Day 3 vs Day 5 embryos

[lucieloos]

I am due to cycle again next week. I never seem to get many eggs only 2-3 which luckily so far have fertilised and I have 4 hatching blasts frozen as I'm embryo banking. However this time around I will be having a fresh cycle and transfer and can't decide if I only get a couple of eggs again is it worth putting them both back at day 3 or growing them onto blasts again and then transferring as at least then we will know they have good potential? What have you done and what was the outcome?

Sorry for the delay luci. It turns out that I only have the results on file for two of my IVF cycles. You ask for my progesterone levels on the day of trigger, but since the study says that a rise in progesterone levels on the day of trigger indicates that day 5 provides for a much more viable pregnancy, I have the results for the day prior to trigger and the day of trigger, so it can be seen if there actually was a rise:

14.09.13 Day before trigger progesterone result 1.8nmol/L
15.09.13 Day of trigger progesterone result 2.3nmol/L
Day two transfer of two embryos at 2 cells. BFN.

01.12.13 Day before trigger progesterone result 4.6
02.12.13 Day of trigger progesterone result 3
Day two transfer of one embryo at 4 cells. BFN.

02.12.14 Day before trigger progesterone result 3.2nmol/L
03.12.14 Day of trigger progesterone result 3.6nmol/L
Day 3 transfer of 11 & 13 cell embryo. Early miscarriage.

I don't actually have the result for my final IVF cycle which was successful after a day 3 transfer of two embryos... which would probably be the most useful one to see if this study proves true. I'm sure I did do the blood test but I was too scared to see my Dr and get the results as I had gone ahead with the transfer anyway and thought it would just stress me out during the two week wait. I was lucky that my acupuncturist was also a GP who was happy to provide me with several blood referrals so that I could just get the tests done when ever I wanted during my IVF cycles. I believe your system there makes it harder to get a simple blood test and it sounds like it might just be an extra stress having to pay privately for it.

I was very study obsessed in my trying to make sense of all my failed IVF cycles. I had also read studies like this one showing that the estrogen growth rate during the stim phase of the IVF cycle determines egg quality and IVF success, and ended up creating the very complicated chart to plot my estrogen levels and see if my results were within .3 to .4 as the studies showed my estrogen rise needed to be for top quality embryos. I was also assessing my blood results based on this study which showed that if my estrogen levels plateaued at =/-10% after the trigger instead of continuing to rise, that my chance of pregnancy success dropped by 25%, and that if my estrogen levels dropped by greater than 10% after the trigger, that my chance of success decreased by a whopping 40-50%. Because I was a poor responder and I often had to make the hard decision about if the cost of egg collection was worthwhile when I would only have 3-4 mature follicles in a cycle, I thought this information would help me decide. But like I said, in my final IVF cycle, I was too scared to get the results from my GP to see where I fared in relation to these studies, as I was about to turn 38 and didn't feel like time was on my side to wait if the results were not great. Now that I am discussing it with you, I am curious where I fitted into all these studies and will definitely get the results and find out. I am 38 weeks this Saturday and want to see her for acupuncture so that I am not overdue and don't need to be induced so I will find out at that appointment.

Wow shell you have done a lot of research and thanks for copying out all the results for me. It's very interesting as I have been consulting with Dr Sher and he says a progesterone level higher than 2-3 would indicate premature lutenisation and he would not transfer on a fresh cycle as the chances of success would be a lot less and he would freeze instead and transfer later. Interestingly he also said that's opks are a reliable method for detecting premature lutenisation which then in turn causes the progesterone rise. He said that if the opk turns positive this would indicate that premature lutenisation has taken place and probably wouldn't bode well for the cycle. I queried whether opks could be used if Menopur was used in the cycle as that contains LH but he said Menopur contains hcg rather than LH itself and hcg wouldn't show positive on an opk.

Anyway so as it goes I'm not going to be able to have the progesterone test as my egg collection has been moved forward. I had my first scan on Tuesday which was day 10 of my cycle and day 8 of stimms and already I had 5 follicles on the right side two of which were 18mm and another 16mm so I have triggered tonight and egg collection is now Friday rather than Monday as we originally thought! The bad news is that my left ovary failed to turn up to the party this time and only has 3 very small follicles which won't be any good. This has never happened before so it's a little nerve wracking really as obviously I'm worried as to whether we will collect anything at all and then will it be mature or fertilise but I'm trying not to let it get to me too much and what will be will be. It helps that this is a free cycle so I'm just treating it as a bonus. I had an acupuncture session tonight which was nice and relaxing and have another booked in for Monday incase we have a day 3 transfer. The good news is my opks have all been negative so hopefully I don't have too much LH floating around!

