Friday, October 29, 2010

Four Weeks Post First IVF & Positive BHCG: Not Rising Adequately & Possible Ectopic


Question:
Hi Dr. R. -

I am 39 years old and we have male factor infertility. In our first completed IVF cycle we had 27 eggs retrieved, 20 good, 14 fertilized, and 3 - day 5 blasts transferred. I had a very light implantation bleed and a positive Hcg at day 14 post retrieval.
1st Hcg 132 14 days post retrieval (this was 2 days early as I had to go out of town)
2nd Hcg 183 19 days post (this was a few days late since I was out of town)
3rd Hcg 278 21 days post (also requested a progest test which was 119 or so, can't remember exact #).
4th Hcg 479 23 days post

Had a u/s 23 days post which showed nothing other than very large ovaries. I understand the data on Hcg doubling but am curious about the 10-20% of women who do not have doubling - not a lot of literature on these patients. My RE said there is zero chance of the pregnancy progressing and said it was a chemical pregnancy and would monitor for an eptopic, I was advised to stop progesterone supps. Also, I had preg symptoms day 12-18 post but they have become less this past week. I have had no bleeding or cramping during the entire process. Any thoughts on my prognosis would be appreciated. Are my levels just too low and too slow?

One other question, my ovaries are "as big as grapefruits", is the only option to wait until they resolve and how long can that expect to take? Again, I am 4.5 wks post retrieval.

Thank you! J. from the U.S.A.

Answer:

Hello J. from the U.S.,

The minimum requirement for HCG rising in a normal pregnancy is an 80% rise, not 100% (doubling). However, your bHCG's have not been rising adequately. For example, the first bhCG at 132 should have risen to 238. The fact that your bHCG's are not rising adequately means that it is unlikely to be a normal progressing pregnancy, but you are still pregnant. In addition, an ectopic (tubal) pregnancy cannot be ruled out yet because the level is not high enough to see a pregnancy in the uterus. The level generally has to be above 2500. It is wise to keep a close eye on your situation.

The ovarian size is due to the increased stimulation you received. It will take up to two weeks to resolve in size from the cessation of the pregnancy. Remember, even though your first cycle has not been successful, you and your husband were able to go through all the steps needed to accomplish IVF, with some good embryos to transfer. I hope that you will consider trying again.

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.

Sunday, October 24, 2010

Empty Follicle Syndrome In 40 Year Old Attributed To Age Factor


Question:

Hello Doctor,

I am from Cuba but I live in Miami. I am 40 y/o now. I had my first IVF cycle at 39 that failed, back in July. I started 2nd round in Sept.- Oct. but it was just cancelled due to empty follies. It is possible that I have no more eggs in my ovaries?

I have another theory but I am not an expert and I don't know if it is possible to be true. The first step was taking birth control pill. I took them for 21 days. After that I had NO PERIOD. I did have symptoms "as if" my period was there (cramping, pain) but no bleeding. I did an ultrasound but the endometrium was not big enough to shed. At day 7 after the last pill, my Dr. told me to start the stimulation for IVF anyways. There were 6 follies formed but empty. What do you think? Could this (bcp) be the cause for no eggs retrieved? Thank you very much. I am very frustrated. T. from Florida

Answer:

Hello T. from Florida,

We tend to see a higher incidence of "empty follicle syndrome" with increasing age. This is indeed because there are fewer and fewer eggs left. However, no eggs at the time of retrieval is not related to having used the birth control pill and not having a period. There are other reasons, besides age, where no follicles are retrieved as well.

I have had several cases of EFS in my career (16 years) of doing IVF and in some cases they were in younger women, so the age factor did not apply. Those younger cases I attributed to a lack of adequate HCG triggering. I used to use a generic HCG, and it is possible that either the medication was not stored correctly and lost its efficacy, or it was not injected properly, or it was a bad batch of medicine. For that reason, I switched to Ovidrel, which is what I still use. I have not had a case of EFS in a young woman since. I still do see older women that have no eggs retrieved, however, and that is the age factor. Nothing can be done about the age factor except continuing to try in the hopes that (1) the next cycle will yield some eggs and (2) there will be a good one in the group.

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.

Saturday, October 23, 2010

Marathon Runner Has Amenorrhea And Is Trying To Conceive: May Need Gonadotropins


Question:
Hi, I am a 25 year old, PhD student and I am a competitive marathoner. My husband and I would like to get pregnant over the next 8 months. I was on the pill until last April, when I went off the pill. I had been on the pill for nine years and my cycle was regular before I went on the pill. During the years I was taking the pill my cycle was fairly regular, light and short in duration, but still regular. I have not had a period since I went off the pill 6 months ago. I am 5 7' and about 108lbs.

