Husband & Wife With Different Blood Types: Did Rh Factor Lead To A Fetal Demise?

Question:

Hi,

I'm 33 years old my husband is 39. We are a healthy couple. Twice in one year we've gotten pregnant. First pregnancy, very early, I began to have spotting and eventually was diagnosed with an ectopic pregancy, I was given Methotrexate. This past May I was pregnant again, and during my first evaluation at 6 weeks everything was fine, except my progesterone level was low (12.17) and I began using shots and pills daily. After one week my levels reach 96.14.

At 8 weeks my evaluation showed no heartbeat, I was diagnosed with fetal demise. I'm concerned because my husband and I have different Rh and blood group (B- and O+) is this a problem? What should we do next? Infertility evaluation?

Thank you, M. writing from Puerto Rico

Answer:

Hello M. from Puerto Rico,

First of all, your difference in blood types does not lead to miscarriages. However, regarding your blood type differences, if you have a negative Rh factor (B-) and your husband is positive (O+) then you will need to receive an immunization called Rhogam (an Rh immune globulin injection), which should be given with this miscarriage, and should have been given already with the ectopic. This is because in a future pregnancy, the fetus can be affected by an immune response and develop a disorder called erythroblastosis fetalis. This is because your Rh antibodies may cross the placenta and attack the baby's red blood cells. The Rh positive baby then may develop Rh disease, a life-threatening condition that could cause anemia or other serious problems. For more on Rh factor, please visit the Mayo Clinic website: http://www.mayoclinic.com/health/rh-factor/MY01163

Secondly, you have to separate your two pregnancies because they are completely different. An ectopic is a pregnancy that implants in the tube. This is different from a miscarriage, which is in the uterus. They are not related. The only conclusion you could make is that because of a previous ectopic, you are at risk for another. However, you have already shown that you can get pregnant within the uterus despite this risk. Miscarriages are a natural occurrence. They occur in up to 40% of pregnancies, and the most common cause is a chromosomal abnormality in the developing fetus. The body (nature) realizes that the fetus is abnormal and stops the pregnancy or severe defects in the fetus causes it to die off. The good news is that most women that have miscarriages are eventually successful. You just need to keep trying and I don't think that you need to do anything different, necessarily.

Because of the progesterone issue, you might want to add supplemental progesterone after ovulation, just as a precaution. This can be given as injections or vaginal suppositories.

Despite the setbacks you have had, I am confident that you will be successful. Please follow up with your Ob/Gyn regarding your Rh factor!

Sincerely,

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.

Diminished Ovarian Reserve: I Have Failed 3 IVF Cycles, Blighted Ovum -- Where Should I Go Next?

Question:

Dr., I am 34 and have been diagnosed with diminished reserve.

I have done three IVF cycles. In the first, we got 5 eggs, after fertilizing all had testing and all found to have some anomoly, none transferred. Second, the clinic let me ovulate...didn't even get to extract eggs. Third got 2 eggs, only 1 fertilized, only a 4 cell with a lot of fragmentation, & I knew it was not going to work. Just found out I have a blighted ovum.

My question: Obviously my chances are not very good on my own and I realize donor eggs are my best option but I am finding it difficult to give up.

I am in health care and I guess my question if you can offer any advice is: For example in certain types of cancer there are certain centers that are more leading experts than others for certain types of cancers. Is that possibly the case with this disease? Is there a center that is the leading expert at diminished ovarian reserve that can help me? I had these 3 IVF at 2 different clinics and neither were very compassionate and treated me just like a number taking a shot in the dark at my protocol.

The last clinic the MD REALLY got my hopes up and now that it hasn't worked has dropped off the face of the planet. So my question is, are there leading experts in this arena that maybe know more specifics about what type of protocol might work best for me??

Answer:

Hello B. from the U.S.,

First of all, let me say that diminished ovarian reserve is NOT a disorder and is not a cause of infertility. It simply means that the patient's ovaries don't stimulate well and is often indicated by a high cycle day #2 or 3 FSH level. It is not an indication of egg quality in any way. Secondly, you are still young. You still have a good chance of pregnancy with your own eggs even if only a few are retrieved. I would still expect your pregnancy rate to exceed 50% per cycle (ours is 73%). I would not have wasted any of the cycles because there is no way to know if the good egg was in that batch. Even normal women do not ovulate good eggs all the time, and that is why it can take several months of trying to get pregnant. It is the same with IVF. Even if my patient has only one follicle I still try for this reason.

In terms of your question regarding the best center for your problem, I'm afraid there is no one center that is best for this problem. All IVF clinics have patients with decreased ovarian reserve, and each IVF center has different statistics and different ways of taking care of their patients. We all use different protocols as well. One question I would ask is what was your protocol? Were you given the max stimulation (600IU of FSH in either pure FSH (gonal-f, follistim, bravelle) or a combination (one of the previous with Menopur, Pergonal, Repronex). These latter medications have FSH in them as well so for instance if you took 450IU of Follistim + 150IU of Menopur, you would have a total dose of 600IU of FSH. I use this as my highest protocol.

In addition, timing is critically important. If the HCG trigger was given with the follicle size of 18 mms, it is possible that the egg did not have adequate time to mature, whereas 20 mms or 24 mms would have been better. As you can see, there are many variations in treatments. That is why there is no one center that is better than any other.

In my center, for example, I have extensive experience with low responders and use a high protocol for those patients. I also am a smaller, boutique-type center that prides itself and excels in providing one-on-one personalized care from beginning to the end. I am the only doctor, involved with my patients' progress from day one. That is what makes us different from some of our competitors in the big cities that operate more impersonally and do not give you access to the RE as much. All of these are facts and qualities that a patient should look for and seek out. They are paying a LOT of money for this treatment so they should demand their money's worth in all aspects.

With all that said, low responders are difficult because part of the success of IVF comes from having a large pool of eggs to work with. We know that in all cycles, there are going to be good eggs and bad eggs, so if we have an increased number, then there is a higher likelihood of getting a good egg. For low responders who don't stimulate well, and hence, don't give a lot of eggs to work with, that just means it may take more attempts before that good egg emerges. I would recommend that you NOT give up. After all, you have really only done two IVF cycles since the second one was cancelled. I am confident that you will be successful if you can continue to try. If you want a quicker solution, then donor eggs would be the option, only because a donor with normal ovarian function will yield more eggs to work with. Since you have had a blighted ovum, it means that the IVF cycle worked (remember, IVF only can produce embryos. The pregnancy, because of the last implantation step, still has to occur naturally). This confirms that you can get pregnant, and it is just a matter of getting a good egg/embryo into you. If you were 40, I would advise differently and lean more toward donor, but at your young age, you should keep trying.

Maybe you should consider coming to Monterey :) ! It is a beautiful place to visit as well.

Good Luck and don't give up hope!

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, and follow me on Facebook at http://bit.ly/9Iw9oV

Male Factor Infertility -- IVF Cycle FET Positive But Ended With Miscarriage: Should I Seek A Second Opinion?

Question:

Dr. Ramirez,

My husband and I are a 29yo healthy couple with male factor infertility. Motility is less than 1%, morphology is about 25-30%, and count is pretty low-normal. There are no female issues. We have done 2 IVF/ICSI cycles and one FET (frozen embryo transfer). The first IVF (in vitro fertilization) cycle, I was mildly hyperstimmed. The egg quality wasn't great, and we had about a 50% fertilization rate. We transferred 2 grade A embryos that did not result in pregnancy. No embryos made it to day 5. IVF #2 was much better and had an 80% fertilization rate. 2 day-3 grade A embryos were transferred, but there was no implantation. There were 2 day-6 blasts that were frozen. Both were starting to hatch upon thawing, and the FET resulted in a singleton pregnancy with a heartbeat at about 7 weeks. Unfortunately, I miscarried (no heartbeat) at 8 weeks.

My question to you is when should I seek a second opinion? We had planned on obtaining a 2nd opinion if the FET was unsuccessful, but we feel like technically it was successful. We like the place we go to right now and feel that they are familiar with us. We are planning to do IVF #3 in the near future and are torn as to whether we should stay here or move on. If we stay with the current practice, we will not be changing the protocol since it was successful last time. Although it has been suggested, we are not ready to use donor sperm since we were able to grow 2 blasts and achieve a pregnancy. We are located in Missouri.

Thanks in advance for your time.

Answer:

Hello L. from Missouri,

I agree with your statement that technically the FET was successful. In fact, the FET cycle WAS successful. Remember, IVF can only give you the opportunity to become pregnant. It cannot MAKE you pregnant because the last two steps in the natural process, embryo hatching and implantation, are NATURAL steps and we don't have the technology to make that happen. So, the fact that an embryo did those two steps and the pregnancy went to 7 weeks is a success. And, it is a very good sign because it now shows that what you are doing can work!

