IVF # 5 – Trigger Day 2 !! – The 411

baby - novarel trigger

Today, my day started off kinda rocky.  The hotel called last night and arranged for a car service to come and pick me up at 10:15 am to take me to my fertility clinic.  At 10:30, I was still awaiting their arrival and I was supposed to BE at CNY at 10:30 am.  I was LIVID!  One thing that irks me is waiting for people.  I am PAYING you, you are not transporting me for free.  The driver arrives and explains that he was told to run someone up the street to Hertz.  I of course checked him and then moved on.  He got me to the clinic in 5 minutes LOL.

I went in CNY Fertility Center and Spa- Albany and did my intralipid infusion of two bags of intralipids and I hung out with my nurse, Kimmy.  We took a few selfies and chatted for two hours.  I absolutely LOVE my nurses, Kimmy, Stacy, and Aileen !  They are the most down to Earth, calming spirits.  That is a good thing when you are going through such a trying time.

After I finished my intralipids, the clinic called a cab for me and then I came back to my hotel, ate some lunch and then watched my soap operas and the Real before getting concierge to take me grocery shopping.  I did my shopping and came back in and made a nice juicy burger for dinner since I did not feel like going to the mall.

My ovaries feel ridiculously inflated and I am a bit uncomfortable.  It will only get worse tonight after my double trigger shot.  But I hope this pushes my follicles right to the edge and all the eggs in there mature and are ripe for the picking in the morning when they put me on that table !

I just lathered my backside with Emla cream to numb the area I am going to do the IM injection of the Novarel at 9:30 pm.  I want to go to sleep, but the film crew will arrive at 11:30 – 12 so I will probably lightly sleep until then so I can greet them when they come in.

I am very tired, but also excited about what possibility tomorrow can bring !  I am claiming this to be MY cycle !  I am claiming that my eggs WILL be mature and they WILL fertilize and I will more eggs than I need for Tuesdays transfer and will have a few to freeze for another time.

I am hoping and praying for 10 or more eggs. Putting that out there in the universe and whispering it into the ears of God !  If He wants to give me more than 10 dynamic eggs and wants to give me 14 or 15, hey, I am not arguing !  lol

Thanks to you all for your prayers, your concern, and for sticking this out with me.  You all mean so much to me !  xoxo

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IVF #4 – Trigger Two – The 411

Twas the night before Retrieval…….

baby - bravery socks ivf 4

I arrived in Albany this morning, went to my hotel, checked in, had the concierge take my mom and I to Cheesecake Factory for lunch, then we came back to the suite and unpacked.  One great thing about being a repeat customer, the entire staff knows me and my film crew and they also give me the best suites in the house !  This time, they gave us a two bedroom suite.  I love that this hotel has a full kitchen in every suite.  It makes for healthier eating because I can cook what I want to eat.  The hotel served a full hot breakfast every day and serves a nice full course dinner Monday thru Thursday nights.

After getting unpacked, I put on my “bravery socks” that were sent to me by my Canadian sock buddy.  I love the double pink !!! Twin girls?

baby - baby dust

I have my baby dust that my sock buddy gave me as well.  I have taken it to all of my appointments and I have it here with me for good luck.

Tonight, I will do my double trigger of 10,000 Novarel.  Last night, I did the injection intramuscular since I have read that the HCG is more concentrated in the blood when done IM as opposed to Sub-Q (which can be affected by body weight and body fat).  I am debating if I should do a Sub-q injection for the second trigger. I have until 10:30pm to make up my mind.  The doctor’s office always gives Sub-q instructions.

baby - novarel trigger

In the morning, I have to be at the fertility clinic at 8:30 am so that I can check in and then go to acupuncture prior to the procedure.  I am praying that this double trigger coupled with the adding of HGH will help me produce mature quality eggs that will fertilize.  I will be asking my doctor in the morning about doing regular fertilization first and then converting to ICSI if it is possible for me to have a higher fertilization rate.  The fertilization also depends on egg maturation and quality as well.

