Question:
Hello Dr. Ramirez,
I am a 36 year old woman who has just attempted my first IVF cycle after 5 unsuccessful IUI's. I have been diagnosed with PCOS and ovarian resistance even thought my FSH has always been low on my day 3 blood work. I do not have a regular period and have needed clomid and Puregon injections in order to ovulate for the IUI's.
This past IVF cycle my numbers were as follows: Day 3 - FSH 5.7, Estrogen 112, Progesterone 3.5 and LH 7.6. I commenced 150 of Puregon on Day 3 and continued on Day 4 and 5. On Day 6 my blood work results were: Estrogen 334, Progesterone 3 and LH 4 and I had many follicles at 1.0. I upped my Puregon to 200 for Day 6 and 7. On Day 8 my blood work was Estrogen 717, Progesterone 2.7 and LH 2.7 and none of the follicles were progressing. I went back in on Day 9 for a follow-up ultra sound and there was no change in follicle size. My IVF cycle was cancelled.
My question is what would the IVF protocol be for someone who has a history of ovarian resistance? Would my dosage need to be increased or combined with other medication? I have had a egg reserve blood test done and I apparently have a very high number of eggs for someone my age. I would assume that would be because I do not ovulate on a regular basis. The question then comes down to egg quality. If I do not ovulate, does that compromise egg quality? Any advice or light you can shine on my situation would be very helpful.
B. from Canada
Answer:
Hello B. from Canada,
First of all, having BOTH PCOS and Ovarian resistance does not compute. Ovarian resistance is when the ovaries do not respond well to stimulation. PCOS patients tend to over-respond to stimulation. Somehow, I'm not sure your doctors have it right. You should be one or the other.
You do not have ovarian resistance based on your description of having "many follicles". You were also on a low protocol, probably in anticipation of being a high responder due to PCOS. Based on your estradiol levels, you were progressing well, but your follicles were small as is characteristic of PCOS patients. They tend to stimulate and grow a lot of follicles, which progress more slowly, instead of selecting a few and growing them more rapidly. Keep in mind that 200IU or Puregon is a low dose. My highest protocol is 600IU. I don't know why your doctor canceled your cycle. Maybe he/she felt uncomfortable with number of follicles you had and did not want to risk hyper-stimulation syndrome. Obviously, your doctor is not used to treating PCOS patients. Also, you were only cycle day #8 which is still early in the cycle. Most patients will go to cycle day #12 or 14 before the follicles are ready. Since your estradiol was only 717, you were not at risk for hyper-stimulation syndrome as yet. Patients that develop hyper-stimulation syndrome tend to have estradiol levels over 2000 by cycle day # 9.
Also, you should keep in mind that at 36, you are still young and most of your eggs should still be at good quality. You have a good FSH. Age is not an issue for you yet.
In terms of protocols, I cannot give you a standard protocol because every program and doctor has different protocols and combination of protocols. I prefer to use a "mixed" protocol which combines both FSH and FSH/LH (I use Follistim for FSH and Menopur for FSH/LH). In your case, you just were not stimulated enough, and the doc should have kept going and increasing the dosage, whether you use the single agent protocol like you did or use a mixed protocol.
I hate to say this, but I might suggest that you consider seeking out a different clinic or doctor, because I am leery about how your first cycle went. Again, I don't think you are a "low responder" so you might want to discard that label for yourself. Low responders barely respond to 600IU or more of medication and often the estradiol doesn't get much above 300-400.
Keep trying and 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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