Delay IVF to improve egg quality or not?

[2mumlife]

I'm starting to get ready for our second egg (and last) collection round.

I had a poor outcome on our first egg collection, depsite being 32 with AMH of 18.8. I did a long protocol, with Prostap downreg, 2 x 200iu of Menapur first 2 days of stimulation, then 200iu of Meanpur a day. My clinic stimmed me for very few days before telling me to take the trigger after my first (and only) scan that cycle.

On scan I had 2 clear lead follicules over 18mm, and another 5 fairly large follicules, with a lot of smaller follicules. The clinic expected 7 eggs at EC, I got only 4. The reason I was gien for less eggs was that the eggs weren't mature and were 'stuck' to the follicule wall. Only 2 of our eggs were mature. Luckily, both made great fay 5 blasts, a 5AA and 4AA. I had 1 transfered fresh, BFN after I started AF only 4dpt5dt. Second embryo was replaced during FET which has just ended with chemical pregnancy.

Clinic has said they want to retest my AMH levels, and have proposed a flare protocol for next collection.

What I'm uncertain of is whether to go with the egg collection next cycle we can (so with my next AF probably end July / beginning August) or delay.

The delay is whether I should take a longer period of time to adjust diet, start accupuncture (which I've never tried before) etc. in the hope that this might improve our outcome.

However, We've been at this over a year now (we tried IUI before IVF) and I want to get on with things. Plus, over the summers would be a lot more relaxing due to workload being a lot lighter.

Just looking for advice and thoughts?

Hiya, I’m very similar to you in that I have good AMH and only get a few eggs:

Cycle 1: 10 eggs only 5 mature
Cycle 2: 5 eggs, 5 mature
Cycle 3: 4 eggs, 4 mature (BFP and live birth)
Cycle 4: 3 eggs, 3 mature

I usually have an ok amount of follicles but the eggs are stuck somehow.

The positive thing is that although I get few numbers, I have a high fert and blast rate.

Depending on how you are feeling emotionally, I would just crack on with your next cycle. Acupuncture isn’t proven to help and I doubt that diet will make a massive difference.

Also ask about doing a short protocol. My first three cycles were short which generated the most eggs (I did long on the last one following an endo diagnosis).

The good thing about you is that you really only need a few eggs as you’re so young. Don’t give up!

Hi @2mumlife I remember from when we chatted for the first time a few months ago that I was a bit shocked at your outcome from your first EC. Your initial numbers looked good so I would have expected more eggs. I think it probably comes down to your clinic getting your protocol right with little that you will be able to do to improve the situation. I would have thought that your AFC would be more important than the AMH, your initial AMH is very good, so I don't see how a repeat would change decisions.

As for when you do the EC that is completely up to you and I would say if you feel you need more time to prepare yourself, have a holiday, do some enjoyable things etc, then absolutely do that. Acupuncture is going to make no difference, it might help you relax a bit, but outcome wise I doubt it will add anything.

Lifestyle wise, people often recommend the book it starts with an egg. I think for those who know they are not making unhealthy decisions (smoking, excessive alcohol, excessive caffeine, unhealthy diet)- then yes they would benefit from taking time to make some changes. But given you've just had a FET I doubt you're in that category.

Sorry to hear about the chemical by the way, mine was a BFN from the start as always. I know we had a chat about even a chemical being at least a step forward, it means it's likely you were receptive and there was implantation, I think those are good signs. So I think there are positives for you for the future with the next transfer. I hope you get a good result from the next EC and it all works out with the next transfer.

I don't know why I put a double negative about the healthy stuff and then wrote something that not even I understand! I meant if someone is smoking, drinking excessive alcohol etc, then they would benefit from taking some time to make lifestyle changes.

@FingersXssd83 Hi! I'm sure we've talked before on another thread. The Flare protocol will be a short protocol. I think part of moving it was that my bleed took a long time after Prostap downreg, and they said at the time something about I might have had a big initial flare which is why it took longer for me to bleed, so I'm hoping an intentional flare protocol might work.

@Gardenlady543 Sorry to hear about your BFN. I know that will be really dissapointing given all the investigations and prep you did for this cycle. What is your next plan? I'm trying to hold on to the chemical as a positive sign. Consultant wanted to re-test my AMH as it was taken just before Covid started, so I've aged. They also said they wont move me to Flare if my AMH suggests I'm at risk of OHSS, but I don't know why they'd think that when at 18.8 I'm no where near their line of being at risk, and I'm older now than before so there is a fair chance my AMH will be lower now anyway (unless being healthier the last year has had an effect!). I've not got the 'it starts with an egg' book but been reading up about it since you first mentioned it. I've always been pretty good on the healthy eating, improved my diet quite awhile ago in terms of caffine consumption and alcohol which were my worst areas. I did move to non-alc beers for quite awhile but I've not even been drinking them now. I've really ramped up following mediterranean diet last couple of days and started up the CoEnzy10 again in prep, but I didn't know whether I should be trying to leave 90 days now until another egg collection. I'm not sure how much 'development' follicules would have gone through during the FET cycle considering they supressed ovulation etc (so have the current eggs taken 90 days to develop, or longer because of the FET drugs?) and how far in the past bad habit might have an effect.

Because I work in Higher Education, summer is a blissful period with very little students to deal with, and a lot more possibility for time off work.

I guess I just not sure how much of a difference I might be able to make with diet, or if I really am in the hands of clinic getting my protocol right this time....

@2mumlife Oh I'm not sure about leaving time between the FET and next fresh cycle, I know lots of people go into them one after the next and seem to do fine, I guess your clinic will be best to advise on how long it is best to leave between these kind of cycles.

