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kiwi - September 22nd, 2006 11:41 AM

Good Morning Dr. Smith,

I've been reading your post for these days and your expertise and experience are very impressive to me...
I do hope that you can give us some advice on our case...

All ICSI's (Male Factor)
Here is some history...

1st IVF (3/11/06)
# of oocytes retrieved: 21
# of oocytes ICSI: 10
# of oocytes fertilized: 10
# of embryos transferred: 3 (day 3)
(one 5 cell, two 4 cell embryo)
# of embryos frozen: 0

2nd IVF (5/28/06)
# of oocytes retrieved: 23
# of oocytes ICSI: 17
# of oocytes fertilized: 12
# of embryos transferred: 3 (day 3)
(one 8 cell, one 7 cell, one 5 cell embryo)
# of embryos frozen: 0

3rd IVF(9/3/06)
# of oocytes retrieved: 17
# of oocytes ICSI: 12
# of oocytes fertilized: 12
# of embryos transferred: 3 (day 3)
(one 9 cell, one 6 cell, one 4 cell embryo)
# of embryos frozen: 1

I was very probably over stimulated by taking Gonal F (225u twice per day) and Lupron (10 u per day) for our 1st try. I had over 30 follicles but only retrieved 21 eggs.

And for 2nd IVF:
I was given half the dose of Gonal F (150u twice per day),.... and half price as well!

However, it might have been too close to the first try (within 1 month). This time I had ~26 follicles and retrieved 23 eggs.
My 1st and 2nd IVF were all with the same IVF clinic.

3rd IVF: We changed to a new IVF clinic for our third try
I was taking Gonal-F (150u twice per day) and 10u Lupron and I had ~18 follicles and retrieved 17 eggs.

We now still have one frozen day 6 blastocyst embryo left and I do know that our chance is slim since they put the best quality embryos into my uterus on day 3 and what was left were either 4 cell or less embryos of unknown quality.

But why did the "best quality" embryos not implant in my body and one 4 cell or less embryo can make it to the blastocyst stage?
What do you think of our chances?

I wish I would have tried to go for Blastocyst stage but based on my first two failure IVF, I would not dare to give it a shot since all the leftover embryos did not make it to the blastocyst stage.

Do you think that I have embryo quality or implantation issues? Should we try the day 5 transfer if we start a fresh IVF next time?

We are eager to have second option before we see our doctor next Tuesday.
Your advice will be very much appreciated by us.

Thank you so much!
Susan
p.s. I am 36 yrs old and my FSH level is 7(good responder)

Dr Smith - September 22nd, 2006 3:33 PM

Ran out of time today (Friday). Will try to answer all your questions over the weekend or on Monday.

kiwi - September 22nd, 2006 4:45 PM

Dear Dr. Smith,
I'd like to ask a few more questions about my third IVF:

1. I had some spotting since 9/14 followed by a negative pregnancy result on 9/17. I've been spotting on and off for almost 6 days until 9/19 which is weird to me since my period is very regular ("light-heavy-light")...i also had constipation, mild cramps and headaches those days...I am wondering if these symptoms are normal? and what is the cause?

2. I have also experienced cold and hot flashes for few days ago right before the pregnancy test...does it mean my hcg levels are going down?

3. I had failed ivf before(mentioned in my previous message) and never got spotting like this time (just heavier period) I even thought that spotting was due to implantation :( forgive my wild imagination...does it mean i was getting closer this time? i even got a 9 cell embryo on day 3 and one non transferred embryo made it to the blastocyst stage for freezing ...I have only had 8 cell embryo for day 3 and nothing could make it to blastocyst stage before ...( I was probably over stimulated before though)...
Have a nice weekend!
susan

Dr Smith - September 26th, 2006 12:24 PM

It would appear that there is an embryo "problem". I think it is related to the number of follicles developing on these cycles. Contrary to what you may think, more eggs is not better. The optimal number of follicles/eggs developing on a stimulated cycle is 10-15. When there are too many follicles developing (as in PCOS), the egg quality is compromised. This manifests in delayed are arrested development of the embryos. There may not be anything anybody can do about this. You have tried lower dose protocols to try to slow down the stimulation and keep the E2 within a reasonable range. But these have not improved egg quality. Alternatively, there may be an implantation problem. To determine if this is the case, additional immune and clotting factor testing would be necessary. You can discuss these options with your doc.

You second post is more medical in nature and out of my field of expertise. Please repost on Dr Jacob's mesage board.

kiwi - September 26th, 2006 9:19 PM

Dear Dr. Smith,

Thank you so much for your replies.

After discussing our latest cycle with our doctor this afternoon, she said that she doesn’t know the reason for our not getting pregnant. The embryos seemed to be fairly good quality, but they grew somewhat slower than normal (all were 2 cells on day 2 but all were at least 4 cells on day 3) Most had less than 10% fragmentation. My uterine lining was good (11 mm on the day of transfer) and my hormone levels were all good (estrogen almost 4000 on the day before transfer.

Our doctor agreed with our wish for a day 5 blast transfer. She didn’t like a straight day 5 transfer because she feared no embryos would make it to day 5, but since we already have a frozen day 6 blast, we could thaw this for our next transfer. With my history, how long should we wait before we start another cycle? Can we start after one more period or should we wait longer? Our second cycle was started with only one month of rest, and since I believe I was overstimulated on my first cycle, perhaps the second cycle wasn’t indicitive of what is typical. Could we have started the second cycle too soon? What should we do with our next attempt? Based on you experience and our history, do you think we will have any embryos surviving till the blast stage?

Thanks again, we really appreciate your advice.

kiwi - September 27th, 2006 10:26 AM

By the way, our doctor will lower dose protocols to 225u.per day instead of 300u per day...thanks, s.

Dr Smith - September 29th, 2006 10:08 AM

In most patients, back-to-back cycles do not cause any problems, but in your case, your extrogen was pretty high. It might be prudent to wait another cycle and let things calm down a bit (i.e. 2 cycles in between). I know you're in a hurry to get pregnant (as is everybody here), but you also want the next attempt to be optimized.

Most docs are reluctant to agree to blastocyst transfer after an IVF failure for the very reason you gave - afraid there will be nothing to transfer. The logic in this is flawed. If no embryos make it to the blastocyst stage in the lab, then there's something wrong with them. Transferring embryos that have something wrong with them won't make them "right". So what's the point of putting a patient through the two week wait, progesterone shots, etc. when the outcome is already known? Also, instead of giving the usual lame response "I don't know why it didn't work. Lets just try another cycle" your doc may be able to provide a difinitive answer for an IVF failure if the embryos do not develop to the blastocyst stage. Duh.

However, in your case, I think that it is very likely that some of your embryos will make it to the blastocyst stage. Based on your history, it may take until Day 6, but some'll make it. At least then, the question of the embryo's developmental capacity can be answered. Lots of pregnancies result from Day 6 trnasfers.

Best of luck.

kiwi - October 2nd, 2006 10:32 AM

Dear Dr Smith,
Thank you so much for your advice. Have a great day!
S. Song

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