A Step By Step Guide To The IVF Process: Step Five -- Fertilization

Dear Readers:

This is the fifth part in the series I have begun to help answer what In Vitro Fertilization (IVF) is and how it works with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I also hope that this will not only clarify what you will go through, but explain why things are done a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series will continue to be posted over the next few weeks in installments. (For earlier installments in correct order scroll down to the beginning of July 2012.)

STEP FIVE: FERTILIZATION

In the previous step, the eggs were aspirated and retrieved from the ovaries, the equivalent of ovulation in the natural process. These eggs have been collected and the embryologist now isolates each egg within a petri dish. The eggs are prepared for the fertilization step. In the natural cycle, after ovulation, the egg needs to pass through the culdesac of the pelvis to find the fimbria of one the tubes. In the normal anatomical position, the fimbria of the tubes are lying within the culdesac. If there is scar tissue within the culdesac or the anatomical positions of the tubes are altered, then this “pickup” step may not occur. This would be an indication to do IVF. If this does not occur, then that is the end of the process in that cycle. If it does find the tube, it is then brought into the tube and through peristalsis (muscular motion) within the tube it is pushed to a portion of the tube where the sperm need to be waiting to accomplish fertilization. Again, if the sperm are not there, then fertilization will not take place and the cycle ends at that point. If the sperm is in the correct position at the correct time, then sperm attach to the egg and one sperm penetrates the egg to accomplish fertilization. In IVF, these two steps are accomplished by laboratory means, so there is little chance that those steps will not be accomplished. This is another step that IVF accomplishes for your body, thereby enhancing your chances of success. It is not left to chance as in the natural process.

At this point, there are two ways to accomplish fertilization. It can be allowed to occur by natural means, meaning the sperm can be added and the egg-sperm interaction allowed to happen on its own, or it can be assisted, also known as ICSI or "intracytoplasmic sperm injection". In order for the fertilization process to occur, a sperm needs to penetrate the outer lining (shell) and enter the egg and then there is an elaborate process within the egg whereby the nucleus of the egg and the nucleus of the sperm unite. This latter process is the actual process of fertilization. Just putting a sperm into the egg is NOT fertilization. The second part of the process, a natural step, has to occur on its own. In other words, just doing ICSI is not fertilizing the egg and does not guarantee fertilization. ICSI is just putting the sperm within the egg so that fertilization has the possibility of happening.

If natural fertilization is going to be done, the egg and sperm are put together and the sperm is allowed to penetrate the egg on its own. But if injection of the sperm is going to be done, then the embryologist removes the filmy lining of the egg, called the cumulus. This will also allow evaluation of the maturity of the egg. Only mature eggs, in Meiosis stage II, can be fertilized. Eggs can be in either Meiosis stage II (M2), Meiosis stage I (M1) or Germinal Vesicle (GV) stages at the time of retrieval. As explained previously, the follicles, and the eggs within, don’t all mature at the same rate. That leads to some larger follicles and some smaller follicles. The larger follicles have the matured eggs, eggs that have had the time to mature, and the smaller follicles have immature eggs. As a result, eggs in the various stages can be retrieved, but only the mature ones will fertilize. In the case of Meiosis stage I eggs, these can be left in culture and allowed to mature, if the clinic has an egg maturation program and the proper media in place, or in some cases, just waiting will allow the egg time to mature to the mature Meiosis stage II. They can then be fertilized at that time. So with ICSI, an anatomically normal appearing and swimming sperm is identified and aspirated into a glass needle. This needle is then inserted into the egg and the sperm is then injected within. All of this procedure is done microscopically. ICSI essentially assists the step whereby the sperm enters the egg. This procedure is done mostly in cases where there is an abnormality of the semen analysis, since it is known that with abnormal semen analysis, there is a high possibility of a functional problem i.e. that the sperm cannot fertilize the egg. Also, it is recommended in older patients (>37 years old) because the shell of the egg is thicker and sperm have a more difficult time penetrating the shell normally. In some cases, patients will choose to have ICSI because they don’t want to take the risk of fertilization not taking place (fertilization failure), which will essentially end the cycle at that point. Without fertilization, embryos are not formed, and no embryos means there will be nothing to transfer.

