Seventh IVF Cycle Brings Success But Patient Worried About Progesterone Levels

Question:

Hi Doctor!

I have recently become pregnant after my 7th IVF, and am currently 6 weeks. I had 2 very good quality blastocysts transferred and am awaiting my 7 weeks scan next week to see the heartbeat and hopefully tell if it's twins. I have been going in for blood tests to monitor my progesterone levels and initially I was taking 2 cyclogest (400mgs) a day, it then increased to 3 and now 4 a day. This was because my prog levels were fluctuating from 80 and 150 and my FS feels 150 is a good level. My last test showed it at 200. From doing my research, I realise that normal prog levels can be anything above 30 and less than 100. Are mine too high? IS there any danger of having prog at 150-200?

My Bhcg has also been monitored every 2-3 days and they have been climbing nicely, from 193,447,1863, 4990 and now 13900. Are those indicative of a viable pregnancy?Many thanks for your help and advice.

Regards, N. from the U.K.

Answer:

Hello N. from the U.K.,

Congratulations! I'm glad you persevered because most patients would not try IVF 7 times. All your levels are fine. Your progesterone is not too high and there is no danger with a level of 200. I'm surprised your doc is chasing the levels. Your bHCG levels are great. With a level of 13,900, the gestational sac should already be visible within the uterus, so your doc should go ahead and do a scan this week rather than wait until next week. At this point it is important to confirm the uterine pregnancy because there is a 2-5% risk of ectopic pregnancy with IVF (tubal pregnancy). If it were in the tube, this would be the time to treat it as medication can be used instead of surgery.

I don't mention this to scare you, but I normally do my first ultrasound at 6 weeks gestational age for this reason. You might want to ask your doctor to do so as well. More than likely everything will be fine. Again congratulations!

Follow-Up Question:

Hi Doctor,

Thanks so much for your advice, I really appreciate it. I took your advice and scheduled a scan for today, which confirmed a single uterine pregnancy and we saw the heartbeat. So it is a relief! I am currently 6 weeks and 4 days. Is there any chance of things going wrong after seeing a heartbeat? I haven't had any bleeding or haven't had any major cramping. I also haven't been experiencing nausea and morning sickness, but I have had lower back pain, fatigue, and strangely enough throbbing ankle or feet pain now and then. Thank you for your time and help. Regards, N.

Follow-Up Answer:

Hello N.,

Congratulations! At 6 weeks with the findings of a fetus of appropriate size and a good heartbeat, those are good signs for the pregnancy. There is still a risk of miscarriage that runs about 40% until 8 weeks gestational age. Your doctor should probably repeat the ultrasound in two weeks. If everything looks fine at the next ultrasound (8+weeks), then the risk of miscarriage drops to 5% until 12 weeks gestational age.

Of course there are lots of problems that can occur in pregnancy. Everyone has the same risks. But if you worried about every possible risk, you would go crazy and not enjoy your pregnancy. For now, I would recommend that you take things in stride and day to day. Don't worry about the future because you don't necessarily have control over it. Hope for the best because that is the most likely outcome. And as the sailors of olde used to say, pray for good winds!

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.

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

More Questions Regarding IVF and ICSI: Can I Have Twins, SET, And Other Post Retrieval And Transfer Questions

Question:

Hello again, this is S. with some follow-up questions from my earlier email.

Thanks for answering my questions. I have a few more. I know that obviously it depends upon the number of viable eggs removed during egg retrieval for IVF with ICSI but how many of the eggs would they try to fertilize and use at a time? How does it work with the frozen embryos? What are the chances of twins or triplets with this type of procedure? Can I decide if I want twins if I have more than 1 egg that is ready? After the egg is fertilized and put back do I have to be off of my feet for a time? How long does it take for the process to take place?

Sorry I'm just really unclear about all of this. Do I have to go back for ultrasounds afterwards and if so how often do I have follow up appts? Thanks again!

Answer:

Hello S.,

You're welcome to follow up with additional questions any time. I probably did not address the ICSI (intracytoplasmic sperm injection) question you had in your first email. With ICSI, all mature eggs are injected since not all with fertilize. If they only took a few and did ICSI, which I understand some clinics will do, that could impair the number of embryos you have to work with if they don't fertilize.

These are then allowed to divide over a 3-5 day period. An appropriate number is then chosen to transfer. That number is decided between you and your doctor. With frozen embryo transfers, the embryos are thawed, allowed to expand, and if they survive, are transferred. Usually the number thawed are the number transferred because re-freezing is not necessarily a good thing.

If three embryos are transferred, the risk of twins is about 35% and triplets less than 10%. This risk declines as the number of embryos transferred decreases. Because of the high pregnancy rates these days, many clinics have moved to doing a single embryo transfer, or SET, in order to minimize the risk of twins or more. This is based on new recommendations that have come out from the American Society for Reproductive Medicine and the Society for Advanced Reproductive Technology. There has been strong political pressure for IVF centers to reduce the incidence of a multiple gestation (twins or more). If you want twins, then you have to discuss this with your doctor and see if that is something the doctor feels comfortable with. Depending on your age, either two or three embryos would be transferred to try to achieve twins.

Once the embryos are transferred, you do not have to "rest" for any period of time. I have my patients do light activity for three days after the transfer to allow for implantation to take place, but I do not want them to be at bedrest. From that point it is a natural process and is the same that your body would go through if you were trying on your own.

