Thursday, April 28, 2011

Patient Fails One Fresh, One Frozen IVF Cycle: Will Another FET Work?



Hello,

My name is S. from Boston. I am writing with a question regarding what I am going to be undergoing next week, a second frozen transfer. Just to give you some history, I had a first attempt successful IVF (in vitro fertilization) cycle in 2008 and delivered a healthy baby. We are now trying for baby #2 and had an unsuccessful fresh cycle, and an unsuccessful frozen cycle in the last few months. I still have several frozen embryos so my insurance is mandating that we use them prior to doing another fresh cycle.


I know the success rate is lower with frozen embryos but I wanted to know another opinion, if I should proceed with a fresh cycle if this one is negative. I have 3 frozen embryos left, that are all 6 cell and high implantation potential. I am not optimistic that this one will work, because the other two cycles they put in 2 8 cells and they didn't take. My doctor says there is no difference between 6 and 8 cell embryos, but if that is the case, then why do they always choose to transfer the 8 cells first? I know I could also lose some cells in the thawing process, so does that lower my chances more, and are there are risks associated with the baby, if I do become pregnant this cycle? Thank you so much!


Answer:

Hello S. from the U.S.,


These are very good questions that you should direct to your doctor. It is his/her responsibility to keep you informed.


Let me take the easy questions first. The reason why we use the 8 cell embryo first is because embryos are graded based on their appearance. Yes, that is we give them a higher grade, the better they look, just like a beauty contest. The cell number is the number of cells the embryo has divided into by that particular day, which I presume to be post-retrieval day#3. Again, we prefer embryos with more cells than less cells. That does not necessarily mean the embryos with more cells are BETTER than the embryos with less cells. In fact, preimplantation genetic testing often shows the opposite. So a higher number of cells does not guarantee a good embryo. The factors that make a good or perfect embryo are not things that we have the technology or knowledge to apply at this point in time. Maybe in the future. My preference is for my embryos to be between 6 cells and 8 cells at this point. Most pregnancies will result from embryos within this range, either grade I or grade II.



Frozen embryo transfers have a lower pregnancy rate probably because the lesser embryos are left to be frozen and the better embryos are transferred fresh. Also, it may be because of the freeze and thawing of the embryos, but the technique has gotten so good that I don't think that is much of a factor any more. But, that does not mean that a frozen embryo can't implant and produce a good pregnancy. I would still recommend that you use them first before another fresh cycle because the medications required are less, AND there are some studies that show that implantation is better if there is no ovarian stimulation, as in Donor cycles. That might be an advantage. You just have to hope that the embryos are still good enough.


I might suggest that you ask your doc to culture the embryos remaining to blastocyst stage. That will be a further validation of the embryos, and may lead to fewer embryos to transfer, but they will be at a stronger stage. That does not necessarily give you a better chance at pregnancy, but the assumption is that if the embryo can survive further culturing then it has a better chance of continuing to implantation. That way, you can further screen the remaining embryos that you have. The ones that don't make it to this point will be discarded, then you will need to move to a fresh cycle. If you have extra blastocysts, you should only transfer two max at this stage, they can be frozen and are in a better stage for the freezing.Finally, there are no added risks for a normal baby if by frozen eggs or embryos. If the embryos are abnormal they usually will not work (implant) or will end in miscarriage. You have not given your age, but this can be a factor in terms of embryo quality, success and genetic risks as well if you are 35 years old or older.


Good luck,


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

Thursday, April 21, 2011

Cancelled IVF Cycle: Australian Wonders If She Can Risk Conceiving Naturally



Dear Doctor,

I found out today that my IVF (in vitro fertilization) cycle was cancelled due to not enough follicles stimulated. I was day 11 of my cycle and had 6 follicles in total but only 3 measuring over 10 - at 16, 14 and 11. Another was 9. This is my first cycle - I have an AMH level of 3 and DH has a low sperm count and motility. I have been taking 400iu of FSH (puregon) and an antagonist. What are the risks if we were to have intercourse? Would I need to take my HCG injection prior to intercourse?

