Wednesday, December 16, 2009
IVF For The Third Time - Embryos Arrested at Eight Cells
I get many, many questions from patients outside the United States. Here is one from Europe from a young IVF patient with very disheartening outcomes.
Hi, I hope you can help me as honestly don't know where to go from here as been such a tough journey. Here's a bit of history.
DH (38)- asthenozoospermia
Me (35)- very slight PCOS, normal FSH levels
Clomid pregnancy 2008 - sadly ended in Stillbirth at 38 weeks (sept 08), cause confined placental mosaicism.
IVF 1 March 09 - cancelled poor response on too low stim drugs
IVF 2 July 09 - 14 eggs collected, 9 fertilised, 6 day 3 embryos. Transferred good grade 8 and 6 cell at Day 3 - BFN
Natural pregnancy Sept 09 - Miscarriage at 6.5 weeks
IVF 3 Nov 09 - 9 eggs collected, 8 fertilised. Day 3 - 5 X 8 cell 2 X 6 cell embryos. Plus 2 frosties (IVF 2) All looking good and then at Day 4 - all fresh arrested development at 8 cell. 2 frosties reduced cell number - no transfer
Tests so far:-Full chromosome anaylsis with me and DH - clear
Sperm DNA Defrag - within normal levels
Auto-immune tests (me) - slightly raised levels but not significantly. On all IVF's I have been on Short Protocol (Puregon, Luveris) and we have done ICSI. Plus support drugs of Clexane, Aspririn, Prednisolone (3rd cycle only),intralipid infusion (3rd cycle only) Progesterone and estrodial patches (post egg collection).Clinic doesn't seem to have any answers and seems to think worth trying one more time but do you think it would be worth changing clinics?
Are there further tests that would be worthwhile? Is it time to look at Donor and if so is this more likely to be an egg issue or a sperm issue or is it both? Do you think there might be a link between poor quality embryos and stillbirth and miscarriage?
Thanking you in advance for any help you can offer.
Hello, let me answer your questions in order:
1. I think it might be reasonable to try a different clinic. Of course it could be just bad luck, but you have had real bad luck. One cancelled cycle and one cycle with arrested development. That's not a good statistic for a clinic, especially considering that you are young. In my clinic, my 2009 pregnancy rates in your age group are 74% per cycle with a 63% delivery/continuing pregnancy rate. I think the national average in the U.S. is 50-60%. Pregnancy rates are highly dependent on the clinic you attend because it can be influenced by the laboratory quality and techniques, as well as, the transfer quality and techniques. Good 8 cell embryos should not arrest, at least not all of them. Some may, because they are inherently abnormal genetically, but not all. I am highly suspicious of this.
2. It sounds like you have been tested for everything that can be tested for and you are fine. I cannot think of any other testing that I would recommend.
3. Abnormal embryos can be an egg issue or a sperm issue. Certainly, PGD can be done to check the embryos with another cycle to see if they are chromosomally normal or not, but I do not recommend it. Recent studies have shown decreased pregnancy rates with PGD, probably due to embryo injury or affects from removing one of the blastomeres. However, I don't think that this is your problem since you have been naturally pregnant twice in the past. If you were going to test your theory however, I would first try donor sperm, since it is the least cost. If you still have poor embryos after that, then you can go to donor eggs. I don't think you should go to donor eggs that this time. I would recommend that you try another clinic and continue trying with your own eggs. For example, I have a patient about your age who recently underwent IVF with me. She had done 5 IVF cycles at another clinic on the East Coast of the U.S. After the 5th cycle, they told her that she had poor egg quality and should use donor eggs. She then moved to my area. I recommended that because she was young, she should continue to try with her own eggs, at least a couple more times.
In her first cycle, she had a great stim, good fertilization, but the embryo quality wasn't so great. Her best embryo was a 6-cell embryo on day#3. She did not get pregnant. In the second cycle, we had great embryos. I transferred 3 8-cell embryos and she is pregnant with a viable pregnancy (singleton). And, it is hers genetically. Sometimes you just have to hang in there.
I hope that helps a little,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.