When cycles go bad- what to look out for during an IVF cycle

Cyst present before starting stims

Sometimes Lupron will cause patients to have cyst formation and this may lead to cancellation. Lupron first stimulates the pituitary and then suppresses it, and it may be that the luteal stimulation phase causes these cysts. Your clinic should also check your baseline estrogen level. It if is too high (i.e. 100 pg/ml) on a type of protocol you may need to cancel because of inadequate suppression.

Everyone should have a baseline scan and e2 check prior to starting stimulation medication for their IVF cycle. You need to make sure that you are suppressed and there are no cysts or follicles present before you start stims. Without a baseline scan, if you start stims with a cyst, the cycle will likely fail and you will have wasted a lot of time and money.


Premature luteinization

Your doctor should be checking your estradiol, LH and progesterone levels throughout your IVF cycle. If you progesterone level starts to rise too soon, your uterine lining may be compromised.

Premature luteinization is a phenomenon where progesterone levels rise in the serum before the normal post ovulatory period. In the normal menstrual cycle, the LH surge induces ovulation and then LH stimulates the corpus luteum to produce progesterone which is required for normal implantation. The uterine lining goes through a specific series of changes in response to progesterone when it develops during the ‘implantation window.’ Premature luteinization has been suggested when the progesterone levels rise above 2 ng/ml. Some, but not all, studies have shown that the pregnancy rates are lower when the progesterone levels rise. This may affect implantation and may not be due to an increase in LH. Sometimes, when we ‘coast’ the over stimulated patient, premature luteinization may occur and this may be responsible for the lower implantation rate seen in some patients that coast >4 days. Many programs monitor the LH and progesterone levels to assess the stimulation for evidence of premature luteinization.

Fluid in the uterine cavity

In a very small number of patients, and actual fluid collection is seen during the stimulation. This may be seen in patients that are very over-stimulated or under-stimulated, patients with hydrosalpinges (blocked tubes and fluid going back into cavity), or patients that may have a sub-clinical uterine infection. The pre-op HSG should rule out any tubal factor. Regardless of the cause, and there is no uniform consensus about the exact mechanism, the pregnancy rates are lower when this fluid is seen. The options include cancellation of the cycle outright and switching to a different protocol, or obtaining the eggs and freezing the embryos. Some have suggested using a small catheter to aspirate the fluid and still do the transfer, but it may accumulate and affect implantation.