Dr. Edward Ramirez is the medical director of Monterey Bay IVF, a women's fertility & gynecology center located in Monterey, California. He hopes to provide those who read his infertility blog with insights into the latest advances in women's health & infertility issues. He respectfully shares his knowledge as a specialist with women and men from all over the world. Visit his center at www.montereybayivf.com
I was detected with a dermoid cyst in my right ovary in 2005. I underwent laparoscopy in 2006 and my right ovary was also removed. Post surgery I had normal cycles every month however some months my menstrual flow is less. Last week I had some hormonal tests which turned out to be normal. I also underwent an ultrasound which detected a right 22x13 mm hydrosalpinx. Left ovary and tube is normal. Will the right hydrosalpinx be a problem in me conceiving naturally? I am unmarried and it will be at least 5 years before I will have a baby. Please advise.
Thanks in advance for your support. M. from India
Answer: Hello M. from India,
First of all, the presence of a "hydrosalpinx" means that the right tube is blocked. Therefore, it will not be available to pick up the egg to achieve pregnancy. However, if the left tube is normal, that is all you need. You would still be able to become pregnant naturally.
However, there is a second issue. It is known that a "hydrosalpinx" that is visible on ultrasound examination can interfere with implantation in IVF. It is presumed that the hydrosalpinx has inflammatory fluid that back-flows into the uterine cavity leading to a low grade endometritis or inflammation of the endometrium. Pregnancy rates with IVF in this situation are seen to decrease by 50%. For this reason, it is recommended to remove or clip the tube so that it is separated from the uterus before undergoing IVF.
Having said this, however, this policy or recommendation is for hydrosalpinges that are visible on ultrasound AND are in "naturally occurring" hydrosalpinges due to a previous pelvic or tubal infection and NOT for dilated tubes that were caused by a tubal ligation. So the question is was your hydrosalpinx due to the surgery i.e. either the end of the tube was cut or scar tissue was formed from the surgery. In most cases of doing an oophorectomy (remove the ovary), the tube is usually taken with the ovary. If this is the case, the hydrosalpinx is iatrogenic, meaning surgically caused and not due to a previous tubal infection. In that case, it is logical that there would be no inflammatory fluid to leak into the endometrium and so the recommendation to remove it prior would not hold. This particular instance has not been tested by study, however.
So, in your situation, if the hydrosalpinx was not there prior to the surgery, and the tube was not cut/damaged or scarred from the surgery, then the hydrosalpinx subsequently occurred through a pelvic infection, then it could possibly affect your pregnancy rates. Then the left intact tube could have scar tissue as well not visible with ultrasound. However, if it was due to the surgery, then it would not.
I hope this clarifies things for you. As far as waiting five years to have a child, it would not make any difference, depending on your age of course.
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.
So, I took your advice and immediately wasted no time, and moved directly to IVF (in vitro fertilization). Dx: DOR (diminished ovarian reserve) @ age 35, one previous live birth 2 years ago, natural conception, (baby came from left ovary) after 12 months of trying @ 32 years old.
My recent HSG showed tubes open, but right tube slightly dilated. RE said not to worry about it at this time, as it was only slightly dictated and still spilling. Always have right ovary pain w/ ovulation, never left. I had b/w done on day 3 of my cycle before my ivf. FSH 10.4, e2 45, AFC 10, AMH 0.87. I started bcp's (birth control pills) for 21 days prior to stims. My AFC (antral follicle count) dropped to 6! ugg. For the last year i monitored my cycles very closely. 26 day cycles when i had ovulation pain on my right ovary, and 30 days when I had no pain from my left ovary. In my humble opinion I don't think my right ovary functions like it should.
Last month was my left ovary's turn, the month I had an AFC of 10 (6 antrals in left and 4 in right). This month it is my right ovary's turn and I only have 3 AFC in each #small too!~bcp's?. I also ovulate on cd 18 with my right ovary and cd 16 with my left, not sure if that is relevant.
My stims are NOT going well. I am on 300 follistim and 150 Menopur, I took no meds between ending BCP's and starting Follistim/Menopur 3 days later. On my the morning after my day 3 stims my e2 was a whopping 32.5! My clinic said to continue on my meds, no changes. Come back in 3 days for b/w and u/s. Per the nurse, "some people take a little time to get going". My questions are: why didn't they increase my meds? Did they expect a low e2 because I am DOR? Could this be over suppression with bcp's? Since I normally ovulate later in my cycle and not earlier like most DOR, could this just be my norm~my body taking it's time to develop the eggs? My cd3 e2 have always been between 30-45, I thought that was good for stimming? Could this be due to decrease blood flow to ovaries? I was told to stop my fish oil/baby asa/vitamin e before stims b/c they are blood thinners, but i thought these could help during stims?
This is my first IVF. Do you think they are just riding this out to see how I stimulate for next time? I am waiting for RE to call me back, but I want all the opinions I can get.
Hello K. from New York.,
If I am understanding you correctly, your CD#3 E2 with this cycle was 32.5. That would be your baseline E2 for this cycle and does not necessarily indicate that you are not stimulating. The first estradiol level to check for stimulate would be four to five days after starting the stimulation (Follistim/Menopur) and you would be monitored approximately every three days after that to determine your progress. It is at the second E2 that you doctor might adjust your protocol and increase it if their protocol is not already at the highest. Some clinics use 450IU of medication (300IU Follistim/150IU Menopur) as their highest protocol. I go a little higher with 450IU of Follistim and 150IU Menopur. Because of your decreased ovarian reserve, it is expected that your ovaries will probably not stimulate strongly, but you will have to wait and see how things go. The goal is to have a peak E2 of around 2000 (when the follicles are ready to trigger).
I use low dose aspirin in all my IVF cycles, but not the Vit E or Fish oil. There is no problem with that.
It is certainly difficult to know how a person is going to respond in the first IVF cycle. There is a little guess work in determining how much medication to use with each patient. Your doctor has probably chosen this protocol as a good place to start and may make adjustments henceforth. You'll have to be patient and wait and see how things turn out. You may want to ask your doctor if you are on their highest protocol.
I never asked what my baseline e2 was, but the 32.5 was after 3 nights of stimulation. I had an u/s today (after 6 nights of meds) and NO CHANGE to baseline u/s, 6 unmeasurable follies. Waiting on new e2, but suspect it is going to be the same. I feel like I was completely suppressed. My cycle prior to this my CD3 u/s showed 10 juicy follicles, 6 in left and 4 in right. I know that this is a low count but I can't help to think that if i started my stims on that cycle I would have produced some eggs.
I am sure I will be cancelled on Monday. I hope my ovarian function returns. When they call w/ my e2's from this AM and if they don't increase my dose, I will ask why. I was told not to take any blood thinners (and listed: ASA, VitE, Foil due to risk of bleeding w/ ER.) When I suggested not using BCP's next time if needed they said ok, switch to Lupron, but wouldn't that suppress me too? Why can't we just start meds on CD3?? Thank you so much for your time!
Thanks for the clarification. The E2 on the third day of stimulation is called the CD#5 E2 level. It is the first check to see how you are stimulating, and you are correct, it shows that you are not stimulating at all. I don't do an ultrasound on that day because it is too early and the follicle sizes will still be small. The next check is usually done on CD#9 and an ultrasound is done with that visit. If you were in my clinic and the E2 were only 32 on CD#5, I would have increased your Follistim to 450IU. That is my maximum protocol (450IU Follistim/150IU Menopur). Then we would see how it goes from there. However, you have to understand that every clinic and every doctor is trained differently and uses different protocols. No protocol is better than any other. Your doctor's max protocol may only be 300/150. So you'll have to ask.
In terms of your decreased response, I don't think that it is due to the birth control pill,but there are some studies that show a decreased response if not enough days are given after the last pill and the start of stimulation. Basically, not enough time is given for it to leave your system.
In DOR (diminished ovarian reserve) patients I will usually want 6-7 days off the pill before starting stimulation. Again, you are correct that Lupron would also suppress the ovaries (this is known as the long protocol), and in fact, it will suppress the ovaries stronger than the birth control pill. I don't think that is any better.
The non-pill cycle that you are referring to is following the IVF cycle after a natural cycle. There are some clinics that do that but scheduling and making sure everything is suppressed appropriately, stimulated appropriately and timed appropriately is harder after a natural cycle. Some older studies also showed a better response if the ovary has been suppressed with the birth control pill for at least three weeks in the preceeding cycle. I always precede a cycle with birth control pills. That allows me to control the ovarian response. Decreased ovarian reserve or DOR basically means that your ovaries will not respond well to stimulation. That is to be expected. But, you should have had at least one follicle developing and that may mean that you are not being stimulated hard enough.
Hi there. I am a "mostly" healthy 30 yo female, G2 P2, with chronic HTN, obesity, and history of 1 run of VTAC 5 years ago which was deemed idiopathic in nature. History of pre-e w/baby #1... induced labor, emergent c-section due to fetal decels and failure to progress. Baby #2 was attempted VBAC, which ended in a crash-c.
During the crash C-section, the surgeon nicked my uterine artery. He had a hard time getting the bleeding to stop and I was close to getting transfused. The surgery took 3 hours. He joked with me about having a "metal clamp" on my uterus permanently, but I don't need to carry a card with me to the airport to get through metal detectors..., but I was so out of it, I never got any education or clarification. Is a nicked uterine artery a big deal? It's been 2 years post baby/surgery... should I be healed by now? Is there a possibility I really do have a metal clamp in me? What are the ramifications of a nicked uterine artery... can this lead to infertility and/or problems down the road with trying to conceive and/or childbirth?
Thanks! J. from the U.S.
Hello J. from the U.S.,
In answer to your questions:
1. No a nicked artery is not a big deal if it was repaired. In fact, the uterus is so resilient with blood supply, that you could tie off or remove the two uterine arteries and it still will function just fine.
2. The metal "clamp" he is referring to is probably a vascular clip, which we use a lot in surgery. It is usually a very small titanium clip and will not affect anything.
3. You should be healed from the surgery as of 8 weeks post surgery.
4. Yes, you probably have a metal clamp inside, as explained above.
5. I answered this last question in answer #1. Not to worry, there are no long term consequences to this problem.
Glad that baby #2 was delivered healthy despite the emergency and you are well! Congratulations!
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
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.
Laproscopy-- Ut normal size. retroverted congestion, Small Seedling fibroid, both ovaries are normal size and healthy.
Both Tubes Patents and healthy.
B/L adhesions, Endometriotic patches seen on both sides.
Now i completed 2 months course with DANAZOLE (200) which i am taking daily twice, only one month left. after laparascopy on 6 jan my period come after 21 days i.e. on 27 of Jany and i started Danazole Therapy on 17 of Jan. but still my periods not come almost 18 days left.
I asked the doctor she said some women concieve with Danazole also and some may not, so first complete the course of one month then try to concieve with Letrofil and all medicine.
But now i am thinking i dont want to waste time so instead of continue with Danazole i want to take LUPRON Depo Injection. Please guide me is it right ? Or good for me altough its expensive,. Please tell me should i take only one injection of Lupron or more than one becoze already i completed 2 months course with Danazole. Also, when my period expected and when should i try to concieve doctor, i m very much crazy about child.
Thank you. S. From India
Hello S. from India,
Danazol is a medication that is given for the treatment of endometriosis. It inhibits estrogen production and therefore ovarian function. Because of this ovulation will usually be inhibited and pregnancy is not possible. It will also cause you to not have periods. Sometimes you will get breakthrough (irregular) bleeding in the first cycle but by the second and third cycle, the periods will stop.
Lupron is another similar medication. It is slightly chemically different but does the same thing. I like the Lupron because it has less side effects than Danazol. Danazol is really an older treatment. We rarely use that anymore in the U.S. Instead, Lupron depot can be given as a 3.75 mg monthly dose for three months or an 11.25 mg single dose that lasts for three months.
Once you finish the three month therapy of either of these medications, you can begin trying for pregnancy. I would recommend aggressive treatment with either ovulation induction and IUI or IVF. You will have about a 6 month window before the endometriosis will return again. Endometriosis is usually given a stage from 1-4. If you have stage 3 or 4 endometriosis, you should go directly to IVF as the treatment of choice. If it is stage 1or 2, then IUI would be appropriate.
From time to time I receive letters from women who have no where else to turn for advice. Some months ago I received this letter. In this case, an indiscretion is causing this woman a great deal of anxiety and her positive IVF cycle result hinges on my being able to reassure her as best I can. A physician can never allow moral judgement to get in the way of medical reasoning. Yet, a physician also has to consider the mental health of their patients, hence the final advice that I give in the following Q&A. Even though the letter writer gave her permission to publish, I have changed dates/times/text to give it further anonymity.
I'm not sure where else to go. My husband and I have been trying for X years to have a baby. He has some viscosity problems and motility is low also with some abnormalities. We have been put on Letrozole, we have done IUI's, we have done X# IVF/ICSI cycles and X# frozen cycles...all have failed.
Our private life has become a trial and I have been unhappy with it. Our doctor put me on Letrozole on *** 30th for 10 days, we were to try on our own and then do another Single embryo FET. Stupidly and sadly I had an affair on *** 11th. I felt sick about it. I had my HCG shot on *** 13th. My husband and I tried the following day and the next day. I then had the transfer on *** 18th. By ***1st I had blood work. The next day they called to tell me I was pregnant with HCG level at 70. Four days later on the 5th another blood test which was reported at HCG level of 600. My doc thinks it's either twins, although he could only see 1 sac.
My concern is that it is not my husband's, as he has never been able to get me pregnant. I am thinking of taking steps, though I'm not sure how at this point to terminate. What are the chances it could be another man's, and what do you recommend? It was a horrible mistake and I just don't know who to contact or where to go from here. Please Help. Writing from ***.
First let me say that I avoid moral judgements so my opinion is based on reason alone.
There is no way to know 100% if by some odd chance your pregnancy is a result of your indiscretion. However, FET cycles are very strictly scheduled and timed because there is only a small window where the embryo can be transferred and implant. Even 1 day too early or too late could cause the cycle to fail. In addition, there is only a 12 hour window for fertilization to take place after ovulation.
The HCG was given to induce ovulation and since the ovaries are monitored with an IVF cycle, it is unlikely that you ovulated prior to the HCG.So, that means that your indiscretion was not timed appropriately for you to become pregnant. Despite the fact that you don't feel like you can become pregnant with your husband, your doctor has done what it takes to help you achieve a pregnancy with him and my professional opinion is that there is certainly a good chance that you could become pregnant with your husband's sperm. Therefore I think that for you to even consider terminating this pregnancy would be a big mistake. I would celebrate it with your husband, not think about the indiscretion any more and move forward with your life. If you went forward with the termination, I feel that not only would you have the guilt of the indiscretion, but you will also have the guilt of the termination. That is a LOT of guilt to have to bear.
Although the ultimate decision lies with you, I do believe that you'll be better off to put it behind you and celebrate your success.
My husband and I recently went through our first IVF. We have been trying for 2.5 years to get pregnant and have done 6 failed IUIs. We have stage 2 endometriosis that was cleared out by a laparoscopy last Fall. Aside from that we are unexplained infertility. We retrieved 10 eggs and 9 fertilized naturally. We transferred 2 blastocysts on Day 5 that were graded 2BB and 3BB at transfer. We had 5 others that made it to freeze on day 6.
I have been a little stressed out about the quality of the blastocysts. I know that 4AA is the highest. Will our blastocyst quality impact implantation rates? R. from the U.S.
Hello R. from the U.S.,
The answer to your question is yes and no. It is ambiguous because grading does not necessarily predict whether implantation, pregnancy or a successful delivery will take place. I have often been surprised when I get a pregnancy from embryos that are "graded" as poor quality. I have also seen cases where when we do genetic testing called PGS (preimplantation genetic screening) the test results reveal that the good quality embryos are abnormal and the real bad one is normal! So I don't think you can say that the way your blastocyst are graded will necessarily have any impact on their ability to implant.
At this point in time, we do not have the technology to evaluate embryos fully to know which ones will implant and which ones won't. As far as I'm concerned, all embryos have the potential to implant and lead to a successful pregnancy. In my opinion, only God knows for sure. It is a good sign that you had embryos to transfer and freeze...Good luck with your transfer results!
I am 44 turning 45 this June. I have had 3 failed IVFs - 1 didn't go beyond retrieval because I pre-ovulated so no eggs to retrieve. My recent failed ivf cycle I had 3 follicles 19mm, 18mm and 16.5mm. The biggest follicle had no egg, the second largest had a degenerative cell and the third an immature egg. I took 300 iu's of follistim and 1 vial of menopur increased to two mid cycle.
Can taking too little or too much meds (follistim/menopur) cause this outcome?
We are trying a gentler dose and using follistim instead of gonal f. My first few cycles I was taking 600 iu's of gonal f and 150 iu;s of menopur. They had me doing this protocol for months and I started to respond poorly to it. I insisted on changing the meds or trying a gentler dose.
We interviewed with a new doctor here and his approach is less is more, less meds and get better quality vs. quantity eggs. And is it true that the smaller follicles esp. women my age will have bad eggs? My last cycle debunked that whole theory because the dominant follicle or the two largest didn't have any eggs. The smallest follicle did have an egg but it was immature.
I know that on the average I produce 5-8 follicles per cycle. I think it's important to save as many of the follicles we can, we can't afford not to even if they have bad eggs in them. I am not young and producing 20 follicles. How much do you recommend women my age take in meds (follistim/menopur)? The new doctor wanted to put me on 150iu's of follistim every other day or maybe everyday? That did not seem enough? He only wants to stimulate the dominant follicle or larger follicles. I don't want to take so little that it doesn't stimulate enough or take too much that I can get overstimulated and not respond well. I know my body and I am very sensitive to the drugs. I have also used micro-dose lupron and I responded poorly to it.
What protocol do you at your clinic use on women my age? My recent baseline fsh is 8.6, E2 is 30 and my AMH 0.27. It started low and increased up to 0.7 taking dhea and in the last few months started to decrease. I have no other issues other than my age and thyroid disease but it's under control. Do you change dosage depending on blood levels, number and size of follicles? The doctors I went to never did that.
Do you use clomid or birth control pills? I am not fond of either of them but I have heard and read that if you are on clomid you third ivf cycle will be successful? I prefer to use estrace or patches over the birth control pill to suppress. Why do clinics use birth control pills? I have read clomid was found to give cancer to lab rats?
Your help is greatly appreciated. I don't have time to waste anymore.
Thank you, C. from New York
Hello C. from New York,
In general I don't comment on specific protocols because each doctor has their personal preferences and there are none that are perfect or better than others. However, I don't think I like your new doctor's recommendations or protocols and I'll explain why.
The biggest hurdle that you are facing is an age related decline in egg quality AND a decreased ovarian reserve. There is nothing that can be done about the egg quality but the goal with IVF is to increase the number of eggs recruited and available in the hope that a good egg is still present and we can find it. So, the protocol is always to try to stimulate an increased number of follicles and hopefully eggs.
I have read studies where the argument is if you use a natural cycle (no stimulation or decreased stim cycle), the egg quality will be better, but I believe that to be nonsense. Why would decreasing the number of follicles or relying on a natural cycle (only one follicle) produce better eggs? That is illogical. The quality of the eggs are already predetermined. Stimulation or lack thereof does not influence its quality. Again, I believe that the only way to overcome the age factor is to try to get the maximum number of eggs out at a time. For this I use a high protocol or mixed protocol that is 450IU of follistim and 150IU of Menopur. I also Do Not Use Lupron (called the long protocol) because I think it is inhibiting the ovaries too much at the time of follicle recruitment. Instead I use an antagonist protocol where the antagonist is given for only 1-3 days.
The only time I will decrease the amount of medication is if the patient has gone through one or two IVF cycles and still the number of follicles encountered or eggs retrieved are few. I decrease the protocol because I don't want her to spend lots of money on medications if the increased amount is really not doing too much. The ovaries do get to a point where they won't stimulate much despite increased dosage of medications. Unfortunately, your ovaries sound like they are there already. Again, the reason for doing this is to reduce the cost of medications.
I do alter my dosages as the cycle goes on, but only if I am starting from a lower dose and the patient is not stimulating, in which case I increase the dosage, or if I start on a higher dosage protocol and she is stimulating too strongly, in which case I decrease the dosage. Other than that, the dosage stays the same for most of the cycle without alterations.
I would not even consider Clomid for an IVF cycle. Some clinics do again to decrease the cost of medications but multiple studies show that the injectables are superior to Clomid.
Finally, in terms of the birth control pill, I do use it. Several studies have shown a better response if preceded by birth control pills. It suppresses the ovaries in the cycle preceding the IVF cycle and there may be a rebound effect so that the ovaries stimulate better. Estrogen does not suppress the ovaries unless given in very high amounts such as with the birth control pill. I have read of clinics trying to do IVF after a natural "unsuppressed" cycle, but I don't think it makes much difference. The other reason to use the birth control pill is that it allows us to take control of your cycle so that we can be sure that timing is correct. Timing is absolutely critical with IVF. There is a very small window of opportunity for the embryo to implant and if you miss it, then the cycle will fail. Also, using the birth control pill helps with scheduling if you batch patients (put them in the same group).
I think it is meritorious that you are trying to achieve pregnancy with your own eggs at 45 years old, but you have to understand that pregnancies rarely occur after 43 even with IVF unless donor eggs are used. However, I always remind my patient that the oldest woman to achieve pregnancy through IVF using her own eggs was 49 years old. It did take her two years of doing IVF, so persistence can count if you can afford it and want to wait that long to have a child. But you also have to be realistic and not let your expectations be too high. I hope that your journey will go well nonetheless, and that you achieve your goal of having a child.
Edward J. Ramirez, M.D., FACOG Executive Medical Director The Fertility and Gynecology Center Monterey Bay IVF Program www.montereybayivf.com