WWYD/Help me decide ("hard" IVF cases come in please!)

[seeyalater52]

I had a call with my RE this afternoon to discuss the results of my 4th transfer, which as you probably know was another early loss/CP (more history below for those who don't know the saga.) We have two frozen embryos remaining, 3AA and 3BB, untested and we need to make a plan for another transfer in April. I am 99% sure we will transfer these embryos both together.



History: 31f, donor sperm (proven donor), egg retrieval at 30.


1+ year home inseminations and 3 IUIs all with donor sperm (3 different donors), no pregnancies.


Diagnosis is unexplained infertility.


1 IVF retrieval yielded 7 embryos visual grades ranging from 4AA-3BB. No PGS.



1 fresh and 3 frozen transfers (2 singles and one double) = 5 embryos transferred so far, resulting in 3 chemical pregnancies (only pregnancies ever.)
Frozen transfers were done using a natural start (no BCP priming) oral estrogen and progesterone (PIO and endometrin) protocol. 

RPL, clotting, immune testing etc turned up nothing. ERA was receptive using the same protocol I’ve used for all my transfers (except the fresh one, obviously.)


My RE is really unwilling to do anything resembling an immune protocol for this next transfer even though I strongly suspect immune issues (I know somewhat controversial.) I think she would be more amenable were we to have failures with PGS embryos. She does not think the benefits outweigh the risks. I essentially have two options currently for this last transfer:

1) Modified natural transfer cycle with letrozole and trigger, with progesterone and estrogen support after transfer. I could do 5-7 days of medrol before transfer most likely with this. (I did that during one of my other FET cycles that ended with CP.)

2) Microdose Lupron priming transfer (Lupron starting a week after ovulation) and medicated with estrogen and progesterone on the same schedule as my receptive ERA cycle (mock cycle didn’t have Lupron.) Could this potentially help if silent endo is the issue?
Should I push harder for depot Lupron instead?

Or is there some other different transfer protocol I should consider? If so, what?

I’m not really sure what to do next and I’d love some thoughts before we decide, especially from anyone who has done multiple failed embryo transfers or has had RPL during or before doing IVF. 

[vmars]

I don’t have any medical advice, but if you don’t feel like you are being successful with this RE would you go get a second opinion from another one?

[seeyalater52]

Feb 22, 2019 20:47:21 GMT -5 vmars said:

I don’t have any medical advice, but if you don’t feel like you are being successful with this RE would you go get a second opinion from another one?

We have 3 other consults scheduled in the next couple of weeks, so we definitely are considering several second opinions.

Either way, we will transfer these last embryos at our current clinic (just one transfer for both.) With treatment being covered it just doesn’t make sense to shell out $$$$ to transport them to another clinic at this point, and it would cause a pretty long delay in both the transfer and in proceeding with another retrieval.

Unfortunately the other local clinics aren’t too keen on outside the box protocols either, although one of the consults is at a fairly new CCRM location that opened in our area so they might be a bit more forward-thinking.

[thoseareradishes]

I have endometriosis and adenomyosis. We never got a normal embryo so we moved on to donor eggs with PGS. First transfer was a CP, so we added lupron and were successful on our second transfer. Do you have any indication that you may have endo? It can really wreak havoc on your egg quality.

[lovelyshoes]

From what my dr told me, the grading doesn’t matter so much. We had no luck with high grade embryos. Any reason they didn’t recommend pgs testing?
I think your plan of transfering the remaining embryos sounds completely logical. I hope that it works for you, but if it doesn’t I think getting a different dr’s input would be my next step. I know that traveling out of state might not be feasable, but I would look into that if it’s a possibility at all.
Wishing you lots of luck and peace.

[vmars]

seeyalater52, that’s good! I know what you mean about forward thinking. My boss said he had to find an RE like that to be successful after 7 years of trying. Coincidentally, we have the same RE.

[seeyalater52]

Feb 22, 2019 21:09:13 GMT -5 thoseareradishes said:

I have endometriosis and adenomyosis. We never got a normal embryo so we moved on to donor eggs with PGS. First transfer was a CP, so we added lupron and were successful on our second transfer. Do you have any indication that you may have endo? It can really wreak havoc on your egg quality.

Absolutely no definitive endo symptoms or indications BUT I’m going to insist on a ReceptivaDx biopsy or an exploratory lap before we transfer any tested embryos. That and another retrieval are what’s next for us after this final transfer from this round.

