QUESTION:
Dear Dr. Ramirez,
I'm 39 years old and have done 3 IVFs (in vitro fertilization cycles). During the
first two IVFs, half of my eggs were immature. I had 25 retrieved (age 37) the
first time, and 16 retrieved (age 38) the next time with 50 percent maturity in
both cases. However, I just had an egg retrieval where 15 were retrieved and
only 2 eggs were mature. They used generic HCG in this case, and the doc seems
to want me to try the transfer the pretty crappy embryos that resulted from
this retrieval. He is offering no answers as to why just 2 eggs were mature
upon retrieval and the embryo quality was my worst yet.
Does the kind of HCG trigger make a difference? For the
second retrieval, I didn't use generic HCG but Novarel. I think I used Ovidrel
for the first trigger. Do you think I have a genetic defect and should be
tested? I also think I have some of the signs of PCOS (acne and some sideburn
hair that I remove), but doctors don't think I have PCOS because I have regular
periods and am not overweight. Yet, I've heard many PCOS (polycystic ovarian syndrome) women produce immature
eggs. Also think I may be insulin resistant and have heard a connection between
this and immature eggs as well.
Would appreciate your insight. Emma from California
ANSWER:
Hello Emma from the U.S. (California),
Egg maturity at the time of retrieval is based on two
things: (1) the size of the follicle when triggered and (2) adequate HCG
stimulation.
First, let me answer
the HCG question. If the HCG is an
inadequate dosage or not a quality product, then it is possible that the
follicle and consequently the egg within, will not get adequate hormonal
stimulation to go through the final maturation phase. Sometimes the egg will not release from the
wall and so no egg will be retrieved but otherwise, it would not be
mature. In terms of follicle size, it is
usually a requirement that the follicle reach a minimum of 16 mm to insure that
the egg within has matured.
Physiologically, as the follicle grows from FSH stimulation, the egg
grows toward maturity. When it reached
mature size, the final act is for the HCG or LH which is the physiologic
trigger, causes the egg to go through the final phase of maturation and release
from the wall. If the follicle is less
than 16 mm, an egg could still be retrieved but it would not be mature. This is where the "art" and
experience of the physician comes into play.
It is his/her decision as to when the optimal time to trigger is. The goal, or what should be the goal, is to
trigger when the majority of follicles are of mature size but not let it go on
so long that you begin losing the larger follicles. That balance is the key. In my case, I use 50% maturity as my baseline
measure, since follicles tend to grow at different rates. That is to say, that I strive to have at
least 50% of the retrieved eggs to be mature.
In most cases it is much more than that.
You are correct that PCOD patients tend to have a lot of
immature eggs but that is because they have so many follicles that result from
stimulation. Where a normal woman
might produce 15-20 follicles, a PCOD patient will often produce 30-40
follicles. Since they develop at
different rates, that leads to different maturity levels. In terms of medication, I favor Ovidrel. In my experience (22 years), I have had cases
where the eggs don't mature as a result of Novarel or Generic HCG, so I
abandoned them. In addition, Ovidrel is
a subcutaneous injection whereas the HCG is intramuscular so, it hurts more.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
---------- FOLLOW-UP QUESTION ----------
QUESTION:
Thank you, Dr. Ramirez. There was one more piece
of information I forgot to include. Before I started this last cycle, I had
been on a three-month dose of lupron. I began stimming exactly three months to
the day of my lupron injection, even though I still had hot flashes and only
had six follicles to start. Follicles grew from 6 to 8 to 12 the day of the
trigger. Normally my number of follicles are in the teens at the beginning of
the cycle. I even mentioned this to the doctor and told him that I was still
having hot flashes as well. Is it possible that my ovaries were
over-suppressed, which resulted in just two immature eggs out of 15?
Thank You,
Emma
Answer:
Hello Again,
Usually the stimulation, if given in adequate dosage, is
enough to overcome the Lupton suppression, but I think that your thinking may
be right, and that your ovaries may have been suppressed enough so as to not
perform as well in the last cycle and the stimulation was not enough to
overcome that suppression.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Monterey, California, U.S.A.
Executive Medical
Director
The Fertility and
Gynecology Center
Monterey Bay IVF
Program
Monterey, California,
U.S.A.
