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.


  1. Hi Dr Ramirez,

    I am 19 y/o, and have been trying to conceive for 3 years now. I fell pregnant on my first month of trying, but it turned out to be ectopic and I lost my right tube.

    About 6 months later, I fell pregnant again, but miscarried the day after I found out I was expecting.

    I'm now due to have a HyCosy tomorrow, and am extremely scared. Smears and internal ultrasounds cause me great discomfort and I'm really worried I'm not going to be able to get through the test! My specialist is quite sure my remaining tube is blocked because my periods are extremely irregular (sometimes taking up to 3 months to arrive) and since the miscarriage I have been completely unable to fall pregnant.

    If I find out my tube is blocked, what would be the best route to go down? My specialist told me that if the HyCosy suggests my tube is blocked, she would perform a laparaoscopy to investigate further, and try to unblock it if possible. Is it worth trying the laparaoscopy to try to unblock it, or should I just skip it and go straight to IVF?

    I'm in the UK and although we have the NHS, certain things aren't covered by the health system, and I don't want to put myself through unnecessary pain and trauma if it's unlikely to help me, so I wondered if going straight for IVF instead of investigating further with the laparoscopy would be the better option?

    I'm so confused about the whole situation, everyone tells you different things and I don't know who I should trust!

    Thank you in advance.


    1. Hello Sophie,

      Usually the things that cause tubal blockage damage the internal part of the tube hence leading to the embryo getting stuck in the tube (ectopic pregnancy). The most common source is a sexually transmitted bacterial infection such as Chlamydia. If one tube was damaged, I would assume the other is damaged as well. If it is completely blocked, then obviously it is damaged, then the internal canal is the problem. This cannot be treated by laparocopy so I would not recommend the surgery (besides the fact that this surgery has risks). In the U.S., and I agree with this, IVF would be the recommended treatment. I know that many Gynecologists will suggest laparoscopy but that is because they cannot do IVF. If they did IVF, then would go straight to it. That is also the problem that I have seen in socialized health care systems such as yours and in Canada.

      So the bottom line is that IVF is the treatment of choice for you and the chances of success are high. I would insist that your Gynecologist refer you to an IVF clinic and NOT do the surgery.

    2. I forgot to mention, the HSG is a very painful procedure, especially if there is tubal blockage because it stretches the tube (like the pain you probably had with the ectopic). If you are very sensitive to this pain, I would recommend that you advise the doctor that will be doing this and ask that he/she premedicate you with something to reduce the pain/discomfort and anxiety. Given that you have had an ectopic in the past, as mentioned above, I don't think you need to prove whether or not the tube is blocked. Keep in mind that internal tubal damage is NOT diagnosed by HSG unless the tube is completely blocked (fluid can get through even the smallest partial blockage). I would assume that the tube is damaged.

    3. Also meant to mention that you have a very cute picture.

    4. Thank you so much for your answer. I was thinking this myself but I needed to hear it from someone who knows what they're talking about and has no ulterior motive.

      I'm thinking of cancelling my scan tomorrow and finding myself a private specialist who will help me go straight for IVF rather than going through so much pain and heartache first. I really appreciate your help. Thank you so much!

      And thank you for the compliment! :)

  2. Dr. Ramirez,

    Not sure if this is the right place to ask you this..but I am desperate! I just completed an ET on 3/18 and I started bleeding heavily with clotting the next day! I did have some spotting since the ER and my doc assumed it was leftover blood from that. Today, it's off and on. Does this mean my cycle is done? I know that you said some bleeding is ok but this is somewhat heavy red blood flow the day after. I wonder if the timing was all off. This was our last try and we had three good embryos which is awesome for us since we have DOR and tend to have poor quality eggs. Please tell me there could be some chance of hope.


    1. There is always hope and I can't tell you what is going on since I don't have the ability to examine you via the internet. We do see bleeding with the vaginal progesterone but it is usually not heavy like a menses but more like spotting. The fact that you had bleeding after the transfer is worrisome. Blood within the uterus will kill the embryos, but who know where this bleeding is comgin from? It is definitely not a residual from the retrieval unless you had bleeding from the puncture site and that re-opened, but that would be highly unusual this far out. Wish I had better news for you.

