Mini-IVF In A Woman Over 40 Years Old

Question:

I am from Canada and will turn 42 in a few weeks. I am trying to conceive my second baby after already having a baby boy with a previous IVF cycle. My first cycle for baby number two was unsuccessful. It consisted of Lupron from day 21 then Gonal F and Repronex. This was not successful as they retrieved only 5 eggs from fourteen follicles. All five fertilized but only 1 made it to the 5 day transfer. This cycle my RE has me on Clomid from day 3 to 7 with Gonal F and Menapur starting on day 7. I will be taking Cetrotide at some point. I have tried to find this protocol on the web and couldn't find it anywhere. I will be taking 100 mg of Clomid, 150 Gonal F and 75 Menopur. It seems like these amounts appear to be very low. I am so worried that this protocol does not seem very aggressive. Do you have any experience with this type of protocol for someone with my age?? I assume that egg quality is the issue. My FSH is low after three months of DHEA. Thank you, S. from Canada

Answer:

Hello S. from Canada,

The protocol you are using is a "mini-IVF" protocol and mainly used to help reduce the cost of medications. It is probably reasonable in a young woman that responds well to stimulation, because the Clomid will be adequate to recruit sufficient follicles, but I think it is not appropriate for you at your age. 

(Readers: Since the writing of this blog post there has been a Yale University study published in April 2012 showing that Mini-IVF is highly overrated and results in lower pregnancy rates as well as take home baby rates. See article "Mini IVF Yields Mini Success" and the study brief  "A case-control pilot study of low-intensity IVF in good-prognosis patients".)


This is a very low protocol. You would be at high risk of having a minimal stimulation and very few follicles. In truth, I can't believe your RE is planning this. Since you didn't give me the amount of medications you used on the first cycle, I can't tell whether you were adequately stimulated or not, but if you were my patient (and keep in mind that protocols vary widely amount doctors and no one protocol is better than another), I would be stimulating you aggressively with a high dosage. Namely 450IU Follistim and 150IU Menopur (or Repronex) in a continuous dosage.

In terms of your previous cycle, you had fourteen follicles and that is a very respectable number. I am worried about the fact that only 5 eggs were retrieved. Without looking at your records, I cannot know for sure, but I am inclined to think that you were probably triggered (with HCG) a little too early. If the eggs within do not have time to begin maturing, they do not release from the follicle wall and don't get retrieved. I expect to have at least a 60% retrieval rate in my clinic, so that would mean that you should have gotten at least 8 eggs retrieved. Since all 5 of your eggs fertilized, that means that they were all mature, which is a good maturity rate. The lack of development was due to the "age factor", which is the decline in egg quality that occurs with age. I would NOT have taken them to blastocyst, as that puts them through an unnecessary extra step, and instead, would have opted to transfer all at D#3. I believe the uterus is a better incubator than the laboratory.

Because of your age, keep in mind that it is going to be harder to become pregnant, but not impossible. Since your ovaries are still responding well, you still have the opportunity to become pregnant with your own eggs. You will just have to be resigned to having to go through several attempts to become successful. The only alternative is donor eggs, and you will always have that option as it takes away your age as a factor.

Follow-up Question:

Thank you so much for your response. As predicted the cycle was a bust. I had four follicles only and at one point they decreased in size (after my Cetrotide shot) I have been told that my lead follicle that reached 1.4 (which is when I was instructed to take my Cetrotide) may of been a cyst that they saw on day three. Anyway, I have a couple of questions about my upcoming cycle. So far I have had two awful cycles when taking Cetrotide. My first cycle before conceiving my son my Estrogen dropped significantly after Cetrotide. Do you think I should do another cycle with Cetrotide or do you think I should go back to Lupron?? Is it possible to just start Lupron the same day as my injections instead of going back to CD21.

I am at a loss as what would be the best plan for me given my age. As far as medication amount, you were accurate that I was on 450 of Lupron and 150 of Repronex. I believe the cycle that I had my son my Lupron was stopped as soon as I started my medication but he doesn't seem to be wanting to do that. Could you please give me advice on what protocol would be best given my age?? Thanks

Follow-up Answer:
Hello Again,
If you are going to use Lupron, then you have to start from CD21 of the preceding cycle. It is called the "long protocol". I would not recommend it in you.

