Implantation Problems & Causes Of Chemical Pregnancy

Question:

Hi again, it's K. in NY. I have written to you in the past about my difficulties staying pregnant. I have had 7 chemical pregnancies in the past 18 months and one miscarriage at 9 weeks after using femara (you felt it was probably due to a respiratory virus I contrated around 6 weeks). I tested positive for MTHFR mutation heterozygous but also this didn't appear to be the issue.

I guess I have a 2 part question for you. The first would be related to causes of chemical pregnancies. My progesterone levels have been on the low side of normal (even during the pregnancy that ended in miscarrige) and I really thought that was the cause. I was placed on 50 mg suppositories 2 months ago and I did get a positive result this month (8 DPO Hcg 12, progesterone 18.8, took femara and progesterone) but my HCG level was back to <5 on 10 DPO.

Are there other implantation issues that could be my problem besides chromosomal abnormalities and low progesterone that lead to a pregnancy not progressing? I know I shouldn't test early, but I was trying to establish if low progesterone levels were the cause of my losses.

Part 2: is it possible to just have an underlying HCG level that elevates above 5 regularly, and if so, what would that signify? As you may remember, my old RE wrote off the HCG values as me eating too much cereal and developing an antibody to HCG that triggers pregnancy tests. I will be visiting a new RE soon and want to be sure to ask the right questions and supply the best information.Thank you very much for all of your insight and for volunteering your services. Merry Christmas!

Answer:
Hello K. from the U.S. (New York),

Let me take the second question first since it is the easier of the two to answer. The answer is NO, you can't have an underlying HCG level from cereal or any other source other than pregnancy. Serum pregnancy tests are very sensitive and testing for the beta subtype (bHCG), so there is no cross reaction even if the cows you were using the milk from were given hormones for some reason (I presume that is what your old RE was thinking as a source. A little far fetched if you ask me).

In terms of your chemical pregnancies, that is a difficult problem to answer. If you have already undergone a complete recurrent miscarriage evaluation (hormones, infectious diseases, anatomical, genetic, immunologic) then we may not have the technology to find the exact cause. However, the hormonal is easy to check through blood tests, and I automatically place my patients on progesterone supplementation just in case; anatomical testing would take an ultrasound and hysteroscopy, again an easy test; and infectious diseases and genetic are also easy to test. The only one that is difficult and not completely understood is the immunologic component. Many authorities have looked into many different immune factors.

If you look at a website by Reproductive Immunology Associates, who have made a practice of the immunologic causes of miscarriage, you will see lots of different test that they recommend. Because this component is so difficult to define, experts have conflicting opinions.

If you were my patient, I would put you on a protocol that I use and, for the most part, have been successful with. It involves taking aspirin 81 mg per day starting at the beginning of the cycle, medrol (prednisone) 16 mg per day taken from the beginning of the cycle then decreasing to 8 mg after ovulation, progesterone vaginal suppositories beginning after ovulation and, finally, heparin 2000 units twice per day subcutaneously beginning at the start of the cycle. The aspirin, medrol and heparin treat for subclinical immunologic problems and the aspirin and heparin also help to increase blood flow at the microvascular level at the implantation.

Good Luck & Merry Christmas to you too :) ,

Dr. 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 SO much for your opinion. I will definitely have to look into these additional things. Glad to hear that I am doing all that I can do on my own and that I am advocating for the right things. It makes a HUGE difference when you have an idea what direction you should be headed so that you can work with a doctor to get there. Merry Christmas!

39 Yr Old TTC With Previous Miscarriage: Clomid Vs. Gonadotropins? Flare Vs. Antagonist Protocol?

Question:

Dear Doctor,

I am from India. I am 39. I had two missed abortions at 36 and 37 both in the eighth week and after the heart beat was felt.After leaving a gap of four months I have been trying to conceive naturally for 14 months without any result.

Subsequently I started Clomid 100 mg (day 3-7) at the advice of doctor.I did 3 cycles with Clomid out of which I got two follicles of ovulatory size (more than 18mm) in two of the cycles and one follicle (20mm) in one of the cycles.I did not conceive. My FSH and other hormones are normal.

I consulted a IVF specialist who examined me and said that my ovary volume is good and said that she will go for two cycles of IUI, if they are not successful she will go for IVF.

In my first cycle of IUI, the doctor did a trans-vaginal ultra sound on day 2 and gave the following medications from day 2 to day 5 (1) Suprefact 10 markings in the insulin syringe with 100 markings (BD 100 mark syringe) (between 1 to 2 pm daily)(2) GMH (human menopausal Gonadotropins (FSH+LH)) 225 IU (between 7-9 pm daily)

On day 6 she checked and told me that there is no response and the follicles have not grown.She changed the medication to GMH 375 IU per day on day 6 and day7 (between 7-9 pm daily) (She stopped Suprefact)

On day 8, she checked and told me that the follicles have not grown and advised cancellation of the cycle.Further she said that my follicles are not good enough for future trials of IVF or IUI and advised IVF with donor egg.

I asked her how I could get two ovulatory sized follicles (above 18mm) with Clomid in two of my three monitored cycles but nothing in this cycle and she is ruling out the possibility of the future trials. Her answer was that with Clomid or Letrozole even empty follicles grow and give a false impression that the follicles are growing and ovulating. But with Gonadotropins only follicles with good eggs will grow and that is the reason why my follicles did not grow with Gonadotropins. Is the above statement about Clomid and Gonadotropins correct. I will be grateful for your answer. R. from India

Answer:

Hello R. from India,

The simple answer is "NO. Her explanation is NOT correct." The gonadotropins are more effective than Clomid or Letrozole in recruiting and growing follicles because it IS the hormone the brain sends to the ovary for that purpose. Clomid and Letrozole work by an indirect method to cause the brain to increse its FSH output.

Also, she is NOT correct that gonadotropins only grow "good" follicles whereas Clomid grows "false" follicles. This explanation is made up and not scientific at all. In fact, no such thing exists. Sorry.I am not sure why your doctor cancelled your cycle. If the CD#8 ultrasound (which is early) or Estradiol level are showing a low response, the proper protocol is to continue going. Sometimes the follicle can grow slower. I have had patients get up to 21 days before ovulation occurs. In addition, the FSH should be increased if the stimulation is slow. I do not expect to have ovulatory sized follicles until at least CD#12.

I agree with you that since you stimulated with Clomid previously, you should readily stimulate with Gonadotropins as well. Maybe you should find a new IVF specialist. One thing to keep in mind, however, although your chances are still good at 39 years old, your previous miscarriage show what part of the problem is, which is that the eggs have aged and more and more of them are not of good quality. As a result, there is a higher chance of abnormal embryos which increases the miscarriage rate. IVF should help that because it increases the amount of eggs that are retrieved which in turn increases the possibility of finding an egg that is still good quality. You probably will need a high dose protocol using up to 600IU of FSH. IVF is definitely the way to go!

Follow-Up Question:

Dear Doctor,Thanks for your kind advice.The IVF specialist said the protocol given to me is the flare protocol meant for poor responders. Is that so? Then I do not understand why I did not respond to the protocol.

During my Clomid cycles my follicles reach ovulatory size by day 12. Do you think the poor response in the Gonadotropins cycle could be due the Suprefact Injection which was given from day 2 to day 5 along with Gonadotropins? Also kindly advise if it is necessary to add Suprefact or lupron early in the cycle or giving only FSH will help. Besides doctors here give Gonadotropins (FSH+LH) not Recombinant FSH. Is it better to give Recombinant FSH?

Kindly advise. R.

Follow-Up Answer:

Hello Again,

I do not like to comment on protocol specifics because there is no one way to do things. Please keep that in mind as I answer your questions. The "flare" protocol is one type of protocol used to stimulate the ovaries with IVF. It has no advantage over other protocols, but sometimes is used in patients that are designated as "poor responders". Studies have not shown it to be any better. I personally do not use the flare protocol. My preference is to use an antogonist protocol so that there is no suppression of the ovaries during the initial recruit phase, but I am in the minority in terms of centers that use this type of protocol.

In terms of your stimulation, I still think that a higher amount of medication may be warranted.

Both Suprefact and Lupron are medications called "gonadotropin agonists" and what they do is suppress the brain from producing FSH and LH.Gonadotropins are either pure FSH, pure LH or mixed FSH/LH. This is the name for that class of medications. Some IVF clinics only use FSH, some will use a mixed protocol of FSH and FSH/LH. Examples are Follistim (pure FSH) and Menopur (FSH/LH). My preference is the mixed protocol but many clinics will use FSH only protocols and some will use only the mixed FSH/LH medications. Studies have not show a necessary benefit of any of these protocols so they cannot be compared or criticized. Each doctor and/or clinic has their preferences. The most important aspect is how much FSH is being given because FSH (follicle stimulating hormone) is the hormone that stimulates follicle growth in the ovaries. Also, Natural vs Recombinant forms are equal. There is no difference.

Wishing you good luck with your TTC journey,

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.

