Hope And Encouragement During IVF: Is It Necessary?

Dear readers old and new,

The main purpose of my blog, Facebook entries, Twitter entries and All Experts advice are to give people hope; to urge them to continue their quest to have a child; to give them explanations and to help them in their quest.

I and my staff are my patient’s cheerleaders. We want the very best for them and hope and pray with them. We feel sadness when they fail and are overjoyed when they are successful. We put our hearts into them. This is a closeness that most large IVF clinics do not have the time or energy to do. This is personalized care, and it affects us because of the stresses it puts on us. Nameless, less personal and faceless care would be a lot easier for us. It would be less stress. It also would be less sadness for us, but that is not the type of care I or my staff like to give.

But today, I was criticized for something completely different. I had two patients give us feedback that we were “too encouraging” so their feeling of failure was worsened. They were angry at us for this. We were criticized for giving too much compassionate care, so that we enhanced their expectations and hence their fall when they received the negative result. I am mystified as to when good care or good service is no longer acceptable. Should we create more of a distance from our patients? Is giving hope to patients really just fueling false hope and subsequent depression? Is the anonymous factory-type care that many large centers provide, better than our approach? Is this really what infertility patients want? Are my efforts actually more destructive than they are constructive? I’d love to hear from readers of this blog about their thoughts.

As infertility specialists, we deal with a very personal issue. So personal and private that most patients won’t even acknowledge us to their friends or family. For example, I was at a B’nai Mitzvah recently for twins that, not only did I help conceive, but I also delivered. It was a celebration of the children, and there were acknowledgements of everyone in their lives, including their teachers, rabbi, friends, travel partners, etc. but, alas, there was no mention of me; the one who not only made it possible for their mother to have them, but who physically brought them safely into their world (I delivered these twins as well).

I have accepted the fact that what I do is highly personal and private. I have accepted the fact that many patients will not acknowledge me in mixed company, or in the store or on the street. Being a “fertility specialist” can have a negative impact on their standing among friends. That is certainly something that all fertility specialists have to accept. I do accept that. Unlike many other medical specialties, the praises we receive are received in private. We don’t mind that because we know that in their hearts, they appreciate the care and gift that we gave them.

It can be a bit disheartening though, at times.

Edward Ramirez, MD, FACOG
http://www.montereybayivf.com/

38 Year Old With One Fallopian Tube: Miscarriage With 2nd IVF

Question:

Hello Dr. Ramirez!

I am 38 and trying to conceive my 2nd child. I did 2 rounds of IVF at 35 and had a healthy daughter at age 36. We just went through another round of IVF and got pregnant, however it ended up in a miscarriage at 10 weeks. We can't afford another IVF so we're trying a few rounds of IUI with Clomid 100 mg. I'm now going for my second round.

My issues are stemmed from a ruptured appendix at 16 which left one of my fallopian tubes badly scarred. I did have a laparoscopy and had that one closed and my other one is totally open. In all the testing for my IVF, everything came back good..."for my age". My husband has a fantastic motility and count, so there's no issues there. My questions are:

1. My RE says that follicle growth is completely random and that they do not alternate sides every month. What are your thoughts on this? I hate to waste the time and money if the follicles grow on the bad side.

2. Have you seen much success with clomid/IUI at my age? Everything is totally normal with me and my husband. We eat good, (I was a smoker from 16-30 but haven't smoked in 8 years) and I rarely drink.

3. If this doesn't work, any suggestions on where to go from here?

BTW, I'm writing from Milwaukee! Thanks!

Answer:

Hello L. from the U.S. (Wisconsin),

First of all, it is wonderful that you were able to already have one child via IVF! This is encouraging.

1. Yes, your RE is correct that it does not alternate but is random. Also, your assumption that the side that it ovulates on is the side where it enters the tube is not correct. In fact, the ovary, being three dimensional, can have a follicle rupture at any part of its surface, even the side that is opposite where the tube is located. So how then does it get to the tube? Well, when the ovary ovulates the fluid surrounding the egg rushes out taking the egg with it and flow down-hill into a space called the culdesac. The culdesac is like a little bowl. The fluid collects here and then with simple fluid motion, it moves around. In normal anatomy, the end of the tube that picks up the egg, called the fimbria, is located in the culdesac, so it you are lucky, the egg contacts the fimbria of one tube and is brought into the tube (like an elevator) where it meets the sperm. This is why a woman who only has one tube on one side and one ovary on the opposite side can get pregnant.

