Patient Has Only One Tube, One Ovary & A History Of Ectopic Pregnancy: What Are Her Chances Of Conceiving?

Question:

Thank you for taking the time to answer my question. I am a 27 year old female with a history of endometriosis. I had my left ovary removed two years ago due to a cyst. My Dr found endometriosis that had pulled my bowels up to my uterus and did a laparotomy a few months later to correct this. I was then put on 10 months of Lupron injections to try and keep the endo from growing so fast and got pregnant two months after coming off of them. However, that resulted in an ectopic when I was only about 3 or 4 weeks along. My tube ruptured and he had to remove it. He also found more endo that he was able to remove. So I now I'm left with a right ovary and a left tube. It's been 5 months since my ectopic and I have yet to get pregnant again.

I've switched to a high-risk OB/GYN. He did an HSG and my tube looked good. He also put me on 50mg of Clomid days 3-7. I had two ultrasounds to show that I had indeed ovulated and then he started me on progesterone suppositories (my progesterone in my first pregnancy was 7). It has been over a month since my last cycle, but all of my pregnancy tests have come back negative, so I believe the progesterone has delayed my period. My question is, do you think there is a chance of me conceiving again. My Dr told me to be saving for IVF (which my husband and I cannot afford right now). I would like to have 3 or 4 kids, but I don't know if that's possible now. I'm devastated over this and I would appreciate any advice you can give me.

Thank you. K. from the U.S.

Answer:

Hello Kasey from the U.S.,

Normally, it is possible to get pregnant when you only have one tube and one ovary that are opposite from each other. In fact, in nature, the egg ovulated from one ovary, say the right side, does not necessarily go into the right tube. This is a misunderstanding. The Fallopian tubes actually hang 2 cms (1 inch) down below the ovary and the egg can be ovulated from any part of the ovary. In reality, the egg is expelled from the ovary with all the fluid that surrounds it in the follicle. That fluid rushes out taking the egg with it. It then falls into a space called the culdesac located behind the uterus, where the ends of the fallopian tubes hang. Then by simple fluid motion (think of a spec of dust in a small puddle of water), the egg either contacts one tube or the other. It does not always find a tube. So in this way, it can contact either the right tube or the left tube and in your case, it can contact the opposite tube.

I think you might have another problems, however. Maybe two major problems. One is that you have endometriosis. That is a pelvic disease whereby the endometriotic implants cause an inflammation in the pelvis. This inflammation can attack and destroy the egg before it has a chance to be picked up by the tube. The second issue is that you have have multiple pelvic surgeries. Surgery tends to cause scar tissue in the pelvis and culdesac. Scar tissue (adhesions) are like spider webs in the pelvis and can block the egg and tube from getting together. There is a third problem as well, but not one that will prevent you from getting pregnant, but one that could be devastating, and that is that you have a history of ectopic pregnancy. Ectopics occur when the egg gets caught in tube, and is usually the result of scar tissue within the tube. This is most often from a previous infection that got into the tube and caused formation of the scar tissue from inflammation. It does not necessarily need to be bad enough to block the tube so the tubes would be open on HSG, as in your case. It could mean that there is scar tissue in the remaining tube, that could either prevent the egg and sperm from getting together i.e. damage the structure within the tube so that it is not functional, or lead to another ectopic.

With all of this going on, IVF is in fact the best treatment for you. Try to find a center that may help you with a financial plan (we have many) that fits your budget, even if it is far away. Your Ob/Gyn can monitor you for the IVF clinic if it is too far for you to visit.

I hope this helps,

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.

Confused Canadian IVF Patient Told She Is PCOS & Ovarian Resistant: Not Possible! What Is The Right Approach?

Question:

Hello Dr. Ramirez,

I am a 36 year old woman who has just attempted my first IVF cycle after 5 unsuccessful IUI's. I have been diagnosed with PCOS and ovarian resistance even thought my FSH has always been low on my day 3 blood work. I do not have a regular period and have needed clomid and Puregon injections in order to ovulate for the IUI's.

This past IVF cycle my numbers were as follows: Day 3 - FSH 5.7, Estrogen 112, Progesterone 3.5 and LH 7.6. I commenced 150 of Puregon on Day 3 and continued on Day 4 and 5. On Day 6 my blood work results were: Estrogen 334, Progesterone 3 and LH 4 and I had many follicles at 1.0. I upped my Puregon to 200 for Day 6 and 7. On Day 8 my blood work was Estrogen 717, Progesterone 2.7 and LH 2.7 and none of the follicles were progressing. I went back in on Day 9 for a follow-up ultra sound and there was no change in follicle size. My IVF cycle was cancelled.

My question is what would the IVF protocol be for someone who has a history of ovarian resistance? Would my dosage need to be increased or combined with other medication? I have had a egg reserve blood test done and I apparently have a very high number of eggs for someone my age. I would assume that would be because I do not ovulate on a regular basis. The question then comes down to egg quality. If I do not ovulate, does that compromise egg quality? Any advice or light you can shine on my situation would be very helpful.

B. from Canada

Answer:

Hello B. from Canada,

First of all, having BOTH PCOS and Ovarian resistance does not compute. Ovarian resistance is when the ovaries do not respond well to stimulation. PCOS patients tend to over-respond to stimulation. Somehow, I'm not sure your doctors have it right. You should be one or the other.

You do not have ovarian resistance based on your description of having "many follicles". You were also on a low protocol, probably in anticipation of being a high responder due to PCOS. Based on your estradiol levels, you were progressing well, but your follicles were small as is characteristic of PCOS patients. They tend to stimulate and grow a lot of follicles, which progress more slowly, instead of selecting a few and growing them more rapidly. Keep in mind that 200IU or Puregon is a low dose. My highest protocol is 600IU. I don't know why your doctor canceled your cycle. Maybe he/she felt uncomfortable with number of follicles you had and did not want to risk hyper-stimulation syndrome. Obviously, your doctor is not used to treating PCOS patients. Also, you were only cycle day #8 which is still early in the cycle. Most patients will go to cycle day #12 or 14 before the follicles are ready. Since your estradiol was only 717, you were not at risk for hyper-stimulation syndrome as yet. Patients that develop hyper-stimulation syndrome tend to have estradiol levels over 2000 by cycle day # 9.

Also, you should keep in mind that at 36, you are still young and most of your eggs should still be at good quality. You have a good FSH. Age is not an issue for you yet.

