stimulation protocol/egg quality
5 Replies
shansy - August 3

Hi Dr. Smith,

I am currently doing an IVF cycle and I have been on Gonal-F since last Friday. I have 24 follicles and the largest one is 17 mm while the others are anywhere from 9-14 mm. What happens if the 17 mm follicle grows even larger while the others haven't caught up? Will it try to ovulate on its own? I am also on 5 units of Lupron.

My E2 level today is at 2029. My RE is taking me down from 225 units of Gonal-F last night to 75 units tonight (Previously it was 300 units each night), as he didn't want me going over 2000 in my E2 level. Shouldn't you have 200 in your E2 level per follicle? Also, the nurse said I may possibly do ER on Sunday. In your opinion, is it too early to do the trigger shot after being on Gonal-F for 7 days? (I don't know if they have you do the Gonal-F shot the same night as the trigger, if so, then it would be 8) To me, it seems fast. I am concerned about the eggs not being mature enough.

I also have PCOS by the way in case this should affect your response.



Dr Smith - August 8

Sorry to be so late in getting back to you. I had a family "situation" that required my complete attention.

It is not unusual for the "lead" follicle to be bigger than the rest. There is usually a wide variation in follicular size for any patient. As long as you are lupron, you will not ovulate and a single follicle will not ovulate on its own. Ovulation during a stimulation is all-or-none. If you have an LH surge and begin to ovulate, all the follicles will ruture and release their eggs.

Ovarian stimulation in patients with PCOS is difficult to control and, if the E2 gets too high, can easily lead to hyperstimulation syndrome. In short, its very tricky. The ideal stimulation is 9-11. Eight days is the minimum for optimal results. Since you had 7, I expect that around half of the eggs will be immature (they will still be diploid) and therefore not even fertilizable. Of the ones that do fertilize normally, I expect a significant number of them will stop growing before reaching the blastocyst stage due to inadequate cytoplasmic maturity. However, that being said, there may still be one or two that will be O.K. Unfortunately, if they are transferred on Day 3, there will be no way to know if they chose the right ones. It is not until Day 4 when it becomes apparent which embryos are going to continue to growth and which ones are not.


shansy - August 8

Hi Dr. Smith,

Thanks for responding. Hope all is OK now with your family situation.

Well my ER was Sunday- they retrieved 20 eggs of which 16 were mature. They ICSI'd those and 9 fertilized. Tomorrow we go back to do the ET and we are putting back 4. I am praying that you are wrong (not to be mean:)), but I hope all 9 did not arrest and that we have at least 4 viable ones to put back in.

Based on this ER outcome, do you think we have a chance of having 4 viable eggs or do the results still stand with what you stated before?



Dr Smith - August 9

It is likely that there will 4 viable Day 3 embryos, but PCOS is sneaky. In PCOS patients, even viable Day 3 embryos can still arrest development between Day 3 and Day 5. We also notice that the blastocysts that do develop in PCOS patients tend to be of lesser quality (lower number of stem cells). I wish you the best of luck, but you're not out of the woods yet.


shansy - August 9

Dear Dr. Smith,
Thank you for your earlier response. Today at the ET we were able to transfer 4 eight cell embryos, 3 of which had 5% fragmentation, the other was 0% fragmentation. Based on this information, what percentage rate do we have for pregnancy according to statistics? Due to the PCOS I am currently taking 1500mg of Metformin.



Dr Smith - August 14

Sorry, but it is impossible to predict outcome from Day 3 transfers. There are too many unknowns. We don't know if the embryos are capable of reaching the blastocyst stage (and they must in order to attach to the endometrium and initiate implantation). Assuming one or more make it to the the blastocyst stage, we don't know if there will be an adequate number of stem cells in these embryo to make a baby. That's the problem with Day 3 transfers; it leaves you hanging.



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