It only takes one!

Now some of you that read my last post are thinking - "Sure it's easy for him to say that you only need one embryo but I KNOW that I need more than that..." But I remain steadfast in my view that measurement of ovarian reserve can only get you so far.

For example, here is another clinical vignette right out of our practice here at Dominion Fertility:

TM is a 37 year old with a history of slightly irregular periods who had been treated previously at another fertility clinic. She was successful in 2004 conceiving after a cycle of CC/FSH/IUI. In 2006 she returned to that clinic and underwent another treatment of CC/FSH/IUI but had a biochemical pregnancy. Later that year she had another cycle using the same medications and ended up with a quintuplet pregnancy. She ultimately delivered healthy twins but clearly wished to avoid that situation at all costs in the future.

When I initially saw her back in Oct 2008 her ovaries looked rather small with a low antral follicle count. Her AMH was 0.3 (low) and her FSH and E2 were 13.9 and <20. Considering her relatively recent quintuplet pregnancy, it seemed pretty surprising that her ovarian reserve was now problematic but so it goes.

So my thought was that we were looking at a one egg/month situation in a patient who wished to avoid multiples but had previous IUI success, and thus we elected to go ahead with IUI for a couple of cycles.....no luck after 3 attempts. At this point we discussed Natural Cycle IVF as an option.

Now, the advantage of Natural Cycle IVF over IUI in this setting remains unproven in radomized double blind clinical trials but anecdotally we have had success in such cases. The patient agreed and underwent a cycle of Natural Cycle IVF in May 2009. Although her betas rose initially they soon fell to <5. She went immediately into a 2nd Natural Cycle IVF and again conceived but this time all went well and her sonogram this AM showed a singleton pregnancy with good cardiac activity. Needless to say she was very pleased and agreed to let me tell her story on the website.

So what is interesting here..... Well a couple of points jump to mind. First of all, ovarian reserve can diminish rapidly in some patients. Here we went from hyperstim (quintuplets) to hypostim (low AMH, AFC and high FSH) in just 2-3 years. Secondly, IVF may be more successful than IUI even in patients with normal tubes, normal sperm and previous success. In this case, we were 0/3 on IUIs and 2/2 on Natural Cycle IVF. Go Figure! Thirdly, after a biochemical pregnancy the body is ready to go when you start cycling..no waiting necessary. Finally, it is a case of good things happening to nice patients. It would be hard to imaging a more pleasant and upbeat couple than these two and just remember that "you catch more flies with sugar than with salt." Not that we play favorites but always nice to deal with easy-going individuals.

So for those who say that Natural Cycle IVF doesn't work, I restate my premise that it only takes one good embryo to make a baby!

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What is AMH?

Clearly the issue of ovarian reserve strikes many doctors and patients as "clear as mud!" Remember from our past discussions that ovarian reserve relates to the number of eggs that a patient has and the reproductive potential of those eggs. Ovarian reserve is not truly a test of egg quality as a woman's age is the final arbitrator of egg quality. As I am currently unable to make any patient younger, although I could retire if I could, we need to keep the difference between egg quantity (ovarian reserve) and egg quality (age) segregated in our mind.

So in trying to determine how a woman might respond to fertility drugs we use a variety of tests to predict her response. Day 3 FSH and estradiol, antral follicle count on sonogram and the clomid challenge test (CCCT) have been the methods used most recently. However, for the past 2 years we have also been measuring anti-mullerian hormone (AMH). This protein is made in the cells that line the follicles (the fluid filled cysts that contain a woman's eggs - 1 egg per follicle). The more follicles, the higher the AMH and the better the response to fertility drugs which resue the extra eggs that were doomed to run out of gas during the menstrual cycle.

Apparently AMH is getting some attention in periodicals outside of the medical literature as you can see in this link to the Wall Street Journal. We still rely on Day 3 FSH, estradiol and sonogram to get a complete sense of how a patient will respond to fertility drugs, BUT the AMH has proven helpful in many patients as we try to pick a stimulation protocol.

However, in doing Natural Cycle IVF, all tests of ovarian reserve may fail to predict success since by its very nature...natural cycle IVF is unstimulated. So if a patient is doing Natural Cycle IVF, whether or not they would respond to fertility shots is a moot point! What has been amazing to us is the ability of patients with high FSH, low antral follicle counts and low AMH to generate a beautiful embryo in Natural Cycle IVF. What matters is pregnancy and delivery but we have many patients whose ovarian reserve testing is poor and yet they have had success with Natural Cycle IVF. "It only takes one good embryo" as many patients are fond of saying!

So should you have an AMH level done. Yes, as long as you are working with a doctor who can interpret the results for you given the "big" picture and not lose sight of the forest for the trees.

Good luck

DrG

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Gestational Carrier IVF

Fertility doctors are pretty popular at cocktail parties (or so I hear since I really don’t get out much). Between OctoMom and the latest Hollywood star announcing that they are pregnant with twins using a surrogate, there is always some interesting aspect of reproductive gymnastics to be discussed.

In the past month I have discussed the use of a gestational carrier with a wide range of patients. Some have had previous uterine surgery that has made pregnancy problematic. Another has a history of severe medical problems that make her a risk for pregnancy and yet she and her husband do not want to consider adoption. Finally, another patient has experienced multiple unexplained pregnancy losses in the mid-trimester. All of these are valid reasons to consider this alternative pathway to family-building.