Wish me luck !  Send up prayers !  Thanks for the support 🙂

IVF #4 – Trigger Day 1 – The 411

baby - novarel trigger

I went in for monitoring this morning and the nurse called after getting my sono results.  I have 6 large follicles and 14 other smaller ones.  They decided to do my first trigger tonight of 10,000 Novarel and then another trigger tomorrow night of 10,000 Novarel and my egg retrieval will be on Saturday, unless something weird happens with my blood work, which was not in at the system as of yet this morning.  Since the nurse has not called back, and my blood work should have posted by now, I am leaving on the 4 am with my mother to Manhattan and then taking the 8 am connecting to Albany !

I am nervous that I have so many smaller follicles, but hoping that I have more than just six eggs in there. I am doing a double trigger to try to help mature the eggs before retrieval so this double dosage should do something, right?

I am not looking forward to the -1 temps in Upstate NY, but am glad to be getting this show on the road.

Please keep me and these eggs in your thoughts and prayers.  THIS IS MY CYCLE !!!

IVF – Double Trigger – The 411

baby - trigger shot

** Credit:  http://www.ovarianresearch.com

Co-administration of GnRH-agonist and hCG for final oocyte maturation (double trigger) in patients with low number of oocytes retrieved per number of preovulatory follicles-a preliminary report

Abstract

Background

Recently, the co-administration of GnRH agonist and hCG for final oocyte maturation- 40 and 34 hours prior to OPU, respectively (double trigger) was suggested as the treatment of genuine empty follicle syndrome. In the present study, we aim to evaluate whether the double trigger improves the number of oocytes retrieved in patients with low (<50%) number of oocytes retrieved per number of preovulatory follicles.

Methods

In this proof of concept cohort historical study, we compared the stimulation characteristics of 8 IVF cycles, which include the double trigger to the patients’ previous IVF attempt, triggered with hCG-only.

Results

Patients who received the double trigger (study group) had a significantly higher number of oocytes retrieved, number of 2PN, number of embryos transferred and significantly higher proportions of the number of oocytes retrieved to the number of follicles >10 mm and >14 mm in diameter on day of hCG administration, with a tendency toward a higher number of TQE, as compared to their previous cycles (hCG-only trigger). Three ongoing clinical pregnancies were recorded in the study group and none in the hCG-only trigger group.

Conclusions

Co-administration of GnRH-agonist and hCG for final oocyte maturation, 40 and 34 hours prior to OPU, respectively (double trigger), is suggested as a valuable new tool in the armamentarium for treating patients with low/poor oocytes yield despite an apparently normal follicular development and E2 levels and in the presence of optimal hCG levels on the day of OPU.

Keywords:

Oocytes retrieval; GnRH-antagonist; hCG; GnRH-agonist; Final oocyte maturation; IVF outcome

Background

Controlled ovarian hyperstimulation (COH) is considered a key factor in the success of in vitro fertilization-embryo transfer (IVF-ET) because it enables the recruitment of multiple healthy fertilizable oocytes [1]. Moreover, human chorionic gonadotropin (hCG) is usually used at the end of COH, as a surrogate LH surge, to induce final oocyte maturation and resumption of meiosis [2].

Lack of oocyte yield during ovum pick-up (OPU), following COH with an apparently normal follicular development and E2 levels and in the presence of optimal hCG levels on the day of OPU- the genuine empty follicle syndrome (EFS) [3], is a rare entity, with an estimated prevalence of 0–1.1% [4,5]. On the other hand, a more frequently encountered situation is the normally responding patients with a low oocytes yield, i.e. a low ratio (<50%) between the number of oocytes retrieved to the number of follicles >14 mm in diameter on the day of hCG administration.

Despite many years of clinical experience [6], the underlying mechanism of the aforementioned conditions is still obscure and no precise prevention methods exist [5]. Several strategies were offered to patients with EFS [summarized in [5]], including another standard ART cycle; shifting from an GnRH-agonist to GnRH-antagonist COH protocol; re-administering hCG from a different batch and aspirating the second ovary; changing the hCG from a urinary to a recombinant preparation; using GnRH-agonist for final; prolonging the interval between ovulation triggering and OPU; and follicle flushing during oocyte retrieval [7].

