Friday, April 27, 2012

You Can Do IVF With A Low AMH !

Question:

Hello Dr. Ramirez,

I am 36 and have been unable to conceive for 3 years. The diagnosis we have been given is diminished ovarian reserve. I have tried 3 IUIs (intra uterine insemination) with clomid. Each time I ovulated only 1 egg (I already ovulate on my own). I decided to move on to IVF. I went to a new clinic because they have very high success rates (30% higher than my current clinic). Over the last year, my antral follicle count has only been between 6 - 8. FSH has been between 7.6 to 9.5 (my very first cycle a year ago it was 12.5, but that was tested on day 4, so I'm hoping that made a bit of a difference). Estrogen is always low on day 3, so my FSH is not artificially suppressed. The new RE insisted on an AMH test (my previous clinic offered it, but I declined as it is not covered by insurance and wouldn't have changed my treatment plan - only possibly caused more worry - my previous clinic was okay with my decision).The AMH test came back with very bad results (2.4 pmol/L - I understand there are 2 units for measuring this and for pmol/L this is very low). The new RE says there is no point doing IVF with that AMH result. He said my chances of success are less than 2%. He said you usually get half the number of eggs of your AMH (so I would be lucky to get 1). He would only do IUI with injectables if I wanted to, but recommends I move straight to donor eggs based on the AMH test.

I am wondering if the new clinic has such great results because they exclude patients from IVF that may not respond so well OR if the doctor really does know what he is talking about and I would just be throwing money away. Obviously, I would prefer to have a chance at a biological child and wanted to move to IVF ASAP. In your opinion, should I visit another clinic that would allow me to do IVF (understanding with low AFC and low AMH, my results may not be positive) or do you think this doctor is right and it would be a waste of time to try my own eggs and move to donor eggs immediately. I know donor eggs would have a better success rate, but there is not a time limit on this option (as there is on my own eggs) so that could be a future option. Thank you very much for your time, L. from Toronto, Canada

Answer:

Dear L. in Toronto

It always angers me when Doctors draw these type of conclusions. A recent study that I read showed that despite a low AMH number or an elevated FSH, there is still a pregnancy rate of about 20%. What that basically shows, as I have always argued, is that it only takes ONE good egg to be successful. When a woman tries on her own naturally each month, she only has one egg to work with. I often get letters from patients whose doctor has cancelled their cycle because they only have 1-3 follicles. But, what if the perfect egg was in one of those follicles? FSH levels and AMH are only indirect measures of ovarian function. They are NOT measures of egg quality or your chances of pregnancy. Please see more on AMH here: Understanding Infertility: Age Factors.

Naturally, part of the statistical chances with IVF occurs from being able to get many eggs to work with i.e. more eggs increases the statistical chances. Imagine that you have a dice and want the number 6. If you only have one dice, you have a 1 of 6 chance. Two dices double your chances, three dices etc. So with IVF, since we can't predict if the egg that is retrieved will be the perfect egg, and because we don't want to have to do this over and over again due to cost, we want to have lots of eggs. But that doesn't necessarily mean it won't work if you have fewer than is ideal. It might take more than one try (statistically). But, as I ALWAYS tell my patients, who are usually older than you, it only takes one good egg to be successful.You might want to find a clinic that is more willing to work with you instead of make decisions for you. I can see that you are good at analyzing the situation and I am confident that you will make the right decision.

Good luck and don't give up!

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

Follow-Up To This Post:

Please scroll down to November 6, 2013 to see this writer's good news and how by persevering she conceived with a low AMH :)!

"I am the one that originally submitted this question to you and I want to thank you for being positive as even with the low AMH we did end up getting pregnant and are currently 4 months away from meeting our 'miracle' baby."

68 comments:

  1. Great post about IVF and low amh! This was so helpful and informative, I'm definitely going to share this with my sister. Thank you for sharing this with us!

    ReplyDelete
    Replies
    1. Agree - this was very helpful information, thank you!

      Delete
  2. This is so great to know. I am a 37-year-old with very low amh, going in for an IVF soon (after a hysteroscopy to remove a polyp). This gives me hope. Having said that, I understand that the IVF could go either way. But I don't want to give up without a fight!

    ReplyDelete
    Replies
    1. In life, you can only do the best that you can do. The outcome is not predictable and only God knows what will happen so definitely give it your all.

      Good Luck

      Delete
  3. Dr. Edward Ramirez,

    Thank you for your positive thoughts and information! I just turned 43... I have one 14 year old son. No problems then.... Been trying for about2 years. Had two pregnacies last year... lost both early. Moving on to ivf. Had first cycle cancel... dominent follicle.. and about to try again for the last ivf try..... Thank you so much!

    ReplyDelete
    Replies
    1. You are welcome and good luck, but make sure to keep your expectations realistic. IVF is not a perfect treatment or science.

      Delete
  4. Dr. Ramirez, my wife who is 37 and has low amh (.16-.3 range) has undergone 3 ivf cycles two of which resulted in pregnancies which miscarried due to trisomy 15 and 21. Subsequent trisomic pregnancies seems quite rare so we are wondering if we just had bad luck or if our eggs are bad or if it was even possible for high stimulation could have adversely affected the development of the egg. Thank you for your thoughts.

    ReplyDelete
    Replies
    1. Hello,

      What you have experienced is what we call the "age factor" or the effect of age on your wife's eggs. As a woman ages, her eggs become more debilitated leading to poor quality eggs and embryos. Many of these embryos have spontaneous genetic abnormalities due to breakage at the time of cell division. So, each pregnancy is at risk.

      This problem has nothing to do with AMH and that is just an indirect measure of ovarian reserve or ovarian capacity. It does not indicate egg quality.

      At this point, you know that your wife can get pregnant so it is just a matter of time before a perfect egg arrives. Therefore, you have two options, continue trying and hoping for a perfect egg or go to do nor eggs to eliminate the age effect.

