Saturday, December 22, 2012

Sixteen Year Old Does Not Have Her Period Yet: What To Do?

Question: Hi, writing from Califonia!

My name is E. and I am 16 years old, will be 17 on June 9th, 2013. I'm 5'9" and I am overweight, but not terribly obese or anything. I have always been active, and I have been a swimmer since I was 7.

I am wondering if something is wrong with me. I still have not gotten my period. Ever. I just feel so out of place when my friends are all talking about theirs and I just stand there. I don't understand why I haven't gotten it yet. I have pubic hair, I have leg hair, armpit hair, I have breasts, and sometimes I see that my underwear is like a light brown (and it smells weird, but not terrible) but it has never been red.

My Dr. told me that if I don't have it by the time I'm 18 then to come in for some tests.

I just wish so badly that it will have it already. Is there anything I can do? Could this in anyway help the process of it starting?

I heard that drinking lots of green tea can help?

Could it be me being overweight? I am currently in the process of losing weight and I have lost 15lbs so far. I also heard that it might have been because my mom breastfed me for longer? She nursed me until I was 3, not a lot after the first year, she said it was normally just to get me to sleep.

Please help! E. from California.


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

Since you have secondary sexual characteristics (pubic hair etc.), that means that your ovaries are functioning and producing estrogen. It may just be a matter of time now before the periods start, but it is a little unusual to not have periods by 17 years old. I don't agree with your doctor. This is something you might want to talk to you mother about and urge her to allow you to see a pediatric endocrinologist, adolescent gynecologist or reproductive endocrinologist. These are all specialists with more advanced training in hormones than your regular pediatrician or family practice doctor. A blood test can be done to check your hormones to make sure there is not something amiss. Medicine can also be given to help you start periods, or if your hormones are unbalanced, to help balance them.

Having a hormonal imbalance can cause long term side effects, like facial hair, that is not reversible so I would not recommend doing nothing.

As a side note, don't buy anything on the internet that says it does something medical. Anything that is medically effective has to have FDA approval and then it is sold in a pharmacy or doctor's office. Only non-medical items can be sold via the internet to non-medical people.

Thank you for writing and try to see a specialist soon. Good Luck,

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

Monterey, California, U.S.A.

Monday, December 10, 2012

Second IVF Fails Despite Implantation: Thin Lining? Embryo Issue?

Question: Dear Dr. Ramirez,

I am here to seek your advice once again. I just found out my second IVF (in vitro fertilization) attempt finished with a chemical pregnancy. I tested HCG levels at 11dp2dt and it was 19,2 miu/ml (pretty low), and 48h later it was already 4,7 miu/ml.

I am nearly 37yo, have high FSH levels and my antral follicle count was 12 for this past cycle, 8 follicles grew, 6 were collected and 4 eggs retrieved. We got 100% fertilization and we transferred two 8-cell embryos with perfect morphology and no fragmentation.

I think my biggest problem is my endometrium. It is usually very thin. Although I still have 2 frozen embryos from my first IFV, two transfer cycles were cancelled due to thin lining that would never pass 6.9mm. I tried estradiol patches, vaginal estradiol (creme and pills) which resulted in poor endometrial growth (estradiol levels reached 3500pg/ml in one cycle) even after 3 weeks of use. I also tried vaginal viagra, vitamin E, baby aspirin, prednisone, and nothing worked... the endometrium would grow up to 5.5 to 6mm in the first 8-9 days of the cycle and then would take 14-21 days to reach 6.9mm. In one of the cycles it even decreased 1mm in one week.

Before my first IVF I did a hysteroscopy and everything looked fine. I have a couple small intramural fibroids, none projecting into the uterine cavity. I had a big fibroid removed 4 years ago, but it was intramural and the endometrium was not touched during surgery.

So, in my last IVF that turned out as a chemical pregnancy, my endometrium was 7.1mm at the 6th day of stimulation with FSH (Bravelle), which was really encouraging. However, 2.5 days later, it decreased to 6.4mm... Because at that time I already had bid leading follicles, my doctor wanted to triger that night. He then injected into the uterine cavity, using a catheter, 300 ug of filgrastim (G-CSF), since there are two papers from Dr. Gletcher that mention it as a possible treatment for thin lining. My RE explained to me it was experimental and I agreed to try it.

48h latter and on the time of egg retrieval, my endometrium was 7.6mm. Still not ideal, of course, but the best I got in a long time, so my RE advised us to carry on with the transfer (2 beautiful 8-cell embryos).

So my questions are:

1)What is more likely to be the cause of the chemical pregnancy: genetically abnormal embryo or my thin lining?? I know my age is a factor, but I have been taking Coq10 for nearly a year now. My embryos always look good and I have 100% fertilization rate.

2) Also, I wanted to know if it is normal to have a 8-cell embryo at the end of day 2 (I collected the eggs on Mon 9am and the embryos were transferred Wed 6pm).

3) Is it normal for the endometrium decrease during stimulation phase? What could have caused mine to go from 7.1 to 6.4mm in a little over 60h?

3) Do you think I should try filgrastim on my next transfer cycle? I don´t think my body likes synthetic estradiol though, it never responded well... so maybe a natural cycle (in which I usually reach 7mm) with filgrastim could work?

Taking my history into account, what would you recommend for my next FET in order to be suscessful in overcoming thin lining? Should I start to look into surrogacy?

As always, I really appreciate your time and expertise, and most of all the beautiful work you do here at your blog (for which I am a subscriber :)  C. From Brazil

Hello C. from Brazil, Thank you for your kind words and for following my blog! Let me answer your questions in sequence to make it easier.

1. If endometrial thickness were the problem, implantation would not have occurred. Technically, the minimum endometrial thickness required is 6.5 mms so your lining was adequate for implantation to occur, which did happen. The miscarriage was most likely a genetic issue considering your age. Unfortunately, we do not have a technology to evaluate internal egg quality nor change the quality. Keep in mind that the CoQ 10 study was in mice and not humans so we don't know if that will work or not.

2. An 8-cell embryo on D#2 is not normal. That is a rapidly dividing embryo and may indicate that it is genetically abnormal, as has been found on preimplantation genetic studies in the past. Division rate is one of the criteria I use to evaluate embryos, in addition to the external quality.

3. The endometrium does not decrease. The difference in widths are variations in ultrasound measurements. Because we are dealing with mms, the difference between 7.1 and 6.4 (0.6) is within the margin of error and not significant.

4. I cannot comment regarding the "filgrastim" as I am not familiar with this medication or its usage. I would recommend that you consider the frozen embryo transfer in a natural, unmedicated cycle, but I would follow a natural cycle without transfer first to evaluate if your body growth the endometrium to adequate width. Then if it does, I would schedule to make do the transfer in the next cycle. I would still use supplemental hormones after the transfer, namely progesterone to help support implantation and the early pregnancy.

5. If the FET fails, despite everything that has been done, the only other recommendation I could make, if you are still going to try your own eggs, is to have preimplantation genetic screening done (trophectoderm biopsy) on a Day #5 embryo. Some studies have shown increased pregnancy rates in older patients when embryos are screened for normal genetics. That will at least give you an indication on the genetic health of the embryos you are making and whether or not you should consider donor eggs. I would only recommend surrogacy if you are absolutely sure that you cannot get implantation and in your case, you've had implantation. I think it might be more of an embryo issue.

Good Luck,

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

Sunday, December 2, 2012

40 Year Old TTC After Termination Of Trisomy Pregnancy

Hello, Doctor.

I am a 40 YO who has never had any trouble conceiving. I've been pregnant seven times. I had a child when I was 37; all went fine.

My husband and I are TTC (trying to conceive). GYN did an AMU (.86) a year ago. He said there was little hope. Nevertheless, I was pregnant in January, but the CVS @ 11 weeks revealed a double trisomy (13/21). We terminated the pregnancy.

Beginning with that particular pregnancy I have experienced pronounced pg symptoms within days of fertilization. They are symptoms I would expect to arise @ 6 weeks. I have had these symptoms each month when my husband and I try (with the exception of one month). My assumption is that I am experiencing hormone surges, but I have my period on time, and I have not had a positive urine test. I have tried a "control month" of abstiinence, and there were no symptoms. Also, no symptoms one other month (although we had tried).

I had a hormone panel on day 3 of my cycle, and another when I had begun to experience the nausea, tenderness, food aversion, fatigue, etc. GYN reported that the baseline was totally normal (FSH 3 and all other #s in range). The second test indicated that levels had changed, but still in normal range and not consistent with pregnancy. He has no explanation for these symptoms U/S's have been clear. No cysts or fibroids.

I did not experience these symptoms with my daughter or any other pregnancy.

I began taking lamictal in 09 150mg daily and .5 Klonopin daily. The addition of these meds and age are the only variables. My dx is Bipolar 1. I have found no research that supports either medication as interfering with implantation. The genetic counselor said the meds are a nonissue.

I have wondered if perhaps the procedure with the trisomy situation has harmed me somehow. My GYN said I never should have been able to implant an egg so defective.

So it seems, now, I will continue to experience these incredibly uncomfortable symptoms every time I fertilize an egg although my prospects for implantation seem dismal. I get all the bad stuff and hope for a good result that doesn't materialize.

Any words of wisdom would be appreciated.  Thanks, S. from California


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

Your symptoms are confusing and not easily explained. First, you cannot tell whether or not fertilization takes place. That occurs within the embryo and nothing within the body is changed at that point. You would not have symptoms. It is possible that the symptoms you are having are "hormonal shifts" or physiologically the result of the rise in progesterone in the luteal phase. Why would you be more sensitive to this now than before? I can't clearly explain that but you are also older now than you were before so maybe that had something to do with it. Normally, the pregnancy symptoms don't begin until weeks after implantation occurs, so it is unusual. But the progesterone is the culprit for PMS (premenstrual syndrome) which does have some of the symptoms that you describe. I don't think it was the D&E (dilation and evacuation).

Your doctor is right and wrong about the trisomy. It is well known that age is a significant factor and leads to increased numbers of embryos with chromosomal abnormalities. This leads to infertility and increased miscarriage rates. In most cases of complex or multiple abnormalities, the embryo never gets to the point of implantation. But if the defect is not significant enough, as in trisomies, implantation can occur but then most will end in miscarriage. Few will continue to the point where genetic testing finds the abnormality but they do occur.

As you continue to attempt pregnancy you have to remember these facts. Due to your age, it will be more difficult for you to get pregnant, you have an increased risk of miscarriages and an increased risk of abnormal embryos. Aside from your one successful pregnancy, you note that you have had six that miscarried which is troublesome. You have what we call "secondary infertility". Since there is no technology that can change the quality of your eggs, the only way to increase the chances of a successful pregnancy in older patients (over 35 years old), is to increase the number of eggs that have the opportunity to implant. This is done by increasing the number of eggs that ovulate (superovulation) or through IVF (even higher numbers of eggs). In addition, with IVF, genetic testing can be done on the eggs to eliminate the ones that are genetically abnormal so that only normal embryos are transferred. This is just food for thought.

I hope I was able to ease your concerns.

Good Luck,

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

Tuesday, November 20, 2012

32 Year Old With Two Failed IVF Cycles With Positive Beta's: Chemical Pregnancies?

Question:  Hi Doctor,
I live in Idaho where we only have 1 IVf (in vitro fertilization) clinic, so I don't have the option of a second opinion and can't decide if it's worth the six plus hour drive to find out if anyone else would do anything different so I really appreciate you reading this.

A quick medical run down is my infertility was both blocked tubes which 3 years ago I had opened, since they've been open I developed endometriosis which I had cleared last September. I am 32 years old with no medical issues. I have had 8 failed IUI's before finding the endo and then 4 failed IUI's since clearing it. I did have one pregnancy with the IUI but they thought it was ectopic and it aborted itself. I have just completed my second failed IVF. By the way DH has all "normal" counts and morphs for his samples. Both protocols for meds were the same I took Doxycycline and Medrol right after ER (embryo retrieval) and started Progesterone vaginal inserts day after ET (embryo transfer) and was on prenatals and baby asprin the whole time. Both transfer's were done with guided ultrasound with no complications.

1st IVF-September 2012. 10 eggs,10 matured, 4 embryo's fertilized (no ICSI) 1-six cell, 3-eight cell all grade 2's. Two embryo's transfered, last 2 died on day 6 before making it to blast. First beta was 9, second 32, then on day 11 I started spotting,cramping and clotting. Day 13 beta was 7.

2nd IVF-November 2012. 21 eggs, 18 matured, 13 fertilized with ICSI, 1-eight cell grade 1, 6-eight cell grade 2, 4-seven cell grade 2, 1-nine cell grade 2, 1-two cell grade 3. Transfered 2 embryo's back (one was hatching) and cryopreserved 6. Beta test 1 was only a 3 and then the second beta nothing improved. I started bleeding day 11 again.

I have not yet met with my RE but I am trying to gather all the info I can before meeting with her. This last fresh cycle will have been the last one that I think I will do just because the stress on my body of being on meds off and on for 3 years now I think is too much. So the 6 frozen are very important to me to use wisely. I read that you said a chemical pregnancy is not an implantation problem so does that mean that you think it would be a problem with the embyo's? My RE felt last time that there was no need for genetic testing and that my endo was not an issue. I'm just lost as to what my next step should be, what to test for or what I should do with my remaining embryo's (gestational carrier or gamble with them). Thank you again for your time, your blog's have been so much help for me while searching for answers. M. from Idaho, U.S.A.


Hello M. from the U.S. (Idaho),

Once you get a positive bHCG, that means that implantation occurred. To be more specific, it means that after the embryo was transferred into the endometrial cavity (the limit of what IVF can do), the embryo progressed in its development, hatched out of its shell, attached to the endometrial lining and the lining grew and enclosed the embryo. These last steps are all natural steps that we do not have the technology to make happen. They have to happen on their own. The take away message from this is the knowledge that you can achieve a pregnancy with IVF. The ensuing problem, of miscarriage, is a pregnancy issue. Whether or not the embryo progresses to developing a successful pregnancy and ultimately a normal and healthy baby is based on the pregnancy alone.

Miscarriage is a more common occurrence than people think. We know that up to 50% of pregnancies can end in a miscarriage, many of which are chemical pregnancies like you had. In most cases of early miscarriage, the reason is because of an abnormal embryo, meaning the embryo had some sort of genetic abnormality. In most of these cases, it is a spontaneous abnormality that occurred at the time of embryo division and not something that you carry. But just to make sure, you and your husband might want to undergo genetic testing if you have not already done so.

One other thing I noticed is that your embryo quality, based on its external appearance because we don't have the technology to know the internal quality, was not optimal for someone your age. This could be related to an inherent problem with the eggs, sperm or lab conditions. In a woman under the age of 35, I would expect most of the embryos to be 8 cell, grade 1 embryos. Genetic testing in the embryos, PGS, is an option but I too would not have recommended it in your age group. In addition, PGS may do some harm to the embryo thereby reducing your pregnancy chances. You'll need to discuss this further with your doctor.

I don't think that any of this has to do with your endometriosis, which is not an issue with IVF.

Ultimately, because you have achieved chemical pregnancies, you have to keep in mind that the IVF can work. Now it is just a matter or time, or more specifically, a matter of getting the perfect embryo. That will take continuing to try and ultimately I am confident you will be successful. It is unfortunate that you only have one option for an IVF clinic in your area because pregnancy rates vary highly from clinic to clinic. That may be another option i.e. travelling to another clinic. We call that distance IVF where patients travel to another state to have the IVF done. It is easily coordinated and arranged so you don't have to limit yourself to one option only. There is more that can be said or advised, but a thorough review of your medical records would be required.

Good Luck,

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

Comment: I was amazed at the timely response and all the information given. I feel confident that the Dr. is giving a knowledgable response as well as very honest without pushing his own clinic which was comforting. Thank you again for your time.

Monday, November 12, 2012

Woman Has Two Failed IUI's With Donor Sperm: Needs An HSG


I am a 35-year-old woman writing from Missouri. My husband and I have been trying to conceive for 15 months. After we'd been trying for a year, we went for testing, and my husband was found to have no sperm. We decided to move forward with donor sperm. I had some blood work done (thyroid, progesterone checked) which was normal/ovulatory. I also had a sonohysterogram and endometrial biopsy to investigate my heavy periods; neither of these tests revealed any problems.

So far, I've had two IUIs (intra uterine inseminations) with donor sperm. Neither has been successful (though I had a 21-day progesterone test after both that confirmed ovulation). My doctor is having me use Clearblue Easy OPKs to determine the timing of the insemination. The clinic does one insemination per cycle. Is this the typical procedure? I'm concerned about getting the timing right.

I haven't had a HSG (hysterosalpingogram) test yet. I asked about scheduling one just after my last failed IUI and the secretary indicated that I wouldn't be able to do an IUI and HSG in the same cycle. I'm not sure why. So I don't know whether to do another IUI this cycle, or have the HSG. Any recommendations? What are the risk factors for blocked tubes? I've never had an STI or HPV, if that is relevant.

I know that even though we've been trying a long time, due to my husband's infertility, we've only really had two chances to get pregnant. Psychologically, though, it feels like this has been going on forever. The fact that I'm 35 just increases my anxiety (especially since we'd love to have two children eventually). How many IUI cycles would you recommend before moving to IVF?

Thank you so much. I have appreciated your blog and your thoughtful answers to others' questions for a long time.

K. from Missouri, USA

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

Using only one IUI per cycle is acceptable and used by many infertility specialists and Ob/Gyn's. It is really the doctor's preference. If you've been reading my Blog ( you will see that my preference is two IUI's per cycle (24 hrs and 48hrs). There are two schools of thought regarding this matter and studies do not endorse or disprove either method, so either method is fine. I like to have fresh sperm as close to ovulation as possible and so that is the reason for two since it cannot be known exactly when ovulation occurs. However, using donor sperm, that would be more expensive.

I would not attempt another IUI without having done an HSG. In fact, I would not have recommended an IUI without first having done this test. This is because if your tubes are blocked, for whatever reason, the IUI's will fail. Sometimes women can have mucous blocking their tubes and the HSG can unblock them.

In general, the recommendation is to do no more than four IUI's because most patient will be pregnant by 4 attempts. After four attempts, the pregnancy chances drop drastically, probably because there is something else going on. You have an age issue so you don't want to waste a lot of time. Has your husband had a testicular biopsy to determine if he is making sperm but it is just not getting out? If you decide to pursue IVF, that is something you might want to have done by a Urologist to check and see if you can have a child with his genetics. The sperm, if he is making it, can be aspirated (TESA) and used in IVF to inject into the eggs and fertilize them.

Good Luck,

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

Monterey, California, U.S.A

Comment: Dr. Ramirez, Thank you for taking the time to answer my question. My husband and I both appreciate your helpful, thorough response very much. We feel much more prepared for our next visit with the RE. We now know the questions we want to ask and the direction we'd like to go. Again, thank you. K. in MO P.S. Your blog is very helpful too!

Saturday, October 27, 2012

High Responder Fails Two IVM and Two IVF Cycles: PCOD & Follicle Maturation Issues


During the last year we did two IVM (in vitro maturation) and two IVF (in vitro fertilization) cycles at different clinics at Montreal, Canada. All failed. I'm 39 years old and my husband is 40. My FSH was 11.1 and AMH 2.2 two years ago. The first IVM was without stimulation, I was triggered when the lead follicle was 13mm, 11 eggs were collected, 7 managed to mature in the lab and 4 fertilized. By the day 3 we had transferred 2 embryos 6 and 8 cells (they did not give us their grade). Endometrium was 6.8mm by the day of collection. No pregnancy...

The second IVM I had 3 days light stimulation (about 150UI Puregon days 3-5 + Estrace from day 6). I was not aware of my hormone test that shown the E2 level fell on day 6. We had collected only 8 immature eggs from 17 follicles, the only egg fertilized and on the second day the weak embryo was transferred. Endometrium was 7.3mm. Of cause, no pregnancy.

We moved to another clinic and did there two IVFs. The first one I had stimulation from the second day: 225 Gonal-F + 75 Luveris. After 4 days dosage was increased up to 300 Gonal-F + 150 Luveris. On the day 13 I was triggered when I had one follicle about 22mm, 2 about 18mm, and many smaller ones. We collected 16 eggs, 12 were mature, 9 fertilized. My doctor decided to wait till day 5 for the transfer. We had one blast, the other embryos stopped developing. The lining was 8.2mm at the day of transfer. No pregnancy.

As the clinic doesn't work during weekends, the stimulation for our second IVF started on day 4 and lasted 9 days. It was more aggressive: 300 Gonal-F + 150 Luveris from the start and about 200 Gonal-F + 150 Luveris at the end as I had developed mild OHSS. I was triggered when my follicles were 1-19mm, 1-18mm, 3-16mm, and many 15mm and less. As I said the clinic doesn't work weekends. My collection was Friday. I asked to wait for follicle growing bigger and the answer was: no, they are big enough. We collected 25 eggs, only 13 were mature, and only 5 fertilized. They were stopping developing one after another. The last one stopped at day 6 on the morulae stage. The lining was perfect: 13.5mm. It was an epic failure: nothing to transfer... I was told that the issue is my egg quality (my husband has no issues with his sperm).

I see that I had the only follicle bigger 20mm at the collection and we had the only blast. So I really would like to understand whether it's not a coincidence? If there is a way to have more equal size of follicles by changing the protocol? If I'm a good responder and have many eggs and they usually fertilize good (if they are mature) but they stop developing - does it mean they are poor quality? Or they were not fully mature at the day of collection? As I'm getting older and we have no time to experiment with different protocols I would like to maximize our chances by using more effective protocol for our next attempt. It would be great to hear your opinion on it. Could the change in protocol give us better chance for success?

Thank you in advance! O. from Canada.

ANSWER: Hello O. from Canada,

I can't give you specific protocol recommendations because each doctor and each clinic do different things. There is no one way to do IVF as you have found out.

The latter stimulation cycles show that you are NOT a poor responder but a high responder with PCOD tendencies. That means your ovaries are very sensitive to stimulation and that is a good thing. Yes, your age and therefore your egg quality are issues. However, hope is not lost because there is a chance that you still have a few good eggs left. As long as your ovaries respond well to stimulation, your chances of finding the good eggs are high. However, it also means that you need to find the right clinic because pregnancy rates will vary highly depending on the skill of the clinic and factors such as when to retrieve. I think it is a mistake to go to a clinic that only does egg maturation, and a clinic that doesn't work weekends. Both clinics are short changing you. It's time to find a better clinic.

It is also known that when OHSS develops, the pregnancy rates also drops. Probably because the majority of the eggs are not adequately matured. So one goal would be to decrease the stimulation and try for fewer eggs and a longer stimulation to get higher quality eggs. That is my goal with patients that are high responders. One method I use to try to even out the stimulation is to use the "sandwich protocol" which is to use 2-3 days of antagonist prior to starting the stimulation (I don't use the long Lupron protocol)to suppress the ovaries so that the follicles all start at the same point. Not all doctors use this protcol.

One final note: I let my follicles reach 20 mms before trigger. In some cases, I'll go up to 24 mms on the lead follicles if there is some unevenness, the goal of which is to try to get as many mature eggs as possible. Again, these things/variations are what make clinics and doctors different. You need to find a clinic that has a respectable pregnancy rate for your age group (and that will stay open on the weekends) so that you don't waste any more IVF cycles.


Dr. Ramirez,

At first, thank you very much for your fast and detailed response.

I've forgot to mention that our infertility is unexplained and I always have a lot of follicles at any given cycle (the first time we asked medical help for infertility 4 years ago).

Today I've got some new details about my IVFs: first time the E2 was about 8000 at the day of trigger and progesterone was about 4. The second time E2 was more than 22000 and progesterone was 6.4 so that my doctor didn't wait anymore and triggered me when the lead follicle was still 19mm (and not because they do not work weekends, as he explained). Is it possible that the E2 level could compromise egg quality the second time?

My doctor told me that assisted hatching is not possible for a blast as it can be easily damaged. Do you agree with that? Is assisted hatching used for day 3 embryos only?

Also my doctor is tended to wait for a blast and do 5-day transfer as he believes it would give stronger embryo and higher chances of implantation. As I see we had many good-looking embryos on day 3 and 1 or no blast at day 5. Would it better to transfer at day 3 instead?

Thanks again for sharing your knowledge

Regards, O. from Canada.


Hello again,

You have to understand that my advice is my personal opinion and not necessarily the gold standard or generally accepted standard because there are many many variations in the stimulation portion of the IVF cycle. But let me give you my opinion.

Both cycles led to overstimulated cycles. If the peak E2's are correct, you went very very high and in the U.S., in general, we don't like the E2 to go above 4000. Yes, it has been shown that when hyperstimulation occurs, i.e. the E2 goes above 4000, there seems to be a decline in egg quality and pregnancy rates.

You don't necessarily have a diagnosis of "unknown" infertility. You have the "age factor" which means that your egg quality could be compromised based on your age. That is a diagnosis. My approach to transfer is to use D#3 transfers unless I have so many good D#3 embryos that it is harder to determine which ones to transfer. In that case I will proceed to D#5. I am not a big D#5 person because I don't think that it is an absolutely perfect technology and we probably lose some good embryos because of it (that has been shown by genetic testing of the embryos on D#3). Not all blastocysts are genetically good embryos. Because of your age, I don't think it makes any difference which day you transfer, but I would prefer to put back more and let nature decide that the lab. YES, assisted hatching can be done on blastocysts.

The only other option that might help you, is to consider preimplantation genetic screening so that only normal embryos are replaced. I would also recommend tranferring at least 4 embryos because of your age. PGS might decrease your pregnancy chances a little, depending on the expertise of the clinic, but can help you to distinguish the genetically normal from the abnormal. PGS can be done on D#3 or D#5.

Good Luck,

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

Comment: Dr. Ramirez gives detailed and clear answers. He is extremely helpful and very knowledgeable.

Saturday, October 13, 2012

40 Year Old UK Woman Trying IVF After Implantation Failures: Assisted Hatching & PGD?

dear doctor ramirez, i am so glad to find you on this website and would very much appreciate your help. I will try to give you some background.

i have had 3 failed iui, then found problems with my fallopian tubes which led to bilateral salpingectomy, myomectomy, adhesiolysis and cornual tubal occlusion, left ovarian cystectomy, i also have fitz hugh curtis syndrome.

so then after recovery from the above op i had

one fresh ivf cycle - 18 follicles, 14 eggs collected, 8 fertilised, 3 day transfer of 2 embryos(8 cell, grade 2)on 18/10, started bleeding 30/10

fet - 19/3. 2 embryos transferred (5 cell grade 2 & 7 cell

grade 1-) Negative test 4/4

fet - 9/8. 2 embryos transfered (6 cell grade 3/3 & 3 cell grade 4/4) Negative test 24/8

on each occassion as you can see i had 2 embryos put back (blastacysts on the last fet) and all failed at implantation stage. these were in 2006 & 2007.

now in june 2012 i have started my ivf journey again. so far:

low amh result (i am 40 in october)

2 new fibroids found on ultrasound, advised to proceed anyway

down regulation extended 1 week as lining not thin enough

stim injections all went to plan

15 follicles (2 v large suspected to be cysts)

10 eggs retreived

7 fertilised

7 made it to blast but one left to perish as structure wasnt great.

2 fantastic blasts put back after using embryoscope which i was told had started collapsing which was explained as a very good development.

4 frozen.

so, 2 put back in and progesterone pessaries used one morning & 1 night.

day 5 post transfer sign of period.

evening of day 6 post transfer period definately started with heavy bleeding & clots, continued until today (day 9pt) flow seems to be slowing down.

negative test today 9dpt

clinic advised me to continue with pessaries and re-test on saturday (day 11 pt)
theres the background for you, so here are my questions:

1. why am i failing at implantation stage every time?

doctor says it just nature but i cannot help feeling something else could be wrong and i am running out of time

2. is there any kind of contraception or other medication that i could use to stop producing eggs, thus preserving the small reserve i have left?

3. what tests can i have done to rule out ANY other problems? ie immunology, uterine probs, endometrium probs?

4. fibroids-what should i do have them removed or is there any medication available that may shrink them before my next fet

5. assisted hatching-could this help?

6. pgd (preimplatation genetic diagnosis)?

7. having read my history but you advise i do????

if need be i will pay for any tests that they wont complete at my clinic. i feel if i can rule all other possible problems out then i can admit that yes it is in gods hands and just a matter of keep trying but at the moment i feel what if there is something else that is being overlooked?

many thanks for your help in advance doctor.

as you can see i am getting pretty desperate now!

lisa, uk


Hello Lisa from the U.K.,

The term "Implantation failure" means that the last two steps of the reproductive process did not occur. These last two steps are natural steps and we do not have the technology to make them happen. That is why IVF is not a perfect technology. Once the embryo is placed into the uterus, the embryo has to hatch out of its shell and attach to the endometrial ining. Then the endometrial has to engulf the embryo (implantation). So either of these two steps could have been the source of failure. In addition, it is well know that pregnancy rates will vary from doctor to doctor and clinic to clinic because the transfer technique can play a significant role.

In your previous cycles, your embryo quality was poor. I am not surprised that they failed. In this last cycle, despite having good blastocysts, there is still a potential deficiency that they have. This is because of your age, or what I refer to as the "age related egg factor." We know that as the eggs age, the internal structures of the egg become more debilitated and so less likely to thrive. One of these deficits is the chromosomal structures are more brittle and can lead to chromosomal abnormalities as the cell is dividing. Without doing genetic testing, these cannot be detected. Even chromosomally abnormal embryos can turn into good looking embryos but not necessarily into pregnancies. That is another possible source of failure. IVF helps to overcome this problem by increasing the number of eggs retrieved and therefore, statistically, increases the chances of finding the perfect egg. But that does not occur every time. You will have to keep trying in the hopes of finding the perfect egg eventually. The good thing is that your ovaries are still very responsive (you don't have decreased ovarian reserve and stimulate well), which gives you a good chance.

In terms of your other questions, I would not do anything with the fibroids, any birth control pill can stop your ovaries from going through the ovulatory cycles and hopefully preserve your eggs and I can't think of any other testing. Without thoroughly reviewing your medical record, however, it is difficult for me to give you specific advice.

I would recommend assisted hatching as this has been shown to increase pregnancy rates in older patients. I would also recommend that you scrutinize your clinic, because of all the failures. Pregnancy rates can be very clinic and doctor dependent. You should try to find one that has good pregnancy rates for your age group. I am getting a 57% pregnancy rate in 40 year olds and many of the clinics in the U.S. are getting similar results. I would also recommend that you consider transferring more than two embryos (we allow up to 4 in 40 year olds).

You faith in God will help you through this, and eventually it will happen. You may have to change course at some point and look at a different approach, but your faith will get you to that dream of having a child. When I complete my embryo transfers, I say a prayer with each of my patients and ask God to bless my couple with fruit of the womb and grant their wish for a child. I am confident that he will do so as He wills it.

Good Luck

hi doctor

thank you so very much for your speedy and detailed response, it has set my mind at rest on a lot of points. it is interesting to be told that the quality of the embryos on our cycle a few years ago were of poor quality. although that is sad, at least now i can accept that maybe that is why we failed on those 3 occassions. i had been under the impression that the embryos were good quality, particularly on the first fresh cycle after egg collection.

i have read lots on assisted hatching and am glad you agree this may be a way forward for us.

can i please just take a few more minutes of your time to clarify my point on pgd & other test (point 3&6)

When you mention checking the quality of the eggs/embryos were you suggesting asking our clinic to go ahead with pgd for our next fet?

also what is your opinion on other testing such as Natural Killer cells, immunology, uterine/endo probs? Which of these or any other tests would you suggest i rule out before going ahead with our fet?

also you mention my ovarian reserve being good but i was under the impression that the AMH test i had done suggested i was on the bottom level in terms of my remaining eggs? this has confused me slightly?

thank you in advance.

many many many thanks for you time again. Lisa


Hello Again,

There are pros and cons about using PGS. It can help to identify embryos that are chromosomally abnormal so that you can be more selective in the ones that you transfer. The downside is that there is a decrease in pregnancy rates, probably because of the impact of the biopsy on the embryo.

I check certain immunologic testing on my patients that fail two or more IVF cycles. The tests I choose do not include natural killer cells because I don't believe in that concept as a source of implantation failure. Despite this testing, I also automatically place my patients on low dose aspirin, low dose heparin and medrol, as well as, increase the progesterone supplementation. The latter is the treatment for patients that have endometrial biopsy for beta integrins and find that they are deficient. I figure, why waste money on doing the test and just cover any ways, since increasing the progesterone is the treatment.

Remember that AMH is an "indirect" test for ovarian reserve and does not necessarily predict how you will respond. Your have already shown good response so it is not an issue.

Good Luck,

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

Monday, October 8, 2012

Smoking And Infertility


Dear Dr. Ramirez,

I'm 18 and I just started smoking, but I'm afraid it will effect my ability to have children. I know smoking can cause cancers, but in females, does smoking cause permanent infertility? A friend of mine told me it just causes temporary infertility, and since I'm 18 and no where near ready for a baby, I wasn't too worried. But I do want to have children when I'm older. Could you please help give me advice on this? A. from Georgia


Hello A. from the U.S. (Georgia),

Smoking does not cause permanent infertility but has been shown to affect fertility i.e. reduce the chances. More importantly, it can cause other permanent diseases such as lung cancer, heart disease, throat cancer, stroke and deep venous thrombosis. Smoking at the time of pregnancy can lead to poor fetal development, poor fetal outcomes and other complications.

Because smoking reduces the blood vessel diameter (vascularity), it affects the chances of pregnancy by reducing blood flow to the implantation site, developing embryo and placental flow. There is also an increased risk of miscarriage.

I hope that gives you enough reason to stop while it is still easy to do so. Keep in mind that smoking is a ADDICTION and gets harder and harder to stop with time.

Good Luck,

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

Sunday, September 23, 2012

A Step By Step Guide To The IVF Process: Step Seven -- Embryo Transfer

Embryo Transfer
Dear Readers: This is the seventh and final part in the series I have begun to help answer what In Vitro Fertilization (IVF) is and how it works with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I also hope that this will not only clarify what you will go through, but explain why things are done in a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series has been posted over the past weeks in installments. (For earlier installments in correct order scroll down to the beginning of July 2012)


In my previous entries, I have been discussing each of the steps involved in In Vitro Fertilization (IVF). By this point, the ovaries have been stimulated with fertility drugs to recruit and grow follicles, where the eggs are located, these follicles have been aspirated to retrieve the eggs, the eggs have been put with the sperm and allowed to fertilize and the fertilized eggs, now embryos, have been cultured and allowed to grow. We are now at the step where the embryos have to be returned into the womb (uterus) for the final stages to occur so that a pregnancy can result. Embryo transfer is essentially the last step for IVF and the farthest this technology can take us to influence whether or not a pregnancy can occur. This is the step that replicates the natural step where the embryo enters the uterus. From that point, the embryo has to hatch out of its shell and attach to the uterine lining, and then the lining has to grow around the embryo, which is implantation. At that point, beta HCG hormone will be produced and testing for this hormone will be detectable by blood testing. This is a positive pregnancy test. So, as you can now understand, IVF is NOT a perfect technology and, in reality, cannot get make you pregnant. It can help you to become pregnant or expedite the natural process. It still requires your body or nature or God to influence the final steps so that a pregnancy can ensue. Because of the limits of current technology, we cannot yet attain 100% pregnancy rates.

Failure after the embryo transfer of good embryos is often referred to as "implantation failure" but this is not necessarily the cause of the failure. There are many little steps in this final process, which I will explain, that influence whether or not actual implantation will occur. If you fail an IVF cycle, it may not necessarily indicate that there is something wrong with you. It could be the embryo’s fault, the doctor’s fault, the uterine lining’s fault or your body’s fault. Unfortunately, there is no testing that can be done at this step to help with the specific identification of what did not occur and so it is lumped into one big category, “implantation failure.”

The exact protocols and procedures done at the embryo transfer step can vary widely among clinics. They can vary even among doctors in the same clinic. I’m sure that I will not be able to explain all or cover all variations, because many are clinic, country and physician specific, but I will mostly cover the protocol that I use, and of course, think is the best way. But don’t fault your doctor if they don’t do it the same as I do. I’ll try to generalize as much as possible.


In most clinics, the doctor doing the transfer will meet with the patient to go over the findings of the embryo culturing and reveal how many embryos are available to transfer, what they look like and give some type of recommendation as to how many to transfer. The number to transfer will likely depend on the patient’s age, the quality of the embryos (based on their appearance) and specific regulations or laws governing the clinic. An example of the latter is that many European countries with a large Catholic base disallow transferring more than one embryo. In the U.S., we don’t have a specific law or regulation that restricts the number of embryos to transfer, but most clinics are members of the Society for Assisted Reproductive Technology (SART), a division of the American Society for Reproductive Medicine (ASRM), which over sees IVF, and the society has specific recommendations for the number of embryos to transfer for each age group and based on embryo quality. This was put into place because of the desire and need to reduce the incident of multiples (twins or higher) that occur with IVF. When evaluating clinics and their pregnancy rates, that is something you may want to look at. Studies have shown a near equivalent pregnancy rate with single embryo/blastocyst transfer but all those studies don’t look at per cycle rates but cumulative rates. That is, it may take two to three cycles to get the same pregnancy rate as a clinic that transfers two to three embryos in a single cycle. But it seems that those single embryo transfer rates are getting better and closer to multi-embryo transfer rates per cycle. Eventually we will probably have the technology to identify the perfect embryo in its entirety so that we can just choose one to transfer and not have to hedge our bet by transferring more than one. At this point in time, we don’t have that ability. So this is one aspect of IVF that you might want to check on when choosing an IVF clinic, that is, do they have a policy that restricts you to single embryo transfer (SET) and what is their per cycle pregnancy rate.

Prior to the embryo transfer, my procedure is to meet with the couple and do a review of the cycle up to that point, explaining each step and the results. I then show them a chart that indicates where each embryo is in terms of the number of cells they have attained to that point, and the quality based on how they look (grading). I also show them a chart that has tracked their development each day so that we can see how each embryo has evolved and to verify that they are dividing at a good rate. This latter chart or evaluation is important because it is one way to help determine which embryos are behaving as healthy embryos versus ones that are not dividing well, or unhealthy. This also helps to eliminate embryos from being transferred and that are eligible for freezing. I will then provide them with a counseling sheet, that they sign, that shows what the SART recommendations are and what category they fit into based on their age. I also give them my personal recommendations and share my multiple gestation rate based on how many embryos were transferred (this is based on cumulative data over the 18 years I have had my clinic and when we were transferring a lot more embryos than we do now). I am not yet personally confident about single embryo transfer and so do not encourage it unless a patient does not want to take the risk of a twin pregnancy at all. I average transferring two embryos now and try to follow the SART guidelines. I rarely do single embryo transfers but again, keep in mind that this is a personal preference and I don’t like to risk a failed cycle with my patients. There are many clinics that now only do single embryo transfers and, as long as their pregnancy rates support that decision on a per cycle basis, then that is fine. If their per cycle pregnancy rates suffer because of this policy then I feel they are not taking the patient’s emotional and financial risks into consideration.

Because I usually transfer two to three embryos, I make sure to explain the risks associated with a multiple gestation, especially the risk of loss of the pregnancy due preterm delivery, as well as, the complications that can cause the pregnancy to be a hardship for the patient. Ultimately I believe the patient has the right to make the decision, since they are paying for the procedure, but, at the same time, I will not allow them to go overboard on how many to transfer and make a poor decision, so the ultimate decision is a combination of their choice, as well as, my endorsement of that decision. Once we have had this discussion, we then decide which specific embryos to transfer. Due to the lack of any other technology to help us decide which embryos are the best embryos, we will choose the two embryos that look the best (highest grade) and have been developing appropriately. In my consultation sheet, I indicate which two embryos this will be so that the embryologist knows what we chose. I then also recommend what to do with the remaining embryos as to whether to freeze, culture further or discard them. I then indicate those specific choices as well on our transfer form. Finally, the patient signs this transfer form to verify their choices since, after all, the embryos belong to them and we need their permission to do anything with their embryos.


In this step, clinics will vary highly so this is only a guideline based on what I do. It may not be the only way or the way your doctor proceeds. I put on sterile gloves and then measure the embryo transfer catheter and mark how far the catheter should be inserted. This measurement is based on the MET (mock embryo transfer) that I did prior to the start of the IVF cycle. Before the ultrasound was used to verify the position of the catheter (ultrasound guided embryo transfer), this measurement was the only way that we knew where to put the embryos. Fortunately, someone was smart and astute enough to think to use the ultrasound to help identify the position of the catheter within the uterus, which I think immensely helped increase pregnancy rates. Since doing ultrasound guided transfers, I have had many situations where I changed the position of the catheter beyond the original measurement based on the ultrasound visualized position. In any case, I still mark the position on the catheter just in case I am unable to visualize the catheter by ultrasound, which can happen in heavier patients, patients with retroflexed uteri and patients without sufficient urine in their bladder. It’s my back-up.

The embryologist will then come to the transfer room and I will give her (it’s a her in my clinic and this is not intended to be sexist), and recite the name of the patient and the number of embryos to be transferred. The embryologist then repeats that information back to me. This is my protocol for verifying the identity of the patient and to make sure the embryologist knows who the patient is as well. From this point, the embryologist returns to the laboratory to load the appropriate embryos into the catheter. Some clinics with multiple embryologists might have an additional identity verification step in the lab when the embryos are being drawn into the catheter where a second embryologist recites the name of the patient and confirms that the identifying information for the embryos is the same as the name they’ve recited. Our embryos are strictly identified as to which incubator they are in and where in the incubator they are placed, as well as, identifying information on the Petri dish. The petri dishes are placed apart and in unique positions i.e. different incubators, different racks and different positions on the rack, so that they don’t get mixed up. All that information is noted in the embryologist’s log. Verification of all this information is part of the embryo identification protocol.

