QuestionDear Dr. Ramirez,
My husband and I have just finished our 1st IVF/ICSI cycle. We are both 29 and have secondary male factor infertility (0% morphology). Our first child (3 yo) was conceived naturally.
My IVF protocol included BCP, Synarel, Puregon, Repronex. During the stimulation phase, my E2 level increased quickly (E2 of 1200 and 39 follicles on d6 u/s). My RE responded by gradually reducing my medication to where I was only taking 75 IU of Repronex. On d8, following my first day of only Repronex, my E2 was 1642. The next day, my E2 fell to 1217. My medication was increased again and my last E2 before ER was 1585. I was triggered with 7500 IU of HCG.
I had 8 eggs retrieved (7 from one side), 7 eggs were mature, 4 fertilized, and 2 divided. My clinic took those 2 embryos to the blastocyst stage and I had a 5dt of one blastocyst (rated "good"). The other embryo was cultured until day 6 and then discarded.
I am currently in my luteal phase and taking Endometrin TID until beta. My clinic has a success rate of 66% with women under 35 (avg 1.6 embryos transfered).
I expected more mature eggs, a higher fertilization rate, and more embryos with some left over to freeze. Could my fluctuating E2 level have decreased my egg quality and be the reason we only got 2 embryos? Or, is this a result of my husband's poor sperm morphology? Should we expect similar results with a subsequent IVF/ICSI cycle? Should we give this clinic another chance?
I really appreciated the time and energy you put into answering these questions. Thank-you!
Laura from BC, Canada
AnswerHello Laura from Canada
It looks like your doctor was surprised by your hyperstimulation and it was lucky that you didn't develop hyperstimulation syndrome. Basically a decreasing estradiol means that some of the follicles "died off" i.e. stopped developing. Each developing follicle produces estradiol in increasing amounts as the follicles grow. The drop in estradiol pretty much is an indication of how many eggs would be retrieved, so your numbers are consistent with the low number of eggs retrieved. Also, it can definitely indicate a reduction in egg quality. In the next IVF cycle I am sure that your doc will adjust your protocol so that you don't create as many follicles, which should lead to better quality eggs.
However, the other aspect that affects embryo quality is certainly the contribution made by the sperm so I can't definitely pin the poor embryo outcome to just the stimulation. The sperm could have contributed as well.
I think that before you "give up" on this clinic, you might want to sit down with the doctor and review this cycle and see what he/she has to say about it. I usually will have a post-IVF cycle meeting with all my patients to do exactly that. In that meeting, I outline where and why I think the cycle might have failed and what I will do differently (if anything) in the next cycle.
For you, number one change would be a total change in protocol. You have a PCO-type of stimulation pattern so your doctor will need to be very careful with the stimulation protocol. I would probably go with a low slow protocol where I start with a low amount of follistim/menopur and slowly increase it over time to try to reduce the number of follicles recruited. Secondly, I don't think I would necessarily go to blastocyst stage if there are so few numbers of embryos. You were lucky in that you had an embryo to transfer at that stage, but in most cases, the embryos are lost in the culturing for the extra two days. I would prefer to transfer at the D#3 stage (I think the uterus is a better incubator and culture media than the lab). Thirdly, I would not trigger with HCG if there area a high number of follicles and an estradiol over 4000. My preference is to use an antagonist protocol and trigger with Lupron 0.5 mg.
I hope this helps,
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
