37 Year Old TTC With Past History Of Hyperplasia & Endometriosis Is Desperate To Conceive

QUESTION:

Ok, I went to the Gyno in Dec of 2009 because I wasn't getting my period. He sent me for an ultrasound Jan. 2010 and the lining of my uterus was thickened so he did a biopsy which led to my first D&C which was April. I was diagnosed with hyperplasia of the uterus and he said I was producing too much estrogen so he put me on Depo provera.

I got my first shot April 19. 2010 and he told me if I didn't go on the depo shot I would definitely get cancer. I had my second shot July and then I had another D&C September and everything came out good, hardly any tissue. After the D&C the Gyno said he wanted me to stay on the depo till I go through menopause ughh!! I've had three more shots, one in Oct.. one in Dec. and my last shot was March 21, 2011. I want to have a child and in late July I will be 38. My gyno said I could go off the depo shot, so I asked him what if it takes me a year to get pregnant? He said, "You're not allowed to take that long you'll get cancer of the uterus for sure."

I think I need a second opinion & I'm hoping my withdrawal from the depo isn't so horrible. One thing I think you should know is I was diagnosed in my mid 20's with endometriosis and my gyno (back then different doctor) said I didn't have a lot of tissue he also never told me I couldn't conceive, he just said after you have children just get a hysterectomy. I was put on different forms of BC (birth control) over the years and my last form of BC was the NUVA ring. I always had bad cramps w/ my periods so he had me wear the ring continuously. I would wear it for three weeks and take it out and put in a new ring right away to avoid periods, when I was doing that I had break through bleeding all the time & that's where I think all the excess tissue came from with the hyperplasia. I've been on the depo shot for a year and three months then I'm due for my next shot which I don't want.

I'm writing from South Jersey. I only want to have one child! Please tell me what you think. Thank you for all your time. :)

ANSWER:

Hello A. from the U.S.,

First, I don't think you need to worry about the hyperplasia at this point. You have been adequately treated for it. You just need to make sure that you have regular cycles because not shedding the lining at least every three months is what can lead to hyperplasia, and if left untreated the simple hyperplasia can turn into atypical hyperplasia (precancerous) which can then turn into cancer.

I think that pregnancy is a good idea for it and you need to pursue it aggressively! Your age is the number one issue at this point, in terms of getting pregnant. A second issue with getting pregnant is the history of endometriosis. Depo Provera is certainly a good treatment for this disease but endo can recur and can impede pregnancy. Considering your age, I wonder if there are other factors as well since you have never gotten pregnant to date. My recommendation, in general, to patients at 37 years old or older is to strongly consider IVF (in vitro fertilization). Other than age, you don't have an absolute indication for this, unless something else is found wrong, but the chances of pregnancy are so much higher with IVF than any other treatment at your age.

For example, your natural chance of pregnancy is approximately 3% per month or 5% per month with IUI. On the other hand, with IVF it is 69% per month in our clinic, and at least 50% across the country. That is a significant difference. The problem with age is that the majority of eggs that you still have will be of poor quality so the only way to increase your chances to find an egg with good quality is through IVF. You can certainly try with more natural methods but with each month that you fail, your chances are decreasing (it's like chasing your tail).

I would strongly recommend that you go to a good IVF clinic and have a consultation. I know that there are some excellent ones in New Jersey.

Follow-Up Question:

One more question, being on the depo shot for this time period (one year & 3 months) I'm afraid as to how long it will take to get out of my system. Reading posts by women who've been on it much longer than I (like 7-12 yrs.) say it can take 6-18 months to start a normal period & ovulate again. Any suggestions on how to rid the depo from my system when I'm actually due for my next shot? I've read lots of water and excercise.

Thanks again after this no more questions I'm sure you're busier than ever.:) A. from New Jersey.

Follow-Up Answer:

Hello Again,

I don't have any solutions to how to speed up the return of your natural cycles. The Depo can linger for a while but I have never seen it take more than 2-3 months. If you want to start trying for pregnancy sooner, you could undergo ovulation induction and that will get your ovaries to stimulate and ovulate.

You are very welcome to ask your questions and thank you for your patience in waiting for my reply.

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: Dr. Ramirez was very helpful to me I really appreciated his input. Thanks again!!

Three IVF Cycles With Immature Eggs: PCOS and HCG Trigger?

QUESTION:

Dear Dr. Ramirez,

I'm 39 years old and have done 3 IVFs (in vitro fertilization cycles). During the first two IVFs, half of my eggs were immature. I had 25 retrieved (age 37) the first time, and 16 retrieved (age 38) the next time with 50 percent maturity in both cases. However, I just had an egg retrieval where 15 were retrieved and only 2 eggs were mature. They used generic HCG in this case, and the doc seems to want me to try the transfer the pretty crappy embryos that resulted from this retrieval. He is offering no answers as to why just 2 eggs were mature upon retrieval and the embryo quality was my worst yet.

Does the kind of HCG trigger make a difference? For the second retrieval, I didn't use generic HCG but Novarel. I think I used Ovidrel for the first trigger. Do you think I have a genetic defect and should be tested? I also think I have some of the signs of PCOS (acne and some sideburn hair that I remove), but doctors don't think I have PCOS because I have regular periods and am not overweight. Yet, I've heard many PCOS (polycystic ovarian syndrome) women produce immature eggs. Also think I may be insulin resistant and have heard a connection between this and immature eggs as well.

Would appreciate your insight.  Emma from California

ANSWER:

Hello Emma from the U.S. (California),

Egg maturity at the time of retrieval is based on two things: (1) the size of the follicle when triggered and (2) adequate HCG stimulation. 

