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Getting pregnant after (+38) – success stories

Halyna Strelko, MD
Co-founder& Leading Reproduction Specialist at IVMED Fertility Center, IVMED

Category:
Advanced Maternal Age, Success Stories

ama-patients-successful-ivf-IVFWEBINARS
From this video you will find out:
  • What does the theory of follicular waves mean?
  • Which is better- starting stimulation in the follicular or luteal phase?
  • How does age influence IVF outcome?
  • When is PGT-A testing recommended? Is it always recommended in patients of advanced maternal age?
  • When is it time to turn to egg donation?

What are the treatments options for getting pregnant after 38?

During this webinar session, Dr Halyna Strelko, the Co-founder & Leading Reproduction Specialist at IVMED Fertility Center, Kyiv, Ukraine, talked about advanced maternal age (AMA) patients & presented 2 IVF cases where all the steps were thoroughly discussed.

What are the treatments options for getting pregnant after 38? - Questions and Answers

How can AMH levels vary? Is it good to check it a couple of times during a month, or it is not necessary?

I have seen recently an article about AMH level variability, and at first, AMH level was thought to be stable, but in fact, it may change during the cycle by 20-30% in a different phase of the cycle. It is increased when the LH level is higher and decreases when the LH level is lower. It can also vary between 20-30% from cycle to cycle. Another important thing about AMH level is that the level in blood circulation and the level you receive in your analysis may be different. It may be influenced by the lab that does the analysis.

Sometimes if your blood was frozen or heated or not put 3 hours and waiting to store for a couple of days or something else before it was put in the machine, it may affect the result. You can check AMH level even 3 times per cycle, but as for me, it’s better to do an ultrasound and check the antral follicular count (AFC) to check how many antral follicles you have in your ovary and take blood for AMH and see if both results are more or less the same. I think it’s enough to understand your real ovarian reserve. If, for example, you have a higher antral follicular count and lower AMH level, it’s probably necessary to take into consideration the antral follicular count. There is also very interesting work where they compared people with high AMH level and low antral follicular count and the opposite and showed that if there is a discordance, it’s better to consider antral follicle count.

I’m 43, my AMH is 1.01, and I did 10 IVF rounds until now, only one was successful, what is your suggestion for my age for the next IVF, I tried egg donation last month, but it wasn’t successful as well.

It’s a difficult situation because you already had 10 IVF attempts. To understand this situation better, it is necessary to see how many eggs were produced during all these attempts, the percentage of fertilization, the percentage of blastulation if you have done the genetic test of embryos, if you have done, for example, the specific test of endometrium receptivity because if in most of these attempts, you had excellent, genetically normal embryos, and for example, but you never tested your endometrium, it would be probably better to do such test and check your receptivity.

About egg donation, it is also necessary to see how many eggs were used, how many blastocysts, the quality of these blastocysts, protocol of preparation, so that is difficult to answer without more details.

Do you have experience using growth hormone to increase male fertility?

Personally, no, I don’t work with a male partner. Our urologist works with them, but he does not use growth hormone. We are using the stimulation with FSH and hCG mostly in case of azoospermia, and sometimes we receive a couple of sperm cells after this stimulation but grows hormone, unfortunately, no, I have no experience with male partners.

What is the best number of days with progesterone before frozen embryo transfer?

There are also different publications on that. Some of them say that it is maybe 5-6 days, if we start progesterone on Monday, we should do the transfer on Saturday, but another publication says that it’s better to follow 120 hours and a recent publication, for example, if you are using natural cycle IVF, 2 hours after hCG triggering your progesterone is rising. It means that if you would like to do a natural cycle and you would like to do your transfer on Saturday, your trigger should be done in the evening on the previous Sunday, not 1 day before like for ovulation, but a bit later because progesterone rises more quickly. For egg retrieval, we are doing it 36 hours before egg retrieval, but for cryo embryo transfer, we are doing it just a couple of hours before you start your progesterone. That’s why it should be 120 hours of progesterone in a normal case, but if you have done the endometrium receptivity with the ERA test, it is sometimes necessary to do it 140 hours or less like 72 hours, it depends on the result of your test.

