TTC After Surgery For Stage Four Endometriosis

Dear Readers,

As the year draws to a close I want to wish all my readers near and far the very best in their lives as you move forward into 2014. I hope that the blessings of health and peace are with you all and for those of you who continue to struggle with infertility, I can only wish with all my heart that the journey will come to a positive conclusion for you in 2014.

Thank you for following my blog and God Bless.

Edward J. Ramirez, M.D.

 

Question:

Hello,

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why?  I understand surgery can affect ovarian reserve but am looking for better understanding.

What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas?  Thank you.

C. from California

Answer:

Hello C. from the U.S. (California),

Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates.  This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding).  In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis.  These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means.  For that reason IVF is the only option.  Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen.  However, statistically speaking these cases are very, very few.

In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming.  For that reason, you can form new endometriomas, despite the previous ones being removed.

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.

Fertility At 40 After Having Had Children Earlier In Life: Is It Still Good?

Question:

Hello. I just turned 40 years old. I am healthy. I had 1 miscarriage in my early 30s. I waited a few years to conceive after that and conceived two children back to back in the first month of trying so I am hoping my fertility is still good. Obviously Im reproductively old and there is an issue of egg quality. Is it always better to try to conceive naturally. We are worried about chromosomal disorders. I had testing done at a fertility clinic. My AFC was 14, my FSH was 6 point something and my AMH was 5 point something. Can you help me interpret this? Again, is it always better to try to conceive naturally? Thanks!!! S. from the U.S.

Answer:

Hello S. from the U.S.,

Having had children previously does extend your fertility in my opinion so although you are "reproductively old", you may still be quite fertile.

The tests mentioned, AFC, FSH and AMH are all INDIRECT measures of ovarian function and NOT fertility or egg quality.  They give us an idea of how well the ovaries will respond to stimulation, which statistically can increase or decrease your chances of success.  In older women, the more eggs you get in an IVF cycle, the higher the chances of finding a good egg because there are fewer good eggs with increasing age.  That is all that those tests reveal.

In terms of what may be the best way to get pregnant, certainly trying natural has significant advantages: it is more fun and pleasurable, it costs less.  The disadvantages are: there is an increased risk of genetic disorders (based on your age), it may not work, and there is a higher risk of miscarriage.  So, in terms of whether to try naturally or go with a technological means, it depends completely on your personal preference and goals.  Unless you want to do something like genetic testing of embryos for normality or sex selection or want to increase your chance of pregnancy in the shortest possible period, then I would recommend that you try naturally for at least 6 months.   If not successful by that point, then I would recommend that you consider proceeding directly to IVF, which is the recommendation if you say yes to either of the previous criteria.  The downsides of IVF are: cost, not fun, unnatural and it's a medical procedure.  The upside is it is more efficient (higher chance of pregnancy per attempt, you can genetically test the embryos to minimize the risk of miscarriage or genetically abnormal child and you can achieve pregnancy faster.  Because your ovarian testing is so good (more like a 20 year old), you are a very good candidate for IVF and I would probably give you a high chance of success per attempt (50-60%) in a good IVF center.

 

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

 

Poor Responder Needs To Know IVF Is Not All About Numbers: It 's About One Good Embryo

Question:

Hi Dr. Ramirez,

My name is A. and I am writing from Michigan. I am 33 years old and have DOR with an AMH of <.16, Hashimoto’s and positive ANA’s. I am on day 10 of stims for IVF #2 and responding poorly compared to our first attempt. I am hoping you could answer a few questions regarding the cause of the diminished response (compared to the first) and also give your opinion regarding canceling the cycle.

IVF #1 (March 2013):

BCP suppression 5 weeks

225 iu Bravelle, 150 iu Menopur, Ganirelix days 8-10. Stimmed for 10 days.

Day 5 of stims: 6 follies: 9-10 mm, E2 301

Day 10 of stims: 7 follies: 19-21 mm, E2 724

Retrieved 8 eggs, 6 mature, 4 fertilized with ICSI, 2 transferred (grade B’s, no frag), none to freeze.

IVF #2 (in progress):

BCP suppression 4 weeks

225 iu Bravelle, 225 iu Menopur, Ganirelix added day 8 of stims.

Day 7 of stims: 6 follies: 12, 12, 9, 9, 9, 9 mm, E2 243

Day 10 of stims: 4 follies: 15, 14, 11, 10 mm, E2 495

There are five factors that have changed since the first cycle. 1) Menopur was increased by 75 iu. 2) Ganirelix was introduced when follies were smaller at just 12 mm. 3) Slightly less time on BCP suppression; less one week 4) Added Methylprednisolone 16 mg. 5) Discontinued DHEA 50 mg and Myo-Inositol 2 g.

What could be causing the poorer response, loss of follicles and slow growth? Is there anything that can be done to speed up growth and/or catch up the 10 and 11? Does the slow growth speak to poor egg quality?

