32 Yr. Old Losing Hope After One IUI Miscarriage and One IVF Chemical Pregnancy: I Say Don't Give Up!!!

Hello, I don't even know how to begin because my infertility process has been so exhausting. I suppose I have diminished ovarian reserve. My last FSH check was 8.5. My AMH is 1. My stimulation cycles response seem to change--one time will be a nice response and the subsequent ones won't be. I started my first IVF this year and I fear repeating the same pattern as last year. Last year, my first IUI on 75 follistim/femara produced 4 mature eggs. I conceived, hcg was high, but ultimately a miscarriage due to trisomy 3. Did a complete RPL work up (I had a chemical pregnancy unmedicated 6 mos earlier). Nothing was abnormal, even karotyping. I had two more IUIs after that, producing 2 eggs, then only 1 egg. No success. I battled recurrent simple follicular cysts for about six months (would bounce from one ovary to next, two cyst aspirations and they would still come back) and finally had a cystectomy and laparoscopy in early February 2013. He found very mild endometriosis and treated it. I had started birth control pills in early January, on for 5 weeks, and then carried on with an antagonist protocol later in February with 150 follistim/75menopur. My day 4 E2 was over 700, thought I had another cyst, but instead had several follicles, dropped follistim to 75, then E2 dropped to 500, then up to 100 follistim and eventually my growth balanced out. Ultimately, I had 14 follices, 12 mature, 9 eggs retrieved, 6 fertilized, 4 day 3 embryos, then 2 highest grade blastocysts, 1 morula. Transferred the two blasts. Positive beta, 175 14 days after transfer. But my 48 hour beta dropped to 77. So I'm having another chemical pregnancy/miscarriage. This is exactly a year from my last miscarriage. I am terrified that in continuing IVF I will repeat this same pattern--that the next IVFs will not work. I just don't know what to do. I don't want to be 32 and have bad eggs when I know I don't have a translocation. I feel like I do respond to lower doses of medications, which should be indicative of decent reserve, but I don't know why I would keep having such problems likely due to embryo abnormalities. I suppose my uterus may have not been ready after the surgery and it wasn't the embryo but I took the good stuff-PIO, vivelle, dexamethasone, prednisone. Anyway, can these protocols be causing me an increased risk for aneuploid embryos? What could be changed? Any comforting words that I won't face the same fate with more IVFs that I did with the repeat IUIs? With it happening the same way all over again, I am believing I'll never have a baby. Last year was so hard, this IVF was hard. I’ve had to miss so much work, surgeries, U/S, procedures, etc. And I love my husband so much. I hate that I put him through this. Thank you, L. from Oklahoma Answer: Hello L. from the U.S. (Oklahoma), First let me clarify and emphasize to you that the IVF cycle worked, and you certainly have a good chance that it will continue to work in the future.  Your doctor probably did not explain that IVF only gives you the "chance" to get pregnant.  It, in fact, cannot MAKE you pregnant because the last three steps of the reproductive process are still beyond our technology to make happen.  These steps have to happen naturally (that part is still in God's hands).  So the fact that you got pregnant on your first IVF cycle is significant because it shows that you can get pregnant!  It is unfortunate, however, that it ended as a miscarriage. In terms of going through all of your previous pregnancies and this one, that would involve a more comprehensive analysis and explanation, that is beyond this venue.  I can do that by private consultation only. Second, I think you need to get the terms "decreased ovarian reserve" and "never" out of your vocabulary.  You DON'T have decreased ovarian reserve.  Keep in mind that in IUI cycles, we only want up to three mature sized follicles so that you don't get triplets, quadruplets, etc.  So, your responses were appropriate.  With your IVF cycle you were on a very low dose protocol and the yield was appropriate. . . not too strong and not too light.  You certainly could have been stimulated a little stronger, but it looks like your ovaries are very sensitive to the fertility medications so some care needs to be taken, as your doctor did. Finally, there is no technology that can predict or evaluate for internal embryo quality.  We can evaluate chromosomes so one option you certainly could consider with IVF is to have preimplantation genetic screening (PGS).  If you decide to do PGS, I would recommend a D#5 biopsy to reduce harm to the embryo, but your embryos would need to be frozen and transferred at a different cycle.  But that would allow you to evaluate the genetics of the embryo prior to transfer.  Your doctor would also need to stimulate a little stronger to have more embryos to work with and test since surely some will return abnormal.  This will then allow you to transfer normal embryos. All clinics, doctors and the protocols they use differ and that is what influences the pregnancy rates which vary from clinic to clinic.  There are other treatment protocol options; for example, I use low dose aspirin and low dose heparin in my recurrent pregnancy loss patients.  It has been well documented to help.  You might want to discuss that with your doctor. I want you to not lose hope.  You are young, your ovaries are still responsive and you've been pregnant, so now the goal is just to get a perfect embryo so that you can have the perfect baby.  Statistically, your chances are very very high, so you will eventually be successful.  You just need to hang in there and get the best treatment that you can.  Then once you have your baby, let me know so that I can celebrate your success as well.  You are on the road to success.  The only way you will surely fail, is if you deviate from than road.  Like Law school, this is a hard road, and it may not be fair, but in the end, it will be the most wonderful experience you've ever had in your life!  Greater than falling in love.  It was for me, and I thank God for his blessing that gave me my beautiful soon to be 16 year old IVF daughter.  Keep the faith in your path and in yourself.  Sorry for the long answer...good luck! Dr. Edward J. Ramirez, M.D., FACOG Executive Medical Director The Fertility and Gynecology Center Monterey Bay IVF Program www.montereybayivf.com

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!