IVF After A Myomectomy & Low Ovarian Reserve

Question:

Hello, Dr. Ramirez,

D. from VA here! I wrote to you a few weeks ago concerning my RE wanting to freeze my eggs, give me a myomectomy, then do implantation. You didn't understand why he wanted to do things in that order, and neither did I. He thought that my fibroids were blocking my left tube, and I also have hostile cervical mucus and low ovarian reserve. I want to thank you for your response to my question, it really made me think about things. I am having a myomectomy in a few weeks (by my gyno) and decided to hold off on any aspect of the IVF until later in the year, when I was fully recovered from the myomectomy (and had saved up some more money.) I do have a couple of questions.

First, is it a good idea to put off having the IVF, given all of my problems? Especially the low ovarian reserve. Part of me is hoping that by doing the myomectomy, I'll improve my chances of being able to get pregnant naturally. But because of the low reserve, I'm afraid if I wait too long I will have missed any chance of conceiving. Question #2: is there anything that can be done to improve cervical mucus? Or is the best option to bypass it with the IVF? Is intratubal insemination a good option? Thank you for any answers you can give me!

Answer:

Hello D. from the U.S. (Virginia),

Low ovarian reserve is an indication that your ovaries might not stimulate well with the fertility medications and so less eggs will be retrieved. That is its ONLY implication. It does not mean that you cannot get pregnant or cannot get pregnant on your own. It is only important for IVF. Now, if you have to do IVF for specific indicated reasons, such as tubal blockage or sperm problems etc, then you will want to do it sooner than later because your ovaries might get to the point where they will not stimulate at all and that will decreased your chances of success with IVF.

In terms of your fibroids, it is not that uncommon for a patient to become spontaneously pregnant after a myomectomy. I am sure that every fertility doctor has had patients like this. As long as your ovaries are functioning then you have that possibility. Low ovarian reserve has nothing to do with spontaneous ovulation.

In terms of cervical mucous, if you are trying naturally (non-IVF), then you can try Robitussin taken daily to help thin the cervix or you can proceed to IUI (intrauterine insemination) where the sperm is injected into the uterus and thereby bypasses the cervix (there is no such thing as intratubal insemination).

Good Luck,

Dr. 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.

40 Yr Old Austrian Doing 2nd IVF: Use PICSI Or "Embryo Glue"? Antibiotics OK?

QUESTION:

Dear Dr. Ramirez, my name is J. from Austria. I am 40 years old, have a failed 1.IVF (in vitro fertilization) this year (6 eggs, 4 fertilized, only 2 were transferred, because the other 2 arrested development before the transfer) , FSH of 10.6 mIU/mL, AMH of 0.8 ng/mL. My husband has anti-sperm antibody. So, we used ICSI (intra cytoplasmic sperm injection). I want to try the 2.IVF.

An IVF-clinic in Austria offers PICSI or "embryo glue". Are PICSI and embryo glue useful? They also use Prednisolon 5mg to avoid immune system reaction and Aspirin 100 and Lovenox 40 to to make blood more liquid/avoid congestion problem during embryo implantation. Are Prednisolon, Aspirin and Lovenox really helpful? All of these things I did not have at my last IVF.

Do you think that antibiotic taken before egg collection is recommendable? Thank you for your time. Best wishes! J.

ANSWER:

Hello J. from Austria,

Failing the first IVF is not that uncommon. The chances of pregnancy in the first try is 60% That means that 40% have to try more than once. That is because IVF is not a perfect technology. It mimics the natural cycle. There are 9 steps the body goes through to achieve a pregnancy. IVF accomplishes 7 of those 9 steps. The problem is that the last two steps are still natural steps and despite the best embryos and circumstances, it does not always occur.

I would not recommend PICSI or embryo glue. Embryo glue is a total fallacy and has never been proven to help. Implantation is an endometrial lining process, NOT the embryo just attaching to the wall. I do use aspirin, Lovenox and Prednisolone in my patients. They do help. I recommend low dose aspirin 81mg, Lovenox 40 is fine, and Prednisolone (Medrol) 16 mg then decreased to 8 mg after the transfer. Antibiotic should not be given prior to the egg collection but is started on the day of the egg collection.

You have two very big problems: your age and your decreased ovarian function. Age affects the quality of the eggs. The elevated FSH, which is an indication of ovarian function, shows that the ovaries will not stimulate well and so you won't get a lot of eggs. The only way to overcome the age factor is to get a lot of eggs in the hope that a good egg will be found. Because of this, it may take you multiple IVF attempts. You have to be persistent. There is nothing that can reverse the age factor.

Good Luck,

Dr. 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.

Canadian With Recurring Ovarian Cysts And Thick Endometrial Lining: Does She Go On The Birth Control Pill?

QUESTION:

I'm 28 years old and have recently been referred to an OBGYN for recurring ovarian cysts. My most recent pelvic ultrasound suggests that I may also have a slightly thicker than usual uterine lining. My new OBGYN has prescribed a birth control pill (Alesse-21) for paroxysmal but intense pain associated with the cysts, as well as to thin out the lining of the uterus. I havent filled the prescription yet, as I am trying to learn more about its indications prior to doing so. My OBGYN instructed me to take the pills everyday for three months, then take one week off, during which I should get my period. I am supposed to continue on this schedule for at least one year. She did not explain WHY I should take the pills for three MONTHS, then one week off, as opposed to the usual three WEEKS on and one week off. Can you suggest any reason she would perscribe the medication in this way?

Further, I am expected to have a hysterosonogram next month. I was instructed to call in on the first day of my July period in order to schedule the appointment, as they need to make sure that the uterine lining is at its thinnest for the test. However, I will not be having a period next month because I will on the birth control pill (for three months straight). Therefore, does it matter when I schedule the hystersonogram? If I start taking the pills on the first day of my period this month (June), will the lining of my uterus be thin enough at ANY time in July, or should I wait a certain amount of time before scheduling the test?

Finally, I hope to eventually get pregnant. If I thin the lining of my uterus now, and control the growth of the ovarian cysts, does this increase my chances of getting pregnant once I stop the pill?I would really appreciate some knowledgeable guidance. I thank you in advance for your assistance.

Sincerely, M. from Ontario, Canada

Answer:

Hello M. from Canada,

Without reviewing your medical records it will be difficult for me to know exactly what your doctor is thinking and planning. It would be a good idea for you to ask her directly to explain the treatment plan in detail.

If you were found to have an ovarian cyst, there are many types of cysts. The most common type of cyst is a physiologic ovarian cyst and treatment with the birth control pill will help it to go away. However, this should take no more than one month. If the cyst does not resolve after one month on the pill, then there is a likelihood that this is some form of tumor (mostly benign forms) and so surgery will then be required to remove the cyst/tumor.

If the endometrial lining is thickened, there is the possibility of a disorder called "endometrial hyperplasia." Some forms of this can be atypical or precancerous so an endometrial biopsy is indicated. If the biopsy is negative for cancer, then it can be treated with the birth control pill to thin the lining. However, this treatment is NOT done until after a biopsy is taken because you DON'T want to use the birth control pill if precancerous cells or cancerous cells are present in the endometrium. With the birth control pill it can take 1-3 months to thin the lining but the standard treatment is to have a period each month so that the lining can be shed and NOT to use the every 3 month sequence. That sequence is only used for people that need contraception and don't want to have a period every month. So, again this does not make any sense to me.

In terms of the sonohysterogram, once you are on the birth control pill for at least one month, the lining should be thin enough to have it done at any time.

In terms of your fertility, this treatment plan does not work for or against your chances for pregnancy unless you have an endometrial cancer that is missed and then requires a hysterectomy.

I would urge you to speak with your doctor.

Good Luck,
Dr. 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.

COMMENT: You have given me a lot to think about. Thank you for being so thorough in your response. As this doctor of mine seemed to be heading in her own direction with this treatment as opposed to offering any alternatives or discussing the possible risks (as you have outlined here), I am very much inclined to seek a second opinion from another OBGYN. Thanks again for your outstanding assistance.