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caschere - November 29th, 2006 1:20 PM

Dr Smith

I am 34 yrs from Buenos Aires Argentina. Normal day 3: FSH (6) LH (3) and actually I have all the blood test normal (estradiol, LH, FSH in day 3 and day 13) I have normal u/s in uterus and ovarian and I am normally ovulating every month arround day 13. My husband had a varicocelle and low motility and was surgery removed 3 yrs ago. I did 5 IUI negatives.
1st IVF Oct 2003- Long Lupron and started 200 Gonal-F, follicles grown very slownly so they did increase to 300 gonal from day 7.
9 oocytes retrieve, 7 were mature but none fertilization by ICSI (embriologist said oocyte cytoplasm immature).
2nd Jan 2004. During my natural cycle without any meds when my own follicle reached 17mm HCG shot. 1 oocyte retrieved, ICSI, 1 embryo 3day 7cells transfer. Normal pregnancy my baby borned in Oct 2004. Now she is 2 yrs old.
I am trying to have a 2nd baby, but with natural cycle in 4 oportunities they could not obtained the oocyte during the retrieval procedure. They did several washes and the oocyte did not come.
I did last month IVF long lupron 300gonal-F in day 7 we added 75 Menopur. I want to tell you how was my response to this stim. During the first days of the stimulation with gonal-F only, the follicles did not grow very much and in day 7 were less follicles than in day 5 and were in size about 12mm. When we added Menopur (day 7) we did an u/s day 9 and the response was really different, much more follicles than day 7 and bigger in size, actually 2 day latter we did the HCG shot when at least 4 follicles 18 in day 11. We got 12 oocytes, 9 mature, ICSI 6 fertilized, only 2 good embryos that were 2day transfer (4 cells). 1st beta 13dpt106, 2nd 163, 3rd 224, 4th 224. Stop meds. Beta is 7 days later in 150 so is comming down slownly ( may be It was ectopic or I do not know).
Questions:
1)Why we could not get the oocyte from my natural ovulating cycle and when is the best day to do HCG shot ( once I did later and I ovulated).
2)Why I do not have good results with stimulations IVF. It seems that again in the 2nd IVF I also had an oocyte maturation problem. Do you think that when we added Menopur my follicles grown too fast? Do you think I could try an stimulation just with Menopur , because it was really noticeable the follicle size and number when we added menopur compared with gonal only.
Suggestions
Kindly
Carolina

Dr Smith - November 29th, 2006 1:39 PM

I agree with the embryologist that the reason for the failed fertilization following ICSI on the first cycle was likely due to inadequate cytoplasmic maturation. As far as your other questions regarding the stimulations and natural cycles, I will forward your post to Dr. Jane Miller, the Reproductive Endocrinologist I work with. I think she will be able to interpret what happened better than I.

caschere - November 29th, 2006 1:50 PM

Thak you very much for your response. Another thing is that during the screening fertility issue in 2003 we did also a Laparoucopy and they found a minimal endometriosis but one Dr. said that in 50% of healthy women who practice a Lap usually found minimal endometriosis so he did not think that this would be the couse of our fertility problems. Onother Dr. said that endometriosis could be one contribuiting factor. Do you think I should do again a Lap to see if I have again some endometriosis?

Dr Jane - November 30th, 2006 3:17 PM

Hi Carolina,
As women get older it is not ucommon to find empty follicles. However we usually see this in women in their late 30ies or 40ies and not at 34. On a natural cycle the optimal time to retrieve is 36 hrs after HCG. I do believe that a stimulated cycle is more likely to work for you at your age than a natural cycle. Your last stimulated cycle produced a pregnancy - albeit unsuccessful. Remember that you are older than you were when you conceived your child and you have written that there is also a "male factor". The early loss was probably nature's way of stopping the growth of a pregnancy that was not geneticlly normal. Early losses are also more frequent as women age.

On a cycle down-regulated withe Lupron you need LH as well as FSH for optimal stimulation. The LH is best begun at the same time as the FSH - not added after. the requisite # of stim. days to effect cytoplamic maturation is usually 10 - 12. A 9 day stim. is occasionally ample.

caschere - November 30th, 2006 3:28 PM

First of all thank you for your complete and clear response.
My last question is: Taking in to account that my 1st failed IVF (2003) with no fertilization at all stimulating with Gonal-F only. Do you think I could try an IVF protocol just with Menopur and anagon insted of long lupron + gonal-F+menopur. Because my follicles increased in size only when we added menopur.
Many Thanks

Dr Jane - December 1st, 2006 8:48 AM

Sure that is possible but with Antagon instead of Lupron follicular dyssynchrony may occur. You were concerned about cytoplasmic maturation: smaller follicles are more likely to yield immature eggs. Follicular dyssynchrony doesn't happen to everyone but, because it is not infrequent, IVF cycles are usually executed with Lupron to avoid this occurrance. All follicles need FSH to initiate growth so it is advisable to combine an FSH product with the LH containing one . We have had excellent results using a mixed protocol with Menopur and Bravelle.

caschere - December 1st, 2006 9:55 AM

Bravelle is not recombinant fsh and is from the same lab as menopur (Ferring)?
In my last IVF I was on 225 puregon + 75 Menopur, I understand that you said is better to start both together. If I use Bravelle + Menopur in which dosis you suggest to use it?
Many thanks

Dr Jane - December 5th, 2006 1:42 PM

Hello Carolina,
Yes, Ferring manufactures bothe Menopur and Bravelle. I vary the doe with the patient depending upon follicle count, weight, and prior response. Generally, though, I begin with 3 Bravelle and 2 Menopur vials for the first 3 days. Then I adjust accordingly.
Yours,
Dr. Miller

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