Also see fact
sheet – Assisted
Reproduction, IVF
success, ICSI,
and Cryopreservation
Disadvantages of IVF
Considering IVF, Hysteroscopy?
What is the success with cryopreservation? How long can embryos
be stored?
Failure of fertilization with ICSI
Christianity and assisted reproduction
Polyps, antibodies, sperm, age
IVF and positive immune testing
Age limit for IVF
Lupron for IVF
Improved IVF success after tube removal
In vitro oocyte maturation
Multiple failed IVF cycles
Irregular cycles, possible tubal disease
Hydrosalpinx and decreased IVF success
Asynchronous follicle development
Age & IVF success
Why didn’t the embryos implant
Failure of fertilization with ICSI
Try again after failed IVF cycle and IVF with miscarriage?
Lowest sperm number not to consider ICSI?
Age 28 , FSH 14
Age 31, FSH 13, donor eggs?
Aspirin
Question: What are the
disadvantages of IVF?
Comment:
- It might not work. Success rates vary between 0 and 50%
depending on patients and labs.
- It's very costly. Costs vary between $3000-$20,000 per
attempt depending on clinics.
- It is artificial. Reproduction is relegated in part to
the laboratories and third parties.
- It's inconvenient. It requires multiple office visits,
ultrasound and blood testing.
- Some parts are mildly to moderately painful. (Blood testing,
injections, aspiration of eggs from the ovary.)
In addition, the following are listed in our consent after
the above have been discussed.
- There may be a poor response to ovarian stimulation with
no or too few follicles, maturing. This results in cancellation
of the IVF attempt before follicle aspiration.
(5-40% of cycles are canceled depending on the type of ovarian
stimulation and patient characteristics)
- Ovulation may occur prior to aspiration resulting in cycle
cancellation, or inability to retrieve oocytes at aspiration.
It is not possible in all cases to determine accurately when
a follicle will mature. The precise time for follicle maturation
may be misjudged with no, or abnormal oocyte(s) obtained at
aspiration. (Risk 1-30% of cycles depending on type of ovarian
stimulation and patient characteristics)
- Access to the ovary for aspiration may not be possible.
(Risk less than 5%)
- Oocytes may be abnormal, too immature, or too old for fertilization.
(60% of oocytes determined to be normal are expected to be
fertilized.)
- The male partner may not be able to produce a semen sample.
(Risk about 1%)
- Sperm count, or quality, may be too low for fertilization
to occur. (This risk, in part, can be predicted by previous
semen analysis. The poorer the semen quality the less the
chance of fertilization. In some cases there may be fertilization
failure despite normal semen parameters)
- There may be multiple fertilizations of a single egg (polyspermy):
in such cases, a resulting embryo will not be transferred.
(1-5% of oocytes)
- The fertilized egg may fail to divide (cleave) or grow.
(Almost 90% of fertilized eggs will divide and at least half
will appear normal upon laboratory examination).
- Transfer into the uterus may be impossible. (Risk less
than 1%)
- The embryo may be expelled prior to implantation. (Risk
unknown)
- The embryo may not attach or grow, once transferred to
the uterus. (Risk unknown)
- The culture medium may be defective resulting in failure
of fertilization, or embryo formation. (Risk unknown)
- A laboratory accident or equipment failure may result
in the loss or damage to the egg(s), sperm, or embryo. (Risk
unknown)
- The conception may be miscarried. (Risk 10-25%)
- There may be an ectopic pregnancy. (Risk 0.5%-3%)
- The discovery of abnormal development, through ultrasound,
amniocentesis or otherwise, may lead to the participating
couple's decision for pregnancy termination.(risk unknown)
- If more than two embryos are transferred and if a clinical
pregnancy occurs, there is approximately a 25-50% chance of
twins and 5-15% chance of triplets, or above which significantly
increases the risk of prematurity and obstetrical complications.
Prematurely born infants may experience serious or life threatening
complications, or permanent medical disability.
