(In)Fertility Journey- 9. IVF Considerations

It’s 2021 now, and my husband and I recently finished taking the antibiotic course for endometritis. We’re taking extra good care of ourselves by continuing our vitamins, eating well, and going for walks. Our tongues are slowly returning to a normal state, aided by regular use of our new tongue scrapers (these things are great!).

Notes from our doctor during our video conference: “Your ovaries are not playing by the rules.”

1. With my egg count and AMF level, expected more follicles developing. I was on a medium high dose of medication. There was 12 follicles at egg retrieval. ==> push ovaries more with more medication.
2. Only 6 eggs from those follicles, so push for more maturity. They were good on size, but not retrievable.
3. 5 out of 6 eggs retrieved were mature, which is a good number. ==> more aggressive stimulation protocol. Increase dose of Gonal-F and Menopur.
4. Everything good up to egg retrieval, estrogen levels were high, good. Estrogen level consistent with 12-15 mature eggs. Expected 10-12 eggs retrieved. Estrogen level only tells us that more eggs should be available.
5. Only 2 out of 5 eggs were fertilized. ==> recommend ICSI on all eggs. Even though sperm sample looked great. The sperm has a problem penetrating an egg, or the egg is resistant to penetration. Even if we did other sperm tests, the answer would still be do ICSI.
6. Eggs must be denuded for ICSI. Doctor says it’s “rare” that the eggs are damaged. Do ICSI 60-70% of IVF cases.
7. Egg maturity is seen during cleaning, at 4 hours after egg retrieval, for ICSI.
8. Arresting after 3-4 days hard to say, only 2 embryos, could be egg or sperm quality. Another hormone to that might affect egg quality is to add growth hormone to the stimulation protocol. ==> Omnitrope Routinely do for women over 40. or when worried about stimulation not going the way wanted. or to help with egg quality. Might help, won’t hurt, expensive. Add $1500 to the medication cost. Taken for 10 days. Never made it past 30-cell stage. ‘Fair’ after 3 days. Like to see at day 3 between 6-9 cell stage. 1-4: 1= looks great, 4= bad. One at 6 cell and grade 1. Other at 4 cell and also grade 1.
9. Greater success transferring at day 3, yes for some people, but don’t have enough information on me to say that is the case here. Usually recommend when lots on day 3 and only few or none made it to day 5. More estrogen stress makes it less likely to work for implantation for fresh transfer with more stimulation.
10. Push follicles to 20-22mm size before trigger, instead of 18mm. Very rare that follicles spontaneously release eggs. ==> all about the maturity of the follicles. Can get overripe, but doesn’t seem to be a problem here, because only 5 of 6 mature. Change the timing and type of trigger. Everything more aggressive. Embryologist can tell if overripe- eggs fall apart when overripe. Change to Ovidrel, less likely to get OHSS because stay in the body shorter time than other HCG, I am at risk of OHSS. Probably check AMH again (LabCorp or Quest).
11. PGT if Mosiac, depends. NexGen. Low mosiac call rate. If the case, will try to rerun. If chr 9, not too worried about, will transfer. If 21, would not risk by transfering that one.
12. BCL6 negative indicates no inflammation due to endometriosis. Does not say there is no endometriosis. I asked, and during egg retrieval, can look for signs of endometriosis, and none (cyst) were detected during our egg retrieval. For endometriosis, can check for cysts, can do laproscopy, or do BCL6. 2 out of three indicate not.
13. Because only 2 embryos, can’t really say, but most commonly because those were not normal.
14. Everything else say that if we tried again, everything is saying it’s worth trying again. Everything says it should happen. Everything up to egg retrieval great, even 6 eggs retrieval is fine. All these recommendation puts me at higher risk of OHSS. His feeling is that things should work, and very optimistic that things would work on a second round.
15. See something, make these adjustments, and most of the time making these adjustments work. Could be an egg-sperm interaction problem. Because the low fertilization rate. Our situation is uncommon, but not rare.
16. All the follicle were normal, all had follicular fluid, and all were still there.