Friday, March 8, 2013

Infertility Specialist Incompetent: Cancelled IVF Cycle Prematurely

Dear Doctor,

I am 40. I had two missed abortions at 37, both in the ninth week after heart beat was felt. Subsequently I did not conceive and my RE suggested IVF. I have regular 29 day cycle.

My Day 3 FSH is normal. My RE put me on Lupron (0.5cc) from day 17. On day 2 of the period, she started with 600IU of HMG and 0.25 cc of Lupron for 3 days (cd 2-4). On reviewing after on CD 5, she said no follicle and no endometrium growth is seen. She continued the medication for two more days and (cd 5, 6) and examined me cd 7 and said that there are no follicles or endometrium and cancelled the cycle.

I stopped all medications and on cd 12, I checked with a local ultra sound center. The Ultrasound specialist said there are about 12 follicles on both ovaries, the largest being 10mm.

I checked my FSH and E2 on the same day and the FSH was 12.76 and the E2 is 58.00.

On Cd 16 I checked again and the Ultrasound specialist informed me that one follicle is 13 mm and others are still small.

Can I do anything at this stage to get a multiple ovulation in this cycle so that I can try naturally in this cycle (Like one or two doses of clomid or letrozole)?

What do you infer from my endometrial thickness of 10mm though my follicle size is only 13mm.

What is your advice for future IVF cycles? Thanking you in anticipation. R. from India


Hello R. from India,

It may be too late to rescue this cycle but if you have any Menopur, you could use it but the dosage would need to be significantly reduced to minimize the number of follicles that grow to ovulatory size. Unfortunately, the reality is that the eggs will not continue to grow and mature if it does not receive enough FSH hormone and will proceed to atrophy (wilt). If your natural FSH production kicks in then you might still have one follicle ovulate as you would in a natural cycle. I guess that is what you will have to hope for.

An endometrial lining of 10 mms is adequate and appropriate for implantation. It is also a sign that you have adequate estrogen levels because endometrial growth is dependent on Estrogen. Did your doctor ever check your estrogen levels?

My second piece of advice is for subsequent cycles. Your age is a factor from this point on so I would advise you to find a competent specialist. Your doctor is incompetent and does not know what she is doing so I would dump her (find a new doctor). It is expected, and usually the case, that there will not be much follicular growth by CD#7 of stimulation. Some people take longer,as you have shown. In IVF cycles, you have to continue to follow the Estradiol levels to see if they are rising, which is proof of follicular growth (stimulation), and measure the follicle. Most people do not have ovulatory sized follicles until CD#10-12.

I often wonder, do doctors in India have to train to be specialists? Your doctor cancelled the cycle prematurely and just wasted your money. I would demand a refund!

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.

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