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Sae

When to use an embryoscope

By Research No Comments

After egg collection comes the week of wait-and-see. You wait and see how many of your eggs fertilise, how many cleave at the right time and grow into blastocysts. They’ll often be graded at this point, based on how even the cell sizes are, and what kind of fragmentation they have.

I’ve gotten pictures on all these days – pictures of my little embryos. It’s a hard week, as often the number of eggs you start with is not the number of blastocysts you get at the end.

This last round we’ve decided to use an embryoscope, in the hope that it’ll help our embryos get to blastocyst level.

What is an Embryoscope?

Typically your eggs and embryos are placed in a special incubator that maintains the environmental conditions necessary for embryos to grow. Every day, at set time points an embryologist will remove your embryos from the incubator to take photos and ensure they’re developing on time. This has to be done quickly, because any environmental stress can potentially damage the embryos.  Based on these observations, an embryologist will grade your embryos to tell which embryos are most likely to result in pregnancy and will select an embryo that develops along a set timescale.  **

An embryoscope is an incubator that maintains the environmental conditions – just like a standard incubator. It has an incorporated time lapse camera system – it will take a picture every 20 minutes. This means your embryologist can monitor embryo development while the embryos are still in the incubator – they won’t have to remove the embryo to examine it, making for more stable culture conditions. 

It also means an embryologist can make more informed decisions, particularly with embryo selection as there is more information to consider.  Time lapse observation is more thorough way to understand what is happening with the embryo. Embryo cells aren’t static – they move. With a single static observation per day it’s difficult to judge correctly what stage the embryo is at. For example, an embryo that has just cleaved and is pulling itself back together at the time of observation may be misjudged for extreme fragmentation.  With more information, embryologists can can better tell which embryos will have a better chance at success.

Who should use an embryoscope?

An embryoscope is an expensive piece of equipment, adding to an already hefty IVF price tag.  You’ll want to weigh up the advantages of using an embryoscope with the cost.

– People who have lots of eggs/embryos for selection.

As using an embryoscope provides more information about an embryos development, there is a more informed chance of selecting a viable embryo for transfer. ** 

– People who would like more information about the embryo, when past cycles have not gone as expected.

Sometimes more information about an embryo is helpful in situations where there is repeated implantation failure, advanced maternal age or a history of recurrent miscarriage. It can help people make informed decisions about future treatment plans or sometimes bring closure.

– People who have a limited number of rounds.

IVF is such an expensive treatment and many of us can only afford a handful of rounds, if that. By ensuring a more stable culture environment you know you’re doing everything you possibly can to help your embryos along. 

What does the research say?

Unsurprisingly there has been loads of research around embryoscopes – they provide so much more information and have been used in a fair number of studies.  

This study (Source) found that culturing embryos and selection improves reproductive outcomes. While there was no significant difference in pregnancy rate (the beta taken after the 2 week wait), the ongoing pregnancy rate (where there was a heartbeat at 12 weeks) was much better with the embryoscope than standard incubation. Implantation rates were also better with embryos selected from the embryoscope, and that early pregnancy loss was much less likely to happen.

This French report (Source) found that better embryo selection (according to embryo movement parameters and better observation of abnormal cleavages, along with greater quality control and flexibility) lead to an overall increase in success rates in IVF cycles.

This study (Source) echoes a similar message. by providing more accurate information about the embryo potential, it allows for better selection of embryos with high reproductive potential. This study (Source) goes on to suggest that by selecting embryos with good morphology and normal cleavage rates, they could, one day, provide the basis of a qualitative algorithm for embryo selection.

Should you use an embryoscope?

Essentially, there is no harm in using an embryoscope. It only offers positives – a more stable culture environment and more information about your embryos. If you can afford it, perhaps talk to your doctor about incorporating it into your cycle plan. 

 

** Side note: While an embryo that cleaves on time, has little fragmentation and whose cells are symmetrical might look good – it still might chromosomally abnormal which will not result in a healthy pregnancy. More on chromosomal quality here. How an embryo looks is not the be all and end all, so if your embryos grade poorly please take it with a grain of salt.

Egg Collection

By Personal No Comments


October 2015.

It’s easier this time – I know everyone, I know how it goes and whats expected of me. This familiarity makes it easier to ask questions and I was surprised to find out how much power I had.

I was terrified that I’d ovulated my eggs away before we could retrieve them. Everyone told me they were still there but I wanted to see for myself. So, with some bargaining I was allowed to stay awake for the first part of the procedure, while they cleaned me up and scanned everything. Sure enough, my follicles were still there. I relaxed, and they sedated me.

There’s a new anaesthetist who let me ask questions, and surprisingly, responded with such reassurance and compassion. Unlike previous rounds, I was allowed to move the central line from my hand into my inner elbow (which is why I’m so grateful for the new anaesthetist). I hate having it in my hand, it almost always hurts and swells up and is horrid. I have nice veins on my inner elbow, and as long as they strap my arm down there’s no fuss. 

I also managed to negotiate a different form of pain relief – one through my veins rather than up my behind. I’m not sure this was a great idea, actually. The collection went fine, and I rushed through the checklist (Eat something, drink something and pee) that they do before you’re allowed to leave. I always prefer to recover at home, so I downed loads of water and forced my body through it so we could go.