- Drugs used to stimulate the ovary may cause the development
of ovarian cysts (non-cancerous, fluid-filled structures
in the ovaries), which usually resolve with menstruation,
or in the next 30-60 days. These cysts are usually not painful
or dangerous. In rare instances, an ovarian cyst may distort
the ovary to such an extent as to require surgery. Rupture
of an ovarian cyst may be associated with pain and/or bleeding
requiring surgery and/or blood transfusion. Rarely, these
cysts can result in the loss/removal of an ovary. Drugs
for ovarian stimulation may result in serious ovarian hyperstimulation
(multiple cystic enlargements). This is more likely with
pregnancy. In extreme cases this may require bed rest, or
hospitalization. While exceedingly rare with modern monitoring
and management techniques, there has been death from severe
hyperstimulation. This must be weighed against the fact
that IVF can result in a pregnancy when there is no hope
otherwise and all other methods have failed. sst
Question: My husband is 38 and has low-normal sperm count,
I am 38 and my tubes are open, hormone levels are OK, and
we've had three failed attempts with Clomid and IUI. We are
planning on IVF in a couple months. Is a hysteroscopy advisable
before we try an IVF cycle?
Comment: Make sure the FSH on cycle day 3 is less than 10.
In terms of the uterus, most centers perform some form of
screening procedure to evaluate the uterine cavity before
IVF. This could be a sonoHSG where the uterine cavity is filled
with water and observed by ultrasound, a traditional HSG (which
sounds like you have already had), or hysteroscopy. Hysteroscopy
is certainly most reliable but may also require a surgical
procedure. If the ultrasound and sonoHSG or traditional HSG
were normal, most would consider this as satisfactory screening.
sst
Question: I recently gave birth to my son, Brett. He was a
product of IVF with ICSI.
I have 9 frozen embryos. My question is: What are my chances
of conceiving another child/children, with the frozen embryos.
Is there a life span if they are frozen? Can I go a natural
cycle, or do I need to do Lupron again? The infertility was
due to male infertility.
Comment: Not trying to pass the buck, but these are questions
that should be easily and best answered by your IVF center.
Success rates with frozen embryos are center specific. A reasonable
estimate is that the success with frozen embryos should be
about the center’s fresh pregnancy rate. Some do better,
others not as good. The fact that it appears that primarily
a sperm issue, should give you quite good chances of success.
If your cycles are regular and especially if you ovulate on
your own, many centers do transfers with minimal preparation.
No one knows how long viability remains for frozen embryos.
There have been successful pregnancies after 10 years. All
agree the quicker out of the freezer the better, but this
is largely for other reasons than the health of the embryo.
See Fact Sheet on Cryopreservation sst
Question: What are the possible reasons for fertilization
NOT to occur with ICSI?
Comment: Some would say that fertilization always occurs with
ICSI, but then there can be failure of union of the male and
female genetic material and/or further development does not
always occur. Failure of ICSI can be related to either male
(sperm), or female problems (egg). Sometimes this can be predicted
by why the ICSI procedure is being performed, for example
severe male factor with an otherwise healthy ovulatory female.
Maternal age can also be a significant factor. Sometimes it
is not a male problem at all and the true diagnosis of the
fertility problem: an egg issue is discovered. The best information
comes form a frank discussion with the fertility specialist
and perhaps the embryologist at the center where the procedure
was performed. Sometimes the answer still remains "I
don't know". sst
Question: What do you think about IVF in the view point of
Christianity? Hope I can get an answer from you.
Comment: Science itself is neither good nor bad, it is its
application that determines it value. I often sit across the
consulting desk from loving couples that, due to circumstances
completely out of their control, are unable to have the family
they truly deserve. I have spent the last 25 years studying
the science of reproduction and its application to human disease.
