Young Canadian With Hydrosalpinx And Endometriosis Complicating IVF Cycle

Question:
Hello Dr. Ramirez,

I am 27 years old and last year stage 4 endometriosis was discovered and I had 2 large cysts removed from both my ovaries, one was 12cm and and the other was 5cm. My left ovary is almost completely gone and both my tubes are not functional. My hormones as far as I know it are normal and my antral follicle count is 8.

My first IVF with ICSI (my husband has blood in his semen due to unknown reasons) was last November with an antagonist estrogen priming protocol. I had 10 eggs retrieved, 5 mature, 3 fertilized, and ended up with 1 good quality day 3 embryo to put back. The cycle ended with a chemical pregnancy. I was on 400 puregon and 75 repronex.

I did my second IVF cycle with ICSI this month on the exact same protocol. They saw 11 follicles before my retrieval and 6 was retrieved, but none fertilized at all. My RE said that egg quality was very poor and may not suggest another cycle for me.

My questions are:
1. Is my endo the cause of bad eggs?

2. Will changing the protocol help better egg quality?

3. They noticed 2 small cysts on a recent ultrasound, and also a hydrosalphinx on the left. Would it help to have another surgery?

4. Do I have any hope in becoming pregnant with my own eggs?
Thank you so much for your information!

Thanks... A. from Canada

Answer:

Hello A. from Canada (Ontario),

I don't think that endometriosis is causing the egg problem, but that is certainly debatable. There are some studies showing better results if the IVF cycle is preceded by 3 months of Lupron depot in stage 3 and 4 endometriosis. There is definitely an effect if there are endometriomas that are penetrated at the time of egg retrieval. These endometriosis debris has been found to be detrimental to egg quality. Because of that, I am very careful to avoid the endometrioma at the time of retrieval, or if it is penetrated, I replace the needle and tubing before continuing.

In terms of protocol, you certainly seem to be stimulating well, which is the goal of the protocol and there are many variations that can be used. Each doctor has their own preferences. There is not one protocol that is better than another. However, I would probably use a stronger protocol if you were my patient (you are currently using a 475 combination protocol# such as a 600 IU combination protocol #450 FSH + 150 FSH/LH (Menopur)). Changing the protocol will not improve egg quality, but having more eggs may help with getting more embryos to work with.

If you have a hydrosalpinx, you definitely need to have that surgically removed or excised from the uterus. Numerous studies have shown a reduction in pregnancy rates with IVF by 50% if a hydrosalpinx is present. In the U.S. it is now considered the standard of care. The cysts are not an issue.

I am always hopeful for my patients, in terms of your last question, even those that have a minimal chance because they are way too old. I see exceptions all the time and believe in miracles.You are only 27 years old. Your chances should be much much better and I am leery of the results you have had thus far. Frankly, it doesn't make sense to me, but I would have to review your medical records to see what might be going on. At your age, you should not have an egg quality issue and fertilization should be at least 60%. In my clinic, your age group has a 76% chance of pregnancy per attempt. That makes me worried about the quality of the clinic you are going to. You may want to seek a second opinion.

Good luck and don't hesitate to keep me updated,

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.

Hydrosalpinx & Fertility: The Difference Between Surgically Caused & Naturally Occurring Hydrosalpinx

Question:

Hi Doctor,

I was detected with a dermoid cyst in my right ovary in 2005. I underwent laparoscopy in 2006 and my right ovary was also removed. Post surgery I had normal cycles every month however some months my menstrual flow is less. Last week I had some hormonal tests which turned out to be normal. I also underwent an ultrasound which detected a right 22x13 mm hydrosalpinx. Left ovary and tube is normal. Will the right hydrosalpinx be a problem in me conceiving naturally? I am unmarried and it will be at least 5 years before I will have a baby. Please advise.

Thanks in advance for your support. M. from India

Answer: Hello M. from India,

First of all, the presence of a "hydrosalpinx" means that the right tube is blocked. Therefore, it will not be available to pick up the egg to achieve pregnancy. However, if the left tube is normal, that is all you need. You would still be able to become pregnant naturally.

