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Your Question Answered

Anonymous asked:
Any comments on 5 embryos being transfered into a 40+ y/o woman using intra-fallopian transfer?

Well, Anonymous, I’m glad you asked if I had any “comments” vs. “opinions”. Because obviously I don’t know the specifics of the circumstances, so I’ll comment, but only because you asked, and please do bear in mind that I know absolutely nothing about the situation at hand.

Now that I have that out of the way, there’s another important thing to point out. You don’t say if this was Gamete Intra-Fallopian Transfer or Zygote Intra-Fallopian Transfer. Actually, I take that back – you said embryos. So I guess it’s Zygote. Though, do bear in mind that with ZIFT the fertilized eggs, as far as I understand, are transferred into the fallopian tubes immediately after fertilization, before they’ve had any time to develop in the laboratory environment.

You say that the woman is 40+ y/o, but you don’t give any additional information. Were they HER eggs used? Had she had previous ART failures? What is the reason for her doing ZIFT vs. IVF?

I’ve actually never known anyone to do ZIFT for any reason. I don’t know why anyone would. I do know people who have done GIFT for various reasons – the primary reason being religious reasons that bar in vitro fertilization, but would permit fertilization to occur within the woman’s body where medically chances would still be greater by going through egg retrieval for whatever reason. Still, GIFT and ZIFT are becoming a far less popular. Many clinics don’t even offer ZIFT at all (and many also don’t even offer GIFT either). Actually, even the people I know who have had GIFT – well, I don’t know anyone who’s had a successful GIFT cycle (and like I said, I don’t know anyone who’s done a zygote transfer at all).

My quick little bit of research with Dr. Google suggests that the “normal” number of embryos to transfer in a ZIFT cycle is between one and four. So five is out of that range, but not significantly. Further, the success rate with ZIFT is approximately 26% and the chance of multiple gestation if you do get pregnant is 35%. My guess is that there’s also a slightly higher rate of ectopic pregnancy with ZIFT than with IVF also, but of course IVF raises your rate of ectopic pregnancy over spontaneous pregnancy anyway.

Frankly, I can’t find a single article via Dr. Google that suggests any reason for doing ZIFT over IVF. Does anyone know? I can understand the reasons for doing GIFT, but ZIFT? It’s more expensive, more risky, less successful, has a high rate of multiple pregnancy when you do have a successful pregnancy (not very often), involves invasive surgery, and doesn’t have the advantage that GIFT has of having fertilization inside the body thereby avoiding the ethical/religious issue that IVF has for some people. So what gives?

Oh! I *just* found one thing suggesting a reason to do ZIFT. ONE! From the Huntington Reproductive Center:

The use of ZIFT is not that widespread. However, at HRC we have leaned towards performing ZIFT on a select group of patients because early on we noticed an increase in pregnancy rates especially amongst older patients and those with unexplained infertility.HRC’s overall take home baby rate for 500 egg retrievals performed for ZIFT is 48%. This elivered rate includes 81 egg retrievals performed on patients over 40 years of age.

The above data suggests that at our center patients who have had multiple failed IVF cycles or who have patent tubes but are older should consider ZIFT/TET as a treatment option. It is possible that the fallopian tube may have the capacity to rescue “marginal embryos” as well as allowing the developing embryos to remain in the tube and then as in a natural pregnancy move into the uterus at the appropriate physiological time for implantation.

At last! A reason!

Okay, so let’s assume this 40+yo woman has had multiple failed IVF cycles and she has marginal embryos. Let’s also remember that the ASRM/SART guidelines for IVF (and I can only assume that they’d be the same for GIFT) for a woman that age is to not transfer more than five embryos in a cycle. So five embryos is within those guidelines.

Would I do it? Would I take that risk? No. But I’m 33, and I already have kids, so it’s easy for me to say, isn’t it? I’ve also had a set of HOMs and I’m flat out petrified of that happening again, but the risk of HOMs in a woman over 40 is much lower, because, frankly, the pregnancy rate is much lower. So I don’t have the same circumstances.

SO… all that being said – I’ll have to assume that this mystery 40+y.o.’s doctor was acting responsibly with her best interests in mind with the best available medical literature at his or her fingertips. And I wish her the best of luck and a healthy SINGLETON pregnancy as a result.

