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Third Party Reproduction - When Is It Time To Move On?
October 9, 2007 - Tuesday
1:21 PM to (EST)
Guest Speakers: Guy Ringler, M.D.
Categories
Donor Egg •
Fertility Drugs •
IUI •
IVF •
Pregnancy
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| meisha | hello |
| Corey_Whelan | hi everyone, welcome to tonight's AFA chat. I'm Corey Whelan, your moderator tonight and the AFA's Director of Development. Tonight we are very pleased to have Dr. Guy Ringler, of California Fertility Partners as our guest speaker. Dr. Ringler will be here in a few minutes and will be discussing third party reproduction. |
| Corey_Whelan | so hi! Guess we're a crowd of next steppers tonight. |
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| Stacie | Yes... never thought I'd be here, but here I am. I know I'm not alone. |
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| guy_ringler__m.d. | Welcome everyone.... |
| Corey_Whelan | Hi Dr. Ringler, thank you so much for joining us! Folks, please feel free to jump in and ask your questions of Dr. Ringler. |
| Milena | When is it time to move on? |
| Corey_Whelan | Milena, how many cycles of IVF have you done? |
| meisha | Hello Dr--thank you for your time tonight--Milena has a good question and is what we are pondering as well |
| guy_ringler__m.d. | It depends on age, responsiveness, and how many cycles of IVF that you have tried. |
| guy_ringler__m.d. | The most important factor affecting IVF success rates is age |
| Stacie | I'm always looking for assurance that taking the next step is appropriate. We starting trying for a child when I was 31... I'm now 35. I've had 6 miscarriages, done 4 IUI's, 3 IVF's. Our next step is donor egg from my sister since my FSH is slightly elevated at 12.3. |
| guy_ringler__m.d. | Age affects the quality/viability of the eggs that are developed in the cycle. |
| sb10847 | Define good responsiveness for a person in the 38-40 yo range with regard to IVF |
| pamelah | I just turned 40 and have had one cycle of IVF with one blocked fallopian tube. My Dr. basically said it wasn't worth it to try again. |
| meisha | yes, i am 38 and we have done 2 IUI's--our DR says that we are not 'candidates' for doing an IVF, so we have started thinking about 'alternativess' |
| guy_ringler__m.d. | At age 38-40 we hope to transfer four good embryos. To obtain four good embryos we should have 6-12 eggs in a cycle |
| guy_ringler__m.d. | With higher egg number we can ultimmately be more selective about which embryos are transferrred. |
| guy_ringler__m.d. | if you only have 1-2 embryos available at age 38-40, it willl affect your success rates.. |
| pamelah | I had 12 eggs retrieved, but only one turned out to be a somewhat viable embryo. Does the quality of the eggs change from month to month -- or might there still be some "good" eggs left? |
| guy_ringler__m.d. | Donor egg is an option for women who do not respond well to gonadotropins...low responderss... |
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| meisha | Our Dr immediately recommended DE, but we are hesitant b/c we would really like to try with my eggs--at what point do we give up trying w/my eggs and seriously think about DE? |
| pamelah | yes, that's the question! |
| guy_ringler__m.d. | egg quality is affected by age, an individuals own genetics, and how the ovaries are stimulated.....you may want to try a different stimulation protocol....or approach. |
| guy_ringler__m.d. | meisha - why are you not an ivf candidate? |
| guy_ringler__m.d. | pamelah - was there an egg factor? why only one good embryo? |
| meisha | b/c our DR said with my FSH baseline level at 20, we would not be able to get pg w/IVF |
| meisha | i did the Clomid test and it only came down slightly--does that REALLY mean I do not have any 'good eggs'? |
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| guy_ringler__m.d. | the fsh level affects responsiveness to medication, but not pregnancy rates directly.. |
| guy_ringler__m.d. | if you do not produce multiple eggs in response to meds, you will have lower success with ivf... |
| meisha | so does that mean b/c i did not respond well to Clomid that it is probable that i will not respond well to FSH inj? |
| guy_ringler__m.d. | the clomid test is like the fsh test - it predicts repsonsiveness to meds, |
| meisha | it's a different drug, so is it still possible to have a good response to FSH but not the Clomid? |
