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I have recently had two IVF failures (in August and November) and am trying to decide what to do next. Some background. I am 38 (almost 39) years old, my FSH is good (below 5 on CCCT and several subseqent tests) and all my other tests were normal. My husband is also normal with a very high sperm count. I have no health problems.
Did 2 IUIs with clomid (no success) and 4 IUIs with Repronex (one chemical pregnancy, one with only one follicle due to dominant follicle). First IVF attempt - 11 follicles with 9 mature eggs retrieved, 8 fertilized (half ICSI, both groups same fertilization rate), transferred 3 good embryos on day 3 (1-10 cell and 2-8 cells) with one having a little (10%) fragmentation. Assisted hatching was performed. None of the remaining embryos survived to the blast stage. Second IVF attempt - 10 follicles with 9 mature eggs, 8 fertilized, transferred 4 embryos (1-9 cell, 2-8 cells and 1-7 cell). While this time the embryos divided normally, there was more fragmentation this time - 2 under 20%, 1 at 20% and 1 at 25%. None of the remaining embryos made it to blast. My seven day progesterone was always good, although lower than it had been for my IUIs.
My RE believes that there may be an egg quality issue despite the fact that my FSH is good and the eggs fertilize well and divide normally - he believes that my reproductive process is inefficient due to high numbers of chromosomally abnormal embryos, although he admitted there would be no way to test this short of doing PGD (which he feels would be risky to my embryos considering how many I've had and that fact that none have made it past day 3). What do you think? What could cause the increased fragmentation? Is this an indicator of poor egg quality? I don't believe that any of the remaining embryos were above 6 cell.
I am trying to decide whether to try once more with my own eggs. I am in a relatively small city, but my RE seems good and has relatively good overall live birth rates (greater than 40%). What can a larger, more renowned clinic do differently? Would you have tried to take the embryos to blast, and would that have possibly made a difference considering the total number and that none of the non-transferred embryos had made it to 8-cell on day 3?
If I do decide to go the donor egg route, would you recommend any further testing to determine (i) uterine problems, such as a test for the integrin adhesion molecule or (ii) immunological problems (we did test for antiphospholipids which were normal, but my RE does not fully buy into the whole concept of reproductive immunology – he really thinks it’s an egg issue).
Thank you so much - I really need some objective advice right now.
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I agree completely with your RE's interpretation of your history. I think there is an egg quality problem. Culturing the embryos to the blastocyst stage would have answered this question definitively, but in view of the information you provided, I don't think it would have made a big difference in outcome. If you are in a hurry to be pregnant, I think you should proceed to donor egg.
Unless you have a history of endometriosis, the beta-3-integrin test is uncessary. Before proceeding to a donor egg cycle, I would recommend testing for natural killer (NK) cell number and abnormal activation. I realize that not everyone is convinced of the importance of NKs, but your early miscarriage may have been caused by abnormal NK activity, or you may have subsequently aquired abnormal NK activity because of the miscarriage (another theory out there in the scientific literature). My thinking is that you want to make sure everything is evaluated before proceeding to donor egg (DE), because, if the DE cycle is unsuccessful, you don't want to be thinking "It didn't work because..." In other words, better to be evaluated and find the NK level and activation to be normal than assume they are normal and then be left wondering if the cycle is a bust.
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Thank you so much for your thoughtful and detailed response - it is very helpful (so much more so than other experts that I have tried). We appreciate it!
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