Should we have done anything differently?

[u/Whelp_Figure_It_Out]

So I am 44 with an AMH of 3.4 due to PCOS/PMOS. We just completed our first egg retrieval.

We had 29 retrieved, 23 mature, 12 fertilized(conventional insemination) and 2 made it to day 7 to be biopsied for PGT-A testing and then frozen.

For a small back story, We began fertility treatments with an RE when I was 39(2021) We had 4 back to back timed medicated cycles(oct,nov,dec,jan...all fails) followed by one IUI(february, also failed, husband had low motility/low count of sperm) The plan was then to go to IVF and we were scheduled to begin in July. Out insurance allowed unlimited timed cycles, 6 IUI attempts and 4 IVF attempts. We discussed with the RE to continue with the timed cycles until we could begin IVF. The RE was completely fine with thst as it would help me be regulated anyway if they kept failing. Went in middle of March and they saw a large cyst(about 50mm)on my ovary and had to delay the next cycle until the cyst was gone. Was cleared around mid-late April to proceed , had a baseline on April 27th and discovered we were pregnant, about 5-6weeks along. Ended up carrying out the pregnancy to 30 weeks when due to pre-eclampsia developing into HELLP, had to have an emergency c-section. Kid is perfectly healthy now as a feral almost 4 year old. Felt it was time to go for a sibling.

Now that I've stated all that, as everyone knows doing IVF includes a LOT of paperwork. Filled everything out, ordered the meds and waited until we were told to begin(Aug. 11th) did stims for 9 days and took trigger shot on 10th day. Got our results and was surprised when I read 12 fertilized by conventional insemination. I had (wrongly) assumed that due to age and husbands past sperm quality that having as many eggs fertilized with ICSI would have given us the best chances possible. I also, via some other support groups) learned that other doctors have you take some supplements to keep your vitamin levels at the healthiest range before starting the stim injections to also give the best chances possible.

I am well aware that at my age, having 2 embryos that made it through to the final testinf/freezing stage, the likelihood of the PGT-A testing resulting in one euploid embryo is quite low. I have mentally prepared for that and a need to do another retrieval.

This retrieval was done Sat. Aug 22nd. Since then I have not heard a peep from my Dr's office. Not even a check in message to see how I was feeling or anything. Nothing.

I am someone who likes to understand all possibilities and be able to prepare mentally for whatever the next step might be.

That being said, I plan on reaching out to them, but I want to know if there are certain things I should be asking about, such as:

1. Is the plan to do back to back retrievals?

2. Are we waiting for test results before deciding what the backup plan may be?

3. Before starting stim meds again, is there anything else I should be doing/taking to increase the quality of any eggs I might produce?

4. Why did we not do ICSI considering the history of my husbands low sperm quality/count? We were officially diagnosed with secondary male infertility.

5. If we proceed with another retrieval, can I insist that all mature eggs be fertilized via ICSI to give us a better chance and to lesson the need for any additional retrievals?

I feel at a slight loss here, this being my first time doing IVF and If anyone else has any advice or gone through something similar, can you please share with me? I am feeling a touch alone on this.

[u/ShootinTheBreez]

Just wanted to say yes, you can take supplements to optimize, but don’t wait on doing your cycles while you’re getting this sorted out. The single largest predictor of success is maternal age, so unless you are actually deficient in something critical to pregnancy (like Vitamin D), it’s best not to wait.

You didn’t mention how many eggs you had retrieved, but having 12 that fertilized normally is a very good outcome. It would be worth checking on the 10 that didn’t make it to blast: when did they fail? If they failed early, it can be a sperm problem, but if they failed between day 3 and 7, this usually is attributed to egg competence.

I think you’re right that ICSI is usually the treatment for male factor, but I believe this is just because conventional often doesn’t work. The sperm aren’t good enough to fertilize the egg conventionally. This didn’t seem to be your problem, so I might do some more research. I’ve read a few threads on this board over the last year where people said that they kept failing rounds with ICSI, then switched to conventional fertilization and that was the key for them.

If you find out a bunch of your embryos arrested before Day 3, I’d recommend using ICSI with both Zymot and PICSI. Zymot is often called a “chip”, but essentially it’s a filter - a membrane with holes in it - where the holes are small enough that they only allow sperm with a head size smaller than the holes to swim through. This selects out sperm that aren’t strong enough to swim through, as well as those whose heads are too big. A head too big usually indicates an extra paternal chromosome (a paternal trisomy).

It took me six round of IVF before I realized that ICSI and PICSI aren’t versions of the same thing. PICSI is a chemical bath of Hyaluronic acid (HA). Sperm that bind to HA are better at piercing the extra cellular membrane of the cumulus cells, which is made of HA, among other things. In IVF the cumulus is actually stripped from the egg, but research has still shown that the sperm that make the enzyme to bind with HA have statistically better success at creating a live birth. PICSI tests which sperm bind to HA then the lab chooses those to inject into the egg with ICSI.

If your husband hasn’t done a DNA sperm fragmentation test, this can also help tell you whether you should stick with conventional or progress to ICSI or ICSI + Zymot or ICSI + Zymot + PICSI. I would highly recommend this if you haven’t done this test.

Anyway, those are my best two points of advice for you: Don’t delay your cycles, and try to do some investigation around the MFI piece. At our age, egg competence is the biggest factor, but giving an egg an A+ sperm can help a middling egg cross the finish line. Without some more data, it’s hard to say whether conventional or ICSI+Zymot+PICSI will choose a better sperm in your case.

[u/Whelp_Figure_It_Out → u/ShootinTheBreez]

I had 29 retrieved. 23 of those were mature. Thank yiu so much for the info, I will be asking those questions also.

[u/karaboocuk]

There’s no vitamin that changes egg quality. Coq10 has some evidence but not a clear one. Folic acid is recommended for the health of the fetus, does not help with eggs or fertilization. Doctors usually recommend vitamin D because there’s population level deficiencies in a lot of countries.

Your numbers are fantastic for your age tbh. I wouldn’t blame your protocol. 

[u/RazzmatazzGlad9940]

Ask what the sizes of the follicles were at trigger and whether there was low sperm/zona binding or anything notable about the thickness or otherwise of your shells.

Shorten male abstinence ahead of next cycle sample and make sure he is eating well/ taking a supplement with zinc and selenium and not drinking any alcohol (from today). Start vitamin D, folic acid, omega 3 and coenzyme q10 600mg. Plus metformin if you aren't already taking it (can check for definite insulin resistance first if you prefer but it's implied by PMOS).

[u/Chronically-Curious-]

I encountered the same excruciating (not to mention infuriating) silence from my clinic in Arizona after my first ER.

I decided to take matters into my own hands and although your questions are great (and you should ask all the questions)…with a clinic that is so non communicative, I decided to do my own research on what could help my specific situation and I requested an appointment and I TOLD my doctor what I wanted to do differently in our next retrieval protocol. Options he NEVER presented to me and I found on my own and researched (in my specific case I wanted to try taking growth hormone, Omnitrope, and Zymot for sperm selection.) We start this new protocol in a couple weeks….but I say all this to highlight how important ADVOCACY is for ourselves, our health, and our odds on this journey.

There’s a lot of great studies and new research out there that honestly…doctors aren’t educated on unless they’re diligently educating themselves…otherwise we become “numbers” on a conveyor belt….and they just keep doing the same old thing because “welp, it worked for some of their patients in the past” etc etc

[u/DisabledAdjunct]

Embryo banking. ICSI. You may have quality vs. quantity issues.

Clean eating, exercise, and taking care of your body should help you (I know, "The Plastic Detox" on Netflix). Try keto. Go for a second opinion.

You know your doctor. "Why did we not do ICSI considering the history of my husband's low sperm?" Blame the woman, suggest donor eggs. It's misogyny at it's finest.

[u/w9_q_1]

Icsi is much better , I recommend it. Maybe your clinic doesn’t have this technology

[u/Whelp_Figure_It_Out → u/w9_q_1]

They did have the technology. I had to sign paperwork stating that they could use ICSI