Tuesday, February 2, 2010

PCOS Patient Beginning IVF Treatment, What Questions Should She Ask Her Doctor?


I have PCOS and I've started IVF (in vitro fertilization). I have concerns because I don't really understand what is going on. They say they want my estrogen level up and that it is going in the right direction but they keep increasing my medication. Why? How can I tell if it is working?

I have started since January 22nd. Is it normal to continue and what questions do I ask my doctor to see if my chances remain good?


Thank you for your question, it's always good to know exactly what is going on so don't hesitate to ask your doctor as many questions as you can. Take a pad of paper with you and write down the answers if you need to.

Let me begin with our protocol at our clinic for patients such as yourself. With PCOS patients we have to be very careful because if you over-respond, you could develop and illness called ovarian hyperstimulation syndrome (OHSS). Many IVF programs use a protocol called a "step-up" protocol whereby you start on a lower dose and it is slowly increased based on your estradiol levels and ovarian response. They should be doing ultrasounds at the same time to see how many follicles are growing and what size the are. Once it looks like you are stimulating, the dose is usually kept constant until the follicles reach the appropriate size for retrieval (18-24 mms).

If you started on the 22nd of January, your cycle is definitely going kind of slow. Most patients will respond within 10-16 days. I would presume you are getting closer.

If your doctor is not explaining these things, then you need to be more insistant that you want an explanation at each visit. Most doctors, or their respective nurses, will then explain how things are going and what the goal and timeline is. We can usually predict, within a day or two, when you will be ready to retrieve.

What you should ask is:

1. How am I doing?

2. Am I responding to this dose or protocol? Are my follicles increasing?

3. How many growing follicles do I have?

4. When are you expecting me to be ready to retrieve? Transfer? Explain that you need to plan the date.

5. What if I have too many follicles? Will you cancel me? Do you Coast? Will you trigger with HCG or Lupron? (Lupron is what I use because it has a shorter duration of action and has been shown to decrease the incidence of OHSS if there are too many follicles and the estradiol is too high (over 4000).

6. What is my estradiol level? (the goal is to have a level of 2000-4000 at the point that the follicles are ready for retrieval. If the estradiol level is over 4000, then the risk for OHSS is higher).

I hope this gives you enough questions to ask for now. Keep informed and stay in touch! Good luck!

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF program
Monterey, California, U.S.A.


  1. This comment has been removed by a blog administrator.

  2. Great Post.....

    I found your site on stumbleupon and read a few of your other posts. Keep up the good work. I just added your RSS feed to my Google News Reader. Looking forward to reading more from you down the road!

    Thanks for sharing....

  3. Thank you for your comments and interest. I hope that it is an informational source for people and beneficial. I'll keep posting new material.

  4. Great Post.....

    I found your site on stumbleupon and read a few of your other posts. Keep up the good work. I just added your RSS feed to my Google News Reader. Looking forward to reading more from you down the road!

    Thanks for sharing....

  5. Hi Doctor,

    Any advice welcomed! Im 36, healthy, but have low ovarian reserve, 3miscarriages, habitual aborter fsh high 10.2, positive for Factor V elevated protien c values of 140. Activated protein C resistance ratio low values 1.8.. My question is do you think with IVF treaments I could possible have a healthy baby? If so, what IVF treatment plan would you recommend. Oh, and im a poor responder durning ivf. Only have 6 antal follicles and responce to treatment 6 embryos. Thanks in advance for your help.

  6. Hello,

    You have several problems going on simultaneously that affect your ability to have a successful pregnancy. In addition to the immune factors, you have decreased ovarian reserve, which means that your ovaries do not stimulate well, and you are 36 years old, which means that your egg quality is diminishing. Certainly I think that IVF is the best treatment option that you have if you want a genetic child. The only other alternative would be to consider donor eggs to treat both the age factor and ovarian factor.

    In terms of the immune system issue (positive Factor V leidin, Elevated protein C), that is a more difficult issue to address.

    In terms of treatment, I would recommend using low dose aspirin 81 mg per day and mini-dose Heparin 2000 units twice per day (lovenox could be substituted for this). For the stimulation protocol, I would recommend a high dose (Follistim 450IU and Menopur 150IU) protocol using the antagonist and NOT the long protocol with Lupron (too much ovarian suppression). I would also recommend Medrol 16 mg per day and increased progesterone given both vaginally and intramuscularly. Finally, I would strongly recommend that you go to a good IVF clinic (not all IVF clinics are the same).

    After that, you have to hope for the best.

    Good Luck.

  7. Hi Doctor
    Please advice. I am 34. My Doctor had difficulty inserting catheter during IVF. I am worried if that will decrease my chance of getting pregnant by damaging the embryo.

    1. Yes. You are correct. The embryo transfer part of the IVF treatment is very important. My teacher taught me that you can have the absolute best embryos but if they are not transferred into the uterine cavity correctly, then it will fail. It is not an absolute that it will fail, but your chances will certainly be decreased. That is why choosing your IVF doctor is so important. You want one that has a lot of experience and has done a mock embryo transfer before the IVF cycle in order to anticipate a difficult transfer.



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