Fresh cycle coasting, does this mean low quality eggs?


#1

The cycle below is showing how my cycles have panned out.

1st fresh cycle wentfine with 17 eggs being collected, 10 were mature of which 6 fertilised and divided and 2 where put back at day 2 (4 cells grade 1 – 2 and 2) none of the remaining were suitable for freezing so under grade 3 but failed to result in a BFN.

The 2nd fresh cycle lead to 21 eggs being collected and having a freeze all at day 1 due to risk of OHSS out of which 10 eggs fertilised and were all frozen at the 2pn stage.

The first FET we unfroze 5 embryos, 5 of which made it through the thawing process, and 2 were replaced at 7 – 8 cells (grade 1-2 and 2-3) on day 3 which resulted in a BFN

After the 1st FETfailed we decided to have all of the level 1 & 2 tests carried out on both of us which revealed I had a high NK cell count and both me and my partner share a similar DQ Alpha gene.

The medication given for this was intralipid, clexane and prednisolone.

On the 2nd FET we had the same results as the first and I was on the additional medication - we unfroze 5 embryos, 5 of which made it through the thawing process, and 2 were replaced at 7 – 8 cells (grade 1-2) on day 3 which resulted in a BFN

We did a little further investigation and it turns out that with us both sharing the same DQ alpha cell the best remedy is to only replace 1 embryo so that it is a good chance of not being the one with the same DQ alpha cell.

So we began a fresh cycle in October and this is how it went (badly to say the least!!!)

17/10/13 - Last natural period began

31/1-/13 – Started Suprecur0.5ml daily on day 14 of my cycle as they are irregular/short cycles usually 23-25 days

11/11/13 – down reg scan cancelled due to no period

14/11/13 – Period started

18/11/13 – Down reg scan showed quite a large cyst on one of my ovaries and lining not thin enough to begin stimulation
Advised – Inject 1 Pregnyl powder with 1 water that night to get rid of the cyst and bring on another period

28/11/13 – Next period started

2/12/13 – Down reg scan cyst had gone and lining was at 5mm,
Advised – Start Menopur 2 powders (150) to 1 water that night

8/12/13 – Started prednisolone 20mg once a day

9/12/13 – Scan showed there were approximately 30-4- follicles all growing at a good pace and uterine lining was at an average of 11-12mm
Advised – Decrease the dose of Menopur down to only 1 powder (75) that night

9/12/13 – Intralipid Infusion

10/12/13 – Normal dose of Menopur 2 powders (150)

11/12/13 – Scan and blood test showed oestrogen levels to be at 21,000 and this was too high to be able to give the final injection and there were approx. 49 follicles half being around the 15-18mm mark
Advised – To start coasting (come off the menopur completely, only taking 0.5ml of suprecur)
Condition – Was feeling very sick, bloated and had headache, all of which was told to the nurse

13/12/13 – Scan and blood test showed oestrogen level dropped to 19,500 and there were approx. 4-5 less follicles showing on the scan
Advised – Ok for collection and arranged final injection (pregnyl) and date for EC

14/12/13 22:00hrs – Final injection administered Pregnyl 2 powder/1 water

16/12/13 10:00am – Egg Collection 17 eggs were collected, only 15 were viable

17/12/13 – Embryologist called to inform me that out of all 15 eggs only 6 were mature enough to fertilise and only 3 did fertilise

Basically what I am trying to find out is that as the number of eggs collected and fertilized on the 2 previous cycles have been quite a high number and more than 50% have fertilised, why this time, when I have been coasted due to high oestrogen levels (21.000) only 15 eggs out of 45 follicles were recovered and only 3 of those fertilized?

Also why if my consultant knew that we had to have a freeze all the embryos on our last fresh cycle (due to risk of OHSS), has he chose to give me the exact same dose of Menopur on this cycle and not decrease it by any, could it be his misdiagnosis of the correct dose that has led to me needing coasting and the egg quality suffering?

Is this just the luck of the draw or is it due to my body overreacting with the medication and the coasting that has made the eggs not mature enough and of a poor quality?
Thank you for your time and any advise to help me understand would be greatly appreciated.

