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.

 

Woman Has Two Failed IUI's With Donor Sperm: Needs An HSG

Hello,

I am a 35-year-old woman writing from Missouri. My husband and I have been trying to conceive for 15 months. After we'd been trying for a year, we went for testing, and my husband was found to have no sperm. We decided to move forward with donor sperm. I had some blood work done (thyroid, progesterone checked) which was normal/ovulatory. I also had a sonohysterogram and endometrial biopsy to investigate my heavy periods; neither of these tests revealed any problems.

So far, I've had two IUIs (intra uterine inseminations) with donor sperm. Neither has been successful (though I had a 21-day progesterone test after both that confirmed ovulation). My doctor is having me use Clearblue Easy OPKs to determine the timing of the insemination. The clinic does one insemination per cycle. Is this the typical procedure? I'm concerned about getting the timing right.

I haven't had a HSG (hysterosalpingogram) test yet. I asked about scheduling one just after my last failed IUI and the secretary indicated that I wouldn't be able to do an IUI and HSG in the same cycle. I'm not sure why. So I don't know whether to do another IUI this cycle, or have the HSG. Any recommendations? What are the risk factors for blocked tubes? I've never had an STI or HPV, if that is relevant.

I know that even though we've been trying a long time, due to my husband's infertility, we've only really had two chances to get pregnant. Psychologically, though, it feels like this has been going on forever. The fact that I'm 35 just increases my anxiety (especially since we'd love to have two children eventually). How many IUI cycles would you recommend before moving to IVF?

Thank you so much. I have appreciated your blog and your thoughtful answers to others' questions for a long time.

K. from Missouri, USA

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

Using only one IUI per cycle is acceptable and used by many infertility specialists and Ob/Gyn's. It is really the doctor's preference. If you've been reading my Blog (womenshealthandfertility.blogspot.com) you will see that my preference is two IUI's per cycle (24 hrs and 48hrs). There are two schools of thought regarding this matter and studies do not endorse or disprove either method, so either method is fine. I like to have fresh sperm as close to ovulation as possible and so that is the reason for two since it cannot be known exactly when ovulation occurs. However, using donor sperm, that would be more expensive.

I would not attempt another IUI without having done an HSG. In fact, I would not have recommended an IUI without first having done this test. This is because if your tubes are blocked, for whatever reason, the IUI's will fail. Sometimes women can have mucous blocking their tubes and the HSG can unblock them.

In general, the recommendation is to do no more than four IUI's because most patient will be pregnant by 4 attempts. After four attempts, the pregnancy chances drop drastically, probably because there is something else going on. You have an age issue so you don't want to waste a lot of time. Has your husband had a testicular biopsy to determine if he is making sperm but it is just not getting out? If you decide to pursue IVF, that is something you might want to have done by a Urologist to check and see if you can have a child with his genetics. The sperm, if he is making it, can be aspirated (TESA) and used in IVF to inject into the eggs and fertilize them.

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: Dr. Ramirez, Thank you for taking the time to answer my question. My husband and I both appreciate your helpful, thorough response very much. We feel much more prepared for our next visit with the RE. We now know the questions we want to ask and the direction we'd like to go. Again, thank you. K. in MO P.S. Your blog is very helpful too!

34 Year Old With One Tube, Endometriosis, Abnormal ANA: What TTC Strategy Do You Recommend?

Question:

Hi Dr. Ramirez,

I am writing to you as I am now desperate with our situation and hoping to get some push from someone who is knowledgeable in this field. I am 34 and my husband is 40. No kids from both sides. We've been TTC for 2.5 years now. When we started, our bloodwork both came back normal as per my family doctor although he mentioned that my ANA (anti nuclear antibodies) is out of the normal but he said he's not sure if it has something to do with fertility or not and he'll leave it up to our RE to decide. My ANA is positive 2+ speckled pattern.

I've always been regular with a 26-29 day cycle. We first visited our RE in April 2011 and he said I should go for additional bloodwork which I did and came back normal. So he said I am generally healthy, no weight or smoking problems. My husband didn't smoke too. I also did BBT (basal body temperature) charting and my RE confirmed that I am ovulating regularly. I went for an HSG (hystergosalpingogram) in June 2011 and they said they can't get the fluid to get into my cervix or uterus so they considered me blocked.

