Question about injectables

[jazcat]

Hi all, we've been TTC #2 for 9 months now. I had my first RE appt (for #2) last week. We sat down for a while and reviewed all the options. He mentioned that if/when we get to an IUI, he likes to do it in conjunction with the injectable, "to provide more targets".

I'm concerned that the injectable will release a large number of eggs, for two reasons. One, let's say there's 5 eggs - big chance for multiples, right? But also, that's 5 less eggs I'll have, which mean they won't be available for future tries. He counted my follicles with a vaginal u/s and found "at least 15" on each side, but I don't know if that's just for this cycle, or a lifetime.

Thanks for the help!

[YummyYarnAddict]

Let's see if I can help explain. When you are born, your ovaries contain all the eggs they are ever going to have. They may or may not all mature and release and some just die off without having the opportunity to mature and/or release before you reach menopause. In "normal" usage, between the onset of menarche and menopause, your ovaries release one to two eggs per month for an average of 12 per year during your childbearing years, expect, of course, when your pregnant or otherwise anovulatory.

Injectibles are essentially growth hormone and usually (but not always) cause a larger number than usual of eggs to mature than they would naturally. During a baseline ultrasound at the beginning of a woman's cycle, they can get an antral follicle count from the ovaries. See here for more information: http://www.advancedfertility.com/antralfollicles. An AFC of 15 is good.

Because we don't necessarily use up all of the eggs that our ovaries contain, we aren't necessarily depleting them of their potential by using growth hormone/injectibles. Five is sorta toward the upper end of what you want to get for an IUI for many REs. Some have 3 as a limit, though it largely depends on your individual diagnosis and history.

For my particular issues, I stuck with IUIs way too long, and I probably "used" about 60 eggs for IUIs w/injectibles. When I had my first fresh IVF cycle (I've also had 3 frozen IVF cycles), I produced 21 eggs. For my second, 17 eggs, for my 3rd, 15 eggs, and for my 4th, 34 eggs. If I were to do a 5th fresh IVF cycle (which I'm not because I have 18 frozen embies so it's frozen here on out if I want more children), I don't think I'd have trouble producing more eggs in spite of my age (not too far from 40) b/c egg production isn't one of my issues.

HTH as least a little.

GL!!

[RunnerDuck]

As I understand it... you won't go through your eggs more quickly by using injectables. Every month when you ovulate normally you don't just use one egg - your ovaries actually have several follicles that begin to grow. Then one of them wins the race and that is the one that actually releases a mature egg. I *think* that injectables simply causes more eggs to mature, not more eggs to be used - I think the ones that don't mature in a normal cycle just die off anyway. I could be wrong about that but that is my understanding.

But you are wise to think about and be concerned about multiples... before you get pregnant is the time to research and discuss that possibility.

[YummyYarnAddict]

Originally Posted by RunnerDuck

As I understand it... you won't go through your eggs more quickly by using injectables. Every month when you ovulate normally you don't just use one egg - your ovaries actually have several follicles that begin to grow. Then one of them wins the race and that is the one that actually releases a mature egg. I *think* that injectables simply causes more eggs to mature, not more eggs to be used - I think the ones that don't mature in a normal cycle just die off anyway. I could be wrong about that but that is my understanding.

But you are wise to think about and be concerned about multiples... before you get pregnant is the time to research and discuss that possibility.

Actually, the eggs that are matured w/an injectible cycle are "usually" released when triggered (which is usually done with an injection of hcg) which is why the risk of multiples is, in fact, higher when using injectibles -- more mature eggs are released therefore more can be fertilized. And oftentimes even eggs that aren't mature are released as well, especially if you're talking instances where a lot of eggs are released/retrieved. For example, with my first IVF cycle, I had 21 eggs retrieved and all 21 were mature. That was unusual. With my 2nd fresh IVF cycle, 17 were retrieved and only something like 6 were mature (I'd have to look at my notes, I'm doing this off the top of my head right now, but I'm pretty sure it was only 6). With my third fresh IVF cycle, only 4 of the 15 retrieved were mature. With my fourth fresh IVF cycle, 26 of the 34 retrieved were mature and that was actually highly unusual, as they were expecting only about half to be mature given my age and u/s (my e2 was very high when I triggered).