First, let me answer the HCG question.  If the HCG is an inadequate dosage or not a quality product, then it is possible that the follicle and consequently the egg within, will not get adequate hormonal stimulation to go through the final maturation phase.  Sometimes the egg will not release from the wall and so no egg will be retrieved but otherwise, it would not be mature.  In terms of follicle size, it is usually a requirement that the follicle reach a minimum of 16 mm to insure that the egg within has matured.  Physiologically, as the follicle grows from FSH stimulation, the egg grows toward maturity.  When it reached mature size, the final act is for the HCG or LH which is the physiologic trigger, causes the egg to go through the final phase of maturation and release from the wall.  If the follicle is less than 16 mm, an egg could still be retrieved but it would not be mature.  This is where the "art" and experience of the physician comes into play.  It is his/her decision as to when the optimal time to trigger is.  The goal, or what should be the goal, is to trigger when the majority of follicles are of mature size but not let it go on so long that you begin losing the larger follicles.  That balance is the key.  In my case, I use 50% maturity as my baseline measure, since follicles tend to grow at different rates.  That is to say, that I strive to have at least 50% of the retrieved eggs to be mature.  In most cases it is much more than that.

You are correct that PCOD patients tend to have a lot of immature eggs but that is because they have so many follicles that result from stimulation.  Where a normal woman might produce 15-20 follicles, a PCOD patient will often produce 30-40 follicles.  Since they develop at different rates, that leads to different maturity levels.  In terms of medication, I favor Ovidrel.  In my experience (22 years), I have had cases where the eggs don't mature as a result of Novarel or Generic HCG, so I abandoned them.  In addition, Ovidrel is a subcutaneous injection whereas the HCG is intramuscular so, it hurts more. 

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

---------- FOLLOW-UP QUESTION ----------

QUESTION:

Thank you, Dr. Ramirez. There was one more piece of information I forgot to include. Before I started this last cycle, I had been on a three-month dose of lupron. I began stimming exactly three months to the day of my lupron injection, even though I still had hot flashes and only had six follicles to start. Follicles grew from 6 to 8 to 12 the day of the trigger. Normally my number of follicles are in the teens at the beginning of the cycle. I even mentioned this to the doctor and told him that I was still having hot flashes as well. Is it possible that my ovaries were over-suppressed, which resulted in just two immature eggs out of 15?

Thank You,

Emma

Answer:

Hello Again,

Usually the stimulation, if given in adequate dosage, is enough to overcome the Lupton suppression, but I think that your thinking may be right, and that your ovaries may have been suppressed enough so as to not perform as well in the last cycle and the stimulation was not enough to overcome that suppression.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Monterey, California, U.S.A.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com 

Monterey, California, U.S.A.

TTC After Surgery For Stage Four Endometriosis

Dear Readers,

As the year draws to a close I want to wish all my readers near and far the very best in their lives as you move forward into 2014. I hope that the blessings of health and peace are with you all and for those of you who continue to struggle with infertility, I can only wish with all my heart that the journey will come to a positive conclusion for you in 2014.

Thank you for following my blog and God Bless.

Edward J. Ramirez, M.D.

 

Question:

Hello,

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why?  I understand surgery can affect ovarian reserve but am looking for better understanding.

What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas?  Thank you.

C. from California

Answer:

Hello C. from the U.S. (California),

Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates.  This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding).  In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis.  These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means.  For that reason IVF is the only option.  Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen.  However, statistically speaking these cases are very, very few.

In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming.  For that reason, you can form new endometriomas, despite the previous ones being removed.

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.

Poor Responder Needs To Know IVF Is Not All About Numbers: It 's About One Good Embryo

Question:

Hi Dr. Ramirez,

My name is A. and I am writing from Michigan. I am 33 years old and have DOR with an AMH of <.16, Hashimoto’s and positive ANA’s. I am on day 10 of stims for IVF #2 and responding poorly compared to our first attempt. I am hoping you could answer a few questions regarding the cause of the diminished response (compared to the first) and also give your opinion regarding canceling the cycle.

IVF #1 (March 2013):

BCP suppression 5 weeks

225 iu Bravelle, 150 iu Menopur, Ganirelix days 8-10. Stimmed for 10 days.

Day 5 of stims: 6 follies: 9-10 mm, E2 301

Day 10 of stims: 7 follies: 19-21 mm, E2 724

Retrieved 8 eggs, 6 mature, 4 fertilized with ICSI, 2 transferred (grade B’s, no frag), none to freeze.

IVF #2 (in progress):

BCP suppression 4 weeks

225 iu Bravelle, 225 iu Menopur, Ganirelix added day 8 of stims.

Day 7 of stims: 6 follies: 12, 12, 9, 9, 9, 9 mm, E2 243

Day 10 of stims: 4 follies: 15, 14, 11, 10 mm, E2 495

There are five factors that have changed since the first cycle. 1) Menopur was increased by 75 iu. 2) Ganirelix was introduced when follies were smaller at just 12 mm. 3) Slightly less time on BCP suppression; less one week 4) Added Methylprednisolone 16 mg. 5) Discontinued DHEA 50 mg and Myo-Inositol 2 g.

What could be causing the poorer response, loss of follicles and slow growth? Is there anything that can be done to speed up growth and/or catch up the 10 and 11? Does the slow growth speak to poor egg quality?

I am okay with going to retrieval with so few follicles as I realize I have DOR and cannot expect a normal response. However, with having had a better response previously, would you recommend canceling at this point? Why?

This is such a stressful time for us, so I greatly appreciate your attention and feedback.

A. from Michigan

Answer:

Hello A. from the U.S. (Michigan),

First, you should know that ovaries can and will respond differently with each cycle regardless of the protocol used.  That is to say that even poor responders will respond better or worst from one cycle to the next.

In your case, I can make several observations which may be helpful to you:

1.  Despite a low AMH, you have responded pretty well with each cycle.  You had 14 follicles and 10 in the second.  This is not a sign of a poor responder.  Poor responders tend to have less than 10 total follicles.  In addition, your stimulation was not that high, so I would say you are a pretty average (normal) responder.