In the meantime, I then prepare the patient for the procedure. The patient is placed into the lithotomy position, the same position as doing a pap smear. In the center where I trained, the patient was placed either on her tummy with the bottom up or on her back in the lithotomy position based on whether the uterus was angled up or toward the back. That type of positioning has not been shown to make any difference in pregnancy rates so I just use the one lithotomy position. In patients with a uterus that is angled up (anteverted or anteflexed), I will tilt the bed a little more so that the patient’s head is lower than her bottom but not so steeply that she is uncomfortable. Again, using sterile gloves and sterile technique, a sterile speculum is placed into the vagina. I will then irrigate the cervix and surrounding area with culture media using a forceful but gentle squirting technique. No antiseptics are used because this can kill the embryos. Next, I remove my first set of gloves and help position the abdominal ultrasound transducer to find the uterus, and make any adjustments I need to make to the ultrasound machine. My assistant has been trained to do this as well and holds the transducer in the proper position. That frees me up to do the transfer procedure. Because the ultrasound sound waves have to pass through the abdominal tissues of fat and muscle to reach the uterus, there has to be adequate filling of the bladder for the sound waves to pass through and get deep enough to see the uterus. Too much filling is just as bad as not enough because it pushes the uterus further back and farther away from the ultrasound transducer. A bladder that is uncomfortably full can also cause bladder spasm, causing pain, and uterine contractions which will adversely affect the chances of pregnancy. Inevitably there are cases where we can’t proceed with the transfer because the bladder is not full enough and therefore have to allow the patient to drink and fill her bladder, or have to have the patient go to the bathroom to let out some urine or sometimes use a bladder catheter to drain some. But if the bladder is filled properly, we can see the uterus and, more importantly, the endometrial lining so that we can see the catheter pass within. We are then ready to proceed with the transfer procedure.


By now, the embryologist returns to the transfer room with the loaded catheter. As she enters the room, she again recites the name of the patient for verification. Both I and the patient acknowledge that she is correct. I then put on new sterile gloves, since I will be handling the catheter with the embryos. Since most uteri are angled, and since I already know the specific direction of the patient’s canal based on the previously performed MET that I have documented on an MET form, as well as, what I know from her previous ultrasounds, I will usually need to put a curve in the introducer. I use an embryo transfer catheter that has an outer sheath (introducer) through which the catheter passes. The embryo transfer catheter is very very soft and without an introducer, would get stuck in the crevices of the cervical canal. The introducer helps it to pass through the canal and get into the endometrial cavity. I put the curve in the introducer after the catheter has been pulled back a bit so as not to squeeze the catheter inadvertently (that would be very bad because the embryos could be pushed out from that pressure). Sometimes in doing the transfer it can take several attempts to place the introducer because it can take several attempts to get the right angle, or the introducer doesn’t hold the angle long enough. I then advance the introducer into the cervix to the point of the internal cervical os but not farther. I do not advance the catheter with the embryos through the introducer until I know that the introducer is in the proper place, just beyond the internal os. I don’t want any resistance or difficulty advancing the catheter, which could influence pregnancy rates.

The technique of the embryo transfer is one of the most important steps in IVF. I cannot emphasize that enough. It is this technique that usually causes varying pregnancy rates among doctors. This step is important because even if you have the most beautiful and healthy appearing embryos, if the transfer is not done properly and with utmost gentleness, pregnancy will not occur. Many studies have been done comparing transfer techniques among Physicians and even among Physicians in the same group and found wide variations in pregnancy rates. This is attributed to the technique of and gentleness of the embryo transfer. It is absolutely critical that no bleeding is induced, because blood is toxic to the embryo, and that the back of the uterus is not touched, which can cause uterine contractions leading to failure. For this reason, I consider it very important that the Physician doing the transfer knows your uterus because he/she has done the MET before and practiced the transfer, and is not learning your cervical canal and uterine cavity for the first time. This point is especially important if you have a very deviated, curving or abnormal cervical canal. This is a problem with many, if not most, large IVF clinics because you may have the transfer done by a doctor that has never met you due to their cross-coverage schedule.

I also think that this is where experience is very important. You want to choose a doctor that has done a lot of embryo transfers. A recent study in the U.S. found that a Fellow (an Ob/Gyn doctor undergoing specialty training) graduating from an infertility fellowship (advanced training) in the U.S., has only done an average of three embryo transfers. That would be like a new doctor that has only done three cases in a specific surgery. Essentially, they are not yet expert in that technique or surgery and therefore still need to “practice”. I agree that all doctors need to gain experience when they are just starting out, and most fellowship programs are unable to allow an untrained doctor to learn on their cash paying patients, but if you have a choice and since you are spending $10,000 or more for this treatment, just like with surgery, wouldn’t you want the doctor with the most experience so that you have the best chance of success?

To continue: so now, the introducer is in place and the catheter is very gently fed through the introducer into the endometrial cavity to a point that had been pre-measured. The ultrasound also helps to see the catheter tip to verify its location and make sure that it is in the proper place. If the catheter is seen as not in the proper place, then the position is adjusted to put it in the correct position. Technically the catheter is not placed all the way to the end of the endometrial cavity. Studies have shown that the optimal placement is 0.5 to 1 cm from the top of the endometrium. The embryos are then very slowly injected into the cavity. The embryos are within a bubble of culture media so that fluid injected can be seen but the embryos cannot because they are too small. I then allow the embryos to settle for 30 seconds but that is how I was trained. Other doctors may just quickly remove the catheter which is okay as well. Studies show no difference. From this point, I tell my patients not to move, cough, sneeze, laugh or talk above a whisper in order to minimize abdominal pressure on the uterus. Again, this is a precaution I take but probably is not an absolute necessity. I then return the catheter to the embryologist and she returns to the lab to verify that the embryos have been expelled. Sometimes embryos will reflux back into the catheter. Studies have shown that if the refluxed embryo is returned to the uterus immediately, pregnancy rates will drop because of the likelihood of disturbing the embryo that remained. In some cases, the previous placed embryo can be aspirated with the second procedure and be injured. For this reason, my recommendation is not to do a second procedure to replace the refluxed embryo. It is left out and allowed to be frozen. I have already counseled my patients about this possibility in the pre-transfer counseling so the plan is already set. The only situation where I would repeat the procedure is (1) if all the embryos refluxed and there are none left inside, which can occur when mucus plugs up the catheter opening, or (2) if the best embryo refluxes in a group where several embryos are being placed and the other embryos are poor quality (as in a patient that has a low number of embryos to transfer).

Once the embryologist informs me that there were no refluxed or retained embryos, we then place the patient in position to rest for 30 minutes. It is my protocol to have the patient rest after the transfer, more for psychological reasons than medical reasons. In fact, studies have shown no differences in pregnancy rates if the patient rests or gets up right away. Since the patient is in lithotomy (pap smear) position, and we don’t want the patient to use any muscles to move into place, I put the table into a head down or trendelenberg position (this is where the patient is tilted to be head down). In this position, I and my assistant have the assistance of gravity to easily slide the patient up to the top of the bed without the patient pushing. I then return the bed to a flat position so that she can rest.

From this point in the overall IVF treatment, the patient continues the medications that were started at the time of the egg retrieval to support the luteal phase and prepare the endometrium for implantation. Again, these medications and hormones are to help with the implantation step but cannot make implantation take place.

So now the IVF procedure is essentially done. There are no other techniques or procedure to be done because this is the extent of the technology. The process is again a natural process from this point. The embryo needs to continue developing to a blastocyst, if it was a day #3 transfer, needs to hatch out of its shell, attach to the endometrium and then the endometrium needs to engulf or grow around the embryo (implantation). Failure at any one of these remaining steps can cause failure in the cycle. As mentioned previously, if the transfer is not done well, then despite having the very best embryos, failure will occur. Also, if the embryo does not continue its development to the blastocyst stage then that is the end of the process; or if the embryo does not exit (hatch) from its shell, then it will not be able to attach to the endometrium and that is the end of the process; or if the endometrium does not engulf the embryo because it is not in the correct anatomical form, timing is not correct, or other possible factors that we don’t completely understand, then the process is at an end. Any of these factors can lead to what we refer to as “implantation failure” and is the reason why we often don’t have solutions for failure at this step. Some people might ask about “assisted hatching” which I have not explained yet. Assisted hatching is where a small hole is placed into the shell of the embryo. All it does is give the shell a defect where the inner embryo can emerge from, but the process of emerging or hatching is still dependent on factors within the embryo. So having assisted hatching does not guarantee that the embryo will in fact hatch out of the shell. However, in older eggs, where we know the shell is often too thick or if the embryologist measures the zona (shell) and finds that it is too thick, it may be a good idea to have assisted hatching done.

I would also like to mention some technologies that have been advertised that are not yet verified and accepted universally. One of those is laser drilling of the endometrium, where a small laser is introduced into the endometrial cavity to make a hole where the embryo can be placed. You need to understand that implantation is NOT the embryo making a hole and burying itself into the endometrium, rather, it is the process by which the endometrium grows around the embryo. As logic dictates, making a hole probably does nothing to help the process. A second technique that I have heard of is using “embryo glue”. I don’t have detailed information about this “glue” since it is proprietary, but again, this may help the embryo to stabilize itself in a certain point in the endometrium, but it does nothing to help the embryo hatch out of the shell or help the endometrium to grow around the embryo. So, again logic dictates that it doesn’t make sense for this to help with implantation. As a result, and expectedly, neither of these techniques have been shown to be of benefit in any legitimate studies.


So we have now come to the end of the IVF procedure and the maximum that our technology can help a person to achieve a pregnancy. We are at the point where we have to wait to see if the next steps happen on their own. If a day #3 transfer was done, it will take approximately 7 days for the remainder of the process to be completed and for the pregnancy test to be positive. For that reason, I do my pregnancy tests at 8 or 9 days post transfer. For a blastocyst transfer, you only need three more days to get a positive pregnancy test. I know that some clinics want to be absolutely sure so they wait for 14 days but the problem with that protocol is that an early chemical pregnancy will be missed, and in my opinion, it is important to know if a chemical pregnancy occurred or not. This event is important to know because it verifies that the patient can become pregnant with IVF and that the last steps actually occurred. With that knowledge the patient can be reassured that this treatment can work, that her body can do what it needs to do, and it is just a matter of getting a perfect embryo into her womb for her to be successful. The majority of chemical pregnancies occur because the embryo is genetically abnormal. It would be good to know that those last steps, those steps that are beyond our technology, can occur on their own.


Before I leave the patient to rest after the embryo transfer, I say a little prayer because I know that this is the point where God takes over, and so I will leave this prayer for you to use if you wish to pray to whichever God you believe in: “Dearest Lord God, Bless this couple with fruit of the womb and Grant their wish for a Child. We ask this through your Son, Jesus Christ. Amen”. I hope that this series has been valuable to your understanding of the process that you will be or are going through, and I wish you the best of luck and blessings to eventually realize the wonderful dream of having a child. It may seem very expensive, arduous, stressful and emotionally draining but when you are successful and hold that baby in your hands, you will realize that it was more than worth what you went through.

My mother used to always tell me that “if you want something bad enough and it is something very valuable, there will be no easy way to get there and you will have to work harder for it.” She was referring to careers and my desire to become a doctor, but as a former IVF patient, I know that this same advice applies to doing IVF as well. It is neither an easy path nor a guaranteed path. With the technology that is now available in fertility treatments, the only thing that can cause you to ultimately fail is yourself, when you give up trying. Otherwise, if you are open to all the options available and want a baby bad enough, you only have to choose to keep trying, consider all your options, revise your strategy and not forget to look forward to your goal, the success in the end; holding that new baby, and not the failures of the past or the path you had to go through.

God Bless you on your journey.

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA

Tuesday, September 4, 2012

A Step By Step Guide To The IVF Process: Step Six -- Embryo Development

Dear Readers: This is the sixth part in the series I have begun to help answer what In Vitro Fertilization (IVF) is and how it works with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I also hope that this will not only clarify what you will go through, but explain why things are done a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series will continue to be posted over the next few weeks in installments. (For earlier installments in correct order scroll down to the beginning of July 2012.)


At this point, we have gotten the eggs out of the ovaries, put them with the sperm or injected the sperm into them and fertilization has occurred. Each of these steps has lead to a decrease in numbers from the original number of follicles. Not all the follicles had eggs retrieved from them, not all of the retrieved eggs were mature and therefore could not be fertilized, and not all of the mature eggs fertilized or fertilized normally. So now we are left with a cohort of embryos that have fertilized normally and are ready to grow and develop into embryos that can be transferred.

At the end of fertilization, normal embryos are in a 2PN stage, or two pronuclei and is one cell. These are placed into special media that provides the proper nutrition for these early embryos to grow and develop. This is key for the growth of embryos. Embryo culture media has been researched and developed over the evolution of IVF technology, researching and finding the proper combination of chemicals to mimic the intratubal environment. In the natural process, the embryo is within the tube and develops and divides as it makes its way down toward the uterine cavity. So the culture media has to match the media that would be found within the tube. In addition, the environment, such as gas ratios and temperatures, have to match as well. So the requirement for embryo development is to have the proper nutrition within the Petri dish, the proper temperature within the incubator and the proper gas mixture within the incubator as well. Also, the embryo needs to be protected from airborne contaminants outside of the incubator. These factors are so critical that they will influence the success rates of an IVF clinic.

Many embryology labs, such as mine, are designed and constructed to the standards of a “clean” room, such as that used in Silicon Valley for making silicon chips. The airflow within the room is isolated. In other words, the airflow is completely separated from the air outside of the room so that there is little contamination from in the outside. In my lab, the airflow is set to be a positive flow, meaning the air pressure within the room exceeds the pressure outside the room so that when the door is opened the air pushes out rather than allow the outside air to push into the lab. In addition, the airflow within the lab is cleaned by a HEPA filter and Charcoal filter to filter out small particles and chemicals, called VOC’s or volatile organic compounds. VOC’s are the fumes or gasses you can smell after a room is painted or a road is repaved, but there are VOCS’s that can’t be smelled as well. These chemicals can kill or injure embryos so that they don’t continue their development. Finally, the embryology lab temperature must be maintained so that when the embryos are taken out of their warm environment to be checked, their temperature does not drop abruptly. When choosing an IVF clinic, it would be wise to ask about their lab set up and, if possible, tour the lab to see how well the environment is. Many centers have certification by the College of American Pathologists (CAP) which means they have undergone a survey, which includes evaluation for many of the aforementioned criteria for labs, and have passed and received certification of their lab.

If all of the above quality controls are in place the embryo can proceed with development to a stage where they can be transferred into the uterus. The embryo actually can be transferred at any point in its development, but time and research has identified the two optimal embryonic ages as day #3 or day #5. These are the two ages that most IVF centers in the world use in their transfer protocols.

So, by the day after fertilization (48hrs after retrieval) has taken place, the embryo has developed into a 2-4 cell embryo, in normal development. Sometimes embryos will have progressed further than 4 cells but that can either be because the evaluation of the embryo was later in the day (48hrs) or the embryo is developing faster than expected, which could be an indication of an abnormal embryo. Embryos are also examined for external features and a grade is given. There is no universally accepted standardized method for grading but they are all essentially similar. They are all based on the external or “morphological” characteristics of the embryo as viewed through a microscope. Almost all labs will count the number of cells that the embryo has on that particular date, up to the Morula stage where individual cells are no longer visible. They will also give it a grade (A,B,C or 1,2,3) based on the clarity of the embryo. That is, the amount of fragmentation or debris located within the cell. These fragments are pieces of tissue that have been extruded in cell division. Although cells with high amounts of fragmentation have been related to decreases in pregnancy rates, that is not an absolute. I have had the worst looking embryos lead to pregnancy, as have many other clinics. But, we know that most successes come from cells that either don’t have any fragmentation or a minimal amount. Finally, most clinics will look at the symmetry of the cells; do they look fairly equal or are there larger and smaller cells. In my practice, we use a simple 1,2,3 grading system where the embryos are evaluated for fragmentation and symmetry, and the combination of those two factors lead to a grade. Some clinics break these down and give two grades for each embryo; one to represent fragmentation and one to represent symmetry, and some use letters instead of numbers. In 2010, the Society for Assisted Reproductive Technologies released guidelines for grading embryos in the hope of standardizing this among IVF centers within the United States. In their system, cleaved embryos (those before morula stage) are evaluated for the number of cells present, fragmentation (0%, 1-10%, 11-25%, >25%) and cell symmetry (perfect, moderate asymmetry and severe asymmetry). Embryos are then given a score of Good, Fair or Poor.

