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Question 1

I am 39 years old. My AMH is 15.5, FSH 8.9. My AFC was 7/8 on each ovary. I had three rounds of IUI and one round of IVF ICSI (7 mature eggs collected, only one fertilised and it was abnormal by day 2). I am concerned my next round will have the same result.

Accepted Answer

It seems that you belong to the group 2 of Poseidon. The parameters of ovarian reserve are not excellent but not too poor either. In such a case, we consider that an improved response is possible in a new cycle. Maybe with higher doses of gonadotropins and a longer stimulation and LH effect, the greater number of eggs is possible. So it is worth to repeat a cycle and we may see the improvement.

Question 2

Are there any benefits in mild stimulation to get better quality eggs in older women?

Accepted Answer

To be honest, I have never heard that mild stimulation increases eggs’ quality. In my opinion, the general use of mild stimulation has no sense. The vitrification process is an excellent strategy to achieve the benefit of a higher response to get more embryos to be selected or make PGS. Mild stimulation doesn’t increase the quality of the eggs.

Question 3

When you are discussing group 2 vs. group 4, does it mean only antral follicle count or also how many mature eggs there are? I had one cycle with 8 oocytes retrieved with 150 Menopur/300 Gonal-F, but 4 months later I did a cycle with 150/150 (Menopur/Gonal-F) and got only 3 oocytes. However, in both cycles only 3 oocytes were mature and able to have ICSI.

Accepted Answer

It is a difficult question because the rate of mature eggs can be influenced by several factors like e.g. the timing or the size of follicles at the moment of recruitment. When we talked about suboptimal and poor responders, we said that we can increase follicle recruitment. But it is still not clear how to get more mature eggs. Maybe by using the LH effect and increasing the number of days of the stimulation and delaying it a little bit, we can help to get more mature eggs.

Question 4

What dose of coenzyme Q10 is recommended?

Accepted Answer

Usually, the normal supplements for daily use are about 30-60 milligrams. But as the scientific papers say, the doses should be higher: between 100 and 300 mg. It is said that when we want to improve the quality of eggs, the doses should be higher. For some neurological problems like Parkinson, the doses are even up to 1200 mg. But for normal daily supplements, 30-60 mg is a normal dose.

Question 5

What’s the risk of not using a mosaic embryo after PGT-A which otherwise could be viable?

Accepted Answer

It is a very controversial question. Some genetic laboratories decide to transfer such embryos while others would never transfer them. So finally, it is always the decision of the genetic laboratory. I can ask my colleague who’s in charge of PGT-A and we can email you about any problems with mosaic embryos. He can answer this question without any problems.

Question 6

I am 40 years old. I had AFC of 7 last year but this year there was no egg in one ovary and they couldn’t really see the second ovary because of fibroids. What can I do? Because I really want to use my own eggs. Can ovarian rejuvenation help? Or can I do egg banking monthly?

Accepted Answer

Freezing eggs may be a good option for you. 40 years is not obviously an optimal age but low ovarian reserve at this age does not mean that pregnancy is not possible. It is true that you have enough time to try to get pregnant with frozen eggs. Ovarian rejuvenation is actually an experimental treatment. The effectivity of this treatment is still very poor at this moment.

Question 7

I’m a 40-year old woman and I have just experienced my 5th miscarriage. I suffer from unexplained subfertility and unexplained recurrent miscarriage. Each pregnancy ends around 7th week. NK cell testing – done! Various autoimmune issues tests – done! There are no concerning results in my hysteroscopy. Can you suggest any further issues I could be tested for, which may be causing the miscarriages?

Accepted Answer

First of all, when a woman is 40 years old we cannot talk about unexplained subfertility and unexplained recurrent miscarriages. The risk of chromosomal miscarriages is simply too high at that age. To be honest, I don’t believe much in immunological treatment as in most cases it is not effective. We may recommend you to undergo IVF with PGS to obtain more information with respect to the chromosomes of your embryos. Probably, egg donation is an option. Egg donation does not only increase the pregnancy rates but it also decreases the miscarriage rate up to 30-40%. And in this case, it is highly possible that chromosomal problems are the reason for miscarriages.

