Woman With Prior Anxiety Disorder Hopes To Use Donor Eggs Despite Being Fertile: What Is Donor IVF & Will I Qualify?

Question:

Hello Dr. Ramirez,

Although I'm fertile I don't want biological children who have my genes. However, my husband and I want our children to be biologically his. Is there a way I could go through IVF with a donor egg despite the fact I'm fertile? If this is possible, please explain, how the process would differ from (the more usual) process of IVF with donor egg for someone who isn't fertile.

Thank you, C. fom Rhode Island, USA

Answer:

Hello C. from the U.S.,

Yes, of course this is possible. Infertility specialists have been doing this for years. Here is how the process works and is called Donor-IVF.

Assuming you have chosen a donor and completed all the necessary legal paperwork that is necessary, here is how it goes. The donor is stimulated with fertility medications to recruit and mature multiple eggs. At the same time, your ovaries are suppressed with a medication called Lupron and your uterine lining is stimulated to grow with estrogen. Once the donor's eggs are mature, they are "retrieved" by passing a needle through the vagina and directly into the ovaries. These donor eggs are then put together with your husband's sperm and allowed to fertilize. The fertilized embryos are then allowed to grow and then 1-2 are carefully transferred into your prepped uterus. If they implant, then you become pregnant and carry the pregnancy to term. Sometimes there are additional embryos that can be frozen and used for another cycle as well.

The child will then be genetically your husband's and not yours, but biologically yours since you are the one that delivers the child. Almost any IVF center can help you with finding a suitable donor and doing the IVF procedure. You can even go to a clinic far away to have this done since your specific participation does not require a lot of visits.

You state at the very end of your question about how it would be done in "someone who isn't fertile". I am not sure what you mean by this statement. Do you mean someone without ovaries or someone without uterus or someone with the problem of recurrent miscarriages or someone with an autoimmune disorder, or someone with an inherent genetic abnormality, etc.? As you can see there are many different scenarios and we would have to adjust the process based on what exactly the "isn't fertile" reason was. Nowadays, we have many different options and variations to get someone pregnant and have a child.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Follow-up Question:

Thanks for answering my question. I have an additional question that is even more specific to my situation. When I was quite young I had depression and then anxiety (my particular form of anxiety is related to OCD) and this is why I don't want to have children that are genetically mine. Considering all this, would it be difficult to find an IVF center willing to allow me to go through Donor-IVF? (I was thinking maybe they prefer to work with people who have "more legitimate" reasons for wanting IVF such as women who simply can't have children without ART).

Also, do you happen to know, if I would have any more "hoops to jump through" such as going through counseling to establish why I don't want children who are genetically mine? Any other criteria specific to this scenario?

It's appreciated, C.

Follow-up Answer:

Hello Again, I can't imagine that you would have difficulty finding a clinic that would allow you to do a donor IVF cycle with your explanation. Some clinics might want you to have counseling to make sure, but I doubt that the majority would. You are the consumer, and the patient, and you do have the right to dictate your treatment preferences in this case.

Good Luck and don't hesitate to write again if you need further advice,

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

Comment: Thank-you, Dr. Ramirez, I am relieved and grateful! C. from R. I.

In Vitro Fertilization Gives You The Opportunity To Become Pregnant But It Is Never A Guarantee: Perseverance Is Key!

Something I have been thinking about as I read through infertility blogs & remarks on Facebook, which I think needs to be clarified and clearly understood by all fertility patients. There is a general misconception that In Vitro Fertilization, or IVF, is the "be all" fertility treatment. It is the ultimate "magical" treatment that will get everyone or anyone pregnant. This could not be further from the truth. IVF CANNOT make you pregnant. It can only give you the OPPORTUNITY to become pregnant, by making and placing embryos into the "womb". From that point on, it is in God's or Nature's hands. IVF also CANNOT give you a baby. That is propaganda that has been propagated by SART and the CDC through the use of their "delivery rate" statistic.

Yes, our goal is for you to have a baby. That is what we and you want. But to think that we have an ability to make that happen, and to use that as a measure of IVF success is misleading. We, as infertility specialists, and IVF as a treatment, have absolutely no control over the pregnancy, its course, its complications or its outcome. That too is in God's or Nature's hands. Any pregnancy, whether it is a chemical pregnancy, miscarriage or continuing pregnancy, is an IVF success because the limit of IVF is to give you the chance to get pregnant. Getting a positive pregnancy test and losing the pregnancy is a sad outcome, but at the same time should give you hope. It showed that the IVF worked, and if it can work once, it can work again and hopefully, result in a baby the next time! Perseverance will get you the baby that you want, although the pathway to that dream may sometimes take you in a different direction from your original intended route.

Edward Ramirez, MD, FACOG
Monterey Bay IVF
www.montereybayivf.com

Infertility Bloggers Offer A Great Support Network!

Dear Readers:

I would like to refer you to some of the blogs that I follow that I consider worthwhile. Some of these ladies are still going through IF, some have finally achieved the pregnancy that they have been hoping for, some are going the adoption route & all are infertility advocates. I admire them for being willing to share their infertility journey publicly. They all welcome your comments & laments. Here are some: http://www.thefertilityblogs.com/ (a collection of bloggers), http://www.pouringoutmyinsides.blogspot.com/ , http://www.infertilityoverachievers.com/ , http://www.fromiftowhen.com/(in her 2ww period now), http://www.roadtohappilyeverafter.com/ (PCOS w/6 IUI's now pregnant), http://www.fertilitychick.blogspot.com/ (one of my fav's...on a break from IF treatments) and of course, one of the most popular blogs out there, the very funny, sometimes heart-breakingly so, http://www.999reasonstolaugh.com/ .

Another great resource: A few months ago I participated in Melissa, "The Stirrup Queen's", very rewarding "ICLW " infertility blogroll (http://www.stirrup-queens.com/2010/08/icomleavwe-august-2010/). On her website you will find a links this month to 166 blogs !!! Melissa has been blogging since 2006. To quote her: "Blogging is a conversation and comments should be honoured and encouraged. I like to say that comments are the new hug–a way of saying hello, giving comfort, leaving congratulations." In addition to Stirrup Queens, she also writes the daily Lost and Found (LFCA).

If you have a blog that you want to add to my list...please leave a comment & I will add it! Good luck on all your journeys, and remember:

"All of life is a journey; which paths we take, what we look back on, and what we look forward to is up to us. We determine our destination, what kind of road we will take to get there, and how happy we are when we get there." from A Little Book of Happiness

Edward Ramirez, MD

Infertility Blogger...& Friend

36 Year Old With 3 Miscarriages On Prometrim Using OPK : Continue With Calendar Method or Go For An Infertiity Consult?

Question:

Hi, My name is R. I am 36 years old living in Atlanta GA. My husband is 41 we do not have any kids and would like to have a baby.

In the past I have had 3 miscarriages. prior to my miscarriages, I had a hystersalpinogram(sp) when I was in my early 20's unblocking both of my tubes. Recently I had been diagnosed with Pcos and placed on Metformin 750mg 2x a day, although I have always had a regular period lasting only 3 days but it comes like clockwork every 28 days. So now let me bring you up to date. Today 08/15/2010 I had detected my LH surge via clearblue ovulation kit. But last month my doctor recommended the Clearblue ovulation test and prescribed me Prometrium.

I do not understand why I was prescribed the medication and 2 I am confused as to when to take it, the bottle says to take 3 days after ovulation, when is that? I just detected the LH surge so when should I begin taking it? In the meantime, shouldn't me and my husband be having intercourse to try and conceive? The Prometrium is a 30 count, so should I take the medication starting day 3 until its all gone? I am so confused and excited, I have never used the ovulation predictor and so I am surprised that I see this happy face, what should I do next? Beside sit and worry!

