QuestionQUESTION: Hi Dr. Ramirez,
I am writing from NYC.
My boyfriend is 41 and I am 36. We just finished an unsuccessful IVF process. We knew beforehand that he had a male factor issue, low count and low motility, so we went straight to IVF ICSI as the count was too below to even attempt IUI.
I have had almost all of the bloodwork and tests you recommend and all of the results were encouraging, and better than expected for my age.
We started the protocal with 14 days of lupron, then started 3x75 of gonal-f and 1x75 of menopur. After ten days on the stimulants my estrogen level was over 4,000 so my dr cut me back to 1 gonal-f and no menopur.
On retrieval day we had 15 eggs, many of which were deemed abnormal by the embryologist. Seven fertilized and we had four embryos. By day 3, only one embryo had 5 cells, two had 4 cells, and one had 2 cells. The doctor decided not to transfer any but to wait until day 5/6.
We have so many questions:
was this a male or female issue, is there any way to know for sure?
if male, is there any test we can do beyond the SA we've done several times already?
if female, are there any tests we can do?
is it possible that the protocol and overstimulation led to the abnormal eggs?
I understand from reading all of your answers to prior posts that 15 is a decent number of eggs and that 4/7 fertilizing is close to your 60% target.
What would you suggest we do next?
Thanks so much for this wonderful service you provide.
ANSWER: Hello Margaret,
Yes, this cycle did not go well in my estimation. First, you over-stimulated (did you develop hyperstimulation syndrome?). It has been shown that in patients who are sensitive to stimulation, such as PCOD patients, overstimulation leads to a preponderance of poor quality eggs. That sounds like you. So the first problem you encountered was that the majority of eggs were of poor quality and probably not very mature. (how many follicles did you have?) The protocol you were on was a fairly low protocol and needs to be amended to be lower the next time around. Secondly, out of the seven that fertilized, how many were actually ICSI'd. In order to be ICSI'd, the egg has to be Meiosis II. That is how you figure the fertilization rate (number ICSI'd divided by number fertilized). Our threshhold is 60%. Thirdly, the embryo development was poor. By day # 3 we usual prefer the embryos to be 6-8 cells. This could be due to the egg factor (due to age) or the sperm factor. There is no way to know which it is. I would not have waited to transfer. That is just dooming the embryos because they would probably not survive. No matter what anyone says, the uterus is a better culture media and incubator than the lab. So, overall you failed because you did not have any quality embryos to transfer. Fortunately, that is not a prediction of things to come. It is unique to this particular cycle. Hopefully, if you continue to try, your results will be better the next time. I strongly urge you to keep trying. You will ultimately be successful.
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.
---------- FOLLOW-UP ----------
QUESTION: Thanks so much for your response and for being so encouraging, I appreciate it very much.
Yes, I developed hyperstimulation syndrome: my lower abdomen was visibly swollen, I was very uncomfortable and felt like I could feel the ovaries (or something) moving inside me, and I was light headed.
I had 15 eggs, but I'm not sure how many follicles.
Four of the 7 mature eggs fertilized, though I don't know how many used icsi vs not. My understanding is all of them were icsi'd as the sperm count and motility are so low.
I would like to have transfered on Day 3 just to give the embryos a better shot but the clinic refused to do this.
Do you see any downside to switching to another clinic? The success rates are above average but the communication is weak. I'd prefer to go somewhere else but I don't want to make any decision that will set back our chances of success.
If we do switch, how should we compare success rates on SART versus those on private websites hosted by a clinic? There seems to be a vast difference.
Thanks again
AnswerHello Margaret,
I am sorry to hear that you developed hyperstimulation syndrome. That is not good.
I think your idea of switching centers is a good idea. Every center is different and has different strengths and weaknesses. You need a center that will watch you very closely so that you don't develop hyperstimulation syndrome. I, for instance, have not had one in at least 5 years. It is difficult to compare pregnancy rates between clinics. The SART/CDC data does not show the whole picture because of their method of collecting the data, but that is a good place to start. The best way to compare is to look at the 35 and younger pregnancy and delivery rates. That is where most clinics should be high. At least 50% pregnancy rates and 35% delivery rates. Don't look at my 2007 data because it was terrible! My building was undergoing remodeling that year which decimated my pregnancy rates. I am now in a brand new facility with a closed air flow and filtered air system for the embryology lab and procedure areas. Our pregnancy rates have been much better since then, exceeding 60%. Even a small program can be a good program. Sometimes they are better because they know you personally and individually, whereas the larger programs are more like factories and impersonal.
So bottom line, use SART/CDC data as a guideline, and look at their published rates and compare. They should be close to the same. If the SART rates are real low but the published rates are real high, then you have to question their data. I would look back at least 3 years worth of data and rates to make sure they're not going through a drastic change like I did. Then I would interview the clinic and find out how they manage hyperstimulation, what kind of protocol do they use for PCO patients, how many embryos do they transfer and which day. Review your story with them and see if they would do anything different. And, if you can't find anyone you like, come see me in California.
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.
