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 (womenshealthandfertility.blogspot.com) 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!


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