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Hello,
I am 38 years old. Never pregnant. My fsh levels at day 3 blood tests are low but i am responding poorly to stimulation drugs/shots. For my 1st ivf i produced 4 follicles and had three immature eggs, with icsi they all fertilised at 8, 7, & cell with qualities of B&C's. The 1st ivf failed. For the 2nd ivf, I produced 5 follicles and 5 immature eggs. I am currently in my 2nd ivf stage ready for ET tomorrow morning. For 2nd IVF, there are 3 embryos with ics with 2, 6-cell and 1, 7-cell embryos with C qualities. My RE took my estrogen levels at 200 for 5 follicles which were at 20mm leading when I took my hcg shot.
My questions for you are: Why am I responding so poorly to the stims meds to produce few eggs?
Since all of my follicles had immature eggs, does it mean that that without any fertility treatments that my eggs are immature when there is an LH surge?
Third and most importantly. Will the quality of the above embryos result in an abnormal baby or that implanting will be unlikely?
Thanks a lot.
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A1. The stimulation medications (FSH/LH) do not make more follicles [i]per se[/i]. That is to say, taking more more medication will not make more follicles. At the begining of a cycle, a certain number of follicles get "recruited" into the growing pool of follicles. We do not yet completely understand the mechanism of recuitment and have no medications that target the process. Accordingly, whatever starts growing is all that there's going to be on that cycle. By day 5-6 of a natural cycle, one follicle establishes dominance and the remaining follicles undergo a process called atresia (they die off). The stimulation medications (FSH/LH) act to sustain the growth of all the follicles that begin to grow on that particular cycle and prevent follicular atresia. So, there is no clear answer to your question about why you do not recruit more follicles on a given cycle, even when your FSH is normal (indicating a normal ovarian reserve). Unfortunately, its just how you are and we don't currently have a way to make your ovaries recruit more follicles on a given cycle.
A2. Probably not. The high proportion of immature eggs at the time of retrieval is a bit of a puzzle. As long as the stimulation was an adequate length (minimum of 9 days) and the peak estrogen level reflected adequate folliclular maturation (about 150-200 pg/ml E2 per mature follicle; i.e. >16 mm) and the retrieval was timed appropriately (between 34 and 36 hours after hCG, then it should have been fine. When the stimulation is adequate, we expect about 80% of the eggs to be mature at the time of retrieval. We did have a patient once that did not respond to urinary-derived hCG and all her eggs were immature at retrieval (twice!). We change to a recombinanat hCG product for the third cycle and more (but not all) of the eggs were mature. It seemed that most patients respond to urinary-derived hCG, but the occasional patient does not. You may want to discuss with your doctor or about switching brands of hCG (from recombinant to urinary-derived or vice versa).
A3. As always, its difficult to predict from Day 3 cell stage and morphology grading. Abnormal embryos rarely develop to the point where they can attach and implant (blastocyst stage). So it is highly unlikely that these embryos will result in an abnormal pregnancy (although I never say never), in the worse case, they will just stop development shortly after transfer.
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Hi Dr. Smith,
Thanks for the reply. In regards to the immature eggs at retrieval, all of the procedures you mention above were taken. As this was also my 2nd ivf with immature eggs. During my 1st ivf, I also had 4 immature eggs. I am still waiting to see if i am pregnant.
My concerns grow as the days to the pregnancy test. The competentency of my re is on my mind since she was completely baffled about the immaturity of the eggs (for both my ivf cycles). I feel that I will never get pregnant at this rate.
Since we also attempted 2 iui's before moving on to the ivf cylces, could the trigger shot issue haved caused my eggs to be immature during these 2 iui's?
If I undergo an iui for the next cycle, is there a chance that I could bypass the trigger shot? Or is having an hcg trigger crucial once you have been stimulated? Or is it a matter of scheduling convenience? Can my body detect that my follicles are mature and ovulate on there own?
Thank you so much for being out there.
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Yes, the eggs from the IUI's may have ben immature as well.
Yes, your body can "sense" when the follicles are ready to ovulate. However, if you try to rely on your own endogenous LH surge to cause the final maturation of the eggs and ovulation, it might not work. The hCG trigger shot is a much higher amount of the LH analog than your pituitary gland would normally relase. Its not just convenience, it is to ensure there is enough LH to go around.
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Sorry, but it is impossible to predict the fate of embryos that have not progressed beyond the 8-cell stage. The 4 to 8-cell division is a crucial one, as this is when the majority of genetically abnormal embryos arrest development. When embryos are transferred on Day 3 (before they exceed the 8-cell stage of development), its simply impossible to predict post-transfer embryo survival.
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Dr. Smith, you are giving me something to think about and I guess I should be questioning my dr. I am still hopeful and faithful.
thank you
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