The Egg Factor - Decreased Ovarian Reserve

August 21, 2007 - Tuesday
5:28 PM to (EST)
Guest Speakers: Nanette Santoro, M.D.

Categories
Donor Egg • Infertility • IUI • IVF • PCOS • Pregnancy Loss

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Corey_Whelan	Welcome to tonight's AFA chat. I am Corey Whelan, The AFA's Director of Development and your chat moderator tonight. Tonight we are most honored to have as our guest speaker, Dr. Nanette Santoro. Dr. Santoro is a Professor and Director of the Division of Reproductive Endocrinology and Infertility in the Ob/Gyn and Women's Health Depts. of Albert Einstein College of Medicine in NYC. Dr. Santoro is also affiliated with Montefiore's Institute for Reproductive Medicine and Health.
Corey_Whelan	Dr. Santoro will be joining us momentarily. Please stand by! We'll get started soon.
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Corey_Whelan	Hi all, we are waiting for Dr. Santoro to begin. Please hand in there. We'll be talking about decreased ovarian reserve. While we wait, can I get a roll call of where you guys are from and where you are at in your treatment?
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bcgradgirl	Im from NY...I have had 5 unsuccessful IUI's and several months on injectable drugs
mistiraz	Birmingham, Alabama. No current treatment because of diminished ovarian reserve [FSH of 28] diagnosed after one round of Follistim.
jneencruz	I am in New Jersey. I have done 2 rounds of IVF due to PCOS. I have a 9 year old daughter conceived without any problems and now have no idea why the 2 rounds of IVF didn't take or why my eggs don't continue to develop after fertilization. First round of IVF, had 11 eggs and 2 fertilized, second round 16 eggs and 3 fertilized.
bcgradgirl	If you dont mind me asking, how old are you all?
LeahD	Hello Dr. Santoro! I've had 1 doctor diagnose me with DOR and a second tell me I do not have DOR. FSH was always normal. Second doc told me I am just a poor responder. What is your opinion? Husband with very poor sperm count and quality.
Corey_Whelan	Hi, I have Dr. Santoro on the phone, she is having some technical difficulties, please hang on
mistiraz	I just turned 33, if you're asking me.
LeahD	29, 27 when started infertility treatments
bcgradgirl	Im 31
bcgradgirl	i was just curious...I started trying at 29
jneencruz	i am 34, started infertility treatments about 2 years ago. I put the last cycle of IVF on hold for a bit.
bcgradgirl	was IVF painful for you? ANyone who has undergone it...
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LeahD	bcgradgirl, have you been diagnosed with DOR?
mistiraz	I did three rounds of clomid, took a break, then one round of Follistim, then BOOM. We're done, other than egg donor IVF.
jneencruz	i wouldn't say painful, there is some discomfort. I guess it depends on your pain threshold too
bcgradgirl	yes, my FSH was 14.9
LeahD	the most painful part of IVF was when it failed twice
jneencruz	that is the truth, LeahD
jneencruz	i know that pain
bcgradgirl	Im sure that was difficult
mistiraz	I can't imagine. The financial burden is painful enough without the emotional trauma.
jneencruz	what is DOR
mistiraz	diminished ovarian reserve
jneencruz	my insurance covered it
bcgradgirl	diminidhed ovarian reserve
LeahD	diminished ovarian reserve
jneencruz	thanks
bcgradgirl	oops, dimished
LeahD	jneencruz, where in NJ are you from?
bcgradgirl	lets try that again, diminished
jneencruz	Ridgefield Park
jneencruz	you?
LeahD	I used to live in Hackensack...moved to DE 2 years ago
Corey_Whelan	guys, she is still trying.
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LeahD	mind if I ask what doc you are seeing?
michal69	is Nanette Santoro here yet?
jneencruz	every time I join one of these chat rooms the doctor has difficulty and can't join
jneencruz	I went to see Dr. Lesorgen but I am not going to be using him when I go again
Corey_Whelan	yup, I know, I'm sorry. Dr. Santoro is giving it her best effort.
jneencruz	I feel like I have 3 chances for this and I have used 2 on him, so I am going to go to RMA in Englewood. My Obgyn recommend Sloey (not sure of the spelling)
Corey_Whelan	You mean Mike Slowey. He is with RMA of NJ
jneencruz	did you see doctors here before you moved
jneencruz	yes, thanks i wasn't sure how you spelled it , I had only heard it.
Stacie	Hi all, thought I'd share while we are waiting. Been trying since I was 31... just turned 35. 6 miscarriages... 2 on my own, 1 from IUI, 3 from IVF. FSH 12.3. Moving on to donor eggs... my sister actually.
jaworska	Hi, I am in California. Just tried IVF for the first time, developed only one egg and cancelled after 7 days of styms. Is anyone over 40?
LeahD	I saw one...Dr. Navot. I think he misdiagnosed me with DOR.
bcgradgirl	Is there a particular doctor anywhere in the US that specializes in cases of DOR?
jneencruz	where was Dr. Navot located?
LeahD	Westwood
LeahD	bcgradgirl, I've never heard of one
jneencruz	sometimes I feel that I am being misdiagnosed or that there is something besides PCOS that they are not seeing and taking into account.
LeahD	I know it gets very frustrating!
moesbaby	I'm 42.4 and was seeing Levine in Westwood moving on to Cornell
bcgradgirl	I went to Cornell for a consultation
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LeahD	mosesbaby how did you like him? Do you have, or did they "say" you have DOR?
jneencruz	I was going to try another round this month and then I found out my husband may be losing his job come the end of september so i thought it was best to wait and see what comes of that. i figure I have waited 5 years to get pregnant what is another 6 months.
mistiraz	I just feel like something was "missed". My FSH in January was 6, and to go to 28 in less than 6 months was devastating to say the least.
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michal69	I am 38 and my FSH is 19 I just had a cycle cancelled b/c only one good egg was visible, the rest were very small. I think it also had to do wi th being on birth control for a month before, i think that supressed me a little. There is a relatively new test called Anti-muellarian (AMH) that gives the RE'S a better picture (in addition to FSH) of what your reserve looks like
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jaworska	Hi moesbaby. Would you mind sharing a bit about your experience?
bcgradgirl	whats a RE?
