Recurrent Pregnancy Loss: 5 Miscarriages Since 2009

Question:

Hello Dr. Ramirez,

My husband and I have been trying to conceive since 2007. I have PCOS (polycystic ovarian syndrome) and I have had 5 miscarriages, first one in April 2009 at 10 weeks and the others at 6 weeks. I've also lost a baby due to an incompetent cervix at 6 months. My most recent miscarriage was last month after an IFV cycle at 6 weeks. I was on baby aspirin, progesterone shot, metformin and Estrace. My fertility specialist was not able to say why I am having these recurrent miscarriages. My doctor has done blood work and all standard testing.

After numerous IUI cycles we went ahead with IVF which also led to a miscarriage. I still have four embryos left and don't want to pursue with another IVF cycle until I can get some answers as to what might have gone wrong or what I can do to change the outcome. Do you have any suggestions for me? Any feedback is greatly appreciated. N. from Canada

Answer:

Hello N. from Canada,

I am sorry for all your losses! The incompetent cervix is something that can easily be handled with your next  pregnancy by doing a cerclage (either a TVC or a TAC by the 16th week of gestation--a TAC can also be done pre-pregnancy). But you need to achieve and hold that next pregnancy. First, let me say that you should also read my website page where I have written extensively regarding evaluation of Recurrent Pregnancy Loss (RPL) and a possible protocol for treating this problem. Anyone who has miscarried three times or more needs to have this type of comprehensive evaluation. Some of the possible reasons you may be miscarrying include:

• Genetic/Chromosomal Causes (you don't state your age, but that could be factor)
• Polyps, Fibroids & Uterine Disorders
• Hematologic Disorders
• Hormonal (you have PCOS, so your cycle day 9 & 10 LH needs to be checked )
• Infectious, Genetic & Immune Factors

With a diagnosis of "Recurrent pregnancy loss", there is a protocol that is usually followed to evaluate for the possible causes. As stated above, this includes genetic testing (both you and your husband), immunological testing, infectious disease testing, anatomical testing, hematologic testing and hormonal testing. It is quite an extensive array of tests and can take up to two months.This is what should be done BEFORE you proceed with any more IVF cycles. The treatment will then depend on what is found. In some cases, for those with genetic causes, IVF with PGD (preimplantation genetic diagnosis) can be done to test the embryos for viability and chromosomal abherrations.

What is good is that you are able to ovulate, that your eggs fertilize and that you have been able to get pregnant. It is very difficult to go through as many miscarriages as you have and I hope that with proper evaluation you will be able to deliver a beautiful, healthy child in the near future.

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.

"Infertility Nightmare" After TTC For Seven Years & Two Failed IVFs

QUESTION:

Hi, I was very much hoping you could help me with my infertility nightmare!

Myself - 30 yrs old, AMH: 3 / FSH 9 / ttc 7 years / diagnosed this year with severe endometriosis mostly around my ovaries.

My partner - 39 yrs old - no issues

After trying unsuccessfully naturally for 4 years (tried using ov kits but no signs of ov) I consulted my gp and was referred to our local hospital for 'basic fertility tests'. No issues apparently found and I was diagnosed with 'unexplained infertility'!

I was then given 3 months of clomid and a follow up appointment for 6 months later! Clomid did nothing for me (no ovulation detected on ov kits). My periods were horrendous whilst on this and shortened to 24 days following it. They went back to 28-29 days after a few months.

I was then referred to another hospital for IVF. Again only the basic tests were carried out (blood, semen etc). This was when I was found to have an AMH of 3.

IVF 1 - 0.5 burselin / 4 vials of menopur / gonasi hcg trigger shot / 2x 200mg cyclogest.

Stimmed for 12 days in total - produced 10 eggs of which 5 fertilised. Transferred 1 hatching blast on day 5. Other 4 embryos did not make it to freeze.

Day 3 started to spot pink blood & by day 5 had period. I did have a very strong 'immune reaction' the day after transfer (flu like symptoms which lasted 12 hrs).

My consultant advised he thought the egg quality was to blame causing the early bleed after implantation.

