Question of the Day: Failed FETs, what to do next?

Question of the Day:

Hello Dr,
I had egg retrieval in sept 2011 5 blastocyst and 6 third day embryo.I ended having OHSS and transfer was cancelled. I had my FET done with one five day embryo in october 2011 which did not work.
I had one more FET done with two embryos from third day. Today is 12th day and I got -ve on HPT.I also gave my blood this morning will have results tomorrow.I am afraid that result may be -ve.
At this I do not know what to do for IVF to work.I have followed all the instructions religiously.

What would you suggest if I was your patient. Or what you do different in my next FET cycle.
Thanks.


DrG answers:

Clearly a very frustrating situation. Here a patient had a great response to IVF medications…so great that she had to freeze all the embryos. The embryo development sounds pretty good as 5 blastocysts and 6 D3 cleavage stage embryos were frozen. Following 2 FET attempts nothing has worked.

However, I don't have all the details. Why were there both D3 and D5 embryos frozen? Why did the second FET involve the transfer of D3 embryos instead of D5 embryos? How experienced is the clinic with D5 freezing?

A few years ago we changed to ultra rapid freezing or vitrification of our blastocysts. Slow freezing is not as good an option when dealing with more developed embryos. We usually see a 95% survival rate with D5 embryos and the implantation rates are identical for fresh vs. frozen embryos. However, not all clinics have as good a track record so these questions needs to be asked in order to better understand why there has been no success in spite of the cryo-all…

However, let's assume that this is my patient and I have a great confidence in my FET program. I think that if the actual embryo transfers have been easy then one has to consider there may be a uterine factor. Patients in this situation may benefit from a hysteroscopy and an endometrial biopsy to further investigate the failure to initiate a pregnancy. Interestingly, performing an endometrial biopsy may improve implantation in the following FET cycles. The mechanism of action may involve reparative changes in the lining following the biopsy but no one really knows…. Finally, I assume that assisted hatching (AH) has been used in the prior FETs but if not then clearly AH should be used...

Read More

Question of the Day: Blocked Tubes and IVF

Question of the Day:

My doctor said she will remove my left blocked tube to help IVF without mentioning whether I have a hydrosalpinx. Is it possible that my tube doesn't have this condition? Do they have to remove a blocked tube no matter whether it has a hydrosalpinx? I am frustrated because they don't tell you enough and I cannot ask suitable questions as obviously I don't know enough as a patient.

DrG answers:

So first of all we need to define "hydrosalpinx." This term literally means a water/fluid filled tube as "hydro" is latin for water and "saplinx" means tube. So a hydrosalpinx is a fallopian tube that has become blocked at the end that is furthest from where the tube attaches to the uterus. The far end of the tube has the fimbria which are delicate finger-like projections that allow the tube to capture the egg as it is released from the ovary. Unfortunately, if the fimbria become damaged by infection or trauma (surgery) or inflammation (endometriosis) then they can clump together effective sealing off the end of the tube. Since the tube produces fluid from the cells lining the inside, this fluid begins to accumulate once the end becomes sealed and a hydrosalpinx is formed.

The fluid within a hydrosalpinx contains inflammatorty proteins that apparently decrease implantation rates both in spontaneous conceptions (if the other tube is normal) or in IVF when embryos are transferred into the uterus. So most REs recommend that patients undergo a surgery to prevent the fluid from backing up into the uterus. This procedure may be removal of the tube or performing a tubal ligation to simply divide/block the tube. Less commonly, patients undergo a hysteroscopic procedure to occlude the tube as it exits the uterus (Essure). Patients must wait several months after an Essure procedure and have a follow-up hysterosalpingogram to confirm occlusion of the tube.

Tubes that are open but abnormal may not need to be removed but doing so may further decrease the possibility of an ectopic (tubal) pregnancy occurring after IVF. Tubes that are very abnormal may progress to a hydrosalpinx so again removal may be justified depending on the laparoscopic findings. Tubes that look normal but have proximal occlusion with no dye entering the tube do not need removal in my opinion.

The final comment of the post is particularly disturbing to me.There is no reason that patients should feel that they cannot ask their doctor appropriate questions. How very sad….My patients certainly don't appear shy at asking my opinion...

Read More

Natural Cycle IVF Success After Essure

This has been a busy month for patients with prior tubal ligations. Although some patients with a prior tubal ligation will opt for a surgery to reverse their tubal ligation, most will pursue IVF. The data seems to favor IVF over tubal reversal if the patient is over age 37. Of course, other factors also come into play when making this decision. The presence of male factor infertility, the ovarian reserve of the patient, the desire for additional children etc…

More recently those patients seeking sterilization have undergone hysteroscopic sterilization with Essure. Essure is a procedure in which silicone-free inserts made of a polyester fiber, nickel-titanium and stainless steel alloy titanium coils are placed into the fallopian tubes from the uterus during hysteroscopy. The resulting inflammation causes the fallopian tubes to become blocked as they exit the uterus (proximal occlusion). Patients like Essure because the procedure is done hysteroscopically and is therefore less invasive than a traditional tubal ligation performed laparoscopically.