2. Pregnancy rates at 38 years old are around 5% per cycle, which is not very good but it is not zero.The pregnancy rates are less with Clomid than IVF because you and your body still need to go through the 9 step process to achieve a pregnancy whereas with IVF, steps 1-7 are done by the IVF procedure and there is only two steps left to contend with.

3. Monterey, California :) I'm only kidding. You have already shown that IVF can work. The reason that you miscarried is because the embryo was probably abnormal, which is a risk that you have because of your egg. The goal is to eventually get a perfect egg that will give you a perfect and healthy baby. That is probably just a matter of time. The only alternative, which gives you a higher chance for pregnancy per cycle and less chance of a miscarriage, is using donor eggs. But you can do that at any age, so I would try again with IVF if you are not successful with your Clomid cycles, although I understand that finances are an issue. You don't have much time, though. If you do manage another IVF cycle and it fails, then you can always do donor eggs. I recently had a patient who tried IVF in her early 40's, miscarried then failed, and then gave up. At 55 she decided she wanted to try again and went with donor eggs. She now has a beautiful daughter. With donor eggs, your age is not a significant factor.

Good Luck,
Dr. 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

Third Failed IVF Cycle: New Protocol Needed? Compare SART Stats?

Question:

Dr. Ramirez,

I just had my 3rd failed IVF cycle and I'm looking for some guidance. A little history:

I am 31 have a short luteal phase but PIO and estrace seem to do the trick. Day 3 testing normal. My husband has low morphology.

My 1st IVF attempt I responded very well (long lupron) to low doses of meds. Stimmed for 7 days. They obtained 10 eggs and 9 fertilized with ICSI... all were very good quality on Day 3. Transfered 1 and 5 frozen on Day 3.

2nd IVF attempt- Antagonist Protocol- very slow to respond on highest doses of meds. Didnt have any measureable follicles until Day 10... stimmed for 15 days. Obtained 6 eggs and only 3 fertilized with ICSI. Transfered 2 embryos on day 3. Negative beta 10dp3dt and stopped meds. Discovered 2 weeks later that I was pregnant and miscarried.

3rd IVF attempt- back to Long Lupron- very slow to respond again on highest doses. Stimmed for 15 days- obtained 8 eggs- 4 fertilized and only 2 were viable on Day 3. Beta negative.

Questions:Any thoughts on why I would have such a different response from cycle #1? All 3 cycles were done in 2011.Would you suggest trying a different protocol? Do you think I may be a good canidate for Micro-Flare Protocol?In both 2nd and 3rd cycles my e2 level was 22 and 24 at suppression check compared to 59 in cycle 1. Any insight? Could this mean that I am oversuppressed? Also AFC was lower in past 2 cycles.How much time do you suggest in between fresh cycles?Any thoughts that you would be willing to share would be greatly appreciated. I am getting very discouraged and you have been so helpful in the past. Thank you, D. from Massachusetts

Answer:

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

It is difficult to critique protocols and I generally do not. There are many different ways to accomplish the same thing so any one particular protocol may not be better than another.I do not favor the long protocol, however, for two reasons. I think there is too much ovarian suppression at the beginning of the stimulation and you have to take many more injections. For that reason I use the antagonist protocol, which usually only required 2-3 injections. So, I would not go back to the long protocol. There is not question that the long protocol is the classic method, in fact, most REI's use this protocol because they are not familiar with the antagonist protocol.

In terms of your stimulation, there can be significant differences from one cycle to the next. For example, I have a patient who only produced one follicle in her first cycle with the maximum dosage of medication, yet in the second cycle, with a reduced protocol, she produced 8 follicles. This shows that each cycle is unique and the ovaries will respond differently. You don't mention of these cycles were done back to back i.e. consecutive months, but in general there should be a one month rest period between IVF cycles to allow the ovaries to recover. A stimulation of 12-14 days is not unusual and sometimes preferable. Sometimes a short stimulation phase leads to less quality eggs. Also keep in mind that you were successful in the second cycle, which means that you can be successful again. You have to be persistent. You are lucky that you are in an insurance mandated State for IVF.

