what to change for IVF #5

[boston#5]

Our history:

Me: 36 yo female with low ovarian reserve; husband = 37 yo with no male factor problems

After 1 year of TTC without success, diagnosis was unexplained infertility

Went to specialty clinic and did:
5 IUIs (2 with Clomid and 3 with Follistim/Ganarelix) - all BFN
4 IVFs -
#1 Follistim/Ganarelix; 7 eggs;7 fertilized;2 high quality embryos transferred on day 3; positive beta = 144; MC due to trisomy 21 at 8 1/2 weeks; D&C
#2 Follistim/Ganarelix; 8 eggs;6 fertilized; 3 high quality embryos transferred on day 3; negative beta
#3 Microdose lupron protocol (300 Menopur and 300 Follistim); 9 eggs; 6 fertilized; 5 lasted to day 5; PGD performed (which found 4 to be genetically abnormal) and 1 genetically normal embryo transferred on day 5; negative beta
#4 Microdose lupron protocol (ditto to above); 7 eggs; 5 fertilized; 3 good quality embryos transferred on day 3; chemical pregnancy = beta = 29; two days later = 9

Diagnosis has now changed to diminished ovarian reserve; FSH = 10; slightly elevated prolactin (32) on most recent Day 3 labs.

Wondering the following with regard to #5 IVF:
1) should we change clinics/labs?
2) should we do the Estrogen Priming Protocol instead of Microdose Lupron Protocol (estrogen last cycle was 1800 at peak)?
3) should we get immune testing done prior to next cycle?
4) should we do micro-array testing or CGH instead of PGD?

Is there anything else to be considered?

Thank you very much for your time and consideration. I really appreciate it.

[Dr Jeffrey Fisch]

We find many patients like you with unexplained infertility/ decreased ovarian reserve will have subtle hormone changes that make the eggs more likely to develop abnormally. We also think the standard antagonist protocol, as well as the micro flare protocol and protocols with a lot of LH ( i.e. Menopur/ Repronex) will actually make the chances of getting a normal egg worse. We have developed a different approach called agonist antagonist conversion with estrogen priming (AACEP). Our data was published in Feb 08 in the journal Fertility and Sterility. If you contact me directly, I would be happy to review your case and our approach with you in more detail. It is definitely time for a second opinion, even if you don't change clinics. Many patients from around the world do travel to Las Vegas for IVF treatment with us. You would need to be here less than 2 weeks to do a whole cycle.

Jeffrey Fisch
jfisch@sherinstitute.com

[LHAUB75]

Sorry to barge in to this conversation but Dr. Fish, I was interested to know why does Menopur cause makes the chances of getting normal eggs worse. I have been going through over a dozen IVF procedures (also with donor eggs) before we discovered that I have immune issues. I am also a poor responder so we have tried all the protocolls. Now we are back to mini-ivf's because I get as much as with Clomid than with high dosage of stimms. However, along with Clomids, I do take 150 IU of stimms on days 8, 10 and 12 and I suggested to my doctor that since I have enough Menopur left, we would use it and he said yes. I think if you say is true I should opt for Gonal-F or Puregon instead. Right?

Many thanks

Laura

[Dr Jeffrey Fisch]

Some women with unexplained infertility have an oversensitivity to the male hormone component of the medication. This can predispose the eggs not to develop correctly. For this reason we stick mostly to pure FSH in our protocols. It is reasonable to use some Menopur at the end of a cycle, but we especially avoid it at the beginning of stimulation. I am not sure Clomid is useful in your case. We like FSH better, even if the number of follicles is the same. We find the quality of the eggs we get is better.

I would be happy to review your case and our approach with you in more detail if you contact me directly.

Jeffrey Fisch
jfisch@sherinstitute.com