33 Year Old Fails Multiple IUI and IVF Cycles: What Are Her Options?

Question:

Hello, first, thank you for offering this service. I appreciate the detailed responses and the stories give me hope. I am a 33 year old female from Seattle. I have a beautiful 2 1/2 year old conceived on my third round of iui with femara. My husband and I have been trying for a 2nd for nearly 2 years. My husband’s morphology is in the 3-4% range. I’ve had an extremely stressful year at work and since quitting my job, my day 3 fsh has dropped from 11 to 2. My amh is normal.

We tried four rounds of iui (intra uterine inseminations) and only had one chemical pregnancy. My doctor recommended ivf (in vitro fertilization) and we just found out today that our final round of FET was a failure. This year we have done three fresh cycles and 1 frozen cycle. We have no more frozen embryos. We retrieved 16-18 eggs each time, with 13-14 being mature and 8-9 fertilizing.  My embryo quality has ranged from 6aa to 3aa and my lining has always looked good. I did have a lap and a saline ultrasound and the physical structure looks good.

So….what are our options? Personally I’m ready for a break from IVF and I’d prefer to go back to IUI IF it would still have decent odds of success. Are there additional tests we should have? Also, what are your thoughts on supplements and / or alternative therapies like acupuncture, mayan abdominal massage, naturopathy and / or yoga? Thank you for responding to my long question. C. from Washington State

Answer:

Hello C. from the U.S. (Washington),
First, my general philosophy and recommendation is never to go backward in treatment plans.  That means don’t back from IVF (77% pregnancy rate per cycle) to IUI (24% pregnancy rate per cycle).
You have done a lot of IVF cycles and without extensive review of your records, I can’t tell you why they failed.  I am a little concerned about the embryo quality description of 6aa being your best embryos.  I presume you did Day#3 transfers?  If that is the case, although 6aa is adequate, it is not as good as I would expect.  The ideal embryo in a Day#3 transfer would be 8aa embryos.  Could this mean that there is an embryo quality problem?  Possibly.  Again, to verify I would need to see the embryology reports.

I am also concerned that you failed so many cycles, with no chemical pregnancies either.  At your age in my clinic, we have a 77% pregnancy rate per cycle with fresh embryos and a 65% pregnancy rate per cycle with frozen embryos.  Statistically, almost 90% of patients will be pregnant by 3 cycles.  If I am reading your letter correctly, you have undergone 4 cycles and not achieved a pregnancy.  That is odd for most good IVF centers nowadays.  It certainly questions whether there is an inherent embryo problem going on or the quality of your clinic.  Keep in mind that the clinic pregnancy rates are highly variable from clinic to clinic.  You can check your clinic by looking up the CDC ART annual pregnancy rates.  Look specifically at the pregnancy rate and implantation rate for your age group and see how they compare to the national statistics.

In terms of alternative therapies, I do advocate using acupuncture in conjunction with IVF in my patients.  I DO NOT advocate or encourage abdominal massage or naturopathy.  Yoga, regular massage therapy, meditation or other such psychological therapies can help reduce stress with IVF and might be helpful.  In failed IVF cycle, I also use a more aggressive protocol adding medications such as medrol, heparin, aspirin, estrogen, increased progesterone but that is my clinic specific and not necessarily done by all clinic, meaning it is not a standard of care.

Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG