Friday, February 22, 2013

Making a case for not messing too badly with nature

This is a hopelessly  technical post- its mostly a prelude for the discussion with my RE.

I'm somebody in whom, the natural process, at a surface glace, works beautifully.

  • My ovulation are extremely predictable. 
  • My estradiol levels per mature follicles are bang on target(around 250/ single mature follicle) .
  • My LH surge is huge, regular and easy to identify. My levels are super low on CD 3 (around 2.5 in one test) and go up to around 40 on day of surge. 
  • The appearance of the uterine lining elicits extravagant praise from doctors. 
  • My natural progesterone levels  (only during pregnancy) are usually perfect, over 40 ng/ml.
  •  And since I've corrected my vitamin D levels , my luteal phases have been perfect in length, usually around 15 days (Note: In my days of vitamin D deficiency, they were much shorter, around 10-11 in a particular cycle pattern)
  • Most importantly, all of this usually results in a pregnancy rate/cycle far above the population average.
On the other hand, when I did IVF, everything went to hell. Basically, shutting down my pituitary and hitting me with monster doses of FSH had a shitty outcome.
  • While my E2 levels were even higher than normal (3521 pg/ml, with 11 eggs being extracted, translating to around 320 pg/ml per follicle), only 3 of these eggs managed to fertilize, even with ICSI.
  • As my estrogen levels got higher and higher, my cervical mucus disappeared- it was abundant during the first 4-5 days of FSH injections and then as my E2 climbed, it just vanished. It actually makes sense- whatever stimulates a process at one concentration can inhibit the same process at a much higher concentration.
  • My luteal phase was a short 10 days- very striking. 

My RE blames my weird response to the drugs on the fact that my AFC, which was 30 in 2010, had dropped in half. Few issues with this line of thought---
  • My AFC has maintained around 16 for an entire year before the IVF and its drop correlates to the time when my Vitamin D levels tripled. Its hard to correlate a drop in AFC to a bad response to  FSH- After all I managed to get pregnant  naturally in response to the FSH my pituitary manufactured, well after the drop.
  • I think MY RE is stuck on this theory because it is natural for an RE to connect a poor response to IVF protocol to ovarian aging because these 2 normally do go hand in hand, a 40 year old woman would have had a large decrease in AFC in the past few years of her life and she may be a poor responder as well by this age . However, mine is not the typical scenario: I believe my drop in AFC was the end result of the reactions caused by the increase in my vitamin D levels and is conclusively NOT due to ovarian aging, so trying to link the two is trying to compare apples to oranges- there is no logical connection.  
I think that my protocol really did not suit me. Why that is hard to say. How to fix it is even harder.

What we all forget- the natural process has about a 1000 intricate layers, and is beautifully controlled- in comparison the IVF protocol, which often shuts down the pituitary and all feedback mechanisms, is like a caveman with a club- I'm not disputing that it works, only noting that in me, the natural process appears to be superior to IVF.

So what I'm trying to do with my next IVF cycle:
  • Keep my stimulation to a minimum, using a mini-IVF
  • I really want to keep my pituitary gland in play for as long as possible. During IVF, this is shut down with agonists/antagonists. I want my body to tell me when the the follicles it is making are mature, through all the feedback mechanisms it possesses- In other words, I want to trigger when my body decides to go with its LH surge.  I don;t want the doctor to decide this just through just looking at follicle size/E2 levels- this worked really badly the last time, but maybe it was also because of asychronization of follicles- I believe that the first 6 follicles that grew first yielded the 4 M2 and 2 M1 eggs and these were kept waiting for about 3-4 days while we tried to get other follicles to grow.
  • Option 1: I'm debating trying to get my doctor to agree to avoid pituitary suppression using antagonists and allow a natural surge. I recognize that this is entirely antithetical to the nature of IVF itself and most people may say I'm nuts to risk 'premature luteinization' of follicles  and  yes, there is a good chance it may end badly, in cycle cancellation. However, in the indian system you don't end up loosing too much--- meds cost very little, and anyway I'm going with low doses.The real investment is in the pickup of follicles and subsequent in vitro fertilization steps. However, I need to understand the role of LH and how it rises in me. I know that In normal cycles my baseline LH is super low and rises gradually to a full surge. How will it be in an IVF cycle? Will such a natural rise make better eggs compared than suppressing it entirely? What causes the LH surge? Is it only the rising Estrogen or is it other factors as well, which 'tell' the pituitary when the egg is ready? 
  • Option 2: Alternate to avoiding antagonist use completely, as a compromise, can one delay its administration as far as possible?Here is an interesting article about women who showed a premature surge (which was then suppressed through antagonist admistration), who actually ended up making decent it brings in to question the benefit of LH in a cycle. I think this is really multifaceted issue...


  1. Somewhat late in the game, my RE asked me what was a pretty good question:  what's the most important thing to you here--money, time, genetics?  She had an answer for each one.  For me, saving time=donor egg.  I was just DONE.

     So I'm assuming here--no judgment, just trying to read what you're saying-- that what's important to you is genetics... or you wouldn't have done an IVF cycle with a surrogate.  But maybe not.

    If it's not...I don't see why you'd want to do a "mini" IVF cycle.  I'd go back to what you know works (IUI) or try donor eggs (whether transferring to you or a surrogate).  Just my thoughts.

    I appreciate how complicated all this is.  How many variables, both practical and emotional.  I wish it were all easier.

  2. Well, you have read the situation correctly-----having a child with my own genetics is definitely an avenue I want to explore to the fullest of my ability. I want to feel like I've given it my best shot.

    My last post was where I listed all options I am willing to explore- donor eggs is a possibility down the line, but I'm not there yet!

  3. I have read about IVF cycles where they pick up one natural egg at a time (mini IVF?) over several months with almost no drugs.  And then do the fertilization. Seems like  along process (time wise) but may be a good option as you mentioned. Also if your best success is with IUI's then you could try some more?  Its great that you are so well informed and know the ins-outs of the process. All the best!

  4.  I hear you!

    In my own case, for whatever it's worth, my pregnancies (successful, that is) resulted from unmedicated IUI and IVF with DE.  Stims--clomid, femara, injectables, did it all in all kinds of combos--just didn't work for me in terms of producing good embryos, even in my late 20s.  Constants were heparin/lovenox (taken from conception/retrieval) and high dose progesterone.

  5.  I've thought about natural IVF cycles as well- but the issues with that is I have only 2 vials of swimmers left- plus you end up forking out quite a bit for each retrieval/fertilization :(

  6. I like how you talked about how intricate the natural process is, and how it has a 1000 layers to it. That is where the strides in IVF and hopefully will start decreasing the IVF costs as well are being made. The closer they can come to mimicing the natural reproductive cycle the better it gets.