Empty Gestational Sac After IVF

Question:

Hello, Dr. Ramirez,

Does In Vitro increase the odds of an empty gestation sac? I am 6 weeks pregnant and had an ultrasound with no heart beat detected. I bled just before the ultrasound but there was no bleeding before that.

Two frozen embryos were implanted but only one sac is visible on the ultrasound after the bleeding. The sac is round and empty. What do you think?

Answer:

Hello,

I'm sorry about the news. The answer to your question is no, IVF does not increase the risk of genetic abnormalities in the fetus. An empty gestational sac is due to the lack of development of the fetus. That occurred AFTER implantation, and therefore, after the IVF. It probably occurred due to a genetic defect in the embryo that implanted. It is considered a form of miscarriage, which can occur in up to 40% of pregnancies whether natural or IVF.

Many women who get pregnant naturally are not aware that they are even pregnant before they "lose" the pregnancy. Because we test and ultrasound IVF patients soon after transferring the embryos, they have the opportunity to learn if their pregnancy is proceeding or not proceeding earlier than most. This is not necessarily a bad thing, since actions can be taken to prevent miscarrying in subsequent IVF cycles.

Good luck and keep trying!

Sincerely,

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

30 Yr. Old TTC'r With Elevated Estradiol Levels- May Be Physiological Cyst

Question:

I am 30 years old and have been trying to get pregnant for 3 years. I have had 4 cycles of Clomid including 3 cycles of IUI. I ovulate on my own, have regular painless periods, and no apparent endometriosis. HSG shows clear tubes.

Bloodwork done 7 months before shows estradiol, FSH and progesterone within the normal range. My husband who is 32 has low sperm motility (about 47%) and morphology shows 71% abnormal sperm heads. We decided to go ahead with IVF+ICSI and since my RE thought I may not need to supress my ovaries too much, I was on birth control pills for only 2 weeks starting in the luteal phase. For my baseline appointment and bloodwork they discovered that I had elevated levels of estrogen (about 190) so I was called in after 4 days.

I did my second set of bloodwork today (had taken my lupron shot before going in) and my level was 185 which they thought was still high so they have canceled my IVF this month. Since I live in a small town and we have just one RE I have been scheduled for November. I am very disappointed and I wonder what went wrong. Can you please help me understand why the levels went so high.

Answer:

Hello, to answer your question as best I can without being able to evaluate your condition myself, an elevated Estradiol level is an indication of ovarian hormone production. The ovary needs to be down regulated prior to starting the stimulation medications. Usually a persistent elevated Estradiol occurs because there is a persistent cyst present in the ovary.

This cyst is producing the estrogen. If then continued the cycle, you would not stimulate well, and pregnancy would not ensue. I would have cancelled the cycle as well. I'm sorry that you have to wait until November, however.

I presume that your RE put you back on OCP's so technically you would be ready to start the cycle in September.

Follow Up Question:

Thank you so much Dr.Ramirez, however I have not been diagnosed with PCOS and my ovary did not seem to have a cyst during any ultrasounds. I was always told that the ovaries looked great and the lining was great.

Do you think it might have been missed?? :-( I have been reading on the internet and came across an article about how a weak liver can not filter the estrogens. I have had malaria thrice and maybe the meds I took made my liver weak? I have also worked in a research lab and handles a lot of teratogenic material..do you think that might have affected something?

I know I sound paranoid, but it's the first time I have had a test report that was not normal.

Follow Up Answer:

The cyst I was referring to is a physiologic cyst, not the cysts of PCOS. If there was no cyst at the time of your baseline ultrasound, then something is producing estrogen. There are very few things that produce estrogen. It is not from your history of malaria. The liver has to be in failure before it significantly affects the processing of hormones and medications. You would know if you were in liver failure!

Your history of working with teratogenic materials would also have no impact. Something else is producing hormones. You might want to ask your doc what it could be. Hormones can only be produced from hormone producing structures and the ovary is the only structure that produces estrogen. You are not taking estrogen from another source such as medication are you? The only non-ovarian source would be certain types of tumors.

If the estrogen level goes down after your course of birth control pills, then that would rule out any type of tumor. In that case you should be good to go.

Good Luck!

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

No Period, Low BMI Can Equal Hypoganodotropic Hypogonadism

Question:

I'm a 27 year old woman. I'm not pregnant. I went off the pill 7 months ago, and have not had a period since, though I had light spotting in response to a progesterone challenge. I'm about to be evaluated for PCOS, but I have a hard time believing this is what I have.

I have always been thin, and in the past I was told this was why I did not menstruate when I tried to go off the pill. I have made the effort to gain a little weight and my BMI is about 19 now. I work out regularly, though not more than 50 minutes a day. I have no family history of PCOS, diabetes or insulin resistance.

In the past 7 months I have developed benign PVC's of my heart, and have had a mild increase in facial hair and hair around my navel (this is why they think I might have PCOS).

