Friday, April 2, 2010

U.K. Infertility Patient Had Four Fibroids Removed, Now Has Pain Upon Ovulation - Ovarian Adhesions?


Hi Dr. Ramirez,

I am a 28 year old lady who has been trying to conceive for 18 months. I had an ectopic pregnancy last June, but thank God both tubes are still intact as I was diagnosed early.

I decided to have a laparoscopy in February 2010 to find out what is wrong and my doc took out 4 fibroids and I also had mild adhesions to the right ovary but apart from that the tubes and the uterus looked healthy. But since the laparoscopy, I have been having this unbearable ovulation pain on the right side which I never experienced before. It lasts for 3-4 days. The pain is very uncomfortable and right hand side of the abdomen is very sore and tender. It feels exactly like the pain I had when I had the ectopic.

My question is could the adhesions be back on the right ovary already? If so, if they were mild before the lap, is it possible they got worse after the lap? Also, would the laparoscopy affect the functioning of the ovary as I have been having abnormal basal body temperature since the lap.Lastly, is it possible to ovulate from the same ovary every month, as I don't think I am ovulating from the left ovary at all?

Is my only chance of conceiving IVF?

Many thanks in advance for your suggestions. Regards, B. from the U.K.


Hello B. from the U.K.,

Yes, adhesions can return and usually return within 24 hours. Also, any surgery, including laparoscopy, can result in adhesion formation. Normally, when you ovulate, your ovaries swell thereby "moving". Unfortunately, the adhesions may be fixing the ovary in place causing you to have uncomfortable pain. I would not expect the laparoscopy to affect your ovarian function if the ovary was not damaged in any way or its blood flow affected.

Yes, it is possible to ovulate from the same ovary every month.

My opinion is that you have tubal disease that was probably caused by some type of event, like an infection in the past. That usually leads to internal tubal damage and scar tissue formation. If significant enough, you can also get scar tissue within the pelvis and around the ovary and tubes. The main problem is that if there is damage within the tube, it cannot be fixed. These internal adhesions are probably what caused the embryo to get stuck in the tube, leading to the ectopic. Certainly patients that have had ectopics before do subsequently have normal pregnancies, but there is no way to know which category you will fall into. With the combination of problems, ectopic and peri-tubal adhesions, I would expect that your natural chances of pregnancy are low, in which case, IVF would be the treatment of choice. That is how I would advise you in my clinic. You could certainly continue trying with a more natural method such as ovulation induction with timed intercourse or ovulation induction with IUI. You need to be seen right away if you get pregnant because of your increased risk of recurrent ectopic.

If you don't get pregnant after a period of time, I would set it at 6 months or no more than 4 IUI attempts, then I would proceed directly to IVF.

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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