I have met with my Dr and she suggested that I go on the pill for a month so I can at least have my period to shed my uterine wall. Then she said if my period does not stick around I may need to gain a bit of body fat. I have also done blood work to make sure there are no other issues. Do you think that I will have to gain weight before I can get pregnant? Or can I just cut back on my training and lose some muscle mass and avoid gaining weight? Also can I get pregnant with my period being absent? Thanks! A. from Canada

Answer:

Hello A. from Canada,

The problem with competitive runners is that they lose a tremendous amount of body fat and so cannot produce hormones. They develop a disorder called hypogonadotropin hypogonadism. For this reason, they do not cycle normally. The birth control pill artificially takes over ovarian function and so you have an artificial period, but it is not because the ovaries are working. Having stopped the BCP (birth control pill), you are now at your normal state and your ovaries are not working. This is the reason your doctor recommended that you gain fat weight. Hormones are made from cholesterol. It is the chemical basis for all hormones. Unless you gain fat weight, you will not ovulate naturally and so will be unable to get pregnant.

I would not recommend another course of BCP's at this time, however. You can wait and see if you get a period, which you only need to have every three months at a minimum, and if it does not occur by itself, then you can take progesterone for 5 days to start the period. That way you will have the opportunity to become pregnant should ovulation occur.

The only other option for getting you pregnant would be to give you the hormones that your brain is not making to stimulate the ovaries. This is a medication called a gonadotropin. We would use a medicine called Menopur that is FSH and LH hormone. These hormones stimulate the ovaries to ovulate. You cannot use Clomid or Femara because the hypothalamus needs to be working for these to work and yours is not working.

Although there are many reasons for primary & secondary amenorrhea (absence of menstruation), I believe yours is due to your pattern of exercise and has a good chance of being corrected. See the Mayo Clinic website for more information: "Amenorrhea: Causes".

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.

Wednesday, October 20, 2010

Patient Runs Risk Of High Multiples With 7 Mature Follicles In IUI Cycle


Question:
I am on my 7th IUI cycle (a miscarriage on the 4th attempt). This month I have 7 follicles mature and ready to go. I am 36 years old. We would gladly welcome twins or even triplets.

What is the risk of higher order? A. From the U.S.A.

Answer:

Hello A. from the U.S.,

I would not continue the cycle with 7 ovulatory sized follicles (>15 mms) because of the risk of a super-multiple gestation (>2). I cannot give you a statistical risk as that number does not exist, but I would expect the risk to be high. Keep in mind that even twins are a high risk pregnancy and should not be taken lightly! I had an IVF patient this week who was pregnant with twins that just lost both at 23 weeks due to premature labor and delivery. It is heartbreaking. That is why we try not to have twins and definitely, try not to have triplets.

I will allow up to 5 mature follicles at 36 years old, but no more than that. Some RE's will not allow more than 3. I don't think you should take that chance.

You did not say if you are seeing an Ob/Gyn or an RE. I would like to comment on the fact that this is your 7th IUI (intra uterine insemination) cycle...I would hope that you have had a thorough infertility evaluation. One very simple reason that many women fail their IUI's is that their tubes are blocked. I can't tell you how many patients I have seen that have done multiple cycles of Clomid and IUI's who end up having this problem. If you have had a complete workup and you still fail, at 36 y.o. I would only have had you try 4 to 5 IUI cycles. At this point I would be counseling you regarding a more advanced fertility procedure, IVF (in vitro fertilization). Time is not on your side after the age of 35 as fertility begins to decline rapidly.

See my blog post: "Tips On How To Increase Your Fertility" for more information.

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.

Sunday, October 17, 2010

Trying To Conceive For One Year: Clomid Vs. Laparoscopy?


(If the blog radio program comes on, you can pause it by going to my Oct. 1st post. I will be keeping the show up for the month of October.)

Question:

Hi. I've been trying to conceive for about a year and my doctor and I are ready to take a more aggressive approach. We have generally discussed both clomid and laparoscopy as next steps in the coming months. I am wondering if you can give some advice as to the order of trying clomid first or having a laparoscopy first.

My sister and aunt both had endometriosis so I expect that could be the culprit. I personally lean towards having the laparoscopy first, but I want to understand which is usually recommended. Thank you. V. from the U.S.

