After Failing 3 IVF, Reader Has Pregnancy Success After Writing To Me

Dear Readers, Sometimes I get great news from one of the many couples I help on AllExperts.com and this is one I would like to share with you. Over a year ago I began corresponding with this woman regarding her failed IVF cycles. Her original questions appear right after the good news I received from her a few days ago. Makes it all worthwhile :)

October 7, 2013

Comment:   Dr. Ramirez helped me conceive from across the country thanks to his blog. We've never met and my husband and I credit him with the birth of our healthy baby boy. When my RE rejected our suggestions, Dr. Ramirez provided facts that played a major role in our "self" treatment which was to try naturally with baby aspirin. More doctors should provide online guidance and provide proven medical facts and suggestions to help those of us who are skeptical of patient forums. 

July 2012

Question:

Hello Dr. Ramirez,

I am writing from the United States.  I have been TTC for 2 years.  I began RE treatment 6 months after trying to conceive naturally at 34 yrs old. I am 36 now. I have failed 6 Intra Uterine Inseminations and Three IVF (in vitro fertilization) cycles. Below are the details: (for privacy purposes I have omitted the precise details of each cycle…except for the transfer details)

First IVF: 7 mature eggs, All ICSI 1 fertilized, transferred 4 cell Grade AB on day 3

Second IVF: 17 mature eggs, 9 fertilized, transferred 2 Grade AA on Day 3, one made it to blast and freeze (poor quality)

Third IVF - 18 mature eggs, 14 fertilized, 9 made it to blast, transferred 2 Grade AA, froze 6 good quality blasts ranging from Grades AA - BB

I never had a positive beta or urine test.  I've done all the preliminary testing, water sono, bloodwork, HSG, etc. everything is normal.  My husband’s tests and sperm are also normal.

I asked about immunology testing and Doctor said there is nothing to support that treating it helps.

I don't believe the early bleeding is normal. My luteal phase naturally is about 11 days long.  Dr said the PIO is plenty for me and would not recommend increasing it.

I asked about baby aspirin and heparin. They said baby aspirin is ok, but heparin can be dangerous.  I've read in your posts that you recommend that if there is one IVF failure.

Is there harm in taking heparin? I don't know what else to do to make them implant.  What are your thoughts considering my history?  I do not want to transfer any frozens unless the protocol is changed. I feel like continuing the same PIO / medrol protocol is setting me up for failure again.  I appreciate your advice. Thank you!

Answer:

Hello,

Since you have had decent embryos to transfer in at least two of your three IVF cycles, this would be regarded as implantation failure.  Thanks for reading my posts.  I also discuss these issues in my blog.

Your doctor is right in that the correct general opinion, kind of like being politically correct, is that the studies do not show any benefit to treating for immunologic problems in IVF.  However, it remains to be seen and depends which studies you prefer to believe.  There are certainly studies that show that immunology plays a role in miscarriages and some studies that show immunological treatments help with IVF.  I don't think it can be discounted completely but at the same time, don't believe in every treatment that is offered.

I certainly advocate low dose aspirin, low dose medrol and low dose heparin in my patients that fail two cycles of IVF for no clear reason.  I have had many be successful thereafter with that protocol, which I have been using for the past 18 years.  There is NO danger in using low dose heparin.  Full dose heparin is another matter.

I think that the dilemma you now face is whether to continue with this doctor or not.  If you want more, such as using the protocol mentioned, then you'll probably have to find a doctor that will provide that to you.  I certainly think your doctor needs to reevaluate and consider what else he/she can do since what is being done so far has failed.

You certainly can always fly out to California. :)  For an FET cycle, you would only need to be here for one day.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Follow-Up Question:

Hello again,

We consulted with our RE again regarding the transfer and he suggested doing nothing differently and chalked it up to bad embryo genetics.  Again he reiterated no baby aspirin so we pleaded for him to do immunologic testing, cytogenetics (on us) and blood clotting work ups to which he agreed.

Everything came back normal, including cytogenetics on my husband, with the exception of my protein s free antigen level. It was 151 and regarded as "high" by the lab that ran it.  He referred me to a hematologist who ran protein s activity testing which thankfully came back normal. He said a high level protein s is not concerning and that only a low level would be.

So here we are again with his recommendation of transferring with the same protocol.  I asked again how about baby aspirin and he remained firm on "no".  I told him 3 doctors, including one at his practice, the hematologist and an online doctor i have emailed have said there is no harm in using it along with my friends who have used it with no pre-existing blood clotting disorders and went on to have successful IVFs.

He said taking baby aspirin with no blood clotting problem can cause more complications than help.  He said it can interfere with the growth of the placenta.  Is this true?  So far he is the only doctor that has said no to baby aspirin including the doctors of everybody I know who has gone through ivf unexplained.

Are there any facts you know of with baby aspirin and placental defects?

Again, I truly appreciate your knowledge and advice and thank you for your responses.  There should be more doctors like you who help others online with honest, professional opinions!

Follow –Up Answer:

Hello Again,

There are no studies that show any adverse affects of low dose aspirin on embryo or placental development.  In fact, and either you or he can look this up in any Infertility textbook, low dose aspirin is an approved and advocated treatment for recurrent pregnancy loss (now why would they endorse it if it caused placental problems?).  We have extrapolated its use in failed IVF with the same idea that it increases blood flow to the implantation site and reduces the formation of micro-clots in the tiny vessels supplying the implantation site.  There is no way to test for these. 

Since this doctor is not willing to work with you on this very simple and innocuous treatment, which may or may not help, I think you should seriously re-consider using him.

Good Luck,

Edward J. Ramirez, M.D.

Follow-Up Question:

QUESTION: Hello again

Have you noticed this email is more than nine months after your last reply?

Our RE did not budge again on the baby aspirin so we decided to wait on the next transfer and try naturally with baby aspirin.

That month I became pregnant for the first time. I went to my RE and he confirmed it with blood though the levels were low and I was bleeding and he did not offer progesterone cream. He said he doubted the pregnancy was due to the baby aspirin. At 5 weeks I miscarried, and although it was sad, I was elated at the fact that I did get pregnant. So we tried again naturally the following cycle with baby aspirin (2 weeks after miscarriage) and what do you know?

I got pregnant again.  I went back to RE and he confirmed with a blood test. I started bleeding again so he suggested progesterone cream.  I told him we did the baby aspirin thing again and if I should continue taking it and he said YES! 

He followed my progress until 2 months and referred me to my obgyn to monitor the pregnancy. I continued the progesterone cream until the end of the 3 months and continued taking baby aspirin until 37 weeks. Yes, 37 weeks.

Our healthy baby boy was born at 41 weeks, weighing 9lbs, 4oz and measuring 20.5 inches.

If I did not read your blog, he would not exist. My husband and I attribute his existence to your blog and cannot thank you enough.  Please continue your public advisement as it made our dreams come true.

