs per month. And in reality, I've been able to get the equivalent of 3 months' worth of eggs for certain individuals and create blastocysts in this advanced stage within a 6 week period, which is really amazing if you think about it. Really amazing. You're doing 3 months, so you're really shortening the time and the amount of money that they're spending and the amount of medication that they're taking on a on a day to day basis. Right. Yeah. Yeah. We it's definitely interesting in the lab. We see you know, we'll have a patient with the original cohort of oocytes that were, you know, were at the end of their their cycle time where they're we're doing embryo biopsies, and we're preparing for the next day of retrieval. And often for those patients, we'll have embryos that we're able to biopsy and freeze from the first group, and then we go right into the second. And we're doing another group that we're biopsy and freezing. So it's really interesting to do that. Right? Yeah. Right. And and the the whole issue is it takes time. Not every physician is comfortable in doing gluteal face stims, and it and it took me a a bit of time to get, acclimated. And I think the way that we do it is a little unique here at g and f. And as a result, I I think that's why sometimes our results may be outliers compared to other groups because we are aggressively, for our patient population trying to maximize the number of eggs and embryos formed for them. And, you know, then doctor Broussard, maybe you could talk about this is a paper that we coauthored together, regarding luteal phase stimulations and how it increases and improves the outcome in women with split cohorts. Right. Yeah. So I think the main point of the the study was that, you know, we showed that we were getting comparable results from both cohorts of of oocytes and embryos, so the original cohort in the follicular phase. And then the luteal phase, we were getting very similar results as far as, like, blastocyst development, eployty rate, all those, you know, kinda endpoints that are very important to us. But what we were seeing is that so in one, you know, menstrual cycle, basically, we were able to get more embryos. So more embryos we could biopsy, more euploid embryos, and especially for these patients who are older and they may not have a lot of years, months, etcetera ahead, being able to maximize the number of embryos that we were able to biopsy that ended up being euploid and reusable, in a given cycle is is really, you know, game changing for them. Yes. Absolutely. Absolutely. So that's one of the strategies that we use, and I figured and this is another topic that doctor Broussard and I work very closely with, and we have the 1st in the world, clinical trial looking at PRP or platelet rich plasma versus, placebo, which is just serum, which has no platelets in it. So, basically, when you look at what is PRP, well, there are 4 main components of the blood. So PRP is just a blood product. But what you're we are doing it with this blood product, we're removing the red blood cells, the white blood cells, and we're leaving the fluid of the circulation of your bloodstream there, which is the serum. And we're just concentrating the amount of platelets, and we're increasing it by about 500 to a 1000% compared to what's naturally circulating in your in in your body. And the platelets, I think of more like the general contractors of the body. They're the ones that go and they stimulate, or whenever there's injury to any organ or tissue, they go and surround the area and what they are essentially doing is improving DNA synthesis, cell division, just increasing what's called neovascularization ization or blood growth into the area. It's been used in a whole host of different areas and aspects of medicine from dental surgery to dermatology, plastic surgery, for hair transplant therapy, and for just hair loss therapy. I know there's a lot of people, experimenting with this, as well as with, really in orthopedic surgery as well. So for for ovarian, this is what's called or considered ovarian rejuvenation. This has been something that's only been utilized in reproductive medicine since 2018. At g and f, we've been utilizing PRP with some pretty, impressive results, I think. And I think doctor Broussard may may share some thoughts on this as well, compared to, like, pre and post. When you look at PRP, there's different ways that we can utilize it. There's endometrial PRP. That's for women with really thin endometrial linings despite taking a lot of estrogen. In certain circumstances, the PRP may help promote the growth of the endometrium, and it and make the these cells more responsive in the basalis layer, responsive to, the estrogen that's being in the circulation, increase growth there. And there's different ways you could do it in fusion or injecting it into the endometrial cavity. And obviously, ovarian PRP, which is what our study is looking at, which we're trying to say is can you actually improve the quantity and potentially quality of the eggs and the embryos that are formed, with these procedures? Mhmm. Well, so this is one of the things that we looked at. So the what we looked at is, 20 patients who came to g and f, and this is how we actually utilize the small dataset Mhmm. To understand how do we make a larger study and make a clinical trial that is going to say, okay. How many people do we need in this trial to assume that these were actually improving outcome? And these are women you could see over 41 years of age, almost 42. They did an average of 5.5a half IVF cycles prior to PRP treatments, and then they did an average of 3.2 PRP treatments. You could see over another year or so, they did this. And, low egg reserve, you can see, obviously, AMH under 1, average of 0.56, and they did an average of 3.4 egg retrievals flanking these PRP therapies. And when we compare the post PRP therapy to the pre PRP therapy, we found that you had nearly a 50% increased number of eggs, mature eggs, embryos formed, as well as a 12% increase in high quality blastocysts and a doubling, which was an amazing finding to me, doubling in the euploid embryo rate. Mhmm. When you looked at those women who had embryos that were eligible for transfer, post PRP versus pre PRP. In this group of 20 women, remember, these are women who are almost 42 years of age and older when they started therapy. We had a total of 5 women pregnant. One of them was prior to PRP, and 4 of them had embryos post PRP, which is an amazing thing. So if you think of it on a statistical basis, that would increase the chance of a pregnancy on my birth by about 300% in this population of patients. Really, could be super powerful. Most studies have not looked at blastocysts, and that's why we're the first study, in the world to actually do double blind placebo control where I don't know. The patient doesn't know what they're receiving, and they can be getting the placebo, which is just the fluid of the circulation with no platelets, red cells, or white cells in it, or they're getting the actual PRP. And then what we're looking at is what is their actual blastocyst and euploid blastocyst rate? That's never been looked at before. And you need hundreds and hundreds of patients to do this. And, doctor Haigh, we've been doing PRP at our clinic for quite some time. I I think, what, about 3 years or so now? Since 2021. That's correct. Yeah. Yeah. So We have over 900, PRP therapies that we've done in about 350 patients or so. Yeah. And so part of our study, let's just kinda mention really quick just a kind of overview of the study. The patients in the study end up getting 2, treatments, either PRP or placebo, and they get 2, IVF cycles with, PGTA testing for the embryos and then any subsequent transfers with, with embryos that are suitable for transfer, which, you know, is is such an interesting, you know, study. The way that we've built in so many different factors of the study and data points that we're able to gather, it's really a pretty powerful study. Right. And I I don't know the data so far. Doctor Broussard knows. So I'm assuming you're sitting here and you're not, blanking your screen because maybe it is showing something. That's what I'm assuming. But I don't know. I don't know. Yeah. So it's a blindness study. It's a blindness study. Yeah. So we're working on a degree for from Doctor. Haid. Yeah. So I don't know, but it's it's really interesting. And and, all I can tell you is in both arms, there are people who have eligible embryos for transfer. And we're looking at women 35 to 42, you know, with very low reserve AMH less than 1, and and you're having you know, that you meet the below your criteria. Age over 40, AMH less than 1.1, poor ovarian response, having, 3 or fewer follicles, under 7 antral follicles on ultrasound. So it's it's really, it's it's it's a fantastic study, IRB approved. Great. And people can can take a look at it. Anyone who actually, and I'm assuming, Destiny, there's a link somewhere. If anyone is listening that's eligible or wanna be considered to look at this study, it's amazing. Yeah. There's certain Right? They're getting offered nominal fee. Going right here that says join the PRP study here. So that is a clickable link, and you'll also find that information, in the docs section as well. And it'll take you right to our PRP page. So there's a lot great resources out there, and we encourage you to check them out. And it has what the price is. Right? Because they get anesthesia for it. You're free of freezing of all embryos, PGTA, 2 IVF cycles, 20% reduction in the cost of beds. Mhmm. There's so many things that they're getting for this. Right. And, yeah, all for the and I think what was the low price of, I think, like $12,000 for the entire 2 IVF cycles with PGTA? And it's you can't get that in the United States. It's just it's unheard of. And certainly, if they don't meet the criteria for the PRP study, we certainly do offer