Answer:

Hello V. from the U.S.,

In order for you to achieve pregnancy, if you have been having trouble, you have to find the reason so that you can get the appropriate treatment. The term "fertility treatment" or "fertility drug" is a misnomer. The treatment has to treat the problem. There is nothing that makes your more "fertile" no matter what the problem.

Clomid is a fertility medication only in that it is used to treat infertility. In actuality, it is an ovulation inducing drug. That is, it gets the ovary to ovulate if the ovary is not already ovulating. Doctors use this medication in women that ovulate also to increase the number of eggs they ovulate so that there is a higher chance for one of the eggs to reach and enter the tube (because that does not happen every time).

Laparoscopy is a surgical procedure that is used as an infertility test. It is part of the infertility evaluation because it is the only method to assess if there are any pelvic abnormalities. This is important because the third step of the body's process to achieve pregnancy (brains sends FSH/LH to ovary > ovary grows follicle and matures an egg > ovary ovulates and egg enters pelvis > egg has to get to tube . . .) is for the ovulated egg to pass through the pelvis and get into the tube. If there is anything within the pelvis, like scar tissue or an inflammatory disease like endometriosis, then then egg may not make it to the tube (endometriosis causes inflammation that can destroy the egg).

I presume that you have had a complete infertility evaluation prior to your doctor's recommendation to use Clomid or do laparoscopy? I dislike it when general Ob/Gyn doctors jump to unnecessary conclusions such as go directly to Clomid or laparoscopy without making sure that is what is needed. Clomid is used for ovulation problems or in conjunction with IUI (if there is a sperm problem). Laparoscopy is done if all the other preliminary tests are normal, or if there is an increased chance of having endometriosis such as severe menstrual cramping or pelvic pain or pain with intercourse. It is usually one of the last tests to be done. Is that where you are?

These are the things that need to be considered and if you see the right fertility specialist, it is more likely that the appropriate things will be done to help you to become pregnant. If you see the wrong person, then you might just be wasting your time.

If you give me more detailed and specific information (such as your age and what tests have been done), then I would be able to give you my recommendations on what needs to be done next.

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.

Saturday, October 16, 2010

The Importance Of Choosing A Qualified Infertility Specialist: 41 Year Old Patient Losing Time


(If the blog radio program turns on, please go to my October 1st post & pause it! I will be keeping the show up for the month of Oct.)

Question:

I have started evaluation with a RE at the beginning of August. I have so far been diagnosed as having low progesterone and not ovulating properly. I am just turned 41 and had a miscarriage at age 38 at 9 weeks.

My Dr said if my problem is only hormonal, it is an easy fix. He had me on prometrium for 10 days and now I go back for another ultrasound at the end of my menstrual cycle. I know other people have been put on Clomid with the prometrium. I just wondered what would be his justification or reason behind only giving me prometrium. I asked the nurse and she the prometrium was to help me ovulate. I am curious, I think my doctor is fabulous. I just want another opinion. Thanks! M. from the U.S.

Answer:

Hello M. from the U.S.,

I am glad that you wrote to me because your case disturbs me. You may like your doctor but he is wasting your time. If what you say is correct, neither he nor his nurse know what they are doing and they are leading you in the wrong direction!

If you ovulate correctly, then the progesterone level should be in the normal range. When that does not occur, it is called a "luteal phase defect" and the progesterone is used to help the endometrial lining of the uterus to convert correctly and support implantation. It DOES NOT cause you to ovulate. However, if your ovulation is not correct i.e. you are not ovulating, which would also lead to a low progesterone, then the treatment is to use a fertility medication to get the ovaries to ovulate properly, thereby correcting the problem.

There is another very very large issue, however, and that is that you are 41 years old. Did your "RE" talk to you about the age effects on your fertility? Did he tell you that your chances of a spontaneous natural pregnancy are only 1% per month or slightly less than 10% per year? Did he tell you that you may be wasting your time and possibly losing your ability to have a genetic child if you don't proceed in a more aggressive manner?

If your "fabulous" doctor is indeed an RE, then he should be very concerned about the impact of your age on your fertility and time. He would not be wasting your time with fruitless treatments like prometrium. He would be doing a more aggressive treatments like IUI (intra uterine insemination) or in vitro fertilization, IVF (preferred). Also, if he is indeed an RE, he would be doing IVF in his clinic. Does he? If not, then he may not be an RE at all.

