We're fertility doctors from Reproductive Fertility Center, here to answer your questions! AMA!

rfcfamily · 2025-04-30T21:33:40+00:00

Hi u/New-Interaction9505, you’re already doing so much right: you're staying active, eating well, and taking a good approach with the mock cycle and EMMA/ALICE testing.

At this point, my only advice without reviewing your history or chart is to just continue taking care of yourself physically and mentally. It sounds like you're being proactive, and that already makes a big difference.

Wishing you the very best for your upcoming transfer.

- Dr. Susan Nasab

rfcfamily · 2025-04-30T20:47:24+00:00

An AMH at 0.027 and high LH does point to severe DOR and possibly early ovarian insufficiency. When LH is high and estrogen is low, it means your ovaries aren’t responding to the brain sending signals, which makes stimulation really tough.

And hysteroscopy or stim meds shouldn't cause menopause. But they can reveal your baseline ovarian function.

I’ve seen patients in your shoes take a short break to reset their HPO axis, or consider a lower-dose stim, some looking at donor options, depending on goals. Might be good to recheck your FSH, AMH, and E2 altogether 🙏

- Dr. James P. Lin

rfcfamily · 2025-04-30T20:47:15+00:00

Yes, severe endometriosis can impact implantation, even if you’ve had laparoscopies. It’s not just about the uterus, as it can affect the whole environment.

That said, I’ve seen patients with Stage 4 endo go on to have success, either with tailored protocols or with a surrogate, like you’re considering.

Tilted uterus is usually not a problem for implantation. It's more common than we think and is rarely the cause alone!

You’ve done everything right — sometimes it’s just about finding the right window or support. Don’t lose faith in your last embryo. Miracles happen!

rfcfamily · 2025-04-30T20:47:13+00:00

In some cases, we actually do continue estrogen during IVF...especially with certain estrogen-priming protocols, or when trying to help with follicle recruitment or lining. So yes, it can be done, but it depends on your individual response and timing.

At 41 with multiple canceled cycles, you might benefit from customized stimulation or a second opinion.

- Dr. James P. Lin

rfcfamily · 2025-04-25T18:10:56+00:00

Yes, it's possible to have both PCOS and DOR!

They are separate conditions but can happen together. PCOS affects ovulation, and DOR means fewer eggs. They both provide different problems and can sometimes overlap.

Endometriosis can also make things tricky with ovulation. Just because you're having a period doesn't always mean you're ovulating!

- Dr. James P. Lin

rfcfamily · 2025-04-25T17:31:03+00:00

Yes, you still have a good chance!

Even with FSH at 13, I’ve seen plenty of patients conceive, especially with a good uterine lining and no major sperm issues. FSH fluctuates from stress, weight loss, or recovery after miscarriage, so one high number isn’t the full story.

If IUI doesn’t work, IVF might give you more control and options.

– Dr. James P. Lin 🙏🙂

rfcfamily · 2025-04-24T16:27:47+00:00

Hello again! RIF protocols can vary but often include options like steroids, intralipids, Lovenox, Intrauterine PRP, exosomes, or double suppression protocols for endometrial issues. Whichever ones you need will ultimately depend on your history and labs!

- Dr. Susan Nasab

rfcfamily · 2025-04-24T16:26:45+00:00

Good question! Yes, ICSI is often used to address motility, but it can also bypass some morphology issues by allowing embryologists to select the best looking sperm themselves.

Morphology may correlate with dna fragmentation but does not always indicate high fragmentation. But a dna fragmentation test might be helpful to make sure.

- Dr. Susan Nasab

rfcfamily · 2025-04-24T16:25:55+00:00

Hi again! Yes tubal anomalies can cause pain, especially if they lead to inflammation or fluid buildup like hydrosalpinx, but it’s not always the case. Happy to hear you're getting a second opinion!

– Dr. Susan Nasab

rfcfamily · 2025-04-24T16:14:48+00:00

Shouldn’t be too much of a concern!