However, there is a second issue. It is known that a "hydrosalpinx" that is visible on ultrasound examination can interfere with implantation in IVF. It is presumed that the hydrosalpinx has inflammatory fluid that back-flows into the uterine cavity leading to a low grade endometritis or inflammation of the endometrium. Pregnancy rates with IVF in this situation are seen to decrease by 50%. For this reason, it is recommended to remove or clip the tube so that it is separated from the uterus before undergoing IVF.

Having said this, however, this policy or recommendation is for hydrosalpinges that are visible on ultrasound AND are in "naturally occurring" hydrosalpinges due to a previous pelvic or tubal infection and NOT for dilated tubes that were caused by a tubal ligation. So the question is was your hydrosalpinx due to the surgery i.e. either the end of the tube was cut or scar tissue was formed from the surgery. In most cases of doing an oophorectomy (remove the ovary), the tube is usually taken with the ovary. If this is the case, the hydrosalpinx is iatrogenic, meaning surgically caused and not due to a previous tubal infection. In that case, it is logical that there would be no inflammatory fluid to leak into the endometrium and so the recommendation to remove it prior would not hold. This particular instance has not been tested by study, however.

So, in your situation, if the hydrosalpinx was not there prior to the surgery, and the tube was not cut/damaged or scarred from the surgery, then the hydrosalpinx subsequently occurred through a pelvic infection, then it could possibly affect your pregnancy rates. Then the left intact tube could have scar tissue as well not visible with ultrasound. However, if it was due to the surgery, then it would not.

I hope this clarifies things for you. As far as waiting five years to have a child, it would not make any difference, depending on your age of course.

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.

Young PCOD Patient With Tubal Blockage Unable To Conceive: Surgery or IVF?

Question:

I'm really searching for some advice. I was diagnosed with PCOS (not insulin resistant) this month (after four years of "maybe yes") as well as finding out I have a blocked fallopian tube.

I'm seeing an IVF specialist who recommended having hysteroscopy and laparoscopy surgery to clear the blockage and determine if there is scar tissue or endometriosis that can be fixed. I've suffered from very heavy irregular periods for the last 4 years.

I was told that if I chose not to go with the surgery the next step will probably be IVF. I thought IVF was a little extreme, completely skipping over Clomid and other fertility drugs. I know it's possible to get pregnant with one working tube, and I really don't want to do surgery unless it's absolutely necessary. I've been told by family I should get a second opinion, that sometimes surgeries are recommended when it's not really needed, because of money, etc. My Dr office did tell me I have excellent health insurance coverage. I don't think that's the case but it just seems like 2 extreme methods. I'm at one of the best fertility clinics in South Florida and feel like they should know better than me.

I'm 26 and not overweight (I lost 40 pounds 3.5 years ago), I've been off birth control for 5 years, and we've actively been Trying to conceive for over 8 months. My husband's sperm count is great. I used ovulation kits for 3 months but was never able to get a positive result. Is surgery the only way to tell if I have endometriosis?Would it be more beneficial to have the surgery then to start IVF without it?Is it usual to skip all other fertility medications in situations like mine and just use IVF? Is this a situation that you would recommend getting a second opinion?

Any advice you can shed is greatly appreciated.

Thank you, S. from Palm Beach County, FL

Answer:

Hello S. from Florida,

I guess I can be your second opinion. As you have described, you have two problems thus far: PCOD and tubal blockage. Certainly if PCOD were the only problem, ovulation induction with Clomid, Femara or injectables would be an option and could be combined with intercourse or IUI. However, keep in mind that most PCOD patients do not respond well to these medications and many (up to 85%) end up having to go to IVF because of this. However, if this were the only problem, then you would have more options.

Tubal blockage is another problem. The more problems you have, the worst the prognosis for achieving a natural pregnancy and the more you need to consider IVF. Tubal blockage by itself is enough to consider IVF, however. You don't describe where the tube is blocked but the only situation where surgery might help with tubal blockage is if it is blocked at the very end AND there has been no internal tubal damage, such as is caused by endometriosis. If the tube is blocked anywhere along the tube, it cannot be repaired and surgery would therefore not be indicated. The most common cause of tubal blockage is some form of inflammatory disease that ascended into the tube via the vagina and uterus. Because both tubes open to the uterus, this inflammation/infection problem got into both tubes but affected them unevenly such that only one tube is completely blocked. That does not mean that the other tube is normal, however. It could mean that the other tube was affected and damaged but did not scar enough to block completely. Usually when I see one side blocked, I make the assumption that the other tube is also not functional based on the fact that if it were, the patient would probably have achieved pregnancy on their own. Considering how long you have been trying, that makes me suspicious that the open tube is not functional. In that case, the ONLY treatment option is IVF because that is the only way to bypass the tubes. Remember that the internal part of the tube cannot be repaired and repair of the tube at the very end of the tube does not work well (1% pregnancy rate).