PRP, has just, you know, a routine, offer at Generation Next as well. So even if they inquire about the study and they don't meet the criteria for it, we can certainly offer PRP treatments, aside from the study. Or I've had people who just wanna do PRP, and they are not interested in doing this study, as well. You know, we we offer we're trying to do real science here, and we wanna prove that the therapy is beneficial because the reality, nobody should be doing IVF cycle who is a poor candidate for IVF without doing PRP first if it truly is giving these type of outcomes that we suspect it may be doing. And it would be the first to prove that it increases the quality of the eggs, and then we could then isolate what are the factors in PRP that's actually improving the outcome. Really amazing stuff. And then the last thing I thought is what's also not all groups offer is also adjuvant other adjuvant therapies like growth hormone, and what we think growth hormone may do. And really it's for women who are over the age of 40, who have very low reserve, poor hormonal functioning. When you look at the what growth hormone may do in these individuals, it may enhance follicular development, response to hormones, increase egg quality, formation, and boost mitochondrial number of function, which is also acts as a natural ants antioxidant and reduce the amount of these follicles that can die. When you look at people who have done studies, and we have not done studies here in growth hormone, but when you look at the studies, and there have been double blinded placebo controlled trials, it's pretty pretty compelling. In in that population, increased number of egg retrieved by 21%, embryos transferred by 22%, clinical pregnancy rates increased by 16%, and live birth rate by 17%. So that's really powerful and impressive data there, to be honest with you. And that's why I look at it like what we do here is we individualize the treatments to the individual and say, listen. For you, these are other options and alternatives if you failed other places. Or if we just think based on your age and what your history may be, these are the different strategies that we can utilize for you to really maximize and improve the likelihood of obtaining a healthy egg embryo for eventual transfer. Mhmm. Yeah. Agreed. Awesome. And now, doctor b, I wanted to ask you a question. Mhmm. What are some of the IVF success rates when we think about DOR? Like, could you share some insights from a laboratory perspective when it comes to success rates with patients with DOR, whether they're using PRP or luteal face stim? Is there a difference? Yeah. I mean, we're we're definitely seeing the difference. We have several patients that either, you know, had shared with us experience in other programs, or even had started out doing treatments with us before adding in either PRP or LPS. And then once we started, adding in those treatments to their cycles, we definitely started seeing an increase in, in embryos that well, first of all, an increase in oocytes that we were able to retrieve, oocyte quality, blastocysts that we were able to biopsy. We have many patients that had cycles where they didn't have blastocysts that were suitable for biopsy in their cycle. And then after the addition of particularly PRP, or PRP and LPS, we're able to end up with euploid blastocysts, and we're able to have successful frozen embryo transfers and, you know, are either pregnant or have given, have had live births. I can think of many, many patients that come to mind that fall into this category, that, you know, we we had tough conversations with on previous cycles because they just didn't have good embryo development. And then, you know, after a few of these innovative treatments, they were able to actually be successful. Yeah. I just actually did a procedure on someone this morning who said she wants to be the spokesperson for PRP. Yeah. I know. Yes. Yeah. I know that's what you're talking about. Yeah. Which Very much so. We did multiple things. We did PRP, LPS for her. This is not her first, center that she started treatment at, and, hopefully, it's her last center because Mhmm. We were able with these both PRP and LPS. She went from making an average of 1 to 2 follicles, no blastocyst. Today, I retrieved, like, 6 eggs for her, and she had a euploid embryo last time in her last cycle. Right. So she's just trying to bank some. So really amazing stuff. Really amazing, amazing stuff. Right? Wow. So I know the both of you see a lot of DOR cases. Can I ask, what is the difference between dealing with one egg versus several eggs? I mean, is there a difference? Or I mean, from the laboratory standpoint, I I don't know how many times in 21 years years I've had the conversation with patients that it's really quality over quantity. I will take one really good quality egg that's capable of baking a uploid blastocyst over 20 mediocre eggs that don't develop to a good quality blastocyst. Certainly, with, you