Protocols for egg quality

HazelJo · March 2018

Hi All, I'm new here. I'm 37, FSH, (7.2 and 8.3), AMH 2.152, AFC usually around 10. We have been TTC for about 18 months, with an RE for about 6 months. We have 2 failed IVFs. IVF #1 I did BCP for 1 month. On CD3, my FSH, which had previously been 7.2 shot up to 17! It came back down after a few days and my RE chalked it up to a weird reaction to BCP. We proceeded with antagonist protocol, (300 iu Follistim, 300iu Menopur, Ganirelix for 5 days, Ovidrel trigger). We got 9 eggs, 5 fertilized, 2 made it to freeze and PGS, both came back abnormal. RE said poor egg quality. For three months I did DHEA, CoQ10, Royal Jelly, Vitamin D, Maca, etc. Tried again, IVF #2, same protocol except no BCP, just went into natural cycle. 6 eggs, 3 fertilized, none made it to blast. I know I'm older, but I'm still in my 30s and my labs are good. I have a feeling the IVF drugs are actually messing with my egg quality - we decided to do IVF because of MFI. Please suggest clinics, doctors and/or protocols that specifically deal with older women and egg quality. My RE is already talking to me about donor eggs and I think it's premature. I'm looking for some positivity and some practical advice on how to be my own detective.

What do people think of:
AACEP
Mini IVF
Microflare protocol
Testosterone priming
Human Growth Hormone

Thank you!!!

Kp214 · March 2018

I’m sorry for what you’ve been through so far. It’s very difficult. If you can see my signature, you will see my history. ***tw**I did EPP protocol for my successful cycle, which resulted in 6 blasts, 3 of which were PGS normal. That was also the cycle that I took hgh the longest. I think 5 days. I also took a break to supplement. I did acupuncture as well. If I were to do it again, I would do everything the same way as I did for my last one. Good luck!

katie35 · March 2018

I don't have a lot to add/give but wanted to jump in. We have gone through 5 transfers without success. We are gearing up to potentially do another round of IVF and I stumbled across the book "It Starts With The Egg". I don't know if this will help at all but the focus of the book is what we can do to help with egg quality. I am about a third of the way through the book and am glad that I started reading it. Lot's of good information! Good luck to you!!

ndz2018 · March 2018

Hey @HazelJo Welcome and sorry you find yourself here. Agreed about reading it starts with an egg... I’m also 37 and we also have MFI too. I don’t have much to add but if it helps I’m the same age as you I did my ER back in Dec they retrieved 29, 21 fertilized , 12 made it to blast and after PGS testing we have 5 normals(and 3 mosaics) and have yet to do my transfer( I had A minor surgery in Jan and needed to wait two cycles to heal).
There are a lot of fertility diets out there too. Dr Google should point you in the right direction with that. I was/am taking prenats w DHA , 600 of ubiquinol 300 twice a day( make sure your CoQ10 is ubiquinol) and vitamin D and C.

HazelJo · March 2018

Thanks @katie35. I'm sorry about your struggles so far. I've already read "It Starts with an Egg" and followed its advice. But don't be discouraged with my lack of success with it - I've seen lots of other ladies benefit from it. Also, look at acai berry - CCRM (often acclaimed as the best clinic in the country) is seeing some great results with it in a clinical study they're conducting. I haven't tried it yet and plan to add it to the mix.

@ndz2018 - Sounds like you're all set. If you've got 5 normal embryos to work with, I have no doubt one will result in a healthy pregnancy. I'm just not in the same boat. Trust me, I've been all over Google.

What I'm really looking for is recommendations on clinics, doctors or protocols that are best for women with poor egg quality. I believe some protocols are easier on the eggs, so to speak. Believe me, I have the at-home supplements and alternative treatments covered. I just need to know which way to proceed with the medical route.

HazelJo · March 2018

@Kp214 Thanks for your feedback! So EPP and human growth hormone was the ticket for you - that's helpful! You're a bit younger than me, but some of your retrieval numbers look similar. So glad that worked out for you. Can I ask did you do an antagonist protocol with the EPP?

artemis618 · March 2018

Hi @HazelJo - I’m sorry you find yourself here. I am older than you are (4 of my cycles were when I was 39 last year, the last two last month at 40). My history is in my signature, and while I know everyone is different, I’m happy to share my experience/thoughts. I’ve been through 6 IVF cycles (and an extra insemination cycle with my frozen eggs from 2012).