I insisted on further tests and 3 months later has a Hysteroscopy and LAP (laparoscopy). I was then diagnosed with severe endometriosis. I was also given a cervical dilation due to a difficult transfer. I apparently have a small and narrow cervix and a forward tilting uterus.

IVF 2 - 0.5 buserelin / 6 vials of menopur / gonasi hcg shot / 3x 200mg of cyclogest (after my insisting).

Stimmed for 13 days and was very slow to respond this time. Six eggs collected of which 3 fertilised. Two blasts transferred on day 5 (1 more advanced than the other). Day 4 after transfer pink spotting again again developed into period. Felt slightly unwell the day after transfer (but not as intense as the first ivf).

Both IVF's resulted in negatives.

My questions are:

1. What is your opinion on the early bleeds? Do you think it's embryo quality (I don't know there officially grading by the lab). Or is it an immune issue possibly lined to the endo? Or both? My aim next is to have level 1 and 2 immune testing.

2. Do you think the progesterone support is enough? May I possibly also need estrogen support? My doctor does not believe in this!
My aim is to try with DE next time due to my poor response on IVF 2. Do you agree? My main concern is the amount of time I have been infertile plus the 2 failures. I have never achieved a pregnancy yet. Do I have hope in your opinion?

Thank you so much for taking the time to read this.

N. from Ireland

ANSWER: Hello N. from Ireland,

Please note that detailed and comprehensive recommendations cannot be given without review of your medical records. This venue only allows for short and succinct answers so I hope it suffices.

Embryo quality DOES NOT cause post-transfer bleeding. If bleeding occurred, there is probably no way to know exactly what the bleeding was from, however, the first question would be whether or not there was an adequate luteal phase i.e. whether the progesterone you took produced adequate levels. If you took the medication orally, it would not be adequate. The only way to take progesterone with IVF is either vaginally or by injection. Vaginal progesterone can, however, cause some cervical bleeding because of some eroding effects on the cervix. This is not an indication of an immune problem.

Estrogen is required for adequate endometrial formation as manifest by endometrial thickness and a trilaminar pattern on ultrasoud. Estrogen is also required in the implantation phase and is easy to use so many IVF programs do add this to the regimen.

I'm afraid I don't know what you mean by "DE", so cannot comment.

There is always hope. The key is to find the proper treatment, the proper doctor and the proper clinic to make that happen. I tell my patients, "we can get almost anyone pregnant. It is just a matter of what needs to be done to do so." The only sure way to fail is to stop trying.

Good Luck, Dr. Edward J. Ramirez, M.D., FACOG

FOLLOW-UP QUESTION:

Hi Dr Ramirez, many thanks for your reply and for taking the time.

Regarding the progesterone I was taking this rectally by Cyclogest pessarie 400mg x3 daily. The reason for taking it rectally is that i tend to suffer from thrush. I'm now wondering whether taking this rectally was not sufficient. I am also concerned I am not maybe absorbing the progesterone enough therefore and I'm now keen to try injections next time.

I do tend to suffer with a shorter luteal phase of 10 days before spotting / bleeding on natural cycles.

I will defiantly suggest using estrogen next time. I can not understand other than a hormone in-balance why i would twice suffer from such an early bleed. My lining on the last scan was found to be 10.9 and of a trilaminar pattern.

'DE' stands for donor eggs. I was advised after my first failure not to try more than 3 times with my own eggs. After my poor response to this cycle and the outcome again I am almost definitely considering trying with donor eggs on my third cycle. I just hope to try and determine any other causes for failure before doing this.

Other than the above and the immune testing the only other issue I'm concerned about was the fact both of my embryo transfers have not been straightforward. Although the second transfer was not as painful as the first, I could still feel the catheter going all the way up into my uterus which was incredibly uncomfortable.

Its such a pity your clinic is far, far away!

Thanks again for your time. If I am to reach a successful outcome in the future I will be to sure to come back and update this to hopefully give other women possible clues to their failures.

N. from Ireland

FOLLOW-UP ANSWER:

Hello Again,

I see no reason why you need to consider Donor eggs. Rather, I think you need to consider changing to a different clinic! Pregnancy rates vary highly from one clinic to another. For example, we have 14 clinics within 100 miles of my center and based on Nationally reported statistics (we are required to report to the Federal Government annually), our clinic has the third highest pregnancy rates within this area. The lowest clinics have rates that are 1/2 of our rate. So where you go makes a difference.

Upon reading your follow-up letter, I saw a significant problem that you have. The embryo transfer is one of the most critical steps, if not the most critical steps, in the IVF treatment process (see my Blog posting on "Step Seven: Embryo Transfer" ). You can have absolutely PERFECT embryos but if they are not transferred appropriately, the cycle will FAIL. The transfer should be a completely PAINLESS procedure and you should not feel a thing. If the catheter touches the back of the uterine cavity or there is bleeding, either of these will cause failure. Maybe that is the main problem? Technique is part of what makes one doctor different from another in terms of pregnancy rates.

I know that I am "far away" but I have had the pleasure of seeing patients from France, Italy, Serbia, Germany, South Korea thus far. Many of these patients tried in local clinics and failed. So, yes it is a 12 hour trip by air, and would definitely cost more for hotel, etc., but if the result is a positive one, would it not be worth it? I'm not trying to induce you to come to my center, but the point I am making is that patients don't have to suffer and endure multiple failures with their local clinic if it is not the best one.

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 once again Dr Ramirez, I was very interested to read your answer & your article regarding embryo transfer & will be taking this up with the hospital on my follow up appointment in the new year. N.

Sixteen Year Old Does Not Have Her Period Yet: What To Do?

Question: Hi, writing from Califonia!

My name is E. and I am 16 years old, will be 17 on June 9th, 2013. I'm 5'9" and I am overweight, but not terribly obese or anything. I have always been active, and I have been a swimmer since I was 7.

I am wondering if something is wrong with me. I still have not gotten my period. Ever. I just feel so out of place when my friends are all talking about theirs and I just stand there. I don't understand why I haven't gotten it yet. I have pubic hair, I have leg hair, armpit hair, I have breasts, and sometimes I see that my underwear is like a light brown (and it smells weird, but not terrible) but it has never been red.

My Dr. told me that if I don't have it by the time I'm 18 then to come in for some tests.

I just wish so badly that it will have it already. Is there anything I can do? Could this in anyway help the process of it starting?

http://www.amazon.com/gp/product/B0009ETA6M/ref=ox_sc_act_title_1?ie=UTF8&smid=ATVPDKIKX0DER

I heard that drinking lots of green tea can help?

Could it be me being overweight? I am currently in the process of losing weight and I have lost 15lbs so far. I also heard that it might have been because my mom breastfed me for longer? She nursed me until I was 3, not a lot after the first year, she said it was normally just to get me to sleep.

Please help! E. from California.

Answer:

Hello E. from the U.S.(California,

Since you have secondary sexual characteristics (pubic hair etc.), that means that your ovaries are functioning and producing estrogen. It may just be a matter of time now before the periods start, but it is a little unusual to not have periods by 17 years old. I don't agree with your doctor. This is something you might want to talk to you mother about and urge her to allow you to see a pediatric endocrinologist, adolescent gynecologist or reproductive endocrinologist. These are all specialists with more advanced training in hormones than your regular pediatrician or family practice doctor. A blood test can be done to check your hormones to make sure there is not something amiss. Medicine can also be given to help you start periods, or if your hormones are unbalanced, to help balance them.

Having a hormonal imbalance can cause long term side effects, like facial hair, that is not reversible so I would not recommend doing nothing.

As a side note, don't buy anything on the internet that says it does something medical. Anything that is medically effective has to have FDA approval and then it is sold in a pharmacy or doctor's office. Only non-medical items can be sold via the internet to non-medical people.

Thank you for writing and try to see a specialist soon. 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.

Second IVF Fails Despite Implantation: Thin Lining? Embryo Issue?

Question: Dear Dr. Ramirez,

I am here to seek your advice once again. I just found out my second IVF (in vitro fertilization) attempt finished with a chemical pregnancy. I tested HCG levels at 11dp2dt and it was 19,2 miu/ml (pretty low), and 48h later it was already 4,7 miu/ml.

I am nearly 37yo, have high FSH levels and my antral follicle count was 12 for this past cycle, 8 follicles grew, 6 were collected and 4 eggs retrieved. We got 100% fertilization and we transferred two 8-cell embryos with perfect morphology and no fragmentation.