I am okay with going to retrieval with so few follicles as I realize I have DOR and cannot expect a normal response. However, with having had a better response previously, would you recommend canceling at this point? Why?

This is such a stressful time for us, so I greatly appreciate your attention and feedback.

A. from Michigan

Answer:

Hello A. from the U.S. (Michigan),

First, you should know that ovaries can and will respond differently with each cycle regardless of the protocol used.  That is to say that even poor responders will respond better or worst from one cycle to the next.

In your case, I can make several observations which may be helpful to you:

1.  Despite a low AMH, you have responded pretty well with each cycle.  You had 14 follicles and 10 in the second.  This is not a sign of a poor responder.  Poor responders tend to have less than 10 total follicles.  In addition, your stimulation was not that high, so I would say you are a pretty average (normal) responder.

2.  As mentioned, your stimulation protocol was in the mid-range (375 IU and 450 IU).  The max protocol that most clinics use is up to 600 IU (450 FSH + 150 FSH/LH (menopur).  So in terms of stimulation, you have lots of room to improve.

3.  You mentioned starting Ganerelix when the follicles were 12 mms.  That is way too soon in my opinion.  Based on European studies and over 10 years of use by myself, I do not start Ganerelix until the lead follicles are at least 16 mms and preferably when the 30% or more are between 16-18 mms.  The purpose of Ganerelix is to prevent premature ovulation so I hold it until the very latest that I can to allow the follicles to develop without suppression.  Starting too early will lead the smaller follicles to stop growing.

None of this implies low egg quality or poor outcome.  It is part of the "art" of assisted reproduction and what distinguishes one doctor or clinic from another.  Bottom line is that IVF is not all about numbers.  It is about getting at last one good embryo to attach and lead to a pregnancy.  For that reason, even if there are fewer follicles I recommend that you keep going just in case the perfect embryo is in this group.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

 

After Failing 3 IVF, Reader Has Pregnancy Success After Writing To Me

Dear Readers, Sometimes I get great news from one of the many couples I help on AllExperts.com and this is one I would like to share with you. Over a year ago I began corresponding with this woman regarding her failed IVF cycles. Her original questions appear right after the good news I received from her a few days ago. Makes it all worthwhile :)

October 7, 2013

Comment:   Dr. Ramirez helped me conceive from across the country thanks to his blog. We've never met and my husband and I credit him with the birth of our healthy baby boy. When my RE rejected our suggestions, Dr. Ramirez provided facts that played a major role in our "self" treatment which was to try naturally with baby aspirin. More doctors should provide online guidance and provide proven medical facts and suggestions to help those of us who are skeptical of patient forums. 

July 2012

Question:

Hello Dr. Ramirez,

I am writing from the United States.  I have been TTC for 2 years.  I began RE treatment 6 months after trying to conceive naturally at 34 yrs old. I am 36 now. I have failed 6 Intra Uterine Inseminations and Three IVF (in vitro fertilization) cycles. Below are the details: (for privacy purposes I have omitted the precise details of each cycle…except for the transfer details)

First IVF: 7 mature eggs, All ICSI 1 fertilized, transferred 4 cell Grade AB on day 3

Second IVF: 17 mature eggs, 9 fertilized, transferred 2 Grade AA on Day 3, one made it to blast and freeze (poor quality)

Third IVF - 18 mature eggs, 14 fertilized, 9 made it to blast, transferred 2 Grade AA, froze 6 good quality blasts ranging from Grades AA - BB

I never had a positive beta or urine test.  I've done all the preliminary testing, water sono, bloodwork, HSG, etc. everything is normal.  My husband’s tests and sperm are also normal.

I asked about immunology testing and Doctor said there is nothing to support that treating it helps.

I don't believe the early bleeding is normal. My luteal phase naturally is about 11 days long.  Dr said the PIO is plenty for me and would not recommend increasing it.

I asked about baby aspirin and heparin. They said baby aspirin is ok, but heparin can be dangerous.  I've read in your posts that you recommend that if there is one IVF failure.

Is there harm in taking heparin? I don't know what else to do to make them implant.  What are your thoughts considering my history?  I do not want to transfer any frozens unless the protocol is changed. I feel like continuing the same PIO / medrol protocol is setting me up for failure again.  I appreciate your advice. Thank you!

Answer:

Hello,

Since you have had decent embryos to transfer in at least two of your three IVF cycles, this would be regarded as implantation failure.  Thanks for reading my posts.  I also discuss these issues in my blog.

Your doctor is right in that the correct general opinion, kind of like being politically correct, is that the studies do not show any benefit to treating for immunologic problems in IVF.  However, it remains to be seen and depends which studies you prefer to believe.  There are certainly studies that show that immunology plays a role in miscarriages and some studies that show immunological treatments help with IVF.  I don't think it can be discounted completely but at the same time, don't believe in every treatment that is offered.