Thanks for your answer, I am anxiously awaiting to hear back from you.

Answer:

Dear R. from Georgia.,

I don't know why you have the diagnosis of PCO if you have very regular cycles, but there is a variant of PCO that you would fit into. You would not need to take Metformin, however. Did your doctor check an insulin level or how did he decide to put you on Metformin?

In terms of timing your ovulation, that is good but if you want to save yourself money, since you have such a regular cycle, the calendar method would work just as well. If using the OPK, when it turns positive, you begin intercourse (on that day#, once per day for four consecutive days #only one ejaculation per episode). With the calendar method, mark you calendar on the first day of your period then count each days in sequence. Stop having intercourse on cycle day #10 then on CD#13 begin having intercourse once per day for four consecutive days as explained above. In both cases, start the Prometrium on CD#16 and use it twice per day. Because this will suppress your menses, you will need to do a pregnancy test around CD#30.

You know, I need to emphasize that time is a critical factor in your case. I presume you have been trying for pregnancy for a while, so you & your husband really should see an infertility specialist. Your age, the miscarriages, previously blocked tubes and possible PCO diagnosis all indicate that it may be necessary. The specialist will lead you in the right direction, doing the tests that need to be done before starting an arbitrary treatment plan, and be the most efficient in helping you to get pregnant. Sometimes it may only take doing one Intra Uterine Insemination. With each year, your pregnancy rates are decreasing, even with the highest level of treatment, which is IVF, so don't waste time.

Good Luck,

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

Paciente Con Endometriosis Severa Y Fracaso De Implantación FIV

I recently received a question from a woman in Mexico that addressed the problem of IVF Implantation Failure...I have decided to publish it in Spanish. Many who read this blog are Spanish speakers & need to translate the Q & A's. Since I speak Spanish, I would like to publish this one in it's entirety for my followers en español.

Question: Pregunta:

Dr. Ramírez.

Leí en la página web de su clínica de Reproducción que usted habla español. Agradezco mucho que se tome el tiempo de leerme y contestarme.

Soy L. de México. Tengo 29 años y mi esposo 33.

Lo busco pues estoy un poco desesperada... Llevo tres años en tratamientos continuos.

Mi padecimiento es endometriosis severa que afectó a mi reserva ovarica, actualmente tengo una fsh de 15. También mi esposo tiene astenoterato- zoospermia. Mi primer IVF (fertilizacion in vitro) fue con tres embriones día 3 de calidad II con hatching, y fue icsi - negativo. Mi segunda IVF fue con 1 embrión dia 3 de calidad II, con icsi, negativo. Mi tercer IVF fue sin estimulación ( sin medicamento alguno a diferencia de las otras dos), fue un IVF natural con un embrión que llegó a blasto día 5. negativo. Siempre al momento de la transferencia mi endometrio es aproximadamente de 12 mm y es trilaminar.

No se que estudios me recomiende adicionales pues creo que el problema puede estar en la implantación... o algo que me recomiende tomar adicional a la aspirina de 100 mg y la progesterona vaginal que me dan cada 12 horas siempre.

Agradezco de nuevo su tiempo. Saludos.

Answer: Respuesta:

Sra. L.,

Gracias por su pregunta y discúlpame que estoy tarde con mi respuesta.

Definitivamente, con su historia médica, fertilización in vitro (FIV) es la única opción por tratamiento porque este es la única tratamiento que puede cubrir endometriosis severa y la problema de esperma. Pero, un problema más grave es su reserva ovárica. Porque su fsh es 15, este es una indicación que los ovarios no están respóndanlo a la hormona fsh y la medicina que nosotros usamos por stimulacion es pura fsh. Por eso, el número de huevos aspirado es bajo y los embriones formo es minimo también. Pero, porque usted está joven, si la cualidad de los embriones están bastante, la posibilidad de embarazo debe ser máximo (es 73% cada vez en mi clínica con su edad). Por eso, usted está pensando que la problema es implantación.

