Trigger Shot or No Trigger Shot…That is the Question..

Author: Ciera Roberts, MSN, APN, WHNP-BC

One of the questions that patients often ask us in the office here at Southeastern Fertility is whether or not to use an HCG trigger shot for the timing of an intrauterine insemination (IUI). So is it better to use a trigger shot than to use an at-home ovulation predictor kit? The answer is (drum roll please): There isn’t one correct answer.

We aim to do an IUI at the optimal time in a treatment cycle. The optimal timing of an IUI is at the time ovulation occurs; therefore, it is important to be able to accurately predict that time frame. Ovulation is triggered by a surge in luteinizing hormone (LH), which is released by the pituitary gland, when the ovarian follicle or follicles become mature. The egg is released from the follicle about 36 hours after the LH surge.

When we plan to use an HCG trigger shot, the patient is monitored via transvaginal ultrasound and hormone blood tests at intervals until the ovarian follicle or follicles are determined to be mature. Once we estimate that the follicle is ready (usually when it measures 18-22 mm in average diameter), an injection of HCG is administered. HCG is very similar to LH and thus the trigger shot serves as the LH surge, and IUI is scheduled accordingly anticipating that the egg(s) will be released about 36-42 hours following the HCG injection.

How does this compare to using an at-home ovulation predictor kit (OPK)? Well, in most patients the LH surge will be detectable in the urine after the surge is noted in a blood test. Usually the egg is released the day following a positive OPK. So, an IUI is ideally performed the morning after a positive OPK. Patients will typically begin testing on cycle day 12 and test every day until the test is positive.

Current research indicates no significant difference in either clinical pregnancy rates or live birth rates when comparing home monitoring of ovulation with OPKs to ultrasound monitoring and HCG triggering. Therefore, the choice is patient specific.

If your schedule doesn’t allow the time commitment for multiple ultrasound visits and lab draws, and you are confident in your ability to do in-home monitoring, then OPKs may be the best option for you. However, if you have had difficulty interpreting OPK results in past cycles, or you’re simply afraid that you might miss the positive result, then ultrasound monitoring and HCG trigger shot may reduce your anxiety and uncertainty. Using a trigger shot also takes some of the guesswork out of the timing of an IUI, and may be beneficial if there are potential scheduling conflicts near ovulation (such as you or your spouse leaving town on a business trip).

The bottom line is that there is no right or wrong answer, and you should talk to your doctor about what is going to be most beneficial for you.

Stepping out in Faith

Author: John David Gordon, MD

Anyone who has been in my office can readily guess that I am a dog person and not a cat person. If you are a cat person, then you have my sympathies…Dogs have families and cats have servants. Making the decision to move to Knoxville was clearly a case of stepping out in faith. I am someone who is loathe to change toothpaste brands and who, much to my wife’s chagrin, always orders the exact same menu items whenever and wherever we go out for Indian food. So the decision to move was not insignificant. But sometimes making a leap is the right call (like moving to Knoxville) and sometimes making a leap can end up with you getting a bit of a surprise…

A few summers ago we adopted a second four-legged friend from a high kill shelter in South Carolina. Lucky was heartworm positive and his life had taken a turn for the worse since he had been abandoned by his former owners. Fortunately, he responded very well to medical treatment and was declared healthy prior to making the journey up to join our family.

Although we think that he may be a Goldendoodle, we really have no idea about his doggie DNA. He has shown absolutely no interest in swimming and after getting a bath to get whatever that black deer musk is off of him he now refuses to go anywhere near a bathroom!

But one thing that he absolutely loves is riding in the car. He sometimes sits in the minivan while it is in the garage in hopes that one of us will decide to take him for a spin. Since a boat is kind of like a car with no roof he quickly decided that tooling around on our boat was pretty awesome.

One summer day we were out on the lake and pulled up to the dock at the market to grab a snack. Lucky was happy to get back on land for a few moments to use the doggie facilities (nearest tree). Suddenly he realized that just 20 yards away there were a bunch of Canadian Geese. However, they were not on land. They were happily gliding around the end of the docks seemingly oblivious to Lucky. As we walked back to the boat he decided to check out the geese from a different vantage point. I walked with him to the end of the dock and we stood for a few moments watching the geese mill around about 10-15 yards away from us.

Then Lucky launched himself into the air and off the end of the dock. I have no idea what he was thinking… He hit the cold water and immediately turned back toward the dock…all hope of catching a goose quickly forgotten. As I helped him clamber up on the dock he seemed a bit embarrassed by the whole affair. However, his happy personality soon returned and he dried out quickly in the heat of the day.  He now clearly regards swimming as a near-death experience.

So what does this shaggy dog tale have to do with infertility? Well, on some level pursuing fertility treatment is a leap of faith. Our patients are making the assumption that there is a good egg, a good sperm and a uterus capable of carrying a pregnancy. We really wish that we had definitive tests to figure out if these assumptions are correct, but we do not.

AMH, FSH/estradiol and antral follicle count will predict responsiveness to fertility medications for stimulated IUI or stimulated IVF cycles. However, these tests will not predict who will conceive either with or without treatment.

Recently I had this discussion with a patient who was over 40 years old but with poor ovarian reserve as evidenced by her AMH, antral follicle count, FSH levels and previous response to fertility medications. I explained that the further use of medications was unlikely to improve her odds of success and that NC IVF probably made the most sense in her situation unless she was interested in Embryo Adoption or traditional adoption. I explained that NC IVF pregnancy rates per embryo transfer depend upon her age (which I cannot change) and are NOT dependent upon ovarian reserve.

Making that leap of faith is difficult. Sometimes you come up short…just like Lucky in his attempt to secure a tasty lunch of Canadian Goose….BUT sometimes the leap is successful. The only way to find out is to take a deep breath and take the plunge.

Dr. G says “Hello Knoxville!”

Author: John David Gordon, MD

It is with mixed feelings that I ended my nearly 20 years at Dominion Fertility a little over 6 months ago. I am so proud of the wonderful staff at Dominion and so thankful to the patients who trusted me to be their fertility specialist. I rejoiced in their successful pregnancies and mourned along with them in the failed treatments.

When I arrived here in Knoxville back in July, it was like coming home without realizing that I had ever been away…The amazing staff at Southeastern Fertility and the wonderful people who make up the National Embryo Donation Center have been so welcoming to me….a Bostonian by birth no less! We have quickly found a wonderful church and have begun making friends.

It is a real pleasure to work alongside Dr. Jeffrey Keenan, and with our combined 50 years of fertility practice, we have had some very interesting discussions about the care and treatment of the infertile couple.

Slowly I am learning how to pronounce the names of local towns without the staff bursting into laughter, and I have been introduced to all sorts of new cuisine, including Petro’s Chili and Chips…

Over the coming days, weeks and months I will be blogging here on the brand new Southeastern Fertility website and covering a wide range of medical questions. This blog will also keep everyone updated on practice events including our Trying 2 Conceive Tuesday (T2-CT)…[It’s not my fault… I’m a Star Wars fan and if we can have R2-D2, C-3PO and BB-8, then why not T2-CT?]. Well, if anyone has a better name for our upcoming in-office information sessions then feel free to email me…

Fondly,

DrG