Protocol does make a difference (and all the _It Starts with the Egg_ stuff can’t hurt - and certainly at my age I can use all the help I can get), but honestly at this point it feels like a bit of a craps shoot (for me at least). I’ve had two cycles with no blasts and two with all abnormal.

I will say that I am NOT a fan of testosterone priming - I feel like that negatively affected my egg quality (a la Dr. Sher’s theory - but I’ve also had the best results on a natural start microdose lupron (MDL) flare protocol, which he would apparently never use for AMA ladies because of our endogenous LH). My first RE had me testosterone prime for my three cycles with her - we got only one normal from 8 blasts to test from all three cycles combined. I think the idea is to make us more PCOS-like (theoretically good for #s but not for quality). But also think the quantity thing involves luck each cycle (see the difference between my 4th and 5th IVF cycles). Without testosterone (or any) priming on MDL, we got 6 normals from three cycles (but still one no blast cycle in between there - I honestly think that eating a bunch of sugar over the holidays contributed - as the no blast retrievals were a year almost to the day apart. Not good, I know, but this last holiday season I felt like crap after I *TW* miscarried the first PGS normal we transferred *END TW* Thanksgiving week).

Regarding HGH, I used omnitrope for all of my cycles. First RE had me use two vials per cycle from the start of stims, current had me use three (but I stimmed for fewer days - 7-9 vs 9-11 on natural start MDL than on BCP/antagonist for IVF #1 or luteal lupron for #s 2 &3). Actually, for my last cycle (after another disastrous no blast cycle, RE had me get a 4th vial and explicitly told me to use it the night of trigger and the night after - before I’d just taken whatever I had left (if anything) with trigger. To me it seems more helpful at the end of stims with maturation than at the beginning, if I had to choose between front or back loading.

I’m no pro, but I don’t think your AFC indicates you for mini IVF just yet. I agree that your RE is a bit premature with bringing up donor eggs. Protocol does make a difference (and I’ve learned that antagonist is NOT my protocol). Regarding AACEP, I asked my first RE about it and she just told me she didn’t recommend it because it hadn’t been proven (kind of like how Rebecca Fett said that doctors hesitate to do anything that’s not proven). Estrogen priming is great for some people but oversuppresses others - I haven’t ever tried it. One thing I noticed with my first MDL cycle (which just seemed freakishly magical and easy peasy for me - it was after we’d taken the summer off) was that because I stimmed for only 7 days, the total amount of meds for the cycle was a lot lower than for my previous three cycles (also, my REs have had me at least start with max stims of 450 - never 600 total). Also, current RE stepped down my meds, while our first one just kept me at 450 the whole time. I really thought this contributed to higher quality (we never dreamed we’d get 4 normals from one cycle after having gone through our first three cycles - and that retrieval was a couple of weeks before my 40th birthday). But I think the stars just aligned that month because my baseline AFC was nearly twice what it usually was, and replicating the exact same protocol 4 months later (though stimming longer because my response wasn’t as good) yielded no blasts. The other nice thing about natural start is how quick it is (as you know from your last cycle - also how nice it is not to have to do anything before you start stims) - I was able to do two retrievals last month (it’s amazing how quickly that clinic takes my money), so got two more normals out of this last cycle.

I suspect being a little younger gives women better odds with PGS normals (but also we - DH and I - just seem to have terrible luck with all of this. Our *TW* natural pregnancy was NIPT-normal too...). I know of one AMA woman on here who has *TW* miscarried 4 PGS normals (one at a time), so it’s no silver bullet, but it’s the best technology we have right now.

Good luck! Where are you located?

Edit: typos. Also it seems a lot of this is really expensive trial and error

Bababatty · March 2018

@HazelJo If you’re looking for clinics and you’re anywhere near NYC, I recommend Weill-Cornell. I believe they are the best in the city. They’re our 2nd clinic and while we haven’t been successful (*TW* my first fresh transfer with them just resulted in another CP *TW*) we have been very pleased with how this, our 2nd IVF cycle went. I can tell you more about our experience if you’re interested.

