G-CSF or IVIg? Elevated FSH

parent2b

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Reply G-CSF or IVIg? Elevated FSH Posted on: Mar 24, 2011 at 10:00am
Dear Dr Braverman,

I am writing from Australia. I am 45 and have been TTC for 7 years. My eggs have always been good quality, but I am a poor responder. We have always tried ICSI because my husband has had a vasectomy reversal. Reversal was successful, but count is low and motility is not always the best. We always manage to produce above average embryos (graded 3 out of 4) but have had 15 failed ETs. We did manage 1 successful ET 4 years ago and that was the first time I took Prednisolone and Cardiprin and used Dr Gleicher’s (CHR) RAFS protocol. However, the embryo had an extra set of chromosomes and we lost it (after heart beat detected) around week 7 or 8.

I have felt ever since then, we have an implantation issue. The embryologist says my eggs are A grade and perfectly healthy – I just don’t seem to have many of them!

I am hypothyroid and occasionally suffer from urticaria, slightly positive ANA and sometimes positive SLE. I had immune testing recently. Please see results at bottom of page.

My new RI suggests IVIg with Dexamethasone (0.5mg bd) and Clexane 40mg (Lovenox) and high dose progesterone (at least 800mg) in luteal phase.

Having got the new test results however, my FSH has just jumped up (32 on day 2 of this cycle). I began having hot flashes along with extreme itching. I had no CM this cycle and assumed I would not ovulate. By day 19, still no CM so I had a scan (endometrial lining 2m) and blood tests: E2 <70, P4 1.1, LH 53, FSH 115, Prolactin 140. I don’t know if that means I’m peri-menopausal or menopausal. My IVF doctor immediately put me on the OCP for 21 days and will test FSH again on day 2, next cycle.

I feel I am obviously running out of time/eggs so I would like to give it my best shot in the next ICSI cycle. Unfortunately it has taken many years to find the information that led me to an RI and the right testing and now it may be too late.

If I am lucky enough to get another low FSH and have ICSI again, would you recommend IVIg or G-CSF? (please note G-CSF is not available in Australia, to my knowledge)

Is there anything else you would recommend in terms of ICSI stimulation protocol and/or immune treatment?

NK Assay
50:1 14.2
25:1 6.6
12.5:1 3.0
IgG conc 12.5 50:1 ** 7.3
IgG conc 12.5 25:1** 5.5
IgG conc 6.25 50:1** 3.7
IgG conc 6.25 25:1** 7.9
%CD3 87.5
%CD19 5.6
%CD56 3.8
% of CD19+ cells, CD5+ 7.1

** > 10% reduction in killing at each effector/target ratio

LAD
Flowcytometry Negative
T-cells IgM+ 4.2
T-cells IgG+ 17.9
T-cells IgM+ 29.3
B-cells IgG+ 79.4

DQ Alpha
(me) 0102, 0505 (husband) 0104, 0201

DQ Beta
(me) 03,06 (husband) 03,05

TH1:TH2
TNF-a:IL (CD3+CD4+) 19.5
IFN-g:IL (CD3+CD4+) 15.3

Immunohistochemistry
CD56
OlympusBX40-1hpf=0.34square mm, Diam=0.66mm
CD56 positive cells per high power field (average): 10255
Range from 55 to 136 per high power field

CD57
OlympusBX40-1hpf=0.34square mm, Diam=0.66mm
CD57 positive cells per high power field (average): 3.3
Range from 2 to 8 per high power field

Thank you so very much for your kind assistance Dr Braverman.

Dr. Braverman

2024 Posts
Re: G-CSF or IVIg? Elevated FSH Posted on: Mar 28, 2011 at 2:01am
I am very sorry for all your difficulties. You have quite an extensive history it would not be possible to give you a fair opinion without going over your history with you in detail. I am sure if you needed we could get neupogen to you. I would also like to know your AMH and anti ovarian antibody levels. You do have a small window but I can better asses this with those levels. I need to see more on your immune testing than you sent and would be happy to assist you in getting all the correct testing done asap.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

parent2b

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Reply Re: G-CSF or IVIg? Elevated FSH Posted on: Mar 30, 2011 at 3:09am
Thank you Dr Braverman. My AMH is 0.4. I must reiterate though, the comments of our embryologist, that my eggs are "A grade" and healthy. I take a lot of supplements and also have acupuncture and Chinese herbs.

I tried to get some more blood tests done yesterday, including anti ovarian antibodies, but my IVF doctor has never heard of the test and the pathology collect centre have no idea what it is either!!

I would love to have your opinion and would be happy to provide whatever details you require. Please note, the results I posted previously, were obtained from Rosalind Franklin University, Chicago. I had to send blood samples from Australia to the US, which was a costly exercise. So I'm hoping any further tests I need to produce, can be done in Australia.

I am two and half weeks into the "21 day" pill cycle as prescribed by my IVF doctor and the original plan was to cease the pill, have a bleed and check my FSH level on day 2 (i.e. mid next week). If my FSH is acceptable, I am supposed to get on a plane and fly to Sydney to have IVIg therapy. However, under the current circumstances (high FSH, hot flushes and possibly out of time), I am thinking it may be best to obtain your opinion first, because I really want to give the next round if ICSI my absolute best shot. Perhaps I could continue taking the pill a while longer, to give us some time to sort this out?

Please let me know what the next move is from here and what you need from me. I look forward to your suggestions.

Kind regards and many thanks

Dr. Braverman

2024 Posts
Re: G-CSF or IVIg? Elevated FSH Posted on: Mar 30, 2011 at 10:10pm
we can get by with what you have already done as far as being able to give you advice( If needed I can probably get a better arrangement to get your blood shipped out). Please call our office and ask for Kim she will schedule a consult and we can review everything. I look forward to speaking with you.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.