In terms of protocols, I cannot give you a standard protocol because every program and doctor has different protocols and combination of protocols. I prefer to use a "mixed" protocol which combines both FSH and FSH/LH (I use Follistim for FSH and Menopur for FSH/LH). In your case, you just were not stimulated enough, and the doc should have kept going and increasing the dosage, whether you use the single agent protocol like you did or use a mixed protocol.

I hate to say this, but I might suggest that you consider seeking out a different clinic or doctor, because I am leery about how your first cycle went. Again, I don't think you are a "low responder" so you might want to discard that label for yourself. Low responders barely respond to 600IU or more of medication and often the estradiol doesn't get much above 300-400.

Keep trying and good luck,

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.

Husband Has Severe Varicocele: Surgery or IVF?

Question:

My husband has a severe varicocele on the left. The sperm count is 0.8 million in total and has 5% motility after 1 hour. What should be our first option: should we do varicocele repair first or should we go for IVF/ICSI?

Thank you for your help in advance. S. from Illinois.

Answer:

Hello S. from Illinois,

The severely decreased sperm count is probably not from the varicocele but other factors. Several studies have shown that removing the varicocele make little difference, and so nowadays it is not recommended. Many Urologists will recommend it and do the procedure because that is the only treatment they can offer. I think most infertility centers will recommend proceeding directly to IVF/ICSI. That is what I recommend. Besides, if your husband goes through this surgery and the semen analysis is still abnormal, you will still have to go to IVF with ICSI.

Why not go to your infertility clinic directly and get pregnant? :)

Good Luck,

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.

36 Yr. Old Irish TTC'r With Low AMH & Scar Tissue From Cystectomy Needs IVF

Question:

Hello,

I have a number of queries.

I am a 36 year old female from Dublin, Ireland who has been TTC for 2.5 years. After one year of trying myself and my partner were referred to a fertility clinic. At that time, ultrasound and MRI showed that I had a 4.5 cm dermoid cyst on my left ovary and I was referred for a csytectomy in April 2009. My surgeon chose to do a laparotomy saying that there would be less likelihood of the cyst rupturing during surgery and having to clean up the pelvis so I went with his advice, while I was open he took the cyst on the left ovary but also took what he thought was another cyst on the right ovary as it was hemorrhagic. The histology report showed that the cyst from the right ovary was actually my corpus luteum for that month.

After the recovery period for the surgery my partner and I began to try and conceive naturally with no luck. At this stage (December 2009) we were frustrated with the first fertility clinic we went to so we changed clinics and in February of this year I had an AMH test and pelvic sonogram in preparation for IVF. The AMH results show that I have low ovarian reserve (0.5). The left ovary had no follicles on it at ultrasound and the right one only had four or five. I do know from past ultrasounds that I have been ovulating from my right ovary every month since the surgery (and probably before that since I always had pain on this side every month).

I was also diagnosed with uterine polyps at the sonogram which I am going to have removed via hysteroscopy and d and c prior to starting a cycle of IVF in April.

My questions are these:

- could the removal of the corpus luteum on the right ovary and the cyst on the left have damaged my ovarian reserve?

- do you have any suggestions for maximising my chances of success with IVF given my low ovarian reserve? Would you recommend DHEA?

- since the surgery I have had consistent pain where I perceive my right ovary to be and menstrual like cramping at odd times of the month - could this be related to the surgery. I have asked doctors about it and since they can't see anything wrong with an ultrasound they tell me not to worry about it.

I am very concerned about the effect that the surgery had on my fertility as well as the fact that my surgeon nor the first fertility clinic I was with did not warn me of any risk associated with the surgery.

Thank-you for your time

ANSWER:

Hello N. from Ireland,

The previous surgery would not have had an effect on your ovarian reserve. However, the type of surgery you had (exploratory laparotomy with cystectomy) could have altered and worsened your fertility. Unless a lot of the ovary was removed, however, it should not have affected your ovarian reserve.

In reality, low ovarian reserve is just a description of how you will stimulate with the fertility drugs. AMH (anti-mullerian hormone) is only a test that gives us a measurement of ovarian reserve but it is not an indicator of your fertility. Keep in mind that you only need ONE good embryo to get pregnant. In fact, I did IVF on a patient this month who ended up only having one embryo to transfer, because of low ovarian reserve/low response, and today her pregnancy test is positive!

You are still young so your chances are still good. I would go with a high stimulation protocol (not the flare protocol), then you can only hope for the best. I don't advocate DHEA (which is dehydroepiandrosterone, an endogenous hormone i.e. made in the human body, and secreted by the adrenal gland). Make sure the IVF clinic you go to has a good and high pregnancy rate. You don't want to waste time on one that doesn't.

In terms of your pain, it is possible that you have scar tissue that formed around the ovary as a result of the surgery. Scar tissue cannot be seen by ultrasound. You would need a laparoscopy to see it.If worst comes to worst, you could always come to the US, although I know that is a very expensive proposition. I've had patients from as far away as Serbia on the European side and China on the Asian side.

Follow-Up Question:

Hi Edward,

Thanks for your response, particularly about the impact of low AMH on fertility. I have a couple of follow-up questions:

- how could the type of surgery (laparotomy) I had have adversely affected my fertility?

- what is a decent pregnancy rate for a fertility clinic?

- would you advise a laparoscopy to check for scar tissue prior to the IVF or should I just go forward with my cycle?

Thanks, N.

Follow-Up Answer:

Hello Again,

Whenever surgery is performed abdominally, especially an open surgery and one around the reproductive organs, scar tissue formation can be induced. This will interfere with the passage of the egg from the ovary to the tubes.

In your age group, we are hitting a 68% pregnancy rate per attempt with IVF. I know that in general in the U.S., pregnancy rates are 50-60% per IVF transfer. I don't know what they are in Europe, but you might want to use that as a guide. We break that down into age groups and the statistics I gave you are based on your age, and not across all ages.

I do not recommend laparoscopy to check for scar tissue formation prior to IVF. Only do this surgery if you are dead set on trying to get pregnant naturally. IVF will bypass the pelvis completely, and is the ideal treatment for severe pelvic scar tissue/adhesions, so the surgery is not required.

Good Luck,

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.

Is There A Link Between Late Ovulation And Miscarriage?

Question:

I recently read (in "Making Babies" by Dr. Sami David) that a follicular phase that lasts more than 20 days is a problem because it means the estrogen is building up too slowly which results in deterioration in egg quality and an increased risk of chromosomal abnormalities.

I recently experienced a missed miscarriage at 11 weeks. The cycle I conceived, my follicular phase was 30 days and I'm wondering if continued late ovulation could be increasing my risks of experiencing this again? Your thoughts?

J. from New York

Answer:

Hello J. from the U.S.,

I do not agree with Dr. David, and do not know where he would get that information. There is no relationship between follicular phase length and miscarriage. Most miscarriages occur because of some overt abnormality of the embryo or pregnancy, and usually are specific just to that particular pregnancy. Most patients with miscarriages will ultimately have a successful pregnancy.

Good Luck,

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.

Twitter with me at @montereybayivf

Estrogen Patches Vs. Estrogen Injections: Which Is Better For Pregnancy Success?

Question:

I have four frozen embryos which I would like to have transferred. My question is what has a better success rate with prepping the uterus, the Vivelle dot 0.1mg patches vs. the delestrogen injections? I had a baby two years ago from a donor egg and how they prepped me was with the delestrogen. I have since moved away from that IVF Clinic who used this protocol. I have recently consulted with a different clinic where I presently live and they would rather use the patches.

This makes me wary since I am not sure if this will hinder my success rate. Please advise.

Thank you. B. from the United States

Answer:

Hello B. from the U.S.,

There is no difference in pregnancy rates between these two forms of estrogen. Any estrogen can be used. Some clinics will use oral tablets, others will use vaginal suppositories, in addition to the patches or injections. The key is to make sure that enough estrogen is being delivered to form an adequate uterine lining. Certainly protocols can vary, and it is the specifics of the protocols that are important i.e. are they using enough estrogen with the patches vs the injections. Without looking at the two protocols, I cannot tell you if the patch protocol is adequate. You would have to send them to me in order for me to review them and give an opinion on those specifics.

Keep in mind that frozen embryo transfers have a lower pregnancy rate than fresh transfers, so that may affect your chances of pregnancy. The rates are roughly 50% less (30% vs 60%). Let me hear from you if you have further questions.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, USA

German Woman Suffers Multiple Miscarriages Over Two Year Period - Proceed To Clomid Superovulation?

Question:

I´m 31 years old and writing from Germany. I have no children and have suffered four miscarriages. My husband and I have been TTC for 2.5 years now. After using the implanon hormone implant for birth control, I had it removed in 09/07 to begin TTC. In 11/07 I fell pregnant only to miscarry at about 5w3d. My hormone levels showed an hcg level of less than six. I was told to wait three months and try again, that I would have better luck. In March of 08 I fell pregnant a second time. At my first appt. at 8w5d it was discovered that there was a large sac with no fetal pole. I began to miscarry at 11 weeks and had an emergency D&C because I was losing so much blood. I asked that the tissue be analysed, but was told it was not done for a second loss and that this was in all likelyhood caused by a chromosomal problem. I was told to wait three months before trying to conceive again. Exactly 28 days after the D&C I got my period. I fell pregnant the next cycle, but did not realize it until I started miscarrying. My doctor did not do a blood test, only looked at an ultra sound, shrugged her shoulders and said I wasn't pregnant anymore, if I had ever been. She suggested that I could go for genetic counseling if it would make me feel better.

My husband and I went for genetic counseling, had kareotypes done, both of which came back normal, were tested for various thrombophilic conditions and immune disorders plus thyroid. My results came back as normal for everything but Leiden Factor V. I carry one copy of the gene. I was told by the geneticist that it would be good to start heparin at 8weeks in my next pregnancy and sent on my way.

In December of 08 I fell pregnant a fourth time, was given 100mg of aspirin to take starting at 4w5d. At 5w1d I began to bleed, but the ob/gyn felt that my lining still looked good, gave me progesterone supplements to take and told me to come back in five days for another ultrasound. On my return visit she could not find a sac in the uterus, and was unsure if she wasn´t seeing a sac in müllerin duct. I was told to stop the progesterone immediately and go to the hospital immediately should I have any sharp pains. Otherwise I was to report to the hospital in another five days for a beta draw. After stopping the progesterone I miscarried the next day. Three days later my hcg levels were drawn at the hospital and found to be 144, so I was required to come back every 48 hours for another draw to be sure that they were indeed falling. My levels fell nicely and I was sent home to wait three months before ttc again.We have been trying for a year now, and have not been able to get pregnant.

I have charted, used the clear blue fertility monitor and opk's to no avail. After six months I went to see an RE hoping that he would be able to give me some answers about my miscarriages, but he offered no ideas as to why, only said that my miscarriages were not a result of the Leiden Factor V. He did some bloodwork at CD13 to check my hormone levels, which he said looked very good, did a SA for my husband and a penetration test and said he saw no reason for us not to be pregnant. He suggested a doing a lap but made no further recommendations.

My regular ob/gyn was not in favor of the lap and suggested that I try a bit longer, and that if I wanted to we could try clomid and progesterone to get a stronger ovulation.I am unsure and very confused as what my next course of action should be testing and treatment wise, and if I really have a chance at having a biological child. I would appreciate any thoughts you might have on this subject. Thank you very much for your time.

Answer:

Hello L. from Germany,

Recurrent miscarriages are a difficult problem. The most common reason is because of a spontaneous chromosomal abnormality. That means it occurred when the egg was dividing, and not because you are carrying something. Hematologic disorders, such as Factor V, have been shown to increase the risk of miscarriage. Since you underwent evaluation and that was the only abnormality found, that is good because most patients with recurrent miscarriage due to spontaneous abnormalities will eventually be successful.

You mentioned that you were 31 years old, which is a good thing. Age plays a significant role in the risks of spontaneous anomalies and increases the risk of miscarriage with increasing age, especially after 35 years old. I call this the "Age related egg factor." Most patients that have recurrent miscarriages are because of age related spontaneous genetic defects. In your case, although there may still be "abnormal" or "weakened" eggs within your ovary, your chances of spontaneous defects are low. That means that your chances for success are high.

It sounds like your RE was addressing the issue of your infertility and not the recurrent miscarriage problem. Laparoscopy would be indicated to evaluate for infertility only. I don't think it is indicated at this point as well, but I wonder why you have not gotten pregnant after 1 year of trying. Something has changed and an evaluation is definitely warranted. I would go back to doing a full basic infertility evaluation and not make any assumptions, despite having gotten pregnant in the past. A hysteroscopy would be warranted to evaluate the uterine cavity because of your history of D&C. Therefore, you might also want to consider laparoscopy to complete an infertility evaluation, but not for evaluation of recurrent miscarriages.

If you don't want to do an evaluation but want to proceed with trying for pregnancy, then it is a little shot in the dark. Certainly doing Clomid "superovulation" is an option. This is where the fertility drug Clomid is used to increase the number of eggs that you ovulate per month. This can be paired with either timed intercourse or IUI. I might suggest the latter, IUI (Intra Uterine Insemination) for a higher pregnancy rate between these two. You might want to use low dose aspirin (81mg)per day and heparin (2000 units/twice per day) and medrol 16 mg per day starting from the beginning of the cycle, as well as, supplemental progesterone (vaginal or injectable) and estrogen.

The other option would be to proceed with IVF (in vitro fertilization). In this case, embryonic genetic testing, called PGS (preimplantation genetic screening) can be done to determine which are the normal embryos so that only these would be transferred. If you decided to pursue this option, I would recommend that you choose a clinic that has experience doing this and can do testing at the blastocyst stage (trophectoderm testing), rather than an earlier stage where they take one of the cells, and test with CGH (comparative genomic hybridization) .

I hope this gives you some information to consider.

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.

Young PCO Austrian Had 5 IVF Cycles Over 3 Years And Is Ready To Give Up - Short Protocol, CGH Advised & Keep Trying!

Dear Dr. Ramirez,

Thanks for taking the time to do this, I have read several of your previous answers on the website and I am looking forward to hear your thoughts on our case. I am writing from Austria. Both my husband and I are 30, we have been doing IVF/ICSI for the past 3 years (5 cycles) with no success. My husband has the CF gene and no vas deferens (0 count). Everything is fine with me (blood work, hormones, etc). I had a laparoscopy/hysteroscopy in 2006 (prior to the treatments) where an endometrial cyst was removed from one ovary, as well as one polyp from the uterus and some adhesions from the tubes. I have been getting continuously checked since then and my uterus, ovaries are clear from anything. My husband has had 3 TESE procedures, and good looking sperm was found each time and lots of it has been frozen.

We had 2 treatments in 2007, 1 in 2008, and 2 in 2009. In the first cycle (with fresh sperm) I had 14 eggs, 3 fertilized, and 2 grade A embryos were transferred. In my second and 3rd cycle I had 20 eggs (different protocols used in each of the treatments) and none fertilized. I hyperstimulated severely in cycle # 2 and ended up in the hospital. I was told we had an egg issue and to try with donor eggs. We took a year off to think about it and switched clinics. In 2009, cycle # 4, we had 15 eggs (frozen sperm), 3 fertilized and 2 grade A embryos were transferred on day 3. In cycle #5, we had 15 eggs again (frozen sperm), 7 fertilized, and we had 2 morulas transferred. We have a lot of trust in our doctor and clinic used for the past 2 treatments, and have a great relationship. The clinic is a stat of the art building with all new technology. This doctor does not think I have egg quality issues since I had good embryos (although very few of them) in the last two cycles, and thinks we should keep trying. However, we know it is not normal that within our age group we have not succeeded yet. It is hard to not think that there is something wrong with us. I stimulate very well in terms of numbers, and the protocol has been decreased (amount of drugs) with each treatment (always yielding a high number of eggs). We have tried acupuncture, yoga, bed rest, no bed rest, and all kinds of things. We do have a possibility to try one treatment in the US (due to the expenses), but are not sure of what we should do.

Any thoughts would be appreciated. What do you think of my egg quality issue? Would a US clinic suggest donor eggs? I would really like to try with mine...Best regards from Austria.

ANSWER:

Hello S. from Austria,

Based on the history you have given me, it sounds like you may be a PCO-type ovarian stimulator. That is why you have so many eggs, and had hyperstimulation syndrome. The good part of that is that you yield lots of eggs. There have been some studies that show a decrease pregnancy rate in PCO patients, however, and it is thought that it is because they stimulate too much. This leads to unequal maturation of the eggs within. Certainly, you seem to have had good quality (albeit external quality) embryos in the latter two cycles. At your age, I would have expected a pregnancy, easily. One concern is whether the sperm is contributing to poor embryos (again internal quality/genetically), because of your husband's CF gene. The embryo could still look good but be genetically abnormal. The only way to know this is to do preimplantation genetic screening, preferably by polar body biopsy and CGH, to verify that only normal embryos are transferred. CGH, or "comparitive genomic hybridization" is a genetic test that analyzes the chromosomal integrity of an egg or embryo. In IVF, it is ideally done in women under the age of 39 who have more than 6 healthy embryos after fertilization. They can be her own or donor eggs.

I would not recommend that you give up yet. If you give up, you certainly will fail. Since your ovary stimulates so well, and you are young, I think your chances of pregnancy are still high. The alternative to the above genetic testing on the embryos, would be to go to donor sperm, rather that donor eggs, in order to eliminate that paternal genetic factor. I know that you husband would probably prefer a genetic child, however, so in that case, you just have to keep trying.

If you came to me or any other clinic in the U.S., I don't think we would be ready to give up with your eggs. I think we would continue to encourage you to keep trying with your own eggs. I recently had a patient, similar to you that seemed to have poor embryo quality in another clinic. They did three IVF cycles there and then were recommended to use donor eggs. Fortunately, her husband got transferred to my locale and they came to me for consultation. I encouraged them to try at least one more time with her own eggs, again since her ovaries stimulated well. They decided to go with my recommendation and in their first attempt, became pregnant.

Follow-Up Question:

Thank you Dr. Ramirez for your answer.

In the meantime, I just had a hysteroscopy 3 days ago and a polyp removed from the uterine wall, this polyp was not showing up on ultrasounds. Could you please elaborate on why you think I have PCO? I do ovulate every month, no diabetes issues, no acne, no absence of menstruation, none of the signs I have read are present in me, but since it is the first time I hear that, please explain me how I could have it and how does it affect stimulation? How is it better to deal with it?

I forgot to mention that in the last two treatments (with 2 embryos/morulas transferred each time) we did polar biopsy of the eggs and only the 2 perfect/healthy ones were transferred each time, still no success. My doctor recommends that we continue to do this polar biopsy and we will. What kind of stimulation would you recommend for me? What could have caused this polyp I just had removed? Could it be the same stimulation drugs (estrogen), which is given to me as part of the treatments that made my uterine tissue grown into a polyp? (it was a long, flat polyp, not the regular ones that can be seen by ultrasound).

With regards to the couple you mention in the last paragraph, what did you do different from their 3 previous treatments that could have led to success? Is it just a matter of numbers/attempts, that we need to keep trying? The more one fails, the harder it is to believe it could happen....and I know mental power can do lots for either direction.

We might try one more treatment here (much more affordable) and then have a final treatment in the States. We are definitely not ready to give up! Thanks again!

