When Enough Is Enough - Switching to Third Party Options or Adoption

July 17, 2007 - Tuesday
5:37 PM to (EST)
Guest Speakers: Michael Feinman, MD
Huntington Reproductive Center

Categories
Egg Donation • IUI • IVF • PCOS • Third Party Reproduction

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Corey_Whelan	Welcome everyone to tonight's chat. I am Corey Whelan, the AFA's Director of Development and your chat moderator tonight. I am very pleased to welcome Dr. Michael Feinman, of the Huntington Reproductive Center in California as our guest speaker tonight. Dr. Feinman is board certified in Obstetrics and Gynecology, as well as Reproductive Endocrinology and Infertility.
Michael_Feinman	One of the most difficult issues doctors who care for infertile couples must deal with is helping them decide when enough is enough. On the one hand, we do not want to take away hope. On the other hand, doctors with integrity and compassion do not want to see women going through expensive and difficult treatment with futility. On the darker side, there are accusations of some doctors extending treatment for financial gain.
Corey_Whelan	Shiraz and Marcia, welcome. Please feel free to post your questions for Dr. Feinman.
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Michael_Feinman	Clearly, the modern trend of delayed childbearing and new marriages have created a situation where older women want to have children and may have unrealistic expectations. May of these women need egg donation and one of the challenges we face is how to help such women make this decision, while not alientating them. Similarly, women who have experience multiple IVF failures often find themselves lost in a sea of choices as they try to understand which factor is failing: sperm, eggs, or uterus. Hopefully, tonight, we can address some of these sticky problems.
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jill	Hi everyone. Dr. Feinman, I have done IVF 2X and was not successful. I am 39. Both times I had two embryos put back. Should I try for more embryos or move on? I have pcos
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jill	I mean implant more at a time
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Michael_Feinman	Jill: I am a big proponent of putting in fewer embryos. However, at your age, with PCO, there may be a lower chance for individual embryos to implant. A third embryo sounds reasonable. Another option would be to use PGD to better select normal embryos.
jill	what would pgd show?
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Michael_Feinman	Which embryos are normal. You are old enough to have abnormal embryos, and young enough to get triplets! PGD could help you transfer lower numbers of embryos.
jill	wow, thanks.
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shiraz26	Dr. Feinman. My husband has low sperm count. During his first marriage they tried IVF once and were unsuccessful. I'm 34 and he's 44. We have tried IVF twice this past year. Had 2 good quality embryos put back the 1st time and 3 minimal/poor quality embryos put back the 2nd time. There is nothing the doctor can come up with as a cause. We're torn whether to try again or to just move on. Any words of wisdom?
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nkobal	i have forgotten my stats. what are the odds of a woman with PCOS conceiving naturally and taking glucophage to regulate menses
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marciatmann	Hi Dr. Feinman, I have had 2 failed IUI's and 1 failed IVF. I have also done some immune treatments and gearing up to do another IVF. How do I get to "place" that this is my last try before moving towards adoption? I always think that we can try one more time....In other words, how do some women just let go?
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Michael_Feinman	Shiraz: You might consider getting the SCSA test on your husband's sperm. If this is poor, there are a few things you can do to possibly improve the outcome.
Michael_Feinman	nkobal: If you really have PCO, the chance for natural conception are low becasue you do not ovulate. There is no good evidence that Metformin is superior to Comid for inducing ovulation. In fact, the largest study done shows Clomid is better.
shiraz26	I believe we did that. I'll have to check, we found out from multiple tests that he had low mobility and of the sperm he had he had I believe you say it, high morphology.
shaymer01	Hello Dr. I have recently had my 4th loss in 1.5 yrs (one at 9 wks, the other 3 at 5-6 wks, first 2 conceived naturally, 3rd IUI, 4th IVF). I am being told to go to donor based on my age (39) and low response to stim meds. I am having an HSG to confirm no uterine issues. I am wondering if immunity testing is a good idea at this point as I am also hypothyroid (treated) with a family history of rheumatoid arthritis.
Michael_Feinman	Marci: Although one failed IVF seems painful, if you are under age 40, there is still a strong chance that you will succeed.
shiraz26	Just googled SCSA and I don't think we did something that indepth
vjp	Dr. Feinman, I lost my tube due to an etopic. I was born without an left ovary and fillopian tube. I have had 6 failed IVF. My right ovary is perform as if I have two. Any suggestions!
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shiraz26	I also have Hashimoto's disease and wonder if that could have any effect on a successful IVF cycle. The dr. monitored my thyroid levels throughout and were satisfied with my numbers, but I still wonder.
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Michael_Feinman	Shaymer: I would recommend a hysteroscopy over HSG--more accurate. If you have anormal uterus, PGD may help you see if you are losing normal embryos or abnormal ones. If you are not generating normal embryos, egg donation should work. Immune teting is controversial; ther are some tests that are now considerd "standard." Your RA may be a factor. If so, you would need a surrogate.
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Michael_Feinman	vjp: There is an interesting test done at Yale called the endometrial function test (EFT). This test helps determine if the uterus is the problem. Your history suggests this is possible.
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Michael_Feinman	Shiraz: The theoretical realationship between Hashimoto's and reporductive failure has nothing to do with thyroid levels. It is based on autoimmunity. In my opinion, this is not a problem, but others aggressively treat the immune problem.
s1976	dr I have just been told that none of the day 5 blastocysts from IVF were frozen does that speak to the quality of the 2 which have been transferred
Michael_Feinman	s1976: NO
shaymer01	Thank you Dr. I don't actually have RA, my mom does, and my neice has JRA. Is it possible to expand upon what immune testing is standard now that I should have? I have been reading too much on the internet that makes me afraid of the NK cell possibility.
vjp	My Doctor is considering using Viagra to strenghten my lining during my next cycle. I have a lining of 7. What are you thoughts on Viagra and what is a suitable lining. If my uterus is the problem what else can you suggest.
shiraz26	Thank you Dr. Feinman, you mentioned the SCSA test, assuming it is poor (not sure) you mentioned "If this is poor, there are a few things you can do to possibly improve the outcome." What steps are those? We know he has varicose veins.
Corey_Whelan	Hi folks, are there any other questions for Dr. Feinman?
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Michael_Feinman	vjp: your family histroy is not a factor. I cannot give a detailed discussion of testing here. I would be happy to do a phone consult (if you are out of town) at 805-374-1737.
Michael_Feinman	shiraz: Correction of varicoeles may improve SCSA results. Get the test!
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vjp	Dr. considering long term health how many times should one try IVF?
shiraz26	Adding on to vjp's questio, statistically when is enough, enough?
Michael_Feinman	vjp: I know who your doctor is! That doctor claims great results with this treamtent. However, i do not believe there is a controlled study to show this works. Moreover, the molecule that acts a recptor to Viagra does not exist in women. Your lining definitely sounds thin. A treatment that I have seen thicken the lining is the short ternm use of nitro patches. This causes increased blood flow which may help the uterus. They can cause bad headaches. There is no good evidence to show there are longterm health risks to doing IVF. The answer to your question depends on age and other factors. It has been shown that for women under 40, the success rates with a fourth IVF attempt are similar to the first try.
Michael_Feinman	vjp and shiraz: There is no one answer to this question. I try to help women decide based on egg quality, embryo quality, histroy, age, and with tests like the SCSA and EFT, when appropriate. I review all the factors in the past cycles and try to figure out which piece is missing or "broken."
shaymer01	If IVF were free, I would be more willing and able to keep trying!
vjp	Thank you...this has been helpful!
shiraz26	I thought that the more attempts yoy had with IVF your chances reduced, you mentioned success rates can be similar. Thanks for this piece of information.
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Michael_Feinman	shaymer: I totally understand. That is why the answer to "when" is not always medical. That is why I try hard to help couples figure out what is wrong before they run out of money. That is also why our group has multi-cycle plans to help couples "stay in the game" longer. You can understand why i sometimes feel frustrated when egg donation is the obvious solution, but patients/doctors keep pursuing IVF---by the time egg donation is acceptable, the patient is burned out financially and emotionally.
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Michael_Feinman	shiraz: for women under 40, it takes several failed cycyles to find the few women destined not to conceive. That is why some of the immune tests, etc. are controversial. Doing nothing fancy still results in success most of the time!
shaymer01	Yes, my doc actually suggested egg donation quite early I thought. I had only one failed IVF (no eggs retrieved) and he said I was a poor responder and it would be my best chance. I had 4 eggs for IVF #2 and 3 fertilized - 2 looked 'great'. This was a chem pg and donor was brought up again. I am just at the point where I feel if I go the additional expense of donor, I also want to throw in every other possible intervention (throw everything at the wall and see if it sticks).
Corey_Whelan	folks, we're just about at the half way mark, so please don't hold back!
Michael_Feinman	shaymer: It is hard to make snap judgements here. It sounds like egg donation is reasonable at this time. Very few doctors recommend egg donation lightly.
shaymer01	Thank you!!!
marciatmann	isn't egg donation a higher margin for the doctor?
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joank	Hello Dr. - I am 35 and have "unexplained" infertility after almost 3 years of procedures. I did 5 IUI's and then on my 1st IVF I got pregnant, but miscarried at 11 weeks (after seeing the H.Beat twice) Testing showed Turner's. so for the 2nd IVF we did PGD, I had 3 "normal" embryos and we transferred 2. no pregnancy... any suggestions??
Michael_Feinman	Marcia: Not significantly. The extra work makes up for it! Even so, I do not think many doctors think about this when they recommend egg donation. They understand the difficult emotional choice this represents. I know I do!
vjp	Dr. speaking of NK Cell mine are slightly elevated. I'm a 9. What level cause concern and how should elevated NK Cells be treated?
Michael_Feinman	joank: Have you had a hysteroscopy? If so, keep trying.
Michael_Feinman	vjp: This is the most controversial of all the immune factors. Slight elevations should not concern you , since most reproductive endocrinologists do not even believe this is a valid issue.
joank	I have had the HSG. Is the hysteroscopy the fluid sonogram??
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Michael_Feinman	Joank: No. It is a scope placed into the uterus. It is more accurate at finding things like septums than either of the other tests.
Michael_Feinman	Joank: PS: You have only had one unexplained IVF failure.
vjp	Dr. I was told my embryos needed to be test before considering surrogacy. What tests are needed and why?
joank	Well, I did have a positive pregnancy test from my 2nd IUI, but the betas didn't double and they saw no fetal pole on the sonogram, so as soon as I stopped the PIO shots, it was over...
Michael_Feinman	vjp: They must mean PGD. This would prove whether or not you are having failed cycles with normal embryos. If the embryos are normal, this would increase the likelihood of surrogacy being the right choice.
shiraz26	One follow up question regarding my Hashimoto's. You mentioned: "The theoretical realationship between Hashimoto's and reporductive failure has nothing to do with thyroid levels. It is based on autoimmunity" Hashimoto's is an autoimmunse disease where my body attacks the thyroid. The 2nd IVF cycle they gave me an anti-rejection drug (can't remember the name right now) at 1 week post ET my hormone level was at a such an increased level that the dr's and nurses were expecting a pregnancy. Any chances that the drug helped eliminate any auto-immune type issues with my body and the embryo (similar to my hashimoto's I know it isn't the same just using it as reference) when I finished the drug and went in for the 1st pregnance test I was back down to a hormone level of 20 and no preg. Sorry for the long one!
Michael_Feinman	Joank: Get a hysteroscopy. Also, consider the SCSA for your husband. Poor results are associated with higher miscarrriage rates.
shaymer01	Is the SCSA a common test with recurrent miscarriage?
Michael_Feinman	shiraz: This question is too vague. Sorry. I do not know what hormone level you are referring to and that immune drug should have no effect on hormones.
Michael_Feinman	shaymer: No, but maybe it should be!
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marciatmann	Dr. Feinman: my failed IVF explained by my doctor that it was poor egg quality (i'm 38 yo). i'm suspicious of that answer because we did PGD and the first embryo was a grade 1 and the second embryo was a grade 3. Is poor egg quality still a possibility? my uterine lining is a 9.
joank	thanks!! 1 more question-- do you think I would need to PGD again wth any furture IVF's? I had 3 "normal" embroyos out of 12 tested.
Michael_Feinman	marcia: Sounds like you had adequate egg quality. I would need mor info for a definitive answer.
Michael_Feinman	Joank: PGD helps define what is going on, when you are unsure. 3/12 is typical.
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Michael_Feinman	I am not trying to sollicit patients here, but i would be happy to discuss previous IVF cycle outcomes in detail with any of you to help give you a fresh view on what might be reasoable tests or treatments, even with your own docotrs.
moondreams	Sorry for joining late...I am about to start a natural FET cycle with estrace and have a 16mm follicle. Since my cycles are far apart, not sure how fast it's growing. Does it matter if it's still hanging out around transfer time? Just want to make sure it wouldn't interfere with anything. Thanks.
vjp	Dr.after I had surgery to remove my right tube from the etopic...later that night I had 5 blood vessel rupture behind my uterus. I had to have another surgery that evening to cauterize the blood vessels. I also had two blood transfusion. My lining was a 9-10 prior to the etopic. Could that have caused a decrese in my lining?
Michael_Feinman	Sorry for the typos!
Michael_Feinman	vjp: Loss of blood supplly!
shaymer01	thank you so much doctor!
Michael_Feinman	moondreams: If you are using Estrac, this is not anatural cycle. In my opinion, the presence of a small follicle syst lie you described is not a worry.
vjp	Can you clarify your response?
Michael_Feinman	shaymer: You are welcome. good luck with whatever you pursue.
Corey_Whelan	folks, thanks to all of you so much for being here tonight and thanks especially to Dr. Feinman for giving us all so much information. Please make sure to join us next week for "Till Baby Makes Three - sex, love and intimacy". And also please, when you log off, would you mind roll calling your states? Thanks so much to everyone.
Corey_Whelan	After moondreams, our chat is officially over.
Michael_Feinman	vjp: It sounds like you have had vacular injury to the uterus which may result in less blood flow. It has been shown that thin linings are associated with decreased blood flow to the uterus.
marciatmann	Thank you Dr. Feinman!
marciatmann	I'm in California
Corey_Whelan	So is Dr. Feinman!
moondreams	i skipped lupron, thanks for clarifying it isn't a natural cycle. do you do FET in your westlake office?
Michael_Feinman	Moondreams: Of course.
joank	I am in Virginia- --the D.C. area. Thanks Dr!!
moondreams	great
Michael_Feinman	Joank. Feel free to call.
vjp	In GA! Thank you!
Corey_Whelan	Dr. Feinman, you can give your tel if you'd like
Michael_Feinman	vjp: my sister-in-law is from there. Please feel free to call.
kgrothe	In Mississippi. thanks
Michael_Feinman	805-374-1737
Corey_Whelan	good night all.
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When Enough Is Enough - Switching to Third Party Options or Adoption

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