QuestionDear doc,
I am 36 yo, and have PCOS. I suspect that I am a difficult case of PCOS, since I have only got a period spontaneously once in my life, at age 15. I am athletic body type, 5.6in/140 pounds.
I have gone through 3 IUIs and 1 failed IVF at this point (and no response to Clomid). In the IVF they used a down regulating protocol (30 days of pills, overlap with Lupron, etc). I had 19 eggs retrieved, 16 mature, 13 fertilized (no issues with husband), out of which 8 'normally' fertilized. My E2 reached 3750 at trigger. I had ET of 2 blasts. The IVF has failed, and no embryos to freeze (I think that the lab may only freeze them on day 5-6).
I am concerned because two days after ET I had some cramps, followed by some blood; and, four days after ET I had more cramps, that were followed by more substantial amount of fresh blood (like first day of period). After that I had milder spotting of fresh and old blood. I was taking 1cc of IM Progesterone, starting from ER. Before that, in the IUIs, I always got the period early, after 11-12 days. The nurse didn't seem to care much about me bleeding, since it was not extra heavy. However, I am very disappointed that even with IM Progesterone, my lining seemed to break apart after some cramping. BTW, the lining was 6.5-7mm at ET.
Is it possible that my problem is in the lining receptivity? after all, I had good response and a decent number of eggs. What else can be done in this respect? what can be the reason to bleeding like that? if it's substantial (fresh blood, and more than just spotting) and so early, then it must interfere with possible implantation, no? any advice about this will be highly appreciated. Perhaps I should ask for PGD, to make sure that the embryo quality is ok?
Finally, since I currently have low hope that repeating IVF will lead to a different result (although I intend to keep trying), do you think that I have a reasonable chance to have a baby through a carrier?
Thank you very much.
AnswerHello Anna from the U.S.,
It is difficult for me to analyze IVF cycles without having your medical records. There are many variables. That being said, I can offer the following observations:
Your cycle went well and your doc did a good job at your stimulation. Considering that you are a PCOS patient, the risk you run is to develop hyperstimulation syndrome. You were managed well and had a good peak E2 level, good number of follicles, good retrieval rate, good fertilization rate and okay embryo quality rate. I am surprised, however, that you had nothing to freeze, but that is more common than not.
The only part I was not satisfied with is your endometrial thickness at the time of transfer. It is preferred that the lining is 9.0 mm or greater. Yours was inadequate. That means that despite the high estradiol level, the lining did not develop appropriately and could be the reason that implantation failed. Endometrial lining is very much cycle dependent so that is not necessarily something that you need to worry about in a subsequent cycle. However, your doc might want to add a vaginal estrogen supplement to the progesterone supplement.
In terms of the bleeding and cramping after transfer, that is not normal and is unusual as well. It is also inappropriate. That in itself could inhibit implantation. However, without further information, I cannot tell you what may have caused that, and therefore cannot offer any advice. I DO NOT recommend PGD. Except in patients that have a known genetic abnormality that they are screening for, I do not think that PGD offers any benefit in terms of pregnancy rates. That is the position of the American Society for Reproductive Medicine as well.
I also don't think that you need to consider a surrogate either (carrier). IVF is not a perfect technology. The last two steps, embryo hatching and implantation, are still natural steps that we cannot make happen. That is, we do not have the technology to make sure that it works. For that reason, we do not have 100% pregnancy rates. In most cases, patients need to try 2-3 times, just as a normal 22 year old has to try 8-12 months to get pregnant. Your chances of pregnancy are very high and you should definitely keep trying. Don't get discouraged just from one failed cycle.
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 facebook and twitter with me at @montereybayivf
