Ivf

Priming protocols-what with and who for?

I am going to address a very debated topic and one of huge interest for those who carry the tags DOR or POF and need ovarian stimulation for assisted reproduction.

The way IVF works, we all know the more eggs we make, the better it is. And this because in vitro fertilisation is all about narrowing down the chances to finding the best egg(s). It is a matter of logic because more eggs retrieved will give us more fertilised eggs, hence higher chances of pregnancy. Also, women who respond better to stimulation protocols usually have a better egg quality (PCOS do not enter in this category of better egg quality, we will discuss this later on). Last but not least, “the more eggs the merrier” principle has also financial connotations. With prices so high for stimulation meds, monitoring, retrieval and laboratory, you’re far better off paying thousands and thousands for ten eggs than for one.

While women over 35 and those under 35 but dealing with POF and DOR might be worse responders than the fertile population generally is, lots of protocols have been invented and experienced over the years, some of them with great results and quite encouraging pregnancy rates. One of the approaches is that of using luteal phase adjuvants, hoping to create a better environment for the follicles and preparing the ovaries for the following stimulation cycle.

BIRTH CONTROL – By far the most used approach before a medicated cycle. Its main purpose is to give your ovaries a rest, and give them the chance to start the next cycle with a clean slate. Useful for reducing cysts, it also comes, unfortunately, with a bad side effect: the dreaded suppression. BC pretreatment in IVF protocols establishes an estrogenic environment and increases sex hormone-binding globulin levels while decreasing follicular androgen levels. But by putting the ovaries to sleep the risk is they might not wake up well enough… Sometimes, we end up with a lower antral follicle number, and we are facing the need of stimulating for a longer period of time, and with higher doses of stims, which might in turn, affect egg quality for older patients.

Here is a very interesting study, where  even young egg donors have experienced lower AMH levels and lower numbers of oocytes after being put on birth control.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637242/

If in the case of a young donor, having  5 eggs retrieved  instead of 10 might not make much of a difference, because donors are chosen to be young and healthy, therefore having a great egg quality, things are quite different with us, older women, where quality as well as quantity might be a problem.

TESTOSTERONE PRIMING- Relatively new,  and controversial. If you listen to Dr Sher, a very famous and respected Reproduction Endocrinologist, you should run away from testosterone exposure, especially if you are not very young anymore. If you listen to me, LOL, my biggest failure of a cycle was the one I primed with testosterone gel. While I usually would have an antral follicle count of 9-10, one week of testosterone gel reduced my AFC to a whopping 2 (two), and thats what I got until the end of stims, when I told my RE there is no way I am going to waste an IVF cycle on two eggs, and converted to IUI. Even he himself later admitted that testosterone priming was a mistake in my case (I was 41 at the time, this might have been a reason) and he is known to be a very stubborn and proud one…And it was no coincidence: all the other cycles I ever did (and we are talking 12 with full protocol, my afc was never under 8)

This being said, there are many studies out there who scientifically prove testosterone priming works for many low responders. If you read this analysis of several studies (https://http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061182/) you will see the mean age of the patients was 36-37, so there….probably that’s the key, being younger is better for testosterone priming. I personally guess there is no way of knowing until you try.

Oh, and most important: I grew no beard during the treatment, neither did I engage in violent exchanges with people in pubs 😛

ESTROGEN PRIMING– It avoids the suppressive effect of BCP on the ovaries. In addition, the use of estrogen during the pretreatment cycle prevents premature recruitment of follicles that can reduce the number of follicles available for stimulation. Studies have shown that this protocol allows more gradual and coordinated growth of follicles resulting in improvement of embryo quality and quantity. For me this has been the only way I could avoid the growth of the horrible LEAD follicle, the scarecrow of IVF…I personally took estrace pills, but patches are used with the same success.

You might want to read this study https://www.ncbi.nlm.nih.gov/m/pubmed/22160464/ and also this analysis of several studies https://www.ncbi.nlm.nih.gov/pubmed/23887073

I believe it is essential to have a doctor you really trust. I, for one, could not trust any doctor who insults my intelligence by imagining that in this age and time I have no ways of gathering enough information as to educate myself on matters concerning my health and my life. Would this auto-education give me a medical degree? Obviously not! And I do not pretend it does. What it does give me, is at least basic knowledge, so useful in understanding where I stand, and if the direction I am heading to is the good one. It gave me the power of standing up and saying NO, when I knew for a fact that the approach I was suggested would be wrong for me (I wish I knew what I know now, when I was suggested the testosterone priming…) It gave me the power to fight me RE for the estrogen priming protocol, that as an anecdote he himself invented, but not so much used afterwards, for fear of oversupression. I fought him and he gave in, and later admitted I was right. It also gave me the power to say NO to him for yet another high dose stimulation protocol, and when he wouldn’t give in and would insist low dose is “counterproductive” for low responders (sic!) I would say bye to him, and find another RE who was willing to try on me my estrogen priming low dose protocol. And we got 8 eggs, instead of my usual 2-3.

