A Marathon of Infertility Questions
As this Sunday was the New York City Marathon, I figured I would have my own little marathon and answer all of the outstanding questions. Here it is.
It took me a few days to cross the finish line, but I was able to eat and sleep along the way, possibly experience some weight loss, and I seem to be injury free.
From October 4th
Niki has had a very tough time trying to have a child. She has had a number of bio-chemicals and worse (see her post). Her basic questions are 1) is a thinish lining the reason, or is it an immune problem, or some other problem we just don’t know about?
I also do not buy into the immune issues. These have been studied now for many many years and never has anyone produced a quality study showing they mean anything. However, you have few choices, so it may be reasonable to consider getting tested and treated, if something shows up. I am not recommending one way or the other. You should give equal consideration to a carrier.
Esther had open tubes on hsg and a few weeks later had both tubes blocked at laparoscopy. She is being told she needs IVF.
I am not so sure. When I have open tubes on HSG, I don’t even check at laparoscopy. Why? Because it is common for tubes to be open on hsg and closed at laparoscopy. It’s a mechanical issue. Sometimes the doctor just has trouble getting dye out the tubes at laparoscopy. Now it depends on where the blockage is. If you have proximal occlusion (blocked at the uterus), this may be a false finding. If he says you have bilateral hydrosalpinx (blocked near the ovaries) that’s different and real. If there is any question, the answer is simple, just repeat your hsg. If the tubes are open on your next hsg, there were not blocked at your laparoscopy.
Mosche and his wife need IVF with ICSI due to male factor, however even with ICSI, there was no fertilization.
I have only had one young patient make many eggs and not fertilize with icsi. So it can happen, but it is rare. It’s a little more common when there are also issues with advanced maternal age and low egg number.
Ruby asked about sperm antibodies.
I do not believe in them because no good recent scientific paper written showing me that sperm antibodies are relevant.
Angie did a clomid IUI cycle, and the sperm count was 18 million with 56% motility.
The count sounds reasonable for iui. Although you should still ask for the total motile count, and look for that to at least be over 5 million, preferably over 10.
Tabi did 4 IVF cycles, 3 with lupron, one without. The non-lupron was her worst.
We don’t know if it was the no lupron, or was it just going to be a bad cycle for you that month, independent of your stimulation protocol. It may be that in your case lupron is better. For most women who make few eggs, this is not the case, but not all women are the same. I don’t think you are declining.
Ali did IUI. The sperm count was 143 million with 48% motility. However for the iui, only 3 million were recovered.
This is strange and does not make much sense; unless the initial volume was very low (2cc is normal). I am not worried about his morphology. “Abnormal” sperm are not removed when preparing for iui.
Manny and his wife are trying to conceive. He is asking if the lining could be an issue, especially because she takes anti-migraine medication that theoretically could restrict blood flow to the uterus.
The question is interesting, but unknown. One option is to measure the lining on and off the medications. Or, try to conceive off the medication. Another option is to look elsewhere for a potential problem. Do the basic workup i.e. semen analysis, HSG, day 3, to see if there are not bigger problems with more known quantities.
Anonymous has PCO and 2 weeks of bleeding after clomid.
This is not normal. Actually, the first cycle sometimes the bleeding can be unusual, but once you get into a pattern of periods, they should not be 2 weeks long. You need a good exam and ultrasound and maybe an endometrial biopsy.
Anonymous is 42 yo with 3 failed IVF cycles. Some borderline FSH levels and 1, 1 and 3 embryos available for transfer. Should she stop?
Your odds are what they are, low. It depends on your clinic, but your chances are probably about 5-10% per try. Many women, probably most, would stop here. But some persist, and a few get pregnant. As you know there are emotional, physical and financial issues to wade through. You can’t say you didn’t try. I hope it works out.
Mark is asking if he and his wife should consider natural cycle or minimal stimulation IVF vs. the standard IVF using more drugs.
You will need to decide. My only comment on your post is that it is not true that fertility drugs for regular IVF will ruin the eggs forever. But the opposite is also true. If you do a natural cycle, you can always do a regular cycle later. Regular IVF may not be for everyone, however, for most people, it has a higher pregnancy rate, which means a better chance of having a baby. The cost is less for natural, but with its lower pregnancy rate, it is common (not in every case) to spend at least as much money because the cost of multiple cycles really adds up fast. If you get pregnant early, great, you were the lucky one.
Erika has had 9 pregnancy losses and IVF is now recommended.
I understand the theory; if you put more than one embryo in, maybe if one fails another one will stick and you can have a normal pregnancy. Certainly, your odds of loss will be higher than the average person, even with IVF. I don’t think we can tell you that your odds of loss will be lower than from a natural pregnancy. However, your options are limited, so it may be worth a try.
Dizzy has totally unexplained infertility. All tests are very normal and she is 31. She has done 6 FSH iuis and is considering IVF, but insurance does not cover.
IVF is the next step. No one will be able to tell you why you are not getting pregnant, but IVF has an excellent pregnancy rate, even if you have failed FSH iui. You odds with FSH iui are now going down, because it has not worked. Of course you could do more FSH iui, and it may work, but it may be more of the same.
Purple Mocha has a 3 mm lining on clomid.
Sounds a little too thin. You can try again, or change to FSH. You could also check you lining in a no drug cycle to see what your baseline is. Of if you want to get going, just go to the FSH.
Mtroth has some endo and failed one IVF cycle, which was complicated by hyperstimulation. She has frozens. Did an undiagnosed biochemical pregnancy lead to her hyperstimulation?
You may have had a biochemical, but probably had plain old hyperstimulation. Your estradiol was high and you needed to be coasted. I do not think the endo was an issue. You can’t prepare for the FET. The good news is you seem to have nice embryos and should do well.
Athena has 8 months of infertility, short luteal phases of about 10-11 days, and serious pelvic pain. Her doctor will not see her until she has a year of infertility.
Maybe you have insurance that will not pay your doctor until there is a year of infertility, or maybe he is not a nice person. See which it is. If you think your timing has been good, it would be better if you saw him or another doctor soon. In general I do not believe in luteal phase problems, but you may be an exception because your luteal phase is so short. But do not only get that treated; work on other things at the same time. Get the hsg and ultrasound to look for cysts and endometriosis. Get the sperm checked.
Anonymous is an over-exerciser and because of this does not get her period on her own and does not bleed after provera. Because clomid starts after the period she does not know that do about starting the clomid.
You can start the clomid without a period, providing you get a pregnancy test. I am fine with you trying the clomid, but may women like you do not ovulate on clomid because, due to the exercise, your pituitary does not have much FSH or LH, and clomid works by releasing FSH and LH from the pituitary. Most of time, injected FSH is necessary to get you to ovulate. But you can try, sometimes it works.
Milka is 37 and her doctor told her her IVF failure was age related. He also wants to repeat her sonohyst and cultrures
I do not repeat those tests unless there is a good reason. Failing IVF is not a good reason. Your failure was not age related, you are young compared to many fertility patients.
From October 15th
Niki wrote back and did her IVF cycle, froze all due to lining issues. She is considering a carrier and does not want pgd.
It all sounds reasonable to me. It will have to be your choice.
Anonymous has pco and endometriosis. She did 8 clomid cycles and is in her last FSH iui cycle. Should she do IVF?
If you have done 2-3 FSH iui cycles, IVF is the next step. I like the way your doctor is doing the FSH iui. I am very optimistic. You are 28 and have eggs, that’s all it takes (in most cases). I expect you to do well and get pregnant quickly.
Anonymous is 33 and has had 3 miscarriages.
You odds are still excellent of having a baby in your nest pregnancy. Your doctor needs to do a miscarriage workup.
Anonymous has a normal pap with some cells missing and burning and numbness in her vagina.
As long as your doctor and the report say the pap is normal, it’s normal. I do not think the burning is related to antibodies, and it’s not due to the pap.
Diana was diagnosed with a septum and that was corrected. She then had to delay fertility treatment for treatment of thyroid cancer. New she is trying again without success. She is 35.
Give it the 3th month, but start making plans if things do not work. As far as your next steps, you know the drill. Get the options, get the pregnancy rates, and then decide which treatment sounds best for you. Be sure all of the septum is gone. I see many patients who have had septum surgery, only for me to tell them their doctor left a lot of septum still in place.
Anonymous does not get her period and is starting with a SIS.
