Questions about IVF, IUI, PCO and Male Factor Infertility
Hello Again, I hope everyone has had a mostly enjoyable summer. The weather in the Northeast has been summer-perfect.
Here are the answers to some recent questions.
IUI and IVF
At 45 should you dismiss the idea of IVF and just do iui? Most IVF programs around the country have never had an IVF success with a 45 yo woman using her own eggs. I know it sounds harsh, but it is the reality. At NYU we have had some and I am sure that there are other programs around the country that have one or more. The odds of success with iui are always lower than IVF, so that doesn’t sound so good either, but at least with iui you can try multiple times less expensively. So at any age, IVF on a per try basis is better and may be the best first choice, but iui is more attractive to some.
31 yo, severe endometriosis, 225 units of drug and 6 follicles, cancelled to iui. Was this the right choice? Can a higher drug dose increase the egg production? I do understand the "maybe you will do better next time" philosophy, but you don;t know that next cycle will bring. You may make a few more eggs on a higher dose. The left ovary only made one, which means it could do better next time, or it is damaged from the endometriosis and there is a lower number of eggs there. For someone who is 31, not more than 4 eggs are needed to still have a good chance. There may not be much of a difference in pregnancy rate between 6 and 10 or even more eggs. So for me 6 would have been fine and if you make 6 in your next cycle you should talk to your doctor about having a retrieval.
45 years of age with multiple fertility problems and multiple failed IVF cycles. Is freezing for a carrier one option? Anything is an option, but realistically, I would discourage it. If it’s a must do for you, then find a way to get it done. This really requires a sit down discussion with you and your doctors.
Embryo Donation: I 100% endorse the process. We seem to have a problem getting embryos. We get many couples who before their cycle start, say they wish to donate their embryos. But it is extremely rare for any couple to actually make the decision to donate their frozen embryos. There are obvious advantages of embryo donation and I wish there were more couples who were comfortable with the process of donating.
High percentage of immature eggs. Remember having 10-20% immature eggs is normal. High percentages of immature eggs could be a function of a few things. First, maybe you received the hCG too early, and waiting 1-2 more days may have increased the percentage of mature eggs. Most people on average do not have an excess of immature eggs when receiving hCG once their biggest follicles reach about 18 mm. Some women however, need their biggest follicles to be 20 or 22 mm before most of their eggs are mature. There is no way to know this in advance of the first cycle. But changes should be made for subsequent cycles. There are some women, who no matter how long we wait to give the hCG, still have a large percentage of immature eggs. We can’t explain this and it’s just a case of dealing with what you have. In general we don’t want to wait too long before giving hCG because eggs can get over-mature and this could show up later as poor quality embryos.
What if you make 3 follicles on 225 units of drug, will a higher dose help next time? On average the answer is yes. I think that for most people, once you get to 300-450 units per day, adding more will not help, or will not help much. There are many cases where I do use the higher doses, as much as 600 units. However, going from 225 units to 450 units usually ups the egg number. I would not expect to go from 2 to 15, but even 4-6 would be a big improvement.
Reproductive Surgery
Will a laparoscopy help find the cause of abnormal luteal phase bleeding? Most doctors would say that at least a hysteroscopy would be indicated, which would take a look inside the uterus to be sure there are no hidden polyps or fibroids. However, if the HSG and sonohysterogram are perfectly clean, odds are the hysteroscopy will be normal and maybe could be skipped. If medicated cycles fix the problem, then you are set. A laparoscopy (surgery through your navel) will probably not find anything related to abnormal bleeding of the uterus and may not be indicated.
Are there complications of uterine surgery for a septum? Yes, but the odds of having a complication are very low. Uterine perforation, bleeding and infection are possibilities, but there are very rare. Your doctor should be able to discuss the risk of miscarriage if you do not have the surgery and the rates of surgical complications. I perform my septum surgeries using ultrasound guidance to lower the odds of complications.
Ovarian Wedge/Ovarian Drilling will not help at age 44.
Failed ivf and iui with a fibroid in the cavity? It is tough for me to comment on this without doing the ultrasound myself. In general, regardless of the surgical problem, the threshold for advising surgery changes as time goes by. If there is a fibroid you may be less interested in removal initially, but as each cycle passes unsuccessfully, the option of surgery may receive more consideration. If I were to do the scan and agree that there is a fibroid of notable size in the cavity, I would be concerned that implantation could be hampered. But you really need to get a second opinion.
PCOS
If you have PCOs and are not responding to clomid, yes FSH is one of the next options.
You are 37 and have PCOS but with regular cycles? By most definitions, you can’t have PCOs unless your cycles are irregular. There are some groups who say that you can have PCOS even if you have regular cycles, however most doctors feel part of the definition of PCOS should include menstrual abnormalities.
It is not necessary to measure the LH level in women with PCOS. Irregular cycles and many follicles on ultrasound are all that’s necessary to make the diagnosis. Other tests may be necessary to rule out diabetes or other metabolic disturbances, and sometimes we check for adrenal problems, but most of us no longer measure the LH, or the ration of LH to FSH.
PCOS, 37 years old and not getting pregnant on clomid. Should you keep trying on your own? Well if you are not getting pregnant, eventually you need to change the plan. In general, clomid is used for about 3 tries, but in the case of PCO and anovulation, more tries are acceptable. This is because clomid levels the playing field. Someone who does not ovulate, but does so with clomid, has about the same pregnancy rate as a normal ovulating woman, so why panic after 3 months? Giving clomid to a normally ovulating woman is not as successful, so switching to injections or IVF after 3 months is the typical time frame.
Next steps: if you have not become pregnant after a number of cycles of clomid and then injection cycles, IVF is the next step. Of course you can continue with iui if you wish, but you need to talk to your doctor about the options and success rates of each.
Sperm
Is there a protein in sperm that kills eggs? There is not.
If you have a testicular biopsy that shows no sperm, can clomid help? It’s a discussion you need to have with your reproductive urologist. If you are unsure about the advice, get a second opinion. If clomid were an option, I am assuming it would have been an option prior to the surgery. Homogenous means that the tissue was abnormal, without the usual network of sperm making cells.
What if the sperm has 0% morphology. This may or may not be an issue. As you have read, a very low percentage of normally looking sperm does not bother me. However, occasionally, we see a sample that is unusually abnormal and this does raise a red flag. I would repeat the semen analysis to see if there is consistently 0% normal forms. Trying another lab may give you more information.
Obesity
If you are 31 and 300 lbs you need to seriously lose weight regardless of your fertility issues. Being pregnant at 300 lbs is not safe for you or your baby. If you lose weight you may start to ovulate regularly. I know this is all easier said than done, but you need to seriously look at all of your options including medical and surgical approaches.
Thanks, enjoy the holiday, and please read the disclaimer 5/17/06.
Dr. Licciardi
Here are the answers to some recent questions.
IUI and IVF
At 45 should you dismiss the idea of IVF and just do iui? Most IVF programs around the country have never had an IVF success with a 45 yo woman using her own eggs. I know it sounds harsh, but it is the reality. At NYU we have had some and I am sure that there are other programs around the country that have one or more. The odds of success with iui are always lower than IVF, so that doesn’t sound so good either, but at least with iui you can try multiple times less expensively. So at any age, IVF on a per try basis is better and may be the best first choice, but iui is more attractive to some.
31 yo, severe endometriosis, 225 units of drug and 6 follicles, cancelled to iui. Was this the right choice? Can a higher drug dose increase the egg production? I do understand the "maybe you will do better next time" philosophy, but you don;t know that next cycle will bring. You may make a few more eggs on a higher dose. The left ovary only made one, which means it could do better next time, or it is damaged from the endometriosis and there is a lower number of eggs there. For someone who is 31, not more than 4 eggs are needed to still have a good chance. There may not be much of a difference in pregnancy rate between 6 and 10 or even more eggs. So for me 6 would have been fine and if you make 6 in your next cycle you should talk to your doctor about having a retrieval.
45 years of age with multiple fertility problems and multiple failed IVF cycles. Is freezing for a carrier one option? Anything is an option, but realistically, I would discourage it. If it’s a must do for you, then find a way to get it done. This really requires a sit down discussion with you and your doctors.
Embryo Donation: I 100% endorse the process. We seem to have a problem getting embryos. We get many couples who before their cycle start, say they wish to donate their embryos. But it is extremely rare for any couple to actually make the decision to donate their frozen embryos. There are obvious advantages of embryo donation and I wish there were more couples who were comfortable with the process of donating.
High percentage of immature eggs. Remember having 10-20% immature eggs is normal. High percentages of immature eggs could be a function of a few things. First, maybe you received the hCG too early, and waiting 1-2 more days may have increased the percentage of mature eggs. Most people on average do not have an excess of immature eggs when receiving hCG once their biggest follicles reach about 18 mm. Some women however, need their biggest follicles to be 20 or 22 mm before most of their eggs are mature. There is no way to know this in advance of the first cycle. But changes should be made for subsequent cycles. There are some women, who no matter how long we wait to give the hCG, still have a large percentage of immature eggs. We can’t explain this and it’s just a case of dealing with what you have. In general we don’t want to wait too long before giving hCG because eggs can get over-mature and this could show up later as poor quality embryos.
What if you make 3 follicles on 225 units of drug, will a higher dose help next time? On average the answer is yes. I think that for most people, once you get to 300-450 units per day, adding more will not help, or will not help much. There are many cases where I do use the higher doses, as much as 600 units. However, going from 225 units to 450 units usually ups the egg number. I would not expect to go from 2 to 15, but even 4-6 would be a big improvement.
Reproductive Surgery
Will a laparoscopy help find the cause of abnormal luteal phase bleeding? Most doctors would say that at least a hysteroscopy would be indicated, which would take a look inside the uterus to be sure there are no hidden polyps or fibroids. However, if the HSG and sonohysterogram are perfectly clean, odds are the hysteroscopy will be normal and maybe could be skipped. If medicated cycles fix the problem, then you are set. A laparoscopy (surgery through your navel) will probably not find anything related to abnormal bleeding of the uterus and may not be indicated.
Are there complications of uterine surgery for a septum? Yes, but the odds of having a complication are very low. Uterine perforation, bleeding and infection are possibilities, but there are very rare. Your doctor should be able to discuss the risk of miscarriage if you do not have the surgery and the rates of surgical complications. I perform my septum surgeries using ultrasound guidance to lower the odds of complications.
Ovarian Wedge/Ovarian Drilling will not help at age 44.
Failed ivf and iui with a fibroid in the cavity? It is tough for me to comment on this without doing the ultrasound myself. In general, regardless of the surgical problem, the threshold for advising surgery changes as time goes by. If there is a fibroid you may be less interested in removal initially, but as each cycle passes unsuccessfully, the option of surgery may receive more consideration. If I were to do the scan and agree that there is a fibroid of notable size in the cavity, I would be concerned that implantation could be hampered. But you really need to get a second opinion.
PCOS
If you have PCOs and are not responding to clomid, yes FSH is one of the next options.
You are 37 and have PCOS but with regular cycles? By most definitions, you can’t have PCOs unless your cycles are irregular. There are some groups who say that you can have PCOS even if you have regular cycles, however most doctors feel part of the definition of PCOS should include menstrual abnormalities.
It is not necessary to measure the LH level in women with PCOS. Irregular cycles and many follicles on ultrasound are all that’s necessary to make the diagnosis. Other tests may be necessary to rule out diabetes or other metabolic disturbances, and sometimes we check for adrenal problems, but most of us no longer measure the LH, or the ration of LH to FSH.
PCOS, 37 years old and not getting pregnant on clomid. Should you keep trying on your own? Well if you are not getting pregnant, eventually you need to change the plan. In general, clomid is used for about 3 tries, but in the case of PCO and anovulation, more tries are acceptable. This is because clomid levels the playing field. Someone who does not ovulate, but does so with clomid, has about the same pregnancy rate as a normal ovulating woman, so why panic after 3 months? Giving clomid to a normally ovulating woman is not as successful, so switching to injections or IVF after 3 months is the typical time frame.