Frustrating that your body produced more eggs on your first cycle and now you are again at 3 mature follicles in line with all subsequent cycles. I have read a study showing that these first eggs to mature are the ones our body is naturally selecting and studies show that these contain the best/most genetically normal eggs. So I always tried to remind myself of that as I too was a poor responder, but somehow I always still got deflated when only 3 or 4 of my follicles matured each time. So I know the feeling. But hopefully the reason that the left ovary didn't put on a show is that your 3 best eggs are on your right ovary this cycle.

Day 11 is early for a trigger - are you on a higher dose of meds this time? Was the thought to get more follicles to grow? But instead the energy has just been put into 3 which have grown faster instead?

Are you in America to consult with Dr Sher, or can you consult with him online? I've read some of his info online. Sounds like he knows his stuff.

Yes it is frustrating shell I don't understand why we went from a half decent number the first time to low numbers. I do think what you say about they first ones being the best is right though as even when we got 7 eggs collected, 6 were mature and fertilised. On day 3 all 6 were still going and were between 6-9 cells but on day 5 only 2 were blastocysts, one hatching and one fully hatched. None of the others were suitable for freezing. On all of my other cycles (3) we have only collected 3 eggs, only 2 of the 3 have ever been mature. The first time both of the 2 made it to blast and the 2nd and 3rd one of the two made it to blast each time which is still not bad and kind of ties in with what you have said about the lead follicles being the best.

I normally always trigger on day 12 but this time the follicles on my right side seem to have responded really well and grown quickly. I had my scan on day 10 which was day 8 of stimms but I hadn't actually taken the 8th dose as I do the injections in the evening so I had 7 doses of stimms and already had 2 at 18mm. I was on 300iu of Menopur so fairly high but not stupidly high. I have been on this dose before and they haven't grown as quickly although on my first ever cycle I was on 225iu Menopur only and had similar results with quick growing follicles. On that one my largest follicle was 17mm on day 8 so hopefully we will manage to collect something. My biggest fear is that there will be nothing at all but we will soon find out!

I'm not in America but Dr Sher has a forum where you can ask any question you want to. He is amazing and responds to every single question within a day. It is very interesting reading.

I only ever had either one or two embryos and the one time I decided to wait to day 5 to transfer, my lone embryo didn't make it. The following cycle I again had 1 embryo and thought I would try a day 3 transfer but the embryo didn't make it to day 3 that time. So at least your embryos do seem better quality than mine and despite only 3 eggs for your last 3 cycles, you do have something that goes all the way to blast each time. But then I guess that is little reassurance to you when you have had two blasts transferred and still got a BFN.

My fertility Dr explained to me that with the IVF medication, it is not like Panadol where they put in exactly 500mcg of Paracetamol in each dose. With the IVF meds (Menopur, Puregon...) they can only test the 'bio-availability' (whatever that means, but that is the word she used) of the medication, so it could actually have 20% more or 20% less than the prescribed dose. So you could open one vial of Menopur and get 20% less than the 300 dose you think you are taking, then open the next one and get 20% more. And she said that is sometimes why there is a varied response from cycle to cycle on the same medication. So perhaps that's why your follicles grew a bit quicker this cycle. Or perhaps our bodies just vary from one cycle to the next because sometimes I would start with 16 follicles and then other times I would start with only 6-7 despite the same preparation. Who knows!

It's early Saturday morning here and I think you are 11 hours behind, so it should be late Friday there if I am correct, and you will be resting up after EC. Hoping all went well and you at least got the 3 eggs you were expecting. How soon after does this clinic call with an update?

Bio availability normally varies between individuals and not between vials within the same person

Bio availability usually means how much your own system metabolises

So my Dr said with my pain meds that the bio availability with oral morphine was notoriously variable - whereas one person will take 10mg and their metabolism means 8mg goes to the brain, someone else with a different metabolism will get 3mg from the same 10mg tablet

Usually the bio availability of a any substance doesn't vary massively between the same drug taken at different times by the same person - and usually it's to do with oral medications

Normally injecting medications means the bio availability is fairly stable as there's no first pass metabolism to worry about as with oral medications. So I would expect the bio availability of Panadol to vary much more than Menopur

Interesting that your Dr says it differs so much, fascinating!!