I’m filing this under “FAQ’s” even though, clearly, this is not a frequently asked question.

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A Fair Question

Anonymous asks, re: my post about PIO counteracting my Allegra…

Could you actually be allergic to the PIO?

I could be, sure. But it’s unlikely. I’m not displaying symptoms in a way that would suggest that. First, my allergies are at their worst when I’m in my house. Around my cats. Coincidence? I think not! Second, if I had an allergy to the PIO, it is unlikely that it would come across with symptoms similar to seasonal and cat allergies.

More likely, I’d be reacting to the sesame oil. But, though I don’t care for sesame a great deal, I’ve never had a reaction to sesame in anything. But if I were to have a reaction to the sesame, I’d probably have an on-site reaction at the injection-site first. It would be itchy, possibly red and swollen. If it were a terrribly bad reaction, I imagine I could even have a systemic, anaphylactic reaction. But – thank heavens, I am not allergic to sesame.

As for the progesterone … according to the all-mighty pharmacist in my household, the progesterone in the PIO is derived from potatoes. Or yams or something. I don’t know, I’d like to say I was hanging on his every word, but something about it’s easier to derive from a plant substance than to weasel it out of a human being or whatever. So, unlikely that I’m having an allergic reaction to that either, unless there was some kind of impurity in it from the manufacturing process, but that’s unlikely, and again – the symptoms I’m having are unlikely to be the result of this kind of allergy.

Now, there is some evidence of estrogen and progesterone allergies, but those are with naturally occurring estrogen and progesterone – and those “allergies” are linked with menstrual-cycle-related asthma and migraines. Neither of which I have (I do have migraines, but mine have no relationship to my menstrual cycle whatsoever).

Dr. Beer suggests that there is evidence of a progesterone allergy, stating: Some autoimmune women develop allergies to their own hormones, including progesterone. The antibody which they have produced can be detected by looking for progesterone antibodies in the blood or by doing a skin test that shows the allergy to progesterone. These antibodies further decrease the levels of progesterone in the blood. The cells responsible for this are the CD 19+5+ cells. By 10 weeks of pregnancy these cells are usually suppressed to normal numbers and the progesterone allergy is less of a problem.

But, again, there’s no suggestion that this should, say, make me sneeze.

Truthfully, it could just all be coincidental. But I think there *might* be a relationship. When I was pregnant, my Allegra all-out stopped working and I was miserable for months until *boom* it started working again. And I know that “they” say when you’re pregnant, allergies are often exacerbated. So I suspect that there is *some* correlation between the worsening of my allergy symptoms and the high levels of progesterone in my system right now. My guess is that the Allegra just isn’t able to counterbalance it right now.

That’s my theory anyway. And we all know my theory is worth exactly what you paid for it.

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While I do try to keep this particular blog focused specifically on issues of infertility, IVF, cycling, etc. I also recognize that I confuse my readers by posting things without a lot of explanation sometimes. Not all my readers are Jewish, so I get a lot of questions (usually via email) regarding the Jewish terms and customs I allude to. Since my last FAQ sparked two Jewishly-related questions, I’ll post them here, though I’m pretty tired and foggy, so no guarantees on my coherence…

Q: what exactly is shabbos prep? while i lived in a neighborhood with large orthodox jewish population for several years and am familiar with some of the practices, there are a lot of things with which i’m unfamiliar.
So… on Shabbos (the Sabbath), there are lots of things we don’t do. It is a complete day of rest, in which normal weekday activity is suspended. No cooking, no affecting electricity (in other words, I don’t turn on lights, but neither do I turn them off – so it’s not like I’m sitting in the dark all day), no driving, no sewing, computer, no phone, no um, winnowing, no, well, lots of other stuff. So, while I don’t love to describe Shabbos as a series of negatives, go with me here on the set up, okay?

You can imagine that with all of the things that I can’t do, in order to have a day completely set apart from the rest of the week – a day focused completely on my family, my faith, and my community – I have to make sure that my house and my meals are completely ready before the sun sets. I should also point out that the Sabbath is a day of celebration, every week. It is a Holy Day – and it is special. Our houses should be clean, we use our finest china, our nicest table cloths, we cook our nicest meals, we have guests or we are guests at other peoples’ homes (right, because we get so many invitations out these days…but I digress). Anyway, all the cooking for three meals (Friday night dinner, Saturday lunch, and a lighter “third meal” Saturday late afternoon/early evening, depending on the time of year) has to be done ahead of time. Children, if you have any, should theoretically be clean (hah), and changed into Shabbos-clothes (good luck with that) before sundown. At the very least, a tablecloth should be put on the table before you light candles at sundown, but preferably, the table should be fully set (this is brilliant if, like me, you have cats … again, good luck with that. And if you’ve got a toddler in the house? I highly recommend against setting the table before you absolutely must).

So, um, those are the basics. There’s cooking. And cleaning. Oh, and making sure all the lights, etc. in the house are where you want them to be, since you can’t change them once Shabbos starts. It’s always a whirlwind at the end here. It’ll be interesting to see what happens tomorrow when I can’t be lifting my kids, running around, standing in the kitchen, or any of that stuff… But, it’s not like I’ve never been on bed rest before.

Q: I agree that Jewish law regarding embryos is complex, but I’m confused by your saying there isn’t a lot of choice involved because of the complexity and don’t understand what you are indicating.

I’m actually not going to get too deep into this, because everyone’s rabbi poskens differently on this. My rabbi (who has a specialty in this area of halacha) has one very straightforward opinion on the one and only thing that may be done with leftover embryos that are not going to be used for a future pregnancy. I have other friends (both in “real” life and “inside the computer”) whose rabbis rule the exact opposite of my rabbi – but that doesn’t mean that my rabbi or their rabbis are wrong. They simply interpret and apply the halacha (law) differently. Some Jewish legal scholars do not allow embryo donation/adoption under any circumstances. Some allow it only if you can guarantee that the embryo will be donated to a Jewish couple. Some allow it under any circumstances. Some rabbis allow embryos to be donated to research – but others require that the embryos be destroyed and discarded. The reasons behind each individual rabbi’s decisions are, honestly, beyond my understanding. While I spend a great deal of time working to understand the logic and the details behind my treatment protocols and my medical care – when it comes to the halachic details – truthfully, I simply ask for my rabbi’s guidance and leave it at that. So I won’t speak for his answers, I will simply say that I haven’t been left with a lot of choices in terms of the disposition of any leftover embryos once our family building is complete.

But, I’ll point out, I haven’t made any firm commitments on when our family building will be complete.

Anything I missed?

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I know, I know, ever since my recent media appearances, it’s been hard to escape my adoring fans, the ruthless paparazzi, the constant phone calls, the text messages, the overflowing mailbox, the neverending emails… It’s a hard life, but someone has to live it, right? At least I can say that stardom has most definitely NOT gone to my head.

So you, my adoring fans, have questions. And, it turns out, I have a couple of answers. . .

Q: What time will your transfer be tomorrow?
Well, I’m glad you asked. Because I just got a call from my nurse answering that very question! I’m scheduled for 11:15 tomorrow morning. Be there at 10:45 with a “moderately” full bladder and instructions not to use the bathroom upon arriving at the office. Now, I find this incredibly hilarious. Have you ever tried to exactly provide a “moderately” full bladder? Yeah, it doesn’t happen. Either you end up with an empty bladder, or you’re sitting in the waiting room absolutely DYING and eventually a nurse says, “Okay, you can pee, but only THIS much.” And really, have you ever tried to pee just, say 30ccs with a completely overflowing bladder?? Yeah, it doesn’t actually work that way. So good luck with that. (I will say that the serious advantage of having had HOMs is that I never had to have bladder-filled ultrasounds in my pregnancy… that would have been sheer misery)

Q: But what about Shabbos preparations? How will you manage?
Fortunately, I’m not the only super-hero in my household. My husband, darling man that he is (see? I can say that now that I’m not on Lupron!), can totally handle Shabbos prep all on his own. That, and I’m going to cook as much as I can tonight so that it doesn’t ALL fall on him.

Q: How long will you be on bed rest?
My clinic, apparently, is “East Coast Conservative” on this issue. There have been several studies done on the benefits of no bed rest after transfer vs. 24 hours vs. 48 vs. 72 etc. So there’s some benefit to bed rest, but 72 hours seems to (maybe) be overkill. So we’re a 24-hour clinic. Look at me, referring to the clinic staff as “we”. Yeah, I’m there so much I feel like I work there. I assure you, I don’t. Though for all the free press I give them, I ought to be on the payroll.

