Infertility/Fertility/Ovaries not "waking up" until day 8 of IVF stims
I came across your blog today as I was doing some research after my first failed IVF attempt. I am 37yo and my husband is 34yo. We began going to an RE last August and started with IUI's. Our second (out of 6) IUI resulted in a chemical pregnancy. We decided to change to IVF last month. My AMH is 2.6 and FSH is 7.9, and my husband has a normal sperm analysis. My doctor thought we would have a terrific outcome with IVF based on all our "numbers." He started us on the antagonist protocol (Menopur 75/Folistim 225). However, it turned out that my ovaries didn't respond to this. At all. The only reason he didn't cancel my cycle is because my E2 levels kept doubling (started out at 57 on day 4 of stims). He upped my Folistim to 300 on day 4, and doubled my menopur to 150 on day 7 of stims. On day 8, it looked like my ovaries finally "woke-up." I stimmed till day 12 and then took the Norvel trigger shot that evening. My retrieval was 36 hours later. They collected 14 eggs, but only 8 were mature. Of these, 6 were able to be inseminated with ICSI, and 5 fertilized. We had 2, 8-cell embryos transferred on day 3 (Grade A-). The other embryos (none of which were 8 cell on day 3) arrested.
My RE was disappointed with the fact that we only got 14 eggs, and that only 8 were mature. He believes this was a result of my ovaries not beginning to respond until day 7-8 of stims. He is still considering what type of protocol (or the same) we should try with my next cycle. I guess my questions are as follows:
1) Is my response to stimulation puzzling to you based on my strong AMH and FSH levels? Have you seen this type of response before?
2) Would you suggest another round of the antagonist protocol and hope/expect my ovaries respond differently next cycle?
3) My RE wondered if it would make sense to begin my cycle with Clomid/Femera to "wake-up" my ovaries and the proceed with the antagonist protocol as normal? I had a good response to Clomid and Femera during my IUI cycles, which is another reason my RE was so puzzled at my response to the IVF drugs. Have you ever used this technique? Did it work well?
4) Do you feel like I still have a good chance of getting pregnant with our own genetic baby? Failing an IVF is devastating. It's even more difficult not knowing what our next steps are yet. My numbers are in my favor, and I did get pregnant from my second IUI (chemical), so it seems hopeful. I just don't understand my late response to the injectable IVF medications... Which is obviously key to having a successful cycle.
Thank you so much for reading my story and for your consideration of giving me your thoughts on our unique situation.
Hello Krista from the U.S. (Tennessee),
1. No. You started on a low stimulation protocol. With an FSH of 7.9, I would have started you on a mixed (Follistim/Menopur) protocol of 450IU/150IU to start and then down to 375IU/75IU after three days. However, keep in mind that every doctor in the U.S. and the world are trained differently and therefore use different protocols. Mine is certainly NOT the gold standard. Based on how you responded, you did pretty well!
2. It is my goal to have 15-20 follicles and retrieve at least 50% of mature eggs. So based on that criteria, I probably would increase your medication protocol in the next cycle. Given adequate stimulation, your ovaries will respond better. Also keep in mind, that MOST people are not mature until CD#12-14, NOT CD#8 or 9. So, in fact, your stimulation went just fine and I can't explain why your doctor was so worried. Is he new to the field? How long has he been doing this? (maybe you should ask since it affects your chances: less experience = lower pregnancy rates).
3. I disagree with that recommendation but that is only my opinion. Again, I think you did just fine with some minor changes: (1) increase the beginning ,(2) I don't know when the antagonist was started but it may have been started too early. I wait on starting the antagonist to the very last moment possible (because it suppresses the ovaries and will stop the smaller follicles and eggs from growing/maturing, (3) hold off on the HCG trigger until the majority of follicles have reached at least 15 mms. The "ART" of IVF is exactly this: deciding when to trigger because once you trigger, the smaller eggs will not be mature. The goal is to try to get the most number of follicles to reach maturity size.
4. I ABSOLUTELY have confidence that you will achieve a successful pregnancy in time. This cycle does not mean anything. It was only the 1st try. Many things, some of which have been mentioned, can be improved upon. Remember, in reality it only takes ONE GOOD EGG to get you pregnant, just as you did in the IUI cycle. You don't need to worry. Getting the right person to help you is the key!
Dr. 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 out my blog at http://womenshealthandfertility.blogspot.com
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