I think my biggest problem is my endometrium. It is usually very thin. Although I still have 2 frozen embryos from my first IFV, two transfer cycles were cancelled due to thin lining that would never pass 6.9mm. I tried estradiol patches, vaginal estradiol (creme and pills) which resulted in poor endometrial growth (estradiol levels reached 3500pg/ml in one cycle) even after 3 weeks of use. I also tried vaginal viagra, vitamin E, baby aspirin, prednisone, and nothing worked... the endometrium would grow up to 5.5 to 6mm in the first 8-9 days of the cycle and then would take 14-21 days to reach 6.9mm. In one of the cycles it even decreased 1mm in one week.

Before my first IVF I did a hysteroscopy and everything looked fine. I have a couple small intramural fibroids, none projecting into the uterine cavity. I had a big fibroid removed 4 years ago, but it was intramural and the endometrium was not touched during surgery.

So, in my last IVF that turned out as a chemical pregnancy, my endometrium was 7.1mm at the 6th day of stimulation with FSH (Bravelle), which was really encouraging. However, 2.5 days later, it decreased to 6.4mm... Because at that time I already had bid leading follicles, my doctor wanted to triger that night. He then injected into the uterine cavity, using a catheter, 300 ug of filgrastim (G-CSF), since there are two papers from Dr. Gletcher that mention it as a possible treatment for thin lining. My RE explained to me it was experimental and I agreed to try it.

48h latter and on the time of egg retrieval, my endometrium was 7.6mm. Still not ideal, of course, but the best I got in a long time, so my RE advised us to carry on with the transfer (2 beautiful 8-cell embryos).

So my questions are:

1)What is more likely to be the cause of the chemical pregnancy: genetically abnormal embryo or my thin lining?? I know my age is a factor, but I have been taking Coq10 for nearly a year now. My embryos always look good and I have 100% fertilization rate.

2) Also, I wanted to know if it is normal to have a 8-cell embryo at the end of day 2 (I collected the eggs on Mon 9am and the embryos were transferred Wed 6pm).

3) Is it normal for the endometrium decrease during stimulation phase? What could have caused mine to go from 7.1 to 6.4mm in a little over 60h?

3) Do you think I should try filgrastim on my next transfer cycle? I don´t think my body likes synthetic estradiol though, it never responded well... so maybe a natural cycle (in which I usually reach 7mm) with filgrastim could work?

Taking my history into account, what would you recommend for my next FET in order to be suscessful in overcoming thin lining? Should I start to look into surrogacy?

As always, I really appreciate your time and expertise, and most of all the beautiful work you do here at your blog (for which I am a subscriber :)  C. From Brazil

Answer:
Hello C. from Brazil, Thank you for your kind words and for following my blog! Let me answer your questions in sequence to make it easier.

1. If endometrial thickness were the problem, implantation would not have occurred. Technically, the minimum endometrial thickness required is 6.5 mms so your lining was adequate for implantation to occur, which did happen. The miscarriage was most likely a genetic issue considering your age. Unfortunately, we do not have a technology to evaluate internal egg quality nor change the quality. Keep in mind that the CoQ 10 study was in mice and not humans so we don't know if that will work or not.

2. An 8-cell embryo on D#2 is not normal. That is a rapidly dividing embryo and may indicate that it is genetically abnormal, as has been found on preimplantation genetic studies in the past. Division rate is one of the criteria I use to evaluate embryos, in addition to the external quality.

3. The endometrium does not decrease. The difference in widths are variations in ultrasound measurements. Because we are dealing with mms, the difference between 7.1 and 6.4 (0.6) is within the margin of error and not significant.

4. I cannot comment regarding the "filgrastim" as I am not familiar with this medication or its usage. I would recommend that you consider the frozen embryo transfer in a natural, unmedicated cycle, but I would follow a natural cycle without transfer first to evaluate if your body growth the endometrium to adequate width. Then if it does, I would schedule to make do the transfer in the next cycle. I would still use supplemental hormones after the transfer, namely progesterone to help support implantation and the early pregnancy.