Steph x


#2

Not that I know a good answer for your question (and it may just be that no one knows), but I am very surprised that despite your good and fast response, your stimulation was 12 days. That is way too many, especially, for a high responder, like you. You should have been given instructions to trigger around 11th of December. At least, that’s what my practice would have done. Here is my experience. I had two cycles, ~23 follicles in the first one and ~13 follicles in the second one. In the first one, 22 eggs were retrieved, 21 mature, and most fertilized. In the second one, only 7 eggs were retrieved, and out of them only 3 were mature and fertilized. In the second cycle, the rest of the follicles were believed to have had eggs so bad, they would not separate from the follicle lining. In both cases, the stimulation phase was only 8 days. I am a fast responder, just like you. Actually, in my first cycle, they almost triggered me after 7 days, and in the second, they could have waited for another day, easily.The first cycle was “long luprone” protocol, with full suppression of the pituitary, and recombinant FSH drug (Gonal-F). The second cycle was antagonist, with Ganirelix suppression right before the ovulation. Menopur was used in the second cycle. Let’s identify things that may have impacted the result: 1. Protocol itself. It seems to me that the full suppression gives you slightly even follicle growth. Maybe that’s good. Who knows. I have heard that the antagonist is good for older women, but then again, it may be because it makes the follicles grow faster. 2. Number of days of stimulation. I am not sure how significant it is, but obviously, you don’t want to either undercook or overcook your eggs. I would like to get to ~10 days of stimulation in my next cycle. 8 seems to be a bit too short, and 12 is a bit too long, especially, if they had to wait for 3 days after your leading eggs were 18 mm. 3. Maturation. That’s done by the trigger injection. I got 10K IU both times. You are not stating your dosage, but it is possible that you have gotten 5K IU because of OHSS possibility, and that resulted in sub-maturity. 4. Drugs. I have read conflicting reports about the use of Menopur. Menopur is the only drug that has LH in it (and thus it is materially different from all other FSH drugs), and some research claims that it improves egg quality, but some doctors think otherwise. I am totally switching back to recombinant FSH my next cycle based on the fact that it worked better for me the first time around. 5. FSH co-trigger. That’s something I read in the research. The body naturally has a release of FSH with LH when ovulation is triggered. This does not happen in IVF. There are some research that suggest that an FSH co-trigger can improve egg maturation. I will be asking my doctor about it. It is also relevant to your case because “coasting” means that you are not getting much FSH toward the end of your stimulation, and it may impact egg quality. http://www.pnwfertility.com/portals/0/dr.%20lamb%202011%20publication%20in%20fertility%20and%20sterility.pdf


#3

All of my paragraph breaks disappeared… :frowning:


#4

Hi, I will not go into the egg quality since I don’t know your age and diagnosis. However, I’m positive that prolingef use of hormones affects the egg quality. For women who overstimulate, lupron is administrated. That’s according to my dr. Finally, being tested for dq alpga is not enough. All hla matches should checked. Perhaps you need more thsn prednisolone.


#5

Cosmo I wouldn’t continue to eat it, but I don’t think you caused any harm to your pregnancy. Just because they are able to do it in japan doesn’t really mean much. Their immune system and their food processing is very different than ours. Like in most of Europe they keep their eggs at room temp. But they also don’t wash the outside of the eggs like we do. There is evidence that washing the eggs can allow for organisms to get through the shell, so we can’t just start storing our eggs at room temp like they do in Europe. Because keeping them in the fridge stops whatever bacteria that got in during that processing from growing. Sometimes we do more harm than good in America. Lol. Anyway the point is that it’s just not comparable. Another example is the whole unpasteurized cheese thing, unless you are getting imported cheeses most soft cheeses that they tell you to avoid are actually pasteurized. So you CAN eat them. You can always look at the package in the store and check if it’s unpasteurized. The only cheese I cared about last pregnancy was feta and that is almost always pasteurized. Try not to stress too much about what you have already done because it’s most likely just fine. But I don’t eat any cold meats during pregnancy because I actually know a person who lost their baby due to listeria. So in my opinion it us unlikely but after all we went through it’s not something I want to chance. Ps come over to the Ivf due date boards.


#6

Cosmo I wouldn’t continue to eat it, but I don’t think you caused any harm to your pregnancy. Just because they are able to do it in japan doesn’t really mean much. Their immune system and their food processing is very different than ours. Like in most of Europe they keep their eggs at room temp. But they also don’t wash the outside of the eggs like we do. There is evidence that washing the eggs can allow for organisms to get through the shell, so we can’t just start storing our eggs at room temp like they do in Europe. Because keeping them in the fridge stops whatever bacteria that got in during that processing from growing. Sometimes we do more harm than good in America. Lol. Anyway the point is that it’s just not comparable. Another example is the whole unpasteurized cheese thing, unless you are getting imported cheeses most soft cheeses that they tell you to avoid are actually pasteurized. So you CAN eat them. You can always look at the package in the store and check if it’s unpasteurized. The only cheese I cared about last pregnancy was feta and that is almost always pasteurized. Try not to stress too much about what you have already done because it’s most likely just fine. But I don’t eat any cold meats during pregnancy because I actually know a person who lost their baby due to listeria. So in my opinion it us unlikely but after all we went through it’s not something I want to chance. Ps come over to the Ivf due date boards.


