Question:
Dear Dr. Ramirez,
I would like your opinion on whether I should move on to donor eggs. I am 40 yr and I have 5 failed IUI (intra uterine inseminations), 3 of the IUI was with Menopur injections. The last IUI, my RE (reproductive endocrinologist) prescribed 22 vials where I used 3 vials for 7 days. Each IUI, I have one matured follicle whether its clomid, clomid combo injections or injections only.
One of the IUI resulted in pregnancy but I miscarried at 7 weeks 4 days in 2011 at age 39. Previous to my 5 IUIs, I was able to conceive naturally and got pregnant but miscarried at almost 10 weeks in 2010 at age 38. My FSH is 12 in 2012 but was 20 in 2010. My amy level was 0.5 in early 2011 and 0.25 in feb 2012. I have not tried IVF (in vitro fertilization) yet but I would like to know if the different protocol will make any difference producing more matured follicle. My RE doctor states that he needs at least 3 matured follicle to transfer, if there is not one, the cycle will get cancel and change to IUI. I have already find a donor but i found myself going back and forth to see if its worth going to a IVF cycle or not.
Please help! Thank you, D. from Texas
Answer:
Hello D. from the U.S. (Texas),
I think I would have recommended IVF back when you were 38 years old. In general, if a patient is 37 years old or older, I strongly recommend IVF rather than IUI. The main reason is that the chances of pregnancy with IUI at 37 is 5-10% per cycle vs 60% for IVF. In addition, seeing that your FSH level was already elevated at 12, that would have made a strong argument that time was critical so I would not have wasted it on a low yield treatment plan. But that is "spilled milk" as they say.
Now, you have two things going against you in terms of trying with your own eggs. One is that you are 40 years old so your chances of pregnancy are decreased, but still around 50% per attempt. More critical is that your FSH level is very very high and your AMH level is low. These are not good and indicate that the ovaries would probably not stimulate well. Sure, it only takes one good empyo to achieve pregnancy, which is what I tell my patients, but at the same time, the only way to increase your chances because of your eggs is to try to get a lot of eggs (it is know that the number of good eggs decreases with age). If only a few eggs are retrieved, then the chances of having a good egg, decreases. By the way, I don't agree with your doctor's policy to change to IUI if you have less than three follicles. IVF is clearly better than IUI because more of the steps are accomplished, pinging you closer to implantation, whereas IUI requires that your body go through ALL the steps naturally. In addition, I and many others in the assisted reproductive speciality have experiences with only one empyo leading to a pregnancy. Why give up IVF when it is your best option in such a cycle?
However, given your age, FSH level and AMH, I think that if you are willing to consider donor eggs, that is now the best way to go. I do let my patients try IVF despite these adverse factors because many desire to try at least once with their own eggs before giving that up. If you can afford it, that is an option. But you should clearly understand and be prepared for a failure and be ready to go to IVF with donor eggs.
Thank you for writing and good luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