Recently, a new treatment modality has been clinically implemented to EFS patient, with the co-administration of GnRH agonist and hCG for final oocyte maturation- 40 and 34 hours prior to OPU, respectively (double trigger) [5]. This method combines the advantage of both: (1) the prolongation of the time between ovulation triggering and OPU; and (2) the GnRH agonist trigger with the consequent simultaneous induction of an FSH surge.

Prompted by this new remedy, we offered the double trigger to all our patients, who underwent the GnRH-antagonist COH protocol, resulting with poor oocytes yield due to low (<50%) number of oocytes retrieved per number of follicles > 14 mm in diameter on day of hCG administration. In the present study, we aim to further evaluate whether the double trigger improves the number of oocytes retrieved and the ratio between the number of oocytes retrieved per number of follicles > 14 mm in diameter on day of hCG administration.

Methods

All consecutive patients with poor oocytes yield, despite normal response to COH, due to low (<50%) number of oocytes retrieved per number of follicles > 14 mm in diameter on day of hCG administration, who were treated in our IVF unit during one year period were evaluated. Of whom, only those who received in the subsequent IVF cycle, a double trigger (GnRH-agonist and hCG) for final follicular maturation were included. The study was approved by the Institutional Research Ethics Board of our center.

All patients underwent the multi-dose GnRH-antagonist COH protocol during both IVF cycles. In both cycles, ovulation induction was performed by the administration of recombinant FSH, started at the 2nd or 3rd day of menses, using the same starting dose in each patient. Once the leading follicle had reached a size of 13 mm, or/and E2 levels exceeded 1200 pmol/L, co-treatment with the GnRH antagonist 0.25 mg/day, was initiated and the recombinant FSH was substituted by human menopausal gonadotropins. Gonadotropins doses were further adjusted according to serum estradiol levels and vaginal ultrasound measurements of follicular diameter, obtained every two or three days. Final follicular maturation was triggered by, either:

(1) In the first IVF cycles: recombinant hCG (Choriogonadotropin alfa, ovitrelle 250 mcg, Serono), 36 hours prior to OPU, or; (2) In subsequent cycles: the co-administration of GnRH-agonist (Triptorelin acetate, decapeptyl 0.2 mg, Ferring Pharmaceuticals, Israel) and recombinant hCG (250 mcg), 40 and 34 hours prior to oocyte retrieval, respectively.

Routine IVF or intracytoplasmic sperm injection (ICSI) was then performed, as appropriate. Transvaginal ET was performed 48 to 72 hours after OPU in both cycles. All patients received luteal support with progesterone.

Data on patient age and infertility-treatment-related variables were collected from the files. Ovarian stimulation characteristics, number of follicles >10 mm and >14 mm in diameter on day of hCG administration, number of oocytes retrieved, embryo quality and number of embryos transferred were assessed and compared between the study (double trigger) cycle and the previous (hCG-only trigger) control cycle.

Embryos classification was based on the individual embryo scoring parameters according to pre-established definitions [8]. While a top quality embryo (TQE) was defined as seven or more blastomeres on day 3, equally-sized blastomeres and <20% fragmentation, poor quality embryos consist of all the rest. Clinical pregnancy was defined as visualization of a gestational sac and fetal cardiac activity on transvaginal ultrasound.

Statistical analysis was performed with Student’s paired t-test and chi square, as appropriate. Results are presented as means ± standard deviations; p value < 0.05 was considered significant.

Results

Eight consecutive patients were evaluated. Mean age and body mass index during the study cycle were 38.0 ± 4.8 years and 27.7 + 5.4 kg/m2, respectively. The clinical characteristics of the IVF cycles in the two study cycles are shown in Table 1.