Next steps: if you have not become pregnant after a number of cycles of clomid and then injection cycles, IVF is the next step. Of course you can continue with iui if you wish, but you need to talk to your doctor about the options and success rates of each.
Sperm
Is there a protein in sperm that kills eggs? There is not.
If you have a testicular biopsy that shows no sperm, can clomid help? It’s a discussion you need to have with your reproductive urologist. If you are unsure about the advice, get a second opinion. If clomid were an option, I am assuming it would have been an option prior to the surgery. Homogenous means that the tissue was abnormal, without the usual network of sperm making cells.
What if the sperm has 0% morphology. This may or may not be an issue. As you have read, a very low percentage of normally looking sperm does not bother me. However, occasionally, we see a sample that is unusually abnormal and this does raise a red flag. I would repeat the semen analysis to see if there is consistently 0% normal forms. Trying another lab may give you more information.
Obesity
If you are 31 and 300 lbs you need to seriously lose weight regardless of your fertility issues. Being pregnant at 300 lbs is not safe for you or your baby. If you lose weight you may start to ovulate regularly. I know this is all easier said than done, but you need to seriously look at all of your options including medical and surgical approaches.
Thanks, enjoy the holiday, and please read the disclaimer 5/17/06.
Dr. Licciardi
posted by Dr. Licciardi at 7:44 AM
24 Comments:
This comment has been removed by a blog administrator.
This blog is AMAZING. Thank you SO MUCH, Dr. L.
Dear Dr L.
We have been trying to get pregnant for 2 years, I am 31 and my husband 32. One year ago my husband was diagnosed with reduced fertility, mainly low morphology and sometimes also low sperm count (it varied a lot). I underwent all the tests and all was fine. We tried 2 IUIs, no luck there. Now we've changed countries and I had an ultrasound for the antral follicle count, the result was 4 follicles. My husband's tests came back normal. My dr said that we shouldn't expect much from the 1 IVF next month since the odds are that I will be a poor responder to FSH. She prescribed 300 units instead of 225 of FSH. May I ask what your experience has been in terms of such circumstances? Does the AFC vary from month to month? What could be the reasons for such a low AFC at 31? My dr wants to see how I respond to FSH and I guess only then she will decide on the next steps. I am truly shocked about this result and would appreciate any information to calm my mind.
Thank you in advance!
Tif.
Forgot to say that my Day 3 FSH was 9.9 (1.5 years ago). That wasn't tested at the current clinic.
Tif.
Sorry, one more question (just can't gather my thoughts around that subject yet).
When is the best time to perform the pelvic ultrasound for AFC? Mine was done on Day 9 of the cycle.
Thanks so much.
Tif.
I have had one IUI, with two other months of fertility medications. I have PCOS, my husband sperm is 20 million. I'm not sure if we should try IUI one more time or go straight to IVF?
Thanks,
Lisa
Hi! I am in the dreaded two week wait after my first IVF cycle. A few of my eggs fertilized abnormally - where more than one sperm snuck into the party. (We did get one good grade embryo for a day 3 transfer.)
My question is this: Just because a few of my eggs fertilized abnormally, does that mean that all of them will have some sort of issue? Meaning, is the one that was transferred have the possibility of not "taking" because of egg quality? Would ICSI help avoid this?
For OP Lisa, I had 1 IUI with fertility meds (injectibles). DH had sperm counts of 5 million and 3million for back to back IUI's that cycle. We luckily got pregnant even though our docs told us not to expect too much with those counts. So there is hope!
Hello Dr. L,
After 7 years, and 11 IUI's (3 with FSH),my husband and I finally saved enough to do an IVF cycle. I stimmed for 10 days with 225iu of FSH, with a peak E2 of 2993.
We retrieved 6 eggs, all mature, but only 2 fertilized. 1 arrested on CD2, and the other was 3-celled graded "fair". We did a day 2 transfer with assisted hatching, but I am left with little hope.
Is there a possibility that the the embryo's "grade" can actually improve once transfered? I know they can't actually grade it, but is there a better chance that it will thrive now that it is in my uterus?
