Friday, June 25, 2010

Diminished Ovarian Reserve: I Have Failed 3 IVF Cycles, Blighted Ovum -- Where Should I Go Next?


Question:

Dr., I am 34 and have been diagnosed with diminished reserve.

I have done three IVF cycles. In the first, we got 5 eggs, after fertilizing all had testing and all found to have some anomoly, none transferred. Second, the clinic let me ovulate...didn't even get to extract eggs. Third got 2 eggs, only 1 fertilized, only a 4 cell with a lot of fragmentation, & I knew it was not going to work. Just found out I have a blighted ovum.

My question: Obviously my chances are not very good on my own and I realize donor eggs are my best option but I am finding it difficult to give up.

I am in health care and I guess my question if you can offer any advice is: For example in certain types of cancer there are certain centers that are more leading experts than others for certain types of cancers. Is that possibly the case with this disease? Is there a center that is the leading expert at diminished ovarian reserve that can help me? I had these 3 IVF at 2 different clinics and neither were very compassionate and treated me just like a number taking a shot in the dark at my protocol.

The last clinic the MD REALLY got my hopes up and now that it hasn't worked has dropped off the face of the planet. So my question is, are there leading experts in this arena that maybe know more specifics about what type of protocol might work best for me??

Answer:

Hello B. from the U.S.,

First of all, let me say that diminished ovarian reserve is NOT a disorder and is not a cause of infertility. It simply means that the patient's ovaries don't stimulate well and is often indicated by a high cycle day #2 or 3 FSH level. It is not an indication of egg quality in any way. Secondly, you are still young. You still have a good chance of pregnancy with your own eggs even if only a few are retrieved. I would still expect your pregnancy rate to exceed 50% per cycle (ours is 73%). I would not have wasted any of the cycles because there is no way to know if the good egg was in that batch. Even normal women do not ovulate good eggs all the time, and that is why it can take several months of trying to get pregnant. It is the same with IVF. Even if my patient has only one follicle I still try for this reason.

In terms of your question regarding the best center for your problem, I'm afraid there is no one center that is best for this problem. All IVF clinics have patients with decreased ovarian reserve, and each IVF center has different statistics and different ways of taking care of their patients. We all use different protocols as well. One question I would ask is what was your protocol? Were you given the max stimulation (600IU of FSH in either pure FSH (gonal-f, follistim, bravelle) or a combination (one of the previous with Menopur, Pergonal, Repronex). These latter medications have FSH in them as well so for instance if you took 450IU of Follistim + 150IU of Menopur, you would have a total dose of 600IU of FSH. I use this as my highest protocol.

In addition, timing is critically important. If the HCG trigger was given with the follicle size of 18 mms, it is possible that the egg did not have adequate time to mature, whereas 20 mms or 24 mms would have been better. As you can see, there are many variations in treatments. That is why there is no one center that is better than any other.

In my center, for example, I have extensive experience with low responders and use a high protocol for those patients. I also am a smaller, boutique-type center that prides itself and excels in providing one-on-one personalized care from beginning to the end. I am the only doctor, involved with my patients' progress from day one. That is what makes us different from some of our competitors in the big cities that operate more impersonally and do not give you access to the RE as much. All of these are facts and qualities that a patient should look for and seek out. They are paying a LOT of money for this treatment so they should demand their money's worth in all aspects.

With all that said, low responders are difficult because part of the success of IVF comes from having a large pool of eggs to work with. We know that in all cycles, there are going to be good eggs and bad eggs, so if we have an increased number, then there is a higher likelihood of getting a good egg. For low responders who don't stimulate well, and hence, don't give a lot of eggs to work with, that just means it may take more attempts before that good egg emerges. I would recommend that you NOT give up. After all, you have really only done two IVF cycles since the second one was cancelled. I am confident that you will be successful if you can continue to try. If you want a quicker solution, then donor eggs would be the option, only because a donor with normal ovarian function will yield more eggs to work with. Since you have had a blighted ovum, it means that the IVF cycle worked (remember, IVF only can produce embryos. The pregnancy, because of the last implantation step, still has to occur naturally). This confirms that you can get pregnant, and it is just a matter of getting a good egg/embryo into you. If you were 40, I would advise differently and lean more toward donor, but at your young age, you should keep trying.

Maybe you should consider coming to Monterey :) ! It is a beautiful place to visit as well.

Good Luck and don't give up hope!

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

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

50 comments:

  1. Dr. Ramirez, you echo what my RE has been saying to me, and for this, I thank you. It is open-minded, client-centred doctors like you who make it possible for those of us with Diminished Ovarian Reserve to keep on trying with our own eggs.

    Best,
    Maddy (38 and still trying!)
    www.lateforaveryimportantpregnancy.blogspot.com

    ReplyDelete
  2. P.S. One point I wanted to make to B. from the U.S. is perhaps to next try a few cycles with the same, supportive RE to give them a chance to get to know your response to the meds and how to the adjust the protocols to work better the next time.

    ReplyDelete
  3. I have a similar question.

    I am 40 years old.

    I went thru one IVF cycle, which was aborted and converted to IUI cycle because it was found that only one folicle developed after taking below mentioned injectables for 9 days.

    CD#2 twice Lupron 10unit and CD#4 (450IU Folistim + 150 Menopur). The folicle size was found to be 18mm on cd#13th day morning hence hcg was administered that day. IUI was carried out 36hrs after hcg was triggerred. This also failed.

    My question is -
    Should I try another cycle of IVF or IUI with above mentioned medicines or clomid + above mentioned medicines? Will clomid help in growing more folicles/eggs? Or do you have any other suggestion as far as the protocol is concerned? What do you think will be the chances of succeeding in the above case?

    Please let me know if you have any other suggestions.