La ultima dos partes del procesos para tener un embarazo en su cuerpo es saliendo de embrión de su piel (eclosión) y implantación junto con el endometrión. Fertilización in vitro (FIV) no puede controlar o cambiar este dos partes. Todavia es natural. Este parte es en la mano de Dios. Pero, muchas diferentes cosas pueden afectar la posibilidad de implantación. Por ejemplo, el técnico de su doctor es más importante. Usted puede tener embriones perfectos pero si el técnico para transferir los embriones es malo, el tratamiento no va a funcionar. Por esta razón, una opción que usted tiene es para cambiar su doctor o clínica. Mi profesor siempre me dijo que usted puede tener embriones perfectos pero si usted no se transfiere los embriones en la matriz perfectamente, todo es por nada. El tratamiento no va a funcionar. Este parte es la parte más importante!

Pienso que usted ha tenido un histeroscopia para confirmar que la cavidad de matriz y salio normal. Correcto? Si no ha tenido este estudio, yo recomendó que usted tiene esta estudio para ser seguro que no tiene nada anormal adentro. (La histeroscopia es un método de diagnóstico que consiste en introducir una lente a través del cuello del útero para visualizar la cavidad uterina.) Si usted tiene confianza en la técnica de su doctor y el procedimiento de transferencia de embriones paso bien, esta es un problema más difícil. En esto caso, yo recomendo usando aspirina 81mg cada día empezando con el ciclo de tratamiento, medrol 16mg cada día empezando con el ciclo de tratamiento y bajanda el dosis en el día de transferencia a 8 mg, estrogeno adicional como climara 0.2 mg parche o estradiol pastillas vaginal y heparina 2000 mg dos veces al día o lovenox 35mg por cada día. Todos empieza con el tratamiento y continua hasta el resultado del estudio por embarazo.

Últimamente, si Usted continua a tratar por un embarazo y tiene embriones con calidad buena, usted tendrá un embarazo. Buena Suerte!

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

32 Year Old Has Multiple Miscarriages With Secondary Infertility On Clomid With No Success: Should She See An RE?

Question:

I am 32 and writing from Texas. We are trying to have our 4th child. In Jan. 2010 I had a miscarriage at 7 weeks and subsequent D&C. It took 2 months for my cycles to even begin. Then I was put on Clomid 50mg days 5-9 for 4 cycles. I was monitored with progesterone blood checks, 14th day ultrasounds, hcg shots, and checking for over-stimulation. I ovulated every time (with a progesterone level of 27) and the doctor said my follicles and lining looked good. However, I am not pregnant and it has been 6 months since the miscarriage! My first child was conceived with clomid the 1st time.

Why is the clomid not working for me? Has it changed the cervical mucus and lining? Do other women struggle to become pregnant after a miscarriage too? The last two times that I conceived (3rd child and miscarriage) I became pregnant naturally the 1st effort made. Does miscarriage change your fertility? Should I not have clomid??

My doctor wants to take a break and then come back later and 'blow out' my tubes. Is this necessary? Do I need a different regime of medicine? I feel as though I am out of luck since the clomid did not help in conception. Should I see an RE (reproductive endocrinologist) soon?

Thank you for helping! I feel overwhelmed and just want to bring this baby into our lives. L. from Texas

Answer:

Hello L. from Texas,

I think the easiest way to answer your questions is to take them individually one at a time:

1. Since you are stimulating with the Clomid (and I presume you are ovulating more than one egg per cycle because that is the purpose of Clomid), you are responding to the Clomid. I don't know why your doc even put you on the Clomid since you were able to get pregnant on your own before. Any idea? All Clomid will do is increase the number of eggs you ovulate. It does nothing else. The body still has to go through the 9 step natural process for a pregnancy to occur. It is NOT a magic drug.

