Concerned About Tubal Blockage

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

Answer:
Hello Concerned from the U.S.,

You basically have two options:

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

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

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

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

I hope this helps,

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

Monterey, California, U.S.A.

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

Birth Control pills before IVF

Question:

Hi Dr Ramirez,
I am 42 y/o with an fsh of 6. I am to start IVF soon. Before I start stimming, my RE wants to put me on birth control pills for one month .

Is there any benefit to being on BCP for 1 whole month before
IVF? I feel like this is delaying my Ivf for too long.

Thank you, Lisa from Tustin.

Answer:
Hello Lisa from the U.S.,
　
You certainly don't need to go on the birth control pill, however, previous studies have shown it to be an advantage for several reasons:

1. It puts your ovaries in a stasis mode so that it will be more responsive to stimulation.
2. It allows us to take control of your ovaries more tightly when the stimulation begins
3. It allows us to program your cycle.

I too use BCP prior to starting IVF for the above reasons. Other than having to wait a little, it has no other detrimental effects. If you trust your IVF doctor, then you need to trust him completely so that you will get the best possible outcome. Your age is already a significant factor, and we do all that we can to try and overcome this and have developed specific protocols for that. The best you can do is follow your docs advice and not try to second guess him, especially via the internet (which has too much nonspecific information). If you don't trust him/her, then you should find a doc and/or clinic that you have complete trust in. After all, it is a very expensive process you are going through.

Good luck,

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

Monterey, California, U.S.A.

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

Recurrent Miscarriage and Factor V Leiden

Question:
Hello Dr Ramirez,
I hope you can help me.
I live in London England. And am a patient at Kings College Hospital London.I have recently miscarried for the fourth time.I had 3 previous miscarriages and following tests discovered i am heterozygous for factor v leiden.Following this I had a successful pregnancy using one low dose clexane and baby aspirin daily.I now have a beautiful baby daughter who is 8 months.I got pregnant quickly afterwards but miscarried recently at 10.5 wks again using clexane and aspirin.Can you shed any light on why I miscarried again.I thought I would be ok using the clexane etc,I thought this was the answer,but it didn't seem to work this time round.Is it likely this may happen again if I get pregnant?Is there anything else I should be trying?I hope you can advise.
Kind Regards

Answer:
Hello Nicola from the U.K.

Factor V caused recurrent miscarriage through an increased risk of blood clots at the tiny vessels feeding the pregnancy. Therefore, the key to treatment is to use medications that decrease this clotting. Obviously the low dose aspiring was sufficient for your previous pregnancy. I don't think the Dexane (dexamethasone# contributed much. It is a steroid and used mainly to decrease the inflammatory response, however I also use it for my IVf patients to reduce the chances of rejection of the embryo. The recommended treatment is to use low dose heparin #2000 units twice per day) or Lovenox beginning at the start of the menstrual cycle or treatment cycle, in addition to the aspirin. I use both. I think that your overall chances for another successful pregnancy are good. You still might have additional miscarriages but that could be due to other reasons as well. There is an overall risk of miscarriage in 40% of pregnancies just due to random abnormalities. But don't worry about it too much. Keep trying, and I am confident that you will be successful.

Sincerely,

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

Monterey, California, U.S.A.

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

Permanent infertility from past infections?

Question:
I am 35 years old and have never achieved a pregnancy. In the past I have been diagnosed with chronic BV, trichomonas, HPV, PID, and endometriosis. I recently read that all of these conditions could be symptomatic of a unicellular microorganism called microplasma genitalium. What information do you know of this organism? I have been successfully treated for each of these infections. Is there a specific fertility treatment that I should try with these past issues? Is my infertility permanent? I have been symptom free since my divorce 3 years ago.

Answer:
Hello Lynn from the U.S.,

The main problem with this variety of infections, is that some of them could have led to tubal damage. That is, the bacteria ascend into the tubes leading to inflammation and scarring. Once the tubes are damaged, they do not function and so natural pregnancy cannot occur. The way that we currently check for this is using a test called the HSG (hysterosalpingogram) to see if the tubes are open. This still is not specific enough but if there is severe damage to the tubes, it will return showing the blockage. If one tube is blocked, you can assume that the other is damaged as well, although it may not be blocked. If the tubes are blocked there is no other alternative other than IVF for treatment of the infertility. IVF works by bypassing the tubes by extracting the eggs directly from the ovaries.

Endometriosis can also be a cause for infertility. Endometriosis is a pelvic disease that causes the pelvis to be inflamed. It is thought that this inflammation attacks and kills the egg at the time of ovulation. In addition, it can cause scar tissue formation in the pelvis that will prevent the egg from getting to the tube. Again, in cases of severe endometriosis, IVF is the treatment of choice.

At 35 years old, your age is now going to be a factor A woman's fertility decreases significantly after the age of 35. Therefore, if you are contemplating getting pregnant or having children, you might want to start aggressively trying with IVF. If you have never undergone an infertility evaluation, then you should start there. IVF may not be your only option.

Sincerely,

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

Monterey, California, U.S.A.

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

Progesterone Injections & Travel After IVF

Question:

Dear Sir,

Our first IVF (during June 2008) failed and so, we are going for the second IVF which is FET (frozen embryo transfer). I have the following questions:

a) Progesterone-in-oil shots: During the last IVF it was very difficult and stressful to have the intra-muscular shots every day. After a week, the muscle became very rigid and at some point could not even poke the needle into the muscle. Will it be okay if I do a hot water massage after every shot? I am concerned because some nurses are saying it may raise the body temperature and could cause problems.

