Thursday, October 2, 2014

Upcoming Frozen Embryo Transfer #4: Do I Transfer 1, 2 or 3????


I have a son via FET. I have now had three cycles of FET total. The first did not work, the second we got my son, and this last one worked- however I had a miscarriage at 6.5 weeks pregnant. I now have 4 embryos left frozen and am starting my next IVF cycle. They are frozen in vials of 2 each. I am so concerned if only one survives: do I only implant only one and pray it works, or do I thaw the last two we have and implant all 3? I obviously want the ultimate outcome: a pregnancy. 
My doctor is NO help when I ask what he recommends.  I am scared to only implant one.  Yet I am scared to use all of them in this one last attempt we have.  Is only implanting one pointless? Can you give me a recommendation on what is best if this situation were to happen on the day of transfer? The transfer is only a couple weeks away so I am so nervous.
Thank-you so much.
S. from Illinois. Nervous mom!!!!!!!


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

Since you haven't given me your age, I can't give you specific recommendations but will have to answer your question in more general terms.  Also, another significant piece that would help answer the question is whether your embryos were frozen on day#3 (cleaved) or day#5 (blastocyst).

We always consider age when counseling patients on the number to transfer because this affects the quality of the embryos and therefore their chances of implantation.  Of course, the younger you are, the higher your chances of implantation and pregnancy per embryo.  Because the technology has gotten so much better over the years, pregnancy rates have gone up and we have realized a problem; namely, an increase in multiples, especially those over twins.  As a consequence, every IVF Physician is wary of putting to many back for fear of getting too many in return.  As a result, the American Society for Reproductive medicine and the Society for Assisted reproduction, its subgroup, have produced recommendations or guidelines for transfer.  these of course are dependent on the age and the stage of development.  Their recommendations are as follows:

 Cleaved embryos:   
                             35    35-37    38-40  40 years old
   Favorable         1-2       2         3        5+
   Unfavorable        2        3         4        5+


   Favorable          1        2         2        3
   Unfavorable      2        2         3        3

I have my patient sign a counseling for that they have been informed regarding these guidelines and either choose to follow them or choose a different number.  I do let my patients decide within reason.  Because you have gotten pregnant with these embryos before, that would be an additional piece of information making me more cautious.

So here's the decision.  Unless you are over 35, I would recommend no more than 2 if they are blastocysts.  If these are cleaved embryos, then I would recommend 2-3.  But, the risk is of getting multiple implantations leading to at least twins.  With blastocysts and transferring 2, my twin rate is 56%.  With cleaved and transferring 3, my twin rate is 35%.  Are you willing to take the risk of having twins?  The pregnancy is harder and there is an increased risk of fetal loss.  If you are not willing to take the risk of twins then you would only transfer 1 no matter what stage.  If you are not willing to take the risk of triplets, then you would not transfer more than 2.  I do not recommend triplets.  The fetal loss rate can be as high as 50%.  The down side of transferring less than 2 is a decrease in pregnancy rates per cycle, but not necessarily over all.  It make take more attempts to get pregnant doing single embryo transfer.

I hope this gives you the information you needed to help with the decision.

Good Luck,

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

Monterey, California, U.S.A.


Thursday, August 21, 2014

Recurrent Miscarriages: Is It A Hormonal Issue?


Dear Dr. Ramirez,

I am writing from Pennsylvania. In 2006, I had two or three miscarriages.  After that, I went to a fertility clinic and had TSH, prolactin, DRVV, and anti-cardiolipin antibodies tested.  All were normal.  I also had progesterone level checked at the very beginning of one of the pregnancies as well as a non-pregnant menstrual cycle after ovulation.  Both were normal.  I had irregular cycles that were anywhere from six to ten weeks apart.  I knew when I ovulated because I got pain in whichever ovary released the egg and always had a luteal phase of 14 days. I also conceived easily.  
The doctor felt the lining of my uterus was getting too old to sustain a pregnancy since so much time elapsed between cycles. In February 2007, I conceived on one round of Clomid and carried that child full-term.  I then had two more children in 2009 and 2011 with no help despite still having the same irregular cycles.  My cycles are a little better now and usually five to six weeks apart, but I have had three miscarriages again in September 2012, December 2013 and June 2014.  All the miscarriages I ever had were missed abortions with embryo development ending between week 5 and 6 with the exception of the most recent which ended at 11 weeks 5 days despite fetus having a strong heartbeat and normal looking development.  Since a drop in progesterone causes shedding of the lining of the uterus, is it safe to assume that since my miscarriages were not spontaneous that progesterone was not an issue?  Could other hormones be issues or was chromosomal defect the likely issue all these times? 