2. Clomid at high doses can change the endometrial lining causing it to thin because it is an estrogen receptor blocker and similarly change the cervical mucous. Often a Clomid cycle will have to be supplemented with estrogen if this is the case, or changed to a different medication such as Femara. The lining can easily be seen and measured by ultrasound.

3 Miscarriage is very common. It has been reported that the miscarriage rate is as high as 40% of pregnancies. This includes women who have late periods that don't even realize that they are pregnant. Statistically, 85% of women that have miscarriages will go on to have a successful pregnancy so you shouldn't worry. Your previous miscarriage does not worsen you chances of getting pregnant unless you had a major complication from it such as hemorrhage or uterine rupture.

4. The procedure to "blow out" your tubes is actually called an HSG (hysterosalpingogram). It is the test that we use to see if the tubes are open. Sometimes women will form a mucous plug in the tubes thereby inhibiting sperm passage. The HSG can push out this mucous plug and open it. It is worthwhile to make sure that the tubes are open but I would not count on it for anything else. It does hurt by the way.

5. I think that if you want the expertise of a specialist in infertility, and feel you are not getting it with your current doc, then an RE (reproductive endocrinologist) would certainly be more specialized and have more knowledge. You might want to consider that. It would be the same as going to see a Cardiologist for your heart instead of being treated by your Family practice doc. The basic knowledge of a specialist and the treatments they can offer are greater.

Good Luck,

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

Infertility Patient Worried About Side-Effects From Lupron Trigger Shot

Question:

Hello. I am about to undergo a cycle in which we will use Lupron as a trigger. I recently have read frightening stories of women who have had long-term, debilitating physical and cognitive side effects after using Lupron even once (usually to treat medical conditions). I am wondering if using Lupron as trigger shot could subject me to the same permanent, debilitating side effects. (I do have endometriosis, and I don't know if that makes one more susceptible to the dangerous effects of this drug)?

Thank You. L. From the U.S.

Answer:

Hello L. from the U.S.,

The lupron you are reading about is for the treatment of endometriosis and not the same dose that is used for the trigger. The endometriosis dosage is 3.75 mg or 11.25 mg, whereas the trigger dose is 0.5 mg. There are no known serious side effects from the Lupron trigger. Some mild side-effects might include: hot flashes, vaginal dryness, and headaches. If these side effects occur they will usually resolve after you start taking gonadotropins. After ovulation is triggered, there is no further need to continue on Lupron.

Besides, I and many other docs use full-dose Lupron for the treatment of endometriosis all the time and I have yet to have a patient with the horror stories that are published on the internet. Keep in mind that internet stories are not edited or filtered so you have to believe them carefully and with a little reservation.

Good Luck and don't worry,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Couple TTC, Husband With Diabetes & 42 Yr Old Wife on Fertomid (Clomid): What Can Be Done?

Question:

Hello. My husband and I have been trying to conceive for over one year. I am 42 yrs old and have one ovary. I have regular menstrual cycles but when the ovulation test was done there was no ovulation. I have started to take Fertomid for the first time. The first treatment was a month ago. Also my husband is diabetic, type 2. Can this affect his fertility? He is age 36.

I appreciate any advice you can give. B. from Ohio

Answer:

Dear B. from Ohio,

Yes, diabetes can affect male fertility. Diabetes affects the blood vessels in our body and causes the vessels to shrink, thereby limiting blood flow. This is the reason that diabetics end up getting leg ulcers and require amputation. In the genital region, it can reduce blood flow to the testicles and reduce sperm production. To check your husband's fertility, all he would need at this point would be a semen analysis. It is a simple test and will answer the question of whether or not his diabetes is affecting his fertility.

Your one ovary is not an issue, the bigger issue, which you mentioned in passing, is your age factor. Your chances of natural pregnancy at 42 years old is only 1% per year. That is probably the major factor in your failure to conceive. Fertomid is NOT an appropriate treatment for you (Fertomid is the generic form of Clomid).

