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onova - November 27th, 2006 10:51 PM

Hello,

IVF #2 ended with a negative beta last week. The staff at our clinic are meeting to discuss what they suggest as next steps tomorrow. In the meantime, I am trying to gather information and questions to ask upon our next meeting.

In a nutshell:
ME 36, DH 32--MFI (moderately low counts and morphology, consistently poor motility)

IVF #1
On Micro-dose lupron flare, only my right ovary responded. 8 mature oocytes retrieved, 6 fertilized with ICSI. Transferred 3 "lovely" 8-celled embryos on day 3. 2 continued to become blasts, though not high enough quality to freeze. BFN

IVF #2
Same protocol, different meds. Retrieved 10 mature oocytes (from both ovaries). 6 fertilized with ICSI. Transferred 2 "lovely" hatching blasts on day 5 and one pre-hatching. Froze 2 blasts. BFN

So, with NO implantation, the fear is just that the embryos are BAD, even though the embryologists indicate they developed normally. Is there anything I should be asking about more? What about further testing? PGD? Immune testing? Karyotyping? Sperm DNA fragmentation?

Thanks so much for any insights/advice you can provide.
O

Dr Smith - November 28th, 2006 12:29 PM

I agree with the embryologist. The embryo development and blastocyst rate/quality are all within what I would expect for a patient your age. One of the advantages to blastocyst transfer is weeding out the "lovely" Day 3 embryos that arrest development. You can't tell which ones will get over the Day 3 hump until you look on Day 4. Day 3 transfers are a crap shoot 'cause the developmental potential of the embryos is unknown. Your second cycle was better than expected (for your age) with 5/6 making it to the blastocyst stage and of good enough quality for transfer and cryopreservation. There does not appear to be an issue with sperm DNA fragmentation. Karyotyping doesn't make much sense either because the impact of anueploidy is either on Day 3 or later on during the first trimester.

That leaves "the luck of the draw" or an implantation problem. Is the endometrium of adequate thickness? >8mm is O.K. I would recommend immune testing to rule out "rejection" of the embryo. If there is an immune problem, it can be treated. You should have this testing done before proceding further. WARNING! Some REs do not believe that immune problems contribute to reproductive failure. They will not perform the testing. I disagree, but that's only my opinion.

The nest step is the FET (after the testing). If that fails, I would suggest one more IVF cycle. If that fails, cross that bridge when you come to it.


onova - November 28th, 2006 6:54 PM

Thank you so much for your reply.

I just got a call from a not very confident or informative nurse. She said that the docs decided at their weekly meeting to recommend karyotyping for both DH and me. When I asked why, she only offered that it was because of the 2 negative cycles. She could not answer my more specific questions.

I then asked if I could do a "natural" FET before that testing and she was unable to approve that. . . Frustratated, I asked to speak with someone who could further explain the panel's recommendation of genetic testing. Now I am waiting to hear back from my RE or someone who can help explain the theory better.

BTW, my lining was 11 or so at the final pre ER/ET scan and looked "perfect" on ET day. I am positive for ATA, but have not had a full immune panel. My protocol did involve daily baby aspirin, and medrol between ER and ET.

DH and I need to stop treatment at some point, of course. And, without knowing what, if anything other than bad luck is preventing IVF from working for us, it is difficult to go on, as it is to stop.

Again, thanks so much for your response. I am curious about your statement regarding the timing of the impact of aneuploidy--is this common understanding that my clinic should be considering?

O

Dr Smith - November 29th, 2006 1:12 PM

Karyotyping may provide some useful information, but, in all likelihood, it will be normal and you will be no farther ahead. I still recommend immune testing, but they might not jump at the chance.

The timing of the impact of anueploidy during embryonic development is is relatively common knowledge amongst senior level embryologists. The technical term for the Day 3 developmental hump is "activation of the embryonic genome". This is when the combined sperm and egg DNA becomes very active in directing the embryo's continued development (or arrest as the case may be). Physicians (RE's) do not receive formal training in human embryology and often have only a rudimentary understanding of embryonic cell biology. In many programs, the physican is in the driver's seat and does not necessarily take the embryologist's opinion/recommendations to heart. RE's are often more interested in clinical management than basic science. Too bad, since it combination of both medicine and basic science that drives IVF.

The success rates for controlled FET cycles and natural FET cycles is virtually the same. Controlled cycles make things more convient for the physians and lab staff. There is no reason why you shouldn't be able to request a nutural cycle FET. However, for scheduling reasons you doctor may be reluctant.


onova - December 27th, 2006 3:40 PM

Thanks for the useful information, Dr. Smith!

Unfortunately, it looks like the FET yeilded the results we have been getting used to. Both of our blasts "survived" the thaw, but like the other cycles, failed to do anything (that I know of) once inside of me. . .

We are trying to decide whether seeking more information (another professional opinion, more testing) makes any sense when it does look like we make "bad" embryos. This should be working, and it is not. I will look into the immune testing through our GP. It is so hard to decide if it is time to stop trying!!!

O

Dr Smith - January 8th, 2007 2:15 PM

Best of luck. As in many endevours, persistence usually pays off (as long as you don't do exactly the same thing each time).

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