Tuesday, June 22, 2010

Male Factor Infertility -- IVF Cycle FET Positive But Ended With Miscarriage: Should I Seek A Second Opinion?


Dr. Ramirez,

My husband and I are a 29yo healthy couple with male factor infertility. Motility is less than 1%, morphology is about 25-30%, and count is pretty low-normal. There are no female issues. We have done 2 IVF/ICSI cycles and one FET (frozen embryo transfer). The first IVF (in vitro fertilization) cycle, I was mildly hyperstimmed. The egg quality wasn't great, and we had about a 50% fertilization rate. We transferred 2 grade A embryos that did not result in pregnancy. No embryos made it to day 5. IVF #2 was much better and had an 80% fertilization rate. 2 day-3 grade A embryos were transferred, but there was no implantation. There were 2 day-6 blasts that were frozen. Both were starting to hatch upon thawing, and the FET resulted in a singleton pregnancy with a heartbeat at about 7 weeks. Unfortunately, I miscarried (no heartbeat) at 8 weeks.

My question to you is when should I seek a second opinion? We had planned on obtaining a 2nd opinion if the FET was unsuccessful, but we feel like technically it was successful. We like the place we go to right now and feel that they are familiar with us. We are planning to do IVF #3 in the near future and are torn as to whether we should stay here or move on. If we stay with the current practice, we will not be changing the protocol since it was successful last time. Although it has been suggested, we are not ready to use donor sperm since we were able to grow 2 blasts and achieve a pregnancy. We are located in Missouri.

Thanks in advance for your time.


Hello L. from Missouri,

I agree with your statement that technically the FET was successful. In fact, the FET cycle WAS successful. Remember, IVF can only give you the opportunity to become pregnant. It cannot MAKE you pregnant because the last two steps in the natural process, embryo hatching and implantation, are NATURAL steps and we don't have the technology to make that happen. So, the fact that an embryo did those two steps and the pregnancy went to 7 weeks is a success. And, it is a very good sign because it now shows that what you are doing can work!

I would not give up on that clinic yet. In fact, pregnancy rates with FET are lower than fresh cycles, so a success with an FET is good. They deserve the credit. Now that they have stimulated you twice, know how you react, etc., they are hopefully in a good position to build on that the next cycle. You have to give them some credit for that.

Overall, I would hang in there. You've proven that it can work. Whether or not the pregnancy continues is solely and completely dependent on the embryo. It was probably an abnormal embryo. Now, you just need to get a good one there and you'll go all the way. Don't look back, just look forward. You should now be more encouraged than before because you know that it can work. It is just a matter of time!

On a personal note, I have a patient that I was able to get pregnant on her first try at the age of 36 and she had a beautiful child. She just came back to me for her second child at 39 (worse chances statistically) and became pregnant again, but it was an abnormal pregnancy and ended in a miscarriage. I found out today, that she is planning to transfer to another clinic because they have a "special" research program going on that gives patients a significant discount. You can't believe how heart broken and how I feel rejected by this. I put my heart and soul into my patients, and they get the best care that they can receive. I know that logically the cost is a significant issue, and this is what is driving the patient, but having gotten so close to a success, when we have been successful before, is difficult for me. That is what your clinic will think too. They'll ask themselves, "why is she leaving when we were successful under less odds?"

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.

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

Comment: Dr. Ramirez clearly stated his opinion and seemed to have genuine answers. I appreciate his advice and his providing this service


  1. Dr. Ramirez,

    Thank you for sharing your knowledge and expertise with us all. We truly appreciate all you do to enlighten us.

    My husband and I have been trying for 4.5 years. I have been diagnosed with stage II endometriosis and mild pcos (all blood work is always normal), with my husband being diagnosed with low morphology. Per suggestions from my RE and his urologist we are going to have the sperm penetration assay done. What are your thoughts on this? Is it reliable?

    We had an unsuccessful IUI last fall and pretty much every cycle since then I have had spotting around cd8-10 and this cycle I have been cramping more (I am currently on cd9). I never had anything like this before the IUI. I used Follistim 75IU for five days, if I recall correctly, and a trigger for that IUI. This resulted in a chemical pregnancy, I do believe as I was getting positive tests long after the trigger should have left my system. Do you think my protocol aggravated my endometriosis? Is that possibly why I am spotting each cycle? Why would it happen around the same cd?