Given our history, I don't see why we couldn't try to conceive naturally? Thank you! C. From Australia


Answer:

Hello C. from Australia,

I don't understand why your cycle was cancelled because it only takes 1-2 good embryos to get pregnant. Although you did not have a large response, you did have a sufficient one. Also, your doctor could have increased your medication up to 600IU of FSH or have added Menopur (FSH/LH).


In any case, you could convert your cycle to an IUI (intrauterine insemination) cycle or intercourse at this point. IUI would probably be the better choice. You would continue on the medication until the lead follicle is at least 18-20 mms, visible with ultrasound. The goal would be to have 3 ovulatory sized follicles (greater than 16 mms) at the trigger, then you would take the HCG and have the IUI's at 24 and 48 hrs after the trigger or have intercourse for the next four consecutive days.


I am in agreement with you that you should not give up this cycle so easily.


Good Luck,


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

Sunday, April 17, 2011

Tubal Reversal Vs. IVF: Which Would Be Better? Asks 38 Yr. Old Mom Who Wants One More Child


Question:


Dear Doctor, I've just turned 38 and I have three children. Right after the birth of my third, I had my tubes tied. Somehow it made sense at the time but now I regret it. My kids are between the ages of 6 and 9 all delivered by c-section, and we would like one more. My ObGyn highly recommends IVF instead of a tubal reversal. I have a consultation with an infertility doctor in a few weeks and I am a little nervous. I would like some information or advice for a woman in my situation. I had no problems conceiving at all, have never missed a period, except during pregnancy, and I ovulate every month without fail.


My husband and I would consider adoption as well. Either way, IVF or adoption, they both are expensive and carry a risk of not working out, so we really want to make the best decision for our family. We just know that we want to expand our family. Thanks so much. K. from Maine


Answer:


Hello K. from Maine,


Your question is a common one and one that I have to discuss often. Hopefully I will be able to give you the facts so that you can make your decision. I have to commend your Gyn doctor for his recommendations, as I think he/she is correct, and I am sure that your infertility doctor will concur. Here is what I tell my patients to consider.


Let's look at the pros and cons of each option:


First let's consider tubal reversal. What tubal reversal (called a tubal reanastamosis) does is it brings the previously damaged or separated tubes back together so that they are open again. There are two initial considerations when considering this procedure. One is what type of tubal ligation was done. Some tubal ligations, and the doctors that do them, are more permanent. Most doctors doing tubal ligations realize and fear that if the tubal ligation (or "BTL" bilateral tubal ligation) fails, they are at risk for a malpractice suit. For that reason, they make doubly sure that it doesn't fail by doing as much damage to the tube as possible i.e. either remove/burn a large portion of the tube or remove the end of the tube "fimbria". This is especially true when the BTL is done immediately after a delivery or during a c-section, called a postpartum tubal ligation. Because the tube is readily accessible, the Physician will usually cut, tie and burn a large segment. The more damage a tube undergoes, the less chances that it can be repaired or that the repair will work.


The second consideration is how much tube is left to repair. The Fallopian tube needs a minimal amount of length and structure for it to be a functional tube. If the fimbriated end is removed or a large portion of the tube removed or burned, there will not be sufficient tube to repair for a tube to be functional. The tube is after all, a functioning structure with muscle and cilia within. If the proper segments are not available it doesn't work. The fallopian tube is not just a tube. So based on the fact that your tubal ligation was done at the time of a c-section, I would make the assumption that there is not sufficient tube to repair.


Another disadvantage to consider, of course, is what if the surgery is not successful. Not because there is not enough tubal length, but because it does not come together properly or heal properly. Because a surgery is being done, you cannot control how it heals or repairs itself. We can only bring the tube together and hope for the best. What I mean is that the tube can become misaligned so that it is not patent. Or, you can develop scar tissue at the site of repair which can block the tube completely or partially. So even if we assume that there is sufficient length of tube, it may not work due to factors that you cannot control. If the tube heals partially so that there it is only partially open or has scar tissue, you would then be at risk for a tubal pregnancy or "ectopic", which is a surgical emergency and carries the risk of death from rupture and hemorrhage.


