Treatment for Women Over 35
Joe Massey, MD
November 3, 2004
The opinions expressed herein are the guest's alone. If you have questions about your health, you should consult your personal physician. This chat is meant for informational purposes only. The following chat transcript has been edited.
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[RESOLVE] Hello to everyone who has joined us this evening! RESOLVE's chat on Treatment for Women Over 35 is being hosted by Joseph Massey, MD, well-known Reproductive Endocrinologist with Reproductive Biology Associates (RBA) in Atlanta, GA. Dr. Massey established RBA, the first in vitro fertilization program in Georgia, with a colleague in 1983. We are thrilled he has agreed to share his extensive expertise with us this.
[Nancy] I just turned 43. I had one cancelled IVF due to not enough follicles. I started this cycle with being on birth control pills for 19 days. I'm now on Microdose Lupron, Gonal F 600, and 75 iu repronex. My last ultrasound, after 3 days on stimulation drugs and 5 days on lupron, showed 4 follicles (10-12 in size) but on 22 estrogen. I am going tomorrow for a second ultrasound and they may cancel IVF if my estrogen does not go up significantly. Should I be on a different protocol? I feel as though the lupron and birth control pills are suppressing me too much.
[Dr. Joe Massey] Nancy, you are on beyond the maximum dose that could be effective. It would appear that the ability of the ovaries to respond has been accurately tested. I would not recommend a third protocol in this situation.
[Art C.] My wife and I have gone through 3 Inuit's last year. At that time her FSH was 3. We took a year off to build a house and recently resumed trying. Currently she is 35 and her FSH has increased to 9 and her doctor now refused any new tries and has recommended egg donation or adoption. Is level 9 really too high to expect success? Another consideration is that she underwent a very successful kidney transplant 5 years ago and is currently in good health.
[Dr. Joe Massey] Art C, No, 9 is not too high. It is within normal limits, unless there is something I don't know about the specific laboratory. Results vary between labs, but I have never heard of anyone been turned down for 9. It's definitely worth another try. You may consider a second opinion.
[Birdie] Dr. Joe: I'm approaching 38. What Assisted Reproductive Technologies are the most effective for a woman my age?
[Dr. Joe Massey] Birdie, even at age 38 most people will try ovulation induction and IUI before IVF. As long as your hormones are otherwise normal, try IUI first then IVF. The average age of people doing IVF is 36-37, so 38 is not so daunting.
[Lee] I am 36 and have been through 4 IUI's with clomid, 2 IUI's with clomid and repronex and 1 IUI with just repronex. I have had all the standard tests with no problems detected, however my HSG was assumed normal but indicated "limited technical ability." I have had a "great response on paper" but always end up with a negative pregnancy test. My diagnosis is unexplained. We are planning to move on to IVF but I was wondering about whether I should do a laparoscopy to rule out any issues before proceeding to IVF. I realize IVF bypasses the tubes but could I have some undiagnosed issue that may impact implantation. I am self pay for IVF so want to be certain there are no problems before we proceed. Any recommendations what to do in my situation?
[Dr. Joe Massey] Lee, I generally feel laparoscopies should not be abandoned. It is good to check for possible Endometriosis. You should discuss this with your doctor.
[DHill3] I'm 39. I had one pregnancy that ended in a miscarriage. We are ready to try again. My doctor says that Clomid would not be effective at my age. Do you have experience using Clomid with "older women"?
[Dr. Joe Massey] DHill3, Generally Clomiphene is less effective than Gonadotropin in IUIs, but if you are willing to be patient, it can be tried in high doses for a couple of months. It's a judgment call to discuss with your physician.
[RESOLVE] RESOLVE's Family Building magazine, Winter 2003 and Autumn/NIAW 2004 issues, feature articles written on a similar subject. Please contact the RESOLVE HelpLine, 888-623-0744 or info@resolve.org, for more information.
[Forty-Six] I'm, you guessed it, 46 years old and had my first child, naturally, at age 41. After 3 miscarriages, and several attempts at IUI and one IVF attempt, it looks like my only option now is egg donation. I, of course, would prefer my own DNA over egg donation. I know a few babies have been born using cytoplasmic transfer. Is anyone anywhere doing this?? I realize federal funding was halted. Thanks!
[Dr. Joe Massey] Forty-Six, no one in the world is doing that right now.
[Lisa Mcorlito] I'm 35 and have Cushing's disease...Is it safe for me to get pregnant?
[Dr. Joe Massey] Lisa Mcorlito, you will need to be closely monitored by an endocrinologist.
[Lisa Mcorlito] I was told by my endocrinologist that it wasn't safe for me to try and get pregnant because of the high levels of cortisol...have you known anyone with Cushing's at my age to have children?
[Dr. Joe Massey] Lisa Mcorlito, I don't know your specific situation and do not know of a case myself. If you have an adrenal disease your endocrinologist may be right, but I would still seek a second opinion about your specific situation.
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[KLiC] I'm 37, with endometriosis, and debating between IVF and adoption. I'm not sure how to make the decision, do you have any recommendations?
[Dr. Joe Massey] KLiC, endometriosis is one of the most common causes of infertility. I would be in favor of attempting to conceive with In Vitro and use adoption as a backup. Don't give up. You are only at the average age for the In Vitro population.
[Lara] Further to Dr. Joe's response to Birdie. How many months of IUI do you recommend before going to IVF? My age is 37.
[Dr. Joe Massey] Lara, the most conservative approach would be 3 clomiphene and IUI cycles followed by 3 Gonadotropin and IUI cycles. This should give more pregnancies than one In Vitro attempt. It is a judgment call on whether you go that long with IUI. At least 40% of people at your age would conceive with this approach.
[lmhunt] I have a high FSH level and am 36. Do you recommend testing to see if the level goes down or is one test enough to establish ones fertility odds?
[Dr. Joe Massey] lmhunt, the general rule is that if an FSH level is elevated, the patient is at risk for low ovarian reserve. But this does not spell the end for everyone. The numbers are just the numbers and the ultimate test is the response to ovarian stimulation and the outcome. Don't give up if your FSH is just slightly elevated. If your FSH is over 20, that is a very dark cloud. Numbers between 10-20 are a gray zone. The higher they go, the darker the gray. Again, they are just warning signs and not necessarily the end of the line.
[LNewby] In June we went through our first IVF cycle. At 39, we have now gone through 5 IUIs and then the one IVF. We conceived via IVF however were unsuccessful at sustaining our pregnancy at 9 weeks. We have 2 "frozen" embryos left which we are scheduled to have transferred next week. What is the probability of successfully thawing these embryos and having them still viable for transfer? Is it promising for us?
[Dr. Joe Massey] LNewby, typically it's about half of the success rates for frozen. But it is easy and should be tried. Most IVF couples have remaining embryos for a decent try for later success.
[sobrien2] I am 35 and have had 3 laparoscopies and myomectomy-all for cysts and fibroids. I have already had one miscarriage in 2002 and haven't been able to get pregnant since. My last laparoscopy was October 27th and everything was stuck together-tubes, ovaries, and colon. This has been going on for two years now. What should my next step be: IUI or IVF? My laboratory results are all within normal limits for me and my husband. Any thoughts would be appreciated.
[Dr. Joe Massey] sobrien2, IVF. IUI does not work when the tubes are abnormal.
[Birdie] Dr Joe: What is the percentage of conception rates for IVF, ZIFT and GIFT for women 37-40? Are these techniques widely available?
[Dr. Joe Massey] Birdie, GIFT and ZIFT are not better than IVF in good centers. GIFT and ZIFT are out of style. Take home baby rates for IVF in the late 30's range around 35-40% in good centers. Do your homework. Be sure your center is reporting rates like this to SART. Your RESOLVE chapter can help you find this information.
[Kristina] I am 41 years old I am on both repronex and gonal and lupron and have no follicles developing??? What is happening? It is my first try.
[Dr. Joe Massey] Kristina, 20% of all IVF cycles are canceled. At least half of those can do better in another cycle with a different drug protocol and at a different month of the patient's life. Sometimes it's because they didn't get the "right" drug for the specific person. But sometimes it can vary from month to month. Don't give up. Ask your doctor what to try next.
[DHill3] Thank you for your recommendation to me on Clomid. I have another question. I've heard of women using Clomid with Femara. I thought Femara was a breast cancer drug. Are you familiar with this treatment? Are there non-injectectables that can be taken with Clomid to increase its effectiveness?
[Dr. Joe Massey] DHill3, there is a class of drugs called aromatase inhibitors. Tamoxifen and letrozole, which are used for breast cancer, are now emerging as useful in ovulation induction. There is no published data on Femara and Clomiphene. Some people are using a new class of drugs instead of Clomiphene. I think the combination makes some sense, but there is no published data. Some doctors have experience with this, but I have not. I have tried letrozole and it has the advantage of better endometrial lining than clomiphene in some patients, but I have never used the combination myself.
[Guest] I am 37. I had 6 cycles of IVF; two fresh and four frozen. I got pregnant once with twins but miscarried at 16 weeks, no reason found. I had another result in a cervical ectopic, but survived after embollization and three injections of methotrexate. I had an EFT done at Yale and that came back normal. Both my tubes are blocked. Other than that, I stimulate very well and have produced a lot of good eggs. We are at a loss, but want to try again. I am healthy otherwise. Is there any specific test that you could recommend? Thank you.
[Dr. Joe Massey] Guest, the only thing I can suggest is Preimplantation Genetics Diagnosis (PGD) during In Vitro Fertilization. Many older patients have failed pregnancy losses and miscarriages because of genetic errors in their eggs in this age group. This is the biggest problem that can not be overcome in some people. Some women, age 37, have PGD and find 50% of their embryos are abnormal genetically. Most of this is due to the age of their eggs. In some people with terrible stories like yours, we find 75-90% of their embryos have identifiable errors in the chromosomes of their embryos. This is only after very complex tests which reveal 80% of possible abnormalities in the major chromosomes. If it turns out that you are in that category, and I hope not, your best hope would be egg donor even though you are making lots of eggs. Find a center where PGD can be done. It is not readily available everywhere.
[s-ny] I am 45. I have had two failed IVF's, each had 3-4 blastocysts transferred and am now on my 3rd IVF. I did PGD and resulted in 4 A+ embryo's transferred, I also did an IVIG just in case there were any issues and also did acupuncture 3 times. If I do not get pregnant this time, what other possible issues could there be?
[Dr. Joe Massey] s-ny, there's only one issue and that is the age of the eggs. Across the country and around the world, there are very few patients that have babies from IVF at the age of 45 with their own eggs. Even though embryos look good, even after PGD, there are chromosomes that can be either missing or broken with pieces missing, resulting in lack of further development. Most people in your shoes would be seriously considering egg donation. Once you're pregnant with an egg donor (50-60% success) you will be smiling instead of frustrated.
[kharber] I'm 35 and finally became pregnant after five months of 200 mg of clomid, only to find out the pregnancy was tubal. What are the odds of another tubal? One doctor has suggested we go straight to IVF to bypass the tubes. Another doctor has suggested I try the clomid again.
[Dr. Joe Massey] kharber, if the other tube was normal at surgery and is open on x-ray, the IUI could be attempted again and ectopic risk would be higher than normal. However, 80-90% of most pregnancies would be in the uterus, not in the tube.
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[Carmen] Hi, I'll be 40 this month. Our second IVF result was negative as of yesterday. My FSH is low, good embryos, each time, and 4 of A quality. Everything seems to go better than expected. My question is, severe endometriosis was found and treated with laser 1 Â? years ago. Endometriosis was removed from my gallbladder, uterus, bladder, but there is still some on my liver. My first doctor spoke of a second laparoscopy within a year. My IVF doctor has not directly addressed the endometriosis, but treated it with lupron during cycles. Each time I've had bad cramping or sharp pains with sudden movement over my ovaries, could either of these two be prohibiting implantatation?
[Dr. Joe Massey] Carmen, I think Lupron therapy for three months makes more sense than another operation to me. Your symptoms of pain won't cause implantation failure. Pain like that sounds more like adhesions than endometriosis itself.
[RESOLVE] Last question Dr. Joe GA
[Sabrina] What is the oldest age a person can be for IVF with donor eggs?
[Dr. Joe Massey] Sabrina, the answer to this question is largely philosophical. Most clinics cut this off somewhere in the mid fifties. I hope you don't want to challenge the world record, which is age 62.
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[RESOLVE] Dr. Joe GA, do you have any final thoughts or suggestions you would like to pass on to women over 35 who are seeking infertility treatment?
[Dr. Joe Massey] RESOLVE, the questions indicate that we have a very educated group of patients in the chat room who are being cared for by knowledgeable physicians. Many of the medical problems that exist, which cause infertility, are simply compounded by age, but almost everyone is in the same situation. There are practically no 25 year olds in our infertility clinic. So don't despair if you are in your upper 30's. At the same time, realize it gets very rough when you pass 40. Keep an open mind and always remember if age itself or ovarian reserve become problems for you, then donor egg would dramatically increase your odds of successful pregnancy.
[RESOLVE] Dr. Massey, thank you for your time and ongoing support of RESOLVE and your dedication to this family building issue. We also send a special thank you to everyone for your participation and all of your great questions.
[RESOLVE] Providing the chat on Treatment for Women Over 35, hosted by Joe Massey, MD, has been our pleasure. We hope you have found this information to be helpful. If you have further questions, please contact the RESOLVE Helpline at 888-623-0744, Monday through Friday, 9am-12pm 1pm-4pm ET and Monday evenings from 7pm-10pm ET.
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