I just turned 29, my FSH was either 4.9 or 3.9 (can't remember for sure) , and my AMH was 1.1. My husband's count (he's 31) on the day of the retival was 110mil with 93% motility after wash. What else could we have done to improve our odds? I feel like we went through all of this for nothing, and all we have to show for it is more questions, and a very poor chance at pregnancy.
Is a higher cell count favorably associated with pregnancy? Would a 10-cell embryo on Day 3 have a better chance of implanting than an 8-cell assuming they both look very good and no fragmentation.
Hi Dr. L. Thank you so much for this blog. You are truly a man devoted to your profession. I have read the whole blog through.
I am 30 years old, FSH 9.5, PCO. Have had 5 cycles of Clomid/Femara and HCG shot when follicles were a good size. 1 of the cycles resulted in an excellent progesterone level of 20, no pregnancy. The other 4 progesterone levels were 7 of under. Shouldn't I be getting progesterone supplements in the luteal phase. My doctor says I haven't ovulated 4 out of 5 times, but ultrasound showed good follicle sizes each time, then had HCG shot and follicles collapsed on subsequent ultrasounds in luteal phase. Doesn't this show that they popped? What is your opinion about this low progesterone? Ovulation or no ovulation?
My RE is against inyectables and is recommending ovarian drilling or IVF.... Really frustrated.
I am being treated in Miami Florida but am considering going to NY for another opinion.
Thank you so much and God bless you,
-Nube
Extremely helpful information! Thank you so much for your blog!
My question:
I'm a single woman who at 38decided to become a choice mom. I conceived my daughter on my third unmedicated IUI with anonymous (frozen)donor sperm. I had purchased several additional vials and, when it was time to try for a sibling, I used them for 2 more IUI and 2 IVF cycles, all unsuccessful.
Unfortunately, this donor has stopped donating and there are no vials available either at the cryobank or through other sources. After my 2nd IVF, I had asked the lab to refreeze any leftovers. When they thawed the refrozen specimen during my last (third) IVF, they were able to use the sperm (with ICSI) to inseminate four eggs and create four class A embryos. They inserted all four and I had a positive pregnancy test (and a visible sac on the u/s) but then my HCG started to go down and I was told that there was a chromosomal abnormality. I stopped taking progesterone and miscarried.
So, here's my question:
I'm now 42 and am going to try again using donor eggs. The lab has said that they still have one vial of my donor which they think will be good for ICSI. I really, really would like to have a child that is at least a half sibling to my daughter but I haven't been able to find much data on the viability of twice frozen (frozen, thawed and refrozen) sperm and I would like to hear what you think.
Obviously, it was probably the age of my eggs that caused the chromosomal abnormality but I'm wondering if the refreezing might also contribute to increased chromosomal abnormalities.
Do I have an okay chance of conceiving a healthy child with the refrozen sperm or is it too risky?
This comment has been removed by a blog administrator.
34 years old, 3 successive miscarriages over 2.5 years. All testing normal (apart from irregular cycles and PCO morphology)Will Clomid increase chance of miscarriage and should I try something else to help with ovulation i.e. Metformin or injectables. Any advice welcome!
thank you for answering my question!
Hi there. I am a 27 year old female who has NO ourward signs of Polycystic Ovaries, but my doctor thinks that I might have it based on blood results. I have always had regular periods (28 day cycle, cramping halfway through indicating ovulation, 5 - 6 days of actual menstruation). I am starting the process of trying to get pregnant, but I am very concerned that this will not be possible. I have NO history of infertility in either side of my family, neither does my husband. Could me irregular bloodwork (that was done on the 23rd day of my cycle) indicate something else other than PCOD? Please help.
All RE's know this... But in a healthy male that has a low or very low sperm count and no pathology or blockage, clomid does not help at all. There are no studies that show that clomid will significantly raise the sperm count. A man's count varies from day to day anyways.
And yes, you can get pregnant on maximum FSH and low follicle count, it's just going to be a battle.