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michal69	RE=reproductive endocrinologist
bcgradgirl	thanks Michal
Corey_Whelan	Dr. Santoro has joined us. Welcome Dr. Santoro. Our chat will go until 9:30 p.m. for those who can stay
moesbaby	I loved him as a person but they never wanted to change my med same protocol. Dr. Davis at Cornell is doing different protocol I start in Oct.
Corey_Whelan	Please feel free to ask your questions of Dr. Santoro
jneencruz	what is the protocol going to be? do you know yet?
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Christine	Dr. Santoro
Stacie	Hi Dr. Santoro...
Dr._Santoro	Hi Sorry to be late, technical problems.
moesbaby	Hi Dr. Santoro
jane	hi, dr. santoro, i am getting prepared for my second IVF at age 40. before my RE discovered a blocked tube/hudrosalpinx, i went through 4 cycles of gonadatropins and 1 IVF. how many times is it safe for a woman to take the drugs?
athena7814	Anyone here with Diminished Ovarian Reserve?
mistiraz	What happened to cause my FSH to go from 6 to 28 in less than six months? I had an "aberrent" response to clomid and a "low" response to Follistim, 150 units. Athena, yes, I have the official DOR diagnosis.
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Dr._Santoro	Newer medical evidence suggests that there is not such a hazard to exposure to gonadotropins. WOmenw ho have done several cycles do not appear to have increased risks of disease in the future.
Christine	I have had 5 IVF's and every time our embryo's do not do well. I do not produce a lot of good eggs. Do I have any options to help with the IVF?
bcgradgirl	Dr. Santoro- I am 31, have had 5 unsuccessful IUI's, do you think an IUI could be successful with DOR and a FSH of 14.9 or would you reccommend IVF?
Dr._Santoro	FSH levels are maddeningly variable when women begin to enter the transition period into menopause. So they can be completely normal one month and then, without any warning at all, they are high.
LeahD	Dr. Santoro, I am 29 years old and was diagnosed with DOR by my first doc, only to have a second tell me I do not have DOR. FSH has always been normal. 3 failed IUI's, 2 failed IVF's. Second doc says I am a poor responder. Husband poor sperm count and quality. What would you think?
Stacie	I have been trying for over 3 years... FSH 12.3. 4 rounds of IUI, 3 IVF's, 6 miscarriages. I have made the decision to use donor eggs (my sisters) and just want some reassurance that I have exhausted all I can to have my own child with my own eggs and that the decision is a good one at this time.
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mistiraz	So, egg donor IVF is truly the only option at this point?
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jane	dr. santoro, i also wondered if you could clarify for me the relationship between FSH and egg quality. i am 40 and typically have 8-9 antral follicles each month on each ovary. at my 1st ivf, i had 17 follicles--of that, 11 mature eggs, 8 embryos.
Dr._Santoro	Christine it is worth going for another opinion if you have not already done so to better understand why your embryos do not look good. Sometimes tweaking the protocol a bit in the IVF lab improves the embryos
michal69	Hi Dr Santoro how accurate is the AMH test. My FSH went to 19 and the last IVF cycle we did was cancelled b/c I was to I had one good egg. We have been doing IVF the past year 1 cancelled cycle in Sept 2006 2 unsuccessful IVF's one IVF resulting in a misscarriage and the last cycle we moved so I am different doctors the gave me less meds and birth control the month before and I had such a poor response the cancelled the cycle.
jane	thank you very much for your response
jane	my FSH is 8.8 now, but was 10.9 in january and 7.7 in may. i am curious about the varying levels, too. thank you again.
Dr._Santoro	Being a poot responder probably means you do have DOR but it's just not been diagnosed yet because of how elusive an elevated FSH can be in the early stages of this condition.
athena7814	I am 42 and have FSH of 18. Should I go for Donor Eggs. I only did 1 IVF and 3 IUIs.
Christine	Thanks I have just joined with Dr. Schattman at Cornell, but we have to take it slow b/c they do not accept insurance. I have already tried blastocyst. With my old dr - I had three with no luck, one mis and the last attempt did not work. What can I ask him to try that may help with my egg quality?
Dr._Santoro	bcgradgirl, with a high FSH and multiple cycles it's always a tough decision. It's not a bad idea to see how fertilization goes in an IVF cycle before you make a decision to do more IUIs. If you have ever had a pregnancy before that also makes it easier to consider continuing with IUI cycles. But sometimes there's a concern that fertilization just isn't happening and hten the IUIs may be futile.
LeahD	I see, thank you. So in addition to not producing many eggs, they could also have been poor quality? Is IVF pretty much out of the question for me and my husband, considering his poor sperm?
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bcgradgirl	thanks Dr. Santoro- I have never gotten pregnant before . I have coverage for IUI's and have some strong fears aout iVF
Dr._Santoro	Stacie you have done a lot of IVF and IUIs. A sister donor is a great option. The gain is so much greater with donor egg when you have tried this hard and not gotten results. The odds are just against you. So even though you can keep trying IVF and IUI, it might be easier to do that when you are thinking about your SECOND baby, and start your family with a donor egg baby.
michal69	I am 38 FSH 19 is it worth doing IVF again after the failed cycle
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athena7814	Dr. Santoro, I am 42 with DOR, FSH 18 and 1 failed IVF Cycle. IS it worth continuing?
jane	dr. santoro, is ICSI worthwhile if we are using excellent quality donor sperm and in my first IVF, 8 of 11 mature eggs fertilized? my new RE charges an additional $2,000 for ICSI, so we don't want to add that cost if it is unnecessary. i am experiencing secondary infertility and have been for 2 years of infertility treatments. thank you for your response.