      Good Luck

      Delete
  5. Dr. Ramirez,

    In July of 2012 (38 yrs old) I was tested and had an AMH of 0.93, a day 4 FSH of 16.4, and an AFC of 10 or 11. HSG good to go. I was told my only option was IVF due to my numbers, and that by the time I was 39 (I am 39 now) my only option would be donor eggs. I was/am sick. I have had a spot-on 28 day cycle ovulating on CD 13-14, so I thought I'd at least have a chance. I took a one year breather to deal with our grief and shock, but now I am considering IVF. I called and scheduled another AMH test for day after tomorrow. They told me don't bother another FSH, because all they care about is that it was once 16.4. I don't know if it being CD 4 instead of 3 mattered (3 was on a Sunday-lab closed). My husband and I are beyond heartsick. Is there no hope?

    Respectfully,
    Audrey

    ReplyDelete
    Replies
    1. Your AMH and FSH levels do not mean that you cannot get pregnant by IVF, rather it means that your chances are significantly reduced because the ovarian stimulation will not do well. Part of the increased pregnancy rate with IVF, especially in older patients, is by increasing the number of eggs that are available to fertilize, grow into embryos and transferred to the uterus. That is completely dependent on ovarian function and your ovarian function is reduced. However, ultimately it is YOUR choice as to whether to proceed with your eggs, as long as you understand the consequences. It is NOT your doctor's choice. It is a risk you have to be willing to take. If your doctor does not allow this, then find a new doctor. The choice that will give you the BEST chances for success if donor eggs.

      Delete
  6. Hello Dr Ramirez, thanks for answering my question. I am 38, amh level 0.5, fsh 20, drawn cycle day 3, back in. Feb 2013. Husband was told around same time that his morphology of sperm was only 3% normal. we have tried 2 iui since, and 2 IVF since then. At each cycle, I had one egg only, good lining,. first IVF cycle was unsuccessful due to early ovulation after hcg trigger. Second IVF cycle, blood preg test was negative. possibly implantation error, genetics, immune problems, technical problem with transfer... we don't know. Would like to ask you what IVF protocol would be best for me. We had grade 2 ( 1 being best) embryo transferred on day3. When should ganirelix and at what dose should be started for low amh poor responders. Can menopur use hurt by having lh thus androgens. would it help if I take melatonin supplements ( since I work night shifts) on egg quality. Should we have another sperm analysis and try iui with injectable meds if morphology is fine. Thanks..

    ReplyDelete
    Replies
    1. Hi,

      Let me start with the last question first. I would not recommend going "backward" to IUI at this point unless you absolutely cannot afford IVF. IUI has a pregnancy rate of only 2% per month in your age group. Additing injectables would do nothing to increase those chances because it is basically a natural treatment option.

      Please keep in mind that I try not to discuss protocols specifically because there is no absolutes or gold standards when it comes to protocols. There are lots of variations. However, I have been doing the antagonist protocol for over five years and, I think I know it well so I'll tell you how I do things.

      I always use a "mixed" protocol with both pure FSH and FSH/LH (Menopur). In your case I would probably use a high dose protocol (450 fSH/150 Menopur) with the antagonist. I try to hold the antagonist until the very end in order to prevent any ovarian suppression, so I wait until the lead follicles are at least 16 mms and try to get the maximum number of follicles to at least 15 mms before trigger. In most cases only 2-3 days of the antagonist are needed.

      Well that is about the most I can provide in this forum. If you want a more comprehensive consultation, I can do that and will review your medical records fully. Just contact me via my office email.

      Delete
  7. Dr. Ramirez,

    I want to thank you for answering questions - your help is so much appreciated by myself and many others.

    I am the one that originally submitted this question to you and I want to thank you for being positive as even with the low AMH we did end up getting pregnant and are currently 4 months away from meeting our 'miracle' baby.

    It wasn't easy - my first IVF cycle (natural start) was converted to IUI due to poor response (2 follicles). The second cycle (estrogen priming) resulted in zero fertilization via ICSI of 4 eggs retrieved. I switched clinics for our third cycle (another estrogen priming cycle). I was given the option to cancel as it looked like we would only get 3 eggs. I continued and we ended up with 2 embryos to transfer (5 cell & 8 cell). One of them took and we couldn't be happier.

    For the women out there with low AMH, success is possible. To find success, it may take longer, but there is a chance. I didn't think it would work for us, but am so happy we didn't give up.

    Thank you Dr. Ramirez for your advice.

    L from Toronto

    ReplyDelete
    Replies
    1. Hello Again. Thank you so for your follow up. I hope that many of my readers see and read your letter so that they understand that persistence is a key factor AND that it only takes ONE GOOD EMBRYO to be successful. That is the problem with the indirect measures such as AMH, FSH, AFC and ultrasound. For that reason, I almost never cancel a cycle, eve if I only have one follicle and egg. I have had patients get pregnant with only one. There is no way to know if that one egg is the perfect egg and cancelling the cycle absolutely eliminates the chance of getting pregnant! Women take chances for getting pregnant with only one egg all the time when they are trying to get pregnant naturally. Even with only one egg, IVF still has a higher pregnancy chance than trying naturally!

      Congratulations on your success and thanks for letting all of us know.

