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Infertility/Fertility/Seeking your advice on our last try


Hello Dr. Ramirez,

I sought your advice back in 2011 prior to our first IVF. Then I was 35 (husband 30) with one left ovary (lost right to a dermoid cyst in 2007). Husband had a morphology at 5%. Everything else is normal.

FSH normal and AMH in low normal range.

Your advice for a protocol was 350-400 unit of puregon and some LH as well.

At our first clinic (Ottawa fertility), my RE did not believe in giving me LH as my LH level was normal. I was on 9 day stimulation and did 3 day double transfer and ended up in negative results.
Because I was so determined to combat IF, I switched to a clinic in Montreal (Montreal Fertility Clinic under the care of Dr. Mahutte and his wife Dr. Ohuillal). They put me on a short protocol of 10 day stimulation with 300 units of Puregon and 75 unit of Menopur. We got pregnant at the first try. Now my daughter is almost 22 months.
We attempted another IVF in October 2013 (I was 37 & husband 31). I believe my FSH and everything else is somewhat the same (all normal except AMH lower range of normal). We were put on the exact same short protocol for 10 days and again got pregnant but ended up with a missed miscarriage around 8 weeks.
In April 2014, we tried again but this time, I was put on 8 day stimulation because the leading follicle was much bigger. Egg count and fertilization was awful but one of them surprisingly made it to Day 5; however, it ended up in negative outcome.

Here is the summary:

# of leading follicles    # of eggs collected    # of mature eggs    # of fertilization

Oct 2011 (9 day stimulation no menopur)
9     5    4    2     :2 Day 3 transfer (BFN)  

Nov 2011 (10 day stimulation)          
8     7    6    6     :1 Day 5 transfer(BFP)

Oct  2013 (10 day stimulation)          
7     6     4    2    :1 Day 5 young blastocyst (miscarry)

April 2014*  (8 day stimulation)          
8     6     1    1    :1 day 5 transfer of excellent blastocyst  (BFN)

We are going to try for the last time in August and that will be our last try (QC government offers up to three free cycles per child).
To me, it seems I need 10 day stimulation to produce good stats. So I am going to insist on 10 day stimulation. We also only do 5 day transfer to increase our odds. I think the clinic will put me on the same protocol (300 unit of puregon & 75 unit of menopur) for 10 days. I just need your feedback on the protocol. This will be our last try.
I am terrified that my fertility level has decreased even further although AFC stayed somewhat stable. I would much appreciate if you can assure me. Thank you so much in advance.
Best regards,


Hello Sook from Canada,

In general, I don't comment regarding protocols that are used by other clinics because there are way too many variations and no absolute gold standards.

You are now facing an added problem and that is the "age factor".  That is, as a woman ages, more and more of the eggs deteriorate and the quality of the embryos decline.  Also, the risk of miscarriages increase and can be 40-50%.  That is probably what happened in your miscarriage cycle.  In older patients, my strategy is to get as many eggs as possible.  The thinking is that there are still some good eggs left in the ovary and the only treatment option we have is to try to find a good egg.  This can be done by getting a lot of eggs out at one time or doing multiple cycles.  I strive to get as many good eggs as I can and so I stimulate the ovaries much harder.  In your cycles, the number of follicles you had was low and the stimulation protocol that you used was a low protocol.  I think there might be room to stimulate harder, but that is just my opinion.

In the end, the goal is to get one good egg.  That is all it takes to have a successful pregnancy.  Hopefully, that egg will be in the next group.

Good Luck,

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 check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  I now provide personalized fee for service consultations/advice/direction via email and payable via Pay Pal.  If interested, contact me via my email at  This service will allow you to have your own personal on-demand infertility expert  


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Edward Joseph Ramirez, MD, FACOG


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.


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.

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

American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

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

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