#7

I’ve done two fresh IVF cycles. I’m a super high responder. With my first, I started with Follistim 150 and Menupur 75. 5 days later, the scan showed 40+ follicles, and the dose was reduced. Two days later, my E2 level was over 5000, and I was coasted for 3 days before the trigger shot. About 50 was retrieved, but only 15 or so was fertilized, and it was down to 3 by Day 3. Only 3 survived to Day 5 (2 morulas, 1 early blast; poor quality). Due to the other issue I had, the three were frozen. 8 months later, I did FET, which ended with BFN. Fast forward to the 2nd IVF, I got pregnant with twins (I’m at week 11 or so). I emphasized “quality over quantity.” Before going into this cycle, I studied a lot and did a few IUI cycles with injection to learn how my body responds to a different dose. I set my own protocol because I knew I was not a “typical” patient (high responders are much rarer than poor responders). I did Follistim 100 and made sure to start it by CD3 (when it’s started on CD4, it was too late for my body). Naturally, my body ovulates on CD14/15, so I wanted my trigger to occur on CD12/13 (when the length of stim was shortened or lengthened, my body didn’t take it well). Research shows a steady incline of E2 level (double every other day) to be ideal in terms of quality, so I ensured the dosage was not increased unnecessarily. In fact, I stayed on Follistim 100 from CD3 to CD11 and triggered on CD12, and my E2 level doubled every other day throughout the cycle. I ended with 13 retrieved, 11 mature (I knew it would be 11 mature from the scans), 9 fertilized, 7 made it Day 5. Two 5AA blastcysts (one was hatching) were transferred, and I am pregnant with twins. 5 frozen embryos are all great quality (the lowest is 4AB or something…my clinic has a very high standard and rarely rates an embryo 5AA). I definitely think that coasting affects the egg quality negatively. I also definitely question your doctor for freezing the embryos on Day 1. Some people/embryos do better with Day 3 transfer rather than Day 5, but based on my research, as long as the clinic has a quality lab, the success rate is higher if the embryos are frozen on Day 5. Those embryos that do not survive till Day 5 are not likely to survive in the uterus. How is your clinic’s success rate? Many REs seem to do better with poor responders. If you are sensitive to meds like me, you want to do your own work. Slow and steady (i.e. comparable to your natural follicular phase if you ovulate naturally) leads to good quality. On the side note, you did not mention your husband’s sperm quality. Most REs are careless about the quality of sperm, especially when doing an IVF as long as the husband can produce a sample. I found it odd and worked on improving my husband’s sperm quality, specifically the motility for this IVF. It used to be less than 50% post-wash, but for this IVF, the motility post-wash was 100%. He took FertilAid for Men and FertilAid Motility blend with fish oil. He’s not a big drinker, but he did not drink alcohol at all for two months before the collection. On my end, I took CoQ10 for three months before the 2nd IVF cycle with prenatal. I switched to high protein/low carb (NOT no carb!) diet. I also had a subclinical hypothyroid, meaning my thyroid (TSH) was within normal limit but not ideal for someone trying to get pregnant. After extensive research, I decided to take meds for this to bring my TSH down. It was 3.8 in May, and by the beginning of the 2nd IVF cycle, it was below 2, which was my goal. When I found out I was pregnant, my TSH was 0.78. I don’t know about other things, but what I learned is you gotta be your own advocate. Many times we can’t choose which doctor we go to unless you live in a big city with more than one doctor within a reasonable distance. I don’t know about your situation, but your doctor does not seem to be treating you as an individual case. You don’t want to offend the doctors because you kinda depend on them to make your dream come true but definitely sit down and demand for explanations.


#8

I agree with you, quality over quantity, and lower dosage is better. I am considering asking my doctor to reduce my dosage to 150 IUs from 225 IUs in the last cycle. Also, no Menopur. Way too many women who had a high percentage of immature eggs and non-retrievable eggs were on Menopur. I also agree with the right total stimulation time. I wish there was a definite answer there, but I am planning to get my E2 to at least 1,500 two days before the trigger (for some reason my E2 is low even though I have a ton of follicles and had OHSS in the past). Can I ask you if you had agonist or antagonist protocol the last time around? I responded well to both, no surprise here, but the egg quality was better on long Lupron (agonist), so I am thinking to switch back to it.