Friday, January 28, 2011

40 Year Old U.K. Woman With One Miscarriage Feels Time Is Running Out For Her: More IUI's, More IVF Or Donor Eggs?

This post concerns a woman in England who has written to me several times regarding her infertility journey. I would like to publish the entire correspondence for those of you who have a similar dilemma, that is, what to do if you have gone through multiple intra uterine inseminations, actually get pregnant naturally but miscarry, but because of your age, needed to consider IVF as the next step. Unfortunately, the first IVF cycle you do fails. What next? You can read my final response and advice at the very bottom. It is interesting to see how women in the U.K. receive infertility treatments through the National Health Service and the limitations of this government sponsored health care.


Hello Doctor Ramirez,

Hope you are well. It's L. from England again! I have added my previous questions below and your answers below as I didn't know how to add a link to my history. I have had my first round of IVF (NHS) and it did not go well. First I down regged with Buserelin Spray and this did not work after 3 weeks I was switched to the injection which then worked after another 2 weeks so all in all 5 weeks of down regging. I was then given Menopur 300 ui (Maximum dose at my clinic) after 12 days of stimming this has only produced 2 follies ( I have had 4 follies on puregon at a much smaller dose) at my scan today they have said the they will convert me to IUI as they need 3 min for IVF.

I am now so confused about what my next step should be if the IUI does not work. Unfortunately I am only really able to afford one more go at IVF, at a push with the help of family maybe 2 and wanted to ask what you thought my best option was. I have heard that mild/mini IVF may be better for me at my age however I am worried about my response, but then can't help thinking that my response was poor because I down regged for too long.

My niece has agreed to be a donor for me but im not sure she will be accepted by the clinic as her BMI is high and she is only 21 (she has a 1 year old daughter). My clinic said usually the lower age limit is 23. (I could possibly look at other European clinics with not as strict egg donation guidelines).

Or should I try again with my own old eggs? I have read about the benefits of taking DHEA to improve egg quality but feel that here in England I would need to self medicate this as I don’t think doctors here have taken this approach on board yet. What would you suggest I take if you indeed think it is appropriate. I am already taking the low dose aspirin and of course folic acid. Basically what I am trying to ask is if you were me what would you do in view of my low follie count on this IVF cycle. What regime would you put me on if I were at your clinic? or is it better to give up on my eggs and do down the donor route? Thank you in advance for your response. I always feel much better when I receive your advice. L. from the U.K.


Question: Hi, I am having IUI in England. My first attempt was cancelled as I ovulated myself before the follicle was large enough. My 2nd attempt I took 50 puregon every other day from day 5 and then had IUI on day 17 (I have a short cycle of 24 days), my period came on day 24 as usual. My 3rd attempt I again took 50 puregon every other day from day 5 and had IUI on day 14, again my period came on day 24. After reading many forums on the internet a lot of people seem to be having a larger dose every day from earlier in their cycle. Is it better to try and carry out IUI within my natural cycle or should the puregon be making my cycle longer? Should I be injecting earlier in order to have a follicle that is the correct size by my natural ovulation day of day 10? I have tried to contact my consultant but he never returns my calls and unfortunately I am starting to lose confidence in him. Thank you for your time. L. from the U.K.


Hello L. from England,

First, if your doc does not return your calls, then find a new doc. He is not helping you. For example, my patients have access to me via by cell phone and via email, which I receive on my cell phone.

Second, I presume that your doc is monitoring you by ultrasound to determine the optimal day for trigger. Is he not? If not, then he is not the right person to see. If he is, you should be forming at least 3 follicles per cycle in order to optimize your IUI's. That's my goal and the number that studies have shown to increase pregnancy rates per cycle. In addition, you should be going on Progesterone the day following the IUI to supplement your luteal phase. The fact that your cycles are short, despite ovulating on CD#14-17, means that you have an inadequate luteal phase (luteal phase defect). Without adequate progesterone support, implantation will not occur or the pregnancy will not continue. With the additional progesterone, you will not have a period until the progesterone is stopped, which should be after a negative pregnancy test is done 12-14 days after the IUI. If it is positive, then the progesterone would be continued until you are 10 weeks gestational age.

I hope this helps, Good Luck. Edward J. Ramirez, M.D.,

Follow-Up Question:

Hi, I wonder if you could please give me your advice once again.

After your last reply I spoke to my fertility nurse and she indicated that I may have luteal phase defect but said that they did not use progesterone to help in IUI she basically said there was nothing I could do, I then managed to speak to the consultant who was very angry with the nurse as he did not think I have luteal phase defect. I argued with him about this but he was adamant. (I agree with you that I do have LPD) Just so you know my consultant has the best success rate in the country for IUI !My consultant was monitoring me with ultrasounds to check the size of the follicles and at my next scan I had 4 follicles he usually aims for 2 (The rules are different in England regarding multiple births, I had also been injecting a higher dose of puregon than the consultant recommended) He advised me to cancel the IUI as the risk of multiples was too high and told me to use contraception. Against his will I took my pregnyl trigger shot that night and had sex. I also purchased Pro-Gest progesterone cream (on the internet as it is not readily available in England without a prescription, is the cream as effective as pessaries?) and used it a couple of days after the trigger shot.Imagine my surprise and delight when I became pregnant!! Unfortunately at 9 weeks I had a missed miscarriage leaving myself and my partner devastated, I took pills at the hospital to expel the foetus rather than have a D&C.