I went for laparoscopy on July 2011 and my RE told me that I have stage 2 endometriosis but he was able to clear it out and my left tube is open while the right is still blocked. He said we only need 1 tube to get pregnant so he prescribed me with Clomid in August and did a scan at cd 12 and he saw 2 mature follicles in my left ovary. We didn't get pregnant that month so I went for another month of Clomid but I noticed that month, I didn't get the cervical mucus that I usually have during my fertile days. I told my RE so in October he switched me to femara and had another HSG done. He said he unblocked my right tube so I am perfectly healthy. We did another scan at CD 12 and my RE confirmed that I have 2 mature follicles, one from each side so he said I should get pregnant pretty soon. He gave me 2 more prescriptions of femara and told me not to come back to him until Feb 2012 or when I am pregnant. I am now in my final dose of my femara and really desperate :(. While taking femara I didn't notice my cervical mucus coming back to normal. I think it was the same case as with clomid. I am dry during my fertile periods so I started using preseed in November.

Now my questions are, what do you think are the other options that we can take besides IVF? I've never tested positive in a test since we started TTC. I've never taken birth control pills in my entire life. Do you think my positive 2+ ANA has something to do with our infertility? My RE seems to ignore it and I am not too sure if I still have to remind him about it. What do you think about the fertilaid supplements? I am just in a desperate mood now so I think I am taking any chances. Any advice on the next steps to take?

Sorry for the long post. I would really appreciate your reply on this. I hope you had a fantastic holidays!

Here's my husband's numbers:Volume 3.5 mlpH 7.6Motility 50%Speed 4Count 48 million/mlMorphology 80% normal. I don't have some of my bloodwork numbers so I cannot post but my RE said it looks ok. Thanks in advance for your reply. F. from Canada

Answer:

Hello F. from Canada,

First let me say that you should not feel "desperate" at this time. You have plenty of time to work with because you are young, and options open to you. You are just beginning your journey so you just have to accept your situation and move forward through it, do what must be done and look forward to your eventual success.

It is worrisome to me that you only have one tube open. Why is there a tubal problem at all? Could this imply that although the tube is open that it is not functional i.e. that there is internal damage? If the tube is not functional then natural pregnancy cannot occur as the tube is an essential part of the process required to become pregnant by natural means.

The second problem you have is the endometriosis. Endometriosis, even if treated surgically, can still be present in microscopic form. It is surmised that this ectopic tissue, i.e. tissue that is not supposed to be present in the pelvis, causes a low level inflammatory reaction that that interfere with the egg in its travel from ovary to tube and therefore prevent pregnancy from occurring. One consideration would be to undergo a 3 month treatment with Lupron in order to get rid of any microscopic residual endometriosis followed by aggressive treatment to achieve pregnancy.

The alternative is IVF to bypass the pelvis altogether. Yes, Clomid and Femara (to a lesser extent) can block estrogen receptors and therefore lead to reductions in cervical mucous and endometrial thickness (that is how they work..they trick the brain into thinking it is not making enough estrogen so that it stimulates the ovary harder, which in turn makes more estrogen). These are side effects. These can be treated by giving vaginal estrogen tablets.

I don't think that the ANA is having any affect on your lack of pregnancy at this time. But, you could take an 81 mg tablet of aspirin daily to help overcome this. It's an easy treatment. (For my readers information, an ANA test detects antinuclear antibodies in your blood. Normally your immune system makes antibodies to help you fight infection. In contrast, antinuclear antibodies often attack your body's own tissues — specifically targeting each cell's nucleus. But some people have positive ANA tests and are perfectly healthy.)

I am not a proponent of fertiliaid. I think the product is just preying on people like you who are desperate and will try anything. I don't think that it helps.

In terms of other options, if the simple ovulation induction with Clomid, Femara or injectables is not successful, and I would not recommend continuing with this strategy if no pregnancy occurs within 6 months, then the next level of treatment is IUI. I would not recommend more than 4 attempts at IUI. If all the above don't work, then you should move to IVF.