know, these older patients, norm populations, or even just patients with, you know, a little bit poorer prognosis, we do see where we're able to use some of these innovative treatments and maybe only get one oocyte or a couple oocytes, and we're still able to get, you know, embryos developed to beautiful blasts as we're able to biopsy and have them come back euploid. So it really does just take 1, one egg. It it doesn't have to be, you know, 20 for us to have success. Right. And that's part of the thing why some centers actually don't they actually cancel cycles. We have patients who come here because they had cycles that were canceled because they had too few follicles. Some some centers have a strict 4 or more follicles in that are mature in order to do a retrieval, which I find is silly in what you're alluding to, doctor Broussard, that that you all you need is 1 you all you need is 1 healthy egg to give you a baby. And that's why I started with everyone on this platform probably came from a cycle where only one egg was so the system works. Yeah. It does. And just from the laboratory standpoint Yeah. From the laboratory standpoint, you know, we really take pride in making sure we have a really robust culture system, that we have excellent fertilization rates so that we're able to take, you know, just one oocyte or a couple oocytes and make beautiful, healthy, robust embryos, and we're able to thaw them with with great survival and, you know, all those just little attention to details, every single step, and every little piece along the way. Absolutely. I know we do have some questions to get to, and we are coming somewhat close to the end of our session. But I wanted to highlight a few questions. Perfect. Jasmine, is there hope for someone who's had some ligation done? I'm so curious to know. Oh, the answer is absolutely. Absolutely. So when you're looking at someone who had tubal surgery and I have actually looked at studies that that of, address women with tubal ligations versus those who have blocked tubes from other issues. Mhmm. Usually, those women have higher rates of pregnancy with tubal ligations with IVF compared to those with blocked tubes but may require slightly higher doses of medication because 20% of the blood flow to the ovary comes through an area, an artery underneath the fallopian tube. So when you ligate the the fallopian tube, you're moose removing some of that blood flow so they get the same amount of medications and may require additional amounts of medication. But overall, prognosis is excellent for people with tubal ligation. But again, the primary factor is age. It depends. If you're coming in and you're 50 and you had a tubal ligation and you wanna do IVF, your prognosis is still only as good as your your your age. It may be lower than we hope it to be. But, as far as if it's just tubal ligation is your only issue, excellent, excellent prognosis. Yeah. Awesome. Thank you so much for answering that. I know we have a few more. Let's see. Oh, and she's 39. Just wanted to put that out there. Yeah. That that's all good news. All good factors. Mhmm. Fantastic. Okay. Next question. Let's see. Okay. How long does the treatment take, and in how long do you see results? And which treatment are we referring to? I think we're talking about PRP here. Yeah. Right. So when you look at PRP, that's an it's a great question, and it's the it's a great unknown. Most women who do PRP, if you look at most papers, they'll show that there's an improvement in response, and that response usually is number of eggs retrieved Mhmm. Is within 34 days, but there is an early phase response and the late phase response. And that's why when you look at PRP, it's really based on the number of injections that are given. You can't just do one and say I'm done. I've done the PRP. It's it because the when you're preparing PRP, the platelets, once they're activated, release their they only live for a few days, and they release their fact growth factors, cytokines, immune modulators, all these different amazing chemicals, within minutes to hours following the preparation and injection. And what that's doing is it think of it like if you had a fish tank. It's a water treatment system for that, for that environment, and what you're doing is just improving the environment. So the PRP is not actually changing the follicles and eggs. You're improving the environment that the follicles and eggs coexist in. And as a result, you you can't just clean a fish tank once and expect it to be hospitable forever. You have to keep reconditioning the environment to keep improving the outcome. But it's speculated it may last for up to 3 months following. But I've had patients after several treatments. They didn't see an improvement until 8 months, 9 months later, which is when those primordial follicles eventually would have become antral follicles to compete in an ovulation because you have follicles in different stages of development. So it it's a