I certainly advocate low dose aspirin, low dose medrol and low dose heparin in my patients that fail two cycles of IVF for no clear reason.  I have had many be successful thereafter with that protocol, which I have been using for the past 18 years.  There is NO danger in using low dose heparin.  Full dose heparin is another matter.

I think that the dilemma you now face is whether to continue with this doctor or not.  If you want more, such as using the protocol mentioned, then you'll probably have to find a doctor that will provide that to you.  I certainly think your doctor needs to reevaluate and consider what else he/she can do since what is being done so far has failed.

You certainly can always fly out to California. :)  For an FET cycle, you would only need to be here for one day.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Follow-Up Question:

Hello again,

We consulted with our RE again regarding the transfer and he suggested doing nothing differently and chalked it up to bad embryo genetics.  Again he reiterated no baby aspirin so we pleaded for him to do immunologic testing, cytogenetics (on us) and blood clotting work ups to which he agreed.

Everything came back normal, including cytogenetics on my husband, with the exception of my protein s free antigen level. It was 151 and regarded as "high" by the lab that ran it.  He referred me to a hematologist who ran protein s activity testing which thankfully came back normal. He said a high level protein s is not concerning and that only a low level would be.

So here we are again with his recommendation of transferring with the same protocol.  I asked again how about baby aspirin and he remained firm on "no".  I told him 3 doctors, including one at his practice, the hematologist and an online doctor i have emailed have said there is no harm in using it along with my friends who have used it with no pre-existing blood clotting disorders and went on to have successful IVFs.

He said taking baby aspirin with no blood clotting problem can cause more complications than help.  He said it can interfere with the growth of the placenta.  Is this true?  So far he is the only doctor that has said no to baby aspirin including the doctors of everybody I know who has gone through ivf unexplained.

Are there any facts you know of with baby aspirin and placental defects?

Again, I truly appreciate your knowledge and advice and thank you for your responses.  There should be more doctors like you who help others online with honest, professional opinions!

Follow –Up Answer:

Hello Again,

There are no studies that show any adverse affects of low dose aspirin on embryo or placental development.  In fact, and either you or he can look this up in any Infertility textbook, low dose aspirin is an approved and advocated treatment for recurrent pregnancy loss (now why would they endorse it if it caused placental problems?).  We have extrapolated its use in failed IVF with the same idea that it increases blood flow to the implantation site and reduces the formation of micro-clots in the tiny vessels supplying the implantation site.  There is no way to test for these. 

Since this doctor is not willing to work with you on this very simple and innocuous treatment, which may or may not help, I think you should seriously re-consider using him.

Good Luck,

Edward J. Ramirez, M.D.

Follow-Up Question:

QUESTION: Hello again

Have you noticed this email is more than nine months after your last reply?

Our RE did not budge again on the baby aspirin so we decided to wait on the next transfer and try naturally with baby aspirin.

That month I became pregnant for the first time. I went to my RE and he confirmed it with blood though the levels were low and I was bleeding and he did not offer progesterone cream. He said he doubted the pregnancy was due to the baby aspirin. At 5 weeks I miscarried, and although it was sad, I was elated at the fact that I did get pregnant. So we tried again naturally the following cycle with baby aspirin (2 weeks after miscarriage) and what do you know?

I got pregnant again.  I went back to RE and he confirmed with a blood test. I started bleeding again so he suggested progesterone cream.  I told him we did the baby aspirin thing again and if I should continue taking it and he said YES! 

He followed my progress until 2 months and referred me to my obgyn to monitor the pregnancy. I continued the progesterone cream until the end of the 3 months and continued taking baby aspirin until 37 weeks. Yes, 37 weeks.

Our healthy baby boy was born at 41 weeks, weighing 9lbs, 4oz and measuring 20.5 inches.

If I did not read your blog, he would not exist. My husband and I attribute his existence to your blog and cannot thank you enough.  Please continue your public advisement as it made our dreams come true.

Thank you!!!!!!
 

Follow-up Answer:

Hello,

I am absolutely delighted for you.  Congratulations :)  I'm saddened to see that you had to prescribe a therapy for yourself, but glad that it might have done the trick.  No one will ever know for sure if it helped or not and what the mechanism is, but it seems to help many people with your type of history.  I now put all my infertility patients on low dose aspirin from the beginning, IVF or not. Another possible factor is that you tried soon after your miscarriage--studies show that there is a higher chance of pregnancy after a miscarriage.

I'm shocked and a little disappointed that your Ob doctor allowed you to go post-dates (41+ weeks) because that posed significant risk to the baby such as a fetal demise, fetal distress, etc.  I NEVER let my infertility or IVF patients go past 40 weeks.  The sooner the baby was out the safer it was at that point.

Thank you for reading my blog and using this service (AllExperts) as well.  I do it in tribute to the task and gifts that God has given me, which is a part of the love he has for us.  Your baby is also a gift from God for you to treasure and teach of his ways.  Devote your love to this son and shower him with Goodness so that when he grows up, he will shower others with goodness as well, and thereby contribute toward making this world a better place.  It is not often that I get feedback of successes attributed to my writings, but know that your feedback reinforces my dedication to this task.