I don’t know if it is my journalistic background, or maybe just me being a stubborn Aries, but I am a strong believer in the “Knowledge is power” part, as much as it might sound  like a cliche.

Apparently you believe so too, or else you wouldn’t be here, trying to find out more ❤

Sources: NCBI

 

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Infertility

The CD 3 tests-how important and what do they predict?

If you are familiar with fertility treatments or  if you just had an assessment of your ovarian reserve because you are trying to conceive, the term “3 day tests” rings a bell to you.

Day 3 testing (can also be done and day 2 or 4) consists of bloodwork used to measure hormone levels (FSH, Estrogen, Progesterone, LH) and a scan, meant to measure the number and size of your Antral Follicles. Your AMH level can be measured anytime and if you need to have it measured more than once, it is preferred to do so using the same laboratory, because measurement scales vary for every lab.

E2 (Estrogen) is the main female reproductive hormone, it is being secreted by the ovary and helps to stimulate follicle growth and prepare the lining for implantation, in case conception occurs. The majority of the fertility clinics would want you to have an E2 level under 50 (some under 80) on your day 3. Too high an estrogen level on this day might suggest you have a cyst producing estrogen, in which case stimulation might not be advised. Feeding it stimulation meds, the cyst might not only “eat up” the meds destined for your other normal sized antrals, but also grow and grow until it bursts. A too low estrogen level is not ideal either, suggesting diminished ovarian reserve and possibly  peri/premenopause. Also, very important, when your Estrogen levels are high, the value of the FSH is artificially lowered.

FSH (Follicle-stimulating hormone) as the name tells us, is the hormone that stimulates the ovary to make the eggs grow. Released by the brain, the FSH tends to get higher and higher as we age, and our ovaries struggle more and more to produce an egg. The ideal FSH level is under 10, the lower the better. Some clinics would accept you for fertility treatments with an FSH under 15, but there are tons of studies out there showing success rates diminish seriously as 3 day FSH levels increase. That might explain why older women with high FSH have better chances getting pregnant naturally than with IVF treatments. This being said, if you need help to procreate, there are lots of clinics who offer natural IVF for women with high FSH-meaning no meds, egg retrieval for possibly just one egg, and fertilisation as needed (normal or ICSI, IMSI etc)

LH (Luteinising hormone) helps mature the follicle and eventually, when an LH surge occurs in the end of the follicular phase, helps the release of the mature follicle. The ideal level is under 7 mIU/ml with a ratio LH:FSH of 1:1. An LH much higher than the FSH might be an indication of PCOS (Polycystic Ovary Syndrome).

P4 (Progesterone) should remain low during the follicular phase (under 1ng/ml) and rise after ovulation, as proof the ovary released the egg. The low limit used as indicator for ovulation at 7dpo is 5, but the higher the better. Some women with low progesterone might need progesterone supplementation in order to maintain pregnancy.

AMH (Anti Mullerian Hormone) is a free circulating hormone released by the small antral follicles present in your ovaries, and it is used to assess your ovarian reserve, as in “how many eggs do you still have”. Taken alone, it doesn’t amount for much, and it is far more reliable when discussed in conjunction with the other day 3 levels, and most important, with the day 3 scan. Also, it is important to know that the AMH level has been proven to be artificially lowered by low Vitamin D levels.

Ovarian ultrasound/scan: it is meant to count and measure the antral follicles. The antral follicles are small follicles (between 2-10 mm) found in your ovaries at the beginning of the follicular phase. They are an extremely important and very useful assessment of the way your body might respond to fertility treatments. Each antral contains an immature egg that might develop and ovulate. During natural cycles, the body recruits what is thought to be the best follicle, and makes it grow and eventually ovulate once the Estrogen level is high enough (200-600 E2 level/mature follicle) and the LH surge occurs. In stimulated cycles, all antrals have potential to grow, and even sometimes, some more follicles pop up during stims.

