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hopefully trying - March 16th, 2006 3:41 PM

I've written to you before and you've been very helpful. thank you in advance. I'm 40 DH is 49 turning 50 in a month. I have unexplained fertility. Hx of hypothyroidism and recent dx of sperm antibodies. Hx of slight to absent periods my whole life...never regular. His counts are still in normal ranges. I just failed 1st IVF attempt with ICSI and PGD. I did BCP, lupron 10mg, and follistem 450 iu. They retrieved 9 eggs, 8 mature and fertilized, 3 normal and reached blast stage (1 grade A and 2 grade B - 2 filled out) and were transferred, 5 were abnormal. My endometrium reached 5+ and had stripes. This is the thickest it's been and it's never had stripes before (I've had 3 IUI - 2 on clomid and 1 on 150 iu follistem). Needless to say we are devastated this didn't work. The RE has stated there is no reason not to try again. He is recommending change in protocol stay with Follistem but do a microdose lupron flare (as I understand it I would start the follistem earlier than the 1st protocol had me doing to "take advantage" of the initial surge). We have insurance coverage for 3 total IVF and have done 1. We're wanting to maximize our chances.

1) Do you think this change is protocol is sufficient? Would you suggest a different medication or are all the medicines about the same as my RE suggested?

2) What can be done if anything to increase endometrium? I'm currently on baby aspirin/day and RE suggested adding vitamin E but said other than that there is nothing else much we can do. (I had an estradiol level of 2700 day before egg retrieval and he said that estrogen is what thickens the endometrium and he's not sure why with that level I wouldn't have been thicker)

Thanks so much for your help!! I've also post to Dr Jacobs but didn't know if you'd have anything different to offer.

Dr Smith - March 17th, 2006 7:49 AM

I'll answer you questions as best as I can, but Dr Jacob will probably answer your questions better. My two cents worth:

A.1 Microdose flare is the stimulation of choice for older women and may result in a few more follicles. The meds are all the same thing - FSH, just labelled differently. No reason to change brands.

A2. Your endometrium is gonna do what its gonna do. Although stimulated by estrogen, the thickness is not strictly proportional to the estrogen level (i.e. not strictly dose-dependent). On a natural cycle, the endometrium develops fully and is exposed to a peak estrogen level of about 300, so after your reach a few hundred pg/ml, additional estrogen is not going to make a diiference.

Best of luck next time.

hopefully trying - March 17th, 2006 8:54 AM

Thank you for your response so much. Help me understand. If FSH drugs are all the same, why is it that so many women talk about changing protocols i.e. going to "other drugs" like repronex, (I'm forgetting the names)and getting different responses. I know Gonyl F and Follistem are the same but what about the others?

I"m so frustrated with my endometrium. Why can't it grow right? Why can't we fix it? The RE have learned so much about fertility but it seems that little is known. I'm suspecting that it may have something to do with my hypothyroidism since puberty but can't anything be done? She asks with tears in her eyes and desperation in her voice? I know ya'll can't wave a magic wand but God I wish you could!

Dr Smith - March 18th, 2006 8:41 AM

Some gonadotropin products contain Follicle Stimulating Hormone (FSH) only, others contain a mixture of Luetinizing Hormone (LH) and FSH. At the molecular level, FSH is FSH and it doesn't matter what label you put on the package. Drug companies would like you to believe that one product is better than another, and doctors get caught up in this marketing ploy, but in the end an FSH molecule is an FSH molecule. Patient's who are desperate to change something to make it work the next time get suckered into the marketing and think a change in the brand of medications made a difference. It didn't. There are good cycles and bad cycles no matter what medication is used (even when the same medication is used).

The stimulation protocols are a completely different issue. There are several protocols (methods) to use FSH and LH to stimulate the ovaries. Some patients do better with one protocol, others with another. The skill of the RE also comes into play here. Some docs are good at managing stimulations, others really suck.

The endometrium does its own thing and, other than estrogen (in its various forms of administration), there is nothing else that can be done to stimulate the growth.

hopefully trying 2 - March 18th, 2006 7:32 PM

Thank you for your reply. Again, it is so helpful to have specific information. I don't know why the RE can't explain this stuff to us. It would be so anxiety reducing. Again, thank you so much for your willingness to be available.

I know that the FSH is what stimulates the ovaries. What does the LH do? Is Lupron an LH?

Dr Smith - March 20th, 2006 10:44 AM

Like FSH, LH comes from the pituitary gland. During the first part of the cycle, LH is released from the pituitary in small amounts and (although no one reallys knows exactly how) appears to aid in the stimulation of follicular growth. At midcycle, there is a big surge in the secretion of LH and this causes the final maturation of the follicle and the egg and then causes ovulation about 40 hours after the onset of the surge. Lupron, when used in the long down-regulation protocol, supresses the release of FSH and LH from the pititary gland and thereby prevents premature ovulation. Since the pituitary gland is not secreting FSH or LH, the follicles are stimulated to grow by the FSH and LH you are taking in the shots. The final maturation is induced by the hCG shot (a very similar hormone to LH) that you take at the end of the stimulation. The eggs are removed from the follicles at about 36 hours after the shot (before the follicles pop and release the eggs).

hopefully trying - March 21st, 2006 10:02 AM

Dr. Smith,

Once again thank you so much for taking your time to help educate me so I can understand the issues better, make more informed choices for my care, and perhaps most importantly, manage my anxiety and fear!!!!

Dr Smith - March 22nd, 2006 10:33 AM

Knowledge is power and power can reduce anxiety and fear. Glad I could help.

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