I use the antagonist protocol almost exclusively in my practice. The problem that I see from what you told me is that you started the Cetrotide too early. If you do that, you suppress the follicle growth and get what you saw. The antagonist (Cetrotide or Ganerelix) should only be started when the follicles have reached 16-17 mms. The rule of thumb is that at least 30% of the follicles should be this size. I will sometimes wait until the lead follicle is 18mms if the other follicles are not sufficient enough size. With that, I do see an estradiol drop so I don't pay attention to it much any more. I think it is showing a decrease in activity of the smaller follicles that have been stunted. Using the antagonist is where the art of medicine comes into play because there are no hard and fast rules. It is very dependent on the experience and judgement of your doctor.

As I mentioned previously, if you were my patient, I would use the antagonist Cetrotride, not Lupron,and use the highest protocol of 450IU Follistim and 150IU Menopur continuously (no adjustments).
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 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.

After Failing IVF Three Times 45 Yr Old Wonders, Higher Stim or Lower Stim? Use BCP?: I Recommend A High Stim Mixed Protocol & BCP

Question:

Hi Dr. Ramirez,

I am 44 turning 45 this June. I have had 3 failed IVFs - 1 didn't go beyond retrieval because I pre-ovulated so no eggs to retrieve. My recent failed ivf cycle I had 3 follicles 19mm, 18mm and 16.5mm. The biggest follicle had no egg, the second largest had a degenerative cell and the third an immature egg. I took 300 iu's of follistim and 1 vial of menopur increased to two mid cycle.

Can taking too little or too much meds (follistim/menopur) cause this outcome?

We are trying a gentler dose and using follistim instead of gonal f. My first few cycles I was taking 600 iu's of gonal f and 150 iu;s of menopur. They had me doing this protocol for months and I started to respond poorly to it. I insisted on changing the meds or trying a gentler dose.

We interviewed with a new doctor here and his approach is less is more, less meds and get better quality vs. quantity eggs. And is it true that the smaller follicles esp. women my age will have bad eggs? My last cycle debunked that whole theory because the dominant follicle or the two largest didn't have any eggs. The smallest follicle did have an egg but it was immature.

I know that on the average I produce 5-8 follicles per cycle. I think it's important to save as many of the follicles we can, we can't afford not to even if they have bad eggs in them. I am not young and producing 20 follicles. How much do you recommend women my age take in meds (follistim/menopur)? The new doctor wanted to put me on 150iu's of follistim every other day or maybe everyday? That did not seem enough? He only wants to stimulate the dominant follicle or larger follicles. I don't want to take so little that it doesn't stimulate enough or take too much that I can get overstimulated and not respond well. I know my body and I am very sensitive to the drugs. I have also used micro-dose lupron and I responded poorly to it.

What protocol do you at your clinic use on women my age? My recent baseline fsh is 8.6, E2 is 30 and my AMH 0.27. It started low and increased up to 0.7 taking dhea and in the last few months started to decrease. I have no other issues other than my age and thyroid disease but it's under control. Do you change dosage depending on blood levels, number and size of follicles? The doctors I went to never did that.

Do you use clomid or birth control pills? I am not fond of either of them but I have heard and read that if you are on clomid you third ivf cycle will be successful? I prefer to use estrace or patches over the birth control pill to suppress. Why do clinics use birth control pills? I have read clomid was found to give cancer to lab rats?

Your help is greatly appreciated. I don't have time to waste anymore.

Thank you, C. from New York

Answer:

Hello C. from New York,

In general I don't comment on specific protocols because each doctor has their personal preferences and there are none that are perfect or better than others. However, I don't think I like your new doctor's recommendations or protocols and I'll explain why.

The biggest hurdle that you are facing is an age related decline in egg quality AND a decreased ovarian reserve. There is nothing that can be done about the egg quality but the goal with IVF is to increase the number of eggs recruited and available in the hope that a good egg is still present and we can find it. So, the protocol is always to try to stimulate an increased number of follicles and hopefully eggs.

