QuestionI am 41 years old and already have two children aged 14 and 12. Both children were conceived within the first month of trying and I had no complications during either pregnancy. After 5 years of trying to conceive with my second husband we had tests and it was discovered my husband has a very low sperm count. We visited a clinic here in Spain where we live and were told that Artificial Insemination was our option. We had three failed attempts at this so decided to try IVF. During the first two attempts of AI I responded very quickly to Puregon and only had to take it for 4 days. The third attempt I responded slower. I took Puregon again for the IVF for a period of 11 days and had 6 follicles all over 17mm, the largest was 24mm. Today I had the egg retrieval and discovered that all the follicles were empty. The doctor informed me I was most probably going through the menopause but this has left me slightly confused as I have regular periods and have no symptoms connected with this. I now don't know what to think. I presumed that there would be eggs in the follicles but considered that there would perhaps be a problem with the eggs due to my age? One year ago I had hormone tests on day 3 of my period which showed and FSH H level of 6.6, LH of 7.5. No test was done prior to this IVF.
AnswerDear Helen,
Thank you for your question and your history. IVF is certainly the best option for you at your age, notwithstading the sperm problem. I recommend that you continue.
What happened in this first cycle is called "Empty follicle syndrome." It is not very common but common enough. I have had three cases in my 15 years of doing IVF. Most often, it is due to inadquate HCG stimulation. Either an inadequate dose was given, the injection was not given properly or it was a bad batch of HCG. I used to use a generic HCG but since those three cases, I have switched to a recombitant HCG calle Ovidrel. It is made by Serono. I would recommend this medication in your next cycle.
We also see an increased number of empty follicles with increasing age. However, with the number of follicles that you had, I would have expected to retrieve at least 1 egg. That is why I suspect the EFS.
I do not think that you are menopausal or pre-menopausal, although this is mainly a clinical diagnosis and not a laboratory diagnosis. Definitely, your FSH and LH levels look good. You had a good stimulationn for your age, as well. I use a high dose of medication in your age group (600 IU, mixed protocol with Repronex (FSH) and Menopur (FSH/LH). These are the American brand names but there are equivalent medication in Europe. Basically you would take 450 IU of the Repronex and 150IU of the Menopur. In Europe they use significantly lower doses because they have restrictions on the number of eggs that they can implant. For this reason, they do not want to stimulate too strongly. My goal is always to get 15-20 follicles with a 60% yield on the retrieval. Because the numbers go down at each stage i.e. 15 at retrieval leads to 9 fertilized which will lead to 3-5 good embryos to transfer. That is why we want to start with so many follicles.
You need to keep in mind that your age is a significant factor and commensurate with this, is a significantly decreased chance of pregnancy from before. You're in a completely different situation now. In the U.S., your chances of pregnancy are 27% per IVF cycle, where as less than 35 the pregnancy rate with IVF is 63%. What this means is that it will just be harder for you to be successful and you may have to try many more times. Good luck. Don't give up. If you don't try you don't have a chance to get pregnant.
I hope this helps.
Sincerely,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
