Women who are
who have low
ovarian reserve in particular,
they have low number of eggs.
They need less dose of medication
and pills
is enough to grow those follicles.
I'm going to give you an example.
Hi, everybody.
It's Claire with FertilitySpace.
I wanted to jump in really quickly
just to give you a preface
to my conversation with Dr. Merhi.
So Dr. Merhi
is a fertility physician
in New York City
at Rejuvenating Fertility Center,
and he provides
a lot of really interesting
alternatives in conjunction with IVF
for fertility patients
specifically that have poor egg quality
or diminished
ovarian reserve or primary
ovarian insufficiency.
So I thought that you might find
these alternative treatments
really interesting
because he's seen really good outcomes
with his patients
as far as improving their egg quality.
First, we started off
talking a little bit
about needle-free IVF.
So at his practice,
you can actually do an IVF cycle
without having to use any needles.
So no injectables, no blood draws.
So I thought that was
really interesting.
So he explained how that works
and why some patients
want to do that.
Primarily for patients
that really don't want to deal
with needles,
it's a good alternative
for their IVF cycle.
We also talked about Mini-IVF
or minimal stimulation IVF,
where someone would use
a lot less fertility
medications than what is typical
in the conventional cycle.
Oftentimes he uses this for patients
that had poor egg quality
or low ovarian reserve.
So it's cheaper
but also he's seen really good outcomes
with patients
that have had
poor egg quality
in previous conventional IVF cycles.
So I hope that you find this helpful
and that you get something out of it.
First of all,
thank you so much for having me
and I hope we'll have more awareness
regarding infertility
and help more people have children
and freeze eggs
and everything like that.
So
as far as the IVF,
in conventional IVF patients
usually take two shots, two or three
shots per day, right?
For like ten days or so.
I do a lot of gentle IVF or Mini-IVF,
which is basically a combination
of pills and injections.
However,
a lot of people
are scared of injections
or they might not need them either.
So I only focus on pills
in order to grow the follicles.
Women who are
who have low
ovarian reserve in particular,
they have low number of eggs.
They need less dose of medication.
And pills is enough
to grow those follicles.
I'm going to give you an example.
If you and your partner,
each one is a follicle.
All right.
I want to.
The medication,
the shots
and all those are food
for those for you to grow
both of you. Right?
If I - if I cook for two people
and give you the food,
you would be happy.
If I cook for ten people
and shove it in
your mouth, you're going to vomit.
So really,
give them what they need.
And Clomid and Letrozole
which are pills,
they're enough to feed you
and your partner.
It's enough for two people.
Why do I need to give you shots?
So no matter how many,
how much medications you give,
it's not going to create a new follicle
or new egg.
I cannot create a new person,
by just giving you a lot of dose.
So what I'm trying to say
is the following.
We look at the number of follicles
or the reserve.
The lower the reserve, the less
the medication.
You reach a point
where pills are enough
and you really don't need injections.
However, I have a phobia from needles.
OK.
Believe it or not, yes, I'm a doctor.
So.
So you know,
if you have a lot of follicles,
needle-free without
any injection
might not give you the same outcome.
You might get less number of eggs. Why?
Because the food that I'm giving
is not enough for all of them.
So if you are ten people
in the family in the house,
and I cook for two,
A lot of people - only
two people are going to grow. Not ten.
So getting more food would be better.
I don't know if I'm making sense.
I like food.
So all my comparisons are food.
They actually can grow up
to seven to eight eggs - Clomid and Letrozole.
Remember,
they're pills that you can give
one pill each up to three pills each.
So if I give six pills
per day, three of Clomid,
three of Letrozole,
I get,
and we've published
that - we've published.
That's not something that you know,
so you can get up to eight eggs.
Actually, look,
there is a lot of studies.
I mean, and I do believe what I see
every day.
Even women about 40 have, you know,
their eggs are fragile.
Even if they have
a lot
of follicles,
you shouldn't really pump them
with a lot of gonadotropin
because it's like you're pushing
someone on the face to wake up
and it hurts them.
Look,
when you and I were
baby kids, we would fall on the floor,
we bounce back, right. Now,
If I fall on the floor,
you need to call 911
to pick me up.
So what I'm trying to say is
our body is not the same,
and the egg becomes more fragile
and the
gonadotropin shots, bam,
bam, bam is way too much.
And there is data.
Everything I'm telling you,
there is data behind it.
There's data showing that the higher
the dose of medication
we give, the worse the quality.
