My wife and I were under your mediacl care in 2006, yesterday we celebrated my son’s 3rd birthday. I wanted to take this moment to express my thanks to you.

Thank you so much. It is not possible to describe in words the happiness that you gave us. You have a rare combination of not only being extremely in your knowledge base but also a very compassionate and caring individual.

May god bless you.

HS

Due to a childhood illness i suffered with primary ovarian failure. Over the past year my husband and i have had four attempts of IVF with an egg donor. Our initial attempt was with a fresh embyro and subsequently with FET. We now have one day 5 embyro left.

I have added complications to my health suffering with metabolic syndrome (type 2 diabetes, high cholesterol, high blood pressure, etc). Due to this only one embyro has been transfered at a time.

I have been trying very hard to optimise my chances, by controlling my diabetes (HB1AC is currently 5.7%), eating well, exercising, not drinking caffiene, acupunture.

I am about to turn 35, and i hope to have our last attempt before the end of the year (last attempt was May 22nd. Do you have an advise on what could help me with a succesful implantation on this attempt.

Dear Annabelle,

With several attempts behind you, the choices ahead are not as clearcut as they may have seemed to be at first. I would consider the following:

*You mentioned a childhood condition. One of the common causes for induced primary ovarian insufficiency is childhood cancer. If pelvic radiation was required, it can affect the implantation potential of your lining. Make sure that your endometrial thickness (ET) is at least 7mm…and hopefully much more, like 9 or 11. There is no treatment for radiation damage; you would have to consider a gestational carrier if ET is a problem.

*The next thing to consider is the frozen embryo transfer (FET) success rates of your clinic. It is worth asking after the FET “implantation rate” (the success rate per embryo transferred). Quoted pregnancy rates are often much higher than implantation rates b/c unlike your situation, we usually transfer more than one embryo at a time. Many clinics have an FET pregnancy rate of about 20%, so the implantation rate may be as low as 10%…which would explain why it is taking so long to become pregnant.

*I understand that you will transfer the one embryo this time. But, if you need to do a fresh cycle in the future, think about your relationship to selective reduction. If, morally, you could handle selective reduction, then you could transfer more than one embryo at a time. Ongoing pregnancy rates per transfer in my clinic in 2008 with donor eggs were 82%…but we always transferred two embryos, and the twin rate is as high as 40%.

Annabelle, FET pregnancy rates are not as high as fresh in most centres, but those that do have success most often employ GnRH Agonist (Lupron) down-regulation as part of the cycle. We are not sure why, but Lupron may improve implantation rates for many patients.

Best,

TGH

I just had my embryo transfer. It is a 2dt of 2 embryos. One 2 cell and one 6 cell. Although they do not have any fragmentation they are much slower or fater than their developmental age. Can a 6 cell develop on day 2 (48 h post insemination)?

TGH replies

Dear Alana,

yes, your embryos could result in pregnancy, though two embryos on day 2 is not as many as we often see during an IVF cycle. For more on the topic of assessing embryo quality, see my post here.

Best,

TGH

TGH replies,

Dear Darma,

The significance of urea/mycoplasma is controversial. I used to do the test, but couldn’t see any difference in outcomes, and found that the treatments were interminable, so I stopped. But researchers continue to look at this topic, so your doctor is not alone in this regard.

Thanks,
Dahlia

TGH replies,

Dahlia, I cannot really comment on the necessity of the test. But I can say unequivocally: no procedure should hurt. With modern anaesthesia, there really is no excuse for it. For example, in your case, you could ask about misoprostol (to soften the cervix), Ativan (for you), and a local-freezing-spray for your cervix. The procedure itself should never stand in the way of your desire to become pregnant. Hope that helps.

I have found your articles very interesting. I was wondering if you would have any suggestions for our issues.

I am 38, my husband 39. We had several IUIs back in 2007 and I had a laparoscopy in 2007 to treat some minor endometriosis, my tubes were also checked and were fine.

We had our 1. IVF /ICSI in May 2008. From 14 eggs 12 fertilised, and 7 reached blastocyst level, one hatching blastocyst was transferred. It did not implant. Before FET I had some additional tests done and was diagnosed with Hashimoto. I now take thyroxin (100) 6 times a week. All together I had 5 FETs, only one embryo failed to thaw.

We had our 2. IVF/ICSI in May 2009 and today I have again found that my test was negative. This time we had 9 eggs, 8 fertilised, one was transferred and 5 frozen. All of them blastocyst.

I fear the problem is not with the embryos but rather with me. Apart from thyroxine and folic acid I do not take any other medication. We are both non smoker and otherwise healthy.

Please advise.

Thank you

TGH replies

Dear Oli,

When a couple consistently makes many blastocysts -as you and your partner do- it almost always implies good embryo quality.

That said, there are two issues with your transfers to date:

1. You have been doing elective single embryo transfer. eSET has the laudable goal of minimizing risks for multiples, but it comes with a reduced pregnancy rate per transfer. Any given blastocyst only has a 50%ch for being genetically viable.

2. Frozen embryo transfer cycles, in many programs, don’t have a very high success rate when compared to fresh cycles.

This means that, in your case, you may still, after all this time, still have a good chance for pregnancy.

My advice:

1. Ensure your testing is up to date (3D sono or hysteroscopy, autoimmune, coagulation, hormonal, and genetic screening).

2. Ask for counselling around preimplanation genetic screening for embryos (I don’t usually advise PGS, but this might be the right time to get as much information as possible).

3. Ask about the endometrial biopsy that can be done on the cycle prior to transfer.

4. Consider transferring at least 2 fresh blastocysts. If you do an FET cycle, assuming you can handle the uncertainties (medical, moral) of selective reduction, transfer at least three.

Because if your next fresh transfer doesn’t work, you may seriously have to consider gestational carrier.

So many variables to consider! I really cannot offer a complete second opinion in this forum. But I hope these comments are enough to get you started.

Tom Hannam

TGH replies:

If you call the clinic, they might tell you that a little spotting could be an “implanation bleed”. In all honesty we have no idea why some women spot a little bit; but if it only lasts a day or two, and is barely noticable (pink or brown), it does not seem to matter or affect prognosis.

Success rates from FET cycles are in the 15-40% range for most clinics. I hope that you prove to have a successful cycle.

I had my 3rd IVF - ICSI this month. Everything went on well but I got my period one week after transfer (embryo was transferred after on 5th day).

I’m not sure what to do?

Please advise me.

Thanking you
Bhuvana

TGH replies

Dear Bhuvana

I am sorry to hear that your menses came early…before the end of the ‘two week wait’. In my practice, we use both progesterone and estrogen support during this time. Since I added estrogen to our luteal support protocol, I cannot recall the last time I saw early menses.

I am age 39 and just starting to research fertility treatment options.

When I was 22, I underwent laser cone surgery for cervical cancer (no reoccurrence since). In March ‘09 I was diagnosed with a 12mm hemorrhagic cyst on my right ovary. I have a follow up ultrasound scheduled for this week (April 23/09).

Given my age and history, and assuming my husband’s sperm are healthy, will I be a candidate for IUI? I had a laparoscopy (and D&C and blue dye) in October 2008 which indicated functioning tubes and no evidence of Endo. My cycles are always 28 days. I can feel my right ovary on Day 13 and consistently experience bleeding at this time in my cycle, particularly following intercourse.

Dahlia

TGH Replies

Dahlia,

With reason to suspect a cervical factor (due to LEEP) and no other compromises identified, you are an ideal candidate for up to three IUI attempts.