The importance of tailor-made protocols and solutions in Assisted Re​production

Well, I will start with the second question: Do all women react the same? No, of course not. The response to the hormones to the treatment we give will depend on many factors. The first one will probably be your age and your egg reserve, so we stimulate you to get as many eggs as possible. If you have a low ovarian reserve, you’re not going to respond the same as a lady who has a good ovarian reserve. The response will be different, of course, we will try to adapt the medication to do our best, but you cannot expect the same response. It also depends on your weight or body mass index may affect how you respond to the medication so women might have certain resistant to a particular medication. We need to try different medications. They don’t respond the same, taking that into account is it necessary to undergo hormonal treatment for the ovarian stimulation during an IVF. The idea of the ovarian stimulation is to optimize the treatment, o if I give you a hormonal treatment, the idea is to get let’s say 7-8 eggs. If I get then 8 eggs, and I guess for example you get 5 embryos out of these 8 eggs, your chance of getting pregnant is going to be higher because it’s more likely that I will get some good embryos out of this pool of 5 embryos. What I’m trying to say is that we kind of try to get as many as possible to optimize your chances with 1 treatment. Having said that, some women, unfortunately, have a very low very and reserve no matter what you give them, they are going to respond only with one egg. In these cases, if you’re talking for example about a lady who is young and you assume the quality of the egg is going to be good, but she only produces 1 egg, in these cases, I think it is acceptable to do what’s called natural IVF, which means we don’t give her any hormonal treatment. If she’s going to get only 1 egg with ovarian stimulation, you might as well do it in a natural cycle because it might be better for these eggs without any hormones. In this case, I think it’s a good idea to do a natural, but in any other cases, where you have an acceptable ovarian reserve I think by doing a hormonal treatment, you’re optimizing your chances.

As a matter of fact, at Instituto Marques, we generally like to work with fresh eggs, we have a broad pool of donors, we have our own bank of donors that allow us to call these donors and start a fresh cycle. That means that we will synchronize the patient with the donor, so they get the period more or less at the same time, and they are synchronised all the time, so this way the patient gets a fresh transfer and it comes from a fresh pool of eggs. If you have any special circumstances or because you are travelling abroad or you change your mind etc. we can use frozen eggs if needed. But generally, we like to work with fresh, they give us better results, we understand that it is the best treatment and this is what we’re offering to our patients, so it wouldn’t make sense to offer them frozen when we have the option of doing fresh. I know not everybody has the option of doing fresh, but if you have your own bank, that’s something we can do. I can call the patient the donor myself, I know the patient, I know the donors, so that allows me to do a good matching and then I call the donor, I start the process, and we synchronize and so on.

First, I will ask two questions. First one: Is she a good donor and the second question is: Is she a good donor for you? Then the first one is what we will have to do when we decide if we can accept the donor or not. All the donors have to be healthy, and if they have any medical history of any illness, they cannot be donors. We have to be very strict with the donors we accept. They have to be less than 35 years old, and we are doing a very thorough screening, we start with a psychological test, it is important to see that they don’t score high for the tendency to for example depression and anxiety, the psychological test I think is important and some patients value that very much because they don’t know the donor so at least they want to have this reassurance. We perform an infection screening, we make sure they don’t have Hepatitis B or C, HIV, the most important infections diseases. We do a karyotype, check if the chromosomes are normal, and we check that they don’t have any mutations for cystic fibrosis because this is one of the more severe and frequent mutations that you can have nowadays. If she is a good donor, is of a good age, has good medical history and good ovarian reserve and she passes all the tests, then the second question is: Is this donor good for you? What Ido, first of all, I have to speak to the patient, I take into account the physical details and blood group that’s the most important thing, but I also ask them what is important for you because apart from the colour of your eyes or hair maybe for you it is important that in your family everybody has let’s say wavy hair, I can do my best to try to fit that. We have a broad number of donors, and we can choose accordingly.