You need to go to the advanced treatment level called IVF (in vitro fertilization) if you truly want to have the opportunity to get pregnant. Anything less than that is a waste of precious time, such that even at 43, IVF could still be an option without donor eggs. I would strongly recommend that you go see a Fertility specialist that provides IVF as soon as possible. Your age combined with your husband's possible male factor problem would indicate that this might be the best option for you both at this time. I see way too many patients like you, after the age of 40, that have wasted years doing simple treatments with their Ob/Gyn docs. Then, when they come to see me, it is too late and I have limited resources to offer them. Most leave very disappointed. Don't let this happen to you!

Good Luck,

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.

45 Year Old Danish Couple On Sixth IVF Attempt: Should They Alter Meds & Blastocyst Transfer?

Question:

Dear Dr. Ramirez,

We are a 45 year old couple from Denmark on our sixth IVF attempt. The first three attempts produced 5/5/9 eggs with 225-275 units of Gonal-F and a fertility rate of 100%/60%/60% respectively. Eggs for transfer were three 8-cells on try one on day three, two 8-cells and one 10-cell on try two on day three and two morulas and a 10-cell on the third attempt on day five.

We then increased Gonal-F to 375 units and got 12 and 13 eggs in the next two attempts and a fertility level of 85%-100% and decided to go for Blastocysts and had two BC's and a Morula in the fourth attempt on day six and one BC and a Morula transferred the last time on day six. On the recent attempts we've been supplementing with Ovitrelle prior to aspiration (as well as folic acid, acupuncture and considerate food and no alcohol of course). After aspiration a dose of 16mg Medrol was administered for four days, then 8mg and then 4mg, as well as 81mg of Aspirin for the duration.

Our questions are: 1)should we continue to go for Blastocysts for transfer, and 2) do you have any suggestions as to an altered protocol perhaps in terms of increasing the dose or frequency of Medrol or any other meds that might help us?

Thanks in advance for your reply. T. From Denmark

Answer:

Hello T. from Denmark,

The good news is that your wife's ovarian response is still good and strong. She has done very well on her current stimulation protocols. The problem that you have is not so much the external quality of the embryos formed, they have been good, but the internal quality of the embryos. We know that with age, the quality of the eggs and thus the embryo quality deteriorates. That is probably what is leading to your failure. We rarely see pregnancies after the age of 43 in a woman using her own eggs. However, there was a case in New York of a woman who was successful at 49 years old, and is currently the oldest to become pregnant with her own eggs using IVF. It did take her two and 1/2 years of trying, however. Statistically, your chances of pregnancy with IVF are less than 1% per attempt based on age factors alone.

In terms of whether to do D#3 or D#5 transfers, I don't think it makes any difference. One is not better than the other. The embryos that would make it to blastocyst would still have done so in the uterus. In fact, I think the uterus is a better culture environment than the lab. I generally transfer at D#3 for this reason. In fact, in your case if you were my patient, I would transfer ALL embryos back on D#3 to maximize your chances.

In terms of what other protocols, I use Medrol starting at the beginning of the cycle (D#2) taken as 16 mg until the transfer then decreasing to 8 mg thereafter. I stop with the pregnancy test. I also use aspirin 81 mg per day starting at the beginning of the cycle and heparin 2000 units twice per day injections starting at the beginning of the cycle. I also use a "mixed" protocol of Gonal-f or Follistim + Menopur/Repronex for a total FSH dose of 600IU to start. In most cases, the patients stay at that level but some will decrease based on their response. In your case, your wife does not need more meds since she stimulated well, but a mixed protocol might be advised.

Your only option is to keep trying or move to donor. I am amazed that you have done so many cycles already. Most in the U.S. will not do that many cycles due to cost issues.

Good luck with this upcoming cycle & never lose sight of your goal...it can be achieved if you are open to options.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.