I does not matter if you see her or a RE, but you need assistance ovulating ASAP. I don’t get the SIS, unless she sees something suspicious on ultrasound. You need to ovulate and this will probably require medication. Ask the doctor about getting the HSG before you try, or trying a little while (with ovulation) and then getting the HSG.
April did an IVF cycle with some immature eggs and late icsi. The embryos did not look good.
It sounds like there were a few issues with your cycle, but they seem correctable in the next try. It’s hard to tell if there was a problem with your IVF clinic, or things just want bad on their own. If you think you are at a very good place, give them another try. If you have reason to believe there is a better clinic near you, make the switch.
Shari in Chicago has endometriosis. She was treated with lupron and is waiting a long time for her period to return.
It works like this. The lupron is given every month (unless you have the 3 month version), and that lasts about 5-6 weeks in your system. Then you need to start your cycle again, and most women ovulate 2 weeks after that, and get a period 2 weeks later. That means you get your period about 8 to 10 weeks after you last shot.
Christine asked if IVF babies were born earlier and or smaller than non-IVF babies.
The answer is maybe. Some data suggests this is the case. However not all studies break out singletons from multiples, which usually deliver early. If there is an association, it may be due to the fact that some women with infertility may have uterine abnormalities that cause premature delivery. It is also possible that infertile people are more likely to have subtle genetic issues interfering with the length of pregnancy or the size of their babies. Or it may be that there is no difference at all and the right studies have not yet been done. Or maybe the IVF process is flawed and babies are smaller and deliver early. At this point, if there is a difference it does not seem to be great.
Alesha is trying to have her second IVF baby. Her first was at age 32, she will be 35 in January; her FSH is normal. Because she is a teacher, she wants to wait till summer to try. Her doctor says try now; her ovaries may change in the next 7 months.
It will be a little harder then, but if you are very fertile now, you will be very fertile then. Although there is a small chance he is right. Don’t forget you will be 3 years older than you were at your first try. I think it’s up to you, but consider this. Many women become very sad when they get pregnant on their first try, but not on their second, because it seemed so easy the first try. This could happen, and your following cycle will need to be during school, which is what you were trying to avoid. Therefore, why not just do one during school now. The logic is a bit of a stretch but I hope you get the point.
Leila has endometriosis and a fair response to meds. Her first 2 cycles yielded few eggs, and she did much better with a day 2 start than with lupron or microdose. If this fails, should she try again?
This cycle was very encouraging. You are only 36 and make 11 eggs, not bad at all. Question for your doctor: do you really need icsi? It sounds like you are on the right track. Consider the same protocol or estrogen priming.
Anonymous asked why go to FSH iui after 6 failed clomid cycles? Why not go to natural iui?
For younger patients, natural iui has a 5% pregnancy rate and FSH iui has a 20% rate. You can do whatever treatment you are comfortable with, just know the odds.
Anonymous is 42 years of age and has a FSH of 18. She failed a response using 14 days of lupron and 750 units of FSH. Should she stop?
It really does not sound encouraging. If you really wanted another try, ask your doctor about the estrogen priming protocol. Lupron is not the best for poor responders.
Anonymous has irregular cycles and is trying with clomid. She is using cervical mucus to time things.
Use an ovulation predictor kit instead. You can get pregnant with mucus that is thicker, but, if the clomid does not work after 3-6 times, ask your doctor about FSH. You may get pregnant before you get to the FSH.
Anonymous did 2 clomids, 3 FSH iuis and one IVF. She made 9 eggs but had slow embryos.
Get yourself to the best IVF clinic available. It may be where you are, or you may need to switch. Check rates at SART.ORG. Use a different protocol. I hope it works out.
Beth was diagnosed with endometriosis and is not ready to conceive. Should she go on Lupron for 9 months?
9 months sounds like a long time to me. The pill is definitely an alternative to lupron. Ask your doctor or get a second opinion.
Amila had an iui, had intercourse that evening and then had an iui the next day. The second iui had a lower count.
Probably too much. Stick to the iui’s.
Jesse b: Wife 30 he is 34. They just started the workup and were found to have one blocked tube and a low morphology. Their doctor is already talking about IVF.
Wow, they are going fast! First of all, if the tubal blockage is “proximal occlusion” a laparoscopy is aggressive. It is an option, so is repeating the hsg. It may have been spasm. If it shows distal occlusion, maybe surgery is more indicated. The morphology is probably not an issue. I don’t why they don’t just consider clomid first. Even if one tube is blocked and one is normal, it may be worth a shot with clomid. Of course, ask your doctor or get a second opinion.
Anonymous is 37, has a bicornuate uterus and a poor response. 4 failed ivf cycles, 0-6 eggs each. Her husband had a vasectomy.
Since your last protocol seemed to work best you could try one more cycle. You could also consider stopping. If you do another, consider the same protocol you just used. The reversal is not a bad idea, because at least you can try every month. But, they don’t always work, or they work but the counts are low.
Lisa tried many natural donor sperm cycles then used low dose FSH and got only 1 egg. She is worried that if she made only one on FSH, maybe she made none on her own or on clomid.
I believe you made one on your own and one or more on clomid. Your doctor did the right thing trying to control your dose, but now it seems you need a little more. It can work with the one. If not you may need a little more drug.
Anonymous has a doctor who wants to do an endometrial biopsy the month before the IVF cycle to promote a better lining.
Most of us do not do this. If your doctor can do a study, or maybe he has seen such a study proving it works, fine with me. But I am not aware that this method is of any value.
Kate is 31 yo and she did 2 IVF cycles. Her response is fair, 5-6 eggs, and after her first cycle her embryos did not look good. They got rid of the lupron and in her second cycle she had nice embryos. A pregnancy ended in a miscarriage at 6 weeks. She was told she has bad eggs.
I do not see that you have bad eggs. Your last cycle gave you nice embryos, and it almost worked. I think your chances are still very good. You could change to a microdose, or you can stick with your last stimulation, or you can consider an estrogen prime protocol. They will all be similar, it’s hard to say which one will be the best for you. Check pregnancy rates, if their results are good stick with them.
Murgdon’s husband has very low counts and her RE and urologist feel there is nothing practical that will raise counts, leaving them with IVF as their only option.
It’s hard for me to give specific advice about your husband’s condition, but in most cases, the advice you have received is correct.
Indigirl is 40 with a couple of cancelled ivf cycles for poor response. She switched to the estrogen prime and had 10 eggs. Her FSH is 10-12 and she has a bad AMH level. Is 10 a bad count?
10 is a very nice number, definitely enough to work with. We do not know enough about AMH to know if a bad level means pregnancy is not possible. Right know it’s a guide. The technology of PGD changes for the better every day, but ask your doctor what he thinks about not doing PGD. There is an element of embryo damage that can occur. PGD may be the best thing for you, but double check.
EAS is considering IVF with PGD because she has had a biochemical, 6 week misc at 6 weeks, and now a beta that does not look promising.
As long as you are informed about the pros and cons of PGD, then the choice to use PGD is reasonable. I just get upset when patients are led to believe that PGD is a perfect science.
Anonymous is 27 and does not ovulate or get her period, even with provera and clomid. What should she do? Her doctor is suggesting metformin.
Some women go great with metformin, but they are a mininority. The down side to metformin is that you need to wait another 3-6 months to see if it works. Certainly, it’s less expensive than getting FSH injections and monitoring, and you don’t need the doctor’s visits. It is a less aggressive way to go. Weigh your options.
Kahla’s husband has a low count. They got pregnant and had a baby on their first IVF try. The next 2 cycles failed and she had a 6 week miscarriage on her 4th try. She has had it and is considering iui.
It depends on the sperm counts, and you need to know your odds with iui and IVF. Most people find it really hard to go back to iui after doing IVF. But, if the counts are at least adequate for iui, you could do iui, and IVF later if necessary.
Jennifer’s mom has the BRCA gene discovered after being diagnosed with breast cancer twice. Should Jen take clomid?
Maybe you should get another opinion. Clomid is not that different than tamoxifen, a drug used to treat breast cancer. However, breast cancer is not my area, so I will defer. You could use letrazol to stimulate ovulation. This can cause ovulation, but is also used a breast cancer drug. Make sure you are not pregnant if you take it. Make sure you are fully screened for cancers before you try.
Elize has had enough history for 5 women. Check her entry for details. Now she is left with multiple major surgeries, miscarriages, and a uterine scar.
