Fresh transfer - high hormone levels, cancel?

[whatcangowrong]

Wondering if anyone has any insights... I’m 3 days post egg collection and have a good number of embryos growing at the moment, 2-3 looking good and 6 more looking ok. I was planning to do a fresh transfer on Saturday.

Blood test came back today with 5000 pmol for estradiol and 500 pmol for progesterone. Doctor is saying these are too high.

I want to go ahead anyway... I’ve had 3 failed transfers out of 4 under good conditions and all FETs. I feel like it just usually fails anyway! And this fresh transfer is incl in cycle whereas waiting for FET adds £2k more.

My plan would be to put a less good embryo or even day 5 morula back this time and hope for the best, but with low expectations of success. If it works it would be a huge bonus and if not next month continues the same but with a much better embryo, same one we would be using that month anyway.

If most of my embryos stop growing before Saturday I would reassess and not waste one.

Any thoughts or anyone want to talk some sense into me (aside from my highly experienced and handsomely paid gynaecologist of course!)

Oh by the way my lining also looks v thick, apparently thick is good but this is more thick than would be preferred.

Hi @whatcangowrong that estradiol doesn't seem that high for a fresh cycle, mine was 6000 I think and they had no issues with me carrying on. I then developed a unrelated issue (a rash because I'm allergic to progesterone) and my specialist said we had to cancel, she let me go ahead with transferring the lowest graded blast though.

Unless there are signs of OHSS I would push for a transfer. Also how thick is too thick, my understanding is that it's the thicker the better unless it's ridiculously huge. I would also be keen to transfer in your position given you have only had FETS to date and some people only get a good lining with stims, so it's a wasted opportunity.

If it is safe to do so and you want to push for a transfer, then you will need to really push for it. My specialist said we had to cancel two of my cycles so far and I've had to fight to have them go ahead.

Thank you @Gardenlady543 - you’re always replying to my technical queries and seems like you know your stuff!!

I’m not sure on lining and I also though the thicker the better but at my first scan 10 days ago it was already 13+ so I imagine it’s much more now. My doctor took one look at it that day and just said that lining is too thick. I did some reading and seems like up to about 16 is still good but then it does start to have a detrimental effect. But I don’t actually know how thick it is now.

She’s said today it’s my decision whether to go ahead but we would be mad to put in our best embryo, that was before the bloods came back after which she said up to you - for context she usually only does freeze all as a blanket policy as she believes a calm uterus is always better. I think basically this also suits her approach which seems to be to throw high doses of drugs at the situation! I’m not complaining as she helped us make our son :-) And as I’m now quite a long standing patient with my own opinions and I read up on everything she’s prepared to let me make some decisions against her advice in places. My feeling is it’s all bloody luck anyway and I just want a chance to get pregnant each month like a normal person! At least we know the egg is fertilised and growing even if other things aren’t spot on.

Sorry @Gardenlady543, after my comments come my questions!!

Do you happen to know which day you had 6000? As if that’s peak estradiol it was probably lower than mine which is still 5000 now 5 days after my last jab? I tried researching (as usual) but the studies seem to be on measurements on the day of hcg trigger and also a lot of them focus on embryo quality and not endometrium. I couldn’t find much measuring for 2 days pre transfer as they don’t measure it before you do a FET and I think for a fresh cycle they measure earlier to rule out OHSS perhaps.

When I have done FET my lining has always thickened well, I’ve always done medicated anyway.

@whatcangowrong haha me answering technical issues may be a case of everything that could possibly go wrong in my treatment... has! I've developed 3 issues that nobody at my clinic has ever come across before so far!

It's funny that you mentioned this estradiol level as I'm in a FET right now and my specialist wanted to cancel my transfer as my estradiol was 8000. Nobody has a clue why it's so high, it's completely unheard of! Anyway we went ahead.

There is no evidence that a freeze all approach is preferable to a fresh cycle, so don't let that put you off.

There are some studies looking at outcomes with various lining thickness, but lining usually contracts with progesterone anyway.

I agree that if in doubt, save the best embryos, that's what we did in my fresh cycle and we went with the worst one. Sometimes an embryo is graded as not freezable but could result in a live birth, if that's the case then I see no reason to waste it. I would be inclined to transfer the worst embryo on transfer day from what you've said.

@whatcangowrong my AFC is 34 so I was at a high risk of OHSS, they only took my estradiol level twice in the fresh cycle, on day 6 it was just under 2000, and then a day or 2 later it was 6000. I didn't develop OHSS luckily. I think your decision to go ahead needs to be made on the risk you will develop OHSS, if your specialist thinks there's a high risk then don't go ahead. If they aren't worried at all, the transfer :)

Thanks so much for sharing thoughts it’s really helpful to get input from someone going through it. V interesting that lining contracts with progesterone I didn’t know that.

I agree that most of the evidence says fresh and frozen are pretty comparable and I also found commentary saying that you would expect FET data to look good as the eggs are obviously younger than the woman, sometimes by a year or two if it’s a second+ baby. I’m not sure if they always adjust for that properly...

however I did find a study showing that this fresh=frozen outcomes holds true UNTIL you look at drugs dosage ... and for that highest dose category fresh outcomes do decline. This does make sense to me tbh. And I’ve always been on 450 stims so I’m in that top bracket.

Doesn’t stop me wanting to press on however!!