Those are the main tests performed during the day 3 assessment. The list is not exhaustive, though. Depending on your clinic and your health issues, you might have your prolactin and thyroid levels checked, or any other test your doctor might consider appropriate.

Unfortunately, there are some clinics who perform this testing once a year, and consider it available in subsequent cycles. Whether for logistic or financial reasons, this is bad. Hormones fluctuate every God given month, and once you have your period, they are reset and you start the new month with a clean slate. It is possible to have an FSH of 6 in January, and an FSH of 14 the next month, and you surely won’t have the same response to meds during those two months if you are to cycle. Hence the importance of demanding those 3 day tests at the beginning of each and every cycle using stimulation meds, to spare you the heartbreak, the false expectations and yes, the waste of money.

In a future article I will bring to your attention a list of supplements with great effects on your fertility, and the links to the medical studies that attest it.

 

 

About

I wish I didn’t have to…

I wish I didn’t have to write this blog.

I actually never imagined I would, neither could I have imagined to be staring at Infertility’s ugly face one day.

Yet here I am, and here’s my story…

I am 43, living in Paris, France. I am the fortunate and very happy mother of two amazing teenagers, born from a previous marriage. Left widowed when my kids were young, I met the love of my life, an amazing man who loves my children as if they were his own, and to make this love official, he adopted them. My husband having no biological kids, the natural next step was to try for a baby, a fruit of our love, a most desired addition to our very happy family.

We started trying to conceive in April 2013, and having never had any fertility issues whatsoever, I was absolutely convinced we would soon be blessed with a positive pregnancy test. And we were! In May of the same year, i.e after the first month of trying, we found out we were expecting.

Having had some surgery on my cervix several years before, I expected a cerclage would have to be put in, and it was, at 12 weeks. That’s when we run all types of tests to make sure our baby was healthy for I was 39 and the risks would have been higher than for someone younger. Tests came back perfect, the stitch was in, and the hell was about to get loose, but little did I know…

After 3 weeks of complete bedrest due to contractions post TVC, my cervix getting shorter and shorter, after 3 visits to the ER bleeding because the stitch tore through my cervix, my water broke one night, and we lost our baby boy at 15 weeks. I will spare you the details of our heartbreak, though even if some of you cannot relate, you definitely can imagine what it felt like.

As devastated as I was, I knew the time was not on my side, and if I wanted to have a living baby, I had to move fast. I also knew a TVC would never be in the cards again, so I would have to find another solution. This solution presented itself under the name of Transabdominal Cerclage, currently known as TAC, and it was placed by the famous Dr George Davis, in the USA in the spring of 2014.

Free to try again, relieved by the pressure of cervical incompetence, we started TTC as soon as we wear cleared, in July.

One month, two months, three months…..nothing. I bought my first ovulation tests, used them and again…one month, two months….nothing… Fear would creep up my spine and I started googling, and reading….and I found out about AMH. Got it tested…0.2…my world fell apart. I lost 4 pounds from crying over that week-end. I wish someone told me the real truth about AMH back then, and how it was far from being the be all end all….but there was no one back then. So I suffered more or less in silence and went to see my obgyn who put me on Clomid and trigger. Fail.

Between March 2015 and this moment- May 2017, I have seen two REs, consulted  another one over the phone and email, had 6 IUIs with full IVF protocol, 6 IVF with 12 embryos transferred in total, 4 cycles Femara and trigger only, numerous timed intercourse monitorized cycles. All fail.

I am a moderator for two amazing groups on FB, one for low amh and DOR, the other one for high FSH and TTC over 35, and during these two years of hope, disappointment, pain, heartache, frustration, hope again I had the chance and privilege of virtually meeting amazing women, brave and fierce, who would not give up on their right of being informed and their right of having a word to say in the way fertility professionals choose to deal (or not) with them.

My blog springs from my desire of helping women get educated on issues like DOR, POF, Low AMH, High FSH, and all the fertility problems that they bring with them.

I am no doctor, I do not give medical advice. I am just pointing into directions that have been useful to me, that helped me understand exactly where I stand and where I should be headed.

If anything, this blog is meant to empower you, Ladies, to understand what doctors do not explain to you, and to make you understand you have the right to choose what is best and more appropriate for you. The way I wished someone did explain to me. And the way someone eventually did, later on, when I found my wonderful FB groups.

You are more than welcome and I hope you will feel at home and loved here <3.