Much depends on how much scar there is. If it’s a little area, and most of your uterus looks good, and your normal endometrium looks thick enough, you may be ok, even if the scar comes back. If scarring returns after the first surgery, the odds of a second of third operation permanently removing the scar are much lower, especially if the scar takes up a large amount of the enodmetrium. We are not sure why you had the miscarriages, so I can’t say that you are at high risk for another miscarriage. Rupture is really rare, more common if you needed to have a large uterine incision for your myomectomy. A scar will incresase your odds of miscarriage and premature labor, but again it depends on the size of the scar. Scar will increase your odds of placental problems such as increta (where the placenta grows too deeply into the uterus)
Jesus my best friend has a unicornuate uterus with an open tube, and was encouraged to try on her own.
It sounds like a good plan to me.
OK, see you next time with a topic, probably blastocyst.
And please see disclaimer 5/17/06.
Dr. Licciardi
It took me a few days to cross the finish line, but I was able to eat and sleep along the way, possibly experience some weight loss, and I seem to be injury free.
From October 4th
Niki has had a very tough time trying to have a child. She has had a number of bio-chemicals and worse (see her post). Her basic questions are 1) is a thinish lining the reason, or is it an immune problem, or some other problem we just don’t know about?
I also do not buy into the immune issues. These have been studied now for many many years and never has anyone produced a quality study showing they mean anything. However, you have few choices, so it may be reasonable to consider getting tested and treated, if something shows up. I am not recommending one way or the other. You should give equal consideration to a carrier.
Esther had open tubes on hsg and a few weeks later had both tubes blocked at laparoscopy. She is being told she needs IVF.
I am not so sure. When I have open tubes on HSG, I don’t even check at laparoscopy. Why? Because it is common for tubes to be open on hsg and closed at laparoscopy. It’s a mechanical issue. Sometimes the doctor just has trouble getting dye out the tubes at laparoscopy. Now it depends on where the blockage is. If you have proximal occlusion (blocked at the uterus), this may be a false finding. If he says you have bilateral hydrosalpinx (blocked near the ovaries) that’s different and real. If there is any question, the answer is simple, just repeat your hsg. If the tubes are open on your next hsg, there were not blocked at your laparoscopy.
Mosche and his wife need IVF with ICSI due to male factor, however even with ICSI, there was no fertilization.
I have only had one young patient make many eggs and not fertilize with icsi. So it can happen, but it is rare. It’s a little more common when there are also issues with advanced maternal age and low egg number.
Ruby asked about sperm antibodies.
I do not believe in them because no good recent scientific paper written showing me that sperm antibodies are relevant.
Angie did a clomid IUI cycle, and the sperm count was 18 million with 56% motility.
The count sounds reasonable for iui. Although you should still ask for the total motile count, and look for that to at least be over 5 million, preferably over 10.
Tabi did 4 IVF cycles, 3 with lupron, one without. The non-lupron was her worst.
We don’t know if it was the no lupron, or was it just going to be a bad cycle for you that month, independent of your stimulation protocol. It may be that in your case lupron is better. For most women who make few eggs, this is not the case, but not all women are the same. I don’t think you are declining.
Ali did IUI. The sperm count was 143 million with 48% motility. However for the iui, only 3 million were recovered.
This is strange and does not make much sense; unless the initial volume was very low (2cc is normal). I am not worried about his morphology. “Abnormal” sperm are not removed when preparing for iui.
Manny and his wife are trying to conceive. He is asking if the lining could be an issue, especially because she takes anti-migraine medication that theoretically could restrict blood flow to the uterus.
The question is interesting, but unknown. One option is to measure the lining on and off the medications. Or, try to conceive off the medication. Another option is to look elsewhere for a potential problem. Do the basic workup i.e. semen analysis, HSG, day 3, to see if there are not bigger problems with more known quantities.
Anonymous has PCO and 2 weeks of bleeding after clomid.
This is not normal. Actually, the first cycle sometimes the bleeding can be unusual, but once you get into a pattern of periods, they should not be 2 weeks long. You need a good exam and ultrasound and maybe an endometrial biopsy.
Anonymous is 42 yo with 3 failed IVF cycles. Some borderline FSH levels and 1, 1 and 3 embryos available for transfer. Should she stop?
Your odds are what they are, low. It depends on your clinic, but your chances are probably about 5-10% per try. Many women, probably most, would stop here. But some persist, and a few get pregnant. As you know there are emotional, physical and financial issues to wade through. You can’t say you didn’t try. I hope it works out.
Mark is asking if he and his wife should consider natural cycle or minimal stimulation IVF vs. the standard IVF using more drugs.
You will need to decide. My only comment on your post is that it is not true that fertility drugs for regular IVF will ruin the eggs forever. But the opposite is also true. If you do a natural cycle, you can always do a regular cycle later. Regular IVF may not be for everyone, however, for most people, it has a higher pregnancy rate, which means a better chance of having a baby. The cost is less for natural, but with its lower pregnancy rate, it is common (not in every case) to spend at least as much money because the cost of multiple cycles really adds up fast. If you get pregnant early, great, you were the lucky one.
Erika has had 9 pregnancy losses and IVF is now recommended.
I understand the theory; if you put more than one embryo in, maybe if one fails another one will stick and you can have a normal pregnancy. Certainly, your odds of loss will be higher than the average person, even with IVF. I don’t think we can tell you that your odds of loss will be lower than from a natural pregnancy. However, your options are limited, so it may be worth a try.
Dizzy has totally unexplained infertility. All tests are very normal and she is 31. She has done 6 FSH iuis and is considering IVF, but insurance does not cover.
IVF is the next step. No one will be able to tell you why you are not getting pregnant, but IVF has an excellent pregnancy rate, even if you have failed FSH iui. You odds with FSH iui are now going down, because it has not worked. Of course you could do more FSH iui, and it may work, but it may be more of the same.
Purple Mocha has a 3 mm lining on clomid.
Sounds a little too thin. You can try again, or change to FSH. You could also check you lining in a no drug cycle to see what your baseline is. Of if you want to get going, just go to the FSH.
Mtroth has some endo and failed one IVF cycle, which was complicated by hyperstimulation. She has frozens. Did an undiagnosed biochemical pregnancy lead to her hyperstimulation?
You may have had a biochemical, but probably had plain old hyperstimulation. Your estradiol was high and you needed to be coasted. I do not think the endo was an issue. You can’t prepare for the FET. The good news is you seem to have nice embryos and should do well.
Athena has 8 months of infertility, short luteal phases of about 10-11 days, and serious pelvic pain. Her doctor will not see her until she has a year of infertility.
Maybe you have insurance that will not pay your doctor until there is a year of infertility, or maybe he is not a nice person. See which it is. If you think your timing has been good, it would be better if you saw him or another doctor soon. In general I do not believe in luteal phase problems, but you may be an exception because your luteal phase is so short. But do not only get that treated; work on other things at the same time. Get the hsg and ultrasound to look for cysts and endometriosis. Get the sperm checked.
Anonymous is an over-exerciser and because of this does not get her period on her own and does not bleed after provera. Because clomid starts after the period she does not know that do about starting the clomid.
You can start the clomid without a period, providing you get a pregnancy test. I am fine with you trying the clomid, but may women like you do not ovulate on clomid because, due to the exercise, your pituitary does not have much FSH or LH, and clomid works by releasing FSH and LH from the pituitary. Most of time, injected FSH is necessary to get you to ovulate. But you can try, sometimes it works.
Milka is 37 and her doctor told her her IVF failure was age related. He also wants to repeat her sonohyst and cultrures
I do not repeat those tests unless there is a good reason. Failing IVF is not a good reason. Your failure was not age related, you are young compared to many fertility patients.
From October 15th
Niki wrote back and did her IVF cycle, froze all due to lining issues. She is considering a carrier and does not want pgd.
It all sounds reasonable to me. It will have to be your choice.
Anonymous has pco and endometriosis. She did 8 clomid cycles and is in her last FSH iui cycle. Should she do IVF?
If you have done 2-3 FSH iui cycles, IVF is the next step. I like the way your doctor is doing the FSH iui. I am very optimistic. You are 28 and have eggs, that’s all it takes (in most cases). I expect you to do well and get pregnant quickly.
Anonymous is 33 and has had 3 miscarriages.
You odds are still excellent of having a baby in your nest pregnancy. Your doctor needs to do a miscarriage workup.
Anonymous has a normal pap with some cells missing and burning and numbness in her vagina.