Once the eggs are put with the sperm, the petri dishes are placed into an incubator. Fertilization will take a minimum of 12 hours to occur so most clinics will re-evaluate the eggs the next morning for fertilization. It is expected that some eggs will fertilize normally, called a 2PN stage, some will not fertilize and some will fertilize abnormally (1PN or 3PN). Because of this, there will be another reduction in the number of eggs available to use. With fertilization, the egg is now referred to as an embryo. A typical threshold to evaluate fertilization is to expect a minimum of 50% of the available (mature) eggs to fertilize. If that threshold is not reached, it could be because of egg quality, sperm quality or lab quality. Only the fertilized embryos can be cultured to develop into embryos that can be transferred back into the womb, so this number essentially establishes how many might be available for transfer. Fertilized embryos are now transferred into a new culture media and placed in incubators that have a specific gas content and temperature to allow them to grow.

We will continue this discussion soon with the next installment, "Step Six: Embryo Development". Thank you for joining me today!

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA
http://www.montereybayivf.com/

Fourth IVF Cycle Ends In A Chemical Pregnancy: What Can Be Done?

Question:

Hi Dr. Ramirez,

I have been on a rollercoaster ride for the past week and I am hoping that you can offer me your opinion.


I received a positive beta after my 4th IVF on Monday (11dp3dt). It was 14.3 and my RE said that it was quite low. I held out hope as I am convinced that I tend to implant a little later than others. In a previous cycle I had a negative beta 12dp3dt and found out that I was pregnant a couple of weeks later. I tested 3 days later and my beta was up to 52.8. I was so excited and felt so much better about things. I am scheduled to go back on Sunday morning for another beta.

I am currently taking Crinone 2xday. For the past week, I have had dark brown Crinone gunk(sorry for TMI). Last night and this morning there was some red blood on the applicator tip. At 1st I thought it was just irritation but for the past couple of hours, when I wipe there has been more red blood. I am also getting some minor cramping.

I am freaking out and I am so worried that things are moving in the wrong direction. I called my clinic and they said that they cant know anything until Sundays beta. They said it could be start of a miscarriage given the low beta #'s or it could be irritation from the Crinone or even pregnancy spotting.

I was hoping that you could offer some advice as I remember in the past that you prescribe Crinone to your patients.

Is RED spotting normal? How much spotting is normal? Was I foolish to be hopeful after my #'s doubled? Do you think its likely that this will end in miscarriage?

Any insight would be greatly appreciated. I dont know if i can hold out until Sunday's beta.

Thank you,

D. from Boston, Mass.

Answer:

Hello D. from the U.S.(Massachusetts),

The advice that your doctor gave you is completely correct. It could be from the Crinone, and I have seen an increased incidence of spotting in my patients using Crinone), it could be implantation spotting or pregnancy spotting or it could be indicating an abnormal pregnancy. There is no way to know which of these is the correct diagnosis. In general, I reassure my patients not to worry about spotting. I only worry if the bleeding is bright red flow like a period with accompanying cramping. The only way to determine the fate of this pregnancy at this point is to continue to follow the bHCG's every other day. This trend will then give you a better idea of how the pregnancy is doing. AS long as the bHCG is rising, then you can be reassured. If it plateaus or drops, then that is not a good sign.

Follow-Up Question #1:

 Dr. Ramirez,


Thank you for getting back to me. Unfortunately, my beta level dropped on Saturday so it looks like I will be having another chemical pregnancy. I am devastated of course. I was hoping that you might be able to provide me with some insight as to an explanation as to why this keeps happening.

A little history:

Me: 31 years old- normal FSH but AMH is .8

Husband: Very low morphology (less than 1%)

This was our 4th IVF cycle and 3rd chemical pregnancy. I have had tons of testing... RPL work-up, HSG, genetic testing, uterine biopsy and all came back normal.

I am a low responder and in previous cycles have had poor egg quality. I just switched REs and had a better response with an Estrogen Priming Antagonist protocol. He used a low dose HCG with Gonal F. Quality and ICSI fertilization rate was much better so I was hopeful that this was it.

