Wednesday, March 31, 2010

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
Monterey, California, U.S.A.

8 comments:

  1. Ramirez
    I appreciate your good explanation on ectopic pregnancy. I am surprised why all the doctors doesn't have the information you have.

    My wife has only one ovary(Left) as her other ovary(right) was removed due to cyst 8 years back.
    We have been trying to conceive for the past 3 years with no success. We had two failed IUI's and then we went for IVF. At that time bcoz of the high dosage of medicines there was a OVarian torsion and luckily the left ovary was recovered without any issue. Since all the eggs were retrieved before the torsion we freezed them. So after 2 months we did the Frozen embryo transfer. We did get a chance to see the heart beat but after few weeks it was a miscarriage.
    We changed the fertility doctor after that as we want to do an IUI instead of IVF.
    We did a IUI recently with just Clomid 50mg. But our fate this time it was a ectopic pregnancy. Its on the right Fallopian tube the same side where the ovary was removed 8 years back. We were wondering how the Fertilized ovum could travel there and we did ask this question to the surgery doctor and even to our fertility doctor. The answer was only surprise and no proper reply. The doctor has removed the right fallopian tube. Now we have a left ovary with left fallopian tube. Could you please advice whether its good to go for IUI or IVF next time taking into consideration of the recent ectopic pregnancy. Doctor is saying the left fallopian tube looks good.
    We don't know why God is giving us so much trouble :(
    Thank you so much. God bless you.

    ReplyDelete
  2. Hello April 8th,

    First let me explain how an egg from one side ovary gets into the tube on the opposite side. There is a wide misconception that when an ovary ovulates, the egg goes into the same side tube because the end of the tube is wrapped around the ovary. That in fact is anatomically incorrect. The tube hangs down about 2-3 cms from the ovary into a space called the culdesac, not wrapped around the ovary. So when the ovary ovulates, which can happen from any surface of the ovary, the egg, propelled by the fluid within the follicle, flows downhill into the culdesac. By fluid motion, the egg then contacts one tube or the other.

    Having had an ectopic that means that there was potential scar tissue within the tube. The cause of this scar tissue is unknown but was most likely some type of bacteria that got into the tube. This usually happens on both side. So the tube can be open so that fluid flows through it, but it may be partially blocked which would lead to an ectopic. My assumption is always that this is the case and so I recommend IVF as the treatment of choice. That is not an absolute, however. Currently, there is no technology to evaluate the inside of the Fallopian tube so this has to be assumed. You have to decide if you want to take the risk for another ectopic or not.

    My recommendation would be to continue with IVF. After all, it was successful before. IVF cannot keep a miscarriage from occurring. That is completely due to the pregnancy, which is beyond IVF. But in all likelihood, you will eventually be successful.

    God does not cause bad things to happen. Because of his immense love as a loving parent, he has granted us free will and allowed us to experience all without his intervention. For that reason he lets life occur as it does, lets events occur as they may and lets us show our love and devotion to him by choosing how we live our lives. After all, God gives us opportunity. He does not choose for us. I have learned through my hardships that how you live with the obstacles of life and what choices you make are what's important and how we serve God and reaffirm to him that we are faithful.

    Good Luck

    ReplyDelete
  3. Thank you for taking time to answer my question,three years ago I found out that I had an ectopic pregnancy and I lots my left hand side tube,while the doctor was oparating me he found out that my right hand side ovary was bigger than its normal size so he removed it. My question is what is it that I need to do to fall preganant as I have started taking prenatal vitamins.

    ReplyDelete
    Replies
    1. If you have not seen an infertility specialist, that would be the first step. Also, surgery can cause scar tissue formation within the pelvis that can then interfere with movement of the egg from the ovary to the tube. This can prevent pregnancy. The only treatment option in that case would be to use IVF.

      Good Luck

      Delete
  4. Willing to hear any possible thoughts
    Age 37-38, 4 retrievals after cornual ectopic s/p IUI and salpingectomy as cornual on u/s was not definitive
    First cycle antagonist, long stim, only 4 retrieved with about 7-8 on u/s. frozen . Preceded by ocp
    2nd attempt at antagonist--converted to IUI due to uneven growth. Preceded by 2 weeks estrogen. Peak e2 2500
    2nd retrieval: micro flare protocol, 5 retrieved, 4 fertilized, e2 5000
    All eggs frozen, only one thawed at day 2 and did not iplant
    3rd retrieval elsewhere microflare, with dexamethasone
    e2 4100, 9 retreived, one blast frozen and 3 day 4/6 cell fresh transfer. All failed
    4th microflare, 17 retrieved, e2 7500+, only 8 fertilized. frozen day 3, 5 frozen at day 3 but qualit not so good
    4 thawed, but 3 fragmented one 4 cell failed to implant

    Almost all eggs are on strong ovary, other side has 6 antrals but only one stimulated recently

    ReplyDelete
    Replies
    1. The biggest problem that you are facing is the "age related egg factor" which means that the majority of your eggs are of poor quality as a result of age. Many of the formed embryos confirm this issue. I tell patients to imagine a bucket with 1000 blue balls and 5 red balls. The red balls represent the good eggs. Now what you are doing is trying to find a red ball, but the majority of balls (eggs) that you get are blue balls. As you can see, that is the big hurdle that you are trying to overcome. The good thing is that your ovaries are responding fairly well, so there is still a chance to find a good egg. However, it may take several attempts.

      I'm not quite sure why they are freezing all your eggs, however. That just exposes them to additional risk.

      You have two choices at this point: (1) continue trying until you succeed using your own eggs or (2) move to donor eggs. If you have the finances, the patience and the emotional stability to do so, I would recommend you keep trying with your own eggs.

      Good Luck

      Delete
  5. Hi

    I have problem too,I hd an ectopic pregnancy on 2011 november,I tried to concieve again but no lucky.I went to my Dr and he took my blood to count my ovaries then after 2 days I go bk to him to findout the result and he told me I hv 22 somthng ovaries in dis left egg so I hv many chances to fall pregnant again so he gave me fertomid 50 mg for 2 mnths treatment..so any one who's using fertomid and what da result?am scared and worried cos I wish can it work..

    ReplyDelete
    Replies
    1. Based on your history of ectopic pregnancy, your doctor is not using the correct protocol. I would recommend that you go see an infertility specialist. You may want to consider IVF in order to avoid having another ectopic. Just so you understand my comment about your doctor, because you are at higher risk of another ectopic, you should be monitored closely. In addition, Clomiphene (Fertomid) should NEVER be given for a two months treatment without monitoring the progress i.e. whether you are responding to the medication, how many follicles are growing (so you don't have too many) and when ovulation is going to occur. This requires ultrasound surveillance. Finally, what is the reason for using the Fertomid? What is he treating? It is not a magic fertility drug. It has a specific purpose and anticipated response.

      Find a new doctor!

      Delete

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