Thank you!!!!!!
 

Follow-up Answer:

Hello,

I am absolutely delighted for you.  Congratulations :)  I'm saddened to see that you had to prescribe a therapy for yourself, but glad that it might have done the trick.  No one will ever know for sure if it helped or not and what the mechanism is, but it seems to help many people with your type of history.  I now put all my infertility patients on low dose aspirin from the beginning, IVF or not. Another possible factor is that you tried soon after your miscarriage--studies show that there is a higher chance of pregnancy after a miscarriage.

I'm shocked and a little disappointed that your Ob doctor allowed you to go post-dates (41+ weeks) because that posed significant risk to the baby such as a fetal demise, fetal distress, etc.  I NEVER let my infertility or IVF patients go past 40 weeks.  The sooner the baby was out the safer it was at that point.

Thank you for reading my blog and using this service (AllExperts) as well.  I do it in tribute to the task and gifts that God has given me, which is a part of the love he has for us.  Your baby is also a gift from God for you to treasure and teach of his ways.  Devote your love to this son and shower him with Goodness so that when he grows up, he will shower others with goodness as well, and thereby contribute toward making this world a better place.  It is not often that I get feedback of successes attributed to my writings, but know that your feedback reinforces my dedication to this task.

Congratulations!

 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.

 

32 Year Old With Two Failed IVF Cycles With Positive Beta's: Chemical Pregnancies?

Question:  Hi Doctor,
I live in Idaho where we only have 1 IVf (in vitro fertilization) clinic, so I don't have the option of a second opinion and can't decide if it's worth the six plus hour drive to find out if anyone else would do anything different so I really appreciate you reading this.

A quick medical run down is my infertility was both blocked tubes which 3 years ago I had opened, since they've been open I developed endometriosis which I had cleared last September. I am 32 years old with no medical issues. I have had 8 failed IUI's before finding the endo and then 4 failed IUI's since clearing it. I did have one pregnancy with the IUI but they thought it was ectopic and it aborted itself. I have just completed my second failed IVF. By the way DH has all "normal" counts and morphs for his samples. Both protocols for meds were the same I took Doxycycline and Medrol right after ER (embryo retrieval) and started Progesterone vaginal inserts day after ET (embryo transfer) and was on prenatals and baby asprin the whole time. Both transfer's were done with guided ultrasound with no complications.

1st IVF-September 2012. 10 eggs,10 matured, 4 embryo's fertilized (no ICSI) 1-six cell, 3-eight cell all grade 2's. Two embryo's transfered, last 2 died on day 6 before making it to blast. First beta was 9, second 32, then on day 11 I started spotting,cramping and clotting. Day 13 beta was 7.

2nd IVF-November 2012. 21 eggs, 18 matured, 13 fertilized with ICSI, 1-eight cell grade 1, 6-eight cell grade 2, 4-seven cell grade 2, 1-nine cell grade 2, 1-two cell grade 3. Transfered 2 embryo's back (one was hatching) and cryopreserved 6. Beta test 1 was only a 3 and then the second beta nothing improved. I started bleeding day 11 again.

I have not yet met with my RE but I am trying to gather all the info I can before meeting with her. This last fresh cycle will have been the last one that I think I will do just because the stress on my body of being on meds off and on for 3 years now I think is too much. So the 6 frozen are very important to me to use wisely. I read that you said a chemical pregnancy is not an implantation problem so does that mean that you think it would be a problem with the embyo's? My RE felt last time that there was no need for genetic testing and that my endo was not an issue. I'm just lost as to what my next step should be, what to test for or what I should do with my remaining embryo's (gestational carrier or gamble with them). Thank you again for your time, your blog's have been so much help for me while searching for answers. M. from Idaho, U.S.A.

Answer:

Hello M. from the U.S. (Idaho),

Once you get a positive bHCG, that means that implantation occurred. To be more specific, it means that after the embryo was transferred into the endometrial cavity (the limit of what IVF can do), the embryo progressed in its development, hatched out of its shell, attached to the endometrial lining and the lining grew and enclosed the embryo. These last steps are all natural steps that we do not have the technology to make happen. They have to happen on their own. The take away message from this is the knowledge that you can achieve a pregnancy with IVF. The ensuing problem, of miscarriage, is a pregnancy issue. Whether or not the embryo progresses to developing a successful pregnancy and ultimately a normal and healthy baby is based on the pregnancy alone.

Miscarriage is a more common occurrence than people think. We know that up to 50% of pregnancies can end in a miscarriage, many of which are chemical pregnancies like you had. In most cases of early miscarriage, the reason is because of an abnormal embryo, meaning the embryo had some sort of genetic abnormality. In most of these cases, it is a spontaneous abnormality that occurred at the time of embryo division and not something that you carry. But just to make sure, you and your husband might want to undergo genetic testing if you have not already done so.

One other thing I noticed is that your embryo quality, based on its external appearance because we don't have the technology to know the internal quality, was not optimal for someone your age. This could be related to an inherent problem with the eggs, sperm or lab conditions. In a woman under the age of 35, I would expect most of the embryos to be 8 cell, grade 1 embryos. Genetic testing in the embryos, PGS, is an option but I too would not have recommended it in your age group. In addition, PGS may do some harm to the embryo thereby reducing your pregnancy chances. You'll need to discuss this further with your doctor.

I don't think that any of this has to do with your endometriosis, which is not an issue with IVF.

Ultimately, because you have achieved chemical pregnancies, you have to keep in mind that the IVF can work. Now it is just a matter or time, or more specifically, a matter of getting the perfect embryo. That will take continuing to try and ultimately I am confident you will be successful. It is unfortunate that you only have one option for an IVF clinic in your area because pregnancy rates vary highly from clinic to clinic. That may be another option i.e. travelling to another clinic. We call that distance IVF where patients travel to another state to have the IVF done. It is easily coordinated and arranged so you don't have to limit yourself to one option only. There is more that can be said or advised, but a thorough review of your medical records would be required.

Good Luck,

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

Comment: I was amazed at the timely response and all the information given. I feel confident that the Dr. is giving a knowledgable response as well as very honest without pushing his own clinic which was comforting. Thank you again for your time.

35 Year Old Responds Well To Low Dose Clomid IUI Cycle: NOT A Low Responder!

Question:

Dr. Ramirez,

My husband and I have been infertile for more than 2 years now. We have gone through a wide variety of tests. I have had a polyp removed through operative hysteroscopy and we were asked to try on our own for 3 months afterwards (unsuccessfully). I am 35 years with borderline bad FSH (around 10 on day 3). I have a low antral follicle count (usually around 7 if they can see both ovaries during the ultrasound). We have tried 1 IUI (negative for pregnancy) and I was prescribed 50 mg Clomid on days 3 - 7 for the IUI. I ovulated 3 eggs with this dose and was triggered with an HCG shot when the 3 follicles were between 1.7 - 2.0 and IUI took place approximately 24 and 48 hours after this injection.