    ReplyDelete
  4. Hello,

    The fact that you were on a max protocol with Follistim and Menopur and only formed one follicle shows that you have a condition known as "decreased ovarian reserve" or are a "poor responder". This means that the ovaries are NOT stimulating with the extra medication. This is a major problem in that the only way we have to overcome the "age factor", which is the decreased egg quality within the ovaries, is by increasing the number of eggs stimulated and removed at IVF. It is a statistical difference. The more eggs we can get, the higher the chances of finding a good egg. That is not to say that you can't have a good egg from one follicle, and this is the reason I don't cancel cycles, but the chances of a successful cycle are lessened.

    I still think that despite this, IVF is better than IUI. IVF accomplishes 7 of the 9 steps your body goes through to achieve a pregnancy. IUI only accomplishes 2 and the rest are left to nature i.e. chance. For this reason, the chances of pregnancy with IVF in your age group is 50-60%, but only 1% with IUI. I also would not use Clomid, it is a worst stimulator than the injectables and the only savings grace is that it is easier to use and cheaper, but not at all ideal.

    Keep in mind that studies have shown that even in poor responders, each cycle is different and unique, and the quality of the egg will therefore be different. Therefore the chances are the same with each cycle. These studies have shown that with repeated attempts a reasonable number of these patients will get pregnant. However, it may take multiple cycles to accomplish this. The alternative would be using donor eggs, which would give you the highest chances of success. I think that would be my recommendation if it is an acceptable option to you.

    Good Luck

    ReplyDelete
  5. Hello Nov 5,

    I am sorry to say that your doctor does not know what he is doing. The proper way to do stimulation protocols with gonadotropins (gonal-f or follistim) is to continue the dose and increase every 3-4 days as necessary until the follicle reaches ovulatory size. In both instances that you went through, the doctor terminated/cancelled the cycle prematurely. He should have kept going and probably needed to increase the medication dosage. In addition, your do not have decreased ovarian reserve. That is a completely WRONG diagnosis. Decreased ovarian reserve is based on an elevated FSH level (>10), decreased AMH (<1) or decreased antral follicle count. It is also meant to have meaning ONLY with IVF cycles, not standard ovulation induction cycles with timed intercourse or IUI. Do not believe this doctor. You need to go see a REAL infertility specialist doctor. Preferable one that does all levels of infertility treatments including IVF. If the doctor does not do IVF, then you know that the doctor is NOT an infertility subspecialist.

    Good Luck.

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  6. This is a fantastic blog! Thanks so much for the useful information, Dr. Ramirez.

    I am 38 years old and my first IVF cycle failed because I was a low responder. I was taking 375 ius of Gonal F plus 75 units of Menopur and I only had 2 eggs at retrieval (though I had 6 follicles), but one was immature and the other didn't fertilize. My doctor recommends another IVF cycle with Ganelerix instead of Lupron and 450 ius of Gonal F.

    I have heard taking supplements such as Myo-Inositol, Melatonin, and L-Arginine 700 mg have helped poor responders. Is this true? Is there else anything I can do to increase the quality of my eggs? Would it be best to wait a month or two to do the next IVF cycle and try some supplements, or just carry on?

    Thanks!

    ReplyDelete
    Replies
    1. At this point in time, there is nothing specific that I can advise to either increse the ovarian response or the egg quality. I am using CoQ 10 600 mg per day in my patients, however, become some animal study that was recently published, showed improvement in egg quality. I figure it can't hurt. I also advise acupuncture in my patients. I am not a big fan of supplements but again, it can't hurt.

      In terms of protocol, every doctor has their own preferences so I don't comment on any specific protocol. However, my max protocol in poor responders (high FSH patients) is 450 of Follistim or Gonal-f and 150IU of Menopur. I also use the antagonist (Generelix) exclusively. I no longer use the long Lupron protocol. I believe this gives the ovarie the ability to maximally respond to stimulation without being inhibited by the lupron.

      Delete
  7. hello Doctor,
    I am 41 years old. I have 3 children already yougest is17. I have my left side tube blocked so my doctor said my only chance is with IVF.I've had 4 early m/c with clomid, 1 failed iui so now my dr said ivf is the only way i can conceive. my day 3 FSH levels i'm told are good, 5.76 and my cycle is every 24 days. my doctor said I have diminished ovarian reserve that is why my cycle went from 28 days to 24 days. I have no other health issues, but I thought DOR occured when FSH level was high? do you think I will be wasting my time with IVF with icis?

    ReplyDelete
    Replies
    1. Hello,

      Decreased ovarian reserve is based on an elevated FSH level or poor response to ovarian stimulation. If your FSH level was 5.76, then yes, you do not technically have decreased ovarian reserve.

      The main problem that you need to overcome at 41 years old is the age related "egg factor". This means that there are few good or healthy eggs left in your ovaries. It is not an ovarian function problem. IVF is the ideal treatment beause it is the only medical treatment that can increase the number of eggs available for you to fertilize and implant, thereby increasing the chance of finding a good egg. Since you have been pregnant in the past, we know that you can get pregnant, but now it is just a matter of getting a healthy and normal egg/embryo. That may take time, but IVF will give you your best chances.

      Delete
  8. I recently had a failed IVF cycle at age 41. 5 mature follicles but only 2 retrieved. Both fertilized with ICSI for a 3 day transfer but failed to implant. (Prior to my cycle my AMH was .67 but my FSH was never tested.) I had three days of Estradiol pills, then was on 450 Gonal-F and 150 Menopur until trigger. Clearly I was a poor responder. My question is, if high meds only achieved 2 eggs, it seems logical that a mini-ivf (which typically achieves the same) would make sense, no? Since I am completely out of pocket my cycle was $18k and I cannot afford to do that multiple times whereas a mini-ivf I could do 3 times for the same cost. Would love to hear your thoughts on this option. I am NOT interested in donor egg as an option due to cost and personal feelings. Thank you in advance.