My RE said that it was likely a chromosomal issue with the embryo and probably because of poor egg quality and we just need to keep trying and hopefully will get that “one” good egg. I don’t know if I am comfortable with that answer. We only have 2 insurance tries left and I want to make sure we are exploring all options before proceeding again. What would you recommend for your patients at this point? Do you think that it is worth doing a Sperm DNA fragmentation test?

What could be the reason for all of these chemical pregnancies?

Any insight is greatly appreciated.

Follow-Up Answer #1 :

Hello Again,

The exact reason cannot be known, of course but the most common reason for chemical pregnancies are a genetic abnormality in the embryo. With poor morphology in the semen analysis and your young age, definitely the genetic weakness could be from the sperm. I don't recommend the sperm DNA fragmentation test because it only gives the indication for the batch of sperm that it tests and not the sperm as a whole. In addition, the treatment recommendation is to use ICSI, which I presume you are doing already. So you won't gain anything from that test. If we suspect the sperm, other than ICSI you have the choice of either using donor sperm the next time or maybe try using a supplement for three months before doing IVF again. The supplements that your husband can try, which might help with sperm quality, are either Proxeed or Fertility Blend (vitamins) and CoQ10 600 mg per day. He will have to wait three months because sperm are on a 90 day cycle #the sperm made today won't be expressed for 90 days.

The only other options I could give are what I would do with my patients who have recurrent miscarriages (which is what you have even if it is a chemical pregnancy). Studies have shown the benefit of these meds and it is standard of practice to use these with recurrent miscarriages.

I would add: aspirin 81 mg per day, Medrol 15 mg per day until transfer then decrease to 8 mg per day, Heparin 2000 units twice per day and CoQ10 600 mg per day, all starting with the start of the cycle (CD#2). The Aspirin and Heparin are withheld from the day of HCG trigger until the day after the retrieval. The only other option you might want to consider is genetic testing of the embryos prior to transfer, called preimplantation genetic screening (PGS). That way you will know if the embryos are normal genetically or not. The downside of using PGS is I have observed and some studies have shown a drop in pregnancy rates after this. Some of my colleagues say that if it is done by a very experienced embryologist who does lots of these procedures, the pregnancy rate does not drop.

You'll have to discuss these options with your doc. I'm afraid there are no exact answers to your dilemma. But, studies on patients with recurrent pregnancies have shown that eventually these patients are successful. So, hang in there, even if your insurance coverage expires.

Follow-Up Question #2:

Thank you so much for your thorough response. I really appreciate it.

I am only 31 years old but I do have a low AMH (only .8) so along with that and the fact that I am a low responder, my RE suspects that I may have a diminished ovarian reserve. So, unfortunately, both my husband and I seem to have issues.

Do you think that the low AMH and dimished ovarian reserve contribute to the repeat miscarriages? Or do you think it is likely a sperm issue?

Is there any way to tell who is main contributor to this issue? We are not ready to talk about donors at this point and will continue to try with our own eggs/sperm for now but in the event that we need to explore other options, it would be helpful to know if we would be more likely to succeed using donor egg or donor sperm.

My RE has given us the impression that it is more a egg issue but hasn't given us any explanation of why.

Any help with this would be hugely appreciated.

Follow Up Answer #2:

Hello Agian,

There is no way to know what the exact cause of the recurrent miscarriages is. It could be egg or sperm derived since the genetics of the embryo come from both. Considering that you are ONLY 31 years old, I would suspect that it is NOT an egg issue but there is no way to be sure.

It is definitely not related to AMH or low ovarian reserve. The AMH is a measure of follicle availability and low ovarian reserve is a description of ovarian response to stimulation.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/

U.K. Woman On Clomid For Five Months, Husband With MFI: Periods Are Shorter Now, Why?

Question:

Hi, I have been taking clomid for 5 months because my husband has a low sperm count. I have noticed my periods becoming less and less the last 2 months I have only bleed for 1 day and that was mostly a black/brown color. My periods normally last for a full 7 days. Is this because of the clomid? D. From the U.K.

Answer:

Hello D. from the U.K.,

You should NOT be taking Clomid every month. It leads to a thinning of the endometrial lining because it is an antiestrogen and blocks the estrogen receptors. This is probably why the bleeding has decreased. This lack of adequate uterine lining will prevent implantation.