I know there is a condition when FSH receptors are irresponsive to FSH. Where can I test this condition, can it be treated in some way?

It is indeed described as FSH receptor mutation, and they are not receptive to standard FSH therapy. Sometimes we can use hCG for stimulation, and sometimes we can use LH, unfortunately, it is impossible to treat it because it is a congenital condition, but we can try to use it if, for example, your own ovary is working and sometimes you have your own ovulation, it means that your body detects your own FSH. For stimulation, you can use protocols like anti-estrogens which will produce the rise of your own FSH, and after adding something like low dose hCG or LH, sometimes it may be helpful.

Some genetic laboratories specialize in performing these tests, and they can detect the mutation of FSH and LH receptors. Our laboratory, unfortunately, does not do this test, but I know a couple of laboratories where you can do that for sure.

Is there any way to limit risk factors such as high blood pressure when receiving a transfer at advanced maternal age?

It is true that in advanced maternal age the main risk is obstetric complications like high blood pressure, diabetes, thrombosis, placenta previa, etc. If a woman is overweight, it will be good to decrease her weight. The second point is to see insulin resistance before the treatment because insulin resistance provokes the concentration of a deposit in the belly, and these increase the probability of insulin resistance and high blood pressure. It is like a circle, and during the pregnancy, progesterone increases insulin resistance, so if you’re in late reproductive age with abnormal weight, it will be good to try to decrease it.

Also, the less medication a woman will receive, the better it will be for her health. Finally, in this case, try to do a natural cycle, and also there are scientific works that say that the natural corpus luteum produces some specific substances and growth factors which improve the probability to go with the full-term pregnancy and artificial cycle sometimes may increase the probability of high blood pressure. All methods which improve the placental blood circulation also will decrease the probability of high blood pressure.

Do you offer the option of non-anonymous donors in Ukraine?

In Ukraine, we do not have very strict legislation, so as a clinic (IVMED), we have no right to give personal information about our egg donors, but we have an agency that is not a clinic, and they can provide this information and give you a full profile of the egg donor.

Does taking a higher dose of Estradiol and Estrofem create fibroids?

The fibroid is estrogen-dependent, and progesterone also depends on the benign tumour, so if you take during them for a long time and with a big dosage probably per se, it will not provoke, but if you have a little fibroid, it will cause this fibroid to increase the size.

However, the preparation protocol normally lasts for about 2-3 weeks, but pregnancy lasts for 9 months. During the pregnancy, fibroids are growing much faster than during the preparation of whatever dosage you’re using. The main problem is not if you have a fibroid, not the preparation, but pregnancy which will produce the growth of this fibroid.

Some IVF centres suggest doing Endometrial BCL6 Testing with Cooper Surgical, do you think it is important?

We can think about that. We don’t use this method at our clinic (IVMED), so I have no personal experience, so it is necessary to talk with your doctor about it.

There are different options, different approaches, some doctors propose to do a surgical intervention, some doctors propose to use medication to shrink the fibroid a bit before they do further preparation. There is a very interesting method called High-Intensity Focused Ultrasound (HIFU). During this method, a specific Doppler ultrasound increases the temperature inside this fibroid, and after that, the fibroid shrinks. Different approaches exist, and it is necessary to see the exact situation, the location of your fibroid, the blood circulation, and if this fibroid is close to the endometrium and if there is a big risk to harm endometrium during the treatment, so a lot of things should be taken in consideration.

I’m 39 from Scotland. My embryos are not genetically tested as it is a standard in my clinic, during my first cycle of IVF in August, I had 13 follicles, 6 eggs, 4 fertilized. One day-5 blastocyst (3BB) was transferred but failed, and 2 4AA blastocysts were frozen on day-6. I have had 2 frozen embryo transfers, but these both failed, as well. Are day-6 embryos less likely to implant due to slow-growing? Based on the above, would you advise trying again with my own eggs or look for a donor?

