Freezing, OHSS and PCOS

Given that it is a brisk 19 degrees here in the Nation's Capitol, I thought that it would be appropriate to share a patient story that had some freezing in it...The use of cryopreservation has really helped us to reduce the risk of multiples and improve the overall long-term success rates with ART. More recently, vitrification, an ultra-fast freezing technique, has been used by our clinic and others to markedly improve the success rates with blastocyst stage embryos. The previously used slow-freezing approach was OK for day 3 embryos (as seen in this story) but not very good for day 5 embryos.

This story also points out how tricky stimulated IVF can be in patients with PCOS and why I always ask patients to get copies of their previous IVF cycles so I can review the pattern of response to meds.

FYI, this weekend I will be camping with the Boy Scouts out by the Naval Academy....so if I don't post next week, it could be because my fingers are still frozen. I plan on running by Dick's Sporting Good later today for some battery powered socks! Think of me when you are all warm and cozy in your beds on Friday and Saturday nights!

Clinical Vignette #2: Fertility Treatment Is Dynamic (patient BE)

Medicine is a dynamic discipline and all patients respond differently and even the same patient may demonstrate different responses to the same treatment. It is important to individualize care to each patient and not practice “cookie-cutter” medicine. The case of BE is an example of how a patient may need a flexible approach to her treatment plan.

BE presented as a new patient at age 30 with over a year of infertility. She had been diagnosed with PCOS by her Ob Gyn but had failed to conceive with 5 cycles of Clomid at doses of 50 and 100 mg. We began treatment with metformin (Glucophage) and she conceived within 4 weeks. Her pregnancy was uneventful and she delivered a healthy 6lb 11 oz baby.

She returned 2.5 years later desiring another baby. She had restarted metformin 6 months earlier and had again failed to conceive with 6 months of clomid with her Ob Gyn. She and her husband elected to undergo ovulation induction with Gonal F. After 3 excellent cycles yielding a single mature follicle she had failed to conceive.

The couple then elected to pursue IVF. We started stimulation at a low dose of 75 IU of Gonal F and 75 IU of Menopur. Her response was excessive and after 24 eggs were retrieved we elected to freeze all of the embryos to avoid severe OHSS. 9 embryos were frozen and she underwent an FET of 2 embryos that resulted in a twin pregnancy. One of the sacs contained no fetal pole but she eventually delivered a healthy boy weighing 7 lb 8 oz.

One year after delivery she underwent another FET but failed to conceive. In spite of their concerns about OHSS the couple elected to pursue another IVF cycle. This time I cut her dose in half to 37.5 IU of both Gonal F and Menopur. The stimulation was perfect with 8 eggs retrieved and 2 blastocysts transferred. She had no symptoms of OHSS. She conceived and just delivered her second son who weighed a hefty 8 lb 11 oz.

This case demonstrates the dynamic nature of our branch of medicine. Here a patient conceived and delivered 3 healthy children through 3 different approaches. This case also reveals the need to consider past response to fertility meds when planning future cycles. There are few patients that will respond so well to fertility shots at age 36 that you can prescribe such a low dose. However, this is where the art of medicine comes into play as the patient relies upon the experience and judgment of her physician to make the best decision possible on her behalf.