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42 Year Old U.K. Woman With One Failed IVF and Tubal Disease: How Should She Proceed?

Posted Apr 06 2010 11:50am

What follows is a question (with a follow up) from a woman in England who is faced with age-related infertility. She has done one IVF cycle and failed. She writes to me with some dismay over the news she received during her follow-up appointment with her fertility specialist. Read on:


Dear Doctor:

I am 42 years old, and have recently had a failed IVF cycle. It was my first IVF cycle and I had a low response. I had a total of 3 eggs harvested.

There were 2 from mature follicles and 1 from a small follicle. I know this is a poor response because I was on the maximum amount of drugs. I was on Buserelin 1mg/ml - 0.5ml per day, puregon 300 units and menopur 300 units per day. Not only did I have a poor response but the egg quality was also very poor. The egg from the small follicle burst before the embryologist could perform ICSI on it. The other 2 eggs did not change or develop in anyway when ICSI was performed on them. And ICSI was done because my husband's sperm is low in number and has problems with motility and morphology.

I recently had a follow up session with the fertility specialist and he advised me to not do any more IVFs and to consider egg donation if I want to proceed. And he even went on to say that even if by some miracle I did get pregnant my egg quality is so poor that the child would most probably have serious birth defects. I was so devastated.

My questions are I only had one IVF and the FSH on day 3 was 9.3, so can my doctor tell from one IVF that I have a low egg reserve and all my eggs are of poor quality. I forgot to say that both my tubes are blocked so an IUI wouldn't be useful.

Could it be that on another cycle an IVF might give better results? I have always had regular periods. Could my ovaries just have responded badly the first time and might they respond better to a second IVF? And most importantly, even if by some miracle I get pregnant, does my poor egg quality in this IVF cycle mean that a child would most probably have serious birth defects?

I want to do another IVF cycle. I want to see if a different drug protocol might cause a better result. Please tell me if you think that I should have any hope for a better result or if I must face the brutal truth that there is no hope and I must only consider egg donation.Thank you so much for taking the time to answer my questions.

ANSWER:

Hello P. from the U.K.,

In answer to your questions:

1. Low ovarian reserve (the stimulation response) and low egg quality are two different factors. You had both in this cycle. The elevated FSH of 9.3 is an indication that the ovaries probably will not stimulate very well with maximum stimulation as you did. It does not indicate poor egg quality,however. Your age is more of a factor indicating poor egg quality. As you know, pregnancy rates decrease significantly with increasing age, especially after 35. This is mainly due to poor egg quality. There is no way to correct poor egg quality other than trying to recruit and extract multiple eggs in the hope that a good egg will be present in that group. I don't think that all your eggs are poor quality but certainly the majority (90% or more) are.

2. There have been several studies on poor responders showing that each cycle is unique and yields a different result. So, there is still a chance, that even with one embryo, you could be successful in a subsequent cycle. However, to keep from giving you false hope, the chances would be low so you would need to be prepared for failure and to have to try several attempts. There was recently an article in the New York Times here in the U.S. about a 49 year old woman who conceived and delivered by IVF using her own eggs. I believe she is the oldest in the world to have done so (get pregnant with her own eggs by IVF ). However, they were clear to point out that it took her two years of doing IVF to attain that success.

3. I disagree with your doctor's statement that if you got pregnant you would almost certainly have an defective child. Because of your age there is a strong risk for miscarriage or a genetic abnormality such as Down's syndrome. However, abnormal embryos rarely implant or lead to a successful pregnancy. The only reason Down's syndrome gets by is because it is a mild genetic defect (only one chromosome is abnormal). If you get pregnant, and it successfully progresses beyond 8 weeks gestational age, your chances are good of having a normal child. We do recommend genetic testing, however, for those few that are abnormal. Poor egg quality usually leads to an embryo with multiple abnormalities, poor embryonic development and either no pregnancy or an early miscarriage.

4. I don't see any reason why you can't keep trying with your own eggs as I mentioned above. I see miracles happen all the time. However, you have to be prepared for a bad result, and if you can handle that, go ahead and keep trying as long as your ovaries still respond. You can switch to donor eggs at any time and at almost any age (although we tend to limit it to below 50) so that option will always be there. That being said however, I would probably have counseled the same as your doctor because we want you to be successful in the shortest time, least amount of attempts, least amount of emotional cost, and least amount of financial cost.

Follow-Up Question:

Dr. Ramirez,

Hello, it's P. again.

My next question concerns trying to fix my blocked tubes.

I wonder if I should consider a procedure to have one or both of my tubes unblocked. I have read that sometimes a tube can be so scarred that even having a procedure to unblock it doesn't work.

If one of my tubes was unblocked and remained so, then I could become pregnant naturally, couldn't I? I know I would still be battling with a poor egg reserve and a lot of eggs that are poor quality because of my age. Do blocked tubes mostly remained blocked even after a tubal opening operation? I am also very overweight, will this make a difference to how easily a surgeon could perform such an operation?

Dr. Ramirez, do you think this could be an option for me? Thank you for answering my questions. It is truly wonderful that you give up your time to help women like myself. God Bless you for your kindness.

Follow-Up Answer:

Hello Again,

Despite what anyone may tell you, tubal damage is NOT repairable or reversible except for two exceptions:

1. The fimbriated end of the tube is blocked by scar tissue that was causes externally, such as by previous surgery or a ruptured appendix.

2. The opening to the tube at the uterus is blocked by mucous, in which case, an HSG can sometimes unblock them and they would function normally.

Anything else that caused tubal damage cannot be fixed, and surgery does not exist for this. In addition, because of your age and ovarian reserve, even if that technology did exist (such as tubal transplantation), your "natural" chances of pregnancy would only be 1% per year of trying. It definitely would not be worth the surgical cost or risks. IVF has a better chance of 25-27% per attempt.

Good luck, P. and don't lose heart!


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