QuestionI'm 40. One child conceived age 32 naturally. I'm almost 41 and was terrified
Of genetic probs. decided to do ivf with PGd. Not high stimulation
My follicles grew nicely they said. I had 14. Fsh 7 and they said amh was very good
My e2 worries me from reading. It's been steadily rising and doubling every
2 days but on trigger day was only 450 ish. I asked they said that my dominant
Follicles were large 19 and 21 and they go by follicle size more than e2. On boards some
Women seem to have decent egg retrieval with low e2 that defies the need for 150-200
Units of e2 per mature egg. Someone claimed 16 eggs retrieved 14 mature
With an e2 of 900. Is this biologically possible. The dr said rising e2 makes it ok
And that I've no knowN Reproductive issues so not to worry but I am very panicked
Ill fail this cycle Any thoughts on e2 and follicle size Have you had women with lower e2 get decent number
Of eggs?
AnswerHello Sharon from the U.S. (New York),
Most mature follicles produce approximately 200 ng/ml of estradiol. So if the E2 is only 450, that means you probably have two mature follicles and the rest of the 14 are smaller. Although we choose to trigger based on the biggest follicles, the experienced IVF specialist actually takes everything into consideration when choosing when to trigger. This is the part that is the "art of medicine" in this specialty. The problem with going solely with the largest two or three follicles is that you may get a lot of immature (unusable) eggs. So, we look at follicle sizes and estradiol levels. For me, the ideal estradiol level is going to be 2000-4000, and even if I have some large follicles, I will push them to try to allow the smaller ones to grow so that I can get the maximum number of mature eggs as possible. The ideal maturity size of a follicle is >15 mms and the maximum size is about 24 mms. After this point the egg will be immature and unusable. If there is a big discrepancy between sizes, let's say there are two large embryos like you describe but the rest are 12-13 mms, then I will prefer to lose the two large ones to get more from the smaller ones i.e. allow the follicles to grow another 2 or 3 days.
Keep in mind that although we try to get a large number of eggs with IVF, that is because there is an attrition rate in each step. For example if you start with 20 follicles, you may only retrieve 16 and of these 16 there may only be 10 mature eggs. Then the eggs are placed with the sperm and only 6 fertilize normally. These are then allowed to grow which may only result in 3 or 4 good embryos. But in reality, as I remind my patients, it only takes ONE good embryos to get a pregnancy. Certainly based on your age you want a lot of eggs, because the majority of your eggs will be bad, but I've had older patients with only one follicle, retrieve one egg, fertilize that one and form one good embryo, and they end up pregnancy with a successful pregnancy. It only takes ONE.
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.