It is impossible that I would not call forth every ability
I have to help individuals achieve their goal, if not right,
to have a healthy child. I have the extreme privilege to witness
the miracle of life. I even have a front row seat from which
to watch. Fortunately, it is not I who creates life or even
decides who will be pregnant. That comes from a much higher
power. Instead of assisted reproduction being contrary to
Christian doctrine, I believe just the opposite. It is its
essence. sst
Question: Does having an endometrial polyp pose a risk for
embryo implantation failure (with an IVF cycle with assisted
hatching and ICSI)? My infertility doctor couldn't give me
an answer. They told me I had a small one seen on the ultrasound
(5-8 mm). My husband (40) and I (just turned 42, but very
healthy) had our first failed IVF cycle. All my blood tests
(observation cycle) were normal and I am ovulating. My husband
has a low sperm count and low morphology, one semen analysis
showed <3% normal and another <5%. He has a large left
varicocele (since teen years). With the embryo retrieval I
had 5 eggs. 3 fertilized 2 being grade 2 (very good) and 1
being grade 4. All 3 were transferred. Should I ask my doctor
about doing tests for antibodies to thyroid and phospholipids,
which might be interfering with embryo implantation? Or should
we just do another cycle when we can?
Comment: A poster at the recent American Society Reproductive
Medicine addressed this problem of polyps and IVF. If the
polyp was small, less than 10 mm there did not seem to be
an adverse effect. This is only one study and conventional
wisdom has been to correct any polyp or fibroid of the endometrial
cavity. This is usually an easily accomplished procedure by
hysteroscopy. Sadly, at age 42 the greatest reason for the
IVF failure is probably egg number and embryo quality. It
sounds like there was a reasonable chance given you response.
There appears to be a male factor, ICSI would seem a very
good option, if there were a repeat attempt at IVF. Personally,
I do not favor immunologic testing. The vast bulk of studies
on the effects of various antibodies on IVF report no alteration
of success rate. Even if there is an antibody problem, no
therapy has been shown effective in controlled scientific
studies to improve outcome. Varicocele repair is at least
controversial. At this stage and if you are to the point of
IVF and especially with ICSI, varicocele repair would seem
superfluous and unnecessary. sst
Question: I recently had immunological tests, which were positive
for antinuclear antibodies, anti phospholipid antibodies,
increased/activated CD56 (Natural killer) cells, elevated
anti-thyroid antibodies, low blocking antibodies. I have received
specific recommendations for treatment that involve: immunizations
with paternal lymphocytes, infusion of IVIG and heparin/baby
aspirin. Are you familiar with the effects of the above immunological
conditions on infertility? I would appreciate knowing this
information as soon as possible so I can decide about my IVF.
I have a 3-year-old daughter who was full term when she was
born. During my pregnancy with her, I had mild thrombocytopenia
and a positive ANA. Afterwards, I was diagnosed as hypothyroid.
Since then I have not been pregnant to my knowledge, except
for the chemical pregnancy last week.
Comments: Almost with my apologies, I have problems with both
the diagnosis and treatment of immunologic infertility. While
I am certain there is such an entity, I have never been impressed
by the previously reported studies that treatment for it matters.
With the number of tests positive that you report, I am concerned
that there is a problem, but each of these tests have been
refuted and have been shown not to affect IVF success. Most
patients I see could not afford this gamble, especially the
use of IgG, and even paternal wbc's. As a tangent, reduction
of stress alone has been shown, in itself to increase natural
killer cells. A very important fact is your previous successful
pregnancy. It is very important that your TSH level be in
the mid range of normal values.
In summary while I believe that you clearly have evidence
of autoimmunity, it is less clear that immunologic therapy
will help, although I generally use low dose aspirin in such
cases. If other causes of fertility have been excluded, I
am not sure why you need IVF if immunologic therapy will correct
the problem. Having said all this, I do believe in IVF as
an effective therapy for infertility. I am not sure that immunologic
therapy will do harm and I probably would have no objection
to its use. sst
Question: I was wondering about an age limit for IVF. I've
done many cycles already—two Gifts, three IVF, and one
FET--but have had no success. On my third IVF retrieval, I
got a dreadful infection that turned into an ovarian abscess
and I ended up losing an ovary. Even so, I did two subsequent
IVF after that and stimulated very well. With two ovaries
I produced 21, 25, and 32 eggs. With only one, I produced
11 and then 15. I am now 44, and started all this when I was
42. I've had microsurgery to clean up the mess from the infection,
but am considering more aggressive treatment in the future.