My recommendation would be for you to go see a real infertility specialist, preferably one that does IVF, so that you can be counseled appropriately. I recently had a consult with a patient who, like you, went to a doctor that said that she was a fertility specialist. She was with this doctor from 36 years old to 45 years old. She was never referred to see a real infertility specialist, and so now, her only option is to use donor eggs with IVF. If she would have come to me sooner, we might have been able to get her pregnant using her own eggs. Please don't make that mistake!

Good Luck and keep asking those questions!

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

Friday, October 15, 2010

Faith Salie Comes Out On Her Choice To Undergo Egg Freezing

(If the blog radio program comes on, please go to the Oct. 1st blog & pause it. I will be keeping the show up for the month of October.)

Dear Readers,

For those of you who missed this, Faith Salie, a multi-talented American writer, television and radio host decided to "come out" regarding her decision to freeze her eggs. Her experience was filmed and shown on CBS's Sunday Morning Show on October 10th. Her slightly tongue-in-cheek account has a powerful message, nonetheless, and that is, "Choice". Now, young women do have a choice to prolong their fertility. It is not inexpensive but those who never had this choice and are now faced with undergoing multiple IVF cycles or using donor eggs would probably be the ones to tell you that they wished they would have had this opportunity. The development of better ART to freeze and thaw has made egg freezing a reality, a viable option for women like Faith Salie.

As she put it in her piece for CBS:

"Let’s talk eggs.

Not the ones on your breakfast plate. No, the ones I have frozen at the NYU Fertility Center.I want to talk about egg freezing, because I don’t think enough young-ish women know about it. I even made a video diary of my eggs-perience, in which I chose to shoot myself up with fertility drugs, visit my doctor twice a day for bloodwork and ultrasounds, and check myself into the hospital for the big retrieval.

I knew two things: I really, really want to have a baby; and I really, really don’t know who should be the father. Now I know a third thing: The option to freeze one’s eggs is just about the most empowering choice a single woman who knows she wants to be a mother can make."


Thursday, October 14, 2010

Guest Blogger Mindy Berkson: Building The Foundation For Surrogacy Brick By Brick

(If the blog radio program comes on, please go to the Oct. 1st blog & pause it. I will be keeping the show up for the month of October.)
Dear Readers:

Mindy Berkson is visiting my blog once again with an excellent guest post on surrogacy. For many, surrogacy is the only option. Recently, I had a patient who had an emergency hysterectomy after the birth of her first child. She was grief-stricken at the prospect of not having the ability to have another child until she decided upon surrogacy as an option. The whole process went forward without a hitch, with her and her husband undergoing IVF at our center with a surrogate they had found through a reputable agency. Her gestational carrier is now pregnant and will be delivering soon.

This is a complicated process and one in which Ms. Berkson has a wealth of experience as an infertility consultant. One of the first in the country to work with infertile couples on a case-by-case basis, she is both professional and compassionate when guiding her clients through what can be a very difficult and emotional treatment path. See the end of the blog post for more information on Lotus Blossum Consulting.

Building The Foundation For Surrogacy Brick By Brick


With so many moving parts to surrogacy it is no wonder the process can be overwhelming. Learning to be your own best advocate, effectively planning financially, physically and financially help you maximize your chances of success and minimize your financial expenditure.

The first step in building the foundation is preparing to pay for treatment and the ancillary costs associated with surrogacy. Finances are specific to individual circumstances. Sometimes savings are available, often the sale of portfolio items are used to fund treatment. A third popular option are various borrowing opportunities. All of the above should be discussed with a tax professional and or financial planner in the context of your individualized circumstances. It is also vital to plan and prepare for multiple treatment cycles. In my experience balancing hope with caution is what helps my clients to approach treatment with clear expectations and realistic parameters.

The second step in building the foundation is to identify the fertility center, the Reproductive Endocrinologist and the Embryologist who have above national average success rates for the type of treatment you are exploring as well as a specialty in treating your specific diagnosis.

The next resource is identifying the right donor and/or surrogate. Seeking ideal criteria in a perfect stranger is often a very intimate process. There is always some level of risk in the decision making process. Being your own best advocate is helpful in mitigating and or eliminating potential stumbling blocks. Identifying a candidate on line can be risky since they are not screened and you will not have the benefits of a third party to act as an intermediary. On the other hand, it is necessary to be aware of onerous contracts with recruiting agencies.

