Infertility/Fertility/High vit. D and IVF

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QUESTION: Hi doc,

I have been writing to u since long regarding any IVF queries and ur response has helped me alot.

To go again,  I am 31 yr old trying since 4 years, 3 yrs with IVF.
4 failed IVFs to my kitty.
All implantation failures.
Now doc found out hydrosalpinx and has clipped the tubes.
My vitamin D was very low, so she put me on supplements.
Now I have started ovarian stimulation for the 5th cycle, checked my vit. D level and it came out to be 280 nmol/L.
which is quite high.
and TSH has also increased but T3 and T4 are normal.

Please suggest how Vit. D3 level can be decreased, can the high values compromise the IVF results in any way?

Moreover, are Folicullin and Foligraf different in there effectiveness? As I responded well(follicles growth) in all cycles where Foligraf was given in first 5 days. And didnt respond at all in cycles where Folliculin was given.

Thnx for the help

ANSWER: Hello Ria from India,

A hydrosalpinx would have been the cause for the failure of the first three IVF cycles, so you can just throw those out and think that you are starting all over again.  I am glad that you have not given up.  Vitamin D has no bearing on getting pregnant.  You don't need to take it.  Folligraf is the same as Follistm but just a different brand.  Despite a normal T3 and T4, the TSH level should ideally be below 2.0.

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.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate


---------- FOLLOW-UP ----------

QUESTION: Hi doc,

Thnx for your response.

I have started with 6th Cycle had Foligraf 300 IU s/c for 4 days.
Had ultrasound today, the doc could not see any follicle growth,
Dormant follicles were present 10 on each ovary.
But it failed to grow. My E2 on day 2 was 76. No down regulation was given in this cycle.

The previous month 5th cycle was cancelled as there was no response with Foliculin(Urofolitropin) 300 IU. In that cycle doctor had put me on Decapeptyl injection 1 shot which lasts for 1 month. Then stimulation  ws done along with down regulation with Lupron.  She gave me Methoxy progesterone , period arrived after 10 days.

In cycles 1,2 ,4 , I was given 225 IU of foligraf which resulted in 12 eggs.
In 3rd cycle I was given 600 IU HMG, that too yielded 12 eggs.

In August 2012 I had undergone tubal clipping(burn n clip) because of hydrosalpinx.

My Vitamin D had risen from deficient levels to 280 nmol/L in just 2 months.
My TSH was 1.5 when I started off with this cycle , yesterday it came out to be 9.7 (with the same dose).

My doctor has now cancelled my 6th cycle as there is no response from the ovaries(but she can see good antral follicles on both).

My questions:
1) Does IvIg has any negative impact on the immune system of the body, as    to hamper any normal functioning?
2) What could be the cause of no ovarian response? AFC is good(tested today) and AMH was good (tested 6 months back). Doc says I have polycystic appearing ovaries.
3) Can tubal ligation effect ovarian functioning?
4) Would I be ovulating naturally now? Doc(New RE) saw a maturing follicle when I had first consultation with her in Aug 2012.
5) Suddenly my TSH has jumped to 9.7, where before stimulation it was 1.5?
Do U think any antibodies might be causing all the turmoil?

Sorry doctor for asking too many questions.
But I am in dilemma.

Thnx a lot doctor for your time.

ANSWER: Hello Again,

1.  IVIG would have no effect on your normal ovarian function.
2.  In terms of the lack of response, it is possible that you are not getting enough stimulation (medication).  The protocol probably needs to be adjusted.
3.  Tubal ligation usually does not affect ovarian function unless the ovaries are damaged at the time of the surgery.
4.  I am unable to answer this question.  It is not answerable.
5.  Unless you are referring to anti-thyroid antibodies as the possible cause for reducing your thyroid function, antibodies should not affect your ovarian function as far as is known currently.

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.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate


---------- FOLLOW-UP ----------

QUESTION: Hi doc for ur response.

The follicle size after 4 days of ovarian stimulation with 300 IU of Foligraf was:
RO- 8,9, 5-6 mm
LO- multiple 4-6 mm

ET- 11 mm

Bilateral ovaries normal in position, bulky in size, stromal echogenicity is increased suggestive of mild polycystic pattern.
8-10 follicles are seen on either side.

pls see if this shows some response or dose modification

thnx again

Answer
Hello Again,

Why is your doctor doing a scan at 4 days of stimulation?  It would be too early to show any response, as your scan shows.  Usually the earliest I will do a scan is 7 days of stimulation.  Estradiol levels are used to check for response which is the only method I use at 4 days of stimulation, just to make sure it is increasing.

My recommendation would be to stay at the current dosage for now and rescan at 7 or 8 days of stimulation and see where your dominant follicles are at that point.

Please find a better doctor who knows what they are doing.  PCOD patients are difficult patients to stimulate and problems can occur if the doctor is not wary.

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.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate  

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Edward 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 19 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, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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