I have 2 questions:

1. Is the fact that I developed 3 eggs on Clomid a good or bad sign? My doctor says I will likely be what he calls a poor responder to medications because of my low antral follicle count and IVF may not be more worthwhile than IUI because of this. Does the fact that I got 3 with Clomid mean I might do better with injections then he thinks or are the 2 medications so different that my response to Clomid doesn't indicate anything?

2. What is the purpose of a blood test the day of my second IUI? I have a lot of problems with all the blood work that is required for monitoring due to bad veins (day 3 plus 4 more days of blood tests/ultrasounds before my IUI). I thought when I was triggered that would be my last blood test, but I was told I needed another blood test/ultrasound the day of my second IUI (48 hours post trigger). I asked the nurse if the blood test was essential and she said yes and it is part of the cycle monitoring that all fertility clinics require it so I forced another blood test through my already bruised veins. I understand the ultrasound was to show if the follicles released, but what would the purpose of this blood test be and is it really as essential as they say it is? (I was also on progesterone suppositories 200 mg twice a day following the IUI so I don't think it was to measure progesterone since those were prescribed regardless of the blood results).

I really appreciate you providing this service and if we do decide to travel for treatment, California will be our choice. Thanks again, A. from British Columbia

Answer:

Hello A. from Canada (British Columbia),

The fact that you responded well to low dose Clomid is very, very reassuring and I completely disagree with your doctor's opinion. FSH levels and Antral counts are indirect measures of ovarian response but not absolute. In other words, studies have shown that these numbers can vary from cycle to cycle and so the response can vary from cycle to cycle. Besides, an FSH level of 10 is not necessarily that bad. Sure, we prefer the level to be 7 or less, but it is much better than a level of 12 or greater, which I often see. Even these patients do respond to stimulation albeit only a few follicles.

So, considering that you responded well to Clomid, low dose Clomid no less, is more of an indication that you are NOT a low responder. A low responder would have only one follicle despite high dose (250mg) of Clomid. One thing these two levels do tell you, however, is that you may not have as much time to work with as you would have thought. You will need to use your time wisely and strongly consider a more aggressive approach (such as IVF). I would not recommend more than 4 IUI attempts. If that does no work (which is the number where most patients will be pregnant), then you have to go to IVF.

In terms of your second question regarding the blood test, I have absolutely no idea why it is being done. It must be something specific to your doctor. You will have to ask him. Now, I do an ultrasound after each IUI so that I can see if ovulation has occurred. That way I know that the timing was good. Since I don't know what test they did or what it could be, I can't try to explain why they would do it. It can't or shouldn't be a progesterone level, which is what we often use to determine if ovulation occurred, but that test is not valid if progesterone supplementation is given.

Thank you for your question and consideration...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.

Conceiving After The Age Of 40: What Are My Chances?

Question:

Hi. I am 43 and began my quest for motherhood about two years ago. I have been on Clomid and Femara and have tried IUI about 5 times. I most recently tried Follistem and IUI. Last month I was on oral contraceptives because of a cyst and returned this month to discover the cyst was still there AND I had another cyst on the other side. The doc gave the option of aspiration of cysts or to consult to discuss options such as donor eggs.

I have been pregnant once, with no fertility help, about 3 years ago (at 40 yo) which resulted in miscarriage at 8 weeks. We had a heart beat then lost the pregnancy. What are your thoughts about my fertility history and recommendations for an otherwise healthy 43 year old? The cysts are producing estrogen--level was checked. Thank you for your opinion. I am writing from Iowa....thanks! S.

Answer:

Hello S. from the U.S. (Iowa),

First you need to understand that you are trying to beat the odds and that statistics is only a reflection of real life, not an exact predictor of it. There are always exceptions. However, we try to make the best decision based on the information that we have.

It is well known and scientifically proven that a woman's fertility decreases with age beginning at 30 years old. This is due to the fact that a woman is born with all the eggs she has for her entire life and those eggs age with her. In addition, she is using up lots of eggs with each cycle so there is also a reduction in the number of eggs available.

We also know that by 40 years old, the remaining eggs will be of poor quality. This leads to a reduction in pregnancy rate or a significant increase in miscarriages, and was probably the reason you miscarried at 40 years old. Your statistical chances of pregnancy with IUI (intra uterine insemination) at 43 years old is less than 0.5% per cycle. This is due to the fact that IUI is still a "natural" treatment method and requires that your body go through the normal steps to achieve pregnancy. As you can see, your chances are not zero, but are pretty slim. (A 20 year old woman has instead a 20% chance of pregnancy per cycle.) At your age, with IVF (in vitro fertilization) using your own eggs, the chances of pregnancy rise to 33% per cycle. Unfortunately, because of pregnancy and miscarriage losses the delivery rate is 13%. It is still significantly better than IUI because most of the steps required are performed by the IVF and only two steps are left to natural processes. With donor eggs and IVF, the chances increase dramatically due to younger and healthier eggs, to 75% with 59% delivering.

Most fertility specialists would recommend donor IVF, but it is a personal choice that you have to make. Most of my older patients want to try at least once with their own eggs and I will give them the chance to try because as I said up above, there are always exceptions!

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 Wonders: Should I Use Donor Eggs After Failing Five IUIs?

Question:

Dear Dr. Ramirez,

I would like your opinion on whether I should move on to donor eggs. I am 40 yr and I have 5 failed IUI (intra uterine inseminations), 3 of the IUI was with Menopur injections. The last IUI, my RE (reproductive endocrinologist) prescribed 22 vials where I used 3 vials for 7 days. Each IUI, I have one matured follicle whether its clomid, clomid combo injections or injections only.

One of the IUI resulted in pregnancy but I miscarried at 7 weeks 4 days in 2011 at age 39. Previous to my 5 IUIs, I was able to conceive naturally and got pregnant but miscarried at almost 10 weeks in 2010 at age 38. My FSH is 12 in 2012 but was 20 in 2010. My amy level was 0.5 in early 2011 and 0.25 in feb 2012. I have not tried IVF (in vitro fertilization) yet but I would like to know if the different protocol will make any difference producing more matured follicle. My RE doctor states that he needs at least 3 matured follicle to transfer, if there is not one, the cycle will get cancel and change to IUI. I have already find a donor but i found myself going back and forth to see if its worth going to a IVF cycle or not.

Please help! Thank you, D. from Texas

Answer:

Hello D. from the U.S. (Texas),

I think I would have recommended IVF back when you were 38 years old. In general, if a patient is 37 years old or older, I strongly recommend IVF rather than IUI. The main reason is that the chances of pregnancy with IUI at 37 is 5-10% per cycle vs 60% for IVF. In addition, seeing that your FSH level was already elevated at 12, that would have made a strong argument that time was critical so I would not have wasted it on a low yield treatment plan. But that is "spilled milk" as they say.