The fourth brick in the foundation is understanding the legal terrain and how it affects your specific situation. Surrogate friendly states vary across the country. Surrogate friendly means that parentage can be achieved at some future point after birth. But from state to state this varies greatly. Some states require pre birth orders to get intended parents names on the birth certificate after the birth and other states require a formal adoption after the surrogate delivers. Other states are favorable in getting intended parents names on the birth certificate at birth, as long as one parent is biologically related to the child. Furthermore, often how the embryos are created, and with whose biological material is relevant to the big picture. Thus, the individualized situation can and does impact the selection of a surrogate candidate from state to state. Finally, selecting a surrogate with like-minded intentions for the term of the pregnancy is essential.

There is still more to consider. Most health insurance policies have exclusions for surrogates. Therefore, it is essential to analyze policy alternatives that may help you to save thousands of dollars in the future. Some states offer maternity policies, other states offer nothing. Disability and complications only polices can often be purchased to offset financial risk. But it is the gap analysis performed by the licensed insurance agent that can help uncover what is best for your given situation, the surrogate, the state where she will deliver, and how these factors impact your individual risk adversity given your personal financial situation.

Another extremely important and often overlooked resource in family building is estate planning. Prior to surrogates going to embryo transfer it is essential to engage an estate planner to draft directives and desires and prepare effectively for any unforeseen circumstances. This provides the most protections for all involved parties.

Building the foundation for treatment is essential. Knowing all available options, researching the viability of each options, interviewing several reproductive specialists to determine if you are in the right place are all very relevant and key factors to consider before patients begin the journey.
When making educated decisions to pursue treatment options, I encourage my clients to take into consideration all the facts. Because making informed medical decisions is the best way to maximize their chances of success and minimize their financial expenditure.

As one of the first infertility consultancies in the United States, Lotus Blossom Consulting, LLC was founded by Mindy Berkson in 2005. With more than a decade of experience at physician’s offices, and egg donor and surrogacy agencies, Berkson assists individuals working through the often-challenging roadblocks of infertility, by providing the best information and resources available to them from around the world – all in one location.

Lotus Blossom Consulting works with individuals on a case-by-case basis, taking into consideration clients’ emotional, physical and financial infertility issues and then develops an individualized, comprehensive plan, to help clients make informed decisions and pull together a team of unbiased professionals to accomplish a treatment cycle. Mindy is a sought-after infertility expert and has appeared on countless media programs and speaker panels educating audiences on the topic of infertility, egg banking and surrogacy. For more information about Lotus Blossom Consulting, LLC, call toll free (877) 881-2685, email mindy@lotusblossomconsulting.com or visit the web at www.lotusblossomconsulting.com or www.infertilityconsultant.com.

Saturday, October 9, 2010

Chances Of Pregnancy After Myomectomy: With Or Without IVF


(If the blog radio program turns on, go to the Oct. 1st blog post and pause it...I will be keeping the show up for the month of October.)
Question:

Dear Doctor,

Hello. I am writing from Atlanta, GA. I wrote once before (concerning my dermoid - thank you for the information!) and was hoping you would consider a second question. Much like everyone else here, I've had a complicated TTC journey.

April - laparoscopic dermoid removal from right ovary. Ovary was not removed but is small and has not produced follicles since (despite being on letrozole).

July - HSG. Right tube open. Left tube did not spill dye. Proximal block. No history of STDs or infections, thinking maybe it's scar tissue from surgery?

Sept - Large fibroid (~4cm) found on US (significantly distorts the uterine cavity). RE recommends abdominal myomectomy before moving forward with IVF. I also have a uterine polyp (~5mm) that will need to be removed at the same time (if possible) or during a 3rd surgery.

I am 36 years old and have never been pregnant. While on letrozole I produced 2 eggs the first month and 1 egg the second month. However, we are open to the use of donor embryos. My question is, what do you think is the risk of a complication from abdominal myomectomy (during the initial surgery or during a resulting pregnancy) and what is the probability of achieving a pregnancy after such a procedure? I am feeling discouraged given that there are issues with my ovaries, tubes, and uterus, and want to have a clear understanding of the potential for complications versus the potential for pregnancy if I move forward with the surgery.Thank you again for your time, J from Georgia

Answer:

Hello J from Atlanta,

Basically at this point you have two choices: you could attempt IVF without the myomectomy or have the myomectomy first before IVF.

The studies are controversial regarding the influence of fibroids on pregnancy rates in IVF. Some show that any fibroid can reduce the PR, whereas others show that only the ones that enter the uterine cavity do. In my experience, if the myoma is very large and takes up a good portion of the uterine muscle, it seems to impact fertility. I have had many patients get pregnant spontaneously after a myomectomy in those cases, or achieve pregnancy with IVF after they failed previous cycles. What I counsel my patient is that the studies are not clear and so the decision is really whether you not you want to do everything you can to maximize your chances with IVF or do you want to try the IVF without the surgery and take the risk. It is a toss up. I will go with whichever choice my patient makes. Neither option is a guarantee anyways. I have had patients that do the myomectomy and still fail with IVF, for whatever reason.

