Sunday, July 19, 2009

Two Failed IVF - LOW AMH

Questioner: SA
Subject: Two Failed IVF - LOW AMH

Hello. This is a followup from June 22nd. Recap: 39 attempting for 11 months. Jumped into assisted treatment due to maternal age. 3IUI and 2IVF (both rounds all eggs fertilized and went to blastcyts) results 8w pregnancy from the 3rd IUI and two chemical pregnancy results from IVF. We have no known issues given multiple testing and family history outside of maternal though have a low AMH (1.3/pmol). Recent Laprosphy showed tiny polyp at entrance to uterus which was removed. Gearing up for next round of IVF will be 375 Gonal F stimulation (usually 9 follicles w/ 2-3 fertilized - all mature eggs always fertilise). Discussed using DHEA within clinic which they had no issue. Implantation due to old eggs seems to be the most resonable answer. What other options can I consider to make this round successful?

Kind Regards (am located in London but am American)




As you know, every clinic has differing protocols. I certainly have mine. There is no treatment for "old" eggs. The advantage of IVF is that you can stimulate the ovaries so as to get out many many more eggs that you can naturally. This is with the hope that there will be one good egg in that crop. If not, you have to keep trying until you find one. You are still relatively young so there will still be some good eggs left.

Once my patients fail a cycle, I do what I call a "full court press." This means I give them everything under to sun to cover everything that I can and give them the best chances that I can. There are no studies to justify this, but it is all that I can do. In some cases it is successful and in others not. I would treat with a maximum protocol which is Follistim 450/Menopur 150 taken daily. I do not split the doses, but some clinics do. This is to try to stimulate the ovary to give a maximum number of eggs. Remember the goal is to find that one good egg left in the ovary so we need to get as many eggs out as possible. I also use the following:

Aspirin 81 mg daily beginning from the start of the cycle.
Heparin 2000 IU twice per day beginning from the start of the cycle.
Medrol 16 mg daily until the transfer then decrease to 8 mg until pregnancy test.
I use BOTH injectable and vaginal progesterone (double up).
Climara patches 0.2 mg (two patches) weekly beginning at the time of retrieval (estrogen supplementation).

I do not use the "long protocol" which is starting Lupron on day # 21 of the preceding cycle, or the "flare" protocol which is starting Lupron on cycle day # 2. I avoid ovarian suppression until the follicles are 17 or 18 mms then use Ganerelix (antagonist). This is to allow the ovaries to stimulate as strongly as possible (again to maximize the yield).

If you were coming to my clinic, this is what I would do. But each doctor has his own philosophy regarding these regimens, so yours may not approve.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

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