Although there have been a few reports of pregnancies using IVF in patients with Essure inserts in place, none have been in Natural Cycle IVF to my knowledge…until now that is. I have been concerned that the presence of the inserts could decrease implantation rates. Our patient had inserts that were clearly visible on sonogram. She and her husband did not desire stimulated IVF and were much happier with the NC IVF option since no extra embryos would be created. She conceived on her 2nd NC IVF attempt and everything looks great so far on sonogram.

Essure has also been suggested as an option for patients with hydrosalpinges who need surgery to block off the tubes prior to IVF. Although several studies have looked at this option, again the numbers are pretty small but reassuring. I may consider suggesting this option in the future but would still like to see some additional published series that address this question.

Read More

DrG on NBC

This morning one of my favorite patients, Kaet Ruffner, joined me on the Midday Show on NBC channel 4 here in Washington, DC. The topic was the comments that Mr. Gingrich had made concerning oversight of IVF and specifically concern about extra embryos. Of course, there are no extra embryos in Natural Cycle IVF ....one egg, one embryo, one baby. So off we went to NBC to talk about NC-IVF....

View more videos at: http://nbcwashington.com.

Read More

Endometriosis and NC IVF

One thing is true in medicine and that is that you never want to be an interesting patient! Seriously. You should aim to have the condition that your doctor sees all the time and knows exactly what to do. As soon as you start getting a lot of "hmmms" and "wow, that is unusual'" then you may feel free to panic a little bit. Not a lot. Just a little. Because being an interesting patient doesn't preclude a happy outcome! It just means that when you are successful then the medical team feels like they deserve a victory lap. So here is a headline for today's blog about an interesting patient....

NC IVF results in only 2nd pregnancy ever reported in a patient with endometriosis hemorrhagic ascites undergoing IVF!

Ascites is a medical condition in which excess fluid accumulates in the abdomen. Usually we see this in young patients with OHSS. Oncologists see it in patients with cancer. This past year I saw a patient that had recurrent ascites resulting from severe endometriosis. How rare is this condition? Well there have only been 63 reported cases worldwide since 1954 ! That's pretty darn rare.

The patient had first noticed the problem in 2009 and had undergone several procedures to drain the blood fluid that accumulated slowly every day. Lupron dried up the fluid but she came to see me because she wanted to conceive.

We performed a laparoscopy in April 2011 and I was shocked to see how severe the endometriosis was at that time. I thought that it was actually ovarian cancer but the pathology proved it to be endometriosis.

Her options for fertility treatment were limited since we were concerned that the use of fertility drugs could make the whole process a lot worse. Her tubes were very damaged by the endometriosis that was everywhere so she needed IVF…..

Natural Cycle IVF to the rescue! She underwent one cycle of NC IVF. Egg collection was a bit unusual as the ovary was literally floating around in her abdominal fluid but we got a healthy egg, a beautiful embryo and a positive pregnancy test. She is currently almost 12 weeks pregnant and doing great! Another first for NC IVF and Dominion Fertility!

Read More

Question 61. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?

We often have drug reps in the office at lunchtime. As there are only really 4 companies that make pharmaceuticals that are used in fertility we get to know the reps pretty well. This past week we were speaking with a couple of reps about vaginal progesterone in lieu of PIO. The data is very good regarding success with vaginal progesterone but honestly some patients just prefer the shots because the suppositories are so messy.

Both Endometrin and Crinone may prove less annoying to patients who want a shot-free 2ww but these products are also more expensive. I advise the husbands that they do NOT have a vote in this decision unless they are willing to take IM injections themselves. Just because I am driving a new car with the vanity plates CR1NONE should not be taken as evidence that my support of a product is based on anything except a careful review of the medical literature. But seriously, I really do not believe that most doctors are swayed to prescribe a drug just because they got a free pen or because the drug rep is a former cheerleader (although in fact, most drug companies do advertise in Cheerleader magazine according to this NY Times article).

So as we head into a beautiful weekend here in Washington DC here is the latest excerpt from 100 Questions and Answers about Infertility....

61. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?

Following follicle aspiration, most clinics place patients on progesterone supplementation. The rationale behind the supplemental progesterone is that following egg collection, ovarian hormone production may be impaired because many of the hormone-producing cells are removed at the time of follicle aspiration. In addition, the use of GnRH agonists such as Lupron may diminish ovarian steroid production following egg collection. Progesterone supplementation has evolved over the years to include patients undergoing both stimulated IUI cycles and IVF.

Although many clinics tend to use progesterone-in-oil injections, equivalent pregnancy rates have been reported in patients using only vaginal progesterone supplementation. Allergic reactions to progesterone are infrequent, but switching patients to vaginal progesterone usually resolves the problem.

Read More