IVF Protocol For High FSH

Question:

Dear Dr. Ramirez,
I am 39 years old in 2 weeks and about to undergo my first ivf (in vitro fertilization). I have only one fallopian tube, which an hsg has shown to be blocked, probably by adhesions (my other tube was removed due to damage from extensive adhesions - a reaction to previous surgery to remove a dermoid cyst on my left ovary).


My FSH level was 14 in March. Two weeks ago my FSH dropped to 8 and my AMH level was 7.42. An ultrasound scan and follicle count showed 9 follicles on my right ovary and 3 on my left (the ovary which the cyst was removed from).

My consultant has suggested the long protocol, as he thinks I will respond ok. I have read much about the short protocol being better for my age group, and if fsh has been high. I am anxious to get the correct protocol from the outset. What do you think my response might be, based on my levels? Do you think a short protocol would be better in my case? Many thanks, R. from the U.K.

Answer:

Hello R. from the U.K.,

The worst thing you can do is try to second guess your doctor, especially with information that you read on the internet. You are not an expert and don't have sufficient knowledge to make a proper decision. However, it is good to be educated regarding what you will be going through, and certainly, I have the knowledge to answer questions, so you can trust my input. But, given that you are not my patient, I don't have all your medical information and am not doing the procedure, the answers I give you have to be generalities and cannot be specific.

I personally don't criticize "protocol" questions because there is not one way or best way to do IVF. There are many different protocols and usually the specific protocol is based on the training and experience of your doctor. They all have the possibility to work. Some doctors stimulate less, some more, some use only pure FSh, some use mixed protocols, some use the long Lupron protocol, some use the antagonist protocol and some use the micro-dose flare protocol. There is not way to predict how any one will respond to any given protocol. But studies have shown no benefit to the micro-dose flare protocol (short protocol) in comparison to any other protocol, just as there is no study that shows that the long protocol is better than the antagonist protocol. I prefer the antagonist protocol because there are less injections in comparison to the long protocol.

Because you have had an elevated FSh level, despite it being lower more recently, you would still be considered a poor responder (or at least have the potential of being a low responder). For that reason, my preference would be to NOT inhibit your ovaries with Lupron in the stimulation phase, and only begin ovarian suppression once the lead follicles are at least 16 mms. This is the technique used in the antagonist protocol. With the long protocol, your ovaries are suppressed by the lupron starting from the previous cycles and may not respond as well. Before the antagonist protocol was developed, the micro-dose protocol was developed to reduce that suppression phase. Without criticizing your doctor's choice of protocols, my personal choice would have been different. But that is what makes Infertility doctors and clinics different and gives them different pregnancy rates.

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

You Can Do IVF With A Low AMH !

Question:

Hello Dr. Ramirez,

I am 36 and have been unable to conceive for 3 years. The diagnosis we have been given is diminished ovarian reserve. I have tried 3 IUIs (intra uterine insemination) with clomid. Each time I ovulated only 1 egg (I already ovulate on my own). I decided to move on to IVF. I went to a new clinic because they have very high success rates (30% higher than my current clinic). Over the last year, my antral follicle count has only been between 6 - 8. FSH has been between 7.6 to 9.5 (my very first cycle a year ago it was 12.5, but that was tested on day 4, so I'm hoping that made a bit of a difference). Estrogen is always low on day 3, so my FSH is not artificially suppressed. The new RE insisted on an AMH test (my previous clinic offered it, but I declined as it is not covered by insurance and wouldn't have changed my treatment plan - only possibly caused more worry - my previous clinic was okay with my decision).The AMH test came back with very bad results (2.4 pmol/L - I understand there are 2 units for measuring this and for pmol/L this is very low). The new RE says there is no point doing IVF with that AMH result. He said my chances of success are less than 2%. He said you usually get half the number of eggs of your AMH (so I would be lucky to get 1). He would only do IUI with injectables if I wanted to, but recommends I move straight to donor eggs based on the AMH test.

I am wondering if the new clinic has such great results because they exclude patients from IVF that may not respond so well OR if the doctor really does know what he is talking about and I would just be throwing money away. Obviously, I would prefer to have a chance at a biological child and wanted to move to IVF ASAP. In your opinion, should I visit another clinic that would allow me to do IVF (understanding with low AFC and low AMH, my results may not be positive) or do you think this doctor is right and it would be a waste of time to try my own eggs and move to donor eggs immediately. I know donor eggs would have a better success rate, but there is not a time limit on this option (as there is on my own eggs) so that could be a future option. Thank you very much for your time, L. from Toronto, Canada

Answer:

Dear L. in Toronto

It always angers me when Doctors draw these type of conclusions. A recent study that I read showed that despite a low AMH number or an elevated FSH, there is still a pregnancy rate of about 20%. What that basically shows, as I have always argued, is that it only takes ONE good egg to be successful. When a woman tries on her own naturally each month, she only has one egg to work with. I often get letters from patients whose doctor has cancelled their cycle because they only have 1-3 follicles. But, what if the perfect egg was in one of those follicles? FSH levels and AMH are only indirect measures of ovarian function. They are NOT measures of egg quality or your chances of pregnancy. Please see more on AMH here: Understanding Infertility: Age Factors.

Naturally, part of the statistical chances with IVF occurs from being able to get many eggs to work with i.e. more eggs increases the statistical chances. Imagine that you have a dice and want the number 6. If you only have one dice, you have a 1 of 6 chance. Two dices double your chances, three dices etc. So with IVF, since we can't predict if the egg that is retrieved will be the perfect egg, and because we don't want to have to do this over and over again due to cost, we want to have lots of eggs. But that doesn't necessarily mean it won't work if you have fewer than is ideal. It might take more than one try (statistically). But, as I ALWAYS tell my patients, who are usually older than you, it only takes one good egg to be successful.You might want to find a clinic that is more willing to work with you instead of make decisions for you. I can see that you are good at analyzing the situation and I am confident that you will make the right decision.

Good luck and don't give up!

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

Follow-Up To This Post:

Please scroll down to November 6, 2013 to see this writer's good news and how by persevering she conceived with a low AMH :)!

"I am the one that originally submitted this question to you and I want to thank you for being positive as even with the low AMH we did end up getting pregnant and are currently 4 months away from meeting our 'miracle' baby."