    ReplyDelete
    Replies
    1. Hi,
      I think that part of your thinking is correct but not completely. "mini IVF" means that low dose stimulation is used vs the high dose that you used. Certainly if the high doses only caused three follicles to grow, then it makes sense not to use all that medication. The problem is, the ovaries are stimulated by FSH and that is what fertility drugs do. If you didn't respond well to high dose medication then low dose medication will have a lower response. So, in that case you may not have 5 follicles but only 1. If you don't mind lowering your chances and having to do many more IVF cycles, then mini dose IVF will at least same you money for the cost of medication.

      The main way that IVF helps with age is getting more eggs out at a time. Getting more egg increases the chances of finding a good egg, which are fewer and fewer with age. The only alternative is to increase egg quality by doing donor eggs. Instead of doing and spending for multiple IVF cycles, maybe it might be better to go to donor eggs?

      Good Luck

      Delete
  9. Dear Dr. Ramirez,

    Just yesterday, I failed my first IVF at 40.5 yrs old. After successfully having a son in 2006 all naturally, I developed hypothyroidism. Our second son was born through the 3rd IUI with Follistim (2 clomidn IUIs didn't work). We are now desperately trying for #3. We did another Follistim/IUI cycle in January and immediately went to IVF due to my age. My AMH is .18 and my FSH is 7. My husband has no known issues. My protocol was 2 weeks of birth control pills, then 150 menopur with 350 follistim. Added ganirelix and for trigger 2 ovidrils. After a VERY slow start (stimmed for 12 nights, trigger the 13th night) he was able to retrieve 5 3ggs. 4 were mature, 3 fertilized with ICSI. 2 made it to 3 day transfer (1 had an abnormal cell). I was on Crinone 2x a day, Estrace 1x a day vaginally and doxycycline and medrol around the retrieval. We are devastated. Our insurance will only cover 1 more try. My doctor (from a one-doc practice in NJ is wonderful. Very hands on and I see him at every appt.) told me they could try a different approach with "patches"? I think I was too upset to hear clearly. Did the birth control suppress me too much? He did tell me that of the two embryos one was great a 9 cell. The other was 5-6 cells. Both had some fragmentation. And assisted hatching was done. I've had two previous children...why wouldn't they implant? What can we do different?

    Thank you so much for your time and input.

    NJ mom

    ReplyDelete
    Replies
    1. Hello,

      I'm sorry that your IVF cycle did not work, but like many patients I seen, you give IVF a little too much credit. All IVF is actually doing is replacing the natural steps that your body would go through to get pregnant, and in fact, there are still three of those steps that IVF cannot help; the last three steps. These steps: embryo development to blastocyst, hatching and exiting the shell, attachment to the lining and overgrowth of the endometrium are natural steps that we don't have the technology to make happen. They are still in God's hands. For that reason, IVF does not have a 100% pregnancy rate.

      It sounds like you have a great doc and all the right things were done. There is the "age factor" remember that you are trying to overcome. That means essentially, that you are trying to find one of the few perfect eggs left in your ovaries. That may take several attemtps, just like the normal young woman can take several months of trying to get pregnant.

      My recommendation would be to consider increasing the stimulation to 150 Menopur/ 450 Follistim to stimulate the ovaries maximally. I wish I could offer you more.

      Good Luck

      Delete
  10. Dear Dr. Ramirez,

    I am 35 years old and have been trying for a health pregnancy for almost 2 years.I have an FSH of 10.6 and an AMH of 0.03. I got pregnant "naturally" in 8/11 and miscarried naturally at 6wks and got pregnant in 9/12 and had a missed miscarriage at 9wks after hearing a slow hear beat and then no heartbeat. The tissue was tested after the D and C and showed trisomy chromosome abnormalities. I have been diagnosed with DOR and RPL. My husband has had two seamen analysis done both showed morphology and motility in the low normal range. We have both had genetic testing done in keeping with an RPL diagnosis and all tests game back normal.

    MY RE suggested we move to IUI or IVF since even though I can get pregnant on my own it takes us quite a while and my DOR and the fact that I'll be turning 36 this summer makes sooner rather than later the best approach. My husband and I decided to go straight to IVF. I was nervous about not having a good response due to my DOR but did well on the micro flare protocol and at Egg Retrieval they were able to get 10 eggs (9 mature). The specimen my husband produced the day of Egg Retrieval was great in terms of motility and morphology so they decided not to use ICSI. However, the next day we got the call telling us none of the eggs had fertilized.

    We have had our follow up meeting with our RE and he is suggesting the same protocol but this time with ICSI. Do you think ICSI can help us? I am concerned that since I have had two natural but unsuccessful pregnancies and that my husband's sperm seemed fine the day of the Egg Retrieval that this means my eggs are just all really poor quality and that we will get the dreaded zero fertilization call again. I am concerned that donor eggs are my only option. Thank you for any insight you can provide.

    Sincerely,
    KA

    ReplyDelete
    Replies
    1. Hello,

      I think your RE is giving you the correct advice. Since the stimulation part of the cycle was good, it is unfortunate that you had fertilization failure. Because of this risk, I offer ICSI to all my patients and my ICSI rate is in the 80th percentile. My recommendation would be to try again and use ICSI this time no matter what. Don't change the plan!

      Since you have been pregnant in the past, and based on your younger age, your chances of a successful IVF are high. Your RPL was due to spontaneous genetic abnormalities, probably due to age or poorer egg quality, so IVF is definitely the way to go.

      Good Luck

      Delete
  11. Hi
    I have just been to see a fertility specialst. I am 30 years old and have been trying to conceive for over 14 months. I have a 20 month old son who I conceived naturally in the first month of trying
    My Fsh came bac at border line High at 9.5 but e2 was 165 . Antrical follicle count was only 2 follicles in right ovary none in the left. The doctor is waiting on results of amh but has diagnosed poor ovarian reserve and poor responder.
    My doctor is recommending clomid and iui to start.
    My question is would clomid work to stimulate more
    Follicles or would I b better trying on injectables straight away as my doctor is emphasising the importance of aggressive treatment sooner rather than later
    My other question is would I even b viable for Ivf with such low follicle count and would injectables increase this count
    Many thanks
    Emma


    ReplyDelete
    Replies
    1. Hello Emma,

      First, the FSH you did is not valid and should be repeated. The elevated Estradiol level is what invalidates the FSH. The Estrogen has to be at its lowest level and that is usually below 100.

