When I was 38 years old and had never been pregnant before. After a normal workup and multiple failed IUI cycles using a combination of oral and injectable meds, SW was diagnosed with infertility of unknown origin and started IVF treatments.

Dr. A, at a very well respected center in San Diego, chose a classic “antagonist” protocol for stimulation but took the “shotgun” approach, meaning that the plan was designed to include as many different treatments as possible in 1 cycle with the hope that “everything” could be covered: estrogen prime, testosterone prime, 300-450 U FSH+HMG injections for 7-10 days, dexamethasone, GnRH antagonist injections for 3-5 days, a combination GnRH agonist + HCG trigger, a general anesthesia egg retrieval, blastocyst culturing, and freeze all. A “shotgun” approach is both complicated and costly. SW produced 20 eggs, which lead to 3 blastocysts.

The frozen embryo transfer was an artificial cycle, almost as complicated as the stimulation (which was intentional). Although Dr. A was trying to replicate the hormonal environment of the stimulation phase as much as possible, I think this actually defeats one of the major benefits of a frozen embryo transfer. This was followed by a traditional trans-abdominal ultrasound-guided transfer of a single blastocyst which, unfortunately, failed.

At this point, Dr. A performed a hysteroscopy to address a possible uterine issue, which was a very reasonable thing to do. SW followed up with another HRT frozen embryo transfer with her 2 remaining blastocysts. This failed once again.

Since there were no embryos remaining, SW underwent IVF again in a similar fashion as before. This produced 6 eggs but no blastocysts.

SW gave it one more try, producing 20 eggs and 1 blastocyst. This time Dr. A tried a natural cycle transfer which resulted in a “chemical” pregnancy (essentially an early miscarriage).

At this point, Dr. A recommended donor eggs.

SW and her husband were not ready to go that route, but were not ready to completely give up since they had already invested a great deal money and suffered quite a bit both physically and emotionally. Through a referral, they found our center and approached me.

After meeting with SW and her husband, here were my thoughts:

• Based on SW’s age and the blastocyst embryos produced, they should still make embryos good enough to have a child.
• If we are dealing with a fallopian tube issue, IVF should be successful.
• If we are dealing with an endometrium issue, the hysteroscopy that was performed should have helped (but, recall, she had a chemical pregnancy after the hysteroscopy).
• Even though there was a chemical pregnancy after the hysteroscopy, the second transfer failure involved the second and third best embryos of the first cycle. The leading embryo was transferred before the hysteroscopy.
• SW did have a chemical pregnancy in a natural cycle.
• SW never had a fresh transfer.

I was left to one conclusion: try again, with some small tweaks to the plan. Based on everything that we knew, it seemed like it was merely a matter of time before she would be successful.

The small tweaks that I thought would give us a better chance for success:

1. Reduce the medication. It was possible, I thought, that all the medications was creating a poor environment for a successful pregnancy. The purpose of doing a “freeze all” is, in part, to eliminate the risk of OHSS, but also so that we can later place the embryos in a more ideal environment that is not affected by the stimulation medications. A highly medicated HRT embryo transfer cycle, which had been her previous plan, defeats the purpose of that latter reason.
2. Perform a fresh transfer. As I mentioned above, one of the purposes of a “freeze all” is to place the embryos in a more ideal environment. Many patients, however, conceive just fine from fresh transfers. While it is true that vitrification allows for highly successful freezing/thawing, it isn’t perfect. Perhaps one of SW’s embryos was damaged in the process and the couple would fare better with a fresh transfer.

I treated SW with a classic Japanese Minimal Stimulation protocol using Clomid (50mg) and FSH (150mg x 4 injections). Egg retrieval was performed under local anesthesia and produced 6 eggs. Since SW’s environment looked ideal, I transferred a fresh, day 5 embryo under transvaginal ultrasound guidance. During the transfer process, I noted resistance to the outer catheter. Could this be the reason that the previous IUIs and transfers did not work? The Japanese-designed transfer catheter that we use is smaller than the Western catheters and allowed me to bypass this area without difficulty. After one try with a single embryo, SW was pregnant! I have since graduated SW to her obstetrician and I am just waiting for the birth announcement.

The moral to this story? More is not always better; sometimes less is best!

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