I would strongly recommend against the Micro-flare protocol. This has been shown to not be of any benefit.Finally, there are other reasons for failure of an IVF cycle. You are young and had good embryos to transfer. So maybe it was something else? Implantation failure can occur if the transfer technique is not good by the Physician, as an example. Or you may need some additional meds to reduce your immune response or increase blood flow. There are differences between IVF clinics/centers. We are not all the same and therefore pregnancy rates differ.

Follow-Up Question #1:


Thank you so much for your thorough response. I have a few more follow up questions if you do not mind...What are your thoughts on the Estrogen Priming Protocol? Do you usually use a FH and FSH while stimming? I have read that adding Menopur in too soon can effect egg quality. The article that I read suggested adding it in after 4-5 days of stims and then lowering the FSH dosage. Any thoughts on this? My current RE had me starting Menopur on the 2nd day of stims.The past 2 cycles fertilization was only 50% with ICSI compared to 100% my 1st cycle. The embryologist noted that my eggs were "brownish". Any thoughts on this? Do you think it was due to egg quality? Lab issues?You mentioned additional meds to reduce your immune response and increase blood flow... what type of meds do you usually prescibe?How much emphasis do you put on SART scores.

I am contemplating switching clinics and I am looking for some guidance. Mass General has the highest success ratings in my age group but I have heard that they are very focused on scores, etc. I have heard great things about a RE at Boston IVF but there SART scores are lower. Would this be a deciding factor for you?Yes, I agree... I am very lucky to have insurance coverage! Again, I really appreciate your help. This process is so stressful and I am so overwhelmed!

Follow-up Answer #1:

Hello Again,

Let me take your questions sequentially for ease.

1. I don't have any feelings one way or the other regarding estrogen priming. I don't use it because I don't think it has been shown to be of any benefit. By I lack the experience to know for sure.

2. I am a believer in the "mixed protocol" which uses both pure FSH and a combination FSH/LH (my preference is Follistim/Menopur). Many studies have shown benefit to having LH present in the follicular phase. It has been found to increase the egg quality although there is not real technology to determine egg quality. I was trained on this method and my experience has been that the stimulation is better i.e. higher number of follicles. My pregnancy rates are pretty good as well. I don't agree that it will decrease egg quality. That has not been my experience.

3. Brownish or discolored eggs signify a basic egg quality issue. This may be why the fertilization rate was not as good. The minimum fertilization rate should be 50% and will vary from cycle to cycle because the eggs will be different each time. I don't think anyone has any explanation for why the eggs would have a "brownish" or "discolored" appearance.

4. I use low dose aspiring (81mg), Medrol (16 mg) and low dose heparin (2000 units twice per day). These all start with the start of the stimulation and continue through the cycle. The aspirin and heparin are stopped on the day of the trigger injection and not restarted until the day after the retrieval.

5. SART scores are certainly one thing I would look at. The problem with SART scores or the CDC scores is that they only look at one year, not cumulative scores which is more revealing. That's because clinics can have a good year and bad year depending on the types of patients they have, embryology problems, change in personnel, etc. But since these two organizations don't give cumulative statistics, you might have to ask the clinics if they have them. If you are going to use SART scores, then try to look at the last three years and compare. Also the problem with these scores is that they are 2 years behind and IVF technology is ever-changing.

Also, if you are going to look at the SART/CDC stats, the only one you should look at is the implantation and pregnancy rates per cycle and transfer in patients under the age of 35. Don't necessarily look at your specific age group. Those two statistics are the important ones and we use under 35 years old as the gold standard because those are inherently the most fertile patients (ie no age factor). Certainly your age group statistics are also important because you want a clinic that does well with your age group. If I were going to a new area and had no idea which clinic to go to, I would use the SART/CDC statistics to help me decide. Then I would go check them out, ask about their program and see how personal the care is (just like you would if you were buying a car). I don't recommend going to a factory type program. You want a program where you have one doctor attending you through the entire process and don't get a different doc for the transfer, which is one of the most critical steps. Sometimes smaller clinics are better than larger ones because of this, as long as the pregnancy rates are equivalent. Try to get the clinic's current statistics if you can or the most recent ones, and not necessarily the ones from two years ago submitted to SART. Most clinics will have the previous year's stats.


Follow-Up Question #2:

Thank you very much for your response. The info that you provided re: the SART scores is very helpful. I appreciate the tips!!One more follow up question re: the "mixed protocol". Do you usually start the Menopur at the same time as Follistim? Or do you wait a couple of days.Also, would you reccomend that I try any supplements? I have done some reading about DHEA? What are your thoughts?

Follow-Up Answer #2:

Hello Again,

The Menopur (FSH/LH) is started at the same time as the Follistim (FSH). I don't recommend any supplements. There are none, especially DHEA, that have been proven to work but I did see a recent article touting DHEA is older women. They claimed it increased embryo quality, but I am doubtful. That shouldn't be a problem for you because you are young.

Things that I do add in patents that have failed a previous cycle:
1. Acupuncture (it is not proven, but some studies show benefit and it doesn't hurt to try everything after failures.)
2. Low dose aspirin - 81 mg orally per day starting at the beginning of the cycle.
3. Low dose heparin - 2000 units SQ twice per day starting at the beginning of the cycle.
4. Medrol 16 mg orally per day starting at the beginning of the cycle and decrease to 8 mg on the day of transfer (you would stop this at the time of the pregnancy test).
5. Both progesterone injections and progesterone suppositories. I don't start the suppositories until the day after the transfer.

Good Luck,
Dr. 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.

Comment: Dr. Ramirez is always very kind and helpful. I am very thankful for all of his help.

How Can I Have A Year Of The Dragon Baby?

Question:
Dear Doctor,

We are a Chinese couple who would like to have a baby this year. We have been trying for many months in the natural way for timing the baby for the Dragon year but we are not successful so far. We are thinking that maybe we can make our chances better for a baby this year if we go see a baby specialist here in Hong Kong. My wife is 34 years old and I am 38 years old. We have been trying for six months now. If we try for test tube baby, can we choose for a boy or girl? What would you suggest would be the proper next step for us?

Thank you, you are very kind for your advice. L. from Hong Kong

Answer:

Dear L. from Hong Kong,

I appreciate the fact that many Chinese couples are looking forward to having a child in the Year of the Dragon. If you wish to time your wife's pregnancy for a delivery within this Chinese lunar year, you do not have much time to spare! In essence, since you have been trying to conceive already for six months, it may be time to look at alternatives. I will go over all your options, from least complicated to the most aggressive:

First option:

What I would suggest if you still choose to go the "natural way" for just this month, is that your wife begin taking prenatal vitamins that have at least 1 mg of Folic acid within it, and that you keep in mind that the actual fertile days are pretty narrow - 2-3 days. If your wife has regular and predictable cycles, you can predict ovulation by counting back 14 days from the period. That would show where ovulation probably occurred in the previous cycle and by counting from the first day of her period, gives you an idea of what cycle day ovulation occurred. Then with this information, you can use the calendar method by counting from the period the number of days where you can both expect ovulation to occur. You need to stop intercourse 5 days from that anticipated ovulatory day, then start intercourse two days prior and have intercourse daily, once per day, with having only one ejaculation per day for five days.

Second option:

I think that an IUI (intra uterine insemination or artificial insemination) is a better starting point and should be done right away, but you need to make sure that the appropriate treatment is being done to increase your chances. IUI's are better than trying naturally because the number of eggs ovulated are increased with fertility medications, timing is better known by ultrasound surveillance and the sperm is injected into the tubes to await the egg. Ideally, your wife should be ovulating 3 eggs per cycle, or have 3 eggs of ovulatory size (18-24 mms) so maximize the chances that an egg will find and get into a tube. You did not say if either one of you have been tested for infertility. In your age group (34yo), your chances of natural pregnancy are about 10% per month and with IUI, up to 24% per month.

At my center, typically, we do an hsg (hysterosalpingogram) to see if the woman's tubes are open and viable. We also do a semen analysis on her partner. A negative result in either of these tests would make it quite difficult for you to immediately succeed with either an IUI or naturally.

Third and probably best option:

Considering the fact that you do not have much time and that you are considering gender selection, then IVF (in vitro fertilization) or "test tube baby" may be the best choice if you wish to conceive within the next few months.

With IVF the woman can produce many follicles and as long as you get at least one good embryo, IVF has a better pregnancy chance than IUI because it is accomplishing 7 of the 9 steps your body goes through to achieve pregnancy (IUI only accomplishes one). The remainder have to be accomplished by your body. That is what gives IVF a pregnancy rate of 60-76% per cycle in your age group.

If you wish to do gender selection, then IVF with PGS (pre implantation genetic screening) is the only option you have. A microscopic biopsy of the trophectoderm (the outer cell layer of an embryo) is done by the embryologist and sent to a lab for analysis. Recently it has been shown that the pregnancy rates from a single PGS-selected euploid embryo were 58% and 60.7% compared to 42% and 40.7%, respectively, from a morphologically comparable but non-PGS-selected embryo. Interestingly, the miscarriage rates were seen to decrease to 6% and 6.3% from 12% and 12.5%, respectively. With transfer of one embryo, the risk of multiple gestation is essentially eliminated.

I know that in China, Korea and Japan, genetic screening for gender selection is not allowed. Here in California it is, though. We have had Asian patients come to us who have chosen to have PGS for gender selection and succeeded. Your chances would be reasonable if normal embryos were obtained and transferred. You can choose to freeze or vitrify some embryos and transfer one fresh (vitrification is a method of rapid cooling of embryos that minimizes ice crystal formation which has further improved success). If one is transferred and it takes (implants), I would expect that there would not be any abnormalities in the fetus or child.

I wish you luck in the Year of the Dragon and hope that you will find a good physician in Hong Kong or abroad that will be willing to work with you and help you succeed in your quest for a child this year.

I hope all this information is helpful.

Dr. 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.

34 Year Old With One Tube, Endometriosis, Abnormal ANA: What TTC Strategy Do You Recommend?

Question:

Hi Dr. Ramirez,

I am writing to you as I am now desperate with our situation and hoping to get some push from someone who is knowledgeable in this field. I am 34 and my husband is 40. No kids from both sides. We've been TTC for 2.5 years now. When we started, our bloodwork both came back normal as per my family doctor although he mentioned that my ANA (anti nuclear antibodies) is out of the normal but he said he's not sure if it has something to do with fertility or not and he'll leave it up to our RE to decide. My ANA is positive 2+ speckled pattern.

I've always been regular with a 26-29 day cycle. We first visited our RE in April 2011 and he said I should go for additional bloodwork which I did and came back normal. So he said I am generally healthy, no weight or smoking problems. My husband didn't smoke too. I also did BBT (basal body temperature) charting and my RE confirmed that I am ovulating regularly. I went for an HSG (hystergosalpingogram) in June 2011 and they said they can't get the fluid to get into my cervix or uterus so they considered me blocked.

I went for laparoscopy on July 2011 and my RE told me that I have stage 2 endometriosis but he was able to clear it out and my left tube is open while the right is still blocked. He said we only need 1 tube to get pregnant so he prescribed me with Clomid in August and did a scan at cd 12 and he saw 2 mature follicles in my left ovary. We didn't get pregnant that month so I went for another month of Clomid but I noticed that month, I didn't get the cervical mucus that I usually have during my fertile days. I told my RE so in October he switched me to femara and had another HSG done. He said he unblocked my right tube so I am perfectly healthy. We did another scan at CD 12 and my RE confirmed that I have 2 mature follicles, one from each side so he said I should get pregnant pretty soon. He gave me 2 more prescriptions of femara and told me not to come back to him until Feb 2012 or when I am pregnant. I am now in my final dose of my femara and really desperate :(. While taking femara I didn't notice my cervical mucus coming back to normal. I think it was the same case as with clomid. I am dry during my fertile periods so I started using preseed in November.

Now my questions are, what do you think are the other options that we can take besides IVF? I've never tested positive in a test since we started TTC. I've never taken birth control pills in my entire life. Do you think my positive 2+ ANA has something to do with our infertility? My RE seems to ignore it and I am not too sure if I still have to remind him about it. What do you think about the fertilaid supplements? I am just in a desperate mood now so I think I am taking any chances. Any advice on the next steps to take?

Sorry for the long post. I would really appreciate your reply on this. I hope you had a fantastic holidays!

Here's my husband's numbers:Volume 3.5 mlpH 7.6Motility 50%Speed 4Count 48 million/mlMorphology 80% normal. I don't have some of my bloodwork numbers so I cannot post but my RE said it looks ok. Thanks in advance for your reply. F. from Canada

Answer:

Hello F. from Canada,

First let me say that you should not feel "desperate" at this time. You have plenty of time to work with because you are young, and options open to you. You are just beginning your journey so you just have to accept your situation and move forward through it, do what must be done and look forward to your eventual success.

It is worrisome to me that you only have one tube open. Why is there a tubal problem at all? Could this imply that although the tube is open that it is not functional i.e. that there is internal damage? If the tube is not functional then natural pregnancy cannot occur as the tube is an essential part of the process required to become pregnant by natural means.

The second problem you have is the endometriosis. Endometriosis, even if treated surgically, can still be present in microscopic form. It is surmised that this ectopic tissue, i.e. tissue that is not supposed to be present in the pelvis, causes a low level inflammatory reaction that that interfere with the egg in its travel from ovary to tube and therefore prevent pregnancy from occurring. One consideration would be to undergo a 3 month treatment with Lupron in order to get rid of any microscopic residual endometriosis followed by aggressive treatment to achieve pregnancy.

The alternative is IVF to bypass the pelvis altogether. Yes, Clomid and Femara (to a lesser extent) can block estrogen receptors and therefore lead to reductions in cervical mucous and endometrial thickness (that is how they work..they trick the brain into thinking it is not making enough estrogen so that it stimulates the ovary harder, which in turn makes more estrogen). These are side effects. These can be treated by giving vaginal estrogen tablets.

I don't think that the ANA is having any affect on your lack of pregnancy at this time. But, you could take an 81 mg tablet of aspirin daily to help overcome this. It's an easy treatment. (For my readers information, an ANA test detects antinuclear antibodies in your blood. Normally your immune system makes antibodies to help you fight infection. In contrast, antinuclear antibodies often attack your body's own tissues — specifically targeting each cell's nucleus. But some people have positive ANA tests and are perfectly healthy.)

I am not a proponent of fertiliaid. I think the product is just preying on people like you who are desperate and will try anything. I don't think that it helps.

In terms of other options, if the simple ovulation induction with Clomid, Femara or injectables is not successful, and I would not recommend continuing with this strategy if no pregnancy occurs within 6 months, then the next level of treatment is IUI. I would not recommend more than 4 attempts at IUI. If all the above don't work, then you should move to IVF.

Good Luck,

Dr. 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.

Woman Wonders: Natural FET Cycle Vs. Controlled FET Cycle?

Question:

Dr. Ramirez, I have some embryos frozen. I have adenomyois and endo and chronic endometritis diagnosed.

Have done antibiotic treatment with uterine lavages and IVs.

After depot lupron treatment, is it better to do a natural FET (frozen embryo transfer) or medicated FET. Since it takes about 2-3 months to wait for period to arrive is it better to do a medicated FET? I am concerned about medicated FET as the last time I did a medicated FET I had fluid in the uterus although nearer to transfer it disappeared and I did go on to transfer although BFN (big fat negative).

My RE seems to want to wait for a period before transfer but would not that waste 2-3 months since you said the endo can return in 6 months? Will the cycle be regular and as in ovulation or will it be not regular when I do FET. At the moment my cycles are regular. I have also heard of high dose progesteone treatments treating endo and adeno. Can you explain how this works?

I am confused what to do as we have limited embryos and want to do everything as possible as once the embryos are used up we are done.

Thank you. R. from Rhode Island

Answer:

Hello R. from the U.S. (Rhode Island),

Your RE should have explained that one of the critical steps in getting pregnant, natural or with IVF, is the state of the uterine lining at the time the embryo reaches it for implantation. We know that there is a very limited time that the embryo can implant and the endometrial lining has to be in a very specific and correct microscopic state for implantation to occur. This is where timing is absolutely essential. If you miss this "implantation window", then it will fail.