Next you have to consider what are your chances of pregnancy if the reversal were successful. If the repair is successful, that is that all the previous criteria is met, then it will restore your natural chances of pregnancy. However, because you have aged since your last child and are now 39 years old, your natural chance of pregnancy has decreased significantly. Your last pregnancy was at the age of 32 years old when you conceived. At that time you had a 50-60% chance of pregnancy per year or 15% per month of trying. Now you are 39 years old. Your natural fertility rate has declined due to age and is now 12% per year or approximately 1-3% per month.You will also need to consider that this is a surgery, done either by a small incision "minilaparotomy", large incision like your c-section "laparotomy" or by laparoscopy. It carries all the risks of surgery and requires general anesthesia. There is also the risk that you may have scar tissue formation around the tubes due to the prior c-sections and tubal ligation that would make the surgery difficult or not possible. It is not a simple surgery like the tubal ligation. (As someone who has done hundreds of cases and come up against mega scar tissue, believe me it is not a walk in the park.) It is actually a very difficult microsurgery that requires a Physician with the proper skills to complete properly.


Finally, there is the issue of cost. In my surgery center, it will cost $10,000 for a tubal reversal (Physician fee and Surgery center fee). That will vary according to your area so you will need to check to see what the price will be for you. I did have a patient go to North Carolina for a tubal repair, at 38 years old and it cost her about $8000. She is still not successfully pregnant. She did get pregnant but had a miscarriage (partly because of the decreased fertility rate due to age). In any case, is $8000-10,000 worth a 1-3% chance of pregnancy per month?


In your case, you also have to consider that since you want only one more child, after all this expense and surgery, will you then have another tubal ligation? Also, having had 3 c-sections, you know that you will need to have another c-section. Finally, you also need to consider that you have a genetic risk of Down's syndrome that is 1/100 births due to your age i.e. it is significantly increased and your risk of miscarriages is increased.


Now let's examine the alternative, which is IVF. In this procedure, the eggs are taken directly from the ovaries so the tubes are bypassed and not required to be repaired. First, it is not a surgery but a procedure where a needle is introduced through the vagina to retrieve the eggs, under ultrasound guidance. Sedation is used but general anesthesia is not required. There is some risk but nothing like a surgery. So, the benefit is that as long as your ovaries are still working well, so that they stimulate well and produce an adequate number of follicles that have eggs in them, you can be sure that the procedure can be completed in it's entirety. There is no risk that the treatment cannot be completed. Now, there is the risk that a pregnancy will not result, different from reversal in that there is both the risk that the surgery will fail and that a pregnancy will not result, because the last two steps your body has to go through to achieve the pregnancy are still natural steps and we don't have the technology to make it happen. But because IVF accomplishes 7 of the 9 steps required for a pregnancy to naturally occur, the chances of success are higher. Also, despite this, at 39 years old pregnancy rates are 50-60% per treatment cycle (i.e. per month of trying). As you can see, this treatment also helps to overcome the age factor as well because more eggs can be retrieved and so there is a higher chance that we will get a good egg. There is still the genetic and miscarriage risks due to age, but I think those are reduced because IVF is less of a "natural" procedure and the weaker eggs/embryos do not survive the process. But, those risks are still there.


In the 17 years that I have been doing IVF, I have only had two cases of Down's syndrome in my patients, both in patients over 40 years old.