By adding Lupron do you mean microdose Lupron after ovulation, or did you do the depot Lupron for a month before starting the transfer cycle? I know the latter is more of a “best practice” with endo, but I’m wondering if the former could also be helpful in some way.

[seeyalater52]

Feb 22, 2019 21:09:48 GMT -5 lovelyshoes said:

From what my dr told me, the grading doesn’t matter so much. We had no luck with high grade embryos. Any reason they didn’t recommend pgs testing?
I think your plan of transfering the remaining embryos sounds completely logical. I hope that it works for you, but if it doesn’t I think getting a different dr’s input would be my next step. I know that traveling out of state might not be feasable, but I would look into that if it’s a possibility at all.
Wishing you lots of luck and peace.

They didn’t recommend PGS testing because when we started IVF there was no indication of any sort of risk for higher than typical abnormal embryos. I was 30, unexplained infertility, and all treatment and transfers are fully covered by insurance (whereas PGS is not) so it wasn’t medically indicated and it was expensive without any sort of cause. We will obviously do the testing next time.

Traveling out of state is definitely not an option as we have full treatment coverage with providers in my insurance network (limited to MA and RI and the one RI clinic isn’t particularly good.) That said, there are a ton of totally top-rate clinics in our area that are in my network so we have a lot of great options and consults on the books with nearly all the best ones coming up. We will see what they have to say and make a plan for another retrieval and next steps.

[awick14]

I have no medical experience here but I would defiantly talk to the other REs about their thoughts.

It took us a while to find a solution to have our daughter. And then we had to switch OBs because mine did not like the idea of me taking asa and the blood thinners. As it put us too “high risk” for her. (And it turns out the Doctor The did follow my care messed up the protocol as well by doing what she thought was best and not what the specialist thought!!)

All this too say make sure that you are getting care that you feel like is the best and that you feel like you are well taken care of.

[thoseareradishes]

I did microdose lupron after ovulation, and looking back on my calendar, I apparently was on birth control also.

[seeyalater52]

Feb 22, 2019 21:25:53 GMT -5 thoseareradishes said:

I did microdose lupron after ovulation, and looking back on my calendar, I apparently was on birth control also.

Thanks! That’s what my RE is suggesting in option 2, so good to hear it worked for you.

[stellelinds25]

I don’t have any advice/experience, but I am glad to hear you are going to get some other opinions...it can’t hurt to have some other eyes on your records. I know someone who is doing the full immunology protocols via CNY, however, she hasn’t been successful yet (1 CP and one or two unsuccessful), but is getting ready for another transfer next month. I don’t know a lot about it, but wanted to throw that out there in the event you could swing a consult with them. I hope they can come up with something to make this work for you because no one deserves a take home baby more than you <3

[seeyalater52]

Feb 22, 2019 21:23:34 GMT -5 awick14 said:

I have no medical experience here but I would defiantly talk to the other REs about their thoughts.

It took us a while to find a solution to have our daughter. And then we had to switch OBs because mine did not like the idea of me taking asa and the blood thinners. As it put us too “high risk” for her. (And it turns out the Doctor The did follow my care messed up the protocol as well by doing what she thought was best and not what the specialist thought!!)

All this too say make sure that you are getting care that you feel like is the best and that you feel like you are well taken care of.

Thank you. On the one hand I love my clinic and my doctor has been great and so proactive. We might be hitting a wall with her so I think doing the consults will help. I’m doubtful any of the other clinics locally will dabble with immune protocols (and to be fair there’s no clear evidence the issue is immune related, it’s just this hunch I have) but it will be good to hear their ideas and what they have to say.

It’s possible other clinics will be more open to the blood thinners which is another possibility for RPL (as I know you know) even though I don’t have an identifiable clotting issue.

I’m also considering getting a proactive referral to an MFM to establish a relationship (in case a pregnancy ever were to progress) and get a pre-conception workup and any ideas or suggestions from that side that might be worth running by the REs.

[seeyalater52]

Feb 22, 2019 21:30:33 GMT -5 stellelinds25 said:

I don’t have any advice/experience, but I am glad to hear you are going to get some other opinions...it can’t hurt to have some other eyes on your records. I know someone who is doing the full immunology protocols via CNY, however, she hasn’t been successful yet (1 CP and one or two unsuccessful), but is getting ready for another transfer next month. I don’t know a lot about it, but wanted to throw that out there in the event you could swing a consult with them. I hope they can come up with something to make this work for you because no one deserves a take home baby more than you <3

Thank you, that is such a sweet thing to say. CNY isn’t in our network but I miiiight just have access to their immune protocol info through a certain little mole. 😉 All the elements they use are on my list to ask during the consults, and some of them (antihistamines for example) I might just go rogue and do anyways even if the doctors think they’re stupid.

