Hello Again. I will spend the next few blogs catching up on questions. It’s been a while and I see that many were time sensitive, so I am sorry if missed your immediate problem. I’ll try to keep more up to date. One problem is that not all readers like the questions, but I like doing them, and if I make the answers relevant to a group of people, I think they work for a larger group of people. I got caught up in a bunch of topics that I wanted to cover, but for now, back to the questions.
What if you are young, make many eggs and embryos, have very nice quality, a normal uterus and are not getting pregnant? Could it be an implantation issue related to the uterus? Chances are this is not the case. Your doctor may be right, it could be bad luck. It could also be that you need to try another IVF clinic. It could also be there is some unknown genetic problem with your eggs or sperm, but the answer here is years away. Some would consider PGD in this case, but it is questionable if it would help.
If you do clomid, do you need to wait 2 weeks and provera to start? No. Your doctor wants 2 things. He wants you to bleed before the clomid, and he wants you not to be pregnant when you take the povera or clomid. There are ways around this. If you have not bled in many many months, it’s not a bad idea to get a period to start, so provera is not a bad idea. If you have had a period in the past few months, provera is probably not necessary. To be sure you are not pregnant; you can just do a progesterone blood test. You can’t be pregnant if you never ovulated, so if your progesterone is very low, it’s ok to start the clomid (if your doctor says it’s ok). If it’s high, you did ovulate, and you will need to wait less than 2 weeks for your period. If your period does not come, do a pregnancy test.
What if you were diagnosed with stage one enodmetriosis and were told to take Lupron for 3 months. Here is today’s ARGHHHHHHHHHH!!!!!
No one has ever shown that being on Lupron after surgery does anything to reduce endometriosis or improve pregnancy rates. It works like this. Endometriosis grows from estrogen; when Lupron takes away the estrogen the endometriosis stops growing. But Lupron does not kill the endo, it just suppresses it. So once the lupron is stopped, the endometriosis goes right back to where it was. Yes staying on the lupron will take away pain, but once the lupron is stopped, the pain comes right back. So the 3-6 moths of lupron will not help you become pregnant, it just makes you older and more frustrated. A new endometrioma should not appear on Lupron. If the cyst was not well removed at surgery, it can reappear, even if on lupron.
Is a large clot during the period a problem? Probably not. A very large clot is probably not coming from the uterus. It’s from fresh blood that flows from the uterus into the vagina, then sits there and clots. If you think overall the amount you are bleeding is excessive, there could be issues related to fibroids, polyps, etc.
Do we know more about Unexplained Infertility? The problem with writing about unexplained infertility (UI) is that patients are put in the category of UI only after the things we know about have been excluded. It is true that in the past many years, no new meaningful tests have been developed to get people out of the UI group and into one of the groups that are explained.
What if you have severe endometriosis and are not getting pregnant with IVF. Women with endometriosis do make few eggs than average, but 16 is plenty. Should you go to another IVF center? Look up their stats at SART.org. If the numbers look good, stay, if not, get another opinion. Genetic testing is always an option. With a mostly normal family history, the odds of a chromosomal problem are 1-3%.
What if you are 37-38 and your FSH is very normal buy you only make 4 eggs? Well FSH is not the whole story. It’s a good guide but if your number is low, it doesn’t mean you will definitely make many eggs. If you are starting on 2 Follistim and one Menopur, there is definitely room to increase your dose, which could make a difference.
What about a poor responder with normal FSH levels and antral follicle counts? Our pre cycle predictions don’t always match what we get during the cycle. Estrogen prime is probably as good as day 2 start. But if you have tried one, it makes sense to try the other next time.
What if you spot for 51 days straight? You need a pregnancy test and an ultrasound. Things may be just fine but there could be problems with ovulation (or non-ovulation) or uterine issues.
Are frozen embryos any worse because of ICSI? If they were frozen on day 3, is it ok to they and transfer day 5? Yes it is. ICSI will not negatively affect the embryo’s ability to grow from day 3 to day 5 after the thaw, depending on the labs experience with day 5 culture.
If you have regular cycles can you have mild PCO? No, because by definition, PCO women have irregular or lengthy cycles. Now this does not mean you can’t have ovaries that have a high number of eggs and follicles. So your ovaries can look like they are pco, but you don’t have a disease or syndrome. It also means that clomid could still be indicated, even if you do not have PCO.
Someone actually had a conversation with her doctor and he paid attention, and now she is pregnant. One of the most important things I learned in medical school was, “If all else fails, listen to the patient”. “When all else fails examine the patient” is another good one.
Should you have the laparoscopy or do the IVF? It would be easy to answer of either could get you pregnant right away. With a family history of endometriosis and severe cramps, and infertility, a laparoscopy is very reasonable. On the other hand, if you are a good candidate for IVF, the pregnancy will do a good job in suppressing your endometriosis, and some women have a permanent reduction in endometriosis pain after a pregnancy. If your tubes are open on HSG, and there are no endometromas of your ovary (ultrasound visible cysts of endometriosis), the odds of meaningful endometriosis (endometriosis severe enough to be preventing pregnancy) are low.
What about the third biochemical pregnancy in a row? The testing is normal so far. Here are just a couple of suggestions. If you and your husband did not have the blood karyotype test, that should be done. Even though you had a laparoscopy, consider a hysterogram.
After testicular surgery, will a sperm count of 18 million and 20% motility improve with time? It could go either way. At 31 you have few more months to see. Getting pregnant on your own with these numbers is not unheard of, but it may take longer.
I think I should have more frozen embryos. It is very disappointing to have 17 eggs, 12 embryos , 2 for transfer and none to freeze. There could be a few reasons related to the lab for this. If they transfer on day 3 and wait till day 5 or 6 to freeze, they may not have enough experience going to day 5, if they did they would do more fresh transfers on day 5. It’s also possible that the embryos look fair on day 5 and they just do not want to freeze them. There are 2 elements to this. One is a cycle using frozen embryos has a lower pregnancy rate than a cycle using fresh embryos, and that’s when using embryos that look very nice when they are frozen. So if you freeze embryos that are marginal looking, the pregnancy rates will be even lower, and many times not worth the freeze. The other element is that some programs are too restrictive on the quality of the embryos they freeze. I other words, they want their frozen rates to be high. One easy way to do this is to just freeze the really nice embryos and not the ones that look ok or worse. Lastly, it is possible you have some average or good embryos to transfer and all of the others are not really that nice. It may have nothing to do with the lab. Modifying your protocol may possible improve the quality of the lot.
We do not recommend amnio based on just ICSI. However, every case is different. For some, amnio may be indicated.
We have never dealt with a day 7 embryo.
Progesterone orally or vaginally? For IVF we use IM because we had some bad experiences with vaginal. However that was years ago, and maybe the preparations are better now (that’s what’s claimed). The oral is too unreliable to be used alone. If we use oral, it’s in combination with vaginal. Oral progesterone may make you very tired or dizzy.
What if you ovulate every month and on clomid, nothing, no ovulation? Yes indeed, this can happen. Why, we do not know, but it is pretty rare. If you are taking estrogen with the clomid, the estrogen may stop your cycle (like the birth control pill ) . But otherwise, we really don’t know why. If you take clomid another month, odds are you will ovulate. These types of problems usually do not recur.
Is it bad to switch doctors because the first doctor has your history? No not at all. We can all tell exactly what’s going on with you by listening to you in person and studying the paper work. IVF is about the stimulation and embryos, both of which should be clear in the documents.
It seems that there are doctors who tell patients that IVF is the way to go because in their case FSH iui is too risky. It is a little risky but it can be handled correctly. Start on a low dose, get monitored and stop the cycle you are on track to make too many eggs. If a low dose causes a big response, use even less drug next time. Yes, it’s easier to do IVF but if you chose to do FSH iui, talk to your doctor about trying.
If you hyperstimulated during an IVF cycle, and have frozens, generally it does not make sense to do another fresh. The point about saving young embryos for later is valid, although I do not push for that much. Saying you can get kids from a frozen cycle is not appropriate. You really don’t know if you will get pregnant from any embryos, fresh or frozen. If your plan is to have 3-4 kids, doing another fresh and saving the frozen is reasonable. Clearly you need a much lower dose of drug for the next fresh cycle.
OK that’s it for now, more to come.
Thanks and see disclaimer 5/17/06.
Dr. Licciardi