Not so clever once we were home. I crashed out in bed almost immediately and was in a lot more pain than the previous rounds. I felt like I couldn’t use my abdominal muscles at all. This got even worse when I stood up to go to the bathroom – I made it across the hall, but blacked out while in the bathroom. I now have massive lumps on my head and my shoulder where I hit the tub. I don’t know how long I was out for, but when I came around I was super hot, dizzy and nauseous. I made it back to bed but oh, I felt horrid.

There’s a six on my hand, from where Zee wrote the number of eggs collected so I could see it when I woke. Six. It’s not the twelve from last round, or the three from the first. Six is okay. I am disappointed, though. I feel like if I’d done more – stuck to the diet and been a bit more strict with my lifestyle choices we could have got more. We’ll see. They say at least four are mature, so that’s helpful for setting expectations. 

We’ll see. I’m hopeful all four come through fertilisation and grow into healthy blastocysts. Fingers crossed! 

Counting Down – Four days to go!

By Personal No Comments


October 2015.

We’re on the tail end of this round and everything is getting really hard. I’m super tired (though I’ve been reassured this is a good thing). The shots are becoming a massive hurdle now – my belly is so sore and tender that it’s uncomfortable (more than usual!) to do them. It’s often three or four a night and I have to psych myself up and push through – definitely not like at the beginning of the round where you just get on with it. 

I worry that I’ve overdone myself and planned too many things (we’re going away for a 6oth, and I’m doing a favour for my hairdresser), but feel obliged to push through. Zee says I’m handling this round better than the last two – I’m less hormonal, I think? I’m not sure. I’m definitely sleeping more, anyway.

My biggest fear going into egg collection is that I’ve ovulated all my eggs away. We’ve been a bit fast and loose this round, and I know, I know we had two cetrocide shotes on the last day but…. I still can’t share the fear.

I hate this bit, where everything just gets so hard. Eye on the prize through – we’re only a few more days out. We’ve set a date for egg collection. Only four days from now. Only four more days!

Kick Off – Costs of IVF

By Personal No Comments


October 2015.

The kick off for this round was tonight. It wasn’t so bad, really. Zee and I are pro’s at this now. Zee mixed everything up like it was no big deal and we did shots just like we’ve always done them.

The hard part this time was the cost.  The cost of this is heart breaking – we’re on our fourth round which just feels crazy. I hate worrying about money like this, but this is the first round where I haven’t been able to wave off the cost like it was no big deal. I’m feeling the pinch and I hate this. I’m weighing up the treatments that might give us a better chance (like IMSI with it’s improved fertilisation options) and the cost of it (an extra £1700 on top of already a £6600 price tag).

I just… feel like it’s unfair to have to choose between whats best and what we can afford. We had to borrow from family to cover this round. I won’t lie – my pride has taken a hit. I’m unbearably grateful that we have such generous people in our lives but as an independent asking for money because my body is broken is hard. I hate being in this position. I hate asking for hand outs, but I also feel like this is our only shot at a family.

I’m between a rock and a hard place. Infertility – it’s hard. So many tears.

I asked friends to pray for us today. If this is our last round (which is likely because we can’t afford another round) then I feel like we should do all we can, really.

Oh infertility. You’re the worst. 

CD2 – Bloods, chaos and practicing patience

By Personal No Comments


October 2015

Pre-round bloods today. The clinic was chaos. I hate going during my lunch break – everyone else is trying to squeeze whatever they need into that free hour too. 

The receptionist I liked is gone (she’s moved upstairs to behind the scenes) and the replacement is stressed and full of disdain, rather than smiles and gossipy stories. Most of my favourite nurses have left. The nurses that are there are stressed out with too many patients. There was too much going on and the waiting room was struggling with extended waiting times and oh. It was not a fun visit. 

I feel terrible about it now, but at the time I made a bit of a fuss because I ended up waiting over an hour for bloods. I’d forgotten that the only reason a clinic is backed up like this is because something has happened to another patient. A patient that could essentially be me – if anything ever happened I’d hope they’d look after me rather than shunting me out the door to deal with the long line of other patients. I’d like to be better at practicing patience.

My nurse was new, I liked her. She was lovely but very very new. I think it helped that I knew what bloods we were taking – LH, FSH, E2 + AMH, where to go and what coloured vials she needed. I even went as far as tourniquetting myself up and sterilising my inner elbow for her. I was glad that there was no drama, just bloods. She was pretty amazing, the best blood taker I’ve had! Didn’t even feel it.

Truth: I’m not sure that my FSH will be low enough to move forward. It’s been such a stressful month. We’ll see. I’ll find out tonight, anyway.

——

My FSH levels are low (hurrah!), but heartbreakingly my AMH has dropped 5 points since I got it done last December. My AMH is getting lower and lower and lower, and my odds with them. Oh. Sadness. The ups and downs of infertility, hey?