Dr._Santoro	michal69 AMH is being investigated as a better test of ovarian reserve and shows some promise in picking up DOR. It has the advantage of being independent of cycle day so you don't have to run into the office when you have your period to get the blood test. On the other hand, it's not been completely investigated so it's use in a clinical setting is not now known. As someone who is studying it as a marker of menoapuse in big epidemiologic studies, I will say that I'm enthusiastic about it but it's not ready for prime time and we don't know all the other things that influence its production.
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moondreams	what is the possibility of an unproven 24 year old donor with low FSH having unviable eggs? she produced 8 high grade day 5 embryos. my husband and i passed all our tests and have not gotten pregnant in the last 3 attempts using 2 embryos per try. we have 2 left and wondered what are the chances the last 2 are viable? we have had no thawing problems. any specific tests i should have before our last attempt?
Dr._Santoro	athena at age 42 and with an FSH that high your chances of a pregnancy with your own eggs are tragically low! You have a much better chance of becoming and staying pregnant with donor eggs, so from a 'gain-for-the-pain' perspectice, I would encourage you to consider that option strongly!
jaworska	Hi Dr. Santoro. I am 41.8. FSH 12.4 with E2 around 110. New to treatment. 2 months ago I had 4 antral follicles, but when we tried IVF this cycle I developed only one follicle. My doctors don't want to do any more treatment just after this one try. Is it worth trying again or should I move to donor eggs. Do I have any options?
LeahD	Is there any cause for DOR in someone 27 years old?
michal69	my RE is had me do a random cyle AMH, as the last cycle i did I had poor response. the past year I had better response 9 eggs and recently I just had 1 the gave me birth control for a month (which I did not do before) and less menopur and Gonal-F than I was taking previously as well. what do you think about the birth control before a cycle?
Dr._Santoro	LeahD IVF is not out of the question but again, you have two gamete problems in all likelihood and you have to make decisions based on the amount of pain, effort you have to put in to get an embryo and balance it against the likelihood of pregnancy. And in your circumstance without at least one of you using a donor gamete the chances of success are low.
jane	for the months preceeding IVF, is it possible to improve egg quality by eating high protein foods and taking supplements such as coq10, pycnogenol, antioxidents, goji berry juice, etc? or are our eggs simply our eggs, no matter what we eat or drink? can a too high dose of gonadatropins negatively effect egg quality?
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moesbaby	Dr. Santoro I am trying naturally this month but had my period 2X (never happened before) and I keep getting a positive on my ovulation tests. Is it just wacked out hormones or is this another sign of something else?
Dr._Santoro	jane usually when your fertilizatin is that good it is not worth the additional costs of ICSI, I see your point. It's always a hard decision because if fertilization is not that good the second time around, you can wind up second guessing the decision NOT to do ICSI. That's always an unhappy office visit for the doctor! As long as you are OK with the possibility that it might not be 8/11 this time, save your $2,000.
Corey_Whelan	please feel free to post your questions at this time
Dr._Santoro	moondreams if the embryos thaw OK and if fertilization was good they are probably not non-viable eggs. There could be a problem with the embryos, but if they look good and sirvive the thaw then keep going with them until they are gone, it is VERY unlikely that they are somehow mysteriously bad.
moondreams	i meant to add i didn't go full term with all my attempts, but did get pregnant with fresh. it lasted 9 weeks and then i miscarried. frozen was a chemical. i wondered what the odds of 1 out of 8 five day embryos with donor egg having a chance for full term pregnancy.
jane	dr. santoro, does ICSI increase the likelihood of having genetic problems in the embryos? is the reason an egg doesn't fertilize most likely the quality of the egg? thank you very much for your perspective.
michal69	thank you
mistiraz	Is it true that you're only as good as your "worst FSH" [28 for me]? If it did come back down [which it hasn't been rechecked], would it mean anything significant?
Dr._Santoro	jaworksa usually in your circumstance with age AND FSH working against you, it's not helpful to continue trying due to the low chance that it's going to work out. So donor egg is often recommended to increase your chance of a pregnancy that's going to go the distance.
bcgradgirl	Dr. Santoro- do you know of any doctors in the US that specialize in DOR? We are considering IVF as our next step but with the cost being so high, I want to make sure I am going to the best doctor possible
Dr._Santoro	Leah there are many possible causes for DOR. A low egg supply at birth or even before birth can make for DOR at very young ages. Sometimes it's a genetic problem and sometimes related to other diseases or problems. There are even developmental causes. Not much is known about how it happens, though, because as doctors all we ever wind up seeing is the end result--DOR, so we can't catch the events around the actual time that the eggs are declining (which would be be great because then we could maybe find a way to prevent it from happening)
Christine	I have tried varying the IVF drugs and have switched drs. Is there anything the new dr may be able to do to improve my egg quality
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Dr._Santoro	michal69 your numbers are not encouraging. I can't tell you NOT to try, that would be too presumptuous, but you need to take a long hard look at the numbers and with an FSH that high in our program women rarely, rarely get pregnant and carry to term. About 1%
bcgradgirl	Are there certain stimulating medications that people who are poor responders to meds seem to do better with?
frances1	I am 45. FSH 9.4 with estradiol of 25. FSH of 5.8 with estradiol of 54. Highest was FSH of 10 with estradiol of 80. I had six antral follicles on first ultrasound. I had no response to highest doses of Bravelle and Menopur. I was surpressed with BCP for 4 months. I am trying one more time but had only been surpressed for two weeks with two follicles one 1.1 cm and the other 2 cm with estradiol of 111. So I am continuing on with the BCP for one more week to surpress more. Any hope or only donor eggs in your opinion? I have never had a problem getting pregnant just couldn't carry due to fibroids, endo, adenomyosis, adhesions, bleeding so much I needed transfusions, etc. I have a gestational carrier.
Dr._Santoro	moondreams 1 out of 8 embryos ought to get you there from a super donor but it's always like flipping a coin each time you try so a baby can never be guaranteed.
moondreams	i definitely plan on completing what i started next cycle. many thanks for the hope.
LeahD	Thank you so much Dr. Santoro. You have given me straight answers that I have been waiting for, for the past 2 years.
Dr._Santoro	mistiraz this is true--your WORST FSH level tells us the MOST about your likely reproductive potential. It's a marker for what's going on in your ovaries and when we get a poor predictive value it doesn't change.