Male infertility, we know that the quality of the sperm is decreasing nowadays probably due to contamination, we are currently doing a study about that in Ireland. There are different levels of diagnosis of sperm abnormality. The basic thing will be to do a medical fertility history and then to do a sperm test, to evaluate the count, the number of the spermatozoa, how they move, how they look like, that’s called morphology, so this is the first test you need to do, and we evaluate that. We have to take into account the whole history. You might have perfect sperm, but if you have a long history of infertility, you should think that this test is not enough. We need to look into more detail into this perm and evaluate if genetically the sperm is okay, so that’s a test called FISH, not everybody needs that as I said you need to take into account the history of the couple. Sometimes, for example, if the male patient history of heavy smoking or any toxic factors, we may evaluate doing a fragmentation to see what’s the quality of this sperm, so a sperm test is not enough sometimes. When it doesn’t fit into the infertility picture you think, the sperm looks normal, but something must be going on because the age of the woman is right, the tubes are open, there is nothing else going wrong. Let’s see if there is something else, so it would be a different level of investigation, checking the FISH and the fragmentation of the sperm. When we need to use a sperm donation, well there are probably four different groups. One of them will be single ladies, they will use the sperm donation for that, we have the premium sperm bank here. Then there are the same-sex couples, again situation, is similar to the single ladies. Then there are patients where the man has no sperm that something called azoospermia and when I say no sperm I mean that they haven’t even tried for example to retrieve it surgically and when there is definitely a situation of no sperm, then need donor sperm. The fourth scenario is a bit more complicated, it is when there is sperm, but the quality is not good, you’ve done many cycles, but they don’t work well, the embryo quality is not good, you see it might be a sperm factor, eventually you decide to do, sperm donation. It might not be easy such decision, and sometimes we only can do what’s called half and half, it means that you might use half of the sperm of the patient and half of the sperm of the donor, trying to respect the fact that the couple might not be completely ready for the donation, but at the same time, they want to have a baby. I would say that those are those 4 scenarios where you need to have a sperm donation.

It depends on the country. The current legislation to use the sperm of your friend means that you’re using a non-anonymous donor, so the non-anonymous donation is possible for example in Ireland. We have a clinic in Ireland, and this is where we are doing treatments with known-donors. A known donor means that you either provide the donor yourself, or you buy the sperm from a bank where they have non-anonymous donors, so in certain countries, you can do that. If you use a friend, you need to bear in mind that they will have to do some tests on this particular person, they will have to do some infection diseases screening and genetic testing, even if he’s your friend, and you know him, that doesn’t mean that you don’t have to check the quality of the sperm and this male donor. In these countries like Ireland also the UK, you can do it, and only non-anonymous donation is possible. If we are talking about doing treatment here in Spain, it is only the anonymous donation allowed, that means that you cannot bring your friend as a donor but what you can do is use a sperm bank, where we will choose the donor that’s more suitable for you and with all the guarantees. You will be able to know physical characteristics, age, blood group, but we won’t be able to provide the name because, by law, it has to be an anonymous donation.

There are two issues here. One of them is an early ovarian failure, as you have mentioned. The other will be the fibroids. I think that if you are 43 and by saying that you have early ovarian failure, you mean that you have a low ovarian reserve, I think that trying IVF treatment for example with your own eggs will be a bit tough because not only the quantity is affected, but the quality of these eggs is going to be affected. You have to think that at this age maybe if you are able to get 5 embryos, maybe only 1 of them will be genetically normal. That means if you are able to get 5 embryos that get to day-5 and we can analyze them, so I think you should consider an egg donation program. About the fibroids, well it depends on the size of the fibroids, probably the ideal thing would be to do a hysteroscopy. I don’t know the exact details of the size of your fibroids, but the main thing is checking how much it’s affecting the cavity, or it is affecting the cavity. If we can remove it surgically, then it’s okay, we can leave a cavity that is okay for the transfer, and that probably can be sorted out. But if you are 43 with a low number of eggs, I think that is a tough one, and I think your best option will be egg donation.

With a low ovarian reserve, we try to use a high dose of medication that has both what’s called FSH and LH. It’s a combined hormonal action trying to compensate for the low LH action in a woman that has low ovarian reserve but sometimes apart from that we can add other treatments, we can consider to do a treatment before with estrogens. In some cases, we can use kind of testosterone for a while, trying to increase the chances of this woman to respond later to the medication, so it’s not just the medication you give during the cycle, it is also what you give before the cycle.

As I said, it depends. I mean it is not always necessary if you have a patient with a good ovarian reserve, then you don’t need to, but in patients that you might suspect that they might have a lower response or they might have something called non-synchronized response that means that if they have let’s say 4 follicles and one of them is going to shoot out while others are not going to respond, you want all of them to grow at the same time. So sometimes we can do a treatment before with estrogens or testosterone, we have to consider it by case-by-case, but yes we do pre-treatments before.

I know some studies suggest that it may increase the response to the treatment, but currently, as far as I know, is not used. We probably need more studies to determine that it is worth using it, so there are many treatments out there that can increase the treatments success rate, but they are not evidence-based. This is one of the streams that probably might help, but we need more studies until we can do that clinically to all the patients

When we suspect somebody may have chronic endometritis, I think what we need to do is have a look at the lining, where the endometritis has occurred. We do that with hysteroscopy, we bring a camera through the neck of the womb inside the cavity, and we check how this tissue looks like. That’s the first thing, but that’s not a diagnosis, then what you have to do is take a sample of this tissue and analyze it, so that’s called a biopsy and you have to do also a culture to see if there is an infection. In summary, there is a hysteroscopy with an individual biopsy and culture. If we can see for example plasmatic cells on these lining, this endometrium, we might need to do treatment with anti-inflammatories. If there is also an infection added to this inflammation, we need to do antibiotics. So depending on what we find could be a combination of anti-inflammatories treatment and antibiotics.

The endometrial biopsy doesn’t have any other name. On the market, there are many brands, which check different types of infections. There is the EMMA, the ALICE, but the procedure itself is an endometrial biopsy, and various labs might have a different range of bacterias and microorganisms they are checking like EMMA and ALICE. They are different, but the idea is the same.

It is not necessary, it is recommended. If you want to do a natural cycle with donor sperm, of course, you can do it. We have to perform ultrasounds very often to make sure we don’t miss ovulation but what we see is that when you do stimulation of the ovaries trying to get 1 or 2 eggs, the success rate of insemination increases. Having said that if you already have regular cycles you’re a young woman with good egg quality and you want to do a natural cycle, I don’t see a reason why not to do it. The recommendation, however, will be to do it with stimulation because this way you ensure you’re going to have proper ovulation. You will know when it’s going to happen, we can time when the insemination is going to happen because we give you an injection to release the egg and 36 hours later. It makes it more successful, and I have to say you might need only 10-11 days of medication, of a low dose hormone, so it’s not that bad, but we can do natural insemination if the patient wants it. We need to adapt also what the patient circumstances, preference etc. are.

It’s not easy to answer this question because I don’t know the size of the fibroids. The fibroids of a big size, which are impinging into the cavity, so they are affecting the cavity, they might affect let’s say the blood supply of this area and sometimes that makes it difficult for the embryos to implant. 1 in every 10 pregnancies ends up in a miscarriage, at 36 it is probably just bad luck, so I wouldn’t be able to tell you if it was a result of a fibroid. I think the first thing we need to know is this fibroid inside the cavity and how much it is affecting the cavity because if this is affecting a big portion of the cavity probably I would recommend to remove it. If it’s a small fibroid that is not impinging and is just positioned next to the lining but not in the cavity, then I wouldn’t do anything if I were you. The first thing to know is what’s the size of this fibroid and where it is located, and if it’s located inside the cavity what you can do is to remove this fibroid and then restart the process. At 36 you might be worried about what if I remove the fibroid, there’s going to be waiting lists etc., my egg reserve my be delayed, but there are options like for example doing the fertility process and IVF process, freezing the embryos, leaving them frozen and then dealing with the fibroid and then once the endometrium is fine, and you can do the transfer of the embryo that you already have frozen, so there are different ways to adapt to the circumstances of the patient.