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.

Previous Ectopic, Left Salpingectomy, Painful HSG: Can I Still Get Pregnant?

Question:

Dear Dr. Ramirez,

Approximately 8 years ago, after the birth of my first child, I had an IUD (copper T) inserted. About 6 months later, I lost the thread,and went back to the medical practice for it to be removed and replaced, but was told that losing the thread wasn't a threat. Anyway, 2 more months later, I had an ectopic pregnancy which ruptured my left fallopian tube and resulted in an emergency salpingectomy...... the entire tube was removed (about 7 cm).

Fast forward 8 years, I am ready to have another child, however an HSG (hysterosalpingogram) revealed proximal blockage to my right tube. I was in an immense amount of pain during this procedure.....that I cried. I am not convinced that the results of the HSG are accurate because of the pain (similar to labor pains)that I felt. Also because the ectopic was due to a foreign object, I don't feel that there should be anything wrong with my right tube. Anyway, my questions are as follows and I really appreciate your time:

1. Since the IUD was the cause of my ectopic pregnancy, would I be considered a high risk for another ectopic (assuming my right tube is not blocked#?

2. Based on the pain that I was in, could the proximal blockage be a result of a tubal spasm? What are the stats on false hsg readings for proximal blockage?

3. Is it possible that a left salpingectomy could result in scar tissue blocking the remaining right tube?

4. And finally, my uterus and ovaries (I still have both) are healthy per the scan. There is evidence of scarring from my previous c-section. How feasible is it for my right tube to pick up an egg from my left ovary as I usually feel ovulation cramping on my left?

Thank you very much in anticipation. E. (age 35),USA

Answer:

Hello E. from the U.S.,

You cannot be sure that the IUD was the cause of the ectopic. That would be a false assumption. Certainly having an IUD in place can increase the risk of an ectopic but intrauterine pregnancies also occur with IUD's in place. The IUD does not block the tube, it creates a hostile bed for implantation of the embryo. Ectopic pregnancies mostly occur because of fine adhesions within the tube which prevent the embryo from migrating into the uterus. As a result, the embryo implants there. The most common reason for these adhesions are from some form of inflammatory event in the past, often a sub-clinical (no symptoms) infection by a bacteria. Chlamydia is the most common form but some studies also point to multiple different bacteria. In any case, this infection gets into the tube, causes the tubal lining to become inflamed thereby resulting in scar tissue formation. It is possible that this inflammation is was led to the blockage of the right tube, whereas the left tube was only partially blocked, hence the ectopic.

In terms of the pain with the HSG, yes, it could mean that you had tubal spasm but the more likely source was that because the tube is blocked, the increased pressure or pushing by the doc caused increased stretching of the uterus and hence increased pain. I would have to look up the statistics for false readings on HSG, but it is low and so HSG is the gold standard for the diagnosis of tubal blockage. I am sure there is some false positive or false negative readings, however.

If the surgery was performed without incident, a salpingectomy on the left should not cause blockage of the right tube at its entrance. Any pelvic surgery could lead to scar tissue formation within the pelvis and lead to blockage at the end of the tube, however (your previous c-section).

If the right tube is normal at the fimbriated end, and there are no adhesions within the pelvis, then there is a good chance of egg pickup even if ovulation is from the opposite side. The reason is that the egg from one side of the ovary does not necessarily go directly to the tube on that side. The opening to the tube is not that close to the ovary. In fact, the egg falls into a pool of fluid within the culdesac, a space behind the uterus, where the tube lies and through fluid motion, gets to the tube. So pregnancy can and have occurred in patients with a functioning ovary on one side and a normal tube, without an ovary, on the opposite side.

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.

Comment: Dear Dr. Ramirez, Thank you very much for your response. You are very knowledgeable and I feel very enlightened. Again, many thanks, E.

Woman Underwent Medical Miscarriage 8 Months Ago & Had Continuous Spotting, No BFP Yet: Should She Be Concerned?