[red]

I don’t have any particular advice in your case, but I just wanted to chime in that I treated at CNY for several years and was unsuccessful with 2 IVF cycles there. Also mostly unexplained and they threw everything at me (intralipids, steroids, LDN, metformin, lovenox, aspirin, acupuncture, etc etc). My current RE thinks they’re full of woo-woo when he looked through my records. Who knows if this cycle will be any better in the end though.

[seeyalater52]

Feb 22, 2019 22:16:14 GMT -5 red said:

I don’t have any particular advice in your case, but I just wanted to chime in that I treated at CNY for several years and was unsuccessful with 2 IVF cycles there. Also mostly unexplained and they threw everything at me (intralipids, steroids, LDN, metformin, lovenox, aspirin, acupuncture, etc etc). My current RE thinks they’re full of woo-woo when he looked through my records. Who knows if this cycle will be any better in the end though.

This is definitely the prevailing opinion of most REs, especially those that are more data/study driven. And it seems to me like when you add that many components to a protocol it’s a little hard to get a handle on what is working/making a difference!

At the same time I feel my losses are incredibly suspicious in their uniform timing (down to the exact day) and really wish I could get some sort of middle ground option that felt less like the standard same old same old because this process of endlessly transferring embryos is getting... old.

[kellikans]

We transferred 6 embryos (5 FETs) before having success with DS. 1 ended in m/c at 8 weeks (trisomy 7), 1 was a chemical pregnancy, the others never took. We were also unexplained. We chalked it up to bad embryos.

We ended up switching to a different RE for our successful cycle and actually followed the same protocol that I did with my m/c cycle, except added in HGH. Who knows if that's what made a difference in egg quality, but we ended up with 2 pgs normal embryos, one of which is DS. I also swear by acupuncture. For all of my bfp cycles I did acu.

I'm so sorry you find yourself here. I know what it's like to do transfer after transfer with no happy result.

[scm1011]

Feb 22, 2019 21:26:52 GMT -5 seeyalater52 said:

Feb 22, 2019 21:25:53 GMT -5 thoseareradishes said:

I did microdose lupron after ovulation, and looking back on my calendar, I apparently was on birth control also.

Thanks! That’s what my RE is suggesting in option 2, so good to hear it worked for you.

I wasn’t a “hard” case, but that was my successful protocol as well.

If one of your consults is at MGH, know that I was initially turned off by my RE there’s seemingly cold attitude, but I’m so glad stayed with them. I’ve heard that from others as well, so just a warning if you meet with a Dr. S

[seeyalater52]

Feb 23, 2019 7:47:32 GMT -5 scm1011 said:

Feb 22, 2019 21:26:52 GMT -5 seeyalater52 said:

Thanks! That’s what my RE is suggesting in option 2, so good to hear it worked for you.

I wasn’t a “hard” case, but that was my successful protocol as well.

If one of your consults is at MGH, know that I was initially turned off by my RE there’s seemingly cold attitude, but I’m so glad stayed with them. I’ve heard that from others as well, so just a warning if you meet with a Dr. S

Thanks! We can’t swing MGH. Their monitoring hours are just too early to be realistic for where I’m coming from in the morning (Id have to leave home at 4am :/ ). We are consulting with literally everyone else, though.

[seeyalater52]

Feb 23, 2019 0:46:24 GMT -5 kellikans said:

We transferred 6 embryos (5 FETs) before having success with DS. 1 ended in m/c at 8 weeks (trisomy 7), 1 was a chemical pregnancy, the others never took. We were also unexplained. We chalked it up to bad embryos.

We ended up switching to a different RE for our successful cycle and actually followed the same protocol that I did with my m/c cycle, except added in HGH. Who knows if that's what made a difference in egg quality, but we ended up with 2 pgs normal embryos, one of which is DS. I also swear by acupuncture. For all of my bfp cycles I did acu.

I'm so sorry you find yourself here. I know what it's like to do transfer after transfer with no happy result.

HGH is definitely a possibility for another cycle.