HazelJo · March 2018

@artemis618 Thank you for the thoughtful and detailed account of your history. It's really heartening to see how much cycles can vary with time and different protocols. I just have a hunch that a different protocol could give me a better result. I can't believe you got 33 eggs retrieved on your 4th cycle! I cannot even imagine myself getting that much right now. I would be happy with double digits and one PGS normal at this point.

You've given me some good ideas to try going forward. There are things I like about my RE, but I'm open to changing in the future. I've even considered traveling just to go to the very best clinic - just trying decide which clinic that is and which is best for me specifically.

I live in Milwaukee, WI - where are you? I agree that it is very expensive trial and error, but we're not done yet.

HazelJo · March 2018

@Bababatty I'm not in NYC. I actually live in Milwaukee, but I'm starting to consider traveling for better care. You're younger than me but your first IVF cycle numbers are similar to mine. What protocols did you use with your first and second IVF's?

adirat · March 2018

@HazelJo Since you're in Milwaukee, have you considered Fertility Centers of Illinois? I've heard really good things about them (especially Dr. Rodgers) for difficult cases.

Question -- if your diagnosis is MFI, why are they assuming egg quality instead of sperm quality? I think it's really smart to try other protocols and I think previous posters did a nice job laying out options, but I don't see why they're assuming the eggs are the problem...

JamieH2000 · March 2018

@hazeljo- I’m actually in mke, Wi too! Not sure if you can see my siggy but I had 1 cancelled ivf, 2 failed IVfs and now I’m doing Donor eggs. For whatever reason, my quality is just crap despite ttc since I was 27 (currently 30). I don’t think that most REs think that protocol really effects quality, except for Dr. Sher which I am sure you have read about on google already. I started with dr schell at Milwaukee OBGyN. But then wanted a bigger clinic when We decided to do IVF. We had consults at froedert and AFCC and decided to go to AFCC since there stats were great. I found it to not be a great experience mainly bc the nurses do all the communication, even when they cancelled my first Ivf. For round 3 we went to FCI and dr rodgers (from the beat infertility podcasts). We had our best cycle ever. I would highly reco her and FCI. Feel free to message me if you want more specifics. Also I’m part of a mke Resolve group if you were interested in joining!

Kp214 · March 2018

@HazelJo It was an antagonist protocol. I was also on higher dose stims for the first couple of ivfs, but since that wasn’t increasing the number of eggs, I asked about lower dose stims. My re agreed that there wasn’t much point in it for me. Some believe that the higher doses can “fry” the eggs. Others do well with it. Also, my re said mini ivf can very from place to place as to what’s considered mini ivf.

HazelJo · March 2018

@adirat I haven't heard of FCI until this thread - I'll check it out. They're saying it's an egg quality thing because we did ICSI, so that's supposed to eliminate the MFI issue. I think it may very well be that the eggs are poor after the stims, but I'd like to find out if my eggs might maintain good quality with a different protocol.

@JamieH2000 Wow! I didn't think I'd meet another MKE girl on here so soon! Dr. Schell is my RE. I love how accessible she is and I think the clinic she uses for WFI has a very good lab, but I may change RE's. I want someone who wants to be a detective. Dr. Rodgers at FCI could be a good option. I may message you about the Resolve group, thanks for the invite

@kp214 I was on high does stims too. And I'm just wondering what would happen if we lowered the dose. I've often wondered about high stims "frying" the eggs.

Bababatty · March 2018

@HazelJo Wherever you end up, I’d ask about a TUNEL test for YH if you haven’t done it already. It’s something our new RE at Weill-Cornell suggested and we’re doing it now before another FET. There are a few studies I saw off the bat on PubMed, but essentially it tests for DNA fragmentation. https://maleinfertility.org/understanding-male-infertility/fertility-evaluation/sperm-dna-integrity-tests

As for my protocols, I haven’t done BCP for either IVF cycle. With my first cycle (follistim, ganirelix, Menopur, HCG trigger, progesterone suppositories) I had roughly 18 mature follies of which they only retrieved 9 eggs total (all mature). I was alarmed by this but my then RE (at a consultation after our first FET said maybe it was egg quality or maybe I needed to stim longer. It was basically a response akin to ¯\_(ツ)_/¯. He also would have expected higher fert rates but chalked that up to the MFI.