Question:

Hello, I am a 29 year old female from Pennsylvania. My husband (also 29) and I started trying to conceive last year. We got pregnant on our 2nd month trying, and were very excited. At my first ultrasound, there was only a yolk & gestational sack, which showed growth only until 5w5d. I should have been much further along. I opted for medical management, offered by my doctor, to force the miscarriage. I took a mix of Mifepristone & Misoprostol - 4 pills were inserted vaginally, 24 hours after I'd taken the first pill orally.

The miscarriage began right away, and took days to complete. After 7 days, I went to my doctor for a checkup where she deemed the miscarriage complete with no side effects. I had spotting for months, which my doctor said was normal, and my period resumed in 4 weeks. Since then, we have tried for 8 months to get pregnant, with no luck. We track my cycles through BBT & OPK's, and it ranges now. I used to be regular, now I ovulate anywhere from day 11 to day 18. But I do ovulate every month. My period ranges from day 24 to day 29, depending on when I ovulated. My luteal phase went from 14 days pre-miscarriage to about 11-12 days post miscarriage. Are these cycle changes potentially a bad sign, or can they be normal?

My doctor does not seem concerned at all. She's run blood work, and done an internal ultrasound (last month) and said everything looks fine. She said that a medical miscarriage cannot cause scar tissue or block tubes. Is this true? I find it hard to believe because it was so painful w/so much bleeding. So my major concern is that my miscarriage caused me to become infertile. Is this something you have heard of? Is there a chance of scar tissue if I never had surgery, had no infections, and have never had an infection or any problems before my miscarriage? My husband has had all the male tests run as well, and they have said his tests are perfect.

My doctor will not put me on a fertility drug or run an HSG, as she said it is simply stress causing me to not get pregnant again. Is there anything you think I am misinformed about, or anything you recommend I do different? I am concerned that I took a really scary medication that did damage to me. Thank you so much for your help! J. from Pennsylvania

Answer:

Hello J. from the U.S.,

In general, a medical induction of miscarriage should not lead to scar tissue formation within the uterine cavity (known as Asherman's syndrome). This syndrome is usually a result of over-scraping of the uterus at the time of a D&C. However, if not all the products from the pregnancy were discharged, as can happen from time to time, then the resultant inflammation caused from the retained tissue can prevent pregnancy. It would be the same mechanism as an IUD. By checking you, I presume that your doc did an ultrasound and the cavity looked completely empty. To be absolutely sure, a hysterosonogram or hysteroscopy can be done. If the cavity is normal, then your current fertility issue is not due to the miscarriage.

The fact that you got pregnant easily before shows that your body does have the ability to get pregnant. We don't consider a woman to have an infertility problem until she has been trying for at least one year without success. At that point, an infertility evaluation should be done. I never never tell my patients that they are not getting pregnant because of "stress." Sure stress can impact the chances of pregnancy, but it is not significant enough to be a birth control device, so not good enough to be the cause of pregnancy failure or infertility. It is a patronizing remark. More than likely, you just haven't been as lucky this go around as you were the first time. Because you got pregnant so easily, you are assuming that you will again. But in fact, the average woman under the age of 30 will take 8-12 months to get pregnant naturally. So you still have to give yourself a chance.

The BBT's and ovulation predictor kits is ONLY to help you predict when ovulation is about to occur. They DO NOT say when ovulation has occurred. There is no way to know that. They also cannot be used to diagnose a short luteal phase, known as luteal phase defect. This has to be done by endometrial biopsy dating. The fact that there is a little variation in your cycles does not indicate irregularity. Cycles can vary +/- 7 days normally.

I understand and sympathize with your concern, but also advise you to keep it in perspective. Give yourself a chance for your body to do what it needs to do without undue pressure on yourself or your husband. Then if it does not happen in a few months (which would make it over a year of trying for you both), then insist on an infertility evaluation. At this point, evaluation and/or treatment might be premature.

Good Luck,

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.

32 Year Old Has Multiple Miscarriages With Secondary Infertility On Clomid With No Success: Should She See An RE?

Question:

I am 32 and writing from Texas. We are trying to have our 4th child. In Jan. 2010 I had a miscarriage at 7 weeks and subsequent D&C. It took 2 months for my cycles to even begin. Then I was put on Clomid 50mg days 5-9 for 4 cycles. I was monitored with progesterone blood checks, 14th day ultrasounds, hcg shots, and checking for over-stimulation. I ovulated every time (with a progesterone level of 27) and the doctor said my follicles and lining looked good. However, I am not pregnant and it has been 6 months since the miscarriage! My first child was conceived with clomid the 1st time.

Why is the clomid not working for me? Has it changed the cervical mucus and lining? Do other women struggle to become pregnant after a miscarriage too? The last two times that I conceived (3rd child and miscarriage) I became pregnant naturally the 1st effort made. Does miscarriage change your fertility? Should I not have clomid??

My doctor wants to take a break and then come back later and 'blow out' my tubes. Is this necessary? Do I need a different regime of medicine? I feel as though I am out of luck since the clomid did not help in conception. Should I see an RE (reproductive endocrinologist) soon?

Thank you for helping! I feel overwhelmed and just want to bring this baby into our lives. L. from Texas

Answer:

Hello L. from Texas,

I think the easiest way to answer your questions is to take them individually one at a time:

1. Since you are stimulating with the Clomid (and I presume you are ovulating more than one egg per cycle because that is the purpose of Clomid), you are responding to the Clomid. I don't know why your doc even put you on the Clomid since you were able to get pregnant on your own before. Any idea? All Clomid will do is increase the number of eggs you ovulate. It does nothing else. The body still has to go through the 9 step natural process for a pregnancy to occur. It is NOT a magic drug.

2. Clomid at high doses can change the endometrial lining causing it to thin because it is an estrogen receptor blocker and similarly change the cervical mucous. Often a Clomid cycle will have to be supplemented with estrogen if this is the case, or changed to a different medication such as Femara. The lining can easily be seen and measured by ultrasound.

3 Miscarriage is very common. It has been reported that the miscarriage rate is as high as 40% of pregnancies. This includes women who have late periods that don't even realize that they are pregnant. Statistically, 85% of women that have miscarriages will go on to have a successful pregnancy so you shouldn't worry. Your previous miscarriage does not worsen you chances of getting pregnant unless you had a major complication from it such as hemorrhage or uterine rupture.

4. The procedure to "blow out" your tubes is actually called an HSG (hysterosalpingogram). It is the test that we use to see if the tubes are open. Sometimes women will form a mucous plug in the tubes thereby inhibiting sperm passage. The HSG can push out this mucous plug and open it. It is worthwhile to make sure that the tubes are open but I would not count on it for anything else. It does hurt by the way.

5. I think that if you want the expertise of a specialist in infertility, and feel you are not getting it with your current doc, then an RE (reproductive endocrinologist) would certainly be more specialized and have more knowledge. You might want to consider that. It would be the same as going to see a Cardiologist for your heart instead of being treated by your Family practice doc. The basic knowledge of a specialist and the treatments they can offer are greater.

Good Luck,

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.

39 Yr. Old U.K. Patient With FSH Of 10 Has Failed IVF With Own & Donor Eggs: Can She Still Succeed? Possibly!

Question:

I am 39 years old, and have a son of 5 years old whom I conceived naturally. I was born with one ovary and one fallopian tube (left ovary and fallopian tube missing).

I had a failed long protocol IVF and aborted the trial as we only had one follicle of a good size. We opted for IUI, and was unfortunate to get an infection of the womb, which turned into salpingitus. As a result my fallopian tube is now blocked.

With a decreasing AMH of about 3.5 and FSH of 10, I was advised that my chances of having a successful IVF with ICSI was very small. The clinics opinion was that we looked at egg donation. I have had two attempts this year of egg donation which have failed.

A friend of mine with an AMH of 1% and 15 FSH levels has just fallen pregnant after IVF. Although so early days yet, this has made me want to reconsider undergoing IVF/ICSI with a short protocol.

Can you give me your opinion? Many thanks in advance. S. from the U.K.

Answer:

Hello S. from the U.K.

