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Questions about IVF, IUI, PCO and Male Factor Infertility

Posted Aug 28 2010 4:44am
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
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