Young IVF Patient Fails Two IVF Cycles: Empty Follicles

Question:

Dear Dr. Ramirez, I am 31 years old, have never been pregnant. My husband and I haver been trying to conceive for about 3 years, tried 5-6 cylces of Femara.

I had three failed IUI's and two failed IVF cycles. The first IVF cycle there was one egg but it disintergrated before it could fertilize. The second IVF cycle there were no eggs. Each cycle had 14-16 follicles 8-10 of them being mature. My AMH level is 2.19. My husband has been tested and is fine. I have a left blocked tube, which they say could be a spasm reaction from the dye. During the IVF I was on Bravelle, Menopur and Ganerelix injections, along with the trigger shot. It is emotionally and financially draining. Any thoughts? Thanks, H. from New York

Answer:

Hello H. from the U.S. (New York),

There is a finding called "empty follicle syndrome" where no eggs are within the follicles. But this occurs in a single cycle and those patients generally have eggs when retrieved in subsequent cycles. I have had young patients, and many older ones, with no eggs retrieved. In older patients, many of the follicles don't have eggs i.e. they have run out of eggs, so it is fairly common. But, this is not common in young women.

In most cases when eggs are not retrieved in a young woman, it is often because either (1) the HCG trigger was not adequate, or (2) the follicles sizes were not mature enough and therefore the eggs were not mature. I am suspicious that you fit into the latter category based on your first cycle. It is possible that you are being triggered too soon. In terms of the HCG not being adequate, when I previously encountered empty follicles in my young patients, I came to the conclusion that either the HCG had a manufacturing defect, was not stored properly or not given properly. I used to use generic HCG. I have now switched to the brand HCG, Ovidrel, and have not had a repeat of that problem.

I also worried that in more obese patients, the depth of the injection was not adequate to get the HCG into the tissues so I have my obese patients given the HCG injection into the back of there arm where the fatty tissue is less, rather in the abdomen where the fatty tissue is thicker.

Finally, if it is that the follicles were not allowed to grow sufficiently, that is a procedural problem. So you either can ask your doctor to wait a little longer to trigger you (I have found in my experience that I have to wait until the lead follicles are 21-22 mms rather than the 18 mms that most doctors will trigger at) or you can try a different clinic/center because each doctor and clinic are different and the outcome can be different.The bottom line is not to give up.

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.

Progesterone Injections & Travel After IVF

Question:

Dear Sir,

Our first IVF (during June 2008) failed and so, we are going for the second IVF which is FET (frozen embryo transfer). I have the following questions:

a) Progesterone-in-oil shots: During the last IVF it was very difficult and stressful to have the intra-muscular shots every day. After a week, the muscle became very rigid and at some point could not even poke the needle into the muscle. Will it be okay if I do a hot water massage after every shot? I am concerned because some nurses are saying it may raise the body temperature and could cause problems.

Are there any alternatives for intra muscular injections (for progesterone)? One of the nurses is suggesting to apply directly into the vaginal area. Since we haven't done that before we are not sure how tedious is that and the possibilities it could go wrong.

b) Will it be okay to travel long distance (approx. 3 hours) in a car - three days after the transfer?

Thanks so much in advance for your valuable suggestions.

Roger

Answer:

Dear Roger,

The progesterone injections are probably the worst of all the injections because it requires a bigger needle and the fluid is thick. I have changed from a prgesterone in sesame oil to a progesterone in canola oil that my pharmacy make us (MDR). Because it flows easier, we can use a smaller bore needle to reduce the pain and it doesn't harden up. You might want to check into that formulation. MDR Pharmacy is an infertility specialty pharmacy and you can get your meds via mail. It is also less expensive.

In terms of hot packs at the injection site, that would be fine. I don't expect that will change anything at all if it stays local.

Also, make sure you are rotating the sites i.e. one buttock then the other. You can also change the specific sites in the buttocks as long as you are in the upper outer quadrant. Make sure your nurse shows you all the areas that you can use.

As an alternative to IM progesterone, you can also use vaginal progesterone. There are several formulations: Crinon 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM progesterone. However, most RE's are trained on IM Prog and so don't want to make any drastic changes. I happen to use both. Some programs, such as USC, have switched to vaginal completely. If your wife cannot tolerate the IM Prog or has an allergic reaction to it, then you can switch to the vaginal version. Crinone and Procheive are twice per day, and Endometrin is three times a day. They are messy but they don't hurt.

In terms of travel, yes it is okay to take a three hour trip after the transfer. As long as your wife is in a resting position, such as sitting, then you can travel. I only don't recommend strenuous activities such as exercise, karate, horse back riding, running and the like.

I hope this helps!

Edward J. Ramirez, MD

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

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