I now have a dilemma as I can stay with the Consultant. I currently have another 4 cycles of IUI for free or I can go to a new clinic and receive 1 cycle of IVF free on the NHS. I realise that its great I can have this free treatment but there are drawbacks in that you cannot choose your doctor, you have to go to the clinic that your GP refers you to and each time you visit the clinic you may see a different doctor.

So in your opinion what is my best chance of getting pregnant? I am 40 in December 2010 and time is running out should I take the 4 rounds of IUI using higher doses and progesterone cream (as at least now I know I can get pregnant) or is the 1 round of IVF with a new consultant my best option?Which ever option I choose if it doesn’t work I will find the money to have at least 1 round of IVF at a private clinic even if I have to put it on my credit card then possibly look at donor eggs.Im sorry this is so long and hope it makes sense. Thanks very much in advance. L. from England

Follow-Up Answer:

Hello L.,

I presume that your consultant does not do IVF and therefore is not a fertility subspecialist? In any case, you have proven that you can get pregnant by natural means, so indeed you have a dilemma. Let me see if I can help you sort it out but ultimately, you will have to make the decision. Your age is a significant factor. Your natural chances of pregnancy is only about 10% per year of trying, or less than 1% per month. With IUI it is only slightly higher than that. This is mainly because (1) your body has to go through the entire natural process to become pregnant (there are 9 steps) and it does not do this perfectly every time, and (2) you have an age related quality of egg issue, I call "age related egg factor", that diminishes your chances as well. The probably cause of your miscarriage was an abnormal embryo. IUI will not help that.

IVF, on the other hand, has a much higher pregnancy rate than IUI because (1) it is not a natural process and does not necessarily rely on the body to do each of the steps except for the last two steps: embryo extrusion from the shell and implantation. For this reason, your chances of pregnancy with IVF runs about 40-65% per month in the U.S. (it is 68% in my program). This also reduces the chances of miscarriage because more eggs are recruited, giving a higher chance of finding a healthy normal embryo. There is still a miscarriage risk but as you can imagine, that risk is reduced. In addition, because you have gotten pregnant previously, you have shown that implantation can occur and all you need is a good healthy embryo. So, in my clinic I would advise you to do IVF, but with the caveat that it may take more than one attempt (remember the last two steps are still "natural" steps that we cannot control.

Certainly if you attempt the several IUI tries, for which your consultant has not been very cooperative mind you, you could get pregnant but I would be prepared for more miscarriages. In addition, at your age, I would try for 5 ovulatory sized eggs to increase your chances. The chances of a multiple are slim at your age. But I think IVF will give you a better chance, ultimately.In terms of donor eggs, I would not consider than unless you fail several IVF attempts (3-4), or you reach 43 years old, whichever comes first. You can do donor eggs at almost any age so time is not critical.

Most Recent Answer:

Hello L. from England,

Thank you so much for inserting your previous questions. As you probably can surmise, I get lots of questions and can't remember everyone.

I still think that you have a chance for pregnancy with your own eggs. I know that financial issues preclude that, but I am not convinced that you need donor eggs yet. That being said, if I were you I would find a different clinic. Go out of country if you have to. Your clinic is NOT giving you the best chances. 300IU of Menopur is an inadequate stimulation dose in your case. I am also concerned about your down regulation. I have not seen anyone need 5 weeks of down regulation. I would certainly do things differently.

First of all, my highest protocol is 450IU of Follistim and 150IU of Menopur, which is the highest protocol used in the U.S. Again the goal is to get the maximum stimulation so that we can retrieve the maximum number of eggs. That is the only way to overcome the "age factor."

Secondly, I NEVER cancel cycles even if I have only one follicle. That is because I have had many cycles with only one follicle, resulting in one egg retrieved and one embryo transferred, AND it may be the perfect egg that you just wasted.

Thirdly, we will allow directed donors (donors that you find and use) as long as they are over 18 years old (legal age).

Remember, as I mentioned before, you can do donor eggs at almost any age. So time is not an issue, whereas, it is an issue using your own eggs because of your age. What I mean by that is if you fail with an IVF cycle or two using your own eggs (in a good clinic), then you can save up your money for a year or two then do donor eggs. Of course if you don't want to wait and want the maximum chance of getting pregnant quickly, then donor eggs would be the way to go, and I would go elsewhere. I feel for you and hope that all goes well.

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.

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