2.  As mentioned, your stimulation protocol was in the mid-range (375 IU and 450 IU).  The max protocol that most clinics use is up to 600 IU (450 FSH + 150 FSH/LH (menopur).  So in terms of stimulation, you have lots of room to improve.

3.  You mentioned starting Ganerelix when the follicles were 12 mms.  That is way too soon in my opinion.  Based on European studies and over 10 years of use by myself, I do not start Ganerelix until the lead follicles are at least 16 mms and preferably when the 30% or more are between 16-18 mms.  The purpose of Ganerelix is to prevent premature ovulation so I hold it until the very latest that I can to allow the follicles to develop without suppression.  Starting too early will lead the smaller follicles to stop growing.

None of this implies low egg quality or poor outcome.  It is part of the "art" of assisted reproduction and what distinguishes one doctor or clinic from another.  Bottom line is that IVF is not all about numbers.  It is about getting at last one good embryo to attach and lead to a pregnancy.  For that reason, even if there are fewer follicles I recommend that you keep going just in case the perfect embryo is in this group.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

 

Similar IVF Protocol But Different Results: Why?

Question:

Hi Dr. Ramirez,

I'm back again with a question about my recent IVF (second one). This IVF (in vitro fertilization) cycle we did the same protocol as last time (antagonist) but started off at a higher dose of Gonal-f based on my response last cycle. This cycle we started off at 300iu gonal-f and 75iu menopur whereas last cycle we started with 225iu gonal f and 75 IU menopur but had to increase to 300 IU gonal f after day 4 showed an E2 of only 90. Both cycles I started out with similar AFCs of 10 and 12 at suppression check. My usual AFC is between 16-20. Last cycle it seemed that I recruited more follies along the way and ended up with an E2 of 3030 and 23 eggs retrieved (17 of which were mature based on icsi and conventional fert rates as we did 50/50 split fertilization). This cycle my E2 was 2100 at trigger and they retrieved 12 eggs (still waiting on fert report today but we are doing all conventional fertilization).

My question is why did I have such a different response this cycle given that we started off at a higher dose this cycle compared to last? Last cycle we went up from 225iu gonal to 300 IU gonal at day 4 and stayed there until trigger. this cycle we started at 300iu gonal and stayed there until we added ganirelex on day 7. At that point my E2 stalled and do they increased my gonal f to 375iu gonal f and kept me there until trigger.

As always thanks for your advice/insight. S. from the U.S.A.

Answer:

Hello S. from the U.S. (Virginia).

The human body is not a consistent nor predictable structure so I can't explain why your response is different.  I have always explained to patients that have low response to stims that the ovaries can react differently each cycle and your experience is a case in point.  That being said, I would not have increased your dosage since your stimulation was so good the previous time and you bordered on entering OHSS territory.  In any case, IVF is not a contest where the person with the highest number of follicles or eggs wins the prize.  The goal is to find 1 or 2 perfect eggs that will lead to perfect embryos and a successful pregnancy.  So despite the fact that you stimulated less, that might be a better thing.  Bottom line is you only need one good one.  Also, there have been some studies showing that when a patient stimulates hard with lots of follicles, sometimes the egg quality suffers and the pregnancy rate drops.  This is especially true in PCO patients.  In those patients, our preference is to stimulate less and get fewer follicles.

So, in any case, as the saying goes: "I don't think you should sweat the nitty gritty" i.e the fine details.  Hope for the one perfect one.  That is the goal.

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.

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.

 

36 Yr. Old Has Repeated Implantation Failure With Great Embryos...What's Wrong?

Question:

Dear Dr,

We have just had our 4th failed IVF (in vitro fertilization).

Our history.  I am 36, my husband is 39. 1st pregnancy was in 2009 after 3 IuI's (intra uterine insemination) and clomid, but had to terminate at 15 weeks due to large enphaloceale (was a random genetic mutation)and my 2nd pregnancy with IUI was a success with a full term healthy baby boy.

Started with IuI's for 2nd child in 2011! We had 10 IuI's and now 4 IVF's.  Each IVF has been with icsi (intracytoplasmic sperm injection) and this time we had Embryo hatching. Last 3 transfers were 3 top grade 8 cell embryos each time on day 3.  I am not a great responder and only ever have 5-7 eggs, of which usually 4 fertilise.

I have had all the immunity checks done, my husbands sperm dna damage is within normal, fertilisation rate is good.  My ovarian reserve was also checked and the level was 1.0- My specialist said that he wasn't overly worried about the reserve for my age.  I have had a hysteroscopy and all normal.  I have been on various drug protocols and this last one was the long Lupron cycle with menapur.

We are just not sure what to do next?  Do we keep going, as my doctors are very positive and we have the finances. Are my doctors missing something?  Is there anything else we can do to improve our chances.  I am on DHEA and Royal Jelly, and my hubby is also on supplements.

I am writing from CapeTown, South Africa.

Thank you for your consideration, R.

Answer:

Hello R. from South Africa,

The exact cause of your failure cannot be known as there are still four steps your embryo has to go through in order to produce a pregnancy: embryo has to develop to blastocyst, the blastocyst has to hatch our of its shell, it then has to attach to the uterine lining and the lining has to grow around it.  As of now, there is no technology that can make this happen.  "Assisted hatching" is just making a defect in the shell so that the embryo can exit (hatch) more easily.

Something I always worry about when I have patients tell me they have failed multiple cycles despite good embryos, is the quality of the final step of the IVF process, which is the transfer.  You can have the absolute best and perfect embryos but if the transfer technique is not done well, then it will fail.  This has been shown by numerous studies.  Since you have been going to the same clinic, I wonder if that is not the problem, in which case, I would recommend that you seek out a different clinic.

One thing that I do with my patients that is not universally accepted but done by many of us, is to use a recurrent miscarriage protocol to reduce the immune system, thinking that a heightened immune system might be at fault.  For this regimen I add low dose heparin or lovenox, medrol, low dose aspirin, extra estrogen and extra progesterone (both injectable and vaginal).  I don't think that DHEA does anything so I don't use it.

At 36 years old, I have a 66% pregnancy rate in my clinic.  By two to three attempts with good 8 cell embryos, you should already be pregnant.  Your rate should especially be increased over other 36 year olds since you have been pregnant before.  For these reasons, I think the fault may lie in your clinic and not in you or your husband. 

Good luck in your journey to have a second child,

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

 

Monterey, California, U.S.A.

Is A Big IVF Clinic Better Than A Small One?

Question:

Hello,

I am writing from Japan and want to ask that can big, crowded clinics be good or are small ones always good? Which is a worst choice...I'm very confused actually....like the crowded one has all the plus points, it is experienced, and cost is little bit lower than other. The big one has the pioneer in begining the IVF (in vitro fertilization) in Japan, the other has good success rates but only opened 6 yrs back...I'm totally confused!

How many cycles should a clinic do per year and what can I use to make my decision?

Please help ! H. from Tokyo

Answer:

Hello H. from Tokyo,

I run a smaller, low volume clinic and have better pregnancy rates that they large ones in my area, including the ones at Stanford University and the University of California, San Francisco.  I feel that I give better more personalized care because I am caring for them personally and completely.  I don't have other people doing what I should be doing.  The biggest disadvantage of a very large clinic is that it is a factory and depersonalized.  IVF should be a personal and intimate procedure, NOT a mechanical one.  So, of course I have a bias.  I would not recommend a small clinic that has a poor pregnancy rate, but if it has a good pregnancy rate, I think that is the better place to go.  I don't care how big and famous the larger clinic is or how many cycles they do, if it were me and my wife doing this I would want a clinic where the doctor is going to give us personalized attention the entire way, including personally do the retrieval and transfer procedures. I know that at the larger clinic in Japan you will rarely if EVER get to see the "famous" doctor,  so what good is it to go there? The smaller clinic will probably give you a better experience even though it is at a slightly higher cost.

In the U.S., people prefer to go to clinics where they get one on one personalized care, not where they are treated as another number.

幸運 ... 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.

 

High Responder Fails Two IVM and Two IVF Cycles: PCOD & Follicle Maturation Issues

QUESTION: Hello,

During the last year we did two IVM (in vitro maturation) and two IVF (in vitro fertilization) cycles at different clinics at Montreal, Canada. All failed. I'm 39 years old and my husband is 40. My FSH was 11.1 and AMH 2.2 two years ago. The first IVM was without stimulation, I was triggered when the lead follicle was 13mm, 11 eggs were collected, 7 managed to mature in the lab and 4 fertilized. By the day 3 we had transferred 2 embryos 6 and 8 cells (they did not give us their grade). Endometrium was 6.8mm by the day of collection. No pregnancy...

The second IVM I had 3 days light stimulation (about 150UI Puregon days 3-5 + Estrace from day 6). I was not aware of my hormone test that shown the E2 level fell on day 6. We had collected only 8 immature eggs from 17 follicles, the only egg fertilized and on the second day the weak embryo was transferred. Endometrium was 7.3mm. Of cause, no pregnancy.

We moved to another clinic and did there two IVFs. The first one I had stimulation from the second day: 225 Gonal-F + 75 Luveris. After 4 days dosage was increased up to 300 Gonal-F + 150 Luveris. On the day 13 I was triggered when I had one follicle about 22mm, 2 about 18mm, and many smaller ones. We collected 16 eggs, 12 were mature, 9 fertilized. My doctor decided to wait till day 5 for the transfer. We had one blast, the other embryos stopped developing. The lining was 8.2mm at the day of transfer. No pregnancy.

As the clinic doesn't work during weekends, the stimulation for our second IVF started on day 4 and lasted 9 days. It was more aggressive: 300 Gonal-F + 150 Luveris from the start and about 200 Gonal-F + 150 Luveris at the end as I had developed mild OHSS. I was triggered when my follicles were 1-19mm, 1-18mm, 3-16mm, and many 15mm and less. As I said the clinic doesn't work weekends. My collection was Friday. I asked to wait for follicle growing bigger and the answer was: no, they are big enough. We collected 25 eggs, only 13 were mature, and only 5 fertilized. They were stopping developing one after another. The last one stopped at day 6 on the morulae stage. The lining was perfect: 13.5mm. It was an epic failure: nothing to transfer... I was told that the issue is my egg quality (my husband has no issues with his sperm).

I see that I had the only follicle bigger 20mm at the collection and we had the only blast. So I really would like to understand whether it's not a coincidence? If there is a way to have more equal size of follicles by changing the protocol? If I'm a good responder and have many eggs and they usually fertilize good (if they are mature) but they stop developing - does it mean they are poor quality? Or they were not fully mature at the day of collection? As I'm getting older and we have no time to experiment with different protocols I would like to maximize our chances by using more effective protocol for our next attempt. It would be great to hear your opinion on it. Could the change in protocol give us better chance for success?

Thank you in advance! O. from Canada.

ANSWER: Hello O. from Canada,

I can't give you specific protocol recommendations because each doctor and each clinic do different things. There is no one way to do IVF as you have found out.

The latter stimulation cycles show that you are NOT a poor responder but a high responder with PCOD tendencies. That means your ovaries are very sensitive to stimulation and that is a good thing. Yes, your age and therefore your egg quality are issues. However, hope is not lost because there is a chance that you still have a few good eggs left. As long as your ovaries respond well to stimulation, your chances of finding the good eggs are high. However, it also means that you need to find the right clinic because pregnancy rates will vary highly depending on the skill of the clinic and factors such as when to retrieve. I think it is a mistake to go to a clinic that only does egg maturation, and a clinic that doesn't work weekends. Both clinics are short changing you. It's time to find a better clinic.

