Hi Dr. Sher,

I’ve been through 8 IVF cycles with two separate clinics. Overall, despite changes to protocols, I’ve encountered the same issues. The first issue is that, though my ovaries produce a good number of oocytes, not enough of them are mature. The second issue is that very few of them seem to make it to day 5 blastocysts. There is no MFI. I’m wondering if you could help recommend a protocol. Below are details of how it’s gone overall:

Total results of all cycles (***doesn’t include Cycle 1)
138 oocytes retrieved
93 mature oocytes (67%)
73 fertilized (78%)
16 blastocysts (22%)
6 euploids (37.5% transferrable)
If including 1 low risk mosaic (44% transferrable)
If including 4 high risk mosaic (69% transferrable)

The reason why I didn’t include results of our first cycle is because our first cycle was a standard short protocol. At the time, although I was 34 and showed an AMH of 4.3, only a few follicles responded to stims very quickly, resulting in a stim period of 2-3 days before retrieval. We did prep for this particular cycle with birth control (which I’ve not taken since this cycle). Because we had these issues with synchronization, neither clinic I worked with prescribed the short protocol with me again. Every cycle since then has been the long protocol, which for me meant I was started on 10ml of Lupron for 7-10 days prior to my period which I continued it through stim at 5 ml until HCG trigger.

By the way, I have been diagnosed with PCOS before, though I am lean and some doctors seem to think I don’t have it. I’ve always been an “on the fence” case. However, my high AMH, poor egg quality, oily skin, and sugar cravings convinces me I do.

Anyway, doctors have basically had 3 separate approaches to stims with me, all of which are long protocol. They are:
1) what I’d call “Normal” – 150iu of FSH + 150 iu of menopur a day (usually 8 days) until hcg trigger.
2) what I’d call “low LH” – 300iu of FSH for 4 days, then 150 iu of FSH + 150 iu of menopur for 4 days until hcg trigger
3) what I’d call “high LH” – 300iu of menopur (actually it wasn’t menopur but some kind of stim with a lot of LH) until hcg trigger

Below are the outcomes of the 3 different stim protocols:

Normal Stim Outcomes (3 cycles, 34 & 35 yo)
77 oocytes retrieved
41 mature (53%)
31 fertilized (76%)
8 blastocysts (26%)
3 euploids (37.5% transferrable)
If including 1 low risk mosaic (50% transferrable)
If including 2 high risk mosaic (62.5% transferrable)

Low LH Stim Outcomes (2 cycles, 35 & 37 yo):
50 oocytes
34 mature (68%)
28 fertilized (82%)
7 blastocysts (25%)
2 euploid (28.5% transferrable)
If including 2 high risk mosaics (57% transferrable)

High LH Stim Outcome (1 cycle, 37 yo):
24 retrieved
? mature (guess is 17-18 mature, so maybe 70%)
14 fertilized (78%)
1 blastocyst (7%)
1 euploid (100% transferrable)

As you can see, there doesn’t seem to be much difference between the “Normal” and the “Low LH” stim protocols. BUT, the one time the doctor prescribed a ton of LH in the effort to increase maturity rates in the “High LH”, there was an increase in mature eggs, but a huge decrease in egg quality. Clearly, though we only have a data set of one, a lot of LH seems to have a negative impact on egg quality, which is consistent with PCOS patients. Furthermore, though you can’t see this in the data I’ve included above, the BEST blastocysts I had was on a “Low LH” protocol. I had 2 euploids, one of which was AA and the other AB. Every other embryo I’ve ever had has been about BB, including all euploids.

Also one more thing – all hcg triggers have been 5000 iu except once I was given 10,000 iu. This was on my second IVF cycle when I was prescribed less stim dosage and only produced 10 oocytes. However, of the 10, 8 were mature, 5 were fertilized, and eventually only 1 went into blastocyst stage and came back euploid. This is only one data set but it makes me wonder if the high HCG dose was responsible for the higher maturity rate, or if that happened because my ovaries had less eggs to handle at the time.

Anyway, from what I’m seeing, I think the key takeaways are that LH seems to have a negative impact on me, but I struggle with maturity rates. I’m wondering if you think doing stim with only FSH and ending with a high HCG dose at the end would help? Would prepping for IVF with birth control in conjunction with Lupron help?

I’m very curious to know. You’re the only doc I’ve ever seen online that has explained the connection between LH and egg quality. None of my REs ever mentioned this.

Thank you so much for your time.