Thank you for your time. Sincerely, M. from Pennsylvania


Hello M. from the U.S. (Pennsylvania),

There are basically five known causes of recurrent miscarriages from the following abnormalities: genetic, anatomic, immunologic, hormonal and infectious.  When a woman has had two or three miscarriages, she automatically has earned the diagnosis of "recurrent pregnancy loss" and as such, needs to undergo a thorough evaluation of these elements.  The most common cause of miscarriages is genetic abnormalities and is responsible for 85% of miscarriages in women over 35 years old.  A recent study showed this cause to be less in younger women.  Genetic abnormalities can be caused from an inherited disorder or a spontaneous disorder, whereby the egg makes a genetic error when it is dividing leading to an abnormal embryo.  Most of these pregnancies will end before 12 weeks gestational age.

The recommended testing is as follows:

Genetic: wife and husband chromosomal analysis, saliva DNA analysis

Anatomic: diagnostic hysteroscopy, pelvic ultrasound, end cycle endometrial biopsy for dating and b-Integrin

Immunologic: Complete antiphospholipid antibodies, natural killer cells, Factor V Leiden, MTHFR, Antinuclear antibodies, Lupus anticoagulant, anti-Thyroid antibodies

Hormonal: FSH, LH, TSH, Prolactin, Estradiol, Mid-luteal Progesterone

Infectious: GC, Chlamydia, Ureaplasma/Mycoplasma, Toxoplasmosis

Age is probably the most common major cause which leads to an increase in genetic abnormalities.  Since you don't mention your age, that could be part of the problem if you are over 35 years old.  The good news is that most women with recurrent miscarriage will eventually have a successful pregnancy.

Good Luck,

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


Monday, June 2, 2014


Dear Readers,

It has been a while since I last posted to this blog, and to my readers I apologize.  Things have been quite busy, hectic and stressful this year.  As you know, we are still in a recession here in the U.S. (not officially of course) which has placed a great deal of stress on my practice.  Although I have continued to answer questions that come in daily in the comment sections, posting in this blog is one of my duties that I have neglected.  I'll strive to do better from here on out!

This post is a little different and a little off subject, but something important that I want to request from my readers. Yes, instead of you asking something from me, I'm asking something from you this time.  As you know, the internet has become the biggest driving force for information and patients also use this to choose their doctors or clinics.  This is a good thing, as anyone who has ever looked for a doctor, plumber, contractor, etc. realizes, but at the same time, the current sites that rate are flawed and often unreliable which make it a bad thing.  It also can be used as a weapon against competitors.  This latter point is something that I've only recently come to realize.  I usually don't pay any attention to the rating sites, such as "Yelp" but just by chance, while looking for something else, I came upon it and saw some ratings of me "Edward J. Ramirez MD".  My overall rating was a 2 (out of 5) based on four reviews, three of which were terrible!  Interestingly, all three were within 1 week of each other so I decided to see if I could recognize who these "former patients" were and figure out why they hated me.  The site had the first name and the initial of the last names listed so I thought I would look them up using that criteria.  I have electronic medical records so it is not a difficult thing to do.  I also had the time period (April 2014) to help with the search.  Interestingly, I could not find any patients with the first names and last name initials to match these three patients.  I also found the exact same texts in reviews on two other review sites!  What I concluded is that these three "patients" were not actual patients but could only have been staff from a competing clinic that is trying to drive patients away from me by using these review sites.  Why do I suspect a competitor?  Because each of the reviews mention going to a "bigger Bay area clinic or another doctor".   Of course they wouldn't state the clinic or doctor by name because that would them reveal who was placing these malicious reviews.

Many of you, my readers/followers, have never met me and don't know me personally.  However, from my writing, I hope that you can see my devotion to patients and to treating them properly and respectfully.  My consultations are 1+ hours long, and I don't limit the number of questions, how much time spent with the patients or tell the patient what to do.  I also give my patients my email address in order to have almost immediate access to me for additional questions. I always try to make sure that the patient(s) understand everything that I have explained fully and clearly, even drawing diagrams and giving handouts regarding the topics.  At the end of the consult, I give each patient a "consultation diagnosis and treatment" summary with a written explanation of their options.  As you have read here in this blog, I believe that patients should be given options and should understand the pros/cons, risks/benefits, approximate costs and approximate pregnancy rates for each option; and I believe that this is a personal problem that they need to decide for themselves.  Each patient has different priorities and needs and therefore, the decision will be different for each.  As such I DO NOT TELL PATIENTS WHAT TO DO!  I give them options.  My role, as I explain to each new patient, is to be their consultant, adviser, advocate and therapist to help them reach their goal.  I am here to help them to the best of my abilities via the path that they choose, even if it is against my recommended path. Some patients can't afford IVF so prefer to try IUI or prefer it because it is more natural, whereas other patients want to be pregnant immediately so want to  bypass the easy treatments like ovulation induction or IUI and go straight to IVF.  I believe that is THEIR choice, not mine.  I'm there to help them in whichever path they choose.