I have read studies where the argument is if you use a natural cycle (no stimulation or decreased stim cycle), the egg quality will be better, but I believe that to be nonsense. Why would decreasing the number of follicles or relying on a natural cycle (only one follicle) produce better eggs? That is illogical. The quality of the eggs are already predetermined. Stimulation or lack thereof does not influence its quality. Again, I believe that the only way to overcome the age factor is to try to get the maximum number of eggs out at a time. For this I use a high protocol or mixed protocol that is 450IU of follistim and 150IU of Menopur. I also Do Not Use Lupron (called the long protocol) because I think it is inhibiting the ovaries too much at the time of follicle recruitment. Instead I use an antagonist protocol where the antagonist is given for only 1-3 days.

The only time I will decrease the amount of medication is if the patient has gone through one or two IVF cycles and still the number of follicles encountered or eggs retrieved are few. I decrease the protocol because I don't want her to spend lots of money on medications if the increased amount is really not doing too much. The ovaries do get to a point where they won't stimulate much despite increased dosage of medications. Unfortunately, your ovaries sound like they are there already. Again, the reason for doing this is to reduce the cost of medications.

I do alter my dosages as the cycle goes on, but only if I am starting from a lower dose and the patient is not stimulating, in which case I increase the dosage, or if I start on a higher dosage protocol and she is stimulating too strongly, in which case I decrease the dosage. Other than that, the dosage stays the same for most of the cycle without alterations.

I would not even consider Clomid for an IVF cycle. Some clinics do again to decrease the cost of medications but multiple studies show that the injectables are superior to Clomid.

Finally, in terms of the birth control pill, I do use it. Several studies have shown a better response if preceded by birth control pills. It suppresses the ovaries in the cycle preceding the IVF cycle and there may be a rebound effect so that the ovaries stimulate better. Estrogen does not suppress the ovaries unless given in very high amounts such as with the birth control pill. I have read of clinics trying to do IVF after a natural "unsuppressed" cycle, but I don't think it makes much difference. The other reason to use the birth control pill is that it allows us to take control of your cycle so that we can be sure that timing is correct. Timing is absolutely critical with IVF. There is a very small window of opportunity for the embryo to implant and if you miss it, then the cycle will fail. Also, using the birth control pill helps with scheduling if you batch patients (put them in the same group).

I think it is meritorious that you are trying to achieve pregnancy with your own eggs at 45 years old, but you have to understand that pregnancies rarely occur after 43 even with IVF unless donor eggs are used. However, I always remind my patient that the oldest woman to achieve pregnancy through IVF using her own eggs was 49 years old. It did take her two years of doing IVF, so persistence can count if you can afford it and want to wait that long to have a child. But you also have to be realistic and not let your expectations be too high. I hope that your journey will go well nonetheless, and that you achieve your goal of having a child.

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.

39 Year Old IVF Patient, DH Severe Male Factor, Surprised By Treatment Protocol: May Also Have PCOS & Will Need Med Adjustment

Question:

Can you help figure out what the next step should be? I'm 39 but have day 3 tests of 6.4 FSH, 53 estradiol and 25 antral follicles. Also great uterine ultrasound. We're doing IVF due to severe male factor. Just finished our first cycle, during which I somewhat overstimmed (16 eggs, sky-high E2 levels) but we got 3 good embryos, froze 1 and implanted 2 (my lining was 10.2 if I recall correctly), but they didn't take. I feel like I got a bit of a "cookie cutter" treatment from current RE and am wondering what changes you might recommend.

What felt "cookie cutter" was that despite my great day 3 tests, RE put me on microdose Lupron flare protocol with 300 units of Follistim (150 twice a day). Isn't that kind of an aggressive protocol for someone with day 3 numbers like that? Couldn't that risk sacrificing egg quality to quantity? I just feel like all they saw was my birthday (almost 40), not the day 3 numbers, good health and family history (women in my family stay fertile pretty late).

Anyway, after 4 days of 300 units of Follistim I had tons of follicles and my E2 was too high--almost 900--so that day and the next they had me skip the PM dose of Follistim (in other words on days 4 and 5 I had 150 of Follistim once a day). The E2 kept climbing, to 1100+ on day 5 and 1900+ on day 6. So on day 6 they had me go back to two 150 unit doses of Follistim. The next day (day 7) my E2 shot up to 4300+ so they had me coast. By day 8 E2 had spiked to over 7300, but it fell to 5300+ on day 9.