Can I Thicken Endometrium With Estrogen?

Question:

Dear Dr. Ramirez,

I´m 35 years old (will be 36 in Feb). I have been trying to get pregnant for 2 years (had a miscarriage a year ago). After going to a reproductive clinic, I´ve tried Clomid for 2 cycles with no success, an it really thinned up my endometrium, which usually wasn´t very thick (7-8mm). So my RE recommended to change to Menopur in the next cycle and do a IUI (My husband´s Kruger morphology is 5% - lab reference 4% all the rest is good). This current cycle (no meds) she did an sonogram on me on day 12 (my last period, which followed the Clomid treatment, was only 21 days longer and she wanted to check me for cysts). I had a 20mm follicle and several smaller ones, but my endometrium although trilaminar was only 7mm. For all I have been reading 7mm is not optimal thickness, although my doctor seems to think it´s ok and there´s no need to do anything.

So I was wondering how can I prime it before ovulation? Will taking estrogen help? Will it interfere with ovulation? What are the cycle days you normally recommend your patients to take it and what is the dosage?

Thanks for your time. I really appreciate it. C. from Brazil

Answer:

Hello C. from Brazil,

Yes, you can use estrogen in addition to the Menopur. I use it as an estrogen patch (Climara 0.2 mg per week up to 0.4 mg) or vaginal tablet (FemHRT, Estrace 1 mg up to 4 mg per day). As the follicles grow, they produce more and more estrogen so that should help as well. 7 mm is the minimum size needed, but ideally it should be 9 mms.

In terms of treatment, keep in mind that you have three problems going on. My opinion is that the more problems there are, the higher the treatment level you need to use. The problems identified are: (1) thin endometrial lining, (2) age factor (going on 36yo) and (3) severe male factor. Because of the age and SEVERE male factor, I would advise IVF with ICSI as the treatment of choice. The sperm may not have the ability to fertilize the egg naturally and so ICSI is required. This can only be done with IVF. IVF is also the only treatment that helps to increase pregnancy rates related to age, which is an egg problem, by increasing the number of eggs available to fertilize.

Follow-Up Question:

Thanks for answering my question, Dr. Ramirez.

When would I start taking the estradiol, cd1 and go up to ovulation? I´d like to know so I can talk to my doctor about it.

Also, now I am really concerned about the severe male factor. Is a 5% Kruger morphology that bad even if the sperm concentration is high (85 million/ml) and they show good motility (>70%)? For the IUI procedure, after swim up test and washes, can the doctor choose only the sperm that have good morphology? I´ve read that some doctors think that the Kruger method is really too strict and based on it, most males would be called fertile. What´s your opinion on that? Is there any treatment for sperm morphology (my husband is 37yo)?Thanks again for your valuable time and input! C. from Brazil

Follow-Up Answer:

Hello Again,

1. The estradiol patch or vaginal suppository would begin with CD#1 or 2.

2. If only 5% of the sperm are anatomically normal (morphology), even with an 85 Million count that means only 3.2 Million are available to actually fertilize the sperm (85 Million x 75% motility = 63.75 Million motile x 5% = 3.2 Million). This is inadequate for natural fertility. In addition, when there are sperm abnormalities, there is a high chance that there could be a defect in its ability to fertilize, and there is no test for that other than with IVF. For that reason ICSI is recommended. The embryologist will only take anatomically normal forward swimming sperm for the ICSI (if they are good embryologists).

3. I somewhat agree with the opinion regarding Kruger, but the decision has to be made based on the information that you have. Even 5% normal morphology is pretty low using Kruger.4. Unfortunately, other than ICSI there is no good treatment methods available to change morphology. There are two products that he can try, which are basically vitamins, called Proxeed and Fertility Blend. These can be purchased via the internet. He would need to use them for 3 months minimum. He can then repeat the semen analysis and see if this helps at all.

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.

Comment: Thank you again Dr. Ramirez. I wish I was still living in the US to go to your clinic :)

Did IVF Then Got Shingles: Could It Have Caused BFN?

Hello,

I was 5 days into my 2ww after a second IVF (in vitro fertilization). My first IVF unfortunately was a BFN (big fat negative), when I got my first ever shingles outbreak.

Then, my IVF ended up as BFN! Could shingle cause an IVF to fail. I had 4 gradeA embryos transferred. I am devastated! Thank you for your answer. A. From Georgia

Answer:

Hello A. from Georgia,

I am so sorry that your second cycle resulted in a negative and that you had to suffer shingles on top of that. I've had it myself and it is not a pleasant condition at all.

To answer your question: Yes, it is possible that a shingles outbreak could affect an implanting embryo. The immune response would be greatly heightened and could kill the embryo. That may not be the reason for the failure, but is a possible cause.

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.

No Period, Retained Cysts & Fibroids, After IVF Cycle Cancelled: 47 Year Old IVF UK Patient Worried

QUESTION:

I am 47yrs. I had my 6th IVF (in vitro fertilization) cycle in September 2011. The drugs used were climara patches10 days before the cycle began, prednisolene 10mg daily, aspirin 81mg daily, bravelle 6 vials every morning, menopur 2 vials every evening later increased to3 vials and antagoni ganirelix acetate injection. I had 5 follicles before the cycle was abandoned. One on right side 9.5 and four on the left 16, 11, 7.5 and 6. My cycle was abandoned because the follicles didn't grow at same rate and the antagonist may have been administered late.

I have two issues:

1) I have not had a period for about 50 days, though I had spotting and a discharge 10 days after the ivf cycle was abandoned. A vaginal US 2 days ago which indicated that I have multiple large follicle/small cysts ..3 large follicles of 20mm each on left ovary and 1 follicle 4.3 mm on right ovary, endometrial thickness was 9.1mm. Urine peg test was -ve. I am awaiting results Blood tests of hormone levels and peg test. My question is is it normal not to have a period long after after some types ivf cycles.since my period returned to normal 10days after my other 4 previous cycles? Or could the drugs have triggered menopause? Would the 3 large follicle disintegrate eventually?

2) I have 6 uterine fibroids, between 20-28mm, outside the womb. Also, a recent immune blood test revealed that I have a raised Th1:Th2 cytokines ratio of 33.2 and Cd19,Cd5 cells of 13.6. The clinic I attend does not think I should be bothered about these issues since the challenge is for me to produce good quality eggs but I wonder if I should continue ivf treatments. What do you advise? I am writing from UK. With regards, M. from the UlK.

ANSWER:

Hello M. from the U.K.,

It's unfortunate that your cycle had to be cancelled. I had to do the same with a patient of mine this month because the follicles were not growing. It happens with decreased ovarian reserve. You have been quite dedicated to your desire to become pregnant and hopefully your dedication will pay off in the end. As long as your ovaries are still stimulating, then there is a chance, given your age.

In terms of your menses not starting, that is probably because you have the three retained cysts present. They are probably still hormonally active and so there is not the hormone withdrawal that i needed to start the menses. You can either wait it out, or your doctor can prescribe the birth control pill to suppress the cysts.

In terms of the fibroids, they are rather small and should not interfere, but there are some studies showing that fibroids can reduce the chances of pregnancy. I agree that the main hurdle you have is your age and the resultant quality of eggs. But, if you were wanting to do everything possible to increase your chances of pregnancy (short of using donor eggs), then you might want to consider having the fibroids removed prior to another attempt. It is not absolutely necessary, but only an option. In terms of the killer cells, I don't anything more needs to be done.I am impressed that the clinic you are attending is being very aggressive in your treatment, and allowing you to continue to try with your own eggs. That is commendable. Many of the letters I received are from patients whose clinics are not very aggressive.

Follow Up Question:

Many many thanks for your answer. It was amongst my junk mail so I did nt see it earlier. I was very encouraged.

My follow up questions are:

1) How long after an abandoned ivf can I try again? Given that my periods have not started. My clinic had advised that I take the pill for two weeks and then start another ivf cycle immediately on day 2/3. However, I choose to wait for the periods to start naturally and then attempt the following month...that would be about 4 months after the abandoned cycle. I wonder if the drugs may still be in my system now and if it will help provide more good quality eggs if I take the advice of my clinic.

2) Do you think taking intralipids for the immune problems will help? I noticed that it is gaining popularity. I prefer it to the other edications being suggested i.e taking humira jabs for two months prior to the ivf.

3) Surgery to remove the fibrods is not an option for me....however, I learnt that there are other means of shrinking them but since they are small and dont bother me I dont want to interfere with my ivf treatment since time is not on my side.

4) Since, I missed my periods I have been having dull headaches especially when I wake up, my BP has been hoovering around 148/95, increased acne on chin and back and my hair has been falling out alot. Are thse symtoms of the missed periods or the after effect of the stimulation or the side effects of DHEA Supplementation which I have been taking for about 1 year now.

Kindly advise, M.