So, now, if you combine these two problems, then you can see that IVF is the treatment of choice for you. In that case, why have the surgery? Any other problems found, like endometriosis, will just be additional reason to do IVF. It does not affect your IVF chances. The only reason to have a laparoscopy if you are considering IVF is if the tube is swollen with fluid, called a hydrosalpinx, in which case that tube either needs to be removed or severed from the uterus to prevent the fluid within from leaking into the uterus. Studies have found that IVF pregnancy rates decrease by 50% when a hydrosalpinx is present. The only other reason is if you had any kind of ovarian mass or cyst. That would need to be removed prior to IVF as well. Remember, the treatment has to treat and overcome the problems.

Just choosing a treatment arbitrarily, like fertility medications, does not necessarily overcome all the problems present.

I hope that answers your questions.

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.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

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.

Hydrosalpinges and Miscarriages

Question:
I am 34 years old, writing from Australia. I have had one child (3 years old) and two miscarriages. The first miscarriage (embryo stopped growing 6.5 weeks) on Jan. 09, the second Nov. 09 (9.5 weeks). Just before I became pregnant with the most recent one, I found out I had bilateral hydrosalpinges that showed up on the transvaginal ultrasound.

We were considering having surgery to remove the fallopian tubes ( on the advice of an IVF specialist) then start IVF, when suddenly we found out we were pregnant. Unfortunately, at 9.5 weeks I had a miscarriage.

We are awaiting results of tissue testing to determine if chromosomal abnormality exists. We are also booked in for a repeat ultrasound.

1. Does having bilateral hydrosalpinges cause you to miscarry at 10 weeks pregnant? If so, by how much (i.e. what %)? Gyn says they do not make you miscarry but more likely to not allow implantation.

2. Would the preferred option be to clip them, or just remove them and commence IVF even though I have gotten pregnant naturally? Or would the best option be to give it one more go naturally?

Any other advice would be appreciated.

Answer:

Hello,

You present a very interesting scenario because women with hydrosalpinges usually cannot get pregnant. The reason is because the cause of the hydrosalpinges is a tubal infection that caused the damage to the tubes. Not only did it cause the tube to be obstructed, but it even usually leads to damage of the inner lining of the tube that is important for egg and sperm transport. Therefore the recommendation is to proceed with IVF. Your case negates that thinking.

Hydrosalpinges can lead to non-implantation, and by the same mechanism, miscarriage. It is thought that the hydrosalpinx has inflammatory fluid within that migrates back into the uterus. Several studies have found decreased pregnancy rates in IVF when hydrosalpinges are present. That is why it is recommended to clip the tubes or remove them prior to IVF. This inflammatory fluid causes a mild inflammation of the uterine lining causing the lack of implantation. If implantation were to occur, I would expect that the same inflammation could lead to the death of the embryo from a mild amnionitis. That, however, is theoretical.

Because you have shown that you are the exception to the rule, you have two options. You can have a laparoscopy and have the tubes opened (salpingoplasty) or you can have the tubes clipped/removed. If the tubes are opened, you have the opportunity to become pregnant naturally, like you showed that you could. It would allow the fluid to escape into the abdomen, thereby reducing the chances of backflow into the uterus. However, if there is tubal damage within, you are at increased risk of a tubal pregnancy called an ectopic pregnancy. That can be life threatening if it ruptures and you hemorrhage. The second option, which then requires IVF is certainly the safer option, but the more expensive option. You need to discuss these two options with your docs.

If I were counseling you, I would almost be inclined to recommend the former (tubal repair) as long as you were completely aware of the risk of ectopic and willing to take that chance. I would then watch you very closely if you were to become pregnant to rule out the ectopic at the beginning of your pregnancy.

I hope that this answers your questions.

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf