Woman In Tasmania Has Done 14 IVF Cycles At One Center And Now Faces An FET: What Advice Can You Give Me?

(**If the blog-talk radio starts up, go to the October 1st blog post below & pause it...I will be keeping the show up for the month of October.)

Question:

Dear Dr Ramirez,

Someone wrote a comment on my blog suggesting I ask you. Basically, I was asking what questions to ask my RE. This is the post she was responding to:

Here’s where I am: I’ve been doing IVF/ICSI since July 2006. We started because my husband had a vasectomy many years ago, so it’s not like we’d been trying for years and didn’t know what was wrong and needed a diagnosis. We knew we’d need IVF if we wanted any hope of having a child.

I live in Hobart, Tasmania. There’s one clinic with only 2 REs: one who is part-time (he’s mainly an obsetrician) and one who is full-time. We started off with the part-timer but have been with the full-timer for a few years now. I would say they pretty much don’t have individualised treatment. They have a few standard protocols, but mainly seem to pride themselves on keeping treatment costs low so patients can have many cycles. Quantity, not quality. If you have repeated failures, they don’t do investigations; they just suggest you keep on going on.

To go to another clinic would cost us money, time, more stress, and be logistically difficult. That’s not to say I’m not up for it if need be. However my husband gave me the ‘I’m tired of treatment and would rather not pursue it, but I’m doing it for you’ bombshell the other night. So I don’t know if I could drag him by the testicles to an interstate clinic to try to get different treatment. I’m willing to go without him though. Having a child has become muchmore important than my marriage.

The only investigations I’ve had are a laproscopy, hysteroscopy, hydroscopy a couple years ago (I had endo, which was removed, and the hydroscopy as inconclusive as fluid didn’t move through my tubes but they looked OK). My obstetrician ordered a bunch of blood tests after Blobby’s miscarriage: protein C, protein S, AT 3, Anticardiolipin antibodies, LAC, Factor V Leiden, Prothrombin G20210A mutation MTHFR C677T mutation, MTHFR C677T mutation, and Karyotyping.I find it unbelievable that after so long, they still don’t try to find out WHY we’re having the problems we’re having. They never check hormone levels (not even during stim cycle – he just relies on ultrasounds to tell him what’s happening), they don’t check for implantation issues, there’s been no renothing. Hearing about the testing that goes on in other clinics has really opened my eyes. I would welcome finding out I had a problem because then we’d know whether it would be likely to be able to be fixed or if we had no hope.

Questions I’ve come up with are:

1. As one of our embryos is a 3 day and the other two are 4 day, can the 3 day be thawed used this time and thawed a day ahead? That way if it doesn’t thaw we still have 2 more we can attempt thawing.

2. Is there a wait list for donor semen? (There wasn’t a few years ago when I did 7 DI/IUI cycles, but I think there is now. Want to know just in case.)

3. Might DHEA help my embryo quality?

4. Any news on the egg donor wait list (Australia's)? (This is probably a stupid question; I know other women in Australia on the wait list and we all seem to get difference answers to our questions. Someone who is 27 was told recently she should have a donor by January 2011 – sorry, but that’s a HUGE porky she’s been told!)

5. The best embryo we’ve had was from a down regulation cycle. Is this just a coincidence, or should be try down regulation cycles again?

6. What sort of implantation failure testing can be done?

If you are interested, my blog "Riding The IVF Roller Coaster" is at http://tasivfer.wordpress.com/. I am writing from Hobart, Tasmania, Australia. Australia's island state - and a long way from any clinic other than the one I've been with for soooooo long. . .Cheers,TasIVFer

NOTE: As of 2012, TasIVFer is a MOM! "After 4 1/2 years, 14 fresh IVF cycles, 7 donor inseminations, 4 FETS, and the loss of my dear son Blobby at 14 weeks 2 days, we tried (half) an egg donor. Blood test 10 December 2010 = BFP. Little Spark was born 6 August 2011!!! He LIVES! Now the journey continues with an FET in November 2012 with our last embryo. Perhaps our last ever?" Good for her!!!

Answer:

Hello TazIVFer from Australia,

Let me take your questions in sequence and answer them the best that I can.

1. The Day #3 frozen embryo certainly can be thawed and cultured to align with the Day #4. My recommendation would be to thaw both, one day apart, and allow them to culture to blastocyst if your home lab has that capability. That may give the embryos a better chance of implantation. You don't mention what the cell # and grade was at the time of freezing but that is an important factor. As the saying goes, bad in-bad out. That means that if the embryo is poor quality, culturing further does not make it better quality. It may not survive the culture.

2. I cannot answer your questions regarding donor sperm wait lists. In the U.S., there are no donor sperm wait lists. Donor sperm are readily available. I guess that's because there are more men in the U.S. than Australia.

3. DHEA will do nothing and is not recommended. However, I would recommend that you consult my blog where I addressed the issue of implantation failure. I do have my own, specific protocol that I use for patients that fail IVF. Because I don't have any precise information from your cycles, I cannot give any specific recommendations.

