Clinic notes- Dr Smith, need help understanding them
11 Replies
4everhopeful - August 8

Dr Smith,

Sorry to trouble you again- but I've just received my notes from my previous clinic- and need help understanding them-

These are some of the comments and was wondering if my eggs are no good ??? :-\

Intial comments after e/c- Stringy, dark occs, some granulose, and blood staining

Comments during ICSI- 1 "bullseye" egg, all Pop v ok 1 thin zona

What's a bulleye egg?

Comments about embryo's on day 1-
1x 2PN (Pro nuclei I think?) granules in cytoplasm, scattered small NPB's Bot Cult drop
1x 2PN scattered small NPBs LH culture drop
1x 2PN smaller PN, scattered small NPBs minimal NPB's RH Cult drop
1x 2PN thin zona (is this good?), small NPB's, cytoplasm clearing distinct LH Cult drop
1x 2PN thin zona, scattered NPBs RH Cult drop

What are NPB's?

Comments about embryo's on day 2- transfer day-
4 cell grade 2- cluster of frags (quite large) (this one was transfered)
4 cell grade 3- 1 cell MNB blebs +fragments 3 cells intact ++ frags
6 cell grade 3- 1 cell MNB blebs or cells Uneven cells, fragments +/++
4 cell grade 2- cluster of frags (quite large) (this one was also trasfered)
4 cell grade 2- 1 cell MNB slightly uneven cells and small area of fragments.

Is MNB mean multi- nucleated? What does blebs mean?

The first cycle in Nov 04 sounded better- with one comment reading 2PN good clearing evident, nuclei alligned and with a 4 cell grade 1- and a 4-6 cell grade 2- for transfer.

Your thoughts would be very greatly appreciated :)
Many thanks,
Nat :)


Dr Smith - August 8

Based on the descriptions provided, there was a problem with the egg quality on this cycle.

When the egg is retrieved from the follicle, it is inside a "cloud" of granulosa cells (latin name: cumulus oophorus or "egg cloud"). The combination of the egg and the cumulus cells is refered to as the "oocyte-cumulus complex", or OCC for short. OCCs should appear expanded and easily transmit light (i.e. a big, fluffy cloud). Compact, dark OCCs is one of the first indicators of poor egg quality.

"Bull's eye" is a term used to describe a dense, granular-apearing region in the center of the egg. Usually not a good sign, but not absolutely conclusive either.

NPB stands for nucleolar precusor bodies and refers to structures within the pronuclei of the zygote stage embryo. Evaluating the number and position of NPBs is a type of grading system. Depending on when the observation is made, embryos with the best developmental potential have numerous NPBs that have migrated to the edge of one side of the pronucleus (alligned). Small, scattered NPBs is not a good sign.

MNB stands for multinucleated blastomere and refers to the presence of more than one nucleus in one or more of the embryonic cells (i.e. the cell is genetically abnormal). Blebs are irregularities on the surface of the cell and suggest the cell will form fragments in th near future.

Thin zonas are not an egg quality or developmental issue.


4everhopeful - August 9

Thank you for that Dr Smith :)

My first cycle the comments about the eggs after the retrieval was: eggs in fluffy expanded occ's 3/5 small occ's. So it seems the eggs were better quality on this cycle.

Could my last cycle have been a rogue cycle? As my FSH goes up and down (range 6.3-9.4), I was told by previous IVF nurse that I was one of those people who have "good" and "bad" months- could this have been a bad month- or am I going to be one of those who has to resort to donor eggs, which would be a huge dissapointment ???

Your thoughts would be very gratefully appreciated :)

Many thanks,

Nat :)


Dr Smith - August 9

Every has some degree of cycle-to-cycle variation in egg quality. Some patients have more than others, but since the stimulation conditions are rarely [i]exactly[/i] the same from one cycle to the next, it is always hard to pin down the cause of a "bad" cycle. At 32, we can assume that there are at least a few "good" eggs (from a genetic point of view) remaining in your ovary. So, I wouldn't give up just yet.

And, since you were so kind as to introduce this subject, I will pontificate further...

In many cases, patients do not understand the potential for significant cycle-to-cycle variation in the inherent quality of their eggs (i.e. some cycles yield bad eggs, some yield good eggs). Because of this misunderstanding, after a "bad" cycle, they change doctors and/or programs assuming that the doctor or the lab is "bad". At the new program, they have a "good" cycle and become pregnant. A-ha! they think. The previous doctor/program really was bad and tell everyone to stay away from that doctor/program. They attribute the success of the current cycle to the doctor's skill (or charm), a change in medications, better lab, accupunture, herbs, whatever. The patient then sings the praises of the new program loudly and tell all their friends to go there.

Doctors/programs then perpetuate this misunderstanding by taking credit for the success as if they have some kind of mystical understanding of the reproductive process that other doctors/programs don't have (after all, rather large egos are involved). The scientific reality is that the patient had a "bad" cycle in one program and a "good" cycle in another and it had nothing to do with the doctor, meds, lab, etc. Baaaaa! This drives me crazy.

O.K., I'm finished. Thanks for listening.


4everhopeful - August 10

Thank you so much for your prompt answer Dr Smith :)

I'm very worried that I had a bad cycle, and I am hoping that I still have some good eggs left :-\ Is it possible for a different drug protocol to make a positive difference? Can the stimulation conditions affect the quality of the eggs?
For next cycle I'll be d/r with suprefact and using puregon for stimming. Last cycle I was d/r with the pill and prostap and used Gonal F for stimming.

Is it is possible to improve the overall quality of eggs by herbs, acupuncture, protein shakes, multi-vitamins etc, or in reality is there very little we can do to affect the outcome of a cycle, and all the alternative meds are purely placebo to help us feel we have some control over our treatment?

Should I get my FSH checked before I start an IVF cycle to determine if I am on a "good" or "bad" month? Or is the quality of eggs in any given cycle purely a matter of chance?

Also I was wondering about the latest developments in growing eggs from ovarian stem cells, and wondered when it is likely to become available as a standard part of tx for women with poorer quality eggs?

Many many thanks for all of your kind help, advice and thoughts :)

Nat :)


Dr Smith - August 10

The [i]management[/i] of the stimulation, but not the brand of medications, can effect the quality of the eggs to some degree, particularly those problems associated with the egg cytoplasm (inclusions, slow division, fragmentation, etc). A change in the stimulation protocol can improve egg quality to some degree, but if there is an underlying problem with the eggs, changing the stimulation protocol and/or medications will not solve the problem.

There is very little credible scientific data to support the effectiveness of alternative therapies for infertility. I'd have to say the jury is still out about the therapies you mentioned. With the exception of so-called fertility enhancing herbs (wich have been shown to actually reduce fertility in some cases), these alternative therapies can't hurt and may help.

Day 3 FSH only indirectly reflects the quantity on eggs remaining in your ovary and says nothing about egg quality. So the FSH value will not tell you if this is a good crop of eggs or not.

It appears unlikely that ovarian stem research will result in a therapuetic treatment anytime soon in the U.S. I would not rule out the posibility of it being developed as a therapy in other countries. However, I personally remain very skeptical that fully functional, genetically normal eggs can be produced from ovarian stem cells and that the fertilization of these eggs would result in a term pregnancy and a child with normal development. I think we are playing with fire here.


4everhopeful - August 11

Thank you again for your prompt answer Dr Smith :)

What do you mean by the management of the stimulation? My previous clinic only did u/s the Friday before the week of e/c. Is it possible that clinics who don't leave so much to chance in a cycle can help yield better eggs...more tests, regimes tailored to the idividual, closer monitoring during stims etc.?

It seems from my notes that on my first cycle the eggs were ok and the second they were poor, but neither cycle ended in pregnancy.
I had anorexia as a teenager (aged 16-18), and didn't see AF for 18months. Could this have caused any permanent damage to my eggs?
Apart from this "blip" I've always had a very regular 28 day cycle, and seem to ovulate every month. Also whenever I've had scans done, my lining is always seen to be good.

When we had our first meeting with our new RE, after scanning me and giving my husband a SA, all she said was "very clearly we have a m/f problem here!" Yet our IVF cycles appear to have failed because of my eggs :-\

Sorry for bombarding you with questions Dr Smith, but I'm really worried that I might be one of those who could have an underlying problem with my eggs and just need to get my head round it all :)

Many many thanks,

Nat :)


Dr Smith - August 11

Close monitoring of estradiol levels and follicular growth during the stimulation allows the RE to adjust the dose of gonadotropins to optimize the rate of follicular growth and the length of the stimulation (9-12 days). Both of these parameters can have a direct effect on the quality of the eggs retrieved. When it comes to ovarian stimulation, one size does not fit all. Most successful programs closely monitor the patient's response to the gonadotropins and adjust the dose accordingly.

As far as I know, if you are at a normal weight now, a history of amenorrhea brought on by anorexia in your teens would not have permanently affected your eggs. However, you should be aware that there is an optimal weight range to conceive (not too heavy, not too thin).

I think there are problems with both the sperm and eggs. The sperm problem can be overcome (to some degree) by ICSI and the egg problem seems variable (one cycle the eggs were O.K., the next they were not). With a good stmulation and ICSI, things may work out just fine. If you have another unsuccessful cycle attributable to problems with the eggs, then I would say you should consider other options. However, at this point, I would still suggest another attempt with the new RE.


4everhopeful - August 12

Thank you so much for that Dr Smith :)

I never had my estradiol levels checked at all, in fact I had no blood taken at all during any stage of treatment, and only had the 1 scan right at the end of stimming. The new clinic we have choson scans every other day during stims, so I'm glad we made the decision to change clinics for cycle number 3.

I'm now taking Chinese herbs (from a herbalist) as is my husband, and I've also been having acupuncture- so I'm really hoping that despite our combined problems it's going to be third time lucky on our next go!

Many many thanks for all your helpful advice,

Nat :)


hoping4another - August 12

Please excuse the barge - Dr. Smith would you mind posting the name of the particular "so-called fertility enhancing herbs which have been shown to actually reduce fertility in some cases" you referred to earlier in this thread? This is very interesting info to have ...


Dr Smith - August 15

False unicorn is the most common "problem herb" for women. False unicorn acts a progestational compound which may have some benefit in those individuals that do not produce sufficient progresterone to sustain a pregnancy. HOWEVER, it is often used daily by women self-treating for infertility. When used daily, false unicorn will interfere with the natural balance between estrogen and progesterone that ccurs during the menstrual cycle. When taken daily, it acts as a contraceptive.

St John's Wort is the most common "problem herb" for men. Although promoted as libido enhancing compound, it is actually damaging to sperm.

Most herbs have not been studied sufficiently (i.e. randomized, placebo-controled medical studies) to determine their effectiness. Herbal remedies are mostly a matter of faith.


hoping4another - August 15




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