Wednesday, November 4, 2015

Woman With Endometriosis Failed IVF Cycle: Poor Egg Quality? Age Issue? PGS?

                                                                                                                                                    
Question:
I am 38 years old from Los Angeles. I just had a failed IVF cycle because my six embryos arrested on Day 5. On Day 3, five were Grade A and one was Grade B. They were 10, 8 and 6 cell. Doctor blames my age for the embryos arresting and basically said my eggs are poor quality. I find this confusing, since they were top ranked on Day 3. I've done one previous failed IVF last year at a different clinic (and still have a frozen Grade B blastocyst from that), but the doctor never blamed my egg quality. My AMH is 2 and other hormone numbers are normal. First IVF, they retrieved 27 eggs. This IVF, they retrieved 16 eggs.

I don't know my fertilization rate  for my most recent IVF because my doctor never told me how many of my eggs were immature, only answering that some of them were. For my first IVF about half the eggs were immature, and I had about a 50 percent fertilization rate. I have endometriosis, which has never been treated. It was discovered 2 1/2 years when I was having a myomectomy, but the doctor didn't remove it, only noting that I had significant ovarian endometriosis but no endometriomas. I've read that endo can affect egg quality or do you think the only issue here is my age, and I should just give up on IVF? My next step is to have a laparoscopy to remove the endometriosis.
Thanks for your time. N2N from California.


Answer:

Hello N2N from California USA,

I think that age has a significant effect on egg quality and that is the issue with age.  More and more eggs become less and less fertile.  There was a study recently that looked at IVF patients that were 37 years old and underwent PGS. PGS, or preimplantation genetic screening, is the proper term for testing for overall chromosomal normalcy in embryos. This involves removing a cell from an IVF embryo to test it for chromosomal abnormalities before transferring the embryo to the uterus.  Only 2 out of every 10 embryos were genetically normal.  So, even if they make it to blastocyst, there is still a chance that the treatment would fail because of abnormal embryos.  In general, there is debate as to whether endometriosis needs to be removed prior to IVF because of a potential effect on pregnancy rates, but there is no clear indication that endometriosis absolutely affects eggs unless there is an endometrioma present and/or the endometriotic fluid contaminates the fluid at retrieval.  If you want to be sure that it is not a factor, a laparoscopy followed by three months of Lupron should take care of that issue, but I'm not sure I would have you do it if you were my patient.  I think you are battling an age issue.

It is not unusual for good looking day #3 embryos to not make it to blastocyst.  In one of my patients recently, we had 12 embryos that were good quality (grade 1 or 2, 6-8 cells) on Day #3.  We cultured all of them and only 6 made it to blastocyst.  The rest arrested before Day #5.  So, your doctor is probably correct that this failure was due to egg quality.  That is what you are battling.  The bottom line is that IVF is trying to help you find the one or two good eggs that are still remaining in the ovary and it will just take time.  If you want it to go faster, then you need to move to donor eggs to improve the egg quality, but if you want a genetic child, then you need to resolve that it may take several attempts.  Unfortunately, there are no technologies yet, that can improve egg quality.  Only repetition is the option.  As long as your ovaries still respond well to stimulation, so that we can get a lot of eggs at retrieval, then you have a good chance of being successful if you hang in there.

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.



Tuesday, August 18, 2015

History of Miscarriages, Now 9 Weeks Pregnant: Continue Progesterone Supplement (Crinone) ?

Question:

I'm from the U.S. After a long struggle with secondary infertility and 2 miscarriages, I am pregnant again, 9 weeks along. I'm on supplemental progesterone, Crinone 8% once a day. When can I feel okay about stopping the Crinone? I was supposed to see my doctor in 2 days, but he experienced a family tragedy, and I'm not sure when he'll be back. I think he had talked about stopping the Crinone at 9 or 10 weeks, but I was going to confirm that with him at my appointment, and I have no way of asking now.
Thank you for your time. M. from the U.S.