That's interesting about the AMH, I wouldn't have thought that alone would've affect the protocol choice but then I'm not a fertility expert and they're going to know best on that. I know the AFC can indicate who is likely to experience OHSS. And I think that is a better predictor, Afterall OHSS happens when a lot of follicles are stimulated with a very high amount of oestrogen produced as a result. My AMH is 17.4 but my AFC is a whopping 34. So my AMH alone wouldn't have given any indication of a high risk of OHSS.

I was put on low-dose stims in a short protocol and did very well. Luckily no sign of OHSS in my case.

It sounds like you're already doing all the lifestyle factors, I think that taking time to do further lifestyle changes would probably cause more stress and put you under more pressure m without really adding any extra benefit.

I completely get that you would want to have the cycle during the school holidays, I found the fresh cycle particularly difficult to work through because of the pain from my enlarged ovaries which made sitting painful. I guess maybe you need to consider the balance, are you going to get better results because you're better able to balance the treatment and not worry about work and have all the appointments at the advised times, or is it better to give yourself some more time given the recent cycle? A lot of things for you to think about I reckon and to discuss with your clinic.

Yes my situation is really difficult at the moment. I thought that I'd done everything possible to get myself in the best possible chance of success. With the euploid embryo, the transfer at the appropriate time for my receptive window in the microflora treated as well as being on the aspirin and heparin. My success should've been around 70%. There is a study that shows that with a euploid embryo for those that didn't have success the first time the chance of success the next time is 60%, for those that had no success the first and second time with euploid embryo the chance of success is 60% for the third. What's difficult for me is figuring out where I fit in this data, this was my third transfer but the first one with a euploid embryo and with all these extra things in place like having the microflora treated, so should I be considering it a thirst transfer as if I'm starting a fresh. Interestingly I had a quick chat with my specialist and she recommended in case cells, there's no real evidence in relation to this but I guess it's worth a shot, I've join the waiting list for the implantation failure clinic in Coventry. Meanwhile I think my next step is going to be to repeat my endometrial biopsy especially to see whether the microflora has resolved, some people need more than one course of treatment so that would give me something else to work on.At the same time I will repeat the error to see if my receptive window is right or whether that might have been changed by the microflora.

Sorry about typos, I dictated that into my phone and didn't proof read the last paragraph, it should have read:

Yes my situation is really difficult at the moment. I thought that I'd done everything possible to get myself in the best possible chance of success. With the euploid embryo, the transfer at the appropriate time for my receptive window, the microflora treated, as well as being on the aspirin and heparin. My chance if success should've been around 70%. There is a study that shows that with a euploid embryo for those that didn't have success the first time, the chance of success the next time is 60%, for those that had no success the first or second time with euploid embryos, the chance of success is 60% for the third attempt. What's difficult for me is figuring out where I fit in this data, this was my third transfer but the first one with a euploid embryo and with all these extra things in place like having the microflora treated, so should I be considering it a first transfer as if I'm starting a fresh. Interestingly I had a quick chat with my specialist and she recommended NK cells, there's no real evidence in relation to this but I guess it's worth a shot, I've join the waiting list for the implantation failure clinic in Coventry. Meanwhile I think my next step is going to be to repeat my endometrial biopsy especially to see whether the microflora has resolved, some people need more than one course of treatment, so that would give me something else to work on. At the same time I will repeat ERA to see if my receptive window is right or whether that might have been changed by the microflora.

To be honest I don't think diet / supplements / a

@Gardenlady543 My clinic make you sit out at least 1 cycle i.e. have 1 "natural" / med free cycle between fertility cycles (and to be honest it would be too crazy trying to organsie everything to go right away). So I'll have this AF after my chemical (which is sort of starting now, but just nothing like my usual period) and the month off meds before we could go again. We gave it 2 months between our failed fresh transfer and the FET and that just felt too long, particularly when cycle was longer the month after the fresh transfer, so I'm half expecting to experience that again, so not expecting another AF until end of July / start of August. I'll get my official 'outcome' letter tomorrow and then be able to book a review consultation, so I'll see whats gets said then.

Will you have to do another 'mock' cycle for the ERA or can they do that on a 'natural' cycle? For someone who normally loves statistics, I feel statistics are no longer my friends, as I feel my cumulative odds are not great.

Really wish we hadn't tired ourselves out / wated time and money on the IUIs and just went straight for IVF.

@2mumlife I wouldn't worry about the statistics, you're still doing better than me! With a embryo that isn't PGT-A tested the chance of success is about 1 in 3. So after 2 transfer about 45% wouldn't have success. You will know more about IUI stats than me, but as far as I'm aware it's about the same chance as natural conception, so I think you're still fine with the stats.

This is the paper I was talking about for euploid embryos https://pubmed.ncbi.nlm.nih.gov/33077239/
Basically even with a euploid embryo the chance of success remains pretty constant for the first three transfers. They argue that 95% of people will have success with 3 gos with euploid embryos and therefore further testing for implantation failure is not useful unless people fall in that 5% category. My issue is I may well be one of the 5% especially as my embryos seem to be excellent.

My clinic do the one natural cycle off thing too, I really wanted to go straight into the mock cycle, but my specialist insisted that we check my estradiol at baseline as it went through the roof with the FET.

You may find that this cycle after the FET is closer to your normal cycle length. It's just the fresh cycles that knock it out of sync (mine was 10 days longer), but after FET I get a pretty normal cycle length. I did find it took a few months after the fresh to normalize through.

The ERA has to be in a mock cycle. So I need this natural cycle to end, I am CD3 at the moment, I'll then do the medicated mock FET in August then a month off and I'm looking at a transfer at the earliest in October, but maybe longer depending on this NK stuff.