QuestionQUESTION: Hello Dr. Ramirez,
I am 49 and have been TTC unsuccessfully with donor eggs since 2007. In 2006 I had several fibroids removed that were distorting my uterine wall. In 2007 we began the search for our first donor. We've had two different egg donors and have had excellent embryos both times. Our first donor, 24 and child of her own, yielded 6 eggs (shared cycle) and 4 embryos. We transferred 2 8-9 cell grade A embryos on day 3 but got a BFN. For the FET both thawed and were transferred also resulting in a BFN. Our second donor was a proven donor and also had 3 kids of her own and was 24. We got 9 embryos from this cycle. We transferred 3 10-cell, grade A embryos on day 3 and got our only BFP but it was 21. For the FET, we thawed and transferred 3 and this time used embryo glue but it resulted in a BFN.
We are looking to do our final FET in June. I have had a sonohysterogram and everything is clear. I've had reams of blood work done again and what showed up was that I was heterozygous for MTHFR. I had this work all done by the OB who had done my fibroid surgery, so when I went to my RE last month to get bloodwork updated and say I was going to be doing the FET, he dismissed the MTHFR finding saying 40% of women have this. In past cycles I have been put on estrace, prednisone and baby aspirin leading up to transfer and beginning the day of transfer I started PIO and fragmin (lovenox) injections. As the number of cycles increased so did the dosages of prednisone, PIO and fragmin. During this time I was probably not taking enough folic acid (1mg). I still have regular periods every 28-29 days although they only last about 2-3 days and when on the estrace, I have no problem building a nice cushy lining.
With the MTHFR finding, I have been taking 5mg of folic acid and baby aspiring daily since January. I recently added in 50mg of B6 and 1000mcg of B12. Another blogger who was also heterozygous recommended the B vitamins and also said that for her successful FET she had started lovenox earlier in the cycle, rather than waiting for transfer (which is what I'm considering).
I realize it's a bit long winded, but if you had a patient with a similar history, would you recommend anything different?
Pam
Ontario,Canada
ANSWER: Hello Pam from Canada,
Wow, you have done lots. First, I would probably forget the embryo glue. It does nothing to help with implantation because implantation is a process whereby the endometrial lining has to grow around the embryo, NOT the embryo attaching to the lining.
I use heparin instead of lovenox but lovenox works fine too. I start the aspirin, heparin/lovenox and prednisone at the start of the cycle. I also do give estrogen supplementation as well. There is no harm to the folic acid and B vitamins. You also might want to consider acupuncture, since some studies have show an increase in pregnancy rates with this, and I do recommend it to my patients that fail. Keep in mind that frozen embryo transfer cycles inherently have a lower pregnancy rate.
The only other thing to consider is that IVF success rates do vary by the Physician. This is mainly attributed to transfer technique, and laboratory quality. That may be the other option to consider.
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, and follow me on Facebook at http://bit.ly/9Iw9oV
---------- FOLLOW-UP ----------
QUESTION: Thank you, Dr. Ramirez. Just as a follow up, regarding the heparin, if you start it at the beginning of the cycle, do you stop it at all during transfer or is it okay to take it continuously? And, do you think my age has anything to do with the failures even though I have regular (albeit short) periods? My RE has never indicated my age to be a problem.
AnswerHello Again,
If you use heparin or lovenox, I would stop on the trigger day (HCG) until the day after the retrieval. Then I resume it from that point on until the pregnancy test, if negative, or 10 weeks gestational age if positive. I stop it before the retrieval to reduce the chances of bleeding from this procedure.
Your age has no bearing if you are using donor eggs and have a normal uterus.
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, and follow me on Facebook at http://bit.ly/9Iw9oV