Comment: The bad news first. I don't believe you will be pregnant
using your own eggs. You have been treated in at one of the
best programs in the country, at least in terms of reported
success rate. You have had several cycles of therapy. There
is one ovary and you are 44. I know that I am repeating what
you just told me, but each of these factors is relatively
good predictor of poor chance of future success. It is important
to know your day 3 FSH level. If it is above 10, the chances
are very slim and if above 20, pregnancy is highly unlikely.
sst
Question: I've read some scary things about Lupron and its
side effects. What is your position on its use? Can IVF be
attempted without it?
Comment: If you want to see some really scary things about
Lupron, look at the website specifically directed at Lupron--"the
drug from hell". One must make the distinction of using
Lupron in conjunction with controlled ovarian stimulation
and using it for its other indications such as endometriosis
and uterine fibroids. For IVF, a short course is prescribed
and as soon as ovarian suppression has been reached, the stimulation
is started. The side effects of low estrogen (menopausal symptoms)
are avoided, or are very limited. Generally, IVF patients
report Lupron as more of a nuisance than anything else. Virtually
all IVF programs worldwide use Lupron or similar GnRH analogs
(Buserelin, Nafarelin, and Synarel) in IVF cycles. The trend
has been toward the usage of these drugs. There are two types
of analogs; agonists that first stimulate gonadotropin release
followed by suppression and antagonists that only inhibit.
While the antagonists theoretically are better, they avoid
the initial stimulatory phase (flare). Presently, they are
in limited usage due to their side effects. All GnRH analogs
work by the same mechanism, suppression of gonadotropin release,
and all have the same effect, ovarian suppression. A brief
description is as follows: GnRH (gonadotropin releasing hormone)
is produced in short pulses from a specific area of the brain,
the hypothalamus. This pulsatility is required for normal
ovarian function. GnRH analogs block this pulsatility and
decrease in release of gonadotropins (luteinizing hormone,
LH, and follicle stimulation hormone (FSH) from the pituitary
gland. Without gonadotropin stimulation, the later stages
of follicular development are inhibited. Since estrogen production
comes mostly from these larger follicles, the estrogen production
is depressed because follicular development is suppressed.
A trite analogy might be that theses drugs erase the board
or level the playing field. As such, GnRH analogs clearly
make IVF cycles more predictable and manageable at least for
the medical team. A second, but related action of GnRH analogs,
is the suppression of the LH surge that occurs in about 30%
of patients using gonadotropin stimulation (Repronex, Follistim,
Gonal F) without Lupron. An unwanted LH surge is clearly associated
with increased cycle cancellation rate and with a reduction
in the pregnancy rate. A third potential benefit of GnRH analogs
is the suppression of higher basal (tonic) LH levels that
are commonly seen in patients with polycystic ovarian syndrome.
Now the down side: Lupron, as given traditionally, requires
20-30 subcutaneous injections (much like an allergy or insulin
shot) and may cost $300-800. In addition, more vials of gonadotropins
and probably more days of therapy, are often needed to overcome
the suppressive effects of GnRH analogs. These suppressive
effects in some patients can convert a marginal responder
into a poor responder. Most commonly, Lupron is started about
a week before the expected menses, or around cycle day 21
before the IVF cycle is anticipated. In some cases, GnRH analogs
have been used for up to six months before initiating gonadotropin
therapy. In other cases, GnRH analog therapy is begun with
the menses and continues until ovarian suppression is reached
(estradiol level less than 25-50 pg/ml). Still others use
a flair regimen where gonadotropin and GnRH therapy are started
simultaneously. There are also several other variations on
these themes. There are several studies that report no difference
in pregnancy rates with first time patients. Overall, I believe
that use of Lupron has helped improve the overall success
of IVF. Considering the high cost of IVF in the USA, it would
seem that Lupron is cost effective and efficient. On all counts,
It's neither poison nor panacea. sst
Question: When I had my tubes removed (after a tubal pregnancy)--I
was told that without my tubes I had a better chance for pregnancy
if I chose IVF. Is this true? I am 30 and everything else
is working well (ovulation regular--ovaries in great shape,
and hubby is fine). I have talked with some other women that
have similar problems, and some say that people with a history
of blocked tubes may have a problem with the tubes being “toxic”
for IVF. What are your thoughts?
