Q for IVF

My 3rd IUI will officially end by the end of this month (unless cycle is cancelled). Around the same time we are supposed to be meeting up with my RE to discuss IVF (in case IUI # 3 fails…. Which I hope it doesn’t! As much as I don't want to think of a failed IUI, I need to mentally prep myself for an IVF). My RE has an online course discussing most of the aspects of the IVF. However, I have noticed that there is a lot more beyond what is listed in his notes. So I am doing my own research of possible things that the RE would bring up (so that I am not dumbstruck) or I would like to ask in case he doesn’t discuss it. Below is a summary of all the literature I have gathered followed by the questions I have. This is an ongoing entry, which I will update as I come up with more questions & answers. I thought that I would do this now while I am sane enough (and not all psyched up during the 2WW... you can probably also tell that I am a planner, though I am learning fast that all the plans (hint: baby) don't materialize as per your plan/wish)! Please note that I have just copied and pasted the definitions of the procedures/terminology, you can find more information in the embeded hyperlinks. Some guidance can be found at the RESOLVE Questions to Ask series.

• Basal Antral Follicle Count - Antral follicles are small follicles (about 2-8 mm in diameter) that we can see - and measure and count - with ultrasound. Antral follicles are also referred to as resting follicles. Antral follicle counts are a good predictor of the number of mature follicles that we will be able to stimulate in the woman's ovaries when we give injectable FSH medications that are used for in vitro fertilization. The higher the number of Antral follicle, the higher the number of eggs retrieved, which in turn correlates with IVF success rate.
• Clomid Challenge Test - The test is an evaluation of female pituitary hormone levels. The test utilizes the fertility medication Clomid (clomiphene citrate) to increase the accuracy of finding women with decreased ovarian reserve. Day 3 and 10 FSH levels are monitored and if either the Day 3 FSH level or the Day 10 FSH level in a clomid challenge test is elevated, it is considered abnormal. A high FSH level is a sign of poor ovarian reserve.

Question: How good is my ovarian reserve? I know I have tons of dormant follicles during u/s, but then, I am also not ovulating on my own! Should we be checking it before we proceed to an IVF?

---

• Pre-implantation genetic screening/diagnosis (PGS/PGD) is used as an alternative to prenatal diagnosis and possible termination of pregnancy of an affected fetus for couples who are at risk of passing on serious genetic diseases to their children. The DNA fingerprinting provides information about the quality of the embryo, and thus the chances of implantation and a successful pregnancy. PGS consists of: FISH (Fluorescent In-Situ Hybridization), CGH (Comparative Genome Hybridization) or Microarray (MA). Reference: Preimplantation Genetic Diagnosis (PGD), DNA Fingerprinting Identifies Viable IVF Embryos.

Question: Should we be doing a PGS? (I suspect that my RE will recommend it only if we have at least 1 failed IVF). How many embryos (minimum) are required for PGS to be performed? I suppose if more than 1 embryo (with certain criteria) is required, and thats not available... then PGS gets cancelled? In this case, if one does not do PGS on IVF # 1, # 2 fails, and insurance covers only 2 IVFs... then we are on our own after the second IVF! (I know, I might be sounding pessimistic thinking about 2 BFN IVFs, but I want all my answers before I start!)

---

• My RE’s clinic is performing an “Embryo Quality Study”. There are certain criterias one has to fit in (including 1 failed IVF). The study provides you with a free of cost IVF and the associated medication.

Question: Do I qualify for the study? Is this study the same thing as the PGS?

---

• Mock Embryo Transfer: Before the first cycle a physician performs a trial or mock embryo transfer. This involves passing a catheter through the cervix into the uterus to determine its path through the cervix and to measure the distance to the top of the uterine cavity.

Question: Will I be undergoing a mock embryo transfer?

---

Other IF procedures:

• Gamete Intrafallopian Transfer (GIFT) - In this ART procedure fertilization takes place in the fallopian tube. GIFT should only be performed when sperm level is adequate and at least one fallopian tube is open and functional. The steps involved in GIFT are similar to IVF up to the point of egg retrieval. Egg retrieval is usually performed under general anesthesia, and the eggs and sperm are immediately transferred into a catheter that is used to place the eggs and sperm into the fallopian tube during a laparoscopy. Unlike IVF, there is no ability to document fertilization or to evaluate embryo quality in a GIFT procedure.
• Zygote Intrafallopian Transfer (ZIFT) - ZIFT is a combination of IVF and GIFT: A fertilized egg is transferred into the fallopian tubes. Fertilization takes place in a laboratory, and the zygotes (newly fertilized eggs) are transferred into the fallopian tubes at the time of laparoscopy. With ZIFT, fertilization is documented, but evaluation of the dividing embryo is not possible.
  

Question/Comment: Having had 2 failed IUI and a possible third one if we do end up going on for IVF, I highly doubt that ZIFT or GIFT would be an option. I don’t think the doctors would let the sperms and eggs do their job on their own and we would probably be doing an assisted hatching or Intracytoplasmic Sperm Injection (ICSI)!

---

Other questions/concerns:

• How many mature eggs (minimum) do you expect to be present to continue with IVF (egg retrieval)? (i.e. not all eggs will fertilize, not all embryos will survive... the lower the number of eggs retrieved, the lower the chances of success, so I presume if there are just 2 eggs ready, the cycle would probably be cancelled?)
• What are your standard IVF protocols (lupron/long, flare, antagonist)? Which one suits me best and why?
• What are the chances of me having endometriosis? How can we confirm?
• My progesterone level 4DP-IUI has been around 6 units? Is it normal to be in that range during that time period? If not, is that implying something?
• Should I be concerned about OHSS during IVF? How is that monitored/controlled? Does OHSS lead to IVF cancellation?
• What is the optimum lining of the uterus for implantation? What is triple stripe ovarian lining… how important is it for implantation?
• My low progesterone DP IUI... is that an indicator of issues with egg (quality)? How can this affect my IVF?
• What are the success rates for FET?
• I am considering taking a break of month or two and trying Chinese Herbal Medicine! I have come across a few experiences where folks have had repeated failed IVFs... they went on to take a break from IVF and starting these alternative medicines and then going back to a successful IVF. It seems the herbal meds cleanse and stabilize your system. Though I am unable to find any scientific literature... and most of the info is pretty vague. Would be great to hear more about such experiences! I am also not sure if my RE will be happy with this option!