August 22nd, 2011-WTF appointment with Lizzie

Me: Lizzie, we are very upset.   We don’t understand why we had such a low and horrible response after being on birth control pills for 2 weeks and then coming off of BCP’s and 2 days later beginning to take both menopur and follistim daily for 14 days.  This is way longer and far more drugs than last time and we actually made LESS mature eggs, had a LOWER fertilization rate and had LESS embryos than when we came off of a natural cycle and just FSH stimmed for 12 days last October.  We were expecting since this was a PLANNED IVF cycle-it wasn’t an IUI conversion cycle like our first time- that we would have made twice the eggs.  You said our goal was 20 follicles so we would have enough embryos to make paying for PGS worth the money-we just don’t understand how we could have fallen so far short with only 8 mature follicles after all of that-what went wrong??

Lizzie: YOU are a very unpredictable patient to stimulate.  Sometimes this just happens.

Meanwhile….across town, Dr. Sher is writing this memo for his blog:

Birth Control Pill Prior to IVF – Detrimental or Beneficial?

By Geoffrey Sher, MD
Executive Medical Director, Sher Fertility Institutes

Various sources have stated that it is not a good idea to take birth control pills before IVF – or before starting controlled ovarian stimulation (COS) in a cycle of IVF.  The reason quoted is that it can suppress the development of ovarian follicles, prolong the stimulation regimen, and negatively impact egg/embryo quality.  This is only half of the story and therefore renders this line of reasoning incorrect.

It is a fact that if a woman goes directly from Birth Control Pills to ovarian stimulation without overlapping the last several days on the pill with a GnRH agonist (GnRHa) such as Lupron, Nafarelin, or Buserelin, this can negatively affect the stimulation. However, if GnRHa is given for the last 4-6 days on the Pill prior to beginning COS with gonadotropins, this will NOT be the case. Let me explain why:

Toward the end of a natural ovulation cycle, beginning several days prior to menstruation, the corpus luteum (the structure that produces estrogen and progesterone after ovulation) starts to fail.  At the same time, blood levels of follicle stimulating hormone (FSH) begin to rise, which triggers the final process of egg recruitment and antral follicle development.  Absent this FSH triggering, egg and follicle preparation are more likely to be compromised.

The mechanism of action of the birth control pill (BCP) is through suppression of FSH release by the pituitary gland, blocking ovulation and preventing formation of the corpus luteum.

The problem occurs when a woman is on BCP and immediately begins ovarian stimulation upon menstruation following discontinuation of the pill.  In this case, she would be initiating the stimulation without allowing the process of egg recruitment and antral follicle development to be completed.  As a result, follicular response to the stimulation will usually be delayed and blunted. In the process, follicle and egg development are often compromised, and the length of the ovarian stimulation cycle is prolonged significantly.  This helps to explain why there is a perception that the birth control pill can be detrimental to IVF outcome.  In reality, it is only the case when ovarian stimulation is initiated immediately following discontinuation of the pill.

In my opinion, it is not only acceptable, but even desirable to take the birth control pill for at least one cycle prior to starting ovarian stimulation for in vitro fertilization.  This allows the patient to better plan and time her IVF treatment.

Additionally, since the birth control pill also suppresses LH, it can be very helpful in older women, in those with diminished ovarian reserve, and in those with Polycystic Ovarian Syndrome (PCOS).  In the latter, high LH levels can negatively impact egg/embryo quality).
The bottom line is that the use of a birth control pill to prepare for an IVF cycle should always be overlapped with a GnRHa for several days before ovarian stimulation begins. If this is done, the pill will NOT suppress or compromise response to COH.

Fuck you Lizze.

I can’t believe you blamed ME!  Seriously?  Im an unpredictable patient to stimulate??

Fuck you.