Now, you have two things going against you in terms of trying with your own eggs. One is that you are 40 years old so your chances of pregnancy are decreased, but still around 50% per attempt. More critical is that your FSH level is very very high and your AMH level is low. These are not good and indicate that the ovaries would probably not stimulate well. Sure, it only takes one good embryo to achieve pregnancy, which is what I tell my patients, but at the same time, the only way to increase your chances because of your eggs is to try to get a lot of eggs (it is know that the number of good eggs decreases with age). If only a few eggs are retrieved, then the chances of having a good egg, decreases. By the way, I don't agree with your doctor's policy to change to IUI if you have less than three follicles. IVF is clearly better than IUI because more of the steps are accomplished, bringing you closer to implantation, whereas IUI requires that your body go through ALL the steps naturally. In addition, I and many others in the assisted reproductive speciality have experiences with only one embryo leading to a pregnancy. Why give up IVF when it is your best option in such a cycle?

However, given your age, FSH level and AMH, I think that if you are willing to consider donor eggs, that is now the best way to go. I do let my patients try IVF despite these adverse factors because many desire to try at least once with their own eggs before giving that up. If you can afford it, that is an option. But you should clearly understand and be prepared for a failure and be ready to go to IVF with donor eggs.

Thank you for writing and 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.

39 Yr Old TTC With Previous Miscarriage: Clomid Vs. Gonadotropins? Flare Vs. Antagonist Protocol?

Question:

Dear Doctor,

I am from India. I am 39. I had two missed abortions at 36 and 37 both in the eighth week and after the heart beat was felt.After leaving a gap of four months I have been trying to conceive naturally for 14 months without any result.

Subsequently I started Clomid 100 mg (day 3-7) at the advice of doctor.I did 3 cycles with Clomid out of which I got two follicles of ovulatory size (more than 18mm) in two of the cycles and one follicle (20mm) in one of the cycles.I did not conceive. My FSH and other hormones are normal.

I consulted a IVF specialist who examined me and said that my ovary volume is good and said that she will go for two cycles of IUI, if they are not successful she will go for IVF.

In my first cycle of IUI, the doctor did a trans-vaginal ultra sound on day 2 and gave the following medications from day 2 to day 5 (1) Suprefact 10 markings in the insulin syringe with 100 markings (BD 100 mark syringe) (between 1 to 2 pm daily)(2) GMH (human menopausal Gonadotropins (FSH+LH)) 225 IU (between 7-9 pm daily)

On day 6 she checked and told me that there is no response and the follicles have not grown.She changed the medication to GMH 375 IU per day on day 6 and day7 (between 7-9 pm daily) (She stopped Suprefact)

On day 8, she checked and told me that the follicles have not grown and advised cancellation of the cycle.Further she said that my follicles are not good enough for future trials of IVF or IUI and advised IVF with donor egg.

I asked her how I could get two ovulatory sized follicles (above 18mm) with Clomid in two of my three monitored cycles but nothing in this cycle and she is ruling out the possibility of the future trials. Her answer was that with Clomid or Letrozole even empty follicles grow and give a false impression that the follicles are growing and ovulating. But with Gonadotropins only follicles with good eggs will grow and that is the reason why my follicles did not grow with Gonadotropins. Is the above statement about Clomid and Gonadotropins correct. I will be grateful for your answer. R. from India

Answer:

Hello R. from India,

The simple answer is "NO. Her explanation is NOT correct." The gonadotropins are more effective than Clomid or Letrozole in recruiting and growing follicles because it IS the hormone the brain sends to the ovary for that purpose. Clomid and Letrozole work by an indirect method to cause the brain to increse its FSH output.

Also, she is NOT correct that gonadotropins only grow "good" follicles whereas Clomid grows "false" follicles. This explanation is made up and not scientific at all. In fact, no such thing exists. Sorry.I am not sure why your doctor cancelled your cycle. If the CD#8 ultrasound (which is early) or Estradiol level are showing a low response, the proper protocol is to continue going. Sometimes the follicle can grow slower. I have had patients get up to 21 days before ovulation occurs. In addition, the FSH should be increased if the stimulation is slow. I do not expect to have ovulatory sized follicles until at least CD#12.

I agree with you that since you stimulated with Clomid previously, you should readily stimulate with Gonadotropins as well. Maybe you should find a new IVF specialist. One thing to keep in mind, however, although your chances are still good at 39 years old, your previous miscarriage show what part of the problem is, which is that the eggs have aged and more and more of them are not of good quality. As a result, there is a higher chance of abnormal embryos which increases the miscarriage rate. IVF should help that because it increases the amount of eggs that are retrieved which in turn increases the possibility of finding an egg that is still good quality. You probably will need a high dose protocol using up to 600IU of FSH. IVF is definitely the way to go!

Follow-Up Question:

Dear Doctor,Thanks for your kind advice.The IVF specialist said the protocol given to me is the flare protocol meant for poor responders. Is that so? Then I do not understand why I did not respond to the protocol.

During my Clomid cycles my follicles reach ovulatory size by day 12. Do you think the poor response in the Gonadotropins cycle could be due the Suprefact Injection which was given from day 2 to day 5 along with Gonadotropins? Also kindly advise if it is necessary to add Suprefact or lupron early in the cycle or giving only FSH will help. Besides doctors here give Gonadotropins (FSH+LH) not Recombinant FSH. Is it better to give Recombinant FSH?

Kindly advise. R.

Follow-Up Answer:

Hello Again,

I do not like to comment on protocol specifics because there is no one way to do things. Please keep that in mind as I answer your questions. The "flare" protocol is one type of protocol used to stimulate the ovaries with IVF. It has no advantage over other protocols, but sometimes is used in patients that are designated as "poor responders". Studies have not shown it to be any better. I personally do not use the flare protocol. My preference is to use an antogonist protocol so that there is no suppression of the ovaries during the initial recruit phase, but I am in the minority in terms of centers that use this type of protocol.

In terms of your stimulation, I still think that a higher amount of medication may be warranted.

Both Suprefact and Lupron are medications called "gonadotropin agonists" and what they do is suppress the brain from producing FSH and LH.Gonadotropins are either pure FSH, pure LH or mixed FSH/LH. This is the name for that class of medications. Some IVF clinics only use FSH, some will use a mixed protocol of FSH and FSH/LH. Examples are Follistim (pure FSH) and Menopur (FSH/LH). My preference is the mixed protocol but many clinics will use FSH only protocols and some will use only the mixed FSH/LH medications. Studies have not show a necessary benefit of any of these protocols so they cannot be compared or criticized. Each doctor and/or clinic has their preferences. The most important aspect is how much FSH is being given because FSH (follicle stimulating hormone) is the hormone that stimulates follicle growth in the ovaries. Also, Natural vs Recombinant forms are equal. There is no difference.

