Friday, July 5, 2013

IVF#2: the postmortem and the spewing of many opinions

First, my last 2 blastocysts (which we hoped to freeze on day 6) did not look good, so they did not freeze them. It is so awesome that I was able to respond to this news with a shrug. I'm just so grateful things have gone well so far. Final tally: 8 blastocysts frozen, 5 of which are the best grade my clinic assigns.

The aftermath of the retrieval was ugly though. I had bad OHSS. I  went 3 days without eating; I was so bloated and was ridiculously weak, really no picnic. I have to salute the women who queue up for an embryo transfer when they are feeling like that.

Anyway, here are some of the factors that I felt may have made the difference between this cycle and the last.
  •  My physiological state: Inexplicably, after my vitamin D levels went really high, I feel I fell into a reproductive slump: one failed IUI cycle, a pregnancy with my first autosomal trisomy (bad news), and then that disastrous IVF. As I tapered down my supplementation (from 5000 IU to 2000) IU/day), things did change, but slowly. The most noticeable change was a change of my natural ovulation day (day 17 during the slump period), now moved back to day 20/21.
  • A more natural IVF cycle: The first IVF, LH was very high around day 2 (because when you first give the agonist, it first triggers a burst of LH production, and then the pituitary shuts down) and the LH (300 IU /day)  because of the menagon. This is the exact opposite of what my natural cycles look like. So I picked a cycle that was much closer to my natural cycle: lowish LH throughout, except at the time of the surge, mild FSH stims (only 150 IU/day, as opposed to a staggering 450 IU/day the last cycle).  
  • 1000 mg/day myo-inositol: This one is supposed to help in increasing the proportion of mature oocytes at retrieval in women with PCOS: this is exactly what happened with this cycle, mad coincidence or not. In non-PCOS women this effect has not been observed, but it does help improve implantation slightly. Btw, any women with PCOS considering myo-inositol should read this: the effect of a combination of myo-inositol and D-chiro inositol.  From my own experience, I think I can now vouch for myo-inositol (1000 mg/day).

Now, for the opinions.

I've spent the last few days just thinking about some of the standard practices in IVF clinics, and a lot of them just seem logically flawed in certain ways.

1) High dose Menagon/menopur use, which gives you as much LH as it does FSH. My RE remarked during my cycle that many clinics like to keep blood LH levels  below 2 ng/mL. How many people do a LH blood test while taking 300 IU/day menagon? What would the blood level would be at? I'd say its a fair bet that it would be above 2: do you need that? No. Can it be detrimental to embryo quality? Maybe.

2) Use of higher dose stims so you can increase the egg yield: Multiple studies have shown that if you up your dose of stimulation (from a mere 150 to 225 IU/day), the aneuploidy rate also goes up...from 40% to 70%. The issue is, both the doctor and patient just want the illusion of security provided by many follicles on the ultrasound and a high egg yield . It makes the cycle look good on paper, if say, you get a total of 20 eggs versus 10.

If you can get 10 embryos (with only 3 of them actually being good quality, but you don't have the technology to figure that out), or only 3 embryos that are much more likely better quality, which one should you pick? Sadly, everybody goes for the approach that maximizes quantity, because that is a tangible,albeit potentially misleading measure, as opposed to quality, which is something which is difficult to assess.

This approach puts one through many more embryo transfers and PIO shots and painful 2wws than oone actually may have needed. You could also end up wasting valuable time in trying to find that good embryo among the bad ones. Sometimes, when you are trying to find the one good embryo among a slew of frozen embies, it could take years!

3)Day 3 transfers instead of day 5 transfers: With the improvements in embryo culture, one thing is definitive: the womb offers no advantage over the petri dish. If a embryo can't make it in the petri dish from day 3 to day 5, its not going to do so in the uterus either. This is understandably a really tough pill to swallow, so many people chose not it to swallow it at all. Nobody wants to end up on day 5 with nothing to transfer, so they would rather prolong the receiving of the possibly negative verdict, by paying for a transfer (or do you pay the flat IVF rate), those godawful PIO shots, and the hell of a 2ww. Doctors also perpetuate this when they should be doling out tough love and waiting till day 5. Much respect for the clinics who only do Day 5 transfers.

4) Progesterone supplementation without checking if you need it. First, if you having a FET done, please insist on doing it during your natural cycle, instead of the down regulation + administered progesterone combination. What is the SENSE in this if you have a normal luteal phase? Why not just wait till ovulation, when your body starts to make progesterone naturally? The only time this would be necessary is if you have luteal phase defect, or are undergoing a surrogate cycle (you sure as hell don't want them ovulating).

This brings me to my second point: progesterone supplementation. Doctors just assume you will need progesterone in assisted reproduction. How many people have had their natural progesterone checked? If you make enough naturally, you don't need the PIO shots or the suppositories. Women the world over can provide luteal support naturally. So can many infertile women! But they are still made to suffer through the pain of a PIO shot, just because their doctor cannot be bothered to order a blood test and check.

I've expressed a lot of strong opinions here, and it may offend some people. But this is all coming from a place of trying to make things easier while undergoing these treatments. Many times, you don't need 500 injections to get you pregnant, you just need 50 or so of them. But you still get 500 injections, because no medical professional can be bothered, and everybody just follows standardized protocols without asking...why am I doing this? Is this necessary? Is there an easier way?


  1. THank you thank for this post. You speak common sense !

  2. I did have my progesterone checked before I ever did a medicated IUI cycle. It was borderline- plus my luteal phase was generally 9 days. For me I think the progesterone is definitely worth it. For others, you may be right.

  3. My body is so messed up that no matter what, we had to do medicated cycles. My 1st IVF (225 menopur)I ended up with OHSS, and 8 blasts. 2 transfers later I had no embryos and 2 miscarriages. IVF 2 was a totally different story. 150 menopur got me 9 blasts. Fresh transfer- twins! 21 months old. FET with the same batch I lost 2 blasts in the thaw and transferred a 5 day blast and a 6 day blast and now have 4.5 month old twin boys as well. The only other changes for me were the addition of synthroid, Folgard, and a low dose steroid (prednisone). Its amazing what a difference another cycle can make.

    I love reading all of your science behind the cycles. Its people like you that help figure out the small changes that could lead to success for people. I hope this is your time!

  4. Thanks :) I'm glad things worked out so well for you!

    I think a lot of people may have similar stories (that they did better on lower amounts of medication), both FSH and LH.

    Numerically, 225 seems pretty close to 150, but I think there can be huge differences. Clearly, studies examining the aneuploidy rate allude to this.

    And yes, if your getting LH with your FSH, 150 units may just be the upper allowable limit :)