Tuesday, November 23, 2010

41 Yr. Old South African Woman Fails IVF: Needs Higher Stim Protocol, Menopur Dose Too Low


Hi Dr Ramirez,

I am 41 (42 in March) and have just come through a failed IVF cycle (our 1st attempt). I'm not sure what my FSH levels are but know that I only have 4 and 5 antral follicles left and an AMH of 0.94.

I was put on an 11 day course of 5 amps of menopur a day. I produced 4 eggs, 2 of which fertilised. On day three I had a 6 cell and a 10 cell (neither of which were fragmented) and so the transfer went ahead. Neither took and our result was negative.

I have a 13 month old daughter that we conceived naturally so am reluctant (at this stage) to use a donor egg. The reason we have to go the IVF route is that I have severe Ashermans Syndrome as a result of bad placente accreta from my pregnancy. We are therefore using the services of a surrogate.

I understand that the odds are against us but if we have the means do you think it is worth another attampt or two with my own eggs, and are there any other protocols which may produce a better egg result?
Thanks, M. from Johannesburg, South Africa.


Hello M. from South Africa,

As you well understand, IVF pregnancy rates are very dependent on the age effect on eggs. As a woman ages, more and more of her eggs become debilitated leading to poor quality or abnormal embryos. This is the most likely reason for failure after the age of 40 years old. If you absolutely want to have a genetic child, then the only option you have is to continue trying as many times as it takes to be successful. The only things that may stop that plan are if you run out of money (i.e. cannot afford to continue) or the quality of the embryos is consistently poor. Otherwise, persistence can sometimes yield success.

There is a fairly good pregnancy rate at 41-42. In our clinic it is 55% pregnancy/32% deliveries. Miscarriages are increased because of the higher chance of genetically abnormal embryos. The oldest pregnancy to date in a woman using her own eggs was 49 years old in the U.S., but it took her 2 years of trying. Since you have been able to conceive about two years ago, there is already evidence that you do have good eggs. In your case there is the added factor of using a surrogate, but I assume you have selected one that has had successful pregnancies.

In terms of your protocol, every clinic is different and every doctor is different and prescribes/uses different protocols. It does not mean that one is better than the other. In my opinion, however, your protocol is too low for your age. In order to increase the chances of finding a good egg, a lot more eggs need to be recruited and retrieved. 5 amps of Menopur is only 375IU of FSH. As an example, my highest protocol, which is pretty consistent with other clinics in the U.S., uses 450IU of Follistim (pure FSH) + 150IU of Menopur (FSH/LH) for a total of 600IU per day. The bottom line is that the clinic you are working with and their protocol is highly influential on your outcome. You should check and see what their 41-42 year old pregnancy and delivery rates are, then compare them to other clinics. You may find that another clinic is better than the one you are attending.

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.

Comment: Thanks very much! It was great to receive such a quick and informative response.

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