I cannot give you specific statistics regarding the chances of pregnancy with or without myomectomy because the mixed findings in the studies that have been done. In general, the current recommendation by ASRM is that only fibroids that invade into the uterine cavity need to be removed (because they can interfere with implantation) and 4 cms is not a large fibroid. I would consider 7 or larger to be a large fibroid. In some hands, this 4 cm fibroid can be removed laparoscopically. I also prefer to do the procedure as an open procedure, but that is because of a lack of experience removing deep fibroids laparoscopically. If you don't want the open procedure, then you might want to investigate and find someone that does these laparoscopically and has a lot of experience (the experience is the key in this procedure). That will allow for less pain and a quicker recovery. In either procedure, you won't be able to do the IVF for at least 8 weeks after the date of the surgery.

Good Luck on your journey...it is good that you are leaving yourself open to other options too!

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

Comment: Thank you! Your knowledge and kindness are invaluable.

Thursday, October 7, 2010

Genetic Defect In Husband's Sperm Leading To IVF Failure: Screening With CGH Recommended



(If the blog radio program turns on, go to the Oct. 1st blog post and pause it...I will be keeping the show up for the month of October.)

Question:

Dear Dr. Ramirez,

My husband and I have been infertile for two years. The second year, we began IVF. We have completed 3 IVF rounds. The first was not successful. The second resulted in a chemical pregnancy / early miscarriage at 6 weeks. The third resulted in an ectopic pregnancy. My husband and I are both in good health, with no known infertility factors (endometriosis, etc.). We do not have antisperm antibodies. All our bloodwork was good. On our second IVF round, 1/2 of the eggs were fertilized by standard IVF and none of them merged. 1/2 of the eggs were fertilized by ICSI and did very well. On our third IVF round, all the eggs were fertilized with ICSI and did very well. We have 9 frozen embryos waiting.

After this ectopic pregnancy, we had genetic testing done. Mine were normal. My husband's were abnormal. The interpretation was:

"A male karyotype with a small supernumeray bisatellited marker chromosome was noted in all metaphases analyzed. The majority of bisattellited markers are derived from an inversion duplication of the pericentromeric area of chromosome 15. Apparently this market carries minimal with no phenotypic significance to the patient; however it may lead to decreased fertility, repeated pregnancy loss, or chromosomally abnormal offsrping. Parental follow up chormosome studies are recommended to determine if the marker is familiar or de novo in origin, and to further evaluete its clinical significance. De novo markers are associated with an increased risk for phenotypic abnormalities. Genetic counseling is recommended."

We are going to receive genetic counseling in the future, but what is your opinion about this chromosome 15 abnormality and its effect on conception and offspring? Thanks! A. from the U.S.


Answer:

Hello A. from the U.S.,

Unfortunately I am not a geneticist and will usually go by what the geneticists advise me in terms of the consequences of chromosomal abnormalities.

However, in general, this is what it means to me. Your husband is carrying a genetic abnormality that is "recessive" in nature, meaning that it does not necessarily present itself as an abnormality. Because his sperm can contain this trait, it is possible that this can result in abnormal embryos, which will lead to early embryo death (and lack of implantation) or an early miscarriage. The ectopic pregnancy you had was for a different reason and does not need to be considered in this discussion.

What I would recommend is that the embryos be tested by the relatively new CGH (Array Comparative Genomic Hybridisation) process or PGS (Preimplantation Genetic Screening) prior to transfer. Last year, in England, a 41 yr. old woman who had failed IVF 13 times had her embryos tested with CGH and in September delivered a healthy baby (see article here). If your embryos are D#3 embryos, they should be thawed, and biopsied for genetic testing done by CGH. They would then be cultured to blastocyst and transferred at that time. If they are already blastocysts, then they would need to be thawed, biopsied then frozen again for a later transfer. In any future IVF cycles, the embryos should be similarly tested to look for the normals so that the abnormal embryos are not transferred leading to a negative pregnancy, miscarriage and further disappointment.

Not knowing how the genetic transference of this abnormality is done i.e. does it occur every time with every embryo, or is there a chance that some embryos will not have the disorder? it is hard for me to give any more specific recommendations. Once you have your genetic counseling, they will be able to answer these questions for you, which will help to determine a more specific strategy.