    Thank you for your help if you find time to get to this.



  2. Hello S.R.,

    I am not a big advocate of the sperm penetration assay (hamster egg penetration test), which in my mind, only tells you if your husband's sperm can penetrate a hamster egg. It tells nothing of the interaction with your eggs. But, it is a test that can be done, and I am sure that other docs feel differently about it and think that gives some information. If it comes out abnormal, then you will be recommended to proceed to IVF with ICSI. If it is normal, then you will probably be recommended to continue trying with IUI.

    My thinking is that you have one of two options: (1) you could continue trying IUI for three more attempts, which will be the test to see if you can get pregnant by the natural process, and if it doesn't work, you then proceed to IVF with ICSI or (2) proceed directly to IVF with ICSI. This choice might be your best option, however, depending on your age and how bad the sperm morphology is. If you are 35 years old or older or the morphology is <30%, then IVF is your best choice. Besides, you have been trying for the past 4-5 years without success which proves that there is a defect/problem with the natural process. IUI is still dependent on the natural process. Also, endometriosis is not overcome by IUI, only with IVF. The egg still has to pass through the pelvis, and the inflammation caused by the endometriosis, in order to reach the tube. It may be getting destroyed at that point. Finally, the decreased morphology may mean that there is a problem with sperm function i.e. its ability to fertilize your egg. The only way to overcome that is through ICSI which has to be done in conjunction with IVF. That is why I am thinking this might be the better way to go. Of course, financially this is not always an option for most people.

    In terms of your question regarding the spotting, I don't have an explanation for that. In terms of the cramping, certainly the Follistim can exacerbate endometriosis because this disease is estrogen dependent. The Follistim would increase the estrogen levels in your system.

    I hope this helps.

  3. Thank you very much. I truly appreciate it.


  4. Dear Dr Ramirez,
    I hope you are well. I just wanted to follow-up on your last e-mail. I reveived my AMH result it is 2.55...So my physician says its in Line with the AFC that them saw of only 2. They did not test the FSH I need to go next but he said that at this point he strongly recommends being very agressive with stimulanted IVF...I wanted your opinion? Basically at this point I have a AFC of 2 in the left ovary and 0 on the right however there was a cyst so that might a have Hidden the AFC? AMH 2.55 and my tubes are clear. My husbands sperm count is A1. He then mentioned that yes I was 35 but that my eggs were Like the ones of a 40 year old but i thought that AFC and AMH only have an indication of quantity not quality? I suggested that we try clomid and IUI for 2 or 3 cycles before moving to IVF? What are your thoughts? I also discuss the potential to move to a natural IVF if it does not work...Versus stimulated IVF?

    Let me know your opinion! I truly appreciate it.



    Date: Sun, 7 Jun 2015 18:16:19 +0000
    Subject: [Women's Health and Fertility] New comment on Diminished Ovarian Reserve: I Have Failed 3 IVF Cy....
    From: noreply-comment@blogger.com

    Edward Ramirez, MD has left a new comment on the post "Diminished Ovarian Reserve: I Have Failed 3 IVF Cy...":

    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.

    Post a comment.

    Unsubscribe to comments on this post.

    Posted by Edward Ramirez, MD to Women's Health and Fertility at June 7, 2015 at 11:16 AM

    1. Hello Stephanie. This question came out a little weird on the posting because it looks as if I answered in June when your new question is in July. I guess you must have pasted the old entry within your question to remind me?

      An AMH result of 2.25 is good. It should be greater than 1. Also, the AFC is low and I'm surprised. You are also correct in that a cyst can compress the ovary and hide the actual AFC. Keep my previous reply in mind. It is still the same situation.

      The FSH, AMH and AFC only give an indication of ovarian reserve or the potential of the ovary to stimulate. It is also a timeline, meaning that you need to move quicker to get pregnant rather than use up a lot of time. By a lot of time, I mean years. Doing 2-3 IUI cycles will not change this timeline or make things worst, so I see no reason why you couldn't try it. It's only 2-3 months. Then if it fails you can move to IVF. I would not recommend "natural" IVF as that would be a waste of money. If you are going to spend a lot of money with IVF, you want it to be as productive and effective as possible. For that, you would want as many eggs as possible. If you have extra embryos in the end, that is not a problem because you can freeze them and use them for future pregnancies. But, because not all eggs are good eggs, you want to have many so that you can get at least one or two good embryos.



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