Hi Dr.
On CD 3 during my ultrasound they noticed left over follicles from Cycle #1. Just when I thought I was going two steps forward I feel as though I took two huge steps backwards.
My follistim injectables were 300 iu for 5 days and then they lowered it to 225 iu for 2 days and then I triggered with Ovidrel so I guess the RE really wanted to stimulate those ovaries. Guess what? It worked! When they did my Progesterone levels it showed I ovulated. So not sure what went wrong there.
E2 levels were so out of whack (263). Just a side note, I started taking Estrodial as the prescribed protocol as we were heading toward doing IVF if the IUI didn’t work. I’m 42 years of age and will be turing 43 in Aug. DH for our IUIs had 14 mill. sperm and 12 million sperm. Not exactly sure if that was a problem or not. However, after the IUI didn’t work and AF came early we decided to stay on course with another IUI cycle #2. Also, came off of the Estrodial. So my point here is that I am not sure if my body overloaded on the estrogen and this was a side effect resulting from it. Anyway, the RE recommended I force ovulation and trigger with Ovidrel and come back on March 27th for bloodwork to make sure I ovualted again. With ovulation, I am guessing you get another menstrual cycle and then DH and I will start another IUI cycle hopefully in early -mid April. Keeping our fingers crossed that by having 2 menstrual cycles back to back that all my hormone levels retreat back to normal and all the bad stuff in my body leaves and we can start the process again.
However, after extensive reasearch on the internet and your site, it seems that I now have Polycystic ovarian syndrome. I do have all the sign and symptons of it especially the weight gain around the middrift area.
Do you think I should request a check for insulin resistance to see if I should take metformin and start a excercise & diet plan? I notice the success rate is a bit higher once a good diagnosis has been established for PCOS. Maybe I am wrong it was just what I was reading.
Thanks a million for reading and looking forward to your advice or questions I should be asking my RE about here in NJ so I can be successful in having a beautiful baby.
Becca from NJ.

Dear Becca,
Thanks for sharing your story. Based on what you’ve described, the biggest obstacle, as you probably already know, is the degree of age-related DNA damage in your remaining eggs. In addition, it’s well known that PCOS hinders fertility even if you do ovulate. Now you mention that you “have all the sign and symptons”. Other than truncal weight gain, you didn’t go into detail on what those clues are for you having PCOS. But giving you the benefit of a doubt, I suggest you have your RE test your insulin resistance or alternatively, if they are agreeable to it, they can just empirically try you out on metformin for 2-3 weeks. For example, if you report losing 5 pounds in 3 weeks and noticing a huge boost in energy, it would likely be a good reason to stay on it.

You also asked if you should start an exercise and diet plan. You would have to ask yourself, even if you didn’t have PCOS, what’s stopping you from adopting a healthy exercise and diet plan anyway. Right? You seem to already have many of the answers to your own questions.

Best wishes and by all means, have that talk with your RE!

Journal club is one of those things that I don’t look forward to, but which afterward, I’m glad I went. About once a month, I carpool all the way from Orange County near Disneyland, to a restaurant just a block from the UCLA campus. A fellow RE, an embryologist and I battle the LA traffic and usually get there a bit late. Last night was no exception. We arrived to join a debate already in progress. In attendance, seated in a huge circle was an audience of 25 people, consisting mostly of RE’s, RE fellows, urologists and acupuncturists.

The first article concerned using new ultrasound technology to measure volumes of follicles instead of the way we do it now, which is to measure the diameters. There was a consensus lack of enthusiasm for this technology, although some postulated that follicle measurements could be automated and done by a tech or machine. We then debated the efficiency of letting techs do our ultrasounds despite the facts that the patients love it when the doctor does it. Should we go for efficiency or go for bedside manner?

Today’s second article concerned the proper obtainment of consent from egg donors regarding the potential use of their gametes in stem-cell research. When an egg donor agrees to donate, she is under the belief that her eggs will be used to generate embryos that will be transferred into another woman in the hopes of bearing babies. However, after the couples are successful, they sometimes end up with twins or are just happy to have one baby. So they then have excess embryos frozen for future disposition. If they are sure they have all the babies they want, they can opt that the remaining frozen embryos be adopted out or be used for research. The main debate was this: If we decide to do stem-cell research with the frozen embryos because they were donated by the couple, is it enough to get the couples permission? Or is it necessary to also track down the egg donor and tell her “Hey you remember those eggs you donated four years ago? We have some extra embryos leftover from them and want to use them for stem cell research. Is that OK with you?”