Comment: Please check the "What's up doc?” portion
of our site. It contains a review of an article concerning
this very issue. Your doctor was right. Unfortunately for
some, the first part of preparation for IVF is removal of
fluid filled tube(s) (hydrosalpinges). It is good that this
has already been done for you. You sound like a very good
candidate for IVF. sst
Question: I have had problems getting pregnant due to tubal
scarring. As a result I had to have my tubes surgically removed.
Is IVF my only option for having a baby naturally? My husband
had the opportunity to view (in a recent television program)
some kind of new technology that was without the medication
that induces multiple egg growth. Are you familiar with such
a procedure? Our problem right now is finances. Apparently,
what intrigued my husband most about this procedure was the
fact that it was substantially less money because there was
no medication involved. Not to mention, it seemed a benefit
to me because there would be no side effects. Our own reproductive
specialist did not admit to knowing of such a thing, however,
we felt as though he may just be in favor of the IVF procedure.
Comment: The procedure to which you have referred is a new
technique where immature eggs are remove from small follicles
and allowed to mature in the laboratory. I'm afraid that I
have little confidence in this procedure at present, and that
most of what you have heard is just hype. I believe it still
will cost several thousand dollars per try. The individuals
who reported this were only successful in one out of twenty
patents compared to standard IVF success rates in most clinics.
Sometimes only oral medications are used in IVF. Usually patients
are better off with standard stimulation programs. You would
seem to be a good candidate for IVF, but more information
is needed. sst
Question: I am 36 years old, have had 6 failed IVF cycles
and 1 failed a donor egg cycle. No one seems to be able to
give me a reason for my failed cycles. I have had endometriosis
in the past, in fact lost my right tube and ovary because
of it. My left tube is blocked. However, I do not have a problem
producing eggs for transfer, but just no implantation. I have
recently learned there is a theory that connects immunology
with infertility. Can you tell me your thoughts on this theory
and would you consider me a candidate for further cycles if
testing showed an antibody problem?
Comment: One of my mentors once told me that there are two
diagnoses that could not be made-- the one I don't know about
and the one we don't think about. Certainly you have proven
a most recalcitrant IVF patient. You should be pregnant given
the above therapy. I am assuming that you are attending a
clinic that has at, or above, the national average in success
rates, and that a comprehensive history has been taken and
that your specific issues addressed. The following assumptions
are also made: that you are hormonally normal in terms of
FSH/LH, TSH, and prolactin; that you have had satisfactory
ovarian stimulation with adequate follicular development;
that there was transfer of a number of good quality embryos;
that the uterus is normal at hysteroscopy; that neither tube
is a fluid filled-hydrosalpinx; that your male partner has
a normal semen analysis; that fertilization was normal; that
assisted hatching has been discussed. If all of these assumptions
are correct, then immunologic causes of infertility might
be the issue. Certainly, endometriosis has an immunologic
component. With endometriosis, it is sometimes difficult to
know whether we are dealing with a disease or a symptom. Unfortunately,
the tests for immunologic infertility are not totally reliable
and the treatment is even less so. Some have advocated testing
for phospholipid antibodies, and treatment, if found. Others
have suggested white cell transfusions from your partner.
I generally recommend neither of the two, but you may represent
a special case. I would recommend a second opinion with complete
review of your past history, especially if you have had all
of your therapy through one center. Different eyes see differently.
In the end, our science may be too primitive to know the answers,
but we certainly should make sure we have not missed something
easy. I am sure of your frustration and wish I had more answers
for you. sst
Question: I am concerned about hormone deficiencies and if
they can cause infertility. I have periods anywhere from 25
days to 42 days. I have had two ectopic pregnancies. I have
one ovary that produces eggs but one bad tube on that particular
side. Doctors have suggested IVF but the cost is great for
us. Any suggestions if hormone deficiencies are causing an
added problem and could they be turned around?
