Question:
Hello Dr. Ramirez,
I'm writing to you from Texas. I just turned 45 and in the past 4 months I have gone through 4 IUI cycles (3 w/Femara) and one natural. None worked, but my fertility specialist thought it was worth a try because there is no problem with me (other than my age) or my husband and our ability to conceive. He did mention that there was a small amount of endometriosis, but nothing to be concerned about. We had been trying for over 3 years before I finally went to a specialist. I know I should have gone much sooner.
My question is this: We have decided to try IVF . My big concern is the age of my eggs. My FSH was 13. Is there any greater chance of my becoming pregnant if I use my eggs and my husbands sperm to create an embryo, or if I use a donated embryo from a younger couple? I get somewhat different answers depending who I ask at my fertility clinic and it's quite frustrating. I don't want to change clinics if I can help it, because my doctor is top notch. His staff knows their stuff, but they seem to be too busy to give me any real in depth answers. I look forward to getting your opinion on this issue. I've found all kinds of websites that deal with donated embryos - are there any that you would recommend? Thank you! J. From Texas
Answer:
Hello J. from the U.S.,
I am very, very surprised that your "top notch" doctor recommended you to try IUI's (intra uterine inseminations) that many times based on your age and elevated FSH. Did he tell you that your chance of pregnancy was less than 0.5% per month? Did he tell you that your FSH was elevated and give you the diagnosis of decreased ovarian reserve, which essentially means time is critical for you. You may already be in a pre-menopausal state!
Unless my patient absolutely demands it, I do not recommend IUI in my 42+ year old patients or patients with FSH levels greater than 10. In my opinion, in order to have the best chances of pregnancy in the short time that you have left, IVF is the treatment of choice. At least there is a pregnancy rate at 45 years old that is about .5%, and for this reason I will let them try with their own eggs (many clinics do not), but it is with the understanding and plan that if it does not work then they will proceed with donor eggs. I have also had a few patients decide to mix their eggs with frozen donor eggs so that they don't know which resulted in the pregnancy (they preferred to not know that it was absolutely a donor). These eggs are purchased from an egg bank and are slightly less expensive than going the fresh donor egg route.
I think that based on your age of 45, and the elevated FSH of 13, I would strongly recommend that you proceed with donor eggs and IVF (in vitro fertilization). That will give you a pregnancy rate of 75% per attempt in my clinic and many other clinics.
In terms of finding a donor, there are three options: (1) finding your own donor that is either your family member, friend, acquaintance, which is the least expensive because you don't have to pay the donor but there could be some social issues, or (2) use a donor that is registered with that IVF center if the center has donors registered. This is usually the second least expensive way to go but there may be limited donor choices (3) Purchase frozen eggs from an egg bank or (4) go through an agency. There are many agencies across the country and you have to be very careful which agency to use. Some are reputable and some are not. This is the most expensive way to go and can double the cost of IVF because of the agency fee. We have worked with several agencies in the past, although most of my patients elect to use an egg donor in our registry.
Donor cycles are fairly easy to do from your side and will require a minimal amount of time at the IVF center. Because of this, many patients will travel to an outside clinic for a donor cycle due to price or the location of the donor. Many clinics, such as ours, can even arrange for preliminary and initial cycle visits to be done at a local clinic or IVF center so that the only travel required would be at the time of embryo transfer. So don't be limited by where you are. You have lots of options open to you. You just need to decide how you want to proceed from here.
I don't mean to be critical of your current clinic and I'm sure your doctor appreciates that you have a high opinion of their clinic. However, keep in mind that infertility clinics, doctors and treatments differ greatly. The fact that the staff at your center seem to be "too busy to give you any real in depth answers" should not be acceptable to you, considering the urgency of your situation. For example, our clinic is only one-on-one. Each patient is handled individually, and there is only one doctor that sees you, does your ultrasounds, does your procedures and makes recommendations. My patients have 24/7 email and phone access to me or my key staff. There are no mid level providers. We pride ourselves on being a boutique IVF center. It is what sets us apart from other, high volume, IVF centers that tend to make you feel more like a number. I hope this helps.
Follow-Up Question:
Hello again Dr. Ramirez, After reading your response I felt pretty emotionally bad, for lack of a better way of putting it. I was aware of the limitations with the IUI, the reason I did it is because my doctor felt there was nothing "wrong" with me or with my husband's sperm, and he assumed sluggish motility may have been part of the problem. I was planning on doing IVF next month, either using my own eggs (which I'm not entirely comfortable with) or a donor embryo rather than donor eggs, because of the price disparity. I don't live in CA where infertility treatments are covered under alot of insurance plans.
I said my doctor was top notch, in part because of the high ratings and recognition he has received in his field. That being said, I've never had a true one on one relationship with anyone at the clinic - although I tend to deal w/the same nurse and doctor. The clinic does offer an egg donor program, but based on your answer, I'm not so sure if I should continue on with them, since I don't believe their database is that comprehensive. In fact, I believe they go outside the clinic for donors, and the cost of the IVF with an egg donor is somewhere around 18,000. I asked you about FET (frozen embryo transfer), but you did not comment. I would like to get your opinion about this and if you have any recommended facilities that house frozen embryos. Unfortunately, the clinic I'm working with does not have any recommendations for embryo donors. After reading your answer, I'm not so sure about anything anymore. Thanks for answering, J. from Texas.
Follow-Up Answer:
Hello J.,
I apologize for causing you this strife. I don't want you to give up, rather, I am just here to give you advice and opinion. Certainly you can see that my opinion is greatly different from your doctor's.
California is not a mandated state in terms of infertility, so many of the insurances don't cover it here either. So I am very aware of the costs of treatments. It is a dilemma in my clinic as well where we lose 10-15 patients per cycle because of finances. Yes, I know that egg donor cycles can cost $18,000 or more per attempt.
Embryo donation is a fairly new option. I would recommend that you look at the web and you will find several organizations that assist with embryo donation. Keep in mind, however, that there are not a lot of embryos out there that are donated. Many parents do not want siblings all over the country. This certainly could be a lower cost than standar IVF because the transfer procedure is fairly simple. The medication cost is less and the procedure cost is less involved. Our clinic would charge $3500 for an FET (frozen embryo transfer). That is about what it costs in most of the clinics in our state. I don't know what the cost of these embryos would be, however, and most IVF clinics do not have embryos to donate. Most of the embryo banks are Christian organizations that either facilitate the process or have their own storage facility so that the embryos are not destroyed.
Another option is Frozen Egg Banks, which has now become a viable option. I recently had a 45 year old patient use that method. The costs were still higher than an IVF cycle, because the Frozen Egg cost was high, but it was less than using your own egg donor. Unlike embryos, these are unfertilized eggs that were frozen and can be fertilized with your husband's sperm. The protocol you would go through would be like an FET. It is more expensive than a simple FET because you have to purchase the eggs (I think then sell them in lots of two), ICSI would have to be done and the embryology process would have to be done like a regular IVF cycle. The only step that would not have to be done is the egg retrieval step, which is the most expensive part of the IVF cycle.
For both embryo transfer and frozen egg transfer, the pregnancy rates would be very high (75% per attempt in our clinic). It certainly is better than your own eggs.
Again, I apologize for the comments that I made because they deflated your hopes and made you feel emotionally deflated. I hope these new comments will help you more constructively.
P.S. Kelly Preston (John Travoltas wife) just delivered a healthy baby boy at the age of 48. Of course, she doesn't say whether she used any assisted reproductive technology (and I would bet she did), but if not, then there is always a chance. I never say NO to my patients that want to try, I only make sure they understand all their options and their chances up front.
Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.