5. If the FET fails, despite everything that has been done, the only other recommendation I could make, if you are still going to try your own eggs, is to have preimplantation genetic screening done (trophectoderm biopsy) on a Day #5 embryo. Some studies have shown increased pregnancy rates in older patients when embryos are screened for normal genetics. That will at least give you an indication on the genetic health of the embryos you are making and whether or not you should consider donor eggs. I would only recommend surrogacy if you are absolutely sure that you cannot get implantation and in your case, you've had implantation. I think it might be more of an embryo issue.

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.

40 Year Old TTC After Termination Of Trisomy Pregnancy

Hello, Doctor.


I am a 40 YO who has never had any trouble conceiving. I've been pregnant seven times. I had a child when I was 37; all went fine.

My husband and I are TTC (trying to conceive). GYN did an AMU (.86) a year ago. He said there was little hope. Nevertheless, I was pregnant in January, but the CVS @ 11 weeks revealed a double trisomy (13/21). We terminated the pregnancy.

Beginning with that particular pregnancy I have experienced pronounced pg symptoms within days of fertilization. They are symptoms I would expect to arise @ 6 weeks. I have had these symptoms each month when my husband and I try (with the exception of one month). My assumption is that I am experiencing hormone surges, but I have my period on time, and I have not had a positive urine test. I have tried a "control month" of abstiinence, and there were no symptoms. Also, no symptoms one other month (although we had tried).

I had a hormone panel on day 3 of my cycle, and another when I had begun to experience the nausea, tenderness, food aversion, fatigue, etc. GYN reported that the baseline was totally normal (FSH 3 and all other #s in range). The second test indicated that levels had changed, but still in normal range and not consistent with pregnancy. He has no explanation for these symptoms U/S's have been clear. No cysts or fibroids.

I did not experience these symptoms with my daughter or any other pregnancy.

I began taking lamictal in 09 150mg daily and .5 Klonopin daily. The addition of these meds and age are the only variables. My dx is Bipolar 1. I have found no research that supports either medication as interfering with implantation. The genetic counselor said the meds are a nonissue.

I have wondered if perhaps the procedure with the trisomy situation has harmed me somehow. My GYN said I never should have been able to implant an egg so defective.

So it seems, now, I will continue to experience these incredibly uncomfortable symptoms every time I fertilize an egg although my prospects for implantation seem dismal. I get all the bad stuff and hope for a good result that doesn't materialize.

Any words of wisdom would be appreciated.  Thanks, S. from California

Answer:

Hello S. from the U.S. (California),

Your symptoms are confusing and not easily explained. First, you cannot tell whether or not fertilization takes place. That occurs within the embryo and nothing within the body is changed at that point. You would not have symptoms. It is possible that the symptoms you are having are "hormonal shifts" or physiologically the result of the rise in progesterone in the luteal phase. Why would you be more sensitive to this now than before? I can't clearly explain that but you are also older now than you were before so maybe that had something to do with it. Normally, the pregnancy symptoms don't begin until weeks after implantation occurs, so it is unusual. But the progesterone is the culprit for PMS (premenstrual syndrome) which does have some of the symptoms that you describe. I don't think it was the D&E (dilation and evacuation).

Your doctor is right and wrong about the trisomy. It is well known that age is a significant factor and leads to increased numbers of embryos with chromosomal abnormalities. This leads to infertility and increased miscarriage rates. In most cases of complex or multiple abnormalities, the embryo never gets to the point of implantation. But if the defect is not significant enough, as in trisomies, implantation can occur but then most will end in miscarriage. Few will continue to the point where genetic testing finds the abnormality but they do occur.

As you continue to attempt pregnancy you have to remember these facts. Due to your age, it will be more difficult for you to get pregnant, you have an increased risk of miscarriages and an increased risk of abnormal embryos. Aside from your one successful pregnancy, you note that you have had six that miscarried which is troublesome. You have what we call "secondary infertility". Since there is no technology that can change the quality of your eggs, the only way to increase the chances of a successful pregnancy in older patients (over 35 years old), is to increase the number of eggs that have the opportunity to implant. This is done by increasing the number of eggs that ovulate (superovulation) or through IVF (even higher numbers of eggs). In addition, with IVF, genetic testing can be done on the eggs to eliminate the ones that are genetically abnormal so that only normal embryos are transferred. This is just food for thought.