[leerypolyp]

YummyYarnAddict gave a great synopsis.

In short, you don't have to worry about "using up" all your eggs -- you have literally thousands of potential eggs.

Any good RE will refuse to trigger in a cycle in which you have too many mature follicles -- risk of multiples, and risk of OHSS (ovarian hyperstimulation syndrome). Also, your RE will be doing regular U/S along the way to see how many follicles are developing, and fine-tune your medications.

[RunnerDuck]

Originally Posted by YummyYarnAddict

Actually, the eggs that are matured w/an injectible cycle are "usually" released when triggered (which is usually done with an injection of hcg) which is why the risk of multiples is, in fact, higher when using injectibles -- more mature eggs are released therefore more can be fertilized. And oftentimes even eggs that aren't mature are released as well, especially if you're talking instances where a lot of eggs are released/retrieved. For example, with my first IVF cycle, I had 21 eggs retrieved and all 21 were mature. That was unusual. With my 2nd fresh IVF cycle, 17 were retrieved and only something like 6 were mature (I'd have to look at my notes, I'm doing this off the top of my head right now, but I'm pretty sure it was only 6). With my third fresh IVF cycle, only 4 of the 15 retrieved were mature. With my fourth fresh IVF cycle, 26 of the 34 retrieved were mature and that was actually highly unusual, as they were expecting only about half to be mature given my age and u/s (my e2 was very high when I triggered).

I think I was confusing when I said "more eggs to be used" maybe? I didn't mean you don't release all the eggs - you do. But you don't actually go through any more eggs than you would in a "normal" cycle.

In a normal cycle lets say your body starts working on 10 follicles... but only one wins the race. So one follicle ruptures and 9 die off - can't be used again. But with injectables all 10 would rupture and release eggs, which may or may not be mature.

Either way, you "lose" 10 eggs that cycle. (I'm just picking the number 10 out of the air here - how many follicles start to grow on any cycle varies widely)

Isn't that right?

With IVF generally you will get more eggs because of different medications and a different set of risks (ie eggs will be fertilized outside the body, not in, so multiples can be controlled for and huge numbers of eggs are not a problem from that standpoint, although there is still a risk of OHSS)

Most doctors it seems have a limit for how many follies you will be allowed to trigger with... but I was allowed to trigger with 10 follies, got pregnant with triplets, got scared into reducing to twins - which is why I say to be sure you know your stance on that beforehand. I always thought triplets would be great but I didn't *really* know all my facts and my husband and I never really discussed it because that would never happen, right? Wrong. (I also had OHSS and was in the hospital for a few days)

[kristenok18]

Did you say the your RE counted at least 15 follicles on each ovary? Was this a cd12 scan, and was this cycle using fertility meds? Were they decent sized follicles, or of varying sizes?

[RunnerDuck]

Originally Posted by kristenok18

Did you say the your RE counted at least 15 follicles on each ovary? Was this a cd12 scan, and was this cycle using fertility meds? Were they decent sized follicles, or of varying sizes?

I am assuming she meant antral follicles, which is like all the little baby follicles you have at the start of a cycle which MIGHT respond to treatment...

[jazcat]

You gals ROCK!!!! What a smart and informative group...so glad I found this place. I'm feeling a lot better now about not "wasting" eggs, but the idea of triplets, or even twins scares the heck out of me.

The scan they did was on CD20, 5DPO, and it was a clomid-only cycle. Would clomid create more follicles, thus throwing off the true scan result? Yeah, it was "at least 15" on each side.

I think I know the answer to this question, but just in case....there's no way to tell whether I have less than perfect eggs besides retrieving them and looking at them under a microscope, right?