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Dr._Santoro	jane: ICSI is associated with more genetic problems of a certain type: they are called epigenetic or imprinting defects. It's very uncleat at present whether it's the ICSI itself or the male factor that led to the need for ICSI that is the cause. Current thinking is that it's the male factor. So when we do empiric ICSI to protect fertilization, we typically do NOT think it causes a problem. But it is not definitively known why this happens, so it is wise to consider ICSI carefully.
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Dr._Santoro	Christine you may want to give it one more try with another opinion only and see what the new doc has to offer. I recommend that you pick your doctor based on their being Board Certified in REI, which means they meet certain criteria. An honest doc will tell you if he or she can do something different that might help.
mistiraz	Dr. Santoro, I was on BCP for 15 years. Could this have been a contributing factor, OR did it surpress the signs of DOR?
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Christine	THanks
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bcgradgirl	Thats a good question Mistiraz-I have the same concern
frances1	I also had a anti mullerian hormone test. My level was very low. Is this is an accurate marker of ovarian reserve?
Dr._Santoro	bcgradgirl: It's usually possible to wring eggs from a woman with DOR by giving different stiimulations and some women do better with a particular combination than others. So if you have DOR and you are under age 35, it may pay to try with a few different protocols to see if the egg yield is improved. If not, it's unlikely it's going to work. Women over 35 generally do worse with DOR because the comgination of low egg numbers and chronological aging of the eggs just makes it harder for all the factors to work.
Dr._Santoro	mistiraz: brith control pills MASK the process of DOR so you never know it's happening. If you hadn't been on the pills you might have had a warning sign, but pills will keep those cycles coming every 28 days for most women and they won't have a clue until they stop them that there is a problem. There is very good data to support the notion that pills do not CAUSE DOR--when you look at women with menstrual problems who go on the pill and look at women who go off the pill, the distribution of menstrual problems is identical.
jaworska	Thanks Dr. Santoro. I don't feel quite ready yet to jump to donor eggs since I only started treatment 2 months ago and have only been trying to get pregnant for 6 months prior to that. I was also on BCP before this cycle, so I wonder how that might have affected my poor response. How about the possibility of monitoring follicles at baseline and proceeding with stimulation only if there are at least four?
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Dr._Santoro	frances1 AMH is considered a promising marker but it's just not known how reproducible it is for the same woman over time. Those studies are just now being done.
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bcgradgirl	Thank you Dr. santoro
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mistiraz	Ah, thank you. Just trying to resolve I didn't "wait too long" (started trying at 30). Heavy, painful, very irregular cycles required BCP at 15.
Dr._Santoro	jaworska: the strategy of waiting for a good cycle makes sense on the face of it but in practice doesn't seem to work. Save your money and your time if you want to try on your own and do as much body awareness as you can, and if you want to try a stimulation just go for it when you feel mentally ready.
Dr._Santoro	mistiraz: your cycle pattern before you ever started pills may have been a clue to these problems but there is little understanding and almost no recognition of this in general Ob/Gyn circles. Those types of studies need to be done to increase awareness.
Dr._Santoro	Wow I can't believe I caught up
frances1	do my fsh, estradiol and antral follicle counts show any promise for someone my age? What do you mean by it not know hoe "reproducible" AMH is
frances1	how
moesbaby	Dr. my DH are on a med break for 3 months starting IVF in October. On July 31 I got my period then 8 days later I got it again-never ever had it twice before. Both times were normal flow nothing unsual. But I have been taking ovulation tests almost everyday when not bleeding and they all come out positive.....have you ever heard of this and what could be wrong?
bcgradgirl	Dr. Santoro- are there any doctors that seem to have higher success rates with IVF with patients with DOR?
Dr._Santoro	frances1: AMH fluctuations cycle after cycle are not as well known as other hormones like FSH. There may also be things that happen (taking hormones, stimulation cycles, certain illnesses, etc) that make AMH go up or down and we might make inaccurate predictions based on falsely high or low levels. For example, body weight makes AMH levels lower. A large woman might get a false reading of DOR if only AMH was being measured. Until it's completely understood, the predictive value of AMH is still somehwat experimental.
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frances1	Would antral follicles not respond to IVF meds due to over suppression or is it more related to age
frances1	estradiol didn't rise either
bcgradgirl	Does weight affect ovarian reserve at all?
jaworska	Could you explain a bit what you mean by "body awareness" and how it's supposed to help. Do you mean knowing when I ovulate or something more?
Dr._Santoro	moesbaby it looks like you may be progressing to the next stage of the transition--after DOR comes perimenopause. The periods close together like that and the positive LH test suggests that your ovary is responding erratically to high hormones.
Dr._Santoro	bcgradgirl: this is one of the most frustrating problems in all of REI. I do not know anyone out there bragging about how they are doing great with their patients with this problem, and believe me, I'd send my patients to him or her if they were out there!
bcgradgirl	thank you for being honest
mistiraz	I agree. No doctor mentions fertility when you're 15. I never knew when I'd have a cycle before going on BCP. Regular for 3 months, nothing for 3 months. Then maybe every 2 weeks, then every 3. All over the place. I went back to regular when I went off the pill for almost a year, but then reverted to cycles every three weeks. Weird thing is I'm back to 28 days after coming off of clomid [had periods every two weeks on clomid, hence the label "aberration"]. I just wonder if young women were aware that irregular cycles could be a "sign" of fertility problems, could "harvesting" be done for those women so they could have their own children some day?
moesbaby	Thanks that is what I fear most.....know any good donor egg clinics?
Dr._Santoro	frances1: antral follicles just tell you that the raw material is there. They still need to have all the right receptors on them to be able to respond and they need to develop normally to grow to ovulation size. These events are not guaranteed when DOR is the diagnosis, and all of these steps go awry in the perimenopause, the phase after DOR. So a lack of response of antral follicles can be due to many things. All the signals that allow antral follicles to respond to FSH are not well enough known, if we knew them we could give them back and maybe improve response.