Secondly, Clomid is NOT a treatment for male infertility if given to the female! I have absolutely no understanding as to why your doctor has prescribed this and not followed you with some type of surveillance to see how you are responding. I would strongly recommend that you look up here in my blog where I discuss how Clomid cycles should be done.

Thirdly, in men that have low sperm counts, they will be treated with Clomid on a daily basis, sometimes to try to increase the count. This works only some of the time. It will take three months to know if it is working or not. If the count gets above 10 Million, then IUI is a treatment option. If it is less than 10 Million then IVF with ICSI is the treatment of choice.

Finally, please make sure that your doctor is an infertility specialist and does ALL levels of infertility treatments, including IVF. Otherwise, you may be wasting your time.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

39 Year Old IVF Patient, DH Severe Male Factor, Surprised By Treatment Protocol: May Also Have PCOS & Will Need Med Adjustment

Question:

Can you help figure out what the next step should be? I'm 39 but have day 3 tests of 6.4 FSH, 53 estradiol and 25 antral follicles. Also great uterine ultrasound. We're doing IVF due to severe male factor. Just finished our first cycle, during which I somewhat overstimmed (16 eggs, sky-high E2 levels) but we got 3 good embryos, froze 1 and implanted 2 (my lining was 10.2 if I recall correctly), but they didn't take. I feel like I got a bit of a "cookie cutter" treatment from current RE and am wondering what changes you might recommend.

What felt "cookie cutter" was that despite my great day 3 tests, RE put me on microdose Lupron flare protocol with 300 units of Follistim (150 twice a day). Isn't that kind of an aggressive protocol for someone with day 3 numbers like that? Couldn't that risk sacrificing egg quality to quantity? I just feel like all they saw was my birthday (almost 40), not the day 3 numbers, good health and family history (women in my family stay fertile pretty late).

Anyway, after 4 days of 300 units of Follistim I had tons of follicles and my E2 was too high--almost 900--so that day and the next they had me skip the PM dose of Follistim (in other words on days 4 and 5 I had 150 of Follistim once a day). The E2 kept climbing, to 1100+ on day 5 and 1900+ on day 6. So on day 6 they had me go back to two 150 unit doses of Follistim. The next day (day 7) my E2 shot up to 4300+ so they had me coast. By day 8 E2 had spiked to over 7300, but it fell to 5300+ on day 9.

In order not to lose the cycle they had me do HcG on day 9, even though apparently a lot of clinics won't do the HcG shot unless the E2 is under 4000 due to the OHSS risk. (To prevent OHSS they had me use a half-dose of HcG and also gave me albumin.) Out of 16 follicles we got 16 eggs, of which 14 were mature, and 7 fertilized. On day 3 after retrieval, we had 4 embryos. Two looked great--we transferred them, both 7 or 8-cell--and two didn't look so great. They let those continue growing; one made it to blastocyst and is frozen now.

My RE said, of my response to the protocol, that I "reacted WAAAY more than any of our testing led us to expect." I don't understand what part of my testing suggested that I would have any problem producing enough eggs. Do you see anything that suggests that? I am just trying to figure out if I can trust my RE... I don't know if they actually are less worthy of trust or if I'm just feeling that way because I'm upset at the failed cycle.

More importantly, do you think these estrogen spikes and/or the overly aggressive protocol damaged my egg quality? I've seen some things on the web saying that excess E2 can kind of "toast" the eggs. What would you do now, if I were your patient? My RE wants to switch me to a more standard Lupron downregulation cycle with 225 units of Follistim a day. She said it's up to me whether to precede the Lupron with birth control pills. I don't want to take the pills--it just seems like going from one extreme to another, IVF protocol-wise, and I don't want to risk being over-suppressed. What do you think? Also, is this a situation where you would lean towards antagonists instead of Lupron to avoid over-suppression?

Sorry for the long post. I just wanted you to know enough to comment. And thanks in advance for your help. M. from the United States.

Answer:

Hello M. from the U.S.,

Before I answer the specifics of your questions, let me precede with the disclaimer that (1) there are lots of variations of protocols and opinions in the world regarding stimulation and none are absolute (meaning apply to all people) and none are better than others, and (2) the opinions I give are my own opinions based on my knowledge and experience and (3) the first IVF cycle is hard to predict with everyone because there are too many unknowns as to how a person will respond until you do it the first time and (4) pregnancy does not occur every time a woman does IVF for many reasons.