Follow-Up Answer:

Hello Again,

There are many variations of PCO. Not all fit the classic descriptions. In your case, what makes me think that you have a PCO tendency is the fact that you overstimulated and developed hyperstimulation syndrome. I have had many patients that have surprised me in the same way. They are thin, have regular menstrual cycles, don't have any other PCO-type tendencies, yet they stimulate like a PCO patient. That is, their ovaries are very sensitive to the fertility medications. Since you don't have any of the other PCO findings, the only thing to keep in mind is that your ovaries are very sensitive to stimulation, so that the next time, a low dose protocol will be used and you don't develop hyperstimulation syndrome.

In terms of stimulation protocols, with my PCO patients I use a "step-up" protocol. Patients start at a low dose of Follistim 150IU for three days then the estradiol level is checked for response. If there is not a high response then I step up the dosage to Follistim 150IU + Menopur 75. We continue the same pattern of checking and adjusting the dosage as needed. I don't use Lupron agonist suppression (long protocol), but instead use the Antagonist Ganerelix. When the follicles are appropriate sized, I trigger with Lupron 0.5 mg instead of Ovidrel. This combination and protocol has been shown to be effective in preventing hyperstimulation syndrome.

Polyps are normal. It is very common and is due to an overgrowth of endometrial tissue. The finding is probably not significant in terms of pregnancy chances, but we prefer to remove them anyway so that they can't potentially interfere.

In terms of my couple, I used a completely different protocol than what she used previously, and some additional medications. Different clinics have different success rates because of differences in their protocols and techniques. "Failing" is when you stop trying. As long as you continue to try, you have a chance of success and that is what you have to focus on. Focus on the goal, not the pathway.

Good Luck,

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.

***See continuing follow up to this question on May 16th, 2010...

Chances Of Conceiving At 39 After TTC For Three Years: IUI Cycles Cancelled Unnecessarily

Question:

I am 39 years old and have been TTC (trying to conceive) for 3 years and 4 months now. I had a Laparoscopy done in March 2007 which showed healthy patent tubes, clear ovaries and a normal uterus. I normally have irregular periods ranging in length from 32 days to sometimes 42 days but in general around every 35 days. I usually get my positive on an OPK around day 21.After trying naturally for 1.5 years we went to a fertility clinic where I was put on Clomid 100mg with mid-cycle scanning plus trigger shot and I conceived on my second cycle but unfortunately miscarried in January 2008 at 10 weeks. I took a break of 3 cycles after the miscarriage and then went back on Clomid for 4 months. On each of the clomid cycles I produced 2 to 3 dominant follicles but each cycle resulted in a negative result. I took a break after Clomid for another few cycles and then started into IUI (intra-uterine insemination) just before Xmas 08.

On my first IUI cycle I was on Gonal F 75iu and after 7 days of injecting the cycle was cancelled because I produced 8 dominant follicles. My meds were then changed and I was put onto Purgeon 50iu for 2 further IUI cycles and on each of these cycles I produced 3 dominant follicles and my husbands sample was good yet both cycles produced a negative result. My most recent IUI cycle (June 09) had to be cancelled again as I produced 5 dominant follicles.

My question to you is this? Is it just bad luck that I haven't conceived since my miscarriage or is my age a factor? I had a day 3 hormone profile done in April 2009 and my results were as follows: FSH 5.9, LH 3, Oestradiol 22 pg/mg - do these results look ok to you? Is there any chance my eggs may be of poor quality or would my day 3 results have reflected that?

We still have 2 more IUI cycles to complete and failing those we will be moving to IVF (in vitro fertilization), but I thought I would ask your advice in the meantime.

I hope you can help.

Answer:

Hello,

The hurdle you seem to be facing is probably due to poor egg quality as a result of age. Your natural chances of pregnancy at 39 is 1% per month/12% per year and 3-5% per month with IUI. Not very good odds. This is strictly due to age. Your miscarriage was probably age related as well, as the miscarriage rate increases with increasing age due to spontaneous chromosomal abnormalities (i.e. spontaneous breaks in the chromosomes as they are dividing).

You have been wasting a lot of time and now it is time to become more aggressive if you want to have a child. You have done more than enough Clomid and IUI cycles (six IUI cycles are too many! 3 - 4 cycles are what are recommended before proceeding to IVF). I would recommend that you move directly to IVF as soon as you can, since you are stimulating well. Pregnancy rates with IVF are 50-60% (it is 71% so far in 2009 in our clinic), but this will go down to 27-30% at age 40. Your lab results are good and show that you still have good ovarian function, but that is not a measure of egg quality. Egg quality is the issue. I often tell my patients that with IUI's it's not the sperm that are an issue it's the egg factor. We need to have one good egg to acheive that pregnancy. Because of that, I allow more eggs to ovulate in an IUI cycle (5-8) if the patient is over 37 years old. I would not have cancelled the cycle that you just went through. I have never had a problem with multiple pregnancies since the chances of a multiple are minimal in the 37 plus age group. If a patient with your history proceeds to IVF I will transfer 5-7 embryos.

I hope this helps,

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.

Follow my Facebook page at http://bit.ly/9Iw9oV

Egg Freezing Expands Options For Women Choosing To Delay Childbearing by Mindy Berkson

Dear Readers:

Today I have a guest blogger, Mindy Berkson. She will be commenting on an option that holds great promise for the future. Although still considered experimental by the American Society for Reproductive Medicine, egg freezing/egg banking may soon become a viable way for women to extend their fertility. Mindy is an infertility consultant, owner of Lotus Blossom Consulting. She works with individuals on a case-by-case basis, taking into consideration clients’ emotional, physical, and financial infertility issues, then develops an individualized, comprehensive plan, including relevant financial and insurance information, to help clients make informed decisions for their overall treatment plan. Mindy can be reached at 877-881-2685 or on the web at http://www.theinfertilityconsultant.com/ .

Egg Freezing Expands Options For Women

Choosing To Delay Childbearing

by Mindy Berkson

There are countless numbers of products available to women to slow the visible effects of aging, but what about the parts of the body that are out of sight? Now with egg freezing technology it possible to stop a women’s biological clock allowing them to “freeze” their fertility for the future.

Age matters in many aspects of life as well as in the creation of life. Women are most fertile between the ages 20 to 28 with their fertility decreasing in half by the time they are 35. By age 45, only a 1% chance remains each month of conceiving naturally. This is a startling fact considering the average age a woman has her first child has risen to record high of 25.1 with 20% of women waiting until they are 35 to begin their family.

An increasing number of women choose to delay childbearing due to further schooling, career choice, or are waiting to find their perfect partner. While those choices are understandable and personal, as women naturally age so do their ovaries; affecting their fertility. Oocyte cryopreservation, commonly known as egg banking, provides women up to the age of 38 with a chance to slow down their biological clock and effectively storing their fertility for the future.

A women’s egg supply is finite therefore, freezing your eggs allows you to stop your biological clock until you are ready to conceive, increasing the odds of having a healthy successful pregnancy. Women are born with millions of eggs yet once they reach puberty only 300 of the 300,000 eggs left will have the chance to ovulate. The frozen eggs can be thawed at anytime to be fertilized with the sperm of choice and then refrozen as embryos for future in vitro fertilization treatment cycles.

Egg banking is also an option that is highly recommended for women who have been newly diagnosed with cancer but have not begun medical treatments that may negatively impact their fertility. While treatments such as radiation and chemotherapy are lifesaving, they can potentially leave women infertile. The ability to freeze viable eggs before undergoing cancer treatments instills hope for a family in the future.

Egg banking, the newest technology available in the infertility field, is a wonderful option for those women who plan to delay childbearing for personal reasons or for medically induced situations. Since women do not continually reproduce more eggs over a lifetime, the availability of egg banking technology allows women to protect a precious resource and helps to ensure their fertility until such time that they are ready to begin a family.

Cystectomy For Grapefruit Size Dermoid Cyst On Ovary

Question:

Hello, I'm writing from Nevada. I went in for an appointment with my MD a few weeks ago after trying to conceive for 1 year. While I was there he did a pap and routine exam as well. In the exam he found my uterus was small or off to the side a bit and wanted me to have an ultra-sound done. When we did this they found a grapefruit-sized dermoid cyst in my left ovary. We're planning on having it surgically removed but I have a few questions.

1. With the size of the cyst is there any chance of keeping a portion of my ovary?

2. If it MUST be removed, is there any possibility of saving my eggs?

3. With a cyst of this size is it wise to do the procedure laparoscopically or should it be done with one large incision?

I have no issue with work and recovery time, I just want it done in the safest way to keep my ovary if possible. I do have another appointment with my MD to discuss this information, just looking for some suggestions or input. Thank you.

Answer:

Hello K. from Nevada,

A skilled gynecologist will usually remove the Dermoid cyst without sacrificing the ovary. Make sure that your's will do that. The procedure is called a cystectomy. There is no reason the ovary should be removed.

The technology for preserving eggs certainly exists, although the pregnancy rates are not as good. However, we do recommend this in women that have cancer since they would otherwise lose the option of getting pregnant with their own eggs. This will have to be done in an IVF center, and must be done BEFORE the surgery, not during or after. The ovary has to be stimulated to grow the eggs so that they can be removed and frozen.

The cystectomy procedure should also be done by a method called laparoscopy, using a scope and small incisions. I do this procedure all the time. If your doc can't do it laparoscopically, then find one that can. This is the best method to preserve your ovary and cause minimal damage so that your fertility is not compromised. Try not to have an open (laparotomy) procedure if you can.

I hope this helps,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

New Zealander Wonders: Does A Cervical Cone Biopsy (LEEP) Lead To An Incompetent Cervix During Pregnancy?

Question:

Hi Doctor,

I'm a 33 year old woman from New Zealand. I recently had a missed miscarriage and D&C (22nd Nov 2009) , then one month later I had another D&C due to infection and retained product. I also had a D&C at age 17 years and a termination at 29 years. I also had a LETZ at 25 years. The doctor has advised me to wait 6 months before getting pregnant again to help my cervix strengthen. He is also saying that I will most probably have an incompetent cervix due to all surgery and the only thing they can do is monitor me during my pregnancy. Is there anything I can do before my pregnancy to help? Are there any tests to see how strong my cervix is?

Will waiting 6 months strengthen my cervix? Do you know of anyone else who has had this many D&C's and a LETZ and still been able to carry to term?

Thanks you so much! I haven't been able to find answers to my questions and I'm feeling very anxious.

Answer:

Hello J. from New Zealand,

Many women have multiple miscarriages requiring D&C, or have multiple abortions. They are not necessarily at increased risk of incompetent cervix. They are at increased risk of uterine adhesions from the multiple D&C's. The risk of incompetent cervix comes from the LETZ procedure because a portion of the cervix is removed. (Briefly: the LETZ procedure removes the entire abnormal area of your cervix with a hot wire loop. The tissue is then sent to Pathology for diagnosis. Some doctors, myself included, refer to this procedure as LEEP-"Loop electro-surgical excision procedure"). That is NOT to say that you are definitely going to have incompetent cervix, only that SOME women that have had cervical cone biopsies or LETZ/LEEP seem to have an increased incidence of cervical incompetence.

I have been doing LEEP for a long time and have never had this problem with my patients. It is a procedure I excel at and enjoy doing. It probably depends on how deep of a cut the Physician makes. There is no way to predict who will have incompetent cervix or not. In some cases, where the cervix is found to be shortened or there is a previous history of incompetent cervix, the doctor will do a cervical cerclage (put a stitch in the cervix), in advance. I would not recommend that in your case. For now, your Ob doctor just needs to keep an eye on things by doing serial ultrasounds to check the cervical length.

In terms of waiting 6 months. There is no reason to do that. There is no such thing as "strengthening the cervix or waiting for the cervix to strengthen". The cervix will be repaired and ready within 6 weeks.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.

Follow-Up Reply:

Thank you so much, Dr.Ramirez,

You have made me feel much better, I had been unable to find any info on this (apart from terrible stories from google) and have been worrying myself sick about it. I will pin your email to the wall and remind myself when I get anxious! Again, thank you so much! J.

Very Weak, One-Day Menstrual Flow - Is There Something Wrong & Will It Affect Fertility?

Question:

I am a 26 year old female and for the past few months I have been having very weak periods that often last no longer than a single day. They are so weak that I don't need to use tampons and pantyliner will suffice. They are however extremely regular and fall every 30 days. I came off the pill last year and for after a few months my periods returned to normal. It is in the past 6 months or so that they have become so weak that they are causing me concern. A few years ago, I had a big cyst on my right ovary and late treatment meant it twisted and resulted in me having to have one ovary removed along with the cyst. I have researched possible reasons for weak periods and polycystic ovaries seem to be one of the main explanations. However I do not have any of the other symptoms usually associated with this condition and I am not over- weight.

I am extremely concerned of the implication my weak periods may have on future fertility but when I have taken my concerns to my GP he has dismissed them. I was hoping you could maybe give me some possible reasons as to why this may be happening.

Many thanks for your time. K. from the U.K.

Answer:

Hello K. from the U.K.,

The amount of bleeding a woman has with her periods is dependent on the amount of tissue there is to slough. That is, the thickness of the endometrial lining. Even if the amount is small, at this point it would not be of concern. The amount of bleeding will vary from person to person and cycle to cycle. As long as your cycles are regular, that is the important part. Certainly if the endometrium is not developing adequately, that could impair implantation of the embryo and your fertility. But, I doubt that would be the case. I would not worry about this at this point in time. Just wait and see what happens when you begin trying for pregnancy. If you have difficulty, then testing and evaluation will be done to see if the endometrium is not developing adequately. If that is the case, then supplemental hormone can be given.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Poor Embryo Quality: Donor Eggs Vs. Change Protocol Vs. Change Centers

Question:

I have undergone 3 IVF cycles without success in Canada. First IVF using long protocol, failed to stim and the cycle was cancelled. Subsequent 2 IVF cycles were done in flare protocol.

Of the flare cycles, first one was using Gonal F (450IU) and Luveris, we got 18 eggs, 13 mature, all 13 fertilized, but on day 3 only 2 had divided to 6-8 cells. All others arrested at 2-4 cells. Transferred 2 back with assisted hatching, but failed.

Second flare cycle was using Menopur (375IU), 13 eggs retreived, 8 mature, all 8 fertilized, but on day 3 only 2 were good enough to transfer, one that had started compacting, another at 8 cell, both were transferred back with assisted hatching, but failed again. All others divided will odd cells (3-5) and arrested on day 3. After the 3rd cycle, doctors suspect the egg quality to be very poor and advice us to use donor eggs. All blood/hormone tests are normal, left fallopian tube is blocked at fimbral end. I'm now 33, never been pregnant. My husband's results are normal.

Is this indeed due to poor egg quality? Is there any treatment available to improve egg quality? Is there any other IVF protocol that we can try that might give better results?Any advice based on your extensive experience is greatly appreciated.

Answer:

Dear S. from Canada,

Based on the information you gave me, you certainly did stimulate well in your second and third cycles. One option is to use a combination protocol with Gonal-f and menopur, and the antogonist (ganerelix or cetrotide), instead of lupron flare protocol. That may help with egg development and quality. There have been several studies showing the benefit of the combination protocol. The antagonist allows the ovary to stimulate and develop the eggs without being suppressed, as occurs with lupron. You'll have to ask your docs if they feel comfortable using an antagonist protocol.

There is no direct way to improve egg quality after fertilization. However, eggs/embryos are very sensitive to their environment i.e. laboratory quality. Any airborne gas or contaminant can effect them.

For example, in 2007 I had terrible pregnancy rates. In review, we found that in this year, the building where I had previously had my offices & center had gotten several new tenants and was doing a lot of remodeling. The air flow system in that building was not isolated and the air shared throughout all the offices. We had a very good Hepa filter in the lab but it could not isolate the air effectively with the huge change in parameters. Luckily, in early 2008 we moved our center to a new building where we are the only tenants. I was able to build my lab using the latest technology and air flow recommendations. My under 35 pregnancy rate went from 27% in 2007 immediately to 74%. The only difference was the air quality and control. Our lab is now in an isolated part of the building and does not share airflow with any other part of the office. Environmental controls and air flow have been studied and written about extensively in the IVF literature.

Certainly, if you are consistently having poor embryos, then the only alternative would be donor eggs. But before I would draw that conclusion, you might want to try a different center. Another experience I had was a patient who moved from Washington D.C. to California. She had gone through two IVF cycles there and, like you, had poor embryo quality and also was recommended to undergo donor IVF. But because her husband's job location changed, they moved here and she presented to me. Like you, she was young and I counseled that she should continue trying with her own eggs, at least two more times. Well, in her first cycle with me, she had three excellent quality embryos and became pregnant with twins (all three were transferred). It just goes to show not only that a different center could have a different outcome, but because we know that each cycle is unique, the outcome could be different from just having a different set of eggs and embryos.

I hope this helps,

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.

New IVF Patient Mixed Up Suppositories & Took Progesterone Early - What Now?

Question:

Hello Doctor,

I am one day before fresh embryo transfer and I'm really worried. I'm currently on my first IVF. Two days before my egg retrieval last week I was instructed to use Clindamycin suppository at night for 3 nights last night being the day of my egg retrieval. Well, I mixed up the suppository bags and inserted 50 mg of Prog suppositories for first 2 nights instead of Clindamycin. I didn't realize this mistake till the day of my egg retrieval. So I ended using 2 Prog suppositories for 2 nights before my egg retrieval.

I told my doctor and he said this is a problem in that my uterus was exposed to progesterone too early therefore lining is not optimal for transfer...and that we need to freeze my embryos and do a frozen embryo transfer next month! I was just devastated to hear the news and asked for any alternatives. To make the long story short we are going ahead with a fresh single embryo transfer tomorrow with hopes that not too much damage was done. Given my history what are the chances of me actually getting pregnant? Would it take a miracle?

R. from the U.S.

Answer:

Hello R. from the U.S.,

Keep in mind that miracles do happen.

I'm afraid that I agree with your doctor's response. Progesterone converts the endometrium from its growing state to its implantation phase. If the endometrium is out of phase with the embryo, then implantation will not occur. There is a very small (2 day) window for implantation. It is likely that the progesterone changed the internal architecture (cellular structure) of the endometrium, which will make it inhospitable to the embryo and implantation will not occur. But there is no way to know that for sure. You will just have to wait and see.

If you want to be absolutely sure, then you should postpone the transfer and freeze the embryos. Then do a frozen embryo transfer the next month. If you don't mind risking an embryo, then given it a try. I normally prescribe antibiotics on the day of the retrieval, but all clinics have their own protocols specific to how the physician prefers to tweek their cycles. Like I said at the beginning, miracles do happen.

I'm sorry and stay positive!

Good Luck,

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.

More Questions Regarding IVF and ICSI: Can I Have Twins, SET, And Other Post Retrieval And Transfer Questions

Question:

Hello again, this is S. with some follow-up questions from my earlier email.

Thanks for answering my questions. I have a few more. I know that obviously it depends upon the number of viable eggs removed during egg retrieval for IVF with ICSI but how many of the eggs would they try to fertilize and use at a time? How does it work with the frozen embryos? What are the chances of twins or triplets with this type of procedure? Can I decide if I want twins if I have more than 1 egg that is ready? After the egg is fertilized and put back do I have to be off of my feet for a time? How long does it take for the process to take place?

Sorry I'm just really unclear about all of this. Do I have to go back for ultrasounds afterwards and if so how often do I have follow up appts? Thanks again!

Answer:

Hello S.,

You're welcome to follow up with additional questions any time. I probably did not address the ICSI (intracytoplasmic sperm injection) question you had in your first email. With ICSI, all mature eggs are injected since not all with fertilize. If they only took a few and did ICSI, which I understand some clinics will do, that could impair the number of embryos you have to work with if they don't fertilize.

These are then allowed to divide over a 3-5 day period. An appropriate number is then chosen to transfer. That number is decided between you and your doctor. With frozen embryo transfers, the embryos are thawed, allowed to expand, and if they survive, are transferred. Usually the number thawed are the number transferred because re-freezing is not necessarily a good thing.

If three embryos are transferred, the risk of twins is about 35% and triplets less than 10%. This risk declines as the number of embryos transferred decreases. Because of the high pregnancy rates these days, many clinics have moved to doing a single embryo transfer, or SET, in order to minimize the risk of twins or more. This is based on new recommendations that have come out from the American Society for Reproductive Medicine and the Society for Advanced Reproductive Technology. There has been strong political pressure for IVF centers to reduce the incidence of a multiple gestation (twins or more). If you want twins, then you have to discuss this with your doctor and see if that is something the doctor feels comfortable with. Depending on your age, either two or three embryos would be transferred to try to achieve twins.

Once the embryos are transferred, you do not have to "rest" for any period of time. I have my patients do light activity for three days after the transfer to allow for implantation to take place, but I do not want them to be at bedrest. From that point it is a natural process and is the same that your body would go through if you were trying on your own.

In terms of your last two questions, these are answers that you should be getting directly from your IVF center. You pay them a lot of money for this procedure and they should be giving you almost royal treatment. If they are not, then you should demand it. The IVF process is a three week process, basically mimicking your natural process. The ovaries are stimulated, which takes 10-12 days, the eggs are retrieved at the mid-cycle and allowed to fertilized, then they are allowed to grow in culture for 3-5 days, then they are transferred back into the uterus. 8-10 days later a pregnancy test is done, which usually coincides with the end of the month if you started at the beginning of the month. (You should check out my website and I have an outline of the IVF process.) In the first 10-12 days, ultrasound and blood tests are done periodically to evaluate how you are responding, how many follicles you have, how big the follicles are and when to trigger for the retrieval. These ultrasounds can be done daily, every other day or farther apart depending on how big the follicles are and how close you are to the trigger day (generally as you get closer, the appointments get closer). The egg retrieval is usually done two days after the trigger (35-36 hours from the trigger injection) then the transfer is done 3-5 days after that.

Good Luck,

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.

Injectables with IVF - Is Metformin Indicated?

Question:

Hello-I am from the US and I am 33 years old. My husband is 34. We have been trying for almost a year and saw an RE. I was told I have a fibroid that I am having removed laparoscopically the end of March. I was told by my doctor that since my huband's sperm is below where it needs to be (both count and motility) that I can begin IVF (in vitro fertilization) with injectable treatments about 2 cycles after the surgery. Which drugs are used? She mentioned ICSI (intracytoplasmic sperm injection) also. Will I have side effects from these injectable medications and if so what will they possibly be?

She also mentioned my possibly taking Metformin to try to enhance the IVF to work. I have heard mixed reviews on this medication actually working and was wondering what your take is on it. Can you please advise? I have heard of some unpleasant side effects from Metformin/Glucophage so I am not sure what to do.

What is the chance of IVF or IVF with ICSI to work? She said around 50% which I believe is much better than the 20% chance it would be which we were told if it would happen naturally. Is this true? I have had an ultrasound with saline and an HSG with dye- both came back fine other than the fibroid. I have been put on Synthroid to regulate my thyroid which I was told was slightly elevated. I am also on the birth control pill until I have the surgery to remove the fibroid the end of next month. I have had several blood tests testing my FSH, LH, Prolactin, Estradoil, glucose, etc all which have been normal results. Any additional info. you could provide would be appreciated.

Thanks!- S.

Answer:

Hello S.,

Let me answer your questions sequentially to make it easier:

1. Lots of different medications are used with IVF cycles. This is a question best answered by your doctor, or her IVf coordinator. Each doctor has different protocols, depending on their preferences and how they are trained. The main medications are called gonadotropins and are synthetic versions of the FSH and LH that your brain produces to stimulate the ovary to ovulate. We give higher dosages of these medications in order to make the ovary produce/prepare more that one egg. The goal with IVF, in order to maximize the chances of pregnancy, is to get more than one egg out. Preferably 10-20. This is because not every egg is a good egg.

2. Most women tolerate these medications very well since they are essentially the same as the hormones your body produces. Of course, all medications have side effects and each person is different and can react differently to each medication. The biggest side effect of these stimulation drugs is that the ovaries will enlarge and become tender because so many eggs are being recruited. In addition, some patients will feel bloated. If the ovaries are stimulated too strongly, or the ovaries respond too strongly, you can develop an illness called "hyperstimulation syndrome." This is a very serious and dangerous problem that has to be prevented and managed appropriately. If you have PCO, which I suspect you might have since your doctor recommended Metformin, you are at increased risk for hyperstimulation syndrome. You need to discuss this with your doctor and ask her what she does to prevent this. There are methods that we use to prevent this from occurring such as using lower dosage protocols, close monitoring of blood levels, coasting or drifting if necessary, antagonist protocol, triggering with Lupron instead of HCG.3. Metformin is only indicated in 30-40% of patients that have PCOD. It is NOT indicated in all patients AND, it takes 6-8 months to work so starting it with an IVF cycle is not appropriate. I would not recommend it unless you have been found to have insulin resistance by blood testing.

4. In terms of IVF working, you have a 50-70% chance of pregnancy with each IVF cycle in your age group. You should ask you doctor what her statistic is. Pregnancy rates do vary depending on the clinic and the doctor, so be sure to check both out.5. With a severe sperm disorder, the chances of pregnancy would be much less than 20%. Your natural chances of pregnancy at your age, if there were absolutely no problems, would be about 15% per month of trying. With the sperm problem it would drop it to less than 10%. That is why IVF is the treatment of choice. With IVF and ICSI, we had a 75% pregnancy rate per transfer in 2009. Most clinics are reaching that level as well.

I hope this information helps. Be sure to ask lots of questions. You will be paying a lot of money for this treatment and you should make sure you have had ALL your questions answered to your satisfaction. This type of procedure is like shopping at Saks 5th Avenue. You should demand and get the highest level of service!

Good Luck,

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.