As long as your doctor and the report say the pap is normal, it’s normal. I do not think the burning is related to antibodies, and it’s not due to the pap.
Diana was diagnosed with a septum and that was corrected. She then had to delay fertility treatment for treatment of thyroid cancer. New she is trying again without success. She is 35.
Give it the 3th month, but start making plans if things do not work. As far as your next steps, you know the drill. Get the options, get the pregnancy rates, and then decide which treatment sounds best for you. Be sure all of the septum is gone. I see many patients who have had septum surgery, only for me to tell them their doctor left a lot of septum still in place.
Anonymous does not get her period and is starting with a SIS.
I does not matter if you see her or a RE, but you need assistance ovulating ASAP. I don’t get the SIS, unless she sees something suspicious on ultrasound. You need to ovulate and this will probably require medication. Ask the doctor about getting the HSG before you try, or trying a little while (with ovulation) and then getting the HSG.
April did an IVF cycle with some immature eggs and late icsi. The embryos did not look good.
It sounds like there were a few issues with your cycle, but they seem correctable in the next try. It’s hard to tell if there was a problem with your IVF clinic, or things just want bad on their own. If you think you are at a very good place, give them another try. If you have reason to believe there is a better clinic near you, make the switch.
Shari in Chicago has endometriosis. She was treated with lupron and is waiting a long time for her period to return.
It works like this. The lupron is given every month (unless you have the 3 month version), and that lasts about 5-6 weeks in your system. Then you need to start your cycle again, and most women ovulate 2 weeks after that, and get a period 2 weeks later. That means you get your period about 8 to 10 weeks after you last shot.
Christine asked if IVF babies were born earlier and or smaller than non-IVF babies.
The answer is maybe. Some data suggests this is the case. However not all studies break out singletons from multiples, which usually deliver early. If there is an association, it may be due to the fact that some women with infertility may have uterine abnormalities that cause premature delivery. It is also possible that infertile people are more likely to have subtle genetic issues interfering with the length of pregnancy or the size of their babies. Or it may be that there is no difference at all and the right studies have not yet been done. Or maybe the IVF process is flawed and babies are smaller and deliver early. At this point, if there is a difference it does not seem to be great.
Alesha is trying to have her second IVF baby. Her first was at age 32, she will be 35 in January; her FSH is normal. Because she is a teacher, she wants to wait till summer to try. Her doctor says try now; her ovaries may change in the next 7 months.
It will be a little harder then, but if you are very fertile now, you will be very fertile then. Although there is a small chance he is right. Don’t forget you will be 3 years older than you were at your first try. I think it’s up to you, but consider this. Many women become very sad when they get pregnant on their first try, but not on their second, because it seemed so easy the first try. This could happen, and your following cycle will need to be during school, which is what you were trying to avoid. Therefore, why not just do one during school now. The logic is a bit of a stretch but I hope you get the point.
Leila has endometriosis and a fair response to meds. Her first 2 cycles yielded few eggs, and she did much better with a day 2 start than with lupron or microdose. If this fails, should she try again?
This cycle was very encouraging. You are only 36 and make 11 eggs, not bad at all. Question for your doctor: do you really need icsi? It sounds like you are on the right track. Consider the same protocol or estrogen priming.
Anonymous asked why go to FSH iui after 6 failed clomid cycles? Why not go to natural iui?
For younger patients, natural iui has a 5% pregnancy rate and FSH iui has a 20% rate. You can do whatever treatment you are comfortable with, just know the odds.
Anonymous is 42 years of age and has a FSH of 18. She failed a response using 14 days of lupron and 750 units of FSH. Should she stop?
It really does not sound encouraging. If you really wanted another try, ask your doctor about the estrogen priming protocol. Lupron is not the best for poor responders.
Anonymous has irregular cycles and is trying with clomid. She is using cervical mucus to time things.
Use an ovulation predictor kit instead. You can get pregnant with mucus that is thicker, but, if the clomid does not work after 3-6 times, ask your doctor about FSH. You may get pregnant before you get to the FSH.
Anonymous did 2 clomids, 3 FSH iuis and one IVF. She made 9 eggs but had slow embryos.
Get yourself to the best IVF clinic available. It may be where you are, or you may need to switch. Check rates at SART.ORG. Use a different protocol. I hope it works out.
Beth was diagnosed with endometriosis and is not ready to conceive. Should she go on Lupron for 9 months?
9 months sounds like a long time to me. The pill is definitely an alternative to lupron. Ask your doctor or get a second opinion.
Amila had an iui, had intercourse that evening and then had an iui the next day. The second iui had a lower count.
Probably too much. Stick to the iui’s.
Jesse b: Wife 30 he is 34. They just started the workup and were found to have one blocked tube and a low morphology. Their doctor is already talking about IVF.
Wow, they are going fast! First of all, if the tubal blockage is “proximal occlusion” a laparoscopy is aggressive. It is an option, so is repeating the hsg. It may have been spasm. If it shows distal occlusion, maybe surgery is more indicated. The morphology is probably not an issue. I don’t why they don’t just consider clomid first. Even if one tube is blocked and one is normal, it may be worth a shot with clomid. Of course, ask your doctor or get a second opinion.
Anonymous is 37, has a bicornuate uterus and a poor response. 4 failed ivf cycles, 0-6 eggs each. Her husband had a vasectomy.
Since your last protocol seemed to work best you could try one more cycle. You could also consider stopping. If you do another, consider the same protocol you just used. The reversal is not a bad idea, because at least you can try every month. But, they don’t always work, or they work but the counts are low.
Lisa tried many natural donor sperm cycles then used low dose FSH and got only 1 egg. She is worried that if she made only one on FSH, maybe she made none on her own or on clomid.
I believe you made one on your own and one or more on clomid. Your doctor did the right thing trying to control your dose, but now it seems you need a little more. It can work with the one. If not you may need a little more drug.
Anonymous has a doctor who wants to do an endometrial biopsy the month before the IVF cycle to promote a better lining.
Most of us do not do this. If your doctor can do a study, or maybe he has seen such a study proving it works, fine with me. But I am not aware that this method is of any value.
Kate is 31 yo and she did 2 IVF cycles. Her response is fair, 5-6 eggs, and after her first cycle her embryos did not look good. They got rid of the lupron and in her second cycle she had nice embryos. A pregnancy ended in a miscarriage at 6 weeks. She was told she has bad eggs.
I do not see that you have bad eggs. Your last cycle gave you nice embryos, and it almost worked. I think your chances are still very good. You could change to a microdose, or you can stick with your last stimulation, or you can consider an estrogen prime protocol. They will all be similar, it’s hard to say which one will be the best for you. Check pregnancy rates, if their results are good stick with them.
Murgdon’s husband has very low counts and her RE and urologist feel there is nothing practical that will raise counts, leaving them with IVF as their only option.
It’s hard for me to give specific advice about your husband’s condition, but in most cases, the advice you have received is correct.
Indigirl is 40 with a couple of cancelled ivf cycles for poor response. She switched to the estrogen prime and had 10 eggs. Her FSH is 10-12 and she has a bad AMH level. Is 10 a bad count?
10 is a very nice number, definitely enough to work with. We do not know enough about AMH to know if a bad level means pregnancy is not possible. Right know it’s a guide. The technology of PGD changes for the better every day, but ask your doctor what he thinks about not doing PGD. There is an element of embryo damage that can occur. PGD may be the best thing for you, but double check.
EAS is considering IVF with PGD because she has had a biochemical, 6 week misc at 6 weeks, and now a beta that does not look promising.
As long as you are informed about the pros and cons of PGD, then the choice to use PGD is reasonable. I just get upset when patients are led to believe that PGD is a perfect science.
Anonymous is 27 and does not ovulate or get her period, even with provera and clomid. What should she do? Her doctor is suggesting metformin.
Some women go great with metformin, but they are a mininority. The down side to metformin is that you need to wait another 3-6 months to see if it works. Certainly, it’s less expensive than getting FSH injections and monitoring, and you don’t need the doctor’s visits. It is a less aggressive way to go. Weigh your options.
Kahla’s husband has a low count. They got pregnant and had a baby on their first IVF try. The next 2 cycles failed and she had a 6 week miscarriage on her 4th try. She has had it and is considering iui.
It depends on the sperm counts, and you need to know your odds with iui and IVF. Most people find it really hard to go back to iui after doing IVF. But, if the counts are at least adequate for iui, you could do iui, and IVF later if necessary.
Jennifer’s mom has the BRCA gene discovered after being diagnosed with breast cancer twice. Should Jen take clomid?
Maybe you should get another opinion. Clomid is not that different than tamoxifen, a drug used to treat breast cancer. However, breast cancer is not my area, so I will defer. You could use letrazol to stimulate ovulation. This can cause ovulation, but is also used a breast cancer drug. Make sure you are not pregnant if you take it. Make sure you are fully screened for cancers before you try.
Elize has had enough history for 5 women. Check her entry for details. Now she is left with multiple major surgeries, miscarriages, and a uterine scar.
Much depends on how much scar there is. If it’s a little area, and most of your uterus looks good, and your normal endometrium looks thick enough, you may be ok, even if the scar comes back. If scarring returns after the first surgery, the odds of a second of third operation permanently removing the scar are much lower, especially if the scar takes up a large amount of the enodmetrium. We are not sure why you had the miscarriages, so I can’t say that you are at high risk for another miscarriage. Rupture is really rare, more common if you needed to have a large uterine incision for your myomectomy. A scar will incresase your odds of miscarriage and premature labor, but again it depends on the size of the scar. Scar will increase your odds of placental problems such as increta (where the placenta grows too deeply into the uterus)
Jesus my best friend has a unicornuate uterus with an open tube, and was encouraged to try on her own.
It sounds like a good plan to me.
OK, see you next time with a topic, probably blastocyst.
And please see disclaimer 5/17/06.
Dr. Licciardi
posted by Dr. Licciardi at 4:16 PM
46 Comments:
This blog is such a helpful tool to so many of us. Thank you.
I'd like your advice on my current situation:
TTC 2 years (not one positive pregnancy test)
ME: 33
Clockwork Normal Cycles (27-28 day, with ovulation on either CD13 or 14). Had complete hormone b/w and all results normal. Had HSG - again normal.
HUSBAND: 45
Abnormal SA
Count: 209mil
0% A
15% B
4% C
81% D
Morphology very poor.
We have our first meeting with RE in two weeks. Can you tell me if you would reccommend IUI or IVF/ICSI? My gut says to put all my chips in and go with IVF/ICSI given I'm pretty sure my egg quality is good and the fact that he has almost no motile sperm.
I'd love to hear your thoughts.
Thanks again.
I found your blog while searching for some information on what I am going through with clomid. I am 30 years old, and have one daughter, and we were able to get pregnant with her without any fertility medicine. However, we have been TTC baby #2 for 11 months now. I have always had very irregular cycles. My doctor tested my progesterone, and it ends up I wasn't ovulating on a regular basis. We are now on our second cycle of clomid (50mg). Clomid is making me ovulated; however, it has been difficult to figure out when I am ovulating becuase of the lack of cervical mucous I am having. I know this is a side effect from clomid, but my question is... Is there anything I can do to help increase my cervical mucous while on clomid. I really haven't had any other major side effects. Also, can I still get pregnant if my cervival mucous has decreased?
Thanks in advance.
Thank you so much with your response to me about my open then blocked tubes at lap. Well, good news...I am 5 weeks pregnant!! Without IVF. It was our first try after the Lap/D&C/Hysteroscopy and we caught. Your words have reassured me alot as I have been worrying that this could be an ectopic pregnancy if my tubes were blocked but as you think there is a good chance they were not blocked at all it helps. thanks again
"Be sure all of the septum is gone. I see many patients who have had septum surgery, only for me to tell them their doctor left a lot of septum still in place."
I couldn't agree more. I had a complete septum with a resection done 12-06. I had an HSG and they said it was gone. I went to a new RE and they suggested another HSG because the one following the surgery was not done right and you couldn't see the part where the septum is. Having another one done, finding out it's still there. Only a tiny tiny tiny bit smaller.
Can you give me any inside as to what happened? Why is my septum still there?? My husband is angry and thinks there should be some sort of recourse upon the Dr.
Thanks for your blog. I will be 29 in two weeks and have been TTC for 2-plus years. All my tests are normal, but every since going off of BC (almost three years ago), I have had dark spotting before my period. It seems that it has gotten worse lately, starting 7 to 9 days after ovulation and lasting 5 to 6 days. My RE prescribed prometrium back in June and I have taken that 3 times a day starting the day after my IUIs for 5 cycles. But the spotting still happens!
What else could be causing the spotting (if not a progesterone deficiency)? Is it preventing me from getting pregnant? What else can I do?
Thanks!
I love reading this very informative blog. I have written you before and had further questions. I have had 2 miscarriage, both around 6 weeks. The second pregnancy was twins and we lost them 2 days after seeing the heartbeats. I was on lovenox 40mg/day & 81mg Aspirin for the second pregnancy. It took Follistim, HCG Trigger and Intercourse to get pregnant both times. I have PCOS and I am also Hetero for Factor V and my completed repeat miscarriage work up revealed that I also have MTHFR. I have been put on an extra 4 mg of folic acid a day. All other tests came back normal, including karyotyping on my husband and I.
My questions:
What is your practice for the dosage of lovenox for someone with repeat miscarriages & FVL & MTHFR? Do you think I need to be on a higher dose? I am about 178 lbs and I was told I would be on 40mg/day of lovenox and 81mg aspirin/day for the next pregnancy as well. I am concerned that I was not on enough lovenox. Do you monitor the levels of your patients who are on lovenox?
What is your take on IVIG for the treatment of repeat miscarriage? Is this only beneficial to those with an auto immune factor? Would my repeat loss work up have included testing for the natural killer cells?
Thank you very much.
Hi - Ruby again. Just wanted to clarify sperm antibodies - my husband had an immunobead test which showed
IgG 30% bound on head and tail
IgA 85% bound on head and tail
We were advised IVF with ICSI was the best option for us as his sperm was unable to penetrate my egg - we've just had our embryo transfer. Do you have experience of this?
Dr Licciardi, thank you for this incredible source of information (and comfort!).
I'm 34 and have done 4 IVFs. 2 cycles (long Lupron, estrogen priming) were canceled due to low response, 3rd (antagonist) only yielded 2 eggs which both fert but were pushed to day 6 and did not survive - I didn't agree with this decision and switched clinics. I made it to transfer on the 4th try (Clomid + injectibles protocol), which was unsuccessful but had good embryos (6cell and 8cell, good quality). For both of my retrievals, I had several more follicles during stims but only retrieved 2 eggs - in both cases, the 2 eggs did fert.
Why do you think so many of my follicles were empty? Is this an indicator of egg quality, even though retrieved eggs all fert (and in the last cycle yielded good embryos)?
Thank you in advance for your response.
I've just recently found your blog and am curious to get your thoughts for my next step. My name is Ronni and I'd appreciate any insight you can offer.
I will be 40 in January and we have done 3 IVF w/ICSI cycles since June 2007. Two were done here in Dallas with the first resulting in a chemical pregnancy. The last was done at CCRM and was not successful either. With all cycles, I had 10+ eggs at retrieval and over 70% fertilization rate. (CCRM produced a 100% fertilization rate.)
All cycles proceeded with a 3 day embryo transfer of 3 or 4 embryos of "good" quality - minimal fragmentation and 6-8 cells each. Nothing made it to freeze with any cycle.
I do have an elevated FSH but a good AMH and I believe my response to stims is great considering my age and FSH. We have severe male factor but ICSI has been successful for us every time.
Denver and Dallas doctors believe it's an egg quality issue and suggest moving ahead with donor eggs.
Your thoughts?
Thanks ~ Ronni
I find your blog to be very helpful. Could you do a post explaining protocol for a low stim injectable cycle for PCOS women? I'm on clomid now and terrified of multiples so I would appreciate knowing what another RE considers minimal stims so that if I get there, I will have a reference.
Dear Dr L,
I've just completed my first IVF with ICSI. I responded well to Buserelin/Puregon and Pregnyl. 10 eggs were retrieved but on EC I was told there was fluid in my uterus which meant no embryos could be transferred (we ended up with 9 frozen). Could you shed any light on this? I understand the fluid can be hostile to embryos but I don't know how it got there. There doesn't seem to be much on the internet. We've been offered FET but I don't know if I need further tests on the uterus to check it's ok? Hycosy was all clear last year and lining was strong throughout the cycle.
Thanks for your help.
HI there,
Forgive me if you've heard this question already. Not sure if my last question posted properly.
