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KJar - November 27th, 2006 5:48 PM

Dr. Smith,
Thank you so much for your time, I have truly learned more from this site than going to the RE for the last 5 months. I am 37 and my DH is 33. We have been TTC for 13 months. The first 7 with timed intercourse, then onto the gateway drug clomid, then the needles. We had one failed medicated IUI cycle, before I decided to move to IVF. Besides my age, we have a MF problem with low count, 20 miliion and low morph 18. DH has taken 3 SA in the last 7 months with very little variation. The doctor recomended ICSI.
We had the ET on Thanksgiving, I had to push for a 5 day transfer. I had a Lupron/Bravelle/Menopur 11 day protocol. They retrieved 10 eggs, 9 mature from 14 follicles, 7 fertilized. On day 3 there were 5 grade 3 (4 being best) at eight cells with 1 six cell and 1 five cell. The 5 grade 3 had slight fragmentation. When we went in for the transfer only one embryo was an expanded blast. They decided to put the other two morulas in as well. I did not ask their grade, too nervous I think to ask questions. Of the other 4 left, the embryologist did not feel they were worth freezing. Two had dark spots and were degenerating and the other two were too far behind.
Could the high attrition be caused by a sperm DNA factor or is it my age? Should we have waited until day six to see if the morulas caught up? We can only afford two cycles so I am second guessing all of my decisions. Plus, I seem to have been invaded by a body snatcher, these hormones are really doing a number on my normally good cheer.
Again, I can't thank you enough for your opinion. KJ


Dr Smith - November 28th, 2006 11:36 AM

The stimulation sounds fine. The number of eggs retrieved, the of number mature eggs and the fertilization rate are all within the expected variation. On average, for your age, I would expect around 3 of the 7 embryos to make it to the blastocyst stage by Day 5-6. You weren't that far off the expected rate because once an embryo reaches the morula stage, it usually goes on to become a blastocyst. But, the quality/grade/developmental potential of the blastocyst stage embryo is also important and we don't know that. The only exception to this is when there is a severe problem with the sperm. Then, more than the expected number of embryos crash at the morula stage. In your case, the sperm problem does not appear to be severe.

Embryo development during IVF is like a horse race. They all start out of the gates at the same time, but during the course of the race, some fall behind and some finish the race just behind the winner - win, place, show. O.K., so they didn't win, but they still finished the race.

I think you have reasonable chance of success, so hang in there.

P.S. Morulas are not graded. A morula is a morula is a morula. So, even if you did ask, they wouldn't have been able to tell you very much.


KJar - December 6th, 2006 10:42 PM

Dr. Smith,
Thanks so much for your quick response to my first questions. I had my blood test a few days ago and it was a BFN. My consultation is tomorrow and I am not quite sure what to ask of the doctor before we try the second cycle. The stimulation phase went smoothly, and so did the retrival and transfer. After the transer though I had mild to heavy cramps for 7 days. As this will be the last cycle for us, is there anything we should rule out beforehand? I do not have PCOS, I am 37 with normal range FSH. MY DH has low but not severe sperm count and morph. Should I just chalk this up to the luck of the draw or could there be something we haven't checked? My RE waves off any suggestion of further sperm testing since the count isn't severe. I'll get the grade of the blast that was transferred tomorrow. Thanks again for any guidance you can offer.
Kristin

KJar - December 6th, 2006 11:00 PM

So sorry, two more questions. I have read that you do AH right before the transfer, I had a 5 day transfer with the AH done on day 3, could this make any difference? Also, would it be wise to split the eggs with 50% ICSI and then try mother nature with the others? I am so concerned that this next cycle will be a failure as well with no explanation. I greatly appreciate your opinion. KJ

Dr Smith - December 7th, 2006 12:54 PM

The "hole" made in the zona pellucida when hatching on Day 3 is generally smaller than the hole made on a Day 5 expanded blastocyst. The possible consequences of hatching on Day 3 is that subsequent manipulation on the embryo in the lab could cause one or more cells to "pop" out of the zona pellucida. This would be unlikely, but sh** happens. The other possible consequence is that the expanded blastocyst gets hung up trying to get through the smaller hole when hatching. I also think this is unlikely. Aside from those small concerns, Day 3 hatching is probably fine.

I would not recommend trying conventional IVF insemination and would stick with ICSI. I think there are enough red flags about the "fertilizability" of the sperm to warrant ICSI.

KJar - December 7th, 2006 1:33 PM

Thanks for your input, I'll keep you posted. KJ

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