what to do next
7 Replies
holly-co - October 3

I am 32yo, nl fsh, good response to stims (15-23 eggs each time), healthy, non-smoker etc. We originally went into IVF for mf (low counts, motility and morph but okay SCSA test) but it is pretty clear now that I have a true egg quality prob that cannnot be explained as with all my cycles my eggs themselves look dark, have grainy cytoplasm, thick shells and on one cycle (#3) they even had things like fragmented polar bodies, inclusion bodies, vacuoles etc. I have been on different stim protocols. Here are my IVF results. IVF w/ ICSI and AH #2-#4 have been with Dr. Schoolcraft at CCRM.

#1 at local clinic (29 years old at the time): 15eggs retrieved, 12 mature, 9 fert put back 4 poor quality (not sure of the cell #s), highly fragmented embies on day 4. BFN

Switched to CCRM
#2: 16 eggs retrieved, 12 mature, 11 fert put back 1 8 cell and 2 6 cells on day 3 all of good quality (no/minimal fragmentation, even cell sizes). BFP and now have 20mo dd.

#3 (32yo): 22 eggs retrieved, 18 mature, 14 fertilized only had 1 6 cell, 1 5 cell and 1 4 cell to transfer, all good quality. BFN. This is the cycle (the only one) that the additional dysmorphic egg findings were noted and I can assume the reason for the even worse embie quality. This is the only cycle that all fsh was done.

#4: 23 eggs retrieved (mild OHSS), 16 eggs mature, 9 fertilized, put back 1 8 cell (had been 6 cells but divided prior to transfer), 1 6 cell, 2 5 cell all of good quality. BFN.

Does it sound like it is time for me to throw in the towel or move on to DE or adoption or do you think that with my young age, good response to stims, and the fact I was successful once despite poor appearing eggs that I might still have a decent shot but it may just take a few more tries? I have always heard you should switch clinics after 2 failed cycles but do you think that is true when you are already at what is considered by many a good clinic? Does your clinic offer a different type of culture medium that might help? I am thinking that is really the only thing that can be different somewhere else. Also, I have only ever tried long lupron protocols, have you ever seen any benefit in a situation like mine with an antagon protocol or mdl in terms of improving embie quality? Thanks for your time.


Dr Smith - October 5

I think there clearly is an egg "probelm". CCRM is a good program, so switching programs is not going to help. It is also unlikely that changing the stim protocol will help in your case. I'm afraid that DE is the most likely way for you to get pregnant (although I never say never).


holly-co - October 5

I know that my odds are much better with DE but am not quite ready for that yet at such a young age. With knowing it can work for us despite the egg findings (and just 2 years ago) can it may just be a matter of trying a few more times. I have a hard time believeing that at age 32 my dd is the only good egg that I had/have (and if that is the case, I am so grateful we found it). Would it be reasonable (but I know not with the best odds) to try a couple more times before throwing in the towel since I do respond so well the the drugs and stuff?


Dr Smith - October 10

Sory for the delay in my reply. I've been very sick with the flu.

Economic considerations aside, there is no reason why you can't try as many times as you like. As long as your expectations are in line with the biological reality (you have very few "good" eggs), then I'd say go for it. However, I should mention that we have successfully treated many women in their early thirties with secondary infertility by using donated eggs. Of course, having secondary infertility makes it very hard for them to accept the use of donated eggs. However, as the interval between their first child and the delivery date of a second child expands to several years, the thought of using donated eggs becomes more acceptable. As I mentioned in the first post, the use of donated eggs is the most likely (i.e. efficient) way for you to become pregnant, but not the only way.

Best of luck.


Michelle47 - October 11

In response to your statement that you don't perform ICSI unless there is severe male infertility. What range do you consider severe? We recently went through a Day 5 donor egg transfer in which 38 eggs retrieved, 28 ICSI, 20 fertilized, one transferred and only one Cryopreserved. My husbands semen analysis showed a morphology of 25% and our doctor said that was the reasin for recommending ICSI (their range was 30% or higher). All of the other reuslts were withing the Normal range. Should we be better off next time (if this doesn't result in a pregnancy) not having ICSI performed.

Also you mentioned that you perform assisted hatching on Day 5. Man, I wish we had known that was even possible. Our doctor said that they do not perform assisted hatching on blastocysts, that is was unnecessary. But if you are getting better success rates with assisted hatching on Day 5 eggs, then we may suggest that next time, too! We have learned more on this website than all of the research we have completed. The more we learn about IVF the more questions we seem to have.

Thank you very much and I look forward to your thoughts on the above.


Dr Smith - October 11

My criteria for performing ICSI are sperm morphology of less than 4% (by Kruger Strict Criteria) and/or less than 20% of the motile sperm exhibiting straight and rapid motility (progressive motility). In yout case, the sperm morphology was assessed using an older method (1992 WHO criteria) which is less predictive of fertilization outcome. The justification for ICSI was there, albeit slight.

The major problem in your donor egg cycle was not the sperm or the ICSI, it was the eggs. When a donor hyperstimulates to that degree (38 eggs) the quality of the eggs is seriously compromised. In simple terms, with so many follicles developing, it gets very crowded in the ovary and the individual follicles do not mature properly. In addition, the estradiol level goes through the roof - another bad sign associated with poor egg quality. I know that 38 eggs sounds good (and you think Oh Boy! this is a slam dunk), but the outcome was predictable. The optimal number of eggs retrieve from a donor is between 10 and 20. More than 20 eggs, the quality of all the eggs begins to decrease. Less than 10 eggs, and there may not be enough embryos of sufficient quality to provide two high quality blastocyst stage embryos for transfer.

The technique for hatching blastocyst stage embryos has been around for several years. The argument for assisted hatching of blastocyst stage embryos is even stronger than that for Day 3 embryos, as the protein coat that surrounds the developing embryo (the zona pellucida) is subject to hardening during culture in vitro. The longer the culture period, the more hardening that may occur. We have seen a 9% improvement in implantation rate with blastocyst hatching. I will be happy to provide the reference for the blastocyst AH technique to the embryologist at your program.


Michelle47 - October 11

Thank you very much for that information that no one mentioned to us. Yes, we figured the more eggs the better. Expensive lesson to learn.

And yes, I would like the reference to the blastocyst AH technique so that I may forward it to the embryologist at our fertility clinic.


Dr Smith - October 13

Here's the reference for AH technique of blastocysts.

Healthy twin delivery after day 7 blastocyst transfer coupled with assisted hatching. Sagoskin AW, Han T, Graham JR, Levy MJ, Stillman RJ, Tucker MJ. Fertil Steril. 2002 Mar;77(3):615-7.



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