Ghost - Question about low or no stim cycles

[tali]

Hi,

I am 36 and a poor responder and have had 4 failed cycles:

IVF #1 – BCP, Lupron, FSH and Menopur – Produced one mature follicle, converted to IUI - BFN
IVF #2 – Antagonist protocol, BCP, FSH, Menopur and Ganerelix – Produced 1 mature follicle, which was lost before retrieval??, explanation was that I may have ovulated on my own and I was converted to IUI – BFN
IVF #3 – Antagonist protocol, same as #2 – RE’s recommendation was to keep trying – produced 1 mature follicle, made it to retrieval, embryo did not survive
IVF #4 – Changed REs, EPP protocol, Estrogen patch, Ganerelix, Gonal F and Menopur – Produced 4 mature follicles, transferred 2 embryos (8 cell and 4 cell) on day 3 – BFN

I have always been on very high doses 400 - 600 ius. I have recently heard about low or no stim cycles and have heard that I may respond the same as I have with high doses. Although I realize that this may not increase my chances, it would be cheaper and get us more chances. My last cycle was almost 10k of my insurance money just for the meds.

We have thought about DE as a possible next option, but for now, just can't justify the cost of DE when we still have insurance money left.

Not sure if all REs do this and how the process works, I have a f/u with my RE next week and wanted to have some info on this before I talk to him. I would appreciate your thoughts.

Tali

[Ghost]

Hi,

I am 36 and a poor responder and have had 4 failed cycles:

IVF #1 – BCP, Lupron, FSH and Menopur – Produced one mature follicle, converted to IUI - BFN
IVF #2 – Antagonist protocol, BCP, FSH, Menopur and Ganerelix – Produced 1 mature follicle, which was lost before retrieval??, explanation was that I may have ovulated on my own and I was converted to IUI – BFN
IVF #3 – Antagonist protocol, same as #2 – RE’s recommendation was to keep trying – produced 1 mature follicle, made it to retrieval, embryo did not survive
IVF #4 – Changed REs, EPP protocol, Estrogen patch, Ganerelix, Gonal F and Menopur – Produced 4 mature follicles, transferred 2 embryos (8 cell and 4 cell) on day 3 – BFN

I have always been on very high doses 400 - 600 ius. I have recently heard about low or no stim cycles and have heard that I may respond the same as I have with high doses. Although I realize that this may not increase my chances, it would be cheaper and get us more chances. My last cycle was almost 10k of my insurance money just for the meds.

We have thought about DE as a possible next option, but for now, just can't justify the cost of DE when we still have insurance money left.

Not sure if all REs do this and how the process works, I have a f/u with my RE next week and wanted to have some info on this before I talk to him. I would appreciate your thoughts.

Tali

Sorry to hear of this.

I don't see how a no stim cycle could get the same response as 600 IU of FSH. FSH is no placebo. No stim and low stim cycles are associated with poor response and high cancellation rates.

At 36, the response is usually better than that.

But you are facing a double whammy. The more they stimulate you to finally get some embryos, the worse they make your endometrium. That's why the chance of success, even per transfer, is lower with these poor responders.

Normally this is the point where donor cycle IVF gets recommended, as a donor cycle would have maybe 5x the chance of success. But you have more insurance coverage, so that changes the economics because it changes who pays for it.

There are some interesting, if not convincing, reports of increased ovarian response in low responders after androgen priming. This means that some doctors think testosterone makes the ovaries more sensitive to FSH stimulation. There are two studies of testosterone patches (take a look at Balasch et al 2006, they studied patients with 2 prior canceled stims, and got decent responses from most of them) and of DHEA. The testosterone studies included only 5 days of priming, while the DHEA is often used for months. There are side effects of androgens, some you might or might not like.

Another idea is the flare cycle.

Of course, both could be used.

None of these are miracle cures, but some believe they help. Maybe they do. We've tried flare cycles and gotten some surprisingly high responses, but not reliably so. Never tried the androgens.

[tali]

Thanks so much for your response. I tried DHEA with cycle #3, took 75mg per day, for 3 months with no apparent affect.
I keep thinking that DE is the best option for us, especially since each failed cycle gets harder and harder to deal with emotionally. Kowning that my chances actually increase with DE is promising. I just need to accept the money factor....

[to_have_fun08]

Tali - I know with my insurance they will pay for the medical expenses of Donor Egg. You might want to check into it. I live in Il and their mandate covers 4 total cycles. So I am doing 3 of my own, if this next one doesn't work then might be using the 4th cycle with DE. I still will have to pay for the donor and clinic cost but insurance will pay for drugs, testing etc....


Good luck with your decision.

Chris

[santa]

Ghost, are you saying that the chances of IVF decrease with each cycle?
You said that each cycle damages the endometrium, so that would explain why IVF #6 is less likely to succeed than IVF #1?

My RE said that each cycle is brand new, in the sense that there is the same 10 or 15% chance of success with each cycle (I am 42) but your theory is that your odds decrease with each successive IVF?

I am about to try IVF #4 after 2 m/c and 1 BFN. I have always tried the same protocol - 21 days of BCP and 450 m of Menopur.

Again, many thanks for being on this board, you are amazing !

Santa

[Ghost]

Ghost, are you saying that the chances of IVF decrease with each cycle?

I did not say that, but now that you bring it up, yes, a history of failure indicates an increased chance of failure in a future cycle.

You said that each cycle damages the endometrium, so that would explain why IVF #6 is less likely to succeed than IVF #1?

No. The endometrium is shed each month and grown anew. The "damage" is always temporary, specific to the one cycle. At least, that is the model I have always read.

My RE said that each cycle is brand new, in the sense that there is the same 10 or 15% chance of success with each cycle (I am 42) but your theory is that your odds decrease with each successive IVF?

I am about to try IVF #4 after 2 m/c and 1 BFN. I have always tried the same protocol - 21 days of BCP and 450 m of Menopur.

Again, many thanks for being on this board, you are amazing !

Santa

Yes, the endometrium is new each time. But some causes of failure can persist from one cycle to the next (like poor ovarian response), so that patients that failed before can be thought of as an enriched pool of more difficult patients. This is why many clinics do not accept patients with prior failures, or perhaps more than a certain number of prior failures.

I would not sweat this enrichment theory at age 42. At that age, almost all the patients are pretty difficult, and the 10-15% success rate cannot rapidly take the best patients away.