What different approach do out of state clinics take?

[Anonymous]

After multiple failures at local clinics, it is usually recommended that you go to one of those out of state clinics. What do they do differently? Do they recommend different medications or protocols that work better and if so why wouldn't local clinics also do that? Can you share some experiences about why you think you made a right decision to travel for IVF and where did you travel?
I am someone who has failed multiple times and want to know what differently I can do in a few months from now.

[Anonymous]

What is your issue? I asked because clinics are not one size fits all. People can make recommendations based on similar experience.

FWIW - I was AMA and had high FSH. I went to Cornell after failing cycles locally. Dr. Davis there is the guru for my situation. He used the same protocol I used at SG, but he monitored things more closely and changed dosing of meds more frequently. He also did co-culture for my cycle, which uses cells from your endometrial lining with the embryo as it is being cultured. My cycles there was a BFN, but it was by far one of my best cycles. Had I not been at the end of my IVF journey, I would have cycled there again despite all of the logistics and cost.

[Anonymous]

From what I've heard re CCRM, the big difference is actually the lab. I have DOR, so the expected yield from any given cycle is pretty low. They claim that better embryologists = better embryos = higher likelihood of success, even if you don't retrieve many eggs. They also recommend that almost everyone do CCS/PGD, so almost all their transfers are of chromosomally normal blasts, which produces a higher success rate and a lower rate of miscarriage.

[Anonymous]

Anonymous wrote:From what I've heard re CCRM, the big difference is actually the lab. I have DOR, so the expected yield from any given cycle is pretty low. They claim that better embryologists = better embryos = higher likelihood of success, even if you don't retrieve many eggs. They also recommend that almost everyone do CCS/PGD, so almost all their transfers are of chromosomally normal blasts, which produces a higher success rate and a lower rate of miscarriage.

From my own experience with a local clinic vs CCRM, I think the superiority of the lab, the transfer protocols, and the criteria the clinic applies to which embryos are suitable for transfer are the big differences.

I am a high responder due to PCOS, with 1 kid naturally conceived, but then experienced secondary infertility. Local RE thought it would be a cakewalk, used a well-established protocol, and we had great results: 21 eggs retrieved, 18 mature, 13 fertilized, 7 grew to blasts and were biopsied on Day 5 for CGH testing, 2 normal. 1 fresh and 1 frozen SET. Both BFN.
The transfer protocols consisted of pretty much natural monitoring to find the optimal transfer day, 15 minutes lying down after the transfer, progesterone suppositories, and that's it. Both times I started spotting a couple of days before the beta test.

Second cycle off to CCRM 8 months later(I didn't feel like rolling the dice with the locals again, was approaching 40, and could afford out of pocket cycle with CCRM so went ahead). Exact same stim protocol, I mean literally, maybe one of the meds differed by a few units. Somewhat worse showing, some of it may have been due to my husband's numbers dramatically plummeting between the local and CCRM . 18 retrieved, 13 mature, 10 fertilized, 4 grew to blasts and biopsied, all of them on Day 6 on top of everything, 1 normal. At this point I felt like I had pissed a bunch of money down. This is where the differences between the two clinics became very obvious. CCRM does medicated transfers with ridiculously close monitoring. Recommended acupuncture (very specific electro-acupuncture treatment based on one specific paper), which I did religiously. Also recommended acupuncture immediately before and after transfer (done on site at their clinic), very specific progesterone supplementation (shots and suppositories), which continues after transfer, low dose steroid, antibiotic, complete bed rest without elevating your head above 45 degrees for 2 days, no lifting of anything heavy, no exercise where your heart rate exceeds 140, etc. etc. it was unbelievably prescriptive and restrictive. Since it was my only normal embryo, and the cycle cost so much, and I really wanted to avoid another cycle, I followed everything to the t, even though I really didn't believe it will work. Lo and behold, BFP, and on top of it embryo split so twins. To this day they call me the lady with the 2-for-1 deal.

It is impossible to tell which part made the difference, and no one person can conduct a controlled experiment to say. But there are a couple of other distinguishing characteristics between my local clinic and CCRM. The first is CCRM has strict criteria on which grade embryo they will transfer and which they won't, and don't allow patients any choice (e.g. for gender). Local clinic has the philosophy of "I know women who have gotten pregnant with a D-grade embryo so who am I to take away that chance." This is a fundamental difference that, as long as there is correlation between embryo grading and implantation rate, will obviously produce higher success rates for CCRM. And the higher success rates are there not only for the frozen transfers (most of which are CGH-normal embryos), but also for the fresh (none of which are CGH-tested embryos). The second difference is that CCRM collects and analyzes every data point, whereas the local clinic operates on anecdotes (even though they are big enough to have enough data for analysis.)

What is odd is that as a doctor, I much preferred my local RE than the CCRM one. But in IVF there is only one variable that counts when evaluating outcomes: pregnant or not.

[Anonymous]

Anonymous wrote:

Anonymous wrote:From what I've heard re CCRM, the big difference is actually the lab. I have DOR, so the expected yield from any given cycle is pretty low. They claim that better embryologists = better embryos = higher likelihood of success, even if you don't retrieve many eggs. They also recommend that almost everyone do CCS/PGD, so almost all their transfers are of chromosomally normal blasts, which produces a higher success rate and a lower rate of miscarriage.

From my own experience with a local clinic vs CCRM, I think the superiority of the lab, the transfer protocols, and the criteria the clinic applies to which embryos are suitable for transfer are the big differences.

I am a high responder due to PCOS, with 1 kid naturally conceived, but then experienced secondary infertility. Local RE thought it would be a cakewalk, used a well-established protocol, and we had great results: 21 eggs retrieved, 18 mature, 13 fertilized, 7 grew to blasts and were biopsied on Day 5 for CGH testing, 2 normal. 1 fresh and 1 frozen SET. Both BFN.
The transfer protocols consisted of pretty much natural monitoring to find the optimal transfer day, 15 minutes lying down after the transfer, progesterone suppositories, and that's it. Both times I started spotting a couple of days before the beta test.

Second cycle off to CCRM 8 months later(I didn't feel like rolling the dice with the locals again, was approaching 40, and could afford out of pocket cycle with CCRM so went ahead). Exact same stim protocol, I mean literally, maybe one of the meds differed by a few units. Somewhat worse showing, some of it may have been due to my husband's numbers dramatically plummeting between the local and CCRM . 18 retrieved, 13 mature, 10 fertilized, 4 grew to blasts and biopsied, all of them on Day 6 on top of everything, 1 normal. At this point I felt like I had pissed a bunch of money down. This is where the differences between the two clinics became very obvious. CCRM does medicated transfers with ridiculously close monitoring. Recommended acupuncture (very specific electro-acupuncture treatment based on one specific paper), which I did religiously. Also recommended acupuncture immediately before and after transfer (done on site at their clinic), very specific progesterone supplementation (shots and suppositories), which continues after transfer, low dose steroid, antibiotic, complete bed rest without elevating your head above 45 degrees for 2 days, no lifting of anything heavy, no exercise where your heart rate exceeds 140, etc. etc. it was unbelievably prescriptive and restrictive. Since it was my only normal embryo, and the cycle cost so much, and I really wanted to avoid another cycle, I followed everything to the t, even though I really didn't believe it will work. Lo and behold, BFP, and on top of it embryo split so twins. To this day they call me the lady with the 2-for-1 deal.

It is impossible to tell which part made the difference, and no one person can conduct a controlled experiment to say. But there are a couple of other distinguishing characteristics between my local clinic and CCRM. The first is CCRM has strict criteria on which grade embryo they will transfer and which they won't, and don't allow patients any choice (e.g. for gender). Local clinic has the philosophy of "I know women who have gotten pregnant with a D-grade embryo so who am I to take away that chance." This is a fundamental difference that, as long as there is correlation between embryo grading and implantation rate, will obviously produce higher success rates for CCRM. And the higher success rates are there not only for the frozen transfers (most of which are CGH-normal embryos), but also for the fresh (none of which are CGH-tested embryos). The second difference is that CCRM collects and analyzes every data point, whereas the local clinic operates on anecdotes (even though they are big enough to have enough data for analysis.)

What is odd is that as a doctor, I much preferred my local RE than the CCRM one. But in IVF there is only one variable that counts when evaluating outcomes: pregnant or not.

I am another patient who had success at CCRM. I want to second the point about CCRM being very statistically oriented. The clinic monitors its own outcomes continuously and adjusts treatment strategies accordingly. I also found CCRM to be more willing than Shady Grove to try outside the box strategies like supplementing traditional stim meds with human growth hormone, testosterone, and over the counter supplements. Relative to SG, CCRM also ran more tests before I started treatment, used more menopur in my protocol because of my AMA status, was willing to let my estrogen get much higher than SG was comfortable with before triggering me, and monitored me more closely during stims, prior to transfer, and then throughout the first trimester. At one point shortly after one of my positive pregnancy tests my progesterone dropped inexplicably, and CCRM quickly added injections to my protocol. Shady Grove wouldn't have caught that because at least when I cycled, it didn't monitor either before or after transfer to see how I was absorbing progesterone suppositories.

Also, re the prior poster's comment that CCRM is strict about what it will transfer, this has not been my experience. SG told me it will only freeze embryos that make blast on day 5 or day 6, and only if the grade is an AA, AB, BB, or BA. I currently have two lesser quality embryos on ice at CCRM, including one graded 5BC that did not make blast until day 7. Both tested genetically normal. SG would not have frozen or tested those. CCRM acknowledged that those embryos don't have a great chance of success, but they have seen them result in successful pregnancies so they were willing to give me the chance. Also, while CCRM won't let patients select embryos for transfer according to gender, it does not require patients to transfer their best available embryos at any given time or in any given combination. I decided not to transfer my best embryos first because I felt it would be easier to handle a failure if I knew my better embryos were still available to me. My point is simply that it may not be fair to say that CCRM has a bunch of restrictions in place specifically to boost its own success rates.

Re the CCRM lab, it's hard for me as a non-scientist to know whether it is really superior. However, the whole operation is very systematized and gets shut down twice a year to allow the lab to optimize and maintain all its equipment. Also, relative to other clinics with stats I've seen, CCRM has a higher rate of successfully thawing frozen embryos.

If I had to summarize the difference between CCRM and the local clinics I've had contact with, I'd say its no one big thing, but a hundred different little things that each make a difference at the margins.

[Anonymous]

OP here. I don't know exactly what and how many issues I have. We have male factor, not so great FSH, low AMH, age 35, history of polyps and fibroids that led to multiple surgeries. Tried 5 IUI cycles, 3 fresh IVFs and 1 FET. All unsuccessful. In one cycle I was an extremely poor responder (2 eggs), in another not-too-bad responder (6 eggs) and in the third quite-average responder (8 eggs). I suspect immunology issues also but not tested yet. Infertility forums always suggest that cases like me should go to either Cornell, CCRM or SIRM. I want someone who will support immunology testing prior to doing any new cycles. All cycles have been out of pocket and I need to be wise in picking an out of state clinic.

[Anonymous]

I don't think CCRM supports immunology testing. At least Schoolcraft does not. However, I know at least one patient who did the testing and treatment of some sort with a Dr. Kwak (in CA, I think) before doing IVF at CCRM. She got pg.

[Anonymous]

OP, in your situation I would do the following in parallel:
- use one of the local clinics to do immune testing - I believe Dr. Frankfurter is the only one locally who will do this?
- have your DH start antioxidants ASAP - they take 3 months to fully help. something like Proceptin. This helps with variety of MF issues.
- schedule apt with Dr. Davis at Cornell - he is guru for AMA

Have you had a recent lap/hysteroscopy? Chance of any remaining scar tissue from your surgeries? Any concerns about endometriosis?

To optimize chances (based on research studies) I'd do acupuncture before/after transfer and also try to have some kind of endometrial biopsy done the cycle before you start - co-culture counts.

To answer your question - Cornell very closely monitors/fine tunes your cycle. Great lab (they say to look at DE cycle stats to get a feel for lab quality). Really brilliant team working on your case. This is group that invented ICSI, co-culture, creative protocols (EPP, etc).

Good luck, OP.

[Anonymous]

Also, if you suspect immune issues (why do you?) you can try an anti-inflammatory diet.

How is your thyroid? TSH should really be down around 1-2.

[Anonymous]

Anonymous wrote:OP, in your situation I would do the following in parallel:
- use one of the local clinics to do immune testing - I believe Dr. Frankfurter is the only one locally who will do this?
- have your DH start antioxidants ASAP - they take 3 months to fully help. something like Proceptin. This helps with variety of MF issues.
- schedule apt with Dr. Davis at Cornell - he is guru for AMA

Have you had a recent lap/hysteroscopy? Chance of any remaining scar tissue from your surgeries? Any concerns about endometriosis?

To optimize chances (based on research studies) I'd do acupuncture before/after transfer and also try to have some kind of endometrial biopsy done the cycle before you start - co-culture counts.

To answer your question - Cornell very closely monitors/fine tunes your cycle. Great lab (they say to look at DE cycle stats to get a feel for lab quality). Really brilliant team working on your case. This is group that invented ICSI, co-culture, creative protocols (EPP, etc).

Good luck, OP.

This is good advice, but I think Dr. Abbasi is the local RE known for immune testing.

[Anonymous]

I haven't cycled with SIRM, but I do know that you can ask them questions via their message board. Might be an easy/cheap way to get in touch with them.

Also were you already doing NCIVF down here? You could consult with Dr. Gordon at Dominion about that. But frankly at this point I'd just push to see Davis at Cornell.

[Anonymous]

Anonymous wrote:

Anonymous wrote:OP, in your situation I would do the following in parallel:
- use one of the local clinics to do immune testing - I believe Dr. Frankfurter is the only one locally who will do this?
- have your DH start antioxidants ASAP - they take 3 months to fully help. something like Proceptin. This helps with variety of MF issues.
- schedule apt with Dr. Davis at Cornell - he is guru for AMA

Have you had a recent lap/hysteroscopy? Chance of any remaining scar tissue from your surgeries? Any concerns about endometriosis?

To optimize chances (based on research studies) I'd do acupuncture before/after transfer and also try to have some kind of endometrial biopsy done the cycle before you start - co-culture counts.

To answer your question - Cornell very closely monitors/fine tunes your cycle. Great lab (they say to look at DE cycle stats to get a feel for lab quality). Really brilliant team working on your case. This is group that invented ICSI, co-culture, creative protocols (EPP, etc).

Good luck, OP.

This is good advice, but I think Dr. Abbasi is the local RE known for immune testing.

Thank you! I couldn't remember who it was.

Memory loss from too many cycles.

[Anonymous]

Anonymous wrote:But frankly at this point I'd just push to see Davis at Cornell.

+1 good luck OP

[Anonymous]

What is close monitoring? Do they do u/s everyday and will I be required to stay in NY?
My recent testing is from last year before first ivf and during then thyroid was in range. 2.4 or so. But it was not as low as 1-2. Laparoscopy indicated no endometriosis but this was at least 1 year ago.

[Anonymous]

Anonymous wrote:What is close monitoring? Do they do u/s everyday and will I be required to stay in NY?
My recent testing is from last year before first ivf and during then thyroid was in range. 2.4 or so. But it was not as low as 1-2. Laparoscopy indicated no endometriosis but this was at least 1 year ago.

They do bloodwork and u/s everyday once you reach a certain point and call you each day with med instructions. And it's an RE doing the u/s. I believe that they meet as a team to review protocols - not sure if that's every day though. It probably depends on protocol, but for me: CD2 and CD4 bloodwork & u/s down here and then CD5 bloodwork & u/s up in NY and then I was there until transfer. I went up on CD6 for a different cycle. You could potentially come home between retrieval & transfer, but I was trying to reduce stress so I just stayed up there. It was a mini-vacation for me and DH.