QuestionDear Dr Ramirez,
We've communicated before (I'm Australian but working in Singapore) about
IVF questions and I have another. As you know, I'm very old for still TTC with
my own eggs but still have good AMH and low FSH (6.4 last month - which is
about usual. The highest I've ever had is 7.4).
My question this time relates to LH in a protocol. I usually have an LH level
that's about half my FSH on D2 (so last month, FSH was 6.4 U/L, LH was 3.1
U/L and E2 was 248.6 pmol/L with prolactin of 7.2 ug/L and P4 of 1.73
nmol/L). I had 2 IVF cycles in Jan and March using Luveris (75IU daily +
350IU daily of Puregon). That gave me 1 egg from 10 follicles the first time
and zero eggs from 10 follicles the second. Prior to using LH I usually had
around 10 follicles and around the same number of eggs.
This time we switched back to plain Puregon (100% FSH) and there were 5
eggs from 10 follicles (10 seems to be about my average). I'm planning to do
one more IVf before quitting, and use a low dose (around 150IU).
My question is whether I should re-introduce LH. I have several friends
who've done really well with Follistim which I understand is 10% LH and 90%
FSH. I'm worried that the LH was causing premature luteinization of the
follicles before (I've had many IVFs and had never had empty follicles before
starting with LH) so was pleased to see my numbers bounce back up to 50%
of follicles with eggs in.
I do know all the caveats about women my age trying IVF (I'm 44 - which is
why this will be my last) but wondered what the indicators were for whether
LH should be included in a cycle. Any advice or experience would be
gratefully received (as always !)
Many thanks from the equator :)
Alison
AnswerHello Alison,
I'm probably not going to be able to give you a great answer for your question because whether or not to use LH is currently still being debated. There have been some studies showing decreased egg/embryo quality or poorer response when LH was not present in the protocol. In a natural cycle, your body produces both FSH and LH as the follicle develops. The advantage of Luveris is that you can now give pure LH in addition to the pure FSH, but it really is only indicated in patients that have elevated LH levels in the condition called PCO, rather than normal patients. I am a firm beliver in, and exclusively us, a "mixed protocol" which is one medication with FSH only (Follistim) + Menopur (FSH+LH) in a 2:1 or 3:1 protocol.
The incidence of "empty follicles" that you have had in your cycles seems alarmingly high to me. My standard is to get at least a 50% retrieval rate i.e. at least 50% of the number of eggs as the number of follicles. In most cases it is 80%. Again a lower egg retrieval rate may be due to lack of LH, which assists with the final maturation and release of the egg.
What you are battling, is the quality of the egg, NOT the ovarian response. The hormonal testing shows that your ovaries are still functioning pretty well, but that does not herald good quality eggs. Quality is what suffers with age, and your at the edge of where IVF successes have been. That is not to say you can't be the exeption to the rule, but it is less likely to happen. You might want to try something that one of my recent patients (44 years old), did. She also did not want to have a "purely" donor egg, and her ovaries still stimulate well, but she also wanted to increase her chances. So, she used a new technology called egg freezing. She purchased frozen eggs from a frozen egg bank, and these were fertilized with her husband's sperm and developed into embryos at the exact same time that she went through her cycle. With frozen eggs we can easily synchronize the cycle for this to be done (you can't do this with a live donor because we can't predict when she will retrieve). So, we mixed two donor eggs with 5 of her eggs and formed embryos. All were then transferred and voila, she became pregnant. We don't know, and cant' know, which embryo implanted. Of course if she does genetic testing on the child in the future she can know, but why would she. She is statisfied that she is pregnant and, as far as she is concerned, it was with one of her eggs. This is just some food for thought.
Good Luck,
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
