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Hello Dr. Ramirez,

Recently stumbled upon your blog and happy to be able to ask you a question. From the USA.
My case, I am 38 years old who had polypectomy due to uterine polyps, dx on HSG, no dye to Fallopian tubes. TSH was elevated 2.66 started on 50mcg of Synthroid which decreased TSH to 0.97 with a FT4 of 1.1
FSH 17, AMH 1.1. Despite numbers 8 months prior were TSH:1.46, FT4 0.83, FSH 9.7. Is there anything that can explain this drastic shift upwards? Should I be concerned about a pituitary problem? I did have an IVF cycle with follistim & menopur, started ganirelix on day 6-8 trigger shot on day 9. 5 eggs retrieved, all mature, ICSI( partner sperm- suboptimal), 4 fertilized, 9 cell no frag, 6 cell no frag, 6 cell with frag, 4 cell with frag. All 4 transferred on day 3. Beta negative. Heart break.
On follow-up visit, told number of eggs expected due to DOR (high FSH and age), upon insisting RE agreed to change up protocol, next will use Lupron instead of ganirelix, stims meds same. And she thinks in I should consider donor egg. Do you think I still have a possibility, like you mention I only need one good egg. Do you think this was a horrible cycle? Do you recommend a 5 day transfer vs a 3 day transfer? Would assisted hatching help? Would you recommend PGS due to my age?
Do you ever recommend supplements like CoQ10, DHEA, Vitex. Why and or why not?
No prior pregnancies or miscarriages. No IUI. Do I need any other workup?

Any suggestions are greatly appreciated.

Caroline

Answer
Hello Carolina from the U.S. (North Carolina)

In general I don't discuss protocols or comment on those specifics because there are so many variations and none that are universally established.  Basically, Physicians vary because they can modify stim protocols according to their training and experience.  However, considering that you have an elevated FSH (you have a good AMH), that would indicate some ovarian resistance and so you would need a high stim protocol.  Therefore, results can vary.  If you are not stimulated enough, you may not get many eggs and therefore not find a good egg in that batch.  That is the problem you are trying to overcome; the age factor.  Because of your age, you have less good eggs left in your ovaries.  If you want to use your own eggs, the key is to try to find a good egg.  Since there is a limit on how many eggs you will get with each cycle, you either have to get lots of eggs per cycle or do many cycles, hoping to eventually find a good egg.

In terms of fluctuations of your hormone tests, that is very natural as the body is dynamic and constantly changing.  One month can be good and one month bad, or it can get worst with time.  I don't think you have a pituitary problem.  

This was not a horrible cycle and, actually, better than would have been expected with an FSH of 17.  I think I would have only expected 1 or 2 eggs retrieved and, maybe, one fertilized.  So you did much better.  The quality of eggs is dependent on their inherent quality and the quality of the lab.  If you can get to a day#5 embryo, that is better than a D#3 embryo because it gets the embryo that much closer to the implantation stage.  I definitely would recommend assisted hatching.  PGS is recommended in any one over 37 years old because studies have shown that checking for genetic normality increases the chances of pregnancy in older paitients.  However, if you are going to transfer all the embryos, that probably wouldn't make any difference.  It only helps to let you know if you have any genetically normal embryos to transfer, so you don't have to suffer the let down if it fails if all the embryos were abnormal.

I recommend CoQ10 in all my patients but do not use DHEA or Vitex.  I don't think you need any further testing.  You are doing all you can do.

I can be available to your as you journey through all this, on a more regular basis by subscription to my email consultation service.  You will have unlimited access to me by email and can ask lots of questions as you go through.  I charge $100 per month for this service for a 12 month subscription.  If you are interested, please contact me by email.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

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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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