Woman Suspects She Has Endo: Treat The Pain Or Do IVF?

Question:

Hi there. Hubby and I have been TTC (trying to conceive) for almost 4 years now, with no success. We have been to two different REs, the first performed one HSG (hysterosalpingogram) and we underwent two unsuccessful IUIs (intrauterine insemination). The second ran a lot of tests, told me my eggs were low and wanted to go straight to IVF. In the last couple of years, my menstrual cramps have become unbearable, to the point of awaking me in the middle of the night. I have always had cramps, but nothing like this pain. I also have diarrhea along with my cycle, a yeast infection every month, and terrible seasonal allergies.

Two years ago I had an abdominal myomectomy and at that time, my doctor separated my fallopian tube from my uterus-they had gotten stuck together. I have been reading up on endometriosis and it sounds to me like I may have it. No doctor has ever suggested that I get tested for it. But I seem to have many symptoms of it. Do you think my tube and uterus getting stuck together were a result of undiagnosed endo? Could this be causing our infertility? Thank you for any answers you can provide. Thanks, W. From Virginia.


Answer: Hello W. from the U.S. (Virginia),

It seems that you are smarter than the two RE's that you consulted with. Given this history, you certainly could have endometriosis, and the prior surgery probably made the diagnosis. Endometriosis is one of the major causes of adhesions (scar tissue) formation in the pelvis. It can lead to infertility because it changes the normal anatomy and can prevent an egg from entering the tube. In addition, you have now had an open surgery (myomectomy) which is notorious for causing scar tissue formation as well. These two things on their own would explain your infertility.

At this point you have to make a decision: whether to treat the pelvic pain or get pregnant. Treating the pelvic pain will require additional surgery. Getting pregnant would require IVF, the only option for bypassing an abnormal pelvis. Do not be under the misunderstanding that doing the surgery to diagnose and treat the endometriosis and adhesions will restore your fertility. In fact, the opposite will occur because every surgery leads to further adhesion formation. Only do the surgery if the pain is a significant problem. If pregnancy is the priority, then go straight to IVF. In many cases, getting pregnant will help the endometriosis pain.

Good Luck,

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

U.K. Infertility Patient Had Four Fibroids Removed, Now Has Pain Upon Ovulation - Ovarian Adhesions?

Question:

Hi Dr. Ramirez,

I am a 28 year old lady who has been trying to conceive for 18 months. I had an ectopic pregnancy last June, but thank God both tubes are still intact as I was diagnosed early.

I decided to have a laparoscopy in February 2010 to find out what is wrong and my doc took out 4 fibroids and I also had mild adhesions to the right ovary but apart from that the tubes and the uterus looked healthy. But since the laparoscopy, I have been having this unbearable ovulation pain on the right side which I never experienced before. It lasts for 3-4 days. The pain is very uncomfortable and right hand side of the abdomen is very sore and tender. It feels exactly like the pain I had when I had the ectopic.

My question is could the adhesions be back on the right ovary already? If so, if they were mild before the lap, is it possible they got worse after the lap? Also, would the laparoscopy affect the functioning of the ovary as I have been having abnormal basal body temperature since the lap.Lastly, is it possible to ovulate from the same ovary every month, as I don't think I am ovulating from the left ovary at all?

Is my only chance of conceiving IVF?

Many thanks in advance for your suggestions. Regards, B. from the U.K.

Answer:

Hello B. from the U.K.,

Yes, adhesions can return and usually return within 24 hours. Also, any surgery, including laparoscopy, can result in adhesion formation. Normally, when you ovulate, your ovaries swell thereby "moving". Unfortunately, the adhesions may be fixing the ovary in place causing you to have uncomfortable pain. I would not expect the laparoscopy to affect your ovarian function if the ovary was not damaged in any way or its blood flow affected.

Yes, it is possible to ovulate from the same ovary every month.

My opinion is that you have tubal disease that was probably caused by some type of event, like an infection in the past. That usually leads to internal tubal damage and scar tissue formation. If significant enough, you can also get scar tissue within the pelvis and around the ovary and tubes. The main problem is that if there is damage within the tube, it cannot be fixed. These internal adhesions are probably what caused the embryo to get stuck in the tube, leading to the ectopic. Certainly patients that have had ectopics before do subsequently have normal pregnancies, but there is no way to know which category you will fall into. With the combination of problems, ectopic and peri-tubal adhesions, I would expect that your natural chances of pregnancy are low, in which case, IVF would be the treatment of choice. That is how I would advise you in my clinic. You could certainly continue trying with a more natural method such as ovulation induction with timed intercourse or ovulation induction with IUI. You need to be seen right away if you get pregnant because of your increased risk of recurrent ectopic.

If you don't get pregnant after a period of time, I would set it at 6 months or no more than 4 IUI attempts, then I would proceed directly to IVF.

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.

Pelvic Pain Proper Diagnosis and Treatment Needed

Question:

I have been married almost two years and I have not been able to get pregnant. I have noticed a clear mucus on the tissue when I go to the bathroom. I went to the clinic because of pelvic pain and the nurse told me that she does not see any signs of an infection but gave me doxicyclin and metronodazol for 1 or 2 weeks. She told me that she noticed a lot of cervical mucus. I had also had the same pain issue 5 months prior and was given doxicyclin then by a different doctor whom also said that she did not see an infection but because I recently had an IUD taken out there might be a little bug in there bothering me. I had an IUD removed in Jan/07. I was in for about 3 months. I was not comfortable with the idea of this foreign thing inside me all the time. I feel a sharp pain and discomfort during sex and also I am shocked that I have not been pregnant yet.

I already have one son who was induced a week past due date, and I have been pregnant a few times after but terminated those. I have never seen this heavy clear mucus before. What is it, and why do I keep having this pelvic pain? My weight has also ballooned up 70 pounds in the last 3 years, and I am under a lot of stress. I feel exhausted all of the time and can barely walk up a flight of stairs without taking a break. I am currently at 220pnds and I am 5"8 tall. I hope you can shed some light on my concerns. Thanks.

Answer:

One of the problems seeing a nurse practitioner is that because they have a limited knowledge base, they treat indiscriminately. As in your example, the nurse practitioner did not detect an infection, yet treated you with two antibiotics. She is essentially covering you for two types of infections. That of course, is improper medical treatment.

I am surprised no one has suggested a pelvic ultrasound. If the pelvic examination was not remarkable, then that would be the next step in your evaluation. You may have a cyst or tumor. Some cysts and tumors express increased amounts of estrogen, which could be why you have an abundance of clear mucous. Clear mucous is usually not due to an infection but due to hormones. I would request a pelvic ultrasound. If the ultrasound does not reveal anything, then you should consider a laparoscopy, which is an outpatient surgery to look into your abdomen and examine the pelvis. Considering your fertile history in the past, and now no pregnancy but pelvic pain, there is a high possibility that you may have developed endometriosis or scar tissue. These entities can cause pain and inhibit fertility.

Finally, your weight is the issue for the remainder of your symptoms. Your ideal weight is 140 lbs. Your are carrying an extra 80 pounds which causes you and your muscles to have to work harder. I would bet that the difficulty going up the stairs is partly due to this and partly due to being out of shape. There have been studies showing that increased weight also decreases fertility, so you may want to use this a a reason to exercise and lose weight.

I hope this answers your questions. Start by insisting on seeing a physician and go from there.

Good luck!

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com