Follow-Up Answer:

Hello Again,

I think that two weeks after a failed IVF cycle is a little too soon, but my usual minimum waiting time is 4 weeks (1 month). I place the patient right back on the birth control pill once the period starts and prepare for the next cycle. I don't find a need for a "natural" period to occur. Because time is of essence for you, you cannot predict when your ovaries will shut down, I don't recommend that you wait a long period of time.

Intralipids is not indicated for this problem. It will not do anything to help your eggs. It is mainly used for patients that have an immune factor issue. I would opt to leave the fibroids alone unless you wanted to remove all potential obstacles. Fibroids have not proven to be detrimental to IVF unless the fibroid is within the uterine cavity. It could be a side effect of the DHEA which would increase your serum androgens (male hormones). I am not a big fan of using DHEA.

Good Luck,

Dr. 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.

Surrogate Worried She May Contract Hep B From Transferred Embryo

Hello Dr. Ramirez,

I'm currently signed up with an agency as a gestational carrier (surrogate). I have been matched with an international couple and was set to have their fertilized embryo transfered into my uterus this month. However I was just informed that the intended father tested positive for Hepatitis B core antigens. So he has a positive total antibody level but is negative for IgM. I'm told this means the results indicate either a false positve or that he had a past infection but there is NO current infection. Furthermore I'm told that the chances of me contracting hepatitis B is negligible to non-existent since the hepatitis virus lives in the fluid surrounding the sperm but not in the sperm itself and the fluid is always discarded prior to IVF procedures.

Do you have any expereince with or know if this is safe for me to go forward with this transfer via in vitro fertilization using just the sperm from the intended father as mention above and the intended mother's egg which I'm also told does not have recepters for the hepatitis virus?At this point I'm inclined to not take the risk but I feel obligated to find out as much information as possible before I make my descion.Thanks in advance for your time and help. J. from the U.S.

Answer:

Hello J. from the U.S.,

You have submitted a very interesting and difficult question. I think that it is unknown territory, and not being an infectious disease expert, I had to do some research myself to try and answer your question. There is an infectious disease (hepatitis) expert on the All Experts site on About.com, whom you might want to submit this question to as well.

From my research, based mainly via the CDC recommendations, hepatitis B or C are not transmissible via sperm but can be transmitted via semen, if the person is a chronic carrier If the sperm was prepped via thorough washing, there should be little risk of transmission of the virus to the egg, and in most IVF programs, that is the proper method. Transferring that embryo in to your uterus, would have a very small risk of hepatitis B. If you have been immunized for hepatitis B, which many many persons have been, then the chances of transmission are even less.

Based on the information regarding the sperm donor's testing, I cannot draw a conclusion as to his carrier status, except to say that he does not have an active infection. A carrier would have a positive hepatitis surface antigen, hepatitis core antibody but negative IgM. If he had Hep B in the past and recovered and is now naturally immune, he would also have a positive core antibody but also would have a positive surface antibody. This person would not be at risk for transmission of the virus, as no live virus would be present.

So, as a surrogate your chances would be very low, but it is ultimately your choice as to whether or not to take any form a risk. Even a low risk is a risk.

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.

Progesterone After IVF

Question:

My wife had IVF (in vitro fertilization) in Canada. She was prescribed Gonal-F, Repronex and Orgalutran for the stimulation phase. Two blastocysts were transferred at day 5 and yesterday our day-14 serum HCG pregnancy test was positive.

We were told by the nurses at the fertility center to stop taking the Prometrium pessaries now that the pregnancy test is positive. From reading, Progesterone seems to have many beneficial effect to the fetus, with minimal adverse effects. I think continuing progesterone supplements until the 10-12th wk is important. I am not sure why they want my wife to stop this!

Can you advise? A. from Canada

Answer:

Hello A. from Canada,

Your research is correct. Most IVF programs, if not all, will continue the progesterone until at least 8 weeks. I continue until 10 weeks and some programs will continue until 12 weeks.

I see that your center had your wife on progesterone pessaries (suppositories). For those others reading this post, there are different forms of progesterone to choose from:
• Daily oral progesterone
• Daily intramuscular injections (IM)
• Daily vaginal pessaries. These are mounted in wax, which melts as progesterone is absorbed causing discharge. It may be necessary to wear a panty liner.
• Daily vaginal tablets
• Daily vaginal gel

There are several formulations of vaginal progesterone: Crinone 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM injectable progesterone. However, most RE's are trained on IM Prog and so don't want to make any drastic changes. I happen to use both. If a patient cannot tolerate the IM Prog or has an allergic reaction to it, then they can switch to the vaginal version.

Bottom line: There is no harm in continuing the progesterone, but if removed prematurely, it could jeopardize the pregnancy.

Good Luck and Congratulations,

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

PCOS Patient In India On Clomid: Needs To "Rest" Ovaries & No Ovarian Drilling!

Question:

Hi, I am G. from India. I am 26 yr old and I have PCOS. My LH level (14) is high on day 2. I am trying to conceive now. My gynae suggested me with clomid 100 mg from day 2 to day 7 and hmg 75 on day 2, 3 and 4. After seeing a developing follicle in my right ovary through ultrasound, I was injected with hmg 75 on day 8, 10 and 12. I had 2 eggs with 18 mm measurement on day 14. Then I was administered with hcg 10000 to release those eggs. Me and my husband was asked to have intercourse for 4 days and I was prescribed with progesterone supplement (400 mg) from day 15 for 10 days. In spite of all this, I didn’t get pregnant last month. My husband (age 28) has got healthy sperms. What could be the reason for this failure?

My gynae is suggesting for IUI (intra uterine insemination) this month. How long can I go about with this treatment? Will I succeed in conceiving if I get this kind of eggs in the following month? My gynae also suggests that she has to do a laproscopic drilling if I fail 1 IUI.

Please advice. Thanks in advance.

Answer:

Hello G. from India,

First, you need to understand that fertility treatments are not magic. They don't work 100% of the time. What they do is attempt to restore your reproductive system back to normal, which in your case is to get your ovary to ovulate. For more, in depth information on PCOS please see: Polycystic Ovarian Syndrome.It looks like your doctor did a very good job of treating you in this cycle. She was able to get you to ovulate (probably two eggs) and you had intercourse at the appropriate time. In addition, she supplemented you with progesterone as I would have recommended. Now you need to do that repetitively, just as if you were trying for pregnancy naturally. If you or any woman were trying on their own, they would give up after only one try or wonder why they didn't get pregnant after one try, would they?

The only caveat is that because you stimulated the ovary, you need to skip a cycle in between to give the ovary a rest. You should go on the birth control pill that month to make sure that you have a period in a timely fashion, so you don't have to wait for your natural period to begin. Then you do the same cycle again I would recommend that you continue trying this for 4-6 cycles. Then if it does not work, you can consider other treatments. But, keep in mind that you are assuming that the only problem is PCO. If you have done a complete infertility evaluation, there could be other reasons why the treatment did not work. For that reason, you might want to do an evaluation before moving up to higher levels of treatment. I don't think IUI is an appropriate suggestion at this time. I also DO NOT recommend laparoscopic drilling under any circumstances!

Remember, what you are doing is a "natural" treatment method and your chances of pregnancy, at your age, is 18-20% per month. A normal woman (not using fertility treatments) can take 8-12 months to achieve pregnancy. So, just like someone trying naturally, you have to give yourself time. Don't let your doctor push you into more expensive treatments that you don't yet need.

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.

Comment: Thank you so much for your advise, doctor. I am confident that I am moving in the right path now. So as u said I shall try this treatment for 4-6 cycles. Thanks for your time.

Wondering About Follicle Size And Ovidrel Shot

Question:

Hi, I am on Gonal-f and my US (ultra-sound) yesterday showed I had 2 follicles measuring at 17mm and 14mm, my doctor told me to take one more shot of 75ui Gonal-f last night and to trigger with ovidrel tonight.

Do you think my eggs will be mature enough to ovulate???
Thanks! N. from the U.S.

Answer:

Hello N. from the U.S.,

If the follicles grow normally, they should increase by 2 mms each day. That means that they will be 19 and 16 mms the next day. I NEVER trigger without knowing the follicle size for sure. That is sloppy care. In addition, I would want you to be able to ovulate both follicles so I would probably wait one extra day and use the gonal-f another day. That way the follicle sizes should be 21 and 18 mms, so that both would be ovulatory size. Since follicles don't always follow the expected growth rate, I feel you have to look each day to know for sure.

In terms of your question, if the follicles grow to 19 mms and 16 mms the next day, then the 19 mm follicle definitely should ovulate and the 16 mm follicle may or may not.

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.

Can Lubricants Interfere With Getting Pregnant?

Question:

Hi there. I was wondering if you can tell me if using a lubricant like KY sensitive Jelly can hurt your chances of getting pregnant. My husband and I just started using it a few months ago and we have been trying to conceive. I just read online that it can be toxic to sperm. Does this mean that you cannot get pregnant at all while using the lubricant or that it just lowers your chances? We will stop using it if we don't get pregnant this month. Thank you. J. from New York

Answer:

Hello J. from the U.S. (New York),

The rule of thumb is that lubricants like KY can interfere with sperm mobility and therefore also the ability to achieve pregnancy. Some lubricants can kill sperm but it depends completely on the formulation. Johnson and Johnson does make a version that is compatible with attempting pregnancy and there are other companies that produce "fertility-friendly" lubricants as well. You have to look specifically for one that states that it is compatible with trying for pregnancy. Some alternate brands you might want to look at are "Pre-Seed" or "Conceive Plus".