Wishing you good luck with your TTC journey,

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 Supplementation During An IUI Cycle

Question:

Hello Doctor,

I have been TTC since the past 15 months, I have irregular menstrual cycles. My husband has no fertility issues. I have been undergoing treatment - clomid, ovidrel followed by IUI (intra uterine insemination) since the past 3 months.

My luteal phase is 14 days long. I get a .8/1 degree increase in temperature the day after ovulation.This time ( 3rd IUI ), my RE asked me to take a vaginal progesterone supplement 2 days after the IUI.

There have been no tests performed to find if there is Luteal phase defect. I am scared/apprehensive about taking the progesterone supplements and I think my hormonal levels should be okay as my LP is 14 days long. Can you advise ? Your advise/suggestion on this matter will be much appreciated. Thanks in advance ! S. from California

Answer:

Hello S. from the U.S. (California),

I prescribe progesterone to ALL my infertility patients undergoing treatment. It is an easy medication to use, will cover any possible deficits in progesterone level that could impair implantation or continuation of the pregnancy and has no side effects. I think you should have been doing this from the first IUI treatment. I usually start it the day after the IUI.

You are correct that you don't have a luteal phase defect because your luteal phase is 14 days, but the additional progesterone won't hurt and it will make sure that you have adequate b-Integrin development, which is what is needed for implantation at the cellular level.

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.

After 11 IUI's, Canadian Fails 1st IVF cycle: Poor Embryos, Bleeding Or Implantation Failure?

Question:

Dear Dr. Ramirez,

I'm writing to you from Toronto, Canada. Thank you in advance for your answer!

My husband and I are both 37 years old. I was diagnosed with mild PCOS due to the shape of my ovary (pearl-like follicles) and irregular cycle (28-36 days), and as result was prescribed Metformin. My husband has low sperm count and motility. Last year I was pregnant after 5 attempts of IUI (intra uterine insemination), but unfortunately ended up in miscarriage due to chromosome abnormality. The protocols include Letrozole Femara on its own, Letrozole Femara in combination with Gonal-f and Hcg Ovidrel, and one unstimulated cycle. In all cycles, we only worked with 1 follicle. My husband's sperm ranged from 1-5 million after washed during those cycles. During our pregnant cycle, Letrozole Femara in combination with Gonal-f and Hcg Ovidrel were used, his sperm was 1.6 million after washed.

Three months after the miscarriage we tried again, with 6 rounds of IUI with similar protocols as before, but also include doubling Letrozole Femara with Gonal-f and Orgalutron, as well as Gonal-f injection only but none resulted in pregnancy. With the exception of 1 cycle where we worked with 2 follicles, the rest we only worked with 1 follicle. My husband's sperm ranged from 1-7 million after washed during those cycles.

Recently we went through an unsuccessful round of IVF-ICSI (in vitro fertilization with intra cytoplasmic sperm injection), with 5 days transfer. Protocols include Gonal-f, Repronex, Orgalutron, and Hcg Ovidrel. I was also put on a birth control pill the cycle prior to IVF cycle, and had an endometrium biopsy during the luteal phase of the birth control cycle. Post retrieval include antibiotics and vaginal natural progesterone 100mg in the morning and 200mg in the evening. Post transfer include vaginal natural progesterone 200mg in the morning and 200mg in the evening, and 81 mg aspirin daily.15 eggs were retrieved with 11 matured. 3 were IVF and 8 were ICSI. 1 out of the 3 IVF fertilized, and 4 out of the 8 ICSI fertilized. Since more than 3 eggs fertilized, the clinic's policy is to do 5 days transfer. By day 3 the quality of the 5 embryos were as follows: 10-12 cells grade 2 (good), 8 cells grade 1 (excellent), 8 cells grade 1 (excellent), 8 cells grade 2 (good), and 6 cells grade 2 (good).Unfortunately only 1 of the 8 cells (ICSI) turned into a blastocyst (with quality "not bad" according to my doctor).

The day 5 transfer include the only blastocyst we have and the 10-12 cells embryo. We ended up having no embryos to freeze. I started bleeding 7 days after the transfer.

Sorry for the long background story, my questions are as follows:

What should we do to ensure successful IVF next time? Failing the IVF, do I have an implantation problem?

What could have been done to prevent the early bleeding, could the progesterone injection prevent it? I didn't seem to have luteal phase defect in the past since my period normally come 14-16 days after ovulation.

What would have caused the poor embryo development after day 3? My doctor mentioned about possible sperm DNA fragmentation issue although this still need to be tested. Are there any other tests we should do?

What could have caused sperm DNA fragmentation, my husband doesn't smoke or drink, or exposed to any chemical environment in his day to day.

What protocol would you suggest for an IUI? Just want to mention that I didn't respond well to clomid and therefore my doctor prescribed letrozole. Why did IUI work for us last year and the last 6 attempts didn't? Also, I started taking Chinese herbs subsequent to miscarriage, therefore for the first 5 attempts out of the 6 IUI attempts I was also taking Chinese herbs at the same time, would that be why the IUI's failed?

I very much appreciate your time and help.Yours sincerely, E. from Canada

Answer:

Hello E. from Canada,

Thank you for all the information, it helps a great deal. Let me get to your questions directly.

1. Unfortunately, I don't comment on specific protocols because each doctor, clinic and country use different protocols. There is no right one or wrong one. These variations will often determine pregnancy success, however, and is the reason why some clinics are more successful than others. So, despite what I might advise you as to protocols, inevitably it will be your doctor's opinion, based on his training, knowledge and experience, that determines what protocols you use. Given that, it looks like you stimulated well, had a good number of eggs and embryos formed. The only changes I might suggest, which you have control over is (1) ICSI ALL eggs to allow for maximum fertilization and embryo number, (2) DO NOT PROGRESS TO BLASTOCYST CULTURE without at least 5 8-cell grade 1 or 2 embryos.There is an inherent attrition rate from day#3 embryos to blastocyst that may have nothing to do with inherent embryo quality. Based on preimplantation genetic testing data, sometimes even genetically normal and healthy embryos may not make it to blastocyst. Keep in mind that blastocyst culturing is still in its early development stages and not perfect. If you don't have enough embryos to lose, don't do it.

2. The bleeding after embryo transfer is very very common. I would refer you to my blog where that particular topic is the most often viewed. There is more information to this than I can give in this forum. Basically, however, it is not clear why or where this bleeding is from and how to prevent it. The good thing is that in many, if not most cases, it is of no consequence.

3. As mentioned above, the lack of embryo development does not necessarily have to be due to poor embryo quality. But, embryo quality can certainly affect the ability of an embryo to develop to blastocyst. The sperm fragmentation part . . . I'm not sure I would agree with that. Your age affects egg quality and therefore embryo quality more significantly.

