IVF/ART - What Are Your Options And How Do You Decide

December 12, 2006 - Tuesday
1:10 PM to (EST)
Guest Speakers: Owen Davis, M.D.
Cornell Institute for Reproductive Medicine

Categories
IUI • IVF • PCOS • PGD • Pregnancy • Pregnancy Loss

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Corey_Whelan	test
Corey_Whelan	Welcome to tonight's online educational session. Our guest speaker this evening is Dr. Owen Davis, of the Cornell Institute for Reproductive Medicine, located in New York City. Tonight's topic is IVF/ART - what are your options and how do you decide.
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dizneygrl128	Hi Everyone
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Corey_Whelan	Hi all. I see that Dr. Davis is here early - thank you Dr. Davis. Folks, we can get started if you would like to ask any questions -
Corey_Whelan	I'm your moderator this evening - I'm Corey Whelan, The American Fertility Association's Director of Development
dizneygrl128	Hi Dr. Davis
okdavis	Hi
dizneygrl128	Hi Corey
Corey_Whelan	Hi. Do you have a question for Dr. Davis?
nkobal	hi., my name is nadia. tis is my first time attending one of these sessions.
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okdavis	I'm happy to try to address any questions you might have.
Corey_Whelan	Hi nkobal and enussbaum. You can ask Dr. Davis any questions you have about ART/IVF
Corey_Whelan	Is anyone here currently in treatment for infertility or are you all sticking a toe in for the first time?
dizneygrl128	is it true that after 3 failed IVF's that your chances of ever conceiving go down dramatically? or can you still have a fair chance if given the right medical help?
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Vicki	Hi Dr. Davis. I'm wondering if I can do IVF at 41? My fsh is around 11
okdavis	There is no absolute number: really depends on egg and embryo quality, number, age and ovarian reserve. Protocol changes can sometimes make a difference.
okdavis	IVF can work at 41: FSH is borderline.
Vicki	I have had two miscarriages - is that a good sign or a bad one
Vicki	One mis at 39, one at 40
okdavis	If no serious underlying cause has been identified, the fact that you've conceived is generally considered positive.
Vicki	thank you very much
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okdavis	Welcome
dizneygrl128	how do you feel about incorporating acupuncture with IVF?
nkobal	what is success rate for women with PCOS in conceiving with ART and IVF
Dina	Dr. Davis, I was recently diagnosed with pcos - do you think that metformin is a good way for me to get pregnant or will I have to do IVF, or other forms of art?
okdavis	Some evidence that acupuncture can be helpful: probably can't hurt in most cases.
dizneygrl128	thank you very much
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okdavis	Metformin can be helpful with PCOS: whether you need IVF would depend on many other factors.ART success rates are generally good with PCOS.
dk517	Hi Dr Davis, i am about to undergo my 6th IVF cycle in Jan 07. Are there any new developments as far as protocols for poor responders?
Corey_Whelan	Hi all, we are currently chatting with Dr. Owen Davis of Cornell Institute. He is here to answer your questions on IVF/Art Treatments and Options.
nkobal	spotting for 5-7 days before period starts- is this normal? my doctor says some women spot- i think this is sourace of failed ART
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okdavis	We've been impressed with an estrogen-priming protocol for low responders, but the best choice for a given patient will depend on the details of prior attempts.
Corey_Whelan	Let's let Dr. Davis answer the questions on the floor for a few minutes
okdavis	Causes of spotting should be sought (e.g. polyps, etc.)
nkobal	thank you.
bikinilady	hi Dr. Davis,
okdavis	Hello
bikinilady	How \\\
bikinilady	What is your opinion of PGD for multiple failed cycles?
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okdavis	If lots of embryos are produced, may be helpful, but isn't routine.
4thosespammers	I am 37 with one 3 year son. Ironically I had a D&E today and suffer from recurrent pregnancy loss, so this chat session is very timely! With 8 miscarriages under my belt and having felt like I have done everything we can do or know how to do (IVF with good quality eggs, heparin, prednisone, BA, progesterone), I am at a loss for what to try next. Some of my prior pregnancies have been natural, or had "weak” hcg trends, while others had good starts with valid heart beats found only to end up as a loss (as well as 2 ectopic). None have chromosomal issues and no testing (blood, HSG) has ever shown any evidence to explain my losses. Other than changing fertility practices, what’s a girl to do? Am I at the end of the line and likely will not be successful or should I continue to pursue knowing that the losses may continue? Medically I feel like I have “done it all” and “the right way", so where do I go from here? Emotionally I am want my son to have a sibling, so I want to continue trying and have 10 frozen embryos waiting, but need some direction so that my efforts are futile.
