Question:
Sorry for the long question but I wanted to make sure you had a good picture.....
I am 38 year old and have been trying to get pregnant for a while. I got pregnant using clomid and HCH shot but had a pregnancy lost in 2007 at approx 24 weeks. I did a thrombophilia work up and one of my clotting factors was borderline so the action that I was to go on blood thinners with a next pregnancy. High FSH has been a problem as it peaked at 20.23 during one cycle when I was doing the IUIs. I had to date 3 unsuccessful IUIs and two cancelled IVF due to empty follicles. The first IVF cycle I had two follicles after using Lupron in the beginning and then repronex and gonal F for several days and finished with Novarel HCG shot.
The second attempt my RE did a different approach. I was placed on birth control for one cycle and the next cycle I start with clomid and then repronex and gonal followed by ganirelix and the last norvarel shot before retrieval. Note that my FSH was 8.8 but estradiol was high at about 90 so that made my FSH skewed. I had four follicles (the most I had have) and they were all empty. I was concerned that the shot was given properly but my RE said that does not have anything to do with them being empty. After the miscarriage I was always taking baby aspirin but no heparin.
Mentally I am not ready for donor eggs and my husband has flat out said no. I want to exhaust all options before I give up. As you would say, "pull out the full court press". I want to try one more cycle but I have doubts whether I should try again with this RE or try someone else. Can you shed some light on the empty follicle syndrome and if I have a chance? I am so desperate that I am trying acupuncture and herbs while I am on "ovary rest" break.
Answer:
Hello Patrice from the U.S.,
"Empty follicle" syndrome is a description/name of a condition that is found when no eggs are retrieved from obviously adequate sized follicles. It can occur at any age, but seems to be more prevalent the older one gets. So, a woman in her 40's could still have regular menstrual cycles and ovulation, but no egg will be ovulated so pregnancy does not occur. With IVF, we find this when we go to retrieve and get no eggs back. It is thought that this is the "normal natural condition" in the aging ovary. A woman essentially runs out of eggs. However, that does not seem to be the case in younger woman, since younger women stil have a full complement of eggs. So, "running out of eggs" does not seem to be the whole answer.
I have had several cases of empty follicles in both younger and older women. In the younger patients, I have concluded that they did not get adequate HCG stimulation. Previously I had used a generic HCG and worried that it was not produced properly or suffered some type of inactivation in shipping or storage. I therefore switched to Ovidrel. Since then, the incidence of empty follicles has been resolved except in a couple of exceptions. I had two moderately obese young woman have a very poor retrieval despite lots of follicles (both were PCOD patients). By poor retrieval, I mean that there were either no eggs or we only retrieved 1 or 2 eggs despite 25+ follicles. They had given the Ovidrel as instructed, into there belly. In the subsequent cycle, I had then give it in the back of the arm where there was some fatty tissue but much less than the abdomen. They then had good retrievals. This lead me to suspect that HCG stimulation was the problem, and that the increased fatty layer of the abdomen did not allow adequate absorption of the HCG, therefore the eggs did not release to be retrieved.
In your case, with an elevated FSH level, your age and poor ovarian stimulation, the problem may actually be a lack of eggs. However, you did not mention your weight so you might want to look at that possibility. In addition, you may not be stimulating well if you are not getting a large enough dosage of medication. For example, I use a total of 600IU of gonadotropins in the combination 450IU of Follistim and 150IU of Menopur. Are you using that much? If you are, then the poor stimulation is because of ovarian resistance as manifest by an elevated FSH level.
You certainly have the option of continuing to try with your own eggs if that is your only choice (per your husband) and you can afford continuing to try, AND you doctor agrees to allow you to keep trying. However, based on the cycles you have had, realistically Donor eggs is your best option, and the most cost effective since you would probably get pregnant quickly. Using your own eggs is a long shot.
If you don't think that your doctor is giving you an adequate chance, or being aggressive enough, then you certainly can consider changing doctors. The Doctor-Patient relationship is based on TRUST. If you don't have that trust, then you need to move on. If you trust your doctor's abilities then stick it out, albeit, every clinic and doctor have different protocols and treatments for difficult cases so that must be a consideration as well.
If you were my patient, as I mentioned, I would have you on 450IU follistim/150IU Menopur from the start, Aspirin 81mg per day from the start, Medrol 16mg per day from the start, Heparin 2000U twice per day from the start, Estrogen patches and progesterone from retrieval on and I use Ganerelix once the follicles reach 16 mms, NOT Lupron which will inhibit the ovaries from the start (called the long protocol).
I hope this gives you some information to think about.
Sincerely,
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
Friday, August 28, 2009
Trying for Pregnancy. . . Thank You! Success at last!
QUESTION: I have been trying to get pregnant for 7months. My period is regular every 26 days. Ultrasound and sperm tests indicate normalcy. I was given Clostilbegyt 50mg to take on day 2-6 and Provera for 10 days fron day 16. Does this sound correct? Won't Provera induce a period and stop me from getting pregnent. Oh I'm 33.
ANSWER: Hello,
I hate to see these type of questions because it shows that the doctor you are seeing is not treating you appropriately. Have you had all the infertility testing done? Hysterosalpingogram, Hormone testing, Hysteroscopy, Laparaoscopy, Midluteal phase progesterone level. If not, then you shouldn't be jumping to Clomiphene. For one, if you have regular periods, ovulation is not the problem, although you may have a hormone problem as manifest by a short menstrual cycle. The only other reason is to try "something" since there doesn't seem to be a reason for your infertility. Many general docs give Clomid because they can, and not for any good reason, thinking that because it is a "fertility drug" it will help you to get pregnant. That is incorrect thinking. It should only be used for a specific reason i.e. it is treating a specific disorder.
Technically, if you are under 35 years old, you would not be considered to have an infertility problem yet, because you have only been trying for 7 months. We don't consider a person to have an infertility problem until they have not been able to become pregnant for over one year. If you are over 35 then we shorten that time line. In women under 35 years old, it takes 8-12 months for the majority to achieve pregnancy naturally. So you may just need to keep trying on your own for a while longer. If your cycles are 26 days, then you are ovulating around day # 12, so you should start having intercourse on day # 10 for 5 consecutive days.
Provera is not used with fertility because it is a "synthetic" progeterone. We only use natural progesterones like Prometrium, Endometrin, Progesterone in oil, when augmenting the luteal phase for fertility treatments. That is what me suspect that your doc doesn't have all the knowledge required for your treatment.
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
---------- FOLLOW-UP ----------
QUESTION: Great news, I am now 6 weeks pregnant after following your advice. However, before I got pregnant I had a yeast infection for almost three months. My doctor gave me Canesten tablets and inserts and that did not work.It eased the symptoms for two days and then they returned. She then gave me Flagyl tablets for both my husband and I for ten and five days respectively ( 3 tabs per day). I was also given Klion to insert every night for ten days. That last dose of medication was a nightmare as it caused severe pain and irritation, I stopped after five days. Now I'm still having some irrtiation and itching and extremely painful sex on penetration and afterwards. My new doc gave me Travogen cream and it has helped a little with the itching but sex is still painful. Is this normal? Is it that I may have something more serious? Can this affect my pregnancy? I'm really worried.... please advise me!
Answer:
Hello Rhonda from Trinidad-Tobago,
Congratulations!!! :) :)
If you have symptoms, then you need to be checked and have cultures done. It may be a simple yeast infection that can be treated easily, or something else. Don't go the trial and error route like your doctor did previously. Have the cultures done so that he/she knows exactly what to treat, especially since you are pregnant. There are some medications that you don't want to take at this time. Sex should not be painful, but since you are newly pregnant, you might want to avoid sex until you are further along (12 weeks gestational age).
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
ANSWER: Hello,
I hate to see these type of questions because it shows that the doctor you are seeing is not treating you appropriately. Have you had all the infertility testing done? Hysterosalpingogram, Hormone testing, Hysteroscopy, Laparaoscopy, Midluteal phase progesterone level. If not, then you shouldn't be jumping to Clomiphene. For one, if you have regular periods, ovulation is not the problem, although you may have a hormone problem as manifest by a short menstrual cycle. The only other reason is to try "something" since there doesn't seem to be a reason for your infertility. Many general docs give Clomid because they can, and not for any good reason, thinking that because it is a "fertility drug" it will help you to get pregnant. That is incorrect thinking. It should only be used for a specific reason i.e. it is treating a specific disorder.
Technically, if you are under 35 years old, you would not be considered to have an infertility problem yet, because you have only been trying for 7 months. We don't consider a person to have an infertility problem until they have not been able to become pregnant for over one year. If you are over 35 then we shorten that time line. In women under 35 years old, it takes 8-12 months for the majority to achieve pregnancy naturally. So you may just need to keep trying on your own for a while longer. If your cycles are 26 days, then you are ovulating around day # 12, so you should start having intercourse on day # 10 for 5 consecutive days.
Provera is not used with fertility because it is a "synthetic" progeterone. We only use natural progesterones like Prometrium, Endometrin, Progesterone in oil, when augmenting the luteal phase for fertility treatments. That is what me suspect that your doc doesn't have all the knowledge required for your treatment.
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
---------- FOLLOW-UP ----------
QUESTION: Great news, I am now 6 weeks pregnant after following your advice. However, before I got pregnant I had a yeast infection for almost three months. My doctor gave me Canesten tablets and inserts and that did not work.It eased the symptoms for two days and then they returned. She then gave me Flagyl tablets for both my husband and I for ten and five days respectively ( 3 tabs per day). I was also given Klion to insert every night for ten days. That last dose of medication was a nightmare as it caused severe pain and irritation, I stopped after five days. Now I'm still having some irrtiation and itching and extremely painful sex on penetration and afterwards. My new doc gave me Travogen cream and it has helped a little with the itching but sex is still painful. Is this normal? Is it that I may have something more serious? Can this affect my pregnancy? I'm really worried.... please advise me!
Answer:
Hello Rhonda from Trinidad-Tobago,
Congratulations!!! :) :)
If you have symptoms, then you need to be checked and have cultures done. It may be a simple yeast infection that can be treated easily, or something else. Don't go the trial and error route like your doctor did previously. Have the cultures done so that he/she knows exactly what to treat, especially since you are pregnant. There are some medications that you don't want to take at this time. Sex should not be painful, but since you are newly pregnant, you might want to avoid sex until you are further along (12 weeks gestational age).
Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Friday, August 21, 2009
Endometriosis surgery or Pregnancy?
Question:
I'm 35 yrs old from California. Never had kids and planning on having one, hopefully soon! My husband and I have been trying to conceive for approx. a year with no luck. So the frustration (and old age), has led me to see a doctor. A month ago, ultrasound has shown that I’ve 2 cysts on my left ovary (sizes: 2.1cm and 2.5cm) and so I've been diagnosed with endometriosis (endometrioma). According to my doctor, is severe stage (didn’t specify level) Usually, I have no pain during my periods. Since my priority is having a baby, my doctor gave me the choice of either having the surgery first and then try to conceive, or try to get pregnant first (by using fertility aid, for like 3 months) and then go for the surgery. And that’s my dilemma.
1. What are my chances of conceiving with endo? He said that the endo will melt away if I get pregnant so I’m having a hard time deciding.
2. Will my chances of conceiving decrease after the surgery? Also, I’m worried about:
3. type of surgery: According to my doctor, he’ll not perform a laparoscopy (which is more common and recovery is faster), but a traditional incision surgery. I wonder why? I believe it’s the size of my cysts? Or maybe the cysts are not benign? (He said they were benign!) although there was something unusual about the cysts : they were still present on my ovary when I was having my period. He said they shouldn’t be showing on the ultrasound during that time.
4. will the surgery damage/deteriorate /affect my reproductive system?
5. Time. I’m going to be 36 early next year and the chances of conceiving will decrease if I do surgery firstPlease advise!!! Time is sensitive and I cannot come to a decision, I’m so confused!
Here’s some extra info that might help: I’m 5’3, 115 lbs. Every visit, I have a close to high blood pressure (135/90). On my 3rd menst.day, test showed FSH of 8.9 (which is close to bad) and around ovulation my estradiol was bad: 128.0. However, I ovulated by myself and size of egg was OK. My husband sperm test was good.I don’t know if stress can affect the results of my blood test, but I was going through some difficult times since I was diagnosed with endo (lost my job and my father had a terrible accident, all happening within 2 weeks)I appreciate your help and I thank you so very much in advance.
Answer:
Hello Sarah from California,
Prior to answering your questions specifically, I would strongly recommend that you go have a consult with a fertility specialist. I think that you can be counseled better that way. I am presuming that your doctor gave you the diagnosis of stage IV endometriosis (severe) based on the presence of the presumed endometriomas. This was seen on ultrasound but not based on a laparoscopic evaluation. Endometriosis can only be staged by laparoscopy and endometriomas can only be diagnosed by tissue biopsy obtained from laparoscopy. That being said, there is a high likelihood that your doctor is right since endometriomas have a certain look on ultrasound and the presence of endometriomas usually means severe scar tissue formation in the pelvis, which is stage IV endometriosis. However, that is all a presumption before the fact (as attorney's like to say).
In answer to your questions:
1. 20% of patients with infertility have endometriosis (1 in 5). Most of these patients will conceive, although the method will vary. There is no specific statistic for endometriosis. Studies have shown no relationship between stage I and II endometriosis and infertility, but there is definite reduction of fertility with stage III or IV. If you have stage III or IV endometriosis, IVF is the treatment of choice because the pelvis has been severely altered.
2. Your chances of conceiving can increase after endometriosis has been removed surgically and if you are treated with medication for a 3-6 month period after. However, this is very dependent on the type of surgery you will have. From the type that you say your doctor advises, there is a high risk that the surgery itself may compromise your fertility by increased scar tissue production and damage to your ovaries and tubes.
3. I would NOT recommend the type of surgery that your doctor recommends if it is for fertility. He is probably assuming that there is going to be severe scar tissue formation in the abdomen and the only way that he can remove the "masses" is through an open procedure. However, I usually will approach this by laparoscopy first to see if it is possible to remove by this less invasive and less destructive method. If it is not possible laparoscopically, then I schedule for an open procedure at a later date. The problem with the open procedure, other than the increased risks, hospital days and recuperation, is that it can be a more complicated procedure leading to more tissue destruction, scar tissue formation and the possible removal of the ovary. If you would consider proceeding directly to IVF, then the removal of the endometriosis is not required. However, as I mentioned previously, you cannot know what the masses are until you obtain tissue and that can only be tested after their removal. So that may be the indication for the surgery.
4. Yes, as mentioned above.
5. Your age is a significant issue because fertility decreases with age. With the combination of age and endometriosis (severe), I would strongly recommend that you consider going directly to IVF as the treatment of choice. This way, the surgery does not need to be done. You doctor is correct in saying that pregnancy is a great treatment for endometriosis. However, you have to become pregnant first and endometriosis interferes with this. Endometriosis causes the pelvis to become a hostile environment for the egg. IVF is best because we remove the eggs directly and take them out of the hostile environment. Endometriosis does not affect the inside of the uterus (uterine cavity).
I hope this helps,Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology CenterMonterey Bay IVF Program
www.montereybayivf.com
I'm 35 yrs old from California. Never had kids and planning on having one, hopefully soon! My husband and I have been trying to conceive for approx. a year with no luck. So the frustration (and old age), has led me to see a doctor. A month ago, ultrasound has shown that I’ve 2 cysts on my left ovary (sizes: 2.1cm and 2.5cm) and so I've been diagnosed with endometriosis (endometrioma). According to my doctor, is severe stage (didn’t specify level) Usually, I have no pain during my periods. Since my priority is having a baby, my doctor gave me the choice of either having the surgery first and then try to conceive, or try to get pregnant first (by using fertility aid, for like 3 months) and then go for the surgery. And that’s my dilemma.
1. What are my chances of conceiving with endo? He said that the endo will melt away if I get pregnant so I’m having a hard time deciding.
2. Will my chances of conceiving decrease after the surgery? Also, I’m worried about:
3. type of surgery: According to my doctor, he’ll not perform a laparoscopy (which is more common and recovery is faster), but a traditional incision surgery. I wonder why? I believe it’s the size of my cysts? Or maybe the cysts are not benign? (He said they were benign!) although there was something unusual about the cysts : they were still present on my ovary when I was having my period. He said they shouldn’t be showing on the ultrasound during that time.
4. will the surgery damage/deteriorate /affect my reproductive system?
5. Time. I’m going to be 36 early next year and the chances of conceiving will decrease if I do surgery firstPlease advise!!! Time is sensitive and I cannot come to a decision, I’m so confused!
Here’s some extra info that might help: I’m 5’3, 115 lbs. Every visit, I have a close to high blood pressure (135/90). On my 3rd menst.day, test showed FSH of 8.9 (which is close to bad) and around ovulation my estradiol was bad: 128.0. However, I ovulated by myself and size of egg was OK. My husband sperm test was good.I don’t know if stress can affect the results of my blood test, but I was going through some difficult times since I was diagnosed with endo (lost my job and my father had a terrible accident, all happening within 2 weeks)I appreciate your help and I thank you so very much in advance.
Answer:
Hello Sarah from California,
Prior to answering your questions specifically, I would strongly recommend that you go have a consult with a fertility specialist. I think that you can be counseled better that way. I am presuming that your doctor gave you the diagnosis of stage IV endometriosis (severe) based on the presence of the presumed endometriomas. This was seen on ultrasound but not based on a laparoscopic evaluation. Endometriosis can only be staged by laparoscopy and endometriomas can only be diagnosed by tissue biopsy obtained from laparoscopy. That being said, there is a high likelihood that your doctor is right since endometriomas have a certain look on ultrasound and the presence of endometriomas usually means severe scar tissue formation in the pelvis, which is stage IV endometriosis. However, that is all a presumption before the fact (as attorney's like to say).
In answer to your questions:
1. 20% of patients with infertility have endometriosis (1 in 5). Most of these patients will conceive, although the method will vary. There is no specific statistic for endometriosis. Studies have shown no relationship between stage I and II endometriosis and infertility, but there is definite reduction of fertility with stage III or IV. If you have stage III or IV endometriosis, IVF is the treatment of choice because the pelvis has been severely altered.
2. Your chances of conceiving can increase after endometriosis has been removed surgically and if you are treated with medication for a 3-6 month period after. However, this is very dependent on the type of surgery you will have. From the type that you say your doctor advises, there is a high risk that the surgery itself may compromise your fertility by increased scar tissue production and damage to your ovaries and tubes.
3. I would NOT recommend the type of surgery that your doctor recommends if it is for fertility. He is probably assuming that there is going to be severe scar tissue formation in the abdomen and the only way that he can remove the "masses" is through an open procedure. However, I usually will approach this by laparoscopy first to see if it is possible to remove by this less invasive and less destructive method. If it is not possible laparoscopically, then I schedule for an open procedure at a later date. The problem with the open procedure, other than the increased risks, hospital days and recuperation, is that it can be a more complicated procedure leading to more tissue destruction, scar tissue formation and the possible removal of the ovary. If you would consider proceeding directly to IVF, then the removal of the endometriosis is not required. However, as I mentioned previously, you cannot know what the masses are until you obtain tissue and that can only be tested after their removal. So that may be the indication for the surgery.
4. Yes, as mentioned above.
5. Your age is a significant issue because fertility decreases with age. With the combination of age and endometriosis (severe), I would strongly recommend that you consider going directly to IVF as the treatment of choice. This way, the surgery does not need to be done. You doctor is correct in saying that pregnancy is a great treatment for endometriosis. However, you have to become pregnant first and endometriosis interferes with this. Endometriosis causes the pelvis to become a hostile environment for the egg. IVF is best because we remove the eggs directly and take them out of the hostile environment. Endometriosis does not affect the inside of the uterus (uterine cavity).
I hope this helps,Sincerely,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology CenterMonterey Bay IVF Program
www.montereybayivf.com
High FSH at a Young Age
Question:
I am a 26 year old healthy (extremely healthy) female that has a FSH of 15.7. My estro is 67, LH 6.8, Prolactin 12.8, and thyroid 1.72. My husband is also a very healthy 26 year old but has low sperm count (6 mil), low motility (14.5%), but healthy morphology 5%. Ultrasound revealed 12 follicles on right ovary and 6 on left. What are the odds that we will be able to concieve a child with IVF using my eggs?
Answer:
Hello Amanda from Illinois,
I presume that your FSH level was checked on cycle day # 2 or 3, correct? If not, then it should be repeated on one of these days. This is when the baseline levels should be checked.If your FSH level is correct, then you have increased ovarian resistance, and could be headed to premature ovarian failure. For that reason, I would definitely recommend that you proceed to IVF as soon as possible. As long as your ovaries stimulate and eggs can be obtained (you only need one or two good quality embryos), you would have a 50-70% chance of pregnancy per IVF cycle. There are some IVF programs that will not allow a patient to try with her own ovaries if the FSH level is above 12. I do not have that policy. I don't make decisions for my patients, I only counsel them thoroughly and let them decide what they want to do. In your case, I would encourage you to try with your own eggs as long as the ovaries can be stimulated. If the ovaries don't stimulate well, then your alternative would be donor eggs, but I would recommend you give it the best try that you can. Make sure you choose an IVF clinic that has good pregnancy rates. You don't want to waste your eggs.
Sincerely,
Edward J. Ramirez, M.D., FACOGExecutive Medical DirectorThe Fertility and Gynecology CenterMonterey Bay IVF Program
www.montereybayivf.com
I am a 26 year old healthy (extremely healthy) female that has a FSH of 15.7. My estro is 67, LH 6.8, Prolactin 12.8, and thyroid 1.72. My husband is also a very healthy 26 year old but has low sperm count (6 mil), low motility (14.5%), but healthy morphology 5%. Ultrasound revealed 12 follicles on right ovary and 6 on left. What are the odds that we will be able to concieve a child with IVF using my eggs?
Answer:
Hello Amanda from Illinois,
I presume that your FSH level was checked on cycle day # 2 or 3, correct? If not, then it should be repeated on one of these days. This is when the baseline levels should be checked.If your FSH level is correct, then you have increased ovarian resistance, and could be headed to premature ovarian failure. For that reason, I would definitely recommend that you proceed to IVF as soon as possible. As long as your ovaries stimulate and eggs can be obtained (you only need one or two good quality embryos), you would have a 50-70% chance of pregnancy per IVF cycle. There are some IVF programs that will not allow a patient to try with her own ovaries if the FSH level is above 12. I do not have that policy. I don't make decisions for my patients, I only counsel them thoroughly and let them decide what they want to do. In your case, I would encourage you to try with your own eggs as long as the ovaries can be stimulated. If the ovaries don't stimulate well, then your alternative would be donor eggs, but I would recommend you give it the best try that you can. Make sure you choose an IVF clinic that has good pregnancy rates. You don't want to waste your eggs.
Sincerely,
Edward J. Ramirez, M.D., FACOGExecutive Medical DirectorThe Fertility and Gynecology CenterMonterey Bay IVF Program
www.montereybayivf.com
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