4. Unknown what causes sperm fragmentation.

5. If you were going to return to IUI (which is an option but you have to consider that you will be lowering your chances of pregnancy) I would probably go to injectables only stimulation and not a combination protocol. The goal would be for you to have three to four ovulatory sized follicles (n0t one like you have been having), which will increase your chances of a successful pregnancy. The fact that you have gotten pregnant in the past is an indication that your reproductive system works but you have to overcome the sperm factors and the age factor. For these two, I would probably recommend IVF.

I would caution against adding herbal regimens. These are just un-purified pharmaceuticals. They could certainly have adverse affects.

Follow-Up Question:

Thank you so much for your reply.

In reading your blog on early bleeding, I mentioned to my doctor about using injectable progesterone. She wasn't on board and she still recommends vaginal progesterone. She explained that based on numerous researches, the vaginal progesterone is as effective as injectable, and the injectable create much discomfort. Instead for the next IVF, she will add estrogen patch. Should I insist on the injectable, I'm worried that I won't have enough progesterone support for implantation. Is it possible that's what might have caused the early period bleeding in my last IVF (7 days post 5 days transfer)?

Lastly, could the miscarriage that happened last year after IUI was also caused by lack of progesterone? That cycle I was only prescribed 100mg vaginal progesterone daily. However there was no bleeding whatsoever and after the fetal heartbeat stopped at 2.5 months pregnancy, I had a D&C done.

We will be doing another IVF 2 months later, in these 2 months, 1st month will be natural cycle and the 2nd month will be birth control cycle. Will doing the next IVF this early affect the eggs quality (the quality will be worse) and therefore reduce the pregnancy chance? Best regards, E.

Follow Up Answer:

Hello Again, Your doctor is correct in that studies have shown that vaginal progesterone is just as effective as injectable, and doesn't have the discomfort of the injection (Injectable progesterone has to be given intramuscularly). Injectable progesterone is still the gold standard, however, and if that is the form that you want, I don't see why your doctor can't change. But these kinds of things are what make each doctor different. Extra progesterone does not hurt, so why not? You could continue to argue with her but it sounds like she has her preferred way and will stand by it. The estrogen is a different hormone. I don't see any benefit to that for the bleeding but I certainly supplement with estrogen in my protocols.

Remember, I said that you cannot compare protocols because there is no one way, right way or wrong way. Protocols differ between doctors and clinics and that is okay.In the IUI pregnancy, which found a heart beat, progesterone was definitely not the cause. The lack of progesterone will result in very early pregnancy loss. Way before the placenta develops to produce its own progesterone. After that point, losses are usually due to abnormal pregnancies or fetal development.

The answer to your last question is NO. One can do an IVF cycle as quickly as every other month. Each cycle is different and unique and the eggs retrieved are unique. They can be good eggs or bad eggs, which is already predetermined prior to the IVF cycle depending on the state that the egg is in prior to stimulation.

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.

40 Year Old U.K. Woman With One Miscarriage Feels Time Is Running Out For Her: More IUI's, More IVF Or Donor Eggs?

This post concerns a woman in England who has written to me several times regarding her infertility journey. I would like to publish the entire correspondence for those of you who have a similar dilemma, that is, what to do if you have gone through multiple intra uterine inseminations, actually get pregnant naturally but miscarry, but because of your age, needed to consider IVF as the next step. Unfortunately, the first IVF cycle you do fails. What next? You can read my final response and advice at the very bottom. It is interesting to see how women in the U.K. receive infertility treatments through the National Health Service and the limitations of this government sponsored health care.

Question:

Hello Doctor Ramirez,

Hope you are well. It's L. from England again! I have added my previous questions below and your answers below as I didn't know how to add a link to my history. I have had my first round of IVF (NHS) and it did not go well. First I down regged with Buserelin Spray and this did not work after 3 weeks I was switched to the injection which then worked after another 2 weeks so all in all 5 weeks of down regging. I was then given Menopur 300 ui (Maximum dose at my clinic) after 12 days of stimming this has only produced 2 follies ( I have had 4 follies on puregon at a much smaller dose) at my scan today they have said the they will convert me to IUI as they need 3 min for IVF.

I am now so confused about what my next step should be if the IUI does not work. Unfortunately I am only really able to afford one more go at IVF, at a push with the help of family maybe 2 and wanted to ask what you thought my best option was. I have heard that mild/mini IVF may be better for me at my age however I am worried about my response, but then can't help thinking that my response was poor because I down regged for too long.

My niece has agreed to be a donor for me but im not sure she will be accepted by the clinic as her BMI is high and she is only 21 (she has a 1 year old daughter). My clinic said usually the lower age limit is 23. (I could possibly look at other European clinics with not as strict egg donation guidelines).

Or should I try again with my own old eggs? I have read about the benefits of taking DHEA to improve egg quality but feel that here in England I would need to self medicate this as I don’t think doctors here have taken this approach on board yet. What would you suggest I take if you indeed think it is appropriate. I am already taking the low dose aspirin and of course folic acid. Basically what I am trying to ask is if you were me what would you do in view of my low follie count on this IVF cycle. What regime would you put me on if I were at your clinic? or is it better to give up on my eggs and do down the donor route? Thank you in advance for your response. I always feel much better when I receive your advice. L. from the U.K.

PREVIOUS LETTERS:

Question: Hi, I am having IUI in England. My first attempt was cancelled as I ovulated myself before the follicle was large enough. My 2nd attempt I took 50 puregon every other day from day 5 and then had IUI on day 17 (I have a short cycle of 24 days), my period came on day 24 as usual. My 3rd attempt I again took 50 puregon every other day from day 5 and had IUI on day 14, again my period came on day 24. After reading many forums on the internet a lot of people seem to be having a larger dose every day from earlier in their cycle. Is it better to try and carry out IUI within my natural cycle or should the puregon be making my cycle longer? Should I be injecting earlier in order to have a follicle that is the correct size by my natural ovulation day of day 10? I have tried to contact my consultant but he never returns my calls and unfortunately I am starting to lose confidence in him. Thank you for your time. L. from the U.K.

Answer:

Hello L. from England,

First, if your doc does not return your calls, then find a new doc. He is not helping you. For example, my patients have access to me via by cell phone and via email, which I receive on my cell phone.

Second, I presume that your doc is monitoring you by ultrasound to determine the optimal day for trigger. Is he not? If not, then he is not the right person to see. If he is, you should be forming at least 3 follicles per cycle in order to optimize your IUI's. That's my goal and the number that studies have shown to increase pregnancy rates per cycle. In addition, you should be going on Progesterone the day following the IUI to supplement your luteal phase. The fact that your cycles are short, despite ovulating on CD#14-17, means that you have an inadequate luteal phase (luteal phase defect). Without adequate progesterone support, implantation will not occur or the pregnancy will not continue. With the additional progesterone, you will not have a period until the progesterone is stopped, which should be after a negative pregnancy test is done 12-14 days after the IUI. If it is positive, then the progesterone would be continued until you are 10 weeks gestational age.