So as you can see, when reviews show up that state that "I don't spend time answering questions" or "push them into IVF" or "don't explain things to them", you can bet that it is NOT a real patient writing that review, because that is exactly the opposite of what I really do.

After these many years of writing these blogs, answering questions through All Experts and responding to questions in the comments on this blog, I am asking for assistance from you, my readers and followers.  The best way to overcome these false reviews is to put REAL reviews on these sites.  If you have found me to be helpful to you, despite the fact that you have never seen or met me, but you feel that I've spent time on your questions, given you proper and reliable answers, given you hope, or helped you understand what you are going through, I would greatly appreciate it if you would call up one of these rating sites like YELP and put in a good word for me.  Give me a rating that you feel I deserve and comments that you feel reflect what you feel about me.  In this way, not only will you be helping me, but more importantly, you will be giving potential patients searching for a doctor a VALID review upon which to base their opinion and choices.  I hope that you will go to a review site (type in Edward J. Ramirez MD or Fertility and Gynecology Center or Monterey Bay IVF or all three) and file a review of your experience in return for the information, response or advice that I have given you.

I would greatly appreciate your help in this matter.

Edward J. Ramirez, M.D.
Monterey Bay IVF
Monterey, California

Thursday, January 23, 2014

Could I Be Infertile Or Am I Still Recovering From Surgery For Endo?


Hello. I'm a 29 year old female. My husband and I have been trying to conceive for 7 months now. I had a laparoscopy done in June of 2013, due to an ovarian cyst on my right ovary. As the Dr. was doing the procedure, she said that the cyst had already ruptured ( which I didn't even know, or feel) and she found a little bit of endometriosis, which she got rid of as well. My tubes were wide open with no other complications.
 I'm about 2 1/2 months post op, and we still haven't gotten pregnant. I just saw my Obgyn a few days ago for a progesterone test, and it showed I was ovulatory. I was an 8.4. So the next step is to go get another ultrasound to make sure everything is ok inside, followed by some blood work a few days later. He said we'd check for PCOS. I have no symptoms of that. My periods have been pretty regular all my life. My question is why haven't I gotten pregnant? I thought the laparoscopy was suppose to open things up to help a future pregnancy. Could my body still be recovering from the surgery, and that's why I haven't become pregnant?  Or could there possibly be an underlying problem I have. The Dr. didn't really make me feel that comfortable. I asked a lot of questions, yet I still feel I'm unsure about things. I don't know what to think. He said we might start Clomid, but part of me wants to think I'm still recovering. I really hope I don't have any serious problems. I really just want to be blessed with a child, yet it's been so difficult to achieve.

Any advice/help would be greatly appreciated!  P. from Illinois.


Hello P. from the U.S.(Illinois),

Infertility is defined as the inability to become pregnant after 12 months of trying so technically you are NOT infertile.

In terms of your surgery, you are way past that and it is not the reason you are not getting pregnant unless scar tissue was formed from the surgery inside the pelvis.

My first recommendation is to find a new doctor.  Preferably, find one that is a specialist in infertility rather than a general Ob/Gyn.  The reason is that you are on the verge of wasting a lot of time and money.  Your doctor is jumping to things without good reason.  For example, saying that you have PCOS when you have regular periods.  PCOS is defined as an ovulation dysfunction and you have to have irregular or absent periods as the prime criteria for the diagnosis.  Also, going straight to Clomid without a full infertility evaluation is a waste of time and money.  It's like prescribing a treatment before you know what you are treating.

My recommendation would be to start with a basic infertility evaluation:

  • Cycle day#2 or 3 hormone panel (FSH, LH, Estradiol, TSH, Prolactin)
  • HSG

  • Hysteroscopy or Hysterosonogram

  • Pelvic ultrasound #done#

  • Semen analysis

  • Cycle day #21 or 22 progesterone #should be 10 or greater#

  • End of cycle endometrial biopsy

  • Cervical cultures for GC, Chlamydia and Ureaplasma

  • Laparoscopy (which you have done)

Once all these are done, then you can discuss and consider treatment options. Since endometriosis was treated, you need to try to get pregnant within one year of the surgery or the endometriosis will return and possibly prevent pregnancy.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.


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