There are a couple of things that would be good to clarify, for example, 13 follicles and only 6 eggs, and I would need to know the reason for it. Whether it was because the follicles were not of the appropriate size or because the trigger was done earlier, or you have some problems with the egg maturation. When eggs are not mature enough, we receive fewer eggs. For the stimulation, it would probably be a good option in the second stimulation to postpone it one today and probably give a bigger dosage like a double trigger and increase the egg maturation. There is a nuclear maturation that can be detected with a microscope, and there is a cytoplasmic egg maturation that we cannot, unfortunately, detect. These produce less fertilization, if your cytoplasm is not mature enough, you will not have very good fertilization, you will have slow embryo development and probably not very good blastocyst quality.

As for me, if it is your first IVF attempt, I would prefer to try another stimulation, it is necessary to see your first protocol, but it would be good to modify it and probably increase the dosage and the duration, doing something like double triggering and trying to receive more eggs to see if you will have better blastocyst formation rate. We could use Calcium iodide after fertilization to improve fertilization and embryo development.

Day-6 embryo, the probability of implantation it’s true is a bit less likely because they have a bit more percentage of genetical abnormality, but it is not a rule because it depends on the culture medium. The embryo is growing much faster, in some medium, blastocysts arrive rising on day-6. It is necessary to check it with your embryologist, and also if, for example, your egg collection is at 2 PM, it means that fertilization will be at 4 or 5 PM, it means that your day-6 is not 6 days but more the end of the 5th day, so this it is necessary to check it with laboratory. All these things are necessary to discuss with the team to understand better what happened, but as for me, I would try with a second stimulation in your case.

I am 41, I get 1 blastocyst on average after each stimulation. Is it worth doing PGT-A or not? Some say not, let nature decide. What is your opinion?

I receive such questions almost every day from my patients. PGT-A is a method that does not improve blastocyst, it is the method that permits selection and transfers the best embryo in the first attempt, for the second attempt a bit worse embryo, etc. In case you have only 1 blastocyst, as for me, you should be very careful because PGT-A may give some false positive and false negative errors as any method of testing.

The second point is that the cells which were taken from the embryo may not be representative of all embryos, it means that the cells that are taken from an embryo, from the trophectoderm, so future placenta has normally higher percentage of genetic abnormality than cells staying inside the embryo. If you receive a mosaic embryo or even an abnormal result, sometimes, in some cases, it may not represent the real situation. You will not use this embryo, but it may have a chance to implant and give a healthy baby. If you have only one embryo and have no very serious reason to do PGT-A, I would prefer not to do it because it may decrease your chance to receive pregnancy. However, if you have 5 previous attempts and in each attempt, you have a baby with trisomy, then it is necessary to do the testing. We need to see the exact reason for this test, but in your case, it might be better not to do PGT-A. Also, when you are doing a biopsy and if the embryo is not 5AA, it may be harmful to this embryo, there are different methods of biopsy, different influences, but finally, it may decrease the viability of this embryo.

I am 43, what is your recommendation for my next IVF using donor eggs or my own eggs, my husband has a problem with quality and quantity with sperm, but we have one son. I was pregnant with 4 babies but lost all of them at 26 weeks.

It’s true that at 43 years old, the probability of pregnancy with own eggs is not so good. Regarding your husband’s sperm parameters, if for example, he has very bad sperm parameters, but you have excellent eggs, it can restore some problems and some DNA breaks in sperm, but if we have a problem inside of sperm and inside the eggs, as I have shown, in my slide, it increases the probability of embryo arrest and adds the additional problem of the development of the embryo.

As for me, at 43 years old, it would be probably better to try with egg donation, or if you have tried only once, for example, it may be possible to try with another stimulation to receive more eggs and probably one more try with your own eggs. However, the probability of success is not so high, and it is necessary to understand that whatever intervention we will do, we can only increase the quantity of eggs, but in most cases, we cannot influence the quality.

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Authors
Halyna Strelko, MD

Halyna Strelko, MD

Dr Halyna Strelko is the Co-founder & Leading Reproduction Specialist at IVMED Fertility Center, Kiev, Ukraine since 2012. Dr Strelko is a certified member of ESHRE (European Society of Human Reproduction and Embryology) and ASRM (American Society of Reproductive Medicine), UARM (Ukrainian Association of Reproductive Medicine). She had a medical practice in France and medical practice in leading Kyiv’s infertility clinics with over 23 years of experience. She speaks English, French and Italian.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.
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