I hope I was able to ease your concerns.

Good Luck,

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

32 Year Old With Two Failed IVF Cycles With Positive Beta's: Chemical Pregnancies?

Question:  Hi Doctor,
I live in Idaho where we only have 1 IVf (in vitro fertilization) clinic, so I don't have the option of a second opinion and can't decide if it's worth the six plus hour drive to find out if anyone else would do anything different so I really appreciate you reading this.

A quick medical run down is my infertility was both blocked tubes which 3 years ago I had opened, since they've been open I developed endometriosis which I had cleared last September. I am 32 years old with no medical issues. I have had 8 failed IUI's before finding the endo and then 4 failed IUI's since clearing it. I did have one pregnancy with the IUI but they thought it was ectopic and it aborted itself. I have just completed my second failed IVF. By the way DH has all "normal" counts and morphs for his samples. Both protocols for meds were the same I took Doxycycline and Medrol right after ER (embryo retrieval) and started Progesterone vaginal inserts day after ET (embryo transfer) and was on prenatals and baby asprin the whole time. Both transfer's were done with guided ultrasound with no complications.

1st IVF-September 2012. 10 eggs,10 matured, 4 embryo's fertilized (no ICSI) 1-six cell, 3-eight cell all grade 2's. Two embryo's transfered, last 2 died on day 6 before making it to blast. First beta was 9, second 32, then on day 11 I started spotting,cramping and clotting. Day 13 beta was 7.

2nd IVF-November 2012. 21 eggs, 18 matured, 13 fertilized with ICSI, 1-eight cell grade 1, 6-eight cell grade 2, 4-seven cell grade 2, 1-nine cell grade 2, 1-two cell grade 3. Transfered 2 embryo's back (one was hatching) and cryopreserved 6. Beta test 1 was only a 3 and then the second beta nothing improved. I started bleeding day 11 again.

I have not yet met with my RE but I am trying to gather all the info I can before meeting with her. This last fresh cycle will have been the last one that I think I will do just because the stress on my body of being on meds off and on for 3 years now I think is too much. So the 6 frozen are very important to me to use wisely. I read that you said a chemical pregnancy is not an implantation problem so does that mean that you think it would be a problem with the embyo's? My RE felt last time that there was no need for genetic testing and that my endo was not an issue. I'm just lost as to what my next step should be, what to test for or what I should do with my remaining embryo's (gestational carrier or gamble with them). Thank you again for your time, your blog's have been so much help for me while searching for answers. M. from Idaho, U.S.A.

Answer:

Hello M. from the U.S. (Idaho),

Once you get a positive bHCG, that means that implantation occurred. To be more specific, it means that after the embryo was transferred into the endometrial cavity (the limit of what IVF can do), the embryo progressed in its development, hatched out of its shell, attached to the endometrial lining and the lining grew and enclosed the embryo. These last steps are all natural steps that we do not have the technology to make happen. They have to happen on their own. The take away message from this is the knowledge that you can achieve a pregnancy with IVF. The ensuing problem, of miscarriage, is a pregnancy issue. Whether or not the embryo progresses to developing a successful pregnancy and ultimately a normal and healthy baby is based on the pregnancy alone.

Miscarriage is a more common occurrence than people think. We know that up to 50% of pregnancies can end in a miscarriage, many of which are chemical pregnancies like you had. In most cases of early miscarriage, the reason is because of an abnormal embryo, meaning the embryo had some sort of genetic abnormality. In most of these cases, it is a spontaneous abnormality that occurred at the time of embryo division and not something that you carry. But just to make sure, you and your husband might want to undergo genetic testing if you have not already done so.

One other thing I noticed is that your embryo quality, based on its external appearance because we don't have the technology to know the internal quality, was not optimal for someone your age. This could be related to an inherent problem with the eggs, sperm or lab conditions. In a woman under the age of 35, I would expect most of the embryos to be 8 cell, grade 1 embryos. Genetic testing in the embryos, PGS, is an option but I too would not have recommended it in your age group. In addition, PGS may do some harm to the embryo thereby reducing your pregnancy chances. You'll need to discuss this further with your doctor.