Absolutely.
A lot of time I avoid completely
the injectables,
the injectables, are nonorganic food,
if you want to call it.
Let me tell you why
the pills work through the brain
to increase your brain
hormone, the FSH and LH
to feed the follicles. The brain FSH
hormone or the brain gonadotropin
is not only one
type.
It's actually multiple types
of gonadotropins.
We call them acetylation,
or glycosilated, and acidic, and basic.
So many of those are going
into the blood system
to bind on those follicles and eggs
but the gonadotropin you take in
the pen is only one type.
So it's not
multiple types of gonadotropin.
So yes, the quality tends to some-
in some patients
tends to get better
if you avoid the injections.
And look, Claire,
I always tell people
the first baby in the world
was natural cycle.
That's how it started
46 years ago, zero medication.
So now I feel like, yes,
we're giving medication.
We started pills and shots
and now I think we went too far.
I really do.
Look, everybody's different, right?
So we do here natural IVF.
There are people who cannot
even take anything, you know,
medication.
If someone
is sensitive to the drugs or allergic
or they have medical problems
or some types of cancer,
we cannot give them.
We do a natural cycle, right?
We do now more
we at-
we increase to the pills right,
now then pills plus shots,
then shots, two shots.
So we do all kind of spectrum.
And I really think patients are not
one type.
Patients ask me all the time, well,
why are you giving me
a different protocol
than the last cycle?
Because your body right now
is giving me different
number of follicles
and different number of FSH.
I can't treat the same,
the same thing.
They're different.
You had 12 follicles, now you have eight.
I can't give the same dose.
There is less people to feed,
give them less.
The same. What I do
with Clomid
and Letrozole -
Letrozole, I stop it after five days
and I continue Clomid all the way
til the end.
You continue Clomid up to 14 days.
In summary, of the needle-free IVF,
you take Clomid,
Letrozole, at the end
you give Orilissa,
to stop ovulation.
Orilissa is similar to the Cetrotide
and the Ganirelix.
It's a pill.
It's much cheaper.
It's used for endometriosis
and we got a patent for
it to use it as
suppression for
the ovulation.
And then you trigger with nasal spray.
That's in summary.
Correct. So there is a lot of patients
who are scared of needles
and blood draws
and sometimes
a lot of patients,
they have difficult veins, right?
They're dehydrated.
So instead of sticking them
with a needle
ten times to get blood,
you can really test those in the urine
and the saliva.
But you shouldn't
brush your teeth or eat
anything in the morning
before you give the saliva
or it's not accurate
and it has to be
the first urine in the morning.
If you do that, it's as reliable
as the blood.
Usually they do it at home
because you want to
brush your teeth in the morning.
So you just give the saliva
and then you drop it.
The saliva,
we test the estradiol and progesterone.
And the urine,
FSH and LH.
Remember the urine
ovulation kit
measures the LH surge in the urine.
It's the exact same thing.
You technically
can just use the ovulation kit.
We are monitoring for -
if you want to monitor for ovulation
because in IVF you're stimulating,
but also you want to make sure
a patient doesn't ovulate,
you do a urine ovulation kit.
If it turns positive,
call us
and let us know.
If it's surging
then we'll bring you earlier
for the egg retrieval.
So someone had a
question about Mini-IVF.
So she said,
"I had four follicles
during conventional IVF.
Would Mini-IVF produce fewer follicles?"
No.
The follicles is your spending -
this is the cash
you're spending this particular month.
OK?
Medication does not create
new follicles, as we discussed earlier.
So
all you need is to grow those,
give them what they need,
do not overfeed them.
So for this person,
I will avoid injectables completely.
You're going to get four eggs
this month no matter what you do.
Even if I pump you with 10,000
units per day.
It takes 90 days for a follicle
to show up on ultrasound.
90. 3 months.
So pumping you with drugs
for ten days of stimulation
is not going to create new follicles.
So when you are
looking on the ultrasound,
are you counting
how many antral follicles
someone has to know
how many you would be able
to recruit for an IVF cycle or
or how -
how do you know
how many [eggs] you would be likely to get?
Well,
you do an ultrasound
at baseline, right?
So when the patient gets her period,
we tell them, come
on the second or third day.
Sometimes we give them birth
control pills for a week or ten days
or Estradiol or patches
And we tell them -
tell them, come
for monitoring. That monitoring,
or blood
and ultrasound is their baseline.
I see how many follicles
and then I give them medication.
