Infertility advice

Can you help this reader?

A while back we emailed you regarding S my wife and our strive for children. She is now 42 and we have just tried our first IVF. We had 6 follicles, which went down to 4, then had 2 eggs, but only one fertilized. We went today for implantation to be told by Dr X that the egg did not divide. Dr X said that our chances are not good, as everything points to the same thing…in his view poor egg quality. By way of history, S and I have been trying with fertility drugs for 2 years to no avail. We had a brief stop and S fell pregnant. However when we expected to see the heart beat it didn’t so she had to have an evacuation.

 We decided that we would begin IVF in 2007. Dr X is worried about egg quality, as we only had 2 eggs to fertilize then only one took, but didn’t divide. We have some questions for you and your readers if you don’t mind:

•  After 2 years or so of drugs to stimulate the ovaries, we are wondering how that effects egg quality ? Maybe it would be a good idea to rest the ovaries for a while before trying IVF again - can you shed any light on this ?

• When we begun IVF it was just after a very short 1 day period that was 6 days early. Of the two eggs, one didn’t fertilize as the embryologist said that the egg was immature. We are wondering whether the fact that it was a v.short period may have affected the IVF process ? Perhaps it wasn’t even a period at all, because it was only one day of bleeding?

• We insisted on doing IVF despite Dr X suggesting we do another 2 artificial inseminations first. Does this make any sense to you if the issue is one of egg quality due to age ? 

• Do you or your readers have any advice for us regarding IVF, S’s age and where we should go from here? The doctor said we have a poor chance purely because of age? I would like to know how many people have had IVF at 42 and have been successful?

What advice would you have for this couple?

Comments

[DD]

The best noninvasive test I think out there that can help determine ovarian function is the antral follicle count. Basically an ultrasound early in the cycle of the ovaries without any stims to see how many antral follicles are visible.

Also, poor fertilization is not always due to egg quality. Sperm quality and high DNA fragmentation can contribute to diminished responses to IVF, even if motility and count look normal.

Try not to consider your age as it can bring about considerably angst. Also, one IVF is never like another. She could very well respond quite differently if they decided to pursue this course with an increased dosage.

I hope only for the best possible outcome for this couple, and any couple who feels overwhelmed by IVF/ART.

[Jo]

At 42, and especially given her history of repeated attempts by way of injectibles that did not work, I would not waste a moment's time. Prior to an IVF cycle commencing (on day 3, I believe), there should be blood tests run that show that she is properly suppressed to begin the injection protocol. Assuming all that was done and despite a short period, if she was suppressed (i.e., E2 was low), then I don't think that would be a reason why so few mature eggs were retrieved. I agree that an antral follicle count, combined with a day 3 FSH/E2 blood test would tell a good part of the ovarian reserve story. Then, I would hope your RE would start with a pretty high dose of injectible meds to recruit the maximum number of follicles. Also might consider not using Lupron (if you did) and try an agonist like Antagon, to help increase the number of eggs produced.

However, if having a child that is genetically related to your wife is ultimately important to you, then I would say do NOT take months off. Every month matters at this age (I know, I ttc'd from 41-43.5 myself). My story is that I had good hormone levels and responded fairly well to fertility drugs and produced 5-6 embryos with my IVF cycles, but all I had to show for 6 IUIs and 2 IVFs (and more dollars than I care to admit) was one miscarriage. I did a donor egg cycle and that finally was how I wound up with my G&D twin girls. The good news is, however, that age isn't as big a factor for a DE cycle (in other words, that can wait) as it is in an IVF cycle with your own eggs. So, know that DE is an option should any further IVF attempts with your DW's eggs not prove successful. It certainly comes with some feelings of loss, but the end result -- your own baby(ies) to love and nurture -- cannot be beat!

Good luck to you!