Good Luck,

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


Comment: Thank you. You are an angel for helping with this guidance.

Tuesday, October 5, 2010

Woman In Tasmania Has Done 14 IVF Cycles At One Center And Now Faces An FET: What Advice Can You Give Me?



(**If the blog-talk radio starts up, go to the October 1st blog post below & pause it...I will be keeping the show up for the month of October.)

Question:

Dear Dr Ramirez,

Someone wrote a comment on my blog suggesting I ask you. Basically, I was asking what questions to ask my RE. This is the post she was responding to:

Here’s where I am: I’ve been doing IVF/ICSI since July 2006. We started because my husband had a vasectomy many years ago, so it’s not like we’d been trying for years and didn’t know what was wrong and needed a diagnosis. We knew we’d need IVF if we wanted any hope of having a child.

I live in Hobart, Tasmania. There’s one clinic with only 2 REs: one who is part-time (he’s mainly an obsetrician) and one who is full-time. We started off with the part-timer but have been with the full-timer for a few years now. I would say they pretty much don’t have individualised treatment. They have a few standard protocols, but mainly seem to pride themselves on keeping treatment costs low so patients can have many cycles. Quantity, not quality. If you have repeated failures, they don’t do investigations; they just suggest you keep on going on.

To go to another clinic would cost us money, time, more stress, and be logistically difficult. That’s not to say I’m not up for it if need be. However my husband gave me the ‘I’m tired of treatment and would rather not pursue it, but I’m doing it for you’ bombshell the other night. So I don’t know if I could drag him by the testicles to an interstate clinic to try to get different treatment. I’m willing to go without him though. Having a child has become muchmore important than my marriage.

The only investigations I’ve had are a laproscopy, hysteroscopy, hydroscopy a couple years ago (I had endo, which was removed, and the hydroscopy as inconclusive as fluid didn’t move through my tubes but they looked OK). My obstetrician ordered a bunch of blood tests after Blobby’s miscarriage: protein C, protein S, AT 3, Anticardiolipin antibodies, LAC, Factor V Leiden, Prothrombin G20210A mutation MTHFR C677T mutation, MTHFR C677T mutation, and Karyotyping.I find it unbelievable that after so long, they still don’t try to find out WHY we’re having the problems we’re having. They never check hormone levels (not even during stim cycle – he just relies on ultrasounds to tell him what’s happening), they don’t check for implantation issues, there’s been no renothing. Hearing about the testing that goes on in other clinics has really opened my eyes. I would welcome finding out I had a problem because then we’d know whether it would be likely to be able to be fixed or if we had no hope.

Questions I’ve come up with are:

1. As one of our embryos is a 3 day and the other two are 4 day, can the 3 day be thawed used this time and thawed a day ahead? That way if it doesn’t thaw we still have 2 more we can attempt thawing.

2. Is there a wait list for donor semen? (There wasn’t a few years ago when I did 7 DI/IUI cycles, but I think there is now. Want to know just in case.)

3. Might DHEA help my embryo quality?

4. Any news on the egg donor wait list (Australia's)? (This is probably a stupid question; I know other women in Australia on the wait list and we all seem to get difference answers to our questions. Someone who is 27 was told recently she should have a donor by January 2011 – sorry, but that’s a HUGE porky she’s been told!)

5. The best embryo we’ve had was from a down regulation cycle. Is this just a coincidence, or should be try down regulation cycles again?

6. What sort of implantation failure testing can be done?

If you are interested, my blog "Riding The IVF Roller Coaster" is at http://tasivfer.wordpress.com/. I am writing from Hobart, Tasmania, Australia. Australia's island state - and a long way from any clinic other than the one I've been with for soooooo long. . .Cheers,TasIVFer

NOTE: As of 2012, TasIVFer is a MOM! "After 4 1/2 years, 14 fresh IVF cycles, 7 donor inseminations, 4 FETS, and the loss of my dear son Blobby at 14 weeks 2 days, we tried (half) an egg donor. Blood test 10 December 2010 = BFP. Little Spark was born 6 August 2011!!! He LIVES! Now the journey continues with an FET in November 2012 with our last embryo. Perhaps our last ever?" Good for her!!!


Answer:

Hello TazIVFer from Australia,

Let me take your questions in sequence and answer them the best that I can.

