IVF Consult Appointment

I didn’t do quite a good job at writing down everything during our appointment on Wednesday, so I need to get this out of my brain asap.  I have summarized the general gist of the appointment and, to satisfy my Type A, I have written answers to all the questions I wrote down. Summary of Appointment

• We’re healthy and don’t need to add on too many supplements.  However, with a little nudge, my RE said that I could take 25mg/3xday of DHEA and 600mg of CoQ10 to quiet my need to “do something”.  No major lifestyle changes needed.  Keep the coffee and alcohol consumption in check and, his words, “try not to obsess”.  Great advice, but umm, fixating on things is part of my personality.  An IVF cycle is not going to cure me of this.
• Protocol – EPP and Antagonist.  My nurse went over our general timeline and the meds we will use.  EPP will start beginning of March and IVF cycle will be April.  I originally was hoping to do a Feb/March cycle, but we are on vacation the first week of February and some other odds and ends so March/April is probably best.  Plus, it will take some time to get the pre-authorization from insurance.
  • Mock embryo transfer as soon as possible.  I want to do this in Feb, but I think that is when we will be on vacation.  Ahh.
  • Vivelle Patch
  • Ganirelex, Gonal-F, Menopur are all listed on my worksheet.  We’ll start on a high dose
  • Expect 6-7 eggs
  • ICSI due to T’s morphology.  80% fertilization is typical
  • No PGS this cycle.  If I continue to miscarry / embryos don’t develop we will discuss for a possible IVF #2 cycle.
  • Transfer 1 or 2
  • Light activity for 2-3 days after transfer

Detailed question and answers below.

Lifestyle – Am I taking the right set & doses of supplements? (I have seen DHEA, Vitamin E, Vitamin C, coq10, prenatal, folic acid.  Right now I take a prenatal with DHA, B-complex, 1,000 IUI Vitamin D, and 400 mg coq10).  My RE is of the opinion that there isn’t strong research to suggest that additional supplements would improve  our results and chances.  He did say that it doesn’t hurt anything, and if I want to try it, that he has no objections.  So I can take 25mg/3xday of DHEA and 600mg of CoQ10.  He indicated that T’s low morphology results likely won’t be improved with supplements.  I still want T to take them, he has objections.  More on that in another post.   – Should I be avoiding alcohol? Caffeine? Exercise? For three months prior to cycling? During my cycle? During stims?  The RE said we are both healthy and have nothing to really worry about.  He said to keep caffeine and alcohol under control.  My plan is limit caffeine and alcohol during our stim cycle.  I am sure that once my ovaries blow up I won’t want to run and exercise too much so that too will likely be when I start taking it easy.  Exercise relaxes me, and I need a ton of that right now.   – Update: Is there a way to get T’s morphology up with supplements and lifestyle (reduce caffeine and alcohol?).  Could his low morphology explain the RPL?  I have read that there could be a relationship to DNA fragmentation and then to mc?  We really didn’t get into this too much.  But supplements likely won’t drastically improve the morphology rate.  We didn’t address how morphology could cause RPL.  

Protocol – In your experience, does taking the aforementioned supplements actually make a difference? In AMH/FSH levels? In number of eggs retrieved? In embryos that make it to blast? In ultimate pregnancy outcomes?  The RE doesn’t see a strong correlation in his experience.   – Do you recommend low stim vs high sim given DOR?  (I have seen various protocols for DOR be fellow bloggers.  By far, I typically see antagonist (Ganirelex) some with EPP to increase quantity (in lieu of BC, or if BC is used it is over shorter time period to not over suppress my ovaries).  Common stims seem to be Bravelle and Menopur (to help with egg quality).  Alternate protocols are microdose Lupron, mini-IVF (to not affect quality), agonist/antagonist conversion (need to read more up on Dr. Sher’s research).  My protocol will be EPP (Vivelle Patch), Antagonist.  He doesn’t want to over suppress the ovaries, hence the EPP.  He expects to only get 6-7 eggs (ugh), but we will be doing ICSI due to the morphology and he expects to see about an 80% fertilization rate.  

– What kind of medicine dosage can I expect and how many monitoring visits are needed? Because of the DOR, he plans to start me out on a high dose, monitor, and make adjustments as needed.  

– What kind of results (# eggs, # embryos fertilized, # potentially available to freeze) do you expect, given my test results?  If only a few eggs are retrieved would you recommend banking and doing an FET later?  6-7 eggs expected, 80% fertilization with ICSI so about 4-5 embryos.  70% of that (I think 70% is what typically makes it to 3-day or 5-day blast (?), is about 3-4.  

– Do we need any additional testing/procedures (like mock embryo transfer) before starting the IVF stims?  We will do the mock embryo transfer in February. That will be tricky timing since we go on vacation the first week of February and it needs to be done within 5-10 days of the start of my next cycle.  This will give us time to fix anything prior to the March EPP/April IVF cycle.

– Do you recommend ICSI (single transfer of sperm into one egg) or AH (assisted hatching, where they blow a hole in the outer shell of the egg) or PGS (pre-implantation genetic screening) for us?  I am especially interested in hearing more about ICSI and AH.  Does ICSI eliminate the poorly shaped sperm (you pick out the best?) to ensure good fertilization rates.  Would you also recommend PGS based on DOR and low morphology?  ICSI – yes because of morphology; AH – if needed; PGS – not this cycle.  We discussed doing PGS and the RE said he doesn’t think it is worthwhile for the first cycle.  We would definitely consider for IVF cycle 2, if there is one, if I miscarry more or if the embryos look poor prior to transfer. 

– How often are 3 day vs 5 day transfers? We didn’t discuss. – With my DOR, T’s low morphology, and history of miscarriage would you recommend transferring 1 or 2 embryos? (following national standards it seems 2 would be preferred, but SGFC pushes for 1 even for <35 age and unfavorable diagnosis)  He said 1-2, but it will be a gametime decision (we agree).  He wouldn’t recommend 3-4 (T and I don’t want this)

– What kind of medicine is needed before/after egg retrieval & transfer?  Didn’t discuss.

– Will I be on bedrest after egg retrieval/transfer?  At what times during the cycle do you recommend bed rest/time off work?  Likely will take off work the day of and after the retrieval and the day of the transfer.  They recommend 2-3 days of taking it easy after the transfer.  

– What are your thoughts on testing before beta?  Didn’t discuss

– If the first IVF is unsuccessful, what’s the protocol for a FET?  Didn’t discuss in detail.