      Delete
  8. Dr. Ramirez,
    I am not sure if you can answer my question or not but i'll give it a shot!
    I am 29. My fsh has been 10.1 and most recently 9.7. My amh is 3.97 my afc is 15+ on one ovary and 8-9 on the other.my estradiol level was 45
    my prolactin was 10.9
    my LH was 11.1

    My husband and I unsuccessfully tried for a year to inseminate ourselves due to his inability to ejaculate during intercourse. Our first IUI in march was successful, however it ended at 10 weeks with a d&c due to a blighted ovum.
    I have done 3 unmedicated iuis and one with clomid after my miscarriage and they were all unsuccessful. I believe that most were bad timing. Can you tell me if I move to IVF, if my borderline FSH will be troublesome? I used to smoke when I was younger, about 6 cigarettes per day. The past few years, I smoked maybe one per day until the past few months when I quit. Do you think that could be the cause of my fsh being high and possibly indicating that I have poor quality eggs even though I have a lot? My husband and I are looking into ivf in January if our next 2 iuis are unsuccessful. I read research all day about high fsh and good amh but I just don't understand why it happens and if it's possible for all of my eggs to be of bad quality.

    ReplyDelete
    Replies
    1. Hi. None of the tests you have cited indicate "poor aulity" eggs. They can only be taken as indicators of ovarian function and NOTHING MORE. I put those words in capital letters because I think that many doctors give these numbers way too much credibility and discourage patients. Basically, all they do is give us an indication of how the ovary will respond when stimulated with FSH (fertility medications used in IVF). If the FSH is elevated, it usually means that the ovary already has "resistance" meaning it is not letting all the FSH in and therefore the level in the blood is higher. So what that means when you do your IVF is that you may not get lots of eggs, even though you have lots of them. However, that may not be completely true either. I have had young patients will an elevated FSH level who had PCO and instead of being ovarian resistant, they were hypersensitive. Your doc needs to use caustion.

      In terms of going to IVF, it is much better than IUI (25% PR vs 76% PR) and so you have a very high chance of success. Especially since you have been pregnant before! Also keep in mind that it only takes one good embryo for you to be successful. You don't need 10!

      So hang in there. You're going in the right direction and you will eventually be successful if you do.

      Delete
    2. Thank you so much for taking the time to reply as there are so many conflicting reports on borderline fsh. I've spent many sleepless nights over this issue!! Some drs say it's quality, some say quantity and I've even been told that fsh helps the follicle to grow which matures the egg. If there's too much fsh, the eggs will not grow large enough for the follicle to rupture and cause ovulation. I know that I ovulate each month because I temp. I commend you for what you do and for helping women like myself achieve their dreams.

      Delete
    3. You're welcome but let me clarify something for everyone. FSH stands for "Follicle Stimulating Hormone." It is the hormone that stimulates the follicle to grow. When the FSH level is checked on the 2nd or 3rd day of the period, the purpose is to see what the LOWEST level is in the blood stream. This tells you whether or not the ovary is picking up the majority of the hormone or not. So if it is elevated, this means that the ovary is NOT picking up the majority of the hormone and therefore, giving more does not necessarily result in more ovarian stimulation (follicle growth). We call this "decreased ovarian reserve" meaning the ovary is resistant to stimulation witih more FSH. Why this is important is because the "fertility" medication we use is basically FSH. If you give more and the ovary doesn't absord it/pick it up from the blood stream, then it has basically maxed out.

      Delete
  9. Hi. Thank you for answering questions! What a great thing you are doing!!!

    My husband and I tried for 12 months unsuccessfully before we went to our fertility Dr. I did 4 rounds of clomid with no success and have been on metformin daily.

    My Dr. Checked my amh levels last week and they were .22. I am so beyond sad.

    She wants me to do iui this month with injectables (I'm new to all of this so I hope I'm not saying anything wrong) .

    If that isn't successful she wants me on BC the month of January and straight to ivf February.

    Have you seen much success with that low of an amh with iui or is it a waste of time?

    Thank you

    ReplyDelete
    Replies
    1. I think that you give too much value to amh. It is an INDIRECT test of ovarian reserve or ovarian capacity. It is supposed to give an indication of egg availability and nothing more. It DOES NOT MEAN: you are infertile, you'll neve get pregnant, you have no eggs, you'll start early menopause, you will fail fertility treatments, you have to use an egg donor, your egg quality is bad. Taken alone, it really doesn't mean anything in terms of your fertility. Combined with CD#2/3 FSH, Estradiol, Age and antral follicle count (AFC), it gives us an idea of how well the ovaries would stimulate in an IVF cycle. It does not mean that IUI or simple intercourse won't work.

      In terms of your treatment, it is dependent on the problem or problems that are preventing you from getting pregnant. The treatmet has to treat the problem.

      Delete
  10. I just sent a question and forgot my age. I'm 33 amh .22. Husband is healthy in that dept.

    ReplyDelete
    Replies
    1. You are still young so your chance of success are still very high. Remember, it only takes ONE good egg to make a baby!

      Delete
    2. To follow up, I am pregnant!! Cautiously!!

      I did a FET with two embryos after my fresh IVF cycle failed. I had my HCG tested yesterday, 13 days after a 4 day transfer. My hcg was 1,389, my e2 was 2,302 and my progesterone was 17.4. I’m concerned about my progesterone. Is that really low? I am on endometrin 3x a day and I know they say that it can't be measured by blood but shouldn't my pregnancy be putting of more if it's healthy? I've read on dr google that anything under 20 can mean it is not a viable pregnancy even with an hcg as high as mine. It scares me because my only other pregnancy was a blighted ovum.

      Delete
    3. I don't necessarily believe that the low progesterone is a sign of a non-viable pregnancy, but I certainly would want it higher (preferably over 20). I would add injectable progesterone if you were my patient and do so with ALL my IVF patients. I use BOTH injectable and vaginal supplementation.

      Delete
  11. Thank you so much for the clarification as so many drs say different things about fsh. My fsh was always tested on day 4 of my cycle. Do you think there is a chance that it would be lower on day 2 or 3?

    ReplyDelete
    Replies
    1. ABSOLUTELY YES. It is checked on D#2 or 3 because that is the point in the reproductive cycle that it should be at its lowest point. From that point, it slowly increases as you move toward ovulation because the brain increases the hormone output to stimulate the growth of a follicle for ovulation.

      Delete
  12. Hi Dr. Ramirez,

    Thank you for posting this great article to give women with low amh. It gives me hope! I am not sure if you can see my questions here but I hope you can give me some guidance before I start any kind of treatment.

    I am 32. My husband and I try to conceive by ourselves for a year but no luck. I decided to start my first fertility treatment but I am overwhelmed by the information on the internet.

    Here is my most recent Day-3 blood work result: (WITHOUT any fertility medication)
    FSH was 9.2
    LH was 4.7
    Prolactin is 11.5
    Estradiol level was 68
    AMH was 0.63 ng/mL (After I took 75mg DHEA for 2 months. It was 0.21 before taking DHEA)
    AFC count: I don’t know for sure…but one cycle on Day 13 is 3 on one ovary and 2 on the other. Total of 6. (At time time I have already ovulated)
    My cycle is short. It's about 26 days.

    The first RE I met suggests me to start from IUI. He didn’t explain much, but he mentioned I am still young(?) and due to my low amh, I might be a poor responder and won’t be able to produce a lot of eggs. The second RE suggests me to go straight to IVF because I am running out of time (She also mentioned about donor’s egg, which is not what I want.)

    What’s your take on my situation? Will you suggest me to try IUI first or go straight to IVF? What is the success rate for me to have IUI v.s. IVF? Can you briefly tell me which protocol you will be using if you were my RE? I am so new to this area so I wanted to have some knowledge before I go back to the first RE to tell him I want to be more aggressive, using my own eggs. Do you think I should start with a clomid challenge test in conjunction with IUI on the first treatment cycle? So the RE can know how I react to the medicine and decide which protocol he needs to use for IVF? I just want to be sure I am not wasting the time, money or emotions by pursing IVF using the unsuitable protocol.

    Thank you very much.

    ReplyDelete
    Replies
    1. Hello.

      As mentioned in this article, the ovarian testing for FSH, AMH and AFC are INDIRECT measures of ovarian function i.e. the ovary's ability to stimulate and NOT a measure of fertility. So with this in mind, both of our doctor's are correct. Since you are only 32 years old, and assuming there are no other problems preventing you from getting pregnant (because that would change the situation), then you only need 1-3 eggs to ovulate per cycle to increase your chances of pregnancy by IUI. You would have about a 25% chance of pregnancy per cycle. Since it is less invasive and costs less, this might be a good place to start and I would not recommend more than 4 attempts (4 months). If it fails then move to IVF (76% pregnancy rate in my clinic per attempt).

      Your second doctor's opinion is valid as well because it does show a "decreased ovarian reserve" i.e. your ovaries are decreasing in its function and therefore, may eventually stop functioning. In that case you only option would be donor eggs. BUT, donor eggs is not necessary at this time. Again, because you are young, you don't need lots and lots of eggs. Just a few would be necessary to give you the 1-2 good embryos to transfer and get pregnant. Since time is of the essence, I would counsel that you need to think of IVF in the short term and not the long term. Will 1-4 months make a signficant difference? I don't think so, so I don't think you need to go straight to IVF and can try IUI first, but I would not advise that you wait 1 year or more to do IVF.

      In terms of protocols, that is not advice that I can give you. What I would use in your case may not be the same as what another doctor would use. We all use different medications, combinations and amounts of medications. There is no universally accepted IVF stimulation protocol. However, because you have an elevated FSH and decreased AMH, I certainly would be aggressive and in my case, put you on a max stimulation protocol.

      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.

      for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf. I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal. If interested, contact me via my email at info@montereybayivf.com. This service will allow you to have your own personal on-demand infertility expert.

      Delete
    2. Also, can you tell me if high hcg levels are indicative of downs syndrome? at 13 dp a 3 day FET, my hcg was 1389, 2 days later it was 4553 and the u/s that day showed only one sac. Any reason why my levels would be so high?

      Delete
    3. Not that I know of or anyone has proven.

      Delete
  13. This comment has been removed by a blog administrator.

    ReplyDelete
  14. I am a 34 year old with AMH 1.8 pmol/l and FSH 11.7. I have just been diagnosed with endometriosis as well. What are my options?

    ReplyDelete
    Replies
    1. All options are available to you, but the elevated FSH of 11.7 shows that you have a decreased ovarian potential so time is critical. In addition, 35 years old is where we have determined that age becomes a critical factor. For that reason, you probably need to proceed with a more aggressive treatment plan that attempts to achieve pregnancy in the quickest time possible. I would probably encourage IVF but the choice is ultimately yours.

      Delete
  15. Good Day and thank you so much for being so wonderful and answering so many womens’ questions. How so very thoughtful!!
    I just experienced my first IVF failure with a grade A 3 day embryo. Fortunately, I still have some frozen to use again. My RE does not seem concerned and said there is nothing wrong with me. The only other pregnancy I experienced was a blighted ovum about 9 months ago. I am reading and I believe that just because I had a blighted ovum, it does not exclude implantation dysfunction from being an issue of mine. At what point would you test for this? Also, being that I’m 30, is it possible for all of my embryos, even though they appear great and are of grade A quality, to be chromosomally abnormal. I may just be jumping the gun but I am curious as to when I should as my RE for further testing. My husband and I were tested for infectious disease, my blood count and all other day 3 labs were tested as well as CF. Everything is okay so far.
    Another random question, what is your take on acupuncture before FET? and are you more inclined to encourage SET or are you okay with two?

    ReplyDelete
    Replies
    1. Hi. There is no test for implantation failure. The diagnosis is made after several failed IVF attempts with good transfer technique and good embryos.

      I presume that your endometrial cavity has already been evaluated either by saline sonohysterogram or hysteroscopy. That is how we verify that the cavity is normal and there is nothing to impede the possibility of implantation.

