Dr. Edward Ramirez is the medical director of Monterey Bay IVF, a women's fertility & gynecology center located in Monterey, California. He hopes to provide those who read his infertility blog with insights into the latest advances in women's health & infertility issues. He respectfully shares his knowledge as a specialist with women and men from all over the world. Visit his center at www.montereybayivf.com
We have just had our 4th failed IVF (in vitro fertilization).
Our history.I am 36,
my husband is 39. 1st pregnancy was in 2009 after 3 IuI's (intra uterine
insemination) and clomid, but had to terminate at 15 weeks due to large
enphaloceale (was a random genetic mutation)and my 2nd pregnancy with IUI was a
success with a full term healthy baby boy.
Started with IuI's for 2nd child in 2011! We had 10 IuI's
and now 4 IVF's.Each IVF has been with icsi (intracytoplasmic sperm injection)
and this time we had Embryo hatching. Last 3 transfers were 3 top grade 8 cell
embryos each time on day 3.I am not a
great responder and only ever have 5-7 eggs, of which usually 4 fertilise.
I have had all the immunity checks done, my husbands sperm
dna damage is within normal, fertilisation rate is good.My ovarian reserve was also checked and the
level was 1.0- My specialist said that he wasn't overly worried about the
reserve for my age.I have had a
hysteroscopy and all normal.I have been
on various drug protocols and this last one was the long Lupron cycle with
We are just not sure what to do next?Do we keep going, as my doctors are very
positive and we have the finances. Are my doctors missing something?Is there anything else we can do to improve
our chances.I am on DHEA and Royal
Jelly, and my hubby is also on supplements.
I am writing from CapeTown, South Africa.
Thank you for your consideration, R.
Hello R. from South Africa,
The exact cause of your failure cannot be known as there are
still four steps your embryo has to go through in order to produce a pregnancy:
embryo has to develop to blastocyst, the blastocyst has to hatch our of its
shell, it then has to attach to the uterine lining and the lining has to grow
around it.As of now, there is no
technology that can make this happen."Assisted hatching" is just making a defect in the shell so
that the embryo can exit (hatch) more easily.
Something I always
worry about when I have patients tell me they have failed multiple cycles
despite good embryos, is the quality of the final step of the IVF process,
which is the transfer.You can have
the absolute best and perfect embryos but if the transfer technique is not done
well, then it will fail.This has been
shown by numerous studies.Since you
have been going to the same clinic, I wonder if that is not the problem, in
which case, I would recommend that you seek out a different clinic.
One thing that I do with my patients that is not universally
accepted but done by many of us, is to use a recurrent miscarriage protocol to
reduce the immune system, thinking that a heightened immune system might be at
fault.For this regimen I add low dose
heparin or lovenox, medrol, low dose aspirin, extra estrogen and extra
progesterone (both injectable and vaginal).I don't think that DHEA does anything so I don't use it.
At 36 years old, I have a 66% pregnancy rate in my
clinic.By two to three attempts with
good 8 cell embryos, you should already be pregnant.Your rate should especially be increased over
other 36 year olds since you have been pregnant before.For these reasons, I think the fault may lie
in your clinic and not in you or your husband.
Good luck in your journey to have a second child,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF www.montereybayivf.com
I am writing from Japan and want to ask that can big, crowded clinics be good or are small ones always
good? Which is a worst choice...I'm very confused actually....like the crowded one has all
the plus points, it is experienced, and cost is little bit lower than other. The big one has the
pioneer in begining the IVF (in vitro fertilization) in Japan, the other has good success rates but only
opened 6 yrs back...I'm totally confused!
How many cycles should a clinic do per year and what can I use to make my decision?
help ! H. from Tokyo Answer:
Hello H. from Tokyo,
I run a smaller, low
volume clinic and have better pregnancy rates that they large ones in my area,
including the ones at Stanford University and the University of California, San
Francisco.I feel that I give better
more personalized care because I am caring for them personally and completely.I don't have other people doing what I should
be doing.The biggest disadvantage of a
very large clinic is that it is a factory and depersonalized.IVF should be a personal and intimate
procedure, NOT a mechanical one.So, of
course I have a bias.I would not
recommend a small clinic that has a poor pregnancy rate, but if it has a good
pregnancy rate, I think that is the better place to go.I don't care how big and famous the larger
clinic is or how many cycles they do, if it were me and my wife doing this I would want a clinic where
the doctor is going to give us personalized attention the entire way, including
personally do the retrieval and transfer procedures. I know that at the larger clinic in Japan you will rarely if EVER get to see the
"famous" doctor, so what good is it to go there? The smaller clinic will probably give you a better experience even though it is at a slightly higher cost.
In the U.S., people prefer to go to
clinics where they get one on one personalized care, not where they are treated
as another number.
幸運 ... Good Luck!
Ramirez, M.D. Executive Medical
Director The Fertility And Gynecology
Center Monterey Bay
I have been able to get pregnant naturally, but due to my
kidney disease was not able to carry to term.I have about 50 percent kidney function due to mild segmental mesangial
sclerorsis.I'm planning on pursuing
surrogacy and would like to know what you would recommend for cycling treatment
to reduce to the risk of OHSS (ovarian hyperstimulation syndrome) during the
Thank you, R. from California
Hello R. from the U.S. (California),
First, I would choose a good IVF clinic.OHSS is mostly due to overstimulation.You'll want a doctor that is cautious, has a
protocol to reduce the chances of developing OHSS and watches his patients
Second, OHSS tends to be most common in patients with PCOS
where the ovaries are very sensitive to the stimulation.If you don't have PCOS, then the chances of
developing this problem are lower.
Third, patients at risk for OHSS get less medication than patients not at risk.That is because their ovaries are so
sensitive that they don'tneed much stimulation, and in fact, you don't want to
stimulate them too strongly.So a low
dose FSH only or FSH/LH protocol is used.I also don't use the "long protocol" in patients at risk for
OHSS.The long protocol is using Lupron
injections starting from the luteal phase of the preceding cycle.I use the antagonist protocol (the antagonist
is to prevent spontaneous ovulation by suppressing the ovaries) which then
allows me to trigger with Lupron instead of HCG (such as Ovidrel).
Finally, the estradiol levels and close monitoring of
follicular growth are required so find a physician/clinic that works closely
with their patients.A large
"factory" type of clinic is probably not a good choice. See this
article regarding an American egg donor who underwent an IVF cycle through a
Canadian clinic in 2011 to get an idea of the worst case scenario:http://news.nationalpost.com/2013/03/28/kylee-gilman-sues-toronto-fertility-doctor/
Edward J. Ramirez, M.D. Executive Medical Director The Fertility And Gynecology Center Monterey Bay IVF www.montereybayivf.com