long process, but it's it's a great unknown. And that's why in our study, we're looking at that and saying, okay. Are you getting improvements month 1, month 2? And that's why from different injections. Right. Awesome. Thank you so much for that. Okay. We have a lot of questions, so please keep an eye on it. Yeah. Okay. I will read out the next one. How long has long COVID affected LPS? Do we know about this long COVID question? No. Unfortunately, I don't. I don't. You know, long COVID symptoms, I don't know if it's affecting follicular development and growth. I I don't think there's much data on that. No. There's not. No. There really isn't. Okay. And let's see. We talked a little bit about okay. Well, let's see. Oh, is there hope for someone that's been diagnosed with complex hyperplasia in the uterus? Yeah. So so that's a a precancerous condition, and I'm sorry that anyone has to have these type of problems. And it's usually caused by, constant anovulation where you're not you're not ovulating on a regular basis and having, very low progesterone exposure. But usually by treating the hyperplasia with prolonged progesterones, either in a IUD form or oral pills or injections, usually within a 3 to 9 month window, most people can treat it and then move on to embryo transfers. But there is hope. There is plenty of hope. We we've dealt I've dealt with many patients with even endometrial carcinomas that have been early stages caught, limited to polyps, and didn't require hysterectomies, and were able to go on and carry and deliver a pregnancy. Fantastic. Thank you. Oh, can a 34 year old undergo PRP? The absolute answer is yes. There is no age restriction. For our study, we're only looking at a finite number of of people. But we have some patients who have very low, very, very low, ovarian reserve here, in their twenties who we've been doing PRP and getting eggs and flaccidases and euploid embryos. Am I talking to Priscilla? Yeah. Yeah. Amazing. Really amazing. It's you know, I was very skeptical when I started, to be honest with you, when I came here. We wanted to start the PRP program, and I did a lot of due diligence. And once I've been doing it, it's just this the data is becoming, pretty reassuring is what I can say. That's why I still need to do true scientifically because I've seen people go down the road. Because if you wanna believe something, you can make the belief happen. But I like to do good science, and I know doctor Proustard likes to do Yeah. Good science as well and really prove without a shadow of a doubt. Because then it comes off the experimental slash investigational list, and it becomes just standard of care. And then insurance companies cannot deny you at that point. That's why you have to do these good studies. Right. Awesome. Okay. Next question. Let's see. We're flooded. Okay. What's the best IVF protocol for low ovarian reserve? What would you guys suggest? We talked about quite a few today. Right. So so it all depends on the individual. Right? So it depends on there there is no one that's the best. That's that's the whole thing. Like that. Mhmm. So in some people, it's a natural cycle, and then midway through or near the end of the natural cycle, that's where you start adding medications. For many women, it's a mini stim protocol. Like, in our, study, your your actual protocol is based on the antral follicle count of that cycle. So your antralfollicle count actually predicts what I should do based on your FSH starting basal FSH levels and the antralfollicle counts, and that dictates. So I have very limited say because that's one of the things we wanted to remove bias from the study because that's one way I can skew the results, by just altering in one group versus the other. So I have no say in what protocol is. But but really the protocol should be based. So someone with really low reserve, I will tell you. A lot of people are doing very high doses of medication. That's probably the can be harmful because you're supersaturating these receptors, the FSH and LH receptors, and may make these follicles less responsive to trigger shots and less likely to get eggs. I do think one of the things that GenerationX, now that you speak of that, that does make us unique compared to a lot of programs, coming just even from the laboratory side, is that we do a lot of different protocols for our patients, and we really do specialize it for the patient. And even with PRP and some of these other things aside, I think that's one of the reasons that we do really well with patients, especially patients that have failed previously at other centers, is that we really do specialize, in having, you know, kind of customized, stimulations that are of all different types, here. Fantastic. I couldn't agree more. I know that we are coming on the end of this session. I want everybody to know that don't worry. This is gonna be on demand, so we can keep on going and answering some of these questions. I know a lot of our attendees will