      I am not a big user of SET and the studies show a decline in pregnancy rates although the overall pregnancy rates may be equivalent. It takes more attempts (cycles) with only one embryo versus two. Because of cost, my patients can't be doing several IVF or FET attempts so we try to maximize each attempt by transferring two embryos as long as the patient is willing to take the risk of a twin gestation.

      I do recommend acupuncture in my patients for IVF and FET, although I must say that I am not totally convinced of its efficacy. It does seem to relax patients which is a key factor.

      Delete
  16. Dr. Ramirez,
    I have to say that you are wonderful and to take your time to give advice to women struggling like myself, makes you an angel.
    The testing that I am referring to is the immune testing and testing for NK cells. Do you do that initially? Also, I will be transferring 2 - 8a cell embryos as long as thaw goes okay.
    My day 3 labs were as follows - fsh: 10.1, AMH 3.97, AFC 29, E2- 25
    For some reason, only 8 of my 22 retrieved embryos were mature. I believe it's because I only stimmed for 7 days and my follicle sizes were all over. However, all 8 fertilized and out of the group we had
    1 - 8a compacting - we transferred that one
    3- 8a
    1-8b
    1-6a
    2-5a
    And the remaining 7 all made it to freeze.

    ReplyDelete
    Replies
    1. Hello. I don't do NK assays on my patients. Based on the number of eggs retrieved, it sounds like you are a high responder, like PCOD patients. It those patients, many follicles are stimulated but because of unequal growth, many don't make it to maturity and release from the follicle wall. Hence a lower number of retrieved eggs.

      Delete
  17. Also,
    I think it's great that you look at the financial aspect as well. My RE just keeps telling me not to give up. I just keep telling him that I don't have an endless supply of money!

    ReplyDelete
  18. My RE froze my embryos at day 3. Most were 8 cells. First Fresh cycle failed. They thawed two 8 cell embryos and let them grow a day before FET. So I guess it was a day 4 transfer. One was 12 cells and grade A the other was an early morula. The dr (it wasn’t my regular RE) said that the chance that both would stick was high due to my age (29) and the embryo quality. However, she said that we had a 40% chance at pregnancy. I also asked since I had a blighted ovum about NK cell testing and immune testing. they don’t do that unless there is a family history. Their protocol is also to take baby aspirin and Medrol but would that help if their was an alloimmune issue? And do you think that a day 4 transfer of those embryos was sufficient?

    ReplyDelete
    Replies
    1. Hi. I think your doctor's advice and plan is appropriate. I'm not a big believer in alloimmune testing, and certainly not in a case where you have only failed one IVF cycle. IVF still takes up to three attempts in most cases because the last three steps of the process (embryo hatching and exiting the shell, attachment to the lining and lining growing around the embryo) are still natural steps. .

      Good Luck

      Delete
    2. I just want to thank you again for your input.
      Do the 3 attempts include FETs? We just transferred 2 embryos Tuesday and now have 5 frozen.

      Delete
    3. Hi. Yes, the three attempts mentioned are based on the cumulative statistical chances so FET's do count. However, keep in mind that this is based on statistics only.

      Delete
  19. Hello Dr,

    I just saw this currect RE for 2 appointments now. First appointment, he was optimistic about my chances saying I'm young currently 32 yrs old and success rate for IVF is like more than 50% or I get a refund of so many percentage. However, after my first appointment I got my AMH test and it came back as 0.83%. I'm not sure if that is related at all to my Vitamin D level as it was deficency before. He completely changed the picture of my success rate. He said only 10-360% but that's depends on my FSH and E2 level. I got my FSH and E2 tested on 3/1/14 and it was FSH 7.6 and E2 50. It was that cycle I did HSG as well and I took some herb before my period. I had it retested again on 3/26/14 and ,my FSH was 10.3 and E2 50. He then did a AFC count on day 3 and saw only 5 follicles. Three on the right which he said very small. Two on the left which is ok size. One is 12MM. He basically tells me no meds this cycle and retest AFC next cycle. He just saying that my success rate for IVF is probably less than 5% and tells me to forget about it. I'm so confused. I've never done IVF and I want to try that since my AMH is only 0.83 and I want to be aggressive but now he said to forget about it. Do you think I need a second opinion? I feel so hopeless. I did do a cycle of IUI with another RE and I was on clomid of 50mg and I was producing good 3-5 follicles. I don't understand why he won't give me injectables or anything and just tells me to forget about it. Please help. Do you know a good fertility clinic in LA that would give someone like me a chance with IVF? Thanks!

    ReplyDelete
    Replies
    1. Your doctor must not be very experienced and is putting too much credibility on these tests. The AMH, FSH, AFC and all methods to evaluate how your ovary might respond to treatment, NOT your chances of pregnancy. Certainly some of the success with IVF is dependent on the number of eggs that are retrieved after stimulation, BUT it is more dependent on having a good quality egg and these tests do not evaluate for that. Even if you only had ONE embryo you still would have a good chance of pregnancy because IVF helps 7 of the 10 steps in the reproductive process! So what if you don't have 20 eggs on retrieval? Since you are only 32 years old, your chances are still very good! In my practice it is 70% per IVF attempt. My recommendation is to go find a better RE or come to see me!

      Delete
  20. Hi recently, I was diagnoised with low AMH of 0.83 and my last FSH was 10.3 on 3/26. However, my FSH was 7 on 3/1. For whatever reason my period that month was only 26 days not sure if it has to do with HSG that was performed that month on cd12 and it some how affected my cycle since it was performed on the day I showed positive ovulation. Anyways, my new RE thinks I have very low chance but he needs to see my FSH and AFC in May. I did AFC on cd3 of this month and it was 5. He said that's low too plus I show 12mm follicle on cd3. He said no meds this cycle. I'm confused, do you know why he said no meds? Also, today is cd9 and I still don't show LH surge yet even though on cd3 there is the 12mm follicle. Do you know if I still have chance doing IVF? Do youj have any recommendation of RE that would accept someone like me to do IVF? I feel so hopeless like no doctor will do IVF based on my data. Please advise and your help is greatly appreciated.