      Second, if you have no other reason for not getting pregnant, that is, you have undergone a full evaluation and no abnormalities were found, then Clomid would be reasonable given your age. You should use a higher dose of the Clomid (150-250) with each month and try no longer than 4 months. If no pregnancy occurs within that time, and your doctor has used ultrasound surveillance to confirm that you are producing 3 ovulatory sized follicles, ovulation is trigger at the appropriate size and IUI is done at the correct time, then it would be time to move to IVF.

      IVF is certainly an option of you indeed have decreased ovarian reserve, but it is very costly.

      Injectables are stronger than Clomid and stimulate the ovaries directly rather than indirectly like clomid, but they cost more and that is the reason we tend not to use them in the lower technology/yield treatments.

      Good Luck

      Delete
  12. Thank you so much for ur advise doctor it is greatly appreciated
    I have one last question that I forgt to add in my first letter
    What are the average percentages for a 30 year old like myself which conceived a baby quiet quickly the last time around with this diagnosis of Poor ovarian reserve Firstly in regard to clomid iui and then with Ivf ?? I just feel hopeless with only an andrical follicle count of 2
    Many thanks again
    Emma

    ReplyDelete
    Replies
    1. There are statistics for the overall chances of pregnancy but none for "quite quickly", so I can't fully answer your question. The chances of a natural pregnany in a 30 year old is 18% per month, with IUI it is 25% per attempt and with IVF it is 60-76% per attempt.

      Delete
  13. Hello,
    I am 33 (will be 34 in July) and just had my first ivf cycle converted to iui. This means we've now done 4 iui's and are waiting to see if it worked. Doubtful.

    I was on birth control pills for 10 days and during that time my amh test result came back as 0.26. I Had been stimming for 5 days at 225 follistum and 75 menopur when I had my ultrasound that showed I had four 11mm follicles on my right ovary and one lead follicle at 18 on my left. So we converted to iui.

    My RE said he thinks I can produce more eggs and he'd recommend converting to iui and changing the protocol. He said I will go through one month off, then no birth control and he will give me something to pump up my ovaries before I start a higher dose stims.

    During my iui I saw his partner (I really like all drs there) and asked him more questions. He said I'll prob add femara and do 450 follistum. Before they had said my chance of success per cycle was 50% but his partner said due to low ovarian reserve he'd now say 25-30%. I feel so defeated and hopeless. Also my blood test after stims for 3 days was normal and my cd3 tests a few months back were all normal (fsh, estradiol, etc). Would love to hear what you think my chances are. Thanks!

    ReplyDelete
    Replies
    1. Hello Erika,

      Pregnancy chances are based on age, NOT the number of eggs. However, keep in mind that some of what makes IVF so much better is "statistical" chance. That means that given the knowledge that not all the eggs in your ovaries are good eggs, the goal of IVF is to get enough eggs to find the perfect one. The more eggs retrieved, the higher the chance of finding a perfect egg. That is "statistical chance". However, it only takes ONE perfect egg to achieve a pregnancy. You don't need 20.

      I don't think I would have cancelled your cycle despite the low response because IVF still has a better chance of success than IUI, but I understand why your doctor did so.

      If you were my patient, I would certainly increase your stimulation to get more eggs. I don't know about a Femara/Gonadotropin combination, having never used such a protocol. I don't see the benefit. With a higher medication protocol (you were on a low one with a total of 300 FSH and the highest is 600 FSH), you probably will get more eggs and your chances of pregnancy will be high, equivalent to the stats for all 33 year olds. In my clinic that is a 70% pregnancy rate and 57% delivery rate.

      Good Luck

      Delete
    2. Thank you so much for replying. It's so relieving to read some positive news. ;)

      Delete
  14. Hello, I am 40 and my husband is 37 and we have been trying for 2 yrs. I started with a fertility Doctor last year and have had 2 failed IUI's and one cancelled Natural IVF. I also have a blocked fallopian tube. I am getting ready to do a medicated IVF cycle but do not wish to do donor egg. My ovarian reserve assessment report has scored me as a 3, which is low and I scored the same thing at 39. My Antimullerian Hormone is 0.42, my estradiol value is 44.3, FSH 9.82, OAR inhibin B is 75.9, OAR Luteinizing hormone value is 4.91. My insurance does not cover IVF at all, so we are looking at paying $14k and some add'l charges, which is a total loss if this doesn't work. I believe the test was on day 2 or 3 of my cycle for the scores above. I believe on my natural cycle for IVF, everything looked good. I had two follies on the Left w/ the mean being 14.89 and 11.99 and two on right mean 9.24 and 6.57- it was cancelled due to my estradiol not jumping right before - going from 100.8 to 103, which the Doctor said wasn't a big enough jump and he cancelled. With the IUI's I took Letrozol (spelling) and I responded well, with producing 4 but two were small and the other two were 18.37 height and 16.33 height. My question is, Should I go through with the medicated IVF since I've never taken any stimulating med's except Letrozol, clomid and the HCG shop prior to the IUI. I have a normal cycle each month and have never been abnormal. I'm just worried that I won't produce the eggs needed at the size needed and if they will be healthy. Is there any other test to take that would help me to decide.... Thanks Angie

    ReplyDelete
    Replies
    1. Hello Angie. I don't think your doctor has adequately explained what you are facing. You have the "age factor" and "decreased ovarian reserve". The age factor is due to the age of the eggs. It basically means that less and less of your eggs are going to be good and viable eggs so your chances of pregnancy are reduced. There is no technology at this time that can help with egg quality. The only way to overcome it, which is why IVF is used, is to gather a lot of eggs in the hope that there will be a good egg in the group. There won't always be a good egg in the group so it may take several attempts. There was a nice study done a couple of years ago that showed that in 37 year olds doing IVF, only 2 of every 10 eggs were good quality. So the reason to do a medicated IVF cycle is to try to stimulate the ovaries to grow lots of eggs so that you have a larger group to hopefully find a good egg in.

