Saturday, October 22, 2011

TTC Patient Needs Aggressive Approach After Laparoscopy For Endometrioma or "Chocolate Cyst"


Hi, I have been trying to conceive since 1 year. I am 29 yrs old,and a professional with busy working schedules. I recently got myself investigated and found that my FSH levels r 7.09 and LH levels 3.0, AMH levels 3.29.

I have undergone 2 ovulation induction cycles which showed normal ovulation but I have a tendency towards cyst formation. HSG is normal. My antral follicle count is 6 and 4 in both ovaries. Kindly opine if i should undergo IUI cycles with clomiphene or with gonadotropins or should I directly go ahead with IVF cycle?

I am worried as my FSH levels are on the higher side and also my FSH:LH ratio is >2:1.

I recently underwent a hysterolaproscopy and was found to have a small chocolate cyst of 1cm in one ovary that was removed with cyst wall and spot on the other ovary along with few spots in the P.O.D that were fulgerated. Rest of findings were adhesions, healthy tubes with free spill and good uterine cavity.

From what I have learnt, endometriotic ovaries have a poor ovarian reserve and chances of recurrence of endometriosis is also high. My FSH values are already in the upper range.So what do you suggest i should go for? What sort of induction should I undergo?

Thank you. S. from India


Hello, S. from India,

First, let me reassure you that your lab tests, including FSH level, are all normal.

More important were the findings after your laparoscopy. With an endometriotic cyst present (chocolate cyst or endometrioma), we would automatically classify you has having stage 3 endometriosis. Studies have shown that stage 3 and 4 endometriosis affect fertility. Normally, with these stages IVF would be the recommended treatment of choice. But considering that you are young, there are some lesser options that you can try.

First, let me point out that your diagnosis is "Endometriosis" as the cause of your infertility. It has been treated by laparoscopy thus far. However, we know that if there is visible endometriosis present on a laparoscopy, then microscopic endometriosis exists as well.

For infertility patients, I recommend a 3-6 month course of Lupron depot therapy to get rid of any residual endometriosis before moving forward with any treatment. This medication will put you in a semi-menopausal state for the duration of the treatment but there will not be any long term effects. You can then begin treatment immediately thereafter. Because endometriosis will return within six months after ending this treatment, I would recommend that you proceed with a more aggressive treatment such as insemination. I would recommend four attempts, using Clomid 150mg or higher to have 2-3 ovulatory sized follicles per cycle, alternating with Femara 5.0-7.5 mg since you don't want to take Clomid in consecutive months (it can lead to poor endometrial lining formation and prevent pregnancy, among other things).

If you don't achieve pregnancy by four good IUI cycles, then I would proceed directly to IVF.

The alternative would be to go directly to IVF, in which case, it is not absolutely necessary to take the Lupron treatment, although some docs still will do this. IVF bypasses the pelvis and takes the eggs out of this hostile environment. It is the preferred treatment for stage 3 or 4 endometriosis. It will also be the fastest way for you to get pregnant.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.


  1. Hi we had an ivf done with 3 embryos day 2 transfer 2 with a grade and 1 with b grade we had test on 15th day post transfer but came negative any ideas what went wrong wht can be the reason.

    1. There are three steps that have to occur after an embryo is transferred: (1) embryo has to emerge from its shell, (2) it has to attache to the uterine lining and (3) the lining has to grow around the embryo. The embryo then needs to develop into a fetus. A failure of any of these steps could lead to a failed cycle. These are "God's" steps and there is no technology to make them happen. Sometimes you just need to keep trying to get everything to work.

    2. Hi Dr. Ramirez, same boat here. This is our first IVF and had my blood test yesterday that returned an HCG level of 4. Did a home pregnancy test today and it says positive? I am now confused.. what does this mean chemical pregnancy? I've had 2 miscarriages (Normal pregnancy), 2 failed IUIs and now this first IVF.. done all the test that a woman can do (laporoscopy, sonohysterogram etc and all shows normal)... Do I still have a chance of being pregnant given the home pregnancy today shows positive?

      thank you so much!

    3. Hi, is it still possible to be pregnant and have a successful birth when HPT says pregnant and blood test says not? blood test taken a day before HPT.

  2. Hi Dr. I am now 7dpt from a 5dt. My hpt tested negative this morning. Do you think I still have a chance of being pregnant?

  3. Hi I'm 12dpt and been getting faint positves but today after lunch I got a negative.I have been drinking excessive amounts of water and passing copious amounts of urine as I have cystitis - could this affect the test or is it another chemical pregnancy Thankyou

  4. I did my embryo transfer on 21st of last month and due to curiosity i did my beta hcg on 1st of july which was 11.37 but today i did my upt but it was negative.but have given mine beta hcg sir wanted ask is it a negative really sad with upt test



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