Cooper IVF: we build families and foster dreams.  Your success is our success...

Cooper Institute for Reproductive Hormonal Disorders, P.C.

A fascinating look at two case studies from the Cooper Institute archives…

Dr. Check looks back on a couple of his favorite cases...

Case Study One

 

A woman came to us for consultation from Israel.  She had six years of treatment for her obvious problem of not ovulating (she did not get menstrual periods on her own) but had everything corrected with fertility drugs, progesterone support after ovulation, and intrauterine insemination for 6 years.  She had four laparoscopies and everything was perfectly normal but she did not conceive.  She never did IVF because she could not afford it.

 

In a bittersweet turn of events, this patient inherited enough money to pursue IVF.  She made an appointment first with one of the foremost IVF centers in the United States, but she failed to conceive after two IVF-ET cycles.  She then tried another renowned IVF center in England and failed again to conceive after two more IVF-ET cycles.  She then tried one of the best IVF centers in Israel and they actually transferred back into her 12 embryos at a time!!  But she still failed to conceive after a total of six IVF-ET cycles in Israel.  Thus she had a total of 92 embryos transferred over 10 IVF-ET cycles, the equivalent of 46 failed IVF cycles if one considers transferring two at a time.

 

She next came to see us at Cooper because of our reputation of solving difficult cases.  She conceived on our first IVF-ET attempt!  What did we do different?  Well, we were aware that the fertility drugs, e.g., clomiphene citrate, menopur, bravell, gonal-F and follistim sometimes may create an adverse uterine environment even in women with normal egg reserve (i.e., normal day 3 serum FSH).¹   So we purposely did not transfer fresh any of the 27 embryos but cryopreserved them all.  She conceived the first time we thawed some embryos and transferred five embryos back on day 3.  She delivered a single healthy live baby.²

 

To save the woman a trip back to the USA to have another frozen embryo transfer (we had 20 left) we suggested that she try metformin to try to induce ovulation without fertility drugs.  We advised her that some patients with polycystic ovaries (PCO) will spontaneously ovulate after a delivery.  In either case we advised the use of progesterone supplementation after ovulation.  She returned at age 40 for another frozen ET.  She did in fact have nine regular menstrual cycles starting three months after delivery.  However she forgot to take her progesterone.  We calculated that she was three days after ovulation so she would have to wait another month to transfer the frozen-thawed embryos because she was not in synchrony.  So we added progesterone to her treatment protocol.

 

She conceived and delivered a healthy baby.³

Case Study Two

 

Another woman, a physician in Belgrade, Serbia, gave up her job and took a research position in a nearby US medical school so she could be treated at our facility.  Though only in her 30’s, she had marked diminished egg reserve approaching menopause.  She went to Spain for two donor egg cycles, but failed to conceive.  However, because she never achieved an endometrial thickness of greater than 4mm despite high dose estrogen replacement, they told her in Spain they would not do any more donor egg cycles with her; only if she would use a gestation carrier (i.e., another woman to carry the baby).

 

Because of our work in reversing menopause and making women ovulate and techniques we invented for achieving pregnancies despite marked diminished egg reserve and because of our publications on endometrial thickness and our willingness to treat women with diminished thickness (though we agree a thin endometrium does reduce the chance of pregnancy – but not impossible), she requested that we induce ovulation despite the diminished egg reserve using the mild ovarian stimulation protocol needed for achieving good pregnancy rates when women have high day 3 serum FSH.  We then performed IVF-ET with intracytoplasmic sperm injection (ICSI) (one sperm carefully injected into each egg) because of a male factor problem.

 

We did not have any great tricks to offer her at that time to increase the endometrial thickness  (we are investigating a new method at this time to improve endometrial thickness).⁴  Nevertheless it is not unprecedented to achieve a pregnancy with a 4mm endometrial thickness since there has been one case report of a successful pregnancy with IVF-ET with a maximum 4mm thickness and we published a success without IVF-ET with a maximum 4mm thickness.⁵.

 

We did explain the odds of success based on thickness, not on diminished oocyte reserve, would be low.  Nevertheless, of most importance to her was carrying and delivering a baby herself and she wanted to take a chance.  We were willing to give her that chance even though failure could lower our published pregnancy rates with IVF-ET in the Society for Assisted Reproductive Technology, i.e., SART.  We care more about people’s wants and needs than pregnancy rates!!  Actually she did not lower our pregnancy rates.

 

Though she failed to conceive after the first IVF-ET cycle with a 4mm endometrial thickness, she was very successful on her second attempt despite a peak endometrial thickness of only 3.6mm.⁶

 

Her baby’s picture is still on the corkboard outside of our embryology lab.