Woman Suspects She Has Endo: Treat The Pain Or Do IVF?

Question:

Hi there. Hubby and I have been TTC (trying to conceive) for almost 4 years now, with no success. We have been to two different REs, the first performed one HSG (hysterosalpingogram) and we underwent two unsuccessful IUIs (intrauterine insemination). The second ran a lot of tests, told me my eggs were low and wanted to go straight to IVF. In the last couple of years, my menstrual cramps have become unbearable, to the point of awaking me in the middle of the night. I have always had cramps, but nothing like this pain. I also have diarrhea along with my cycle, a yeast infection every month, and terrible seasonal allergies.

Two years ago I had an abdominal myomectomy and at that time, my doctor separated my fallopian tube from my uterus-they had gotten stuck together. I have been reading up on endometriosis and it sounds to me like I may have it. No doctor has ever suggested that I get tested for it. But I seem to have many symptoms of it. Do you think my tube and uterus getting stuck together were a result of undiagnosed endo? Could this be causing our infertility? Thank you for any answers you can provide. Thanks, W. From Virginia.


Answer: Hello W. from the U.S. (Virginia),

It seems that you are smarter than the two RE's that you consulted with. Given this history, you certainly could have endometriosis, and the prior surgery probably made the diagnosis. Endometriosis is one of the major causes of adhesions (scar tissue) formation in the pelvis. It can lead to infertility because it changes the normal anatomy and can prevent an egg from entering the tube. In addition, you have now had an open surgery (myomectomy) which is notorious for causing scar tissue formation as well. These two things on their own would explain your infertility.

At this point you have to make a decision: whether to treat the pelvic pain or get pregnant. Treating the pelvic pain will require additional surgery. Getting pregnant would require IVF, the only option for bypassing an abnormal pelvis. Do not be under the misunderstanding that doing the surgery to diagnose and treat the endometriosis and adhesions will restore your fertility. In fact, the opposite will occur because every surgery leads to further adhesion formation. Only do the surgery if the pain is a significant problem. If pregnancy is the priority, then go straight to IVF. In many cases, getting pregnant will help the endometriosis pain.

Good Luck,

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

Young Woman With Endometriosis & PCOS Fails Five Clomid Cycles: Next Step?

Question:

Dear Doctor,

Hi, I'm from Minnesota. My husband and I have been trying to conceive since August of 2011. I have endometriosis and PCOS (polycystic ovarian syndrome) since finding out when I was around 17 years old, I'm 25 now. I have had five cycles of Clomid that didn't work. I had laparoscopy surgery for this post December, blocked tubes, suck ovaries, scar tissue, cysts and endometriosis. I'm on metformin because that's supposed to help with infertility and PCOS.

I started femara this month. Had 4 follicle on left and 1 on right from ultrasound. I usually ovulated on the 15th day, this time I didn't ovulate so I took the ovidrel shot and had a positive test. Started estrogen and progesterone day 3po. Currently on day 10po. I have cramps on and off.  I was just wondering what my chances of conceiving are and what is the next step if this didn't work this cycle. Any information or insight would be great! K. from Minnesota

Answer:

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

Your statistical chances of pregnancy with Stage Four Endometriosis (endometriosis with extensive adhesive disease) and PCOD is probably less than 1% using any natural treatment method (Clomid, Femara or Injectables with intercourse or IUI).  That is because you have an abnormal pelvis and this location is critical for passage of the egg from the ovary to the tube.  Scar tissue, which is like spider webs, can block the egg from entering or reaching the tube.  Endometriosis causes a chronic inflammation of the pelvis which leads to the inflammatory cells attacking and destroying the egg as it exits the ovary to reach the tube. Polycystic ovarian disease is an ovarian dysfunction where the ovaries don't function properly and so there is a resultant hormone imbalance and lack of ovulation.  All of these put together significantly reduces your chances.

See my website for more extensive information and explanation of the options available for both Endometriosis and PCOS. I am convinced that with the proper information patients become empowered to make the right decision about their healthcare and can ascertain if they are receiving the best care.

It is my humble opinion that you are probably not seeing an infertility specialist because a good infertility subspecialist would have told you all this and not done all the treatments you have done.  The treatment of choice is to proceed to IVF so that you can bypass the pelvis completely.

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.

Infertility Specialist Incompetent: Cancelled IVF Cycle Prematurely

Dear Doctor,

I am 40. I had two missed abortions at 37, both in the ninth week after heart beat was felt. Subsequently I did not conceive and my RE suggested IVF. I have regular 29 day cycle.

My Day 3 FSH is normal. My RE put me on Lupron (0.5cc) from day 17. On day 2 of the period, she started with 600IU of HMG and 0.25 cc of Lupron for 3 days (cd 2-4). On reviewing after on CD 5, she said no follicle and no endometrium growth is seen. She continued the medication for two more days and (cd 5, 6) and examined me cd 7 and said that there are no follicles or endometrium and cancelled the cycle.

I stopped all medications and on cd 12, I checked with a local ultra sound center. The Ultrasound specialist said there are about 12 follicles on both ovaries, the largest being 10mm.

I checked my FSH and E2 on the same day and the FSH was 12.76 and the E2 is 58.00.

On Cd 16 I checked again and the Ultrasound specialist informed me that one follicle is 13 mm and others are still small.

Can I do anything at this stage to get a multiple ovulation in this cycle so that I can try naturally in this cycle (Like one or two doses of clomid or letrozole)?

What do you infer from my endometrial thickness of 10mm though my follicle size is only 13mm.

What is your advice for future IVF cycles? Thanking you in anticipation. R. from India

Answer:

Hello R. from India,

It may be too late to rescue this cycle but if you have any Menopur, you could use it but the dosage would need to be significantly reduced to minimize the number of follicles that grow to ovulatory size. Unfortunately, the reality is that the eggs will not continue to grow and mature if it does not receive enough FSH hormone and will proceed to atrophy (wilt). If your natural FSH production kicks in then you might still have one follicle ovulate as you would in a natural cycle. I guess that is what you will have to hope for.

An endometrial lining of 10 mms is adequate and appropriate for implantation. It is also a sign that you have adequate estrogen levels because endometrial growth is dependent on Estrogen. Did your doctor ever check your estrogen levels?

My second piece of advice is for subsequent cycles. Your age is a factor from this point on so I would advise you to find a competent specialist. Your doctor is incompetent and does not know what she is doing so I would dump her (find a new doctor). It is expected, and usually the case, that there will not be much follicular growth by CD#7 of stimulation. Some people take longer,as you have shown. In IVF cycles, you have to continue to follow the Estradiol levels to see if they are rising, which is proof of follicular growth (stimulation), and measure the follicle. Most people do not have ovulatory sized follicles until CD#10-12.

I often wonder, do doctors in India have to train to be specialists? Your doctor cancelled the cycle prematurely and just wasted your money. I would demand a refund!

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.