Dr L,
I am 31, my wife is 30. We got married 3 years ago. Wife got pregnant naturally (2-3 months of trying) had a miscarriage Sept 2008 due to cervical incompetence. We started trying after this miscarriage from July-Aug '09. Issues-Wife has irregular period, was not testing positive for ovulation.(no hormone, thyroid issues)My Sperm morphology was 0% (Strict method) in Apr 10. sperm Count (25 Mill/ml), Motility (70% forward, 10% very high speed).Took vitamins, started exercising and it was 3% in Sep 10, Motility & Sperm Count very good as per Gynae( 28 Mill/ml & 70% forward progression)(Am 5'11", weigh 210lbs). Wife was given Clomid-50 mg first cycle, 100 mg second cycle. She ovulated in second cycle but no pregnancy so far. We will start the 3rd cycle in Jan 11.
Any advice would be very very appreciated.
I am in Richmond VA and have a Gynae. Any body you could recommend (reproductive endocrinologist) in this area would be highly appreciated.
Well, its possible I have some form of PCOS and I don't really have irregular cycles!
I'm 30, I've tried to conceive twice, and each time I've succeeded. My pregnancies look stellar to start with and sadly have ended in missed miscarriages around 8 weeks each time. The first baby had a normal XY karyotype and the second had turners syndrome.
As a result of some fairly extensive testing, I've discovered I have polycystic appearing ovaries (AFC between 30-34 on 2 different u/s) and have high AMH (over 5 ng/ml) and highish DHEAS (over 200 ng/ml). As I'm sure you are aware of, AMH is an interesting new marker for PCOS. Everything else is fine and negative,I have low LH (ratio is actually less than 1), testosterone which fluctuates between 20 and 80 ng/ml. No measurable insulin resistance in
fasting blood, though I come from a long line of type 2 diabetics.
Would you prescribe metformin in a case like mine? I've had 2 REs who have suggested it. I know some cases where metformin has helped reduce the PC appearance of the ovaries and also AMH.
One additional issue with IVF is the cost and the unwillingness of health insurance to pay for it. It seems to add an additional level of urgency and stress to the procedures.
I just wanted to say that I have been through the embryo donation process and it is amazing! I wish the idea was promoted more. I had never even heard of it until I was searching the internet one day after my fourth failed IVF cycle. On my second FET I had my miracle boy! If you would like to hear my story you can visit www.ivfsuccessstories.info
Thank you for this wonderful blog!
I just got some very confusing lab results back. I have PCOS (irregular cycles, high AMH, past ultrasounds show many follicles on ovaries). But this time my lab results came back with a very high AMH as well as a high estrodial and slightly elevated FSH. So my AMH was characteristic of PCOS but my FSH was also high (assuming it was artificially lowered by the estrodial). My RE suggested diminishing ovarian reserve but from what I am gathering that is impossible with PCOS/high AMH. I can't make sense of it... please help!
Dear Dr L.,
My husband and I have been trying to get pregnant for almost 20months. I am 24 and my husband is 26. I got diagnosed with PCOs 3/2010. I have regular cycles,and cysts on my ovaries, but not sure if i ovulate on my own or not. My HSG was normal, my husband's sperm analysis was excellent & i've been on clomid. I have gotten pregnant 2x while on it but miscarried both due to low progesterone. Would it be a wise move to ask to get progesterone suppositories after ovulation occured? this month is my last month on clomid (i've been on it for 7 cycles, not back to back) i am on 100mg & taking 81mg of baby asprin as well. My doctor refuses to put me on anything higher than 100mg of clomid. Not sure what else to do besides see a FS/RE. Any advice?
Hi Dr. L.-
I'm new to your blog; thanks for writing it!
Question for you... I'm 31 and was diagnosed with Endometriosis in May through Laparoscopic surgey. My husband and I have been trying to conceive for a year and a half.
My next gyno appointment is in January and at that time my doctor and I are going to talk about next steps and potential fertility options.
My question for you is, what are the chances of getting pregnant with Endo naturally? I would love to avoid IVF if possible (sounds like IUI isn't an option?), but would love to know if I'm being too hopeful.
Many thanks from Denver!
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