This August, when I was still 37, my husband and I did a round of IVF with ICSI. I made 21 eggs, 13 of which fertilized. We transferred one fresh embryo that did not result in a pregnancy.
I have an FSH of 4 and I have remarkably regular periods. My uterine lining was fine. My HSG was normal.
We froze the remaining twelve embryos, two of which are of excellent quality (four are good, four are average, two are less than good).
My questions are these: Are we decreasing our chances of getting pregnant if we wait until December 2009 to transfer four frozen embryos? My doctor says that age of RETRIEVAL is most important, and has told me to exhale a bit, but I am worried...I'll be 39 when we finally do the FET...should we do it now instead and not wait? Would 13 months make that much of a difference? Is maternal age a factor in implantation as well as retrieval? I've just turned 38.
Thanks for your time,
Anonymous
I just wanted to say THANKS for doing the marathon answer session. I wish I lived close enough to have you as my RE- I love how thorough you are. Thanks for your blog.
My husband has 0% morphology. We did 2 fresh & 2 frozen IVF ICSI cycles and did not get pg with any of them. Is there anything that can be done to improve morphology?
Also, I have spotting for 4-7 days before my period really starts and sometimes it can be anywhere from a 21-26 day cycle. Is this okay or is there something wrong?
Thanks!
Thanks for reading through all of these questions. My husband and I have been ttc for 1.5 years. We know its time to get some help, but we are both Catholic and do not believe that IVF or artificial insemination are in our future. Its is worth seeing someone if we aren't willing to go down that path?
Thanks!
I have had 8 miscarriages - of those, 2 IUIs resulted in 2 ectopics, 1 FET resulted in a twin pregnancy and both were lost, 4 additional spontaneous pregnancies resulted in 3 losses and one ruptured ectopic that led to my left tube being removed. We are still hoping for a second child. I have a very friable cervix due to severe endo (no abnormal paps) and my doctor wants to cauterize my cervix to help my bleeding issues. I am worried that the procedure will cause scarring and thus more problems trying to get pregnant. Is it better to freeze the cervix or are the risks similar? I know my sister and my mom both had their cervix frozen before they had children so I feel like that procedure might be less invasive, but it might have been that the technology for cauterizing the cervix was not around when they both had the procedures decades ago. Can you please let me know your opinion on this?
Thank you!
Helen
Hi Dr. Licciardi,
I'm 41, and have had four failed IVF cycles since March. The first was a Lupron Flare, the second Antagon, and the third and fourth back to Lupron Flare, all with 300 ui Gonal-F & 150 Repronex. I tend to have a slow e2 rise on the Flare, and usually require 10 days of stims; however, the Antagon try was a total non-starter with zero reponse.
The Lupron cycles, in order, yielded 6 eggs (3 embryos: 1-9 cell, 2-6 cell yielded a blighted ovum), 8 eggs (3 embryos: 2-6 cell, 1-4 cell), and 5 eggs (started as nine, but lost some late, 2 embryos: 1-5 cell 1-4 cell) The embryos all look very nice with round cells and little to no fragmentation, but each cycle has yielded slower and slower development rates, with fewer cells at transfer each time.
We're taking a break for a few months, but we could see doing a few more cycles before we call it quits. I am happy with my RE, but he does not do EPP. Based on these results, do you think it's worth switching REs to go with an EPP protocol, or sticking with the Flare?
Thank you for answering so many questions!
I am 39. Here's my cycling history:
8/06 - BCP Antagon protocol, FSH 9.4, 3 eggs retrieved, 2 fertilized, 1 transferred, ectopic
10/06 - microflare, lupron dosage error and oversuppression, converted to IUI, negative
3/07 - microflare, 2 follicles, estrogen dropping, cycle cancelled
8/07 - antagon, IUI, negative
9/07 - straight follistim, FSH 7.2, 4 eggs retrieved, all fertilized, all transferred, pregnant with 1, m/c at 7 weeks
1/08 - straight follistim, 4 retrieved, 2 fertilized and transferred, chemical pregnancy
8/08 - estrogen priming, FSH 3.5, only produced 1 follicle, converted to IUI, negative
10/08 - coflare with co-culture, FSH 10.8, 5 mature eggs retrieved, 2 fertilized and transferred, negative
These last two cycles have, obviously, been very disappointing. Last one was my worst fertilization rate (all cycles have used ICSI) and co-culture did nothing to improve quality (20-25% fragmentation).
7 attempts at IVF, 4 retrievals and transfers. Between IVF's 3 and 4 we did the testing and went on the donor waitlist at our first clinic (the last two cycles were at a different clinic) and know it is an option for us, but, I need to know I've done everything I could to have a genetic child.
My question is - would you advise a patient to stop trying and move on to donor egg at this point, or is there hope?
Thank you so much!
Dr L,
I stumbled upon your blog after having my world collapse today. I was told I have a very high FSH. I wasnt sure what the Dr meant until she explained that I may have POF. Im 33, and to hear these words, and to hear her say to me, there is no hope, made me lose everything I have lived for. HOPE. I lost conciousness in her clinic after she uttered these words to me.
I will not give up, I will try options, right now Im waiting for the AMH test which I did today. Takes one whole week for the results, I dont even know how am I going to survive waiting. My FSH was 19.37 and LH 11.33 on cycle day 4. In your opinion, and your experience can someone my age, have no options? NO HOPE?
Can you please explain the benefits of a 5 day transfer vs. a 3 day transfer?
Thank you.
Dr. Licciardi,
We love your blog! We've included a link to your blog on our blog, which discusses from a husband's and wife's perspective our struggles with infertility, IVF, recurrent miscarriage, and a previous diagnosis with cancer. I wanted to share my url for anyone interested:
lifeandloveinthepetridish.blogspot.com.
Thank you for the service you provide women everywhere!
Hello Dr.
This is such a generous thing for you to do, to take the time to help complete strangers with this extremely difficult issue.
I am 24 years old, my husband is 25. My husband has recently been diagnostic with a very rare chromosome 1 translocation (not sure of the exact type of translocation/inversion). This has severely affected his sperm count. His highest count to date is 6 sperm. Not 6 million, just 6. The motility is around 15%. He is perfectly healthy in every other way. I am also completely healthy.
We have talked to genetic teams, and infertility doctors and none of them have given us a good idea of how this genetic disorder will affect our chances of carrying a healthy child.
Have you ever heard of something like this? We will be going through IVF/ICSI as well as some genetic testing on the embrios prior if we can find someone that is able to do it. We know this additional testing will lower our chance of success but they also believe they will be able to pick out the healthiest embrios to implant.
Any help or information would be so very helpful. Thank you so much for your time.
This post has been removed by a blog administrator.
This blog is extremely helpful, thank you for continuously shedding light to couples all over the US who are dealing with IF. Unfortunately, I just had a failed IVF cycle. Here is a brief history:
Both 27 years old- we've both been checked and we are dealing with MFI. Morph is 2% and total number of sperm around 79 million. Looks like most of the sperm had a head defect, half had a tail defect and about 16% had midpiece defects.
Anyway, we decided to go ahead and try IVF. I was put on Lupron, Menopur and Bravelle (was taken off of Bravelle because E2 was high after only 3 days of stimming). At the egg retreival, we got 16 eggs. Of those 13 were mature, 9 fertilized w/ ICSI. We transferred 2, an 8 cell Grade 3 (5best, 1worst) and a 7 cell Grade 3. None of our embies made it to freeze. I am wondering what your thoughts are on our cycle..my response to the stims was good and that was proven by the 13 mature eggs that we retreived. But after that...I am floored. It seems the quality was poor which is why we had only 2 grade 3's to transfer and none to freeze. Is there anything you believe contributes to the quality? Thank you!!!!
I was wondering if you could give advice about tubal reversal surgery. I made a bad decision when I was 21. I had a child when I was very young and quite honestly, I was terrified of being a single mother with 2 children. I am almost 30 now, and married. My husband doesn't have any children of his own, and I want a child with him. I have talked to several clinics that offer this procedure, and am curious if you could give any advice. They all seem pretty confident of their abilities, but I am terrified of choosing the surgeon who is going to hold my reproductive future in his hands. Most of the clinics I have talked seriously with do other procedures as well because the clinics that only do reversals do not take insurance. Do you have advice on how to choose the right surgeon?
