Tuesday, October 23, 2012

IVF # 1---Not off to the most stellar of starts.

I'm on day 5 of my cycle and I had my first follie scan yesterday. It wasn't something that made anybody jump up and down with joy, my AFC was 13.

2 years ago, my AFC was 30 and above. Then I discovered I was vitamin D deficient and I started supplementing, which pushed my AMH considerably. But last year, I had already noted that my AFC had fallen, to around 16, and I also discussed the possible relevance and possible mechanism behind this drop in this post.

Back then, when I was not planning IVF, this was nothing to be bummed about-- I had assumed that my super high AFC for my age reflected my PCOSiness and any deviation from this was a GOOD thing- I thought, maybe decreased quantity might go hand in hand with improved quality, given the finding that women with PCOS have high AFC and can make many, many eggs, often of crappy quality. But since then, I've had one failure to achieve clinical pregnancy and another loss due to aneuploidy, so ummm, it does not look like things have gotten better???

Now that I'm staring IVF in the face, an AFC of 13 is 'not good news', especially when you've come from a much higher number--- it reflects a decreased potential, the best one could hope for is 13 eggs, and in reality you will get less, and you will have fewer than that number fertilize and even fewer that keep going till day 5.

My RE was pretty upset, he still had my AFC of two years ago in his head. While I'd gone in with a daydream of around 20, realistically, I knew I was going to get something in the vicinity of 16, and moreover, I was aware that the metformin I was taking could drop the numbers a touch-- there are a few studies that show that metformin can reduce AFC. So no surprises for me.

I started laughing when my RE finished the scan and he was shocked by my reaction-- he asked me why I was laughing-- I remember thinking it was a preferable reaction to crying.

The scariest part is, I really may have to give up on doing CGH microarray if we get only a few embryos that go past day 3,  for anybody who has done this- how many embryos did you have? My RE puts the cutoff number as 10, and that is a really tall order with an AFC of 13.

This presents so many dilemmas- if I can't do screening--then what? I don't know what percentage of my embies would be aneuploid, and its a very, very scary place to be in, for somebody who has lived with RPL.
Most people get around this by transferring multiple embryos---I really am terrified about transferring 2 embryos and the higher risk pregnancy of twins and the many, many higher risk scenarios that could occur.

Ironically, my number of 13 is in normal range for an Indian woman of 32, according to my RE. I've somebody who is SUCH a grey zone fertility-wise-- I've gotten pregnant out of 3 out of  4 attempts, by nothing more than un-medicated IUIs, which would make one think I'm a fertile frickin bunny till you realize I've managed to lose all of them.Then my AFC is all over the place--does my drop from 30 to 13  have nothing to do with weird vitamin D physiology and instead indicate a sharp drop in fertility?? I have no idea how I'll respond to superovulation inducers...and things have gotten off to a not good start.

Another thing that is an area of contention for me: My RE wanted me to try menagon (which is urine-extracted FSH with a little LH). I freaked out when it was given IM, and indeed, when I took it for the first time, 24 hours later, I still have injection site soreness. So instead my RE said I could take an equivalent of Gonal F(synthetic FSH), no LH, which is given subcutaneously, which was what I was looking for, being a wimp and all. I took that today, I tolerated it fine-- only thing I'm worried about, there is no LH. Here is a theory that some, but not all docs believe in, that a little LH makes follicle development better so they give Gonal F with luveris(synthetic LH). I'm wondering if I should ask for this, for my own peace of mind if nothing else....any opinions anybody?


  1. Whatever happens, happens...true but that doesn't make the getting there any less frustrating. Hang in there

  2. Ugh, sorry about the AFC.  At least it wasn't a surprise.  I would have thought 13 would be on the low side of normal for your age...does the fact that you're Indian play into it?

  3. Yeah, according to my RE, Indian women do present with lower AFC than Caucasian women of the same age.

    Anybody wanna comment on this, your input would be very welcome!

  4. Dear Jay,

    Did you read my post about metformin and decrease in AFC?  Please read my blog post on : From 3 eggs at the age of 29 to 24 eggs at the age of 33. I am sure metformin can decrease AFC drastically. I think I warned you already but since you always said you had lots of antral follicles I thought it should be OK. Only women with Hypogonadal hypogonadism need LH in their stimulation regime. I don't think 13 is bad. Remember, it takes just a single good embryo. Good Luck! Let it be your last IVF too! : )

  5. Thanks Manju! I'd read your post a while ago and I was already familiar with the few studies which show that metformin decreases AFC. however, all published reports show that this effect is mild, AFC drops by around 3-6., which has actually made this phenomenon hard to prove.  My AFC, measured twice last year, well before I started metformin was  around 16, now its 13. 

    Since you had also started DHEA, its hard to know which one contributed more to your increase in AFC, starting DHEA or stopping metformin. Also, biology is complicated, each of us comes to the table of infertility with unique underlying issues--maybe DHEA was really what you needed, or you had an outlyer response to metformin, hard to say.

    The reason I even decided to go with metformin was the hope that it would improve quality. Ending up with a large number of eggs is pretty useless if none of them is euploid, or capable of fertilization/growth/implantation. Hard to say where the mojo is!!

  6.  True ! : ) Might be I am also very longer on metformin- from the age of 26 or so ! Not continuously but most of the time. Jay keep us updated!

  7. On my last cycle I ended up with more eggs than they initially counted with my AFC. I wouldn't worry too much about the numbers. Otherwise, there are just so many numbers to obsess about. Interesting about the correlation between Metformin and AFC though. I don't think I've noticed much difference. 

  8. We did PGD in our 4th IVF cycle with 3 embryos. It was FISH PGD, which I didn't realize at the time only gives us a 50% of a normal embryo given a 'FISH PGD normal' result, but that's what our clinic offered.

    We did CGH with our two donor cycles - both times with lots of embryos (see next paragraph), but I would have done it with 1 embryo. After 2 chromosomal miscarriages, we were happy to pay for something that would help us avoid any more of those...

    For our donor cycles, one cycle had 5 normal of 12 embryos (though 2 of the normals were fragmented physically), and the other cycle had 11 normal of 18 embryos. Donor was 27 for the first cycle and 28 for the second.

    Menagon is the same as menopur, which I used in some of my cycles. For me, the additional LH likely contributed to the oversuppression I had from birth control pills, so in future cycles we did FSH only. My menopur injections were always subcutaneous, though - a quick Google search online shows plenty of people taking menagon subcutaneously, so might be something to ask your doctor about.

    Good luck!

  9. Seek help. This is a very serious matter. Avoid denying the problem or keeping it to yourself.