It is also known that when OHSS develops, the pregnancy rates also drops. Probably because the majority of the eggs are not adequately matured. So one goal would be to decrease the stimulation and try for fewer eggs and a longer stimulation to get higher quality eggs. That is my goal with patients that are high responders. One method I use to try to even out the stimulation is to use the "sandwich protocol" which is to use 2-3 days of antagonist prior to starting the stimulation (I don't use the long Lupron protocol)to suppress the ovaries so that the follicles all start at the same point. Not all doctors use this protcol.

One final note: I let my follicles reach 20 mms before trigger. In some cases, I'll go up to 24 mms on the lead follicles if there is some unevenness, the goal of which is to try to get as many mature eggs as possible. Again, these things/variations are what make clinics and doctors different. You need to find a clinic that has a respectable pregnancy rate for your age group (and that will stay open on the weekends) so that you don't waste any more IVF cycles.

FOLLOW-UP QUESTION:

Dr. Ramirez,

At first, thank you very much for your fast and detailed response.

I've forgot to mention that our infertility is unexplained and I always have a lot of follicles at any given cycle (the first time we asked medical help for infertility 4 years ago).

Today I've got some new details about my IVFs: first time the E2 was about 8000 at the day of trigger and progesterone was about 4. The second time E2 was more than 22000 and progesterone was 6.4 so that my doctor didn't wait anymore and triggered me when the lead follicle was still 19mm (and not because they do not work weekends, as he explained). Is it possible that the E2 level could compromise egg quality the second time?

My doctor told me that assisted hatching is not possible for a blast as it can be easily damaged. Do you agree with that? Is assisted hatching used for day 3 embryos only?

Also my doctor is tended to wait for a blast and do 5-day transfer as he believes it would give stronger embryo and higher chances of implantation. As I see we had many good-looking embryos on day 3 and 1 or no blast at day 5. Would it better to transfer at day 3 instead?

Thanks again for sharing your knowledge

Regards, O. from Canada.

FOLLOW-UP ANSWER:

Hello again,

You have to understand that my advice is my personal opinion and not necessarily the gold standard or generally accepted standard because there are many many variations in the stimulation portion of the IVF cycle. But let me give you my opinion.

Both cycles led to overstimulated cycles. If the peak E2's are correct, you went very very high and in the U.S., in general, we don't like the E2 to go above 4000. Yes, it has been shown that when hyperstimulation occurs, i.e. the E2 goes above 4000, there seems to be a decline in egg quality and pregnancy rates.

You don't necessarily have a diagnosis of "unknown" infertility. You have the "age factor" which means that your egg quality could be compromised based on your age. That is a diagnosis. My approach to transfer is to use D#3 transfers unless I have so many good D#3 embryos that it is harder to determine which ones to transfer. In that case I will proceed to D#5. I am not a big D#5 person because I don't think that it is an absolutely perfect technology and we probably lose some good embryos because of it (that has been shown by genetic testing of the embryos on D#3). Not all blastocysts are genetically good embryos. Because of your age, I don't think it makes any difference which day you transfer, but I would prefer to put back more and let nature decide that the lab. YES, assisted hatching can be done on blastocysts.

The only other option that might help you, is to consider preimplantation genetic screening so that only normal embryos are replaced. I would also recommend tranferring at least 4 embryos because of your age. PGS might decrease your pregnancy chances a little, depending on the expertise of the clinic, but can help you to distinguish the genetically normal from the abnormal. PGS can be done on D#3 or D#5.

Good Luck,

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

Comment: Dr. Ramirez gives detailed and clear answers. He is extremely helpful and very knowledgeable.

A Step By Step Guide To The IVF Process: Overview

Dear Readers,
I get many  many questions regarding what In Vitro Fertilization (IVF) is and how it works that I thought I would share the information with my world-wide Blog audience. What you read here is what I also provide my patients with on a daily basis. I plan on going into some detail but in a way that is understandable to the normal (lay) audience, and not the medical or scientific one. I hope that this will not only clarify what you will go through, but explain why things are done a certain way and what the goals of each step are. I also want to convey that IVF is actually a replacement for some of the “natural” steps required to get pregnant and not some miraculous high tech fertility treatment that gets patients pregnant artificially, as many think it is. It is somewhat of a miracle that we can do as much as we can, but there are still lots of things/steps that we cannot do or influence. I hope this discussion will benefit you. This series will be posted over the next few weeks in installments.

OVERVIEW:
Before I begin explaining each step, let me give you an overview of IVF. As I mentioned earlier, IVF or "In Vitro Fertilization" is actually a replacement for the natural steps your body would go through in order to get pregnant, and it still relies on many of those natural steps to occur before you become pregnant. “In Vitro” means in the laboratory versus “In Vivo” which means in the body. As I’ll explain, IVF is not all done in the lab. Some parts of the process still are required to be in the body, so in actuality, it is both an “In Vitro” and “In Vivo” procedure.

There are basically nine steps that your body goes through in order to achieve a pregnancy:

(1) Your brain (hypothalamus and pituitary) sends a signal to the ovaries to stimulate the growth of a follicle and maturation of the egg within.

(2) The designated follicle grows, and the egg matures, until it reaches a critical size, whereby there is an LH surge to induce ovulation.

(3) The follicle surface ruptures and an egg is expelled with the rush of fluid within (ovulation) and enters a space behind the uterus called the culdesac, the lowest point in your abdomen.

(4) Through fluid motion (this part is not exactly known so it is my personal belief that this is how it happens), the egg contacts one or the other fimbria of the tube, which is hanging into the culdesac in its natural position, and now lies within this puddle of fluid. The egg is then brought into the tube by the fimbria and tubal motility.

(5) The egg moves into a part of the tube where, hopefully, the live sperm are waiting to attach to the egg, and then fertilization occurs.

(6) The fertilized egg slowly moves down the tube, dividing and forming into a blastocyst.

(7) The blastocyst then enters into the uterine cavity and settles there.

