Wednesday, July 1, 2009

Failed IVF Question

Questioner: Claudia
Subject: 2nd failed IVF - what now?

Good afternoon Dr. Ramirez,

I had my 1st failed IVF (10.08) on the flare lupron protocol: 7 eggs retrieved, 5 mature, 4 fertilized, 1 blast + 1 morula d5t, ICSI and assisted hatching.... chemical pregnancy
Yesterday, I experienced my 2nd IVF failure using an antagonist protocol (Ganirelix): 16 eggs retrieved, 13 mature, 10 fertilized, 3 (8 cells grade 1 & 2) and 1 (7 cell grade 2) embryos d3t, ICSI.... BFN

I just turned 39 yrs old and I'm intimidated about future IVF cycles before I don't have clarity on the issues that may have gone wrong? We were diagnosed with unexplained infertility and advanced maternal age, however, I produced a good # of eggs the 2nd time, my uterus lining was above 9 mm each time, I have open tubes and no thyroid, CF issues (tested 08/08).
I'm just wondering if you have any additional tests in mind or suggestions I could consider before going into another round? I really appreciate your response, thanks beforehand.


It sounds like both IVF cycles went well as far as the controllable aspects of the treatment. The second cycle was better because of a higher yield. In the second cycle, out of the 10 fertilized, only four were of reasonable quality. That is the "age factor." We know that with increasing age, less of the eggs will be internally good and lead to abnormal embryos. Despite the fact that your transferred embryos looked good, they still have a high probability of being chromosomally abnormal, hence the chemical pregnancy and failure. This is what happens with age. You need to understand this because, the age problem is not reversible. What it means is that you have to keep trying until there is finally a good egg that makes a good embryo leading to pregnancy. It will eventually happen, it will just be harder. If you want a shorter course (i.e. less attempts), then donor eggs would be the only alternative, but the chances of pregnancy will be higher (73% per attempt this year in our clinic).

The protocol I use with my older patients, especially if they have failed previously, is to use a high protocol (I call it C8c which stands for a continuous 8 amp (600IU) antagonist protocol (the c was for Cetrotide but now I use Ganerelix). The 8 amps is broken down into 450IU of Follistim and 150IU of Menopur on a daily basis.

I also add the following:

Medrol 16 mg per day
Climara patch 0.2 mg per day starting at retrieval
Heparin 2000 Units twice per day starting at the beginning
Aspirin 81 mg per day starting at the beginning
Progesterone 50 mg injections starting at retrieval
Endometrin 100 mg twice per day starting after transfer

Your docs may have their own protocol for previous failures, or may not want to do this same protocol, but it is an option.

These do not treat abnormal eggs nor make them better. They do help with implantation, however, and reduce the immune response a little. That is why I use them. It is a full court press protocol. The bottom line is to keep trying. That is the only way you are going to be successful in the end. If you don't try, you definitely won't be successful with IVF.


Edward J. Ramirez, M.D., FACOG

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