The biggest factor you have working against you in terms of IVF is your age. The biggest plus is that you have had a child in the past, which means you have secondary infertility. With secondary infertility age may play a factor. Part of what makes IVF more successful in older patients is that with IVF we are able to recruit a lot more eggs at one time. It is an increased statistical chance of finding a good egg in the group. If your ovaries don't stimulate well and the number of eggs are decreased, then the chances decrease as well. However, they don't go to zero as evidenced by your friend. I usually will not give up on an IVF cycle, even if there is only one follicle because it could contain the perfect egg and IVF is still better than IUI because more of the steps required to become pregnant are accomplished.

That being said, however, using donor eggs certainly gives you a statistically better chance of success. Remember, we are dealing with statistics here, which is just a reflection of things and not an absolute prediction. That doesn't mean that you can't get pregnant with your own eggs, it just may take many more attempts with IVF than if you used younger eggs. Last year, there was an article in a New York newspaper about a woman who delivered at child at 49 that was conceived by IVF using her own eggs. She is, of course, the oldest to be successfully pregnant with IVF using her own eggs. However, it took her two years of trying to achieve this. It would be the same for you, as long as you ovaries are still responding to stimulation. There is a chance that there is still a good egg present in your ovaries. Finding it is the difficult part.

So, certainly there is the option for you to try with your own eggs, and potentially become pregnant. The donor cycle should have worked and statistically is the better way to go, but since it didn't, I can't necessarily tout it as the best option for you. You have to be willing to attempt several tries with your own eggs, however, so as long as that is what you want and are dedicated to it, then that is the way you should go. Ultimately, it is your decision to make.

Follow-Up Question:

Hi there. Thank you so much for your quick response and informative opinion. It is very much appreciated.I have one final question regarding the egg donor transfers that I had. Both of them seemed to work and then overnight disappeared. Do you think that I need to check as to whether I have Hydrosalpinx, as I believe this could have an impact by fluid spilling out into the uterus cavity and could potentially kill off or dislodge the planted embryo?? The notes I have from my last ultrasound (which I had to check the thickness of the lining of the womb prior to embryo transfer) states there is no evidence of dilation of the fallopian tube?Can I also say how unique this site is to get an experts opinion on fertility, and appreciate you taking time to respond. Best S.

Follow-Up Answer:

Hello Again,

Evaluating the tubes for hydrosalpinx should have been part of the basic pre-IVF evaluation, because it can reduce the pregnancy rate by 50% if left intact. This is done by a comprehensive ultrasound examination, not the ones looking for follicles, or by HSG (hysterosalpingogram). It usually affects implantation, because it causes a low level endometritis (inflammation of the uterine lining.) If this has not yet been done, then I would recommend that you request it. I would also recommend that you seek a different clinic because it is something that they missed and should not have.

Good Luck,

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.

Infertility Workup for Young Woman with Chlamydia and Previous Drug Addiction

Question:

I am 20 years old, married, and have been trying to get pregnant. About 2 1/2 years ago I became very dependant on prescription narcotics because of herniated discs in my back. I was able to get off of the pain medicine and was put on suboxone. I am taking 8mg daily of it. As for trying to conceive, I've never been on birth control pills and we have been "careful" up until 6 months ago. We have been trying to get pregnant for the last 6 months. I am starting to worry that I have some infertility issues. My periods have always been normal, but for the last 3 months they have been lasting about 10 days (when they were 5-7 before) and the first 3 or 4 days I am just barely spotting, but it is brown and really thick. Nothing I have ever experienced before. I have an appointment scheduled this month with a gynecologist, but I am embarrassed to talk to her about these issues.

I also contracted chlamydia about 3 years ago. I am scared that I may have had it for a long period of time. I was treated for it and am okay, but I have read that sometimes if you have it for a long time it can cause scar tissue and make it hard for you to get pregnant. Finally, my last question is, do you think because of the pain medication I could have become infertile? I know I will eventually have to talk to the doctor about these issues. Do you know what kind of tests they could do right off the bat knowing my history?

I think it is wonderful that you offer your time to answer these long questions :) Thank you so much!