Q: If you have 3 good embryos and they implant 1 and you freeze the other two and the first embryo takes and results in a successful pregnancy what do you do with the other two embryos?
Well, first I’m going to nitpick here a little – Doctors can’t implant embryos. They can only transfer embryos into the uterus and hope that it implants into the uterine wall. Implantation = pregnancy (though no guarantee of ongoing pregnancy). If doctors could implant embryos (and who knows? Maybe someday they will be able to!), they would always implant a single embryo in all IVF cycles – because it would be a 100% initial pregnancy rate. The media, for WHATEVER reason has never been able to keep these terms straight. For crying out loud, the frickin’ New York Times can’t even get the term right. If they can’t, who can we expect to get the term right? The problem with getting the term wrong is that it causes the general public to have a skewed view of the reality of fertility treatment. It makes the general public believe that IVF is more of a sure thing than it is. While IVF success rates have skyrocketed in the last several years, it is still not a guarantee. And when the general public perceives that every cycle is a guarantee that each embryo transferred equals a guaranteed baby, they think that women who come out of fertility treatment with multiple babies had it coming. And frankly? That’s unfair. So I’m on a mission to blot out the misuse of the term implant.

But I digress, because I didn’t actually get to the heart of your question, did I? You want to know what I’ll do with any leftover embryos should I have any frozen and should I get pregnant on my first go-round.

Well, I imagine the author of this article would have you believe that having any frozen embryos from this cycle would be an irresponsible consequence and rather poor planning on my part. And, further that the only morally acceptable choice for any remaining embryos that we have would be to enter into an embryo adoption program. But… that author probably never went through IVF himself. I daresay he actually never spoke with an actual IVF patient. And, further, probably never actually spoke with a reproductive endocrinologist or fertility science researcher. No, I’d guess that he never read beyond the abstracts of the studies he cited or the party lines of the political think tanks he references. Instead, he proudly waves the banner of prochoice moralism and dismisses any opinion other than his own, woefully uneducated one.

Right. Off soapbox now (but for a brilliantly written soapbox on this very article – I highly recommend Akeeyu’s post!)

Clearly, I didn’t have the luxury of telling my doctor to make sure to only create one embryo and make sure there were no others that survived. (I mean, that very well may still happen – but if it does, that’s Darwinism in action, not anything pre-planned). I certainly wasn’t going to tell him only to fertilize one egg and hope THAT one was the one that lived. (Don’t worry, I don’t think you, my reader, were suggesting that I should have done so. I’m just still so pissed off at that article… which, by the way, I read over a MONTH ago and my blood is still boiling). So, sure, I ran the risk that I would make more embryos than I needed for my planned single embryo transfer.

But, then again, we also knew that I wasn’t *quite* the ideal candidate for eSET… and so we knew that I wasn’t looking at the standard 67% odds on an eSET cycle that my clinic has. I was looking at 40-45% odds going in, which SuperDoc revised to…oh, 30% about halfway through my cycle. So clearly, having some back ups? Good thing. (again, still don’t know that I’ll have any back ups…)

So what if I get 3 blasts by tomorrow? We transfer one, freeze 2. And then, let’s say, I get a BFP? (Hah! I can’t say that with a straight face yet. But for the sake of argument…) What then?

Well, we’ll start with the knowledge that I’ve already had one late miscarriage, so a BFP for me does not necessarily equal an ongoing pregnancy. So I’m not holding my breath, first of all. But… if I do get and stay pregnant and deliver my (healthy? Please God) singleton baby (9? Please?) months later… what then?

Well, I’m not promising our family is complete with one more baby. Maybe it is. But I don’t know yet. We know that right now, we want at least one more baby. And that probably is it for us. But not because we want to be done, but because of the financial hardship of having more after that point… we’re already stretched financially, so one more? Sure. But two more? Probably more than we can handle. But option one is we hang out for a while until we are certain our family is complete. And that IS the current plan.