That's why it surprises me how
how
some people give a protocol
just by meeting the person.
I don't know
until I see what your body needs
and I'll give you what it needs.
That's why it's very individualized - IVF
stimulation - based on every person.
Right.
Makes sense.
OK, so it's all about what
you see on the ultrasound
and then you kinda tailor it. Exactly.
We have one more question and this one
is about needle-free IVF.
So she asked,
"Can you have this
if you have a low reserve?".
She had two failed
ICSI cycles and tight funds available.
She's concerned about
whether she can do
needle-free IVF
if she has a low ovarian reserve.
Yes.
And needle-free
IVF, as we mentioned, earlier,
is actually
it's
the answer for your pocket
to save you money.
And because, look, I see people
being pumped with tons of drugs
and they develop one follicle.
And I say listen, if you did nothing,
you would have developed
this follicle. This is what it does naturally.
So what's the purpose for this?
This is the most expensive
follicle, $5,000 follicle.
Don't do that.
It's actually bad quality.
So - and a lot of people
don't even develop anything
because the system shuts down.
So she's actually a perfect candidate
for the needle-free IVF or the pills,
the home IVF kit,
if you want to call it.
And really
she would save a lot of money
with the same outcome in my opinion.
When someone does have a really low
number of eggs retrieved,
I know it depends on the doctor,
but some people recommend doing ICSI
just to make sure that essentially
a sperm
gets into the egg
to give it a chance to fertilize.
With your patients,
do you just do conventional IVF?
Does it does it matter?
So ICSI is not - women with low
ovarian
reserve is not an indication for ICSI.
You don't want to manipulate
the egg too much.
ICSI can be aggressive,
especially if the embryologist
is not experienced.
So, ICSI is done for an egg that's frozen
because the shell gets hard,
for the sperm that's frozen
because the shell gets hard, for failed -
previously failed fertilization,
done for
someone who has a very low,
low sperm
count and poor motility and morphology.
But it's not really indicated
for women with low ovarian reserve.
And you'll be surprised
that sometimes, conventional way
,just add the sperm to the egg,
could do better than the ICSI.
But again, it's case-by-case basis.
I can't just generalize.
If she had failed
failed fertilization
with the conventional way,
then ICSI is indicated. Otherwise,
I don't see a reason why you need to do ICSI.
Do some people sometimes do -
do IVF with you remotely?
I think I read that, that
if people wanted to work with you,
they can
they can be in their own state
if they're not
in New York or Connecticut.
But they could work with you.
Yes.
So 40% of our patients are actually
not in the New York State area.
They're outside the area
and also all over the world,
including Hong Kong, Europe,
the Caribbean, Canada.
We send you our protocol -
we do everything.
You only come to us
once, the day of the procedure
or the egg retrieval
or the embryo transfer
or whatever it is.
We - we send you
the prescription to monitor.
All you need to do is to go
any place close to you
any
OBGYN doctor,
the fertility clinic next to you,
even a hospital. Just say,
I'm doing IVF.
I just want to do these results.
They will do the tests and the
form that we send
has all the instructions on
how to get - to send us the results.
We get them back.
I make a plan.
Blood and ultrasound are really simple.
Can be done anywhere, right?
The ultrasound can be tricky
but the blood is is really simple.
They're all similar machines,
they're very reliable.
I can make a plan on just blood
sometimes only, so -
and then we will manage everything.
We will tell - the staff will tell
how much to take,
what to take, when to trigger.
All that stuff.
Then you need to come
only the day of the procedure.
So, yeah, it's very simple,
very convenient. Awesome.
And then
what is the best way
for people
to find out more
about you and your clinic
and the sort of treatments
that you offer?
Sure.
So our website is Rejuvenating
Fertility Center.
My name is Dr. Merhi.
and if you go to our website
under our services,
you will see a lot of
novel things that we do,
you know, under our services.
If you would like to contact us,
you can go to, on the website, 'Contact Us',
and then fill your information
and someone will call you right away.
You are also welcome to send me a -
DM me on Instagram,
@doctor_merhi, M - E - R - H - I.
Or on our Rejuvenating Fertility Center
Instagram account.
Perfect.
Awesome.
Yeah, and I
really like your guy's Instagram,
by the way.
You guys do great
ticktock dances and things as well.
We did one yesterday, so I hope you like it.
Oooh, I'll have to check it out.
Well, thank you for your time.
I really appreciate it.
Thank you so much for having me, Claire.
I really appreciate your time.
And it's really - it was fun.