When we went for a 2nd opinion with what is now our current RE (who is at Weill-Cornell), he took one look at my charts and without any prompting from me about the low ER numbers, said he felt that they had probably overcooked my eggs. IIRC 4 days before ER I had several that were already at 20 and my estrogen was getting high. He was appalled that they had me come back 2 days later and then trigger.

This cycle went completely differently; I added estrogen patches in after O the cycle prior to IVF to even things out, I had A LOT more monitoring, and they adjusted my dosage based on my morning monitoring results. I also did a dual trigger with Pregnyl and Lupron, I believe to stave off OHSS, which I’m a risk for.) The total # of eggs retrieved was actually more than we were expecting, fert was astounding (~88%, even with the MFI) and we ended up with 5 good quality blasts. All in all, both we and our RE were pleased with how the cycle went right up until the end.

We haven’t done any PGS testing because of my age and our suspicion that any issues with the last batch were from stimming too long. (*TW* Obviously our fresh transfer ended in a CP (our 2nd from a transfer) so there could be a problem there beyond anything related to stimming and now we’re doing additional RPL tests and the TUNEL test to rule things out. If indicated, we may thaw and PGS test the remaining embryos.)

TL;DR Ask about the TUNEL test because indications are that IVF with ICSI is less successful with high DNA fragmentation, but there are workarounds. Also evaluate your stim reports with another RE—sounds like there is a good option close to you—and question if they might have stimmed too long and over cooked your eggs.

HazelJo · March 2018

@adirat I haven't heard of FCI until this thread - I'll check it out. They're saying it's an egg quality thing because we did ICSI. I think it may very well be that the eggs are poor after the stims, but I'd like to find out if my eggs could improve with a different protocol.

@JamieH2000 Wow! I didn't think I'd meet another MKE girl on here so soon! Dr. Schell is my RE. I love how accessible she is and I think the clinic she uses for WFI has a very good lab, but I may change RE's. I want someone who wants to be a detective. Dr. Rodgers at FCI could be a good option.

@kp214 I was on high does stims too. And I'm just wondering what would happen if we lowered the dose and if high stims fry the eggs.

HazelJo · March 2018

@Bababatty Ok, I've never even heard of the TUNEL test. My doctor initially suggested we get DH assessed by a urologist and tested for varicocele, but we never did because she said ICSI would solve the problem anyway. I have wondered in the back of my head if the sperm could still be an issue.

I'm also really starting to think there may be something to this frying or overcooking the eggs idea. My last cycle I had at least 12 follicles over 17mm, but a couple were well over 22mm. She says it doesn't harm them to get big. But what if we're losing my best quality eggs, the ones that my body would have selected for ovulation, by waiting for the duds to catch up? We didn't stim that long, just the standard 10 days. But some of my follicles just grew really fast.

I'm having a consult with my RE on Friday, and I'm going to ask a bunch of questions. I'm also considering moving on. I'm going to ask about cutting down on stims/triggering sooner and also about TUNEL. Thanks!

Bababatty · March 2018

@HazelJo Yeah, I’d definitely question your RE about the overcooking. By the time I triggered on my first cycle, I had several that were also at 22 and my current RE felt that was really too big. I wish I’d asked him for the research to back up the theory of overcooking so I could share it with you, but alas. I did find a blog that did a consult with a renowned RE in CA, who said the same thing, though. Definitely go with your gut. I KNEW something had gone wrong with my first cycle, and it was such a relief to find a new RE who called it out before I even asked. You might also ask about adding in estrogen patches the cycle before, which my RE did, if I understand correctly, to try and even out my hormones and prevent a few follies from surging ahead. It seems to have worked in that regard. Even if you stay with the current clinic, I think it’s invaluable to get a second opinion anyway. Let us know what your RE says!

ETA Even DH’s urologist, who specializes in IF, didn’t mention the TUNEL test to us. I think because we already knew the reason for the MFI and he felt ICSI would resolve it. It’s a little frustrating although even our current RE says the literature on the cause of DH’s MFI does not indicate the it causes DNA fragmentation. It sounds like you don’t quite have a definitive reason for YH’s MFI so it’s definitely something to look into!

artemis618 · March 2018

@HazelJo I’m in Los Angeles, so not helpful with respect to clinic recs, but I’m glad it sounds like some ladies have some good ones for you!