Conceivably you could do this with a natural cycle, but then there is a wider margin of error because we don't know exactly what the timing is or what is going on microscopically in the uterus. For this reason, we do not do this in FET cycles. FET cycles are always done as a controlled and programmed cycle. With this protocol, you can have a period induced artificially with medication and then start the cycle, but most clinics will want their patients to be on the birth control pill for at least two weeks period to the FET cycle in order to suppress the ovaries, which then allow complete control of the FET cycle.

If this is in fact gong to be your last attempts at getting pregnant, then I would make absolutely certain that you are in the best clinic that you can be in and that it will give you the highest chances of success. A good clinic would be able to answer these questions and make sure everything is clearly laid out.

Finally, in terms of progesterone treatment with endometriosis and adenomyosis, progesterone has suppressive action or counteracts estrogen in estrogen receptors. AS you probably know, endometriosis/adenomyosis are stimulated by estrogen and therefore, will be somewhat suppressed by progesterone. However, there is still some small amount of stimulation so progesterone is not the perfect treatment. Estrogen receptor blockers such as Lupron are better at suppressing endometriosis. Progesterone is used mainly to slow down the recurrence of the endometriosis after they have been treated with surgery or Lupron.

Good Luck,

Dr. 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.

Congenital Adrenal Hyperplasia & Infertility

Question:

Dear Dr. Ramirez,

Thank-you for reading this message, I greatly appreciate your advice.

My husband and I have been trying for a baby for just under 3 years. During the last year we have had 3 cycles of IUI and 3 cycles of IVF all of which have been unsuccessful.I have PCOS (although the lean variety with normal BMI) and my husband has an above average sperm count, no issues with motability etc etc.Recent blood tests revealed a chemical pregnancy with a level of HCG at 25(this was outwith IVF) and a very high 17-OHP level (13 x normal level). DHEAS level was normal. The tests were repeated however they have refused a follow up 17-OHP due to costs and have just tested DHEAS as my doc is now saying these levels should ALWAYS correlate.

I am worrying that I may have late onset Congenital adrenal hyperplasia (I am aware that sometimes PCOS is mistaken for this) and that the lack of treatment may be preventing pregnancy. I have asked for the ACTH test but have been told i dont need this as DHEAS levels are normal.Can you advise if it is normal to have a markedly elevated 17ohp in the absence of raised DHEAS? Could this be late onset Congenital Adrenal Hyperplasia?Your advice would be most appreciated. From K. in the U.K.

Answer:

Hello K. from the U.K.,

Sorry for the delay in getting back to you. I had to do a little reviewing to answer your question.

17-OHP is a marker of adrenal function in the valuation of hirsuitism (increased hair growth in a woman). It is a good first level screening test. To be most accurate, it should measured first thing in the morning because there could be elevations from the intermittent diurnal pattern of secretion from the adrenal gland (ACTH). Levels should be less than 200 ng/dl whereas intermediate levels of 200-800 ng/dl require further testing. Levels over 800 ng/dl are diagnostic of a 21-hydroxylase deficiency, which is a form of congenital adrenal hyperplasia (CAH). In that case, the DHEAS would be normal.

The next step to diagnose this disorder would be an ACTH stimulation test, which is done by administering ACTH (Cortrosyn or Cosyntropin) intravenously in a dose of 250 mcg. Blood samples are then taken for 17-OHP at time 0 and 1 hr. The testing must be done in the morning (the levels of ACTH change with the body's natural 24-hour cycle of processes "circadian rhythms"). This test is most accurate if it is performed early in the morning. (Reference: "Clinical Endocrinology and Infertility" Leon Speroff et al).

Keep in mind that late onset COH is very rare. Both 17-OHP and DHEAS are measurements of adrenal function. In the cases of most adrenal disease leading to hirsuitism, both 17-OHP and DHEAS are elevated. Both may be elevated with hyperprolactinemia or adrenal tumor.

Good Luck,
Dr. 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.

Comment: Thank you so much for your response, I will pursue the ACTH stimulation test. Thanks again!