Secondary Infertility: Decreased Ovarian Reserve And Low Morphology May Be The Culprits

Hello,

I just turned 33 and I have one beautiful 18 mo little girl who is the love of my life. She was conceived on our 3rd iui using 5mg of Femara. My husband has low morphology (6%) and I have no regular periods. We both exercise / eat as we should and have no other health issues. We are considered unexplained infertility.

For the past 6mos we have been trying to conceive. I just had a large polyp removed and my fsh levels were tested. 2 1/2 years ago they were 7.0. 6 weeks ago they were 12.1. We are trying to figure out what to do next. We definitely want another child (And we would be open to 3). My questions are:

1) What do you recommend for medication? Is Femera a good starting point? Should we use the same dosage or higher?

2) Should we try an IUI or go straight to IVF?

3) Are there any "rules of thumb" for why FSH increases and how quickly it increases? I've heard stress can impact it. Thanks in advance for your help. C. from Washington State

Answer:

Hello C. from the U.S.,

Congratulations on achieving your first baby relatively easily. You do not have "unexplained" infertility as you have two reasons: sperm abnormality/low motility and irregular periods (ovulation dysfunction). Those are reasons enough to prevent spontaneous pregnancies.

In terms of your FSH level, I have to presume that it was drawn on cycle day #2 or 3, because that is the proper time to do this test and the only way that it an be interpreted. If it was, the elevated FSh level of 12.1 is not a good finding. This is called "decreased ovarian reserve", which basically means that your ovaries will be more resistant and less productive if stimulated with fertility medications. It is not an indication of ovarian function, but is somewhat of a time clock. Once the FSH level reaches 15, most IVF clinics will require you to use donor eggs. When it reaches 20, it means you are in menopause, which in your young age would be classified as premature ovarian failure. So from a time perspective, that means you don't have a lot of time to waste.

Certainly IUI is an option for you, and somewhat reasonable since it worked before. The FSH level will have no bearing on its chances of success. Chances of success depends on age and the sperm problem. If you wanted to do IUI first, I would limit it to no more than 4 attempts. You can use Femara, Clomid or injectables for these attempts and even alternate them, but don't waste a lot of time. Keep in mind that the chances of pregnancy with IUI in your age group is 20% per attempt. By four attempts you should be pregnant, otherwise the statistical chances drop dramatically after that.

If the IUI's fail, then you need to progress aggressively and quickly, especially if you want to have more than one more child. In that case I would recommend proceeding to IVF with ICSI. This will give you a 74% chance of pregnancy per attempt in my clinic (and is the treatment level that most infertility specialists would recommend with an FSH level above 10. Most would recommend not even to try the IUI).

I can't tell you why the fSH is elevated. That is an unknown.

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 Yr Old Austrian Doing 2nd IVF: Use PICSI Or "Embryo Glue"? Antibiotics OK?

QUESTION:

Dear Dr. Ramirez, my name is J. from Austria. I am 40 years old, have a failed 1.IVF (in vitro fertilization) this year (6 eggs, 4 fertilized, only 2 were transferred, because the other 2 arrested development before the transfer) , FSH of 10.6 mIU/mL, AMH of 0.8 ng/mL. My husband has anti-sperm antibody. So, we used ICSI (intra cytoplasmic sperm injection). I want to try the 2.IVF.

An IVF-clinic in Austria offers PICSI or "embryo glue". Are PICSI and embryo glue useful? They also use Prednisolon 5mg to avoid immune system reaction and Aspirin 100 and Lovenox 40 to to make blood more liquid/avoid congestion problem during embryo implantation. Are Prednisolon, Aspirin and Lovenox really helpful? All of these things I did not have at my last IVF.

Do you think that antibiotic taken before egg collection is recommendable? Thank you for your time. Best wishes! J.

ANSWER:

Hello J. from Austria,

Failing the first IVF is not that uncommon. The chances of pregnancy in the first try is 60% That means that 40% have to try more than once. That is because IVF is not a perfect technology. It mimics the natural cycle. There are 9 steps the body goes through to achieve a pregnancy. IVF accomplishes 7 of those 9 steps. The problem is that the last two steps are still natural steps and despite the best embryos and circumstances, it does not always occur.

I would not recommend PICSI or embryo glue. Embryo glue is a total fallacy and has never been proven to help. Implantation is an endometrial lining process, NOT the embryo just attaching to the wall. I do use aspirin, Lovenox and Prednisolone in my patients. They do help. I recommend low dose aspirin 81mg, Lovenox 40 is fine, and Prednisolone (Medrol) 16 mg then decreased to 8 mg after the transfer. Antibiotic should not be given prior to the egg collection but is started on the day of the egg collection.

You have two very big problems: your age and your decreased ovarian function. Age affects the quality of the eggs. The elevated FSH, which is an indication of ovarian function, shows that the ovaries will not stimulate well and so you won't get a lot of eggs. The only way to overcome the age factor is to get a lot of eggs in the hope that a good egg will be found. Because of this, it may take you multiple IVF attempts. You have to be persistent. There is nothing that can reverse the age factor.

Good Luck,

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.

40 Year Old IVF Patient In Vietnam On Low Protocol Fails First Cycle: Has Many Questions, Concerns

Question:

Dear Dr. Ramirez,

My name is A. from Vietnam, 40 years old by end of March 2011. Just give you some information about me regarding Infertility/IVF. My menstruation cycles are different every month: 28 days in Feb, 26 days in March and 31 days in April. So, average: 26 days. Period in March was especially longer; maybe it was caused by hormone therapy in March. My FSH on March 6 (2.day of period) was 10.6mIU/mL and AMH on April 9 was 0.8ng/mL.

I started my first IVF cycle on March 6 2011 (2. day of period) and ended it with 2 embryos transferred on March 22. Unfortunately, it failed. On March 6, I got 1 Decapeptyl 0.1mg. However, I reacted allergic to this and the doctor stopped Decapetyl and gave me 2 days later on March 8: 1x Gonal F 300 i.u. each day and for 8 days until March 15. One day later on March 16, I got Pregnyl at 8.30pm. 2 day later on March 18 at 8.30am, I had my egg retrieval. 6 eggs were collected and 4 were fertilized. On Day 3 after retrieval at 8C stage I had 2xnormal embryos with grade 1, 1x embryo with grade 2 and 1 embryos with Monosomy 21. On day 4, 2 embryos were transferred. My husband semen test result shows 25% normal form (morphology) with total live count of 341 million sp/vol and has anti-sperm antibody. So, I used IVF, ICSI and PGD (for down’s syndrome) in March.

For the next IVF: One clinic suggested to give me on the 3.day of my menstruation 1x300 i.u. Gonal-F mornings and 1x 150IU Menopur nights for 4 days first. Based on the follicle count and size in the ovaries, they will decide on further dose. They are likely to follow a step-down protocol. They will not use any drugs like Decapeptyl this time.

Another clinic suggested to give me on the 2nd day of my menstruation 1x300 i.u. Gonal-F for 5 days and will see based on the ultrasound result.

Could you please kindly answer my following questions and tell me what would you do differently?

1. Do I need birth control pills? Why or why not? I think I need it, because my monthly cycles are different. So, with the birth control pills, the embryos will be implanted on time. What do you think?.

2. Which dosage and drugs would you use except for the 2 dosages of 2 clinics?. Which dosage of these 2 clinics does make more sense to you? Which one will give me more eggs with good quality? Last IVF, I just had 6 eggs, 4 fertilized and just 2 healthy embryos transferred at the end. As I know, I need 3 embryos for my age.. Do I need such kind of drugs like Decapeptyl? Why or why not?.

3. On which day would you start the IVF (2. or 3.Day of period)? Why?.

4. Will acupuncture and Chinese herbs support the success of IVF? Or will it be contra productive? If recommended: before or before and during the IVF? I am taking prenatal multi vitamin and 400mcg folic acid. Do the unfreezing eggs have the worse quality compared to fresh eggs?

5. Was the embryos’ transfer late (at the Murola stage) last time? Should it be transferred earlier this time at 8C stage? I will not use PGD this time. Did I have enough eggs (6 eggs last IVF) at my age? Do I need to increase them next time? Does one embryo have 9% success rate for women at 40?

Thank you very much for your time. Best wishes.

Answer:

Hello A. from Vietnam,

It is interesting for me to see that IVF is being done in Vietnam, proving that this is a procedure that spans the world. Keep in mind that protocols used are highly variable between clinics and doctors. No one protocol is better than another so the recommendations I give are based on my knowledge, experience and preferences.

I always use the birth control pill preceding an IVF cycle. I believe the studies that show better response to stimulation by using the BCP. In addition, it causes the ovaries to essential shut down so that they will be more responsive to the stimulation and so that the follicles will start out somewhat evenly when the stimulation is started.

One thing I noticed about the protocols you have been on is the fact that they are low dose protocols. My highest protocol is a total of 600IU of FSH and I prefer a "mixed" protocol using pure FSH and an FSH/LH mixed compound. The preferred medications I use are Follistim (pure FSH) and Menopur (FSH/LH) in an approximately 2:1 ratio. So, my highest protocol, which is what I would use with you, is Follistim 450IU and Menopur 150IU taken every evening. My highest protocol is a continuous protocol, meaning you stay at the same dose all the way through, but it will really depend on your stimulation. Sometimes, if the patient stimulates more strongly than expected, I will drop the dose but most patients with an elevated FSH like yours (decreased ovarian reserve) will stay at the same dose. I do think that you were understimulated and the number of eggs retrieved and resultant embryos was low. In your age group I would prefer to have 4-6 embryos to transfer.

I cannot comment on the two clinic's protocols specifically, as I mentioned earlier. I can only give you my opinion regarding the protocol that I use.

In my center, I start the IVF cycle on an arbitrary day called "cycle day #2" irregardless of when your period actually starts on that cycle. This is because having used the birth control pill, I am in total control of the cycle and don't have to rely on the natural cycle timing.

I do recommend acupuncture as some studies have shown it to be beneficial with IVF.

I do think that the transfer should have been on D#5 post retrieval if PGS was done (blastocyst) but if PGS is not going to be done, then D#3 is better because I believe the uterus to be a better culture environment that the lab. Frozen embryos tend to have a decreased pregnancy rate, mainly because the best embryos are used to do the fresh transfer and the second best left to freeze. Also, the freeze/thaw have a little effect on the embryos but if done right, this should not be significant.

Finally, pregnancy rates are highly variable between doctors, clinics and countries. I cannot compare them exactly. In my center, your chances of pregnancy per cycle is 70% with 60% continuing. The U.S. does tend to have higher pregnancy rates than most other countries. At 41 years old, this decreases to 47% pregnancy and 29% continuing. Since we batch pregnancy rates into a 38-40 yo category, the rate I gave for 40 years old might be a little higher than it should be.

"Chúc may mắn"....Good luck on your next cycle!

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.

42 Year Old UK Woman With Irregular Periods, Hot Flashes: Is She Perimenopausal? Can She Still Get Pregnant?

Question:

I am 42 years old and have had irregular periods for about the last 10 months, also hot flushes, etc. I have had blood tests at my doctors which showed I have started early menopause. How do I know if I am still producing any eggs and if so could I become pregnant? Is there anything I could do to help in getting pregnant or is this not going to be possible? Thank you, S. from the U.K.

Answer:

Hi S. from the U.K.,

The term "early menopause" is actually a misnomer. There is no way to tell if a woman is entering menopause until it actually happens. That is to say, a woman can be in the perimenopausal period, diagnosed by changes such as irregular cycles, mood changes, hot flashes, insomnia, etc., for years (5-10 yrs) before she actually goes into the menopause. During the peri-menopausal period, the ovary is starting to dysfunction as it leads into menopause, where it shuts down. During this "perimenopausal period" the ovary still ovulates, but often in an irregular fashion. Therefore, pregnancy can still occur. However, the chances are low, and some of the times that you ovulate, and egg is not given off i.e. the follicle is empty.

Some doctors will define "perimenopause" if the cycle day #2 FSH level is greater than 10 (between 10-20), but this actually is a measure of ovarian reserve and does not tell you if menopause is coming soon or not.

The biggest problem, however, is if the ovary is dysfunctioning, the hormones are out of balance and so, the steps following ovulation sometimes are out of synchrony so that pregnancy does not occur, and due to age, the ovulated eggs are often of very poor quality such that fertilization does not occur, or an abnormal embryo is formed that does not go to implantation or that the abnormal embryo leads to miscarriage. For these and other reasons, the chances of a successful pregnancy decline.