    ReplyDelete
    Replies
    1. Hello Mei,

      I'm going to paste the answer to the question that was previous to you because it was exactly the same situation. Here it is:
      "Your doctor must not be very experienced and is putting too much credibility on these tests. The AMH, FSH, AFC and all methods to evaluate how your ovary might respond to treatment, NOT your chances of pregnancy. Certainly some of the success with IVF is dependent on the number of eggs that are retrieved after stimulation, BUT it is more dependent on having a good quality egg and these tests do not evaluate for that. Even if you only had ONE embryo you still would have a good chance of pregnancy because IVF helps 7 of the 10 steps in the reproductive process! So what if you don't have 20 eggs on retrieval? Since you are only 32 years old, your chances are still very good! In my practice it is 70% per IVF attempt. My recommendation is to go find a better RE or come to see me!"

      There is always a chance to do IVF, even if the ovaries due not respond strongly. It only won't work if the ovaries don't respond at all and that is not the problem that you have. You don't mention your age and that has a more significant impact on your chances if you are 37 years old or older, because that affects egg quality. Don't give up. Even with a poor stimulation and few eggs, IVF give you a better chance of pregnancy than trying naturally because it helps accomplish 7 of the 10 steps required in the reproductive process.

      Delete
  21. I am 37 yaers old and amh .66 , fsh 7.6 it is possible to convice using own egg through ivf?

    ReplyDelete
  22. Dear Dr Ramirez,

    I am 32 years and was diagnosed with Premature Ovarian Failure last year. My husband and I started trying for a baby 3 years ago in 2011. In the same year, all test results were normal except for low estrogen and it was discovered that I was not ovulating regularly. We had 4 rounds of IUI in 2012, of which all failed. A laparoscopic investigation in 2013 revealed I had very mild endometriosis and a partially blocked right tube and these issues were corrected during the surgery, In July 2013, it was discovered that my AMH levels had dropped to 0.7 while FSH levels remained at about 7. We had our first round of ICSI last November ( birth control in october then simulation with 225 units menopur), during which I produced top quality follicles and 6 fertilized. We transferred 2 top quality embryos on Day 3 in November and one top quality day 3 embryo in January 2014 (frozen embryo). The rest did not survive.

    In February 2014, we discovered by AMH levels had gone up to 1.4 and in June 2014, we had another round of ICSI, again with birth control and 300 units of menopur. This time I produced 7 follicles, of which only 6 were retrieved but only 2 were mature enough to fertilize. Nonetheless, these were frozen and thawed in July. On Day 5, both were morulas, with one beginning to make it to blastocyst stage and the other arresting on the morning of the transfer. Again this cycle failed and it has been so devastating.

    Our doctor is convinced we should try another cycle with my eggs and this time, he is suggesting using a testosterone patch during stimulation. However, he has also advised me that I should be prepared for the idea that egg donation is the only way to go. I would like your opinion as to whether it is worth going through the motions again and what you feel would be my chances of conceiving my own genetic child. Also , are there any more investigations we should be pursuing? If ICSI with my own eggs is still possible, will there be a higher chance of failure if we delay the procedure till next year? We live in Switzerland and tests such as genetic screening is illegal. I am really hoping to hear your thoughts soon. have a lovely day.

    ReplyDelete
  23. Dear Dr. Ramirez,
    I am 38 years old, blocked left fallopian tube, FSH ( 8-11.7), possible signs of endometriosis
    My husband 43 years, low mobility and 3-4% morphology. TTC for 3 years.
    I tried last week my First IVF:
    11 days of BCP, 5 days without medicine
    u/s: 1 follicle of 8mm possible of blood. However, dr told me was OK for stims drugs
    5 days 300 Gonal F/ 150 merional
    6th day: u/s showed one big follicle 20mm and other smalls.
    Cycle was canceled due to dominant follicle due to low ovarian response. Dr. thinks to try with small/short IVF.
    My questions are:
    - Was a good decision to go ahead with the stims meds even though I already had 1 follicle 20mm?
    - What can I do to improve egg quality? I heard about royal jelly, maca, DHEA.
    - What are your opinion about short protocols of IVF?
    - What are my options?

    Thank you so much for your big help.
    Regards,
    Lorena

    ReplyDelete
  24. Hello, thank you very much for answering my question. I am 29 and on August 2014 I was diagnosed Premature ovarian failure (I still have my periods). I have very high FSH 128 and very low amh 0,14. My TSH 2,61, TST 0,68, LH 7,61. On my first IVF (November 2014) I got only one follicle. Do I have chance to get pregnant with my own poor eggs? Or the only chance for me is to use donor egg? Is it worth trying IVF with my own egg or go straith to donor egg?
    Thank you very much!!

    ReplyDelete
    Replies
    1. If your FSH level is correct (and I would have it rechecked because POF causes both FSH AND LH to be elevated, AND you would stop having periods), then your only option is using donor eggs. I'm surprised they even tried an IVF cycle on you. However, depending on your age, one can become pregnant even with one egg leading to one embryo. It may take several attempts, however. The most efficient (cost and time) way for you to get pregnant is donor eggs.

      If you are located in the U.S., especially California, Stanford University is currently researching women with POF and have found a protein that can re-activate the ovaries enough to do an IVF cycle and obtain eggs. They found the protein that may be the cause of POF or cause the ovary to stop working and formed a blocking protein against that. They remove ovarian tissue, bathe it in the new blocking protein then reimplant the ovarian tissue. With that technique they have been able to get some pregnancies with IVF.