I was torn between the day 3 / day 5 question - the embryos from my first round were great on day 3 but conked out by day 5 and nothing made it to blast. I generally think if they didn't make it in the dish they wouldn't have made it in my uterus and they almost certainly didn't have the potential to become a person. If we had transferred then we'd never have known if it failed because of the seed or the soil. Now obv you don't know for sure with a blast either, unless it's PGS tested, as not everything that makes it to day 5 will be chromosomally normal. But it's got a higher chance that it will so if a good quality blast doesn't implant, it suggests there may possibly be an issue with the uterine environment or immunes issue at play. With a day 3 it's harder to get learnings about why a cycle failed I think

I don't know shell it's actually a great reassurance to me that even though I only get 2 embryos a time at least one of those 2 make it to blast every time. It reassures me that the quality must be half decent and that we have a good chance of it working. If I wasn't making any blasts then i would be really worried. Any IVF cycle with blasts or not is more likely to fail than to work so even if you have one transfer of blasts and it fails it doesn't mean it won't work on the next attempt or the attempt after that. It's the nature of the beast that it more likely to take a few goes for most people than work first time but it reassures me having the blasts that the quality is good and therefore the success rates are higher.

It all went as well as it could today...well kind of! We managed to collect all three eggs which obviously both myself and the doctor were very happy about. The other problem now is that my lining was only 5.5mm. I don't know if it is because I had less follicles than normal and therefore not so much estrogen produced but it's typical that on all of my banking cycles my lining has been a perfect 9-10mm and now for some reason when I want a fresh transfer its really thin. They have given me estrogen tablets to take and I have to wait until Monday and go and have it measured again to see if it's improved otherwise I will have to freeze and have a frozen transfer next month which is a nuisance as I was all geared up for fresh but obviously I don't want to put them back into sub optimal conditions so will do whatever is best on the day.

The clinic will call me with an update tomorrow morning on how many were mature and have fertilised so we still have that hurdle to get over yet. I'm a little nervous as its a new lab and embryology team and a new sperm sample from DH so I don't really know what to expect.

Interesting banana that your/your Dr's explanation of bio-availability was different to my Dr's. I specificially remember her saying 'they can only test the bio availability' which left me with the impression of it being tested within the medicine rather than within an individual. Lucky my IVF has worked. I was such a research freak during my IVF (I think it was my minds way of coping with the emotions of it by trying to be research based and make practical decisions rather than deal with the emotions of it). Otherwise I would be googling mad right now. You word it well when you say the day 3 embryos always pose the question of 'was it the seed or the soil'. My first clinic did day 2 transfers and after 3 didn't take, that's exactly what I was wondering and part of the reason why I changed clinics.

Either way luci, I am glad for you that you get some reassurance from your day 5 embryos, and I think you must be statistically above average to get 1-2 embryos all the way to blast each time from only 3 eggs. But grrr, nothing ever goes smoothly does it! Now your lining is not co-operating on the one cycle where you are doing a fresh transfer! I am no expert but can't imagine how it would be because you have less follicles than normal since in a natural cycle you would only produce one anyway which is designed to produce enough estrogen for a cushy lining for implantation. I am glad to hear as I kept reading your post that your clinic takes notice of this and will be monitoring you. My clinic never checked the lining at egg collection, so they seem quite thorough at your NHS clinic.

Will wait for your update!! It's always a long 24 hours waiting for that phone call.

Thanks shell I have been really impressed with the NHS clinic so far. They said they want to monitor the lining and if it doesn't reach 7mm by Monday they would look to freeze. I wouldn't be happy transferring at 7mm though as statistics show that success rates are a lot lower at 7mm. I hope they don't try to pressurise me into that.

The only other thing I can think of is I had a hysteroscopy the cycle before beginning IVF and bled lightly for a week. This stopped around 10-14 days before af arrived. I don't know if that could have affected it. Hopefully if we do need to have a fet it will be resolved and the estrogen tablets will bump it up nicely.

I'm sure every clinic monitors the lining as it's not gonna do their success rates any good to transfer into a suboptimal endometrium - shell maybe it was just fine when they looked on the scan so never mentioned it?

I always asked exactly what mine measured and whether it was triple lined, but it wasn't that he was only measuring it for my benefit, he just didn't give a running commentary on all the bits he was monitoring.

Presumably it was never mentioned because you didn't have any lining issues?

I'm sure every clinic monitors the lining as it's not gonna do their success rates any good to transfer into a suboptimal endometrium - shell maybe it was just fine when they looked on the scan so never mentioned it?

I always asked exactly what mine measured and whether it was triple lined, but it wasn't that he was only measuring it for my benefit, he just didn't give a running commentary on all the bits he was monitoring.

Presumably it was never mentioned because you didn't have any lining issues?

I did actually have concerns over my lining as my periods are very very light... perhaps a tablespoon of blood on the first day and a teaspoon on the second and that's it! When I changed clinics, I mentioned this to the first Dr and his thoughts were that the lining just needs to be 4-5mm minimum, which was not in line with my research. So I paid again to repeat my first consultation with another Dr who listened to my concerns. So glad this is all just for the sake of conversation now and not for the horrid stress of IVF. Now that I have my miracle baby, having light periods will be quite practical! How are you feeling banana? When is your next scan?

luci, I hope no news is good news...