If you are contemplating pregnancy at this point, and have not entered menopause, then you have to worry that time is not on your side. That is to say, your time is short to achieve the pregnancy. Therefore, you need to proceed aggressively and with haste. For that reason, I recommend to my patients to do IVF. It has the highest chances of getting you pregnant in the shortest period of time. Trying by natural means, simple intercourse, ovulation induction with intercourse or IUI, will take much time, and you may lose your window of opportunity to use your own eggs.

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.

43 Yr Old With High FSH Of 30 Asks: Is There A Way To Lower It?

Question:

Dear Dr. Ramirez,

First, thank you very much for taking the time to answer so many questions. Your column has been an important part of my education on IVF.

I am writing from Cincinnati, OH. I am 43 years old and am considering IVF. I just learnt that my FSH is 30, substantially above the cutoff rate for my fertility clinic (their cutoff is 10). Are there any options other than donor eggs? Is there a way to lower FSH? Would love to get your perspective. Thank you. S.

Answer:

Hello S. from the U.S.,

I'm assuming, of course, that your FSH levels were accurately tested. The FSH level is only valid for interpretation if it is done on cycle day #2 or 3. The FSH is a measure of ovarian function (or ovarian resistance). This is mainly important to determine how well the ovaries will respond to stimulation. It is NOT a measure of fertility. However, if the CD#3 FSH level of 30 is correct, that would indicate that you are perimenopausal and your ovaries would be shutting down. You would no longer be having periods and you would have menopausal symptoms such as hot flashes. Is this the case?

If so, unfortunately, with an elevated FSH of 30 you are not eligible for any other treatments other than donor eggs. I'm sorry but there is no way to revive the ovaries at this time. I see on the web that there are many lay people claiming that there are "natural" alternatives like acupressure that can help lower your FSH levels. This is simply not true!

Please see my previous post:"41 Yr Old With High FSH, High Estradiol..." where I go into greater detail regarding this distressing issue. Remember, there are many paths you can take to motherhood and from my experience as an infertility specialist, all those paths can bring happiness.

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.

Diminished Ovarian Reserve: I Have Failed 3 IVF Cycles, Blighted Ovum -- Where Should I Go Next?

Question:

Dr., I am 34 and have been diagnosed with diminished reserve.

I have done three IVF cycles. In the first, we got 5 eggs, after fertilizing all had testing and all found to have some anomoly, none transferred. Second, the clinic let me ovulate...didn't even get to extract eggs. Third got 2 eggs, only 1 fertilized, only a 4 cell with a lot of fragmentation, & I knew it was not going to work. Just found out I have a blighted ovum.

My question: Obviously my chances are not very good on my own and I realize donor eggs are my best option but I am finding it difficult to give up.

I am in health care and I guess my question if you can offer any advice is: For example in certain types of cancer there are certain centers that are more leading experts than others for certain types of cancers. Is that possibly the case with this disease? Is there a center that is the leading expert at diminished ovarian reserve that can help me? I had these 3 IVF at 2 different clinics and neither were very compassionate and treated me just like a number taking a shot in the dark at my protocol.

The last clinic the MD REALLY got my hopes up and now that it hasn't worked has dropped off the face of the planet. So my question is, are there leading experts in this arena that maybe know more specifics about what type of protocol might work best for me??

Answer:

Hello B. from the U.S.,

First of all, let me say that diminished ovarian reserve is NOT a disorder and is not a cause of infertility. It simply means that the patient's ovaries don't stimulate well and is often indicated by a high cycle day #2 or 3 FSH level. It is not an indication of egg quality in any way. Secondly, you are still young. You still have a good chance of pregnancy with your own eggs even if only a few are retrieved. I would still expect your pregnancy rate to exceed 50% per cycle (ours is 73%). I would not have wasted any of the cycles because there is no way to know if the good egg was in that batch. Even normal women do not ovulate good eggs all the time, and that is why it can take several months of trying to get pregnant. It is the same with IVF. Even if my patient has only one follicle I still try for this reason.

In terms of your question regarding the best center for your problem, I'm afraid there is no one center that is best for this problem. All IVF clinics have patients with decreased ovarian reserve, and each IVF center has different statistics and different ways of taking care of their patients. We all use different protocols as well. One question I would ask is what was your protocol? Were you given the max stimulation (600IU of FSH in either pure FSH (gonal-f, follistim, bravelle) or a combination (one of the previous with Menopur, Pergonal, Repronex). These latter medications have FSH in them as well so for instance if you took 450IU of Follistim + 150IU of Menopur, you would have a total dose of 600IU of FSH. I use this as my highest protocol.

In addition, timing is critically important. If the HCG trigger was given with the follicle size of 18 mms, it is possible that the egg did not have adequate time to mature, whereas 20 mms or 24 mms would have been better. As you can see, there are many variations in treatments. That is why there is no one center that is better than any other.

In my center, for example, I have extensive experience with low responders and use a high protocol for those patients. I also am a smaller, boutique-type center that prides itself and excels in providing one-on-one personalized care from beginning to the end. I am the only doctor, involved with my patients' progress from day one. That is what makes us different from some of our competitors in the big cities that operate more impersonally and do not give you access to the RE as much. All of these are facts and qualities that a patient should look for and seek out. They are paying a LOT of money for this treatment so they should demand their money's worth in all aspects.

With all that said, low responders are difficult because part of the success of IVF comes from having a large pool of eggs to work with. We know that in all cycles, there are going to be good eggs and bad eggs, so if we have an increased number, then there is a higher likelihood of getting a good egg. For low responders who don't stimulate well, and hence, don't give a lot of eggs to work with, that just means it may take more attempts before that good egg emerges. I would recommend that you NOT give up. After all, you have really only done two IVF cycles since the second one was cancelled. I am confident that you will be successful if you can continue to try. If you want a quicker solution, then donor eggs would be the option, only because a donor with normal ovarian function will yield more eggs to work with. Since you have had a blighted ovum, it means that the IVF cycle worked (remember, IVF only can produce embryos. The pregnancy, because of the last implantation step, still has to occur naturally). This confirms that you can get pregnant, and it is just a matter of getting a good egg/embryo into you. If you were 40, I would advise differently and lean more toward donor, but at your young age, you should keep trying.

Maybe you should consider coming to Monterey :) ! It is a beautiful place to visit as well.

Good Luck and don't give up hope!

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.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

41 Yr. Old Iranian Woman With Mixed FSH Results: Remember, FSH Levels Are Not A Measure Of Your Fertility, They Are A Measure Of Ovarian Function!