Well I think I have written one of my longer answers :)... so I think I should stop here. As you can see, IVF is better because it has a better chance of success in consideration of your age and type of tubal ligation, and it is less risky. The cost is higher, approximately $15,000 in all, but it has a better chance of working. You should consult my blog where I have written on this subject 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

Wednesday, April 13, 2011

37 Year Old TTC With Past History Of Hyperplasia & Endometriosis Is Desperate To Conceive


QUESTION:

Ok, I went to the Gyno in Dec of 2009 because I wasn't getting my period. He sent me for an ultrasound Jan. 2010 and the lining of my uterus was thickened so he did a biopsy which led to my first D&C which was April. I was diagnosed with hyperplasia of the uterus and he said I was producing too much estrogen so he put me on Depo provera.


I got my first shot April 19. 2010 and he told me if I didn't go on the depo shot I would definitely get cancer. I had my second shot July and then I had another D&C September and everything came out good, hardly any tissue. After the D&C the Gyno said he wanted me to stay on the depo till I go through menopause ughh!! I've had three more shots, one in Oct.. one in Dec. and my last shot was March 21, 2011. I want to have a child and in late July I will be 38. My gyno said I could go off the depo shot, so I asked him what if it takes me a year to get pregnant? He said, "You're not allowed to take that long you'll get cancer of the uterus for sure."


I think I need a second opinion & I'm hoping my withdrawal from the depo isn't so horrible. One thing I think you should know is I was diagnosed in my mid 20's with endometriosis and my gyno (back then different doctor) said I didn't have a lot of tissue he also never told me I couldn't conceive, he just said after you have children just get a hysterectomy. I was put on different forms of BC (birth control) over the years and my last form of BC was the NUVA ring. I always had bad cramps w/ my periods so he had me wear the ring continuously. I would wear it for three weeks and take it out and put in a new ring right away to avoid periods, when I was doing that I had break through bleeding all the time & that's where I think all the excess tissue came from with the hyperplasia. I've been on the depo shot for a year and three months then I'm due for my next shot which I don't want.


I'm writing from South Jersey. I only want to have one child! Please tell me what you think. Thank you for all your time. :)


ANSWER:


Hello A. from the U.S.,

First, I don't think you need to worry about the hyperplasia at this point. You have been adequately treated for it. You just need to make sure that you have regular cycles because not shedding the lining at least every three months is what can lead to hyperplasia, and if left untreated the simple hyperplasia can turn into atypical hyperplasia (precancerous) which can then turn into cancer.


I think that pregnancy is a good idea for it and you need to pursue it aggressively! Your age is the number one issue at this point, in terms of getting pregnant. A second issue with getting pregnant is the history of endometriosis. Depo Provera is certainly a good treatment for this disease but endo can recur and can impede pregnancy. Considering your age, I wonder if there are other factors as well since you have never gotten pregnant to date. My recommendation, in general, to patients at 37 years old or older is to strongly consider IVF (in vitro fertilization). Other than age, you don't have an absolute indication for this, unless something else is found wrong, but the chances of pregnancy are so much higher with IVF than any other treatment at your age.


For example, your natural chance of pregnancy is approximately 3% per month or 5% per month with IUI. On the other hand, with IVF it is 69% per month in our clinic, and at least 50% across the country. That is a significant difference. The problem with age is that the majority of eggs that you still have will be of poor quality so the only way to increase your chances to find an egg with good quality is through IVF. You can certainly try with more natural methods but with each month that you fail, your chances are decreasing (it's like chasing your tail).


I would strongly recommend that you go to a good IVF clinic and have a consultation. I know that there are some excellent ones in New Jersey.


Follow-Up Question:


One more question, being on the depo shot for this time period (one year & 3 months) I'm afraid as to how long it will take to get out of my system. Reading posts by women who've been on it much longer than I (like 7-12 yrs.) say it can take 6-18 months to start a normal period & ovulate again. Any suggestions on how to rid the depo from my system when I'm actually due for my next shot? I've read lots of water and excercise.


Thanks again after this no more questions I'm sure you're busier than ever.:) A. from New Jersey.


