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More Answers to Great Infertility Questions

Posted Jul 26 2009 11:35pm
Here’s a little vignette first.

I have a patient who was told after a hysterogram (HSG) and laparoscopy that her tubes were blocked. So she did an IVF cycle, didn’t get pregnant and came to me.
She was not told what type of blockage. I asked for her op notes and saw that her problem was that her tubes looked normal, but were blocked near the uterus (proximal tubal occlusion).
I told her that there is a way, using another hysterogram, that the tubes could be potentially opened using a wire. She went for the test and one tube did not require fixing, it was open, and the other needed the wire and was successfully opened. So her first HSG was wrong, both tubes were not blocked, and her laparoscopy, the so called gold standard, was wrong. See blog from 10/05/06, Blocked Tubes: 2 Cases of Proximal Tubal Occlusion.
None of this is uncommon. When I have a patient with proximal occlusion I send them for the recanulization hsg (the wire), and in many cases the original blocked tubes were nothing more than spasm, and the next hsg is perfectly normal. Laparoscopy isn’t always good for showing if the tubes are open. Sometimes it’s just hard to get the dye to go out the tubes at laparoscopy. If I am convinced that there is blockage at laparoscopy, I can pass the wire at that time. If this woman had her tube properly opened at laparoscopy, she maybe could have avoided IVF and seeing me.

Are low grade, slow blastocysts chromosomally abnormal? There may be a slight difference; better looking blasts may have better chromosomes than a blast that does not look as good. If there is a difference, it’s too small to make a decision related to transfer. In other words, if you best embryo is a slow blast, you should not be afraid to take it. Odds are if it sticks, it will be normal.

I made 7 eggs, why did the clinic immediately exclude me from a day 5 blastocyst transfer? Every clinic has its own criteria. Yours sounds a little strict, but check their SART stats. If their rates are good take their advice and follow their plan.

What about getting your period early in an IVF cycle? Probably if you were pregnant your period would have not come, even though you got it early. If you are taking suppositories, I would ask your doctor about taking progesterone injections for the next cycle. Sometimes I add estrogen. In general estrogen is not necessary after transfer, but in cases of early bleeding it may help.

What if there is no ovulation with clomid? If you don’t respond to clomid, you can’t keep trying forever. The injections sound intimidating, but most people get it done. If you do injections, it is very important that your doctor start you on a low dose and monitor you carefully.

What if you were planning to go to IVF if this IUI didn't work, but you got pregnant and miscarried? Logic would say it makes sense to do 1 to 3 more IUIs, after all you proved the tubes work, fertilization can take place and implantation can happen. However, most people, but not all, stick to the original plan and go to IVF out of frustration. Plus, usually a miscarriage results in extra lost time, and this gets people to want to get to IVF.

If you are older (I’m 49, so most of you are young to me), do your eggs need ICSI? Is the shell of the egg harder and less penetrable? This is my ARGHHHHH of the day. Simply, the answer is no.

At a young age, can anorexia or exercise induced amenorrhea mess up your eggs later in life? It actually is a very interesting question; however I have not seen any studies supporting this. There is probably no effect.

Could a woman with unexplained infertility donate her eggs? This is a tough one but probably not. Only because the recipients are taking a big financial and emotional gamble on the quality of your eggs. If you have unexplained infertility then have a successful IVF and wanted to donate later, that would be great for a recipient.

What if you are young and all the tests are normal. Your day 3 FSH is normal but you estradiol on day 3 is 20. Low is usually ok. Repeat it if you want piece of mind.

Donor egg or donor sperm? If you are young and the sperm counts are very low, and the embryos don’t look good, of course it could be the eggs or sperm. It really could go either way. Which brings us to a common dilemma. Getting inseminated with donor sperm is quicker, easier and tremendously less expensive that donor egg. So for that reason, if it’s not perfectly clear where the problem lies, and you have accepted the idea of donor egg, it is reasonable to consider a few courses of donor sperm insemination. Couples do seem more reluctant to do the donor sperm than they are for donor egg.

