Question:
Hi, I’m from Calgary, Alberta in Canada. I am 33 and my husband is 30, we are both healthy and we’ve been TTC unsuccessfully for 19 cycles. I have never been pregnant. We have been tested at the fertility clinic and told that there is no obvious reason why we shouldn't’t be able to conceive. I had blood work to check my hormone levels, an ultrasound to check my follicles and an HSG to make sure my tubes were open, my husband had a SA done and it showed good numbers and motility. He does have some antibodies, but less than 50%.
All that being said, I contracted chlamydia about 14 years ago, but it was treated quickly (I believe within 1-2 months). I have also been experiencing some symptoms of endo since going off the BC pill so I am a candidate for the laparoscopic surgery. The doctor said I could also try clomid or clomid with assisted insemination. I’m looking for additional guidance on how to proceed. Given that I have symptoms of endo, would you recommend that I proceed with the surgery before trying clomid or even IVF?
Thanks. J. from Canada
Answer:
Hello J from Canada,
You pose an interesting question and the answer will be based on personal desires.
Given that your infertility evaluation has been negative thus far, and you are only 33 years old, if you want to attempt pregnancy by natural means (intercourse or IUI), then you should proceed with the laparoscopy. This is the only method that can diagnose endometriosis. It can be treated at the time surgically and then followed with a 3 month course of medication (Lupron depot) to eradicate any microscopic endometriosis. You will then be free to try on your own or with IUI for the next six months. That is the window of opportunity. If the laparoscopy shows that the endometriosis is stage 3 or 4, then IVF would be indicated.
Certainly if you decide to proceed with trying by natural mean after the laparoscopy, I would recommend an aggressive treatment plan because you need to try to get pregnant within six months. After six months there is a high chance that the endometriosis will return and you will be back to square one. By aggressive natural means, I mean ovulation induction with Clomid, Femara or injectables and either timed intercourse or IUI.
If you don't want to do the laparoscopy, then the best option would be to proceed with IVF. That is the decision that my wife and I made when we faced a similar point in our infertility evaluation and treatment. This is because IVF will bypass any endometriosis and you won't have to undertake the pain or risks of surgery. But, it is the most expensive way to go.
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.
Sorry but I can't figure out how to post a new comment... My story: I am 36, had a m/c 05/2010 at 11.5w. I have compound heterozygous MTHFR. Do you think that this could have contributed to my m/c? I have been married for 11 years and we really want kids and the clock is ticking... my OB has suggested lovenox when I get pregnant again... what are your thoughts about anti-coagualants? We are TTC and hope for the best. My homocysteine is 7.7 at present. I am on folbee and BA at present. Do I need to take a prenatal as well? Also, is MTHFR linked to fertility problems? Any thoughts/advice on MTHFR would be greatly appreciated.
ReplyDeleteOnce again sorry for posting in the wrong area =-*
how do I post a question for the dr to answer? Im concerned about my health. please respond thank you
ReplyDeleteYou would post your question just as you did this one.
ReplyDeleteHello Iahu,
ReplyDeleteSorry that this is a little out of order. I got both comments at the same time.
MTHFR has been associated with an increased miscarriage rate. The treatment for that is Folic acid, which I would advise that you take as part of your prenatal vitamin anyways.
The most likely cause of your miscarriages is age. We know that miscarriage rates increase with increasing age, especially after the age of 35. It is part of the decrease in fertility due to age. Certainly you could add lovenox and I have used it, as well as, low dose Heparin. Both have been shown to decrease miscarriage rates in patients with recurrent miscarriage due to immune factors, like antiphospholipid antibody syndrome. I will sometimes use it in my patients with no explanation just to cover all my bases.
Good Luck