Question:

Hi! I am 41, with a 22-day cycle. I got married 8 months ago and had a miscariage at very early months (1st month). Then, my doctor prescribed me clomid and letrozol which resulted in production of several eggs. however, I did not get pregnant.My last FSH test result at 21th day was 4.7, while its level at 3rd day (i.e. four days later than my FSH test at 21th day) was 35.5!

I am too much worried about this high level of FSH. What are your recommendations for FSH reduction and get pregnant?

thanks! M. from Iran.

Answer:

Hello M. from Iran,

I am surprised but glad that you are able to search the web, since many of us believe your government has tighter controls. Let me clear something up first of all. The FSH level is only valid for interpretation if it is done on cycle day #2 or 3. I would recommend that you have it repeated because the results you cited don't make sense. The FSH is a measure of ovarian function (or ovarian resistance). This is mainly important to determine how well the ovaries will respond to stimulation. It is NOT a measure of fertility.

However, if the CD#3 FSH level of 35.5 were correct, that would indicate that you are in menopause and your ovaries would be shut down. You would no longer be having periods and you would have menopausal symptoms such as hot flashes. Your ovaries would not respond to stimulation with Clomid or Femara. Yet, you mention that you were able to "produce several eggs" while on Clomid. That is why I don't think that your FSH level is correct.

From a fertility point of view, we want the FSH level to be less than 7. It is of some concern when it is between 7-10, which indicates that there may be less time for the ovaries than we suspected and that the ovaries might be more resistant that expected, and it is of great concern in the level is greater than 10 because that means there is significant ovarian resistance and a shorter time line. Once the level is 15 or greater, most fertility specialists will recommend using donor eggs.

The biggest hurdle that you are facing, in addition to ovarian function, is your age. Your chances of pregnancy with simple Clomid treatments is 2% per month of trying and with IUI is 5% per month of trying. I would not recommend this at your age. I think that time is of the essence, so that you don't lose the possibility of having a genetic child. For that reason I would recommend a more aggressive treatment plan, which would be to proceed directly to IVF. That would give you a 50% chance of pregnancy per month.

Good Luck and thank you for your question,

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

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

39 Yr. Old U.K. Patient With FSH Of 10 Has Failed IVF With Own & Donor Eggs: Can She Still Succeed? Possibly!

Question:

I am 39 years old, and have a son of 5 years old whom I conceived naturally. I was born with one ovary and one fallopian tube (left ovary and fallopian tube missing).

I had a failed long protocol IVF and aborted the trial as we only had one follicle of a good size. We opted for IUI, and was unfortunate to get an infection of the womb, which turned into salpingitus. As a result my fallopian tube is now blocked.

With a decreasing AMH of about 3.5 and FSH of 10, I was advised that my chances of having a successful IVF with ICSI was very small. The clinics opinion was that we looked at egg donation. I have had two attempts this year of egg donation which have failed.

A friend of mine with an AMH of 1% and 15 FSH levels has just fallen pregnant after IVF. Although so early days yet, this has made me want to reconsider undergoing IVF/ICSI with a short protocol.

Can you give me your opinion? Many thanks in advance. S. from the U.K.

Answer:

Hello S. from the U.K.

The biggest factor you have working against you in terms of IVF is your age. The biggest plus is that you have had a child in the past, which means you have secondary infertility. With secondary infertility age may play a factor. Part of what makes IVF more successful in older patients is that with IVF we are able to recruit a lot more eggs at one time. It is an increased statistical chance of finding a good egg in the group. If your ovaries don't stimulate well and the number of eggs are decreased, then the chances decrease as well. However, they don't go to zero as evidenced by your friend. I usually will not give up on an IVF cycle, even if there is only one follicle because it could contain the perfect egg and IVF is still better than IUI because more of the steps required to become pregnant are accomplished.

That being said, however, using donor eggs certainly gives you a statistically better chance of success. Remember, we are dealing with statistics here, which is just a reflection of things and not an absolute prediction. That doesn't mean that you can't get pregnant with your own eggs, it just may take many more attempts with IVF than if you used younger eggs. Last year, there was an article in a New York newspaper about a woman who delivered at child at 49 that was conceived by IVF using her own eggs. She is, of course, the oldest to be successfully pregnant with IVF using her own eggs. However, it took her two years of trying to achieve this. It would be the same for you, as long as you ovaries are still responding to stimulation. There is a chance that there is still a good egg present in your ovaries. Finding it is the difficult part.

So, certainly there is the option for you to try with your own eggs, and potentially become pregnant. The donor cycle should have worked and statistically is the better way to go, but since it didn't, I can't necessarily tout it as the best option for you. You have to be willing to attempt several tries with your own eggs, however, so as long as that is what you want and are dedicated to it, then that is the way you should go. Ultimately, it is your decision to make.

Follow-Up Question:

Hi there. Thank you so much for your quick response and informative opinion. It is very much appreciated.I have one final question regarding the egg donor transfers that I had. Both of them seemed to work and then overnight disappeared. Do you think that I need to check as to whether I have Hydrosalpinx, as I believe this could have an impact by fluid spilling out into the uterus cavity and could potentially kill off or dislodge the planted embryo?? The notes I have from my last ultrasound (which I had to check the thickness of the lining of the womb prior to embryo transfer) states there is no evidence of dilation of the fallopian tube?Can I also say how unique this site is to get an experts opinion on fertility, and appreciate you taking time to respond. Best S.

Follow-Up Answer:

Hello Again,

Evaluating the tubes for hydrosalpinx should have been part of the basic pre-IVF evaluation, because it can reduce the pregnancy rate by 50% if left intact. This is done by a comprehensive ultrasound examination, not the ones looking for follicles, or by HSG (hysterosalpingogram). It usually affects implantation, because it causes a low level endometritis (inflammation of the uterine lining.) If this has not yet been done, then I would recommend that you request it. I would also recommend that you seek a different clinic because it is something that they missed and should not have.

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.

30 Yr Old With Very High FSH Levels Getting Poor Advice From Her Doctor: Has Ovarian Resistance & Possible Future POF

QUESTION:

Dear Dr. Ramirez,

I am 30 years old and recently started trying to conceive. My periods have always been regular and I always been ovulating on day 13. But I still could not succeed after 2 /3 attempt. I did all the blood tests, pelvic ultrasound. My husband did his semen analysis and everything came out OK. I had an FSH 28.5 and LH 81.9 on day 13 (ovulation time) and then again I did the test on Day 1 with an FSH 10.48 and LH 4.72 and again i did on day 4 FSH 8.72 and LH 14.42. Recently my day 3 FSH was 11.54 and LH 4.18. My doctor has prescribed me to take tablet Duoluton L for 3 months.