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okdavis	You're history is very complex, can't offer any quick responses. It shouldn't be hopeless, however.
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dk517	dr davis, what are yout thoughts on IVIg therapy? i have heard that you are one of the few docs at cornell who will support it. sorry if i am putting you on the spot
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christalp	My husband and I have been TTC since June 2005. I am currently seeing fertility specialists. I have been on clomid and metformin with month US followed by HCG injection. This month a week after the injection I had a progesterone level drawn it was 10.8 Is that normal?
okdavis	IVIG is highly controversial- little scientific data to recommend it for most.
okdavis	10.8 could be ok, but levels fluctuate: might want to check 2 days later.
nkobal	have you seen good response using letrazol
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okdavis	We use letrozole primarily for breast cancer patients: ok for PCOS, not necessarily best for routine IVF.
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bikinilady	I just did a pgd cycle - I have a 2yr old from cycle number 3. I had only had 2 normal embies out of 25! I was neg. Would you recommend another pgd cycle? On day 3 I had 10 embies viable for pgd. Do you think if I hadn't done pgd the chances would have been good that those 2 would have been transferred - day 3 - anyways??
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okdavis	Hard to say: PGD can miss abnormalities not tested for , but may also over-call abnormalities in occassionally viable embryos.
dizneygrl128	is it a bad sign when you have a 3dt and have remaining embryos that dont make it to day 5? Would this be a sign of your outcome each time?
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okdavis	No: not all embryos will make it to day 5 even in good prognosis cycles.
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dizneygrl128	ty
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bikinilady	so, would you recommend I do pgd again?? I'm thinking I shouldn't - that it is to invasive.
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okdavis	PGD can potentially have deleterious effects as well as positive benefits.
cgw1984	Doctor, how many un successful attempts at IVF shold someone go through before expecting a change in protocol ?
okdavis	If the results "on paper" look excellent, a change may not be necessary, but you should follow up with your doctor re. how each cycle looked.
kf220	Dr. Davis. I am 32 years old and have had a 15.6 fsh reading and a 10.9 reading. Would IVF work for me? Do you have a standard protocol you use for high fsh?
hoping	can you tell me how often acupuncture shoudl be done, we've been encouraged to try, which we have, but how often before the start of an IVF cycle. We are to begin a ivf cycle in 3 weeks, should we wait to have more accupuncture behind us?
sfhscott	I've just had treatment for endometriosis after trying for 1 1/2 years. we've tried naturally for 2 cycles since treatment. would you recommend trying naturally for more cycles (I'm 35) or moving on to IUI?
okdavis	kf: As you are relatively young, you may have reasoable chance for success even with a high FSH: again, I prefer estrogen-priming in such cases, but there are a number of reasonable protocols.
bikinilady	Is it taboo to switch drs within a practice ?
okdavis	I would defer on acupuncture timing to those who perform it.
okdavis	sfh: if your Fs
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hoping	would it make sense to do 2 more ivf ? we had had a miscarriage at 6 weeks after the last iVF
okdavis	SFH: if your FSH is normal, etc., might try a couple more months.
ilene	Dr. Davis, does your center test for MIS (anti-mullerian hormone) and what are your thoughts on it's effectiveness as a marker for ovarian reserve? Could it be more accurate than FSH?
okdavis	hoping: a pregnancy suggests that you do indeed have a chance for success, but need to know the whole history.
okdavis	MIS is a good marker, but insufficient clinical data to suggest whether better than other markers, e.g. FSH, antral follicle counts.
hoping	several failed iui's, and this was the first IVF--secondary protocol with clomid and Gn's. 37
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dizneygrl128	should a chemical pregnancy bring a woman a little hope? maybe that something began to happen?
okdavis	hoping: sounds reasonable to try again.
okdavis	CHemical pregnancy shows that embryo made it to blastocyst and implanted: all positive.
dizneygrl128	ty
dk517	Dr Davis, is there any scientific evidence that a zinc deficiency may lead to infertility, poor response and/or poor embryo quality?