Comment: A combination of tubal deficiency and hormonal problems
is usually a good reason for IVF. It is expensive, but it
still represents the best option when comparing the success
with other therapies. Laparoscopy could be an option to evaluate
the pelvic anatomy and attempt to maximize fertility. Depending
on the status of the open tube, clomiphene or injectable drugs
may be indicated. I would not suggest over several cycles
of therapy for ovulation induction. A good deal also depends
on the origin of your hormone deficiencies. If you are over
35, an FSH level on cycle day 2 or 3 should be obtained. There
may be specific therapy for the hormonal problems depending
on the type and origin, for example PCOS. sst
Question: I had IVF 4 years ago and have a 3-year-old child.
My tubes are twisted and full of fluid. The doctor recommends
that we remove the tubes before we do IVF again. He said that
there is a study that says the fluid in the tubes is toxic
to the embryos. Would you recommend this to one of your patients?
Comment: I used to not believe that this could make a difference
and was cautious over the first reports of improved IVF success
after removal of fluid filled tubes (hydrosalpinges). Now,
at least four major studies have come to the same conclusion--
remove, or at least occlude the tubes that are fluid-filled.
The tube is a living organ that produces fluid to support
the developing conceptus and prevent it from adhering as it
moves toward the uterus. Even blocked tubes still may function
somewhat and change in size through the normal or stimulated
cycle. There are two possible reasons that a hydrosalpinx
may decrease success. First, it may be a mechanical wash out
of embryos from the fluid back flowing into the uterus around
the time of implantation. Since the distal end of the tube
is blocked, this fluid may leak into the uterus and disrupt
implantation. It is well known that a very small amount of
media must be used when embryos are transferred after IVF.
Increased fluid decreases success. A second reason is that
the fluid itself has been shown to be embryo toxic. Since
most hydrosalpinges, arise form a previous infection, there
may still be agents in this fluid that cause a inflammatory
response and either alter the uterine environment, or the
health of the conceptus (embryo). We still don't know whether
the tube must be removed, or just closed-off near the uterus
(tubal sterilization). We also not know whether larger hydrosalpinges
are worse than smaller ones. I understand your reluctance
for surgery. You may also want to read "What’s
up doc?” -Assisted reproduction section in the CARS
archive that reviews a recent article on this subject. sst
Question: I am 34 years old, my husband is 39. We just experienced
a failed IVF attempt. One previous attempt was not fully completed
because of the different maturation rates of the follicles.
We did not make it to the retrieval stage. On this attempt,
four eggs were retrieved; three fertilized and were placed
in my uterus. My pregnancy tests last week were negative.
The doctor appears frustrated with my low response in terms
of follicle development at my age. I have, over the years,
had six abdominal surgeries, including a ruptured appendix
many years ago, which resulted in adhesions on my ovaries
and fallopian tubes. All of one tube and the majority of the
other were removed nearly two years ago. Our hopes have nearly
been shattered. What could be some of the possible reasons
for the low follicle development and for the embryos not attaching
to the uterine wall? Is there such a surgery as tubal "replacement"
(donor fallopian tubes)? Could an abundance of candida in
the system (male/female) have had any effect on the success?
We may make one more attempt... Is there anything we can do
to increase success or to increase our hopes?
Comments: The ovary has a finite number of oocytes that are
present at birth and are gradually depleted over the next
50 years. In cases of multiple abdominal or pelvic surgeries
it is possible that a portion of the ovary was removed and
therefore would advance the "biologic” age of the
ovary. A second possibility is that ovarian function may be
diminished by altering the blood supply to the ovary. This
is easy to do with tubal surgery. Thirdly, the pelvic adhesion
may encapsulate the ovary and prevent the growth of multiple
follicles. Each of these, or a combination of the three, may
be a possibility in your case. I don't know a way of restoring
normal ovarian activity and if it has been severely compromised,
oocyte donation may be the best solution. You might improve
your chances by changes in the ovarian stimulation protocol.
It's hard to say whether more, or less, would be better. This
is better left to a discussion with your infertility specialist
who knows the details of your response thus far. There is
no possibility of donor tubes because of the high chance of
rejection of the organ graft.
