Question:
Dear Dr. Ramirez,
I write to you from Los Angeles, California. I am 38 and just started an IVF (in vitro fertilization) cycle after two FETs (frozen embryo transfers) that did not take. Those embryos from the FET were from an IVF I did when I was 36 that resulted in my wonderful son. I am on Bravelle and went in for my first ultrasound and they saw only two developing maturing follicles, one on each side, that were outpacing all the rest. Previously, they had seen about five on each side. My doctor has cancelled this cycle but recommended continuing on the Bravelle for two more nights and then trigger ovulation and timed intercourse. My questions is, should I do IUI instead of just timing intercourse? I know that my chances are very low of conceiving anyway, but my feeling is that if we are paying for the meds and these ultrasounds, that perhaps we should optimize our chances, even though they are very low. The doctor was trying to minimize our costs and suggested timed intercourse instead of the IUI.
I am hoping that these two years that have passed since my son was born haven't led me to be a 'poor responder.' The doctor said that sometimes this happens and that we can try a fresh ivf cycle next month and he would increase the amount of the stimulation drugs.Any thoughts on IUI versus timed intercourse or anything else?
Answer:
Hello S. from California,
I don't recommend canceling IVF cycles normally because you never know if the perfect egg is in one of those follicles. In addition, despite the fact that two have outgrown the others, that does not mean you can't get mature eggs from the other follicles. There have been studies that have retrieved mature eggs from follicles as small as 10 mm. So even if there is only one follicle, I like to give it the best chance that we can. I know that this is a more expensive way to go, but I've had numerous pregnancies from just one follicle. Bear in mind that IVF has a significantly higher pregnancy rate, even with only one egg, than any other method at your age, per cycle. In my center it would be 70% pregnancy with 40% continuing with IVF vs 7-10% with IUI.
That is because, if you image how the natural cycle process works, it takes 10 steps for your body to accomplish a pregnancy:
(1)Brain sends FSH to stimulate the ovary to grow follicle
(2) Ovary grows follicle
(3) Follicle ruptures out of ovary (ovulation)
(4) egg is pulled into the culdesac with the fluid from the follicle and finds (or has to find) tube within 12-24 hrs
(5)Egg is picked up by the fimbria of the tube
(6) Sperm and Egg meet within the tube and fertilization occurs
(7) Egg travels down the tube and divides into blastocyst
(8) Embryo enters uterine cavity
(9)Embryo hatches and exits from its shell
(10) Inner mass attaches to the uterine lining and the lining grows around the embryo (implantation)
With IVF, steps 1-8 are accomplished for you and only two steps left up to chance/nature/God, whereas with IUI, only steps 1 and 2 are accomplished for you. The rest occurs naturally.
In any case, there are several issues you have brought up and questions that correspond. One is whether you should do IUI vs try naturally right after a cancelled IVF cycle. Statistically, IUI has a better chance of pregnancy than pregnancy (7-10% vs 5%), so for that reason alone, I would go with IUI. I would recommend following the exact same protocol as you would of with IVF except that retrieval and transfer will not occur. I would do the same progesterone supplementation.
The other issue is regarding your stimulation. It is obvious that you were not stimulated with the max protocol if you doctor commented that they are going to increase it. You may have a decrease in response but without getting maximum stimulation, you don't know that for sure. So, you may not be a poor responder. You just did not get stimulated adequately.
The good news is that you have had one successful pregnancy. It is a good thing that you are pursuing having the second at 38 yr.s, before you become much older and the rate of success drops dramatically.
Good Luck,
Dr. 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.
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