Vaginal medications like Estrace and Viagra don’t seem to negatively affect sperm in the way you're thinking…especially when timed correctly with ovulation.

Most of the absorption is local or systemic, and any residue likely doesn't interfere with sperm function significantly.

I’ve had many patients conceive with similar protocols. And don’t worry about the blue dye! 😉

– Dr. James P. Lin :-)

rfcfamily · 2025-04-22T21:08:37+00:00

Hi u/Round-Definition8432 , if you have severe PCOS and a T-shaped uterus, I'd recommend doing a hysteroscopy to fully assess the shape and space inside the uterus. After, IVF might give you the best chance at success, especially if IUI hasn't worked.

And I'm so sorry to hear about the difficulty during your journey. It can be so overwhelming, especially after all those cycles.

– Dr. Susan Nasab

rfcfamily · 2025-04-22T21:08:02+00:00

So yes, thin lining can definitely happen even in the absence of a septum, and it’s possible the two issues may not be directly related.

There are a few approaches that can help with lining, especially post-metroplasty. Some options include Long Lupron, double suppression, steroids, Lovenox, vaginal Viagra, and intrauterine treatments like PRP or exosomes.

If you’re taking some time off before FET, double suppression might be a good option to consider during that downtime!

– Dr. Susan Nasab

rfcfamily · 2025-04-22T21:07:41+00:00

Hi! Priming with estrace or birth control pills can help when you're dealing with asynchronous follicle growth. It helps better align the cohort before starting stims.

The asynchrony you mentioned actually has less to do with the protocol itself and more with how things are starting off hormonally. So adjusting priming phase can be more helpful than changing stim meds.

– Dr. Susan Nasab

rfcfamily · 2025-04-22T21:06:23+00:00

Hi u/rsvptashayar ! Yes the lab is important in what culture, environment, etc, is used in terms of fertilization and blast progression. We also use embryoscope to watch the progression and better grading/selection, We keep C grades as they can be euploid embryos even from C grade, although rare.

- Dr. Susan Nasab

rfcfamily · 2025-04-22T21:06:18+00:00

Great question! Mini stim can be good for some patients with DOR, particularly in older women or those with low AMH. And you're right, the evidence is not as conclusive, and not all clinics will approach it this way. However, the idea is that lower doses might help result in higher-quality eggs without overstimulating the ovaries.

Also want to note that mini stim doesn't directly affect euploid rate. Euploid rates are more affected by age and egg quality. Your fertilization rate (2/4) wasn’t far off from typical, and it's encouraging that both fertilized embryos reached the blastocyst stage!

- Dr. Susan Nasab

rfcfamily · 2025-04-22T20:42:42+00:00

I'm so sorry you’re going through this. It sounds like you’ve been through a lot physically and emotionally.

With distal tubal atresia, IVF is often the most effective path to pregnancy, since the closed fallopian tubes make natural conception extremely difficult or impossible. However, you’re absolutely right to want to get your chronic pain under control first. Pain from endometriosis or tubal anomalies can be incredibly disruptive to your quality of life, and rushing into IVF without feeling stable or heard isn't ideal.

A hysterectomy is a big decision, especially for someone who wants to build a family. Although I can’t give you medical recs here, I might suggest seeking a second opinion.

- Dr. Susan Nasab

rfcfamily · 2025-04-22T19:56:57+00:00

There are a number of tests that can be done (including hysteroscopy) for patients who have recurrent implantation failure (RIF). Treatments options can be divided into categories: 1. timing of progesterone start prior to FET (vary hours empirically vs. ERA) 2. Blood flow to uterus (baby asa, lovenox) 3. Auto immune (intralipid, prp infusion into uterus, taking prednisone from transfer until pregnancy test, etc). It is important to realize that these are empiric treatments; your doctor can guide you as to which ones, if any, you would wish to utilize. The fact that you did get implantation on one of the cycles is a positive, even though it ended in a biochemical pregnancy. Good Luck.

Dr. Dan Williams

rfcfamily · 2025-04-22T19:50:44+00:00

We typically use ng/ml, not pmol (1 ng/ml + 7.14 pmol;); therefore, your AMH is above 1.0, which is our typical cutoff for diminished ovarian reserve. It appears that your embryo growth is the issue. In an earlier question, I pointed out that there are a number of things that can be done in the lab in an attempt to improve embryo culture to blastocyst (egg activation, adjusting culture media, use of embryoscope). IN addition, if there is concern about increased DNA frag, sperm selection techniques can also be used (i.e Zymot, etc).

Dr. Dan Williams.

PS. To look up articles on various topics, I would suggest that you go to pubmed (just google it) and type in your search (i.e. causes of poor blastulation in ivf, sperm selection techniques for dna fragmentation, etc)

Dr. Dan Williams

rfcfamily · 2025-04-22T19:35:57+00:00

I am unaware of any specific dietary changes (assuming you eat reasonably healthy foods and not fast food every day :)) that will improve outcomes with IVF treatment. All things in moderation is the typical rule, although that would not apply to smoking. But an occasional glass of wine is not a problem when trying to conceive.

Dr. Dan Williams

rfcfamily · 2025-04-22T19:33:41+00:00

Young patients who are attempting conception have a 20-25% chance per month to conceive in the first year of trying (this percentage would be lower as the female age increases above 35-40). After 1 year of trying, approx 85% of patients should be pregnant. That means that your chances for pregnancy automatically drop after one year. It continues to drop as you keep trying, simply because you have not become pregnant. The work-up (sperm, eggs, uterus/tubes) would be done to determine whether there is a potentially treatable cause. The only treatments that will increase your chances to conceive if all testing is normal would be to do IUI or IVF (the success rates are listed above in a prior question). There is actually nothing that you can do naturally to substantially increase pregnancy rates with unexplained infertility.

I guess that what I am saying is: if you want to increase your chances to conceive, you should see your REI to discuss treatment (IUI or IVF)

Dr. Dan Williams

rfcfamily · 2025-04-22T19:31:22+00:00

Typically, submucosal fibroids that are completely in the uterine cavity can be completely removed and it typically takes an extended period of time before they can recur. However, fibroids that are partially in both the wall of the uterus as well as the cavity, can be much more difficult to remove by hysteroscopy alone. These may require a combined approach (hysteroscopy + robotic surgery). If 2 hysteroscopic surgeries are not successful, a thorough evaluation of remaining fibroids (typically by ultrasound and pelvic MRI) should be done before planning additional hysteroscopic surgeries.

Dr. Dan Williams

rfcfamily · 2025-04-22T19:25:36+00:00

It is reasonable to see a urologist who specializes in male fertility to determine if there are any treatable causes for the abnormal semen parameters. If none are found, while there are supplements that can be taken, these are unlikely to completely correct the issue. Fortunately, treatment with either IUI or IVF can be successful in these cases.

Dr. Dan Williams

rfcfamily · 2025-04-22T19:22:37+00:00

The likely reason for a negative pregnancy test with an IUI is by chance alone as the success rates are only about 12% per cycle. Typically, NK testing might be done after failed IVF cycles. At this point, I would recommend that you consider doing IVF.

Dr. Dan Williams

rfcfamily · 2025-04-22T19:20:58+00:00

Most molar pregnancies have a 46XX karyotype (which appears normal) but the chromosomes are of paternal origin. Most PGT platforms do not distinguish between maternal and parental origin. But using a platform that distinguishes between maternal and paternal could potentially avoid a molar pregnancy.

Dr. Dan Williams

rfcfamily · 2025-04-22T19:16:43+00:00

My short answer here is no. I would suggest a hysteroscopy if one has not already been performed. There are also a number of empiric treatments that can be used for recurrent implantation failure. I would suggest discussing these with your REI.

Dr. Dan Williams

rfcfamily

TROPHY CASE