Dr._Santoro	bcgradgril: the question about weight is a great one, it's not well known. Obese women do not have menopause earlier but they seem to have more difficulty responding to stimulation medications
Dr._Santoro	jaworska: by that I just mean awareness of your cervical mucus, breast tenderness or whatever signals your body sends you when your estrogen is rising and your fertility is likely to be maximial.
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bcgradgirl	Dr Santoro- Im taking all my meds IM but am not responding so well to the Bravelle (6 vials daily) or Ganirelix..any suggestions of other meds that may work better?
frances1	What does FSH of 9.4 and estradiol of 25, and fsh of 5.8 and estradiol of 54 and fsh of 4.2 with estradiol of 85 indicate? These have been my readings
Dr._Santoro	mistiraz: there is a movement out there, spearheaded by Dr. Larry Nelson at the NIH, to make a monthly menstrual cycle a 'vital sign' for women's reproductive health. You are right--based on what we know now, doctors can do the most good when the diagnosis of DOR is made EARLY. The younger the woman the more potential there is to freeze viable eggs or embryos and save them for later. So when young women with menstrual problems come in for evaluation, testing for ovarian reserve might make sense--if they have a high FSH, then they might want to do some form of fertility preservation early in life BEFORE they go on the pill for 15 years. Now that these techniques are becoming available for young women getting chemotherapy, that may be one place this field is going to go.
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Dr._Santoro	moesbaby there are many excellent donor egg programs around the country. Again, my best recommendation is to find a Board Certified REI running the place.
moesbaby	Thanks Dr~have a good night
mistiraz	Thank you Dr. Santoro, that is very interesting.
Dr._Santoro	bcgradgirl: there might be some benefit to you of going to a 'mixed protocol' consisting of FSH plus a little LH added, with a low dose Lupron suppression instead of a GnRH antagonist like ganirelix. There's NOTHING scientific about that recommendation, though, it's an empiric maneuver that is sometimes tried and sometimes helps. I do not encourage my patients to go beyond 6 amps of meds a day because the overwhelming evidence is that it only costs you lots more money and very very very rarely gets you a baby. Like maybe one out of a thousand times or less.
Dr._Santoro	frances1 It's not always possible to interpret the FSH levels because they differ lab to lab, but an estradiol over 80 is similar in significance to a high FSH level because it tells me your ovary is rushing to ovulation too early in your cycle--a sign of DOR.
bcgradgirl	What is menopur used for?
weluvpenelope	Dr. Santoro, I'm 40, 4 m/c's, preg 3 times within last year ( 2 on my own, once after 2nd iui). Nornal FSH, ovulate every month, but elevated estradiol. That combined with m/c caused Dr. to dx poor egg quality and suggest donor eggs. Said no advantage to ivf and that pgd would do more harm than good. Agree?
Dr._Santoro	bcgradgirl: Menopur is a mixed protocol like drug that contains FSH with a little hCG added, so it has LH like activity that is long acting.
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Dr._Santoro	weluvpenelope, your track record is dynamite, if you have gotten pregnant 3 times in the past year, I would suggest you keep trying for a while on your own or with IUI before going to donor egg. You DO have DOR and your egg quality probably is an issue, but if you keep getting pregnant enough times you just might get a healthy egg and a beautiful baby without needing a donor. There is now an excellent study showing clearly that PGD in women with DOR to prevent miscarriage is not only ineffective but reduces the chance of having a baby quite substantially, so it is not to be recommended at this time!
bcgradgirl	Under what circumstances would you reccomend using Menopur?
Dr._Santoro	bcgradgirl: most gonadotropin medications are quite similar and I'm not very impressed that one is so much better than another. The advantage of menopur is that if you are giving low doses of medication you can avoid more complicated multiple injections and mixing of meds and for some types of ovulation failure it's handly.
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bcgradgirl	thank you sr.
bcgradgirl	dr. rather
jjt	Dr. Santoro, I'm 37 with FSH 13.5. For the past two years, I have gone through 5 IVF cycles (including canceled ones). The most number of follicles I got was 4 (the first try). The latest three times, I got only 1 or 2 follicles. Each time I was prescribed with the large dose of GonalF (450). I was told there might be chance to get one good egg, although it is not that easy. My question is, if I decide to continue trying IVF, does large dosage of stimulation drug helps ? If the success depends on whether I get a good egg on that particular cycle, given that I produce 1 or 2 follicles an IVF cycle, would it make any difference using different dosages ? Or is there any special protocl (like chromid ?) designed for poor responder ? Or, should I simply give up ?
weluvpenelope	Thank you so much!
Dr._Santoro	jjt in your case the large doses are not helping and there is even some evidence that enormous doses harm the process of egg growth. If you consistenlty make 1 oe 2 eggs I think you should consider stopping IVF attempts, it's a waste of your money and effort since IVF success depends on getting lots of eggs for the most part. Before calling it quits, though, it is worth getting another opinon about the details of your stimulation and considering 'tweaking' the stimulation in the ways you are suggesting or in other ways.
Corey_Whelan	Folks we have around ten minutes left.
jjt	Thank you Dr. santoro
bcgradgirl	Thank you again dr. santoro
jaworska	Are you aware of any data that acupuncture might help with DOR?
robin	i havent had any blood work for over one year now... .but i have noticed my cycles going from 28 to 26-27 day cycles... is this an indication of DOR or menopause.. is it too late to start trying again.. tia
Dr._Santoro	jaworska it is something that I recommend my paitents consider because there is some biological basis for its benefit and there are some anecdotal reports of benefit, but there is not the kind of medical evidence out there adequate to recommend it strongly. The best things about acupuncture are that it cannot harm the process and it is not such an expensive option.
jaworska	Thank you!
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Dr._Santoro	robin when cycles get shorter that is a sign that perimenopause may be at your door, but usually there is more than a day or two of shortening that is observed. However, if you are a very compulsive menstrual record keeper this could be significant. it's not known if this really makes things worse. If you begin to skip cycles altogether, though, that's an indicator that your ovarian reserve is very very unlikely to be adequate to get you pregnant.
LeahD	Thank you, doctor, and good luck to everyone.
bcgradgirl	thank you LeahD
robin	ok, im true to my cycles and all of my blood work in the past has been ok... just wondering if i start trying again if i should initiate some medication etc... not knowing how quick dor occurs i had plenty of eggs according to tests... thank you Dr.!
michal69	i had to leave for a bit so I am not sure if my question was answered. I am 37 going on 38 the last cycle failed I took birth control before, the past year for other cycles I did not and had 9 eggs, do you think rthe birth control had anything to do with it or may have added to supression?
shaymer01	Dr. - is cycle lengthening a sign of perimenopause too?
Dr._Santoro	robin there is nothing that I would recommend on the basis of what you've told me so far.
robin	ok i dont have any of my records handy right now, do you plan on doing another chat soon or how can we reach you for further support etc.?
Dr._Santoro	michal69 usually bcps do not impair ovarian reserve, they sometimes help get better growth because they don't inhibit those early antral follicles from forming...however every woman is different and for you it might have been the pill or just a random event that made the response worse.
michal69	does stress have any part in antral follicles per cycle?
Dr._Santoro	shaymer01: yes longer cycles can also be a sign that perimenopause is coming but usually these are very long cycles, like DOUBLE a normal cycle in length.
Dr._Santoro	michal69: stress is a possible cause for a poor antral follicle count, but it's not been well evaluated or measured. Repeated exposure to fertility drugs cycle after cycle can temporarily deplete the antral follicle count, too.
bcgradgirl	what is antral follicle count?
michal69	when you say repeated how many, how close together. we've been doing cycles for the past year 2 cancelled and 3 full IVF's is that considered a lot?
michal69	whe the see the antral follicles is that the most you can get that cycle or can others pop up with the stims?
Dr._Santoro	bcgradgirl: sorry to not explain the jargon. When a woman is at the beginning of her cycle, one useful way of measuring ovarian reserve is to count the numbers of very small follicles that are visible in the ovary. Usually more than 4 antral follicles per ovary is a sign of adequate ovarian reserve. This gives an index of how many follicles are available to be grown in that cycle or the next. WHen the count is very low it correlates well with DOR.
jaworska	Can stress cause DOR-like symptoms (high FSH, etc) that could potentially return to more normal level and higher chance of pregnancy?
robin	Dr... Does it mean anything regarding DOr if my antral follicles were 9 one year ago.. how quick does the lessening of the follicles occur; 1 month. 6 months, years?
shaymer01	My doc doesn't feel that antral follicle count is worthwhile bc he says my IVF stim actual performance is best basis for future prediction. Would you agree?
Dr._Santoro	michal69: the antral follicle count is just an index of what is available, but even among the antral follicles not all may be truly ready to grow that month, they might not really wake up until the following month. How many follicles grow per month is based on more than just the count--the FSH level matters (more FSH will pull more out of the pool that month, but you may pay a price the NEXT month and have less), and whether or not those antral follicles have been exposed to a hospitable environment also matters.
michal69	hospitable meaning?
Dr._Santoro	robin: 9 is pretty good, but if you wee on the cusp of DOR last year I guess it's possible to go from 9 to less than 4 in a year's time.
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robin	ok thanks
Corey_Whelan	Folks, it is 9:30 and our chat is officially over. Thank you Dr. Santoro for taking the time to be with us tonight. Good night all. Dr. Santoro, feel free to stay as long as you would like to.
Dr._Santoro	shaymer01, I used to think antral follicle counts were sort of bogus, too, and that the stimulation performance was the real life test that mattered, but the evidence is impressive and my colleagues in our practice have deluged me with evidence from our own patients.
bcgradgirl	Do you have a website for your practice or some way we can get in touch with you in the future?
shaymer01	interesting, thank you very much for your time and responses!
robin	Thanks so much Dr. Santoro!!!
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Dr._Santoro	michal69: by hospitable I mean that the follicle needs to have a decent blood supply to its outer layers, the outer layers that make androgens need to be well developed and the other hormones coming from the liver like growth factors, etc, all need to be adequate to make that follicle grow the right complement of receptors so it can respond.
bcgradgirl	thank you again for all your help
robin	Dr. is there anyway to measure this hospitable environment
Dr._Santoro	bcgragirl we are on the Montefiore Medical Center website: Montefiore's Institute for Reproductive Medicine and Health
michal69	do you think I should wait to do another cycle.
bcgradgirl	Thank you
Dr._Santoro	robin there are only indirect ways to tell that things are OK in the ovary. That's why it's so frustrating and we search for these goofy markers in the blood!
Dr._Santoro	michal69 if you have DOR and you are doing cycle after cycle it makes sense sometimes to hold off for 60-90 days which is the time period that the ovary needs to run the tiniest follicles that you cannot see up to the antral follicle stage.
michal69	having done so may cycles is it best to maybe wait or if it is DOR maybe we should do IVF again ASAP? does Hashimoto havw any effect even if I am currently euthyroid Thank you so much this has been very helpful
robin	ok i dont think anyone has ever checked this hospitable environment before.. what would i ask for and when is the best time for the tests.. if there is a best time
Dr._Santoro	If you are currenlty euthyroid your thyroid issues should not be a problem. When considering waiting, you also need to balance that against your age, but usually 60-90 days does not make a critical different.
Dr._Santoro	robin the only tests we have are the indirect ones that measure FSH, estradiol and sometimes inhibin or AMH to see what the overall reserve is.
michal69	have you seen FSH and follicles counts diminsh over a short period ie 6 months
robin	ok thanks
Dr._Santoro	Good night, all. I am going to sign off and thank you all for waiting for me to gain some competency with my computer!
bcgradgirl	thanl you
shaymer01	thank you again!
jaworska	thank you again!
michal69	is my age 37 going on 38 considered old and my FSH the last test being 19 the highest it was before that this past year was 12.4, last Sept 2006 it was 9
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robin	this was great
LeahD	very informative
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bcgradgirl	do any of you know of any good infertility support groups?