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hoping	also the endometrial biopsy is fine. wondering about BMI, and only a little high, wondering if it can make a huge difference in success with tx?
okdavis	Not aware of compelling studies re. zinc
sfhscott	Dr. DAvis, what is your opinion on the effectiveness of progesterone cream and / or prog. pills?
okdavis	BMI makes a difference, but if slightly out of range, shouldn't be a "deal breaker"
okdavis	Prefer progesterone injections or vaginal progesterone where supplementation is needed (e.g. with IVF)
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mamamichie	Dr. Davis - We found out through an sonehysterorgram that both my tubes are blocked and I am 41. Everything else looks good. In your opinion are we better to go right to IVF or try LAP/HSG/HSC to unblock (this is what my surgeon/OBGYN wants to do - try surgery first). They think they are blocked from a uterus infection I got after my sons birth 3 years ago.
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ilene	Would you recommend getting a progesterone level to assess if you are deficient?
okdavis	At 41, generally recommend IVF: is your FSH/E2 normal?
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bikinilady	Dr Davis, do you think it is better to produce 20+++ follicles or take fewer drugs and produce less follicles? I have heard that more is not neccesarily better. What are your thoughts on this?
okdavis	ilene: luteal assessment usually entails length of LP, endometrial biopsy or serial progesterone levels. Whether this is a cause of infertility is still controversial.
okdavis	More is not always better: quality is actually more important- gntler and less prolonged stim is often the best approach.
hoping	what does the endometrial biopsy show?
mamamichie	Yes Dr. Davis - Everything else is minty perfect. They did all the bloodwork etc. I heard that fixing tubes re: LAP can be very challenging and not prove the best results - especially if they are blocked due to scar tissue...is this what you believe too?
okdavis	endo biopsy shows whether the lining is adequately mature ("in phase")- probably more important for eval of recurrent miscarriages.
okdavis	If the tubes are blocked at the ends and filled with fluid (hydrosalpinx), removal should actually be considered prior to IVF.
mamamichie	So we are making the right move by trying surgery first - he is knocking me out and doing HSG, LAP, D&C and HSC.... he figures at my age we should just go for it and get it all done at once...
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cgw1984	Dr. Davis, what are your feelings about ZIFT or ZIFT/IVF in combination for older(40+ year old) women?
bikinilady	I usually produce 20 + follicles but they are only 5-6 celled on day 3 and fragmented - none make it to freeze. Do you think that less stimming drugs could make a difference in the quality of my embies?
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okdavis	mama: I am not recommending tubal reconstruction at 41, rather consider IVF
okdavis	No proven benefit of ZIFT over IVF: just more invasive (laparoscopy)
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okdavis	Slow and fragmented embryos may benefit from a change in stim meds, timing of hCG or even change of cultrue conditions (e.g. co-culture).
mamamichie	So - in your opinion we should bypass all the tests/procedures and move right to IVF?
dizneygrl128	do you think its important to have ultrasound guided transfers?
hoping	how long will the embryo's--8 cell, stay ok to freeze/transfer?
okdavis	mama: without a complete review of your records, etc. can't say that, but it sounds as though you should consult with an R E before undergoing surgery.
bikinilady	I wonder if my hcg timing HAS been off because I usually get my period a day before the preg test while I am on progesterone. Is this unusual?? Maybe suggesting the wrong timing of something??
okdavis	ultrasound not necessary for all transfers, but we find it helpful for some.
mamamichie	I feel silly....what is an RE?
cosmiclobster	RE Reproductive Endocrinologist
okdavis	embryos can be frozen for several years without a problem, if that's what you're asking.
hoping	yes--thanks
mamamichie	thanks...will do and THANK YOU Dr. Davis - appreciate you being here 2nite.
okdavis	My pleasure
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hoping	would a laprascopy give any other answers as to why we had the miscarriage, and or not getting PG the other times?
trishwalla	dr. davis, in your experience how many ivf procedures do your patients in the 35-37 age bracket go thru before a successful pregnancy
okdavis	laparoscopy most helpful for infertility rather than recurrent miscarriages
okdavis	most conceive within 3 IVF cycles
sfhscott	do you have any preference for IUI or IVF for same age range (35 - 37)?
okdavis	sfh: if severe endo, IVF is better; if mild and normal sperm, ovarian reserve testing, etc. can consider either option; IVF should have a higher per cycle success rate.
arwamsted	at the very beginning of this road...but would you recommend a laproscopy after only 4 (unsuccessful for PG but successful for ovulation we think) rounds of clomid with no ultrasound monitoring or dye test or anything except temperature charting?