What schedule did you do the acupuncture on? It’s outrageously expensive here and insurance covers nothing toward it so I don’t think I could afford to go every week, but it’s something we might add in this next go-around.

[vmars]

Feb 22, 2019 21:26:52 GMT -5 seeyalater52 said:

Feb 22, 2019 21:25:53 GMT -5 thoseareradishes said:

I did microdose lupron after ovulation, and looking back on my calendar, I apparently was on birth control also.

Thanks! That’s what my RE is suggesting in option 2, so good to hear it worked for you.

We also have the same RE.

[chocolatepie]

Feb 23, 2019 8:02:53 GMT -5 seeyalater52 said:

Feb 23, 2019 0:46:24 GMT -5 kellikans said:

We transferred 6 embryos (5 FETs) before having success with DS. 1 ended in m/c at 8 weeks (trisomy 7), 1 was a chemical pregnancy, the others never took. We were also unexplained. We chalked it up to bad embryos.

We ended up switching to a different RE for our successful cycle and actually followed the same protocol that I did with my m/c cycle, except added in HGH. Who knows if that's what made a difference in egg quality, but we ended up with 2 pgs normal embryos, one of which is DS. I also swear by acupuncture. For all of my bfp cycles I did acu.

I'm so sorry you find yourself here. I know what it's like to do transfer after transfer with no happy result.

HGH is definitely a possibility for another cycle.

What schedule did you do the acupuncture on? It’s outrageously expensive here and insurance covers nothing toward it so I don’t think I could afford to go every week, but it’s something we might add in this next go-around.

(butting in)

Check to see if your area has a community acupuncture group. That's who I have been using - they are a pay what you can and come/go when you can. Our insurance would cover some acupuncture visits but at $50/each and only with an approved provider, who was too far from me. So I found this other place instead.

The suggested rate is $15-35 a visit, you drop a check/cash in the box on your way in (total honor system), and it's this warm, wonderful community of people. 

Mine has just 4 acupuncturists on staff and they all know me now. I rarely make an appt; just drop in when I can. They recommended I come 2x a week prior and during stim meds and retrieval, and then before/after transfer. During stim meds, I had one particularly emotional week and I went 3 times.

Who knows if it works physically but it became a very centering, spiritual practice for me. But I'm not sure I would feel the same if I was going to an acupuncturist that practiced in a more clinical setting, you know? Mine is a quiet, dim room of recliners with tranquil music and the community and peacefulness of the space was perhaps just as calming as the actual needles. 

Sorry. I'll stop rambling now.

I hope that you find answers soon.

[kellikans]

Feb 23, 2019 8:02:53 GMT -5 seeyalater52 said:

Feb 23, 2019 0:46:24 GMT -5 kellikans said:

We transferred 6 embryos (5 FETs) before having success with DS. 1 ended in m/c at 8 weeks (trisomy 7), 1 was a chemical pregnancy, the others never took. We were also unexplained. We chalked it up to bad embryos.

We ended up switching to a different RE for our successful cycle and actually followed the same protocol that I did with my m/c cycle, except added in HGH. Who knows if that's what made a difference in egg quality, but we ended up with 2 pgs normal embryos, one of which is DS. I also swear by acupuncture. For all of my bfp cycles I did acu.

I'm so sorry you find yourself here. I know what it's like to do transfer after transfer with no happy result.

HGH is definitely a possibility for another cycle.

What schedule did you do the acupuncture on? It’s outrageously expensive here and insurance covers nothing toward it so I don’t think I could afford to go every week, but it’s something we might add in this next go-around.

For my bfp that I miscarried, I think I went for a month beforehand (once a week), then continued once a week after my bfp until I miscarried. For my chemical, I did the same beforehand, but didn't go after transfer. For our successful cycle, I went twice beforehand (2 weeks prior) and the morning of transfer. That was it.

Our insurance doesn't cover acu either, and the first lady I went to was $120 a session. The second lady I went to was *only* $90. But she actually worked a lot with my clinic and I even saw her one morning when I went in for an early scan doing acu for a transfer that day.

I did do acu with her as well prior to my second retrieval to try to get the best quality eggs we could. But the above is with my FET's.

[landmermaid]

I'm so sorry that you've been going through all this. I hope you're feeling ok today. I wish I had advice for you on how to proceed, it's hard and there's so many different ideas out there. I wish you success.

[pickel]

How are you doing, seeyalater? Thinking of you.

[seeyalater52]

Feb 27, 2019 6:45:08 GMT -5 pickel said:

How are you doing, seeyalater? Thinking of you.

Thanks for thinking of me. I am really struggling. I know I haven’t been around the board much. It’s just hard. I’m so happy for everyone but it feels like I’m literally never going to graduate and have a successful pregnancy. Maybe this just isn’t in the cards for me. I feel lost and really scared and I wish we had a better idea of what the problem even is because it feels like we are just shooting in the dark. It feels ridiculous to carry on with work and eating and cleaning and normal life activities when things are so horribly, horribly broken and wrong.

And my stupid period came way earlier than I thought it would and now I’m stressing because my work travel in April is likely going to delay our next cycle. I’m hoping my RE will be open to a short course of bcp so we can delay a week or so instead of a whole extra month.

[stellelinds25]

Feb 27, 2019 8:00:41 GMT -5 seeyalater52 said:

Feb 27, 2019 6:45:08 GMT -5 pickel said:

How are you doing, seeyalater? Thinking of you.

Thanks for thinking of me. I am really struggling. I know I haven’t been around the board much. It’s just hard. I’m so happy for everyone but it feels like I’m literally never going to graduate and have a successful pregnancy. Maybe this just isn’t in the cards for me. I feel lost and really scared and I wish we had a better idea of what the problem even is because it feels like we are just shooting in the dark. It feels ridiculous to carry on with work and eating and cleaning and normal life activities when things are so horribly, horribly broken and wrong.

And my stupid period came way earlier than I thought it would and now I’m stressing because my work travel in April is likely going to delay our next cycle. I’m hoping my RE will be open to a short course of bcp so we can delay a week or so instead of a whole extra month.

I'm so sorry...I can't even begin to imagine what you must be going through. It's not fair. I hope that one of the consults will yield something helpful and that someone can figure out what is going on. Sending you all the (((hugs))) <3

[G22]

I'm so sorry seeyalater52. I've been thinking of you. I haven't had a loss, so I wont even pretend to act like I understand that pain personally, but I do know what it's like to feel line it will never be you turn. ((Hugs)) I spent 5+ years TTC the first time around and saw so many people graduate from this board and felt like that was never going to be me. It's ok to take a break and lick your wounds and regroup. The board is here when you want to reach out again. ❤

[shoeless]

The internet ate my reply

For the next cycle can you do Lupron with Medrol? Is your dr willing to keep you on medrol post transfer? I know Medrol can be a first step against immune issues and I had a friend who after multiple losses was finally successful when she stayed on medrol for the first trimester. Also, are you on baby aspirin, I know there's no clear science behind it, but it doesn't hurt, so I'd add it in if not already part of your protocol.

For reference in the multiple failed transfers/losses with donor egg forums there seems to be three options people pursue (and are generally successful afterwards). These won't help with the next transfer but I'll put it out there.

1. Double sperm donors or just moving to sperm donors. Many had partners who had children from previous relationships (so proven) but for whatever reason their sperm just wasn't cutting it anymore. There are new studies finally coming out that talk about the sensitivity of sperm to things like age, drinking, foods eaten, etc. Basically, everything we've been told to change for better egg quality seems to be true for sperm as well.

2. Treatment of silent Endo. There were a few posters who swore by exploratory laps. Almost all ended up with silent endo diagnosis. After the 'clean out' they were able to carry to term.

3. Immuno issues. Most consult with Dr Braverman or Dr Kwak-Kim. I believe I read that Dr K-K is easy to work with out of town and doesn't require your RE to be 'on board' with her recommended treatment protocol.

Even though the science is woo-y if I had, had a third miscarriage I was going to consult with Dr K-K. (I would have pursed option 1, but the embryos were already made and there was no way to afford another batch of donor eggs and option 2 doesn't work for me since I am post menopausal.)

I'll be thinking of you.

[icedcoffee]

I'm so sorry seeyalater52. I wish I had good advice for you.

The amount of things that are unexplained when it comes to TTC is so frustrating. I remember asking my RE why in 2 IVF cycles only 3 of 51 eggs made it to day 5. The only answer I got was "while the sperm looks good in all the tests we've run there's obviously something still not 100% right there". That's the only explanation I have ever gotten for shitty attrition rates.

I really hope these last 2 work for you and if not that PGS on a new cycle can help. I know it's hard to remain hopeful, but I have everything crossed for you!