Auditorium Dr. Michael Doyle, M.D. on Wednesday Feb 2, at 9 PM ET
Harriet: Hello Dr. Doyle, I have a question regarding PGD and Antagonist for a poor responder. I'd like to know if you recommend it?
Michael Doyle, M.D. : For poor responders, I generally avoid Lupron, so that, yes, an Antagonist is one reasonable way to prevent premature ovulation before retrieval
Joyce: Hi Dr. Doyle. After two unsuccessful IVF attempts what is your opinion of testing for APA (Antiphospholipid Antibodies), Antinuclear Antibodies (ANA), Antithyroid Antibodies (ATA) and Lupus Anticoagulant (LA)?
Michael Doyle, M.D. : If there is history of miscarriage, or unexplained infertility, those tests can be useful, but maybe even before the first cycle !
(Editor’s Note: Please see the basic immunological fact sheet for more information on when to test and what the tests mean.)
Abigail : Dr. Doyle, my question is about immune treatments. I have come back with high ATA and elevated Thyroid Peroxidase levels. I understand that IVIg use is somewhat controversial, are their alternatives? What do you recommend?
Michael Doyle, M.D. : IVIg is controversial. Thyroid peroxidase levels themselves do not determine treatment. TFTs could be important to check also.
India: What medication do you use with poor responders?
Michael Doyle, M.D. : I like Antagon or Cetrotide instead of Lupron in older patients and low or poor responders.
Barbara: Dr. Doyle, I had a normal lap done in 1998, since then the only pg was with my first IVF (in vitro fertilization) and it ended in miscarriage at 10 weeks. We had another IVF that failed. Do you think that we should repeat the lap before attempting a third IVF cycle? Though no endometriosis was found at the time, it does run in my family. Thanks. (Editor’s Note: It is always wise to get and keep a copy of your medical records including the operative notes.)
Michael Doyle, M.D. : A laparosocpy would probably not improve the chances of an IVF cycle working in your case, since pelvic conditions are bypassed, and your pelvis is probably stil normal anyway. Unless you have a hydrosalpinx, which an HSG could detect.
Frances: What was your most successful IVF?
Michael Doyle, M.D. : Wow !! Tough question! I guess it would be the successful pregnancy from a case where there was only one sperm. But ALL successful IVF cases are amazing, even the "easy" ones.
Carrie : My DH (“Dear Husband”) has severe male factor. In our IVF cycle 10 out of 12 eggs fertilized My RE (reproductive endocrinologist) says that all 10 were excellent quality, the “HIGHEST QUALITY” . Four embryos were transferred and we were unsuccessful. What would you think our next step with 6 frozen embryos of high quality should be?
Michael Doyle, M.D. : Make sure your uterus is normal, and proceed with frozen embryo transfer. If they are day 3 embryos, consider thawing them ALL and transferring those that make it to day 5 (called blastocysts) , ideally transferring two of them. Good luck.
Michael Doyle, M.D. : There are various protocols, some begin with Lupron with your period, others a few weeks later after birth control, others a week after ovulation. Your doc will choose the one that's best for you.
Gerry : I have had 4 miscarriages in the past 2.5 years. In May I went to an RE and had all kinds of tests done. Structurally, hormonally and genetically, it would appear everything is ok. In May I tested positive for APA and ACA (anticardiolipin) antibodies. My levels were 90 for IGM AB Phophatidylserine and at 10 for IGM AB Cardiolipin. Since then I’ve lost another in August and one in October . My levels have now risen in Dec to 96 for Cardiolipin and 93 for APA. Do these get worse with each m/c?
Michael Doyle, M.D. : Not always, but more importantly, are you considering treatment with Aspirin, Prednisone, and Heparin or Lovenox?
Veronica : What are the chances of successful IVF at 40?
Michael Doyle, M.D. : It really depends on many factors, including egg quality, sperm quality, and fertility history
Zelda : How concerned should I be with a day 3 FSH (Follicle Stimulating Hormone) of 10.9. I am 30 years old and make 11-15 eggs during IVF stimulation.
Michael Doyle, M.D. : Probably not very concerned, if the quality of your eggs has been found to be good. But it may suggest that your ovarian reserve will probably become an issue at a younger age than you might have predicted.
Teresa : I am getting ready to do my third IVF using a donor's eggs. We have had 7 failed IUI's (Intrauterine inseminations) and 2 failed IVF cycles. I'm 38 and DH is 50, can you suggest we do anything different to assure success of this cycle?
Michael Doyle, M.D. : Egg donation sounds like a very good idea. Pick a great donor and just follow the protocols. As long as your uterus is functional, your chances should be very good. Try to relax, maybe even consider acupuncture.
Michelle: What constitutes a poor responder for a 35 year old woman?