After that, our choices are between my husband and myself, and those decisions are up to us for the moment. We do have a plan, and they are documented in our consent forms with Ye Olde Fertility Clinic (though they’ll have to be revisited at the end of a specified period of time). But it’s our plan, and ours alone. (I will say that Jewish law is pretty complex in this area, so there isn’t a lot of choice involved, but regardless, our plan is documented)

Sorry for the long answer to a seemingly simple question.

Q: What happens to those embryos that don’t make it to freezing or transfer but are still considered viable?
This question came from an anonymous commenter. I’m not entirely certain that I understand this question. Honestly, if by Day 6 the embryos haven’t made it to a stage suitable to freeze, they aren’t really all that viable any more. I’ll check with Ye Olde Fertility Clinic, but I assume any non-suitable embryos are discarded in a respectful manner.

Q: All this fine-tuning seems sensible and makes me wonder how the Hatchery does those batches when obviously tailoring to individual response is needed.
This is from the same anonymous commenter. Yes, YOFC has been doing very sensible fine-tuning, which is fantastic considering that YOFC is an enormous clinic. Other clinics in the area accuse my clinic (without naming names, of course) of being a “revolving door of doctors” and tout themselves as being able to individualize care in a way that the “bigger clinics cannot”. I’m here to tell you – YOFC individualizes every patient’s care and treatment plan. They don’t just have one set protocol and squeeze each patient into it. They have been extraordinarily flexible with my protocol, recognizing that the fine tuning is where the success will come from.

As for The Hatchery – they do batch their patients for the start of their cycles (every two weeks), but they almost have to do so because they have one doctor and one doctor only. This gives him the ability to have one retrieval weekend and one transfer weekend per month on average according to his nurse. But he, too, has built in flexibility. And because he sees fewer patients, he’s able to individualize care plans very easily as well. For example – though they have never done an elective Single Embryo Transfer, and he wasn’t totally comfortable with the idea of having his hands tied on that issue (me saying that under no circumstances would I allow him to transfer two), he was willing to work with me on that. He never takes his patients to blast and always transfers on Day 3. Why? Because when he was doing blastocyst transfers, he found that he had a much higher pregnancy rate, but no more babies. His ongoing pregnancy rate didn’t change with blastocyst transfer. He couldn’t figure out why, either. However what he did say was that with me and me alone he was thinking that to do an eSET, what he’d probably do would be to take me to blastocyst before transferring. So he was definitely flexible in terms of the protocol and the timing, etc.

Obviously, with the batching, there is occasionally some overlap of patients, but it is kept to a minimum for him this way.

Any other questions??

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Lori asked, Why would you both need to take Doxycycline in the last year? That is just strange. No one ever cared if my husband took an antibiotic during our infertility journey.

Well, Lori, you got me. Now, I understand the reason to take Doxycycline during a cycle in general, but why on earth taking an antibiotic any old time at all in the last year matters is beyond me.

Per the Arizona Reproductive Medicine Specialists, Doxycycline, an antibiotic administered in pill form, is given to the male partner during the wife’s stimulation cycle to further reduce the low levels of bacteria that may be found in the semen and which may compromise the performance of the sperm during an IVF cycle.

Now, personally, I think it’s a bunch of crap. I think there’s a lot of voodoo in IVF cycles that’s done just for the sake of “Well it helps a teeney weeney tiny percentage of patients, and it doesn’t hurt any of the other patients, so we may as well make ALL of our patients do it.” Like Progesterone in Oil injections, for example. Crap, absolute, complete crap for most patients. My perinatologist told me the literature absolutely does not support the routine use of PIO injections for IVF patients – and yet, virtually all IVF patients in the US are routinely tortured with these thick, awful, painful injections for weeks at a time. For what? For a theory that it can’t hurt, and it might help.

Which brings me back to Doxycycline. Sure, there may be a VERY small percentage of patients whose male partners have low levels of bacteria in their semen which are causing issues with sperm performance or with implantation. And yes, it could be that taking Doxycycline during the stim cycle of a woman’s IVF cycle helps reduce those low levels of bacteria. However, for most patients, those low levels of bacteria are completely normal and are causing absolutely no issues whatsoever. In this case, of course, what’s the harm in taking five days of an antibiotic, just for kicks? Not much, unless you start getting into all the arguments of why one shouldn’t needlessly take antibiotics willy-nilly.

So no harm, no foul, but I’m not all broken up about the fact that my nurse isn’t making my husband take those darned pills.

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