Tell me about where you’re at with things, are you trying for your first? Hope it hasn’t been too much of a ordeal so far. Where are you being treated?

I don’t think OHSS is a particular concern for me - my AMH is 16 but AFC is like 14 and that’s because only one ovary responds due to previous surgery for an endometrioma which appears to have killed the other one off sadly. I got 14 eggs on high dose of Stims. I don’t feel totally brilliant this week, still bloated etc after EC on Monday but also had second COVID jab on Monday eve so it could also have been that...

@whatcangowrong

Yep trying for first, never ever has a BFP. This is my full story:

Tried for 12 months naturally... nothing
Initial investigations looked fine but my lining was 5.4mm at 9dpo, this was missed.

Has a fresh cycle in November 2020, it went well, 12 eggs harvested, all fertilized, 9 blasts.
Then I developed progesterone hypersensitivity but we went ahead and transferred the worst blast, BFN as always and started bleeding from 8dp5dt.

Went into a FET in January this year, got up to 8mm, at the day of the transfer the specialist thought the lining looked very thin. Another BFN.

I then PGT-A tested my remaining embryos, there had been 7 left, the best one didn't survive the thaw, of the other 6, 5 were euploid. This seems to be a very clear case of recurrent implantation failure, because clearly the embryos are fine.

We did a thrombophilia screen and autoantibodies. I was found to have the MTHFR mutation (so now take methylfolate) and I have an abnormal thrombophilia gene so now on aspirin and heparin on cycles.

I had a ERA EMMA ALICE, there were huge issues getting the sample, the endometrium looked to be present but wasn't actually there. ERA said I'm prereceptive and EMMA showed I had 0.00% good bacteria, so I took antibiotics and probiotics.

Because of the issues getting the sample my specialist mentioned Ashermans syndrome, I saw a specialist and he arranged a HSG and the condition was ruled out. My anatomy looks perfect, wide open tubes and uterus looks fine.

So I then went into FET #2, this time the lining was looking lovely and then I developed the massive estradiol level, also experienced anxiety (never had this before and probably due to hormone levels), no cause found for the high estradiol and as my progesterone wasn't raised (indicating there isn't a follicle) we went ahead with the transfer. On the day of the transfer the specialist said the lining looked good but maybe a bit thin towards the bottom. I am 6dp5dt, did a test BFN. I know there's still time but I mean I don't even know what to do next. Probably repeat the EMMA to check the microflora is resolved. This should have has a 70% chance of success.

Wow, you have had an ordeal then, I’m really sorry. I hope it all comes right for you, preferably sooner rather than later. How old are you and which clinic?

6dp is early so hold tight. I would be testing too so no judgment from me.

I have MTHFR mutation too but found out post first egg collection. Don’t think that makes a huge difference to actually getting pregnant.

I’ve not had all those receptivity tests nor pgt. I guess as I’ve had one baby via ivf I’m inclined to just play the numbers game, but after 3 failed transfers maybe I should consider. I wouldn’t class you or me as recurrent implantation failure just yet though? You’ve only just transferred first embryo you know to be euploid right? My understanding was that it just doesn’t work that often so you have to keep trying :-/ boring and hard though that is.

Can they do more to thicken your lining?

@whatcangowrong I'm 35 and in the midlands. Thanks for the kind words, I feel like I need your username lol!!

Because the issue isn't my embryo and I've never had a BFP it seems that my issue is implantation failure. Normally there needs to be around 3-4 unsuccessful transfers of high quality embryos for the diagnosis.

I think MTHFR is really common.

Part of the issue with my lining seems to have been the microflora issues, so hopefully there's been an improvement in it.

To look on the bright side, lots of euploid embryos is a real win.

I’ve had 3 bfps in 20 years (admittedly many of those years with contraception). One ectopic that took out my right tube, one for my son, and one chemical last month. Not a glimmer in a year and a half TTC with my husband but we have some male factor, endo and one tube. Bfps are great but only when they lead to a baby. Once you get one at least your lovely euploid embryo should stick.

I’ve only had one really good embryo fail, the others were day 6 untested and one looked a bit crap. I’m 38 so chances are not all mine are much good but I’ve been supplementing like a ninja for this round and really hope a good number make it.

Ps I changed my username to this to ask a question as to what was worst case scenario if conceiving too quickly (!) after a c section. LOL, needn’t have worried about that! At the time I think I thought I’d probably get knocked up naturally first time, despite previous evidence to the contrary.

I’ll donate it to you when you get pregnant as a congratulations if you like, before that I think you need more positivity in your life.

Haha @whatcangowrong I think you're right! Not sure where to look for it at the moment though

Ah sorry @Gardenlady543 I hope my comment didn’t come across as insensitive at all! You come across as very positive btw considering how many damn procedures you’ve had at this point!

How are you feeling today and when are you planning to test again?

I had a chat with CARE today about how we will select the right good but not too promising embryo tomorrow. They weren’t that keen on my idea of just chucking in any remaining morulas etc!! I think we will go for something that maybe has good caremaps but bad morphology or vice versa. Fingers crossed there are even enough options though.

That sounds like a plan @whatcangowrong when my cycle was almost cancelled they put in a 2,3 graded embryo but that scored 8/10.

Oh don't worry about anything, I'm just feeling a bit beat up right now. It doesn't help to be on all these hormones. I tested with a FRER today 9dp5dt, negative as usual. I'll test again tomorrow and then call my clinic and get the review booked in.