It depends on the patient, but if you have a case where a patient has good quality embryos, and you transfer them and they do not implant, that’s something called recurrent implantation failure. The embryos are good and you think, well it’s not the embryos, it must be something else, so that’s something that point you to check the cavity. To check if there is an infection into the cavity, if there is an inflammation into the cavity, that’s probably one of the scenarios I will check. Sometimes, it is the history of the patient like you have a patient who had miscarriages before, had some surgeries. We need to be careful, this lining has been through so many procedures, it might be some residual inflammation, let’s check that before we start the process. If you have a history of fluid in the tubes that may effect if there is an inflammation on the tubes, they may be some retrograde infection, so the infection goes back to the lining and it’s good to do a culture or make sure everything is fine and is in a good shape before we do any fertility treatment.

Sperm quality doesn’t decrease as much as egg quality with age, but what we’ve seen is that men that are approaching 50, there is an increased risk of offspring with autism and that may be related to two genetic damages, so it doesn’t decrease as much as with the women, but definitely, it has some degree of affectation of the sperm with age. Men keep their fertility much longer than we do, but the sperm of a 50-year-old is not the same as in somebody who is 30. There is some degree of alteration, and that has to be taken into account. Especially, in men who are over 40, we have to check that they don’t have what’s called oxidative stress, it is recommended to do something called fragmentation to make sure that the sperm is not damaged. If it is, we may need to do some either lifestyle changes and maybe some antioxidants or some kind of medication to compensate for that.

If the sperm analysis is okay, I wouldn’t do the treatment, but as I said before it is not my area of expertise, and the andrologist will respond to that much better than I do. If you have low testosterone and you have to have a testosterone treatment, it’s kind of tricking your body. Your body thinks, I have a lot of testosterone, and then the brain starts producing it as hormones, and that produces less sperm, so it’s kind of funny, but you think the more testosterone the better, and it is not the case. If you give external testosterone with medication, it may have an impact on the sperm, so if the sperm quality is good I think that the testosterone level that has implications in other areas but if he’s not having an implication on the sperm quality is something apart you don’t need to treat it. If you’re talking about doing fertility treatment you can do the fertility treatment and then later you can deal with the low testosterone and which medication you will need for that.

Here, we need to take into account the whole history. For example, did he have any children in the past, or not, what kind of occupation he has if he is dealing with toxins, or high temperatures, is he a heavy smoker, so we need to take the whole history, it is not that straightforward to tell you. If at 46 you have for example a long history of infertility and the sperm test is normal, as I said it also depends on the age of the woman, but if let’s say your partner is young and assuming there are good, normal, healthy eggs and they have a long history of infertility because you have to take into account the history, you might do apart from sperm test could be as I said before a FISH which means that you’re checking the number of the percentage of normal sperm in this sample, so in a sample of sperm you have millions of spermatozoa, so in most of them, they will be normal genetically speaking and some of them might be abnormal. Some men have an increased rate of abnormal sperm in this sample, that means that there are more chances of the abnormal ones that are going to fertilize the egg. We check that by doing something called FISH or sometimes men may have some kind of oxidative stress on the sperm, which can be solved by taking some antioxidants or lifestyle. Other things are worth studying, for example, doing a blood test to check that your chromosomes are fine, that there is nothing abnormal because you might have some alteration on your chromosomes, that doesn’t give you any illness, you won’t know unless you do the blood test but it’s giving you abnormal embryos, so you will see that there is no implantation of embryos or the miscarriages because they are abnormal. If the sperm test is fine and the rest is normal, check a karyotype, so checking the chromosomes of the male in blood, checking the genetic information of the sperm that is called FISH and checking fragmentation, these are options that we can do.

