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Six days is a very short stimulation. Although the follicle size was appropriate for hCG, I think the stimulation was too short to allow adequate cytoplasmic maturation of the eggs. ICSI may improve fertilization, but I anticipate slow embryonic cell division and porportionally fewer embryos reaching the blastocyst stage. I expect if its a Day 3 transfer, there will be only a few 8-cell+ embryos available. The other embryos will probably arrest development early. Unfortunately, many REs do not consider cytoplasmic maturation of the eggs as a factor in the stimulation. They often go entirely by E2 levels and follicle size. Although follicle size and E2 levels are related to egg maturation, it is only an indirect method of assessing the cytoplasmic maturity of the eggs. In these situations, the lab is playing catch-up all the way. However, it may still turn out to be O.K. because donors produce a larger number of eggs, so there is some margin for error.

Why on earth was the donor given estradiol at the beginning of the cycle? I've never heard of that before??

High E2 is associated with poor egg quality, but it is not a direct cause and effect. We usually see excessively high E2s in PCOS patients and they have poor egg quality. Your donor situation is a bit difficult to interpret. So I don't know what effect the early elevation of E2 will have on the egg quality.

OHSS is difficult to predict. Some women with high E2s do fine, others develop OHSS. Some women develop OHSS even at low E2 values. Bottom line: who knows?

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Hello Dr. Smith,

Thanks for your response. As to your question about the estradial, I'm not sure about that... Perhaps some type of estrogen priming or something (Really don't know)... A follow on question I have though regarding cytoplasmic maturation is whether or not the days PRIOR (THREE with estradial plus TWO without) to when she started the stims would factor into the time required for the maturation process - since follicular development was taking place during this time?

I guess I'll really know the answer to the above questions on Friday, which will be the 3-day mark... This is an unproven donor, so I guess they really had no way of knowing that she would stim so fast, although I think they had her on some fairly high doses of GonalF...

BTW, these were follicle sizes:

After 4 days of stims:
On the right, there is a 15, 2 @ 14, 3 @ 13, 2 @ 12, 4 @ 11. On the left there are 2 @ 13, 4 @ 11

After 5 days of stims:
On the right is 18,17,16,15x2, 14x2,13x4 and on the left we have 17x2, 16x2,15x3,14x5, and a 13

Thank you very much.

WannaB

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The endogenous estradiol (not the exogenous estradiol given to the donor) is an indication of the progress of folliclicular maturation. Follicular maturation is an idirect measure of egg cytoplasmic maturation. The clock for follicle maturation (and therefore egg maturation) does not start until the follicle begins to produce estrodiol (i.e. endogenous estradiol). In other words, those first few days when the follicles did not respond to the FSH and did not produce estradiol don't count towards the overall cycle length.

By some criteria, the follicle size on day 5 of the cycle is appropriate for the hCG trigger, BUT I think they should have waited for additional follicular growth/egg maturation before the trigger.

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Dear Dr. Smith,

You are providing a wonderful resource here and I really appreciate you taking time to respond. Just want to give you an update on my cycle so far. All appears to be going well. I have a young donor (21) so perhaps because of this, her eggs were able to circumvent the fast stimming...

She actually stimmed for 7 days (got clarification from doc) and results are:
40 eggs retrieved
30 eggs mature and ICSI-ed
25 eggs fertilized

At day 3 (today):
1 egg didn't divide
2 eggs had very slow growth
This left 21-22 eggs in the 7-12 cell range. The embryologist told me that several of them were compacting too.

I will update again after transfer (in 2 days) and with results (positive/ negative preg test). That way we capture the complete chronology here, as I always hate when I read these sorts of things and you don't know the end of the story.

Take Care, Wannab

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Seven days of stim is better than 6. Notwithstanding, the fertilization rate (62% even with ICSI) was lower than the 80% expected. I'm glad they performed ICSI, otherwise the fertilization rate would have been even lower. Compaction is a good sign, but the end point is blastocyst development. I would be interested in knowing how many made it to the blastocyst stage and how many of those were either transferred or frozen. In a donor egg case, the expected blastocyst development rate is about 60% of Day 1 embryos. In the end, they only need to transfer two good quality blastocysts in order for you to have a decent chance of pregnancy. If you are pregnant, the rest is academic.

So, are you going to keep us in suspense, or what?

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Hi Dr Smith - lol,

Didn't mean to keep you in suspense... I was on bedrest yesterday after transfer... BTW,my clinic calculates fert rate relative to the mature eggs only. Hmm... I guess clinics do things differently... Anyhow, drumroll please ...

On day 5:
2 blasts (5AA, 5AB) transfered. Both had thinning edges, showing that they were getting ready to hatch - per the embryologist.

3 more blasts were close in quality to the ones above. They were frozen yesterday.

7 additional blasts were a tier below the 5AA and 5ABs, but very good too (didn't give me gradings). They were frozen yesterday.

3-4 were "iffy" and will be evaluated today. I'll find out the final tally tomorrow.

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Hey, not bad! O.K., call me Doctor Doom 'n' Gloom... Looks like all my fears were unfounded. It just goes to show how difficult it is to predict outcome. The biological variation in reproduction is high and every case is different. Thus predictions based on averages can sometimes be way off. Looks like 7 days of stim was adequate for egg maturation in this case, although I wouldn't recommend it for every donor cycle.

I stand corrected. I made a mistake in calculating the fertilization rate. They are correct to use mature eggs as the denominator. That's what I do too. Accordingly, the fertilization rate of mature eggs was 83% - right on target. Oops.

Your chances look good. Best of luck.

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Hey Dr Doom and Gloom - giggle... You actually weren't that far off the mark. It turned out that 3 eggs were indeed frozen on day 5, but the other 7 were left to grow a bit more to day 6, along with the "iffer" ones... The net of it is, 7 total were frozen. So we had...

40 retrieved
30 mature
25 fertilized
9 blastocysts (2 transferred, 7 frozen)

Even the doc admitted that 7 days was short...

Not to be greedy, but the 9 does seem like a rather low yield to be... I can't complain one iota though, because I did get a POSITIVE BETA, so I'm pregnant!!!

Thank you Dr. Smith, you're GREAT!

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Congrats!

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