be automatically shifted, to the next session, but don't worry because we're actually coming up on a 15 minute break before we go into egg freezing with doctor Sharon Secchin, fertility specialist. I know it's gonna be exciting stuff. We have doctor of Lillian Horn, acupuncturist Mary Sabo. We have doctor Jennifer Butt, OBGYN. So it's gonna be a really great session. Stay tuned for after the break. But, please, we can continue on a few more of these questions because we do have a little buffer time. So if, backstage, if we're gonna put up a few more questions, I wanna make sure we get to these so that way they will be able to watch. Please. Alright. Here we go. What if suffer excuse me. What if someone suffers from anovulation? What medication would be given? So so it all depends on what that person is looking to do. If you're looking to get pregnant, we have obviously the fertility stimulatory drugs such as clomid, letrozole, as well as the injections are can be used to help stimulate ovulation. But if someone's not looking to get pregnant, then for these individuals, because you wanna reduce the risk of, as you mentioned before, having precancerous and then cancerous changes into the uterine cavity, something like hormonal contraception, like birth control pills or or progesterone only pills for, you know, several weeks out of each month if that's the strategy they wanna use. Awesome. Fantastic. Thank you. Okay. Next question. Oh, as a physician scientist working with stem cells and exosomes, are you aware, any studies utilizing stem cells or exosomes for fertility? So the answer is there are people using, hematopoietic, stem cells to for to get the growth factors like PRP. And they're also using adipose tissue, to create stem cells for PRP. The problem with these, anytime you're creating stem cells, there's risk of conversion to teratomas both benign and malignant. And that's part of the issue and why we don't do it. Number 1, let's prove that PRP works. Let's prove that these growth factors, cytokines, all these different factors are actually improving outcome for individuals. Before you start saying, hey. Let me try using something that makes a higher potentially a higher amount of these growth factors compared to what a platelet can produce. I look at it that I'd rather do something that has less risk to the individuals. So when you're doing something that has less risk because these are, autologous procedures when you're doing PRP, so you're not reverting something to an infantile form, which has a risk of converting it to something else, when you're doing stem cell therapy. That that's the limitation. So there's no proof that p that stem cell therapy is any better because you're not making eggs. I just want people to understand that when you're doing stem cell therapy for the ovaries, you are not making new follicles and or an egg follicle unit. There was one researcher doing that in rats. I know about it at UCLA, which was an amazing amazing, study that she was doing. But the problem is is those eggs that she actually produced were only good for 1 month. And it took hundreds of thousands of man hours to just even to create these. They didn't look like normal follicle egg unit, but they were functional in rats. And you can't really trust a rat model. That's why they call it a rat. Right? So, but you can't trust it. But but that's the reason why we I I personally don't do that yet, or or get involved in that because you're trying not to harm anyone and that you need multiple injections as well. Awesome. Great answer. Thank you so much. Okay. Next question. What would be the next step protocol when 2 conventional IVF cycles have failed and there are no embryos? I'm sorry. Would it be mini IVF or any of the techniques or the technologies explained here? 39 year old DOR patient. That's it. I'm sorry to hear about this story. Yeah. It's really disappointing and and can be discouraging too. But I would tell you don't get discouraged. And so number 1, I always like to do a forensic analysis. So whenever I get records from someone, you know, the the first cycle is the most important cycle that someone does when they do IVF because that teaches me exactly how they responded to the medical therapy, when did they trigger, When they triggered, what were the size of the follicles? How much estrogen were they producing? And at that point, I could see what was the maturation rate once the eggs were extracted, how many eggs actually came out? Did they have at least 70% of all follicles released their eggs? If they didn't, then, you know, what were they triggered at? What size? Were they too big, too small? Then I could see what did they trigger with. So there's I could say, okay. What's the drug regimen I should use to change the trigger? How many follicles did they have? What was the embryo formation, what was the blast formation, and was were they doing embryo biopsy, like, PGTA to determine neuploid status? So it all