Candida is everywhere, especially through out the digestive
tract. It has been linked to immunologic compromise and general
poor health but I know of no relationship between yeasts and
IVF failure. If in doubt, treat-- treatment is usually easy.
sst
Question: I have either no sperm or sometimes very poor sperm
in my specimen analysis. What are my chances of success with
ICSI? I am 44 years old and my wife is 42.
Comment: The first question is why is there an alteration
in sperm number. Is it due to obstruction of the duct system,
or is there a very low number of sperm in the testes? A physical
exam showing smaller testes and an elevated level of follicle
stimulating hormone (FSH) in the blood, indicate that it is
a sperm production problem. In this case, success with any
type of therapy short of donor insemination may have a poor
success rate. If there is a simple obstruction problem, this
may be bypassed by direct aspiration of sperm form the testis
or epididymis. The epididymis is the collection system between
the testis and sperm duct. There is a significant difference
in "no" and "low" sperm counts. If there
is no sperm, only the technique of sperm aspiration is available.
Low sperm counts may be a suitable indication for sperm injection
(ICSI), or possibly even conventional IVF. ICSI rates are
comparable to standard IVF rates and depend on the fertility
of the female partner. At age 42, success rates of IVF with
a normal sperm sample are 5-10% per attempt -- less than half
that at of women under age 40. Perhaps, equally worrisome
is the age of your wife. An FSH level should be obtained on
day 2-3 of her menstrual cycle. If this level is above 20,
the chances of pregnancy, even with normal sperm counts are
very low. With FSH levels of 10-20, the chances of pregnancy
are significantly reduced. Regardless, at age 42 alone, she
has passed the age at which must women will become pregnant.
If your wife were younger, sperm donation might be an alternative.
If your sperm count was higher, egg donation might be an alternative.
Together, your fertility is seriously compromised despite
all of our new technology. Probably a thorough evaluation
and frank discussion with a fertility specialist is the best
advice I can offer. sst
Question: My progesterone level was within normal limits after
receiving progesterone injections nightly. After the IVF procedure
was completed, my hCG was negative. What are some of the contributing
factors to difficulty with implantation? My endometrium thickness
was within normal limits. I returned to work three days later
after the embryo transfer.
Comments: Implantation is one the great remaining "black
boxes" of fertility. Certainly some, pregnancy failure
is due to the quality of the uterine lining. The greatest
source of pregnancy failure after IVF remains embryo quality
and not the preparation of the uterus. With the progesterone
supplementation you describe the hormonal environment of the
uterus should be fine. sst
Question: What are the possible reasons for fertilization
NOT to occur with ICSI?
Comment: Some would say that fertilization always occurs with
ICSI, but the union of the male and female genetic material
and/or further development does not always occur. Failure
of ICSI can be related to either male (sperm), or female problems
(egg). Sometimes this can be predicted by why the ICSI procedure
is being performed, for example severe male factor with an
otherwise healthy ovulatory female. Maternal age can also
be a significant factor. Sometimes it is not a male problem
at all and the true diagnosis of the fertility problem: an
egg issue is discovered. The best information comes form a
frank discussion with the fertility specialist and perhaps
the embryologist at the center where the procedure was performed.
Sometimes the answer still remains "I don't know".
sst
Question: We have undergone two IVF tries. The first time
resulted in no pregnancy but the second resulted in a blighted
ovum. Should we try again?
Comment: This depends on your age and the past overall ovarian
response. If you are near 40, have had marginal response to
the fertility drugs and a low number of eggs aspirated; perhaps
you should consider this as your last try. If there has been
no specific reason why you have failed, try again. The fact
that a pregnancy was established, even though it was blighted,
is very positive. In the final analysis, when to stop is a
personal decision. Of course, the input from your physician
and a frank discussion about your future chances is in order.
sst
Question: What is the low-end threshold for a sperm count
to perform IVF? What is the typical range of a "low"
sperm count for IVF? What are the associated pregnancy rates?