[kristenok18]

One way my clinic judges is by checking the estradiol levels. I haven't gone the IVF route (and won't, since it's financially inaccessible to us), but I have a blood draw once they confirm there is a nice looking follicle, and they look at that before deciding whether or not to continue with the trigger and iui. I also have pcos (poly cystic ovary syndrome), and clomid was not good to me. Left my ovaries covered with cysts that required me to take a ttc-break for 6mo. I'm currently using femara, and our next leap is injectables, if I haven't thrown in the towel by then (3.5yrs of ttc#2 is consuming my life!!!).

There is another thread right now about FSH levels, which might give an indication as to egg quality?

[jazcat]

I'm sorry clomid did that to you...what a pain to have to wait 6 months, on top of 3.5 years! Have you looked into IVF abroad?

My FSH and estroidial numbers were "good" - est=50 and fsh=5.1. I will look for that FSH thread.

[YummyYarnAddict]

Originally Posted by jazcat

You gals ROCK!!!! What a smart and informative group...so glad I found this place. I'm feeling a lot better now about not "wasting" eggs, but the idea of triplets, or even twins scares the heck out of me.

The scan they did was on CD20, 5DPO, and it was a clomid-only cycle. Would clomid create more follicles, thus throwing off the true scan result? Yeah, it was "at least 15" on each side.

I think I know the answer to this question, but just in case....there's no way to tell whether I have less than perfect eggs besides retrieving them and looking at them under a microscope, right?

There are a few tests out there that can help give docs a clue about egg quality, but the only real way to tell is for them to look at them. A test can't tell them the texture of your eggs, what the shell looks like, etc. etc. A test might give a clue as to what your ovarian reserve is and even those tests aren't foolproof, but as for quality, THE test is actually looking at your eggs under a microscope. (And, technically, even then... the most definitive test is testing the DNA of that egg which is something they can't tell under the microscope because sometmes "pretty" eggs are chromosomally challenged.)

ETA: Clomid can do all sorts of wonky things, especially if you have PCOS or any other similar issues. Also, it's entirely possible to have a lot of follicles that do not contain eggs.

[YummyYarnAddict]

Originally Posted by kristenok18

One way my clinic judges is by checking the estradiol levels. I haven't gone the IVF route (and won't, since it's financially inaccessible to us), but I have a blood draw once they confirm there is a nice looking follicle, and they look at that before deciding whether or not to continue with the trigger and iui. I also have pcos (poly cystic ovary syndrome), and clomid was not good to me. Left my ovaries covered with cysts that required me to take a ttc-break for 6mo. I'm currently using femara, and our next leap is injectables, if I haven't thrown in the towel by then (3.5yrs of ttc#2 is consuming my life!!!).

There is another thread right now about FSH levels, which might give an indication as to egg quality?

Estradiol (e2) levels are an imperfect measurement of follicular development. It's possible to have a high e2 level and low number of eggs and/or follicles and, conversely, possible to have a relatively high number of eggs and low e2. In theory, you have a certain e2 level per mature egg (off the top of my head I think it's something like 200-250/mature egg), but it's certainly not foolproof. Furthermore, there's a wide variance per woman, per cycle, and per lab. Also, some women get OHSS at a much lower e2 level than others do. You really have to have the ultrasound monitoring in conjunction with the e2 measurements. You can have two women from the same clinic who have the exact same e2 levels with a totally different follicular development. That's not theory, it's practice.

FSH levels are more indicative of ovarian reserve than egg quality. A newer test which is still in the "beta" stage -- inhibin B -- is supposed to be a better test of egg quality.

[allisonrose]

pg mentioned

Injectables definitely don't guarantee multiples. I'm pg from my first injectable cycle. I had two mature follies with a couple lagging behind before the IUI and an ultrasound at nearly 7 weeks along showed just one bean in there.

[jazcat]

Congratulations! Yeah, I know it's not guaranteed. But I have no reason to believe it wouldn't increase my chances by at least double, if there were 2 follicles. At this point I'm thinking our issue is with the sperm. When we do go to IUI, I think we'll do it unmedicated, or maybe with just Clomid or a progesterone supplement. At least the first IUI

Did you have any probable "diagnosis" before your IUI?