[legalmama]

A few things: I would seek a second opinion if you have an option for another excellent doctor in your area. Don't waste months waiting for one if you can't get an appt. right away, but don't put all your eggs in one basket so to speak. I'm surprised that a doctor would have a woman in her 40s do two years of injectables without IVF, so I'd want to hear what another doctor had to say. It made a big difference for me. I did my first IVF with one doctor at a clinic with an excellent reputation, but my doctor was always doom and gloom about my chances, predicting donor eggs for me although I was only 36 at the time and had normal FSH etc.

First IVF was a disaster, and we got only 5 eggs, none fertilized the first day, one fertilized the second day, and we had a chemical pregnancy. Second IVF, with a slightly different protocol, I got 13 eggs, four fertilized with icsi, but I didn't get pregnant. Third cycle, yet another protocol, I got 12 eggs, 6 fertilized, and we put four back, and I got pregnant with my son. Even once I was pregnant, my doctor was gloomy, worrying about chromsomal abnormalities etc. I never spoke to him again.

When we wanted to try for another, at nearly 40, I went to a different clinic, where they sang a totally different tune, were much more optimistic. First cycle there failed, although I had the most beautiful embryos I'd ever seen. Second cycle, I ended up with 18 eggs. Me, at 40, with 18 eggs. 12 fertilized. Again, dramatically different results from my first clinic. I ended up pregnant with triplets. The three naturally reduced to two and I had twins.

I tell you my long story, just so you can see why it is important to get a second opinion.

Make sure she has had all her proper testing of her hormone levels, which will tell a lot about her egg reserve, and egg quality. If those are normal, then I would try IVF again, with a different drug protocol this time. For me, the protocol that worked was Antagon, with no prior suppression. I wouldn't wait for months to rest. I've heard doctors say that one rest cycle is all you need.

If the next IVF cycle doesn't go much better, then it may be time to quit. It is hard to hear that, but at 42, it may be that IVF will not work. It may actually make more sense to do injectable cycles. For some women, as they get older, their eggs do better without all the extra stress of retrieval etc.

[Pam]

I agree with everyone so far. It surprises me the path your RE chose to take as once a woman turns 40, her chances of conceiving drop dramatically (sorry to be all doom and gloom). Even though my FSH and estradiol levels were good, it seems my antral follicle count was low. (This website can give you some good info on antral follicle - http://www.advancedfertility.com/antralfollicles.htm and FSH and Estradiol levels - http://www.advancedfertility.com/day3fsh.htm). However, at 42, it's not impossible to conceive with her eggs. I would definitely consider going to another clinic for a second opinion and I wouldn't take any time off either. I did everything I could to use my own eggs, but once my RE knew we intended to move forward on IVF and incur the cost, she recommended donor eggs, and at 46, it would be very difficult for me to conceive with my eggs. Once you move to donor eggs (if that becomes an option for you), the chances of success are then based on the donors age.

[Yellowgirl]

I agree the the other posters... DO NOT WAIT! But, you should explore, if you haven't already, Day 3 FSH levels, and maybe do a clomid challenge test as well. Those tests, plus a newer test called AMH, are the "egg quality" tests such as they are. Sounds like you may have fertilization issues too, in which case you should consider ICSI instead of just "normal" IVF fertilization. And different drugs, different clinics can offer VERY different results....shop around! You may have to travel to an IVF center that is excellent and works well with "older" women.

Yellowgirl

[alchemilla]

I would recommend the AMH test: it stands for anti-Mullerian Hormone and European research has shown it to be a far more accurate predictor than FSH of how any given woman will respond to fertility drugs. To be brutal, the level you get roughly corresponds with how many eggs you might produce, and anything at 3 or below and you're advised to consider creating your family by means other than your own eggs.

There's only so much tweaking with the drugs that you can do - and it's better to know if IVF is not the best route. It's also very useful to know if there's still a reasonable chance, and tweak the drugs as accurately as possible.

My sincere wishes for good luck for you and your wife.

[Jessica]

I am 42 and just had a successful IVF cycle (17 weeks pregnant now, and passed my CVS test. whew.). But every couple is different and every cycle is different.