Major League questions about blastocyst. Are cryo’d blasts as sturdy as day 3 embryos? The answer is yes. A day 5 3BB is better than a day 6 4AA, unless the day 64AA was a day 5 3BB or better. It the trick with frozens in the freeze or thaw? Most of the skill is in the freeze, not the thaw.

Sorry, I do not now how to get pregnancy rates from Canada.

Update on 0ne-embryo transfer? Yes, in the past 1-2 years, every clinic has performed more and more one embryo transfers. So ask about their latest stats. I strongly suspect that the pregnancy rates for one embryo are lower in a frozen cycle. One way to up your odds in a frozen cycle would be to thaw a few (if you have them) and transfer the best one.

What if the sperm count is 145 million, with 40% motility and 2% normal morphology? Most REs would tell you that’s normal, but you need to ask yours.

If money is not an issue and you are faced with the choice between iui and IVF, and you want to do IVF, IVF is your best option. The success rate with FSH iui when all the testing is normal depends on your age. At age 37 it’s about 15%. Could be as high as 20%. IVF will be about twice that.

Should you go to surrogate if you are 43, have failed 6 fresh and 2 frozens, your lining is 5-6 mm and have 4 frozen embryos remaining. It’s a lot to consider, but surrogacy is an option. I am sorry but I can’t make more of a recommendation without seeing everything.

Can Lupron’s effects linger after your stop taking it? Anything is possible. However I have not had a patient with that problem.

With fairly good sperm should you spend the money on 2 iui’s or save for IVF? IVF is more cost effective than FSH iui. FSH iui is cheaper but much less effective. IVF is usually 2-3 times more effective than iui. There was a recent study showing going to IVF gets a baby with less time and money compared to FSH iui and IVF later if necessary.

Post coital test? Very few RE’s do this test anymore. It is just not accurate. Even if the test is abnormal, iui bypasses the cervix so antibodies in the cervical mucus (if such a thing matters) do not come into play.

Is IVF the answer if there have been 3 miscarriages and sperm with DNA fragmentation? I can’t be too negative about DNA fragmentation because it’s a little early to really know. However there is no good evidence yet to show those test are predictive of infertility or miscarriage. If your doctor feels differently, ask him or her to show you the studies.

Can very poor sperm lead to biochemical pregnancies and miscarriage? Yes but it’s not common. We all know that ICSI is used for very low sperm counts, and leads to good embryos and excellent pregnancy rates. However occasionally we see very low sperm counts and very poor embryo quality. In these cases, some women want to repeat IVF and expose a few of their eggs to donor sperm to see if there will be an improvement in the embryo quality. In some cases the difference is dramatic, and some couples will change over to donor sperm. If you are getting pregnant on your own without IVF and are having biochemical pregnancies, I’m not so sure it’s the DNA fragmentation.

Is IVF a treatment for 3 miscarriages? There are studies showing IVF without PGD is not very helpful for the treatment of miscarriages. There are some limited studies showing PGD may reduce the odds of miscarriage, but the data is not overwhelming.

What if you have had 3 biochemical pregnancies in a row? It’s hard to put much faith in the platelets, antibody, and autoimmune issues. Early on there is no placenta to speak of. There are no significant blood vessels to clot off. I must be sensitive to those of you who have had early losses and biochemicals, and then normal pregnancies after treatment for autoimmune/clotting factors. Maybe these things helped, but it can be possible that after a number of early losses, it was time for normal pregnancy.

What if you are 36 with all tests normal and 4 months of trying with good timing? Your odds of getting pregnant on your own in the next 4 months are still very good. Clomid or FSH iui are options, but giving it at least a total of 6 months on your own is a good idea.

How’s it going with the Priming protocol? If seems to work as well as other protocols in producing eggs. However the pregnancy rates are a little lower, so far. This is explained by the fact that we save the priming protocol for the worst responders, many of who have been cancelled using other protocols. So even if it’s a good protocol, we may not be seeing it because we are giving it to the patients who have low rates to begin with. So my bottom line is it’s worth trying as alternative, but it’s not a magic potion.

I am sorry I am not aware of co-culture with green monkey cells. Such a process would not be allowed in the US.

Thanks for reading and don't forget to see the disclaimer 5/17/06

Dr. Licciardi

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