High Responder Blues

Being an overachiever can sometimes be harder than being an underachiever....at least when it comes to ovarian stimulation. I certainly don't want my kids to think that I want them to slack off in their academic and non-academic pursuits. Interestingly, my oldest son had to read the book the "Overachievers" for his AP English class. Man, that is like taking alcoholics on a field trip to a bar! The kids are already stressed out about working real hard and then they have to read a book on just that topic....yikes!

Well, being an overachiever in terms of fertility drugs is no fun either and is stressful for both patient, partner and physician. High responder patients are at risk for a wide range of suboptimal outcomes.

First of all there is OHSS. I really hate OHSS. Truly I do. The patient is miserable, the partner is often freaking out and the doctor is trying to navigate through dangerous waters. Patients with OHSS can end up in the hospital and may require draining the fluid that accumulates in the abdomen. Traditionally we have a radiologist drain this fluid but some RE's do it transvaginally as if doing an egg collection and that may make everyone's life a bit easier. Patients with OHSS can become dehydrated and are even at risk for stroke and blood clots in the leg or lungs. Fortunately, these complications are rare.

Secondly, they may end up with eggs that are not really all that good. The HCG may be given a bit early because of worries about the high estrogen levels so sometimes a lot of the eggs are immature. Also, egg quality may not be that great so eventhough there are a lot of eggs the yield is really poor.

Thirdly, you may end up with too many embryos for your confort level. If you start with 35 eggs and end up with 18 cryo'd blastocysts then you may be conflicted about what to do with the extra embryos. These are moral, ethical and religious issues that every couple needs to wrestle with as they pursue fertility treatment.

So the take home lesson here should be that "more is not necessarily better" when it comes to IVF stimulations.

Clinical Vignette: High Responder with ?PCOS

Here is a perspective from a patient who found herself in this situation. I have edited her husband's description of their journey but you get the idea....

Having tried unsuccessfully for years to get pregnant, my wife and I began researching fertility clinics in the DC area. Our doctor recommended Dominion Fertility (DF). We scheduled a consultation, met with Dr. Gordon and were pleased with our visit. As a result, we decided to pursue treatments at DF. My wife was diagnosed almost immediately with PCOS. Someone as slender as my wife wouldn’t normally fall into the PCOS category, yet Dr. G was adamant about his diagnosis. And thus we began our journey through fertility treatments.



As we explored our insurance options we discovered IVF would only be covered at certain clinics, and unfortunately DF was not one of them. Reluctantly, we researched clinics within our insurance network. We found another clinic scheduled an appointment with Dr. X. Our first impression of Dr. X was quite good, given his resume, certifications, awards, etc., and consequently we decided to go with that clinic. After Dr. X reviewed my wife’s file, he shared with us his strong opinion that in fact my wife did not suffer from PCOS. This was contradictory to the diagnosis offered by Dr. G and quite frankly we were relieved. Dr. X was convincing about the potential success with IVF.



As the IVF treatment progressed, my wife began showing signs of hyperstimulation. The doctors reassured us things were fine and to continue the medications. The retrieval date arrived and yet another unknown doctor performed the procedure retrieving 45 eggs from my wife. That’s right, 45 eggs (If you’re familiar with IVF, you know that’s way too many). As a sports fanatic, I thought a high number equated to great success and I wasn’t informed otherwise by the doctors so I was excited. Then I saw my wife in the operating room shaking, feverish, nauseous and bleeding. Something wasn’t right and it just didn’t add up, but again not knowing how these things work I figured this was normal. Everyone in the room appeared to be doing business as usual while my wife was crying and bleeding all over the bed sheets. After an hour recuperating time, I picked up my wife and walked her out of the clinic, hoping that this had all been worth the emotional and physical toll.



Due to hyperstimulation, the cycle was cancelled, meaning we were unable to move forward with a fresh transfer. Only 7 embryos were cryopreserved (not many for retrieving 45 eggs, but not surprising now that we understand how it works). We experienced 2 unsuccessful transfers using all of the cryopreserved embryos. It was disheartening to receive the news that we weren’t pregnant. Nearly a year had passed, and after enduring multiple fertility treatments at that clinic, without blinking an eye, Dr. X shared with us his medical opinion that my wife did in fact suffer from PCOS!



So, we returned to DF for IVF and this time we were well-informed and aware of each step and how my wife was responding. Finally, the day for the beta HCG (pregnancy) test arrived. Not knowing yet the outcome of the test, my wife thanked Dr. G for all he and his staff had done on our behalf. We were overwhelmed with gratitude since the experience was so different this time around. Dr. G. later recounted that he thought my wife had taken a home pregnancy test prior to that visit because she was so optimistic and thankful. Suffice it to say, the results were positive. We are now pregnant!


OK so why did I include this in today's post. Well, first of all I like for my Mom to proud of me and since she may see this post I thought I would include it. Secondly, the diagnosis of PCOS is a tricky one and I often have seen patients that seem to have some factors consistent with PCOS but not enough to make the diagnosis definitively. Thirdly, this case demonstrates the need to match IVF stimulation protocols to the patient. I originally had planned on using a protocol of 75 IU of FSH med and 75 IU of menopur. At the other clinic, she recieved a much bigger dose. When she returned to me I used 75 IU and 37.5 IU and she still ended up with 26 eggs which is a lot more than our average of 11 eggs! Of those 26 eggs, she ended up with 12 nice blastocysts (2 for ET and 10 for cryo). She did not get OHSS, but I was concerned about it given the # of eggs, her high estradiol levels and her probably diagnosis of PCOS. So a nice happy ending and I hope that the rest of her pregnancy goes well.

So that is my last (and first) post for November 2009. Sorry as usual for the long interval between posts. Now for faithful readers of this blog I want to enlist your help in an online popularity contest. Dr. Fred Lucciardi's blog has received about a gazillion votes for the Health Blogger Awards. This is incredibly unfair because not only ifs Fred a really great guy and an excellent RE but he is (presumably) a Yankee fan. So as a member of Bosox Nation it seems inappropriate for Fred's team to have won the World Series and for his blog to win the Health Blogger Award. So if you can find the time to vote for DrG, then please do so....just as in politics: Vote early and vote often! Just kidding...

Vote for DrG for Health Blogger Award
(http://www.wellsphere.com/voteBlogger.s?bloggerId=150461)