Ghost...or anyone... thoughts?

[lou71]

Hi Ghost,

Just wondering what your thoughts are on my current cycle. I've done 3 cycles in the past and got pregnant on my second but unfortunately miscarried. On my last cycle, after 3 days of stims, I had 10 measurable follicles with the largest being 14 mm and an E2 of 450. I started Ganirelix that night and triggered on day 7. I had 10 retrieved that cycle, had 6 perfect 8 cell embies on day 3, and 4 nice blasts and 1 morula on day 5 where I transferred two and ended up with two frozen. I had a uterus problem (see signature) of which I had surgery for in December so I believe that's why that cycle and the FET both failed. RE said that was a "near perfect cycle". He had even given me a 60%+ success rate but we didn't realize my uterus issues at the time. I am realllly hoping for a repeat with a newly improved uterus.I know I can do that.

I had CD3 bloodwork done last month and had an E2 of 42 and a FSH of 6.6, no too bad for a 38 year old. All other labs normal as well. I've also been taking DHEA 25mg three times a day for the past 12 weeks and my testosterone level was around 20 (normal range 11-59), DHEA slightly above normal and DHEA-S level was a bit elevated as expected. This cycle... I did not do BCP's but RE put me on a EPP per my request where I took Estrace 2mg twice daily from 10DPO to AF (4 days total). At baseline, I had 15 antrals and an E2 of 78. Clinic expected higher E2 but I had not missed a dose of Estrace. I started stims that evening (Monday 1/10) of 450 Follistim and 150 Menopur. After three days of stims (today 1/13), my E2 is 93 and I have 5 measurable follicles around 9-10 mm and about 10 less than 8mm. Obviously, it's going slower this time. Any idea on the cause or if this is necessarily a bad thing? I'm continuing the same meds tonight and tomorrow and going back for u/s and bw on Saturday. I'm just puzzled because it's soooo unlike my first three cycles. My first was a long lupron, and second the third were antagonist. I took BCP's before each of those. My nurse told me not to worry at all at this point but it's just different for me to respond like this so it's hard for me to do that. I've never stimmed for more than 8 days. Does the EPP cause a slower stim response?

[lynniecat]

The Estrogen absolutely suppressed you....at least this is what my doctor told me. Your estrogen is similar to mine at start and in fact I had an E2 of 35 on my last successful EPP day 1 so don't worry the E2 is too low...

[Ghost]

Does the EPP cause a slower stim response?

Generally, yes.

[to_have_fun08]

My clinic has said the same thing that estrogen priming does make the cycle slower. Plus you are only on day 3 of stims. My clinic doesn't even do an u/s till after 6 or 7 days of stims. There is lots of time for those follicles to catch up. Comparing one cycle to another can drive you batty. Just relax and take things as they come. FX'd for a bunch of great follices this weekend.

Good luck!!!

[riogirl71]

Lou - you mentioned Femara was similar to what you did, absolutely my RE said that your E2 levels are artificially low and she was expecting that. On day 6 of stimms my E2 was 115!!! And here I am almost in 2nd trimester. So I think it all looks great for you Lou, this will be your lucky cycle. Will you try day 3 or try and go for day 5, how many will you transfer?

Good luck and tons of baby dust - this is it for you my friend, we will be bump buddies!

[lou71]

Thanks Ghost, lynniecat, Chris, and Rio. I appreciate the peace of mind!

Ghost -- So should the EPP result in more antral follicles responding eventually while keeping the others from charging ahead? That has been my issue. 15-20 antrals and I get a small group of them mature at 16-22mm and have another group of them in the 12-15mm. I've had from 4-7 mature eggs in past cycles.

lynniecat -- Was your estrogen 35 while you were ON estrogen? Because I was on Estrace 2mg twice a day when I went it for my blood draw. In fact, I had even taken a dose a couple of hours before. That was my last dose. The important thing is, you had success! May I ask you how old you were at that time?

to_have_fun_08 -- Yikes! On my antagonist cycles, I started Ganirelix on day 4 of stims because my follies were in the 14mm range. If I didn't have an u/s until 6 days in, I may have ovulated. I guess without the EPP, I'm a "fast stimmer". You're right... I need to take it as it comes and pray for the best. My clinic is good and they know what they are doing. So I'm following all of my instructions to the "T".