What is surprising to me is that all my FSH and LH ranges are within the reference range given in the lab test report and more over I have regular periods which start on every 26th day and I am ovulating (which i check through ovulation test kit). I have a normal height and weight, no excessive body hair etc. Why is my doctor considering me a patient of PCOD?

Is my LH and FSH proportion so bad that I have to take these tablets for 03 months?

Please advise, thanking you, Sarika from India.

ANSWER:

Hello Sarika from India,

I'm afraid to say that based on your description, your doctor does not know what she is doing. Sorry to be so blunt. FSH and LH levels only make sense if drawn on cycle day # 2 or 3. We do not draw them at other times in the cycle because the levels can vary. Therefore, the standard is CD# 2 or 3 only.What they tell you, if interpreted by someone who knows what they are doing, is how the ovaries are functioning. The FSH and LH are hormones that the pituitary sends to stimulate the ovary. If the ovary is picking up the hormones correctly, then the levels are low. If not, the levels are high. This is on cycle day # 2 or 3 only.

Your ovaries are functioning correctly as evidenced by regular menstrual cycles. This means that you are ovulating, and based on your cycle day # 3 FSH/LH levels, your ovary is NOT menopausal nor PCOD. However, the worrisome thing is that your FSH level is high (11.54). This is a sign of "ovarian resistance" which means that the ovaries are tending toward menopause, although they have not reached that level yet (> 20). We interpret it as shortening the amount of time you have for ovarian function, therefore we approach this situation more aggressively. I recommend IVF in these patients because we don't want to waste time. There is a disorder called "premature ovarian failure" or POF, whereby a young woman (less than 40) enters menopause early. That is what I would fear with you. So don't waste time. Go see a fertility specialist!!

Follow-Up Question:

Thanks a lot for picking my question! It helped me a lot to understand what's been going wrong for a long time. In the mean time I did my follicular study today (i.e. Day 5) and it showed two follicles in the left ovary : F1 - 18.5mm (dominant follicle) and F2 5.0 mm. So I thought of giving one more try this month also. Is that OK? Or this also indicate that I am moving towards "premature ovarian failure"? Also in the report it is written "Minimal free fluid in Pouch of Douglas". What does this mean? Please help me more with this.

I will be always grateful to you Dr. Ramirez for giving so much information. Regards, Sarika

Follow-Up Answer:

Hello,

If your ovary is functioning, then you should continue to try to get pregnant. Don't give up. You are not in premature ovarian failure yet. Also, the fluid found on ultrasound is a normal finding.

You are wise to question what is going on, please consider switching over to a fertility specialist as I mentioned above! Good luck with your procedures!

Regards,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, USA

44 Year Old Trying IVF For A Baby For The First Time: Can I Use My Own Eggs?

Question:

Dear Dr. Ramirez,

WOW!!!! I am so glad I found this site. You have given lots of great information that is very straight forward. Thank you for that. There are many sites out there and the more you read, the more unreasonable they sound. Here is my question: I am 44 years old, never had kids, and now I want to start a family, and I live in Florida. I did the Fallopean tube test (yes they are clear)and here are the results of my blood work from Jan. 2010 and March 31, 2010: 1st test=FSH 17.59, AMH=0.32, Estradoil=35,March test: FSH=5.1, estradoil=142, AMH=0.2. My RE said I had a few follicles. He STRONGLY recommends donor eggs. He did advised if I want to try Ovidrel and try for natural pregnany he said to go for it, however he said he does not believe with my results I will be successful and he thinks I am wasting my time.

My question: Is it a waste of time to try fertility drugs? Would I be wasting my time begging him to try and retrieve some of my eggs? He never even suggested that. He came highly recommended and I really don't know what to do. I would really like to try my eggs first instead of paying $40,000.00 the first time around for donor eggs. You have seen your share of patients and I am asking you if you had a client at age 44 with these results, would you make ANY attempt to use her own eggs?

I thank you very much for reading my question and I look forward to seeing your opinion.

Sincerely, S. from the U.S.

Answer:

Hello S. from the U.S.,

You have a dilemma that is shared by many these days. I keep seeing the average age of my patients increasing. There are two factors to consider with your results. First, the variations in results, namely the FSH levels, are natural occurrences as a woman ages. Some would attribute these to a "pre-menopausal" stage, where the ovary starts to show some fluctuations. We worry when the fSH level is above 10, and especially if it is above 15 (menopause is a level of 20), because it is a sign that the ovary may not respond to stimulation well, despite normal function. It doesn't mean that you can't retrieve eggs, or that you can't get pregnant with your own eggs, it only means that if you go through an IVF stimulation, you may not get very many eggs. In fact, you may not have any embryos to transfer at all.

Of course, this can vary from cycle to cycle, as your tests have shown, and studies confirm that, because of this variation, even poor responders or low responders, still have the opportunity to become pregnant. Because of this, I don't deny my patients the opportunity to try, or to at least have the comfort that they tried. Remember, the bottom line is that it only takes ONE good egg/embryo to become pregnant. The difficulty is finding or getting that one good egg and as a woman ages, that one good egg becomes more and more scarce. That is the second factor, that I call the "age related egg factor." Egg quality deteriorates with time, leading to less and less good eggs, hence lower and lower pregnancy rates. IVF tries to overcome this factor by stimulating the ovary harder to get more eggs out in the hope that there will be a good egg in the group. It is merely a chance and statistical issue based on numbers. For example, if you were rolling a dice and you wanted the number two. It can take several rolls before you get the number two but eventually you get it. IVF is, in a sense, rolling the dice to find that good egg because the ovaries give us whatever eggs they are going to give. We cannot tell them what eggs to give us. However, if the ovaries don't stimulate well and you don't get lots of eggs out, then your chances of finding that good egg diminishes. In my example it would be the same as if you were only able to roll the dice two or three times, then the chances of getting the number two go down statistically. Then, you may never get the number two.

What your doctor advises is because he doesn't want you to spend lots of money and see you fail. He wants you to have the best chances of pregnancy in the fewest attempts, and so, he recommends donor eggs. On the other hand, many of my older patients don't want to give up the hope of having a genetic child or don't want to have tried at least once with their own eggs. So I justify it to myself, that I have given the best counsel that I could, but my role is to help my patients achieve what they want in the best way that I can. If what they need is to try multiple times with their own eggs or convince themselves that they gave it their best efforts, then so be it. I am not there to tell them what to do. I only advise and am their advocate.

There IS a pregnancy rate at 44 years old, albeit a low one. It is NOT zero, so there is an opportunity to become pregnant. I have not had a pregnancy over the age of 43 in a woman using her own eggs, but have had many many patients try. I look forward to the first patient that becomes the exception to the rule for me, just as the 43 year old patient I had recently did! So, you do have a chance, just know that multiple tries with your own eggs will cost a lot more than one try with donor eggs, and your chances of pregnancy are significantly lower, but not zero. Ultimately, YOU have to make the choice. The New York Post reported last year of a woman that delivered a child conceived at 49 years old using her own eggs, but she had to try IVF many, many times over two years. I strongly admire her perseverance, but most patients cannot afford that nor have the emotional energy or resilience to do that. Only YOU know if you do or not.

I hope this helps, and 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.

38 Year Old TTC'r With Factor V Lieden, MTHFR, High BMI, High FSH & Good Embryos Has Done 3 IVF Cycles: I'd Throw In The Kitchen Sink!

Question:

I am a 38 yo female in the Northeast US. I started menstruating when I was 10 yo and due to irregular (too frequent) and heavy periods, went on BCP's at age 15 thru 35 - after stopping BCP's, my periods are very regular. We started TTC 3 years ago, and after no success, initial tests showed my H had good sperm count but low motility. We started w/ an RE in Jan 09. For me, my problem areas are age, high BMI, hypothyroid (well controlled) and + for MTHFR (Methylenetetrahydrofolate reductase) & Factor 5 Leiden. No PCOS, no endometriosis, tubes are open, endometrial lining develops well, FSH 9.

We were advised to go right to IVF to increase our chances of conception. IVF#1 5/09 Lupron/Gonal F protocol - 13 retrieved, 7 fertilized, 3 day transfer of 3 embryos - all Grade 2 (8, 7, 6 cells), resulted in pregnancy that ended in m/c at 8 weeks due to triploidy. IVF#2 8/09 Lupron Flare protocol - 13 retrieved, 2 fertilized, 3 day transfer of 2 embryos - Grade 2 (6 & 5 cell) BFN. Dec 09 - had a d&c and a month of antibiotics & estrace to prepare for IVF. IVF #3 1/10 w/ acupuncture, Lupron/Gonal F/Menopur - 13 retrieved, 5 fertilized, 3 day transfer of 3 embryos - all Grade 1 (8 cells) another BFN. All IVF's had ISCI and last 2 w/Assisted Hatching and no embryos made it to freeze. My E2 levels were consistent for all 3 - always between 1900-2300. My meds are always prenatal vits, folgard, baby asa, and levoxyl (thyroid). Lovenox only during pregnancy. My RE says that my age is the problem & that although I respond well and fertilize well, my eggs are of poor quality and arrest several days after transfer. I have no more covered IVF's, but do have 6 IUI's. His recommendation was to try 4 IUI's and if I do not get pregnant, to move onto other options, like DE (donor eggs).

My questions:

1. Do you agree with this diagnosis? Would it be worth trying another IVF with another RE? I have been very happy w/ my experience w/ this group.

2. I've read about Natural Killer cells & antibodies & immunology treatments - my RE says the studies do not support this type of treatment and this will not help. Do you agree?

3. I've had my first IUI on 3/31 and am awaiting a beta on 4/13. Do you think trying several IUI's is worth it or are the chances of success so low that I am wasting my time?

4. Is moving onto Donor Eggs my best next step?

Thank you so much for taking the time to read and reply. I really enjoy reading your answers on this site. A. from the U.S.A.

Answer:

Hello Alyssa from the U.S.,

1. In reviewing your history, out of three IVF cycles, you were successful with one (the first one), but in each, you stimulated well, had a good number of eggs retrieved and, except for the second cycle, had decent embryos. So that means that your ovaries are functioning well and stimulating well despite your high FSH level, and you seem to make good embryos. Of course, since embryos are rated only based on how they look, we cannot know if they are normal or not. Your first pregnancy was genetically abnormal and that is the "age factor" i.e. poor quality eggs leading to abnormal embryos. It is possible that the embryos in cycles #2 and 3 were genetically abnormal as well and that is the reason they did not implant. So, I agree that egg quality might be the issue, leading to imperfect embryos. That is the hurdle that you need to overcome and is totally based on your age. You may not necessarily need to change doctors, but it just may take more tries to become pregnant, since the majority of your eggs are not good quality and the goal is to get a good one.

However, pregnancy rates do vary by physician and protocols, and that could possibly make a difference. For instance, I do not use the Long (lupron) protocol or flare protocol. I use a combination (Ganerelix (antagonist) + Follistim + Menopur) protocol. That could possibly make a difference in your stimulation and the number of eggs retrieved, thereby increasing the chances of finding a good egg. Also, a lot of it is just luck of the draw, so to speak. Each cycle is unique and has the potential to yield a different outcome.

2. You have a +MTHFR and Factor V Leidin. That puts you at increased risk immunologically. For that reason, low dose aspirin, Medrol, and possibly Heparin or Lovenox, might make a difference and would be a good idea. I automatically place my failed patients on this protocol. My reasoning is that, despite the studies showing no value to this regimen, it is like stress reduction, acupuncture or any number of other adjuncts that have not been clinically proven in that, it doesn't hurt and it might help. The American Society of Reproductive Medicine does not advocate the use of immunological therapies, so your RE is correct. However, if you keep failing multiple times and that is something you want to try, then go for it. Basically I throw the kitchen sink in to try to overcome the failures. So, what's the harm?

3. If your IUI is positive, great. If negative, then you need to understand that you are doing them because you have the benefit and not because it is a better treatment. It is not. It certainly has a chance of working that is better than trying naturally, but that chance is not that good. At 38 yo, the chances are about 7-10% per cycle, which is much less than the 60+% with IVF per cycle. But, that doesn't mean it can't work. The goal would be to make sure that you are ovulating as least three eggs with each cycle. It should preferably be 5. Use injectables if you have to. It is the ovulation of multiple eggs that increases the pregnancy rate with IUI.