Love your blog. Was hoping you could give me your opinion on my situation. My husband and I are 28 years old. I have severe endometriosis, 2 prior laps. I have had 2 fresh IVF cycles. The first produced 14 mature eggs, 8 of which went to blast. I have also had 2 frozen transfers from this cycle, both resulted in chemicals.
My second cycle was July. We switched clinics and got 22 eggs, 14 of which went to blast. Still not pregnant. Gearing up for a frozen transfer in December.
We have always been told our embryos are textbook and strong. What could my main problem be? Is it still possible that this can happen for me? All blood work and tests are normal. I was told I have MTHFR and am taking folic acid. Thanks for your help.
I have an entirely different kind of question - I have already successfully gone through fertility treatment and am the mother of triplets (plus an older foster son).
Now I would like to return to treatments in hopes of having (ONE) more. (Yes, I admit I'm slightly crazy). I am not returning to the same clinic I originally went to for two reasons: First, they're still pretty angry with me for not reducing my triplet pregnancy to twins, and second, my insurance company has changed and will not cover the old clinic (though I prefer the statistics and experience of the old clinic).
What I am wondering is how you would feel faced with a patient like me sitting across from you. Someone who has triplets (so, why on EARTH am I sitting in your office?), who knows what treatment protocol works, and most importantly, has some very definite ideas about things like SINGLE embryo transfers (the clinic that my insurance covers has never done an elective single embryo transfer... speaking as a woman who went into fertility treatment the first time stating very clearly that triplets or even twins were absolutely NOT an option, I daresay I'd like to do my best to minimize the risk of a second set). Would you laugh me out of your office? Can I really be the first woman who's ever wanted to seek fertility treatment after multiple children?
(FYI, I'm 32, PCOS, anovulatory, 2 pregnancies, 1 miscarriage in the 13th week, 1 triplet delivery at 33 weeks)
Thanks so much for this blog...I find a lot of comfort in it.
This is my first question...
Background: I am a 25 year old female with unexplained infertility...Everything looks good on my end (perfect on paper) and everything looks great with my husbands sperm. We have been ttc for a little more than 18 months.
First cycle with RE was 50mg clomid
Second cycle with RE was 2.5mg femara, trigger and IUI...I had 1 21mm follicle and post wash count was 43 million with a grade of 4...the best he could have gotten....still ended up not pregnant.
This next cycle, she has bumped up the femara to 5mg in hopes of me getting to ovulate a little sooner (I tend to ovulate on my own at about CD18). And thinking about doing back to back IUI's.
I guess my question is, will doing back to back IUI's increase our chances with unexplained infertility and good sperm count/quality?
Any other recommendations...and also, is there any way to naturally increase uterine lining?
Thank you!
Hi Dr. Liccardi-
I can't tell you you how much I appreciate your posts. They give hope to so many of us suffering from infertilty.
I'm not sure if you have time to answer a question of mine. My husband and I started going to a reproductive endocrinologist in 2007. We are both 28 years old.
Our case is male factor. So far nothing with me. Our Dr. gave us the "ok" to go forth with IUIs. We did three (unsuccessful) of them and moved onto IVF/ICSI in October.
Aside from being hyperstimulated (mildly) we still triggered with HCS when my E2 levels were 4200.
We retrieved 16 egg and did ICSI on 15 of them. 11 fertilized beautifully and we took them out to the blast stage (of which 5 made it to blast).
We transferred 2 grade AA blastocysts on day 5. I was mildly hypertimulated (with fluid around my ovaries) but not in any major pain and it wasn't bad enough to delay the transfer.
We received a negative beta test two weeks later and were so saddened considering that our Dr. gave us a 60-70% rate due to my age. We are looking in thaw our three remaining highly graded blastocysts in January for a FET.
My questions are:
1) With a failure on the first fresh cycle, should we be worried about the remaining embryos from that cycle ALSO not implanting?
2) What are some questions we should follow up with our RE when we go in for our next appointment?
Thank you for all of the time you spend answering so many of our questions!
-Faye
thanks for your excellent, excellent blog, and for speaking to patients like we are smart, rational people.
my question: transfer on day 3 vs. blasto? my doc feels strongly in favour of day 3, on the grounds that the embryo may do better inside the patient - natural environment, etc. your thoughts? coming up on a decision point in the next few days.
My husband and I just went through our first IVF. He’s got obstructive azospermia, so we did TESE and ICSI. I’m 39, with stats typical of someone of my age (FSH 10, smallish ovaries); I produced 9 follicles, 6 eggs, 5 mature, of which 4 fertilized. All four stopped growing at the two-cell stage, however, so we weren’t expecting much after transfer and indeed it failed. The RE seemed somewhat excited by the fact that all four eggs had stopped at the 2 cell stage, and suggested based solely on anecdotal experience that it might have something to do with the sperm; the embryologist however had been happy with the TESE results, and had enough to freeze more (this IVF was with fresh).
Have you heard anything about the sperm quality having anything to do with cleavage arrest? Regardless, thinking ahead for round two, does it make sense to use the frozen sperm, or get a new sample? This cycle used Menopur/Gonal F to stim; would a different protocol be likely to result in more eggs, and would that be a favorable thing? The clinic we are using does not specialize in male factor, but does have a very good reputation, does a lot of ICSI, and their stats show more male factor subjects than many of the other clinics that were available when first pursuing this, but that’s only because there are so few places that truly specialize in male factor. There are financial considerations which make us want to stick with this place for round two, but I don’t want to go through it again for naught; given what we know, is there likely to be greater success with a male factor specialist?
Dr.Licciardi,
I'll give you the short version. :) I was diagnosed with endo after it was found during a colonoscopy. I had a colon resection and temporary illeostomy in 05/07 an illeostomy reversal in 08/07. My Re was there for both procedures to make sure all things reproductive were good. We tried on our own for awhile then I had very abnormal spotting. Went to OB/GYN and had SHG and then D&C hysteroscopy 12/07 to remove some abnormal tissue. Everything came back fine. Still no luck so referred back to RE. Blood work all normal and HSG found tubes to be blocked (from scar tissue do to my colon resection) and them to be both hydro. We opted to try to unblock them and it was successful on the right. We continued on with IUI and letrozole 3 cycles then I had another HSG, again showing both tubes blocked and hydro. It also found my uterus to have a very slight curve inward. We have now opted to remove the tubes, RE will also I guess shave back the curve in the uterus and move onto IVF. We also discussed the essure procedure and I was wondering your opinion on either that procedure or tubal removal? Is one better than the other? Is the fixing of the uterus necessary to prevent miscarriage? I'm 29 (30 in March) so is my husband and he has no problems. Thank you and thank you so much for this site and taking the time to answer all our questions.
Kim
Hi Dr.,
This site is so helpful. I am 38 have failed 2 ivfs and have had one chemical preg. in a FET. My second ivf cycle went much better with 20 eggs, 16 fertilized with ICSI and we ended up with 12 blasts, 2 were transferred and 10 were frozen. Last time we had 34 eggs and ended up with 3 blasts (2 to transfer, 1 frozen antagonist protocol). I went on the long protocol this time. Both times, my estrogen was over 30,000 Can.) My RE is now saying that although my body tolerates high levels of estrogen she does not think fresh transfers are good for me going forward. My questions are: Do you agree that high estrogen inhibits implantation and that frozen transfers are better for me? If 10 frozens don't work do you think I should give up? 2 years ago when I started fertility treatments i had hsg and everything was fine. Do you think I need more tests. My RE says it could just be bad luck...I feel so hopeless given everything looks great but it's just not happening.
Hello Dr Licciardi,
If I may suggest, I'd like to read more topics, instead of answered questions. Your site has become very popular over the last year and for one, I don't know how you will be able to cope with the demand and then, I'm sure we would all learn more with topics and most of the time get an answer by ourself anyway. As for the specifics, we all need anyway to consult with our doctors.
I'm sure my opinion won't be very popular, but I know we can all agree on this: thank you Dr Licciardi, you have help so many of us! Hope you can continue for a long time!