If, the partner has asthenoteratozoospermia, which means that the shape of the sperm is abnormal. I mean the percentage of abnormal sperm is higher than normal and is going slower than normal, it depends on the degree. I mean if it’s not very severe, you can do IVF treatment. When we do an IVF treatment we are collecting the eggs of the patient and let’s say we get just an average of 8 eggs, that means that I only need 8 spermatozoids. What we do at Instituto Marques to ensure we have a good fertilization rate, we do ICSI. We inject the sperm into each egg, so I need a reduced number of eggs. You’ve mentioned that they have astheno- which means they are slow, we can check under the microscope which ones are moving faster, which are more active, and you mentioned that they have terato – it means that they have an abnormal shape, so you need to choose a sperm that is moving fast and has a good shape, and because your partner has that, there is not many of them, so what probably will benefit from doing is something called IMSI, that means that there is a microscope that increases the division by 6,000 times, so it’s a very powerful microscope that helps to select the best spermatozoids, so depending on the degree of asthenoteratozoospermia, of course, we might need to do some investigations before. Why is it moving slow maybe we need to check if it’s very fragmented, maybe we need to do the fragmentation test because this patient might benefit from 3 months of antioxidants or may benefit from lifestyle changes. Definitely, there is room for treatment, it’s a matter of choosing the best spermatozoids with for example IMSI or FERTILE Chip that also selects the sperm, that has a better shape, movement and is the best one.

I imagine that your situation is that you might not have cycles and that’s why they proposed to do a mock cycle. If you have regular cycles, there is no need to do the mock cycles what they want to see is that if you don’t have your cycle, we will give you hormones and see if your lining will be able to respond to the medication, will your body respond to the hormonal treatment. That’s the whole idea of the mock cycle, if you don’t have a cycle, we give you the hormones to see if you respond to that before you start the proper cycle. If it is because you have a small fibroid, maybe they couldn’t see the lining and if it was thickening enough. That’s what they are trying to do, see if the lining is thickening enough to have fibroids, I don’t know the details of your history, but small fibroids are not a reason to do a mock cycle unless you are concerned about how the lining is going to respond.

We have a bank of donors, it means that we have donors that have been screened and they are kind of waiting for us to call them. I have a list of donors, I choose the one that I think is suitable for the patient and I call her, and when she’s available she will start the cycle. I tell the patients to start with the pill, and I tell the donor to start the pill and then at some point I tell them both to stop the pill, so they get the period at the same time, this is the way of doing an egg donation cycle with fresh eggs. This is the way to synchronize your periods by giving you hormonal treatments. Our egg donation program is very successful, we have the success of 91% with egg donation per cycle, which means on average they may have 2 to 3 embryos in total. After these 3 cycles, your chances are more than 91% of getting pregnant, so financially I think it is a treatment that is worth doing because it gives you great success. If your first cycles fail, but you have frozen embryos because you might have spare embryos, then definitely you will have to use the spare embryos. That is that the aim of the treatment of stimulating the donors and having spare embryos that will optimize your chances of getting pregnant because you have more than 1 embryo to transfer. You have to remember that we recommend for the embryos to be frozen on day-5, so these are very good quality embryos. We are very strict with the embryos, we cannot freeze any kind of embryo because then we will be disappointed later when we thaw them and they don’t survive, so we only freeze very good embryos on day-5 that have high chances of surviving the thawing process. If they survive, they have the same success rate as the fresh ones in the laboratory. I definitely will use frozen embryos, that’s the ideal situation to do a cycle when you end up with more than 1 embryo, and you can use in that same cycle the frozen ones.

A level of 3.24 if you were not trying to get pregnant regardless if it is egg donation or your own eggs, that would be normal. For a woman who is trying to get pregnant below 4 is absolutely normal, but once you get pregnant, your body’s going to change and the thyroid hormones are going to modify, and so we need to make sure you start on a lower level than that. Ideally, TSH should be less than 2.5, so 3.24 is normal. If you’re talking about planning to get pregnant, we need to drop it to 2.5, so once you are pregnant, you wouldn’t be in a situation where your thyroid is not working as it should.

First, it depends on the degree of teratospermia, so we consider that to be normal, it has to be at least 4% of normal shape in the sperm. Below 4%, it’s called teratospermia, having said that that doesn’t mean that if you have 3% you can’t have children and if you have a 10% of normal sperm you will have children. That gives you an idea of the quality of the sperm, but it is not black or white. Your chance of getting pregnant also depends on the other factors like egg quality. If you’re for example below 35, then I’m assuming your eggs will be of good quality, and your tubes are open, then your chances, of course, are decreased, but they are not down to zero. If apart from teratospermia it happens that you are let’s say 40 years old, and you’ve been trying for a year, or you’ve been trying for many years, then I will say, your chances are low, and you need to restore to fertility treatments. Trying for a year depending on your age, you will need to consider to do a fertility treatment already.

I think we are very innovative about that. I don’t think all the centres use music in the time-lapse incubators. It is true, some studies show that music may affect in a good way the quality of the embryos. Is the music affecting the embryos? The theory is that the vibration of this music may kind of move the liquid around the embryos, and if any particles may affect the quality or any fragmented cells etc. they kind of get cleaned. So these vibrations of the music seem to help, so I think it’s a beautiful idea, we do that, and I don’t think other centres are doing it. Institut Marques in Barcelona, Ireland, Italy, we are the same. We follow the same procedures except for certain things that by law we have to do a bit different like when it comes to donation, but we have to use the same resources, we have to use the top resources we have.

Yes, during the egg retrieval we do a vaginal ultrasound, and under sedation with this needle that will reach the ovaries, so we are not going through the uterus, we are not going through the womb. As we’re not going through the uterus even if there is a fibroid in the cavity, it doesn’t affect it, it’s not in the way to the ovaries, so yes we can retrieve the eggs, and we can produce the embryos. Another issue is if we can we put back these embryos into the cavity, the answer is probably not, we might need to freeze these embryos, fix this cavity and then put the embryos. The egg collection can be done with fibroids inside the uterus, only with big fibroids and I’m talking much bigger than this size, it might be technically difficult if they are in the way of the ovaries.

Elevated FSH is telling you that the ovaries require more hormonal pushing let’s say to work. It is a sign of the ovaries not working well. The good news here is your age, as you’re 30 years old as the eggs are probably going to be of good quality. You mentioned that you have a high FSH, I don’t know if that’s been repeated more than once or it was just one reading, you need to be very careful which day of the cycle you are doing that because it might be elevated because you’re not doing it on the proper date. Let’s say you have a high FSH that means that the ovaries are showing some kind of resistance to the hormones that’s why the hormones are elevated, they are trying to compensate this resistance. We need to know more things, we need to know at 30 how many eggs you have, I mean we know that maybe there is some resistance to the hormones, but how many you have, so you need to do other tests to check your ovarian reserve. I don’t know if you have done something called anti-mullerian hormone (AMH). You also need to do an ultrasound to see how many follicles you have, your antral follicle count. We also need to know what is the sperm quality as well, so if your partner’s semen is acceptable, you have an acceptable ovarian reserve, and you are 30 years old, your chances with an IVF cycle are very high. I mean that’s the first thing we will look when somebody comes to the clinic at this age of the woman because that’s going to determine the success rate, that’s an important factor. Of course, you need to do other tests, you need to check the male factor, but I will definitely go for an IVF cycle, especially if you’ve been trying to conceive for 3.5 years, that’s becoming a long time. I wouldn’t go for example to other treatments like insemination it is not worth it after 3 years, the success rate is not higher. In regards to the add-ons, one that I definitely would recommend is to transfer the embryos on day-5, not transfer them on day-3, so when you do an IVF, and you retrieve the eggs, and you fertilize them, we watch the embryos, and we can watch them during 3 days and transfer them on day-3 or transfer them on day-5, ideally, we recommend to go to day-5 because on day -3 you might have embryos that look similar, but if you give them 2 days more you will have more information of the quality of these embryos, which one is growing well and which one is not growing well. It’s not that by keeping them for 2 days longer, we are making them better, what we are doing is we are choosing better. For example, you have an embryo on day-3, and it looks good, and on day-5 it kind of stopped growing. At least you didn’t transfer that embryo on day-3 because it wouldn’t give you a pregnancy. We’re putting these embryos through a very tough selection but at least this way, we select only the strong ones. So I would recommend Embryoscope, if you don’t have it, the embryologist have to open the lid and checks the embryos, is giving them a score, 24 hours later, he’s going to do the same again, but if you have the EmbryoScope, you don’t have to do that. Not opening the lid means that the temperature and the oxidative stress of the embryos are not affected, the embryos grow better, so that’s the first advantage. A second advantage is that because it’s creating a video, you might have 2 embryos on day-5 and they look pretty much the same, and you wonder which one to choose, you want to transfer the best one in fresh if possible, so if you watch the development of the embryos on the video, you might decide that this one has been growing more steadily and is better than the other, so you are selecting better, so that’s the two advantages. Apart from that, there is the option of having the Embryomobile, which means that these images we are seeing, the patient can see from the mobile, that’s another thing that is nice, it gives reassurance, it decreases anxiety on patients, but in terms of success rate, the first two things are very important. Other add-ons depend on each particular case. For example, we do ICSI because we know it increases the fertilization rate, why are we not using IMSI, the powerful microscopes, because not everybody needs that, we don’t want to do things that patients don’t need. If a patient has a very bad sperm with very bad morphology, he might require an IMSI, but we won’t indicate that, so we have to individualize.

I would say no, it does not affect it. If you have a high FSH with no periods, of course, that means you have gone through menopause. One of the indications for egg donation is for women who have gone through menopause. You have to think that if your egg donor let’s say is 26 years old, your chances of getting pregnant are if you were 26 years old, so the fact that you don’t have periods and you require egg donation is not affecting the egg donation. What we have to do is prepare the lining of your womb, so if you haven’t had a period for many years, it will be worth to check with hormones if you will be able to respond to the treatment, so it is kind of a mock cycle where we’ll give you hormones to see if your uterus is able to respond, the lining is thickening, so you will be able to receive the embryo. If it hasn’t been a long time since you had your period it won’t be any major issue, so the answer is, you can have an egg donation without problems even if your FSH is high, it doesn’t affect the success of the treatment. We only need to make sure that your lining will respond to the treatment.

Well, it will be interesting to have a look at the stimulation protocol they gave you. You can indeed have many follicles, and not all of them will release a mature egg. 10 follicles with only 2 eggs, to me it sounds like a low number, but maybe the follicles were not big enough, maybe you had small follicles, and in reality, it was 2 eggs out of maybe 2 or 3 good follicles. I don’t know if I’m explaining myself. Regardless of that – it is a very low response, so what can you do. An AMH of 1.03 is kind of low. I would expect you to respond a bit better than 2 eggs, and that’s why we need to review the protocol. I don’t want to talk about egg donation being 39, I think we can explore other things. One option will be to try to increase the medication or change the medication and do the accumulation of eggs or embryos, so if you’re 39, you might do one cycle, and if you get 2 or 3 eggs and you’ll get 2 or 3 embryos for example, ideally you should analyze them because you’re 39, so having this low response maybe you want to consider to do more than one cycle to do accumulation that would be one option. Review the protocol, change the dose, change the medication, change the way everything was done and maybe consider to accumulate. Other option if everything was fine and the dose of the medication was already quite high, and you don’t want to go to do accumulation maybe you want to consider to do an egg donation. I would need to know your history in more detail, but there are these two options.

We do have donors from the Caribbean and about the religious background I mean not specifically I ask for that, but when the patients come here they have a kind of a registration form, and they may write something about it. What I do, is if, for example, a patient tells me: I need a donor to be this or I would like a donor who has interested in sports or not, what I do, for me it is as easy as calling the donor and finding out, so I don’t see that as a difficult thing to do, if it’s important. Another thing is that the donor might not want to tell me and if the donor doesn’t tell me, then I have to tell the patient that I don’t know or I might look for another donor etc. but I think it’s doable. And we definitely have donors from the Caribbean.

If they have removed the ovary and provided the other one is normal, yes you could go through another cycle of IVF. Another issue is how many cycles, you want to do, AMH is a bit low, but it’s true that you’re 37 and you still might get some eggs, so in terms of safety provided you have an ultrasound that checks the other ovary, it should be all right.