Good Luck,
Dr. 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.

TTC Patient Needs Aggressive Approach After Laparoscopy For Endometrioma or "Chocolate Cyst"

Question:

Hi, I have been trying to conceive since 1 year. I am 29 yrs old,and a professional with busy working schedules. I recently got myself investigated and found that my FSH levels r 7.09 and LH levels 3.0, AMH levels 3.29.

I have undergone 2 ovulation induction cycles which showed normal ovulation but I have a tendency towards cyst formation. HSG is normal. My antral follicle count is 6 and 4 in both ovaries. Kindly opine if i should undergo IUI cycles with clomiphene or with gonadotropins or should I directly go ahead with IVF cycle?

I am worried as my FSH levels are on the higher side and also my FSH:LH ratio is >2:1.

I recently underwent a hysterolaproscopy and was found to have a small chocolate cyst of 1cm in one ovary that was removed with cyst wall and spot on the other ovary along with few spots in the P.O.D that were fulgerated. Rest of findings were normal....no adhesions, healthy tubes with free spill and good uterine cavity.

From what I have learnt, endometriotic ovaries have a poor ovarian reserve and chances of recurrence of endometriosis is also high. My FSH values are already in the upper range.So what do you suggest i should go for? What sort of induction should I undergo?

Thank you. S. from India

Answer:

Hello, S. from India,

First, let me reassure you that your lab tests, including FSH level, are all normal.

More important were the findings after your laparoscopy. With an endometriotic cyst present (chocolate cyst or endometrioma), we would automatically classify you has having stage 3 endometriosis. Studies have shown that stage 3 and 4 endometriosis affect fertility. Normally, with these stages IVF would be the recommended treatment of choice. But considering that you are young, there are some lesser options that you can try.

First, let me point out that your diagnosis is "Endometriosis" as the cause of your infertility. It has been treated by laparoscopy thus far. However, we know that if there is visible endometriosis present on a laparoscopy, then microscopic endometriosis exists as well.

For infertility patients, I recommend a 3-6 month course of Lupron depot therapy to get rid of any residual endometriosis before moving forward with any treatment. This medication will put you in a semi-menopausal state for the duration of the treatment but there will not be any long term effects. You can then begin treatment immediately thereafter. Because endometriosis will return within six months after ending this treatment, I would recommend that you proceed with a more aggressive treatment such as insemination. I would recommend four attempts, using Clomid 150mg or higher to have 2-3 ovulatory sized follicles per cycle, alternating with Femara 5.0-7.5 mg since you don't want to take Clomid in consecutive months (it can lead to poor endometrial lining formation and prevent pregnancy, among other things).

If you don't achieve pregnancy by four good IUI cycles, then I would proceed directly to IVF.

The alternative would be to go directly to IVF, in which case, it is not absolutely necessary to take the Lupron treatment, although some docs still will do this. IVF bypasses the pelvis and takes the eggs out of this hostile environment. It is the preferred treatment for stage 3 or 4 endometriosis. It will also be the fastest way for you to get pregnant.

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.

IVF Patient Has False Negative On Pregnancy Test: Late Implantation? What Went Wrong?

Question:

Dr.Ramirez,

I have written to you in the past and you have always been such a great sounding board. I need help and closure and I am hoping that you can help.

In September I went through IVF (in vitro fertilization). On 9/7 I transferred 2 embryos- 1 7cell grade AF and a 4cell grade BF. On 9/16 I had some light spotting and cramping. My beta was on 9/19 (12dp3dt)was negative & my RE instructed me to stop taking the PIO & Estrace. A few days later, what I thought was my period arrived. It was a medium flow w/some small clotting & lasted about 4 days & stopped. A couple of days later, I started bleeding very heavily & passing large clots. I went in to see my RE. She conducted an Ultrasound & some blood work to make sure I wasn't anemic. At that time I asked her to run a pregnancy test. She said that there was no way that I could have been pregnant but did it anyway. The next day she called to tell me my beta was 512!

I am absolutely devastated. I can't believe that I was pregnant the whole time. My RE is calling it a biochemical pregnancy and is saying that it probably wasn’t a healthy pregnancy but I am getting the feeling that they are trying to place blame elsewhere. I feel like I need some questions answered by a neutral party. I am having a hard time moving on so maybe you may be able to offer me some closure.

1.Should something have shown up on the beta 12dp3dt? If not, do you think it was a lab error?

2.Could it have shown as negative because of late implantation? If the cramping/spotting on the evening of the 16th was implantation, would HCG have shown up on the morning of the 19th?

3.I have a luteal phase defect. What effect/impact would stopping the PIO and Estrace have on the pregnancy? Do you think that stopping meds was the reason for the miscarriage?

4.My beta was 512 after bleeding for over a week (heavily). I would think it was much higher to start. Do you think that this would have been a healthy pregnancy?

5.Should the clinic have done a 2nd beta?

6.Any suggestions on where to go from here? Any help would be greatly appreciated.

D. from Boston, MA

Answer:

Hello D. from the U.S. (Boston),

Certainly what you have gone through is very unusual and unfortunate. It shows that late implantation exists. I usually do my first bHCG at 8-9 days post embryo transfer. I do two bHCG's, one at that time and another 48 hrs after. I have had a successful pregnancy case where the first bHCG was negative (<1) and the second positive (14) that went on to deliver a beautiful baby. Keep in mind, however, that there are no specific protocols regarding how many bHCG's to do and it is totally up to the medical director of your clinic.
I cannot answer the question about the cramping and spotting on the 16th. If you have a luteal phase defect, then yes, stopping the supplemental hormones can lead to a miscarriage. There is no way to know if this was the reason for your loss because there are many other possibilities as well, such as an abnormal embryo. I cannot answer your question about whether or not this pregnancy would have been healthy. The number was certainly a good and high number.

What is important to keep in mind at this point: This experience showed that you can achieve pregnancy. IVF only has the capability of giving you the opportunity to become pregnant. It cannot force a pregnancy on you. Keep in mind that the last two steps required to achieve pregnancy, embryo hatching and exiting the shell and implantation are natural steps. We don't have the technology to make these happen. That is why I say that IVF can only give you the opportunity. The last steps are in God's hands. The fact that implantation occurred (positive bHCG) shows that the last two steps took place and you can do it again.

Now you just have to maintain your hope, diligence and savvy. You've gotten this close. After all that you have been through, why would you not keep trying? Hopefully, the next one will be a "home run" or "touchdown" depending on which sport you prefer. If you don't try, you certainly won't be any closer to success, so don't give up!

Good Luck,
Dr. 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.

A Little Miracle...Seven Years In The Making

I want to share a special story with you, my readers, about a couple who went through a recent IVF (in vitro fertilization) cycle with us. This couple had come to us back in 2004 for infertility treatment. After the normal trial of IUI's (intra uterine insemination) did not work, they opted to do IVF with us. The cycle went well, the retrieval went well and there were three embryos to transfer. While doing the transfer of all three embryos, one embryo "floated" (aspirated) back out of the catheter. This was an unusual event for me and my staff. The couple decided to freeze that one reluctant embryo. Unfortunately, the patient did not become pregnant with that cycle. As it so happens, she soon became pregnant naturally and in the ensuing years, as sometimes happens, they had no trouble conceiving again, having three children in all.

In the meantime, the frozen embryo remained in our cryobank storage facility. The couple elected to leave the embryo there for the last seven years until recently. Grappling with the options of either continuing to pay for storage, dispose of the embryo or put it up for adoption, the couple opted to go forward with a frozen embryo transfer. We transferred the one embryo successfully and crazy as it may seem, the patient is now pregnant! This child will be both the "oldest" and the "youngest" sibling by virtue of this unusual series of events.

I am a spiritual man, if you have not guessed already. For us, every child is special, but I have a feeling that this child will truly be a special one, for it is my belief that for some divine reason his or her birth was delayed. How often I feel defeated when a cycle does not succeed and yet when something like this happens, I know that we can only do what we can up until a certain point, at which time the final steps of creation are taken out of our hands. Which brings me to one of my favorite quotes from Deepak: "When you live your life with an appreciation of coincidences and their meanings, you connect with the underlying field of infinite possibilities."

Atypia Is NOT An Absolute Indication For Hysterectomy

Question:

Hi Dr. Ramirez,

I'm a Canadian, temporarily living in South Africa. Greetings from Pretoria!

I'm 44 yrs old, diagnosed with PCOS at age 33, on metformin 500mg 2/day since then. I've got about 45 pounds to lose and have been slowly and steadily losing pounds since May (5 kg). I've never been able to get pregnant and throughout my 20s and early 30s, I went months without menstruation. Weight came on very quickly. I exercise regularly.

