# Failed last cycle. where do I go from here??



## FolicAcidIngester (Mar 23, 2012)

I’m in my 40s and had a son early last year as a result of my first IVF attempt (long flare agonist protocol). I’ve just tried another IVF cycle and it was unsuccessful. It was a short flare agonist protocol. Although there were 5/6 antral follicles, only two follicles were of a decent size during the whole monitoring phase, two eggs were retrieved, both of good quality, both fertilised and both were put back (although they messed about a bit about the timing here and I hope to God it wasn’t to prevent them having to come in on a Sunday). Anyhows, my period came on day 9 post-transfer, so as they say it was a BFN. Also during the monitoring phase my oestradiol levels weren’t great but adequate and uterine thickness only came up to par towards the end of stimulation
What do you think is my next step ladies?
I think I’m right in saying that fertilisation isn’t the problem, just egg quantity and implantation…Is this right
I’m thinking of asking them to leave out the down-regulating phase as I understand this can turn the ovaries off a bit especially if they’re already old and knackered like mine and it can be hard to revive them during the subsequent stimulation..or at least I think this is the gist of it.
Might refusing down regulating help?
What about an antagonist protocol?
What about an oestrogen priming protocol?
I definitely want to have the endometrial scratch and I might ask for longer progesterone supplementation post-transfer as even with my son, I bled for 6 weeks during that pregnancy and would like some more early support should I be lucky enough to get pregnant again.

What is your take on where I should target my efforts in the next attempt based on this failure?
Due to my age the clinic told me from the outset that they’d only agree to 2 cycles so the next one is my last one. I don’t want to do a blunderbust method, change too many things and throw everything at it (somethings would probably end up cancelling each other out), but I do want an amended strategy, based on reason, for the next try, so that I can feel confident that it makes sense & stacks up and that I've thought about it.

Any advice welcome, TIA


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## Bax (Feb 25, 2015)

Hi - I can see you've had some advice on other threads, but I didn't want to read and run.

From my experience (I'm 43) I respond much better to the down regulated cycles - I got far fewer eggs and poorer quality in the short cycles.  I wouldn't worry too much about your ovaries being sluggish to recover - you need to focus on the next cycle and not count yourself out before you've even started 

I've just had a follow-up with my clinic and they have suggested oestrogen support post transfer, and also supplementing the cyclogest pessaries with gestane injections.  I tend to bleed before OTD and so we think it's looking more and more like an implanation issue (I knew this right from the start - 5 cycles and 2 years ago!!)

Definately all of these issues are to be discussed with your clinic.  Good luck, wherever you decide to go x


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## FolicAcidIngester (Mar 23, 2012)

Thank you Bax, I thought I was going to be Billy no-mates with no replies. I've attended the review appointment with my clinic and it wasn't really satisfactory. They just said I was lucky to get 2 follicles at my age and to try again using the same protocol but that I need to be realistic (ie that it is unlikely to be successful at my age - which I get - but I want them to try a little harder. As I said, if I was younger I might put the failed cycle down to bad luck, but since this is my last cycle in the UK and probably my last own egg cycle, I think everybody needs to think of ways to optimise the success of the treatment. At the minute it sounds a bit like *they're* counting _me_ out before I've started...and with their pessimism I'm in danger of doing that too. So I don't know whether I'm throwing my money and precious time down the drain with them and I should jump ship possibly to serum - or I should cycle again with them. I'm not in the market for a multiple pregnancy and at the minute this is the inly thing putting me off Serum.
As regards the current clinic, I've suggested the scratch (which they'll do) and progesterone supplementation with both cyclogest pessaries and gestane injections (which they're thinking about and which I note you're getting). I've not heard of oestrogen support post-transfer. I also bled this time before OTD, I wonder what the rationale is...don't look this up if it's not to hand, just wondering aloud.

They say there'd be no obvious benefit to the antagonist protocol for me and that it is usually used for OHSS not poor responders
I asked about oestrogen priming but they hadn't heard of it.

I'm having a telephone consultation with the Lister in a couple of weeks so I can also see what they suggest.

I've made quite a few changes to my diet and reinstitued exercise (which I was doing when I got my BFP with my son) and I'm taking a few supplements (DHEA, Coenzyme Q10, Inositol).

Where you on clexane or aspirin or anything like that?

Sorry to hear about your June cycle, it's really gutting I know and you have to process so much complex information and try to be assertive in difficult consultations that the whole thing is stressful. Are you going again?

Thank you so much for not reading and running, I appreciate it


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## CrazyHorse (May 8, 2014)

Hi, FAI, at your age you are very unlikely to have multiples with OE, even if you have 2-3 embryos put back. This is why I had 2 OE embryos put back shortly after my 41st birthday, although my preference has always been for a singleton. (Now pregnant with singleton.)

I would suggest trying a cycle of mild IVF, which is what worked for me in the end. I was on 2.5 mg letrozole twice/day and 75 iu Menopur once /day, stimmed with these for 8 days (as compared to 18 on my long protocol cycle); no GnRH agonist or antagonist except for two doses of Cetrotide near the end, to make sure no follicles popped before EC. The embryo quality was significantly better than we'd ever gotten before, and I firmly believe that was down to lower dose and duration of stims. It's also worth noting that I got more eggs than on any of the high-dose stim protocols used previously, and that I had virtually no side effects from the drugs.

Like you, I did better on long than short protocol in terms of numbers of mature follicles, but traditional long protocol (i.e., downreg with GnRH agonist and continue it through stims, rather than the flare protocol downregging on BCP and then adding in GnRH agonist) gave me 2 out of 3 embryos with multinucleation -- I think the 18 days of stims really messed up my egg quality, which is a big deal when you're 40 or older.

I did this mild IVF cycle at Reprofit; they treat a lot of older ladies, and are pretty flexible about progesterone support and immunes treatment with prednisone and intralipids. 

Wishing you lots of luck, however you decide to proceed.


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## FolicAcidIngester (Mar 23, 2012)

Thanks Crazyhorse...a Neil Young fan by any chance?? I was going to put Zeke (Neil Young's son's name) as one of my son's second names but I got to 3 (second names, that is) and decided it was excessive!

Good to know that I'm unlikely to have multiples with OE, but I'm worried about that prospect if I move to DE which is probably the next stage for me if the next OE trial fails. Might raid the piggybank and go for another OE cycle with Serum but don't want too much financial stress either.

I'm interested in protocols which increase the number of eggs, if that's possible at my age, so will suggest a mild IVF cycle to them.  Although I'm concerned I'll get a "dunno anything about it/we don't do that here' response from them. I feel a bit guilty about being critical of them, because they're a very nice team and very well organised but just not that into individualising your treatment if you're over-the-hill, as I am. Trouble is, I don't fully feel it!

I'm being a bit of a wuss about the travel thing as my little son isn't that easy to handle on flights and is at the tantrum/kicking stage if things don't go as he expects/wants. I know that is his only way of communicating at the moment so is not a criticism of him at all, he's my numero uno, just a description of what he's like at this stage. I also worry about egg collection abroad and who will look after him when I'm conked out!

Thanks again for replying, I really do appreciate it and it adds to my hope, which as Bax intimated is a must for this kind of enterprise.

I think I'll need another review appointment before proceeding to put some of these options to the team here. Mild stims is definitely on my list of topics to be discussed.

If you are a Neil Young fan, isn't Cowgirl in the Sand epic?! Also many congrats on having you little son on board, what a wonderful time you have ahead xx


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## Altai (Aug 18, 2013)

Folic - I posted a reply to you but it got lost somehow.
I'd echo Crazyhorse that chance of multiples is very low at that age. 
I had 3-4 put in previous cycles and none stuck. 
This cycle I had only 1 embryo transferred and got positive. 

I did the same protocol so called japanese mini ivf - clomid/letrozole/tamixofen combo with low doses of fsh usually 75-100 but I had 100-150 as was going for quantity while hopefully not compromising quality. I tried all combinations. Tamixofen combo worked the best for me. I got more  eggs that with full ivf. 
Letrozole and clomid combos not so much but similar number of eggs as with full ivf. 
And it took me lots of cycles and the battle is not over yet. 

Good luck with your choice

A.


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## CrazyHorse (May 8, 2014)

Haha, FAI    -- not really a Neil Young fan, it was a tip of the hat to my (small amount of) Native American ancestry. My tribe didn't really have any famous warriors, we made the mistake of trying to make treaties with white people instead (and later married them in many cases to try to get a better life for the next generation), so I had to go with a warrior name from another tribe. I'm basically a ******-white person, but one of the reasons I wanted to use my own eggs was that I feel like those Native American genes should get their chance to keep on going.

Anyway, yes, your clinic will give you, I am 99% certain, the "dunno anything about it / we don't do that here / that doesn't sound like it can work with your low AMH" response if/when you bring up mild IVF. To be completely honest, if finances are becoming an issue at this point, and more OE cycles will start eating into your ability to pursue DE, in your shoes I would go straight to DE given your age. But I know it's a hard decision to make.  

Altai, congrats on your BFP! Are things going OK?


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## FolicAcidIngester (Mar 23, 2012)

What a wally about the Neil Young thing...I thought I'd found a kindred spirit/old hippy!

I struggle with the DE issue although less so than I did and in fact I'm really glad it exists as I think it means I can have another child by one means or another. I would like another child for myself, for my son and I would like to carry another pregnancy. I liked the whole business and thought I wasn't too bad at it! And with my little perspective giver holding my hand most days, I'm a fair bit more settled/less anxious a person in myself.

I have enough money for another 2-3 cycles. This next OE one and then the quandary arises if it's not successful of whether to go straight to DE abroad or do a tandem cycle or try to sneak in another OE one. The problem with the latter option would be that if DE IVF didn't work first time I'd be flat out of cash, so it's risky. 

That's all by the by really until I decide on this next cycle. I like the sound of the flexible agonist/antagonist conversion protocol with oestrogen priming a la Geoffrey Sher. I'm gonna try to suggest it to my clinic because otherwise there's a very high probability of it being a failure (as I said above I got 2 eggs the last time but the Dr said he was pressurised into retrieving the second one, so there's a real risk I'll only get one egg) so I want them to apply themselves to doing something about that. I'm gonna have to ask for a 2nd review appointment which I don't think is the norm...but then I don't fancy throwing 6.5 large (w donor sperm) down the drain rather than be a bit more assertive.

Dear me this whole business is stressful!


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