In terms of your last two questions, these are answers that you should be getting directly from your IVF center. You pay them a lot of money for this procedure and they should be giving you almost royal treatment. If they are not, then you should demand it. The IVF process is a three week process, basically mimicking your natural process. The ovaries are stimulated, which takes 10-12 days, the eggs are retrieved at the mid-cycle and allowed to fertilized, then they are allowed to grow in culture for 3-5 days, then they are transferred back into the uterus. 8-10 days later a pregnancy test is done, which usually coincides with the end of the month if you started at the beginning of the month. (You should check out my website and I have an outline of the IVF process.) In the first 10-12 days, ultrasound and blood tests are done periodically to evaluate how you are responding, how many follicles you have, how big the follicles are and when to trigger for the retrieval. These ultrasounds can be done daily, every other day or farther apart depending on how big the follicles are and how close you are to the trigger day (generally as you get closer, the appointments get closer). The egg retrieval is usually done two days after the trigger (35-36 hours from the trigger injection) then the transfer is done 3-5 days after that.

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.

Elective Single Embryo Transfer - Notes from this year's ASRM meeting

At the annual American Society for Reproductive Medicine meeting one of the many courses I attended was one entitled "Elective Single Embryo Transfer". Perhaps no issue in assisted reproductive technologies (ART) is as controversial as the selection of the optimal number of embryos for transfer. Single Embryo Transfer or SET is a method being heavily promoted by the fertility specialists to reduce the incidence of a multiple getstation. Of course, the recent New York Times article about twins that were born with severe deficits was a source for discussion ("The Trouble With Twin Births" Oct. 11, 2009 Opinion").

Indeed, in current years the number of triplets resulting from ART has diminished; but the number of twins has not declined. The most recent guideline published by SART indicates that the number of embryos to transfer in women age 35 and under is 1 - 2 embryos for "favorable prognosis patients and 2 for all others".

The panel consisted of two Physicians and a PhD Embryologist. Both Physicians came from states where IVF is a mandated benefit, so their patients don't pay out of pocket. They presented their data and arguments for proposals to enact a SET policy on good prognosis patients under 38 years old. They condemned all multiple gestations, including twins, because of the increased costs of the medical care.

The main data they showed to support their argument was that cumulative pregnancy rates (PR) (fresh transfer plus frozen attempts) were the same as PR from transferrring 2 embryos (DET) in one cycle. Transferring SET had a lower PR than transferring DET in a single cycle if you did not add the frozens. Because IVF was mandated, the extra cycles were at no extra cost. The other point that they made was that if the patient failed in the 1st cycle, they transferred 2 (DET) embryos in the subsequent cycle. So in essence, in order to achieve the same PR as the DET in 1 cycle, they had to transfer 3 embryos over two or more cycles.

Their final point was that as reproductive specialists and physicians, we are bound to an ethic of "do no harm" and having a multiple gestation is "harm" as explained in the NY Times article. They professed that we should choose for our patients to transfer only one embryo and not let the emotions and "desperation" of patients to choose more than one embryo for a higher PR.

Personally, I too strive for a singleton pregnancy for all my patients. That is the ultimate goal. I am in favor of SET if the PR per cycle is equivalent to DET. We, ASRM, SART and reproductive specialists, are trying to move toward SET as the gold standard. But, we are not there yet! And, when patients have to pay for their cycles, as they do in California, I believe that we also have an obligation to them, as the consumer, to give patients the highest chances of success for the least cost. A "cumulative PR", especially when more than one embryos is transferred in subsequent cycles, with a higher twin PR, is NOT equivalent. This is a fudge of statistic and not truthful counseling.

Also, one has to remember that the NY Times article is an anecdote about a specific couple and should not be interpreted as the "majority" or "usual" outcome of patients or twins. It is absolutely not. With the advances in Obstetrics and Perinatology, most twins deliver at term and do fine, and have no deficits. We should therefore not fear twin gestations. A NY Times article such as the one recently published, is biased and sensationalized, and not based on scientific evidence. Triplets or more is a different story, however, and should strongly be avoided.

In addition, we Do Not have the knowledge or ability to choose the ideal embryo at this time. It is still a best guess. We choose based on external characteristics "best looking" but that doesn't guarentee a perfect internal structure. Many of us have had terrible looking embryos turn into pregnancies and beautiful children. So in fact, although we think we know best for the patient, we may not be doing the best for patients if we limit their choices.

So, I think that DET may still be the best for the patient at this time, in order to give patients the highest chances for success per cycle with a small twin risk and even smaller twin deficit risk. I don't think that patients should be forced into SET but should be honestly and comprehensively counseled regarding the potential risks of twins (as it is, most of our patients are already taking an increased risk of genetically abnormal babies due to age in attempting pregnancy). They the patients should be allowed to choose without interference from the Physician or the Government. After all, they are paying for it. In states or countries where their insurance or government is the payor, then it can be mandated by regulation, and the insurance or government has the right to decide instead of the patient.

When the technology reaches the point where we can accurately distinguish between good and bad embryos with certainty, and SET offers the best PR for the patient, meeting our obligation to the patient, then it will be time to only transfer one embryo per cycle. Until then, we can keep this as our goal and do the best that we can with the information that we have to work with currently, and strive to reduce the higher order multiple PR (triplet or more). We should strive for singletons but allow twins. We cannot forget that success is what serves our patients best.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check me out on Facebook and Twitter with me at @montereybayivf