My new gyne here found a myoma in my uterus in August during my yearly exam. I had bleeding between periods almost every day for a few months. Some days it was spotting; other days it was heavier. The myoma was removed hysteroscopically and examined. The biopsy of the tumour shows atypical cells and the lab report summarizes the microscopy as "these features are most suggestive of an adenomyomatous (endometrial) polyp with focal atypia against the background of a proliferative endometrium."

I understand I need to remove my uterus.The doctor can do the surgery vaginally. Is uterus removal the best course of action? What can I do to prepare my body for no uterus? And Is there anything I can do to protect my ovaries going forward?

Thanks for your help in advance. S. from South Africa

Answer:

Hello S. from Canada and South Africa,

Atypia is NOT a absolute indication for hysterectomy, so no, you don't necessarily need to have your uterus removed. Atypia is not cancer, it is a pre-cancerous finding. It is possible that the only area of atypia was already removed, which then would have solved the problem. A repeat D&C should be done to evaluate the rest of the endometrial tissue. Also you should be cycles for three months then rechecked again by endometrial biopsy or D&C. If there is no abnormality found, then no other testing or treatment needs to be done other than keep you cycling on the birth control pill.

However, if you want you uterus out, and that is understandable, it is certainly a option for you and a vaginal hysterectomy would be fine. Make sure that your doctor keeps the ovaries intact i.e. does not remove them. You still need them to produce adequate hormone that your body needs. It's your choice. Make sure your doctor understands and is told that you want to keep your ovaries. There is absolutely no reason to have them removed.

Thank you for your question all the way from South Aftrica, addressing a problem that many women around the world face as well.

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.

Comment: Thank you Dr. Ramirez! Very timely and useful.

Why Do I Need HCG Injections After Ovulation During IUI Cycle?

Question:

Dr. Ramirez,

My husband and I have been trying to start our family for a few years. I have been pregnant and miscarried 3 times, but is has been over a year and a half since my last miscarriage. I am seeing a Reproductive Endocrinologist and their diagnosis for not getting pregnant again is unexplained infertility. We have are trying the IUI process now using Letrozole and I have also been given a prescription to do HCG injections on days 3, 6, and 9 past my LH surge. I am not finding very much information about using HCG after ovulation. I know their reasoning is to supplement my progesterone... but not sure why then, they don't just use progesterone? Please help!

Thank you! G. from Colorado

Answer:

Hello G. from the U.S. (Colorado),

HCG (human chorionic gonadotropin) injections can be used to support the luteal phase in place of progesterone and there is nothing wrong with that protocol. Most don't use that method because you have to take it as injections and the medication is considerably more expensive. There are many progesterone alternatives such as Crinone, Endometrin, Prometrium that can be used vaginally as a supplement. You should ask your doctor why they don't just use a progesterone supplement.

The other question to ask is "what are they treating or trying to achieve"? Do they suspect that your miscarriages are due to a luteal phase defect i.e. decreased progesterone? In that case testing by an end of cycle endometrial biopsy for dating and/or b-integrin would have diagnosed luteal phase defect and your diagnosis would not be "unexplained infertility." I am not a strong believer in "unexplained infertility" as a real entity. I think it is more like undiagnosed infertility. The cause just has not been found because either a test has not been done to find it or doesn't exist. Often we find that many of these cases of fertilization failures or defects with the sperm (found at the time of IVF) or endometriosis found on laparoscopy. Sometimes age is the problem as well leading to poor embryo quality.

Your question is a good one and you should ask your doctor. Be sure they explain everything to you!

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.

Comment: Thank you so much... for all of your information and quick response! I will follow up with my doctor.

Patient On Metformin To Prevent Miscarriage: Is It Necessary?

Question:

HI Dr. Ramirez,

Sorry to keep this up about the Metformin, but you have been so helpful in the past...thought I would try your take on this.

I talked with my Doc about low dose heparin, and he told me that he does not prescribe this unless tested and confirmed thrombophilia is present, which he says I do not have. He would really like me to take the metformin. I have had one chemical pregnancy and one 9 week miscarriage and am currently 5 weeks pregnant. I took his advice and so far have taken 5 pills. I am extremely nauseated, which I know is from the Metformin as a few hours after it started. I REALLY DO NOT want to take this stuff after just recovering from OHSS. IS there any greater risk of miscarriage stopping now that I've started, and is there a greater risk of miscarriage if I don't take this med. I would love your thoughts on metformin and PCOS. Many sites are saying it really helps in the early stages of pregnancy for PCOS women to stay pregnant.

Thanks so much for your time....once again! C. from Canada

Answer:

Hello C. from Canada,

Metformin does nothing to help with a continuation of pregnancy and does not need to be continued once pregnant unless it was prescribed for diabetes. It is a pregnancy category B medication so is safe in pregnancy if your doctor insists that you continue it. If you were my patient, you would not be on it now. Metformin, given to help some PCO patients ovulate, is for that specific reason only. Once pregnant, the Metformin has done its job and is no longer required. If it is causing side effects, which it usually does, then I think I would recommend that you stop. There are absolutely NO recent studies that show that continuation of Metformin in PCO patients helps the pregnancy to survive or continue. Pregnancies continue or miscarry for many other reasons. Your doctor is mistaken but since he is the doctor you have chosen for your care, you have to decide if you are going to abide by his recommendations or not.

By the way, based on his comment about heparin, it is clear to me that he doesn't understand its use in recurrent miscarriage patients or infertility patients. It is obvious that he is not a specialist in that field. Please see my section on "Recurrent Pregnancy Loss".

P.S. Regardless of what many sites may be saying on the internet, you are wise to ask the advice of a medical professional.

Good luck,

Dr. 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.

Ovulation Induction With Follistim Keeps Failing & Estradiol Remains Low

Question:

We are currently TTC our 2nd baby. My daughter who is 2 was conceived on our second cycle of follistim75iu. We are currently on our 4th cycle of Follistim 75iu. Each cycle I'm told my estradiol is low and they end up increasing my dose of Follistim to 150 iu and even by the time I trigger it's still on the low side.

I understand that ideally estradiol should be 200-250per mature follicle. But this cycle it is 110 with follicle sizes of a 14 and a11. So at this point of my cycle what should it be since they are not mature follicles? Also last cycle they had me do hcg booster shots after ovulation because I had a low estradiol (it was 80) 7 days after ovulation the cycle prior. The boosters helped increase my estradiol to 354. My concern is do the boosters really help achieve pregnancy or are they just masking a bigger problem?? Thanks in advance, S. from Pennsylvania, U.S.A.

Answer:

Hello S. from the U.S. (Pennsylvania),

There is no fixed protocol when using gonadotropins such as Follistim. Basically, these medications are the hormone FSH which is the hormone that your brain produces to stimulate the ovary to produce a mature follicle for ovulation. If the amount of hormone is insufficient to do this, then it has to be increased and this is usually done on an incremental basis. Please see how I do ovulation inductions here: "Ovulation Induction".

For example, it may be started at 75IU but every three to four days, and estradiol level can be drawn and checked to see if it is increasing. If it is increasing then starting on cycle day #9, an ultrasound is done to evaluate the ovaries and see how many follicles are present, what their sizes are and when to trigger. In your case it sounds like that is not being done. For some reason, your doctor is fixated on keeping the same dosage. I'm not sure I understand why.

You are correct about the estradiol level of a mature follicle. If your follicle does not reach the mature size18-20 mms, then the estradiol level will not reach the appropriate size either. Basically the follicle increases in size by increasing the number of cells. Think of it as a chain of cells in a circle. These cells to increase in size, rather, more cells are added to the chain and each cell produces some estradiol. That is why as the follicle increases, more estradiol is emitted. In order for the follicles to grow more cells, increasing amounts of FSH is required. So, if your doctor stops the dosage at 150IU and it is not enough FSH to stimulate follicular growth, then nothing will happen. He needs to keep increasing the dosage until the follicle grows appropriately. Once the follicle reaches the ovulatory size of 18-24 mms, then ovulation can be triggered with HCG (a substitute for the LH surge you would produce in a natural cycle).

The "HCG booster shots" do nothing to help the estradiol rise. Rather, this was merely a coincidence. The growing follicle causes the increased estradiol. The HCG can be used after ovulation to help prime the enodmetrial lining for ovulation. Some clinics use this instead of progesterone. It is also used to trigger ovulation, as I've mentioned previously.

Based on the information you have given me, I'm wondering if you are seeing the right doctor. Your doctor may be comfortable with using Follistim, but is he really an infertility specialist i.e. have a thorough knowledge of the gonadotropins to use them for IVF (in vitro fertilization) if he has to? There are many Ob/Gyn docs that feel comfortable with ovulation induction and use gonadotropins like Follistim on a protocol basis, but in reality, don't know what they are doing. Could you be in that type of situation? Maybe it is time for a second opinion. The best way to find an infertility specialist is to simply ask the clinic or doctor, "Do you do IVF?".