Laura
Thank you so much for this great blog. Here is my question. I am 33, have two kids ages five and three. They were both concieved easily (my first child I took Clomid due to irregular cycles) and were easy pregnancies. When my youngest child was almost two I concieved again, it was a blighted ovum. Two months later, I concieved again. Had a normal ultrasound at seven weeks but a later ultrasound showed no hearbeat and baby stopped growing at 11 weeks. Genetic testing from D&C showed everything was normal. I saw an RE after the second miscarriage and his best guess was the extended breastfeeding of my second child could be contributing to the losses. Fast foward a few months, my child stopped nursing in early August, in late August I became pregnant again only to have a chemical pregnancy (started cycle three days late). Now it has been three months since my child has stopped nursing, I'm pregnant again and my beta only rose from 174 at 14DPO to 385 at 19DPO, so things don't look good. I am taking Prenate Elite, one baby aspirin a day, Crinone once per day (progesterone was in 51 and 40 in two beta draws), and generic Folgard twice per day (MTHFR testing showed Folic Acid issue). So how can someone go from two easy pregnancies to four consecutive miscarraiges within 15 months? I am normal wieght and in good health. Again, I'm 33 and not breastfeeding anymore. Any ideas? Thank you so much for your time.
I read your blog and saw a few comments to others about estrogen priming for poor responders. I am currently 34 and did an IVF cycle in Jan 2007 in which RE only retrieved one egg. We were wonderfully blessed with that egg/embryo turning into a beautiful baby boy and are now looking to expand our family.
I was diagnosed with POF by 2 REs after 3 years of infertility but my FSH levels are still in the normal range (last one was 10) and I have relatively regular cycles with cervical mucus changes, etc. Recent ultrasound showed normal cycle activity (done right around ovulation time). I also have Hashimoto's which was diagnosed by a reproductive immunologist (Dr. Beers)and some other stuff that I don't know enough about to explain and not even sure they are affecting my fertility. I was on prednisone, humira, synthroid, lexapro (something about my serotonin levels?) and did 2 LITs and acupuncture during my successful IVF cycle.
RE suggests doing the Lupron Flare protocol (did long Lupron protocol last time). I mentioned estrogen priming and he said that in essence everyone is "estrogen primed" that takes the birth control pill prior to IVF cycle... said not enough supportive evidence. He was also not supportive of the immunologists additional protocols as he said there was not enough data to support.
I want to follow the best possible protocol but don't know what is helpful or a waste of money and time. What are your suggestions? Do I need to use all those additional meds again? What stimulation protocol would you recommend?
Thank you so much for your time and dedication!!
I recently found this blog and was amazed that you so generously offer your time and advice to internet strangers! Thank you!
I would love your advice on my situation.
I am 28 years old and as far as I know, perfectly healthy. I recently donated eggs to an infertile friend. My estrogen levels went very high quite quickly on 143 IU of puregon (ready to trigger by day 9). I'm not sure what the estrogen number was at that point, but the doctor was very concerned and I did subsequently get OHSS.
They retrieved 48 follicles; 22 eggs; of which all fertilised, and 4 made it blastocyst.
The doctor in charge of the transfer (I wasn't present, nor have I ever met him, but he had my records) told my friend that based on my reaction to the drugs I "almost certainly" had PCOS and should get tested for this.
I would like to know whether this sounds likely to you. I don't have any of the other symptoms of PCOS as far as I know:
The ultrasound prior to beginning treatment showed no cysts
My periods as a teenager, before I went on birth control, were regular (but long cycle - 34 days - and very painful)
I am slim and have only ever been underweight, never overweight.
I have no facial hair and very little acne (one or two spots a month)
I do, however, have quite hairy arms and legs.
I have, however, been on birth control pills for 11 years, and I wonder whether that just might have disguised the condition?
Many thanks!
I should add that while on the pill, over the past 11 years, I have perfectly regular, light and painless periods.
Hi Doc. First I want to say that what you are doing here is wonderful. It is such a blessing to read all your thoughts, and encouragement. You always seem to add a little to each post. Thank you.
Now, I am starting my RE experience. We are going to IUI with my regular cycle (everything looks good with my BW and US). My husband has retrograde ejaculation...the RE we are going to said that he will prescribe oral sodium bicarb to lower the acidity of the urine, to preserve the mobility of the sperm. The only problem is that he wasn't able to nail down the exact dosage. Do you know? What do you do for retrograde ejaculation and sperm retrevial from the urine?
Thank you very much!!
Hi Dr Licciardi - I've been in touch before and thanks for your great advice. I'm 40, partner is 43 - ttc almost 2 yrs, missed mc April '07. Unexplained infertility - all tests (me and him) normal. I've just done first IVF cycle and had EC today. All went well initially but my E2 level reached 27,000 on Monday so I was put on coasting for 3 days (or 4? - Mon, Tues, Weds - triggered Weds pm for collection today, Friday). They collected 9 mature eggs. My questions are around ICSI and going to blastocyst - they've recommended ICSI. Although sperm was 34m, 50% motility; they say eggs 'lose something' thru' coasting so chances of fertilization much higher with ICSI. They'll tell us in 3 days whether they're recommending we go to blastocyst (based on my health after over stimulation and embryo quality). Is there any basis for concern - I feel that I'm layering one area uncertainty (ICSI) on another (blastocyst)? Of course there's the additional cost as well tho' that's not my first concern. Any input would be much appreciated - sincere thanks, Catherine
Thank you Dr for answering questions. I appreciate this.
I'm 40 and I've done 2 fresh DE cycles with different donors, and 2FET's. We had a MC after the first DE cycle, an ectopic after the second DE cycle, and negatives after both FET's. I have had both tubes removed from ectopics and I have about half an ovary left after having cysts removed. We spent 5 years fighting infertility. My lining never got over 7.5-8. My most recent clinic's success rates were in the 50-55% range for both fresh and FET. The previous clinic was ~50% for fresh and <20% for FET.
I'm trying to decide if we should waste any more time and money on the 6 frozen embryos that we have left or if we should know when to say when.
Your blog is great and I'd really like your opinion on my situation.
ME-30, Husbad-34 Both healthy and healthy weight!
ME - healthy weight with irregular cycles since before BCP at age 17 (I don't Ovulate or have AF on my own, only had 2 at age 17)and came off BCP May 2008. Plan was to let body regulate for 6 months before TTC. Well by mid-late July no period so did bloodwork and found low progesterone, so took progesterone to induce period, then waited and nothing so again took progeseterone to induce period and then started 50mg (cd5-9)clomid, and no ovulation. So more progesterone and then 100mg clomid (cd3-7)and switched to RE. He did more bloodwork (waiting on results) and did ultrasound at cd14 which showed pearl necklace Ovaries, he's thinking I have PCOS and will confirm with bloodwork results. I had 2 follicles in one ovary and one in the other but were all too small he said. So he told me to start progesterone and then we'll do 150mg clomid cd3-7. I've asked about metformin. He thinks I don't need it based on the big NEIHS study a year or so back and I say why not give it a try based on what I've researched and heard from other women on it. OThers without insulin issues are using it and they are having luck with Ovulation and preg. He's willing to let me try it and I'm meeting with him next week to discuss how to use it. I will start period probably 2 days before my appointment.
Do you think I might have luck ovulating with both Met and clomid? Or do you have other suggestions? He doesn't think I have insulin issues bc I'm not overweight. I have however read it can still help to regulate.
Thanks so much!
Dear Dr Licciardi,
I just wanted to thank you and your team. In March of 08, after 6 unsuccessful IUIs, my husband Bill and I went through an IVF cycle and it worked. Now I am the mother of a beautiful baby girl delivered by Dr Schweizer at NYU on Nov 24th. We are so happy! Thank you!
Leslie Enright
This post has been removed by a blog administrator.
Dear Dr Licciardi
I am writing from England and enjoy your blog. My dh and I are coming to the USA to find a gestational surrogate through an agency in LA. I have six frozen embryos created when I was 34 (four of good quality). I am considering having one last course of IVF BEFORE using these embryos as my AMH is low (3.8, FSH 9.9). If the surrogacy is unsuccessful I will be 43, and have used up all my frosties and have fewer eggs. To complicate matters I have had ovarian cancer and my doctor has told me if I have another course of IVF I need to have my ovaries removed immediately after. Can I ask your thoughts - if I should have IVF now for use in the surrogate or simply use the frosties instead? Many many thanks.
Nice comments and i m happy about your knowledge because every person have not so much knowledge the main reason is that knowledge in unlimited. as u know that a famous quotation is that get the knowledge from where u can learn.
as the time passed different knowledge are introduce like technology , science and the permanent birth control but the now a day tubal reversal make it possible that a women can get a baby even she have done the permanent birth control.
tubal reversal provides this opportunity for the women who desire to adopt the child after the permanent birth control process the results are mostly 100%
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