Michael Doyle, M.D. : A poor responder might produce less than 4 follicles, and a have a relatively low Estradiol, level (i.e. <600, approximately).
Estelle: Dr. Doyle. Do you know if there is any difference between Repronex (Subcutaneous - SubQ) and the generic form which is an IM injection? Do you feel a difference in protocols using just Repronex vs. Gonal-F or Follistim. I'm asking because of financial considerations. Thank you.
Michael Doyle, M.D. : There is no difference between IM (intramuscular) and SubQ (subcutaneous) Repronex, except that SubQ is reported to burn. I personally prefer the protocol include a significant amount of Follisitm or Gonal F, (i.e., the recombinant FSH) .
Norma : I'm afraid I was over suppressed with Lupron and Repronex and Gonal F. I didn't respond. I also have Hashimoto Thyroiditis. I'm concerned that I haven't cycled yet. I feel like I will any day now but it's been well over 28 days now. What could this mean?
Michael Doyle, M.D. : Your non-response was probably not caused by Repronex and Gonal F. Maybe you should recheck your baseline FSH, or even do a Clomid Challenge Test to assess your ovarian reserve.
Doe : Dr. Doyle, do you recommend low-carb lifestyles to your PCOS patients?
Michael Doyle, M.D. : Yes and EXERCISE if possible. Weight loss can be key to normalizing the high insulin and/or testosterone levels which are often associated with PCOS and which cause ovulation problems
Nellie : I am only 31 years old. How would I know if I was a low responder? My FSH was 4.5 today and e2 was 11
Michael Doyle, M.D. : Those are excellent numbers, so you probably need not worry. The way to know is to see how you respond to fertility drugs, but if you don't need to take them, you shouldn't!
Glenda : I've had 3 miscarriages and 1 successful pregnancy as a result of FET (Frozen Embryo Transfer). The last miscarriage was a chromosome normal female. I've had LAC, APA, and chromosome analysis done on me and husband. My only successful pregnancy was when I took Glucophage. I'm wondering if that might possibly be important to another successful pregnancy. I have started the Glucophage again and will do a FET next week. I am searching for answers as to why I keep losing pregnancies.
Michael Doyle, M.D. : Embryo quality can certainly be improved in women with PCOS and insulin resistance, so tests to determine insulin resistance could be very helpful. i.e. Fasting Insulin or Glucose Tolerance Testing.
Donna : Dr. Doyle, can you compare the MDL to an Antagon protocol for low responders who are less than 35 years old?
Michael Doyle, M.D. : In general, MDL usually provides a bit more suppression, but as a flare, may also produce a few more follicles. Honestly, it is very difficult to predict which would be better in an individual case. You just have to try the one your doc feels is preferable based on previous stimulations... Good Luck!
Nora : My family appears to be cursed with PCOS as every woman has been diagnosed with it. Although each woman in my family (grandmother, mother, aunt, and two sisters) have been diagnosed with PCOS, I am the only one who has difficulty conceiving. My older sister has been pregnant three times in the four and a half years my husband and I have been trying to conceive (TTC). All blood tests and HSG are normal except for a slightly elevated testosterone level. Is this just likely a quirk of PCOS in me?
Michael Doyle, M.D. : PCOS can affect different people differently and remember, fertility depends not only on family connections but also on ovulation and eggs. Perhaps those other factors to consider – Has a Sperm Analysis been done?
Barri : Good Evening Dr. Doyle. I’ve been through 4 IVF cycles with 1 pregnancy, ending in miscarriage. This was a few years ago. Now I am 40 and we very much want to try again, what are chances and what should be our first step??
Michael Doyle, M.D. : At 40 and following 4 IVF cycles your chances are starting to go down, but don't give up. You might start as a first step with a baseline FSH and E2, and perhaps a Clomid Challenge Test?
Denise : Dr. Doyle, another question for you, I've done Clomid Challenge (2003), Metformin (2003) and most recently Repronex and Gonal F in prep for IUI. I didn't respond to any of them. I've always had an irregular cycle, I have Hashimoto's and my mother has Lupus. Do you think any of these factors may be contributing to my lack of response or is it just age, I'm 42? Thanks!
Michael Doyle, M.D. : Honestly, it's probably almost all an age issue.
Cathy : I' am just in the early process of doing PGD (Preimplantation Genetics), I was wondering how long does an IVF cycle last and how long are you doing injections?
Michael Doyle, M.D. : An IVF cycle lasts up to 6 weeks, with injections comprising up to 4-5 of those weeks in some cases, NOT counting the progesterone. GOOD LUCK!
Dora : Other than a Saline Hysterosonogram , what is the best way to "make sure the uterus is normal"?