Good Luck,
Dr. 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.

Secondary Infertility: Decreased Ovarian Reserve And Low Morphology May Be The Culprits

Hello,

I just turned 33 and I have one beautiful 18 mo little girl who is the love of my life. She was conceived on our 3rd iui using 5mg of Femara. My husband has low morphology (6%) and I have no regular periods. We both exercise / eat as we should and have no other health issues. We are considered unexplained infertility.

For the past 6mos we have been trying to conceive. I just had a large polyp removed and my fsh levels were tested. 2 1/2 years ago they were 7.0. 6 weeks ago they were 12.1. We are trying to figure out what to do next. We definitely want another child (And we would be open to 3). My questions are:

1) What do you recommend for medication? Is Femera a good starting point? Should we use the same dosage or higher?

2) Should we try an IUI or go straight to IVF?

3) Are there any "rules of thumb" for why FSH increases and how quickly it increases? I've heard stress can impact it. Thanks in advance for your help. C. from Washington State

Answer:

Hello C. from the U.S.,

Congratulations on achieving your first baby relatively easily. You do not have "unexplained" infertility as you have two reasons: sperm abnormality/low motility and irregular periods (ovulation dysfunction). Those are reasons enough to prevent spontaneous pregnancies.

In terms of your FSH level, I have to presume that it was drawn on cycle day #2 or 3, because that is the proper time to do this test and the only way that it an be interpreted. If it was, the elevated FSh level of 12.1 is not a good finding. This is called "decreased ovarian reserve", which basically means that your ovaries will be more resistant and less productive if stimulated with fertility medications. It is not an indication of ovarian function, but is somewhat of a time clock. Once the FSH level reaches 15, most IVF clinics will require you to use donor eggs. When it reaches 20, it means you are in menopause, which in your young age would be classified as premature ovarian failure. So from a time perspective, that means you don't have a lot of time to waste.

Certainly IUI is an option for you, and somewhat reasonable since it worked before. The FSH level will have no bearing on its chances of success. Chances of success depends on age and the sperm problem. If you wanted to do IUI first, I would limit it to no more than 4 attempts. You can use Femara, Clomid or injectables for these attempts and even alternate them, but don't waste a lot of time. Keep in mind that the chances of pregnancy with IUI in your age group is 20% per attempt. By four attempts you should be pregnant, otherwise the statistical chances drop dramatically after that.

If the IUI's fail, then you need to progress aggressively and quickly, especially if you want to have more than one more child. In that case I would recommend proceeding to IVF with ICSI. This will give you a 74% chance of pregnancy per attempt in my clinic (and is the treatment level that most infertility specialists would recommend with an FSH level above 10. Most would recommend not even to try the IUI).

I can't tell you why the fSH is elevated. That is an unknown.

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.

Use Of Prednisone And Lovenox For IVF Cycle With Donor Eggs: How Long?

Question:

Dr. Ramirez:

I am a 44-yr old with a history of numerous IVF attempts. Miraculously, cycle 1 (2007) with my own egg (yes, only one egg was retrieved) resulted in a healthy baby. 1 additional IVF attempt (2009) with my own egg - unsuccessful. Subsequently, 4 IVF attempts with two different donors (some fresh, some frozen cycles) were also unsuccessful. With each attempt, the blastocysts were high-grade, and other recipients of same donor's eggs resulted in pregnancies.

For my current cycle, which begins this week, we will be using a cryopreserved embryo, and physician is adding two medications: Prednisolone 25 mg daily, starting 10 days before transfer, and Lovenox 40mg daily, starting 2 days prior to transfer. If successful, plan is to continue both meds (along with Estrogen and Progesterone injections) for the first trimester. This seems like an extremely large dose of prednisolone and lengthy duration. I am concerned about the potential side effects on me, as well as the developing fetus, assuming a positive outcome. Do you have any experience and/or information regarding the prednisolone and Lovenox? Thank you, C. from the U.S.

Answer:

Hello C. from the U.S.,

In my patients that fail 2 IVF cycles, I automatically add prednisone, Heparin (lovenox can be used as well). All my IVF patients get the prednisone (I use medrol), low dose aspirin, progesterone and estrogen, so in reality the only thing that is new is the heparin/lovenox. Because of the potential effects on the developing fetus, I do not use the prednisone longer that the first pregnancy test. The heparin, aspirin, progesterone and estrogen are continued until the patient reaches 10 weeks gestational age. In patients that have a history of recurrent miscarriages, I will sometimes continue the medications until 12 weeks gestational age.

I start the heparin (lovenox) with the start of the IVF cycle, just like I do with the prednisone and aspirin.

Incidentally, your experience with a pregnancy in the first IVF cycle with only one embryo transferred, at the age of 40, is the reason why I DON'T ever cancel a cycle if there is only 1-3 follicles. My belief is that this one egg may lead to the one perfect embryo left and I would hate to lose the opportunity to get a pregnancy from it. It may be a lower chance, but it is still the best chance that you've got. So I am glad to hear that your docs continued the cycle and did not cancel it like so many do!

Good luck with your upcoming donor cycle.

Dr. 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 very much for your expert opinion and extremely timely response! I greatly appreciate your time and expertise.

Progesterone Supplementation During An IUI Cycle

Question:

Hello Doctor,

I have been TTC since the past 15 months, I have irregular menstrual cycles. My husband has no fertility issues. I have been undergoing treatment - clomid, ovidrel followed by IUI (intra uterine insemination) since the past 3 months.

My luteal phase is 14 days long. I get a .8/1 degree increase in temperature the day after ovulation.This time ( 3rd IUI ), my RE asked me to take a vaginal progesterone supplement 2 days after the IUI.

There have been no tests performed to find if there is Luteal phase defect. I am scared/apprehensive about taking the progesterone supplements and I think my hormonal levels should be okay as my LP is 14 days long. Can you advise ? Your advise/suggestion on this matter will be much appreciated. Thanks in advance ! S. from California

Answer:

Hello S. from the U.S. (California),

I prescribe progesterone to ALL my infertility patients undergoing treatment. It is an easy medication to use, will cover any possible deficits in progesterone level that could impair implantation or continuation of the pregnancy and has no side effects. I think you should have been doing this from the first IUI treatment. I usually start it the day after the IUI.

You are correct that you don't have a luteal phase defect because your luteal phase is 14 days, but the additional progesterone won't hurt and it will make sure that you have adequate b-Integrin development, which is what is needed for implantation at the cellular level.

Good Luck,
Dr. 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.

After 11 IUI's, Canadian Fails 1st IVF cycle: Poor Embryos, Bleeding Or Implantation Failure?

Question:

Dear Dr. Ramirez,

I'm writing to you from Toronto, Canada. Thank you in advance for your answer!

My husband and I are both 37 years old. I was diagnosed with mild PCOS due to the shape of my ovary (pearl-like follicles) and irregular cycle (28-36 days), and as result was prescribed Metformin. My husband has low sperm count and motility. Last year I was pregnant after 5 attempts of IUI (intra uterine insemination), but unfortunately ended up in miscarriage due to chromosome abnormality. The protocols include Letrozole Femara on its own, Letrozole Femara in combination with Gonal-f and Hcg Ovidrel, and one unstimulated cycle. In all cycles, we only worked with 1 follicle. My husband's sperm ranged from 1-5 million after washed during those cycles. During our pregnant cycle, Letrozole Femara in combination with Gonal-f and Hcg Ovidrel were used, his sperm was 1.6 million after washed.

Three months after the miscarriage we tried again, with 6 rounds of IUI with similar protocols as before, but also include doubling Letrozole Femara with Gonal-f and Orgalutron, as well as Gonal-f injection only but none resulted in pregnancy. With the exception of 1 cycle where we worked with 2 follicles, the rest we only worked with 1 follicle. My husband's sperm ranged from 1-7 million after washed during those cycles.

Recently we went through an unsuccessful round of IVF-ICSI (in vitro fertilization with intra cytoplasmic sperm injection), with 5 days transfer. Protocols include Gonal-f, Repronex, Orgalutron, and Hcg Ovidrel. I was also put on a birth control pill the cycle prior to IVF cycle, and had an endometrium biopsy during the luteal phase of the birth control cycle. Post retrieval include antibiotics and vaginal natural progesterone 100mg in the morning and 200mg in the evening. Post transfer include vaginal natural progesterone 200mg in the morning and 200mg in the evening, and 81 mg aspirin daily.15 eggs were retrieved with 11 matured. 3 were IVF and 8 were ICSI. 1 out of the 3 IVF fertilized, and 4 out of the 8 ICSI fertilized. Since more than 3 eggs fertilized, the clinic's policy is to do 5 days transfer. By day 3 the quality of the 5 embryos were as follows: 10-12 cells grade 2 (good), 8 cells grade 1 (excellent), 8 cells grade 1 (excellent), 8 cells grade 2 (good), and 6 cells grade 2 (good).Unfortunately only 1 of the 8 cells (ICSI) turned into a blastocyst (with quality "not bad" according to my doctor).

The day 5 transfer include the only blastocyst we have and the 10-12 cells embryo. We ended up having no embryos to freeze. I started bleeding 7 days after the transfer.

Sorry for the long background story, my questions are as follows:

What should we do to ensure successful IVF next time? Failing the IVF, do I have an implantation problem?

What could have been done to prevent the early bleeding, could the progesterone injection prevent it? I didn't seem to have luteal phase defect in the past since my period normally come 14-16 days after ovulation.

What would have caused the poor embryo development after day 3? My doctor mentioned about possible sperm DNA fragmentation issue although this still need to be tested. Are there any other tests we should do?

What could have caused sperm DNA fragmentation, my husband doesn't smoke or drink, or exposed to any chemical environment in his day to day.

What protocol would you suggest for an IUI? Just want to mention that I didn't respond well to clomid and therefore my doctor prescribed letrozole. Why did IUI work for us last year and the last 6 attempts didn't? Also, I started taking Chinese herbs subsequent to miscarriage, therefore for the first 5 attempts out of the 6 IUI attempts I was also taking Chinese herbs at the same time, would that be why the IUI's failed?

I very much appreciate your time and help.Yours sincerely, E. from Canada

Answer:

Hello E. from Canada,

Thank you for all the information, it helps a great deal. Let me get to your questions directly.

1. Unfortunately, I don't comment on specific protocols because each doctor, clinic and country use different protocols. There is no right one or wrong one. These variations will often determine pregnancy success, however, and is the reason why some clinics are more successful than others. So, despite what I might advise you as to protocols, inevitably it will be your doctor's opinion, based on his training, knowledge and experience, that determines what protocols you use. Given that, it looks like you stimulated well, had a good number of eggs and embryos formed. The only changes I might suggest, which you have control over is (1) ICSI ALL eggs to allow for maximum fertilization and embryo number, (2) DO NOT PROGRESS TO BLASTOCYST CULTURE without at least 5 8-cell grade 1 or 2 embryos.There is an inherent attrition rate from day#3 embryos to blastocyst that may have nothing to do with inherent embryo quality. Based on preimplantation genetic testing data, sometimes even genetically normal and healthy embryos may not make it to blastocyst. Keep in mind that blastocyst culturing is still in its early development stages and not perfect. If you don't have enough embryos to lose, don't do it.

2. The bleeding after embryo transfer is very very common. I would refer you to my blog where that particular topic is the most often viewed. There is more information to this than I can give in this forum. Basically, however, it is not clear why or where this bleeding is from and how to prevent it. The good thing is that in many, if not most cases, it is of no consequence.

3. As mentioned above, the lack of embryo development does not necessarily have to be due to poor embryo quality. But, embryo quality can certainly affect the ability of an embryo to develop to blastocyst. The sperm fragmentation part . . . I'm not sure I would agree with that. Your age affects egg quality and therefore embryo quality more significantly.

4. Unknown what causes sperm fragmentation.

5. If you were going to return to IUI (which is an option but you have to consider that you will be lowering your chances of pregnancy) I would probably go to injectables only stimulation and not a combination protocol. The goal would be for you to have three to four ovulatory sized follicles (n0t one like you have been having), which will increase your chances of a successful pregnancy. The fact that you have gotten pregnant in the past is an indication that your reproductive system works but you have to overcome the sperm factors and the age factor. For these two, I would probably recommend IVF.

I would caution against adding herbal regimens. These are just un-purified pharmaceuticals. They could certainly have adverse affects.

Follow-Up Question:

Thank you so much for your reply.

In reading your blog on early bleeding, I mentioned to my doctor about using injectable progesterone. She wasn't on board and she still recommends vaginal progesterone. She explained that based on numerous researches, the vaginal progesterone is as effective as injectable, and the injectable create much discomfort. Instead for the next IVF, she will add estrogen patch. Should I insist on the injectable, I'm worried that I won't have enough progesterone support for implantation. Is it possible that's what might have caused the early period bleeding in my last IVF (7 days post 5 days transfer)?

Lastly, could the miscarriage that happened last year after IUI was also caused by lack of progesterone? That cycle I was only prescribed 100mg vaginal progesterone daily. However there was no bleeding whatsoever and after the fetal heartbeat stopped at 2.5 months pregnancy, I had a D&C done.

We will be doing another IVF 2 months later, in these 2 months, 1st month will be natural cycle and the 2nd month will be birth control cycle. Will doing the next IVF this early affect the eggs quality (the quality will be worse) and therefore reduce the pregnancy chance? Best regards, E.

Follow Up Answer:

Hello Again, Your doctor is correct in that studies have shown that vaginal progesterone is just as effective as injectable, and doesn't have the discomfort of the injection (Injectable progesterone has to be given intramuscularly). Injectable progesterone is still the gold standard, however, and if that is the form that you want, I don't see why your doctor can't change. But these kinds of things are what make each doctor different. Extra progesterone does not hurt, so why not? You could continue to argue with her but it sounds like she has her preferred way and will stand by it. The estrogen is a different hormone. I don't see any benefit to that for the bleeding but I certainly supplement with estrogen in my protocols.

Remember, I said that you cannot compare protocols because there is no one way, right way or wrong way. Protocols differ between doctors and clinics and that is okay.In the IUI pregnancy, which found a heart beat, progesterone was definitely not the cause. The lack of progesterone will result in very early pregnancy loss. Way before the placenta develops to produce its own progesterone. After that point, losses are usually due to abnormal pregnancies or fetal development.

The answer to your last question is NO. One can do an IVF cycle as quickly as every other month. Each cycle is different and unique and the eggs retrieved are unique. They can be good eggs or bad eggs, which is already predetermined prior to the IVF cycle depending on the state that the egg is in prior to stimulation.

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.

Woman Has Lost Both Ovaries: Why Does She Still Have A Period?

Question:

Hi,

My daughter has lost both ovaries due to cysts. The doctor has put her on Progyluton. We are aware that she cannot get pregnant but the doc says she will still have a bleed. Is this so and if so, how come? S. in Barbados

Answer:

Hello S. from Barbados,

I sincerely hope that your daughter was not young because having cysts, if they are not malignant cancerous cysts, is not a reason to remove the ovaries of a young girl or young woman. That would be malpractice.

The reason you daughter has menstrual cycles is because she still has a uterus. It is the uterus that bleeds with the menstrual cycle. The ovary is what causes the uterine lining to grow in preparation for an embryo to implant, but if this does not occur then the lining is shed and cleaned out each month. Then the cycles starts over again. This cycle can be replicated with the birth control pill (progyluton is an estrogen or estradiol, used for hormone replacement therapy).

Thank you for writing,

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.

37 Year Old Fails 3 Clomid Cycles & 2 IUI's: What Should She Do Next?

Question:

Dear Dr. Ramirez: thank you for your great service!

I just turned 37 years old and have been ttc for 1 year already. My cycles all my life have been like clockwork (ovulating on day 13 in a 26day cycle). After charting and some blood tests during the early months of ttc, I realized I had low progesterone. I was put on suppositories and after another 6 months of no success, I was put on 50mg Clomid. That's when my cycle was completely thrown off. On Clomid cycle #1, I ovulated on day 19 (much later than normal), on Clomid cycle #2, I ovulated on day 14. Both cycles were followed by unsuccessful IUIs (intra uterine inseminations). On Clomid cycle #3, I ovulated on day 11, so we missed it and didn't do IUI. On cycle #4, I ovulated on day 10 and I did two back-to back IUI (again unsuccessful). My lining is fine, there are no cysts and all my blood work on all hormone levels is good within healthy normal levels. In fact my hormone levels were normal when I tested during my natural cycle before taking Clomid. Only progesterone was low and the suppositories didn't provide enough (day 21 showed 12 only), so 2 months ago I was put on PIO and that works like magic (level was 33 and 36 on day 21).

I read in on your blog that women who ovulate on their own shouldn't take clomid, which may REDUCE their chances of getting pregnant. Did we undertake the wrong treatment? Again, until I started clomid, you could set your watch by my cycle and I could check my ovulation using the monitor. After taking Clomid, my monitor cannot register any hormone changes and peak ovulation anymore. I was told that given my age the next thing to do is move to a more aggressive treatment (injectables), but if I was so regular and ovulating on my own, why do i need the injectables?

The fertility center never did an ultrasound to see how mature my follicles are during my natural cycle (they did this only when I was on Clomid), so my inclination is to get off clomid and try a natural cycle for a few more months again and ask them to see if my follicles are large enough. Would you think that's wise or shall I move to more aggressive treatments? My husband's sperm count varies from 25mil to 100mil during the IUI cycles. He also had average motility of 90%. Semen analysis also indicated 80% morphology.