Round 4 – CD1

By Personal No Comments


Oh. It’s always an odd moment, while you’re sitting on the toilet having discovered that your cycle has come. That pause when you know that from here, time will shrink into moments. It will be counted out in days, slowing itself down to lots of waiting interspersed with scans, bloods and medication. That the next 15 days till egg collection (fingers crossed I get that far) will be quite emotional ones.

Oh hope. I feel like I’m hoping for a miracle, and I’m scared to hope.  I’m scared to hope that I’ll respond well to the meds and will produce many mature eggs. That a large number of them will fertilise well and grow into chromosomal normal blastocysts that survive sampling and freeze well. That’s the happy days plan. Fingers crossed. 

If this round goes well, it will be our last round of IVF. After a year of this I’m hopeful that we’ll be done, that we can go back to living and happiness and life.  

So, CD1. I’ve emailed the clinic to organise bloods to make sure that my FSH isn’t too high, and then we’ll start. We’ll see, the next few days will let us know if we’re moving ahead, or not. 

Fingers Crossed.

IVF or ICSI – WHICH IS BETTER?

By Research 2 Comments

During that last round of IVF I felt like I was fighting an uphill battle. Diminished Ovarian Reserve, Poor Responder, High FSH levels. All of the odds were against me, and I knew it. That didn’t stop me from hoping, though. From reading all the research and taking all the supplements, using all sorts of relaxation techniques, standing outside on a full moon downing royal jelly (okay, not that last one!).  You get the idea. I was doing everything I could. 

We tried a new protocol, I’d be on DHEA + we added in human growth hormone to my protocol. Woop! We were in! My follicles grew, and by the time egg collection came we retrieved 12 eggs!! TWELVE! I was considered a normal responder!! We were over the moon, and I was quietly patting myself on the back for a job well done.

The thing with celebrating early is that you leave yourself open to all the other hurdles. Like fertilisation.

Of our 12 eggs, only 5 eggs fertilised. All my eggs were mature. The sperm sample was good. And less than half, only 41% fertilised. Sucker punch to the belly – I felt like all my hard work was for naught. My disappointment shouldn’t be mistaken for ungracious – I am grateful we that had five little embryos, and that five is better than none. I’m grateful for that.

However, I’m a determined person and want to increase my odds however I can. I’m looking for something more than 41%. The biggest thing for me was should I have asked for ICSI, rather than IVF?

It took me a while to understand the subtleties between the two:

Fertilisation by IVF

With IVF the eggs are placed in a fancy liquid into a glass petri dish and the washed sperm sample is added to the dish near the egg. The sperm hopefully find their way to the egg, burrow in past the shell and cause a chemical reaction (which stops other sperm from joining the party). The sperm kicks off a round of meiosis to bring the chromosomes together and causes fertilisation. 

Fun side note, IVF stands for In Vitro Fertilisation – turns out In Vitro means “in glass”.

Fertilisation by ICSI

An embryologist will select a single sperm from the washed sample. This sperm will be put into a needle which is then carefully advanced through the outer shell of the egg and the egg membrane. The sperm is injected into the inner part (cytoplasm) of the egg, allowing fertilisation to take place. 

Most clinics will only use ICSI if there is an issue with male factor infertility (such as low sperm concentrations, motility or poor sperm morphology), where the benefits are clear. They might also, at a stretch use ICSI for couples who have had pervious IVF rounds with low or no fertilisation with mature eggs that should have fertilised. 

There are some risks with ICSI. In IVF natural selection takes care of things – the fastest and fittest sperm wins the race. However, with ICSI it’s not nature that makes the selection, but an embryologist. If the sperm has a chromosomal abnormality or a genetic defect, this might be passed on to the embryo. In some cases, the chromosomal abnormality may result in a miscarriage.  However, this is also possible when fertilisation is done by IVF. Chromosomal abnormalities aren’t specific to ICSI. 

One concern is that ICSI requires the removal of cell-to-cell communication structures.  When oocytes are processed for ICSI an embryologist will remove the outer cumulus cells around an egg. These cells have little extensions which penetrate through the shell of the egg and touch the egg itself, forming a little communication network between the surrounding cumulus cells and the egg within. 

With ICSI the cumulus cells are dissolved with an enzyme, and helped away with a little shearing of the pipette. This helps the embryologist see inside the egg to check that it’s mature (which is to say that it’s thrown out the excess maternal DNA in the polar body). It also ensures that ICSI is done in a relatively empty area of the egg, rather than through any maternal chromosomes.

While the cumulus cells typically falls off naturally over after fertilisation, with ICSI the communication between the egg and cumulus cells is removed well before fertilisation.  It’s been shown that this effects the fertilisation rate and subsequent embryo quality negatively.  (Source)

There have also been some animal studies in mice that show that with ICSI some genes can be imprinted incorrectly, suggesting that removing the communication network between the cells and the eggs could interrupt a gene printing process. (Source)

Another risk is the introduction of PVP into the egg and the effect it has to both the egg and the sperm.  In some ICSI cycles an embryologist will use PVP (polyvinylpyrrolidone, which is a thick syrupy polymer) to slow down the sperm so they can be easily managed with the pipette. Without PVP sperm are fast and would be impossible to catch and manage for fertilisation.

However, there is research that suggests PVP causes significant damage to sperm membranes  (Source, Source) and are associated with chromosomal abnormalities (Source). 

One study (Source) reported that exposure to PVP prior to ICSI damages the sperm plasma membrane, allowing thiol-reducing agents to gain access to the sperm nucleus (not a good thing).  It’s also possible that PVP loosens the make up of the sperm nucleus, which will eventually condense into cells. 

It’s suggested that fertilisation rates and clinical pregnancy rates could be improved by using a PVP- free solution with ICSI. (Source). That instead of using PVP, an embryologist should use a hyaluronate solution (hyaluronate is naturally found in the reproduction tract) instead. (Source)

Another risk is that the success doesn’t just ride on the quality of your eggs and sperm but on the skill of the individual performing the procedure and the overall quality of the laboratory. It’s a pretty hefty chance to take, so fingers crossed for an amazing embryologist. You might want to have a conversation about your clinic’s embryologist experiences. 

Heavy stuff. 

Alright, here are the questions I had:

  • Is there a better fertilisation rate with ICSI over IVF?
  • Exactly what happens with ICSI?
  • Will ICSI effect the embryo quality?
  • Is there a better transfer rate and pregnancy rate  with ICSI over IVF?
  • What is Rescue ICSI, and does it have a better fertilisation rate?
  • What is IMSI? Does that have a better transfer rate than ICSI?

I did an awful lot of reading and googling, and here is what I found.


ICSI TECHNICAL PROCEDURE

  1. Immediately after egg collection, the oocytes (eggs) are evaluated to see how mature they are. Eggs that are clearly not mature are discarded.
  2. Cumulus cells are removed from the oocyte. First with a enzyme solution and then by moving through a pipette to shear the cells off.
  3. The oocytes are evaluated again to assess how mature they are and their integrity to ensure they’re suitable for ICSI.
  4. Sperm are washed with a viscous medium, and analysed. One sperm is selected.
  5. The selected sperm is immobilised by breaking it’s tail, and aspirated into the needle.
  6. The oocyte is held in place with suction to the holding pipette, and the injection pipette is pushed against the oocyte shell. Once at the centre a break occurs in the membrane, which pushes a flow up into the injection pipette.
  7. The sperm is injected into oocyte.

(Source)


ICSI VS IVF – FERTALISATION, EGG QUALITY AND PREGNANCY  RATES

I really struggled to find clear studies on this. I wanted something concrete, a proper study rather than a clinic’s promotional success rates – most spout something along the lines of 70-85% of eggs fertilise.  The tricky thing with that amazing rate is it’s a bit biased. ICSI is often used to treat male-factor infertility where fertilisation is the main hurdle. This means that the eggs used in ICSI cycles are typically high quality and collected from young fertile women – a very different skew from the typical IVF patient range.  

I did find one study, done in the Netherlands in 2005.  It’s called Conventional in vitro fertilization versus intracytoplasmic sperm injection in patients with borderline semen: a randomized study using sibling oocytes. (Source). Definitely a mouth full but had some interesting results.

At first I discounted it as being 10 years old, but when I realised that it was one of the few studies I could find that was relevant and that rates could only have improved as the technology has, I took a look.

Here’s how it worked: each couple in study had a selection of their eggs split into two groups: Those to be fertilised by IVF, and those to be fertilised by ICSI. This get’s around the ICSI bias, as the eggs are likely to be the same quality across both methods. 

Some couples eggs only fertilised with ICSI, and some with both ICSI and IVF, and the results are split along those lines:

Group IVF-
Couples whose eggs only fertilised with ICSI and not IVF. 
This group is likely to include those couples with male factor infertility.

Group IVF+
Couples whose eggs fertilised both the ICSI AND with IVF.

Down to business, how’d they do?


FERTILISATION RATES

Group IVF – 
IVF Fertalisation Rates – Of the eggs in the IVF group, 0% fertilised.
ICSI  Fertalisation Rates – Of the eggs in the ICSI group, 51% fertilised.

Group IVF+
IVF Fertalisation Rates – Of the eggs in the IVF group, 51% fertilised.
ICSI Fertalisation Rates – Of the eggs in the ICSI group, 51% fertilised.

Pretty consistent results, right? ICSI fertilisation rate is consistent with IVF, if your eggs and sperm are able to be fertilised by IVF. If your eggs/sperm aren’t able, you may loose all your eggs to trying IVF. 

I guess this up to you – if you think it’s worth taking the chance, then IVF and ICSI have pretty similar fertilisation rates. If you’re in the borderline group, you can avoid unnecessary fertilization failure with ICSI. 


EMBRYO QUALITY

In the study, embryos were put into four buckets (1 – 4) based on the number of cell divisions and the fragmentation. They were looking for the best: Type 1 embryos with equal sized cells with no fragmentation and Type Two, with equal sized cells and less than 20% fragmentation.

It’s important to remember this is only a visual guide, and an embryo that looks good may also be chromosonally abnormal, and thus not viable. 

Group IVF – 
Of the embryos that fertalised in the ICSI group, 77% were Type 1/2.

Group IVF+
Of the embryos that fertalised in the IVF group, 72% were Type 1/2
Of the embryos that fertalised in the ICSI group, 83% were Type 1/2

I was surprised by this, but glad to see that ICSI didn’t harm embryo quality anymore than IVF does. In fact, ICSI embryos had consistently better visual quality than IVF.


PREGNANCY RATE

These two are the proper indicators of success – how many resulted in a BFP at the first beta, 15 days post egg retrieval (which I’m calling pregnancy rate) and how many resulted in a positive pregnancy, with a heartbeat at week 12 (ongoing pregnancy rate). 

Group IVF – 
Of the embryos that fertilised in the ICSI group, the pregnancy rate was 54%.
Of the embryos that fertilised in the ICSI group, the ongoing pregnancy rate was 42%.

Group IVF+
Of the embryos that fertilised in the IVF group, the pregnancy rate was 43%.
Of the embryos that fertilised in the IVF group, the ongoing pregnancy rate was 36%.

Of the embryos that fertilised in the ICSI group, the pregnancy rate was 53%.
Of the embryos that fertilised in the ICSI group, the ongoing pregnancy rate was 50%.

Here is the most convincing evidence for me – both ICSI groups has a higher pregnancy rate AND a higher ongoing pregnancy rate than IVF.


RESCUE ICSI

There is a third option, which is Rescue ICSI. If no eggs are fertilised via IVF, some clinics will take those eggs and use ICSI to fertilise them. This comes with risks, because if a sperm is already inside the egg the resulting embryo will have chromosomal abnormalities. 

The research is also not clear. Some studies (like this one) suggest it might be worth a shot if none of the eggs that should have fertilised did. Other studies (like this one) suggest the odds aren’t worth the cost as the success rate is so small. 


ICSI VS IMSI

With ICSI an embryologist will do a sperm morphology analysis and sperm selection at a magnification of 400x.  With IMSI, it’s thought that bigger is better, and this is done at an extremely high magnification (8000x). If you want to see what the difference looks like, here is a youtube video.

This is relevant particularly during sperm selection, as IMSI shows finer details and it is easier to see sperm that have head vacuoles or other abnormalities. One study (Source) found that between ICSI and IMSI the fertilisation rate was the same, but the pregnancy rate was higher and the miscarriage rate was lower for IMSI than ICSI.


TAKEAWAYS

It’s a pretty personal choice.

  • ICSI and IVI have the same fertilisation rate when you discount the male factor bias. However ICSI has the better pregnancy rate, but it depends on the clinic (and whether they use PVP in their ICSI process).
  • There’s the concern that by removing the cumulus cells in ICSI alters the gene imprinting process. 
  • If you are going to go the ICSI route, push for IMSI instead – as it has an even better pregnancy rate since the embryologists can see the sperm better during sperm selection. 

Personally,  I’m leaning towards either half and half or full ICSI/IMSI the next round. The benefits of ICSI I think well outweigh the risks of conventional IVF not fertilising… It’s a tricky choice! It’s hard to know what the right choice is. Hopefully my body will cooperate and the next round will be soon. I plan to discuss it with my RE, anyway. 

QUESTIONS TO ASK YOUR RE

  • Does the clinic offer ICSI, even if you don’t have male factor infertility?
  • What are your fertilisation and pregnancy rates like for half ICSI, half IVF fertilisation method? 
  • Do you use a PVP-free solution in your sperm selection process?
  • Do you have the tools to offer IMSI?
  • How experienced is the embryologist who will be performing ICSI on my eggs? How many ICSI procedures have they performed?  
  • Do you offer Rescue ICSI, and this is an option for me?

As always, I’m not a professional or a doctor – my experience is just that, my experience. I’ve done an awful lot of reading and research which I’m happy to share. If you do have concerns about IVF vs ICSI, talk to your doctor. 


Everything you need to know about AMH and Ovarian Reserve

By Research No Comments

When my doctor told me I may be infertile, I told her she was lying. It wasn’t a great day, to be honest. It was a gut reaction, and turns out that she wasn’t lying. I even got my own copy of the blood test results. My AMH levels were low, she said. AMH is an indication of ovarian reserve and mine waI was at the end of my fertility season, she said.

It was definitely a shock and took me a while to understand what she was saying. There’s a hormone in your blood that can be used to give an indication of how fertile you are, called AMH. AMH stands for Anti-müllerian hormone, which is secreted in the granulosa cells of follicles. Follicles are the cavities in your ovaries that eggs grow in.  Your AMH levels starts high, when you’re at your most fertile age and as you get older, declines as your ovarian reserve does.  It’s measured with a simple blood test, typically included with the regular Day 3 blood work if you’re doing an IVF round. 

To confirm, AMH typically correlates to your antral follicle count. That is to say, how many antral follicles you have on Day 3 (measured with an ultra sound). It’s another method to confirm your fertility potential.

It used to be that FSH (Follicle Stimulating Hormone) was used to gauge ovarian reserve, but FSH fluctuates a lot throughout your cycle as it’s used to kickstart your ovaries into action. AMH on the other hand is a fairly stable measure that doesn’t have the same fluctuation from month to month and is considered a much more accurate guide.

What my not-lying doctor was trying to say was that at age 30, I had an AMH level of 6.4. I had a low ovarian reserve, also known as diminished ovarian reserve, or low fertility. Essentially, I don’t have that many eggs left.


AVERAGE AMH LEVELS (across all ages, pmol/L)
Optimal Fertility: 40.04 – 67.9
Satisfactory Fertility: 21.98 – 40.04
Low Fertility: 3.08 – 21.97
Very Low/Undetectable Fertility: 0.0 – 3.07

AVERAGE AMH LEVEL BY AGE (pmol/L)
Age 25 – 24
Age 30 – 17.5
Age 35 – 10
Age 40 – 5
Age 45 – 2.5

Source: Lister Fertility Clinic


At first I thought low ovarian reserve was the be all and end all of our fertility journey. We’re done before we even started – I was never having a baby. That’s actually not the case – I still have some eggs left even if not very many, and we were reassured that pregnancy was still possible. Having this information was helpful for planning our IVF cycles as AMH can help predict your response to stimulant drugs during IVF.

If you have a low ovarian reserve (like me) you might need some help developing more eggs and require a higher dose of stimulants. If you have a high ovarian reserve, you may have a very high level of fertility and require a much lower dosage of stimulants.

Because AMH is just a hormone, it’s unlikely that increasing the hormone levels will also raise your ovarian reserve. In saying that, there are a few interesting cases that do effect AMH level.

  1. Vitamin D deficiency is linked with falsely low AMH. In fact, it was found that AMH levels decreased by 18% depending on the season, and these effects were mitigated with the supplementation of Vitamin D.  If you’re concerned, get your Vitamin D levels checked.
    Source
     
  2. DHEA has been shown to help with women with low AMH. DHEA (Dehydroepiandrosterone) is a hormone produced by the adrenal glands and ovaries and is involved in the production testosterone and estrogen. As DHEA levels tend to decline naturally with age, it’s thought that supplementation can help with fertility. 
    Source  (If it helps, I used Fertinatal DHEA, available here on Amazon
     
  3. Smoking has been shown to decrease AMH levels. 
    Source
     
  4. Occasionally there can be minor fluctuations within the bounds of lab error. If you’re unsure, insist on a second test.

 

I will say this though – learning about my low AMH levels kicked off this sense of urgency. I didn’t have that many eggs left and I was only losing more as each month ticked by. Because of this we got into IVF right away and we didn’t necessarily take a considered approach. 

What I’d say now is if you’re faced with a low AMH level, even though it feels like it’s best to rush – take some time and consider your situation and what you want to do. We’ve been a year in our IVF journey and my AMH levels haven’t changed. We’ve learnt that taking a month or two to research and understand our situation and emotionally come to terms with low fertility levels is an option, even if it doesn’t feel like it. 

As always, I’m not a professional or a doctor – my experience is just that, my experience. I’ve done an awful lot of reading and research which I’m happy to share. If you do have concerns about AMH, talk to your doctor. 


A TTC Acronym Glossary

By Research No Comments

When I first stumbled across the #ivf tag on instagram, I was ecstatic – here were people who UNDERSTOOD!  I was not alone! I found my tribe of people!! I did a dance I was so happy. It was a comfort to know I wasn’t the only one.

The next emotion was less happy – my tribe were speaking in a language of acronyms I did not understand. Not even in the slightest. It was intimidating and confusing. It made me feel small. 

It took some time, but with some googling, determination and many questions I soon understood what was being said. Here’s a quick glossary to help you understand the #TTC acronyms.

2WW
2 Week Wait. It’s that time between post IVF transfer and taking a beta test to prove pregnancy. It’s a nervous time, hoping the transfer is successful.

AF
Aunt Flo, After Flo, Period, or Menstrual Cycle.

AH
Assisted Hatching. It’s an IVF term, where an embryologist will create a small hole in the embryo shell before transfer. It’s thought that embryos who have assistance hatching are more likely to implant. 

AI 
Artificial/Assisted Insemination. Where semen is injected into the vagina or uterus.

ART
Assisted Reproductive Technology. Essentially any conception assistance that isn’t sex. Examples would be IVF or IUI. 

AMH
Anti-Mullerian Hormone. The hormone that predicts ovarian reserve (that is, the number of eggs you have left in your ovaries).

BA
Baby Aspirin. There is some thought that taking a single baby aspirin can improve pregnancy outcomes with IVF by improving the blood supply to various organs, like ovaries.

Baby Dust
That magic something that ensures the whole pregnancy process goes as planned.

BBT
Basal Body Temperature. Helpful for temperature charting to predict ovulation.

BCP
Birth Control Pills.

BD
Baby Dance, otherwise known as sex.

Beta
The beta is a pregnancy test taken after the 2WW. It measures the levels of the hormone beta-hCG via a blood test, as it is the first measurable sign of implantation.

BFN
Big Fat Negative. When you take a pregnancy test and you’re not pregnant. Sad face.

BFP
Big Fat Positive. What we’re all looking for – when you take a pregnancy test and it is positive. High five! 

BW
Bloodwork. Getting bloods drawn is a fairly frequent occurrence if you’re working with assisted reproduction.

CB
Cycle Buddy. When you have a friend with a similar cycle to you, and you both run through similar IVF/IUI journeys at the time.

CD
Cycle Day. The day of your cycle. The first day of your period is CD1.

CM
Cervical Mucus. Your body produces a mucus around the cervix. It’s typically used to prevent any bacteria moving between the vagina to the uterus. When you’re ovulating estrogen alters the mucus to become sperm friendly, which allows the sperm to move quickly through the uterus to the fallopian tubes.

DH
Dear Husband. 

DHEA
Dihydroepiandrosterone is a hormone that can be taken as a supplement. It’s naturally occurring in most women and converts into androgens (like testosterone). It’s used to improve outcomes for women experiencing Diminished Ovarian Reserve.

DOR
Diminished Ovarian Reserve. A condition where a woman will have a low number of eggs in her ovaries, or impaired development of existing eggs. It’s thought to be one of the main causes of infertility.

DPO
Days Post-Ovulation.

DPR
Days Post-Egg Retrieval.

DPT
Days Post-Transfer. Often it will have a number in front – 5DPT would be 5 days post transfer.

DP3DT
Days Post 3-Day Transfer. This refers to an embryo that was transferred on Day 3 after egg retrieval. 

DP5DT
Similar to the above, except a 5 Day old blastocyst was transferred.

DW
Dear Wife.

E2
Estradiol. Estradiol is the primary female sex hormone. Most importantly, as your follicles grow it triggers hypothalamic-pituitary events that lead to a luteinizing hormone surge which induces ovulation. It will be one of the hormones measured frequently during an IVF round.

ENDO
Endometriosis is a common condition where tissue that behaves like the lining of the womb is found outside the womb.

ER
Egg Retrieval. Where, after being stimulated with hormones during an IVF cycle, the eggs are retrieved from the ovaries.

ET
Embryo Transfer. Where, after being fertilised and allowed to cleave during an IVF cycle, the embryo is transferred to the uterus. 

EWCM
Egg White Cervical Mucus. The kind of cervical mucus where, around ovulation, it takes on a consistency like egg whites.

FET
Frozen Embryo Transfer. Where a frozen embryo is thawed and transferred to the uterus.

FF
Fertility Friend is an app for tracking fertility.

Frostie
Is a frozen embryo.

FSH
Follicle-Stimulating Hormone promotes the formation of eggs in an ovary. It is used as a guide to indicate the quality of eggs on CD3, which can be used to predicate whether an IVF round should go ahead or not.

GnRH
Gonadotropin-Releasing Hormone is also known as a luteinizing hormone which is responsible for the release of FSH and LH from the anterior pituitary gland. 

GTT
The Glucose Tolerance Test is a tool used to diagnose high blood glucose during pregnancy, otherwise known as gestational diabetes.

hCG, HCG
Human Chorionic Gonadotropin is a hormone produced in a placenta during pregnancy. It tells the ovary to continue producing estrogen and progesterone which help the lining of your uterus stay intact.

hMG, HMG
Human Menopausal Gonadotropin (also known as Menotropin) is hormonally active medication used to treat infertility. It contains equal amounts of LH and FSH and is used to help stimulate ovulation

HPT
Home Pregnancy Test.

HSC
Hysteroscopy is a procedure used to examine a womb for fibroids, polyps or adhesions by inserting a narrow camera through the cervix. 

HSG
Hysterosalpingogram is a procedure to ensure the fallopian tubes are clear. It’s done by injecting a dye into the cervical canal and then taking an xray as the dye moves around the uterus into the fallopian tubes.

ICI
Intracervical Insemination is an artificial insemination procedure, which involves placing sperm directly into the reproductive tract to improve the chances of pregnancy. 

ICSI
Intra-cytoplamic Sperm Injection. This is where a single sperm is inserted into an egg to aid fertilisation. 

IUI
Intra-uterine Insemination is a form of assisted conception. Sperm is placed in the uterus near the egg at the time of ovulation.

IVF
In Vitro Fertilization. This is a form of assisted conception, where an egg is removed from an ovary and fertilised with sperm in a laboratory. The embryo is then transferred to the womb to grow and develop.

LH
Luteinizing Hormone is released to encourage your ovary to ovulate. 

LP
Luteal-Phase is the second half of a menstrual cycle that occurs after ovulation. It’s the phase where fertilisation and implantation are likely to happen. 

MC
Miscarriage.

MF
Male Factor Infertility.

O, OV
Ovulation.

OB
Obstetrician.

OB/GYN
Obstetrician/Gynecologist.

OC
Oral Contraceptives.

OHSS
Ovarian Hyperstimulation Syndrome is an occasional side effect of IVF. Your ovaries overreact to the stimulants and produce too many follicles.

OPK/OPT
Ovulation Predictor Kit/Ovulation Predictor Test. Both work by measuring the amount of luteinzing hormone (LH) in your urine. A surge of LH is an indicator of ovulation.

OTC
Over the Counter. Typically refers to medication.

PCOS/PCOD
Polycistic Ovarian Syndrome/Polycistic Ovarian Disease is a hormone imbalance which interferes with periods and other fertility aspects. It’s thought to be the leading cause of infertility. 