In order not to lose the cycle they had me do HcG on day 9, even though apparently a lot of clinics won't do the HcG shot unless the E2 is under 4000 due to the OHSS risk. (To prevent OHSS they had me use a half-dose of HcG and also gave me albumin.) Out of 16 follicles we got 16 eggs, of which 14 were mature, and 7 fertilized. On day 3 after retrieval, we had 4 embryos. Two looked great--we transferred them, both 7 or 8-cell--and two didn't look so great. They let those continue growing; one made it to blastocyst and is frozen now.

My RE said, of my response to the protocol, that I "reacted WAAAY more than any of our testing led us to expect." I don't understand what part of my testing suggested that I would have any problem producing enough eggs. Do you see anything that suggests that? I am just trying to figure out if I can trust my RE... I don't know if they actually are less worthy of trust or if I'm just feeling that way because I'm upset at the failed cycle.

More importantly, do you think these estrogen spikes and/or the overly aggressive protocol damaged my egg quality? I've seen some things on the web saying that excess E2 can kind of "toast" the eggs. What would you do now, if I were your patient? My RE wants to switch me to a more standard Lupron downregulation cycle with 225 units of Follistim a day. She said it's up to me whether to precede the Lupron with birth control pills. I don't want to take the pills--it just seems like going from one extreme to another, IVF protocol-wise, and I don't want to risk being over-suppressed. What do you think? Also, is this a situation where you would lean towards antagonists instead of Lupron to avoid over-suppression?

Sorry for the long post. I just wanted you to know enough to comment. And thanks in advance for your help. M. from the United States.

Answer:

Hello M. from the U.S.,

Before I answer the specifics of your questions, let me precede with the disclaimer that (1) there are lots of variations of protocols and opinions in the world regarding stimulation and none are absolute (meaning apply to all people) and none are better than others, and (2) the opinions I give are my own opinions based on my knowledge and experience and (3) the first IVF cycle is hard to predict with everyone because there are too many unknowns as to how a person will respond until you do it the first time and (4) pregnancy does not occur every time a woman does IVF for many reasons.

In answer to your questions, the protocol you were on (300IU per day) is actually a low dose protocol. Medication can be given up to 600IU per day. However, based on your response, it seems that your ovaries have a tendancy toward PCO-type response even if you are not a classic PCO. That is to say, your ovaries were very sensitive to the stimulation and hyperstimulated. For that reason you had to coast. I don't use the microdose flare protocol, which is indicated for "poor responder" patients or patients with "decreased ovarian reserve", neither of which you fit. Your FSH level was fine and your antral follicle count was more like a PCO. If I see ovaries with PCO-type characteristics in the pre-IVF ultrasound, I will usually defer to a PCO protocol because I don't want to put the patient at risk for hyperstimulation syndrome.I think that the adjustment of the medications was appropriate.

One thing to keep in mind, which I think you already know and have read, is that PCO patients that hyperstimulate have a reduced pregnancy rate because many of the eggs within don't mature. In addition, there does seem to be a reduction in egg quality, and that is further enhanced when coasting is required. That is part of the reason why we try to avoid coasting, but the risk of hyperstimulation is much greater so we sacrifice the egg quality for preventing OHSS.

I also will differ with your doc in that I prefer to use a "mixed protocol" (using both FSH + FSH/LH) because there have been some studies that show that LH is required for egg development and quality. In addition, I ALWAYS precede my patients with the birth control pill to help with quieting the ovaries (putting them at rest) prior to the IVF stimulation, to assist me with stimulation (studies have shown better stimulation) and to help with scheduling/controlling the cycle. Also, I strongly differ with your doc in the number of embryos I would have transferred. I would have transferred or recommended transferring all four of the embryos on day#3 just based on your age (that is totally based on whether or not you would be willing to take the risk of a twin pregnancy). We know that just based on your age, even with the family history of retained fertility at an older age, your chances of quality eggs are reduced, so the goal is to have a lot of eggs and embryos to work with in the hope of getting a good embryo in the end (keep in mind that "good looking embryos" does not necessarily mean that the embryo has good internal quality. We have no technology to access that at this time.) In my 39 year olds, I will transfer 4-6 embryos in order to get one implantation.