Answer:

Thank you for your question. You have several questions and issues within your note. I hope to answer each one, but if I miss any, please let me know.

You are 26 years old and that puts you in the highest fertility years of your life. Statistically, 85% of women in your age group will become pregnant by one year of trying. Anyone exceeding that time frame is considered infertile. Since you have not gotten pregnant in 3 years, it seems that there is some type of problem going on. Part of it could be your addition, but as you know, addicts get pregnant all the time. There are probably some other issues going on. Since you are off the oxycodone, I think the Chlamydia needs to be looked at. The bottom line is that you need to have a complete infertility evaluation. This can be done with a general OB/GYN or a fertility specialist. In order to not waste time, I recommend that you see a fertility specialist (someone that does ALL levels of infertility care and treatments).

Chlamydia is a silent bacteria that can damage the tubes causing blockage. If that happens, you are at risk for a tubal pregnancy (ectopic), or will not get pregnant by natural means. You would need to proceed to IVF (in vitro fertilization) if the tubes are blocked.

The basic infertility workup that I do is as follows:

1. Cycle day #2 or 3 hormone panel to check ovarian, thyroid and pituitary function.

2. Hysterosalpingogram (HSG) to check the tubes.

3. Diagnostic hysteroscopy to check the uterus, ovaries and tubes.

4. Pelvic ultrasound to check the uterus, ovaries and tubes.

5. Endometrial biopsy to check the uterine lining.

6. Semen analysis to check the male.

7. Mid luteal progesterone level to check for ovulation.

8. Laparoscopy (if needed) to check for pelvic abnormalities such as endometriosis and scar tissue.

I know that you were being careful, but the failure rate of being careful is pretty high. Since you were not on birth control pills it is a bit troubling that you have not been able to get pregnant. I think you need to undergo an evaluation. I also think you need to be totally honest and up front with your doctor. He/She needs to be able to see all the circumstances and take them into consideration. At this point, if your doctor tells you to keep trying, I would recommend you see another doctor for a second opinion. Chlamydia blocks tubes by causing scar tissue formation within. It is not surgically repairable. The only way to diagnose this is to do a hysterosalpingogram (HSG).

I hope this helps and good luck!

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

www.montereybayivf.com

Concerned About Tubal Blockage

Question:
hello i am 23 and married, i have had a very hard life, i was raped when i was young and acted out as a teen, i recently had a HSG done and found out my tubes were block well the doctor said my right tube is definitely blocked and that he was not sure about the left. i would want nothing else but to have a baby it will mean the world to me. i am graduating from college and this will be my final goal. i know i can't afford IVF, and i don't want to adopt, so please tell me how you can help.

Answer:
Hello Concerned from the U.S.,

You basically have two options:

1. You can assume that your left tube is open, normal, undamaged and functioning normally.
2. You can assume that whatever caused the right tube to be blocked, also damaged the left tube, albeit only partially, and the tube does not function.

If you assume # 1, then you can try to get pregnant naturally. You would have the same chances of pregnancy with one tube so you should be able to get pregnant within 12 months (85% per year in your age group). If you don't get pregnant after 12 months of trying, then you will have to change your assumption to #2.

If you assume # 2, then the only option you have is to do IVF because tubes cannot be repaired or transplanted at this time, and are absolutely essential to get pregnant naturally. IVF works by bypassing the tube and performing all the functions that would occur in the tube, in the lab. In your age group in our center, you would have a 63% chance of pregnancy, and most reputable clinics are about the same rates.

I know that this is not necessarily what you wanted to hear, but it is the reality of the situation. In my position, I usually have to assume #2. Since you are so young, you have time to work with since your pregnancy rates will not be affected until you are 35. In the meantime, if you have to do IVF, you could begin saving up for the procedure (approximately $20K will be needed for one try), get a good job with good health car benefits that cover infertility/IVF, marry someone wealthy enough to afford IVF, or move to a mandated state such as Massachusetts where IVF is required in their health care coverage. These are alternatives that you could consider.