Michael Doyle, M.D. : Hysteroscopy
Mary : Hello Dr. Doyle. I have a question about use of Lupron vs. Antagon. I am 34 year old and a good responder. Fifteen (15) eggs were retrieved using Antagon and only 10 while using the Lupron protocol. I am going to do my third IVF cycle with Antagon again. Any guess why I do not respond well to Lupron? I have mild endometriosis and Unexplained Infertility. Thank you
Michael Doyle, M.D. : Lupron can sometimes suppress a bit more than we would like. Or perhaps it was unrelated, if there was not enough rest following your first cycle, you might have responded less because of that.
Elizabeth : So acupuncture REALLY can increase/help implantation?
Michael Doyle, M.D. : honestly, thats out of my field, but if your center has a wellness group, ask them. or you can ask our team at http://www.ctwellness.com .
Marilyn : I am on aspirin and that didn't work. My RE thinks these antibodies only affect a placenta at 2 months. She suggested Heparin after week 6 but my miscarriages usually occur before this point in the pregnancy. I went to a hematologist on my own and she thinks Lovenox given 1x daily will help my antibody situation. The RE is not convinced. I have read articles that suggests this affects implantation. When should I start Lovenox before or after ovulation?
Michael Doyle, M.D. : It is very debatable and there are different opinions on treatment. In cases like yours, I start Lovenox when the pregnancy test turns positive. (Editor’s Note: There are differing opinions among Reproductive Endocrinologists on starting antibody treatments pre or post conception. We also suggest you read the basic article on Immunology and then discuss this with your own doctor.)
Laurie : How many embryos do you transfer for a successful pregnancy for IVF patients?
Michael Doyle, M.D. : The number of embryos transferred is dependent on the age of the patient and the embryo quality. We usually transfer 2 or 3. ASRM (American Society for Reproductive Medicine) has guidelines for this which you can find on their website: http://www.asrm.org.
Liz : Is there any way to improve male sperm count with the use of vitamins herbs or other nutritional supplements? If so, do you recommend any particular one to assist with motility? My husband’s sperm did not penetrate the egg on their own during our first IVF cycle.
Michael Doyle, M.D. : I don’t know of any nutritional solution to this issue. Obviously with IVF ICSI (Intracytoplasmic Sperm Injection) (Editor’s Note – See the basic ICSI fact sheet) is performed. I think I would not predict how meaningful one cycle of IVF with failed fertilization is. I have certainly seen patients like this get pregnant later spontaneously!
Dana : I will begin a third IVF cycle and a three day transfer. What is the suggested number of blastocysts to put back at day three for a singleton pregnancy?
Michael Doyle, M.D. : If you really don’t want twins and you are transferring day 5 blastocysts, you probably should put back only ONE high quality embryo.
Gloria : If on Lovenox therapy and carrying to term do I need to be induced? Can I have an epidural safely?
Michael Doyle, M.D. : The Lovenox is stopped before labor and delivery, so epidurals are ok, and induction is not necessarily required.
Martha : When should we start considering surrogacy?
Michael Doyle, M.D. : Surrogacy can be considered when it appears your uterus cannot carry a successful pregnancy. I would suggest you look at the Third Party Reproduction Forum on INCIID with Moderating Physician Joel Batzofin, M.D.
Margaret : I am considering the use of donor sperm. The donor I selected tests positive for CMV (Cytomegolovirus) antibodies, but not CMV. Do I also have to test positive for CMV antibodies to use this donor to avoid complications should I become pregnant?
Michael Doyle, M.D. : No, his antibodies only suggest that he has been exposed in the past, not that he carries the risk of infecting you.
Mel : Hi Dr. Doyle, I'm 37 and have been trying to conceive for 12 years, I’ve had 10+ IUI's, 2 failed IVF cycles, 1 Failed FET and a diagnosis of PCOS annovulatory, and hyprolectimia. After all these years of trying should I give up?
Michael Doyle, M.D. : Wow, that's not my call. You and your partner should sit with your doctor and hash this out, see what options still remain and if they are right for you.... Good luck.
Lottie : I took Gonal-f four years ago and conceived our third daughter on the second round. I was doing twice daily injections of 150iu's each time. We are getting ready to try again and my RE wants to start me on 150iu's of Gonal-f. Is that too low of a dose? Especially since I got PG on 150iu's 2 x's daily. Would 225iu be more of a reasonable dose to try? This is not for an IVF cycle.
Michael Doyle, M.D. : Your doctor probably reviewed your prior response and might be maybe trying to reduce the risks of hyperstimulation or multiples? I would suggest you speak to him about your concerns.
Michael Doyle, M.D. : Thank you very much for your excellent questions. I wish you all the very best.... Good Night !
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Michael Doyle, M.D. is a reproductive endocrinologist from Connecticut Fertility Associates, 4920 Main Street, Bridgeport, CT 06606 He is an INCIID Professional Member and currently moderates the PCOS Forum on INCIID: