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Thursday, January 10, 2013

Why there are so many different ovarian stimulation protocols used in the field of IVF?

Let’s start with the basics. What are ovaries and why do we need to stimulate them for IVF ? Your ovaries are a pair of organs situated in the pelvic region of females, one on each side. They act as the reservoir for our eggs. Eggs are the cells which carry half of the information (genetic blue print) necessary for creating a baby. Such precious egg cells are stored, nourished and protected within specialized structures in ovaries called follicles.  A female foetus at around 18-22 weeks of gestation contains about 2,000,000 follicles in its ovaries and each follicle contains one egg. The follicles which are carrying the eggs are lost continuously (depleted) during the life time of a female and at around menopause only less than 1000 follicles will remain. A woman releases approximately 400 eggs during her lifetime (one egg each month from the time of attaining puberty until reaching menopause). A female ovary carries several immature follicles (and hence several eggs!) but not all the follicles will become mature enough to release a functional egg cell. This means that more than 99.9999 % of the follicles (and hence the eggs) are simply lost.  

What causes the follicles to grow and attain maturity?  


During the start of each menstrual cycle our hypothalamus (a part of our brain) secretes a protein called gonodotrophin releasing hormone (GnRH). This GnRH acts on special cells called gonodotrophs present in the anterior pituitary gland which in turn secretes FSH and LH. FSH and LH are called gonodotropins. Gonodotropins help in the growth of follicles. Follicles which are present in an immature state within the ovary are called primordial follicles. After a woman attains puberty, during the beginning of each menstrual cycle 15 to 20 primordial follicles develop into primary follicles. This process of selecting 15-20 follicles from the thousands of follicles present in the ovary is called the phase of follicular recruitment. These primary follicles grow further and become secondary follicles.  The secondary follicles further develop into antral follicles.  These antral follicles are 2-8 mm in diameter. When a vaginal ultrasound is performed during the initial days of your menstrual cycle (for example on day 3) these antral follicles can be counted and this count gives an indirect measure of your ovarian reserve. Women with high ovarian reserve have high antral follicle counts and women with low ovarian reserve will have a low antral follicle count.  These antral follicles grow in response to FSH. Growing antral follicles will also start secreting estrogen and inhibin which inturn decreases the secretion of FSH from the pituitary gland. Follicles with fewer FSH receptors fail to grow and eventually die (become atretic). The follicle with the most number of FSH receptors grows quickly and becomes a dominant follicle. This dominant follicle carries the egg which will be released during ovulation ; and if all goes well, it will be fertilized by a sperm.

How does ovulation occur in humans?


During each menstrual cycle several follicles start growing in response to the FSH secreted by our anterior pituitary and out of those several recruited follicles only one follicle grows to maturity ( the dominant follicle). The other follicles which fail to reach maturity are lost (die). When a follicle reaches maturity it secretes increasing amounts of estrogen. This rise in estrogen from the dominant follicle triggers the acute rise of another pituitary hormone called Luteinizing hormone (LH). LH helps in the final maturation of the egg present within the follicle, and also causes the follicle to burst, thus resulting in the release of a mature egg. After the release of egg from the follicle , LH also helps in the development of corpus luteum which secretes a hormone called progesterone. Progesterone prepares the endometrium for embryo implantation. During each menstrual cycle , a woman normally female grows only one mature follicle and hence releases only one egg (very rarely 2 or more).

So how do doctors manage to grow several follicles to maturity and retrieve so many eggs during an IVF treatment?


During IVF treatment , the doctor treats you with FSH injections. This huge amount of FSH helps to rescue more of the follicles which were recruited during that particular menstrual cycle. Remember, that in a natural menstrual cycle , only one follicle out of 15-20 recruited follicles grows and becomes mature enough , while the others die. However, during IVF treatment , more of the recruited follicles are grown to maturity (by using high concentrations of FSH) and each mature follicle contains one mature egg . This is the reason why IVF specialists are able to harvest several eggs during an IVF treatment. This is also the reason why IVF treatment will not deplete your ovarian reserve (egg reserve!). The follicles and eggs which would normally have been lost in any case during that particular menstrual cycle are rescued during an IVF cycle. So, during IVF treatment our ovaries are hyperstimulated in a “controlled” manner , thus overriding the natural biological process of the selection of a single dominant follicle in women . ( Remember that this happens routinely in rabbits, who routinely give birth to a litter of rabbits ! This is why they are so fertile. )

Where does the FSH used for IVF treatment come from?


The FSH used in IVF treatment has different brand names like Menogon, Gonal F, Menopur etc.  hMG (human menopausal gonadotrophin) refers to the FSH which is extracted and purified from human menopausal female urine . This is cheaper. Menopur is a highly purified form of hMG and is more expensive than hMG. Gonal F is manufactured using modern recombinant DNA technology and is costlier. But all of them contain the same ingredient FSH and serve the same purpose – helping the growth of follicles. Scientific studies have failed to show the superiority of one FSH preparation over the other. So it is wiser to use the cheaper version of FSH if you are undergoing an IVF treatment.  

Why do some women produce more eggs and some less during an IVF cycle?


To understand this, one must know what ovarian reserve is. Imagine our ovary as an egg bank. Some women have more eggs in their egg bank and hence are able to draw more eggs from it when required (for example, during an IVF cycle) while some women have fewer eggs in their ovaries and hence cannot take withdraw much from it. So the amount of eggs left in a female’s ovary determines her ovarian reserve. But one more important point has to be emphasized when talking about ovarian reserve - egg quality! Just because a women has more eggs it doesn’t mean their quality is good enough to be used for making a much desired baby! If the term ovarian reserve is used to indicate the reproductive capacity of a woman, then ovarian reserve should be defined both by the quantity and quality of eggs present in the ovaries. When a women has both good quantity and good quality eggs , her chance of conceiving a baby is very high. Women who have good ovarian reserve produce more eggs and women who have poor ovarian reserve produce fewer eggs during an IVF treatment. The age of the woman is usually a good indicator of their egg quality. Young women usually produce good quality eggs ; and their egg quality declines as they age.

How will I know whether I have good ovarian reserve?


 There are some tests which can give you an indirect measure of your ovarian reserve.
1)      Blood levels of FSH and E2 (estrogen level) measured on day 3 of your menstrual cycle.
2)      Blood levels of Anti müllerian hormone (AMH) measured on any day of your menstrual cycle.
3)      Vaginal ultrasound to count the number of antral follicles on your ovaries (usually done on day 2 - day 5)
These tests give a quantitative measure of a woman’s ovarian reserve.  The best indicator of a woman’s egg quality is how she actually performs during her IVF cycle – after all, the proof of the pudding is in the eating !

How does controlled ovarian hyperstimulation during an IVF cycle work?


During controlled ovarian hyperstimulation (superovulation) , injectible FSH is used to stimulate the synchronous growth of the follicles which have been recruited during that particular menstrual cycle to maturity. This growth of several follicles at a time causes the estrogen levels to rise and this can trigger a premature LH surge. This LH surge can lead to premature ovulation, which means that the eggs would be lost before they could be collected for fertilization. To avoid this LH surge, GnRH agonists or antagonists are used. GnRH agonists and antagonists suppress the pituitary’s ability to secrete gonodotropins (FSH and LH) , and thus prevent premature surge of LH. Since the LH surge is important for obtaining mature eggs , the doctor uses hCG hormone ( which is similar in structure to LH ) as a trigger (in the form of injection) during the final stages of ovarian stimulation , to induce final maturation of eggs . The mature eggs are retrieved about 36 hours after the hCG trigger is given.  It is very important that you take the hCG trigger at the proper time , so that your doctor can retrieve eggs which are mature enough to be fertilized.

 What is an ovarian stimulation protocol?


