# 3rd cycle, worst ever (IMSI and low AMH. Really really need advice on next steps



## vkv80 (Apr 19, 2013)

Hi Everyone,

This is my first time posting on here, so am very nervous as I have always been a "reader" not a "poster."

Both myself and DH are 35 (soon to be 36!)
DH was diagnosed with a seminoma back in 2012 so had his testicle removed, the remaining testicle isn't working. We froze his sperm before the op, but were told it wasn't great quality. However we were successful on our 2nd ICSI cycle, and our beautiful daughter was born in 2014. She is now 2, and we desperately want a sibling for her.

I also have low AMH (4), which was never mentioned during our previous cycles, but was mentioned when we began ttc #2. We have had 2 failed cycles at Boston Place Clinic (the private arm of Hammersmith hospital where DD was conceived), the 2nd cycle ended in a mmc. We decided to move to another clinic as Boston Place said they wouldn't do anything differently for a 3rd cycle with them.

We have moved to The Lister after meeting them at The Fertility Show, and totally "clicking" with the consultant we spoke to. My consultant asked me to take 75mg DHEA and 300mg Ubiquinol daily in order to improve egg quality, and I did this for over 3 months before starting our cycle in August. It was suggested for us to try IMSI due to poor sperm quality, and the cycle was going so perfectly up until egg collection. Honestly, I have never had such an easy cycle: appointments were on time, the staff were all lovely and informative, and for the first time ever I wasn't vomiting after egg collection (I react to anesthesia so the anesthetist gave me a different mix). We managed to get 5 eggs, which my consultant was very happy with.

4 of these eggs were mature and fertilised using IMSI, we were told they only managed to find grade 2 sperm (grade 1 being the best). By Day 3 we had 2 top quality embryos, 1 that was slightly poor and the 4th that had dropped out. We were asked if we wanted to do a Day 3 transfer and even attended the clinic, but after speaking to the Embryologist and our Consultant, we decided to do a Day 5 transfer as they were super confident that by then we would truly see which was the strongest and the poor one may even do better than the top 2. We were told that if we did a Day 3 transfer then the top 2 would be transferred and the 3rd poor one would be discarded. I think this threw us, it seemed a waste of an embryo, and they were so confident about going to Day 5 and culturing all 3, that we decided to trust them.

Anyway, we got the dreaded call on Day 5 to say that there had been little progression since Day3, and there was no point doing ET that day and to wait another 24 hours to see if they progress. We got the same call on Day6, and ET was cancelled. This is the first time we have not made it to ET. DD was a Day3 transfer as she wasn't the best quality embryo and we only had 2 embryos. I really really wish we had done a Day3 transfer this cycle, I will forever wonder "what if?" and believe it was a risky step to take them to Day5 given that we only had 3 embryos, I am annoyed with The Lister for being so persuasive.

We were completely devastated. This has been our worst cycle yet, despite the DHEA, Ubiquinol and IMSI. We had such high hopes being with The Lister and were so happy with them. My consultant gave me a call and was very nice and sympathetic, she said that there is nothing wrong with my egg quality (given my age) but that the issue is the sperm quality. She did say that they would do exactly the same on another cycle with them and I can go and seek a second opinion before making a decision on what to do next.

We are feeling completely lost, as we really don't want to move to another clinic. We did have a consultation with ARGC before deciding on The Lister, and didn't feel particularly comfortable with the costs, the intensive treatment plan and bootcamp would be difficult to manage with a toddler.

So we would like to stay with The Lister, but are considering having our follow up appointment with another consultant as I have heard good things about Dr Marie Wren and Dr James Nicopoullos (specifically as he specialises in male factor). Does anyone think this is a good idea, to have a follow up with another consultant given that they won't know our history or have been involved in our latest cycle?

Also, we are thinking that a mmc and Day3 arrest is indicative of sperm issues so we also wanted to contact the Andrology department of Hammersmith Hospital as this is where DH's sperm was initially frozen. We are hoping they may have some information on which ampoules contain the best quality sperm. Clutching at straws but we were successful with DD there, so maybe they knew which ampoules to thaw to give us the best chance? DD was straight forward ICSI, so also thinking not to bother with IMSI next time as perhaps the time taken and the strong light were further detrimental to the sperm quality?

Apologies for the long winded post, I just wanted to give you a clear picture of our situation so that hopefully someone can offer some words of wisdom. I really appreciate you taking the time to read this and reply. I would also appreciate any other suggestions you might have for treatment changes if you have been in a similar situation and it worked for you.x


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## Miss Sunshine22 (Mar 12, 2013)

Hi vkv80

I'm so sorry to hear about your cycle    and that you were left with zero to transfer. It is a heartbreaking thing to happen. The same happened to us on our third cycle - we had just one mature egg, fertilised with IMSI. It was my choice to leave it to day 5, as I really do believe that if they don't make it in the lab, they wouldn't make it in the womb either. The embryologist agreed, when I asked if I could delay to day 5. When the embryo didn't make it, he confirmed again that he did not feel it would have developed in the womb and said that I had saved myself a two week wait. Research has also shown that embryos that don't make it to day 5 are by and large chromosomally abnormal.

I know you said that your DD was from a Day 3 transfer of an embie that was not of great quality. In our second cycle, our worst looking day 3 embie went on to become our best of 7 embryos and was frozen on day 6 as a 'very nice blastocyst' according to the embryologist. Based on this, I don't think there is always a correlation between how embryos look on day 3 and on day 5.

As for ways forward, unfortunately, slow growing embryos after day 3 can be a sign of poor sperm quality, so it would be worth investigating this further. 

Sorry again for what you've been through   I hope you find some answers


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## vkv80 (Apr 19, 2013)

Hi Miss Sunshine, thanks for taking the time to reply. I had a follow up appointment last week and it was very informative and realistic, definitely what we needed. James is really nice, and seems to really know his stuff!

Basically as our embryos seems to arrest after Day3, it does indicate a sperm issue. Since we are using my husbands frozen sperm, there really is nothing we can do to improve this. But they can thaw more than one vial in the hope that widening their search will mean they find better sperm. Since we already have 1 child conceived by ICSI, it can work again, but it really is pot luck.

I have low egg reserve and that is what is making this more challenging. They only retrieved 4 mature eggs last cycle, it would be better if we had more quantity to work with as it wouldn't matter as much if we lost a few along the way to Day5, egg quality seems fine. He did say to increase the amount of Ubiquinol I am taking to 300mg twice per day.

He has also suggested to change protocol. Since my DD was conceived in a short antagonist protocol, every cycle since has simply been a repeat of that with variations to the post transfer drugs. James suggested a Microdose Long Protocol using only Menopur rather than Menopur+Gonal F as I have used in the past. This is because Menopur is the more pure form and also contains LH aswell as FSH. So I would down reg with a very low dose of Buserelin for 1 week and then start stimming, this is so that hopefully my follicles will all grow at more similar rates rather than having a few leading and a few lagging follicles. The overall aim is to increase the number of mature eggs at retrieval.

He also said that we need to be realistic and make a decision on whether to keep doing IVF or stop. Since we have now had 3 failed cycles since trying for baby #2, we can't keep doing this emotionally and financially. He said our chances of success are much lower than for other couple our age due to DOR and Poor sperm, around 20%. (We are 36).

We both feel gutted and I've been crying ever since. I think we might give it one last shot and then call it a day if it doesn't work. I desperately hope it does.


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