Rio -- If I have at least 4 stellar embies on day 3, I will go to day 5 with them and transfer 2 of the best and freeze the remaining if they are good enough. I'm too scared of multiples if I transfer more than 2 blasts. If I have a 3dt, then I will transfer 3. But this may change depending on quality. Did you do any estrogen before your last cycle? It didn't look like it from the calendar you sent me.

Hope you all are right and this will be the one for me. I was just initially disappointed with only having 4 measurable. But there was no lead follie and I've got around 10 more hanging out in there. Hopefully a few will come join the party!

Thank you all for your support and answers!

[Ghost]

So should the EPP result in more antral follicles responding eventually while keeping the others from charging ahead? That has been my issue. 15-20 antrals and I get a small group of them mature at 16-22mm and have another group of them in the 12-15mm. I've had from 4-7 mature eggs in past cycles.

The theory is that estradiol is an inexpensive way to suppress the hypothalamus from releasing GnRH so the pituitary will release less FSH, and in theory, make the follicles more sensitive to FSH. I have not seen substantial evidence that the theory really works in practice, but perhaps it does. It does seem the "sensitive" follicles respond slowly to FSH, which I find counter-intuitive.

One option to get more mature eggs is to stim a day or two longer. But there are reports that longer stims hurt endometrial receptivity.

[to_have_fun08]

Lou - When I first went to this clinic i was freaking out because they didn't do u/s till day 6 or 7. They do all their cycles in batches and it is the same way for all the patients. My clinic does a hybrid antagonist cycle. It includes taking lupron for 5 days and then taking a half dosage of ganirelix for several days, and then starting stims. this you already have the antagonist and won't ovulate on your own. I know kind of strange but it works for them and they deal with a lot of older patients.

[lou71]

Ghost -- Thank you. Counter-intuitive indeed about sensitive follicles responding slower! How many days of stims is thought to compromise endometrial receptivity? I've stimmed 7-8 days in the past and my nurse thought I would maybe go 10-11 days this time. Do you think that difference is enough to cause a problem?

Chris -- Oh, that makes sense then if you were taking an antagonist that early. Thanks for the clarification. Are you at SIRM?

Thanks again!

[to_have_fun08]

yep, i'm back to SIRM St. Louis now. Was at SIRM Peoria last year.

[Ghost]

Ghost -- Thank you. Counter-intuitive indeed about sensitive follicles responding slower! How many days of stims is thought to compromise endometrial receptivity? I've stimmed 7-8 days in the past and my nurse thought I would maybe go 10-11 days this time. Do you think that difference is enough to cause a problem?

They did not work it out exactly that way, to my knowledge. A study tried randomizing patients to trigger when the lead follicles reached 17mm or else 2 days later. The latter group had better embryo cohorts, but the former had better pregnancy rates. The likely cause was reduced endometrial sensitivity in the group that went 2 days longer.

[lou71]

Ghost -- Was this just in one study? Do you have the reference by any chance? My RE seems to trigger me when my lead is around 20mm. I'm wondering if it was a good study design and has been validated if I should show it to him and maybe trigger earlier.

Thanks again!

[Ghost]

Ghost -- Was this just in one study? Do you have the reference by any chance? My RE seems to trigger me when my lead is around 20mm. I'm wondering if it was a good study design and has been validated if I should show it to him and maybe trigger earlier.

Thanks again!

The abstract is found here:

http://www.ncbi.nlm.nih.gov/pubmed/15236997

[lou71]

Thanks so much!

[lynniecat]

Yeah I get triggered later too. I wonder if the endometrial receptivity varies. My lining is always super thick (like 12 mm on day 12), but I know it does not need to be that thick...