Thank you kindly for any advice you may be able to offer. L. R. from Lancaster, PA

Answer:

Hello L. from the U.S. (Pennsylvania),

The main problem, and only problem that you have identified, is your age. I call this the age related egg factor. This means that the eggs have aged and have decreased in quality and viability. A study was done to look at embryos created at 37 years old and did genetic testing on those embryos and found that only 20% were normal, a reflection of egg quality. So that is the hill that you are trying to overcome.

In this case, the use of fertility medications is to achieve "superovulation" not ovulation. The main use of Clomid is to induce ovulation in women that are not ovulating but in older women, the goal is to increase the number of eggs that you ovulate to increase the chances that you will ovulate a good egg. In my patients over 35, my goal is to get them to ovulate 3-5 eggs per cycle. In my blog what I am referring to is the tendency for general docs (family practice and Ob/Gyn's) who automatically place an infertility patient on Clomid without finding out the root cause of their infertility, as if Clomid were some magic drug. They are misusing the medication.

In your case, because you stated that you are at a fertility center, I presume that you have undergone an infertility evaluation and nothing was found except for your age, so superovulation would be a reasonable first step. I also don't recommend consecutive Clomid cycles because Clomid works by blocking estrogen receptors and too much Clomid with block the estrogen receptors that are necessary for fertility, such as tubal motility, endometrial lining development and cervical mucous production. In that case repetitive Clomid cycles can lead to infertility by blocking these receptors.

Because of your age, I do believe that you need to pursue an aggressive treatment plan. I usually do not recommend more than 4 IUI cycles as part of an aggressive treatment plan because studies have shown that most patients will get pregnant within four attempts and pregnancy rates decrease dramatically after four. Keep in mind that at your age, your pregnancy rate per IUI cycle is only 12%. But if you want to continue to try IUI, then it is reasonable to try with injectables, although these meds are a lot more expensive, for two more carefully monitored and timed cycles. Then if that is not successful, I would strongly encourage you to proceed to IVF.

By carefully monitoring, I mean that ultrasound screening should begin at cycle day #9 the proceed from there depending on the size of the follicles. The closer you get to ovulatory size, the more frequent the ultrasounds will be. HCG should be given to trigger the ovulation. IUI's should be done at 24 and 48 hrs after the HCG trigger and then the progesterone is started the day following the second IUI and continued until the bHCG. Progesterone should be given as a vaginal suppository 2-3 times per day depending on the formulation.


Good Luck and thank you for reading my blog!

Dr. 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.

Secondary Infertility Patient With Seven Miscarriages: Cannot Afford IVF

Question:

Hello-I am 33 and have a healthy 3 1/2 year old daughter who was conceived naturally. I have had 7 miscarriages (1 before my daughter and 6 consecutive since her birth). I have had 4 chemicals, 2 confirmed blighted ovums and 1 xxx69..this one had a heartbeat and all hormones were great, heart stopped at 8 weeks and did a karyotype on fetal tissue.

I've been to an RE and have had the following tests: Karyotype, HSG, Day 3 Hormone Panel, Clotting Disorder Panel, ultrasound to measure lining of uterus and to check for any abnormalities...all results are "normal". I have also supplemented with progesterone after a positive pregnancy test as well, my LP is usually 11-12 days. My hubby has only had a karyotype and he is "normal" as well. The RE said that our XXX69 was more than likely due to a mutated sperm containing an entire extra set of chromosomes. He has recommended we do IVF (in vitro fertilization) with PGD (pre genetic determination).

Our insurance doesn't cover ANY fertility, so that is really not an option for us.The RE wanted to me to try a monitored clomid cycle as a plan "B". In doing some research, I just don't think clomid will help with unknown recurrent pregnancy loss...what is your opinion? I "O" just fine without any meds. What else would you recommend? I am in excellent shape, eat organic whole foods, don't consume any alcohol or caffeine..

I take prenatals and fish oil daily. Do you think that all my miscarriages could be a sperm issue? I'm really at a loss....what do you think our chances are of having another healthy child without doing IVF/PGD? Thanks, S. from Maryland.

Answer:

Hello S. from Maryland,

I am sorry for your losses. You certainly have recurrent abortion as a diagnosis, but the exact cause is unknown. Granted that the fetal tissue from the last miscarriage showed a genetic abnormality, but if your husband's genetic testing was normal, then I would not expect that all the miscarriages were for the same reason. I would think that it is more likely to be a spontaneous genetic abnormality occurring with division of the embryo. Hopefully that is the case because that means that there is still a good chance of having a normal pregnancy. If the problem is a sperm abnormality causing a genetic problem, then there is very little that can be done to change that other than using donor sperm.

One alternative would be to try IUI (intra uterine insemination), since the sperm will be washed and the best sperm will be made available for fertilization. There is no guarantee with this but it is an option. Your RE is correct in that the only way to make sure that a normal embryo is available for implantation is to do preimplantation genetic screening with IVF. Since you cannot do IVF, then the only option is to continue to try and hope/pray for the best. I do not think you need to do Clomid either. It doesn't help with this problem. The good thing is that you are still young and have time to keep trying. Hopefully with continued trying, you will be successful.

If you were my patient, I think I would add low dose aspirin 81mg per day, PNV with folic acid, Medrol 16 mg per day, progesterone supplementation in the luteal phase (Crinone or Endometrin) and low dose heparin 2000 unit injections twice per day with each cycle. These are more to cover the immunologic causes of miscarriage, but have been shown in numerous studies to help. Since we cannot be sure exactly why the previous miscarriages occurred and can't conclude that it is ONLY a genetic problem, I would favor covering those bases.

Good Luck,

Dr. 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.

Right After A Cancelled IVF Cycle, Try Naturally Or IUI?

Question:

Dear Dr. Ramirez,

I write to you from Los Angeles, California. I am 38 and just started an IVF (in vitro fertilization) cycle after two FETs (frozen embryo transfers) that did not take. Those embryos from the FET were from an IVF I did when I was 36 that resulted in my wonderful son. I am on Bravelle and went in for my first ultrasound and they saw only two developing maturing follicles, one on each side, that were outpacing all the rest. Previously, they had seen about five on each side. My doctor has cancelled this cycle but recommended continuing on the Bravelle for two more nights and then trigger ovulation and timed intercourse. My questions is, should I do IUI instead of just timing intercourse? I know that my chances are very low of conceiving anyway, but my feeling is that if we are paying for the meds and these ultrasounds, that perhaps we should optimize our chances, even though they are very low. The doctor was trying to minimize our costs and suggested timed intercourse instead of the IUI.

I am hoping that these two years that have passed since my son was born haven't led me to be a 'poor responder.' The doctor said that sometimes this happens and that we can try a fresh ivf cycle next month and he would increase the amount of the stimulation drugs.Any thoughts on IUI versus timed intercourse or anything else?

Answer:

Hello S. from California,

I don't recommend canceling IVF cycles normally because you never know if the perfect egg is in one of those follicles. In addition, despite the fact that two have outgrown the others, that does not mean you can't get mature eggs from the other follicles. There have been studies that have retrieved mature eggs from follicles as small as 10 mm. So even if there is only one follicle, I like to give it the best chance that we can. I know that this is a more expensive way to go, but I've had numerous pregnancies from just one follicle. Bear in mind that IVF has a significantly higher pregnancy rate, even with only one egg, than any other method at your age, per cycle. In my center it would be 70% pregnancy with 40% continuing with IVF vs 7-10% with IUI.

That is because, if you image how the natural cycle process works, it takes 10 steps for your body to accomplish a pregnancy:
(1)Brain sends FSH to stimulate the ovary to grow follicle
(2) Ovary grows follicle
(3) Follicle ruptures out of ovary (ovulation)
(4) egg is pulled into the culdesac with the fluid from the follicle and finds (or has to find) tube within 12-24 hrs
(5)Egg is picked up by the fimbria of the tube
(6) Sperm and Egg meet within the tube and fertilization occurs
(7) Egg travels down the tube and divides into blastocyst
(8) Embryo enters uterine cavity
(9)Embryo hatches and exits from its shell
(10) Inner mass attaches to the uterine lining and the lining grows around the embryo (implantation)

With IVF, steps 1-8 are accomplished for you and only two steps left up to chance/nature/God, whereas with IUI, only steps 1 and 2 are accomplished for you. The rest occurs naturally.

In any case, there are several issues you have brought up and questions that correspond. One is whether you should do IUI vs try naturally right after a cancelled IVF cycle. Statistically, IUI has a better chance of pregnancy than pregnancy (7-10% vs 5%), so for that reason alone, I would go with IUI. I would recommend following the exact same protocol as you would of with IVF except that retrieval and transfer will not occur. I would do the same progesterone supplementation.

The other issue is regarding your stimulation. It is obvious that you were not stimulated with the max protocol if you doctor commented that they are going to increase it. You may have a decrease in response but without getting maximum stimulation, you don't know that for sure. So, you may not be a poor responder. You just did not get stimulated adequately.

The good news is that you have had one successful pregnancy. It is a good thing that you are pursuing having the second at 38 yr.s, before you become much older and the rate of success drops dramatically.

Good Luck,

Dr. 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.