      Delete
  25. Quick question, my sis is in her early 40s, amh ranged within the past 6months to a year from 0.016 to either 0.04/.4 to now .11, LH on her last/5th day of her cycle is 5.1, and an fsh on her last/5th day of her cycle of 13.1. I think her last ultrasound showed either 2 or 6 follicles (can't remember which). She's slated to start IVF in 2 weeks. Is she wasting her time or should she go for it?

    ReplyDelete
    Replies
    1. Hello. The purpose of the AMH, FSH and AFC are to determine how responsive the ovary would be in stimulating for an IVF cycle because we want to get the highest number of eggs possible with increased age. If the ovaries are compromised and won't yield many eggs, then the chances of pregnancy go down significantly in older women, because most of their eggs are no longer viable. If your sis is 40+ with these numbers,then her very best option is to consider donor eggs. Other than that, she has no other choice but to try with IVF using her own eggs as that still will give her a better chance than trying naturally. Keep in mind, however, it only takes ONE good egg to achieve a pregnancy. The trick is finding that good egg.

      Delete
  26. I am 41 years old. I have been trying to conceive for five months. I have a FSH9.5 of and my AMH is .166. I have been taking Chlomid for 3 cycles now and have not become pregnant. I do ovulate taking chlomid but still not conceived. So, Thursday I will go in to do the Chlomid Challenge to see if my FSH levels are good and if the chlomid is helping. Why haven't I conceived yet? Should I use IUI next before moving on to IVF?

    ReplyDelete
    Replies
    1. Clomid is NOT a miracle drug. It only assists with ovulation and in your case, because of your age, the goal is to increase the number of eggs that you ovulate per month in the hopes that that will increase the chances of getting a good egg. I hope your doctor has advised you that super-ovulation and intercourse, the treatment you are currently using, only has about a 0.05% chance of pregnancy per month at your age? IUI would barely increase that statistic because all it does is substitute injecting the sperm into the uterus for intercourse. So, if you plan to continue with a natural form of treatment like this or IUI, then you need to be prepared that it will fail the majority of time and possibly take a while before it is successful, if you ever are successful. My recommendation would be to abandon this treatment plan and go directly to IVF. Even with IVF the chances are significantly decreased but at least the procedure gets you closer to becoming pregnant (accomplishes 7 of the 10 reproductive steps) and the pregnancy rates are at least 20% per month. If you keep looking at my blog, I have a entry that talks about the steps to achieve pregnancy and compares ovulation induction with intercourse, IUI and IVF.

      Delete
  27. Hi Dr. Ramirez, I am 39 and have low AMH (0.45) with low AFC (~6-8). I understand the importance of egg quality and am trying everything I can to improve my egg quality. I already had one failed IVF with microdosed lupron protocol (only one follicle grew) and my RE is putting me on estrogen priming protocol. She also suggested taking HGH (omnitrope - 25 mg) for 8 days during stim. After researching the internet and seeing some suggestions that taking HGH prior to stim may be beneficial for follicle development (and egg quality improvement) as well, my RE said I could try taking HGH for 8 days prior to stim if I wanted to (since it's very expensive). I want to see what's your opinions regarding HGH on egg quality and whether it should also be added prior to stim or am I just wasting my money. I also read that taking HGH every other day might work just as well. Since my RE seemed a little noncommittal regarding HGH prior to stim, I want to see what you think. Thank you!

    ReplyDelete
    Replies
    1. HGH has been around for a long time and some studies, long ago, did show some improvement. However, it has not withstood the test of time and I don't use it. In reality there is nothing that can be done to increase ovarian receptivity or egg quality. However, there have been some studies that have shown CoQ10 to help with egg quality in mice, and it doesn't cost much or have side effects, and a recent studies showed similar findings with Melatonin 3 mg at bedtime. It also doesn't cost much or have side effects. For this reason, I feel my patients do not lose if it does nothing and it if does help, then they stand to gain, so I use it will all my older patients.

      Delete
    2. Hi Dr. Ramirez, thank you for your response. Unfortunately my cycle did not yield that many eggs. Although I had a total of 9 follicles at the time of trigger (between size of 21 and 13), my RE was only able to retrieve 4 eggs, two of them did not even mature (with one of them was parthenogenic). Out of the other two mature eggs, one of them was also showing polar body. My RE told me that these are all indication of very poor egg quality. I am very devastated as I have been taking vitamins/supplements and undergone acupunctures for 3 months in the hope of improving my egg quality. I'm actually do egg freezing and is very sad that I may not be able to do that many cycles in order to freeze enough eggs for future use. Do you recommend doing another cycle to see if the result is still the same? Any suggestion re protocol? My RE was only putting me on 250 Gonal and 150 Menopur)...would increase the dosage help with the outcome? Any other supplement or medication I should also be taking? At the end, what's the ideal number of eggs I should freeze? Thank you for your help and advice!

      Delete
  28. Good Morning! Thank you for taking the time to answer so many questions for people.. this is definitely a long and stressful process..
    My story 31. unknown diagnosis. Healthy weight, good thyroid. AT AGE 29, FSH has been 10.1 and 9.7 my amh 3.97 and I have 25+ follicles on each baseline u/s.. had a miscarriage (blighted ovum) in 2013. Did IVF in 1/2014. retrieved 21 eggs, only 8 were mature??? ( not sure if that reflects bad quality) all 8 fertilized. Fresh cycle failed. had 7 frosties put 2 in Feb and started with a twin pregnancy. Lost one at 9 weeks but delivered my daughter healthy in Nov 14. we did a ESET yesterday. They thawed an 8 cell grade A. It lost a cell during thaw but was 9A the morning of and was compacting into what the embryologist said was a blastocyst? Not sure, I thought they went to morula first.
    My questions are.1. is it an indication of bad quality if I only had 8 mature eggs? I used to be a smoker.
    2. is it okay that my embryo lost a cell during thaw? Does that have any negative affects on my chances of conception? Also, is it beneficial that I have already conceived a child from this batch of embryos?
    and is it okay to do light exercise during the wait?

