Infertility/Fertility/FET

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QUESTION: I have a question about what's going on with my FET. I am in a clinical trial for IVF so I never get to talk directly go the drs, and the nurses only give me half information. My Dx is POA/DOR.

Just my way of background, I had one cancelled cycle due to premature ovulation (I was on long Lupron protocol). About 3 days later, I started my (period) but the next cycle ended up being about 35 days (usually a perfect 28 on stim meds). This leads me to believe that my "period" was Moreso a reaction to the meds, and that my follicular phase probably didnt start until maybe a week later. This will make since later in my question.

I went on to have a successful retrieval the next go around but I was triggered early due to my body trying to ovulate on its own. All eggs were immature. 4 matured in the lab and 1 made it to expanded blast stage by day 6.

I am in my FET cycle. First the first 2 weeks, ally follicles were at 10 or less. My lining was also very thin. They started me on Estrace 2mg/day then eventually increased it to 4mg per day. As of CD26, I now have a follicle that was measuring 16. They told me to stop the Estrace and wait for ovulation. My hormones E was 366 that day.

I guess I am just trying to understand what they were doing. My assumption is that they thought I probably was not going to mature a follicle that month, so they decided to prep my lining for a transfer with no ovulation? But they also kept monitoring my LH as well (which BTW rose around CD 21 to the point where I was getting a positive on OPK, but I didn't even have a mature follicle and my P4 never went up). So that was my one theory, but can they do that? Or I was thinking that they were going to use the estrogen to induce a "fake" ovulation for lack of a better word in hopes that my hormones would shift and p4 would go up even though there was no mature follicle and therefore no egg release. That is my theory number 2 but I am also not sure if that is possible. I want to say I think that did occur though. I got a smiley face on a digital OPK around CD21 and I felt abdominal pressure the next day similar to what I feel when I ovulate. But my p4 never went up and days later there is a follicle close to maturity.

My other question is my lining was 9.8 on CD26 when the follicle was 16. I am sure it was partially induced by the Estrace and I am wondering if its possible to be too thick. I'm a normal cycle my lining usually doesn't hit 9 until a day or 2 before ovulation and then even thickens up a little more during the beginning of the luteal phase. I have now stopped the Estrace but if my lining gets to like 12-13, is that top thick? Is there a such thing?

ANSWER: Hello Kellie from the U.S. (Michigan),

For the most part, I'm afraid I can't answer your question.  They are not using a standard protocol.  Maybe that is part of the study that they are doing.  In most FET cycles, ovulation is suppressed using either Lupron, Synarel or Ganerelix.  They don't seem to be doing that to you.  So, your theories as good as any and I'm afraid your going to have to get your doctor to explain it to you.

In terms of endometrial lining, we strive to get it to 9 mms minimum.  So, you are there.  It can't get too thick.  The key to an FET cycle is exact timing.  There is about a 12-24 hour window where the transfer can occur.  That is part of the reason why I don't understand what your clinic is doing.  If the timing is not correct, the endometrial architecture will be incorrect and implantation will not occur.  The way we control that in normal cycles is by starting the progesterone on a specific day prior to the scheduled transfer.  The progesterone is what changes the architecture of the endometrium to make it hospitable to the embryo.

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 it's me again. I never really got an answer to my first question but I do know their FET protocol is somewhat natural. They wait until they confirm you ovulated and then that start you on Estrace and progesterone for 5 days wish the transfer being on the 5th day. Myasthenia cycle was super long. I just had my FET yesterday (2/17/13). But now I am seeing something and a little worried.

For the transfer they transferred 1 6 day expanded blastocyst. They perform assisted hatching. Starting late last night, this may be TMI, but when I wipe there are brownish pieces of something, almost like dead skin. I know I had read in a million places that the embryo cannot fall out, but do you have any idea what this can be that I am seeing? Almost everytime I wipe there is another little piece.

The procedure went very smoothly. Took 5 minutes at the most and I barely felt the catheter touch me at all. Is it at all possible to be the embryo? What about the shell?

ANSWER: Hello Again,

It is absolutely not the embryo or any part of the embryo.  The embryo is not big enough to see with the naked eye at this point.  I can't tell you what the "tissue" was without seeing it and your description does not ring any bells.  Sorry for the lack of an answer again.

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: Hello me again. This really isn't a question I just wanted to share that I got a BFP this morning on a digital HPT and I could not be happier. Thank you so much for listening to my concerns and trying to help me. Dealing with I fertility is so overwhelming and sometimes just knowing that someone cares enough to take time out of they busy day and life to listen is all that matters. Thank you again. And God bless you for being there for so many in my shoes.

Answer
Hello Kellie,

Congratulations :).  God gives each of us a task on this earth and a purpose in life.  Mine is what he has blessed me to do, which is to help people have children.  Despite the fact that I often lament the way medicine is being degraded and demoralized in this Country, one happy patient is all I need to remind me of my task.  I had several IVF ultrasounds today to confirm viable babies and there is nothing better.  Thanks for adding more good news to my day, and may God continue to Bless you through this pregnancy.

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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