Trying To Conceive After Surgery For Cysts & Endometriosis: Do A Clomid Induction Cycle?

Question:

Hi from Wisconsin!
My husband and I have been trying to conceive our third child. My youngest will be turning three in a couple of months. They were conceived quickly with no issues. About a year ago, I was advised to have surgery to remove what looked liked a "complex ovarian cyst" that was causing intense pain. I was on birth control pills at the time. I was told everything else looked good at the time of surgery and I experienced heavy bleeding afterwards for about a week. A year later I was still having pain in that area, so a different MD did surgery and removed an adhesion between my tube and ovary, a small amount of endometroisis, and paratubular cysts everything was located on the same side as my surgery. My tubes were open.

I am about 3 months from the surgery and on our fifth month of ttc and have been having really light periods (which I have always had, so I was surprised by the endo) that start/stop and have brownish spotting in the beginning. I was told it means I am not ovulating. I am doing a progesterone test later this week to see if I am. I did get a positive OPK on day 14 this month and my periods are pretty regular occurring every 28-30 days. Clomid was suggested for my next cycle, which I am nervous about trying. I am 33 and my husband has a normal semen analysis (one of the motility numbers was lower 37% but they said because his total motile sperm number was above 57 million they said it was fine).

Do the light periods have anything do to with not getting pregnant? I also get a lot of white sticky discharge after the egg white mucus and a few days after the OPK positive, is this also a sign something is not working? Will Clomid help me? If I am ovulating will it just increase the number of available eggs? For the next cycle an ultrasound and HCG trigger were also suggested. This is all so frustrating! When asked my MD told me I had a reasonably good chance of getting pregnant on my own but I am worried about being on a time crunch, especially since no endo was seen a year before.
Thank you for your advise. S. from Wisconsin.

Answer:

Hello S. from the U.S. (Wisconsin),

Usually the amount of flow with a period is proportional to the amount of endometrial lining produced. The endometrial lining is produced or grown with increasing amounts of estrogen that occurs in the first two weeks of the cycle. This is called the "proliferative phase" for proliferation/growth of the endometrium. As a targeted follicle grows, it produces more and more estrogen. So, the fact that your periods are very light is a little worrisome in terms of the possibility that there is inadequate estrogen production. If you are ovulating then adequate estrogen should be produced, so maybe there is an ovarian dysfunction going on. I cannot be sure without additional information or testing. Clomid may help this by inducing the ovary to function more normally and increase the estrogen production by increasing the number of follicles that progress to ovulation. Clomid increases pregnancy rates by increasing the number of eggs ovulate in women that are already ovulating normally. This treatment is called "superovulation.".

With clomid ovulation induction cycles, I am a strong advocate of ultrasound surveillance or monitoring. This allows us to evaluate how you are responding to a particular dosage of medication, since there are varying dosages that can be used and people respond differently, how many follicles are being developed, so that you don't ovulate too many eggs and significantly increase your chances of a super-multiple gestation, when the follicle is at the appropriate size to trigger ovulation with HCG and to time intercourse or IUI so that it is at the closest time to ovulation (ovulation cannot be predicted completely).

You are correct about the timeline for your endometriosis. I tell my patients that they basically have a 6 month window of opportunity after their endometriosis treatment. With each cycle, new endometriosis is being produced and some endometriosis that was at a microscopic stage is growing. Eventually, you will return to the pre-surgery state which may be preventing pregnancy. For that reason, I too recommend a more aggressive timeline and aggressive approach to treatment such as superovulation with timed intercourse or IUI.

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.

Will Removing Blocked Fallopian Tube Help This Patient Conceive?

Question:

Hi again Dr Ramirez, it's K. in NY.

I have written in the past about my multiple miscarriages/chemical pregnancies. I tested positive for the MTHFR mutation this past fall. I had a miscarriage at 9 weeks in August, which you believed was most likely due to a virus I contracted. I have followed up with a new specialist recently, and received some new information today.

First of all, my right tube is definitely blocked (although most of my miscarriages/chemical pregnancies resulted from ovulating on the right) We are led to believe that I most likely had a few early ectopic pregnancies. The specialist today suggested that I undergo surgery to remove the right tube completely. I am not sure how I feel about this, as surgery for any procedure is risky. Do you feel that having the tube removed would increase my odds of becoming pregnant? I am willing to do it if it makes sense, but hate to do it "just because". I am not sure if research supports this practice or if it doesn't really make a difference in the long run.

The second piece to this scenario is that my husband was diagnosed with a translocation between chromosomes 11 and 13 (46xy,t(11;13)(q21;14)). IVF (in vitro fertilization) was suggested to us, but we do not have the money for this and it is not an option unfortunately. Our Dr prefers to remove the tube and discuss fertility meds and other options after that point. While it explains many of our losses, I am curious if you have any other treatment suggestions. We have two healthy children that we had no difficulty conceiving. I have taken femara multiple times (pregnancy x1) and progesterone. We have not tried IUI, but were wondering if it would be of any benefit. I am just confused with all of this new information as to how to proceed conservatively. I am willing to take meds and try IUI, but I would rather not have surgery at this time unless there is a strong link between increased fertility and tube removal. Also, if we continue with meds and u/s, is there a point in being aggressive on months where I ovulate on the right?

We are just looking for the best path to take and I am hoping that you have some input to help us make an informed decision. Obviously this journey gets more difficult with every diagnosis. Thank you for your time.

Answer:
Hello K. from the U.S.(New York),

So sorry about your secondary infetility problems. To begin, there are no studies to either validate or invalidate the recommendation to remove a nonfunctioning tube unless it is blocked at the fimbriated end (called a hydrosalpinx). In that case, it has been shown to decrease pregnancies via IVF and is thought to impair implantation. It is recomnended to remove or separate the tube from the uterus. However, your doctor's recommendation is not unreasonable. Considering that it is not predictable as to which tube the egg will go into, each month you have a 50/50 chance that the egg will get picked up by the wrong/damage tube, and therefore will not get pregnant. In addition, you are risking ectopic pregnancy should the sperm get through on that side. I think that removing the tube might give you a better chance at getting pregnant because that only leaves one tube where the egg can go, and it does not matter which side the egg is ovulated from. They all go into the culdesac where the tubes lie.

In terms of your husband's translocation, that certainly can be a cause for miscarriages, just as your postive MTHFR can be a cause. There are no real good solutions for his problem other than doing PGS (preimplatation genetic screening) in conjuction with IVF. You'll just have to take your chances. I am not sure that IUI will offer you any more than trying as you have been, but statistically it does give a slightly increased chance of pregnancy if 2-3 eggs are ovulated at a time. That's the only advantage.

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.

Conceiving After The Age Of 40: What Are My Chances?

Question:

Hi. I am 43 and began my quest for motherhood about two years ago. I have been on Clomid and Femara and have tried IUI about 5 times. I most recently tried Follistem and IUI. Last month I was on oral contraceptives because of a cyst and returned this month to discover the cyst was still there AND I had another cyst on the other side. The doc gave the option of aspiration of cysts or to consult to discuss options such as donor eggs.

I have been pregnant once, with no fertility help, about 3 years ago (at 40 yo) which resulted in miscarriage at 8 weeks. We had a heart beat then lost the pregnancy. What are your thoughts about my fertility history and recommendations for an otherwise healthy 43 year old? The cysts are producing estrogen--level was checked. Thank you for your opinion. I am writing from Iowa....thanks! S.

Answer:

Hello S. from the U.S. (Iowa),

First you need to understand that you are trying to beat the odds and that statistics is only a reflection of real life, not an exact predictor of it. There are always exceptions. However, we try to make the best decision based on the information that we have.

It is well known and scientifically proven that a woman's fertility decreases with age beginning at 30 years old. This is due to the fact that a woman is born with all the eggs she has for her entire life and those eggs age with her. In addition, she is using up lots of eggs with each cycle so there is also a reduction in the number of eggs available.

We also know that by 40 years old, the remaining eggs will be of poor quality. This leads to a reduction in pregnancy rate or a significant increase in miscarriages, and was probably the reason you miscarried at 40 years old. Your statistical chances of pregnancy with IUI (intra uterine insemination) at 43 years old is less than 0.5% per cycle. This is due to the fact that IUI is still a "natural" treatment method and requires that your body go through the normal steps to achieve pregnancy. As you can see, your chances are not zero, but are pretty slim. (A 20 year old woman has instead a 20% chance of pregnancy per cycle.) At your age, with IVF (in vitro fertilization) using your own eggs, the chances of pregnancy rise to 33% per cycle. Unfortunately, because of pregnancy and miscarriage losses the delivery rate is 13%. It is still significantly better than IUI because most of the steps required are performed by the IVF and only two steps are left to natural processes. With donor eggs and IVF, the chances increase dramatically due to younger and healthier eggs, to 75% with 59% delivering.

Most fertility specialists would recommend donor IVF, but it is a personal choice that you have to make. Most of my older patients want to try at least once with their own eggs and I will give them the chance to try because as I said up above, there are always exceptions!

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.

Woman With History Of Endometriosis Wishes Baby #2

March is "Endometriosis Awarness Month" and I thought it would be appropriate to post this recent question from a woman who had endo and succeeded to have her child six months ago. For those of you who wish more information on this reproductive immunologic disease that affects millions worldwide you might begin by visiting the Endometriosis Research Center website.

Question:

Dear Dr. Ramirez,

My beautiful baby boy- now 6 months old- was conceived via IUI (after more than 2 years of trying, painful laser ablation of my endometriosis, 4 rounds of clomid, and two tries with IUI). I have endometriosis. I also happen to have an AMH level of .8-- quite low for age 31, but my FSH and other levels have been perfectly healthy and age appropriate. My fertility specialist urged me not to wait to try for a 2nd baby (given my AMH and the likelihood of my endometriosis returning after pregnancy). So now that my son is 6 months old, and I fear I am beginning to feel some of the painful twinges of endometriosis returning, I am wondering when I should start getting serious about another IUI for baby #2.

I am still breastfeeding (hope to continue for maybe another 6 mo) and my period has not yet returned. While becoming pregnant right now feels a little hard to imagine, given the demands of having an infant, my husband and I DO want a 2nd child, and would like a chance to have another of our own. Is it reasonable/recommended to wait until my period returns (and is normal) before getting serious about this? Or, must I take sooner action? What about breastfeeding-- would breastfeeding interfere (hormonally) with the chance of IUI success/pregnancy? I am trying to temper not feeling quite ready to be pregnant again with not wanting to miss my chance to grow our family... what do you suggest??

So very sincerely appreciated, K. from Atlanta, GA

Answer:

Hello K. from the U.S. (Georgia),

First of all, AMH is an indirect test of the ovary and NOT an absolute. It is used in conjunction with cycle day #2 or 3 FSH and an ultrasonic antral follicle count. So, I would not assume that your time is limited if the FSH and AFC are normal but the AMH is decreased. It is not that critical. Now, it is a little worrisome that your level would be low at your age, so time needs to be kept in mind. But the timeline is not days or months but probably years. For example, I would not wait until you are 35 years old where your age will then start to become an issue as well.

In terms of when to try next, I think you can wait until you have finished breastfeeding, since it would interfere with conception.While you are breastfeeding the ovaries are at rest and not functioning any way so you don't have to rush. In some women, in fact, pregnancy seems to clear up their endometriosis temporarily, so you may have time to conceive after you stop breast-feeding and your period returns. I have had patients like you who have had endometriosis and needed assisted reproductive help for their first baby, who then went on to have baby number 2 & even 3 without the need of further IUI's or IVF.

Congratulations and enjoy your baby!

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.

Young IVF Patient Fails Two IVF Cycles: Empty Follicles

Question:

Dear Dr. Ramirez, I am 31 years old, have never been pregnant. My husband and I haver been trying to conceive for about 3 years, tried 5-6 cylces of Femara.

I had three failed IUI's and two failed IVF cycles. The first IVF cycle there was one egg but it disintergrated before it could fertilize. The second IVF cycle there were no eggs. Each cycle had 14-16 follicles 8-10 of them being mature. My AMH level is 2.19. My husband has been tested and is fine. I have a left blocked tube, which they say could be a spasm reaction from the dye. During the IVF I was on Bravelle, Menopur and Ganerelix injections, along with the trigger shot. It is emotionally and financially draining. Any thoughts? Thanks, H. from New York

Answer:

Hello H. from the U.S. (New York),

There is a finding called "empty follicle syndrome" where no eggs are within the follicles. But this occurs in a single cycle and those patients generally have eggs when retrieved in subsequent cycles. I have had young patients, and many older ones, with no eggs retrieved. In older patients, many of the follicles don't have eggs i.e. they have run out of eggs, so it is fairly common. But, this is not common in young women.

In most cases when eggs are not retrieved in a young woman, it is often because either (1) the HCG trigger was not adequate, or (2) the follicles sizes were not mature enough and therefore the eggs were not mature. I am suspicious that you fit into the latter category based on your first cycle. It is possible that you are being triggered too soon. In terms of the HCG not being adequate, when I previously encountered empty follicles in my young patients, I came to the conclusion that either the HCG had a manufacturing defect, was not stored properly or not given properly. I used to use generic HCG. I have now switched to the brand HCG, Ovidrel, and have not had a repeat of that problem.

I also worried that in more obese patients, the depth of the injection was not adequate to get the HCG into the tissues so I have my obese patients given the HCG injection into the back of there arm where the fatty tissue is less, rather in the abdomen where the fatty tissue is thicker.

Finally, if it is that the follicles were not allowed to grow sufficiently, that is a procedural problem. So you either can ask your doctor to wait a little longer to trigger you (I have found in my experience that I have to wait until the lead follicles are 21-22 mms rather than the 18 mms that most doctors will trigger at) or you can try a different clinic/center because each doctor and clinic are different and the outcome can be different.The bottom line is not to give up.

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.