Physician-To-Physician Consult

Dear Colleagues

29 y.o. trying to conceive 5 years. PCOS olgomenorrhea. Hypertension , gastric banding still obese.
Partner 25 y.o and healthy.
8 cycles of IVF 2 cycles IVM. Sperm analysis in all attempts was: few moving or not moving sperm in HPF
In 2011 during the first attempt pregnancy was achieved but ended in missed abortion. Treated with cytotec to terminate the pregnancy.
7 other consecutive cycles always with ICSI. Fertilization rate 0-30%. Most of the time fertilization by sperm without movements.
Embryos achieved are poor quality.
Can MESA or TESA improve the results?
Any other suggestions?
Dr. Dan Levin MD, Israel

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Answer by John Yovich

Dear Dr Dan Levin
Please fix the man's varicocele using Marc Goldstein technique (sub-inguinal microsurgical).
Post-varicocele, takes 3-4 months to get better sperm (can be worse immediately after varicocele ligation).
Use pentoxifylline to improve sperm prep.
Can use calcium ionophore to improve fertilisation at ICSI.
Can be useful to do split IVF/ICSI to resolve question of spindle damage at ICSI.
What does SCSA or Halo test show; we believe levels >15% DFI are relevant for specific treatment.
Please feed-back info in due course.

John Yovich, Australia

Answer by Norbert Gleicher

Can't make a recommendation until I know her androgens. If she, what would not surprise me, despite her PCOS, has low testosterone, she needs DHEA to raise her T to normal levels before IVF cycle start.
Aside, don't like blastocyst stage culture in marginal oocytes. Would not take her beyond d-3.
Norbert Gleicher, USA

Response: Testosterone total less 0.9 below normal level. Androstenedione within normal range. DHEA Sulphate within normal range, SHBG within normal range

I think she may be what we internally call a "burning out" PCOS (analogy to burning out star!). This means she was a PCOS, likely with high androgens, and now is less of a PCOS functionally with low testosterone. Her ovarian tissues are, however, still "used to" higher T-levels. I, therefore, would put her for 6-8 weeks on DHEA and then restimulate her. Would not be surprised if she will give you better
fertilization. Keep me posted.
Norbert Gleicher, USA

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