(8) The inner portion of the blastocyst then hatches out of the shell and attaches to the uterine lining.

(9) The uterine lining then engulfs the embryo, which is known as implantation and at this point bHCG begins to be produced.

These are the steps that your body goes through to get pregnant, but does not do it exactly or perfectly each month. That is why it may take several months before a human woman gets pregnant. IVF is basically accomplishing most of these steps for you, NOT doing some artificial process. Yes, it is not within your body, or at least some of it is not, but the same processes have to occur. If you know and understand IVF you can see that IVF basically accomplishes steps 1-7. Two steps then have to occur naturally for pregnancy to occur. So as you can see, IVF is still basically a “natural” process because it still relies on natural processes within your body.

In other words, we give fertility drugs to stimulate the ovaries to grow and mature eggs but the ovaries still have to pick up and process these hormones on their own, and growth and maturation of the eggs still have to occur naturally. We can put the egg and sperm together but fertilization still has to occur by itself. Even ICSI (intra cytoplasmic sperm injection) is only putting the sperm into the egg. The actual fertilization process, the merging of the egg nucleus and sperm nucleus, among other processes; still have to occur on their own. We cannot make that happen. We can put a grown embryo into the uterus but we cannot make it hatch out of its shell, attach to the uterine lining or make the lining engulf the embryo (implant). All of these steps are left up to nature or, as I tell my patients, are in God’s hands and the way He reminds me that I am but His humble servant. This keeps my head and ego from becoming too big!

Many patients are devastated when an IVF cycle fails, because they have the false belief that it is the ultimate and perfected technological way to become pregnant, and therefore works every time. It is certainly more technological but not even close to being the ultimate or perfect method, and it doesn’t work every time. For that reason we cannot achieve 100% pregnancy rates, and much research and technological advances still need to be developed before we will get there. Make no mistake, however, we have improved greatly since the first IVF success with Louise Brown, but that took years to occur as well.

Sixteen years ago when my wife and I did IVF, she was 37 years old, and her statistical chances were about 12-15% but now a 37 year old in my center has a 65% chance of pregnancy per cycle. We have improved greatly and come a long way. We can now help a couple acheive a pregnancy where previously there would have been no other option but adoption. IVF is certainly better than trying naturally because more steps are accomplished, whereas in natural cycles, the body does not always do each and every step correctly. For example, ovulation may occur but the egg may never find the fimbria so that month pregnancy will not occur. Just to put things in perspective, a 37 year old has a 5% chance of pregnancy per month of trying by natural means. When trying naturally, women have to keep trying for several months before a pregnancy occurs. In fact it will take 85% of women under 30 years old 8 to 12 months to achieve a pregnancy. In the same way, because IVF is just replicating the process, it can take several attempts before the body does its part of the process correctly. In my center 55% of patients (not adjusted for age), achieve pregnancy in their first attempt. Most patients will be pregnant by three attempts rather than the 12 months it may take to achieve a pregnancy naturally.

We will continue this discussion soon with the next installment, "Step One: Stimulation".

Thank you for joining me today!

Edward J. Ramirez, M.D. F.A.C.O.G.
Medical Director, Monterey Bay IVF
Monterey, CA
http://www.montereybayivf.com/

IVF Protocol For High FSH

Question:

Dear Dr. Ramirez,
I am 39 years old in 2 weeks and about to undergo my first ivf (in vitro fertilization). I have only one fallopian tube, which an hsg has shown to be blocked, probably by adhesions (my other tube was removed due to damage from extensive adhesions - a reaction to previous surgery to remove a dermoid cyst on my left ovary).


My FSH level was 14 in March. Two weeks ago my FSH dropped to 8 and my AMH level was 7.42. An ultrasound scan and follicle count showed 9 follicles on my right ovary and 3 on my left (the ovary which the cyst was removed from).

My consultant has suggested the long protocol, as he thinks I will respond ok. I have read much about the short protocol being better for my age group, and if fsh has been high. I am anxious to get the correct protocol from the outset. What do you think my response might be, based on my levels? Do you think a short protocol would be better in my case? Many thanks, R. from the U.K.

Answer:

Hello R. from the U.K.,

The worst thing you can do is try to second guess your doctor, especially with information that you read on the internet. You are not an expert and don't have sufficient knowledge to make a proper decision. However, it is good to be educated regarding what you will be going through, and certainly, I have the knowledge to answer questions, so you can trust my input. But, given that you are not my patient, I don't have all your medical information and am not doing the procedure, the answers I give you have to be generalities and cannot be specific.

I personally don't criticize "protocol" questions because there is not one way or best way to do IVF. There are many different protocols and usually the specific protocol is based on the training and experience of your doctor. They all have the possibility to work. Some doctors stimulate less, some more, some use only pure FSh, some use mixed protocols, some use the long Lupron protocol, some use the antagonist protocol and some use the micro-dose flare protocol. There is not way to predict how any one will respond to any given protocol. But studies have shown no benefit to the micro-dose flare protocol (short protocol) in comparison to any other protocol, just as there is no study that shows that the long protocol is better than the antagonist protocol. I prefer the antagonist protocol because there are less injections in comparison to the long protocol.

Because you have had an elevated FSh level, despite it being lower more recently, you would still be considered a poor responder (or at least have the potential of being a low responder). For that reason, my preference would be to NOT inhibit your ovaries with Lupron in the stimulation phase, and only begin ovarian suppression once the lead follicles are at least 16 mms. This is the technique used in the antagonist protocol. With the long protocol, your ovaries are suppressed by the lupron starting from the previous cycles and may not respond as well. Before the antagonist protocol was developed, the micro-dose protocol was developed to reduce that suppression phase. Without criticizing your doctor's choice of protocols, my personal choice would have been different. But that is what makes Infertility doctors and clinics different and gives them different pregnancy rates.

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/

Hope And Encouragement During IVF: Is It Necessary?

Dear readers old and new,

The main purpose of my blog, Facebook entries, Twitter entries and All Experts advice are to give people hope; to urge them to continue their quest to have a child; to give them explanations and to help them in their quest.

I and my staff are my patient’s cheerleaders. We want the very best for them and hope and pray with them. We feel sadness when they fail and are overjoyed when they are successful. We put our hearts into them. This is a closeness that most large IVF clinics do not have the time or energy to do. This is personalized care, and it affects us because of the stresses it puts on us. Nameless, less personal and faceless care would be a lot easier for us. It would be less stress. It also would be less sadness for us, but that is not the type of care I or my staff like to give.

But today, I was criticized for something completely different. I had two patients give us feedback that we were “too encouraging” so their feeling of failure was worsened. They were angry at us for this. We were criticized for giving too much compassionate care, so that we enhanced their expectations and hence their fall when they received the negative result. I am mystified as to when good care or good service is no longer acceptable. Should we create more of a distance from our patients? Is giving hope to patients really just fueling false hope and subsequent depression? Is the anonymous factory-type care that many large centers provide, better than our approach? Is this really what infertility patients want? Are my efforts actually more destructive than they are constructive? I’d love to hear from readers of this blog about their thoughts.

As infertility specialists, we deal with a very personal issue. So personal and private that most patients won’t even acknowledge us to their friends or family. For example, I was at a B’nai Mitzvah recently for twins that, not only did I help conceive, but I also delivered. It was a celebration of the children, and there were acknowledgements of everyone in their lives, including their teachers, rabbi, friends, travel partners, etc. but, alas, there was no mention of me; the one who not only made it possible for their mother to have them, but who physically brought them safely into their world (I delivered these twins as well).

I have accepted the fact that what I do is highly personal and private. I have accepted the fact that many patients will not acknowledge me in mixed company, or in the store or on the street. Being a “fertility specialist” can have a negative impact on their standing among friends. That is certainly something that all fertility specialists have to accept. I do accept that. Unlike many other medical specialties, the praises we receive are received in private. We don’t mind that because we know that in their hearts, they appreciate the care and gift that we gave them.

It can be a bit disheartening though, at times.

Edward Ramirez, MD, FACOG
http://www.montereybayivf.com/

Did IVF Then Got Shingles: Could It Have Caused BFN?

Hello,

I was 5 days into my 2ww after a second IVF (in vitro fertilization). My first IVF unfortunately was a BFN (big fat negative), when I got my first ever shingles outbreak.

Then, my IVF ended up as BFN! Could shingle cause an IVF to fail. I had 4 gradeA embryos transferred. I am devastated! Thank you for your answer. A. From Georgia

Answer:

Hello A. from Georgia,

I am so sorry that your second cycle resulted in a negative and that you had to suffer shingles on top of that. I've had it myself and it is not a pleasant condition at all.

To answer your question: Yes, it is possible that a shingles outbreak could affect an implanting embryo. The immune response would be greatly heightened and could kill the embryo. That may not be the reason for the failure, but is a possible cause.

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.

No Period, Retained Cysts & Fibroids, After IVF Cycle Cancelled: 47 Year Old IVF UK Patient Worried

QUESTION:

I am 47yrs. I had my 6th IVF (in vitro fertilization) cycle in September 2011. The drugs used were climara patches10 days before the cycle began, prednisolene 10mg daily, aspirin 81mg daily, bravelle 6 vials every morning, menopur 2 vials every evening later increased to3 vials and antagoni ganirelix acetate injection. I had 5 follicles before the cycle was abandoned. One on right side 9.5 and four on the left 16, 11, 7.5 and 6. My cycle was abandoned because the follicles didn't grow at same rate and the antagonist may have been administered late.

I have two issues:

1) I have not had a period for about 50 days, though I had spotting and a discharge 10 days after the ivf cycle was abandoned. A vaginal US 2 days ago which indicated that I have multiple large follicle/small cysts ..3 large follicles of 20mm each on left ovary and 1 follicle 4.3 mm on right ovary, endometrial thickness was 9.1mm. Urine peg test was -ve. I am awaiting results Blood tests of hormone levels and peg test. My question is is it normal not to have a period long after after some types ivf cycles.since my period returned to normal 10days after my other 4 previous cycles? Or could the drugs have triggered menopause? Would the 3 large follicle disintegrate eventually?

2) I have 6 uterine fibroids, between 20-28mm, outside the womb. Also, a recent immune blood test revealed that I have a raised Th1:Th2 cytokines ratio of 33.2 and Cd19,Cd5 cells of 13.6. The clinic I attend does not think I should be bothered about these issues since the challenge is for me to produce good quality eggs but I wonder if I should continue ivf treatments. What do you advise? I am writing from UK. With regards, M. from the UlK.

ANSWER:

Hello M. from the U.K.,

It's unfortunate that your cycle had to be cancelled. I had to do the same with a patient of mine this month because the follicles were not growing. It happens with decreased ovarian reserve. You have been quite dedicated to your desire to become pregnant and hopefully your dedication will pay off in the end. As long as your ovaries are still stimulating, then there is a chance, given your age.

In terms of your menses not starting, that is probably because you have the three retained cysts present. They are probably still hormonally active and so there is not the hormone withdrawal that i needed to start the menses. You can either wait it out, or your doctor can prescribe the birth control pill to suppress the cysts.

In terms of the fibroids, they are rather small and should not interfere, but there are some studies showing that fibroids can reduce the chances of pregnancy. I agree that the main hurdle you have is your age and the resultant quality of eggs. But, if you were wanting to do everything possible to increase your chances of pregnancy (short of using donor eggs), then you might want to consider having the fibroids removed prior to another attempt. It is not absolutely necessary, but only an option. In terms of the killer cells, I don't anything more needs to be done.I am impressed that the clinic you are attending is being very aggressive in your treatment, and allowing you to continue to try with your own eggs. That is commendable. Many of the letters I received are from patients whose clinics are not very aggressive.

