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The live birth rate for IVF using testicular sperm is lower than that for using ejaculated sperm. In your age group, you could expect the chances of taking home a baby from IVF of about 20-30% per attempt. The more eggs you produce on the stimulated cycle, the better your chances. I would suggest that you try to culture the embryos to the blastocyst stage prior to transfer because, when testicular sperm are used, embryos may arrest development after the sperm DNA kicks in on Day 3. By waiting until Day 5-6, you can be sure that the embryos transferred are of good developmental potential.

Best of luck.

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Dr. Smith,
I was under the assumption that b/c my dh produces mature sperm that by using Mesa that was what would be extracted? Am I wrong on that? Thanks for your insight.


Sylvia

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It depends on the presference of the urologist and whether or not mature sperm can be obtained from the epididymus. The use of epididymal sperm is preferable, but the success rate is still lower than fresh, ejaculated sperm.

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I am 39 and have failed one icsi trial. We had to do icsi because my husband's sperm do not swim well - he is post chemo. All of my pre icsi trial tests were normal. 1 grade a embryo and one grade b embryo were transferred on Day 3. I am confused as to why it did not implant - as I thought our prognosis was pretty good. What questions should I ask my physicians when we meet with him next week?

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There may have been an effect of the chemotherapy on the gentic material of the sperm. When there is a problem with the gentics of the sperm, it shows up after Day 3, not before. So one possible explanation for the failure is due to the sperm genetics.

What appened to the remaining embryos? Did they grow them to the blastocyst stage for freezing? Were they frozen on Day 3? Were there no embryos of adequate quality for freezing? The ansers to these question would be helpful in assessing a heretoforth unknown "egg problem". Remember, all the tests performed prior to the egg retrieval tell us nothing about egg quality. That we discover only be retrieving the eggs and fertilizing them in the lab.

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Dr. Smith
Thank you for your reply and let me give you more info. I was not very clear in my original message. I am a 39 y.o. physician. My pre-cycle eval was normal - fsh-5.3, estradiol-53, lh-2.2. I had 13 follicles on d3 of my cycle . HSG and sonohystogram - normal. My husband froze sperm in 5/04, prior to his chemo - which finished in 10/04. We tried to conceived naturally for 6 months. We then started the above evaluation. Unfortunately, while my husband still produced alot of spserm after the chemo, those that he produced were not very motile and ther were not alot of normal forms. Therefore is was suggested that we use his frozen sperm. The pre freezing analysis demonstrated good concentaration, forward progression.
It was recommended that we undergo ICSI. I had about 10-12 follicles on the day of retrieval, however only 3 eggs were able to be retrieved. When my husband's sperm was thawed - we were told that it still had good motility and "look good". With the three eggs - all three were fertilized with ICSI. But only 2 were satisfactory for implantaion on Day 3 - one was an 8 cell Grade A and the other was an 8 cell Grade B. The third was a 4 cell Grade D and was discarded. Embro transfer occured on D3. My progesterone Level was 70 on Day 8. ON Day 14 I had the hcg which was negative. I had some spotting the night before the hcg test and by the afternoon of the hcg test had just about full flow (and before I had stopped the progesteron injections). I am slender in build.

Needless to say, we are upset and feel like we were not given info and other options that we may have been available to us - ie Day 5 transfers and assisted hatching. We did not know about thses things until we read your website.

We would be most appreciative if you could provide us with your insight to the following questions-
1.Why could the ICSI trial have failed - we though we had a pretty good prognosis?
2.At my age, should we have had assissted hatching?
3. Should we insist on Day 5 transfer? This was not discussed with us - so I assume our facility may not offer it. What is the data that this is better?
4.Since the thawed sperm were ok - would we have a better chance using conventional IVF?
5. Why could more eggs not be harvested?
6. Do people using thawed sperm in general have a lower sucess rate?

Thanks for your time in providing your advice.

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My husband has bilateral undescended testicles. Is there any chance of us being sucessful with ISCI? He is 57 and I am 35. I have never tried to get pregant but assume all is well with me.

Thnaks

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It is unlikely that sperm are being produced in the undescended testicles. Your husband should see an infertility-trained urologist to determine whether or not sperm recovery is possible. Otherwise, it using donor sperm would be the only other way.

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Reply to cde:

A1. Your prognosis is relatively good - for your age. However, you must consider that at 39, the majority of your eggs are anueploid and that, even if fertilized with good quality sperm, only about 20-30% of the resulting embryos are capable of development to the blastocyst stage. Then, each blastocyst stage embryo has only about at 25% chance of attaching, implanting and going the distance to a term pregnancy. If you do the math, you'll need at least 10 eggs to have a decent chance of beating the odds. In your age bracket, the chances of a successful term pregnancy are about 27% per attempted cycle. That means the chances of failure are 3 times that of success. First and foremost, you must be realistic about your chances.

2. Assisted hatching of Day 3 embryos has been shown to be effective in patients over 39 and those with a failed IVF attempt. I would recommend assisted hatching in your case.

3. The pregnancy rate for Day 5 transfer is about the same as that of Day 3 transfers, BUT the implantation rate for blastocysts (implantation/embryo transferred) is double that of Day 3 embryos. That is to say that if the same number of embryos are transferred (say two embryos to reduce the chances of high order multiple gestation), the pregnancy rate for blastocyst transfer is double. But that's not what happens in real life. To compensate for the lower implantation rate of Day 3 embryos, more embryos are transferred. The major advantage of Day 5 transfers is knowing (not hoping) that the embryos that are transferred are capable of attachment to the endometrium and implantation. With Day 5 transfers you get answers about the quality and developmental potential of the embryos transferred. Then, if it doesn't work, you can focus on other issues such as implantation problems.

4. ICSI is the preferred method for achieving fertilization with frozen-thawed sperm due to the decrease in progressive motility and the shortened lifespan.

5. There should have been more eggs retrieved. Somebody goofed up the stimulation, timing of hCG or the retrieval?

6. No. When ICSI is employed to achieve fertilization, the pregnancy rate for frozen-thawed sperm and fresh ejaculated sperm is equivalent.

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Thank you Dr. Smith for your reply. We met with our physician.
With regards to the stimulation, he was surprised that I did not respond well. I used follistim 225mg bid. At time of retrieval I had a 22,20, three 18and a 19 eggs. He said when the eggs get too big - ie the 22 - it is difficult to retrieve. Given my bmi of 17, he thought I would have had more follicles with that dose of follistim. He plans on increasing the dose of follistim during the next cycle, and start my daily monitoring on day 3 instead of day 6 of the stimulation. Any thoughts on this?

When I asked about assisted hatching, he said the process of doing icsi itself is like assisted hatching. He did not recommend assisted hatching with icsi, but said if it was on my mind and I really wanted to try - that he could arrange for it. Have you done assisted hatching with icsi? -- is there any data that doing assisted hatching with icsi is better than icsi alone?

I am 5'9"and weigh about 117 - ie bmi of 17? Does my weight have any prognostic significance? Should I gain weight to increase my chances of success?

I look forward to your thoughts...
cde

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More gonadotropin (FSH) medication does not produce more follicles. The FSH acts to sustain the growth of the number of follicles that have already begun growing for that cycle. It does not act to recruit more follicles into the growing pool. The follicles were on the large side at the time of retrieval and your doctor is right, when they get over 20 mm in diameter it becomes more difficult to retrieve the egg from the follicle. In those cases, docotors can re-expand the drained follicle with culture medium and "flush" the inside and aspirate again. This usually does the trick. If the egg doesn't come out with the initial aspirate, it usually comes out with the "flush". Better yet, don't let the follicles get so big before retrieval (i.e. pay closer attention during the stimulation).

ICSI is not the same as assisted hatching. In ICSI, the protein coat that surrounds the egg (zona pellucida) is penetrated a single time with a glass needle approximately 4 microns in diameter. In assisted hatching, a significant portion of the zona pellucida is removed (disolved) leaving a hole approximately 30 microns in diameter through which the blastocyst stage embryo can escape. As you can see, there's a big difference in the size of the hole. There is no data that I'm aware of to support that the small hole made during ICSI is equivalent to assisted hatching.

You BMI is within the normal range for fertility. As long as you are having regular cycles, no worries.

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Dr. Smith,
So why is my doctor increasing the dose of the fsh? If it acts to sustain growth, my follicles were on the large size already? What is the key to having a sucessful stimulation in my case?

Do you know of a web site where I can check the ratings of my center's lab/embryologist?

Once again - thank you.
cde

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This is a typical reaction to a stimulation that resulted in only a few follicles. However, it rarely makes a significant difference. There is some cycle-to-cylce variation in the number of follicles that are recruited into the growing pool. Sometimes doctors (and patients) think that because they got a couple more follicles growing on a subsequent cycle that it was becasue of a change in brand or dose of gonodotropins. Its simply not true and has no basis in science. If it were as simple as increasing the dose of gonadotropins, then everyone would get lots of eggs on every retrieval and that is simple not the case. Changing the stimulation protocol (i.e. microdose flare) can have a slightly beneficial effect on recruitment, but it won't change the number of growing follicles from, say 5 to 15. Maybe from 5 to 7 would be more realistic. We simple cannot control or the increase the number of follicles that are recruited into the growing pool at the begining of a given cycle with the tools (i.e. medications) we currently have available to us.

Embryologists and labs are not "rated" as a separate entity. All programs, which includes all the doctors and the lab, in the U.S. (and some other contries) report their success rates to the CDC. The U.S. success rates for 2002 (the most recent published) can be found at:

www.cdc.gov/ART/
ART02/index.htm

Most
programs are members of the Society for Assisted Reproductive Technologies (www.sart.org). Laboratories in the U.S. should be accredited through the College of American Pathology (www.cap.org), the Joint Commision on Accreditation of Healthcare Organizations (www.jcaho.org) or the New York State Deartment of Health (www.wadsworth.org). If you go to these websites, you can search to determine their membership and/or accreditation status.

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Hello, DR Smith! My Hb and I went through IVF In June of 05. I am 25 and my hb is 27 now. The reason for IVF was cause we had never conceived after 5 years of trying! So after 4 failed IUI's Naturally the next step was IVF. So we went through all the steps, they collected 21 eggs from me something happened to 2 of them so it became 19 perfect eggs. They put them in the petrie dish with my hb's perfect sperm to do their job. Well the next morning I get a call from the clinic telling me none of the eggs fertilized. The sperm and the eggs just sat around all night doing nothing!!! Much to my distress they offer me ICSI saying there was still hope..... I excepted not wanting it to be a total failure. So they saved what they could and surprisingly 12 of them became 5 cells. They did the transfer right away at 3 days not wanting to loose anymore time being that they lost that vital time of fertilization. Needless to say it failed I am not pg...and my hb and I are thinking about doing it again only this time with ICSI right away. After hearing my story can you give me any ideas as to what happened? I am really freaked out to do it again my only rock is that doing ICSI first is the answer. Please any advise would be very much appreciated. This was a very weird scenario the first the clinic had ever experienced. I guess I am feel silly for not doing ICSI in the first place. Thank you for listening, I look forward to your response when you get back from your vacation. Merry Christmas!!

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Successful fertilization requires a series of steps. First the sperm must bind to the protein coat that surrounds the egg. This binding occurs at the molecular level. If the sperm surface does not have a sufficient number of these binding molecules, the sperm will not bind and fertilization fails.

Next, the sperm must undergo a process called the "acrosome reaction". The acrosome is a small package of enzymes located on the tip of the sperm head. These enzymes are released after the sperm binds to the protein coat and are responsible for digesting the protein coat to make a path for the sperm to swim through to get to the egg underneath. If the sperm fails to undergo the acrosome reaction after binding to protein coat, the sperm is unable to penetrate the protein coat and fertilization fails.

Next, the sperm must bind to the plasma membrane (outer surface) of the egg. This binding occurs at the molecular level. If either the sperm or the egg lack these adhesion molecules, the sperm is unable to fuse with the egg and fertilization fails.

Next, the sperm must be incorporated into the egg cytoplasm and the sperm head must disolve and form a pronucleus. The sperm pronucleus and the egg pronucleus migrate towards each other and fuse to fom the nucleus of the 1-cell embryo. If any of the processes fail to occur, fertilization fails.

So, you can see that all of these steps occur at the molecular level. Failed fertilization cannot be predicted on the basis of just looking at the sperm and eggs. There are no definitive clinical tests that can be performed to determine the "fertilizability" of sperm or eggs before IVF is performed. Since we cannot effectively evaluate sperm or eggs at the molecular level, when "perfect" looking sperm and "perfect" looking eggs are placed together, they may not result in embryos.

Bare in mind that IVF is also a diagnostic procedure in that, by doing IVF, we learn what may have been going wrong all along. This is especially true in cases of "unexplained" infertility that are completely explainable after an IVF cycle.

I think you will have a reasonable chance of success on your next cycle with ICSI. Good luck.

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Dr.Smith,

Thank you so much for your response, My husband and I were both very happy with the information that you supplied. Some time it makes you wonder why all that is not communicated by the doctor espeacially after spending so much money and getting a negative result that info would have been soothing to hear. But at any rate I am glad you shared all that with us. I now have one more question to ask of you! You may not even know about it which is fine but I thought I would throw it out there! We obviously know that we are going to have to do IVF again which we decided will be in July of this next year, But I decided to take Ovulex Just for what the heck purposes......Do you think that is good,bad? Or do you think I should stop taking it due to starting a new cycle of IVF soon.....I just don't know what to think about it or if it is even worth it due to the fact that we need fertilization help with ICSI anyways. Let me know what your thoughts are if there are any...much thanks!

Happy New Year!!!!

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