I went into my follow-up consult on cycle day five, just hoping for some fresh ideas to improve egg quality, and I didn’t want to hear anything fatalistic. I led off by telling my RE, “I know I’m 40 but I’m not coughing dust yet!” And like always my RE delivered. He’s not giving up on me or my eggs, and he was ready to change things up with my protocol. I have no idea if his new plan will work, but I am so grateful for this doctor who is compassionate, intelligent, humorous, and takes the time to really answer questions and explore options with me.
He reviewed the lab’s report for exactly how my eggs fertilized and what my embryo growth patterns were like. It was clear that we are dealing with egg quality, not sperm issues. He said he was really surprised that none made it to blast and they weren’t expecting that. The cycle before I got 1 PGS normal. Could it have gotten that bad in 4 months or was this a bad batch – he said it’s hard to tell now. But he created a new plan to move forward that focuses on quality over quantity.
We are doing a mini IVF. The idea here, which I’ve heard rumor is great for women over 40, is that less stim meds are used to create fewer eggs, and that hopefully allows those eggs to soak up all the resources and energy needed to improve their quality. I’m ready to try this and I was getting worried about the high doses of meds I had been on. Injecting all that stuff can’t be good long term, right?
While there are many different mini stim protocols, mine involves clomid and menopur, then later adding ganirelix to prevent early ovulation. Although I know clomid isn’t always great for women over 35, I’ve responded to it quite well at that age. Plus we are not solely relying on that. We’ll also be doing HGH a bit longer this time – starting on day 3 of stims, simply because I wouldn’t be able to have it in time for day 1, and continuing until trigger shot. And the reason for not having it in time for stim day 1 is because I began my mini stim the night of my consultation! My RE didn’t want to waste any time so he had me start clomid that night and use some leftover menopur from last cycle. He whisked me in for a baseline ultrasound which looked all good to go.
And so we are jumping right back in. I’m ready. The rush at the beginning to get my meds lined up was a bit nerve racking, but everything is ordered. I also had to use gonal f instead of menopur for the second day until my new meds arrived this morning because I didn’t have as much left over from last cycle as I thought. I was assured it was fine this early in the cycle since we are focusing on FSH at this stage, and both are FSH. My clinic would have given me the needed menopur but they were all out too, so gonal f it was. I took my clomid at night for the first 2 nights and then switched to morning administration on the third day because my nurse said it’s better to take them in the AM before the ultrasounds. Changing the timing of the meds that much makes me nervous because I’m so used to them being very specific about sticking to certain times so the body has what it needs on time. But my nurse assured me that we have a lot of flexibility during the first 5 days of stims and that sticking to specific times is more important later. There’s nothing I can do about any of this now and worrying won’t change anything. So I’m letting it go and trusting that they know what their talking about.
My RE told me that there is a special medium filled with antioxidants and other goodies to “supercharge” my embryos as they grow. The idea is that this enhanced medium can better support “older” eggs in doing what they need to do. We didn’t use that last cycle because he didn’t anticipate that the quality would be as compromised.
We also discussed PGS testing and ICSI. I was concerned that maybe ICSI wasn’t working well for me and maybe we should go back to natural fertilization. My RE explained that it’s actually better on older eggs to do ICSI because the egg doesn’t have to expend a significant amount of energy pulling in the sperm. Who knew. I was pleased with our open discussion about PGS. He readily admitted that some embryos can self correct, although it is rare. He told me about a research study he did where they PGS tested embryos but put back some before the results were in to compare outcomes. He said they put an embryo back in a women and later found out it was abnormal (I forget which chromosome abnormality it had). They were all worried and expected her to miscarry, but instead she delivered a healthy baby. He explained that there are a few chromosome abnormalities that we know are incompatible with life and/or lead to significant healthy problems (I can’t remember the ones he said). Those won’t self correct. But the others, well, they just might. He said that when PGS results come back with multiple chromosome deletions or additions, then you can be confident in those results. But if the abnormal finding is do to just one chromosome issue and it’s not one of those dreaded few, then there is a possibility that the embryo could self correct or the result could be inaccurate.
I also asked about the studies showing significant variance in PGS results across labs, indicating that results just aren’t very reliable. He acknowledged those and said that you have to be careful in interpreting the results. He said that you aren’t going to find that anymore among top labs. And that’s when I put back on my psychologist “hat” and remembered what I already knew about research. People readily tout research studies published in peer reviewed, scientific journals as facts. But that simply isn’t true. A motto that was ground into my head during graduate school was, “the devil is in the interpretation.” There are issues with what the labs do, how the research is designed, and what statistics are used – even in published studies. Sadly way more often that you think, the conclusions that authors make to explain their research outcomes are simply not supported by the data. And yes, these are even published in top journals. There are often flaws in research methodology and statistics that do not support the reported conclusions. In every single graduate course I took, we had to tear apart published studies to find the flaws. They were everywhere. Now you might say, “yes but that was psychology and this is a different topic,” however, the statistical analyses and research designs are all exactly the same. It’s math. The sad reality is that most health professionals do not have the statistical expertise to see study flaws in published work. My Ph.D. is from a research-focused program. It’s what we do.
Given all of this, I asked my RE what he would recommend to me. He said, “there are worse things than not getting pregnant,” referring to still birth, late miscarriages, and severe health disabilities. That is true, at least to me. He advised doing PGS and agreed that we would review the results together to determine if any abnormal findings fall into the category of only one chromosome issue and that being outside of the “dreaded few”. If we have any like that – that could possibly self correct and/or be an inaccurate result – then he would do the embryo transfer if I wished. I’m comfortable with this plan as I believe it gives me the peace of mind in hopefully finding a chromosomally normal embryo while reducing the chance of discarding one the could have made it.
So that’s the new plan for IVF #4. My first ultrasound is in 3 days!
Best of luck!
For me, low dose protocol helped me make twice the number of eggs I used to make on high dose. The quality is yet to be determined, we just finished a 7 th (and last) round of ivf. I am 43.
But I’m a strong believer in low dose (although I hate Clomid for personal reasons:)
Go for it and fingers crossed!
Thanks! It’s pretty amazing that a low dose can help get more eggs, but I’ve heard that from others too. I hope quality pans out for you too!
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Yes, in the low Amh Facebook group I’m an admin of, more and more women turn to mini dose Ivf and have succèss with it, after failed “traditional” ivf cycles. I guess our DOR ovaries are just tired-ish and block when pushed too hard. This is a theory backed up by several studies later. Some of them even considering natural ivf even though not as cost effective cause you retrieve one a month. But I’d rather do one good one a month, than 4 badly grilled ones 💁
I’m in that group! Yes, I think that’s where I might be too with my ovaries. Hopefully this improves quality. It’s a challenge with DOR and age.