Similar IVF Protocol But Different Results: Why?

Question:

Hi Dr. Ramirez,

I'm back again with a question about my recent IVF (second one). This IVF (in vitro fertilization) cycle we did the same protocol as last time (antagonist) but started off at a higher dose of Gonal-f based on my response last cycle. This cycle we started off at 300iu gonal-f and 75iu menopur whereas last cycle we started with 225iu gonal f and 75 IU menopur but had to increase to 300 IU gonal f after day 4 showed an E2 of only 90. Both cycles I started out with similar AFCs of 10 and 12 at suppression check. My usual AFC is between 16-20. Last cycle it seemed that I recruited more follies along the way and ended up with an E2 of 3030 and 23 eggs retrieved (17 of which were mature based on icsi and conventional fert rates as we did 50/50 split fertilization). This cycle my E2 was 2100 at trigger and they retrieved 12 eggs (still waiting on fert report today but we are doing all conventional fertilization).

My question is why did I have such a different response this cycle given that we started off at a higher dose this cycle compared to last? Last cycle we went up from 225iu gonal to 300 IU gonal at day 4 and stayed there until trigger. this cycle we started at 300iu gonal and stayed there until we added ganirelex on day 7. At that point my E2 stalled and do they increased my gonal f to 375iu gonal f and kept me there until trigger.

As always thanks for your advice/insight. S. from the U.S.A.

Answer:

Hello S. from the U.S. (Virginia).

The human body is not a consistent nor predictable structure so I can't explain why your response is different.  I have always explained to patients that have low response to stims that the ovaries can react differently each cycle and your experience is a case in point.  That being said, I would not have increased your dosage since your stimulation was so good the previous time and you bordered on entering OHSS territory.  In any case, IVF is not a contest where the person with the highest number of follicles or eggs wins the prize.  The goal is to find 1 or 2 perfect eggs that will lead to perfect embryos and a successful pregnancy.  So despite the fact that you stimulated less, that might be a better thing.  Bottom line is you only need one good one.  Also, there have been some studies showing that when a patient stimulates hard with lots of follicles, sometimes the egg quality suffers and the pregnancy rate drops.  This is especially true in PCO patients.  In those patients, our preference is to stimulate less and get fewer follicles.

So, in any case, as the saying goes: "I don't think you should sweat the nitty gritty" i.e the fine details.  Hope for the one perfect one.  That is the goal.

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.

Is A Tubal Reversal A Good Option For Me?

QUESTION:

I am a 33 year old mother of two. My children are 11 and nearly 10 years old.  After the birth of my second child in 2003 I had surgery to prevent further pregnancies. (I was in an unhappy marriage and only 23, and couldn't see myself ever getting out with 2 children.) The doctor was reluctant, because I was so young, but he decided to go ahead and perform the sterilization surgery. My tubes are not cut or clipped or burnt, they just have little clips on them to prevent the egg from passing through.  But just as many people predicted, now I regret the decision.  

I am divorced, my children are growing up, and I am in a wonderful relationship with a man who has no children of his own but would very much like to have one.  Barring infertility issues on his part, is there much hope of us being able to reverse my tubal and conceive a child of our own?  I don't have any other medical issues. I am healthy and active, average healthy weight, non-smoking, non-drinking...same for him. He is 39 and I'll be 34 this year, so we feel like the clock is ticking on any opportunity for another child.  Can this surgery be done, what are the odds of conception afterwards, what factors do I need to consider, how long do you need to wait after the surgery before trying to conceive.  And what is the average cost??  I appreciate any answers you can give me on the matter.

Thank-you! K. from Kentucky

ANSWER:

Hello K. from the U.S. (Kentucky),

The type of tubal ligation that you have is the best to reverse because the majority of the tube is kept intact and there is minimal damage to adjacent tubes.  Also, considering you are young still, a tubal reversal would be a good option in your case. A good and experienced gynecologist or reproductive specialist can do the reversal either by laparoscopy (using a scope and little incisions) or by a mini-laparotomy (a small incision above the pubic bone. You would want to find a surgeon who is well experienced in this and does them a lot to get the best chances for success.  

I have had a patient who went to North Carolina to have hers done by a doc who only does reversals. The risks for this procedure are the same risks as for any surgery (infection, bleeding, general anesthesia, injury to adjacent structures, failure) but this is not considered a major surgery, but rather should be an outpatient (same day) surgery.  In terms of success, those rates can vary widely so I can't give you an exact number.  A good surgeon will have an 80% success rate in patients under 35 years old after 1 year of trying.  If a pregnancy does not occur within 1 year, then the procedure probably has failed.  

Basically, with a tubal reversal, all you are doing is attempting to restore your natural fertility rate. This rate is very age dependent.  Your chances of natural pregnancy at 25 years old was 85% per year whereas at 35 it will be 30% per year because your eggs have aged.  So, keep these statistics in mind. The alternative to a tubal reversal, and with a higher likelihood of success is In Vitro Fertilization, but the down side is you would have to do this every time you wanted a child from this point on.  With a reversal, you could continue to have children by natural means if you wanted more than one.  Cost wise, tubal reversal will vary depending on the doctor, the clinic and whether or not it is done in an outpatient surgery center or hospital.  The cheapest I have seen is about $6000 and is done in an outpatient surgery center.  Hospital performed reversals will be $15,000-18,000.  I hope that gives you the information you needed.

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, once again. Armed with the information you provided, we can now move forward! I feel like I got lucky having my question go to such a knowledgeable and open volunteer!

Secondary Amenorrhea: A Description, Not A Diagnosis

Question:

Hello Dr. Ramirez,

I'm 20 and 293 pounds. I have had  Secondary Amenorrhea for close to 4 years now. It is apparently being caused by my weight. I'm not planning to TTC for at least another 12 or 13 years. I don't hate babies but it's not just a good time on the emotional or financial level to have them. If I'm able to get down to a decent weight and get rid of this disease,  What are my chances of getting pregnant when it's time for me to TTC???

There's a history of Diabetes in my family and I haven't had a asthma attack since I was 8.My mom had thyroid disease before I was born but I don't think that's genetic. But I don't have any other diseases than the SA at the current moment and my hormone levels were just fine at my last doctor appt which was last October. I've been on progesterone more than I count and it gets me a period but I want to have it without the help of drugs. Is there some kind of natural cure to SA??

I know that it seems a bit silly to ask about this NOW but I'm not getting any real answers about this disease from my OB. Everytime I asked my OB about this, she would tell me not to worry about it or brings a therapist in the room to basically tell me that I'm crazy.

She's since moved her practice out of state and I have a new OB that I'll start seeing very soon. But how in the hell am I crazy for wanting to be proactive about my own health?? I'm sorry for the language but I'm just so fed up about this and at my wits end.

I know that I'm not producing eggs right now but what else could this be doing to my body?? Do I have a reason to be concerned about it besides the obvious infertility scare?? If I do get rid of this disease,  Is there some kind of leftover side effect that could cause me to get Ovarian Cancer in the future??

I don't have these answers and I need to know what's going on. Please help me clear at least some of this up.

Thank You. D. R. from Michigan.

Answer:

Hello D. R. from the U.S. (Michigan),

Good riddance to your previous Ob doctor!  "Secondary Amenorrhea" is a description of a problem and NOT a diagnosis.  It just means that you used to have periods and now you don't.  It doesn't explain the cause.  The most common reason for old women to have secondary amenorrhea is menopause.  The most common reason for young women to have secondary amenorrhea is pregnancy.  However, a close second is an ovarian disorder called "Polycystic ovarian disease."  This diagnosis is manifested by irregular or rare natural menstrual cycles and at least one of the following findings: ovaries that look like PCO ovaries on ultrasound, inverted FSH/LH ratio, obesity, hirsuitism (increased facial hair), elevated testosterone levels, diabetes, elevate insulin levels signifying insulin resistance.  I think that you have PCOD but without a thorough endocrine evaluation, I cannot say for sure. 

With this disorder, you have a hormonal imbalance and that needs to be corrected.  The most simple way to do that is to use a low androgen birth control pill such as Yaz.  Once you are ready for pregnancy, then you will have to use fertility medications, which actually do not increase your fertility but induce your ovaries to ovulate, so that you can give off an egg to get pregnant.  You need to see a COMPETENT gynecologist or a reproductive endocrinologist to be evaluated and treated correctly!

You may want to see a more detailed explanation of Polycystic Ovarian Disease on my website.