Comment: There is no low end, but with reduced counts, sperm
injection (ICSI) should be considered. sst
Question: I am 28 years old and my FSH level is 14. At my
first visit with my fertility doctor he told me that I probably
had a six-month window to get pregnant. He said we should
be very aggressive and start with IVF. Does this sound correct?
Comment: Unfortunately, the highest FSH level obtained is
considered the most diagnostic of success, but there are notable
exceptions. However, I am always suspicious of a single blood
test that is not supported by more clinical information. Interpretation
very much depends on when in the cycle this level was drawn.
FSH is also elevated around ovulation, which can be associated
with enough bleeding to mistake it for menses. A single elevation
in a 28-year-old is much more suspicious of being false than
in a 42-year-old. The test needs to be repeated and maybe
even a CCCT. It is also important to have an ultrasound scan
of the ovaries. The above results would be much more believable
if the ovaries are shown to have reduced volume on ultrasound
scan. I do not know about IVF, but you might not want to waste
time. You could try clomiphene, but not over several cycles.
Perhaps even a cycle of injectable drugs, not only for therapy,
but as to evaluate your response to these medications before
moving to IVF. I question the 6-month time frame. It is impossible
to know how long the FSH has been elevated. We do not have
information on how long fertility will persist at any given
FSH level. Even when all has failed, each year I have at least
one patient, especially when under age 40, that has been counseled
to forego additional therapy with fertility agents. They call
back with a pregnancy on their own. The elevated FSH does
not mean that you are sterile, only that success with fertility
drugs will be less productive. The ovary attempts to ovulate
a single follicle long after its capacity to "hyperstimulate"
with fertility drugs is lost. sst
Question: I'm 31 years old and have been diagnosed with a
high FSH level of 13. I went through 1 cycle of IVF while
on the maximum dose of GonalF. I only produced 4 follicles
and 3 fertilized and were put back but, it didn't work. I
am now taking 450 ml (max my doctor will give) and continue
to try with artificial insemination. Do you think this will
work or do I need to consider egg donation?
Comment: Gonal F is FSH. More FSH will not treat levels that
are already high. We also usually limit therapy at 450 IU,
or 6 amps of injectable drugs. With the above previous response
you would be classified as a low, perhaps even a poor responder.
We are quite usually pleased to have 3 embryos to transfer.
Not only the number of embryos, but their quality is important.
If these were good quality embryos, then I might try IVF again.
No center has good success with poor responders. There are
a number of different protocols for poor/ low responders and
patients tend to respond differently to different protocols.
Sometimes changing form FSH to HMG injection can be useful.
Sometimes using a "Lupron" flare regimen or one
the GnRH antagonists, rather than standard Lupron offers better
chances. Clearly your chances are reduced, but certainly not
zero. The decision to use donor oocytes (eggs) is a very big
step. This decision should be made in concert with your partner
and your physician. When to consider egg donation a question
of economics and efficiency. It should feel "like the
best thing to do". sst
Question: I am 28 and married. We have gone through two unsuccessful
IVF cycles, with no explanation. We are about to do a third
IVF, and I have been researching on the web and have found
a lot of information on taking baby aspirin during the cycle
to help blood flow to the uterus. Is it a good thing to try?
This is our last chance and we are willing to try anything.
Comment: It is unclear to me why you have not become pregnant.
Certainly, it can take more than 2 tries and thus far your
lack of success might be only chance. Still, a "sit down”
with your doctor is in order to review your case and discuss
possible therapy modification as well as estimation of success
for a repeat attempt. Use of aspirin is controversial. There
is one very good and well-publicized study that reports increased
success in IVF after aspirin use. Most successful programs
do not routinely use aspirin. The beneficial effect of aspirin
has not been unequivocally proven and its use needs further
validation. We know that large amounts of non-steroidal anti-inflammatory
agents such as aspirin, ibuprofen and naprosyn can block ovulation
and implantation. Probably small doses have no negative effects.
I do not stop patients from using low-dose aspirin, if they
wish. sst
Also see fact sheet –
Assisted
Reproduction, IVF
success, ICSI,
and Cryopreservation
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