Natalia Szlarb, MD, PhD
Gynaecologist & Fertility Specialist at UR Vistahermosa, UR Vistahermosa
Advanced Maternal Age, Donor Eggs, Failed IVF Cycles, Success Rates
Thank you for the question. After coming back to Europe after 20 years, I have seen a massive positive change in Europe, with countries opening up their borders. My hope is that despite Brexit, borders will stay open for medicine and that patients from the UK will be able to come just like any other EU citizen. As an American citizen, I was still able to stay in the EU for up to three months – so even though you will be outside the UK, you can stay in Spain long enough for us to plan not just one, but three cycles. We do however expect the British Pound to go down following Brexit, so finances might become an issue. Personally, I believe in medicine without borders – everyone should have the same level of access to specialist treatment, no matter where you come from or what language you speak.
There are no evidence-based papers published that link gluten intolerance and poor egg quality. Implementation failure is most commonly a result of three factors: the egg quality, your endometrium receptivity and endo-immunology.
Of course, we provide Skype consultations. I can’t imagine patients coming all the way from the United States, Canada or Australia for a first consultation. Drop an email to email@example.com to schedule a full one-hour consultation on Skype. Make sure you provide all your medical documentation so that the doctor we assign to your case has the time to familiarize themselves with your case before the consultation. This service costs about 150 EUR.
From my professional experience of working in Berlin, pregnancy rates between the ages of 35 to 42 are too low to recommend going forward without additional genetics work. On the other hand, doctors in the United States are reluctant not to perform cycles without any genetics work, because if a miscarriage as a result of a genetically abnormal embryo can result in a lawsuit. If you’re over 42 years old and want to go through with an IVF treatment using your own eggs I’ll be more than happy to support you – however, be aware that while it is possible to carry such a pregnancy to term, statistically it’s very unlikely, which is why for patients over 40 we recommend egg donation.
This approach is problematic, because if a genetic disorder – for instance, trisomy 13, 18 or 21 – is detected during maternal blood testing, you would have to recommend an abortion to the patient. The current approach, which involves freezing embryos for testing actually improves success rates because it allows us to know for certain which of the embryos is most likely to result in a successful pregnancy.
Sometimes we do genetic testing for patients as young as 27 – for example, if they have had three or four failed cycles in their home countries, as a specialist I need to know why those cycles failed. While genetic testing is never truly obligatory, we strongly recommend them in cases such as this, because it’s pointless to attempt a process that has already failed several times – something has to change, and DGP and PGS allow us to give you a different way forward.
You don’t need to meet all three indicators to have embryobanking recommended to you by your doctor. If your AMH is low, for example, and you’re not able to generate enough eggs, that’s when I would recommend it to you. There are many scenarios in which it becomes a viable option – make sure to talk to your doctor.
Yes, it is. Egg donation success rates are the same if you are, for instance, 35 years old and you experience ovarian failure or if you’re 50 years old and have gone through your menopause. As long as your uterus is working and doesn’t have any anatomical abnormalities like fibroids, polyps, clotting issues etc. your pregnancy rate would be around 70% with blastocyst, independent of your age.
We should do a cycle. If you have low AMH, but can generate blastocysts and you develop genetically normal embryos, you can become pregnant by your own eggs. AMH only tells us how many eggs we’re going to generate. However, I would need to see those eggs in a lab to measure their quality and ascertain whether or not they’re going to get to the blastocyst stage. By performing a cycle, we can see if it’s possible for you to become pregnant with your own eggs.
No. AMH only tells me how many eggs we can generate. It does not tell me how strong the eggs are.
Statistically, the more embryos I have, the higher the probability of finding a genetically normal one. The number doesn’t affect the quality, it affects the statistical probability of finding a good embryo for someone who’s over 40 years old.
This breaks my heart. This type of treatment is what we used to do over 20 years ago. These days, we use our own in-house protocol for treating patients with PCOS. With an AMH as high as yours, you could be an egg donor. However, we have to be mindful of egg quality. With a mild treatment and an antagonist (to avoid overstimulation), we could expect over 20 eggs. These eggs, however, are not guaranteed to fertilize well. Usually, for five embryos, the success rate would be about 50%. However, with PCOS that number drops to 30%. Don’t worry, however. If you can generate 30 eggs, I expect about six or seven blastocysts. At your age, 10 percent of blastocysts should be genetically normal. That means out of eight blastocysts, one – maybe two – will be good to go. What you need to do is prepare yourself for a totally different approach. In cases like yours, we focus on the embryo – generate the embryo, freeze, genetics work and biopsy. Then, in the next cycle, we attempt a transfer. However, if we see that despite your being able to generate a lot of eggs but they can’t reach the blastocyst stage due to your age, that’s when I would recommend egg donation. In this day and age, however, I would fight for your own genetics until the very end.
Q10 is FDA approved and there are some papers showing that it has a positive effect on eggs quality, so I would say yes.
The fact that you had blastocysts is already a very good sign. I would like to see your ovarian reserve and your antral follicle count. Please send us your protocols and pictures of embryos that you had when you did cycles at your clinic at home. If you’re able to develop blastocysts, we’d need to measure their quality – if it was at least a B, we will be more than happy to do one more IVF cycle with genetic testing. If their quality is C or lower, the best option would be to go with egg donation.
I do. I’ve performed more than a few egg donation cycles and I’ve seen miscarriages from genetically abnormal embryos of egg donors. It’s not something done routinely, but we do recommend it and I personally believe in the future it will become a standard procedure.
