Saturday, March 27, 2010

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



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


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
Monterey, California, U.S.A.

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