SW was 38 years old and had never been pregnant before. After a normal
workup and multiple failed IUI cycles using a combination of oral and
injectable meds, SW was diagnosed with infertility of unknown origin and
started IVF treatments.
Dr. A, at a very well respected center in San Diego, chose a classic “antagonist”
protocol for stimulation but took the “shotgun” approach,
meaning that the plan was designed to include as many different treatments
as possible in 1 cycle with the hope that “everything” could
be covered: estrogen prime, testosterone prime, 300-450 U FSH+HMG injections
for 7-10 days, dexamethasone, GnRH antagonist injections for 3-5 days,
a combination GnRH agonist + HCG trigger, a general anesthesia egg retrieval,
blastocyst culturing, and freeze all. A “shotgun” approach
is both complicated and costly. SW produced 20 eggs, which lead to 3 blastocysts.
The frozen embryo transfer was an artificial cycle, almost as complicated
as the stimulation (which was intentional). Although Dr. A was trying
to replicate the hormonal environment of the stimulation phase as much
as possible, I think this actually defeats one of the major benefits of
a frozen embryo transfer. This was followed by a traditional trans-abdominal
ultrasound-guided transfer of a single blastocyst which, unfortunately, failed.
At this point, Dr. A performed a hysteroscopy to address a possible uterine
issue, which was a very reasonable thing to do. SW followed up with another
HRT frozen embryo transfer with her 2 remaining blastocysts. This failed
Since there were no embryos remaining, SW underwent IVF again in a similar
fashion as before. This produced 6 eggs but no blastocysts.
SW gave it one more try, producing 20 eggs and 1 blastocyst. This time
Dr. A tried a natural cycle transfer which resulted in a “chemical”
pregnancy (essentially an early miscarriage).
At this point, Dr. A recommended donor eggs.
SW and her husband were not ready to go that route, but were not ready
to completely give up since they had already invested a great deal money
and suffered quite a bit both physically and emotionally. Through a referral,
they found our center and approached me.
After meeting with SW and her husband, here were my thoughts:
- Based on SW’s age and the blastocyst embryos produced, they should
still make embryos good enough to have a child.
- If we are dealing with a fallopian tube issue, IVF should be successful.
- If we are dealing with an endometrium issue, the hysteroscopy that was
performed should have helped (but, recall, she had a chemical pregnancy
after the hysteroscopy).
- Even though there was a chemical pregnancy after the hysteroscopy, the
second transfer failure involved the second and third best embryos of
the first cycle. The leading embryo was transferred before the hysteroscopy.
- SW did have a chemical pregnancy in a natural cycle.
- SW never had a fresh transfer.
I was left to one conclusion: try again, with some small tweaks to the
plan. Based on everything that we knew, it seemed like it was merely a
matter of time before she would be successful.
The small tweaks that I thought would give us a better chance for success:
- Reduce the medication. It was possible, I thought, that all the medications
was creating a poor environment for a successful pregnancy. The purpose
of doing a “freeze all” is, in part, to eliminate the risk
of OHSS, but also so that we can later place the embryos in a more ideal
environment that is not affected by the stimulation medications. A highly
medicated HRT embryo transfer cycle, which had been her previous plan,
defeats the purpose of that latter reason.
- Perform a fresh transfer. As I mentioned above, one of the purposes of
a “freeze all” is to place the embryos in a more ideal environment.
Many patients, however, conceive just fine from fresh transfers. While
it is true that vitrification allows for highly successful freezing/thawing,
it isn’t perfect. Perhaps one of SW’s embryos was damaged
in the process and the couple would fare better with a fresh transfer.
I treated SW with a classic Japanese Minimal Stimulation protocol using
Clomid (50mg) and FSH (150mg x 4 injections). Egg retrieval was performed
under local anesthesia and produced 6 eggs. Since SW’s environment
looked ideal, I transferred a fresh, day 5 embryo under transvaginal ultrasound
guidance. During the transfer process, I noted resistance to the outer
catheter. Could this be the reason that the previous IUIs and transfers
did not work? The Japanese-designed transfer catheter that we use is smaller
than the Western catheters and allowed me to bypass this area without
difficulty. After one try with a single embryo, SW was pregnant! I have
since graduated SW to her obstetrician and I am just waiting for the birth
The moral to this story? More is not always better; sometimes less is best!