Wednesday, March 3, 2010

Injectables with IVF - Is Metformin Indicated?


Hello-I am from the US and I am 33 years old. My husband is 34. We have been trying for almost a year and saw an RE. I was told I have a fibroid that I am having removed laparoscopically the end of March. I was told by my doctor that since my huband's sperm is below where it needs to be (both count and motility) that I can begin IVF (in vitro fertilization) with injectable treatments about 2 cycles after the surgery. Which drugs are used? She mentioned ICSI (intracytoplasmic sperm injection) also. Will I have side effects from these injectable medications and if so what will they possibly be?

She also mentioned my possibly taking Metformin to try to enhance the IVF to work. I have heard mixed reviews on this medication actually working and was wondering what your take is on it. Can you please advise? I have heard of some unpleasant side effects from Metformin/Glucophage so I am not sure what to do.

What is the chance of IVF or IVF with ICSI to work? She said around 50% which I believe is much better than the 20% chance it would be which we were told if it would happen naturally. Is this true? I have had an ultrasound with saline and an HSG with dye- both came back fine other than the fibroid. I have been put on Synthroid to regulate my thyroid which I was told was slightly elevated. I am also on the birth control pill until I have the surgery to remove the fibroid the end of next month. I have had several blood tests testing my FSH, LH, Prolactin, Estradoil, glucose, etc all which have been normal results. Any additional info. you could provide would be appreciated.

Thanks!- S.


Hello S.,

Let me answer your questions sequentially to make it easier:

1. Lots of different medications are used with IVF cycles. This is a question best answered by your doctor, or her IVf coordinator. Each doctor has different protocols, depending on their preferences and how they are trained. The main medications are called gonadotropins and are synthetic versions of the FSH and LH that your brain produces to stimulate the ovary to ovulate. We give higher dosages of these medications in order to make the ovary produce/prepare more that one egg. The goal with IVF, in order to maximize the chances of pregnancy, is to get more than one egg out. Preferably 10-20. This is because not every egg is a good egg.

2. Most women tolerate these medications very well since they are essentially the same as the hormones your body produces. Of course, all medications have side effects and each person is different and can react differently to each medication. The biggest side effect of these stimulation drugs is that the ovaries will enlarge and become tender because so many eggs are being recruited. In addition, some patients will feel bloated. If the ovaries are stimulated too strongly, or the ovaries respond too strongly, you can develop an illness called "hyperstimulation syndrome." This is a very serious and dangerous problem that has to be prevented and managed appropriately. If you have PCO, which I suspect you might have since your doctor recommended Metformin, you are at increased risk for hyperstimulation syndrome. You need to discuss this with your doctor and ask her what she does to prevent this. There are methods that we use to prevent this from occurring such as using lower dosage protocols, close monitoring of blood levels, coasting or drifting if necessary, antagonist protocol, triggering with Lupron instead of HCG.3. Metformin is only indicated in 30-40% of patients that have PCOD. It is NOT indicated in all patients AND, it takes 6-8 months to work so starting it with an IVF cycle is not appropriate. I would not recommend it unless you have been found to have insulin resistance by blood testing.

4. In terms of IVF working, you have a 50-70% chance of pregnancy with each IVF cycle in your age group. You should ask you doctor what her statistic is. Pregnancy rates do vary depending on the clinic and the doctor, so be sure to check both out.5. With a severe sperm disorder, the chances of pregnancy would be much less than 20%. Your natural chances of pregnancy at your age, if there were absolutely no problems, would be about 15% per month of trying. With the sperm problem it would drop it to less than 10%. That is why IVF is the treatment of choice. With IVF and ICSI, we had a 75% pregnancy rate per transfer in 2009. Most clinics are reaching that level as well.

I hope this information helps. Be sure to ask lots of questions. You will be paying a lot of money for this treatment and you should make sure you have had ALL your questions answered to your satisfaction. This type of procedure is like shopping at Saks 5th Avenue. You should demand and get the highest level of service!

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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