My question is, are there any other conditions that might cause my symptoms that I should be aware of when I go to have the blood tests? Should I be tested for premature ovarian failure and hyperprolactinemia as well?

Thank you so much!

Answer:

Thank you for your question.

Your history does not quite fit PCOS. The most likely diagnosis is hypoganodotropic hypogonadism. It is a long name for saying that your brain is probably not stimulating the ovary. It is likely due to a lack of adequate body fat. Not premature ovarian failure. Since you had a little response to the Provera challenge, that shows that you are making a little estrogen, but the increase in hair growth is consistent with an elevation of the male hormone testosterone. If the ovary is not stimulated to ovulate, it does not produce estrogen and the available hormone precursors go to make testosterone.

Body fat is important because it is the chemical basis for the production of all hormones. If the body fat is too low, because of excessive exercise or anorexia or bulimia, the brain shuts down the production of FSH and LH. This leads to a lack of stimulation of the ovary, hence the above result.

This diagnosis can be made with blood testing. You should be tested for FSH, LH, Prolactin, TSH, Estradiol and Testosterone. This would test all the possible sources of your lack of menstruation. They will probably find that your FSH and LH are very low. Your thyroid may also be out of sync because of the same problem. TSH is the preliminary test for thyroid function.

It would be best if you could get your BMI up above 20, and increase your body fat content.

I hope this helps.

Sincerely,

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

Monterey, California, U.S.A.

Tubal Reversal Vs. In Vitro Fertilization

Question:

I was diagnosed with PCOS 6 years ago. I had one treatment of Clomid and became pregnant soon after with healthy twin boys. At the time I had decided to get a tubal ligation soon after delivery but now I am regretting the decision I made. Now after so many years I am finally having a very regular menstrual cycle.

My question is, what would be the better option for me: IVF or a reversal of my tubal ligation?

Answer:

Hello, Here are the pros and cons for both options that I usually share with my patients:

*Tubal reversal or reanastamosis

It is a surgical procedure. Some surgeons do it as a large open incision and some as a small incision. Tubal reanastamosis is not covered by private insurance. The large incision will be very expensive ($20,000-$35,000) with a 6-8 week recovery. The small incision can be done as outpatient surgery but will cost $8 - $12,000. Recover will be 4 weeks. The latter surgery is skill-based and should be done by a physician comfortable with a mini-lap procedure to insure success.

The pros are that if the procedure works, you can get pregnant over and over by natural means.

The cons are that it is a surgery, and that success depends on the surgeon, the length of the tube after repair, and the type of tubal ligation that was done. There is an increased risk of a tubal pregnancy (surgical life threatening emergency). Pregnancy rate will vary by age and will be less than the equivalent rate in the normal population. You will need contraception again if you don't want more than one more child. You have to at least try for one year following surgery to get pregnant and determine if the reversal worked. If it hasn't, then the only option left is IVF for an additional cost.

*IVF or in vitro fertilization

IVF is a non-surgical procedure and will cost approximately $15,000 per attempt (which includes the IVF, medications and lab tests). It is sometimes covered by private insurance.

The pro is that it is not surgery, that you will get pregnant with minimal waiting, it is great for those who want one or two more children and that it has a much higher pregnancy rate than trying naturally, especially if you are older. Sometimes you will have enough eggs fertilize that some can be frozen and used for a later frozen embryo transfer, giving you the leisure of deciding to have another child when the time is right. It is not painful to have the eggs retrieved or transferred into the uterus and it is performed as an outpatient procedure.

The con is that it is expensive (as described above), that you have to take injections on a daily basis for a short period of time (although they are not too bad) and that you may have to do it again and again if you want to have more children. It is not a "natural" process since in vitro fertilization is done in an embryology lab.

In closing, nowadays, because IVF pregnancy rates are so much higher, we recommend IVF over tubal reanastamosis. However, the doctors that don't do IVF tend to recommend tubal reversal. The doctors that do both, as I do, tend to recommend IVF because it is better. It is more of a sure thing than the surgery. However, if you are still under the age of 35 and know that you will want to have more children, then the reanastamosis might be the best way to go, assuming that it works. The costs will be about the same, but if it doesn't work, then you have to do IVF. Most of my patients will choose IVF since it has a better chance of success for the money.

Good luck with your decision and whatever you do decide, I wish you success.

Sincerely,

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

29 Yr. Old IVF Patient Told She Has "Bad Eggs", Husband Has Balanced Translocation

Question:

A bit of history...2 miscarriages in the last 2 years. We were referred to an RE who did testing and found that my husband has a balanced translocation. We were advised to do IVF with PGD - I had no apparent problems. Our IVF cycle resulted in 10 eggs, 7 fertilized, 3 made it to day 3 for pgd and stopped dividing later that day. The PGD revealed very abnormal embryos with multiple trisomies and some chromosomes with only 1 copy.