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LeahD	Resolve
robin	yea its good to know whether the docs i am working with or have worked or competent or not
LeahD	they have chapters in every state and meet monthly
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robin	bc have you gone to ovusoft
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bcgradgirl	I just e-mailed someone from Resolve, thanks Leah
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bcgradgirl	ovusoft? Whats that?
michal69	what is ovusoft?
robin	yea resolve i heard of but didnt know how efficient/supportive they were
robin	let me go get the link.. hold on
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LeahD	I think they are great. Where I am they hold meetings once a month.
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robin	the link is www.ovusoft.com
robin	and when you go on there click on the community link at the top and you will have access to a rather large forum of women with similiar interests etc.
Stacie	www.surrogacy.com has multiple support groups to choose from regarding fertility including one for multiple miscarriage that I belong to. Go to the website and click 'join our online support groups.'
bcgradgirl	thank you guys so much...this has been a rough road for me lately
robin	i found ovusoft when i read a book, "Taking charge of your fertility by Tony ??
robin	i understand bc
LeahD	My e-mail DeFalconRN@aol.com for anyone who ever wants to talk!
bcgradgirl	Mine is bcgradgirl@yahoo.com I would love to talk sometime Leah
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LeahD	sounds good
robin	i would like to talk too... is there a way we can all chat sometimes too
LeahD	I'm not sure, but if I find a way it would be great
robin	hey now that i think about it...there is a way we can all chat at the sametime on ovusoft.com
robin	im not trying to promote ovusoft.com i just know of it
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robin	leah have you ever heard of natural progesterone
robin	awe
bcgradgirl	I will definitely check out that website, thanks
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robin	hey no prob... its been awhile since i have been on there i will need to see what my nickname is.. i kind of put everything on hold as it was just too much..
LeahD	somehow got kicked out...let me know if you find a way on ovusoft
robin	leah did you get my post to you
robin	ok i will and know there is a way on there as many of us in the past have got on there and chatted together
moesbaby	thanks for those websites I usually use ivfconnection.com but always looking for new ones. Good luck to all. Looks like I may be too old ::wacko
robin	hey Leah sorry about the bump... i wanted to ask you if you ever heard of natural progesterone
robin	moes how are your cycles?
bcgradgirl	good luck moes
robin	amd of so Leah whats your opinion
robin	sorry... and if so
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moesbaby	always 28 days but noticed once in a blue 26 or 27 then I had 2 IN ONE month.....Dr. says sign of perimenopause....UGH!
moesbaby	my mom had 10 kids so I always figured I was fertile like hernot!
robin	yea but Moes I think its still possible.. as the dr. said there are other variables and as long as your cycles are normal you have a fair chance still
robin	hey there is a live chat button on ovusoft... but im not sure if one needs to be a member or not
moesbaby	I know I'm wiping the dust off my pants right now and getting back on that horse
LeahD	robin no I didn't how would I get it?
bcgradgirl	I need to get going but I want to thank you all for all of your support and help
bcgradgirl	i wish we could all get together and chat sometime
moesbaby	This wasw the best chat here yet...hope to meet you all soon...hopefully in a pregnacy board
LeahD	bcgradgirl once something is set up we will chat! I will be in touch!
bcgradgirl	wouldnt that be nice???
robin	well its a natural form not the synthetic type and there are many variable with the right type to get and when to use it... i think its good to for leading into menopause.. i havent tried it yet but what it is supposed to do is keep enough progesterone in teh system preventing early menstruation.. giving the bean long enough time to stick
bcgradgirl	thanks leah
LeahD	robin I have never heard of natural progesterone
bcgradgirl	hope you all have a nice evening and good luck!
robin	thanks bc you too... hey leah
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robin	there is a great section on ovusoft and there is a book called what the doctors wont tell you about premenopause or menopause and he discusses in great detail... let me find the forum on ovusoft where they go into great detail about it... hold on...
LeahD	thanks...I just joined ovusoft
robin	oh ok kewl.. its somewhere in the section called
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robin	everything herbal.. i will need to look further to pinpoint it... there is also a group that takes the progesterone on ovusoft too
Wenqi	Hi, is the session still going?
robin	everything herbal is in the section called, "Tryingto conceive....
robin	no wen it ended about 20 minutes ago
Wenqi	oh, can we still chat here? I am wenqi from new york city.
robin	yea thats what we have been doing... even though i need to get off here in a few minutes... hi iam from houston tX
Wenqi	great, nice to meet you robin.
robin	Leah i am noticing several threads that have to do with the progesterone... (try a search on there) additionally there is a faq section on it too, etc...
robin	thanks Wen likewise
robin	the chat was pretty good... i hope she has another one soon
LeahD	okay, thanks!
moesbaby	Robin you saw that book on Ovusoft? Did you read it? Sounds interesting. Wendy I'm from Rockland Co., ny going to Cornell in NYC
moesbaby	Woops sorry Wenqi
robin	yea it was a great book teaching one how to track there cycle and how to read the information they track
Wenqi	I am 33, will turn 34 in no more than 3 months, I got married last year.
Wenqi	moesbaby, what's your name?
robin	i think its good for any woman who simply wants a healthy cycle... not to mention a healthy pregnancy etc.
robin	well congratualtions and you have plenty of time
moesbaby	Maureen nickname is Moe
Wenqi	well, it's frustrating, my friends around me tried only no more than 2 months, they have either have kids already, will will have very soon
Wenqi	I feel I am the only one left
Wenqi	we have been trying since last year
michal69	robin everything herbal is the name of the book?
Wenqi	nothing happened
LeahD	wenqi you aren't the only one!
moesbaby	Yes, you have a lot of time I'll be 43 in 4 months....UGH!
robin	hey leah my nickname is robyne2006
Wenqi	Moe, you don't have kids, do you?
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LeahD	okay robin...mine is the same as here, LeahD
Wenqi	I know some women have kids first, have trouble to have kids again.
moesbaby	Hang in there Wenqi my sister inlaw has been trying for 3 years now is preg with IVF twins she is going to be 35 in Dec.
Wenqi	I see.