4. Donor eggs is certainly an option and an option that you will have until you are 50 years old. It certainly gives you the best chances of success because it eliminates the egg factor and reduces the risk of miscarriage. It's your ace in the pocket. Whether or not to proceed with it at this time is your personal decision. Because your ovaries stimulate well, there is still the opportunity for you to get pregnant with your own eggs. There should still be some good ones left inside. It will just be a matter of time. But, if you would rather not keep trying until you find that good egg, and increase your chances of success in the shortest time, then donor eggs would be the logical option. There was a report in the NY Times about a patient who is now the oldest patient to get pregnant successfully with her own eggs at age 49. She was very persistent and dedicated to being successful, and it took her two years of doing IVF.

I hope this helps, you have the potential to get that one good embryo & it may only be a matter of time and changing up the treatment protocol a bit. I find it heartening that you are willing to stay open to all possibilities, so I know you will succeed!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.comMonterey, California, U.S.A.

Premature Ovarian Failure in 38 Year Old - What Are Her Options?

Question:

Dear Dr. Ramirez, I am a 38 year old from Birmingham, UK. After experiencing irregular periods and sometimes having 3 to 4 month absences, my hormone levels were tested and showed my level as 20. I was told that either I was experiencing premature ovarian failure (POF) or an early menopause. The course of action I was given at that time to determine which I had was to take a months supply of hormone replacement therapy. Obviously the bleed at the end would not have accounted for anything but the idea was to see if my periods came back after that. My gyno told me was that sometimes the ovaries can shut down for whatever reason and because of this the pituitary gland is desperately sending out more and more fsh to try and spur the ovaries into action and they are not responding hence the high FSH.

I was told that by taking a month of HRT it will switch off the pituitary gland and give the ovaries a rest from this constant hammering and that sometimes after this rest the ovaries start working again on their own. They did come back for about 3 months and a day 21 progesterone test showed my level as 20 suggesting some kind of ovarian activity.

I was told if I was in POF or menopause the ovaries would not respond to this but because I did get my periods back after the hrt for about 3 months it showed that I had POF, not menopause. I was also told that if I didn't get my periods back then they would be able to confirm menopause with a laparoscopy. My gyno said that because the HRT brought back my periods it showed that I have eggs so I am not in menopause.

Does this make any more sense to you at all? I have now been advised to stay off HRT for 2 months and then just go and get my hormone levels tested again and if my levels show menopausal then go on hrt permanently. I sort of feel as though I was given false hope. Can I still get pregnant?

Answer:

Hello,

The elevated FSH level is definitely concerning. It needs to be confirmed and should have been done on cycle day #2 or 3 of the first available menstrual cycle. If you are not having periods any more, then a random FSH can be done (done at any time in the cycle). If that level is greater than 20, then your ovaries have shut down and you are menopausal. The only difference between that and premature ovarian failure, is POF occurs in women under the age of 40 (as in your case). Otherwise, the net effect is the same. The ovaries have shut down. In that case, you cannot conceive naturally. Having a period is not a sign of the lack of menopause. You can have breakthrough bleeding or dysfunctional bleeding, which are caused by a lack of hormones, not the result of ovulation.

The exact cause of POF is unknown. Most think that it is an autoimmune problem, whereby somehow the body is shutting down the ovary. However, pregnancies have occurred in POF patients from random spontaneous ovulation. The problem is that the ovary is not picking up the FSH so the levels are increased. Fertility medications work by "bombarding" the ovary with increased FSH. The pituitary does not do that. The pituitary sends FSH to the ovary to stimulate ovulation. If the ovary does not pick up the hormone from the blood stream, the level is increased. I tell my patients to think of the ovary as a ball with lots of holes in it. If the holes are plugged up, the FSH can't get into the ovary and hence the FSH levels in the blood stream are elevated. POF is NOT due to the lack of eggs. It is due to the lack of ovarian stimulation/function. In addition, laparoscopy CANNOT diagnose menopause. It is a purely clinical and hormonal diagnosis.

In order to have a period on HRT, you need to be cycled i.e. take estrogen and then progesterone. In a young woman, the best method for HRT and cycling is the birth control pill. DO NOT USE menopausal hormone replacement drugs. It is too low for a young woman and you won't get adequate estrogen replacement. If you are indeed in premature ovarian failure, then you need to take estrogen and progesterone because your ovaries are not making them. The lack of these hormones will have long term detrimental effects. Since you want to get pregnant, then you need to see a reproductive specialist as soon as possible. Sometimes, in the early evolution of POF, the ovary can still be stimulated with HIGH dose FSH, which can lead to pregnancy. You want to be doing the optimal treatment method for pregnancy to ensue if either of these occur. That optimal treatment method is IVF because it performs 7 of the 9 steps required to get pregnant and has the highest chances of pregnancy.

For that reason, I would definitely recommend that you proceed to IVF as soon as possible. As long as your ovaries stimulate and eggs can be obtained (you only need one or two good quality embryos), you would have a 50-70% chance of pregnancy per IVF cycle. There are some IVF programs that will not allow a patient to try with her own ovaries if the FSH level is above 12. I do not have that policy. I don't make decisions for my patients, I only counsel them thoroughly and let them decide what they want to do. In your case, I would encourage you to try with your own eggs as long as the ovaries can be stimulated.

I counsel patients who are POF to also consider freezing some of thier eggs. Egg freezing techniques have greatly improved over the years and can be an alternative method of extending your fertility. It takes approximately four to six weeks to complete the egg freezing cycle, which follows the same protocol as IVF. Two to four weeks of self-administered hormone injections along with birth control pills to temporarily turn off natural hormones. This is followed by ten to fourteen days of hormone injections to stimulate the ovaries and ripen multiple eggs. Once the eggs are retrieved they can be frozen using a slow-freeze method or the flash-freeze method known as vitrification. They then can be thawed, ICSI'd, and the resulting embryos transferred into the uterus. The egg freezing process should be carefully considered, as it is still classified as an experimental technique by the American Society for Reproductive Medicine (ASRM). We have begun to offer this as a service at our clinic.

If the ovaries don't stimulate well, that means your ovaries have shut down or are shutting down. Then your next alternative would be donor eggs, but I would recommend you give it the best try that you can right away. Make sure you choose an IVF clinic that has good pregnancy rates. You don't want to waste your eggs! Good Luck!

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