Infertility/Fertility/Failed IVF

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QUESTION: Dear Doctor,

I am 40. I had two missed abortions at 37 both in the ninth week after heart beat was felt. Subsequently I did not conceive and my RE suggested IVF.

I have regular 29 day cycle. My Day 3 FSH is normal. My RE put me on Lupron (0.5cc) from day 17.

On day 2 of the period,  she started with 600IU of HMG and 0.25 cc of Lupron for 3 days (cd 2-4).

On reviewing after on CD 5, she said no follicle and no endometrium growth is seen.

She continued the medication for two more days and (cd 5, 6) and examined me cd 7 and said that there are no follicles or endometrium and cancelled the cycle.

I stooped all medications and on cd 12, I checked with a local ultra sound center. The Ultrasound specialist said there are about 12 foolicles on both ovaries the largest being 10mm. I checked my FSH and E2 on the same day and the FSH was 12.76 and the E2 is 58.00.

On Cd 16 I checked again and the Ultrasound specialist informed me that one follicle is 13 mm and others are still small.
Can I do anything at this stage to get a multiple ovulation in this cycle so that I can try naturally in this cycle (Like one or two doses of clomid or letrozole).

What is your advice for future IVF cycles.

Thanking you in anticipation.

Renu

ANSWER: Hello Renu from India,

It may be too late to rescue this cycle but if you have any Menopur, you could use it but the dosage would need to be significantly reduced to minimize the number of follicles that grow to ovulatory size.  Unfortunately, the reality is that the eggs will not continue to grow and mature if it does not receive enough FSH hormone and will proceed to atrophy (wilt).  If your natural FSH production kicks in then you might still have one follicle ovulate as you would in a natural cycle.  I guess that is what you will have to hope for.

My second piece of advise is for subsequent cycles.  Your doctor is incompetent and does not know what she is doing so I would dump her (find a new doctor).  It is expected, and usually the case, that there will not be much follicular growth by CD#7 of stimulation.  Some people take longer,as you have shown.  In IVF cycles, you have to continue to follow the Estradiol levels to see if they are rising, which is proof of follicular growth (stimulation), and measure the follicle.  Most people do not have ovulatory sized follicles until CD#10-12.  Your doctor cancelled the cycle prematurely and just wasted your money.  I would demand a refund!

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: Dear Doctor,

Thanks for your kind answer.

During the ultra sound follow-up, it was observed that two follicles continued to grow and reached size of 21mm and 23mm before they ruptured on CD23.  Endometrium was 13mm.

I have some questions about my future options.

Am I getting too suppressed on Long Lupron protocol? (My normal cycle length is 29 days).

What would be the right protocol for me?

Can I go for antagonist protocol by starting stimulation straight away on day 2 without any suppression on the previous cycle? Will it lead to fewer eggs as the eggs may already start growing by day 2 in the absence of any form of suppression in the preceding cycle?

Do you think I should start my new IVF cycle in the coming cycle or leave one cycle break and start in the next cycle?

I am a little scared of Estrogen Priming as I have a complex cyst in my breast (benign).

Renu

Answer
Hello Again,

From your questions, you obviously have been researching your options, and that is good.  Whether or not to use the Long Lupron protocol vs antagonist protocol is dependent on the preference of the doctor caring for you.  That is about all I can say about choosing a protocol.  I have my preference and as such, I prefer using the Antagonist protocol so as not to suppress the ovarian response too much and to reduce the number of injections required.

I prefer to have my patients let their ovaries rest for a cycle between IVF cycles.  I also use the birth control pill to suppress the ovaries and put it at rest (the ovary does not function when it is suppressed by the birth control pill).  However, I do know of clinics that do back to back IVF cycles and ones that go without using birth control pills as well.  That is a Physician preference.  It is not necessary to use Lupron prior to a cycle or to prime with Estrogen.  Some doctors use Estrogen priming in patients that are low responders in the hope of increasing the ovarian function.

As you saw, your cycle need not have been cancelled since you did progress to develop mature sized follicles!  Because of all these variations and variables, pregnancy rates differ between doctors and clinics.  That is why it is important to choose the right doctor and/or right clinic.

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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