| guy_ringler__m.d. | ideally we like your fsh to be less than 10, but you will respond if it is 10-15.......another predictor of response is the number of basal follicles on cycle day two.... |
| pamelah | yes, I guess there is an egg factor - determined because the fertilized eggs appeared "unfit" within the first 2-3 days of harvesting |
| guy_ringler__m.d. | remember it's age most importantly affecting the egg quality..... |
| guy_ringler__m.d. | some patients are found to have "poor egg quality" during ivf.....due to and invidual's genetic make up or possibly how the ovaries were stimulated... |
| sb10847 | Scenario: Again, 38-40 yo, 2 IVFs- both with good response (16 eggs), both with Day 5 transfer of 2 blasts - No pregnancy.....Try IVF again? |
| guy_ringler__m.d. | if the finding is persistent in repeat cycles, on different protocols, it is a good time to consider donor eggs |
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| guy_ringler__m.d. | age 38-40 with two blasts should give you 40% preg rate per cycle,,,.it may take more than two times.... |
| guy_ringler__m.d. | the decision to move on to donor eggs is deeply personal |
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| Corey_Whelan | welcome karz. Please feel free to jump in with your questions for Dr. Ringler at any time. |
| guy_ringler__m.d. | pregnancy rates are higher with donor eggs....but you must be comfortable using the genetics of another individual. |
| pamelah | are egg donors screened for genetic issues, etc.? |
| guy_ringler__m.d. | egg donors are screened for cystic fibrosis and other genetic diseases basedupon their background. |
| guy_ringler__m.d. | it's a good idea to check a karyotype also.....to rule out a translocation. |
| sb10847 | As a physican, what have you found to be the most difficult part for a woman who uses donor eggs, making the initial decsion to do so or navigating the logistics of finding a donor? |
| guy_ringler__m.d. | definitely, the decision. |
| guy_ringler__m.d. | it's personal and emotional. |
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| guy_ringler__m.d. | your physician can help direct you todonor agencies |
| pamelah | what is the likelihood of pregnancy success with donor eggs for a 40 year old who has never had a pregnancy |
| pamelah | what's a karyotype? |
| guy_ringler__m.d. | you want to use an agency the follows the asrm guidelines and will look out for your benefit. |
| meisha | can you tell us what is financially 'cheaper'--donor egg or donor embryo? |
| guy_ringler__m.d. | karyotype is a blood test that indicates your chromosomal number and whether there are any re-arrangments. |
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| guy_ringler__m.d. | the success rate with donor eggs is approximately 60-65% per embryo transfer cycle....the costs vary depending on donor and agencies... |
| Corey_Whelan | Hi Frances, welcome. Please feel free to jump in and ask your questions about third party reproduction |
| guy_ringler__m.d. | i tell my patients to expect the cost to be about double the cost of an ivf cycle. |
| guy_ringler__m.d. | donated embryo programs are less costly. |
| meisha | for donor eggs or donor embryos? |
| guy_ringler__m.d. | donor embryo cycles will be less costly... |
| meisha | do you find more women go with D embryos or DE? |
| guy_ringler__m.d. | the costs for donor egg cycles are due to the cost of an ivf cycle (which the ed undergoes) plus costs related to recipeint monitoring, plus agency costs, plus donor reimbursment... |
| meisha | if we can't do IVF, what else would you recommend? Is our only 'alternative' to go with DE in your opinion? |
| guy_ringler__m.d. | Donated embryos are harder to comeby.... |
| guy_ringler__m.d. | if you do not produce enough eggs for ivf, and your tubes are open, you may want to try a few additional iui cycles.. |
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| guy_ringler__m.d. | has anyone undergone a donor egg cycle? |
| meisha | is your thinking b/c i may have a few good eggs left, so we might as well try a few more IUI's and see what happens? should i try the FSH inj or is that a 'waste of time'? |
| guy_ringler__m.d. | if you have several basal follicles on each ovary and your fsh is less than 20, you can still make multiple eggs and would have a chance for pregnancy |
| meisha | ok--another question--i have read on forums that women's FSH levels vary quite a bit--high, then low, then high again--what would be causing that? I don't want to get excited if my FSH level goes down to 10 knowing that I started w/ 20! |
| meisha | i have also read that women get pg with insane FSH levels--25, 30, etc--is that just 'luck'? |
