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From the information you have provided, I would say there's no egg or embryo problem. The problem is in the post-implantation period. This is highly suggestive of an auto-immune problem. I suggest that you get tested for Natural Killer (NK) cells [u]and[/u] NK cell activity. The tests are available though Millenova Laboratories and Repromedix. If your current RE pooh-pooh's the idea (as not all RE's are on board about abornal NK activity), find a RE that is willing to perform and interpret the tests. Abnormal NK cell activity can be successfully treated with intravenous immunoglobulins (IVIg). However, IVIg treatment can be very expensive. We have recently had similar success with a low cost alternative to IVIg, Solucortef, a steroid that dampens the immune response (i.e. NK cell activity).

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Dr. Smith:

Thanks for the input. My RE actually brought the NK cells up as well. She did mention that it wasn't mainstream, and that she personally was on the fence about it, and suggested I do my own research. Sounds like I should do the testing, and make a decision after I receive the results. Approx. how much is the IVIg treatment? Solucortef treatment? Would a surrogate still be an alternative given that I test positive for NK activity?

In college I found out I had Graves disease (auto-immune problem), and I have also had a false-positive on a AIDS test, that they said was related to an auto-immune screening test. Don't know if it's related or not, but it sounds like it's worth looking into.

Thanks again.

Erin

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IVIg treatment can run up to $12,000 for a succesful pregnancy (approximately $3,000 if the cycle fails, since you don't need as many treatments). Solucortef costs about $25 and its a one-shot deal (pardon the pun). We've just begun to use Solucortef in your program, but our results so far are comparable to IVIg in NK positive patients. Hurray for a low-cost alternative!

If you have any previously identified auto-immune disorder, I strongly recommend NK cell testing. A lot of RE's are on the fence about NK cell testing. Perhaps you'll make a believer out of your doc.

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Specifically what types of results are you seeing with IVIg, and Solucortef? I've searched the web, and while I can find result statistics on IVIg, I cannot find them on Solucortef. Would very much appreciate a reference for my research, or at least your success percentages with either protocol. Also, what types of studies have been done using Solucortef in pregnancy, and are there any effects to the fetus?

Can't thank you enough for your information. I feel like I still have a hope.

Sincerely,

Erin

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To the best of my knowledge, there have been no published studies showing the efficacy of Solu-Cortef (proper name, I wasn't hyphenating it in my previous post), so its not surprising that your search came up zip. We have tried Solu-Cortef on 4 patients with abnormal NK cell activity - all 4 are pregnant. However, the sample size here is way too low to draw any conclusions. Of the patients with abnormal NK cell activity that we have treated with IVIg (n=62), 72% of them have had a succssful term pregnancy. These data represent ongoing internal data collection and have not been published in a peer-reviewed journal.

Solucortef does not have an effect on early pregnancy.

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After my last HCG drop, I did not go back to the Dr. and follow my numbers down to zero, as I was suppose to. 2 weeks later I decided to I had better, and to our surprise my numbers were on the rise. We followed them for a few days. Looked for an ectopic, and could not find one. HCG numbers were consistent with 5 weeks gestation, (I would have been 8 weeks), were rising, but not doubling. Did and D&C this am.

Is this indicitive of anything useful? I want to go on with NK cell testing, but if this is an indicator that I could have a lasting implantation, then maybe I should forgo that expense and use my frozens. Allbeit, if the frozens do not attach I'm looking at the expense of another full cycke, and NK cell testing, and possibly IVIg.

Thanks again.

Erin

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Your situation is pretty classic for an autoimmune disorder (early miscarriage). I would strongly recommend have autoimmune testing performed, or at the very least, use Solu-Cortef empirically at the time of the FET. Sorry for your loss.

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Dr.

I saw on another thread, a gal mentioned aching joints, and then ANA testing issues.

I have decided that I will do the NK cell work up, but was told that I need to wait 6 weeks post HCG levels dropping to 0.

My question really is, is there a connect between aching joints/body stiffness and auto-immune issues? Since my 1st IVF cycle 16 months ago, I have experienced increasing achiness. MY RE dismisses it as unrelated to IVF. I have also gained 30 pounds in the process, and do admit that packing around extra weight is extra burdon on my body. However, there are days that I wake up and feel 70. Just wondering if this fits into the puzzle at all.

Thanks again.

Erin

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These are medical questions that are outside my field of expertise, so I think you should also post on Dr Jacob's Infertility 101 Message Board.

My take on this:

If your aching joints are the early signs of arthritis, then they may be correlated to elevated NK cell levels or activity, since arthritis can be classified as an autoimmune disorder. As far as I know, the weight gain is unrelated to any autoimmune issues. Its probably related to the stress associated with infertility treament.

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Dr. Smith

Wondering how those 4 patients on Solucortef are doing. I'm still in limbo from my last transfer. Ended up being ectopic. It was odd because we had seen a gestational sac, and then after the D&C, my numbers were continuing to rise. I'm assuming that I lost the baby in utero, thus my numbers dipped, but then went up because of the ectopic. Luck hasn't been on my side.

I'm considering doing the Solucortef emperically with my frozens, but have to wait until my HCG goes down. If I remember right I couldn't do the NK Cell testing until 6 weeks post my HCG getting to zero.

If that doesn't work, I'll do the testing for NK Cells before a fresh cycle.

Thanks again.

Erin

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Sorry to hear of your troubles. Hang in there. Perserverance pays off (usually). All of those Solu-Cortef treated patients (and a few more) have ongoing pregnancies. So, the results continue to be promising. Yes, you have to wait for the NK panel until after your body gets back to its pre-pregnant state. The Solu-Cortef for FET is good idea. Best of luck.

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dr.
I'm 33 and told I have 16 year old ovaries. Our first IVF with icsi for severe male factor, resulted in 16 eggs, 13 mature, 13 fertilized. On day 3 we had 9 good embryos. On day 5 we had 2 blasts stage B1 and B2- hatching? What does this mean? The others were behind, and on day six they said we had 2 more blasts of ok quality. They did not think they would survive freeze and thaw.Is it normal to go from thirteen to two.? Is this genetic, or lab? Please help. Should we look to another clinic?

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On average, for a 33 year old, I would expect about 40% of the embryos to make it to the blastocyst stage. That would be 5 in your case. You had 4. That is within the expected range. However, for someone your age with no contributing male factor, I would have expected that all of the blastocysts would be of good quality. The dimished quality of the blastocysts was probably due to abnormal genetics of the sperm (not the eggs). When sperm from severe male factor patients is used for ICSI, I often see a decrease in the porportion of embryos that reach the blastocyst stage and a decrease in the quality of the embryos that do make it. I published on this a number of years ago and this observation has been verified in other studies.

I think you were wrongly led to believe that IVF/ICSI would solve all your problems. Fertilizing the eggs by ICSI is easy and fertilization rates are high even in severe male factor cases. However, sperm used for ICSI in severe male factor cases, even though they look morphology normal, are often genetically abnormal. This causes the lower than expected blastocyst rate. Unfortunaely, this fact is often omitted when preparing patients with severe male factor for IVF, presumably so the patients will remain positive and upbeat about the treatment. This leads to unrealistic expectations and subsequent disappointment.

The same is true for telling patients that they are stimulating "beautifully" or that they are responding "like a 16 year old" or that their endometrium looks "fantastic". It builds up unrealistic expectations and if the cycle fails to generate a pregnancy, the patients feel betrayed and angry. I wish that doctors would be more realistic with patients, stop using superlatives, and stop worrying that they will be scared away by the facts.

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[quote author=Dr Smith link=board=6;threadid=2196;start=0#21093 date=1151410335]
On average, for a 33 year old, I would expect about 40% of the embryos to make it to the blastocyst stage. That would be 5 in your case. You had 4. That is within the expected range. However, for someone your age with no contributing male factor, I would have expected that all of the blastocysts would be of good quality. The dimished quality of the blastocysts was probably due to abnormal genetics of the sperm (not the eggs). When sperm from severe male factor patients is used for ICSI, I often see a decrease in the porportion of embryos that reach the blastocyst stage and a decrease in the quality of the embryos that do make it. I published on this a number of years ago and this observation has been verified in other studies.

I think you were wrongly led to believe that IVF/ICSI would solve all your problems. Fertilizing the eggs by ICSI is easy and fertilization rates are high even in severe male factor cases. However, sperm used for ICSI in severe male factor cases, even though they look morphology normal, are often genetically abnormal. This causes the lower than expected blastocyst rate. Unfortunaely, this fact is often omitted when preparing patients with severe male factor for IVF, presumably so the patients will remain positive and upbeat about the treatment. This leads to unrealistic expectations and subsequent disappointment.

The same is true for telling patients that they are stimulating "beautifully" or that they are responding "like a 16 year old" or that their endometrium looks "fantastic". It builds up unrealistic expectations and if the cycle fails to generate a pregnancy, the patients feel betrayed and angry. I wish that doctors would be more realistic with patients, stop using superlatives, and stop worrying that they will be scared away by the facts.
[/quote]We were told the Blasts transfered were a one and two and that this was good. They also stimulated me very slowly with low dose meds. Is it unrealistic of me to think that we could have had more mature eggs with higher dose meds? Given all this information, if this cycle does not result in pregnancy would you search out another IVF center?

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Dr. Smith,
Thanks. As for genetic reasons for not becoming blasts, is this true even if all genetic testing was normal? On our next round would you consider PGD? What about varicolcele repair for severe male factor. We were given conflicting information. One urologist said he should have the surgery and it would get us to the insemination stage instead of ICSI. The next guy said that he could probably improve his count, but realistically a count of 3 million even doubled would not get us away from ICSI. He recommended ICSI first if that was our first priority and varicocele repair later for possibly a second child. What are you thoughts?

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The "B" in the "B1" and "B2" grading of the blastocysts suggests they were second grade embryos (i.e. assuming A1 is the best). That is what I was referring to when I brough the point about the sperm's genetic contribution to blastocyst development.

A slower stimulation (10-12 days) is perferable to a shorter stimulation (less than 9 days). Stimulation for more than 12 days can lead to post-mature eggs. A slow stimulation allows for better egg maturation. So, no, a shorter stimulation with a higher dose of medication would not have resulted in more mature eggs - probably the opposite.

With the exception of presenting an overly optimistic picture, I think they handled your case as well as can be expected. I see no need to move to another program if this cycle fails. Every sperm and egg combination is unique, so you may do better on a subsequent cycle.

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