Archive for the ‘Recurrent Implantation Failure and Recurrent Losses’ Category

What is assisted hatching?

Saturday, May 1st, 2010

Assisted hatching is an optional extra procedure used in IVF where a small hole is made in the shell (or ‘zona’) of a Day 3 embryo. This is supposed to help (in some cases) the embryo ‘hatch’ out of its shell and transform itself into a blastocyst (usually on Day 5).

Probably the best site to get a clear understanding of assisted hatching is the one from the Advanced Fertility Center of Chicago, which shows in great detail how the hatching process works, including a pic of an embryo actually in the process of hatching to become a fully hatched blastocyst. Cool!

In New Zealand assisted hatching is not part of the default IVF protocol, so you would need to ask your specialist about it.

My understanding is that public funding won’t cover assisted hatching (I could be wrong about this – please chime in if you know of criteria for eligibility). But, if you were doing a publicly funded cycle and your specialist agreed it might be a good idea, you could presumably pay for it out of pocket (it’s a few hundred dollars).

If you are a self-pay patient, obviously the choice is with you and your specialist, so ask. However (and someone please update me if this is no longer the case), if you have the OK to transfer more than 2 embies, apparently the clinics are not allowed to do AH on more than two. I can’t fathom the reasoning on that (especially for women over 42), but there you go … Minor trivia, but worth knowing in advance (if you’re like me, you hate surprises cropping up during the cycle).

Just to give a broader perspective, in the States, where patients are either paid for by insurance or out of pocket, assisted hatching (AH) seems to be used more widely. The Advanced Fertility Center of Chicago says they do it on all embryos, but they also offer the following useful list of criteria:

Who should be treated with assisted hatching?

The most commonly used indications for assisted hatching with an in vitro fertilization case are:

  • Age factor – Couples having IVF with the female partner’s age over 37
  • Egg quantity and quality factor – Couples in which the female’s day 3 follicle stimulating hormone (FSH) level is elevated
  • Embryo quality factor – Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division)
  • Zona factor – Couples having IVF with embryos that have a thick outer shell (zona pellucida)
  • Previous failures – Couples having IVF that have had one or more previous IVF cycles that failed

In our IVF clinic, we use assisted hatching on just about all cases – because we think it increases the pregnancy and delivery rates.

For the original page, see http://www.advancedfertility.com/hatching.htm

I’m pretty sure that assisted hatching can be used whether you are doing a 3-day or a 5-day transfer, but generally not for 2-day transfers (the embryologists say the embryo is usually too small then and there’s a risk it could break up if the zona is punctured). With a 3-day transfer, they will do this immediately before they put your embies back. With  a blast (5-day) transfer they would presumably do the AH on day 3 before putting the embryos back for their last two days of development. Anyway, these are just a few things to discuss with your specialist.

As for risks, my understanding there is a very very small increased likelihood of conjoined twins if assisted hatching is used. My own specialist told me that, although this was statistically true, the reality was that the increased chances are so miniscule that they don’t really have practical significance.

Who should be treated with assisted hatching?

The most commonly used indications for assisted hatching with an in vitro fertilization case are:

  • Age factor – Couples having IVF with the female partner’s age over 37
  • Egg quantity and quality factor – Couples in which the female’s day 3 follicle stimulating hormone (FSH) level is elevated
  • Embryo quality factor – Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division)
  • Zona factor – Couples having IVF with embryos that have a thick outer shell (zona pellucida)
  • Previous failures – Couples having IVF that have had one or more previous IVF cycles that failed

In our IVF clinic, we use assisted hatching on just about all cases – because we think it increases the pregnancy and delivery rates.

When and how should I seek a second opinion?

Thursday, October 15th, 2009

Suppose you had a friend who was grappling with a cancer diagnosis and kept wondering whether his/her specialist had really considered all the possible treatment angles that might work. Suppose he or she had been receiving some treatment but there hadn’t really been any sign of progress. What would you advise? Probably a second opinion, right?

For some unknown reason, fertility patients seem to struggle with this notion that it’s somehow disloyal to seek a second opinion. Yes, it is awkward. But actually, it’s just good common sense if there’s any little voice inside your head saying “maybe there’s a better way …”  I know several women/couples who have switched specialist within the same clinic and have really agonised over how they are going to “break up with” their initial specialist. But the reality is this happens all the time, and people need to find the fit that’s right for them. My local clinic (FAA) actually makes that transition incredibly smooth and most of the drs are perfectly happy when it happens. [Actually, some may be relieved about getting rid of a “difficult” patient! ;)]

Even if you’re not actually switching specialists, it’s perfectly reasonable to seek out a second opinion if you want to. If you’re publicly funded you may have to pay for the second opinion consult, but that’s money well spent if it’ll give you peace of mind and/or some good ideas that can get you closer to building the family you want.

Remember, just as in any other profession, each individual specialist has certain diagnoses and treatments that they have a particular interest in and more experience in treating. Some gravitate toward the more straightforward cases (early 30s, no tubes, standard protocol, easy success); some specialise in particular issues (endometriosis, PCOS, thyroid problems); some are really passionate about taking on the really challenging cases (women over 40, poor responders, egg quality problems). It’s a good idea to ask around about who’s had success with cases like yours. And that’s a good place to start for a second opinion. Just think, women/couples in the States fly 5 hours from coast to coast seeking a second opinion; we are incredibly lucky that even the other end of the country isn’t that far away! And if travel is really a problem, you can often book a phone consult.

Over the years, one thing I’ve noticed is that the truly professional specialists I’ve spoken to have NO problem at all with my seeking a second opinion. They support my being proactive and are very happy to listen to any ideas I glean from those other consultations. They don’t let egos get in the way of my treatment. While working with my own specialist, I got a copy of all my notes and did a phone consult with a specialist in the States who’s considered the #1 go to guy for women with my particular diagnosis. My specialist in NZ was like nooooo problem – and was very open to the ideas I came back with. We did, of course, have a healthy debate about which of the ideas seemed to make the most sense in my case, but the main thing was that we had that discussion and we made some good decisions together about what to try next.

How do you know you should seek a second opinion?

Well, everyone’s different. For some people, it’s when they’ve just had a failed cycle, they can’t afford to do more than about one more, but the specialist is suggesting just going with the same again. For others, they’ve tried discussing other ideas with their specialist but feel like these aren’t being taken seriously or at least the reasons for not trying these things aren’t being adequately explained. For me, it was feeling like we’d already discussed and tried all the ideas we could think of together, so I needed a fresh perspective, a new source of ideas. Whatever the situation, if there’s a little voice in your head wondering whether you and your specialist have adequately explored all the possibilities, that’s a sign you might want a second opinion. It could just end up confirming what your current specialist is telling you, in which case that’s also useful because it eliminates doubts that you’re doing the right things.

If you think you might want to get a second opinion on your case, here’s what to do:

  1. Get a copy of your notes from the clinic so you know exactly what protocols you have tried already, any testing that’s been done, how you responded to treatment (including E2 levels, follicle sizes, the embryologist’s ratings of embryo quality, etc).
  2. If you can, make a 1-2-page bullet point summary of your history and any testing. This makes it a LOT easier for the new dr to get up to speed quickly on where you are at.
  3. Ask around (e.g. on the Everybody BB’s Infertility forum) to find out which drs at which clinics have had success with your particular diagnosis and history.
  4. Call that dr’s clinic and speak with his/her receptionist; ask for an in-person or phone appointment; ask where and how to send your summary/notes/file.
  5. You don’t have to formally tell your current specialist that you’re seeking a second opinion, but you’ll probably end up informing his/her nurse or receptionist when you request a copy of your file/notes. It’s a courtesy to mention it, but if it’s causing you anxiety then don’t force yourself to. The specialist will understand.
  6. If you are doing a consultation with someone who works at another clinic from your ‘home’ clinic and if you like what they are suggesting as a new plan, discuss with them whether it would be feasible/advisable to (a) ask your current specialist to follow a new protocol; (b) cycle at your local clinic but with the new specialist either calling the shots or providing advice to your own specialist; (c) travelling and doing the whole cycle at the new clinic; or (d) doing egg collection and transfer at the new clinic, but monitoring (ultrasound and bloodwork) locally. All of these options have been done around the country at one time or another.
  7. Don’t worry too much about having to persuade your current specialist to try something new – quite often the specialists will just get in touch with each other and work out how best to work together. Ask your ‘second opinion’ specialist what he/she thinks is the best way to handle this. The politics and the details of this shouldn’t be your problem – you are going through enough stress already!
  8. Don’t worry too much about the ‘disloyalty’ issue either. You have the right to expect specialists (and any healthcare provider, for that matter) to be professional about second opinions and NOT to make you feel guilty about seeking one out. If you find someone is not being particularly professional about it, that tells you more about them than it does about how you handled it. Your priority is to get a baby/family out of this, and their priority should be to help you achieve that dream. The specialists won’t be a part of your life forever, but your babies will!

We’ve had multiple losses – what should we be asking about?

Wednesday, October 14th, 2009

“We seem to have no trouble getting pregnant, but we’ve had several first trimester losses.” Or, “We put back good-looking embryos every time, but they just don’t stick.” If this sounds like you, here are a few ideas you might want to discuss with your doctor.

Miscarriages can be caused by any one or more of the following factors:

  • structural
  • hormonal
  • immunological/autoimmune
  • environmental
  • genetic

Let’s start (as the drs often do) with the fairly basic hormonal tests. One of the first that’s included in a fertility workup is testing progesterone in the luteal phase. Most drs order this for CD21 (Day 21 of your cycle), but actually you should really have it done at 7dpo (7 days past ovulation). Of course, 7dpo=CD21 if you ovulate on Day 14 of your cycle, but if you usually ovulate late or early, or if it’s unpredictable, you might want to track your ovulation using BBTs (basal body temperatures) and go at 7dpo. If your progesterone (P4) levels aren’t high enough, you may need progesterone supplements (like utrogestan pessaries) after ovulation (O). Some specialists believe this is a VERY common problem with older women and that if you’re over 40 and ttc naturally you should take P4 after O every cycle.

Another important one to test early, especially if you have any family history or tend to feel tired a lot, is thyroid conditions. Hypothyroid (underactive thyroid) does pop up reasonably often as a cause for conception and sometimes miscarriage problems and is easy to test for. You can ask your GP for this if you’re not seeing a specialist.

If you’re ttc naturally you should also check whether you have a luteal phase defect, i.e. once you ovulate it takes fewer than 12 days for AF (your period) to arrive. You can usually figure this out by charting your basal body temperatures (BBTs) – and a really good site for learning how is Fertility Friend. Again, if your LP is too short, this can be easily fixed with progesterone support after O.

There’s a panel of blood tests you can ask for that are used to diagnose some of the possible causes of “recurrent pregnancy loss” (RPL) or “recurrent implantation failure” (when those embies just don’t stick). Broadly speaking, they cover three categories of issues – autoimmune issues (your body may be rejecting embryos as foreign bodies), clotting issues (not sure the exact mechanism for this, but if your blood clots too much, this makes pregnancy loss more likely – some clotting issues are caused by autoimmune problems) and some genetic issues. Here’s the list that we were sent for, and I think it’s a pretty typical list for New Zealand (some countries like the States seem to test for half a dozen kitchen sinks, several of which aren’t available in NZ):

  • Coagulation screen
  • Thrombophilia screen
  • Autoantibody screen incl.
  • antithyroid antibodies,
  • anti-gliaden antibodies
  • Factor V Leiden
  • Karotype
  • MTHFR mutation
  • Anticardiolipin antibodies
  • Lupus anticoagulant
  • … and a karotype for DH (who gets off easy, as usual).

Probably the next logical step is to get either a saline sono (ultrasound during which they squirt saline solution into your uterus to help them see better) or an HSG (similar, but it’s an X-ray procedure where they shoot iodine dye into your uterus and can also check whether you have blocked tubes). Either of these should tell you whether you have any structural issues in the uterus that might be preventing you from achieving or holding onto a pregnancy. Examples include uterine polyps, fibroids, scar tissue, and an unusual shaped uterus. The most likely issues can often be treated with some fairly minor surgery.

The main environmental causes of miscarriages are not usually tested for, but things you should look around you to check your exposure. Some to keep an eye out for include lead, mercury, organic solvents and ionising radiation. Other more common culprits like cigarettes, alcohol, coffee and other drugs should be cut right out (or, down as much as possible) while ttc. Some naturopaths will do things like send a sample of your hair for analysis for heavy metals, which can highlight things you are exposing yourself to without knowing it. They also advise avoiding those forms of radiation and related exposure that we are not often aware of. These include long-haul flights (which expose the body to as much radiation as a full-body X-ray, or so they say) and keeping a cell phone in your pocket right next to your ovaries – think about it!! Well, who knows which of these various things are real causes, but if you want to make sure you try everything you can to prevent another loss, you’ll probably do what I did and take the ideas pretty seriously.

But what if my specialist won’t run all these tests?

This is quite a common comment from a lot of women/couples dealing with RPL (recurrent pregnancy loss). It may be frustrating, but there is another way to look at this. OK, you may not be able to test for the entire kitchen sink, but maybe you can ask your specialist to consider treating you as if you did have several of these issues going on but they just may well be undiagnosed. That may sound nuts, but there are actually quite a few low-tech options you can ask about that many doctors will agree fall into the “won’t hurt, might help” category. These include:

  • low-dose aspirin (usually 100mg/day) – addresses clotting issues
  • high-dose folic acid (4-5mg/day) – helps prevent neural tube defects
  • progesterone support (usually Utrogestan pessaries) after O on every cycle you are ttc
  • low-dose estrogen support after O too (2mg estradiol valerate, for example)

If you’re doing IVF, each cycle is a bit more high stakes, so you may be able to push for a bit more of a kitchen sink approach. Some other things that people are often allowed to try even if there hasn’t been a definitive diagnosis of a particular cause for repeated losses/failures include:

  • progesterone shots instead of (or as well as) the pessaries – for after egg collection
  • a low-dose steroid such as Dexamethasone – to address any undiagnosed immune issues
  • Heparin shots – Heparin is a blood thinner, so this also addresses clotting factors

Finally, don’t forget that there’s good evidence that acupuncture improves pregnancy and live birth rates for patients undergoing IVF – and good reason to believe this is also true for couples trying to conceive naturally or with IUI. Click on the category Acupuncture and Chinese Medicine in the left-hand column to see more posts on this topic.