  3. Dr. Ramirez, I need your thoughts on this one. I have a friend who is 42 years old this year and she had ovarian cyst surgical operation done thrice already since it kept growing back. She has been wanting and trying hard to conceive. After the surgery her doctor said she'll have better chances of conceiving. She's afraid her cyst might grow back again, I mean, is that even possible after three operations? Do you think her age and medical history would permit her to conceive at her age?

    1. Ovarian cysts are a common occurrence in ovaries and most don't need to be treated. The only ones that need surgical removal are the ones that persist i.e. don't go away after a trial of suppression with birth control pills. These have to be removed because they are probably tumors and one needs to rule out a malignant tumor. Physiologic cysts, such as what I suspect your friend has been having, do not need to be surgically removed. They usually will either go away on their own or will go away with BCP's. Tumors don't recur once removed. Cysts can recur because it is not the same cyst but a new one!

      In terms of her chances of conception, her age is a definite negative factor. Her natural chances of pregnancy are less than 1% per year. Her best chances of pregnancy would be to either use IVF with her own eggs or consider donor eggs. This is not to say that she cannot get pregnant, and certainly the repetative surgeries are reducing her chances for pregnancy but causing scar tissue around the ovary, but the chances of pregnancy are very low.

  4. Hello Dr. Ramirez, I am Rina from Singapore. Thank you so much for your blog and how I wish you were here to be my ob/gyn and fertility doctor. Need your opinion. I had endometriosis and was removed in 2012. During the surgery, The doctor also performed D&C and discovered that both my tubes are blocked. So off to IVF no. 1 but BFN. Did another IVF last year & got pregnant. However, I suffered PPROM and due to infections, I had my sudden waterbroke when I was 5 months pregnant, stayed in the labour room for 3 days but unfortunately got my contractions on the 3rd day & delivered my baby but she could not be saved. Been told that my total white blood count was 14.9 on the day of my waterbroke but got up higher the day of the delivery to 21.1. When I asked the name of the bacteria that caused the infections, they only informed me about asymtomatic bacteriuria. I was devastated since I felt healthy and my baby was also healthy prior to the incident. I am now on my 3rd IVF attempt. Shall have my OPU next week. However, doctor found a cyst/fibroid in my uterus and need to be check after my OPU to ensure it will not interrupt with the implantation. As such, my embryos shall be freeze first and transfer only after my uterus check-up. My question is, is it possible that the cyst/fibroid is harmless and not get in the way for me to get pregnant? And if I got pregnant, what are the chances that I will get PPROM again? I am so traumatized and scared. Thank you Dr.

    1. Hello. sorry to hear about your loss. I'm not sure what to think about this "cyst/fibroid" that your doctor is talking about. I would need to see the ultrasound to see what he is referring to. Cysts and fibroids look completely different on ultrasound and they should be be able to confuse them. Also, the location of being in the tubes does not necessarily interfere with doing IVF since all that process is within the uterine cavity. However, if the "cyst" is a hydrosalpinx, then the tube needs to be separated from the uterus because it can reduce the chances of success with IVf by 50%.

      If you've had PPROM before, you certainly are at increased risk of it again, but there is no way to prevent that from happening. Your doctor might want to place you on prophylactice antibiotics, as it is thought that bacterial infection from the vagina could be a cause. The exact cause of this obstetrical problem is unknown.

  5. Hi Dr. Ramirez,
    I have been on the depo shot for roughly 14 yrs now. I stopped taking it to get pregnant with my youngest. So I was off it for about 2 yrs then when my son was born I went back on it. It's been 5 years now since I've been on it religiously, I never miss a dose or late getting it? What are the changes of me being pregnant right now? I've been having horrible cramps, my breasts are getting bigger, my pants are snug and just the other day I was in the shower and my right breast was lactating. Also my lower abdomen is tight feeling specially when I bend down. I took 2 pregnancy test and they were both negative. I have a doctors appointment August 6th but I am curious to know the chances or if it's possibly something else or more serious.
    Thank you!!

    1. It is highly unlikely that you are pregnant, but there are always exceptions to the rule. The only way to be sure is to do a blood pregnancy test. Something else might be giving you these symptoms. If I were you, I would ask the clinic to order the lab test in advance so that the doctor has that information when you go to your appointment. Otherwise, you won't get any answers because the doctor will need to order the test and get the results first. Do it before hand.



Related Posts with Thumbnails