dizneygrl128	are statistics still ok for those of us who have done 3 and still continuing, its seems discouraging
okdavis	Arwam: A hysterosalpingogram would be asimpler and less invasive initial test of your pelvic anatomy.
arwamsted	sorry...but what's that...? (hysterosalpingogram)
okdavis	diz: yes, if no specifically poor prognostic tests that I don't know about in your case
ilene	Dr. Davis, do you beleive that a woman who is younger chronologically with a h/o high FSH has more "hope" for conceiving than if she were older with a high FSH level and why? I feel I feel I am being misguided by some who are telling me that at 36, my eggs could be older than a woman who is years older:-(
okdavis	hystero (HSG) is an x-ray test with visualization of the uterine cavity and tubes: takes a few minutes and no surgery or anesthesia.
cosmiclobster	Dr : What is a ballpark number of eggs that you would expect to harvest from a very healthy 42 year old for IFV ?
okdavis	Chronological age trumps FSH level: i.e. better a high FSH at 33 years old than a normal FSH at 43, in most cases
okdavis	COs: no specific number, but success rates better with 5 or more eggs
arwamsted	when prescribing clomid, do you usually monit or w/ ultrasounds/etc or with just temp charts? and...if clomid doesnt work in the first few times is it not an option?
ilene	Thank you Dr. Davis for all you do and your optomistic outlook:-)
cosmiclobster	thanks - our Dr just told us that she would hope to harvest at least 5
okdavis	Other treatment should be considered if Clomid not successful within 3 attempts. Monitoring with LH-kits can be as effective as ultrasound if the kits work for you.
arwamsted	headed to fert clinic in bham vs staying here with current obgyn bc he wants to do laproscopy now (after 4 rounds of clomid) and then shots...should i stay here or get a second opinion?
sfhscott	when testing each month using ovulation kit, I only get one day of positive results instead of the two indicated on the test box. is this common?
hoping	how many eggs should i expect with a clomid/gn cycyle (37)
okdavis	Second opinion always reasonable when surgery is adviesed; generally wise to see an RE with subspecialty training and practice emphasizing the gamut of fertility
okdavis	sfh: one day is ok
trishwalla	i'm 37 and have done 2 rounds of ivf and a couple frozen transfers. however we've had two chemicals and two negatives. seems like they're not attaching - any suggestions to improve things next time around? i've taken progesterone so i don't think it's a hormone issue
corgimommy	I've done 4 rounds of clomid and ovulated on all. (pcos but used met) went onto a clinical trial comparing clomid to an arotasme inhibitor and today is CD13 and I only have an 11mm follicle is that normal? It seems on clomid I would have had a much larger follicle now.
okdavis	hoping: if for IUI, 2-4 mature follicles is generally the goal
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hoping	it is with clomid/stims and IVF
okdavis	trish: would require a detailed review of your stimulation and embryo records: doesn't sound hopeless.
okdavis	cor: everyone responds differently- see how it goes
bikinilady	I had a son on attempt #3. I've just completed my 4th cycle with no success and am now 40. (had son at 38) Would you recommend to keep trying?
okdavis	For IVF, generally want > 5 mature follicles: 10 is probably average
corgimommy	Thanks-so it is still possible to develop a lead follicle at day 13 when largest is 11mm?
hoping	thanks fo rall your help
bikinilady	Sorry, meant to say I have done 4 cycles after having my son with no success.
okdavis	bik: sonds reasonable, again assuming all looked good with respect to your response, embryo quality, etc.
cosmiclobster	I have read about falloscopy - is anyone curently doing this? Is it effective in opening a blocked or somewhat nonpatent tube or is opening a blocked tube something that is not a feasible procedure?
corgimommy	We also just found out husband had really low morphology 2% on the Kruger test. My RE said IUI would help. Should this be a factor into moving onto IVF?
okdavis	bik: if 4 failed cycles after your son, you might want to regroup (e.g. sit down with your IVF doc and review everything).
vickalina	This may be a silly question but,Is there anyway to tell if you have normal FSH levels without having test?
okdavis	falloscopy not much in vogue now: rarely performed
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sfhscott	vickalina - thanks for asking that!
okdavis	2% morphology might indicate a better chance with IVF, but if completely normal count and motility, IUI might be worth a try first.