Congratulations!

 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.

 

Protect Your Fertility!

Dear Readers,
The American Society of Reproductive Medicine has launched a campaign with the aim of educating women on how to protect their fertility by avoiding certain risk factors. The Society has made available a number of fact sheets, graphics and brochures that are all downloadable on their "Protect Your Fertility" page. At our center we also offer the ability to extend the fertility of a woman by either freezing her eggs or her embryos. See "Fertility Preservation" for more information.

Check out the selection of fact sheets, infographics and a brochure on the ASRM page, including:

• "Advancing Age Decreases Your Ability To Have Children"
• "Smoking and Infertility"
• "Protect Your Fertility Brochure"
• "Impact of Age on Female Fertility"
• "Practicing Safe Sex Now Protects Your Ability To Have Children Later"

To quote ASRM: "At the risk of sounding like your high school health teacher, the decisions you make today really can impact your fertility and ability to have kids later. That's why it's so important to learn how to take care of your body. After all, there's a huge difference between choosing not to have kids and physically being unable to conceive if and when you want to."

Be proactive about your fertility health!

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

Follicles Too Big In Clomid Ovulation Induction Cycle

Hello,
I am writing from San Diego, CA.  I was on 100mg Clomid on Cycle Day 3-7, then 2mg estradiol on cd 8-12. I went in for an ultrasound to check follicles on cycle day 13.  My RE said that this was most likely a lost cycle because I had 2 dominant follicles at 26 and 31 mm.  He gave me an HCG trigger because he did not want the follicles to get bigger and become cysts.  My uterine lining was 14 mm, and my RE was happy with that.  My husband and I had intercourse the day of the trigger and the day after, then skipped a day and had intercourse one more time.  

Were the follicles too big?  Do we have any chance of conceiving this cycle?  I have also been feeling cramps since yesterday at 7 days after the trigger.  Is this normal?  

Thanks for your input. L. from San Diego

Answer:

Hello L. from the U.S. (San Diego),

I don't have the ability to foresee the future, and certainly exceptions can occur, however, the follicle sizes were too big.  Usually once the follicle is greater than 24 mms, the egg within is overmature and therefore no longer viable.  Ovulation may occur but that is the main problem.  Also, it is highly likely that these follicles will turn cystic (persist) and have to be suppressed with birth control pills. You need to make sure a baseline ultrasound is done to evaluate for this at the start of your next cycle.

So, statistically and physiologically speaking, this cycle is probably a bust.  Unfortunately, your doctor missed the appropriate point by not doing the ultrasound early enough.  Next cycle he should begin looking at cycle day #9 or 10, which is what I do.  If I'm too early that's okay because nothing is lost and gives me a better idea of follicular development.  If you're too late, as in your cycle, then then cycle is lost; a big price to pay.

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.

Similar IVF Protocol But Different Results: Why?

Question:

Hi Dr. Ramirez,

I'm back again with a question about my recent IVF (second one). This IVF (in vitro fertilization) cycle we did the same protocol as last time (antagonist) but started off at a higher dose of Gonal-f based on my response last cycle. This cycle we started off at 300iu gonal-f and 75iu menopur whereas last cycle we started with 225iu gonal f and 75 IU menopur but had to increase to 300 IU gonal f after day 4 showed an E2 of only 90. Both cycles I started out with similar AFCs of 10 and 12 at suppression check. My usual AFC is between 16-20. Last cycle it seemed that I recruited more follies along the way and ended up with an E2 of 3030 and 23 eggs retrieved (17 of which were mature based on icsi and conventional fert rates as we did 50/50 split fertilization). This cycle my E2 was 2100 at trigger and they retrieved 12 eggs (still waiting on fert report today but we are doing all conventional fertilization).

My question is why did I have such a different response this cycle given that we started off at a higher dose this cycle compared to last? Last cycle we went up from 225iu gonal to 300 IU gonal at day 4 and stayed there until trigger. this cycle we started at 300iu gonal and stayed there until we added ganirelex on day 7. At that point my E2 stalled and do they increased my gonal f to 375iu gonal f and kept me there until trigger.

As always thanks for your advice/insight. S. from the U.S.A.

Answer:

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

The human body is not a consistent nor predictable structure so I can't explain why your response is different.  I have always explained to patients that have low response to stims that the ovaries can react differently each cycle and your experience is a case in point.  That being said, I would not have increased your dosage since your stimulation was so good the previous time and you bordered on entering OHSS territory.  In any case, IVF is not a contest where the person with the highest number of follicles or eggs wins the prize.  The goal is to find 1 or 2 perfect eggs that will lead to perfect embryos and a successful pregnancy.  So despite the fact that you stimulated less, that might be a better thing.  Bottom line is you only need one good one.  Also, there have been some studies showing that when a patient stimulates hard with lots of follicles, sometimes the egg quality suffers and the pregnancy rate drops.  This is especially true in PCO patients.  In those patients, our preference is to stimulate less and get fewer follicles.