      Decreased ovarian reserve, as manifest by elevated FSh and decreased AMH, means that the ovaries are going to be stubborn when stimulating them. That means that you may not be able to get lots of eggs even if you use a high dose stimulation protocol. For that reason, some IVF doctors don't use much medication thinking "what difference does it make?" I personally can't predict how you will stimulate in any given cycle, so I prefer to stimulate the ovary as hard as possible each time because I want to find a good egg.

      I hope this clarifies things for you. Good Luck

      Delete
  15. Thank you Dr. Ramirez. My Doctor did say that I did not stimulate as he would have liked with the pills, but that I may stimulate better with the injectable med's, which is the most case. Have you ever had a case such as mine and if you did have someone with my test results would you recommend following through and trying medicated IVF. My Doctor has said that he will do whatever I want but he has strongly advised against the medicated and wants me to do a donor cycle, which I do not wish to do. It's a wonderful process, but it's not the path I wish to take. Thanks again for taking the time to read my post.
    Angie

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    Replies
    1. Hi. I have certainly had patients similar to you in my 20 years of doing IVF. I have had patients with increased age and elevated FSh levels that only produced ONE follicle, from which I retrieved ONE mature egg, leading to ONE embryo and resulted in a successful pregnancy. What that means is that even if you don't stimulate well, you can still get pregnant and this fact is NOT predictable. For that reason, I ALWAYS give my patients the chance to try. I think that most patients would regret never having tried even if it doesn't work. You have to be READY to do donor eggs psychologically.

      On the other hand, if you have limited funds, don't really care about a genetic child and what the most efficient way to get you pregnant, donor eggs would be better. It offers you a better chance of pregnancy per try. However, you have to be ready and wanting this option. If you're not, then don't give up on your own eggs, BUT be prepared for failing, repetitive trying and maybe ultimately having to use donor eggs.

      I hope that gives you something to think about.

      Good Luck,

      Dr. Edward J. Ramirez, M.D., FACOG
      Executive Medical Director
      The Fertility and Gynecology Center
      Monterey Bay IVF Program
      www.montereybayivf.com

      Monterey, California, U.S.A.

      for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf. I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal. If interested, contact me via my email at info@montereybayivf.com. This service will allow you to have your own personal on-demand infertility expert

      Delete
  16. Hi Dr. Edward

    I am 32 with diminished ovarian reserve (less than 0. 023)and non functional Fallopian tubes (closed one because of hydrosalpinx and other one was okay but was told by dr later that if one tube had hydrosalpinx the other would be abnormal anyway). My FSH was 45 recently. I have taken course of acupuncture and latest result showed 9. I was told for those like me Natural IVF cycle is done and I have 10 % chance of success. That too after multiple times probably. I see in some places they do stimulate ovaries before IVF in my condition as well so I am confused if its best for me to do Natural Cycle IVF or should I chemically stimulate ovulation? Also I am thinking to do another course of acupuncture before IVF to increase my chances of success but at the same time I am worried that my time is running out ( if haven't already). Your advice would be much appreciated. Thank you.

    ReplyDelete
    Replies
    1. Hello,

      Based on the high FSH, it sounds like you might have premature ovarian failure or an early stage of this. That is ";premature menopause." My first recommendation would be to contact Stanford REI department because they have a research protocol going on where they are able to restimulate the ovaries and achieve pregnany.

      I'm not sure the acupuncture is doing much, but if it feels good, then go with it. Your ovaries are in a state of flux. Despite the levels, doing "natural IVF" offers no increase in your chances. It is mainly a financial decision. Natural IVF is used because the ovaries probably will not respond to stimulation any way so why spend the money on the medications? What I mean is, if you use the max protocol of fertility medications and only get one follicle and one egg anyways, the fertility medications did not do more than what your ovaries do natural, so there is no need to use the medications. That is natural IVF. If the ovaries will respond to stimulation, then I always recommend stimulated IVF. Obtaining multiple eggs is always better than obtaining only one.

      Good Luck,

      Dr. Edward J. Ramirez, M.D., FACOG
      Executive Medical Director
      The Fertility and Gynecology Center
      Monterey Bay IVF Program
      www.montereybayivf.com
      info@montereybayivf.com

      Monterey, California, U.S.A.

      for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf. Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate. I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy). Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

      Delete
  17. Hi Dr. Ramirez,
    Thank you so much for taking the time to answer all these questions!
    So here is my story, I am a 33 y.o. with hashimoto's disease, normalized TSH/T4, husband 33 y.o. with male infertility factor averaging around 6-7, good motility and morphology. Had two failed IUIs, moved to IVF due to continued low sperm count.
    Had first cycle of IVF- BCPs for a couple of week, then microdose lupron (20 units) then two days later started on stim meds- follistim 300 IU in am and then Menopur at 150 IU in PM. We had to cancel our first IVF cycle on stim day 6 due to a large follicle (17 mm), the rest of the 5 follicles ranged from 8-12 mm. MD also measure my progesterone, it was at 0.6, which confirmed runaway follicle. He took us aside after our appointment to explain that based on this situation and on other findings he thought I had diminished ovarian reserve. He painted a very bleak picture for us and explained that it would probably take several IVF cycles to achieve pregnancy.
    FSH = 6.4, E2 = 42, AMH = 0.96, AFC = 4-5 on each ovary.

    What do you think about this situation, I am losing hope?
    What protocol would you suggest?
    Can you help clarify what a long lupron cycle is, because I heard it is not the best for poor responders and I think that was the one I was on.
    Thank you again for taking the time for all of us, it is very kind of you!
    Sincerely,
    Tegan

    ReplyDelete
    Replies
    1. Hello,

      Let me reassure you that your chances are NOT miniscule. I am not sure you have the criteria for decreased ovarian reserve (which by the way only means that you won't produce a lot of follicles on stimulation, NOT that you will be unsuccessful or infertile). The protocol that you doctor used was a mid dose protocol (total 450IU of FSH). There is room to try more such as the max protocol I use (450 Follistim/150 Menopur). It seems that your ovaries might take this much to get it going. In addition, your doctor used the "long Lupron protocol" which suppresses the ovaries for a longer period of time. I might suggest using the antagonist protocol instead. That leaves the ovarian suppression to the end, thereby allowing the ovaries to respond to stimulation more readily.

      As you can see, IVF is somewhat of an art in that subtle decisions have to be made by the doctor and these can influence the outcome. These decisions are based on experience and knowledge. That is why pregnancy rates vary from doctor to doctor and clinic to clinic. By no means should you give up hope. The ONLY way that you will fail is if you give up trying. If you want it bad enough, you have to keep trying and it will eventually work. Remember, "decreased ovarian reserve" only means that the ovaries may not produce a lot of follicles and therefore embryos per cycle. That does NOT mean you can't achieve success. It only means that it may take several attempts instead of just one or two (because part of IVF success is having enough embryos available to find the perfect one). You are still very young. Your chances of success should be high EVEN IF you only form one embryo. Keep the faith!

      Good Luck,

      Dr. Edward J. Ramirez, M.D., FACOG
      Executive Medical Director
      The Fertility and Gynecology Center
      Monterey Bay IVF Program
      www.montereybayivf.com
      info@montereybayivf.com

      Monterey, California, U.S.A.

      for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf. Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate. I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy). Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

      Delete
  18. Hello,

    I am 35 an was diagnosed with DOR at 34. I have been pregnant now 4 times (been trying since I was 31), each time conceived very easily - either immediately or within one month of trying. I miscarried in June 2011 @ 8 weeks (sac showed to be a bit small), carried a baby to term in 2012 who was born with Kleefstra syndrome and passed away at 6 weeks old in my arms...we were tested and are NOT carriers. I then let myself heal physically and emotionally, I waited b/c I wanted to try a VBAC, and got pregnant in 2013...I miscarried this pregnancy at 6 weeks (chemical pregnancy); it was after this loss that I requested additional testing and learned about the DOR. I tried IVF, but was a poor responder and insurance maxed out after 2 canceled cycles, so we tried again naturally after being on DHEA, CoQ10, Pregnitude, and Royal Jelly for many months (DHEA and CoQ10 was for 6 months). Again, we got pregnant immediately, but I miscarried on 11/21 just shy of 8 weeks, which sounds like it may have been a blighted ovum (sac present and measured about 2 weeks behind, but no fetal pole seen). After a few months on the DHEA and CoQ10 my Day 3 went from my initial levels of AMH .17 / FSH 13.3 down to AMH .40 / FSH 8.3. Even after all of that we still had the miscarriage this month. My midwife has now recommended seeing the OBGYN they work closely with and trying Clomid to try and get to that good egg. Can you give me any feedback on what you think my chances of having a successful pregnancy might be with a healthy baby based on my history? I was very upset on Saturday reading on a fertility site that if the diagnosis is DOR then chances of live birth regardless of age and method used to conceive (natural vs. IVF) was less than 1%.

    ReplyDelete
    Replies
    1. Hello Kellie,

      Sorry for the delay in my response.

      First let me reassure you that hope is not lost. The terms "decreased ovarian reserve" and "poor responder" only refer to a woman's ability to respond to stimulation. They do not predict or comment regarding the fertility of the eggs. It is only important in older patients where the age factor is significant in that there is a decreased number of good eggs and so the only way to treat this problem is to try to obtain as many eggs as possible.

      The problem that you have is NOT an infertility problem and so I think that you have NOT been evaluated or treated properly. You should be given the diagnosis of "recurrent pregnancy loss", which has a specific evaluation and treatment. None of the meds you have received do anything for this. You need to seek out a specialist that understands this problem, will evaluate you thoroughly and treat you appropriately. I have addressed recurrent pregnancy loss in this blog so if you review that article it will give you the information that you need.

      Good Luck

      Delete
  19. Thank you so much for being open to questions. Can you please help me find a good clinic on the East Coast for a 41 year old? Thanking you in advance.

    ReplyDelete
    Replies
    1. Hello. There are many many reputable IVF clinics on the East Coast and it depends on exactly where you are. One source to look for IVF clinics is via the CDC website on ART(Assisted Reproductive Technology). Another is through the SART.org website. Both of these have a list of IVF centers and their most recent statistics. You can look up previous statistics as well. Look for one that has a decent pregnancy rate for 41 year olds.

      Good luck

      Delete
  20. I am 32 years old and have never pregnant. I have been trying to conceive for a year but have been unsuccessful. I recently went to the fertility specialist where they did major blood work to check on my hormones because I had a missed period in November and June of 2014. My FSH level was 34.4 during November when I missed my period and my AMH was checked in December is 0.03!!!!! In addition, my husband who is also 33 years had zero sperm count and is repeating his test today.

    Given our current situation is there any chance for us to get pregnant with our own eggs & sperms? My fertility specialist told we are not a candidate for IVF because of AMH 0.03 and high FSH is 34.4 number i am poor responder and I should look for donor. I am both shocked and devastated to find this out! All of this came about as BIG SURPRISE!!!!

    Looking to get a second opinion at Hershey Medical Center. Do you have any suggestions or doctors who deals with Diminished Ovarian Reserved in the Northwest Pennsylvania. Any suggestions or recommendation is greatly appreciated.

    ReplyDelete
    Replies
    1. Hello. First of all, was the FSH done on Cycle day #2 or 3 of your cycle? If not, it needs to be repeated. Secondly, the FSH level is indicating that you are menopausal. Have you stopped having periods? If you are having regular periods then this level may not be correct or correctly indicating ovarian function. Thirdly, FSH and AMH are indirect measures of ovarian function and potential, NOT definitive predictors of pregnancy. If your clinic disallows you to try based on this, then find a different clinic (as you seem to be doing). You are young and even if you only have one egg, it has a very good chance that it will be viable. Another option for you is do to IUI if you decide to use donor sperm.