PGD/PGS
Pre-implantation Genetic Diagnosis/Pre-implantation Genetic Screening. This is where an embryo that has grown to Day 5, blastocyst level is sampled and the cells are tested for chromosomal abnormalities.

PMS
Pre-menstrual Syndrome.

POAS
Pee On A Stick. Typically associated with pregnancy tests or OPKs. 

RE
Reproductive Endocrinologist.

SA
Semen Analysis. A sample is taken and a few different factors are checked to rule out male infertility. 

TSH
Thyroid Stimulating Hormone is a hormone secreted by the pituitary gland. It plays a significant role in reproduction and pregnancy. There has shown to be an increase in miscarriages when the TSH levels are off the scale. 

TTC
Trying To Conceive. 


Why should worry about Egg Quality if you’re doing IVF

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There’s a lot of speculation that fertilisation is the crux of getting pregnant. Take one good swimmer plus an egg and boom – nature will take it’s course and produce a healthy little baby. So to fall pregnant all you need to do is introduce an egg to the sperm, right? 

Often when trying to conceive there is a huge focus on fertilisation. There are some complicated ovulation prediction methods to help get the timing right. Like temperature charting and OPKs – peeing on sticks to compare the lines from previous days. The hope is having sex at the right time, the sperm and egg will meet and fertilise. 

Turns out it’s a bit more complicated than that. Truth is,  Fertilisation is only a small part the equation. Only around a third of fertilised embryos will survive and grow in a healthy baby (1). 

Let’s take a moment to process that. Miscarriages are more common than we think, occurring in about 10-15% recognised pregnancies (2). The important part there is “recognised pregnancies”. Most miscarriages happen before you even realise you’re pregnant (3).  In fact, it’s thought that up to 70% of pregnancies end in miscarriage (1).

So despite getting past fertilisation a large number of pregnancies won’t grow to term. It’s been found that the key to getting pregnant (and staying pregnant) is egg quality. That is, whether your egg has the right number of chromosomes or not.  

Each egg starts with four sets of chromosomes. Shortly before ovulation (4) your egg will go through a process of aligning two sets of chromosomes.  Once matched, your egg will dispose of the extra set. It does this twice and if all goes as planned your egg ends up with one copy of each chromosome, ready to ovulate. This process is called meiosis.

Meiosis will define whether your egg will have the right number of chromosomes. This is important, because an egg with the wrong number of chromosomes could result in a miscarriage, or even have difficulty fertilising. If a chromosomal abnormal embryo does grow to term it’s likely to have a genetic disorder. Down’s Syndrome, or Turners for example. 

Chromosomal abnormalities are surprisingly common. In women over 40, it’s thought that more than half her eggs may be abnormal (5), possibly even as high as 70%-80% (6). For women under 35, in one study it was found that up to a quarter of her eggs will have an abnormal number of chromosomes (6).

Putting that in context: for every month that a woman under 35 ovulates hoping to become pregnant, one month of four  it’s unlikely she’ll be able to conceive. If she does, she’s likely to miscarry.

During IVF there is an optional process called PGS – Pre-Genetic Screening. Once fertilised embryos reach blastocyst level they can be screened to check the number of chromosomes. Only chromosomal normal embryos will be transferred back for implantation.

It’s a heartbreaking decision to make. With PGS there is a possibility all the embryos may be abnormal. There may no-viable embryos to transfer. If that’s the case it’s likely even without PGS the outcome would not result in a healthy pregnancy.

There have been several interesting studies (7, 8, 9) on the impact of using PGS with IVF. The most interesting – pregnancy rates increase dramatically when using PGS screened eggs. Embryos that have been checked and are chromosomal normal are more likely to produce a successful pregnancy. 

In one study, the successful implantation rate for ladies between 40-43 years old went from 19.0% to 45.5% when using only screened embryos. The number of ladies in that age bracket who became mothers more than doubled. (7).

Another study repeated in both Beijing and LA found that 69% of IVF patients who used PGS screening and selected only chromosomal normal eggs became pregnant. In the control group (who did not use PGS to select chromosomal normal eggs) had only 41% of IVF patients fall pregnant. (9)

It’s clear that having chromosomal normal eggs – good quality eggs – is fundamental in having a successful pregnancy, and a happy healthy baby, more so than fertilisation. To put it simply: Egg Quality is everything.

The question then becomes, can Egg Quality be changed? If so, how?  Stay tuned for more posts. 🙂

References

1 – http://www.ncbi.nlm.nih.gov/pubmed/14532867

2 – http://humrep.oxfordjournals.org/content/27/8/2297.full

3 – http://humrep.oxfordjournals.org/content/27/12/3583.full

4 – http://www.nature.com/nrg/journal/v13/n7/full/nrg3245.html

5 – http://www.rbmojournal.com/article/S1472-6483(10)00571-7/fulltext

6 – http://molehr.oxfordjournals.org/content/17/5/286.full

7 – http://www.ncbi.nlm.nih.gov/pubmed/25578536

8 – http://www.ncbi.nlm.nih.gov/pubmed/19939370

9 – http://www.molecularcytogenetics.org/content/5/1/24