So, in any case, as the saying goes: "I don't think you should sweat the nitty gritty" i.e the fine details.  Hope for the one perfect one.  That is the goal.

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.

Is A Tubal Reversal A Good Option For Me?

QUESTION:

I am a 33 year old mother of two. My children are 11 and nearly 10 years old.  After the birth of my second child in 2003 I had surgery to prevent further pregnancies. (I was in an unhappy marriage and only 23, and couldn't see myself ever getting out with 2 children.) The doctor was reluctant, because I was so young, but he decided to go ahead and perform the sterilization surgery. My tubes are not cut or clipped or burnt, they just have little clips on them to prevent the egg from passing through.  But just as many people predicted, now I regret the decision.  

I am divorced, my children are growing up, and I am in a wonderful relationship with a man who has no children of his own but would very much like to have one.  Barring infertility issues on his part, is there much hope of us being able to reverse my tubal and conceive a child of our own?  I don't have any other medical issues. I am healthy and active, average healthy weight, non-smoking, non-drinking...same for him. He is 39 and I'll be 34 this year, so we feel like the clock is ticking on any opportunity for another child.  Can this surgery be done, what are the odds of conception afterwards, what factors do I need to consider, how long do you need to wait after the surgery before trying to conceive.  And what is the average cost??  I appreciate any answers you can give me on the matter.

Thank-you! K. from Kentucky

ANSWER:

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

The type of tubal ligation that you have is the best to reverse because the majority of the tube is kept intact and there is minimal damage to adjacent tubes.  Also, considering you are young still, a tubal reversal would be a good option in your case. A good and experienced gynecologist or reproductive specialist can do the reversal either by laparoscopy (using a scope and little incisions) or by a mini-laparotomy (a small incision above the pubic bone. You would want to find a surgeon who is well experienced in this and does them a lot to get the best chances for success.  

I have had a patient who went to North Carolina to have hers done by a doc who only does reversals. The risks for this procedure are the same risks as for any surgery (infection, bleeding, general anesthesia, injury to adjacent structures, failure) but this is not considered a major surgery, but rather should be an outpatient (same day) surgery.  In terms of success, those rates can vary widely so I can't give you an exact number.  A good surgeon will have an 80% success rate in patients under 35 years old after 1 year of trying.  If a pregnancy does not occur within 1 year, then the procedure probably has failed.  

Basically, with a tubal reversal, all you are doing is attempting to restore your natural fertility rate. This rate is very age dependent.  Your chances of natural pregnancy at 25 years old was 85% per year whereas at 35 it will be 30% per year because your eggs have aged.  So, keep these statistics in mind. The alternative to a tubal reversal, and with a higher likelihood of success is In Vitro Fertilization, but the down side is you would have to do this every time you wanted a child from this point on.  With a reversal, you could continue to have children by natural means if you wanted more than one.  Cost wise, tubal reversal will vary depending on the doctor, the clinic and whether or not it is done in an outpatient surgery center or hospital.  The cheapest I have seen is about $6000 and is done in an outpatient surgery center.  Hospital performed reversals will be $15,000-18,000.  I hope that gives you the information you needed.

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, once again. Armed with the information you provided, we can now move forward! I feel like I got lucky having my question go to such a knowledgeable and open volunteer!

Secondary Amenorrhea: A Description, Not A Diagnosis

Question:

Hello Dr. Ramirez,

I'm 20 and 293 pounds. I have had  Secondary Amenorrhea for close to 4 years now. It is apparently being caused by my weight. I'm not planning to TTC for at least another 12 or 13 years. I don't hate babies but it's not just a good time on the emotional or financial level to have them. If I'm able to get down to a decent weight and get rid of this disease,  What are my chances of getting pregnant when it's time for me to TTC???

There's a history of Diabetes in my family and I haven't had a asthma attack since I was 8.My mom had thyroid disease before I was born but I don't think that's genetic. But I don't have any other diseases than the SA at the current moment and my hormone levels were just fine at my last doctor appt which was last October. I've been on progesterone more than I count and it gets me a period but I want to have it without the help of drugs. Is there some kind of natural cure to SA??

I know that it seems a bit silly to ask about this NOW but I'm not getting any real answers about this disease from my OB. Everytime I asked my OB about this, she would tell me not to worry about it or brings a therapist in the room to basically tell me that I'm crazy.

She's since moved her practice out of state and I have a new OB that I'll start seeing very soon. But how in the hell am I crazy for wanting to be proactive about my own health?? I'm sorry for the language but I'm just so fed up about this and at my wits end.

I know that I'm not producing eggs right now but what else could this be doing to my body?? Do I have a reason to be concerned about it besides the obvious infertility scare?? If I do get rid of this disease,  Is there some kind of leftover side effect that could cause me to get Ovarian Cancer in the future??

I don't have these answers and I need to know what's going on. Please help me clear at least some of this up.

Thank You. D. R. from Michigan.

Answer:

Hello D. R. from the U.S. (Michigan),

Good riddance to your previous Ob doctor!  "Secondary Amenorrhea" is a description of a problem and NOT a diagnosis.  It just means that you used to have periods and now you don't.  It doesn't explain the cause.  The most common reason for old women to have secondary amenorrhea is menopause.  The most common reason for young women to have secondary amenorrhea is pregnancy.  However, a close second is an ovarian disorder called "Polycystic ovarian disease."  This diagnosis is manifested by irregular or rare natural menstrual cycles and at least one of the following findings: ovaries that look like PCO ovaries on ultrasound, inverted FSH/LH ratio, obesity, hirsuitism (increased facial hair), elevated testosterone levels, diabetes, elevate insulin levels signifying insulin resistance.  I think that you have PCOD but without a thorough endocrine evaluation, I cannot say for sure. 

With this disorder, you have a hormonal imbalance and that needs to be corrected.  The most simple way to do that is to use a low androgen birth control pill such as Yaz.  Once you are ready for pregnancy, then you will have to use fertility medications, which actually do not increase your fertility but induce your ovaries to ovulate, so that you can give off an egg to get pregnant.  You need to see a COMPETENT gynecologist or a reproductive endocrinologist to be evaluated and treated correctly!

You may want to see a more detailed explanation of Polycystic Ovarian Disease on my website.

Glad you wrote! Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

Woman With Secondary Infertility & Possible Blocked Tube: Misdiagnosed? Surgery? What To Do?

Question:

I had an HSG (hysterosalpingogram) in November. The dye flowed freely through my left tube, which appeared normal and healthy.  However, the dye would not enter my right tube until after the radiologist had me get on my right and then left side. The dye then went into the tube and appeared to flow freely, but then it stopped abruptly mid way in the tube.The visible part of the tube appeared normal and healthy.  My RE told me that it is extremely rare for a woman to have a blocked tube in the middle of the tube unless she's had her tubes tied and that it was possible I was just born with half a tube.

I recently had a laparoscopy in June to get more info about the cause of my infertility and to attempt to repair the right tube. The dye again flowed freely in the left tube. My doctor inspected the right tube, and found that it appeared to be completely normal and healthy in every respect. However, again, the dye entered the right tube and stopped mid way. 

After the surgery, my doctor told me that I had no endometriosis or adhesions of any kind. She also told me that I had no evidence of any tubal disease or previous infection in my pelvic cavity.  The only abnormalities that were found were a large paratubal cyst that had wrapped around my good left tube (the cyst was successfully removed), and a small polyp during the hysteroscopy (also removed).  I also have never had any other surgeries or ectopic pregnancies. 

My RE told me she had no idea what was blocking the tube, but not to worry about it because research shows that having one healthy tube does not really decrease your chances that much for Clomid/IUI or timed intercourse.  Still, it's very frustrating to me because I thought that laparoscopy was 100% method for diagnosing the cause of a blocked tube, but I have no more info about the cause of blocked tube than when I started.

I am 38 and my FSH and AMH values are excellent, and my hubby passed his sperm analysis. I have a 2 year old that was conceived after 8 months and we have been trying for #2 for 1.5 years.  Although I understand that having just one tube should not affect my chances that much, I am still concerned because at this point, it is our only known issue.    

My questions are:  1. What could have caused the blockage in my tube?  2. Is it possible that the tube is not actually blocked but is not flowing for some other reason (I've heard about false diagnoses of blocked tubes due to preferential flow or not enough dye being used)?  3.  Is there any other way to find out what is blocking my tube?  4.  Is it worth it to pursue surgery to repair the tube like I've seen for women who undergo tubal reversal surgery?  

Thank you! C. from Atlanta

Answer:

Hello C. from the U.S. (Atlanta),

To answer your questions in order:

1.  The most common cause of a mid-tubal blockage, that is not from prior surgery, is an internal tubal infection.  Many of the bacteria that cause this type of scarring can do so without any type of symptom.  A laparoscopy would not be able to find this type of injury and, other than the HSG, there is no way to examine the inside of the tubes.

2.  It is possible that there was tubal "spasm" causing the tube to appear blocked, but I doubt it because the Radiologist was able to get the dye to flow down part of the tube.  However, if you think that it my not be an accurate test, then I would recommend that you have another one, but have your doctor specifically request that they pay most attention to the right tube i.e. do the test so that the dye preferably goes down the right side.  Remember, fluid will always go down the side of least resistance.

3.  There is no other testing that can be done to examine the tube.  Scope technology is still not small enough.

4.  NO.  Such surgery can cause pelvic scar tissue and impair your fertility more.

First, I think you need to consider ALL the factors involved in your fertility potential.  Yes, it is possible to get pregnant naturally (intercourse or IUI) with one normal tube, but there is no way to prevent the egg from going into the tube that is blocked, so your chances are actually decreased. 

Second, you are 38 years old which means that your natural chances of pregnancy are already reduced significantly down to 3-5% per month (15% per year), which is further reduced if you add the tubal problem. Even with IUI your max chance of pregnancy based on your age is only about 7-10% per month not considering the tubal issue. The fact that you have been pregnant before is a positive factor and increases your success with assisted reproduction. If you want that second child right away and if you were my patient, I would strongly urge you to consider IVF. 

Third, you have to decide which of two assumptions are correct: the tube was blocked from a prior bacteria, which probably went to the opposite tube as well but did not cause blockage, but did cause damage vs the blocked tube was the only injury and the opposite tube is therefore normal.  If the open tube is injured, which cannot be proven but is possible, it may not be functioning normally despite being open.  Keep in mind that fluid can pass through even the smallest opening.  In that case, you will not be able to get pregnant naturally and so IVF would be the treatment of choice.  Because of your age, I would make the assumption that the tube is damaged (mainly because you have not been able to get pregnant naturally when you were able to previously) and therefore recommend IVF.  It is the most successful and expedient treatment option for you. 

If your doctor wants to waste time and try something less like ovulation induction or IUI, that is fine as you understand that the risk you are taking is losing the opportunity to get pregnant with your own eggs and more time passes. I hope this second opinion is useful to you.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

Finally Pregnant After Multiple Miscarriages: "I Am A Nervous Wreck!"

Hello Dr. Ramirez,

I've written you in the past regarding my fertility challenges and your responses have been very encouraging. In my last, I discussed how I'd experienced an early loss in March after our first IVF attempt. You encouraged me to be strong and keep trying that my chances were good. You were right. I waited until my next cycle began and started a more simple IUI cycle again with just Follistim injections. My first miscarriage in April 2012 after IUI with Femara/GonalF was caused by trisomy 3. I found studies that said use of Femara in some women could increase the chances of aneuploidy. This time we tried without the Femara and I have become pregnant again.

I have gone through the complete RPL panel-DNA analysis, autoimmune, alloimmune, thyroid, hysteroscopy, etc. Everything has been normal. I believe the second miscarriage, because it began just 16 days after embryo transfer, was due to my body being weak (I was very sick during stimulation and had a lap/hysteroscopy/cystectomy 3 weeks before I started stimulants). I am 32, maybe borderline diminishing reserve (last AMH was .9), but otherwise nothing really bad with me.

So I am currently past 9 weeks. My betas doubled and were actually in the higher end of the ranges for weeks along. I did a viability ultrasound at 5 weeks and could see the heartbeat. Embryo measured exactly the right size. At 7 weeks we could hear the heartbeat at 174. RE saw me again at 8 weeks and said I looked good, released me to my OBGYN, said most women miscarry between 7-8 weeks. I've had no spotting or cramping. OBGYN is letting me do weekly scans until I'm through my first trimester. Heartbeat has stayed in the 170 range. Growth is continuing. Last ultrasound at 9 weeks showed the baby kicking its legs.

Here's the thing - I'm a nervous wreck. I'm terrified of something going wrong again. I am fighting to follow reason rather than fear but it is so hard. I have hardly any symptoms certainly none of the "noticeable" ones which means most of the time I don't feel like I'm pregnant. My last HCG was only at 102,900 when it was checked at 8.5 weeks, which I felt was low for where it had been but I know it slows down. My progesterone in the beginning was all the way up to 75 and is now holding at 30 (I had cysts leftover from after the IUI, made 3 follicles).
The statistics are all over the place. Some say less than 5% when heartbeat is detected but that can jump to 20% if you've had prior losses. I read it's even less once you enter the fetal stage past 8.5 weeks.

I feel stupid for asking but your answers are thoughtful. What do you think my chances are of carrying this baby to term? What would you say my change of miscarriage is? And why in the world do I hardly feel anything? I'm a little tired in the evenings and I pee in the middle of the night with crazy dreams, breasts are bigger but not sore, no nausea, etc.  But hardly anything to notice. Thank you so much for your time.  L. from Indiana

Answer:

Hello L. from the U.S. (Indiana),

CONGRATULATIONS :)  Like your RE, I release my patients at 8 1/2 weeks gestational age because the risk of miscarriage is minimal.  Statistics show that the risk of miscarriage is up to 50% prior to 8 weeks gestational age and then decreases to 5% up to 12 weeks gestation.  So you are now at 5% risk but the fact that all the signs have been good, is very encouraging and I would not worry about miscarrying.  At this point, the only risk of a miscarriage would be if there is a major genetic abnormality, and this would be a baby that you wouldn't want to go to term any way.  You should certainly consider genetic testing early to check on that.  There is now a blood screening test that can be done at an early stage.

In my experience, and as evidenced by the data, most patients will have a successful pregnancy and delivery at this point.  The fact that you "don't feel any different" with this pregnancy is irrelevant.  Every pregnancy is different and different people experience pregnancy differently.  Some have pregnancy symptoms and some have none.  You may be one of the lucky ones that doesn't have to suffer with the "morning sickness" or other such symptoms.  For now, pray that all continues to go well and thank God for the blessing.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

38 Year Old Has Five Failed Fresh IVF Cycles But Has Frozen Embies: Should She Try FET?

Question:

Hello - I have been reading you blogs for some time now and am so thankful that you take the time you do with such thoughtful answers.

I am 38 and husband is 41. My history is as follows: 2009 wasted time on clomid prescribed by my obstetrician, 2010 saw RE (reproductive endocrinologist) and began the real journey. Major issue is male factor morphology but I suspect with my age quality may be issue too.

In 2010 we had 2 Fresh IVF (in vitro fertilization) cycles, first was a failure 3 eggs collected, thankfully 3 fertilized and implanted 2 (1 frozen) but no pregnancy, cycle 2 doubled my stim meds to 300 gonal f and 150 repronex, collected 13 eggs but transferred 2 "decent" but beta was very low around 70 the pregnancy continued to around 11 weeks saw heartbeat but clearly there was issues as the size kept loosing ground until miscarriage and D&E. Cycle 3 same meds, 13 eggs, transferred 2 on day 5 and then arrived my beautiful baby girl delivered 12/29/2011.  Fast forward to 2013 where I have done two more fresh cycles same protocol, birth control, 10 lupron, to 5 lupron when stimming, retrievals after 9-10 days of stims. Cycle 4 resulted in collecting 20 eggs, 2 "decent" transferred on day 5 (blastocyst and morula) very low beta resulted in loss about a week later.  Cycle 5 same protocol except menopur instead of repronex, collected 18 eggs, 14 fertilized and transferred 2 blastocysts on day 5. This was a negative. BTW all cycles are ICSI and included medrol, baby aspirin, antibiotics, vivelle patches and  progesterone in oil injections. 

My question is what are your thoughts on FET (frozen embryo transfer).  I have 4 frozen embryos 1 from cycle 1, 1 from cycle 4 and 2 from cycle 5. RE and hubby think I should take a break and try for FET. I and concerned as I don't want to "waste" a cycle insurance will cover on the lower cost option but the meds did really affect me this time and see their point about giving my body a rest. I am at a very reputable clinic in Boston and doc said 4 frozen is a lot due to their strict freezing criteria so am optimistic although obviously embyro age has no advantage. Would FET also be something you would recommend at this point? Fresh cycles are a big logistical challenge as my husband travels 70% of the time.

Also if I go back to fresh cycle is there anything significantly different you would do (btw I am also doing acupuncture). Thank -you in advance for your time. I also want to say I am very grateful for my daughter and don't want to seem selfish but I would really like her to grow up with a sibling. 

J. from Boston

Answer:

Hello J. from the U.S. (Boston),

It sounds like you are in good hands.  Your clinic has accomplished several pregnancies, which is an IVF success.  Keep in mind that IVF can only give you the "opportunity" to become pregnant.  It can't make you pregnant because the last three steps (embryo hatching from its shell, attachment to the endometrial lining, and lining growing around the embryo are natural processes that are in God's hands.  That fact that you got a pregnancy (positive bHCG) shows that those steps occurred.  Continuation of the pregnancy is then based on pregnancy factors and not IVF factors.  Because of your age, your chances of a miscarriage are high due to abnormal embryos.  You've shown that you can get pregnant, and your ovaries stimulate very well.  Now it is just a matter of finding the perfect egg/embryo which will then lead to a successful pregnancy.  I wish all my 38 year olds responded as you do.  So hang in there!

I think I would advise proceeding with the FET cycle before another fresh cycle.  It is a much easier cycle on your body, and some newer studies are showing better pregnancy rates than fresh, probably because of the lack of overstimulation of the endometrial lining.  I don't completely agree that FET is "better" but it certainly gives a good chance.  If they fail, you can certainly try fresh cycles again.  I would advise two FET cycles consecutively.  In fact, I always advise my patients to do an FET cycle, if they have frozens, before trying a fresh cycle again.  You never know. . . the frozen might work.
In terms of additional protocol changes, you are doing everything that I have my patients do in terms of supplemental medications, but I also add low dose heparin (2000 U per day).  Not all RE's agree with this protocol, but it is an accepted protocol for recurrent pregnancy loss so you might want to ask your RE.

Thanks for following my Blog.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Thank you much for the quick and thoughtful answer. I have several time contemplated seeking a more aggressive clinic despite my comfort level. Your response puts many of my worries at ease. You are truly a huge help to those of us in a constant state of limbo. Thanks again.