Are there any alternatives for intra muscular injections (for progesterone)? One of the nurses is suggesting to apply directly into the vaginal area. Since we haven't done that before we are not sure how tedious is that and the possibilities it could go wrong.

b) Will it be okay to travel long distance (approx. 3 hours) in a car - three days after the transfer?

Thanks so much in advance for your valuable suggestions.

Roger

Answer:

Dear Roger,

The progesterone injections are probably the worst of all the injections because it requires a bigger needle and the fluid is thick. I have changed from a prgesterone in sesame oil to a progesterone in canola oil that my pharmacy make us (MDR). Because it flows easier, we can use a smaller bore needle to reduce the pain and it doesn't harden up. You might want to check into that formulation. MDR Pharmacy is an infertility specialty pharmacy and you can get your meds via mail. It is also less expensive.

In terms of hot packs at the injection site, that would be fine. I don't expect that will change anything at all if it stays local.

Also, make sure you are rotating the sites i.e. one buttock then the other. You can also change the specific sites in the buttocks as long as you are in the upper outer quadrant. Make sure your nurse shows you all the areas that you can use.

As an alternative to IM progesterone, you can also use vaginal progesterone. There are several formulations: Crinon 8%, Prochieve 8%, Endometrin 100mg and pharmacy formulated versions. Several very good studies have shown equal efficacy to IM 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. Some programs, such as USC, have switched to vaginal completely. If your wife cannot tolerate the IM Prog or has an allergic reaction to it, then you can switch to the vaginal version. Crinone and Procheive are twice per day, and Endometrin is three times a day. They are messy but they don't hurt.

In terms of travel, yes it is okay to take a three hour trip after the transfer. As long as your wife is in a resting position, such as sitting, then you can travel. I only don't recommend strenuous activities such as exercise, karate, horse back riding, running and the like.

I hope this helps!

Edward J. Ramirez, MD

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook http://www.facebook.com/ejramirez and Twitter with me at @montereybayivf

Alchohol Effects on Sperm

Question:
Hello and thanks in advance for your services. I'm a 24yr otherwise healthy male, and my fiance is a 22yr old healthy female. My question is can alcohol affect fertility? I recently was a heavy drinker and party goer, drinking around 8 beers a day and on the weekends more, I know the health affects it has on my body otherwise that is why I dont do this anymore. Me and my fiance was looking to have a baby and about a week ago, when I was still partying hard, she doesn't drink but MAYBE once a week, and during this particular night she endulged in quite a few, we came home and had unprotected sex in hopes that maybe we could conceive, it was around the 13th-16th day of her cycle. My question is what are the chances we could concieve given my strong previous alcohol use before and that night, and her VERY mild alcohol use before but strong that night?????

Answer:
Hello Michael from the U.S.,
　
Yes, alcohol can affect one's fertility, both male and female. Male sperm is produced on a 90-day cycle. That means that the sperm you are producing today won't come out for 90 days. So, whatever you did 90-days ago (alcohol or drugs) that may have affected the sperm production and quality, will be manifest in the sperm you give out today.

If you are trying to conceive, then both you and your fiance have to lead a healthy lifestyle in order to enhance your fertility and so that you have a healthy baby. That means no smoking, no alcohol, no drugs, healthy diet and exercise.

Sincerely,

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

Monterey, California, U.S.A.

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

PCOS and Infertility

Question:

Dear Dr. Ramirez,

I have been married 17 years, we have had unprotected intercourse for that long. About 10 years ago I went through a year of testing to find out that because of higher than normal testoterone levels my cycle is off kilter and I would not conceive. I went on three rounds of Clomid and still my cycle never evened out and no eggs. Now at 37, for the last year my cycle has started and is becoming actually fairly regular monthly. Without sounding completely brainless, is there a chance my body would be starting to regulate itself enough that I might ovulate, and at this point do you think clomid may help my chances of pregnancy? Is there something I can do to maybe help it along, or am I destined never to ovulate?

Answer:

Hello Shari,

You have or had a disorder called "polycystic ovarian disease". This is an ovulatory dysfunction whereby the ovary does not ovulate on a regular basis. Because the ovary is dysfunctioning, it does not produce the appropriate levels of female hormone so that the male hormone, testosterone, becomes elevated. Most of the patients with this disorder do not respond to Clomid. The appropriate next step would have been to use injectable medications and/or proceed to IVF.

Based on your age, and history, I would recommend that you go directly to IVF. You still have a good chance of pregnancy at your current age, but the chances are decreasing significantly each year. Right now, you have a 40 - 50% chance of pregnancy with each IVF cycle. At age 40, that reduces to 27%.

Certainly, if your cycles have become more regular, then that indicates that you are ovulating. Clomid would help in that case to increase the number of eggs that you ovulate, which is what you want to overcome the age factor. You want to ovulate 3-5 eggs per cycle. If your cycles are not regular, that is 28-30 days each month, then forget the Clomid and proceed to IVF. You have been married a long time to not have had children. Now you are running out of time. You need to be more aggressive if you want to have a child from your own eggs.

Sincerely,

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 http://www.facebook.com/ejramirez and Twitter with me at @montereybayivf