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bikinilady	Maybe different meds etc? I have responded pretty much the same each time - even with successful cycle.
vickalina
okdavis	No way to tell if FSH is normal without the test.
mlkelash	Do you generally recommend 50 mg or 100 mg of clomid?
cosmiclobster	Can anything open a blocked tube or is IVF the only option? I have heard that a second HSG can sometimes open a blocked tube. Is this your understanding?
okdavis	bik: possibly different meds- really sounds like you need to consult as to your various options
dizneygrl128	I have heard Cornell is moving to a new building, will there be anything new for your patients there? I will be doing my first cycle there next year and looking forward to it
okdavis	mlk: depends on the scenario- first attempt with PCOS or very young: 50 a good place to start- if older and unexplained infertility, often start with 100 mg
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okdavis	cos- tubal catheterization can sometimes open a tube without surgery- genuinely blocked tubes generally do better with IVF unless reversing a tubal ligation (reversing sterilization).
corgimommy	Is there anything we can do with a 2% morph? Can we re-test?
sfhscott	thanks dr. davis.
ilene	What is the maximum amount of cycles that you would administer Clomid, and is there a point at which you think it could increase the risk of ovarian cancer? I have a family h/o ovarian cancer -should I be concerned?
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okdavis	diz- the OR's and labs are remaining in the hospital- the new outpatient space (monitoring, etc.) will be a real improvement, based on what I've seen.
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okdavis	2% can change as new sperm are produced: should definitely consider re-testing if only checked once.
msshep3	Dr. Davis.... I am a 32 Mother of 2 and trying for 3rd child for almost 6 months now. I know when I ovulate and thought I would be pregnant by now with careful planning, but I am not. Any suggestions?
okdavis	Clomid- 3 ovulatory cycles reasonable, can occ. consider up to 4-6- connection with ov. cancer still unproven, but prudence dictates moving on if reasonable number ot tries fails.
corgimommy	Would you do injectables with PCOS or is that too risky?
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okdavis	mss: might consider seeing an RE for some simple initial testing if not pregnant in the next month or two
okdavis	injectables can work well with PCOS if oral meds fail, but need to be administered very carefully, e.g. at low doses.
corgimommy	Would you recommend a lap for someone with no signs of endo except normal period cramps if clomid fails 4x before moving onto injectables?
msshep3	Thank you...but what is an RE? Sorry, first time on this board.
corgimommy	RE=reproductive endocrinologist
msshep3	Thanks!
okdavis	cor: it's an option, but not routinely necessary if no other clinical signs
corgimommy	If normal HSG what else would a lap show but endo?
cosmiclobster	RE = Reproductive Endocrinologist
Corey_Whelan	Folks, we're at the five minute mark. Time for probably one or two more questions
cgw1984	Thank you Dr. Davis, you have been so helpful!
bikinilady	Dr Davis, on 2 ivf attempts I had severe cramping the day after transfer. These cycles were neg. I have heard of a drug given before transfer that prevents uterine cramping. Have you heard of this?
dizneygrl128	thank you very much dr. davis for all your help
okdavis	Lap basically looks for endo or scar tissue- once a standard part of all fertility evaluations, now much more selectively performed by most specialists
okdavis	bik: many things have been tried, e.g. valium-type meds, etc.
vickalina	Thank you Dr.Davis!
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dizneygrl128	can those meds be harmful during transfer?
bikinilady	would you recommend these drugs? What was the cramping from?
okdavis	valium probably not, depending on the individual case
okdavis	I do not routinely recommend valium or other meds for post transfer cramping: progesterone is the most important adjunct.
cosmiclobster	I was wondering about the difference between injectible stims and Clomid. Do you think a sucessful IVF cycle can be acheived using Clomid? Thanks!!
Corey_Whelan	Dr. Davis, I want to thank you so much for all of your help and support to the patient community this evening - we can't thank you enough. And I also want to thank all of you for your insightful questions - you are an amazingly educated group of patients!
okdavis	Cos: yes, but lower egg yield and lower success rates than injectables
ilene	Dr. Davis -you were fabulous -thank you for your hope and information!!
Corey_Whelan	This concludes our chat for tonight. Thank you all SO MUCH for coming and joining in. See you next week!
cosmiclobster	thaks again!!!
okdavis	I enjoyed chatting with you all
corgimommy	THANKS
bikinilady	thanks dr Davis
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arwamsted	thank you!!!!
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christy	I know I have joined late, but have a quick question...
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IVF/ART - What Are Your Options And How Do You Decide

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