I hope this helps, Good Luck. Edward J. Ramirez, M.D.,

Follow-Up Question:

Hi, I wonder if you could please give me your advice once again.

After your last reply I spoke to my fertility nurse and she indicated that I may have luteal phase defect but said that they did not use progesterone to help in IUI she basically said there was nothing I could do, I then managed to speak to the consultant who was very angry with the nurse as he did not think I have luteal phase defect. I argued with him about this but he was adamant. (I agree with you that I do have LPD) Just so you know my consultant has the best success rate in the country for IUI !My consultant was monitoring me with ultrasounds to check the size of the follicles and at my next scan I had 4 follicles he usually aims for 2 (The rules are different in England regarding multiple births, I had also been injecting a higher dose of puregon than the consultant recommended) He advised me to cancel the IUI as the risk of multiples was too high and told me to use contraception. Against his will I took my pregnyl trigger shot that night and had sex. I also purchased Pro-Gest progesterone cream (on the internet as it is not readily available in England without a prescription, is the cream as effective as pessaries?) and used it a couple of days after the trigger shot.Imagine my surprise and delight when I became pregnant!! Unfortunately at 9 weeks I had a missed miscarriage leaving myself and my partner devastated, I took pills at the hospital to expel the foetus rather than have a D&C.

I now have a dilemma as I can stay with the Consultant. I currently have another 4 cycles of IUI for free or I can go to a new clinic and receive 1 cycle of IVF free on the NHS. I realise that its great I can have this free treatment but there are drawbacks in that you cannot choose your doctor, you have to go to the clinic that your GP refers you to and each time you visit the clinic you may see a different doctor.

So in your opinion what is my best chance of getting pregnant? I am 40 in December 2010 and time is running out should I take the 4 rounds of IUI using higher doses and progesterone cream (as at least now I know I can get pregnant) or is the 1 round of IVF with a new consultant my best option?Which ever option I choose if it doesn’t work I will find the money to have at least 1 round of IVF at a private clinic even if I have to put it on my credit card then possibly look at donor eggs.Im sorry this is so long and hope it makes sense. Thanks very much in advance. L. from England

Follow-Up Answer:

Hello L.,

I presume that your consultant does not do IVF and therefore is not a fertility subspecialist? In any case, you have proven that you can get pregnant by natural means, so indeed you have a dilemma. Let me see if I can help you sort it out but ultimately, you will have to make the decision. Your age is a significant factor. Your natural chances of pregnancy is only about 10% per year of trying, or less than 1% per month. With IUI it is only slightly higher than that. This is mainly because (1) your body has to go through the entire natural process to become pregnant (there are 9 steps) and it does not do this perfectly every time, and (2) you have an age related quality of egg issue, I call "age related egg factor", that diminishes your chances as well. The probably cause of your miscarriage was an abnormal embryo. IUI will not help that.

IVF, on the other hand, has a much higher pregnancy rate than IUI because (1) it is not a natural process and does not necessarily rely on the body to do each of the steps except for the last two steps: embryo extrusion from the shell and implantation. For this reason, your chances of pregnancy with IVF runs about 40-65% per month in the U.S. (it is 68% in my program). This also reduces the chances of miscarriage because more eggs are recruited, giving a higher chance of finding a healthy normal embryo. There is still a miscarriage risk but as you can imagine, that risk is reduced. In addition, because you have gotten pregnant previously, you have shown that implantation can occur and all you need is a good healthy embryo. So, in my clinic I would advise you to do IVF, but with the caveat that it may take more than one attempt (remember the last two steps are still "natural" steps that we cannot control.

Certainly if you attempt the several IUI tries, for which your consultant has not been very cooperative mind you, you could get pregnant but I would be prepared for more miscarriages. In addition, at your age, I would try for 5 ovulatory sized eggs to increase your chances. The chances of a multiple are slim at your age. But I think IVF will give you a better chance, ultimately.In terms of donor eggs, I would not consider than unless you fail several IVF attempts (3-4), or you reach 43 years old, whichever comes first. You can do donor eggs at almost any age so time is not critical.

Most Recent Answer:

Hello L. from England,

Thank you so much for inserting your previous questions. As you probably can surmise, I get lots of questions and can't remember everyone.

I still think that you have a chance for pregnancy with your own eggs. I know that financial issues preclude that, but I am not convinced that you need donor eggs yet. That being said, if I were you I would find a different clinic. Go out of country if you have to. Your clinic is NOT giving you the best chances. 300IU of Menopur is an inadequate stimulation dose in your case. I am also concerned about your down regulation. I have not seen anyone need 5 weeks of down regulation. I would certainly do things differently.

First of all, my highest protocol is 450IU of Follistim and 150IU of Menopur, which is the highest protocol used in the U.S. Again the goal is to get the maximum stimulation so that we can retrieve the maximum number of eggs. That is the only way to overcome the "age factor."

Secondly, I NEVER cancel cycles even if I have only one follicle. That is because I have had many cycles with only one follicle, resulting in one egg retrieved and one embryo transferred, AND it may be the perfect egg that you just wasted.

Thirdly, we will allow directed donors (donors that you find and use) as long as they are over 18 years old (legal age).

Remember, as I mentioned before, you can do donor eggs at almost any age. So time is not an issue, whereas, it is an issue using your own eggs because of your age. What I mean by that is if you fail with an IVF cycle or two using your own eggs (in a good clinic), then you can save up your money for a year or two then do donor eggs. Of course if you don't want to wait and want the maximum chance of getting pregnant quickly, then donor eggs would be the way to go, and I would go elsewhere. I feel for you and hope that all goes well.

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.

45 Year Old Woman With FSH Of 13, Fails Four IUI Cycles: Go To IVF With Her Own Eggs Or With Donor Eggs?

Question:

Hello Dr. Ramirez,

I'm writing to you from Texas. I just turned 45 and in the past 4 months I have gone through 4 IUI cycles (3 w/Femara) and one natural. None worked, but my fertility specialist thought it was worth a try because there is no problem with me (other than my age) or my husband and our ability to conceive. He did mention that there was a small amount of endometriosis, but nothing to be concerned about. We had been trying for over 3 years before I finally went to a specialist. I know I should have gone much sooner.

