Please help ! H. from Tokyo
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF
I don't even know how to begin because my infertility process has been so exhausting. I suppose I have diminished ovarian reserve. My last FSH check was 8.5. My AMH is 1. My stimulation cycles response seem to change--one time will be a nice response and the subsequent ones won't be. I started my first IVF this year and I fear repeating the same pattern as last year. Last year, my first IUI on 75 follistim/femara produced 4 mature eggs. I conceived, hcg was high, but ultimately a miscarriage due to trisomy 3. Did a complete RPL work up (I had a chemical pregnancy unmedicated 6 mos earlier). Nothing was abnormal, even karotyping.
I had two more IUIs after that, producing 2 eggs, then only 1 egg. No success. I battled recurrent simple follicular cysts for about six months (would bounce from one ovary to next, two cyst aspirations and they would still come back) and finally had a cystectomy and laparoscopy in early February 2013. He found very mild endometriosis and treated it. I had started birth control pills in early January, on for 5 weeks, and then carried on with an antagonist protocol later in February with 150 follistim/75menopur. My day 4 E2 was over 700, thought I had another cyst, but instead had several follicles, dropped follistim to 75, then E2 dropped to 500, then up to 100 follistim and eventually my growth balanced out. Ultimately, I had 14 follices, 12 mature, 9 eggs retrieved, 6 fertilized, 4 day 3 embryos, then 2 highest grade blastocysts, 1 morula. Transferred the two blasts. Positive beta, 175 14 days after transfer. But my 48 hour beta dropped to 77. So I'm having another chemical pregnancy/miscarriage. This is exactly a year from my last miscarriage.
I am terrified that in continuing IVF I will repeat this same pattern--that the next IVFs will not work. I just don't know what to do. I don't want to be 32 and have bad eggs when I know I don't have a translocation. I feel like I do respond to lower doses of medications, which should be indicative of decent reserve, but I don't know why I would keep having such problems likely due to embryo abnormalities. I suppose my uterus may have not been ready after the surgery and it wasn't the embryo but I took the good stuff-PIO, vivelle, dexamethasone, prednisone.
Anyway, can these protocols be causing me an increased risk for aneuploid embryos? What could be changed? Any comforting words that I won't face the same fate with more IVFs that I did with the repeat IUIs? With it happening the same way all over again, I am believing I'll never have a baby. Last year was so hard, this IVF was hard. I’ve had to miss so much work, surgeries, U/S, procedures, etc. And I love my husband so much. I hate that I put him through this.
Thank you, L. from Oklahoma
Hello L. from the U.S. (Oklahoma),
First let me clarify and emphasize to you that the IVF cycle worked, and you certainly have a good chance that it will continue to work in the future. Your doctor probably did not explain that IVF only gives you the "chance" to get pregnant. It, in fact, cannot MAKE you pregnant because the last three steps of the reproductive process are still beyond our technology to make happen. These steps have to happen naturally (that part is still in God's hands). So the fact that you got pregnant on your first IVF cycle is significant because it shows that you can get pregnant! It is unfortunate, however, that it ended as a miscarriage.
In terms of going through all of your previous pregnancies and this one, that would involve a more comprehensive analysis and explanation, that is beyond this venue. I can do that by private consultation only.
Second, I think you need to get the terms "decreased ovarian reserve" and "never" out of your vocabulary. You DON'T have decreased ovarian reserve. Keep in mind that in IUI cycles, we only want up to three mature sized follicles so that you don't get triplets, quadruplets, etc. So, your responses were appropriate. With your IVF cycle you were on a very low dose protocol and the yield was appropriate. . . not too strong and not too light. You certainly could have been stimulated a little stronger, but it looks like your ovaries are very sensitive to the fertility medications so some care needs to be taken, as your doctor did.
Finally, there is no technology that can predict or evaluate for internal embryo quality. We can evaluate chromosomes so one option you certainly could consider with IVF is to have preimplantation genetic screening (PGS). If you decide to do PGS, I would recommend a D#5 biopsy to reduce harm to the embryo, but your embryos would need to be frozen and transferred at a different cycle. But that would allow you to evaluate the genetics of the embryo prior to transfer. Your doctor would also need to stimulate a little stronger to have more embryos to work with and test since surely some will return abnormal. This will then allow you to transfer normal embryos.
All clinics, doctors and the protocols they use differ and that is what influences the pregnancy rates which vary from clinic to clinic. There are other treatment protocol options; for example, I use low dose aspirin and low dose heparin in my recurrent pregnancy loss patients. It has been well documented to help. You might want to discuss that with your doctor.
I want you to not lose hope. You are young, your ovaries are still responsive and you've been pregnant, so now the goal is just to get a perfect embryo so that you can have the perfect baby. Statistically, your chances are very very high, so you will eventually be successful. You just need to hang in there and get the best treatment that you can. Then once you have your baby, let me know so that I can celebrate your success as well. You are on the road to success. The only way you will surely fail, is if you deviate from than road. Like Law school, this is a hard road, and it may not be fair, but in the end, it will be the most wonderful experience you've ever had in your life! Greater than falling in love. It was for me, and I thank God for his blessing that gave me my beautiful soon to be 16 year old IVF daughter. Keep the faith in your path and in yourself. Sorry for the long answer...good luck!
Dr. Edward J. Ramirez, M.D., FACOG