Finally, since we now know that you respond like a PCO patient, I would use a PCO protocol. In my practice, I exclusively use the antagonist protocol rather than the long protocol (Lupron), so that I can trigger with Lupron instead of HCG (which has been shown to reduce the chances of OHSS), and decreases the number of injections required. I call my PCO protocol the "low slow protocol", where I start with a low dose of medication and slowly increase it based on response.

Thank you for providing detailed information, it helps a great deal in formulating my response! I hope this answers your questions and that any subsequent cycles go better than the first.

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.

OHSS: Ovarian Hyperstimulation Syndrome and the PCOS Patient

On Wednesday, February 24th, at 6pm EST, I will be interviewed by Sasha Ottey on her radio show. The subject: "The Real Deal about PCOS and Your Fertility" Join us at http://blogtalkradio.com/pcoschallenge.

Prior to my blog radio interview, I would like to publish a question from last year regarding OHSS, ovarian hyperstimulation syndrome, in a PCOS patient. In this year's January cycle I had a patient with PCOS at my clinic who had undergone IVF last year at another clinic in the Bay Area. There she developed severe, life-threatening OHSS, was admitted to the hospital and stayed there for seven days. Needless to say, that cycle failed. She returned to the same clinic to do a frozen embryo transfer, which also failed. She then came to me. I put her on my standard protocol for PCO patients, low dose stimulation (Lupron/Ganerelix) and carefully monitored her. I'm proud to report that this patient had no adverse reactions and is now pregnant after only her first cycle with us.

Typically, signs and symptoms of OHSS appear within the first 10 days after a gonadotropin injection, when the ovarian blood vessels have an abnormal reaction to the hormone and begin to leak fluid. This fluid fills the follicles, swells the ovaries and sometimes moves into the abdomen in large amounts. Fewer than 2% of women develop the most severe form of OHSS.

Here is a link to the Mayo Clinic's informative website regarding OHSS, definition and symptoms http://bit.ly/bYGk1R .

Question:

Dear Dr. Ramirez,

First I would like to give you some background information. I have PCOS and have been undergoing infertility treatment for apx. 2 years. First, I tried using drugs like Clomid and Follistem. After about 1 1/2 yrs of it not working, we decided to go the route of IVF.

On June 23 I had my egg retrieval. They retrieved 15. After the retrieval they recommended not doing the transfer due to the risk of over stimulation (OHSS). I ended up being admitted to the hospital on June 29 with severe OHSS and on July 1, they drained a little over a liter of fluid. I was sent home on July 2. I had my period on July 5. I went back on July 7 and still had a little fluid around my lungs and my left ovary was still swollen. They were able to freeze 7 fertilized eggs. How long should I wait to do the transfer and can I develop OHSS again with the transfer?

Thanks! I am from Missouri.

Answer:

Hello,

It is unfortunate that you developed OHSS with this cycle. It should have been expected and could have been prevented. There are measures/protocols an RE can take to reduce the chances of developing OHSS such as "coasting" using "antagonist + Lupron to trigger" and lowering the dosage of stimulation.

The Lupron trigger has been used extensively and written about extensively in Europe. It is better than HCG with hyperstimulation because it has a shorter duration, reducing the chances of developing OHSS. I use it with my PCO patients who have a tendency to hyperstimulate and are at higher risk of OHSS. I only given one injection, not two. Lupron used daily or in the higher doses can certainly suppress the ovary. It works indirectly but has the same effect as the Ganerelix. In low doses, it mimics HCG and triggers ovulation. I love the Ganerelix-Lupron protocol.

I have not had a case of OHSS in over 10 years by taking these precautions. In any case, you should not do the transfer until your ovaries have returned to normal. Pregnancy can exacerbate the OHSS. Once this resolves then you can go through the frozen embryo transfer cycle. You will not undergo ovarian stimulation with an FET. Only the uterine lining needs to be prepared. For that reason, you are not at risk of OHSS.

Good luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com