| guy_ringler__m.d. | the fsh level can vary from cycle to cycle.....the more often that it's elevated the less responsive the ovaries will be...o |
| guy_ringler__m.d. | fsh levels are just one of the indicators of ovarian reserve... |
| meisha | but i |
| guy_ringler__m.d. | basal antral follicle count is another excellent predictor. |
| meisha | but I thought that was the "biggie"? |
| ann | I am 40 and have normal 3 day labs, doc says I stim like a 25 year old, embryo quality looks great but all I get is a chemical pregnancy. Last cycle 225 follistim 1 menopur 11 embryos 10 of them 8 celled grade 2. Grade 1 is the best at my clinic. Beta is this thursday , this is a frozen transfer. PGD is not an option for us. Catholic. This is my third cycle. We can do it about 2 more times is it worth it? |
| guy_ringler__m.d. | i have had patients concieve with fsh levels of greater than 20.....it doesnt predict pregancy. |
| meisha | that's good to hear! my DR says that it is the biggest predictor of pg! maybe i should find another RE!? |
| guy_ringler__m.d. | ann how many cycles have you had? |
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| guy_ringler__m.d. | it's always good to get another opinion....different re's have different stimulation philosophies,e tc.... |
| guy_ringler__m.d. | ann - just saw it was your third....yes, yyou should try again, but need to be re-evaluated to make sure that nothing else is preventing success.. |
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| ann | What should we test for immune is fine, fsh is a 4 just older eggs? I don |
| ann | I don't feel like a dinosaur. |
| guy_ringler__m.d. | re-evaluate uterus, check thyroid, etc. |
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| meisha | are my chances "better" since I just had an HSG done yesterday and my DR said everything looked 'perfect'--no blockages, uterus looks great? |
| ann | Doc is one of the best Kevin Winslow in Jacksonville , I really like him |
| ann | I've had a lap and 2 hsgs. Is it really just a numbers game or do some women just make more abnormal embryos? |
| guy_ringler__m.d. | yes, the hsg is a good test for the uterus.... |
| guy_ringler__m.d. | another way to evaluate the uterine cavity is an office hysteroscopy..or sonohysterogram |
| guy_ringler__m.d. | yes.....pgd studies have taught us that some women do have a higher % abnormals than predicted.. |
| meisha | but at this point w/not having tried any other drugs other than the Clomid, should I just wait and see before I do any more 'testing' of my uterus in case that is not the cause of the problem? |
| guy_ringler__m.d. | it's encouraging to me ann, that you respond well and have good quality embryos.... |
| ann | If I had all abnormals in one pgd is that the likelyhood predictor of all future cycles? |
| guy_ringler__m.d. | meisha - it's important to check your fsh levels several times... |
| meisha | why? b/c if they can vary from cycle to cycle what am i really looking for? |
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| guy_ringler__m.d. | no, pgd cannot predict that all embryos will be abnormal, but it's an indicator....just one variable to use... |
| guy_ringler__m.d. | everyone has to decide what their own endpoint is... |
| guy_ringler__m.d. | when to move on to donor egg.... |
| elephantee | i'm joining this chat late inthe hour |
| guy_ringler__m.d. | undergoing ivf is draining - emotinally, physically, financially.... |
| elephantee | may i ask a question |
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| guy_ringler__m.d. | if there is a suspected egg factor - it's a way to bypass that problem.. |
| ann | I pray and believe God will give us the family we are ment to have. I am very resillient. Is 6 cycles reasonable for me or will it drop off. I have done 3 fresh and am awaiting my frozen results in less than 48 hours. |
| guy_ringler__m.d. | yes |
| elephantee | i am 43 year old, fsh 8.9 and had my first and only round of IVF in June. Did not succeed. Dr. told me that my eggs too old (based on appearance, misshappen) and that I should consider donor eggs rather than proceed with another IVF. What do youthink? |
| guy_ringler__m.d. | i think that six cycles is a reasonalble endpoint based upon your history....it doesnt hurt to have another RE look over your files even if you really like your doctor - just to get another's opiion... |
| elephantee | i went to another RE and was also told likely my chances of success with IVF and my own eggs are less than 5%, same as if I went with IUI. |
