When is IVF used instead of IUI for Male infertility?

Question:
I was wondering when ivf is used instead of iui to start when male infertility is involved. What do the stats have to be (count, motility, etc) in order to say iui isn't an option?
　
What are the stats for iui and ivf. Do most women get pregnant using ivf?

Answer:
Hello Bill from the U.S.,
　
IUI and IVF are completely different treatments with significantly different pregnancy rates.
　
IUI is a "natural" treatment option in that the body has to do the same natural processes in order to achieve pregnancy. As such, the highest pregnancy rates are 24% per cycle and drop significantly after four attempts. IUI is mainly used when an ovulation induction/timed intercourse treatment fails or if there are "mild" sperm abnormalities. IUI accomplishes one of the steps required for pregnancy. It gets the sperm into the tube to await the egg, but also helps by timing ovulation better. Usually, it would be indicated with any of the following:
1. Count between 10 -20 million
2. Motility between 30-60%
　
IVF is not a natural treatment option because almost the entire process is taken out of the body. The only "natural" parts of the process are ovulation induction in the ovary, embryo hatching in the uterus and implantation. Because of these remaining "natural" processes, there is not a 100% pregnancy rate. Pregnancy rates are very dependent on the age of the eggs. In under 35 year olds, pregnancy rates are now up to 70+% per cycle attempt and go down from that age group. At 43+, it is 25% per cycle. With IVF, the ovaries are stimulated to growth many eggs, the eggs are aspirated from the ovaries, fertilization then occurs in the laboratory where the sperm are added or injected into the eggs, the fertilized eggs are allowed to grow into embryos and the embryos are placed back into the uterus. IVF accomplishes 6 of the 9 steps required to produce a pregnancy. Hence, it has a higher pregnancy rates. In terms of male factors, except for no sperm, IVF can be accomplished with any level of sperm abnormalities and is directly indicated when the findings are severe i.e. less than the above parameters including morphology less than 30%. TESA (trans-epididymal sperm aspiration) is a new technique for men that don't show any sperm in a semen analysis, but have sperm production within the testicle. In this procedure, sperm can be extracted directly from the testicle and used to inject directly into each egg. You only need enough sperm for the number of eggs that a present. So, even if a semen analysis shows no sperm, there is still the possibility of a genetic child with this technique.

If there is no sperm on semen analysis, and you can't afford IVF/TESA/ICSI or don't mind not having a genetic child, then IUI can be done with donor sperm. Donor sperm usually costs approximately $500 per specimen, so the overall treatment cycle would cost approximately $3000 per month of trying.
　
I hope this answers your question.
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com
　
Monterey, California, U.S.A.
　
for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf

43 yr. old Trying To Conceive Needs High Stim Protocol

Question:

My Medical History: TTC 4.5 yrs. (3.5 with RE) Many IUI's & IVF's. 3 chemical pregnancies - 2 with IUI 1 with IVF. AMA - 43ys young.

Had a Coagulation Panel done - Mutation found -

heterozygous MTHFR C677T

Results negative for Factor V mutation

Factor II DNA Analysis

Results WNL for

ANA

APA

Lupus anticoagulant

Homocystein

Elevated levels for

Protein C Functional (187)

Factor II Activity (133)

Plasminogen (161)

B2 Glycoprotein (low positive)

Do I need to supplement my prenatal with extra folic acid and b vitamins? Baby aspirin? If so - can I just add extra supplements or do I need an Rx for something like Folgard?

Could this be the reason for all of my failed IUI's, IVF's and chemicals? Before finally agreeing to do this testing, my RE kept telling me that immune issues are too controversial and that the risks of their treatment outweighed their assumed potential benefits. I don't know what his thoughts are now as I couldn't get a Dr. callback for 3 weeks.

Many thanks, Dr. Ramirez, for so graciously donating your time in answering our questions! Your services are invaluable! Oh, yes - I am located on the east coast.

Answer:

I'm afraid I am in agreement with your RE, although for slightly different reasons. We do know that the immune system does contribute to miscarriages, although I am not sure that is the problem that you have. There are definitely some very controversial treatments, such as IVIG, which are very expensive and have not been shown to be of benefit in multiple studies. However, the alternative, which I try with all my patients is low dose aspirin (81 mg) per day, progesterone (injections and suppositories) and low dose heparin 2000 U twice per day. This regimen has been shown to help with recurrent miscarriages and is very low risk. That is why I use it. I have had some successful pregnancies in patients with recurrent miscarriages using this cocktail.

However, although you are still very young in my book, your fertility age may be the basic problem. You have shown that you can get pregnant. The problem is an egg problem. It is what I call "age related egg factor." We know that because a woman is born with all her eggs, and they age with her, and the lifetime of the eggs are about 43 years old, they deteriorate with time and age. This deterioration causes internal problems in the egg, including fragile chromosomes. This leads to bad embryos that either don't progress in their development, don't implant or end in miscarriage. There is a 40% chance of miscarriage with each pregnancy in your age group. Chromosomal abnormalities is probably the major reason for your losses.

There are only two ways to mitigate this increased risk: you can keep trying until you are successful (and hopefully you will be eventually) as long as your ovaries are still functioning well, or you can do preimplantation genetic testing (PGD) to identify the normal embryos prior to transfer (however, keep in mind that this is a new experimental technology, is very expensive, and does lower the implantation rate because of the "injury" to the embryo.).

I think that if you were to present to me, I would continue to recommend IVF with a high stimulation protocol and put you on my cocktail. I don't necessarily recommend PGD. I think nature will take care of that. The key would be to keep trying if you are determined to have a baby. There have been successes in your age group but time is running out for you.

I hope this helps,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF program

http://www.montereybayivf.com/

40 Year Old With Multiple Miscarriages Needs Correct Specialist

Question:

I have been trying to conceive for 3 years, have had 3 miscarriages, all between 6-9 weeks (one was trisomy 22, the other two are unknown. Two pregnancies required progesterone suppository supplementation). I am 40 years old, hypothyroid, insulin resistant, have a bicornuate uterus, my DRVVT came back Borderline (lupus anticoagulant, recommended re-test in 12 weeks), positive for ANA's, 1:320 titer, speckled), and compound heterozygous MTHFR gene mutation (variants C677T and A1298C). I am getting ready to try again. I was already taking synthroid 88, and 850 mg metformin twice a day.

My doctor has put me on folgard in addition to my Prenate DHA prenatal vitamin, baby aspirin, 10 mg prednisone twice a day, and I am taking 1 tbs Maca Magic, as well as 1 tsp royal jelly. Should I be taking low dose heparin as well? Lovenox? Start the progesterone suppositories immediately after ovulation?

My high risk pregnancy doctor recommended I not do IVF, because he said that at 40, my eggs are much too fragile to undergo retrieval, fertilization, analysis and reimplantation. He also indicated I would have a harder time getting pregnant after this (likely) failed. Please let me know your thoughts on this. Also, do you have any research you can direct me to, indicating that only 1 in 40 or 50 of my eggs are normal at 40 years old?

Would love to know your thoughts. I can't bear to go through another miscarriage. Thank you.

Answer:

You seem to have lots of reasons for having miscarriages, but probably the most common and predominant reason is your age. This "age factor" leads to spontaneous chromosomal aberrations that lead to abnormal embryos and subsequent miscarriage.In terms of your immune factors, just to cover those bases I would recommend either low dose heparin or lovenox. The progesterone should be started right after ovulation and continued until the pregnancy test is negative or 10 weeks gestational age.

Although you are able to get pregnant naturally, the only method that would increase your chances of a successful pregnancy is IVF. The reason is that multiple eggs can be extracted thereby increasing the chances of having a good egg (normal). It is not for sure, but will statistically increase your chances. At your current age, you probably have 1 out of 40 to 50 eggs that are normal. (When this post was published in 2009 no one really knew how many "good" eggs exist in the 35+ woman...and although it is still not 100% certain, a recent 2013 study has come out with some answers. The study found that 2 out of 20 eggs retrieved from 40 yr old women were chromosomally sound and had the potential of fertilizing and implanting successfully.) When you go through a natural cycle, you are only ovulating one egg at a time, so you can see that your chances that it will be normal is low and the chances of being abnormal is high. That is where IVF can help. With IVF you could get anywhere from 10-20 eggs at a time, depending on your ovarian function. Because time is against you, that is what I would recommend. The aforementioned medications should be used in conjunction with the IVF cycle.

As far as what your high-risk (I assume perinatologist) ob/gyn has recommended, I think you need to decide who knows fertility better. A fertility specialist or a high risk pregnancy perinatologist. As a fertility specialist, I have to disagree with your perinatologist as to your chances of pregnancy. As mentioned previously, IVF is the treatment of choice at your age. He is correct in that the chances of pregnancy are reduced because of the age related egg factor, which means that the majority of your eggs are no longer viable and prone to genetic abnormalities (spontaneous breakages), but is incorrect in saying that IVF will worsen your chances because the "eggs are too fragile for retrieval, fertilization or implantation."

In order to educate yourself regarding age related infertility and egg quality, your best source is ASRM's new website, reproductivefacts.org, sart.org or the CDC website. Each of these have the information you are asking for regarding the age-related reduction in infertility.

Good luck in your journey and don't hesitate to look for the right approach by seeking a second opinion.

Sincerely,

Edward J. Ramirez, MD, FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF

http://www.montereybayivf.com/

Can Tubal Ligation Be Reversed?

Question:

If you have your tubes tied can you have them untied to get pregnant? How is the procedure done and how long does it take and what are the chances of getting pregnant?

Thank you!

Answer:

The term "tied" is actually a misnomer. Basically, all tubal ligation procedures damage a portion of the tube causing the canal to be blocked off. There are various methods and the ability to repair them varies depending on the method. The methods are:

Post-partum tubal ligation (tubes are tied in two places and the tube removed in between). The ends are then cauterized.

Laparoscopic tubal ligation done through a scope. The tubes can be burned, clipped or a ring placed. The clip method yields the best reversal and burning and cutting the least successful reversal.

In addition, there has to be sufficient normal tube present for the tube to function (4 cms). If the fimbria is damaged (fimbriectomy) then this is absolutely not reversable. Most physician do a laparoscopy first to evaluate whether or not the tubes can be reversed before doing the reversal procedure.

Because the tubes are damaged, the chances for pregnancy are reduced and the chances depend on your age. As an infertility specialist and gynecologic surgeon, I can perform microscopic tubal reconstruction. Regardless of age, a complete evaluation is done to eliminate the possibility of other infertility factors. Some of those factors may include: maternal age, surgical risk, and ectopic pregnancy risk. See my page on "Microscopic Tubal Reconstruction".


I do not recommend tubal reversal surgery in patients over the age of 35.

A viable alternative is In Vitro Fertilization, which has a much higher chance of pregnancy per month of trying. Most fertility specialists do not do reversal anymore for this reason. For the same cost, IVF is better and is not a surgery, which means less risk. Cost wise, both are approximately the same and range from $8000-15,000. I hope this answers your question.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

IVF For The Third Time - Embryos Arrested at Eight Cells

I get many, many questions from patients outside the United States. Here is one from Europe from a young IVF patient with very disheartening outcomes.

Question:

Hi, I hope you can help me as honestly don't know where to go from here as been such a tough journey. Here's a bit of history.

DH (38)- asthenozoospermia

Me (35)- very slight PCOS, normal FSH levels

Clomid pregnancy 2008 - sadly ended in Stillbirth at 38 weeks (sept 08), cause confined placental mosaicism.

IVF 1 March 09 - cancelled poor response on too low stim drugs

IVF 2 July 09 - 14 eggs collected, 9 fertilised, 6 day 3 embryos. Transferred good grade 8 and 6 cell at Day 3 - BFN

Natural pregnancy Sept 09 - Miscarriage at 6.5 weeks

IVF 3 Nov 09 - 9 eggs collected, 8 fertilised. Day 3 - 5 X 8 cell 2 X 6 cell embryos. Plus 2 frosties (IVF 2) All looking good and then at Day 4 - all fresh arrested development at 8 cell. 2 frosties reduced cell number - no transfer

Tests so far:-Full chromosome anaylsis with me and DH - clear

Sperm DNA Defrag - within normal levels

Auto-immune tests (me) - slightly raised levels but not significantly. On all IVF's I have been on Short Protocol (Puregon, Luveris) and we have done ICSI. Plus support drugs of Clexane, Aspririn, Prednisolone (3rd cycle only),intralipid infusion (3rd cycle only) Progesterone and estrodial patches (post egg collection).Clinic doesn't seem to have any answers and seems to think worth trying one more time but do you think it would be worth changing clinics?

Are there further tests that would be worthwhile? Is it time to look at Donor and if so is this more likely to be an egg issue or a sperm issue or is it both? Do you think there might be a link between poor quality embryos and stillbirth and miscarriage?

Thanking you in advance for any help you can offer.

Answer:

Hello, let me answer your questions in order:

1. I think it might be reasonable to try a different clinic. Of course it could be just bad luck, but you have had real bad luck. One cancelled cycle and one cycle with arrested development. That's not a good statistic for a clinic, especially considering that you are young. In my clinic, my 2009 pregnancy rates in your age group are 74% per cycle with a 63% delivery/continuing pregnancy rate. I think the national average in the U.S. is 50-60%. Pregnancy rates are highly dependent on the clinic you attend because it can be influenced by the laboratory quality and techniques, as well as, the transfer quality and techniques. Good 8 cell embryos should not arrest, at least not all of them. Some may, because they are inherently abnormal genetically, but not all. I am highly suspicious of this.

2. It sounds like you have been tested for everything that can be tested for and you are fine. I cannot think of any other testing that I would recommend.

3. Abnormal embryos can be an egg issue or a sperm issue. Certainly, PGD can be done to check the embryos with another cycle to see if they are chromosomally normal or not, but I do not recommend it. Recent studies have shown decreased pregnancy rates with PGD, probably due to embryo injury or affects from removing one of the blastomeres. However, I don't think that this is your problem since you have been naturally pregnant twice in the past. If you were going to test your theory however, I would first try donor sperm, since it is the least cost. If you still have poor embryos after that, then you can go to donor eggs. I don't think you should go to donor eggs that this time. I would recommend that you try another clinic and continue trying with your own eggs. For example, I have a patient about your age who recently underwent IVF with me. She had done 5 IVF cycles at another clinic on the East Coast of the U.S. After the 5th cycle, they told her that she had poor egg quality and should use donor eggs. She then moved to my area. I recommended that because she was young, she should continue to try with her own eggs, at least a couple more times.

In her first cycle, she had a great stim, good fertilization, but the embryo quality wasn't so great. Her best embryo was a 6-cell embryo on day#3. She did not get pregnant. In the second cycle, we had great embryos. I transferred 3 8-cell embryos and she is pregnant with a viable pregnancy (singleton). And, it is hers genetically. Sometimes you just have to hang in there.

I hope that helps a little,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Trouble With 2nd IUI & Using Clomid

Question:

Hi, I'm on Clomid for my 2nd IUI (intra uterine insemination), as the first one didn't work out. The first cycle I went for the sonar on cd13 and had the IUI on cd15. The doc would've preferred to do it a day or so later but we couldn't because of lab related things. So this cycle I'm going on cd14. I would like the doc to give me the trigger to do on the eve of cd15 and do the IUI 36 hours later.

I'm worried though, I do ovulate on my own. Is it possible for my body to get the LH surge before I trigger or do I need the trigger to ovulate because I'm on Clomid? I'm taking 100mg a day. Will cd15 be too late? We're dependant on the lab for processing the sperm, so the doc cannot do the IUI on cd16 (a weekend).

