AboutEdward Joseph Ramirez, MD, FACOG Expertise I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.
Experience I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 15 years.
Organizations American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society
Publications American Journal of Obstetrics and Gynecology
Education/Credentials Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco
Question Thank you Dr. Ramirez for providing this service. We've had 1 failed IVF and wonder if it's realistic to expect different results if we try again. I am almost 37, living in Oklahoma City, married for 7 yrs and trying to get pregnant for 2 yrs with the help of a RE. Labs for both have been normal- he has good, normal looking motile swimmers. I ovulate normally and had 10+ antral follicles at each Cycle day 1. Due to "hostile cervical mucous" we tried several cycles of IUI, with clomid then Follistim as clomid seemed to inhibit my lining. We then tried a cycle of IVF, long lupron protocol, with ICSI. My RE was surprised it took 225u of Follistim/Menopur BID to get follicles. Prior IUI cycles only required 66-75u. In end, we had 10 follicles, 8 eggs, 5 fertilized, 2 fertilized abnormally,1 not at all. On day 3 only 2 embryos were left, Grade C. Others had arrested. both were transferred. 1 week post transfer, Progesterone was 24 so IM dose was increased and I was also placed on E2. Alas, it didn't work. My RE said that from the way my ovaries responded this last time, and that the eggs didn't look "great" that he couldn't make a case for trying again. I understand that manipulation can only increases #, not quality, true? So while a part of me is leaning towards another cycle, I don't know if perhaps my expectations are unrealistic given what we know now. Thank you again, sir.
Answer Hello Titi from the U.S.,
I am afraid that I don't agree with your RE's conclusion. There have been several studies looking at a subset of infertility patients called "poor responders", who are people that have an elevated fSH level and don't stimulate well with IVF. These studies show that the response every cycle is different and even these patients get pregnant. In my book, the only situation that is definite is if you don't try, it can't work.
You cycle sounded like a terrible stimulation cycle. Your protocol was not appropriate for you but this is not your RE's fault because when you are trying for the first time, we have to make an educated guess as to how you are going to respond and how much medication to use. You were understimulated, as manifest by a low number of eggs, embryos, etc. Your doctor will need to increase the stimulation. I also would NOT recommend the long protocol in your case. That suppresses the ovaries too much, which may be why you needed more medication with your IVF cycle than your IUI cycle. You should probably use an antagonist protocol with Cetrotide or Ganerelix. I use that exclusively now. If your doctor does not have experience with this protocol then you might want to find one that does.
One of the major factors in your case is your age. You are trying to overcome the "age factor" whereby the majority of your eggs will be poor or decreased quality. Studies have been done using genetic testing on embryos that have shown that at age 37, only 20% of embryos formed are chromosomally normal. That is what you are trying to overcome and why having a strong stimulation to get 15-20 eggs each cycle is so important. Remember, only 2 of 10 will be normal. If your RE has already given up on you, and giving you negative advice, you might want to consider a different clinic that will be more aggressive. There are higher protocols than what you used, and that might make the difference.
Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
