Lots of questions-PCOS and IVF

[waitingimpatient]

Just wondered what type of cycles/medications get the dpbest results with PCOS...

I've had a mild IVF cycle with gonal-f and cetrotide last year and two failed FET cycles too-one with cyclogest and one with cyclogest aspirin and clexane , also take levothyroxine.
I'm wondering if there's a different protocol or drug that would help. I know now that in my last cycle my LH level dropped and was too low (is this unusual in PCOS ? I thought LH was high with poly cystic ovaries??), I was reading up about the benefits of Luveris alongside gonal f , also menopur-is that similar/better/worse than a gonal f/Luveris combo?

I'm wondering too if down regging may help? As I had follicles of varying sizes and would that get them all of to an even start?

Length of stimms-mine was 14 days on same dose last time. Worried that ruined my eggs-is shorter stimming better ? Or even longer but with much lower doses ?

I want to try and clear my mind of all I thought I knew and start again with a fresh mind and see if when I'm ready for another cycle I can maybe suggest some changes ?

How many eggs did you get on your fresh cycle? What dosage of gonal f were you on? And have you had any of the thrombophilia tests to check there are no issues with your FETs?

Definitely don't take menopur, it has LH in it and you don't need any more of that. And don't think down regging is recommended with PCOS either - you want to wake your ovaries up, not put them to sleep!

16 eggs from fresh cycle, 13 mature, 6 fertilised but they froze 2 on day 2 and 1 on day 3-the rest didn't make it

I thought that about LH but keep finding things about Luveris improving egg quality and it's got me all confused
I was given aspirin and clexane due to autoimmune issues (anti thyroid antibodies). FET birth failed but I think more egg quality ?

*both not birth!

112.5 gonal f all the way through. It's odd as they said my LH was very low and bottomed out completely during the cycle-yet I wasn't given any additional LH and I though LH is always high in PCOS?? Opk don't work for me which I thought was due to LH issue. So confused

Well all stims switch off your LH receptors so you get a fall in it - otherwise you'd ov. I think it's only if it's very low that it becomes a problem - do you remember the number? Also what is your fsh? And your tsh? How old are you?

In terms of your egg quality I don't know much about it but many people on here recommend a book called it starts with the egg - there are lots of recommendations for supplements etc to improve egg quality. The main thing with stims is not to go on too high a dose too quickly, and it sounds like you didn't fall into that trap which is good.

Has your DH had any analysis done on his sperm?

Long protocol definitely not recommended for PCOS for two reasons

1. the higher doses of stims usually needed for long protocol are def not advised for PCOS due to risk of OHSS

2. long protocol removes the option of a buserelin trigger, which again can be important if at risk of OHSS

The HFEA guidelines on OHSS state short protocol should be used for high responders. The Wikipedia entry even says antagonist protocol is best to minimise the risk of OHSS

LH wise if you're on short protocol an FSH only stim is generally better especially if you're PCOS, because without down regging you're already producing natural LH before you add in the Cetrotide to slam on the brakes. And in PCOS where LH levels are often naturally higher more LH is the last thing you need. My LH levels were so high we actually started Cetrotide at the same time as Gonal-F, because the Dr didn't want to risk LH levels climbing even higher and risking premature luteinisation

stealth and I both have PCOS, both see the same consultant, both did short protocol with Gonal-F only, and both got loads of mature eggs and good quality blasts

I know our Dr uses Menopur in a long protocol cycle, where you need some LH because down regging removes it completely. Luveris presumably allows the Dr to control the amount and ratio of FSH : LH because you're adding it in separately. But I would imagine this is only really an issue in a cycle where you've been down regged

He also says you shouldn't trigger until 10 days of stims as a general rule - particularly for high responders low and slow is better than stimming too quickly.

I stimmed for 8 days at 150iu Gonal-F, 4 days at 75iu and then coasted for 2 days with no stims at all. Got 28 eggs, of which 22 were mature, of which 19 fertilised, of which 9 made it to blast for PGS testing, of which 6 were chromosomally normal

LH levels in last cycle were 1.30 (after 4 days stimms) and 0.30 after 6 days stimms. I'll see if I can find the others as had bloods every other day.

No idea what FSH is I've never had it tested . I'm 34, AMH is 63.5
I'm just wondering if that was low why was nothing done ?

TSH currently 3.0 , was 1.7 two weeks ago :( it's very hard to control I'm on 50mg day Levothyroxine going to increase to 75

I just want to find the 'perfect' or at least 'most perfect for me' protocol If such a thing exists !

Nothing was done as the evidence base is not yet there to support the proposition that low LH during a cycle results in adverse outcomes. This article sums up some of the research well:

www.ncbi.nlm.nih.gov/pmc/articles/PMC3136063/

there seems to be a single study that supports the view that low LH impacts egg quality - it was done in Australia. Google is your friend

But it's certainly not standard to supplement with LH during a cycle. Perhaps you can bring the literature in to see your doctor. Have they made any comments on why you had a relatively poor rate of fertilisation & embryo development?

Without knowing your fsh/LH ratio pre stims it's hard to make any judgement of what impact PCOS might have had. However PCOS does seem to be linked generally with poorer quality eggs and lower success rates. Are you taking metformin? What is your bmi?

Ps just so you have my stats - I started off on an ovulation induction cycle. Stimmed on gonal f for 11 days at 75iu, then converted to IVF as too many follies. Had 3 days at 150iu then dropped back to 112.5iu for another 6 days. So had 21 days stimms. Collected 37 eggs, 33 mature, 31 fertilised, 30 made it to day 3 and 20 day 5 blastocysts, of which 10 were chromosomally normal (had them PGS tested).

I'll go back over all my bloods

Currently in between treatments so can't really ask a dr but when I start a new cycle I'll be going through all this . BMI is around 18.5-19 (I struggle to keep weight up)
Not on metformin
Diagnosed with PCOS as a teenager from scans and symptoms (acne, excess hair) and irregular cycle

I'll have a google session and see what I can find out

They said egg quality was the problem hence us starting supplements and diet changes following the advice in it starts with the egg

Oh you are a thin PCOSer like banana and I. Definitely follow all the egg quality stuff - I didn't do any of this but banana can tell you all about it.

I would recommend seeing if you can get a gp to prescribe metformin - at worst case it will be ineffective but may help. Oh and it goes without saying that if you can get your weight up it will help - optimal fertility is meant to be around bmi 21 so even if you can nudge it up to 20 that's helpful. I ate lots of good fats like avocado and peanut butter and really tried to make sure I was eating a lot, plus dialled down my exercise intensity as I find it almost impossible to put on weight when I'm doing lots of cardio.

Did you try Clomid and/or ovulation induction before IVF? Did you ov regularly naturally?

Good luck! It's such a mindfuck - so many variables to control. Your protocol is really important so you're doing the right thing hunting for information.

Low LH would presumably be much more preferable to high LH

High LH and risk of premature luteinisation is definitely not good for egg quality

My LH was admittedly very very high. My FSH : LH ratio is classic PCOS, with LH hovering around the 20-23 mark, which is not far off surge range.

FSH is likely to be low with such a high AMH - my AMH was recently measured as 62.2, (so similar to yours - although as you know 8 months prior my AMH was undetectable!) and my FSH has been lurking around the 5 mark or thereabouts

High FSH is a problem for poor response to stims but by definition PCOS puts you at risk of the opposite end of the spectrum, so poor response isn't likely to be too much of a concern