Glad you wrote! Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

Woman With Secondary Infertility & Possible Blocked Tube: Misdiagnosed? Surgery? What To Do?

Question:

I had an HSG (hysterosalpingogram) in November. The dye flowed freely through my left tube, which appeared normal and healthy.  However, the dye would not enter my right tube until after the radiologist had me get on my right and then left side. The dye then went into the tube and appeared to flow freely, but then it stopped abruptly mid way in the tube.The visible part of the tube appeared normal and healthy.  My RE told me that it is extremely rare for a woman to have a blocked tube in the middle of the tube unless she's had her tubes tied and that it was possible I was just born with half a tube.

I recently had a laparoscopy in June to get more info about the cause of my infertility and to attempt to repair the right tube. The dye again flowed freely in the left tube. My doctor inspected the right tube, and found that it appeared to be completely normal and healthy in every respect. However, again, the dye entered the right tube and stopped mid way. 

After the surgery, my doctor told me that I had no endometriosis or adhesions of any kind. She also told me that I had no evidence of any tubal disease or previous infection in my pelvic cavity.  The only abnormalities that were found were a large paratubal cyst that had wrapped around my good left tube (the cyst was successfully removed), and a small polyp during the hysteroscopy (also removed).  I also have never had any other surgeries or ectopic pregnancies. 

My RE told me she had no idea what was blocking the tube, but not to worry about it because research shows that having one healthy tube does not really decrease your chances that much for Clomid/IUI or timed intercourse.  Still, it's very frustrating to me because I thought that laparoscopy was 100% method for diagnosing the cause of a blocked tube, but I have no more info about the cause of blocked tube than when I started.

I am 38 and my FSH and AMH values are excellent, and my hubby passed his sperm analysis. I have a 2 year old that was conceived after 8 months and we have been trying for #2 for 1.5 years.  Although I understand that having just one tube should not affect my chances that much, I am still concerned because at this point, it is our only known issue.    

My questions are:  1. What could have caused the blockage in my tube?  2. Is it possible that the tube is not actually blocked but is not flowing for some other reason (I've heard about false diagnoses of blocked tubes due to preferential flow or not enough dye being used)?  3.  Is there any other way to find out what is blocking my tube?  4.  Is it worth it to pursue surgery to repair the tube like I've seen for women who undergo tubal reversal surgery?  

Thank you! C. from Atlanta

Answer:

Hello C. from the U.S. (Atlanta),

To answer your questions in order:

1.  The most common cause of a mid-tubal blockage, that is not from prior surgery, is an internal tubal infection.  Many of the bacteria that cause this type of scarring can do so without any type of symptom.  A laparoscopy would not be able to find this type of injury and, other than the HSG, there is no way to examine the inside of the tubes.

2.  It is possible that there was tubal "spasm" causing the tube to appear blocked, but I doubt it because the Radiologist was able to get the dye to flow down part of the tube.  However, if you think that it my not be an accurate test, then I would recommend that you have another one, but have your doctor specifically request that they pay most attention to the right tube i.e. do the test so that the dye preferably goes down the right side.  Remember, fluid will always go down the side of least resistance.

3.  There is no other testing that can be done to examine the tube.  Scope technology is still not small enough.

4.  NO.  Such surgery can cause pelvic scar tissue and impair your fertility more.

First, I think you need to consider ALL the factors involved in your fertility potential.  Yes, it is possible to get pregnant naturally (intercourse or IUI) with one normal tube, but there is no way to prevent the egg from going into the tube that is blocked, so your chances are actually decreased. 

Second, you are 38 years old which means that your natural chances of pregnancy are already reduced significantly down to 3-5% per month (15% per year), which is further reduced if you add the tubal problem. Even with IUI your max chance of pregnancy based on your age is only about 7-10% per month not considering the tubal issue. The fact that you have been pregnant before is a positive factor and increases your success with assisted reproduction. If you want that second child right away and if you were my patient, I would strongly urge you to consider IVF. 

Third, you have to decide which of two assumptions are correct: the tube was blocked from a prior bacteria, which probably went to the opposite tube as well but did not cause blockage, but did cause damage vs the blocked tube was the only injury and the opposite tube is therefore normal.  If the open tube is injured, which cannot be proven but is possible, it may not be functioning normally despite being open.  Keep in mind that fluid can pass through even the smallest opening.  In that case, you will not be able to get pregnant naturally and so IVF would be the treatment of choice.  Because of your age, I would make the assumption that the tube is damaged (mainly because you have not been able to get pregnant naturally when you were able to previously) and therefore recommend IVF.  It is the most successful and expedient treatment option for you. 

If your doctor wants to waste time and try something less like ovulation induction or IUI, that is fine as you understand that the risk you are taking is losing the opportunity to get pregnant with your own eggs and more time passes. I hope this second opinion is useful to you.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

Finally Pregnant After Multiple Miscarriages: "I Am A Nervous Wreck!"

Hello Dr. Ramirez,

I've written you in the past regarding my fertility challenges and your responses have been very encouraging. In my last, I discussed how I'd experienced an early loss in March after our first IVF attempt. You encouraged me to be strong and keep trying that my chances were good. You were right. I waited until my next cycle began and started a more simple IUI cycle again with just Follistim injections. My first miscarriage in April 2012 after IUI with Femara/GonalF was caused by trisomy 3. I found studies that said use of Femara in some women could increase the chances of aneuploidy. This time we tried without the Femara and I have become pregnant again.

I have gone through the complete RPL panel-DNA analysis, autoimmune, alloimmune, thyroid, hysteroscopy, etc. Everything has been normal. I believe the second miscarriage, because it began just 16 days after embryo transfer, was due to my body being weak (I was very sick during stimulation and had a lap/hysteroscopy/cystectomy 3 weeks before I started stimulants). I am 32, maybe borderline diminishing reserve (last AMH was .9), but otherwise nothing really bad with me.

So I am currently past 9 weeks. My betas doubled and were actually in the higher end of the ranges for weeks along. I did a viability ultrasound at 5 weeks and could see the heartbeat. Embryo measured exactly the right size. At 7 weeks we could hear the heartbeat at 174. RE saw me again at 8 weeks and said I looked good, released me to my OBGYN, said most women miscarry between 7-8 weeks. I've had no spotting or cramping. OBGYN is letting me do weekly scans until I'm through my first trimester. Heartbeat has stayed in the 170 range. Growth is continuing. Last ultrasound at 9 weeks showed the baby kicking its legs.

Here's the thing - I'm a nervous wreck. I'm terrified of something going wrong again. I am fighting to follow reason rather than fear but it is so hard. I have hardly any symptoms certainly none of the "noticeable" ones which means most of the time I don't feel like I'm pregnant. My last HCG was only at 102,900 when it was checked at 8.5 weeks, which I felt was low for where it had been but I know it slows down. My progesterone in the beginning was all the way up to 75 and is now holding at 30 (I had cysts leftover from after the IUI, made 3 follicles).
The statistics are all over the place. Some say less than 5% when heartbeat is detected but that can jump to 20% if you've had prior losses. I read it's even less once you enter the fetal stage past 8.5 weeks.

I feel stupid for asking but your answers are thoughtful. What do you think my chances are of carrying this baby to term? What would you say my change of miscarriage is? And why in the world do I hardly feel anything? I'm a little tired in the evenings and I pee in the middle of the night with crazy dreams, breasts are bigger but not sore, no nausea, etc.  But hardly anything to notice. Thank you so much for your time.  L. from Indiana

Answer:

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

CONGRATULATIONS :)  Like your RE, I release my patients at 8 1/2 weeks gestational age because the risk of miscarriage is minimal.  Statistics show that the risk of miscarriage is up to 50% prior to 8 weeks gestational age and then decreases to 5% up to 12 weeks gestation.  So you are now at 5% risk but the fact that all the signs have been good, is very encouraging and I would not worry about miscarrying.  At this point, the only risk of a miscarriage would be if there is a major genetic abnormality, and this would be a baby that you wouldn't want to go to term any way.  You should certainly consider genetic testing early to check on that.  There is now a blood screening test that can be done at an early stage.

In my experience, and as evidenced by the data, most patients will have a successful pregnancy and delivery at this point.  The fact that you "don't feel any different" with this pregnancy is irrelevant.  Every pregnancy is different and different people experience pregnancy differently.  Some have pregnancy symptoms and some have none.  You may be one of the lucky ones that doesn't have to suffer with the "morning sickness" or other such symptoms.  For now, pray that all continues to go well and thank God for the blessing.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

38 Year Old Has Five Failed Fresh IVF Cycles But Has Frozen Embies: Should She Try FET?

Question:

Hello - I have been reading you blogs for some time now and am so thankful that you take the time you do with such thoughtful answers.

I am 38 and husband is 41. My history is as follows: 2009 wasted time on clomid prescribed by my obstetrician, 2010 saw RE (reproductive endocrinologist) and began the real journey. Major issue is male factor morphology but I suspect with my age quality may be issue too.

In 2010 we had 2 Fresh IVF (in vitro fertilization) cycles, first was a failure 3 eggs collected, thankfully 3 fertilized and implanted 2 (1 frozen) but no pregnancy, cycle 2 doubled my stim meds to 300 gonal f and 150 repronex, collected 13 eggs but transferred 2 "decent" but beta was very low around 70 the pregnancy continued to around 11 weeks saw heartbeat but clearly there was issues as the size kept loosing ground until miscarriage and D&E. Cycle 3 same meds, 13 eggs, transferred 2 on day 5 and then arrived my beautiful baby girl delivered 12/29/2011.  Fast forward to 2013 where I have done two more fresh cycles same protocol, birth control, 10 lupron, to 5 lupron when stimming, retrievals after 9-10 days of stims. Cycle 4 resulted in collecting 20 eggs, 2 "decent" transferred on day 5 (blastocyst and morula) very low beta resulted in loss about a week later.  Cycle 5 same protocol except menopur instead of repronex, collected 18 eggs, 14 fertilized and transferred 2 blastocysts on day 5. This was a negative. BTW all cycles are ICSI and included medrol, baby aspirin, antibiotics, vivelle patches and  progesterone in oil injections. 

My question is what are your thoughts on FET (frozen embryo transfer).  I have 4 frozen embryos 1 from cycle 1, 1 from cycle 4 and 2 from cycle 5. RE and hubby think I should take a break and try for FET. I and concerned as I don't want to "waste" a cycle insurance will cover on the lower cost option but the meds did really affect me this time and see their point about giving my body a rest. I am at a very reputable clinic in Boston and doc said 4 frozen is a lot due to their strict freezing criteria so am optimistic although obviously embyro age has no advantage. Would FET also be something you would recommend at this point? Fresh cycles are a big logistical challenge as my husband travels 70% of the time.

Also if I go back to fresh cycle is there anything significantly different you would do (btw I am also doing acupuncture). Thank -you in advance for your time. I also want to say I am very grateful for my daughter and don't want to seem selfish but I would really like her to grow up with a sibling. 

J. from Boston

Answer:

Hello J. from the U.S. (Boston),

It sounds like you are in good hands.  Your clinic has accomplished several pregnancies, which is an IVF success.  Keep in mind that IVF can only give you the "opportunity" to become pregnant.  It can't make you pregnant because the last three steps (embryo hatching from its shell, attachment to the endometrial lining, and lining growing around the embryo are natural processes that are in God's hands.  That fact that you got a pregnancy (positive bHCG) shows that those steps occurred.  Continuation of the pregnancy is then based on pregnancy factors and not IVF factors.  Because of your age, your chances of a miscarriage are high due to abnormal embryos.  You've shown that you can get pregnant, and your ovaries stimulate very well.  Now it is just a matter of finding the perfect egg/embryo which will then lead to a successful pregnancy.  I wish all my 38 year olds responded as you do.  So hang in there!

I think I would advise proceeding with the FET cycle before another fresh cycle.  It is a much easier cycle on your body, and some newer studies are showing better pregnancy rates than fresh, probably because of the lack of overstimulation of the endometrial lining.  I don't completely agree that FET is "better" but it certainly gives a good chance.  If they fail, you can certainly try fresh cycles again.  I would advise two FET cycles consecutively.  In fact, I always advise my patients to do an FET cycle, if they have frozens, before trying a fresh cycle again.  You never know. . . the frozen might work.
In terms of additional protocol changes, you are doing everything that I have my patients do in terms of supplemental medications, but I also add low dose heparin (2000 U per day).  Not all RE's agree with this protocol, but it is an accepted protocol for recurrent pregnancy loss so you might want to ask your RE.

Thanks for following my Blog.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Thank you much for the quick and thoughtful answer. I have several time contemplated seeking a more aggressive clinic despite my comfort level. Your response puts many of my worries at ease. You are truly a huge help to those of us in a constant state of limbo. Thanks again.

 

39 Year Old With Recurrent Chemical Pregnancies

Question:

Hello there! I’m writing to you from Florida. I have recently suffered two miscarriages. One in Oct of 2012 and one in March of this year. Both occurred at about two weeks so very early. I guess the term is chemical pregnancy when it is that early. I don't know how I know I am pregnant so early but I just know. My body is sensitive! I am 39 years old so my Dr. watches me closely and had me do the clomid challenge test to check the fsh which I think tests egg quality. Mine was 7.6. I also had a vaginal ultrasound and everything looks perfect. No fibroids or cysts. Then in March 2013 I got pregnant again and I was immediately sent for an hcg blood test. My hcg levels kept going up and down 241 to 119 over the course of three weeks and it would not leave my system completely so I ended up having to have another ultrasound that found nothing as they were worried about an ectopic pregnancy but did not find a sac or anything. I ended up taking a methotrexate shot.

Finally my levels went back to zero and 6 weeks later I did a complete recurrent miscarriage blood panel test and they found that I tested positive for two copies of the mthfr CT677 gene. I also was out of range for the PAI-1 test which was 51. Everything else was normal. My Dr. put me on foltx and a daily aspirin plus I take my prenatal vitamins and she told me that as soon as I find out I am pregnant again I need to start administering lovenox injections and progesterone suppositories. Right before delivery it would change to heparin. I enjoy reading your blog and appreciate all of your knowledgable answers. I would like to know what your thoughts are about the regimen she has planned for me and if there is anything else I should be doing. I am a bit nervous to try again. We really want to have a baby!  

Thank you, M. from Florida

Answer:

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

The CCCT is to check for ovarian reserve (ability of the ovary to respond to stimulation) and not egg quality.  Thought you should know that.

It sounds like your Ob/Gyn doctor is well versed in the evaluation and treatment of recurrent pregnancy loss, which makes her a little better than the average Ob/Gyn doc.  One thing to keep in mind, however, is that you have the "age factor" which means that your eggs are old and debilitated and therefore have a propensity to forming abnormal embryos.  In most cases these embryos will not continue and lead to a miscarriage (especially before 8 weeks gestational age).  The age factor is the main factor that you are trying to overcome.  There is no treatment that can make eggs better.  The good news is that your ovaries are still functioning well, and you know that you can get pregnant.  Now it is just a matter of getting a perfect egg.

The increased folic acid, low dose aspirin, low dose heparin or lovenox and progesterone supplementation are all reasonable and acceptable treatments for recurrent pregnancy loss. What I would recommend is that the heparin/lovenox start immediately with the start of your period, NOT once you become pregnant.  It should already be in your system when implantation occurs to help with increased blood flow at the implantation site, and decrease the immune response to the embryo.  Starting after pregnancy would defeat the purpose.

Based on your age, I would agree with the above regimen, add CoQ10 600 mg per day (found to help with egg quality in mice.  No human studies yet but it can't hurt) and strongly recommend that you consider IVF rather than continuing to try naturally.  I know that you are able to get pregnant naturally, and it may eventually happen, but the only way to increase your chances of success (overcome the age factor) is to increase the number of eggs and embryos you have to choose from.  With IVF, you have a better chance of finding the perfect egg.  I explain it to my patients with the following analogy: imagine that you have a bucket of blue balls and a few red balls. There are mostly blue balls and only 4-5 red balls.  The red balls represent your good quality eggs and the blue balls the poor quality eggs.  These balls are all mixed up together and you lift the bucket above your head so that you can't see inside.  Now you have several options.  You can take one ball out at a time (like you would in a naturally ovulatory cycle) whereby you will eventually get a red ball, but you can see that it will take a long while; or you can take out a handful of balls out at a time (like using superovulation with fertility drugs); or you can dump out a bunch of balls at a time (like doing IVF).  You can see that the latter method is the fastest for getting to a red ball.  That is why IVF (in vitro fertilization) is the recommended treatment.  With a red ball (good quality egg) not only will you get pregnant, but you will have a successful pregnancy because a normal embryo will develop.

Sorry for the extremely long explanation, but I hope my answer has been clear.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVFwww.montereybayivf.com

Monterey, California, U.S.A.