Answer:
Hello M. from the U.S.,

With your history of two miscarriages, I will usually be very conservative and continue the progesterone until 12 weeks gestational age.  However, medically, it would be okay to stop at 10 weeks.  By then, the placenta should be fully functional and providing all the hormone necessary to maintain the pregnancy.

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.
 
**For my readers who are unfamiliar with the use of progesterone to support a pregnancy, here are some additional facts: "Progesterone is essential for the normal functioning of the reproductive system. After ovulation, the corpus luteum (which is the empty follicle from which the egg was released) produces progesterone, which acts on the womb lining and causes it to thicken in preparation for a fertilized egg to implant. This is known as the luteal phase of the menstrual cycle. If an egg implants successfully into the womb, the corpus luteum continues to produce progesterone to maintain the pregnancy until the placenta develops fully. The placenta produces increasing amounts of progesterone until it is fully developed, when it then takes over the production of progesterone to continue to support the pregnancy.
In some women, insufficient progesterone is produced during the luteal phase and this causes problems with implantation of fertilized eggs into the womb lining and maintaining a pregnancy in the early stages. Crinone vaginal gel is used to treat this hormone deficiency. One applicatorful is inserted into the vagina every day, starting either one day after ovulation is known to have occurred, or on day 18 to 21 of the woman's cycle. (Day one is the first day of your period.) The gel is usually continued until the placenta is producing enough progesterone to support the pregnancy.
Crinone vaginal gel is also used to support pregnancy in women having in vitro fertilization (IVF). In this case the gel is used daily, starting after the embryo has been transferred into the womb, for the first 30 days of confirmed pregnancy."
www.netdoctor.co.uk/pregnancy/medicines/crinone.html
 

Wednesday, July 15, 2015

Conceiving After 45: IVF With Your Own Eggs Or Donor Eggs?


Question:

Dr Ramirez,
What are the chances of a 45 year old woman conceiving using IVF with her own eggs? Would it be worth trying or would you recommend using donor eggs? A. from the UK

Answer:
Hello A. from the UK,

There are always exceptions to the rule, however, the chances of pregnancy, even with IVF, are very slim.  In the 2012 National summary produced by our Centers for Disease Control (CDC), based on IVF reporting data, the national averages for women >44 years old is 5% pregnancy rate and 2% delivery rate.  This, of course, is an average and the statistics can be different for different centers.  There have been pregnancies over 44 years old but they are very few.  In my center, the oldest patient to get pregnant using her own eggs (as opposed to using donor eggs) was 44 years old.
I tell my patients that only God can determine who will be the exception to the rule, but if you don't try, then you have a 0% from the start.  However, if you decide to try, you have to go in with the understanding that your chances are slim.  Until you try, you won't know the outcome.  If you want a better chance, the donor eggs will be much better.

I have a 45 year old patient contemplating this now who is leaning toward trying at least once because she wants to reassure herself that she has done everything possible to have another child (she has one already).  I told her, and you should understand this too, that IVF is not a perfect technology even in young women, and like trying naturally, it can take several tries.  So if you want to be absolutely sure that you tried your very best with IVF, then you need to be prepared to try several times.

As to whether or not it is worth it, that is a totally individual decision.  The worthiness of something is defined by yourself.

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.
 

 

Tuesday, July 14, 2015

"How In Vitro Fertilization Works" Video from TED-Ed

Dear Readers,
I recently found this nicely animated video on In Vitro Fertilization created on the new TED-Ed platform. You might find this a good way to not only inform yourself but also friends and family who might have trouble understanding the fertilization process. 

"Infertility affects 1 in 8 couples worldwide. But in the last 40 years, more than 5 million babies have been born using in vitro fertilization (IVF). How does it work? Nassim Assefi and Brian A. Levine detail the science behind making a baby in a lab."

Lesson by Nassim Assefi and Brian A. Levine, animation by Kozmonot Animation Studio.


 
 
 
As always, I am open to questions regarding this complex but important assisted reproductive technology, IVF.
 
 
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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