I hope this helps,

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

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf

INFERTILITY EVALUATION ABC'S

I thought I would share my approach to the infertility evaluation. I have seen many patients referred to me, who have not undergone a complete infertility evaluation. Many physicians approach this haphazardly, checking some things but not others. Like other disease states, in order to find the diagnosis, all the different possiblities must be ruled out. In 30% of cases, there is more than one problem, and in 30% of cases it involves both the man and women. Therefore all these systems must be checked. There are basically 9 steps that are required to become pregnant. These steps are a sequence of events, such that, if there is a disturbance in any part of the sequence, then the entire process fails. These steps are 1. Brain sends signals (FSH hormone) to the ovary to begin the ovulation process, and the Ovary begins the maturation of the egg > 2. Ovulation occurs where the egg is expelled from the ovary into the culdesac > 3. The egg has to find the fimbria of the tube. > 4. The egg enters the tube where the sperm needs to be waiting, such that, the sperm needs to have proceeded from the vagina into the cervix, into the uterus then into the tube. > 5. The sperm has to fertilize the egg. > 6. The egg begins developing and dividing and passes through the tube (7-days). > 7. The formed embryo now enters into the uterus. > 8. The embryo has to hatch. > 9. the embryo has to implant into the lining of the uterus. The infertility evaluation that is recommended, checks each one of these steps and I've listed them with the respective step in the sequence:


1. Hormone levels on cycle day # 2 or 3. This is to test to see if the hormone levels, that the brain is producing, are normal at the start of the cycle. This can also give an indication of how the ovary is functioning and able to be stimulated. If the FSH level is elevated, it could indicate that the ovary is already beginning to slow down and/or approaching menopause. If the FSH is elevated, some physicians will proceed with a Clomid challenge test to see if the ovary is past the point where it can be stimulated by fertility medications. The only way to see if the ovary is maturing an egg is to do an ultrasound, in sequence, and see if a growing ovarian follicle is present. This is not usually done as part of the basic infertility evaluation.

2. Mid-luteal progesterone test on cycle day # 20-22. The progesterone level is increased when ovulation occurs, so this in an indirect test of ovulation.

3. Laparoscopy. Any abnormalities in the culdesac, the part of the female pelvis where the egg passes through and where the fimbriated end of the fallopian tubes sit, such as endometriosis or adhesions or tubal abnormalities, can affect the eggs ability to be picked up by the tube. The only test for this is laparoscopy, where a scope is inserted through the belly button to look inside.

4. Hysterosalpingogram. Sperm and egg get together in the fallopian tube. A hysterosalpingogram (HSG) is done to test if the tube is open. This is an x-ray test where a dye is injected into the uterus and passes through the tubes. X-rays are taken in various intervals to confirm that the dye passes into the pelvis.

5. Semen Analysis. We do not have a test to see if fertilization can occur. Therefore, we test the sperm as an indirect method to assess its potential. This is done with a semen analysis. In this analysis we test for the number of sperm, the number of sperm that are swimming (motility)-which is also a measure of the number of live sperm, and the number of normally formed sperm (morphology). This is not just a test of numbers. It is an indirect indication of sperm function. If there is an abnormality then this may indicate that the sperm may not be able to fertilize an egg. The only way to assess if your husband's sperm can fertilize your egg is to remove your eggs and put them together with his sperm, then see what happens. That cannot be done without in vitro fertilization.

6. There is no test for this step, but the HSG indirectly gives evidence that the tube is open and the egg has the potential to pass through.

7. Hysteroscopy. The uterine cavity is tested by a procedure called a hysteroscopy. In this test, a scope is passed through the cervix and the uterine cavity is visualized directly to make sure it is normal. I do this test in my office but most gynecologists do this test in a surgery center.

8. There is no test for this step.

9. An endometrial biopsy is done at the end of the cycle, just before onset of menses, usually cycle day # 26-28. The biopsy tells us if the uterine lining is developed adequately for implantation.

10. Pelvic ultrasound. I do one additional test, which is a pelvic ultrasound. This allows me to assess the uterus, especially the muscle layer and anatomy, the ovaries to rule out cysts and tumors, and if there are any adnexal abnormalities (the areas around the ovaries). Sometimes a dilated tube can be seen.