No Period, Retained Cysts & Fibroids, After IVF Cycle Cancelled: 47 Year Old IVF UK Patient Worried

QUESTION:

I am 47yrs. I had my 6th IVF (in vitro fertilization) cycle in September 2011. The drugs used were climara patches10 days before the cycle began, prednisolene 10mg daily, aspirin 81mg daily, bravelle 6 vials every morning, menopur 2 vials every evening later increased to3 vials and antagoni ganirelix acetate injection. I had 5 follicles before the cycle was abandoned. One on right side 9.5 and four on the left 16, 11, 7.5 and 6. My cycle was abandoned because the follicles didn't grow at same rate and the antagonist may have been administered late.

I have two issues:

1) I have not had a period for about 50 days, though I had spotting and a discharge 10 days after the ivf cycle was abandoned. A vaginal US 2 days ago which indicated that I have multiple large follicle/small cysts ..3 large follicles of 20mm each on left ovary and 1 follicle 4.3 mm on right ovary, endometrial thickness was 9.1mm. Urine peg test was -ve. I am awaiting results Blood tests of hormone levels and peg test. My question is is it normal not to have a period long after after some types ivf cycles.since my period returned to normal 10days after my other 4 previous cycles? Or could the drugs have triggered menopause? Would the 3 large follicle disintegrate eventually?

2) I have 6 uterine fibroids, between 20-28mm, outside the womb. Also, a recent immune blood test revealed that I have a raised Th1:Th2 cytokines ratio of 33.2 and Cd19,Cd5 cells of 13.6. The clinic I attend does not think I should be bothered about these issues since the challenge is for me to produce good quality eggs but I wonder if I should continue ivf treatments. What do you advise? I am writing from UK. With regards, M. from the UlK.

ANSWER:

Hello M. from the U.K.,

It's unfortunate that your cycle had to be cancelled. I had to do the same with a patient of mine this month because the follicles were not growing. It happens with decreased ovarian reserve. You have been quite dedicated to your desire to become pregnant and hopefully your dedication will pay off in the end. As long as your ovaries are still stimulating, then there is a chance, given your age.

In terms of your menses not starting, that is probably because you have the three retained cysts present. They are probably still hormonally active and so there is not the hormone withdrawal that i needed to start the menses. You can either wait it out, or your doctor can prescribe the birth control pill to suppress the cysts.

In terms of the fibroids, they are rather small and should not interfere, but there are some studies showing that fibroids can reduce the chances of pregnancy. I agree that the main hurdle you have is your age and the resultant quality of eggs. But, if you were wanting to do everything possible to increase your chances of pregnancy (short of using donor eggs), then you might want to consider having the fibroids removed prior to another attempt. It is not absolutely necessary, but only an option. In terms of the killer cells, I don't anything more needs to be done.I am impressed that the clinic you are attending is being very aggressive in your treatment, and allowing you to continue to try with your own eggs. That is commendable. Many of the letters I received are from patients whose clinics are not very aggressive.

Follow Up Question:

Many many thanks for your answer. It was amongst my junk mail so I did nt see it earlier. I was very encouraged.

My follow up questions are:

1) How long after an abandoned ivf can I try again? Given that my periods have not started. My clinic had advised that I take the pill for two weeks and then start another ivf cycle immediately on day 2/3. However, I choose to wait for the periods to start naturally and then attempt the following month...that would be about 4 months after the abandoned cycle. I wonder if the drugs may still be in my system now and if it will help provide more good quality eggs if I take the advice of my clinic.

2) Do you think taking intralipids for the immune problems will help? I noticed that it is gaining popularity. I prefer it to the other edications being suggested i.e taking humira jabs for two months prior to the ivf.

3) Surgery to remove the fibrods is not an option for me....however, I learnt that there are other means of shrinking them but since they are small and dont bother me I dont want to interfere with my ivf treatment since time is not on my side.

4) Since, I missed my periods I have been having dull headaches especially when I wake up, my BP has been hoovering around 148/95, increased acne on chin and back and my hair has been falling out alot. Are thse symtoms of the missed periods or the after effect of the stimulation or the side effects of DHEA Supplementation which I have been taking for about 1 year now.

Kindly advise, M.

Follow-Up Answer:

Hello Again,

I think that two weeks after a failed IVF cycle is a little too soon, but my usual minimum waiting time is 4 weeks (1 month). I place the patient right back on the birth control pill once the period starts and prepare for the next cycle. I don't find a need for a "natural" period to occur. Because time is of essence for you, you cannot predict when your ovaries will shut down, I don't recommend that you wait a long period of time.

Intralipids is not indicated for this problem. It will not do anything to help your eggs. It is mainly used for patients that have an immune factor issue. I would opt to leave the fibroids alone unless you wanted to remove all potential obstacles. Fibroids have not proven to be detrimental to IVF unless the fibroid is within the uterine cavity. It could be a side effect of the DHEA which would increase your serum androgens (male hormones). I am not a big fan of using DHEA.

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.

Surrogate Worried She May Contract Hep B From Transferred Embryo

Hello Dr. Ramirez,

I'm currently signed up with an agency as a gestational carrier (surrogate). I have been matched with an international couple and was set to have their fertilized embryo transfered into my uterus this month. However I was just informed that the intended father tested positive for Hepatitis B core antigens. So he has a positive total antibody level but is negative for IgM. I'm told this means the results indicate either a false positve or that he had a past infection but there is NO current infection. Furthermore I'm told that the chances of me contracting hepatitis B is negligible to non-existent since the hepatitis virus lives in the fluid surrounding the sperm but not in the sperm itself and the fluid is always discarded prior to IVF procedures.

Do you have any expereince with or know if this is safe for me to go forward with this transfer via in vitro fertilization using just the sperm from the intended father as mention above and the intended mother's egg which I'm also told does not have recepters for the hepatitis virus?At this point I'm inclined to not take the risk but I feel obligated to find out as much information as possible before I make my descion.Thanks in advance for your time and help. J. from the U.S.

Answer:

Hello J. from the U.S.,

You have submitted a very interesting and difficult question. I think that it is unknown territory, and not being an infectious disease expert, I had to do some research myself to try and answer your question. There is an infectious disease (hepatitis) expert on the All Experts site on About.com, whom you might want to submit this question to as well.

From my research, based mainly via the CDC recommendations, hepatitis B or C are not transmissible via sperm but can be transmitted via semen, if the person is a chronic carrier If the sperm was prepped via thorough washing, there should be little risk of transmission of the virus to the egg, and in most IVF programs, that is the proper method. Transferring that embryo in to your uterus, would have a very small risk of hepatitis B. If you have been immunized for hepatitis B, which many many persons have been, then the chances of transmission are even less.

Based on the information regarding the sperm donor's testing, I cannot draw a conclusion as to his carrier status, except to say that he does not have an active infection. A carrier would have a positive hepatitis surface antigen, hepatitis core antibody but negative IgM. If he had Hep B in the past and recovered and is now naturally immune, he would also have a positive core antibody but also would have a positive surface antibody. This person would not be at risk for transmission of the virus, as no live virus would be present.

So, as a surrogate your chances would be very low, but it is ultimately your choice as to whether or not to take any form a risk. Even a low risk is a risk.

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.

Progesterone After IVF

Question:

My wife had IVF (in vitro fertilization) in Canada. She was prescribed Gonal-F, Repronex and Orgalutran for the stimulation phase. Two blastocysts were transferred at day 5 and yesterday our day-14 serum HCG pregnancy test was positive.

We were told by the nurses at the fertility center to stop taking the Prometrium pessaries now that the pregnancy test is positive. From reading, Progesterone seems to have many beneficial effect to the fetus, with minimal adverse effects. I think continuing progesterone supplements until the 10-12th wk is important. I am not sure why they want my wife to stop this!

Can you advise? A. from Canada

Answer:

Hello A. from Canada,

Your research is correct. Most IVF programs, if not all, will continue the progesterone until at least 8 weeks. I continue until 10 weeks and some programs will continue until 12 weeks.

I see that your center had your wife on progesterone pessaries (suppositories). For those others reading this post, there are different forms of progesterone to choose from:
• Daily oral progesterone
• Daily intramuscular injections (IM)
• Daily vaginal pessaries. These are mounted in wax, which melts as progesterone is absorbed causing discharge. It may be necessary to wear a panty liner.
• Daily vaginal tablets
• Daily vaginal gel

There are several formulations of vaginal progesterone: Crinone 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM injectable progesterone. However, most RE's are trained on IM Prog and so don't want to make any drastic changes. I happen to use both. If a patient cannot tolerate the IM Prog or has an allergic reaction to it, then they can switch to the vaginal version.

Bottom line: There is no harm in continuing the progesterone, but if removed prematurely, it could jeopardize the pregnancy.

Good Luck and Congratulations,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

PCOS Patient In India On Clomid: Needs To "Rest" Ovaries & No Ovarian Drilling!

Question:

Hi, I am G. from India. I am 26 yr old and I have PCOS. My LH level (14) is high on day 2. I am trying to conceive now. My gynae suggested me with clomid 100 mg from day 2 to day 7 and hmg 75 on day 2, 3 and 4. After seeing a developing follicle in my right ovary through ultrasound, I was injected with hmg 75 on day 8, 10 and 12. I had 2 eggs with 18 mm measurement on day 14. Then I was administered with hcg 10000 to release those eggs. Me and my husband was asked to have intercourse for 4 days and I was prescribed with progesterone supplement (400 mg) from day 15 for 10 days. In spite of all this, I didn’t get pregnant last month. My husband (age 28) has got healthy sperms. What could be the reason for this failure?

My gynae is suggesting for IUI (intra uterine insemination) this month. How long can I go about with this treatment? Will I succeed in conceiving if I get this kind of eggs in the following month? My gynae also suggests that she has to do a laproscopic drilling if I fail 1 IUI.

Please advice. Thanks in advance.

Answer:

Hello G. from India,

First, you need to understand that fertility treatments are not magic. They don't work 100% of the time. What they do is attempt to restore your reproductive system back to normal, which in your case is to get your ovary to ovulate. For more, in depth information on PCOS please see: Polycystic Ovarian Syndrome.It looks like your doctor did a very good job of treating you in this cycle. She was able to get you to ovulate (probably two eggs) and you had intercourse at the appropriate time. In addition, she supplemented you with progesterone as I would have recommended. Now you need to do that repetitively, just as if you were trying for pregnancy naturally. If you or any woman were trying on their own, they would give up after only one try or wonder why they didn't get pregnant after one try, would they?

The only caveat is that because you stimulated the ovary, you need to skip a cycle in between to give the ovary a rest. You should go on the birth control pill that month to make sure that you have a period in a timely fashion, so you don't have to wait for your natural period to begin. Then you do the same cycle again I would recommend that you continue trying this for 4-6 cycles. Then if it does not work, you can consider other treatments. But, keep in mind that you are assuming that the only problem is PCO. If you have done a complete infertility evaluation, there could be other reasons why the treatment did not work. For that reason, you might want to do an evaluation before moving up to higher levels of treatment. I don't think IUI is an appropriate suggestion at this time. I also DO NOT recommend laparoscopic drilling under any circumstances!

Remember, what you are doing is a "natural" treatment method and your chances of pregnancy, at your age, is 18-20% per month. A normal woman (not using fertility treatments) can take 8-12 months to achieve pregnancy. So, just like someone trying naturally, you have to give yourself time. Don't let your doctor push you into more expensive treatments that you don't yet need.

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: Thank you so much for your advise, doctor. I am confident that I am moving in the right path now. So as u said I shall try this treatment for 4-6 cycles. Thanks for your time.

Wondering About Follicle Size And Ovidrel Shot

Question:

Hi, I am on Gonal-f and my US (ultra-sound) yesterday showed I had 2 follicles measuring at 17mm and 14mm, my doctor told me to take one more shot of 75ui Gonal-f last night and to trigger with ovidrel tonight.

Do you think my eggs will be mature enough to ovulate???
Thanks! N. from the U.S.

Answer:

Hello N. from the U.S.,

If the follicles grow normally, they should increase by 2 mms each day. That means that they will be 19 and 16 mms the next day. I NEVER trigger without knowing the follicle size for sure. That is sloppy care. In addition, I would want you to be able to ovulate both follicles so I would probably wait one extra day and use the gonal-f another day. That way the follicle sizes should be 21 and 18 mms, so that both would be ovulatory size. Since follicles don't always follow the expected growth rate, I feel you have to look each day to know for sure.

In terms of your question, if the follicles grow to 19 mms and 16 mms the next day, then the 19 mm follicle definitely should ovulate and the 16 mm follicle may or may not.

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.