When a couple chooses to use a gestational carrier I ask them to arrange for me to interview her as one of the first steps. A few years ago, a couple found a gestational carrier through an agency and asked me to meet her. She lived in the Mid-West so I asked her to fax me a patient questionnaire. She never did (first red flag). One afternoon she appeared in person for an appointment. I asked her about her previous pregnancies. She looked away but said that everything ended up fine by the end (second red flag). Upon further discussion, it turned out that she was incredibly sick every pregnancy with hyperemesis (killer morning sickness) and required multiple hospital admissions and even intravenous feedings at home! Yikes! She didn’t (or wouldn’t) understand that the risk to her was real in terms of pregnancy complications and that the cost of any hospital admissions may be the responsibility of my patients. She called me several times that day on the way back to the airport but I remained steadfast that she should not be a gestational carrier.

So here is one of the few remaining questions from our book 100 Questions and Answers about Infertility…

85. What is a gestational carrier, and when should you consider using one?

Fertility doctors sometimes recommend the use of a third- party gestational carrier if the infertile couple wants to have their own biological child. Many medical conditions necessitate the use of a gestational carrier, including the absence of a uterus in the would-be mother, either because of a congenital (at birth) condition or when a disease necessitated its surgical removal. A gestational carrier may also be the best option when a woman has a systemic disease that may affect either her own or her baby’s health, such as advanced heart disease, severe diabetes, or multiple sclerosis. Likewise, a woman with a history of poor pregnancy outcome—including repetitive pregnancy losses, preterm labor, incompetent cervix, or severe preeclampsia—may be a good candidate for IVF using a gestational carrier.

Prior to the IVF treatment, thorough screening of the gestational carrier is routinely performed using ASRM guidelines. Gestational carriers are usually well known to the couple and may be relatives or friends. In addition, agencies exist that introduce gestational carriers to prospective patients. In such arrangements, the gestational carrier is usually compensated for her time and energy (especially if the pregnancy proves successful).

When using a gestational carrier, IVF is performed by combining the infertile couple’s sperm and eggs to produce their own genetic embryos. However, unlike in standard IVF, these embryos are then transferred into the uterus of the gestational carrier. This process resembles donor-egg IVF in that the process requires synchronization of two patients: the egg donor (genetic parent) and the recipient (gestational carrier). Pregnancy proceeds normally just as if the gestational carrier had become spontaneously pregnant. The major factor in determining the success rate is the age of the woman whose eggs are donated. The ideal gestational carrier is a woman who has had a previous uncomplicated pregnancy and delivery.

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Can my endometrium be too thick?

Wow, what a terrible blogger I have been these past few weeks. No new posts for a while and no insightful hints for the 3 regular readers of this blog (sorry Mom, I promise to call this week!). I could make up some incredible story about how I have been performing 80 hours of community service a week or that I have been traveling to South America with certain public officials from South Carolina or that I have been sick for weeks with the Swine Flu. Clearly, this last excuse may engender some sympathy....but the truth is that I have just been pulled in too many directions. Sorry.

So let's discuss the endometrium here since I recently received a slew of questions on the INCIID site about the thickness of the endometrium and what is ideal for fertility. Abraham Lincoln was once asked "How long should a man's legs be?" He astutely answered "Long enough to reach the ground." The same could be said for the endometrium in that it needs to be thick enough to allow for implantation of the embryo. Most studies suggest that "long enough" is anything over 7-8 mm.

So a few years ago I had a patient that was trying to get ready to do an FET cycle and had not had a period for 6 months and had PCOS. On sonogram the lining was pretty darn thick at 22mm (usual is 7-12mm). Patients with PCOS are clearly at risk for endometrial hyperplasia and even endometrial cancer. So I gave her a couple of weeks of Provera to get the lining to shed. No significant bleeding and the lining was still at 22 mm. So I did an endometrial biopsy which was read by pathology as possible cancer. Yikes! I immediately sent her to one of our local Gyn Oncologists who did an office D&C that yielded only scant tissue.

When I repeated the sonogram the damn lining was still 22 mm. I really was getting concered here but too a step backwards and decided to do a water sonogram in the office. Guess what. There was a large polyp sitting right there in the cavity and since polyps can have an unusual appearance on pathology that would explain the initial concern about cancer. The patient underwent hysteroscopy and I was able to easily remove the polyp. Case closed.

So when patient inquire about endometrial thickness I usually respond that as long as it is a normal lining without a polyp or a fibroid or cancer then thick is fine.

Thin endometrial linings can be another matter. Some patients have a thin lining becasue of previous surgery or simply because that is the lining that they have been giving and nothing can really improve upon it. I have tried all the usual voo-doo for thin linings....vaginal estrogen, Viagra, terbutaline, nitroglycerine, animal sacrifice...you name it. Some seem to help, some don't...I honestly have no recipe that works for everyone. The thinest lining that I ever had that resulted in a healthy baby was 5 mm!

So good luck growing those endometriums but try not to panic if you have an 8 mm and not a 15 mm lining. Anything >7mm should be fine and if waiting an extra week gains you a mm or two then all the better.

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