I don't think that any of this has to do with your endometriosis, which is not an issue with IVF.

Ultimately, because you have achieved chemical pregnancies, you have to keep in mind that the IVF can work. Now it is just a matter or time, or more specifically, a matter of getting the perfect embryo. That will take continuing to try and ultimately I am confident you will be successful. It is unfortunate that you only have one option for an IVF clinic in your area because pregnancy rates vary highly from clinic to clinic. That may be another option i.e. travelling to another clinic. We call that distance IVF where patients travel to another state to have the IVF done. It is easily coordinated and arranged so you don't have to limit yourself to one option only. There is more that can be said or advised, but a thorough review of your medical records would be required.

Good Luck,

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

Comment: I was amazed at the timely response and all the information given. I feel confident that the Dr. is giving a knowledgable response as well as very honest without pushing his own clinic which was comforting. Thank you again for your time.

Woman Has Two Failed IUI's With Donor Sperm: Needs An HSG

Hello,

I am a 35-year-old woman writing from Missouri. My husband and I have been trying to conceive for 15 months. After we'd been trying for a year, we went for testing, and my husband was found to have no sperm. We decided to move forward with donor sperm. I had some blood work done (thyroid, progesterone checked) which was normal/ovulatory. I also had a sonohysterogram and endometrial biopsy to investigate my heavy periods; neither of these tests revealed any problems.

So far, I've had two IUIs (intra uterine inseminations) with donor sperm. Neither has been successful (though I had a 21-day progesterone test after both that confirmed ovulation). My doctor is having me use Clearblue Easy OPKs to determine the timing of the insemination. The clinic does one insemination per cycle. Is this the typical procedure? I'm concerned about getting the timing right.

I haven't had a HSG (hysterosalpingogram) test yet. I asked about scheduling one just after my last failed IUI and the secretary indicated that I wouldn't be able to do an IUI and HSG in the same cycle. I'm not sure why. So I don't know whether to do another IUI this cycle, or have the HSG. Any recommendations? What are the risk factors for blocked tubes? I've never had an STI or HPV, if that is relevant.

I know that even though we've been trying a long time, due to my husband's infertility, we've only really had two chances to get pregnant. Psychologically, though, it feels like this has been going on forever. The fact that I'm 35 just increases my anxiety (especially since we'd love to have two children eventually). How many IUI cycles would you recommend before moving to IVF?

Thank you so much. I have appreciated your blog and your thoughtful answers to others' questions for a long time.

K. from Missouri, USA

Answer: Hello K. from the U.S. (Missouri),

Using only one IUI per cycle is acceptable and used by many infertility specialists and Ob/Gyn's. It is really the doctor's preference. If you've been reading my Blog (womenshealthandfertility.blogspot.com) you will see that my preference is two IUI's per cycle (24 hrs and 48hrs). There are two schools of thought regarding this matter and studies do not endorse or disprove either method, so either method is fine. I like to have fresh sperm as close to ovulation as possible and so that is the reason for two since it cannot be known exactly when ovulation occurs. However, using donor sperm, that would be more expensive.

I would not attempt another IUI without having done an HSG. In fact, I would not have recommended an IUI without first having done this test. This is because if your tubes are blocked, for whatever reason, the IUI's will fail. Sometimes women can have mucous blocking their tubes and the HSG can unblock them.

In general, the recommendation is to do no more than four IUI's because most patient will be pregnant by 4 attempts. After four attempts, the pregnancy chances drop drastically, probably because there is something else going on. You have an age issue so you don't want to waste a lot of time. Has your husband had a testicular biopsy to determine if he is making sperm but it is just not getting out? If you decide to pursue IVF, that is something you might want to have done by a Urologist to check and see if you can have a child with his genetics. The sperm, if he is making it, can be aspirated (TESA) and used in IVF to inject into the eggs and fertilize them.

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, Thank you for taking the time to answer my question. My husband and I both appreciate your helpful, thorough response very much. We feel much more prepared for our next visit with the RE. We now know the questions we want to ask and the direction we'd like to go. Again, thank you. K. in MO P.S. Your blog is very helpful too!