Follow-Up Answer:



Hello Again,


I don't have any solutions to how to speed up the return of your natural cycles. The Depo can linger for a while but I have never seen it take more than 2-3 months. If you want to start trying for pregnancy sooner, you could undergo ovulation induction and that will get your ovaries to stimulate and ovulate.


You are very welcome to ask your questions and thank you for your patience in waiting for my reply.

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

Comment: Dr. Ramirez was very helpful to me I really appreciated his input. Thanks again!!

Friday, April 8, 2011

U.K. Woman On Clomid For Five Months, Husband With MFI: Periods Are Shorter Now, Why?


Question:


Hi, I have been taking clomid for 5 months because my husband has a low sperm count. I have noticed my periods becoming less and less the last 2 months I have only bleed for 1 day and that was mostly a black/brown color. My periods normally last for a full 7 days. Is this because of the clomid? D. From the U.K.

Answer:

Hello D. from the U.K.,

You should NOT be taking Clomid every month. It leads to a thinning of the endometrial lining because it is an antiestrogen and blocks the estrogen receptors. This is probably why the bleeding has decreased. This lack of adequate uterine lining will prevent implantation.

Secondly, Clomid is NOT a treatment for male infertility if given to the female! I have absolutely no understanding as to why your doctor has prescribed this and not followed you with some type of surveillance to see how you are responding. I would strongly recommend that you look up here in my blog where I discuss how Clomid cycles should be done.


Thirdly, in men that have low sperm counts, they will be treated with Clomid on a daily basis, sometimes to try to increase the count. This works only some of the time. It will take three months to know if it is working or not. If the count gets above 10 Million, then IUI is a treatment option. If it is less than 10 Million then IVF with ICSI is the treatment of choice.


Finally, please make sure that your doctor is an infertility specialist and does ALL levels of infertility treatments, including IVF. Otherwise, you may be wasting your time.


Good Luck,

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

Monday, April 4, 2011

Was My IUI Triggered Prematurely?


Question:

Hello, I just had my first IUI (intra uterine insemination) this past Tuesday and although the doctor was not happy with my follicles after Gonal f, he decided that I should trigger anyway with Ovidrel. The ultrasound the day of the trigger showed follicles 16.5mm, 16mm, 15.5mm and also some 13's, 12's and 10's. Were my follicles sufficient enough in size to produce a viable egg or two? :(( also do they continue to grow after Ovidrel? I had my IUI 34 hours after the Ovidrel injection.

I so desperately want a child and am not sure whether I even have a chance with this IUI! Please help. V. From the U.S.A.

Answer:

Hello V. from the U.S., I have to admit I don't understand at all why your doctor triggered you at this point? Why not wait for the follicles to grow bigger? Were they not responding to max stimulation? If you weren't on max stimulation then why not increase the dosage and wait?

In general, in order to achieve maturity, we will wait until the leading follicles are at least 18 mms. It is known, however, that if the follicles reach 16 mms then there is a chance that they will be mature at aspiration (retrieval) during IVF. But, I do think that the trigger was premature with your IUI. Yes, you might get three mature eggs, but all the follicles that are less than 16 mms will be immature. With an intra uterine insemination as opposed to in vitro fertilization, the picture is different. If the follicle does not reach 18-20 mms, it is unlikely that the follicle will ovulate despite HCG (Ovidrel). They do continue to grow a little, but the follicle has not reached ovulatory size.

I hate to burst your hopes, there is always a chance that a pregnancy can occur, but in general, I would not expect you to achieve pregnancy with this cycle because the trigger was premature thereby lessening the chance that ovulation will occur. I think you need to have a serious talk with your doctor and ask why he triggered so early! Was it a scheduling issue i.e. you would have reached maturity on the weekend and he would not have been able to do the IUI? Real infertility doctors work the weekends as necessary. I know that one of the local Ob/Gyn's in my area does not work the weekends. He cancels the cycle or turns it into a timed intercourse cycle if it falls on the weekend. If this is the case, I think you need to consider whether you want to continue to expend time and money on this doctor.

Good Luck,

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

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