The dr said I must have bad eggs - he indicated he was very surprised because all my levels were normal and I'm only 29. he has suggested donor eggs. I'm wondering if I should try another protocol or just go along with the donor eggs. I feel like I'm too young to have bad eggs but since no embryos lived there must be something wrong right?

Any advice would be greatly appreciated!

Answer:

Your history is a little odd, because for someone your age, I would have expected a better outcome in terms of the number of embryos to test. It is most likely that the abnormal embryos are coming from your husband. Not you. I think, unless finances is a problem, I would continue trying. You will eventually have a good embryo, and hopefully, a subsequent cycle will give you more embryos to test. You were not stimulated very strongly and could be. Because of the poor embryo development, I would try to get you to produce 15-20 eggs. That will probably require more medications. PGD can be done to check the embryos with subsequent cycles to see if they are chromosomally normal or not. Keep in mind though, that recent studies have shown decreased pregnancy rates with PGD, probably due to embryo injury or affects from removing one of the blastomeres. In other words, you may harm a potentially "good egg".

If you go another 2-3 tries and still no normal embryos, then I would suggest you consider donor sperm with IUI. You could do IVF but that would be much more expensive. I would think that if you persist in having abnormal embryos it is because of the abnormal sperm. That is why I suggest donor sperm. If you are dead set on having a genetic child from your husband, then you will just have to keep trying using IVF.

I don't agree that your outcome in the first cycle is a sign of bad "eggs", especially at your age.

Good luck and try to keep in mind that you do have options.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

E2 Levels Falling While On Follistim, Why? PCOS Patient Asks...

Question:

Hi, I am a 29/f with PCOS, secondary amenorrhea, non-IR, normal weight. We've done Follistim + Ovidrel + IUI 3 times and it never worked. Upon HCG administration my E2 was around 500 never higher. My RE works at a superbusy teaching hospital clinic.

This cycle we are doing the same thing with injectables. My E2 dropped from 400 to 60 but my follicles are still growing (dose never changed). Why is this? I tried doing some research and journal articles indicate that this is correlated to poor outcomes even in IVF. I also think that I have no LH in my body because before the cycles on Follistim my test line on the OPK's would be half as dark as the control, now I see absolutely no test line on all the days prior to HCG trigger.

Answer:

If the E2 drops despite the follistim, that is an indication that the follicle is either not growing or deteriorating. It is the growing follicle that produces the estradiol. You are correct, this heralds a poorer prognosis. It is possible that you may need some LH in addition to the FSH (follistim).

You should discuss this with your doc. Keep in mind that it is difficult to get a PCOS (polycystic ovarian syndrome) patient to stimulate normally, and at a low rate with injectables. Most will overstimulate and produce too many follicles which necessitates that the cycle be cancelled.

For this reason, 85% of PCOS patients will eventually need to use IVF (in vitro fertilization) to be successful. It is the only way that we can control the number of embryos transferred into the uterus despite the ovaries over stimulating. At your age, your chances at succeeding at IVF with a positive pregnancy are very high and it is possible that there would be embryos to freeze as well for a future (cheaper) frozen embryo transfer if you would wish to have more children.

Good Luck!

Sincerely,

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.

Too Many Rounds of Clomid Will Inhibit Pregnancy

Question:

I have been trying to conceive for two years. So far, I have done 12 total cycles of clomid. We hare having issues getting my follicles mature. I am now taking metformin daily, dexamethasone on CD 1-14, and clomid on days 3-9. I have ultrasounds on CD 14 and usually find immature follicles.

I am wondering, do all these meds seem excessive? All these meds are making me crazy! At what point should conceiving be considered not possible?

Answer:

Thank you for your question. You have already exceeded the number of cycles on Clomid (clomiphene) that is recommended by ASRM (American Society of Reproductive Medicine) and fertility experts. You need to move to something else. I presume you are seeing a General Ob/Gyn for your treatments. Find a fertility sub-specialist and transfer your care. At this point, you should be moving to IUI or IVF, and certainly the gonadotropins. NO MORE CLOMID.

It is this type of prolonged Clomid treatments that get Infertility specialists upset with general OB/GYN docs. All that are strictly recommended are 4-6 cycles at the most. Clomid will inhibit pregnancy after too many consecutive cycles. It works by blocking the estrogen receptors and tricking the brain into thinking it is not making enough estrogen. The brain then stimulates the ovaries harder. After a while, the Clomid will block all the estrogen receptors, which are required to produce adequate cervical mucous, adequate uterine lining and tubal motility. So in essence, it will be preventing pregnancy.

In terms of getting pregnant, it depends on many factors. I tell my patients that I can get anyone pregnant. The difference is what I have to do to get them pregnant. So, you have lots of other options. However, if you don't get out of your current situation with your current doctor, then you will be wasting a lot of time, just as you already have.

Good luck and keep trying, only not in this manner.

Sincerely,

Edward J. Ramirez, M.D.Executive

Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California

www.montereybayivf.com