HazelJo · March 2018

@Bababatty some of mine were up to 26-27mm! My RE wants to try testosterone protocol next, but I think she said estrogen priming was part of that (??). I'm thinking of doing one more cycle with my RE and if we don't see different results, regrouping for a month or two and finding another clinic. Thanks for the advice - it means a lot.

J1006 · March 2018

@HazelJo @JamieH2000. I am also in MKE! We were given a few recommendations: Aurora, Froedert, and Fertility centers of IL. We ended up going with aurora as that was our main healthcare system and it is very close to my work/house so making the many appointments is easy. I have heard great things about Fertility Centers of IL. There are a few places in the western suburbs of Chicago (Naperville, Oak Brook) that I have heard good things about as well. That would be a travel commitment though. I believe there is also a good clinic in Madison.

alfieb-2 · March 2018

@HazelJo I’m 37, too and just finished my third retrieval cycle. I still don’t have a THB yet, but am gearing up for an FET in April.

I think you are on a lot of meds. My AMH (2.25) is similar to yours and my first RE put me on the antagonist with 375iu gonal f and 225iu Menopur for a total of 600iu. That is max for most RE’s. I did get 15 eggs, 10 fertilized, 5 blasts my first cycle, 4 which were PGS normal, and one ever took, but *TW* resulted in a MMC. At the WTF appointment, she did say I was on a lot of meds and would decrease my doses the next time.

So I changed RE’s. My 2nd cycle I was on antagonist again with 225iu gonal f and 150iu Menopur. I got a similar number of eggs, 14, 9 fertilized, 2 blasts, but that cycle was a BFN. I did take Royal Jelly this cycle (which was the worse by far). Royal Jelly is said to elevate estrogen and at baseline my estrogen was in the 100’s, but we started stimming anyway. I don’t know if that had anything to do with it.

Because the embryos were growing well until day 3, when the sperm is said to take over, my RE suggested a sperm dna fragmentation test and we found out that my husband has fair to poor fragmentation. So we did partial donor sperm during this last cycle. We did microdose lupron flare and I got the most number of eggs so far, about 2 years after my first cycle. We did lupron starting cd 2, 225iu gonal f starting cd 3, and 225iu Menopur starting cd 4. 17 eggs retrieved, 12 mature and fertilized, and 5 blasts. I didn’t do PGS this time.

I hope you find the answers you need being your own detective and have your THB soon.

HazelJo · March 2018

@J1006 Hello fellow MKE girl! Yeah, I don't know. I'm kind of thinking if I switch RE's it won't even be for a Milwaukee based doctor - FCI or Advanced Fertility in Chicagoland are on my radar, as are some of the biggies like CCRM and some of the NYC clinics. I'm done messing around. My egg retrievals are done at WFI in Madison which seems pretty solid too.

HazelJo · March 2018

@alfieb-2 Thank you so much for your story. I always have good embryos on day 3 too, and you're not the first to suggest the sperm DNA fragmentation test. Hmmm. It's also helpful to see that your doc reduced your meds and that you had some success with microdose lupron flare. I hope you get your THB soon too

BTW, where are you located? Just curious who your RE's are.

alfieb-2 · March 2018

@HazelJo I’m in Hawaii, so I’m not helpful in recommending clinics. Hope you find some answers. Wishing you all the best!

HazelJo · March 2018

So I had an appointment with my RE yesterday and she spent 3 hours talking with me - I mean that's pretty amazing. I had compiled a bunch of questions on different protocols, doses of stims, when to trigger, and sperm DNA fragmentation. I think she's willing to be more of a detective than I thought, but I think I also have to have a strong voice in all of this. It would be so nice if I could just leave all the decisions to her, but I realize that I have to advocate for myself. I think we're doing this testosterone protocol, but it involves taking estradiol and progesterone along with the testosterone for about a month. I think I'm also going to do the HGH during stimming and when DH gets back from Mexico (work not play), talk to him about DNA fragmentation testing. RE and I also talked about foregoing PGS testing and maybe transferring some day 3 embryos - I haven't even had a transfer yet because we keep pushing the embryos to day 5 and even 6, losing a few that looked good initially along the way. Sometimes I think the hardest part of all of this is making decisions without any concrete guidance.

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