1. The Day #3 frozen embryo certainly can be thawed and cultured to align with the Day #4. My recommendation would be to thaw both, one day apart, and allow them to culture to blastocyst if your home lab has that capability. That may give the embryos a better chance of implantation. You don't mention what the cell # and grade was at the time of freezing but that is an important factor. As the saying goes, bad in-bad out. That means that if the embryo is poor quality, culturing further does not make it better quality. It may not survive the culture.

2. I cannot answer your questions regarding donor sperm wait lists. In the U.S., there are no donor sperm wait lists. Donor sperm are readily available. I guess that's because there are more men in the U.S. than Australia.

3. DHEA will do nothing and is not recommended. However, I would recommend that you consult my blog where I addressed the issue of implantation failure. I do have my own, specific protocol that I use for patients that fail IVF. Because I don't have any precise information from your cycles, I cannot give any specific recommendations.

4. Again, no egg donor wait lists in the U.S.

5. Coincidence probably but I would have to look at your cycle information to do a detailed analysis.

6. There are no specific tests for implantation failure.

I hope this answers your questions adequately. It is unbelievable that you have gone through so many cycles. I don't know of many women and their husbands that could manage the stress and frustration of prevailing through IVF for so long. I wish you the very best of luck with your FET cycle!

Keeping my fingers crossed! 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.

Friday, October 1, 2010

PCOS Challenge Radio Show Summary: Everything You Wanted To Know About PCOS, Fertility, Menopause, Pregnancy & More!

Dear Readers,
On September 29th I was interviewed by Sasha Ottey of PCOS Challenge on her BlogTalkRadio program, for an episode titled: "Ask The Fertility Specialist About PCOS And Your Fertility". I was pleasantly surprised at how quickly the one-hour interview went. It was basically a question/answer format (like my blog ). It was interesting to see how many questions I received from Sasha and her listeners that not only covered PCOS but many, many other issues that relate to women's reproductive health. For more in depth information on PCOS and infertility please see: Polycystic Ovarian Syndrome.

I will attempt to give you some idea of the many different issues that were brought up during this very enlightening hour! I can't list them all, but if any of the topics that I list below interest you, please listen to the radio show through the widget below!


Listen to internet radio with PCOSChallenge com on Blog Talk Radio

  • "What is the difference between a normal menstrual cycle and one that is PCOS?" With an abnormal menstrual cycle you can develop abnormalities in your endometrial lining.
  • "What are the top reasons for infertility?" Probably PCOS is the number one cause for infertility that I see, with tubal factors and age factors coming in close seconds.
  • "While overweight PCOS patients are told to lose weight, lean PCOS patients are at a loss as to what to do?" I go in depth on Clomid, Femara and the injectables that might be the treatment path for "lean" PCO patients.
  • "What is the difference between ovarian reserve and ovarian resistance?" With ovarian reserve you need to evaluate your FSH levels and AMH and tends to come with age, but ovarian resistance has to do with how the ovary responds to fertility medications.
  • "How long do you need to wait to try for pregnancy again after you have a miscarriage?" Surprisingly, recent studies have shown that trying as soon as possible will actually increase your chances of pregnancy. You must wait until you resume your normal menstrual cycle, though.
  • "What about patients that are insulin resistance and overweight, will changing their diet and losing weight help with their fertility?" This will work in a majority of patients, but some of these patients will have to go on Metformin, and possibly ovulation inducing medication.
  • "I am a very heavy-bleeder during my period and are there any options besides a hysterectomy?" You need to establish first whether you want to get pregnant in the future, in which case you want to preserve your uterus. You should find out why you have the bleeding. It could be an ovarian disfunction or perhaps caused by fibroids or polyps which can be removed. Otherwise, if you don't want to get pregnant you can opt to have a D&C, bcp, Mirena, endometrial ablation, or a hysterectomy.
  • "When can I expect to see or hear the heartbeat in early pregnancy?" By the seventh week you should expect to see something.
  • "Can you have menopause and PCO?" Once you become menopausal PCO is not an issue anymore, you have a hormonal imbalance because your ovaries are not functioning anymore. There are treatments for menopause, including estrogen replacement therapy for the first five years.
  • "What is Metformin and Spironolactone?" Metformin is an insulin blocker, while Spironolactone is a diuretic used with PCO patients that have hirsuitism as well.
  • "How do you treat nausea in pregnancy?" There is a great drug out there now that I use with all my patients, including those who have just had surgery, called "Zofran". It is safe for pregnant patients.

    Not all the topics we covered are listed above...so tune in if you want to hear me discuss these issues and more in depth! Thank you, Sasha, for the opportunity to share this knowledge with your listeners!

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

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