The biggest disadvantage of current embryo evaluation methods is that it is essentially a beauty contest, so as I explain to my patients, Grade A or 1 or Good is “beautiful”, Grade B or 2 or Fair is “average” and Grade C or 3 or Poor is “ugly.” We know that most pregnancies come from Grade 1 or 2 embryos and only Grade 3 embryos have a decrease in pregnancy rates. This method does little to evaluate the internal quality of the embryos, which we know is really the main determining factor for embryo health or viability. That technology is yet to be developed. Embryo chromosomes can be determined by removing one of the cells and checking for its chromosomes, a procedure known as Preimplantation Genetic Screening (PGS/PGD), but this still does not evaluate the structures within the cytoplasm, or outside of the nucleus where the chromosomes lie, which are the structures that provide the energy for the embryonic cell. When looking at embryos to decide which to transfer, not only must the embryo appearance be taken into consideration, but its development rate must be considered as well, as an indirect measurement of embryo health. I’ll discuss this decision more in the next step.

To summarize the stages of development, at 24 hrs after egg and sperm have been put together (day of retrieval), the embryo is a 1 cell 2PN; at 48 hrs (Day#2) it is 2-4 cells; at 72 hrs (Day#3) it is 6-8 cells; at 96 hrs (Day#4) it is usually a compacting Morula; at 120hrs (Day#5) it is a Blastocyst. There is some variability to this development scheme as embryos do have differences in rate of division. In a natural (non-IVF) cycle, the embryo is usually at the Blastocyst stage when it reaches the endometrial cavity. In IVF the transfer is done either on Day#3 or Day#5. Because of the political pressure to do more single embryo transfer cycles, or 1 embryo transfers, many clinics are now culturing to Blastocyst stage before doing the transfer. This is because culturing to Blastocyst stage leaves less embryos to choose from and MAY indicate a healthier embryo, but the latter conclusion is not an absolute.

In my center, I have specific criteria to determine whether or not to proceed to Blastocyst. One of these criteria is that there has to be a minimum of 8 good quality embryos (7-8 cell, grade 1) because I know that many embryos will not make it to Blastocyst, and that is not necessarily because the embryos are bad. In doing PGS, I have seen Blastocysts turn out to be chromosomally abnormal embryos whereas an embryo that did not survive to Blastocyst had normal chromosomes (PGS usually is done with Day#3 embryos and takes two days to get the result so by the time the result comes back, the embryos are Day#5). I have also seen ugly poor looking embryos (4 cell, Grade 3) lead to pregnancies when transferred at Day#3 that would not have survived to Blastocyst. My reasoning is that Blastocyst culturing is not a perfected technology yet. A clinic that puts only a few embryos at risk to develop to Blastocyst is basically risking the cycle by not having anything to transfer. For that reason, I want to make sure that there are enough embryos to start with so that there will be embryos to transfer. In addition, it is still my personal belief that the uterine cavity is a better culture environment and media than what we have available in the lab. For this reason, most of my transfers are on Day#3, but I have colleagues who now transfer mainly Blastocysts. So, when looking at these transfer options with your doctor, ultimately the decision has to be made based on pregnancy rates at Day#3 vs Day#5 transfers and not just because you only want to transfer 1 embryo.

In the next entry we’ll discuss embryo transfer and the decisions that go into this step, as well as, the critical parts of the transfer technique.We will continue this discussion soon with the next installment, "Step Seven: Embryo Transfer". Thank you for joining me today!

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA

Thursday, August 16, 2012

A Step By Step Guide To The IVF Process: Step Five -- Fertilization

Dear Readers:

This is the fifth part in the series I have begun to help answer what In Vitro Fertilization (IVF) is and how it works with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I also hope that this will not only clarify what you will go through, but explain why things are done a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series will continue to be posted over the next few weeks in installments. (For earlier installments in correct order scroll down to the beginning of July 2012.)


In the previous step, the eggs were aspirated and retrieved from the ovaries, the equivalent of ovulation in the natural process. These eggs have been collected and the embryologist now isolates each egg within a petri dish. The eggs are prepared for the fertilization step. In the natural cycle, after ovulation, the egg needs to pass through the culdesac of the pelvis to find the fimbria of one the tubes. In the normal anatomical position, the fimbria of the tubes are lying within the culdesac. If there is scar tissue within the culdesac or the anatomical positions of the tubes are altered, then this “pickup” step may not occur. This would be an indication to do IVF. If this does not occur, then that is the end of the process in that cycle. If it does find the tube, it is then brought into the tube and through peristalsis (muscular motion) within the tube it is pushed to a portion of the tube where the sperm need to be waiting to accomplish fertilization. Again, if the sperm are not there, then fertilization will not take place and the cycle ends at that point. If the sperm is in the correct position at the correct time, then sperm attach to the egg and one sperm penetrates the egg to accomplish fertilization. In IVF, these two steps are accomplished by laboratory means, so there is little chance that those steps will not be accomplished. This is another step that IVF accomplishes for your body, thereby enhancing your chances of success. It is not left to chance as in the natural process.

At this point, there are two ways to accomplish fertilization. It can be allowed to occur by natural means, meaning the sperm can be added and the egg-sperm interaction allowed to happen on its own, or it can be assisted, also known as ICSI or "intracytoplasmic sperm injection". In order for the fertilization process to occur, a sperm needs to penetrate the outer lining (shell) and enter the egg and then there is an elaborate process within the egg whereby the nucleus of the egg and the nucleus of the sperm unite. This latter process is the actual process of fertilization. Just putting a sperm into the egg is NOT fertilization. The second part of the process, a natural step, has to occur on its own. In other words, just doing ICSI is not fertilizing the egg and does not guarantee fertilization. ICSI is just putting the sperm within the egg so that fertilization has the possibility of happening.

If natural fertilization is going to be done, the egg and sperm are put together and the sperm is allowed to penetrate the egg on its own. But if injection of the sperm is going to be done, then the embryologist removes the filmy lining of the egg, called the cumulus. This will also allow evaluation of the maturity of the egg. Only mature eggs, in Meiosis stage II, can be fertilized. Eggs can be in either Meiosis stage II (M2), Meiosis stage I (M1) or Germinal Vesicle (GV) stages at the time of retrieval. As explained previously, the follicles, and the eggs within, don’t all mature at the same rate. That leads to some larger follicles and some smaller follicles. The larger follicles have the matured eggs, eggs that have had the time to mature, and the smaller follicles have immature eggs. As a result, eggs in the various stages can be retrieved, but only the mature ones will fertilize. In the case of Meiosis stage I eggs, these can be left in culture and allowed to mature, if the clinic has an egg maturation program and the proper media in place, or in some cases, just waiting will allow the egg time to mature to the mature Meiosis stage II. They can then be fertilized at that time. So with ICSI, an anatomically normal appearing and swimming sperm is identified and aspirated into a glass needle. This needle is then inserted into the egg and the sperm is then injected within. All of this procedure is done microscopically. ICSI essentially assists the step whereby the sperm enters the egg. This procedure is done mostly in cases where there is an abnormality of the semen analysis, since it is known that with abnormal semen analysis, there is a high possibility of a functional problem i.e. that the sperm cannot fertilize the egg. Also, it is recommended in older patients (>37 years old) because the shell of the egg is thicker and sperm have a more difficult time penetrating the shell normally. In some cases, patients will choose to have ICSI because they don’t want to take the risk of fertilization not taking place (fertilization failure), which will essentially end the cycle at that point. Without fertilization, embryos are not formed, and no embryos means there will be nothing to transfer.

Once the eggs are put with the sperm, the petri dishes are placed into an incubator. Fertilization will take a minimum of 12 hours to occur so most clinics will re-evaluate the eggs the next morning for fertilization. It is expected that some eggs will fertilize normally, called a 2PN stage, some will not fertilize and some will fertilize abnormally (1PN or 3PN). Because of this, there will be another reduction in the number of eggs available to use. With fertilization, the egg is now referred to as an embryo. A typical threshold to evaluate fertilization is to expect a minimum of 50% of the available (mature) eggs to fertilize. If that threshold is not reached, it could be because of egg quality, sperm quality or lab quality. Only the fertilized embryos can be cultured to develop into embryos that can be transferred back into the womb, so this number essentially establishes how many might be available for transfer. Fertilized embryos are now transferred into a new culture media and placed in incubators that have a specific gas content and temperature to allow them to grow.

We will continue this discussion soon with the next installment, "Step Six: Embryo Development". Thank you for joining me today!

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA


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