I agree with the previous posters who recommended not wasting any time. Time is critical when you reach this age and every month counts. Also, I agree with recommendations to consult another clinic if you can. I've heard of wildly different results from the same couple with the only difference being the clinic. Good luck.

[Bea]

Whatever they do - don't wait too long to do it. The sad fact is time is not on their side.

Bea

[meredith]

Your RE does seem quite contradictory in saying you should do AIs instead of IVF. But then again, that could be because he/she believes you have just as much chance with an AI as you would with IVF. That is to say (sadly), a very low chance of falling pregnant. Egg quality would definitely be the concern here. I'm no doctor, but I don't believe infertility drugs would affect that much, nor the length of the previous cycle. There is lots of tweaking that could be done which MIGHT improve your chances, but to be brutally honest, I think donor eggs would be the best option here. It's all a matter of how much more you can take. Perhaps the best thing you can do is make a plan of action - one more IVF with own eggs, then move onto donor - whatever it is. That will help you feel more in control.
I started trying to conceive at 38, did numerous AIs before moving onto IVF. 5 transfers later (always "perfect" embryos), I finally achieved a pregnancy - only to lose it at 9 weeks (blighted ovum). At that point, I was 40. I decided to stop treatment at that stage, because I firmly believe that NOTHING will make my eggs younger.
I am so sorry for what you are going through. There may be some cold comfort in knowing you are most certainly not alone.

[Jazz]

Hi

I agree with all that has been said above re: hormones levels tests etc beforehand and forget the AIs.

Age is a major factor but sometimes I think it us used too quickly to explain things that the medical field have no real answers for or don't look for.

E.g. some people react to the drgs given and have better results on other drugs. Others say that may be because the eggs 'recruited' for that cycle might just be a better batch. Luck of the draw quite simply.

Some believe that it is best to rest the ovaries for 3 cycles as it takes 3 cycles to recruit the eggs upon which you can have an effect via diet, no/limited alcohol etc etc. This is along the thoughts of Randine Lewis a well-known fertility acupuncturist in the USA. Her book is very interesting you can find it on amazon.com (The Infertility Cure). She has case studies about the older folk doing fertility treatment.

As always you will find those that have become pg without waiting, so it is up to you both to decide.

I was always told that it is based on 3 cycles with one clinic that gives the best indication of ones chances. The first one is a kind of 'getting to know you' etc and how you respond to the drugs etc. The second and third cycles are the fine-tuning. So perhaps you would have a better idea of quality etc after another cycle. However, just from the short info you have given and the fact that you had to push for IVF while your doc was keen on more AI/IUIs makes me wonder if he is the right doc for you.

You mention that the IVF cycle was started after a short one day period, did he do any tests on that day? to see the hormone levels? I personally have not heard of a cycle taking place so soon? 'Normal' protocol (or at least my lot) have been based on having a day 2 or 3 blood test and then being given the go ahead to start the drugs regardless of if bleeding or not.

Another question that sticks in my mind is, is a one day period/bleed normal for your wife as it seems rather short. A hormone blood test would have indicated if this was really a period or not.

Sorry to hear that your wife suffered a miscarriage.
Was any reason given for the miscarriage? Were any tests done? Has there been any indication that she may have suffered very early loses before? i.e. longer cycles than normal and a heavier flow perhaps?

Has your wife been tested for at least the basic immune panel to see if she has ANA APA. A friend did this after a long time TTCing and once she was started on daily low-dose (70-100mg) aspirin it helped tremendously.

Metformin is used for women with PCOS but it has also been seen to have a positive effect on egg quality in those even with no PCOS. Perhaps this is worth looking into.

Wishing you all the best! It is a crap road to be on. One that I am still travelling too.