| guy_ringler__m.d. | pregnancy rates are low at age 43.......with poor egg quality, even lower.....donor egg sounds like a good medical recommendation. |
| elephantee | how is poor egg quality be determined ? |
| guy_ringler__m.d. | yes, as you approach the mid-forties that benefit of ivf over iui, in terms of success rate, rapidly diminishes... |
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| guy_ringler__m.d. | age, appearance of the eggs in the dish, how the membranes respond to icsi, how the embryos develop in culture... |
| ann | If you have bleeding with cramping during a transfer can that affect the outcome? Previous re could not navigate my tilted cervix, Kevin is fine. |
| meisha | if I do several FSH level testings, what is the best 'indicator' that my chances are still good? another words, i started at 20, even if went down to 7, does that really mean i have a good chance for pg? |
| guy_ringler__m.d. | yes, difficult transfers result in lower pregnancy rates. |
| guy_ringler__m.d. | pain and bleeding will reduce success rate...the transfer should be painless..... |
| guy_ringler__m.d. | pain is an indication that the uterus is cramping which can push out theembryos.. |
| ann | I wish I could see you. I even had one stuck in the catheter with previous doc. Can this hurt my chances as well. |
| elephantee | i also had a very uncomfortable retrieval- i was so tense and they maxed the anaesthetics. is there some way to be anaesthetized (general) during IVF? |
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| guy_ringler__m.d. | if you have more that two FSH levels over 20, the chances are very, very low....if the other levels are all normal and you have normal basal antral follicle counts, you will have a chance... |
| bran | I have done 2 ivf cycles...the highest my FSH has been is 10...I'm 34. Good responder and over half fertilized with ICSI...very few made it to transfer. My RE thinks it is an egg quality issue and I'm not sure why? |
| guy_ringler__m.d. | the egg retrieval should not be painful during the procedure.... |
| elephantee | i was very uncomfortable, and it took 45 minutes. partly had hard time aspirating follicles. had 5 but only 3 eggs retrieved. and didn't look good. |
| meisha | thanks for your time and helpful information--good luck to everyone! |
| guy_ringler__m.d. | try another stimulation protocol.....hcg timing is important...if given too late the egg quality may be affected.. |
| shaymer01 | If you bleed during the retrieval and monsels is used, is this bad for transfer and outcome? Can this cause intrauterine scarring? |
| elephantee | thanks dr. ringler, were you referring to me re: hcg? |
| guy_ringler__m.d. | you may want to consider another center....you should not be feeling pain during retrieval. |
| guy_ringler__m.d. | yes....if the ovaries are stimulated too long....follicles too large...can "over cook" the eggs and affect quality.. |
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| bran | thank you...if FSH and other hormones are normal and I'm a good responder, do you feel like a change in stims or HCG timing would be the best shot or could there still be an egg issue? If so, how likely? |
| guy_ringler__m.d. | no, vaginal bleeding after retrieval will not cause scarring.. |
| ann | Thank you dr. you have helped me sort through my changing reality of my treatment . Have a good evening |
| guy_ringler__m.d. | some individuals have "egg factor" that we cannot find the cause of.... |
| guy_ringler__m.d. | it's good to get a second opiinon from other RE's in these cases... |
| guy_ringler__m.d. | if the egg factor is repetitive from cycle to cycle, donor egg is an excellent option. |
| Corey_Whelan | folks, our chat is pretty much over, it's 8:59 and the hour got away from me! I want to thank you all so much for all of your questions tonight and thanks especially to Dr. Ringler for taking the time to be here with all of us tonight. Thank you! |
| bran | thank you. my re looks for follicles that are 1.6 - 2.0. do you agree with this size range? |
| sb10847 | Thank you so much. |
| guy_ringler__m.d. | Best of luck to everyone..... |
| elephantee | thanks so much! |
| Corey_Whelan | Folks, please consider making a donation to the chat series through The AFA website. Thanks to all of you for being here. |
| guy_ringler__m.d. | hcg when two lead follicles are 17-18... |
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| shaymer01 | ty! |
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