QuestionQUESTION: Hi Dr. Ramirez,
We have a question in regards to our 3rd IVF cycle here at the RSC of Bay Area. Here is a brief summary of our 3 cycles:
Me - 32(severe male factor - low sperm count below 1m/mil)
My wife - completely healthy
1. IVF#1 - Lupron long protocol(Lupron,Menopur 75, Folistim 75) - around 20 follicles seen on US/1, 13 retreived/11 matured and injected with ICSI(using PICSI), 4 fertiled, 3 transfered on day 3, my wife got pregnant but fetus stopped growing at week 8 due to chromosomal abnormality(monosomy 13).
2. IVF#2 - Antagon Protocol(Folistim 200, Garinelix 150) - around 17 follicles seen on US/1, 15 retreived,9 matured and injected with ICSI(using PICSI), 3 fertilized, 3 transfered on day 3, my wife got pregnant but fetus stopped developng at 6 weeks(hb heard at 97bpm) due to chromosomal abnormality(Turner Syndrome).
3. IVF#3 - Lupron long protocol(Lupron,Menopur 75,Folistim 225) - around 9 follicles seen on US/1 from 9-12mm.
Our question is why this third cycle so far we only see 9 follicles even though we are using Filistim 225 compared to last 2 times when it was significantly lower dose?
Also in this 3rd cycle on day 5 of the stims our doctor recommended increasing the Folistim to 300 and Menopur to 150 trying to push the body for more eggs. Is that the right approach and is this the right protocol for us considering the fact that on IVF#1 we used the same protocol and got much more eggs at the ER date? Could it be possible by increasing the meds to see more folicules at tomorrow's US/2?
Any advice will be highly appreciated!
Regards,
Plamen&Cvetelina.
ANSWER: Hello Plamen from the U.S. (California),
I'm afraid that I cannot address specific protocols because each clinic and physician use many different variants, of which all may work. Obviously, your first two cycles were successful considering that IVF can only give you the opportunity to become pregnancy and not make you pregnant. There are two steps that have to occur naturally after the embryos are transferred. Your wife has shown that she can get pregnant. The fact that both were genetically abnormal is a little worrisome. How are you addressing that problem? Have they given you an explanation of why that might have occurred? Are you considering PGS in your next cycle?
It is clear than your wife is not responding as strongly in the 3rd cycle as the first two, but that is not necessarily unusual. Studies have shown that every cycle is different and responses can vary. If I see a low response at day #5 (based on estradiol levels#, I will increase the medication to try to increase the response.
Just as food for thought, your fertilization rates have been low #less than 50%). Have they addressed that issue with you?
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
---------- FOLLOW-UP ----------
QUESTION: Dear Dr. Ramirez,
Regarding the 2 previous cycles the cromosomal abnormality was a random error accoring to the Kaiser Genetic department - we did chromosomal analysis on the tissue that revealed a random error that should not occur again. From this point of view there is nothing else that we can do but keep trying.
We also did karyotype for me and my wife as well as microdeletion of the y chromosome which all came back negative. So from genetic point of view that's about all we can do as of right now.
In regards to the low fertilization rate we don't know how to address that issue - we are going to skip the PICSI procedure this cycle and do a straight ICSI. Hoping that this will give us a chance by manually selecting a single sperm to give us the chance to select the best possible most healthy one.
Please let us know your thoughts.
Regards,
- Plamen.
AnswerHello Plamen,
It looks like you have thought about this carefully and well. You have a plan. Since you have undergone genetic testing that the abnormalities are called "spontaneous" genetic abnormalities, meaning that the chromosomal abnormality occurred from the division that the egg has to go through to create an embryo. One method or option that you have to check this is to consider preimplantation genetic screening prior to transfer. In this procedure, the embryos undergo biopsy of one of the cells to see what their genetics are. In this way, hopefully a normal embryo will be found and transferred, thereby reducing the chances of another miscarriage. You should discuss that with your doctor.
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