LeahD	robin I'm signing off now...hope to chat again soon! How would I find you on there?
Wenqi	I don't want to wait to be too old to be surrounded by pregnant women or women with kids.
moesbaby	No I don't have kids.....always pushed it off career, right man before I knew it I was 39
robin	well im not sure.. ( :... i havent been on there for awhile... i can be reached at n2health@hotmail.com
Wenqi	I have a few female friends, they are around your age, career women, singles, too, no kids. not easy
LeahD	okay...mine again is DeFalconRN@aol.com. Talk soon!
robin	leah i just sent you a quick email
Wenqi	moe, are you in manhattan?
moesbaby	Your young still so don't try to stress too much. I highly believe stress can make it SO much harder. Easier said than done I know. I found I try not to obsess with infertility....can become so consumed in it.
robin	i agree moes...
moesbaby	No I live in Rockland county, ny
moesbaby	20 minutes from the Tee Zee Bridge
LeahD	got it...I'll do the same! Good night!
moesbaby	Where are you cycling Wenqi....where do you live Robin
Wenqi	I see. are you going to Cornell to study or for treatment?
moesbaby	going for treatment
Wenqi	I live in midtown east in the city, but will move to new jersey soon in a few months.
moesbaby	I was born and raised inh Bergen County, NJ
robin	ok kewl Leah... lets chat again.. soon...
LeahD	will do
Wenqi	my friend told me columbia U hospital is very good. she went there. what do you think of Columbia U hospital and Cornell? how do you compare them?
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robin	the Dr. on here tonight was good.. she might have ideas too of where to go..
michal69	i think they're all good. We went to NYU and most of the Dr's studied at Cornell. I have friends that went to Columbia and had twins in jan. 2007
robin	let me see if i can find the section where she said where she worked
michal69	we jusy moved to FL. So now we are at IVF Florida in margate
robin	nice michal.. do you know how old your friends were
moesbaby	I am going to Cornell only because Dr. Davis is the Guru of older chicks like me
moesbaby	I agree with michal69
michal69	they husband is 40 and the wife is 35
robin	oh really moes... interesting... if you dont mind me asking what has the Dr. said thus far... i am an older chick too ( :
moesbaby	My neighbor had triplets at Columbia at 40
robin	wow
michal69	WOW
robin	on meds? which kind
robin	did she have previous probs
Wenqi	great to hear these good news, very encouraging to me.
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moesbaby	only had a consultation with dr. D so far said I should try IVF then see how I responed to the Estrogen Priming Protocol
michal69	what is the estrogen priming protocol?
robin	yea thats what i was going to ask
moesbaby	She had tube problems was there only fertility treatment....how lucky were they!
robin	very!!
moesbaby	they put you on an estrogen patch for a month wait for AF then you do menopur and follistim not sure for how many days. My first IVF.
moesbaby	Where and what are you doing Robin?
michal69	i just did birth control(think same as estrogen priming) for 1 month then menopur and gonal-f and only one really good egg, at NYU the gave me same meds at higher dosage and i had 9 eggs (no birth contro)
moesbaby	there are different EPP's this is what my doc is doing with me
robin	i am in houston texas and backed off the whole idea for the last year... started doing more work etc...
michal69	it is emotionally and physically draining
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robin	never did drugs yet.. did one IUI... but i was getting ready to say... out of all the tests i have done in the past everything was rather perfect... but nothing... i did have a doctor tell me years ago he though i had a pituitary deficiency though.. which is quite confusing as test results were always ok
moesbaby	I agree michal69 sounds like the BC made it worse for you....I'm guessing.
robin	i was intrigued by this chat and thought i would drop in
michal69	that is what the dr on this chat thought as well
moesbaby	I may try NYU for DE if this cycle fails.....can't afford anything else. How is your experience so far with NYU?
michal69	i found from speaking to other friends and myself IUI's never worked
robin	yea without meds anyway
robin	i know a few women who were successfu lwith medicated iui's
robin	and there is so many meds out there i was always too confused on which ones to go with and never really comfortable with my docs
robin	hey michal did you get my email address
moesbaby	do you doubt your docs? I tend to doubt all of them. Don't know why I do this
robin	yep i sure do and dont trust them either.... go figure but the lady on here tonight seemed pretty good even though she too wasnt sure about everything
michal69	NYU does accept Aetna insurance, we were happy there (we were with Dr. Nicole Noyes it's difficult to get an appointment with Dr. Berkley, head of the program), although there were times I just felt like another number, but I guess that is probably most places
michal69	good to here that IUI's work
moesbaby	My Dad was a Dr. go figure! Thanks Michal I have Aetna too. I'll look into Dr Noyes. I feel like a number in even the smaller places
robin	well they have a better chance with meds and even then the ovulater predictore wont work then
michal69	doubting dr's I guess is normal they see so many patients, you hope they remember you and read your file and are doing things for you and not just standard procedures
robin	yes i know and many times they dont explain why thats the protocol to follow
robin	i have seen so many women take this and that protocol and i feel like a wimp
michal69	you just have to make sure to stay on top of things. and if you have questions/concerns just keep calling, asking
robin	yea so true
moesbaby	Glad to hear I am not alone.
robin	your not Moe.. i think its best that way... but many would be mad at my comments so i try to be careful
michal69	robin, will you try again
moesbaby	This oldie is going to get ready to hit the hay. Hope to see you all on a chatroom. I go to IVFconnections.com a lot. If any of you want to chat you can email me at moesapple1@y
moesbaby	moesapple1@yahoo.com
robin	yea... its never really left my mind.. but just go to close to taking meds and needed to back off
robin	will do moe it was a pleasure speaking with you... look forward to talking with you again... soon!!
moesbaby	Good night and good luckbaby dust to all!
robin	my address is n2health@hotmail.com
robin	ditto Moes
michal69	good luck to all
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robin	Hey Mich.. whats your email
robin	i have enjoyed our chat and hope to do again sometime
robin	goodnite all
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Wenqi	good night. bye now
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The Egg Factor - Decreased Ovarian Reserve

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