Question 8

What about the issue with false positives in PGT-A testing? It is estimated that women have been throwing away embryos for false positives (due to undetected mosaicism) in 20-30% of those that test positive. Maybe not necessarily false positives but e.g. embryos that could have self-corrected after transfer through selective apoptosis.

Accepted Answer

Again, the issue is very controversial here. And yes, you can transfer some of them because they can self-correct. The laboratory will report what they have found and then the patient can decide. They can transfer the embryo and then do the prenatal test. So it is very optional and it depends on the clinic you’re working with. It also depends on the laboratory you’re working with because some laboratories will report to you about the mosaic embryos while others won’t. They will just tell you if the embryos were chromosomally normal or chromosomally abnormal.

Question 9

What is your opinion on tests like ERA/ EMMA/ ALIS in older women as well as the use of intralipids/IVIg/ Clexane/Aspirin?

Accepted Answer

If this question refers to the implantation failure, then yes, the test of endometrial receptivity like ERA can tell us a lot about the failure itself. However, intralipids or immunoglobulins are not of any help in this case. There is a very limited number of cases when their use can be beneficial – so their general use is not a good option. Aspirin and Cleaxane can be used if there are serious indications.

Question 10

Do you see any benefit in using calcium culture in the lab before fertilisation/ICSI attempts when using donor sperm? Does it increase the fertilisation rates?

Accepted Answer

We don’t use calcium culture. We have read many studies and there is no conclusive evidence that it is beneficial to patients. Calcium culture is not widely used, at least here in Spain.

Question 11

What, in your opinion, is the maximum number of times an egg donor should be allowed to donate – from the point of view of the donor’s health and, as a result, her eggs?

Accepted Answer

Here the law does not say anything about the maximum number of times a donor should be allowed to donate. It says about the number of positive results. The Spanish Fertility Society agreed that 5 times could be ok but it is not the maximum. If an egg donor wants to donate one more time, she can do it. At our clinic, a donor cannot donate more than 5 times – even if she has good results.

Question 12

Do IVF cycles affect the health of the donor and the health of her eggs if she keeps donating?

Accepted Answer

The answer is: no. It is not going to affect the donor’s health or the health of her own eggs. Of course, there is always a risk in repeated donating – but it is the same risk when you do it for the first time. Several ovaries stimulations don’t influence the number of follicles. Of course, you cannot do it all the time but 5-6 times have no effect on your health and do not affect your fertility.

Question 13

What is your opinion (or evidence) on DNA fragmentation impact on the success in IVF? Can ICSI/IMSI help with this?

Accepted Answer

I’ve done many studies with DNA fragmentation and I think it is important. Here in our clinic, we do DNA fragmentation test, we use techniques with DNA fragmentation depending on the rate the patient has. Then we recommend to do ICSI and, depending on if there are single or double strand DNA breaks, we have to recommend a sperm donor in some cases. ICSI can also help, but not only ICSI. Sometimes we also have to use Annexin-V or – what we are using now – a fertility chip that gives an improvement in pregnancy rates. We haven’t done IMSI but – just like with calcium culture – it is very controversial and there are no conclusive studies showing benefits of this technique.

Question 14

How does egg retrieval affect thyroid? If there is an elevated thyroid after a retrieval, will it stay that way forever? The doctor said they want to start thyroid meds because of the elevated level.

Accepted Answer

I imagine you’re talking about TSH (thyroid stimulating hormone). High levels of TSH may mean poor functioning of thyroid. In this case, it is very important to use levothyroxine to increase the chances of pregnancy. There are women who – after the ovarian stimulation with gonadotropins – may produce changes in thyroid hormone levels. The proper functioning of thyroid is very important before the start of any fertility treatment. Make sure it is neither too high or too low. Your doctor was right to use thyroid meds. It is very important to have thyroid under control before stimulation.

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