[jb]

did not read all the comments so pardon if I am repeating. at 41 there is a dramatic delince in fertility - meaning a 40 yr old woman is going to do much better than a 42 yr old. your wife is not a good responder and I would move on to donor eggs. if you are considering multiple IVF attempts, more than likely one attempt with donor eggs will cost the same. and many women who get pregnant use donor eggs but don't tell people (which I totally understand) but it can make it seem like age it not an issue when in fact it is. there are no easy roads or easy answers when on this path. the best to you both.

[thrice]

I agree don't waste time. I had twins with my own eggs at 41. Our issue was male factor. My clinic did not use BCP's and Lupron for over 40's. The theory, then anyway, was that BCP and Lupron can overyl-shut down an over 40's system, making it too hard for the women to restart. So after AF, I went straight to follistim et al. I did use cetrutride(sp?) at the end.

If you think that you might consider donor eggs if your eggs don't work out, do that sooner than later too. 40+ pregnancies don't get too much press on how hard they are. Twins can complicated things more. I have heart failure from my twin pregnancy. I'm happy to have my children, but I wish I knew how hard the pregnancy was going to be.

Good luck!

[Suzie-Q.]

I got PG on my first cycle using my own eggs. I had to do electro acupuncture to help my low uterine blood flow.
I had 16 follicles. 14 were retrieved. 13 were fertilized. 2 made it to day 5 blast and were transferred.
I delivered gorgeous, healthy and happy Boy/Girl twins from those two embies.
I was almost 44 years old and had been given only a 10% chance of success by my IF Clinic. I went to CCRM (Colorado Center for Reproductive Medicine in Englewood, Colorado, USA... one of the best in the world for women over 40).
My twins just turned two. Don't give up hope. Move on to a second opinion!!!!!!
Best of luck!
Suz

[Suzie-Q.]

Corrected to say, I was 43 years old when i cycled and almost 44 when i delivered.

[millie]

I definitely recommend both an antral follie count and CD 3 bloodwork if that hasn't already been done. It's really important to measure both E2 and FSH as some have suggested.

You mention that your wife has been taking fertility drugs for two years. Were these injectible gonadatropins or just clomid? Were these cycles monitored so you have a sense of how she responded?

What was the protocol for this ivf cycle? Was it a Lupron cycle or an Antagon cycle? Were birth control pills used at all? Some women respond better to a lucrin/lupron cycle, some respond better to antagon/centrotide. There are all flavors of cycles: long lupron, micro-dose flare, etc. What were her estrodial levels like during the cycle? What are his requirements for going to retrieval vs canceling the cycle?

I wouldn't take any or much time off. It's not likely to help and as much as I wish that age weren't such a big factor, that's not the reality. If she's a 'poor responder' then there are some clinics that have specific protocols for that case. I also recommend finding a good acupunturist who has a lot of experience with infertility. It might seem a bit "out there" but it can be really beneficial.

You're likely to get the donor egg speech if you haven't already. It's a great option if you think it might fit for you. There are some great resources for getting more information about that when and if you're ready.

I was an egg donor years ago and I've also pursued donor eggs in Cape Town as a way to build my family. I'm happy to answer any questions about either side of it if you'd like to email me or visit my own blog.

Best of luck to both of you. I've been at this for 4 years and my only regret is not moving on to other ways of building my family sooner. We all have our own paths but I hope yours leads you to parenthood very soon.

[Carmen]

I was in a very similar position a couple of years ago: poor responder and age 39 when I had an IVF after several IUIs. I had 2 embryos that came to nothing, alas. But before considering donor egg or even doing another cycle we knew we were done. We'd spent all our married life pursuing a pregnancy and being very unhappy when it didn't happen. We knew in our hearts that our dream was over. It was very hard to give up on the idea of a biological child but we did it.
So we adopted our baby in Kazakhstan just 8 months ago and are extremely happy. I'm not saying it's the best route for everyone but I am saying that you can be a parent without that biological connection.
If this couple is still in the phase of desperately wanting bio kids then none of this will make sense to them. I know because I've been there too.

I just wanted to put this wonderful option out there, just as others have tried to help with medical advice. The heart is what makes you a parent, after all, not necessarily a genetic connection.
My best and warmest wishes to them.

[sheilah]

Agree. Agree. Agree. Especially with the do not wait. Time is definitely the enemy here. Do the tests as outlined above (for both partners). Definitely consider ICSI.

And have a backup plan if nothing works. Whether that be moving on to DE, adoption or being childfree.

Good luck.

[Jennifer]

Everyone's comments are so great, I don't have anything to add except to wish you luck. Oh, also, if you are not already at a top clinic, I would consider traveling to one for a consultation.

[Nobody special]

First, the fact that you conceived on your own is a great sign. If you got PG once, it can happen again.

IVF is the way to go because now you know that there are egg quality issues and IVF is the only way to guarantee the best eggs are transferred and that you get the best chance at a healthy baby.

Definitely look at tweaking your protocol and get a second opinion. There are things that can be done to improve egg quality and, hopefully, quantity. Another doc might have some suggestions on how to achieve this.

Definitely be wary of any doc that pushes AI on you. It is not the appropriate treatment given your fertilization rates.

Also, you didn't say, but did you do ICSI and assisted hatching? If not, look into that as well.

Just remember, you did get PG. You just need a good embryo and you'll be all set.

Good luck!

NS

[Susan in OR]

I would add that many infertility docs tend to use higher & higher doses, when there are now some indicators that us over-40 women do much, much better with LOWER doses. There are some folks in the US doing low-stim protocols with good success.

Age alone is not an explanation; I personally think that many docs are too lazy to look for true explanations. I was given the donor egg speech a while back without proper evaluation (based only on my FSH & my age). Turns out I was getting pregnant ok but had low progesterone, causing me to miscarry. Once that was supplemented, I got pregnant the next month on my own & now have a 6-month old daughter to look at every morning. I delivered her just a few months before turning 43. Heck, we're planning to try for a sibling.

[Nikki McD]

I wasn't sure from your post if your doctor did this or not, but my doctor put me on birth control pills for one full cycle to supress my ovaries (I live in the Midwest of the USA). Then he hit me with the fertility drugs for the next cycle. During this cycle, he harvested/fertilized eggs. If your doctor didn't do this, it might be worth exploring next time.

Good luck to you! You'll be in my thoughts and prayers.

[sorenson]

Some people I know have managed to improve egg quality by taking Co-enzyme Q10 - but make sure you go to a registered naturopath or herbalist and get it through them (the stuff in the shops is not always high quality enough).

Good luck!

[Tracey Aegerter]

Hi -

I am going for my first IVF cycle with a target date of 5/17. My antral follicle count is very low. Only 4. But the ultrasound tech said that they had a very difficult time seeing my left ovary so there might be one or two more. My FSH is at 9.9 which is barely in normal ranges. I'm 37. Does anyone know of a situation like mine? I'm terribly worried. My doctor immediately started talking about donor eggs. I'm not against that but of course, had always wanted a little girl or boy that was genetically related to me. Difficult to get used to the idea of anything different but I can. I just want to prepare myself.

[Tracey]

Hi -

I am going for my first IVF cycle with a target date of 5/17. My antral follicle count is very low. Only 4. But the ultrasound tech said that they had a very difficult time seeing my left ovary so there might be one or two more. My FSH is at 9.9 which is barely in normal ranges. I'm 37. Does anyone know of a situation like mine? I'm terribly worried. My doctor immediately started talking about donor eggs. I'm not against that but of course, had always wanted a little girl or boy that was genetically related to me. Difficult to get used to the idea of anything different but I can. I just want to prepare myself.

[Ordinary couple]

We are going for our second egg donor cycle at CCRM right now and we are experiencing something unpleasant. How is your experience at CCRM?

[Michi]

I am 41 and have never tried to get pregnant. I just had a FSH level drawn and it was 9.9. People are telling me I should take clomid and have a clomid challenge test. Should I have the take the test? Should I be worried?

Michi