(If the blog radio program turns on, go to the Oct. 1st blog post and pause it...I will be keeping the show up for the month of October.)
Question:
Dear Doctor,
Hello. I am writing from Atlanta, GA. I wrote once before (concerning my dermoid - thank you for the information!) and was hoping you would consider a second question. Much like everyone else here, I've had a complicated TTC journey.
April - laparoscopic dermoid removal from right ovary. Ovary was not removed but is small and has not produced follicles since (despite being on letrozole).
July - HSG. Right tube open. Left tube did not spill dye. Proximal block. No history of STDs or infections, thinking maybe it's scar tissue from surgery?
Sept - Large fibroid (~4cm) found on US (significantly distorts the uterine cavity). RE recommends abdominal myomectomy before moving forward with IVF. I also have a uterine polyp (~5mm) that will need to be removed at the same time (if possible) or during a 3rd surgery.
I am 36 years old and have never been pregnant. While on letrozole I produced 2 eggs the first month and 1 egg the second month. However, we are open to the use of donor embryos. My question is, what do you think is the risk of a complication from abdominal myomectomy (during the initial surgery or during a resulting pregnancy) and what is the probability of achieving a pregnancy after such a procedure? I am feeling discouraged given that there are issues with my ovaries, tubes, and uterus, and want to have a clear understanding of the potential for complications versus the potential for pregnancy if I move forward with the surgery.Thank you again for your time, J from Georgia
Answer:
Hello J from Atlanta,
Basically at this point you have two choices: you could attempt IVF without the myomectomy or have the myomectomy first before IVF.
The studies are controversial regarding the influence of fibroids on pregnancy rates in IVF. Some show that any fibroid can reduce the PR, whereas others show that only the ones that enter the uterine cavity do. In my experience, if the myoma is very large and takes up a good portion of the uterine muscle, it seems to impact fertility. I have had many patients get pregnant spontaneously after a myomectomy in those cases, or achieve pregnancy with IVF after they failed previous cycles. What I counsel my patient is that the studies are not clear and so the decision is really whether you not you want to do everything you can to maximize your chances with IVF or do you want to try the IVF without the surgery and take the risk. It is a toss up. I will go with whichever choice my patient makes. Neither option is a guarantee anyways. I have had patients that do the myomectomy and still fail with IVF, for whatever reason.
I cannot give you specific statistics regarding the chances of pregnancy with or without myomectomy because the mixed findings in the studies that have been done. In general, the current recommendation by ASRM is that only fibroids that invade into the uterine cavity need to be removed (because they can interfere with implantation) and 4 cms is not a large fibroid. I would consider 7 or larger to be a large fibroid. In some hands, this 4 cm fibroid can be removed laparoscopically. I also prefer to do the procedure as an open procedure, but that is because of a lack of experience removing deep fibroids laparoscopically. If you don't want the open procedure, then you might want to investigate and find someone that does these laparoscopically and has a lot of experience (the experience is the key in this procedure). That will allow for less pain and a quicker recovery. In either procedure, you won't be able to do the IVF for at least 8 weeks after the date of the surgery.
Good Luck on your journey...it is good that you are leaving yourself open to other options too!
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Comment: Thank you! Your knowledge and kindness are invaluable.
Have hope... I conceived in December after 3 uterine surgeries (2 open abdominal myos and an emergency D&C. God Bless and I will pray for you!
ReplyDeleteJust as a note to my last comment> I'm 37, never pregnant, told I'd never be pregnant, didn't use fertility pills or IVF. The conception may be a medical miracle as it happened the night after I visited a holy shrine. My tubes had gotten blocked after 1st surgery (and lysed open in 3rd surgery), and may have gotten blocked again after the 3rd, but I couldn't afford the test to get it checked (not covered by my ins.!) I was aware that something had changed in my body but didn't much of it until I (MUCH to my surprise!) found out I was pregnant. If you live in the Northeast, I recommend Brigham and Women's hospital, where my surgeon was out of...I don't know if I can say his name on here! We were 2 1/2 hours (in heavy traffic) away from him when I was a patient, but it was worth it, as the Dr's in my state said they couldn't help me.
ReplyDeleteDear Dr.
ReplyDeleteI am 37.5 year-old-woman I married 8.5 years ago I did 9 times with only one succesful but I missed in month two bev=cause th eembryoy didnot have heart, I had 2 mymectomy and one laparoscopy i did my last mymectomy 3 month ago I have submocuse fibroids ,My doctor remoeved 30 fibroids ,and he recomanded to have an other IVf cycle he said the chance of pregnancy increse after mymectomy and said to me to start ivf after first period of mymectomy, but I have no energy and we prepare our selfto adopt and we tried to homeopathic metod ,butwe havenot get any result till now, some times i get indecesive about another ivf and really i am exhausted please your idea about the matter
In general, you should wait about 6 weeks after a myomectomy to try for pregnancy because the body's inflammation process will take that long to resolve. After that, you certainly can try. I think I would agree with your doctor that you should continue trying for pregnancy with IVF. There is no reason to have to resort to adoption yet. You also have the option of using donor eggs if your egg/embryo quality is not good enough, considering you are 37 years old. However, your chances for pregnancy in my clinic would be 62% per cycle so if your clinic does as well, you should give it a try. Don't give up.
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