Answer:

Clomid does not inhibit your body's natural ovulatory processes, therefore, you can indeed mount an LH surge and ovulate spontaneously before the IUI, if the doctor does not use anything to inhibit ovulation. Drugs to inhibit ovulation are GnRH antagonists, such as Cetrotide, or GnRH agonists, such as Lupron. Most do not use these with IUI cycles. I'm concerned because 36 hours after trigger may be way too late.

There was a nice study done three years ago that showed that if the sperm was not present prior to ovulation, then pregnancy did not follow. Therefore, for docs doing only one insemination per cycle (there is another option of doing two), they usually will plan it for 32-33 hours after the trigger. I prefer doing two, at 24 and 48 hours in order to have fresh sperm closer to the time of ovulation. Unfortunately, the studies comparing these two methods have not shown any significant advantage between them but I believe that is because there are too many variables with IUI. As it is, pregnancy rates are a maximum of 24% per cycle.

Your doc should not be dependent on a lab to do IUI's. He needs to make other arrangements, such as processing the sperm himself in his office.

I hope this answers your questions.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Spotting In First Trimester Not Placenta Previa

Question:

Hi Dr. Ramirez,

I am a 35 yo with no children. I found out I am 7 weeks pregnant and went for blood work and a sonogram since I have been spotting and had sporadic cramps for a few days. My doctor discovered I have low implantation of the embryo and placenta previa from the sono, and low progesterone levels from my blood work.

My doctor said my progesterone levels are 13.5 and should be higher (around 15) so he prescribed Prochieve Vaginal Gel. Is Procheive a good thing and is it needed? Will it produce side effects in the baby?

For the placenta previa, I have read so much negative information which speaks of hemorrhaging to hysterectomy and C-section. While I am okay with the thought of a C-section as it may save my life and the baby's, is there any statistical information available which discusses the probabilities of fatalities and hysterectomies?

With that being said, I am pro-choice and would like to make an educated decision on if I should carry this pregnancy to full term. With all the obstacles in front of me, in your experience and opinion, what are the chances of having a healthy child?

Answer:

First of all, I don't think you need to consider terminating this pregnancy because there is nothing seriously wrong at this point.I think that your doctor is over-calling things. To be frank, the recommendations and diagnosis he/she has given you is inappropriate at this gestational age.

Placenta previa CANNOT be made at 7 weeks gestation. That is a third trimester (after 28 weeks) diagnosis. At your gestational age, the entire amniotic sac is filled with the placenta. The mature placenta has not even developed yet. Placenta previa is when the placenta blocks the cervical opening, which then requires a c-section. As the uterus grows, the placenta will move and 99% of the time, the placenta moves out of the way. So you don't need to worry about it.

In terms of the progesterone, he/she is mistaken about that as well, however, we use progesterone all the time with infertility patients to help support the pregnancy. It is usually started before implantation, however. It would not hurt and Endometrin is the prescription that I use. It will not harm you or the baby. The alternatives to Endometrin, which are just as good, are Crinone and Procheive.

Spotting is very common in the first trimester. We see it all the time with our IVF patients. It does not necessarily mean that anything bad is occurring. However, you are still in the miscarriage risk stage so sometimes, spotting or bleeding could mean that the pregnancy is not doing well and will eventually end in miscarriage. There is no way to know this unless the ultrasound does not show a viable fetus i.e. no heart beat or not growing.

I hope this helps. Don't worry too much.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com

Prolactin Level and Clomid for 30 yr. old TTC'r

Question:



Hi Dr. Ramirez,

I recently had a blood test done and it showed that my prolactin level is 41ug/L (the lab report indicates that normal should be less than 26ug/L) and macroprolactin is 54%. The month that I had this test done was very stressful and my period was about 12 days late. I am usually very regular 30-33 days. I did have a miscarriage in November 2008. My husband and I have been trying to conceive for about 2.5 years.

I just started my first round of Clomid. I am 30 years old. I was wondering if my prolactin level is something to be very concerned about and will it affect my fertility? Will the clomid regulate this? Does my prolactin level indicate hyperprolactinemia?

Thank you for taking the time out to read my question.

Answer:


Hello,


Yes, if in fact your prolactin is elevated, it will affect your fertility. It needs to be brought down to normal first. However, in order to check the Prolactin level, it should be done fasting and preferable in a non-stress situation. So, please have yourself retested, since I see that your level is not too high.

Prolactin is a very volatile hormone. It is affected by sleep, stress, time of day and meals. That is why it should always be rechecked at a fasting level. The normal level should be less than 20. It may be the only thing affecting your fertility. If the prolactin remains elevated, you should see a medical endocrinologist or reproductive endocrinologist for evaluation and treatment. Often this indicates that there is a microscopic tumor in the pituitary. Medication is sufficient to treat this tumor but a larger tumor would need to be surgically removed.

However, if when you are retested and the Prolactin level is normal, the fact that you have not gotten pregnant after two years of trying at your age would be reason for concern. You are still at your peak fertile years and should have gotten pregnant within one year. Before going to treatment such as with Clomid, you should undergo a complete infertility evaluation to find out what the problem is. The treatment is then chosen according to what needs to be treated. For example, if your tubes are blocked, Clomid won't work. If there is a male infertility factor, such as low sperm count, Clomid with intercourse won't work. See my March 2008 blog concerning "Infertility Evaluation ABC's" http://womenshealthandfertility.blogspot.com/2008/03/infertility-evaluation-abcs.html

It seems obvious to me that you are seeing a Family Practice doctor or a general Ob/Gyn. That is the reason you are going straight to Clomid, when in fact since you have regular periods it is a sign that you are ovulating. Clomid will increase the number of eggs that you ovulate, but having eggs available has not been your problem since you have regular cycles. Something else is going on. The problem with non-infertility specialists is that they jump to Clomid as if it were a miracle drug. It is not. It works great for some women who don't ovulate and don't have normal periods, which is certainly not your case.

I would recommend that you seek out a fertility specialist that is going to give you the proper evaluation and care. In answer to your last question, "hyperprolactinemia" means elevated prolactin levels in the blood. If your level is over 20, then you have it. Your single miscarriage in Nov. 2008 is not a major cause for alarm. That being said, get yourself retested and move on from there, keeping in mind what I have advised above.

I hope this helps,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
www.montereybayivf.com

Infertility Workup for Young Woman with Chlamydia and Previous Drug Addiction

Question:

I am 20 years old, married, and have been trying to get pregnant. About 2 1/2 years ago I became very dependant on prescription narcotics because of herniated discs in my back. I was able to get off of the pain medicine and was put on suboxone. I am taking 8mg daily of it. As for trying to conceive, I've never been on birth control pills and we have been "careful" up until 6 months ago. We have been trying to get pregnant for the last 6 months. I am starting to worry that I have some infertility issues. My periods have always been normal, but for the last 3 months they have been lasting about 10 days (when they were 5-7 before) and the first 3 or 4 days I am just barely spotting, but it is brown and really thick. Nothing I have ever experienced before. I have an appointment scheduled this month with a gynecologist, but I am embarrassed to talk to her about these issues.

I also contracted chlamydia about 3 years ago. I am scared that I may have had it for a long period of time. I was treated for it and am okay, but I have read that sometimes if you have it for a long time it can cause scar tissue and make it hard for you to get pregnant. Finally, my last question is, do you think because of the pain medication I could have become infertile? I know I will eventually have to talk to the doctor about these issues. Do you know what kind of tests they could do right off the bat knowing my history?

I think it is wonderful that you offer your time to answer these long questions :) Thank you so much!

Answer:

Thank you for your question. You have several questions and issues within your note. I hope to answer each one, but if I miss any, please let me know.

You are 26 years old and that puts you in the highest fertility years of your life. Statistically, 85% of women in your age group will become pregnant by one year of trying. Anyone exceeding that time frame is considered infertile. Since you have not gotten pregnant in 3 years, it seems that there is some type of problem going on. Part of it could be your addition, but as you know, addicts get pregnant all the time. There are probably some other issues going on. Since you are off the oxycodone, I think the Chlamydia needs to be looked at. The bottom line is that you need to have a complete infertility evaluation. This can be done with a general OB/GYN or a fertility specialist. In order to not waste time, I recommend that you see a fertility specialist (someone that does ALL levels of infertility care and treatments).

Chlamydia is a silent bacteria that can damage the tubes causing blockage. If that happens, you are at risk for a tubal pregnancy (ectopic), or will not get pregnant by natural means. You would need to proceed to IVF (in vitro fertilization) if the tubes are blocked.

The basic infertility workup that I do is as follows:

1. Cycle day #2 or 3 hormone panel to check ovarian, thyroid and pituitary function.

2. Hysterosalpingogram (HSG) to check the tubes.

3. Diagnostic hysteroscopy to check the uterus, ovaries and tubes.

4. Pelvic ultrasound to check the uterus, ovaries and tubes.

5. Endometrial biopsy to check the uterine lining.

6. Semen analysis to check the male.

7. Mid luteal progesterone level to check for ovulation.

8. Laparoscopy (if needed) to check for pelvic abnormalities such as endometriosis and scar tissue.

I know that you were being careful, but the failure rate of being careful is pretty high. Since you were not on birth control pills it is a bit troubling that you have not been able to get pregnant. I think you need to undergo an evaluation. I also think you need to be totally honest and up front with your doctor. He/She needs to be able to see all the circumstances and take them into consideration. At this point, if your doctor tells you to keep trying, I would recommend you see another doctor for a second opinion. Chlamydia blocks tubes by causing scar tissue formation within. It is not surgically repairable. The only way to diagnose this is to do a hysterosalpingogram (HSG).

I hope this helps and good luck!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

www.montereybayivf.com

Estrogen Supplement For Thin Lining

Question:

Hello, I am from Canada and I have been seeing a fertility specialist since January 2009. My husband and I have been TTC for 1.5 years and experienced a miscarriage in September 2008, when I had a D&C. My lining has never been above 4.5 mm and is normally about 2-3mm thick. I have been put on 8 mg Estrace daily for the past 2.5 weeks. Ultrasound today showed no change in thickness, and suppression of the follicle size. What is your experience with thin lining and pregnancy success Is there anything else that you would suggest for me to do to thicken my lining?

Answer:

Did you use the Estrace orally or vaginally? If you have not tried it vaginally, that is a more efficient delivery method for the endometrial lining. Orally is the worst. The second best would be estrogen patches.

If you are using them vaginally and your lining is still not developing, that is a problem. It should be getting to a minimal width of 9 mms. Did you have a hysteroscopy to make sure you didn't have scar tissue after the D&C? That could be a cause of a thin lining that doesn't respond to estrogen. Most people will form an adequate lining with estrogen supplementation, so you would be a rare entity. If the hysteroscopy shows evidence of scar tissue then you must proceed to have that removed prior to starting any infertility treatments. It is difficult to do, so you must find a competent specialist to do it who will then schedule an operative hysteroscopy as an outpatient surgical procedure.

I have seen in the literature, reports of people trying nitroglycerine tabs vaginally, Levitra and Viagra to increase blood flow to the uterus and thereby try to increase the lining. They have not worked universally.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com

Amenorrhea and Bulimia

Question:

I have not had a period since July of 2008 and my gynecologist told me that is is not dangerous to NOT bleed, only dangerous to bleed too much. At first, I assumed the loss of the period was because I had started working out so much and lost a decent amount of weight. However, (ironically) after joining the military, I've been less active, but still have not had a cycle. Someone suggested to me that amenorrhea can be caused by athletic activity or eating disorders. At age 16 I was diagnosed with bulimia, but stopped seeing my psychologist shortly thereafter as he thought I was better.

Truth be told, I've never completely stopped the binge/purge cycle because I don't know how to break it. Now I'm afraid I may have affected my cycle after 7 years of abuse. I don't know what to do and this scares me. I can't talk to doctors on my military post because I don't want them to find out about my issues (as this can lead to separation from the service). Does this type of amenorrhea mean infertility? Is there any way to reverse the effects? Who should I talk to or what should I do? Any help is greatly appreciated. Thank you in advance.

Answer:

Hello.

Your gynecologist is incorrect in advising that not having a period is okay. It is not okay for lots of reasons, one of which is that you may have a hormone imbalance that can have negative long term effects on your body. At the very least, you should be cycled on birth control pills to correct the estrogen/progesterone imbalance.

It is certainly possible that if your weight is too low, that is you have a low body fat content, as occurs with professional athletes, the hormones cannot be created because there are no fat cells and cholesterol to produce the hormones. Also, the hypothalamus can shut down so that the hormones are not produced. This is NOT an acceptable situation. Not only can it be a source of infertility, but it can lead to all the problems that menopausal women have.

In terms of your bulimia, that is also abnormal and needs to be treated. You should not worry that the doctors you see will cause you to be released from the military. That is not true. I was a military doctor (US Army) for 9 years. The requirement that all medical information remain confidential (doctor-patient confidentiality) applies to military doctors as well. I would request to see a gynecologist or medical endocrinologist to begin an evaluation or your hormones and get a referral to a psychiatrist. You should get immediate care for both these problems!

Take care of yourself and don't delay. Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
www.montereybayivf.com

Bleeding After Embryo Transfer

In the course of my volunteering as the Infertility Expert on About.com's AllExperts site, as well as here on my own blog, I have had many questions regarding bleeding right after embryo transfer or in the Luteal phase. What follows is an attempt to answer one of the chief concerns that IVF patients have, namely, "What if I have bleeding after my embryo transfer?" 

**For those who wish to COMMENT with questions or observations, please note that the comment section is CLOSED on this post as it has exceeded the limit Blogger allows. Solution: You are welcome to choose any other blog post to comment on "bleeding after embryo transfer" and I will be able to answer you without a problem. Just return to the home page and choose a recent post. This is the most popular blog post because it is an issue that many go through while undergoing IVF, therefore do not hesitate to comment.**

Answer:

The embryo transfer is the most crucial step in the In Vitro Fertilization procedure/process. You can have the best quality embryos, but if they are not placed into the uterus correctly, then pregnancy will not occur. That is why "transfer technique" is so important. There have been studies showing that pregnancy rates can vary by Physicians within the same group, and this is all because of transfer technique. Once the disparities between transfer techniques were corrected and unified, the pregnancy rates became consistent. For this reason, you want to seek out a Physician who has a lot of experience with embryos transfers and comparable good pregnancy rates. If you go to a clinic that has multiple doctors, ask for the pregnancy rates of each Physician or your particular Physician. Although I know that newly trained REI Physicians have to get experience, most don't have a lot of embryo transfer experience from their fellowship. So, if I were paying $10,000 or more for an IVF cycle, I would ask for a more experienced doc to do the transfer. For more details regarding post embryo transfer bleeding, pain and other symptoms, see "What To Expect After Your Embryo Transfer". 

Bleeding, usually bright red blood, with the embryo transfer is an absolute no no. If blood contaminates the endometrial cavity at the time of the transfer, this will kill the embryos and pregnancy will not occur. The catheter must be placed as gently and atraumatically as possible. That is an absolute requirement. The endometrium, which is now in its fullest growth state, thickened from estrogen stimulation, can be easily scraped and cause bleeding.

At our center, we use very soft catheters, very gentle technique, ultrasound guidance and mock embryo transfers preceding the cycle, to accomplish this. The mock embryo transfer or MET is especially important so that the Physician is not learning the curves of your canal at the time of transfer but has worked it out prior. You should have the same Physician who did the MET doing your transfer. This is especially important in patients whom we consider to have a "tortuous" canal, making it more difficult to insert the catheter with care. In this type of patient I will sometimes do the MET two to three times to become well acquainted with their canal.

You should not worry if brown blood or discharge occurs at the time of transfer, it will usually manifest within the first day or so after the transfer, but not into the mid-luteal phase or later. That type of bleeding would be from a different source.

There are situations, however, when bleeding can occur but not be ominous. Sometimes a woman's cervix will bleed easily from being scraped by the speculum or irrigation or wiping. This external bleeding will not affect the endometrial cavity as long as the transfer catheter is not exposed to the blood. For example, I do not let the catheter get exposed until the introducer is well into the cervical canal, near the internal cervical os (entrance to the endometrial cavity), to begin advancing the catheter.

Bleeding that occurs later in the luteal phase, days after the transfer, is very common if vaginal progesterone is used. This has been shown in various studies using Crinone, for example. In my patients, because I use both vaginal and injectable progesterone, it is almost 90%, but the bleeding tends to occur near the time of the pregnancy test or soon thereafter. This is probably caused by some erosion occuring on the external cervix. The exact cause, however, is not clearly understood. It is usually light spotting and can be anywhere from red to brown. Red is newer blood and brown is old blood. In general I tell my patients not to worry about this. The only bleeding that I would worry about is bleeding that is red and heavy like a period. This is not good, and should not occur if the hormones progesterone and/or estrogen have not been discontinued. Some patients will experience slight spotting 3-5 days after embryo transfer and refer to this as "implantation bleeding." Whether or not this is caused by implantation is not known. Implantation should not cause bleeding. However, again, if it is not bright red blood that is heavy like a period, it should not cause worry.

I certainly hope this information will help those of you who have either queried me or who have Googled for some reassurance in this regard.

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

http://www.montereybayivf.com/

Endometriosis and Conception

Question:

Hello, I am 20 (almost 21) years old. I was diagnosed with endometriosis in September of 2007. I had a laparoscopy done, there was too much to be removed. My doctor at the time said that the endometriosis had not affected my reproductive organs, yet, thankfully. From 10/07 to 1/08 I took Yaz birth control to help maintain my disease, it didn't help. So, 03/2008 I started Lupron Depot, every month for six months. My last shot was Sept. 2008, my first cycle was December 2008 which was only 2 days of dark spotting. March was my next cycle and it was very painful and back to normal like my disease is still there just as before the shot. This month (April 2009) I have had my "third" menstrual cycle and it was horrific. My fiance almost took me to the hospital I was in so much pain. I don't to back to my ob/gyn until June. I have called with concerns but they said to wait it out until June.

My biggest concern is being able to get pregnant now. I have accepted that this is the way I have to live with this disease, painfully. Now I am focusing on having a child. I want a baby more than anything but I can't seem to conceive. I am not on birth control or any type of contraceptive, and never have been except the four months before the Lupron. I am so scared that I will not be able to have a baby, and we are trying. I have not resorted to a fertility doctor because I want to try and let it happen naturally first. But, I do not want to wait too long because I know women with endometriosis are encouraged to have children asap.

My question to you is, could my endometriosis have spread during the birth control or Lupron and gone to my ovaries? Should I have another laparoscopy to see if it has spread or if the injections even helped? Would my disease harm my pregnancy if I ever do get pregnant? Is the Lupron out of my system (it's been 8 months)? And lastly, any suggestions on trying to concieve with my disease and also just dealing with my disease in general, especially with that one day a month when I first start my period that is just so painful words can't describe?

Sorry for so many questions but with me being so young, people kind of don't want to help you get pregnant and tell you to just wait or that I am too young to be trying to get pregnant so young. But I feel like its something that I need and want and so does my fiance. We own our own home and financially and mentally feel that we can do this. Now its just making it happen!

Thanks for you time and help.

Answer:

Hello....let me answer your questions one at a time, since there were so many of them.

1.Birth control pills are not a good treatment for endometriosis because they contain estrogen, which feeds the endometriosis. The progesterone component helps a little, but it would have been my last choice. Lupron is the treatment of choice followed by Depo Provera. So, it is very possible, and likely, that the endometriosis has worsened over time. That is in its nature to do.

2. Another laparoscopy would be indicated, but that depends on the stage of endometriosis that was found to begin with. If you had stage III or stage IV, then the laparoscopy does nothing to help your cause (i.e. getting pregnant). In that case, I would go directly to IVF to achieve pregnancy. If you had a lower stage, then repeat laparoscopy with treatment might help you to become pregnant.

3. Endometriosis will not harm the pregnancy. In fact, pregnancy is a great treatment for endometriosis and that is why we recommend getting pregnant as soon as possible. Unfortunately, getting pregnant is not easy with endometriosis. This disease, whether it is on the ovaries or tubes or not, can prevent pregnancy no matter where it is located because it causes the pelvis to be inflamed. That inflammation kills the egg upon ovulation. Therefore, the entire pelvis tends to be a hostile environment.

4. The Lupron is out of your system by now.

5. As I mentioned above, your treatment would depend on the stage of endometriosis that you have, but the bottom line is that you should try to get pregnant as soon as possible. You certainly have options. You could have a repeat laparoscopy, with treatment of the endometriosis surgically, followed by another course of Lupron Depot for 3-6 months, then aggressively try for pregnancy (possibly IUI's ) or you could proceed directly to IVF. Based on the fact that your doctor said he could not get all the endometriosis out in the first laparoscopy, I would presume that you had stage III or IV endo. In that case, the treatment of choice would be IVF. This is the only treatment that can bypass the endometriosis and get you pregnant. The pregnancy will then help your symptoms, because you won't have periods and, it may even CURE the endometriosis (pregnancy is a great treatment for endometriosis). This latter option is what I would recommend for you.

It sounds like you are NOT seeing the right physician. You should not have to wait so long. I would recommend that you see a fertility specialist so that you can become pregnant as soon as possible. The problem with endo is that it worsens with time. You don't want to end up having a hysterectomy, and not be able to get pregnant, because the pain is too severe and you waited too long!

I have had quite a few patients with the same problem that you have. They opted for IVF and got pregnant. Afterwards, they ended up having a child or children naturally as well, all because the endometriosis they were afflicted with had been resolved by their first pregnancy.

I hope this helps.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com

Polycystic Ovarian Disease In Young Woman

I have had many, many questions regarding Polycystic Ovarian Syndrome or Polycystic Ovarian Disease. As an infertility specialist, I see women every week that suffer from either the syndrome or the disease. If not treated, it can lead to serious health problems such as diabetes and heart disease. It can also cause infertility. PCOS or PCOD is common and affects as many as 1 in 15 women. Often the symptoms will begin in a woman's teen years, like the following questioner from Texas.

Question:

Hi Dr. Ramirez,

I am a 19 year old black female in Texas looking for answers. I started having periods at 12, but I have never had a normal, monthly cycle. I generally skip 3-6 months, after which I have a period lasting anywhere from 2 weeks to 3 months. At first, because I am hirsute and I was overweight, it was thought that I had polycystic ovarian syndrome, but I have been tested numerous times for such and I don't have that. During my long periods it was thought that I had uterine fibroids, for which I was also tested negative more than once.

I've lost 35 lbs. but I still have the same issue. Now I have a "bloodless period", with a brownish or clear fluid. I have been to 4 different ob/gyn's, non with a conclusive answer. The reason I post this in the infertility section is because I don't believe I am fertile, but I want to know what is causing my infertility so maybe I can go and get help to resolve the issue.

Thank you so much!

Answer:

You have PCOD. The is NO specific test for this disorder. It is a clinical diagnosis, which means that it is based on the signs and symptoms. If you have hirsutism, increased weight and very irregular periods, that is enough to make the diagnosis. PCOD has a wide variety of presentations. Some will have an FSH/LH imbalance on blood testing, but not all. Some will have irregular periods, but not all. Some will have increased hair growth, but not all. Some will have elevated insulin levels, but not all. The point is, your doctors are wrong. You have PCOD.

Therefore, you should be on the birth control pill to control your cycles. The problem with PCOD is that the ovary is dysfunctional and not processing FSH and LH correctly. Because of the dysfunction, it does not lead to ovulation and estrogen and progesterone are not produced. Instead, the precursors, the chemicals that usually are made into estrogen and progesterone, proceed to making testosterone, a male hormone. That leads to the increased hair growth, hair loss, obesity etc. By using the birth control pill, the ovaries are shut down, so that no testosterone is formed, and the estrogen and progesterone replace the hormone that you are not producing. The best pill for this purpose is Yasmin because the progesterone type, Drospirenone, blocks the testosterone receptors as well.

There are fertility issues with PCOD patients because they are not ovulating, which means, they are not giving off an egg each cycle. Those patients need to use fertility medication to get the ovaries to ovulate. Once ovulation is resumed, they have a normal chance of getting pregnant.

I hope this clarifies things for you. You might want to see a Reproductive Endocrinologist because this kind of doctor specializes in women's hormonal disorders and understands PCOD.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

Check me out on Facebook http://www.facebook.com/ejramirez and Twitter with me at @montereybayivf

Ovarian Cysts

Question:

I am writing from Melbourne, Australia.

After two months of erratic menstruation, I was referred for an ultrasound which found the following: "The uterus is of normal contour with a normal endometrial echo. Both ovaries were visualised with a large dominant follicle on the left measuring 3.9cm in diameter. There is no septation or other change to indicate it is a pathological cyst. Follicle development is also present on the right ovary with the largest follicle measuring 1.6cm in diameter. There is no free pelvic fluid or other change."

My doctor has advised I wait and book for another ultrasound in 3 months time.

Should I follow this advice or seek a second opinion from a different doctor?

Answer:

Hello,

I don't think you need to wait three months. You should have an ultrasound done within the first 7 days of your next period to see if the cyst is still there. If it is, I would recommend a one month treatment with the birth control pill then another repeat ultrasound. If it is still there after that, then it is probably not a physiological cyst and needs to be removed by laparoscopy.

Sincerely,

Edward J. Ramirez, M.D.,FACOG

Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

Serious Post-Partum Accreta, a D&C & Now No Period...Asherman's Syndrome?

Question:

I am a healthy 28 year old who has never had any reproductive issues. I gave birth to a healthy baby in the spring of 2008. She was my third. At birth, I heard the doctor say, "Hmmm, funky placenta." The nurse looked and agreed. I later found out that it was "lobulated", but that was normal.

I went home after 1 day and all was well. Exactly 2 weeks later, when I was laying the baby down in her bassinet after a 3:00 am feeding - something "burst" and it felt like a a bucket of liquid was dumped between my legs. I had stopped the postpartum bleeding a few days earlier, and that had been light without clots the whole time.

All of a sudden it was like a faucet of bright red blood. I ran to the bathroom and was shocked by the sight of the gushing blood. I sat on a pile of towels on the floor and tried to stop the flow. The ambulance came and rushed me to the ER (30 min away). The doctor there decided that I had retained a piece of placenta and a D&C was to be done. No big deal, 30 min. procedure.
I woke up 5.5 hours later with my doctor at my bedside with a very serious look on his face. It turns out that I had accreta and they had to perform a very aggressive D&C. They could not even do a hysterectomy because I had no blood to spare. I lost 4.5 L in the OR alone. He said that he's not sure how the bleeding finally stopped, or how I lived. He had never experienced placenta accreta, nor had any of the docs in the clinic.

Anyway, after a few days in the ICU, I went home and everything has been great.

EXCEPT...it has been 6.5 months since my D&C and I have not had any period - not one drop. I was birth control pills for 3 months and nothing. So, I went off them a few months ago. Nothing. My hormone levels were checked and I had borderline hyperthydroidism, which at my most recent test seems to be correcting itself. My doc thinks this is the reason for my lack of menses.
However, I do not. I am thinking Asherman's Syndrome. He has not examined me at all since the procedure. I feel that a "borderline" hyper-thyroid (w/o symptoms) would not cause a complete stop to my period. It's hard to put in words, but I can feel a kind of crampiness or pressure in my abdomen (not a period kind). Some sexual positions are uncomfortable or painful. And the last time sex was painful, there was a spot of bright red when I wiped. And that was it. So, new blood. It seems to me that would signify something with my cervix...maybe scar tissue?

I am afraid that the hyper-thyroid will mask the true problem. I am not worried about future fertility, but more about my health in general.

What is your opinion?

Answer:

Hello,

You are wise beyond your years, and maybe even smarter than your doctor. It sounds clearly like Asherman's Syndrome. Let me say first, that it is amazing that you are still alive, and still have your uterus at that. What you went through is a very scary event and in many cases, fatal. Whatever your docs did, they did well, and saved your life. Be very appreciative of that.

There are two possibilities for the lack of menstruation. One is Asherman's Syndrome. This is a situation where the aggressive D&C causes scar tissue formation in the uterus. As a result, the uterine lining is unable to form and hence there is nothing to slough at the end of the month (no period). This is how endometrial ablation works to stop bleeding. The only worry I would have in this scenario, is that your cervical os (outlet) is blocked, in which case you could be having some bleeding, but it is staying within the uterus. The reason for this suspicion are the symptoms of cramping and uterine tenderness. Basically, because the uterus can stretch , it will continue to fill and fill and fill. This is called "hematometria". The easiest way to make this diagnosis is with a vaginal ultrasound. To make the diagnosis of Asherman's syndrome, you need to have a procedure called a hysteroscopy. This is where a small scope is passed into the uterine cavity to examine it. If the cervix is blocked, dilating the cervix in preparation for the hysteroscopy will open it up and the blood will be able to be discharged. If you used the birth control pill and didn't bleed, then the uterus has to be highly suspected because the birth control pill works directly on the uterine lining.

The second possibility is that excessive vaginal bleeding postpartum can lead to a pituitary dysfunction, leading to the lack of hormone production. This would result in the loss of menstruation (panhypopituitarism). That is checked for by hormone testing. If the hormones are all normal, then this diagnosis is ruled out.

I hope this answers your questions and gives you some information to take to your doctor. Please make an appointment to see him soon!

Good luck,

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

Clomid Protocol Not Working

Question:

Hello!

First of all, thank you for being available to answer questions for all of us. I have taken Clomid twice now. The first month I took it I was on 50mg 5-9 and I ovulated on cd 21 with a progesterone level of 19. I have 33 day cycles. The second cycle I was on 100mg 5-9 and I used my Clear Blue Easy monitor and it never peaked just stayed on high. Then I had my progesterone test and it was only 7. But then my OB gave me 100mg again for the next month. Shouldn't I still be on 50mg if that worked better??

I am also thinking about taking the 50mg days 3-7 instead of 5-9 since it is my last month being able to take it according to my OB. On top of the Clomid, she also gave me Estrace (not sure if that is spelled right) to take days 8-12 and Prochieve to take days 16-28. So if I take the Clomid days 3-7 do I take the other meds on different days?? Also, a little background, I have one child conceived naturally, I am overweight but don't have PCOS and don't have blocked tubes (I was tested for both). If there is any way you can help me with my situation it would be very helpful!

Thanks again!

Answer:

Hello,

Although the Clomid worked the first cycle, I too would have increased it to 100mg to get your cycles more normal and shorter. It is possible that the Clomid at 50mg was barely effective, and worked by luck only. That would explain why the 100mg did not work.

I also do not advocate the method your doctor is using. I am a firm believer in the ultrasound surveillance to evaluate whether or not the medication is working, how many follicles there are and to time ovulation. That is a lot more information that your doctor is getting. I also automatically use progesterone with my Clomid cycles to help implantation and support the pregnancy. Sometimes, Clomid can also cause the uterine lining to be thinned, however, your doctor should be checking this with an ultrasound rather than treating empirically, as I've mentioned before.

Finally, whether you take Clomid on days 3-7 or 5-9 does not make any difference in stimulation.

My protocol is as follows with Clomid:

1. Cycle day 2-5: Baseline ultrasound to rule out residual ovarian cyst, give Clomid calendar and prescription.

2. Stop recreational intercourse on CD #10.

3. Start ultrasound surveillance on CD #11 and continue as frequently as needed to determine when the follicle is appropriate size for ovulation. This also rules out a super-multiple (three or more) pregnancy potential. If there are more than three follicles, we cancel the cycle and prevent pregnancy.

4. When the lead follicle reaches 20-22mms, HCG (Ovidrel) is given to stimulate ovulation.

5. Have intercourse daily, once per day, one ejaculation per day beginning the day after HCG, for four consecutive days.

6. Start progesterone five days after HCG and take daily until the pregnancy test.

7. Do pregnancy test (serum) in two weeks.

I hope this helps. Please discuss your situation with your OB and get a second opinion if necessary.

Edward J. Ramirez, M.D.,FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

Hydrosalpinges and Miscarriages

Question:
I am 34 years old, writing from Australia. I have had one child (3 years old) and two miscarriages. The first miscarriage (embryo stopped growing 6.5 weeks) on Jan. 09, the second Nov. 09 (9.5 weeks). Just before I became pregnant with the most recent one, I found out I had bilateral hydrosalpinges that showed up on the transvaginal ultrasound.

We were considering having surgery to remove the fallopian tubes ( on the advice of an IVF specialist) then start IVF, when suddenly we found out we were pregnant. Unfortunately, at 9.5 weeks I had a miscarriage.

We are awaiting results of tissue testing to determine if chromosomal abnormality exists. We are also booked in for a repeat ultrasound.

1. Does having bilateral hydrosalpinges cause you to miscarry at 10 weeks pregnant? If so, by how much (i.e. what %)? Gyn says they do not make you miscarry but more likely to not allow implantation.

2. Would the preferred option be to clip them, or just remove them and commence IVF even though I have gotten pregnant naturally? Or would the best option be to give it one more go naturally?

Any other advice would be appreciated.

Answer:

Hello,

You present a very interesting scenario because women with hydrosalpinges usually cannot get pregnant. The reason is because the cause of the hydrosalpinges is a tubal infection that caused the damage to the tubes. Not only did it cause the tube to be obstructed, but it even usually leads to damage of the inner lining of the tube that is important for egg and sperm transport. Therefore the recommendation is to proceed with IVF. Your case negates that thinking.

Hydrosalpinges can lead to non-implantation, and by the same mechanism, miscarriage. It is thought that the hydrosalpinx has inflammatory fluid within that migrates back into the uterus. Several studies have found decreased pregnancy rates in IVF when hydrosalpinges are present. That is why it is recommended to clip the tubes or remove them prior to IVF. This inflammatory fluid causes a mild inflammation of the uterine lining causing the lack of implantation. If implantation were to occur, I would expect that the same inflammation could lead to the death of the embryo from a mild amnionitis. That, however, is theoretical.

Because you have shown that you are the exception to the rule, you have two options. You can have a laparoscopy and have the tubes opened (salpingoplasty) or you can have the tubes clipped/removed. If the tubes are opened, you have the opportunity to become pregnant naturally, like you showed that you could. It would allow the fluid to escape into the abdomen, thereby reducing the chances of backflow into the uterus. However, if there is tubal damage within, you are at increased risk of a tubal pregnancy called an ectopic pregnancy. That can be life threatening if it ruptures and you hemorrhage. The second option, which then requires IVF is certainly the safer option, but the more expensive option. You need to discuss these two options with your docs.

If I were counseling you, I would almost be inclined to recommend the former (tubal repair) as long as you were completely aware of the risk of ectopic and willing to take that chance. I would then watch you very closely if you were to become pregnant to rule out the ectopic at the beginning of your pregnancy.

I hope that this answers your questions.

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

Secondary Amenorrhea...Low Estrogen?

Question:

Hi! I'm writing from the UK and hoping I can finally get some answers!
I had my last depo provera in Dec 2008. This ran out in March, and I had a light menstrual bleed in April but nothing since. It is now November!

My husband and I are wanting to conceive so in July we went to my GP and I was given Noresthisterone, 3 times a day for 10 days. I did NOT get a withdrawal bleed. I had some blood tests done, and I was told by a lucum doc that they were all normal. But in my opinion he didn't look sure, as he kept looking at them.

I have read that if you don't get a withdrawal bleed it could be due to low estrogen. Do you think this could be the case with me? And if it is, what would be the next step? I am desperate for my menstrual cycle to return so we can start to conceive.

Can you give me any advice, or anything that I could ask my doctor about? Many thanks!

Answer:

Hello,

You are correct in that if you do not get a withdrawal bleed after progesterone (Norethindrone), then that indicates that the uterus was not primed i.e. you did not have estrogen aboard to create an adequate uterine lining. Hormone testing would be the first check. Unfortunately, the FSH, LH test needs to be interpreted, not just checked against the laboratories normal and abnormal. A woman cna have an abnormal level but be within the normal limits for the laboratory testing results. For example, the FSH level could be 35, indicating ovarian failure or menopause, yet this is within normal testing limits. The reason this is important, is because if the FSH level is elevated, that indicates that you ovaries have shut down. An example of this occurring at a young age is called premature ovarian failure. In this case, you will be unable to become pregnant naturally, and without using an egg donor. I am not saying that is what you have, but the hormone test is very important to know where you stand.

Most likely, you have an ovarian dysfunction, whereby the ovary is not working correctly so that you are not ovulating and not producing estrogen. This is the most common reason. The FSH and LH levels would be normal and less than 20. In this case, you will need fertility medications to stimulate the ovaries to ovulate so that you can become pregnant.

I would recommend that you see a fertility specialist if you can. He/She will be able to make the diagnosis and recommend an appropriate treatment. A GP cannot do those and does not have the appropriate knowledge base to help you.

Sincerely,

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

Low Ovarian Reserve & Previous Placenta Accreta

Question:

Hi, I had placenta accreta with my son's delivery in 2007 and lost quite a bit of blood. I did keep my uterus but had to have uterine embolization to stop the bleeding. My doctors alsways said to wait 2 years before trying to conceive, but after seeing numerous doctors recently, I was told I would be risking my life again to consider another pregnancy. I also have a large fibroid about 4 centimeters in my uterus along with a distorted uterus.

The doctors feel the embolization probably caused my ovaries to stop functioning, or even the massive blood loss could have caused it.

We have looked into surrogacy but found out that I have very small ovaries, about 1 centimeter each and low ovarian reserve. The doctor did an ultrasound and said there was blood flow, but feels I am pre menopausal. I went off birth control pills in January and was tested in February. My FSH was 9 and my estradiol was 9. I did 3 days of injections (45) and the doctor only saw one follicle so said to stop treatment. In March, My FSH was 16.75 and E2 was 10. The doctor saw 2 follicles on day 2. The doctor said if I did a full round of IVF the chances would be very low and the quality most likely low. The plan was to do IVF and then have a surrogate. I went to a doctor this week that said I could try knowing the chances are low and to retrieve the eggs, even if there were only 1 or 2.

I am not quite ready to give up, we have also considered egg donor. I am 36 years old. Any suggestions or success rates would be great. Thanks so much!

Answer:

Hello,

I am sorry to hear about your experience. It sounds like you have very low ovarian reserve as demonstated by an elevated FSH level and poor response to stimulation. Certainly, your best option would be donor eggs. That would have a 34 - 63% pregnancy rate per IVF attempt depending on the clinic (our program is 63%). Of course, there is the alternative of trying with your own eggs. Because the stimulation would be low i.e. few eggs retrieved, the chances would go down, but there is still a chance. I have done many older (older than you) patients that have only had one egg produced, one retrieved, one fertilized and one transferred and gotten pregnant and had a baby. So in my opinion, it is more a personal decision on whether to try with your own eggs, al long as you know that the chances are reduced. There is not a specific statistic for your case that I can quote as no one has looked at pregnancy rates based on the number of eggs retrieved. In your age group, I average replacing 3 embryos with a pregnancy rate of 50%. It would probably be less if only one was replaced. European data, where they only transfer 1 embryo, shows pregnancy rates of approximately 33% in your age group. That assumes a higher number of eggs retrieved, fertilized and available to choose from. In any case, I think that if money were not an issue, and you were willing to try with your eggs at least three times (you might even need more), knowing that the chances are significantly reduced, then you should give it a try. If it fails, at least you know that you gave it your best shot, and will be ready to go to donor eggs. I certainly would allow you to have that opportunity in my program.

In terms of your pregnancy risks, you are certainly at risk for a recurrent placenta accreta if you were to become pregnant. However, that can be mitigated by being followed closely and planning for a hysterectomy at the time of cesarean delivery. I would not recommend an attempt at natural delivery in your case. I would also recommend that you consider having the fibroid removed prior to any IVF cycle to maximize the chances that they will not interfere with the IVF cycle or pregnancy. Regarding the surrogacy option. Certainly surrugacy is a good alternative and would eliminate the problems with your uterus, whether you choose to use your eggs or donor eggs. If you go this route, be sure you go with a reputable agency and retain the services of a surrogacy lawyer.

I hope this helps!

Edward J. Ramirez, M.D.,FACOGExecutive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

Nervous First Time IVF Patient - What To Expect On Retrieval & Transfer Days

Oftentimes, first time IVF patients become very worried about how painful the procedure will be. The retrieval should not be painful at all, since it is usually done under some kind of anesthesia. In fact, all the shots that the patient has had to go through prior to retrieval and will continue to do after the transfer are more painful! (The photo above is of a human embryo implanting itself into the endometrium.)

Question:

I'm a little nervous about my upcoming IVF cycle. I'm wondering how much pain I'll be in after the egg retrieval and whether I'll need to take the following day off from work. Also, for the transfer, is there any pain associated with that, and should my husband come with me? Would I need to take the following day off of work with that? Thanks for your expertise.

Answer:

Dear S.,

Unknowns always cause worry. All my patients have gotten through it just fine and I don't have even one patient that regretted the procedure, even if they didn't get pregnant.

It is a difficult procedure, however, because it is regimented, pre-procedure you have to take shots daily and it is emotional. We do the retrieval under anesthesia so you don't feel a thing. Not all clinics do, however, and it does hurt quite a bit if you are not under conscious sedation. After the retrieval you will have pelvic soreness like a strong period. For most patients it is tolerable with Tylenol, Motrin and/or a heating pad. It usually doesn't last more than that day but some patients are sore for a couple of days. The soreness is very tolerable and they usually can go to work the next day without a problem. You will only need to take the day of the retrieval off.

The transfer is a piece of cake! It is like doing a pap smear (which hopefully hasn't hurt you in the past). You should not feel anything. Your husband should be there with you to give you support. After all, he will want to be able to say that he was there when you conceived! I usually recommend my patients to take 3 days off after the transfer in order to lounge around and minimize their activity. Implantation will take 24 hours to 3 days to occur depending on the stage that the transfer occurs. After the 3 days you can go about normal activity, but I recommend light activity, which means no exercise, strenuous activity or sex.

Hope this helps and don't worry, you're in good hands!

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf

To Do Or Not To Do IVF at 42?

Question:

Dear Dr. Ramirez,

I am writing to you from New Hampshire. I am 42, FSH 6, and just completed my first failed IVF cycle using the microdose flare protocol, lupron plus 300 Gonal F and 300 Repronex, stimulated for 11 days. Ten eggs were retrieved, 3 fertilized with ICSI/AH (intracytoplasmic sperm injection/assisted hatching) and 3 were transferred on day 3. Although my RE noted that over 50% of the oocytes were abnormal (likely to be age related with large debris in the perivitelline space), she is now recommending a patch protocol, with the same meds/quantity used in the first cycle. Do you think it would be worth trying another cycle, or should I be realistic and go straight to donor egg or adoption?

Answer:

Hello,

The "age factor" is not an absolute, meaning there are pregnancies in your age group. What you need to decide is how much you want a child with your genetics and how much you want to try and can afford. In your age group the chances of pregnancy are approximately 25% per cycle. So, it means that you may need to try several times before you are successful. This could be up to 6 attempts before you would be successful with your own eggs. On the other hand, the pregnancy rates for donor are 63% in our program. The chances of pregnancy with one attempt are over 50% as well, so with donor eggs, you have a higher chance of becoming pregnant with fewer attempts. The downside is that the baby would not have your genetics. How important is that to you?

Many of my "older patients" will try up to three times, to convince themselves that they have given their best efforts then resort to donor after. I have had many older patients that have only had one egg produced, one retrieved, one fertilized and one transferred and gotten pregnant and had a baby. I cannot comment on your medication protocol since every patient is different and it is up to your RE to decide how you responded to the first cycle and how to "tweek" it.

How to proceed from here is purely a personal choice. In terms of my recommendations, if genetics is not a big concern, then if cost is an issue, go to donor, if it is not, then try at least three times with your own eggs. The good thing is that your ovaries are still responding well to stimulation. Getting a lot of eggs is the key to overcoming the "age" factor!

Good luck and don't lose heart!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

check me out on Facebook and Twitter with me at @montereybayivf

Fertility Possible After Chemo and Radio Therapy

Question:
Hi, I am a 29 year old women who suffered 5 years ago colorectal cancer. I went trhough radio/chemo treatment, and I also got my ovaries moved up to avoid direct exposure to radio, I also got a monthy injection to protect my overies from chemo, finally I got surgery with result of a permanent colostomy. I got recently interested in knowing my possibilities of pregnancy, and just made hormonal blood test. That was made on the first day of my menstruation, and results are: LH 7.17 mUI/ml, FSH 12.5 mUI/mL; Beta Estradiol 29.2 pg/mL and prolactina 13.4 ng/mL. I have not gone to my ginecologist yet, but seems like my FSH is a little bit too high. Can anyone give me a glimpse if I am allright?
Cheers, CE from Spain

Answer:

Hello CE from Spain,

Based on your hormone tests, you still have normal ovarian function. That is, you are still ovulatory. However, the FSH level is elevated from a fertility point of view. We generally like the FSH level to be 7 or less. We worry when it reaches 10 or above. This elevated FSH level normally indicates that the ovaries would be resistant to stimulation if IVF were performed. What that means is that even with high dose fertility medications (which is FSH), the ovary may not stimulate well and few eggs would be retrieved. It is also an indication that time is not on your side so if you are going to get pregnant, you should do it soon.

The analogy I use for patients to explain FSH levels is like this: Imagine that the ovary is a ball with lots of holes in it (like a golf practice ball) so that it allows fluid to easily pass through into the center. That fluid is FSH. Now, imagine that more and more of those holes get blocked, so that less and less FSH can get into the middle. That would then leave more and more FSH on the outside (your blood), so that the levels increase. That is basically what is happening.

The other worry I would have with your history is the egg quality. Although precautions were taken to try to preserve the eggs from harm from radiation, chemotherapy can also damage the eggs, so that may be a major deterrent to getting pregnant.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

check me out on facebook and twitter with me at @montereybayivf