In answer to your questions, the protocol you were on (300IU per day) is actually a low dose protocol. Medication can be given up to 600IU per day. However, based on your response, it seems that your ovaries have a tendancy toward PCO-type response even if you are not a classic PCO. That is to say, your ovaries were very sensitive to the stimulation and hyperstimulated. For that reason you had to coast. I don't use the microdose flare protocol, which is indicated for "poor responder" patients or patients with "decreased ovarian reserve", neither of which you fit. Your FSH level was fine and your antral follicle count was more like a PCO. If I see ovaries with PCO-type characteristics in the pre-IVF ultrasound, I will usually defer to a PCO protocol because I don't want to put the patient at risk for hyperstimulation syndrome.I think that the adjustment of the medications was appropriate.

One thing to keep in mind, which I think you already know and have read, is that PCO patients that hyperstimulate have a reduced pregnancy rate because many of the eggs within don't mature. In addition, there does seem to be a reduction in egg quality, and that is further enhanced when coasting is required. That is part of the reason why we try to avoid coasting, but the risk of hyperstimulation is much greater so we sacrifice the egg quality for preventing OHSS.

I also will differ with your doc in that I prefer to use a "mixed protocol" (using both FSH + FSH/LH) because there have been some studies that show that LH is required for egg development and quality. In addition, I ALWAYS precede my patients with the birth control pill to help with quieting the ovaries (putting them at rest) prior to the IVF stimulation, to assist me with stimulation (studies have shown better stimulation) and to help with scheduling/controlling the cycle. Also, I strongly differ with your doc in the number of embryos I would have transferred. I would have transferred or recommended transferring all four of the embryos on day#3 just based on your age (that is totally based on whether or not you would be willing to take the risk of a twin pregnancy). We know that just based on your age, even with the family history of retained fertility at an older age, your chances of quality eggs are reduced, so the goal is to have a lot of eggs and embryos to work with in the hope of getting a good embryo in the end (keep in mind that "good looking embryos" does not necessarily mean that the embryo has good internal quality. We have no technology to access that at this time.) In my 39 year olds, I will transfer 4-6 embryos in order to get one implantation.

Finally, since we now know that you respond like a PCO patient, I would use a PCO protocol. In my practice, I exclusively use the antagonist protocol rather than the long protocol (Lupron), so that I can trigger with Lupron instead of HCG (which has been shown to reduce the chances of OHSS), and decreases the number of injections required. I call my PCO protocol the "low slow protocol", where I start with a low dose of medication and slowly increase it based on response.

Thank you for providing detailed information, it helps a great deal in formulating my response! I hope this answers your questions and that any subsequent cycles go better than the first.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Four Weeks Post First IVF & Positive BHCG: Not Rising Adequately & Possible Ectopic

Question:

Hi Dr. R. -

I am 39 years old and we have male factor infertility. In our first completed IVF cycle we had 27 eggs retrieved, 20 good, 14 fertilized, and 3 - day 5 blasts transferred. I had a very light implantation bleed and a positive Hcg at day 14 post retrieval.

1st Hcg 132 14 days post retrieval (this was 2 days early as I had to go out of town)

2nd Hcg 183 19 days post (this was a few days late since I was out of town)

3rd Hcg 278 21 days post (also requested a progest test which was 119 or so, can't remember exact #).

4th Hcg 479 23 days post

Had a u/s 23 days post which showed nothing other than very large ovaries. I understand the data on Hcg doubling but am curious about the 10-20% of women who do not have doubling - not a lot of literature on these patients. My RE said there is zero chance of the pregnancy progressing and said it was a chemical pregnancy and would monitor for an eptopic, I was advised to stop progesterone supps. Also, I had preg symptoms day 12-18 post but they have become less this past week. I have had no bleeding or cramping during the entire process. Any thoughts on my prognosis would be appreciated. Are my levels just too low and too slow?

One other question, my ovaries are "as big as grapefruits", is the only option to wait until they resolve and how long can that expect to take? Again, I am 4.5 wks post retrieval.

Thank you! J. from the U.S.A.

Answer:

Hello J. from the U.S.,

The minimum requirement for HCG rising in a normal pregnancy is an 80% rise, not 100% (doubling). However, your bHCG's have not been rising adequately. For example, the first bhCG at 132 should have risen to 238. The fact that your bHCG's are not rising adequately means that it is unlikely to be a normal progressing pregnancy, but you are still pregnant. In addition, an ectopic (tubal) pregnancy cannot be ruled out yet because the level is not high enough to see a pregnancy in the uterus. The level generally has to be above 2500. It is wise to keep a close eye on your situation.

The ovarian size is due to the increased stimulation you received. It will take up to two weeks to resolve in size from the cessation of the pregnancy. Remember, even though your first cycle has not been successful, you and your husband were able to go through all the steps needed to accomplish IVF, with some good embryos to transfer. I hope that you will consider trying again.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Paciente Con Endometriosis Severa Y Fracaso De Implantación FIV

I recently received a question from a woman in Mexico that addressed the problem of IVF Implantation Failure...I have decided to publish it in Spanish. Many who read this blog are Spanish speakers & need to translate the Q & A's. Since I speak Spanish, I would like to publish this one in it's entirety for my followers en español.

Question: Pregunta:

Dr. Ramírez.

Leí en la página web de su clínica de Reproducción que usted habla español. Agradezco mucho que se tome el tiempo de leerme y contestarme.

Soy L. de México. Tengo 29 años y mi esposo 33.

Lo busco pues estoy un poco desesperada... Llevo tres años en tratamientos continuos.

Mi padecimiento es endometriosis severa que afectó a mi reserva ovarica, actualmente tengo una fsh de 15. También mi esposo tiene astenoterato- zoospermia. Mi primer IVF (fertilizacion in vitro) fue con tres embriones día 3 de calidad II con hatching, y fue icsi - negativo. Mi segunda IVF fue con 1 embrión dia 3 de calidad II, con icsi, negativo. Mi tercer IVF fue sin estimulación ( sin medicamento alguno a diferencia de las otras dos), fue un IVF natural con un embrión que llegó a blasto día 5. negativo. Siempre al momento de la transferencia mi endometrio es aproximadamente de 12 mm y es trilaminar.

No se que estudios me recomiende adicionales pues creo que el problema puede estar en la implantación... o algo que me recomiende tomar adicional a la aspirina de 100 mg y la progesterona vaginal que me dan cada 12 horas siempre.

Agradezco de nuevo su tiempo. Saludos.

Answer: Respuesta:

Sra. L.,

Gracias por su pregunta y discúlpame que estoy tarde con mi respuesta.

Definitivamente, con su historia médica, fertilización in vitro (FIV) es la única opción por tratamiento porque este es la única tratamiento que puede cubrir endometriosis severa y la problema de esperma. Pero, un problema más grave es su reserva ovárica. Porque su fsh es 15, este es una indicación que los ovarios no están respóndanlo a la hormona fsh y la medicina que nosotros usamos por stimulacion es pura fsh. Por eso, el número de huevos aspirado es bajo y los embriones formo es minimo también. Pero, porque usted está joven, si la cualidad de los embriones están bastante, la posibilidad de embarazo debe ser máximo (es 73% cada vez en mi clínica con su edad). Por eso, usted está pensando que la problema es implantación.

La ultima dos partes del procesos para tener un embarazo en su cuerpo es saliendo de embrión de su piel (eclosión) y implantación junto con el endometrión. Fertilización in vitro (FIV) no puede controlar o cambiar este dos partes. Todavia es natural. Este parte es en la mano de Dios. Pero, muchas diferentes cosas pueden afectar la posibilidad de implantación. Por ejemplo, el técnico de su doctor es más importante. Usted puede tener embriones perfectos pero si el técnico para transferir los embriones es malo, el tratamiento no va a funcionar. Por esta razón, una opción que usted tiene es para cambiar su doctor o clínica. Mi profesor siempre me dijo que usted puede tener embriones perfectos pero si usted no se transfiere los embriones en la matriz perfectamente, todo es por nada. El tratamiento no va a funcionar. Este parte es la parte más importante!

Pienso que usted ha tenido un histeroscopia para confirmar que la cavidad de matriz y salio normal. Correcto? Si no ha tenido este estudio, yo recomendó que usted tiene esta estudio para ser seguro que no tiene nada anormal adentro. (La histeroscopia es un método de diagnóstico que consiste en introducir una lente a través del cuello del útero para visualizar la cavidad uterina.) Si usted tiene confianza en la técnica de su doctor y el procedimiento de transferencia de embriones paso bien, esta es un problema más difícil. En esto caso, yo recomendo usando aspirina 81mg cada día empezando con el ciclo de tratamiento, medrol 16mg cada día empezando con el ciclo de tratamiento y bajanda el dosis en el día de transferencia a 8 mg, estrogeno adicional como climara 0.2 mg parche o estradiol pastillas vaginal y heparina 2000 mg dos veces al día o lovenox 35mg por cada día. Todos empieza con el tratamiento y continua hasta el resultado del estudio por embarazo.

Últimamente, si Usted continua a tratar por un embarazo y tiene embriones con calidad buena, usted tendrá un embarazo. Buena Suerte!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A

Couple TTC, Husband With Diabetes & 42 Yr Old Wife on Fertomid (Clomid): What Can Be Done?

Question:

Hello. My husband and I have been trying to conceive for over one year. I am 42 yrs old and have one ovary. I have regular menstrual cycles but when the ovulation test was done there was no ovulation. I have started to take Fertomid for the first time. The first treatment was a month ago. Also my husband is diabetic, type 2. Can this affect his fertility? He is age 36.

I appreciate any advice you can give. B. from Ohio

Answer:

Dear B. from Ohio,

Yes, diabetes can affect male fertility. Diabetes affects the blood vessels in our body and causes the vessels to shrink, thereby limiting blood flow. This is the reason that diabetics end up getting leg ulcers and require amputation. In the genital region, it can reduce blood flow to the testicles and reduce sperm production. To check your husband's fertility, all he would need at this point would be a semen analysis. It is a simple test and will answer the question of whether or not his diabetes is affecting his fertility.

Your one ovary is not an issue, the bigger issue, which you mentioned in passing, is your age factor. Your chances of natural pregnancy at 42 years old is only 1% per year. That is probably the major factor in your failure to conceive. Fertomid is NOT an appropriate treatment for you (Fertomid is the generic form of Clomid).

You need to go to the advanced treatment level called IVF (in vitro fertilization) if you truly want to have the opportunity to get pregnant. Anything less than that is a waste of precious time, such that even at 43, IVF could still be an option without donor eggs. I would strongly recommend that you go see a Fertility specialist that provides IVF as soon as possible. Your age combined with your husband's possible male factor problem would indicate that this might be the best option for you both at this time. I see way too many patients like you, after the age of 40, that have wasted years doing simple treatments with their Ob/Gyn docs. Then, when they come to see me, it is too late and I have limited resources to offer them. Most leave very disappointed. Don't let this happen to you!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

TTC For Seven Years & Dealing With Male Factor Infertility: Do We Do IUI or IVF?

Question:

My hubby and I have been trying to conceive for 7 yrs. One specialist told us only IVF (in vitro fertilization)would work, but a second opinion told us IUI (intra uterine insemination) would work.

He has a count of 9mill and motility of 60%. I'm perfectly fine, my eggs and tubes are good all blood work came back good, and I have conceived in the past and have a son.What are our chances with conceiving using IUI and how many attempts do you think will be needed? Any additional advice would be greatly appreciated. Thanks, S. from the U.S.

Answer:

Hello S. from the U.S.,

If you are under the age of 35 years old, then I think that IUI would be an option for you. The sperm findings are abnormal, but there is a small chance. Your chances of pregnancy under the age of 35 would be 20-24% per cycle, and I would not recommend more than 4 attempts. Your best option is IVF with ICSI (intra cytoplasmic sperm injection). In general, if the count is less than 10 million, ICSI/IVF is the recommendation. You have to bear in mind that only 60% of the 9 million are sperm that can fertilize the egg (3.6 million). That is way lower than the normal required for natural pregnancy (20 million is required).

In most cases where the semen analysis is abnormal, that is an indication that there is a problem with sperm function. After all, it only takes one good sperm to achieve fertilization but for some reason, studies have shown that if there is a severe abnormality in the semen analysis, the sperm have difficulty or lack the ability to fertilize the egg. That is how & why ICSI was developed (see my website for further explanation http://bit.ly/9AdrJc ) . So far, over 10,000 babies have been born with this technique from men who were otherwise considered hopelessly sterile, whose sperm are weak or too few to effectively fertilize an egg. These ICSI/IVF babies have long been proven to be physically, mentally and genetically completely normal, no matter how poor the sperm of the father. If I were your doc, I would have recommended IVF/ICSI as your best treatment option, but would allow a trial of IUI if that is what you wanted to do.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Male Factor Infertility -- IVF Cycle FET Positive But Ended With Miscarriage: Should I Seek A Second Opinion?

Question:

Dr. Ramirez,

My husband and I are a 29yo healthy couple with male factor infertility. Motility is less than 1%, morphology is about 25-30%, and count is pretty low-normal. There are no female issues. We have done 2 IVF/ICSI cycles and one FET (frozen embryo transfer). The first IVF (in vitro fertilization) cycle, I was mildly hyperstimmed. The egg quality wasn't great, and we had about a 50% fertilization rate. We transferred 2 grade A embryos that did not result in pregnancy. No embryos made it to day 5. IVF #2 was much better and had an 80% fertilization rate. 2 day-3 grade A embryos were transferred, but there was no implantation. There were 2 day-6 blasts that were frozen. Both were starting to hatch upon thawing, and the FET resulted in a singleton pregnancy with a heartbeat at about 7 weeks. Unfortunately, I miscarried (no heartbeat) at 8 weeks.

My question to you is when should I seek a second opinion? We had planned on obtaining a 2nd opinion if the FET was unsuccessful, but we feel like technically it was successful. We like the place we go to right now and feel that they are familiar with us. We are planning to do IVF #3 in the near future and are torn as to whether we should stay here or move on. If we stay with the current practice, we will not be changing the protocol since it was successful last time. Although it has been suggested, we are not ready to use donor sperm since we were able to grow 2 blasts and achieve a pregnancy. We are located in Missouri.

Thanks in advance for your time.

Answer:

Hello L. from Missouri,

I agree with your statement that technically the FET was successful. In fact, the FET cycle WAS successful. Remember, IVF can only give you the opportunity to become pregnant. It cannot MAKE you pregnant because the last two steps in the natural process, embryo hatching and implantation, are NATURAL steps and we don't have the technology to make that happen. So, the fact that an embryo did those two steps and the pregnancy went to 7 weeks is a success. And, it is a very good sign because it now shows that what you are doing can work!

I would not give up on that clinic yet. In fact, pregnancy rates with FET are lower than fresh cycles, so a success with an FET is good. They deserve the credit. Now that they have stimulated you twice, know how you react, etc., they are hopefully in a good position to build on that the next cycle. You have to give them some credit for that.

Overall, I would hang in there. You've proven that it can work. Whether or not the pregnancy continues is solely and completely dependent on the embryo. It was probably an abnormal embryo. Now, you just need to get a good one there and you'll go all the way. Don't look back, just look forward. You should now be more encouraged than before because you know that it can work. It is just a matter of time!

On a personal note, I have a patient that I was able to get pregnant on her first try at the age of 36 and she had a beautiful child. She just came back to me for her second child at 39 (worse chances statistically) and became pregnant again, but it was an abnormal pregnancy and ended in a miscarriage. I found out today, that she is planning to transfer to another clinic because they have a "special" research program going on that gives patients a significant discount. You can't believe how heart broken and how I feel rejected by this. I put my heart and soul into my patients, and they get the best care that they can receive. I know that logically the cost is a significant issue, and this is what is driving the patient, but having gotten so close to a success, when we have been successful before, is difficult for me. That is what your clinic will think too. They'll ask themselves, "why is she leaving when we were successful under less odds?"

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

Comment: Dr. Ramirez clearly stated his opinion and seemed to have genuine answers. I appreciate his advice and his providing this service