depends. So, yes, if you have few follicles, I don't need much medication. So I can use, like, a mini stim for someone who has 3 or 4 stim for someone who has 3 or 4 follicles to get the same outcome with maybe better quality eggs than giving a conventional stimulation of very high dose injectables, which is really expensive. So if I'm giving you the same number of eggs potentially for half the price, then why would you spend twice the money for for the same outcome? So but, yeah, there there is so many different but before I could even even understand that, you would need to I'd need to do a forensic analysis on all the data that they've collected Right. From past Mhmm. Fantastic. Thank you. Okay. Can diminished ovarian reserve be reversed? Oh, interesting. Yeah. Amazing. It's a great question. So the answer is no, unfortunately. You can't reverse it. But can we improve outcome for these people over a short duration of time? And those are the things that we spoke about, things like PRP or platelet rich plasma therapy with ovarian rejuvenation, with the ovarian injections, luteal phase stimulation, human growth hormone. You know, these are strategies that you utilize to try and improve and increase the environment so that those follicles you have because remember, follicles are constantly dying. So what people don't realize, when you do an IVF cycle, if I extract 10 eggs, that did not reduce your fertility potential or did it decrease your egg reserve? Because those 10 follicles and eggs would have died that month if not extracted and and, you know, encouraged to develop and promote, development and growth through medications. So what these medications are doing is they're just trying and what these different therapies are doing, you're trying to prevent this constant dying of the follicles, so you're trying to increase the amount that are available to compete. And then once the competition starts, you have to treat medically. Saying that, though, we do have people who have done PRP therapy, and I know doctor Prasad can attest to this, who have very, very, very low ovarian reserve, have very irregular periods, have done PRP therapy, ovulated before we can even do an IVF cycle and have achieved pregnancy. Right. Right. Yeah. Wow. Amazing. Okay. Let's see. I'm trying to make sure we got to all of the oh, nope. We need I think we have a few more. Let's see here. Okay. What would be the next step protocol? Oh, wait. No. We just did that one. Yeah. Alright. I think did we get to them all? I hope we did. Oh, it says, sorry. I recently found out I have PCOS. Would that be an issue as well? So if so the answer in the in the short term is no. So it PCOS is is a difficult some people do not with polycystic ovarian syndrome. That's a that's a syndrome where people have an abundance. Too many follicles and eggs, and it creates disruption in the communication between the brain and the ovary. So they tend not to women with this problem tend not to ovulate on a regular basis. It's like LOTA. You gotta be in it to win it. So you have to have an egg to be released in order to have a baby. The problem is that some people have such a high density that even with oral medications to try and try and do therapies like intrauterine inseminations or IUIs, they actually don't respond to the medical therapy and then are forced to do IVF. And I've seen where you can get 80, 90, a 100 follicles, which can actually be dangerous for the individual. And it's a little scary when you see that number of follicles in eggs. But with newer protocols, we can safely extract those eggs and increase the likelihood of having an embryo eligible. So PCOS, I look at it, is not a punishment. It's actually, they have very high prognosis, but it's just a matter of can you do it safely with with less of that invasive and aggressive therapy, or will you require more aggressive therapy like IVF to to get the you know, create a pregnancy. Mhmm. Yeah. Okay. And next question. Alright. What are the PRP costs? So I think, Destiny, that that may be something in the link. Could we add that for people so they could see so they could see what the study costs are, which are phenomenal, and what the PRP and I I would say anyone who's on this forum that's interested in PRP, let's see if we can have some some type of incentive and cost reduction for these individuals. Absolutely. We are offering some some good stuff, and they will be in your doc section as well. So definitely make sure to check that out. I know we have some more questions to get to, but I also know we are running short on time. I wanna thank you so much, doctor Haid and doctor b, for these amazing insights. Please stay tuned. We'll be right back after this very short break. Thank you so much, Destiny. Thank you. And thank you everyone for attending. We really, really, wish you all the best. And, as I always say, we wish your fertility wishes all come true. Yes. Take care. Absolutely. Thank you so much. Thank you. Bye. Thanks. Bye.