 During IVF, certain hormones and drugs (medications) are used to grow several follicles in unison with an aim to retrieve many mature eggs at a time. The medications are used in a variety of combinations called protocols. There are several different ovarian stimulation protocols used in the field of ART.  All of them are based on the following basic principle:
1)      Use of gonodotropins (FSH) to stimulate follicle growth.
2)      Use of GnRH agonist or antagonist to suppress the ovaries prior to stimulation and to prevent premature LH surge.
3)      Use of hCG trigger (or in some cases, a GnRH agonist like lupron is used to the trigger the LH surge ) , to induce the final maturation of eggs.
The basic aim of any ovarian stimulation protocol is to collect many mature eggs that can be fertilized to create good quality embryos , which will ultimately develop into a healthy baby!
 Does every woman respond well to ovarian stimulation protocols?
 Depending on a woman’s ovarian response to injectible FSH, they can be classified as hyper responders, normal responders and poor responders. Hyper responders are women who develop several follicles when their ovaries are stimulated with low doses of FSH . The doctor retrieves several eggs and their estradiol levels exceed 3000 pg/ml on the day of hCG trigger. They are at risk of developing OHSS - ovarian hyperstimulation syndrome. Poor responders are women who develop less than 3 follicles when stimulated with a high dose FSH and their estradiol level is less than 500 pg/ml on the day of hCG trigger. Normal responders fall in between both these categories.
What determines a woman’s response to ovarian stimulation?
Hyper responders are usually women with an endocrine disorder called PCOD ; or young women. These women have a large number of antral follicles ( over 25).  Their response to FSH is excessive (even low doses of FSH are able to stimulate the growth of several follicles). They have a very good pregnancy rate when undergoing IVF since they produce more eggs and hence will get many embryos which are good enough to be transferred to their uterus. However, they are at risk of developing OHSS, and need to be handled with care and respect !
Normal responders are young women who have a decent amount of antral follicles (10-20) in their ovaries. Their ovaries need medium doses of FSH to stimulate the growth of follicles. Their overall pregnancy rate is good too.
Poor responders are women with fewer antral follicles in their ovaries. Women with poor ovarian reserve and older women come under this category. They need larger amounts of injectible FSH to stimulate the growth of follicles. Their egg yield will be less and their chances of success with IVF is lower when compared to women of the other two groups.
Why are there so many different ovarian stimulation protocols?
Protocols vary in the type, dosage and timing of gonodotropins, GnRH agonists and GnRH antagonists used. Normal responders and hyper responders are easy to superovulate – and pretty much any protocol will work well for them ! The probable reason for the existence of so many different IVF stimulation protocols is to help doctors manage poor ovarian responders  , who are challenging patients to treat. A poor response to gonodotropins during IVF can lead to cycle-cancellations; the availability of fewer embryos or embryos of poor quality for embryo transfer ; and decreased pregnancy rates. This has led to the search for protocols which could either increase their yield of eggs ; or increase their chances of pregnancy , even with the meagre number of eggs retrieved from them.  But until now no particular protocol has been identified as a successful method for treating poor responders (PMID: 17253503).
Poor responders usually have poor ovarian reserve with a low antral follicle count. Since antral follicles are the ones which respond to injectible FSH, in a poor responder the use of high concentration of FSH often will not increase the number of growing follicles. The sad truth is that if your egg bank (ovary) in on the verge of bankruptcy, it simply will not allow you to draw an overdraft on it. This is why a poor responder doesn’t necessarily grow more follicles even if the doctor increases the dosage of FSH .
Let me explain using an analogy. Consider an apple tree (ovaries) with lots of apples (follicles) closely packed together. You want to get a good amount of apples from the tree. You decide to throw a stone (ovarian stimulation protocol) at it so that some ripe apples fall down. The amount of apples you want to get will be directly proportional to the force (dosage of FSH) with which you throw the stone.  The more the force you apply, the more strongly the stone will hit a branch , and hence more apples will fall down (growth of more follicles). This is why if an ovary (apple tree) has good ovarian reserve or good amount of resting follicles (apples) , any protocol (any stone) works well !  But what will happen if there are only two or three apples (follicles) present in a big tree (ovary)?  Even if you hit the tree with high force (increase the dose of FSH) , the yield of apples will not change and you have to really struggle to get those apples off the tree , because even if you use different stones, (different protocol) it’s only if you hit that particular branch (the follicles which are capable of responding to FSH), will the apples fall down. The probability of this happening is low; you may have to try several times before you succeed. However, there is one more way to get those apples-just wait for one to ripen and fall down on its own! The same applies to an ovary with a poor ovarian reserve.  Scientific studies have also failed to show any improvement as regards the number of eggs retrieved or in the pregnancy rate with the use of different protocols. This is why mini-IVF or natural cycle IVF has become a popular option for poor responders. This is just like waiting for the apple to fall down on its own! In a mini IVF cycle, the follicle that grows naturally during each menstrual cycle is monitored closely and the single egg present in it is collected for fertilization and the resulting embryo is transferred to the uterus. Although the success rate is not as high with such a strategy, it prevents the futile attempt of stimulating the ovary with a very high dose of expensive FSH! Since FSH is costly and conventional IVF is expensive , this kind of natural IVF for poor responders is becoming increasingly popular. After all, at the end of the day, you just need one winning lottery ticket to hit the jackpot !
So the moral is, different IVF protocols are just different ways of doing the same thing – after all, there are many ways to skin a cat ! In that case, why not use the same protocol for everyone? This is because different REs prefer working with different protocols - and some REs just try to hype and promote their own regime ( often calling it with a catchy acronym) to impress patients ! Many patients fall for the fancy names some IVF clinics use for their different protocols. This is especially true for poor responders who are frantically searching for ways to use their own eggs to get their baby!


  1. A couple may be infertile due to infection in either man or woman or both as well. The general term used for treatment of infertility is Assistant Reproductive Technology (ART) which refers to methods used to achieve pregnancy by artificial or partially artificial methods. Gestational surrogacy India

    Reports says that nearly 30 million couples in India suffer from infertility and the emotional breakdown and disappointment of couples because of infertility affect their general health, relationships and living style too, making infertility more than a mere disease and hence infertility treatment India
    gains utmost importance.

  2. Hello again Manju. Another good post (I liked the comparisons to other species). I have a question I wanted to run by you in case you've run across an answer in your journeys, though it isn't directly related to this post specifically. My wife has one fallopian tube (the other was excised) and it has scar tissue blockage up near the ovary. I'm aware blockage can be a risk factor for ectopic pregnancies, but I'm wondering how much. Would 2-10 percent of pregnancies with scar tissue be ectopic? 25-50? I can't seem to find any literature on the matter. Let me know what you think, and thanks in advance!

    1. Dana give me some time, I will get back to you !

    2. Dear Dana,

      Thanks for asking this question !

      I have only one fallopian tube. My left tube was excised because of hydrosalpinx due to an infection - the cause of the infection was never identified. The doctor who did the surgery to remove my left fallopian tube said I had lots of scar tissues too. My right tube is intact, he said I had a blockage in the upper region and he could repair it and after repair the tube allowed that passage of dye which means it is open. BUT just because a tube is open it doesn't mean it is functional !

      Our fallopian tubes are thin tubular structures. The region of fallopian tube closer to the ovary has many finger like projections. This region is also rich in minute hair-like structures called cilia. The finger like projections should move freely inorder to catch the egg and the caught egg is moved to the uterus (on the way to uterus fertilization occurs and embryo is formed) by the swaying motion of cilia. The fallopian tube has to also contract along its length to push the embryo down so that it reaches the uterus. When there is a pelvic infection there is a danger of scar tissue formation. The fallopian tubes can get attached to or entangled in the scar tissue. It can also get attached to other organs like uterus or even ovaries via scar tissue. If it happens its free movement is inhibited. So even if the tube is open and passes the dye during HSG test freely, it can remain non-functional ! This is why a HSG test cannot say whether a tube is functional but it can say whether a tube is open. A open tube doesn't mean it is functional. Another important thing is-a fallopian tube with scar tissue can become rigid, as a result it cannot contract along its length too - because of this a fallopian tube can totally lose its function.

      I am not sure whether your wife's tube will be functional to catch the egg - only if the egg enters the tube and fertilization occurs there is a chance of ectopic pregnancy. Even if we assume that the tube is functional, it is very hard to asses the risk for ectopic pregnancy in percentage for individual women - not all women have the same degree of tubal damage. A fallopian tube is not the usual place for embryo implantation and I am not sure how conducive is a severaly damaged tube for implantation. In general population the risk of ectopic pregnancy is 1-2%.

      I am not sure whether it helps. Good Luck !


    3. Wow, thanks Manju. Yeah, that's just about what I had been reading. I spent the morning on google scholar reading up on all the lit I could, but the treatment groups were always ill-defined. Tubal factor was always lumped in with infection.

      This all became a big deal to me last night when my wife began mentioning all of symptoms she was having that resembled pregnancy symptoms. This morning, the pregnancy test showed up positive. Then, the unexpected husband freak-out commenced. 50 browser windows later, I determined that, worst case scenario, it looks like with the current knowledge of our condition we are facing a 10-20 percent ectopic pregnancy chance, which I suppose isn't too terrible. The freak-out gradually faded.

      But then we visited the doctor this morning and my wife had her blood drawn. Her progesterone was 8, and we're just entering week 5. 8 is pretty bad. Husband freak-out commences once again. I guess we'll have to wait and see whether it inches up a point or two in a few days. Until then, I'll keep cursing the fact that I don't have access to any of the raw data from these ambiguous studies...

    4. Dana, I am so happy to hear this wonderful news. Please enjoy the moment ! Everything will go on well. What is her HCG level? Your wife's HCG and the way it doubles can say a lot about the pregnancy. My hearty wishes to both of you ! Take care ! I'm crossing my fingers for both of you. Sending lots of positive thoughts your way.


    5. Thanks Manju. We're experiencing the usual feelings: swinging mightily between optimism and guarded despair. We're trying to tell ourselves that it's a freebie: like being given $1000 worth of money that we can spend in a casino. We weren't expecting it, so if we lose it, it's no big deal. But I'm concerned that, if it fails, it might be an indicator of something ominous. When we miscarried during our first cycle, we had very low progesterone. We're kind of facing the same situation that you have, Manju. We went into IVF believing we had one minor issue, but we're gradually learning that we have more than just 1.

      As of now, her HCG levels look okay enough (70 at 4 weeks), but we only have "one point" of data. Until we see it double in 2 days, we don't have a "trend." It's the progesterone that worries me.

      The week before we conceived, we took up running, not knowing that we were going to get pregnant. We wanted her to reach a weight goal before the next IVF cycle. In other words, her body was in pretty hefty weight loss mode. I'm concerned it may have had an inhibitory effect on the pregnancy, which is a very common thing in just about every other mammal. I guess I could go around in circles speculating about all of the things that could be wrong. We'll know one way or another tomorrow when we get her second set of blood work done. Sorry for spamming your blog!

    6. Dana, you cannot undo the past so do not worry or blame yourself ( running, weight loss etc, etc). Even if you say that you are not worried I could sense the worry in each and every word you wrote here. I understand that you are trying to protect yourself from an impending emotional assault (your fear which might or might not come true !) by trying to make your brain believe that even if it doesn't go well it doesn't matter. The truth is definitely not so. If this pregnancy doesn't go well, it pains horribly - accept it ! Do not struggle too hard within you. I agree this is one of the worst time to wade through because of the uncertainity inherent in it. But hold on to hope. Remember the serenity prayer. I am sending lots of good wishes for you both and for the little one too who is trying to root within your wife and establish a strong connection. All will be well ! Take Care !


    7. Nothing you write here is spam - I value each and every word ! It will help someone for sure.

    8. I think the trajectory we were on really complicates our feelings right now. For about 4 years since our emerging infertility issues, there has been a sort of ambient sorrow in our lives. The kind that every infertile couple feels. And almost literally, the moment it started to lift--- the moment we had trained our minds and bodies and looked bravely on to the cycles ahead--- we have this unplanned pregnancy that inherantly entails greater failure risk than an IVF cycle (one which we were unable to prepare for with the proper supplements, condition, etc). So in a way, we want to just believe it will fail so that if it does, we can continue where we left off. If you force the pendulum of hope too far, after all, it will swing back and strike you.

      But you are right. I can't make myself believe consistently that it won't work. I find myself, at unguarded moments, imagining how I might clear out the guest bedroom to make room for the nursery. But then I remember why we choked that room so thoroughly, ceiling to floor, with furniture to begin with... So that we wouldn't have to look at all of the empty spaces. Our minds fill them too quickly with all the happy things that should be there, but aren't. It feels almost like we've taken mounds of earth and smothered the burrow of a venomous snake in the garden. We can't be bitten anymore, but now the leaves have suffocated and the flowers are wilted. I don't know which is worse. I think that maybe there is no right way to resolve these feelings.

      And I'm not sure that hope is a good thing. I always thought the term of "hope" was a way to emaciate those who might otherwise have recourse. After all, isn't it at a person's most powerless, when all faculties have been exhausted, that they resort to "hope"? I don't want to inhabit the last refuge of the helpless. I'd rather "face the facts" and watch calmly the numbers that show up on the dice. But even then, the facts are so often absent or concealed. And when the facts don't speak clearly, I am surprised to find that sinister "hope" has already slithered in to take their place.

    9. Dana, you have beautifully expressed how you feel. Not everyone are gifted with such talent : ) How about writing a blog ? It really helps !

  3. Manju...

    Recently found your blog and it is so positive for people like me.

    I am also eagerly in persuit of having a baby but my condition is not allowing me to treat with ivf procedure. i would like to share my story can i have your email id please.

    1. Nice to hear from you. Mail me. I will be very happy to hear from you.


  4. Thank you . I will write to you asap.

  5. Hi Manju,
    Your blogs never fail to make me cry every time i read them.It feels like somebody knows exactly what i am going through and is giving words to my feelings.Like its me telling my story to the world through you.Thanks for all the wisdom and encouraging words you say to our community of infertiles.
    Despite all this,it is so damn difficult to put up a brave front and move forward.Life is stuck at this phase for so long (5 years now) and its so difficult on the soul to see everybody with me move forward and away in life.But i am still hopeful for some miracle to happen with me too.
    I have had 2 failed IVF cycles - one with my own eggs and one with donor eggs.My FSH levels are between 11-13 and AMH is 0.42.So,with these figures,definitely my eggs are bad and have a Poor ovarian Reserve.So i went for donor egg thing but that failed too.Now i am on alternative medicine and waiting and wishing to concieve on my own.
    My query is - I have undergone genetic testing too in USA.and the report says the following (please read carefully) -
    "Fragile X PCR Test :Result - Female premutation carrier with unusual findings.
    Interpretation - The status of fragile X locus for this female was determined by polymcrase chain reaction (PCR) analyses and southern blot analysis using DNA isolated from a blood specimen.PCR amplification of FMR1 CGG repeat indicated that this individual is positive for one FMR1 allele in the premutation size range .This expanded allele is hetergenous in size with 2 major populations at approx 74 and 88 CGG repeats.One other FMR1 allele in the normal size range with 30 CGG repeats was also detected.The triplet primed PCR analysis was negtive for an FMR1 expansion in full mutation range .Southern analysis was also negative for an FMR1 expansion in the full mutation size range and the pattern of methylation is as expected as a female individual.
    Female premutation carriers usually donot have a mental dysfunction caused by their premutation allele.However approx 20% of female premutation carriers will experience premature ovarian failure.In addition,these people are at risk of passing an expanded FMR1 ALLELE TO THE NEXT GENERATION and having offspring affected by Fragile X syndrome."

    Can you please explain this report to me in detail (and perhaps have a consultation with Dr Malpani too if you can ).What can be the consequences if at all i concieve with my own eggs ?Also,are there some tests to diagnose if i will have normal healthy offsping if i get pregnant? or should i simply put the idea of conceiving on my own away.Also ,does this mean i may undergo an early menopause ?

    All these facts have instilled a never-ending fear in me.I have lost my sleep and i am a nervous wreck.Please please help me find some answers.I am tired of crying and it does not give any solutions.Please help me.

    1. Dear G,

      Thanks for the kind words about my blog !

      G, (((HUGS))) I understand completely what you are going through and I am sorry that you (we) have to go through this struggle !

      To put it in a simple way Fragile X syndrome happens when a particular gene in (FMR1) X chromosome is longer than usual.We have two X chromosomes (females ) and one of your X chromosome has a normal FMR1 gene. Premature ovarian failure you are facing is because of the defect in FMR1 gene in one of your X chromosome.

      If you have a child, the child has 50% chance of inheriting this gene defect (provided your husband carries a normal FMR1 gene in his X chromosome). If it is a female child the maximum problem it can face is what you face now,fertility problem ! If you have a male child perhaps the chance of having some developmental problem is high !

      How old are you G ? Literature says that women with fragile X syndrome do go through early menopause.

      G having said all this, I would say do not panic, do not cry. It will not help. Now you have to decide what you would like to do. I will say try donor eggs. It will give you the best chance of having a healthy baby. Having fragile X syndrome will not cause your donor egg IVF cycle to fail. Using donor eggs doesn't guarantee success the first time around. Have realistic expectation. Try 3 ET with donor eggs. Do not lose hope so soon. Be persistent ! Do not panic about menopause, every women have to go through it sooner or later. If it happens at 35 or 45 doesn't matter. There are many treatments to keep yourself fine even if you go through menopause earlier.

      G, please mail me if you have further questions and need further info (and if you need someone to talk to !). Where did you do your IVFs ?

      G, you are a very strong women. I just love and appreciate yoou !

      Take Care and mail me ! (

      Lots of love,

    2. In my opinion, her Fragile X PCR Test is irrelevant as regards her fertility treatment options

      If she wants to understand the medical gobbledygook in her report, she can read more about this at

      Her best option would be to repeat the donor egg IVF cycle in a program which offers a moneyback guaranteed pregnancy option

      Dr. Malpani ( This is Dr's reply !)

      His mail ID is

    3. Thankyou so much Manju and Dr Malpani for your time and effort to address my query.I really appreciate that.
      So this means i definitely have risks of transferring a defective gene to my offspring anyhow.Ok ....let me just digest this ........
      Hmmm .....the assault of bad news(s) will never stop hurting i guess.
      I am 33 yrs old.I wonder how much time i have till i start undergoing menopause.
      Anywayz,now my question is we donot plan (or cannot afford to) to have more IVF cycles right now.I just had my failed donor egg cycle 2 months back and taking a break now.I had 1st cycle at 31yrs in pune and 2nd cycle at 33yrs in Delhi (Dr Anoop Gupta).What if menopause happens before we can manage to do another cycle?Can we still do it ?
      There are financial and logistical constraints right now.So,i have no other option but to just keep waiting till i can go for next IVF cycle or some miracle to happen.
      What would it cost to undergo donor egg IVF at Dr Malpani's ?
      Pls suggest.

  6. Dear G,

    Menopause has nothing to do with conceiving via donor eggs. So do not panic. Regarding the cost, you should contact Dr. Malpani. Make sure to ask for the money back guarantee option wherever you plan to do your donor egg IVF cycle.


  7. thanks manju.I'll keep that in mind.
    Also,i read the link Dr.Malpani has attached in his reply.It says that Fragile X carriers have 50 % chance of transferring defective gene to offspring.So there's still 50 %chance of NOT transferring the defective gene.Is it correct inference ?
    Are there any tests to diagnose the presence of such genetic abnormailty after conception ?
    And what are the tests that i should insist on for the egg donor in case of IVF via egg donor ?
    Pls guide.Thanks in advance.

  8. G, you have 50% chance of not transmitting the defect in FMR1 gene. There are ways to find out which embryo carries the defect and which not (by performing preimplantation genetic diagnosis on embryos). Your donor will be tested for all dangerous infectious disease like HIV, Hepatitis B and so on. Ask your doctor what are the tests they perform on donor to make sure that she is competent enough to donate egg.


Please do write to me! It makes me happy :)

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