4. Again, no egg donor wait lists in the U.S.

5. Coincidence probably but I would have to look at your cycle information to do a detailed analysis.

6. There are no specific tests for implantation failure.

I hope this answers your questions adequately. It is unbelievable that you have gone through so many cycles. I don't know of many women and their husbands that could manage the stress and frustration of prevailing through IVF for so long. I wish you the very best of luck with your FET cycle!

Keeping my fingers crossed! Good Luck,

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

36 Yr. Old Irish TTC'r With Low AMH & Scar Tissue From Cystectomy Needs IVF

Question:

Hello,

I have a number of queries.

I am a 36 year old female from Dublin, Ireland who has been TTC for 2.5 years. After one year of trying myself and my partner were referred to a fertility clinic. At that time, ultrasound and MRI showed that I had a 4.5 cm dermoid cyst on my left ovary and I was referred for a csytectomy in April 2009. My surgeon chose to do a laparotomy saying that there would be less likelihood of the cyst rupturing during surgery and having to clean up the pelvis so I went with his advice, while I was open he took the cyst on the left ovary but also took what he thought was another cyst on the right ovary as it was hemorrhagic. The histology report showed that the cyst from the right ovary was actually my corpus luteum for that month.

After the recovery period for the surgery my partner and I began to try and conceive naturally with no luck. At this stage (December 2009) we were frustrated with the first fertility clinic we went to so we changed clinics and in February of this year I had an AMH test and pelvic sonogram in preparation for IVF. The AMH results show that I have low ovarian reserve (0.5). The left ovary had no follicles on it at ultrasound and the right one only had four or five. I do know from past ultrasounds that I have been ovulating from my right ovary every month since the surgery (and probably before that since I always had pain on this side every month).

I was also diagnosed with uterine polyps at the sonogram which I am going to have removed via hysteroscopy and d and c prior to starting a cycle of IVF in April.

My questions are these:

- could the removal of the corpus luteum on the right ovary and the cyst on the left have damaged my ovarian reserve?

- do you have any suggestions for maximising my chances of success with IVF given my low ovarian reserve? Would you recommend DHEA?

- since the surgery I have had consistent pain where I perceive my right ovary to be and menstrual like cramping at odd times of the month - could this be related to the surgery. I have asked doctors about it and since they can't see anything wrong with an ultrasound they tell me not to worry about it.

I am very concerned about the effect that the surgery had on my fertility as well as the fact that my surgeon nor the first fertility clinic I was with did not warn me of any risk associated with the surgery.

Thank-you for your time

ANSWER:

Hello N. from Ireland,

The previous surgery would not have had an effect on your ovarian reserve. However, the type of surgery you had (exploratory laparotomy with cystectomy) could have altered and worsened your fertility. Unless a lot of the ovary was removed, however, it should not have affected your ovarian reserve.

In reality, low ovarian reserve is just a description of how you will stimulate with the fertility drugs. AMH (anti-mullerian hormone) is only a test that gives us a measurement of ovarian reserve but it is not an indicator of your fertility. Keep in mind that you only need ONE good embryo to get pregnant. In fact, I did IVF on a patient this month who ended up only having one embryo to transfer, because of low ovarian reserve/low response, and today her pregnancy test is positive!

You are still young so your chances are still good. I would go with a high stimulation protocol (not the flare protocol), then you can only hope for the best. I don't advocate DHEA (which is dehydroepiandrosterone, an endogenous hormone i.e. made in the human body, and secreted by the adrenal gland). Make sure the IVF clinic you go to has a good and high pregnancy rate. You don't want to waste time on one that doesn't.

In terms of your pain, it is possible that you have scar tissue that formed around the ovary as a result of the surgery. Scar tissue cannot be seen by ultrasound. You would need a laparoscopy to see it.If worst comes to worst, you could always come to the US, although I know that is a very expensive proposition. I've had patients from as far away as Serbia on the European side and China on the Asian side.

Follow-Up Question:

Hi Edward,

Thanks for your response, particularly about the impact of low AMH on fertility. I have a couple of follow-up questions:

- how could the type of surgery (laparotomy) I had have adversely affected my fertility?

- what is a decent pregnancy rate for a fertility clinic?

- would you advise a laparoscopy to check for scar tissue prior to the IVF or should I just go forward with my cycle?

Thanks, N.

Follow-Up Answer:

Hello Again,

Whenever surgery is performed abdominally, especially an open surgery and one around the reproductive organs, scar tissue formation can be induced. This will interfere with the passage of the egg from the ovary to the tubes.

In your age group, we are hitting a 68% pregnancy rate per attempt with IVF. I know that in general in the U.S., pregnancy rates are 50-60% per IVF transfer. I don't know what they are in Europe, but you might want to use that as a guide. We break that down into age groups and the statistics I gave you are based on your age, and not across all ages.

I do not recommend laparoscopy to check for scar tissue formation prior to IVF. Only do this surgery if you are dead set on trying to get pregnant naturally. IVF will bypass the pelvis completely, and is the ideal treatment for severe pelvic scar tissue/adhesions, so the surgery is not required.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.