    ReplyDelete
    Replies
    1. Hi.
      1. The number of mature eggs at retrieval is NOT a measure of egg quality. Rather, it is most likely a measure of premature trigger. When you have a lot of follicles like you did (a sign of polycystic type ovarian response), there will be big ones and small ones. I try to get as many ovulatory sized follicles as I can and use that to determine when to trigger with HCG. Other doctors automatically trigger with the two largest reach ovulatory size. So, as you can see, if you trigger earlier, then the smaller ones don't have the time to get to maturity.
      2. I'm not sure that your D#3 embryo was good, but cannot be sure. There is increased risk of embryo loss with D#3 freeze and thaw. For that reason, most will freeze only blastocysts. They tolerate the freeze/thaw better. If you were in my clinic, I would have thawed and cultured the embryo to blastocyst prior to transfer.
      3. It is okay to exercise with a light regimen.

      Good Luck

      Delete
  29. Hi Dr Ramirez,
    I just turned 35 and have been trying for 4yrs.
    Fsh highest 31,4 and 11.8(all taken day 3)
    Amh .009
    Inhibin B 108.9
    Estradiol 47.5
    Lh 3.4
    I have tried clomid 50mg 4 cycles and femara 7.5 2 cycles
    I just did my first iui on 100mg clomid and only had one follicle but looked great at 22mm and hcg trigger. It did not work thou. I was told ivf is not an option so my RE said he would do one more iui with 150mg clomid. Shouldn't I be doing injectables as well? And is clomid better than femara and is it safe to do 150mg clomid? I am not ready for donor eggs yet but I would like some kind of guidance on how to achieve a pregnancy if possible ...please help

    ReplyDelete
  30. Hi Anna. Unfortunately, with an FSH level of 31.4, you have premature ovarian failure. This is an indication that your ovaries will no longer respond to stimulation so NO medication will help. . . not Clomid, Femara or injectables. That is probably why your doc doesn't recommend IVF. An FSH level above 20 is menopause. Therefore, the only option you have left is using donor eggs. I'm sorry.

    ReplyDelete
  31. Dear Dr.Ramirez
    Thank you for helping all these women going through these difficult situations in their lives. My story is that I'm 36. Got married at 34 but fell sick before we had a chance to try to conceive due to endometriosis. Recently found out that I have an amh of .772 and couldn't do a fsh because I have been having dysfunctional uterine bleeding due to hormonal imbalance. My RE has said too take vitamin D as I'm deficient and then come back in two months. Will this help? And shouldn't he be focused on getting my bleeding to stop so I can try naturally as well. I feel like time is running out and I need to be aggressive and so does my doctor.

    ReplyDelete
  32. I am 40 years old, no children just got married and we would like to try. Since we are apart due to citizenship issues, we decided to make our 1 month together higher chance by going straight to IVF. I had all the blood tests and everything was normal: DAY 2 FSH 5.8, LH 4.9, TSH/AMA/etc were all normal as well. Ovariam vol by transvaginal U/S was 5.9 ml R, 5.0 ml L. Last blood test came today AMH was 6.6 pmol/l. This is the one I am worried about. I found one chart that says 6 and over is in normal range, and several which say 1.1-6.9 is reduced fertility. The ranges listed on the report say 1.1-6.9 is 'reduced response' predicted for IVF. That means I am in the reduced response ranges (but at the higher part of that bracket?) and at least I am not in the 'very reduced response' category... do I still have a chance with IVF? This is our only chance because....
    I told hubby I would try IVF but I will never go to donor eggs because I could not deal with looking a child every day that was genetically his and another woman's - but that I was forced to carry. I would feel left out and like I was not the Mother. And nothing will change my mind on that. I'd actually rather adopt that way both of us would be adoptive parents. It's more the idea that I would be looking at a child that was my husband and another woman's.... so basically if we can't try IVF with my eggs, then its a no go all together unless we outright adopt. So is 6.6 pmol/l still workable for stimulation?

    ReplyDelete
  33. Dear Dr Ramirez,
    I'm currently in an IVF cycle at the Navy Medical Center San Diego. My cycle was cancelled today because after 9 days of stims I only have one egg growing. I started with 8 follicles. I'm on a Microdose Lupron protocol, 20u am/pm, 2 vials Menopur in am, 300u Gonal-F pm. I'm 37 with AMH ranging from 1.6 to .3 (it's varied so much over the past two years. I'm devastated because we have been trying to conceive for 3 years and I've been waiting to do IVF for so many months, due to a long wait list at NMCSD. My doctor old me IVF isn't an option unless I use donor eggs. I just can't accept that. If I go to a private clinic, it will cost $20k and with military it's $4k. I need a new game plan! Any suggestions would be appreciated!

    ReplyDelete
  34. Dear Dr Ramirez

    It would be great to get your advice on my experience so far.

    I've never had a successful pregnancy. I've now had 3 MC all within 1 year. They were all very early, I can't seem to get past 6 weeks. I'm 37 and my partner is 39. I've had private testing and so far the only thing that has come back is a AMH low of 9.5, but considering my age I imagine this is realistic. My doctor seemed positive and said to leave it another 6 months and then we could consider IVF. Do you think there is anything else I can do to improve my chances naturally , any vitamins I can take? My tests for blood clotting came back normal but I've read a lot about baby aspirin - could this be beneficial to take? I didn't meet my partner until later in life so I couldn't have started my family planning earlier. I try to stay strong and put it down to just bad luck but would just like to know if there is anything else I can try. We had a genetic test on our genes and all was ok. I've had all the other general tests and nothing else has shown up.

    Appreciate your response.

    Thanks

    Faye

    ReplyDelete

LinkWithin

Related Posts with Thumbnails