I would not give up on that clinic yet. In fact, pregnancy rates with FET are lower than fresh cycles, so a success with an FET is good. They deserve the credit. Now that they have stimulated you twice, know how you react, etc., they are hopefully in a good position to build on that the next cycle. You have to give them some credit for that.

Overall, I would hang in there. You've proven that it can work. Whether or not the pregnancy continues is solely and completely dependent on the embryo. It was probably an abnormal embryo. Now, you just need to get a good one there and you'll go all the way. Don't look back, just look forward. You should now be more encouraged than before because you know that it can work. It is just a matter of time!

On a personal note, I have a patient that I was able to get pregnant on her first try at the age of 36 and she had a beautiful child. She just came back to me for her second child at 39 (worse chances statistically) and became pregnant again, but it was an abnormal pregnancy and ended in a miscarriage. I found out today, that she is planning to transfer to another clinic because they have a "special" research program going on that gives patients a significant discount. You can't believe how heart broken and how I feel rejected by this. I put my heart and soul into my patients, and they get the best care that they can receive. I know that logically the cost is a significant issue, and this is what is driving the patient, but having gotten so close to a success, when we have been successful before, is difficult for me. That is what your clinic will think too. They'll ask themselves, "why is she leaving when we were successful under less odds?"

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, and follow me on Facebook at http://bit.ly/9Iw9oV

Comment: Dr. Ramirez clearly stated his opinion and seemed to have genuine answers. I appreciate his advice and his providing this service

IVF Patient With Positive Beta On Immunoglobulins (IVIG) & Has Questions

Question:

Good day Dr Ramirez,

I wrote to you a while ago. We just completed our 3rd IVF (in vitro fertilization cycle) and 2 , 5-day frozen blastocysts were transferred.

I had a blood test on day 10 post transfer and the result was positive. I suffer from rheumatoid arthritis. My doctor gave me 5ml immunoglobulin (integram) on day 2 of my cycle and 5ml again 10 days post transfer. I am also on 600mg cyclogest as well as folic acid , baby asprin, omega 3 & 6 and staminogro.

I am still concerned about the arthritis and worry about the anti bodies - is the immunoglobulin sufficient - what is the protocol, what do you suggest?

My second question is. From the day of the FET I felt this twitch on my left side of my uterus . From 7 days post transfer I have lower back and stomach pains.

Should I worry? I have heard that it is normal for FET patients to get pains and cramps and it is good pains. I have no spotting though. My first beta on day 10 was 198 and my second beta on day 12 was 416 .Can you please advise. Thank you. V.

Answer:

Hello V.,

I believe the immunoglobulin is sufficient from a fertility point of view, but I don't know in regards to the arthritis. You would need to consult a rheumatologist to get the answer to that question.

The pains you are having are probably normal. Many women experience some uterine cramping or pains in the early pregnancy. We call these "growing" pains. Your bHCG levels are good so things look good. At this point, you just have to hope for the best. Congratulations and stay positive!

Follow-Up Question:

Thank you so much for your reply. Do I understand correctly that the dosage of the immunoglobulin that I got is sufficient for the duration of the whole pregnancy and I don't need to get additional imunoglobulin again? The reason why I ask is that I had a miscarriage 7 years ago ( a natural cycle without any meds)- due to the antibodies of the athritis and I am concerned that it might happen again.

Follow-Answer:

Hello Again,

Because the use of Immunoglobulin in IVF is controversial, there are no set protocols or dosages. Therefore, I cannot comment on the dosage or times of delivery. In my experience, however, it is given at the beginning of the cycle, after the transfer and if pregnant again at that time. I would recommend that you look up the Reproductive Immunology Associates website (www.rialab.com/ivf_immunotherapy.php). They are immunologists that have geared their practice specifically to reproductive issues. They will have more specific information regarding the use of immunoglobulins. They will also answer email questions.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Programwww.montereybayivf.com

Monterey, California, U.S.A.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV

Woman With Stage 4 Endo Worries About Endometrioma: Will Not Interfere With IVF, Can Be Excised At A Later Date

Question:

I am 28 years old & TTC for a while. Diagnosed with stage 4 endo in Dec. 09. I was told to do 6 months of lupron, then another laparascopy from an ob-gyn. I got a second opinion from a fertility doctor in may 09 after not getting pregnant naturally with the assistance of acupuncture and herbs. He said I could do another lap, or start on fertility drugs. I chose to start on clomid 50 mg CD 5-9. I do have a 2mm cyst on my left ovary and am concerned about the cyst growing.