      As to your husband's options, having no sperm on semen analysis does not mean that there is no sperm. It is possible that he has an obstruction of the vas deferens (ducts) or has a lack of the ducts (congenital absence). Sperm can be obtained from the testicle directly in a procedure called TESA/TESE/MESA, and is done by a Urological subspecialist in male infertility. This sperm can then be used to inject directly into your eggs to fertilize them and make embryos to transfer into your uterus.

      So, as you see, you have options. Unfortunately, I don't know what IVF centers there are in Pennsylvania. But find one that will work with you. I don't believe that doctors should be making your decisions. They should only be giving you the options and explaining the pros and cons so that you can make your own personal decisions. After all, you are an adult and it is your money.

      Delete
  21. Hi Dr. Edward,

    Thank you for your reply and giving me hopes. Yes, i do have my period but they are not regular, I had 2 missed period in 2014 and during December 2014 I had two in one month. However, for January and February I had my normal cycles. No, i have not had my FSH tested on Cycle day #2 or 3. I recently went to Hershey Medical Center to get a second opinion. My doctor ordered to repeat the AMH and FSH test in addition to a few other test to check for ovulation, and Adrenal gland. She told me even if they are able to retrieve my husband sperm my chances of getting pregnant with my own eggs using IVF would only be 5 to 10%. She doesn't recommend IUI or DHEA or infertility drug to possibly increase the AMH number. Given the fact I have an existing auto-immune condition called (Pemphigus Vulgaris) that has been in remission for two years she recommends to do IVF as soon as possible.
    Also my husband had a second semen analysis with zero count and is going to see a urologist.

    What is your experience with using DHEA, Royal Jelly and, Acputurue or other supplement or fertility drug to increase AMH? What are the major cause for low AMH? Given my age low AMH level and a auto-immune condition that is already in remission would you recommend IVF or IUI with my own eggs?

    Thank you for help, it's greatly appreciated.

    ReplyDelete
    Replies
    1. Hi Again

      There is not treatment that can increase AMH but I would not expect the lack of eggs to be a problem at your age. The FSH and AMH indicate that the ovary is not fully functional and that is the problem. Because your are young, most of your eggs should be good eggs. Even if they are only able to get a few with IVF, the chances of pregnancy are still higher than if you tried on your own because IVF helps with 7 of the 10 steps your body goes through to achieve pregnancy. I don't agree with the statistic your doctor gave, but maybe that is just in their clinic. Pregnancy rates are based on age, NOT FSH or AMH. FSH and AMH only give an idea of how well the ovaries will respond to stimulation i.e. the number of eggs that might be retrieved.

      IVF is your only option of your husband does not produce sperm by ejaculation. The treatment option would be TESA, and TESA sperm have to be injected into the egg to produce fertilization. Only IVF allows this.

      There is nothing, no technology, supplements, naturopathic treatments or voodoo treatments that can change AMH. I use Acupuncture but not for this reason. I believe it helps with blood flow at the implantation site and decreased stress.

      Good Luck

      Delete
  22. hello Dr., I am 323years old and have also been diagnosed with diminished ovarian reserve. I have clear fallopian tubes and my husband has a normal sperm count. my numbers are as follows: AMH: .85, Fsh: 3.9, E: 76. my RE said I have a very low chance to conceive even with IVF. may I ask what your opinion is please?

    ReplyDelete
    Replies
    1. I disagree with your doctor. The low AMH is the only "low" number in your profile. It is only a measure of OVARIAN POTENTIAL, which is how well your ovary might stimulate with fertility drugs in an IVF cycle, and NOT whether or not your are fertile, have healthy eggs or can get pregnant. Your low FSH, on the other hand, is indicating the opposite, which is that you have GOOD OVARIAN RESERVE, meaning that it will probably not require much medication to stimulate your ovaries. My presumption is that you are "32" years old and not "323" years old, in which case your chances for pregnancy should be very good and high. Maybe you should seek out a different doctor?

      Delete
  23. Hi Dr. Ramirez,

    Thank you for replying to my message. After my test were repeated my test came back with 55, my progesterone is 0.7, AMH 0.03. Today I went to see my doctor at Hershey medical center where I was told I have Primary Ovarian Insufficiency and the best thing to do is to use and egg donor with IVF. My doctor said even with Primary Ovarian Insufficiency the chances of spontaneous pregnancy are 10% naturally; however, there is nothing she can do to stimulate my ovaries. At this time the doctor prescribed me with estrogen and progesterone pills. (2 mg of estradiol once a day and 200 mg of progesterone one time away for the next three month). My questions is given what you already know about my situation do you think we can stimulate my ovaries and retrieve my own eggs and to do IVF? I am confused if there is a 10% for me to get pregnant naturally on my own why is the doctor telling me they can not stimulate my ovaries? Your suggestions and comments are greatly appreciated.

    Below is my most recent test result. Please note I have NOT gotten my FSH and AMH checked during cycle day 2 or 3 because I had a missed period this month.

    Last Period 2/8/2015
    Date of Service: 02/19/2015

    DHEA SULFATE 447 H 23-266 mcg/dL QHO
    FSH 55.0 1.5-116.3 mIU/mL QHO

    Reference Range

    Follicular Phase 2.5-10.2
    Mid-cycle Peak 3.1-17.7
    Luteal Phase 1.5- 9.1
    Postmenopausal 23.0-116.3

    ESTRADIOL 30 357 pg/mL QHO
    ANTI MULLERIAN HORMONE ASSESSR(TM) <0.03 ng/mL
    Date of service: 2/28/2015
    PROGESTERONE: 0.7 (Cycle Day 21)
    Date of service: 3/7/2015
    PROGESTERONE: 0.7 (Cycle Day 28)

    ReplyDelete
    Replies
    1. If I'm reading this correctly, you have an FSH level of 55.0 which indicates that your ovaries are menopausal or in premature ovarian failure. That is, they don't work and cannot be stimulated to grow eggs. Your only option at that point is to use donor eggs with IVF.

      Delete
    2. Hi Dr. Ramirez, thank you for response. Lately I have been going to the doctors and have been repeating my FSH cycle day 2 and 3 test for the past three months. Below are my results, My RE advised me the only option for me to go is use an egg donor to do IVF because having an AMH of 0.03 and AFC of 6 doesn't give us much hope with FSH of 16.9. Based on the test result listed below do you think i have a chance to do IVF with my own eggs? In addition, my husband has a sperm count of 75,000 total count?

      6/3/2015

      AMH 0.03
      FSH 16.9
      LH 5.4
      Estradiol 28
      Progesterone 0.5

      4/28/2015

      AMH 0.05
      LH 15.6
      Progesterone 0.7
      Estradio 196


      3/28/2015

      AMH 0.03
      FSH 12.3
      Estradiol 94
      Progesterone 0.07
      FRAGILE X PCR = Negative

      Delete
    3. I agree with your doctor. Although you certainly can continue trying with your own eggs, the chances of getting a good ovarian stimulation response are not good. Your ovaries will not be very responsive, which decreases your chances per cycle attempt.

      Delete
  24. Hello Dr. Ramirez,
    I am 35 years old with AMH 0.39 and 2 small endometriomas on my left ovary. My first IVF was canceled at day 10 because I only had 3 follicles: 9 mm, 13 mm, and 19 mm. I was on BCP for six weeks before to see if ovarian cysts would resolve before they were declared endometriomas. I did Lupron 20 units x 4 days, then decreased to 5 units. I did Follistim 300 bid. We're doing a similar protocol next except no BCPs first and Menopur 300 in the morning, Follistim 300 at night. I am so afraid of getting my hopes up that this will make a significant difference. What are your thoughts? Thanks so much

    ReplyDelete
    Replies
    1. I think I agree that I would try a higher protocol. If you will be using Follistim 300 twice per day plus Menopur 300, then you are on a higher protocol that I even use. My highest protocol is 450 Follisitm and 150 Menopur. I hope it will make a difference for you.

      Delete
  25. Dear Dr Ramirez,
    I am 34 years old and have been trying to conceive for 6 months. I have regular cycles of between 26-28 days and based on OPK testing I seem to be ovulating every month. As I am getting older we decide to go to a fertility clinic to check if everything was ok. They have done the typical Pap test, a blood test for AMH, a test to ensure that my tubes were not blocked and a AFC. The only result I got at this point is the AFC...The gynaecologist who did the test yesterday mentioned that I had one cyst on my left ovary and she could not see any antral follicles and she could see 2 on my right side Shen then informed me that it was really bad news and she said you probably thought you had the fertility of a 25 year old but you don't. She then said: this does not mean that you will never get pregnant but you did to determine how important this is for you. Since this news I am devastated...I would want a child from both my husband and me and not a donor egg. My question for you: 1) Can she make that conclusion only on my AFC results? 2) Is it possible that she had not seen some of my AF because of the cyst on my ovary? 3) Should I wait for the blood AMH before thinking that there is no hope that I become pregnant naturally? 4) I thought that quality was more important then quantity? Maybe I only have 2 AF but maybe they produce quality eggs?

    Thank you for your opinion

    ReplyDelete
    Replies
    1. Hello Stephanie,
      I would strongly recommend that you ignore everything that this doctor just told you! Nothing, can be determined with certainty by the AFC. It only indicates that you might have a low egg availability but it has to be taken in the context of the whole scenario (FSH, AMH AND AFC), not individually. These three factors DON'T tell you when you can get pregnant or not NOR whether you will have good eggs or bad. They only give an indication of ovarian function in the scenario of IVF stimulation i.e. whether or not you will produce a lot of eggs. But keep in mind, even if your egg retrieval number is low, you are young and you only need ONE good egg to be successful. If your FSH and AMH were good, then the AFC can be ingnored completely. '

      My advice: maybe you should find a more compassionate doctor.

      Delete
  26. Hi Dr. Ramirez,

    I am 27 years old and have been diagnosed with Diminished Ovarian Reserve. I have completed 1 round of IUI with Clomid, Menopor and a Trigger Shot which resulted in a negative. My husband (30 years old) (who had an awesome motility count that our Dr was very happy with) and I want to move to IVF since IUI success rates are so low, we don't want to waste any more time or money on them. I have an appointment the end of August to see a RE in Encino and am going to continue my Kaiser RE's guidance of DHEA and CoQ10.( Kaiser does not cover IVF and while that DR does do IVF out of Loma Linda, I am choosing to use a Dr (Boostanfar) with a higher success rate to increase my chances) I have done some research and know that my chances of success are lower due to DOR, but what I need to know is are the success rates with DOR and IVF...should I prepare myself for failure? I am doing my research (going to read It Starts with the Egg) and going to change my diet with no diary, red meat, start using glass containers, etc. MY FSH was 10.8 and my estradiol was 35.

    Thank you,
    JMH

    ReplyDelete
    Replies
    1. I am surprised by your elevated FSH level at your age. Was it done at the proper time (CD#2 or 3)? How did you stimulate with the IUI cycle and how much medication did you use?

      Even if you don't stimulate well, you have a big advantage, which gives you a high chance for success, and that is your age. YOU ARE YOUNG! Even if you only have one embryo to transfer, which is starting to become the standard in young patients now, you would still have the highest chances of pregnancy. I'm actually thinking if limiting my under 35 year olds to 1 embryo because my twin pregnancy rates (after transferring 2 embryos) has been running about 60%.

      I think you are doing the right thing by going directly ti IVF, even if IUI is an option, because of the elevated FSH. That is essentially a time clock and it means you can't waste time!

      Delete

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