Follow Up Question:

Many many thanks for your answer. It was amongst my junk mail so I did nt see it earlier. I was very encouraged.

My follow up questions are:

1) How long after an abandoned ivf can I try again? Given that my periods have not started. My clinic had advised that I take the pill for two weeks and then start another ivf cycle immediately on day 2/3. However, I choose to wait for the periods to start naturally and then attempt the following month...that would be about 4 months after the abandoned cycle. I wonder if the drugs may still be in my system now and if it will help provide more good quality eggs if I take the advice of my clinic.

2) Do you think taking intralipids for the immune problems will help? I noticed that it is gaining popularity. I prefer it to the other edications being suggested i.e taking humira jabs for two months prior to the ivf.

3) Surgery to remove the fibrods is not an option for me....however, I learnt that there are other means of shrinking them but since they are small and dont bother me I dont want to interfere with my ivf treatment since time is not on my side.

4) Since, I missed my periods I have been having dull headaches especially when I wake up, my BP has been hoovering around 148/95, increased acne on chin and back and my hair has been falling out alot. Are thse symtoms of the missed periods or the after effect of the stimulation or the side effects of DHEA Supplementation which I have been taking for about 1 year now.

Kindly advise, M.

Follow-Up Answer:

Hello Again,

I think that two weeks after a failed IVF cycle is a little too soon, but my usual minimum waiting time is 4 weeks (1 month). I place the patient right back on the birth control pill once the period starts and prepare for the next cycle. I don't find a need for a "natural" period to occur. Because time is of essence for you, you cannot predict when your ovaries will shut down, I don't recommend that you wait a long period of time.

Intralipids is not indicated for this problem. It will not do anything to help your eggs. It is mainly used for patients that have an immune factor issue. I would opt to leave the fibroids alone unless you wanted to remove all potential obstacles. Fibroids have not proven to be detrimental to IVF unless the fibroid is within the uterine cavity. It could be a side effect of the DHEA which would increase your serum androgens (male hormones). I am not a big fan of using DHEA.

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.

Progesterone After IVF

Question:

My wife had IVF (in vitro fertilization) in Canada. She was prescribed Gonal-F, Repronex and Orgalutran for the stimulation phase. Two blastocysts were transferred at day 5 and yesterday our day-14 serum HCG pregnancy test was positive.

We were told by the nurses at the fertility center to stop taking the Prometrium pessaries now that the pregnancy test is positive. From reading, Progesterone seems to have many beneficial effect to the fetus, with minimal adverse effects. I think continuing progesterone supplements until the 10-12th wk is important. I am not sure why they want my wife to stop this!

Can you advise? A. from Canada

Answer:

Hello A. from Canada,

Your research is correct. Most IVF programs, if not all, will continue the progesterone until at least 8 weeks. I continue until 10 weeks and some programs will continue until 12 weeks.

I see that your center had your wife on progesterone pessaries (suppositories). For those others reading this post, there are different forms of progesterone to choose from:
• Daily oral progesterone
• Daily intramuscular injections (IM)
• Daily vaginal pessaries. These are mounted in wax, which melts as progesterone is absorbed causing discharge. It may be necessary to wear a panty liner.
• Daily vaginal tablets
• Daily vaginal gel

There are several formulations of vaginal progesterone: Crinone 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM injectable progesterone. However, most RE's are trained on IM Prog and so don't want to make any drastic changes. I happen to use both. If a patient cannot tolerate the IM Prog or has an allergic reaction to it, then they can switch to the vaginal version.

Bottom line: There is no harm in continuing the progesterone, but if removed prematurely, it could jeopardize the pregnancy.

Good Luck and Congratulations,

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

IVF After A Myomectomy & Low Ovarian Reserve

Question:

Hello, Dr. Ramirez,

D. from VA here! I wrote to you a few weeks ago concerning my RE wanting to freeze my eggs, give me a myomectomy, then do implantation. You didn't understand why he wanted to do things in that order, and neither did I. He thought that my fibroids were blocking my left tube, and I also have hostile cervical mucus and low ovarian reserve. I want to thank you for your response to my question, it really made me think about things. I am having a myomectomy in a few weeks (by my gyno) and decided to hold off on any aspect of the IVF until later in the year, when I was fully recovered from the myomectomy (and had saved up some more money.) I do have a couple of questions.

First, is it a good idea to put off having the IVF, given all of my problems? Especially the low ovarian reserve. Part of me is hoping that by doing the myomectomy, I'll improve my chances of being able to get pregnant naturally. But because of the low reserve, I'm afraid if I wait too long I will have missed any chance of conceiving. Question #2: is there anything that can be done to improve cervical mucus? Or is the best option to bypass it with the IVF? Is intratubal insemination a good option? Thank you for any answers you can give me!

Answer:

Hello D. from the U.S. (Virginia),

Low ovarian reserve is an indication that your ovaries might not stimulate well with the fertility medications and so less eggs will be retrieved. That is its ONLY implication. It does not mean that you cannot get pregnant or cannot get pregnant on your own. It is only important for IVF. Now, if you have to do IVF for specific indicated reasons, such as tubal blockage or sperm problems etc, then you will want to do it sooner than later because your ovaries might get to the point where they will not stimulate at all and that will decreased your chances of success with IVF.

In terms of your fibroids, it is not that uncommon for a patient to become spontaneously pregnant after a myomectomy. I am sure that every fertility doctor has had patients like this. As long as your ovaries are functioning then you have that possibility. Low ovarian reserve has nothing to do with spontaneous ovulation.

In terms of cervical mucous, if you are trying naturally (non-IVF), then you can try Robitussin taken daily to help thin the cervix or you can proceed to IUI (intrauterine insemination) where the sperm is injected into the uterus and thereby bypasses the cervix (there is no such thing as intratubal insemination).

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.