Question:
I am 39 years old and have been TTC (trying to conceive) for 3 years and 4 months now. I had a Laparoscopy done in March 2007 which showed healthy patent tubes, clear ovaries and a normal uterus. I normally have irregular periods ranging in length from 32 days to sometimes 42 days but in general around every 35 days. I usually get my positive on an OPK around day 21.After trying naturally for 1.5 years we went to a fertility clinic where I was put on Clomid 100mg with mid-cycle scanning plus trigger shot and I conceived on my second cycle but unfortunately miscarried in January 2008 at 10 weeks. I took a break of 3 cycles after the miscarriage and then went back on Clomid for 4 months. On each of the clomid cycles I produced 2 to 3 dominant follicles but each cycle resulted in a negative result. I took a break after Clomid for another few cycles and then started into IUI (intra-uterine insemination) just before Xmas 08.
On my first IUI cycle I was on Gonal F 75iu and after 7 days of injecting the cycle was cancelled because I produced 8 dominant follicles. My meds were then changed and I was put onto Purgeon 50iu for 2 further IUI cycles and on each of these cycles I produced 3 dominant follicles and my husbands sample was good yet both cycles produced a negative result. My most recent IUI cycle (June 09) had to be cancelled again as I produced 5 dominant follicles.
My question to you is this? Is it just bad luck that I haven't conceived since my miscarriage or is my age a factor? I had a day 3 hormone profile done in April 2009 and my results were as follows: FSH 5.9, LH 3, Oestradiol 22 pg/mg - do these results look ok to you? Is there any chance my eggs may be of poor quality or would my day 3 results have reflected that?
We still have 2 more IUI cycles to complete and failing those we will be moving to IVF (in vitro fertilization), but I thought I would ask your advice in the meantime.
I hope you can help.
Answer:
Hello,
The hurdle you seem to be facing is probably due to poor egg quality as a result of age. Your natural chances of pregnancy at 39 is 1% per month/12% per year and 3-5% per month with IUI. Not very good odds. This is strictly due to age. Your miscarriage was probably age related as well, as the miscarriage rate increases with increasing age due to spontaneous chromosomal abnormalities (i.e. spontaneous breaks in the chromosomes as they are dividing).
You have been wasting a lot of time and now it is time to become more aggressive if you want to have a child. You have done more than enough Clomid and IUI cycles (six IUI cycles are too many! 3 - 4 cycles are what are recommended before proceeding to IVF). I would recommend that you move directly to IVF as soon as you can, since you are stimulating well. Pregnancy rates with IVF are 50-60% (it is 71% so far in 2009 in our clinic), but this will go down to 27-30% at age 40. Your lab results are good and show that you still have good ovarian function, but that is not a measure of egg quality. Egg quality is the issue. I often tell my patients that with IUI's it's not the sperm that are an issue it's the egg factor. We need to have one good egg to acheive that pregnancy. Because of that, I allow more eggs to ovulate in an IUI cycle (5-8) if the patient is over 37 years old. I would not have cancelled the cycle that you just went through. I have never had a problem with multiple pregnancies since the chances of a multiple are minimal in the 37 plus age group. If a patient with your history proceeds to IVF I will transfer 5-7 embryos.
I hope this helps,
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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