It can be fun to get a bunch of us opinionated doctors in a room and see how many different viewpoints there are. Some people believed that you should give informed consent encompassing not only all the known technology but on future technology as well. So, for example, someday if cloning is perfected, and you wanted to use the egg donors’ embryos to do cloning research, you would have to track her down and re-consent her. From the other extreme were people who pointed out that for years and years, sperm donors were never given a say in what is done with their sperm after they donated. This then evolved into a discussion of the future of our field. One person predicted the cost of IVF would drastically come down and down as we get more efficient. Another person made a bold prediction that I liked. She advanced that perhaps someday it would be routine for all women in their 20’s to go for an annual pap smear and be asked if she wanted a needle biopsy of her ovary to get some tissue to freeze and preserve for her future fertility. There was some anti-lawyer sentiment about how we aren’t even allowed to consent egg donors without paying a lawyer to represent her. We then moved on to the third paper.

The third paper concerned prepubescent boys diagnosed with cancer and undergoing chemotherapy. It’s common knowledge that adults who are about to undergo chemotherapy should be offered the option of freezing sperm beforehand in case the chemo drugs destroy their testicles. But what do you do if this occurs before boys can ejaculate. A children’s hospital in Pennsylvania did a project where prepubescent boys with cancer who were undergoing surgery anyway were given a choice to have a testicular biopsy done at the time of their main surgery. The big issue was that there’s no evidence that this testicular tissue will be of any use in the future, because right now we still wouldn’t be able to extract usable sperm out of frozen testicular tissue. As often happens, this evolved into an ethical discussion about whether 6-year-old boys could give consent to having their testicles biopsied or not. We then argued who should pay for this and whether or not it would turn commercial, comparing it to the way that companies which advertise cord-blood banking try to convince (scare?) parents into pay money to freeze the umbilical cord blood from newborns even though it is very unlikely to ever be of any use. I’m not sure how the conversation migrated, but we then started talking about different ethnicities and their obsession with fertility. Some of the West LA doctors recounted stories of Persian Jewish families who would insist on not marrying their daughter off until the future son-in-law had a documented normal semen analysis.

The final paper concerned endometrial receptivity and preovulatory progesterone levels. The paper was done by a very well-respected RE out of Nevada. Anyone who has been to a lot of journal clubs knows that with any experimental paper, the first thing journal club attendees do is to pick it apart and criticize the materials and methods, many times justifiably so. This time was no exception. Some of us were really critical of the paper author’s practice of altering someone’s IVF cycle if her preovulatory progesterone was over 1.0 ng/ml and then freezing all the embryos in preparation for transfer in a subsequent month on the theory that the prematurely luteinized lining was bad for implantation.

I worked 70 hours this week and spending time relaxing, learning and debating over dinner and wine is a nice break.

1. Fifth-Party Reproduction: Utilize a sperm donor. Utilize an egg donor. Utilize a surrogate to carry the baby.
2. Fourth-Party Reproduction: Utilize two out of the three (egg donor, sperm donor, surrogate)
3. A) Third-Party Reproduction: Utilize either one of a sperm donor, egg donor or surrogate
   B) In-Vitro-Fertilization with PGD: Take the wife’s own eggs and the husband’s own sperm and fertilize together. Analyze the embryos and transfer only those which are likely to produce the healthiest children.
4. In-Vitro-Fertilization with ICSI: Take the wife’s own eggs and the husband’s own sperm and inject the sperm directly into the eggs. Transfer the “best looking” embryos.
5. Standard In-Vitro-Fertilization: Take the wife’s own eggs and “sprinkle” the husband’s sperm over them, allowing them to competitively battle to fertilize the egg without assistance.
6. Intrauterine Insemination: Wash and concentrate the husband’s sperm, separating out the best swimmers. Then, physically transport the sperm exponentially closer to the target destination where the eggs are hoped to be waiting, usually done in conjunction with drugs to boost egg quantity and quality.
7. Ovulation assistance: Administration of medication to increase the number and/or the quality (probability of healthy conception) of the eggs, while allowing the couple have sex naturally.
8. Restoration of hormonal imbalances: Give medications to correct hormonal defects, such as an underactive thyroid or excess insulin production.
9. Counseling: Pointing out to the couple ways they can change their lifestyle habits and sexual practices to boost their chances of conceiving naturally.

When patients come to us, we seek the balance between starting low on the list and moving up as high as necessary and as high as the patient wishes to go in order to have a baby. The sequence is not a pure progression as there is overlap between some of them. For example, 3A and 3B are listed in parallel because they are different branches of increased severity, but not necessarily mutually exclusive, meaning you could do PGD AND do IVF with ICSI AND utilize an egg donor.

I use this list to help patients see the overall “big picture” of what their options are.