My question is this: We have decided to try IVF . My big concern is the age of my eggs. My FSH was 13. Is there any greater chance of my becoming pregnant if I use my eggs and my husbands sperm to create an embryo, or if I use a donated embryo from a younger couple? I get somewhat different answers depending who I ask at my fertility clinic and it's quite frustrating. I don't want to change clinics if I can help it, because my doctor is top notch. His staff knows their stuff, but they seem to be too busy to give me any real in depth answers. I look forward to getting your opinion on this issue. I've found all kinds of websites that deal with donated embryos - are there any that you would recommend? Thank you! J. From Texas

Answer:

Hello J. from the U.S.,

I am very, very surprised that your "top notch" doctor recommended you to try IUI's (intra uterine inseminations) that many times based on your age and elevated FSH. Did he tell you that your chance of pregnancy was less than 0.5% per month? Did he tell you that your FSH was elevated and give you the diagnosis of decreased ovarian reserve, which essentially means time is critical for you. You may already be in a pre-menopausal state!

Unless my patient absolutely demands it, I do not recommend IUI in my 42+ year old patients or patients with FSH levels greater than 10. In my opinion, in order to have the best chances of pregnancy in the short time that you have left, IVF is the treatment of choice. At least there is a pregnancy rate at 45 years old that is about .5%, and for this reason I will let them try with their own eggs (many clinics do not), but it is with the understanding and plan that if it does not work then they will proceed with donor eggs. I have also had a few patients decide to mix their eggs with frozen donor eggs so that they don't know which resulted in the pregnancy (they preferred to not know that it was absolutely a donor). These eggs are purchased from an egg bank and are slightly less expensive than going the fresh donor egg route.

I think that based on your age of 45, and the elevated FSH of 13, I would strongly recommend that you proceed with donor eggs and IVF (in vitro fertilization). That will give you a pregnancy rate of 75% per attempt in my clinic and many other clinics.

In terms of finding a donor, there are three options: (1) finding your own donor that is either your family member, friend, acquaintance, which is the least expensive because you don't have to pay the donor but there could be some social issues, or (2) use a donor that is registered with that IVF center if the center has donors registered. This is usually the second least expensive way to go but there may be limited donor choices (3) Purchase frozen eggs from an egg bank or (4) go through an agency. There are many agencies across the country and you have to be very careful which agency to use. Some are reputable and some are not. This is the most expensive way to go and can double the cost of IVF because of the agency fee. We have worked with several agencies in the past, although most of my patients elect to use an egg donor in our registry.

Donor cycles are fairly easy to do from your side and will require a minimal amount of time at the IVF center. Because of this, many patients will travel to an outside clinic for a donor cycle due to price or the location of the donor. Many clinics, such as ours, can even arrange for preliminary and initial cycle visits to be done at a local clinic or IVF center so that the only travel required would be at the time of embryo transfer. So don't be limited by where you are. You have lots of options open to you. You just need to decide how you want to proceed from here.

I don't mean to be critical of your current clinic and I'm sure your doctor appreciates that you have a high opinion of their clinic. However, keep in mind that infertility clinics, doctors and treatments differ greatly. The fact that the staff at your center seem to be "too busy to give you any real in depth answers" should not be acceptable to you, considering the urgency of your situation. For example, our clinic is only one-on-one. Each patient is handled individually, and there is only one doctor that sees you, does your ultrasounds, does your procedures and makes recommendations. My patients have 24/7 email and phone access to me or my key staff. There are no mid level providers. We pride ourselves on being a boutique IVF center. It is what sets us apart from other, high volume, IVF centers that tend to make you feel more like a number. I hope this helps.

Follow-Up Question:

Hello again Dr. Ramirez, After reading your response I felt pretty emotionally bad, for lack of a better way of putting it. I was aware of the limitations with the IUI, the reason I did it is because my doctor felt there was nothing "wrong" with me or with my husband's sperm, and he assumed sluggish motility may have been part of the problem. I was planning on doing IVF next month, either using my own eggs (which I'm not entirely comfortable with) or a donor embryo rather than donor eggs, because of the price disparity. I don't live in CA where infertility treatments are covered under alot of insurance plans.

I said my doctor was top notch, in part because of the high ratings and recognition he has received in his field. That being said, I've never had a true one on one relationship with anyone at the clinic - although I tend to deal w/the same nurse and doctor. The clinic does offer an egg donor program, but based on your answer, I'm not so sure if I should continue on with them, since I don't believe their database is that comprehensive. In fact, I believe they go outside the clinic for donors, and the cost of the IVF with an egg donor is somewhere around 18,000. I asked you about FET (frozen embryo transfer), but you did not comment. I would like to get your opinion about this and if you have any recommended facilities that house frozen embryos. Unfortunately, the clinic I'm working with does not have any recommendations for embryo donors. After reading your answer, I'm not so sure about anything anymore. Thanks for answering, J. from Texas.

Follow-Up Answer:

Hello J.,

I apologize for causing you this strife. I don't want you to give up, rather, I am just here to give you advice and opinion. Certainly you can see that my opinion is greatly different from your doctor's.

California is not a mandated state in terms of infertility, so many of the insurances don't cover it here either. So I am very aware of the costs of treatments. It is a dilemma in my clinic as well where we lose 10-15 patients per cycle because of finances. Yes, I know that egg donor cycles can cost $18,000 or more per attempt.

Embryo donation is a fairly new option. I would recommend that you look at the web and you will find several organizations that assist with embryo donation. Keep in mind, however, that there are not a lot of embryos out there that are donated. Many parents do not want siblings all over the country. This certainly could be a lower cost than standar IVF because the transfer procedure is fairly simple. The medication cost is less and the procedure cost is less involved. Our clinic would charge $3500 for an FET (frozen embryo transfer). That is about what it costs in most of the clinics in our state. I don't know what the cost of these embryos would be, however, and most IVF clinics do not have embryos to donate. Most of the embryo banks are Christian organizations that either facilitate the process or have their own storage facility so that the embryos are not destroyed.

Another option is Frozen Egg Banks, which has now become a viable option. I recently had a 45 year old patient use that method. The costs were still higher than an IVF cycle, because the Frozen Egg cost was high, but it was less than using your own egg donor. Unlike embryos, these are unfertilized eggs that were frozen and can be fertilized with your husband's sperm. The protocol you would go through would be like an FET. It is more expensive than a simple FET because you have to purchase the eggs (I think then sell them in lots of two), ICSI would have to be done and the embryology process would have to be done like a regular IVF cycle. The only step that would not have to be done is the egg retrieval step, which is the most expensive part of the IVF cycle.

For both embryo transfer and frozen egg transfer, the pregnancy rates would be very high (75% per attempt in our clinic). It certainly is better than your own eggs.

Again, I apologize for the comments that I made because they deflated your hopes and made you feel emotionally deflated. I hope these new comments will help you more constructively.

P.S. Kelly Preston (John Travoltas wife) just delivered a healthy baby boy at the age of 48. Of course, she doesn't say whether she used any assisted reproductive technology (and I would bet she did), but if not, then there is always a chance. I never say NO to my patients that want to try, I only make sure they understand all their options and their chances up front.

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.