myomectomy, asherman's & IVF
3 Replies
aghp - January 26

hello dr. smith,
someone else mentioned it, and i agree...i am impressed by your willingness & availability to offer opinions without a scheduled appt.! thank you!!!

I guess I'm basically looking for any suggestions you might have, realizing that some of this may be your area & some may be dr. miller's area. i'll try to keep it as brief as possible, but my hx is rather complex....

i'm 35 y.o. & husband is almost 39 y.o. we never even had a chance to ttc before dealing with fibroid, asherman's & thus infertility, so we have no idea whether i can get pg or anything.

11/2002 (31 y.o.) - 5 hr. myomectomy for 18 cm. posterior fibroid, 8 units blood lost, infection (fever x 3 days). Asherman's syndrome & hydrosalpinx developed subsequently. AS finally resolved (after 4 operative hysts., 8 office hysts. Q 7 days, innovative uterine stent placed for about 5 wks., like used in interventional cardiac surgery).

3 IUIs failed, 2 with clomid & 1 without.
1st IVF attempted & failed jan./feb. 2006.

husband's SA also borderline. i'm not sure of exact #s at this time, but can find out if you need them....

We are getting ready for another round, but there seems to be a lot of variation in treatment recommendations. I know this is dependent upon individual cases & individual woman's responses, but I guess I'm looking for some (ANY) consensus....

I still have a hydrosalpinx. As my abdomen is "hostile" & "surgically challenging," we've had several drs. recommend NOT removing the hydrosalpinx, even though it's been suggested as much as 50% decrease in implantation rates with a hydrosalpinx.

My dr. says that my "CCCT was outstanding with FSH levels of 4.6 & 6.6." I had Lupron 5 units BID dropped down to 5 units QD. 3 amps of Menopur for 2 nights & 4 amps for 3 nights. Then my Lupron was stopped & my gonadotropin dose raised initially to 3 amps BID & then again to 4 amps BID. I was on gonadotropins for 13 days. Estradiol was 946, P4 1.0 & LH 0.6 on day of HCG. 13 oocytes were retrieved & only 8 were mature. 3 were M1 & 2 were GV. All 8 underwent ICSI & 3 fertilized. The embryologist noted "generally poor egg morphology, coronal cells were underdeveloped with cumulus." Two 4-cell embryos & a 3-cell embryo were transferred. Embryo quality was good. My dr. said visualization was beautiful & transfer was very easy.

He said he was surprised how good the embryos were, given the poor egg quality. He recommended another cycle of IVF, with luteal phase Lupron 5 units BID dropped down to 5 units QD, and the 4 amps of gonadotropins BID. He said he didn't recommend another gonadotropin, but wouldn't have a problem if we wanted to do a different one. We'll do ICSI again & he recommended assisted hatching. He also suggested the possibility of acupuncture on the day of transfer as a possibility.

Also, my endometrial thickness was 7.2 mm on the day of HCG, which he felt was not superb, but was certainly sufficient enough.

He also wanted to try to push another day of stimulation if possible, since 8 or 13 oocytes were mature. He felt supplemental vaginal estrogen treatment was not necessary at present.

any thoughts or suggestions?
i'm a little unclear about the day 5 blastocyte transfer (right?) & know there's some debate between day 3 & day 5 transfers. my dr seems to prefer the natural biological environment to the lab setting, so prefers day 3. he does have a pretty high success rate, especially with FET.

thanks so much for your help!!!
allison

 

Dr Smith - January 30

Most of the history and questions you want advice about is outside my field of expertise. Will forward to Dr. Jane

Yes, there is some debate about Day 3 transfers v. Day 5 transfers. There are reasonable points on both sides of the issue. I prefer Day 5 transfers for a variety of reasons. Some programs achieve better success with Day 3 transfers. A program has to go with what works for them. Not everyone is comfortabe with Day 5/blastocyst transfers.

 

aghp - January 30

dr. smith,
thanks for your response.

what exactly are the pros & cons of day 3 vs. day 5 transfers? it's very confusing to me....

i know the first IVF is often diagnostic. however, do you have any thoughts on the poor egg quality? what does it mean when the oocytes were "M1" and "GV"? is this good or bad? are the 4-cell embryos good? and the 3-cell was not so good, correct?

thanks again!
allison

 

Dr Smith - January 31

See http://sharedjourney.com/ar
ticles/3vs5.html

Thi
s
describes a dialog I had with a patient about 3-4 years ago on the pros and cons of blastocyst transfer.

http://sharedjourne
y.com/articles/blast.html

Thi
s
article was not penned by me, but I agree with almost everything, except that blastocysts do not freeze and thaw as well as Day 3 embryos. That depends on who's doing the freezing and thawing. We have a blastocyst post-thaw survival rate of 89% which is higher than most programs using Day 3 freezing.

GV and MI refer to egg maturity at the time of retrieval. These designations are embryology shorthand to reflect the degree of immaturity of the eggs. Immature eggs cannot fertilize, so the number of immature eggs is important. Overall, about 80% of the eggs will be mature at the time of retrieval and therefore "fertilizable".

There is some biological variation in embryonic growth. The difference between a 3-cell and 4-cell embryo is negligible. No worries there.

 

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