We have to be aware that after so many cycles the endometrium in the womb is not receptive to the embryo. We would recommend a uterus lining biopsy to see if you need five or more days for the implantation window. We have offices all over the UK that perform this type of biopsy for us. If you’d like us to design a cycle for you, drop an email to firstname.lastname@example.org and I’ll be more than happy to put one together so you know when the biopsy needs to be taken.
We have patients that fly from Spain to Australia after a transfer. What you should avoid, however, is hard work, baths, swimming – no underwater activities, basically, just showers. Also avoid standing for long periods of time, cycling and sexual intercourse. These are the things you should avoid. Flying, however, is safe – a lot of our patients fly home the same day as the transfer.
Exclusive egg donation costs 10,000 EUR. PGS comes at an additional 3,000 EUR. We were the first clinic in Europe to introduce an egg donation PGS program.
I would have to know how old you are, what kind of cycles you’ve had before, which hormones were you given and if you have reached blastocyst or not. The key is to know if you’ve had euploid blastocysts – if yes, then the pregnancy rate should be around 70%. If not, you have to start thinking about egg donation. Send us an email to email@example.com and schedule an appointment so we can see your AMH and your ovarian reserve. This will tell us if the numbers are on your side, that is, if it’s possible to work with your own eggs.
What we do in cases like yours is put the patient into an artificial menopause for about two months so that you do not produce any hormones on your own. After this period of down-regulation we perform a test cycle along with an oral estrogen treatment and afterwards we scan your uterus to see what your lining looks like and what dose of hormones you need to grow a proper lining. Then I know enough about how to proceed during the transfer cycle so that the bulky uterus should not be a problem.
You’re already doing a lot to improve your egg quality. If you are able to produce genetically normal embryos at the age of 43, please send us an email to firstname.lastname@example.org, set up a first appointment and a first cycle with genetics. This should tell us if you cocktail of medication allows you to develop an euploid blastocyst. If yes, your chance of pregnancy is 70% per transfer. If we see that your egg quality is not sufficient, then we would strongly recommend a donation treatment.
When you come to the clinic, you sign an agreement which gives you not just eggs, but complete embryos. If for some reason the donor eggs aren’t of sufficiently high quality, we simply stimulate a new donor to make sure we have new blastocyst stage embryos ready to be transferred at no extra cost to the patient.
I have seen it a couple of times in patients treated with (???) due to underlying autoimmune issues. It’s a medication commonly used in chemotherapy, but small dosages are also used to treat autoimmune disorders. AMH going up after such treatments happens, but very, very rarely. Unfortunately, for most people AMH will only go down with age.
Thank you for your support. Every year before Christmas, key people in the company sit down and discuss where to travel next year, where we can find patients that need us. If you say that there are many patients interested in IVF treatments in Norway, we would be more than happy to come to your country in 2020 to organize a meeting with potential patients.
No. The donors cannot have PCOS. They can, however, be high responders.
I like this question a lot because we tend to talk a lot about the female factor while not giving enough attention to the male factor! Our main focus is on producing strong and healthy embryos – I want to have a blastocyst, and I want the embryo to be 100% genetically normal. If your sperm quality isn’t sufficient, here’s what I would do: first, a karyotype analysis. Secondly, vitamin treatment, and, believe it or not, high ejaculation frequency. Many centres in Europe recommend an abstinence period of one week before giving the sperm sample, but this tends to actually lower sperm quality – often, the samples given after such a period have very high fragmentation rates and high op(?) doses. We recommend an abstinence period of just 48 hours. Aside from karyotype analysis, we also do screenings for carrier genes for cystic fibrosis, because we know that goes with some sperm abnormalities, as well as testing for the ACF gene, and hormonal studies. When every single test fails, we recommend sperm donation.
There is an office on Harley Street where Dr Karoshi does biopsy – she serves the central London area. IVF Matters performs biopsies for other parts of the UK. We design a cycle of 15 days of oral estrogen, and two days of progesterone and the biopsy has to be done on day 21. Following the biopsy, the sample is transported with either IVF Matters or Dr Karoshi to the lab, which performs the test and tells us if you’re receptive or not.
Endometriosis is a headache if we’re doing egg retrieval and we encounter chocolate cysts. Endometriosis is something that takes eggs out of the good ovary and occupies the space, lowering your AMH. The treatment for it – out of IVF – consists of long cycles, which means you take birth control pills and you have one or two bleeding annually. This means you do not have your period. Endometriosis is basically your endometrium that originates in your body through retrograde menstruation and is developing inside your tubes and ovaries. This becomes a problem while retrieving eggs. For embryo transfer, however, the “bulky uterus” should be treated with a down-regulation of four to three months before a transfer. Every patient receiving a transfer receives prednisone because endometriosis is seen as an immunological factor.
Due to laws regarding pharmaceutical companies, I cannot tell you which medications we use. I can only tell you that it’s a mixture of FSH and LH, and there are two medications that contain it. One is American – it’s expensive but very good; the other is Italian. I think I already said more than I should have!
The answer is no. Men can have children for a long time – the oldest father we had was 85 years old. As long as the egg quality is sufficient, the age of the father isn’t the problem – low testosterone issues with erection are. So even if your sperm is good, sometimes due to your age and problems with your blood vessels you may have erection problems. If there are no contraindications, we recommend oral medication to solve those issues.