Is Clomid something recommended for someone with stage 4 endometriosis trying to conceive? I asked my doc if the cyst posed a problem and he said if it was larger then he would be concerned, but he said given the size it's not an issue. Well, if the clomid causes the cyst to grow, then that scares me. Not sure if I should consult another fertility doctor? K. from the U.S.

Answer:

Hello K. from the U.S.,

In general, if a patient has stage 3 or 4 endometriosis, then the treatment of choice is IVF. The reason is because the endometriosis, despite the laparoscopy and Lupron, causes the pelvis to be inflamed and is hostile to the egg. Basically the egg gets destroyed before it can make it into the tube. This is not 100% of cases, however. I have had patients with stage 4 endometriosis that become pregnant naturally. How they did it, I cannot explain, but they are definitely the exceptions to the rule. In general, natural pregnancy is very, very difficulty with stage 4. Therefore, if you consulted me, I would recommend IVF to you.

The cyst you had (2 mms) is a normal follicle and technically NOT a cyst. We don't worry about cysts unless they are 2 cms (20mms) or more. The clomid will cause a follicle or follicles to grow. That is what it is supposed to do. Those follicles contain the eggs and they have to grow to 24 mms in order to ovulate and for the egg within to mature.

Because you are young, your doc is probably thinking that you could try something easier for a few tries to see if you might be one of the exceptions to the rule. That is why he is suggesting Clomid. Then if that doesn't work, he might suggest IVF. I would recommend that you talk with him/her again and ask if he/she thinks the Clomid has a good chance of working and what treatment would be the best treatment in light of the severe endometriosis. He/She might change their opinion then. I don't think you need to consult another fertility doctor because you just consulted me. I hope I gave you the information you needed.

Follow-Up Question:

Thank you Dr. Ramirez! You did clarify things for me. I'm sorry I meant to put 2cm cyst, I don't know why I put 2mm. I was told it was a chocolate cyst when I had my laparoscopy in Dec. The ob/gyn said he drained it. It was 4cm then, and now by June it has grown to 2cm again. I guess that is the reason I have been feeling the pain again. Can endometrial cysts dissolve on their own? If not, if it continues to grow does that pose any risk to getting pregnant if my tubes are open, and if I succeed in natural pregnancy could the cyst create a problem during pregnancy?

I just don't know if I should have another laparoscopy so soon. Is 6-7 months too soon? Thank you for any insight on this issue.

Follow-Up Answer:

Hello Again,

The cyst that you have is called an Endometrioma. It is an endometriotic cyst or tumor. Draining it is not sufficient because the endometriosis is still located within the cyst and it will refill as it has done in your case. It should have been excised (cystectomy) at the time of the laparoscopy. It will not interfere with your ovarian function and will not interfere with an IVF treatment. Its presence, however, means that endometriosis and scar tissue are still present and an issue, which reduces the chances of a natural pregnancy (as I explained previously).

If you were lucky enough to become pregnant naturally despite the endometriosis, then pregnancy is a good treatment for endometriosis, and the endometriosis will not complicate the pregnancy. Neither will the endometrioma as long as it does not get too big or does not twist on itself (torsion). If needed, it can be removed during pregnancy.

Six to seven months for another laparoscopy is not too soon. We usually will do a second-look laparoscopy within 4 weeks if we are worried about recurrent scar tissue formation. My advice would be either to have another laparoscopy and this time make sure the cyst is removed, then proceed to IVF or proceed to IVF directly without the laparoscopy. My wife had an endometrioma at the time that we did our IVF which they were able to drain at the time of egg retrieval. It did not interfere and her cycle was successful.

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 and follow me on Facebook at http://bit.ly/9Iw9oV

The U.S. Open Arrives In Monterey...

Just wanted to welcome golf's U.S. Open to our area. For those of you who don't know where I am, I am in Monterey, California where the U.S. Open is being played this week at Pebble Beach Lodge and Golf resort. My office is 15 minutes away. Not only is this area a golf mecca, but it is a secluded travel location where many of the wealthy and celebrity come to get away. We are next door to Pebble Beach, Carmel, Monterey and Big Sur.

For patients it is a relaxing, peaceful, private and tranquil setting, more conducive to avert the stresses of infertility treatments. As you watch the U.S. Open this week, and think, "boy what a beautiful place", I hope that you'll think of us, and one day plan to come visit us and our beautiful location. I will even treat you to a round of golf at our nearby Laguna Seca Golf Ranch!

41 Yr. Old Iranian Woman With Mixed FSH Results: Remember, FSH Levels Are Not A Measure Of Your Fertility, They Are A Measure Of Ovarian Function!

Question:

Hi! I am 41, with a 22-day cycle. I got married 8 months ago and had a miscariage at very early months (1st month). Then, my doctor prescribed me clomid and letrozol which resulted in production of several eggs. however, I did not get pregnant.My last FSH test result at 21th day was 4.7, while its level at 3rd day (i.e. four days later than my FSH test at 21th day) was 35.5!

I am too much worried about this high level of FSH. What are your recommendations for FSH reduction and get pregnant?

thanks! M. from Iran.

Answer:

Hello M. from Iran,

I am surprised but glad that you are able to search the web, since many of us believe your government has tighter controls. Let me clear something up first of all. The FSH level is only valid for interpretation if it is done on cycle day #2 or 3. I would recommend that you have it repeated because the results you cited don't make sense. The FSH is a measure of ovarian function (or ovarian resistance). This is mainly important to determine how well the ovaries will respond to stimulation. It is NOT a measure of fertility.

However, if the CD#3 FSH level of 35.5 were correct, that would indicate that you are in menopause and your ovaries would be shut down. You would no longer be having periods and you would have menopausal symptoms such as hot flashes. Your ovaries would not respond to stimulation with Clomid or Femara. Yet, you mention that you were able to "produce several eggs" while on Clomid. That is why I don't think that your FSH level is correct.

From a fertility point of view, we want the FSH level to be less than 7. It is of some concern when it is between 7-10, which indicates that there may be less time for the ovaries than we suspected and that the ovaries might be more resistant that expected, and it is of great concern in the level is greater than 10 because that means there is significant ovarian resistance and a shorter time line. Once the level is 15 or greater, most fertility specialists will recommend using donor eggs.

The biggest hurdle that you are facing, in addition to ovarian function, is your age. Your chances of pregnancy with simple Clomid treatments is 2% per month of trying and with IUI is 5% per month of trying. I would not recommend this at your age. I think that time is of the essence, so that you don't lose the possibility of having a genetic child. For that reason I would recommend a more aggressive treatment plan, which would be to proceed directly to IVF. That would give you a 50% chance of pregnancy per month.

Good Luck and thank you for your question,

Edward J. Ramirez, M.D., FACOG
Executive Medical DirectorThe Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

Seventh IVF Cycle Brings Success But Patient Worried About Progesterone Levels

Question:

Hi Doctor!

I have recently become pregnant after my 7th IVF, and am currently 6 weeks. I had 2 very good quality blastocysts transferred and am awaiting my 7 weeks scan next week to see the heartbeat and hopefully tell if it's twins. I have been going in for blood tests to monitor my progesterone levels and initially I was taking 2 cyclogest (400mgs) a day, it then increased to 3 and now 4 a day. This was because my prog levels were fluctuating from 80 and 150 and my FS feels 150 is a good level. My last test showed it at 200. From doing my research, I realise that normal prog levels can be anything above 30 and less than 100. Are mine too high? IS there any danger of having prog at 150-200?

My Bhcg has also been monitored every 2-3 days and they have been climbing nicely, from 193,447,1863, 4990 and now 13900. Are those indicative of a viable pregnancy?Many thanks for your help and advice.

Regards, N. from the U.K.

Answer:

Hello N. from the U.K.,

Congratulations! I'm glad you persevered because most patients would not try IVF 7 times. All your levels are fine. Your progesterone is not too high and there is no danger with a level of 200. I'm surprised your doc is chasing the levels. Your bHCG levels are great. With a level of 13,900, the gestational sac should already be visible within the uterus, so your doc should go ahead and do a scan this week rather than wait until next week. At this point it is important to confirm the uterine pregnancy because there is a 2-5% risk of ectopic pregnancy with IVF (tubal pregnancy). If it were in the tube, this would be the time to treat it as medication can be used instead of surgery.

I don't mention this to scare you, but I normally do my first ultrasound at 6 weeks gestational age for this reason. You might want to ask your doctor to do so as well. More than likely everything will be fine. Again congratulations!

Follow-Up Question:

Hi Doctor,

Thanks so much for your advice, I really appreciate it. I took your advice and scheduled a scan for today, which confirmed a single uterine pregnancy and we saw the heartbeat. So it is a relief! I am currently 6 weeks and 4 days. Is there any chance of things going wrong after seeing a heartbeat? I haven't had any bleeding or haven't had any major cramping. I also haven't been experiencing nausea and morning sickness, but I have had lower back pain, fatigue, and strangely enough throbbing ankle or feet pain now and then. Thank you for your time and help. Regards, N.

Follow-Up Answer:

Hello N.,

Congratulations! At 6 weeks with the findings of a fetus of appropriate size and a good heartbeat, those are good signs for the pregnancy. There is still a risk of miscarriage that runs about 40% until 8 weeks gestational age. Your doctor should probably repeat the ultrasound in two weeks. If everything looks fine at the next ultrasound (8+weeks), then the risk of miscarriage drops to 5% until 12 weeks gestational age.

Of course there are lots of problems that can occur in pregnancy. Everyone has the same risks. But if you worried about every possible risk, you would go crazy and not enjoy your pregnancy. For now, I would recommend that you take things in stride and day to day. Don't worry about the future because you don't necessarily have control over it. Hope for the best because that is the most likely outcome. And as the sailors of olde used to say, pray for good winds!

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, and follow me on Facebook at http://bit.ly/9Iw9oV

The Ten Natural Steps To Pregnancy: Where Do Ovulation Induction And IUI Matter Most?

Today's blog post is an attempt to clearly state the Ten Natural Steps that a woman's body needs to accomplish in order to achieve pregnancy. Ovulation Induction and Intra-Uterine Insemination are treatments that give an additional "boost" to a natural pregnancy path.

Step 1: The Hypothalamus/Pituitary complex secretes FSH and LH into the blood stream to stimulate the ovary and start the process toward ovulation.

Step 2: The ovary activates several follicles to start growing but only one becomes the dominant ovulatory follicle.

Step 3: Once the follicle reaches the appropriate size (24 mms), the hormone LH surges, the follicle ruptures and the egg is released into the culdesac, where the fimbria of the tubes are laying.

Step 4: The egg has to find and enter one of the fimbria to get into the tube.

Step 5: The sperm have to be waiting in the tube and when the egg enters, the sperm collect on the egg.

Step 6: Fertilization has to occur by one sperm entering the egg. The egg and sperm's genetic material unite.

Step 7: The fertilized egg divides and grows into an embryo (as it courses down through the Fallopian Tube over the next seven days).

Step 8: The embryo enters the endometrial cavity.

Step 9: The embryo has to hatch and the inner cell mass exits the shell and attaches to the endometrial lining.

Step 10: The endometrial lining has to grow around and accept the embryo (implantation). Pregnancy test will now turn positive and the embryo slowly develops into a fetus.

OVULATION INDUCTION assists in steps 1, 2 & 3.

INTRA UTERINE INSEMINATION assists in steps 1, 2, 3, & 5.

My Sister Has Ovarian Cancer: I Want To Be Her Surrogate, What Is The First Step?

Question:

Hello. My sister has been diagnosed with Ovarian Cancer and is going to have a hysterectomy. We have discussed it, and I would like to carry a baby for her using her eggs and her husbands sperm. I live near Ottawa Ontario and she lives in Calgary AB. I was wondering what the first step would be, and who we should call to get this process started before it is too late.

Answer:

Hello C. from Canada,

I am sorry to hear about your sister, but the good news is that we do have the technology to help her have a child in exactly the way you mention. It is called IVF (in vitro fertilization) with surrogate. Your sister needs to contact an IVF center immediately. They will then have several options: the eggs can be removed to be fertilized and used later, or she could go through the IVF cycle completely and the fresh embryos placed directly into your uterus. In either case, you would be the surrogate. An IVF cycle will take two weeks minimum, so she will need to do this quickly, before her surgery. With ovarian cancer, you don't want to delay much.

The infertility specialist should coordinate things with her Gyn oncologist so that everybody is on the same page. Once the eggs are removed (egg retrieval), she can then undergo her surgery. Stimulation should be strong to try to retrieve as many eggs as possible so that any residual eggs/embryos can be frozen for later use if the first cycle fails or for another sibling. The IVF center will advise you on your role as a surrogate, do all the planning necessary and prepare your uterus to accept the embryos.

For more information, there is a very good non-profit here in the U.S. called "Fertile Hope", (which has recently been acquired by Lance Armstrong's Live Strong organization). This organization has a lot of information regarding cancer patients and their reproductive options. There is a section on the website for healthcare professionals that I have used called "Options At A Glance", which gives you a good idea of all the methods available for fertility preservation. See this link: http://www.fertilehope.org/ .

This is a wonderful thing that you are trying to coordinate and the best of luck to all of you!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV

Young PCOD Patient With Tubal Blockage Unable To Conceive: Surgery or IVF?

Question:

I'm really searching for some advice. I was diagnosed with PCOS (not insulin resistant) this month (after four years of "maybe yes") as well as finding out I have a blocked fallopian tube.

I'm seeing an IVF specialist who recommended having hysteroscopy and laparoscopy surgery to clear the blockage and determine if there is scar tissue or endometriosis that can be fixed. I've suffered from very heavy irregular periods for the last 4 years.

I was told that if I chose not to go with the surgery the next step will probably be IVF. I thought IVF was a little extreme, completely skipping over Clomid and other fertility drugs. I know it's possible to get pregnant with one working tube, and I really don't want to do surgery unless it's absolutely necessary. I've been told by family I should get a second opinion, that sometimes surgeries are recommended when it's not really needed, because of money, etc. My Dr office did tell me I have excellent health insurance coverage. I don't think that's the case but it just seems like 2 extreme methods. I'm at one of the best fertility clinics in South Florida and feel like they should know better than me.

I'm 26 and not overweight (I lost 40 pounds 3.5 years ago), I've been off birth control for 5 years, and we've actively been Trying to conceive for over 8 months. My husband's sperm count is great. I used ovulation kits for 3 months but was never able to get a positive result. Is surgery the only way to tell if I have endometriosis?Would it be more beneficial to have the surgery then to start IVF without it?Is it usual to skip all other fertility medications in situations like mine and just use IVF? Is this a situation that you would recommend getting a second opinion?

Any advice you can shed is greatly appreciated.

Thank you, S. from Palm Beach County, FL

Answer:

Hello S. from Florida,

I guess I can be your second opinion. As you have described, you have two problems thus far: PCOD and tubal blockage. Certainly if PCOD were the only problem, ovulation induction with Clomid, Femara or injectables would be an option and could be combined with intercourse or IUI. However, keep in mind that most PCOD patients do not respond well to these medications and many (up to 85%) end up having to go to IVF because of this. However, if this were the only problem, then you would have more options.

Tubal blockage is another problem. The more problems you have, the worst the prognosis for achieving a natural pregnancy and the more you need to consider IVF. Tubal blockage by itself is enough to consider IVF, however. You don't describe where the tube is blocked but the only situation where surgery might help with tubal blockage is if it is blocked at the very end AND there has been no internal tubal damage, such as is caused by endometriosis. If the tube is blocked anywhere along the tube, it cannot be repaired and surgery would therefore not be indicated. The most common cause of tubal blockage is some form of inflammatory disease that ascended into the tube via the vagina and uterus. Because both tubes open to the uterus, this inflammation/infection problem got into both tubes but affected them unevenly such that only one tube is completely blocked. That does not mean that the other tube is normal, however. It could mean that the other tube was affected and damaged but did not scar enough to block completely. Usually when I see one side blocked, I make the assumption that the other tube is also not functional based on the fact that if it were, the patient would probably have achieved pregnancy on their own. Considering how long you have been trying, that makes me suspicious that the open tube is not functional. In that case, the ONLY treatment option is IVF because that is the only way to bypass the tubes. Remember that the internal part of the tube cannot be repaired and repair of the tube at the very end of the tube does not work well (1% pregnancy rate).

So, now, if you combine these two problems, then you can see that IVF is the treatment of choice for you. In that case, why have the surgery? Any other problems found, like endometriosis, will just be additional reason to do IVF. It does not affect your IVF chances. The only reason to have a laparoscopy if you are considering IVF is if the tube is swollen with fluid, called a hydrosalpinx, in which case that tube either needs to be removed or severed from the uterus to prevent the fluid within from leaking into the uterus. Studies have found that IVF pregnancy rates decrease by 50% when a hydrosalpinx is present. The only other reason is if you had any kind of ovarian mass or cyst. That would need to be removed prior to IVF as well. Remember, the treatment has to treat and overcome the problems.

Just choosing a treatment arbitrarily, like fertility medications, does not necessarily overcome all the problems present.

I hope that answers your 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, U.S.A.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

Patient Wonders: Did I Get Cancer From IVF Medications?

Question:

Amy Demma, Esq. at "Prospective Families Egg Donation Agency" was recently contacted by a woman currently undergoing breast cancer treatment urging Amy to inform both her recipient clients and the donors registered with Prospective Families of a claimed correlation between the medications prescribed for ART and a diagnosis of breast cancer. Amy contacted me to discuss this issue:

Good Morning, Dr. Ramirez,

Recently I was contacted by a woman who was urging me to share with my clients her story of undergoing multiple IVFs and then later being diagnosed with breast cancer. She shared with me the history of her IVF attempts and feels certain that there is a correlation between her experience with IVF and her current condition. I am wondering if there has been any recent research addressing a possible link b/w medicines used during ART and a later diagnosis of breast cancer?

While I realize that each diagnosis is unique particularly with respect to contributing factors, I am interested in your general thoughts on former studies that attempted to make a connection b/w medications used during fertility treatment and later cancer diagnosis.

Warm thanks, Amy Demma, Wellesley, Massachusetts

Answer:

Dear Amy,

I welcome the opportunity to respond to your client's question. I know that this theme is a recurring worry among infertility patients, especially IVF patients because of the misinformation that was publicized by the NIH's WHI (Women's Health Initiative) study linking estrogen and breast cancer. It is logical to think that increased estrogen levels in fertility treatments like IVF might increase the chances for breast or ovarian cancer. However, this has been studied over the past 30 years and there has not been any increased incidence of breast or ovarian cancer in infertility or IVF patients. In fact, a Swedish study published in Human Reproduction in 2007 (Hum Reprod 2007 22(2): 421-426) showed a decreased incidence of breast and ovarian cancer in women delivering after IVF. Also, for your reference, O Magazine previously published an inaccurate article in February 2004 linking ovarian and breast cancer to infertility based on anectodal stories, which ASRM (American Society of Reproductive Medicine) responded to. ASRM strongly criticized the article for misinformation.
This is the link:http://bit.ly/aKORPJ .

Scientific studies, done over the past 30 years, have not shown any increased cancer risk. It is true that most breast cancers are estrogen receptor positive, which means that increased estrogen, including one's natural estrogen, will cause the cancer cells to grow. However, this stimulation has to be consistent over a long period of time. The short durations of stimulation with IVF, even with multiple attempts, is only days long. It is not of sufficient duration to stimulate growth of the cells. Even if we assumed that it did, how would the cells continue to grow once the stimulation is suddenly removed?

A further incongruity between the association of estrogen and breast cancer is the fact that in the WHI study, there were two arms being evaluated: women taking only estrogen (premarin) because their uterus' had been removed previously and women taking an estrogen/progesterone formulation (prempro) because they had intact uterus'.

What people fail to realized, and the media did not publish, is that there was NO increased breast cancer incidence in the Estrogen-only group. That certainly invalidates the logic between the association of estrogen and breast cancer. Maybe it means that our tendency to associate estrogen and breast cancer is much too simple and the relationship is a lot more complex that it seems.

Please reassure your client that the association she has placed between her multiple IVF treatments and her breast cancer is unfounded. It is completely coincidental. I tell my patients considering hormone replacement therapy that the breast cancer cells have to be there already for the estrogen to cause them to grow. Estrogen will not CAUSE or PRODUCE cancer cells. This is probably true for birth control pill users and infertility patients as well. However, again this assumes that there is an association between estrogen and breast cancer. I don't think one can make that assumption. I think that infertility patients should feel confident that their fertility treatments are not putting them at increased risk of breast or ovarian cancer. That fact, has been shown by many studies over many years.

Thank you very much for reaching out to me for an answer to your client's question.

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, and follow me on Facebook at http://bit.ly/9Iw9oV