Table 1. Comparison between IVF cycles with hCG versus double trigger (GnRH-ag + hCG)

In the present study, while using the same COH protocols which differ only in the methods of triggering final follicular maturation, as expected, no differences were observed between the groups in the length of stimulation, the number of gonadotropin ampoules administered, peak estradiol and progesterone levels and numbers of follicles >10 mm and >14 mm in diameter on day of hCG administration. However, patients who received the double trigger (study group) had a significantly higher number of oocytes retrieved (7.0 ± 4.6 vs. 2.3 ± 2.5, p < 0.02), number of 2PN (6.0 ± 4.6 vs. 1.7 ± 1.2, p < 0.002), number of embryos transferred (2.2 ± 0.7 vs. 0.85 ± 0.9, p < 0.002) and significantly higher proportions of the number of oocytes retrieved to the number of follicles >10 mm (80.3% ±31.1% vs. 18.5% ± 16.6%, p < 0.001) and >14 mm in diameter (118.0% ± 71.2% vs. 23.7% ± 21.5%, p < 0.01) on day of hCG administration, with a tendency toward a higher number of TQE (3.7 ± 0.8 vs. 0.4 ± 0.5, p = 0.06) respectively, as compared to the hCG-only trigger cycles.

Five pregnancies were recorded in the study group and none in the hCG-only trigger group (Table 1). Of which, 3 are ongoing, one resulted in a blighted ovum and one was biochemical pregnancy.

Discussion

In the present preliminary cohort historical study, the co-administration of GnRH agonist and hCG for final oocyte maturation- 40 and 34 hours prior to OPU, respectively, to patients with poor oocytes yield due to low (<50%) number of oocytes retrieved per number of follicles > 14 mm in diameter on day of hCG administration, resulted in significantly higher numbers of oocytes’ retrieved and embryos transferred and a significantly higher proportion of the number of oocytes’ retrieved to number of preovulatory follicles. Of notice, the observed improved in oocyte yield was despite a non-significant decrease in the number of follicles of >14 mm and >10 mm on day of hCG administration.

Five biochemical (positive hCG) pregnancies were recorded in the study group (double trigger) and none in the hCG-only trigger group. Of which, 3 (37.5%) are ongoing and one resulted in a blighted ovum. However, it should be emphasized that the increased pregnancy rate in the study group (double trigger) is biased due to the study design which offered this protocol to patients who had failed a previous IVF attempt.

As part of a standard/conventional COH regimen, final oocyte maturation and resumption of meiosis are usually triggered by one bolus of hCG (5000–10,000 units), that is administered as close as possible to the time of ovulation (i.e. 36 hours before oocyte recovery) [2]. In 1990, Gonen et al. [9] have demonstrated that ovulation may be also triggered by GnRH agonist, causing the release of both endogenous LH and FSH, while in 2008, Shapiro et al. [10] have established the concept of ‘Dual trigger’, combining both hCG and GnRH-agonists, aiming to trigger ovulation with the questionable ability to prevent severe ovarian hyperstimulation syndrome [11,12].

Recently, Beck-Fruchter et al. [5] have described a case of recurrent empty follicle syndrome, successfully treated by ovulation trigger with GnRH agonist 40 hours and hCG added 34 hours prior to OPU. They assumed that by prolonging the time between ovulation triggering and OPU and the GnRH agonist trigger with the consequent simultaneous induction of an FSH surge, the “double trigger” could overcome any existing impairments in granulosa cell function, oocyte meiotic maturation or cumulus expansion, resulting in successful aspiration of mature oocytes, pregnancy and delivery.

In the present preliminary report, we further extended the aforementioned indications to the “double trigger” and offered it to patients with poor oocytes yield due to low (<50%) number of oocytes retrieved per number of follicles > 14 mm in diameter on day of hCG administration, despite an apparently normal follicular development and E2 levels during COH. While number of follicles of >14 mm and >10 mm on day of hCG administration wwere non-significantly decrease, we could demonstrate a significant increase in oocytes yield, a trend toward a higher number of TQE, with a reasonable clinical pregnancy rate. These observations are in agreement with Lin et al. [13], who compared the IVF outcome of normal responders, undergoing triggering of final oocyte maturation with either hCG and GnRH-agonist, both administered 35-36 hours prior to OPU, or hCG-only. The double trigger group demonstrated statistically significantly higher implantation, clinical pregnancy and live-birth rates as compared with the hCG trigger group.

Conclusions

“Double trigger” is suggested as a valuable new tool in the armamentarium for treating patients with low/poor oocytes yield, despite an apparently normal follicular development and E2 levels and in the presence of optimal hCG levels on the day of OPU. Further large prospective studies are needed to elucidate the aforementioned recommendation in this and other situations, such as patients with high proportion of immature oocytes or poor responder patients, prior to its routine implementation.

Abbreviations

COH: Controlled ovarian hyperstimulation; EFS: Empty follicle syndrome; hCG: Human chorionic gonadotropin; IVF-ET: In vitro fertilization-embryo transfer; OPU: Ovum pick-up; TQE: Top quality embryo.

IVF #3 – Trigger Day !!! – The 411

baby - ivf 3 trigger day

This morning I went in for my last monitoring appointment !  My ovaries are FULL.   Most of my follicles are 25 now so I definitely have the bloat thing going on lol.  My E2 is now 1800 which is good and is higher that it was my first cycle when I had 12 eggs.

My nurse called this afternoon while I was packing and gave me my trigger instructions and instructions for the next day and morning of retrieval.

I called the car service and made arrangements for them to pick me up tomorrow and drop me to my hotel and I will also have them take me to Walmart to go grocery shop for my week in Albany.

I packed all my stuff and am shipping my clothing and some must have food items to the hotel for early am delivery.  I did not feel like lugging a huge bag with me.  I can now put my laptop in my carry on bag and my meds that I will need.

I contacted the local infusion center to set up my weekly intralipid infusions.  They are contacting my doctor’s office to get all the info and forms needed.

I am beyond worn out !  Every time I have to travel somewhere, I am always running around like mad trying to get ready and making sure I don’t leave anything.  Now I have to go hunt down my heating pad that I loaned my mom.

My best friends, both of whom are pregnant, should be delivering soon.  One had a baby shower this weekend, and I completely forgot about it.  I had planned to be gone to Albany already so I was to miss it anyway.  My other bestie is due on November 6th, my late father’s bday.  Hopefully all this baby stuff will rub off on me 🙂

I hope everyone else is doing well !

Trigger Shot Day, Baseline Appointment – The 411

Trigger Shot Day, Baseline Appointment - The 411

This morning, I had an appointment with my NYC RE, Dr. Singer. Everyone in the office is extremely excited about my progress. I did blood work and my E2 is 1496 and the progesterone is 1.7. During the ultrasound, I saw a ton of follicles and most were in the 20mm + range. All of the smaller ones are around 10mm.

Dr. Singer said everything looked good and for me to discontinue the Lovenox so that I would not bleed out during the procedure.

I got a call from the fertility clinic with instructions to trigger tonight at exactly 9pm.

My egg retrieval is scheduled for Thursday morning. I am exhausted so we are leaving for Albany in the wee hours so that I can get some rest. My film production crew will be coming in on Thursday morning a few hours before the procedure and the entire event will be filmed.

Is It Okay To Completely Freak Out?

Is It Okay To Completely Freak Out?

Okay- So over the past week I have been searching like a mad woman for the perfect donor. I FINALLY found one I like after talking to a geneticist who had IVF using donor sperm who is on a forum I am on.

I got my medication list and quote from my doctor and I seriously in shock that the meds cost MORE than my IVF procedure. I figured with the discount my meds would be $1500 or less but they cost is over $3500 ! WOW ! There goes my favorite stroller and an over the top but on a budget nursery 🙂

The ladies on the forum suggested I call my OB GYN’s office and ask is they have samples of GonalF450, Menopur150, Lupron, HCG Trigger Shot, Estrace, and Cronone Gel 8% and to also inquire if any patients have donated unused meds for the use of other patients who are having IVF.

I am trying to stay calm but all of this is a bit overwhelming. It is hard enough that I am now at PLAN B but now these little surprises are starting to weigh on me. I guess that is what life is… the unexpected and we just have to make it work.