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.

 

Finally Pregnant After Multiple Miscarriages: "I Am A Nervous Wreck!"

Hello Dr. Ramirez,

I've written you in the past regarding my fertility challenges and your responses have been very encouraging. In my last, I discussed how I'd experienced an early loss in March after our first IVF attempt. You encouraged me to be strong and keep trying that my chances were good. You were right. I waited until my next cycle began and started a more simple IUI cycle again with just Follistim injections. My first miscarriage in April 2012 after IUI with Femara/GonalF was caused by trisomy 3. I found studies that said use of Femara in some women could increase the chances of aneuploidy. This time we tried without the Femara and I have become pregnant again.

I have gone through the complete RPL panel-DNA analysis, autoimmune, alloimmune, thyroid, hysteroscopy, etc. Everything has been normal. I believe the second miscarriage, because it began just 16 days after embryo transfer, was due to my body being weak (I was very sick during stimulation and had a lap/hysteroscopy/cystectomy 3 weeks before I started stimulants). I am 32, maybe borderline diminishing reserve (last AMH was .9), but otherwise nothing really bad with me.

So I am currently past 9 weeks. My betas doubled and were actually in the higher end of the ranges for weeks along. I did a viability ultrasound at 5 weeks and could see the heartbeat. Embryo measured exactly the right size. At 7 weeks we could hear the heartbeat at 174. RE saw me again at 8 weeks and said I looked good, released me to my OBGYN, said most women miscarry between 7-8 weeks. I've had no spotting or cramping. OBGYN is letting me do weekly scans until I'm through my first trimester. Heartbeat has stayed in the 170 range. Growth is continuing. Last ultrasound at 9 weeks showed the baby kicking its legs.

Here's the thing - I'm a nervous wreck. I'm terrified of something going wrong again. I am fighting to follow reason rather than fear but it is so hard. I have hardly any symptoms certainly none of the "noticeable" ones which means most of the time I don't feel like I'm pregnant. My last HCG was only at 102,900 when it was checked at 8.5 weeks, which I felt was low for where it had been but I know it slows down. My progesterone in the beginning was all the way up to 75 and is now holding at 30 (I had cysts leftover from after the IUI, made 3 follicles).
The statistics are all over the place. Some say less than 5% when heartbeat is detected but that can jump to 20% if you've had prior losses. I read it's even less once you enter the fetal stage past 8.5 weeks.

I feel stupid for asking but your answers are thoughtful. What do you think my chances are of carrying this baby to term? What would you say my change of miscarriage is? And why in the world do I hardly feel anything? I'm a little tired in the evenings and I pee in the middle of the night with crazy dreams, breasts are bigger but not sore, no nausea, etc.  But hardly anything to notice. Thank you so much for your time.  L. from Indiana

Answer:

Hello L. from the U.S. (Indiana),

CONGRATULATIONS :)  Like your RE, I release my patients at 8 1/2 weeks gestational age because the risk of miscarriage is minimal.  Statistics show that the risk of miscarriage is up to 50% prior to 8 weeks gestational age and then decreases to 5% up to 12 weeks gestation.  So you are now at 5% risk but the fact that all the signs have been good, is very encouraging and I would not worry about miscarrying.  At this point, the only risk of a miscarriage would be if there is a major genetic abnormality, and this would be a baby that you wouldn't want to go to term any way.  You should certainly consider genetic testing early to check on that.  There is now a blood screening test that can be done at an early stage.

In my experience, and as evidenced by the data, most patients will have a successful pregnancy and delivery at this point.  The fact that you "don't feel any different" with this pregnancy is irrelevant.  Every pregnancy is different and different people experience pregnancy differently.  Some have pregnancy symptoms and some have none.  You may be one of the lucky ones that doesn't have to suffer with the "morning sickness" or other such symptoms.  For now, pray that all continues to go well and thank God for the blessing.

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.

 

38 Year Old Has Five Failed Fresh IVF Cycles But Has Frozen Embies: Should She Try FET?

Question:

Hello - I have been reading you blogs for some time now and am so thankful that you take the time you do with such thoughtful answers.

I am 38 and husband is 41. My history is as follows: 2009 wasted time on clomid prescribed by my obstetrician, 2010 saw RE (reproductive endocrinologist) and began the real journey. Major issue is male factor morphology but I suspect with my age quality may be issue too.

In 2010 we had 2 Fresh IVF (in vitro fertilization) cycles, first was a failure 3 eggs collected, thankfully 3 fertilized and implanted 2 (1 frozen) but no pregnancy, cycle 2 doubled my stim meds to 300 gonal f and 150 repronex, collected 13 eggs but transferred 2 "decent" but beta was very low around 70 the pregnancy continued to around 11 weeks saw heartbeat but clearly there was issues as the size kept loosing ground until miscarriage and D&E. Cycle 3 same meds, 13 eggs, transferred 2 on day 5 and then arrived my beautiful baby girl delivered 12/29/2011.  Fast forward to 2013 where I have done two more fresh cycles same protocol, birth control, 10 lupron, to 5 lupron when stimming, retrievals after 9-10 days of stims. Cycle 4 resulted in collecting 20 eggs, 2 "decent" transferred on day 5 (blastocyst and morula) very low beta resulted in loss about a week later.  Cycle 5 same protocol except menopur instead of repronex, collected 18 eggs, 14 fertilized and transferred 2 blastocysts on day 5. This was a negative. BTW all cycles are ICSI and included medrol, baby aspirin, antibiotics, vivelle patches and  progesterone in oil injections. 

My question is what are your thoughts on FET (frozen embryo transfer).  I have 4 frozen embryos 1 from cycle 1, 1 from cycle 4 and 2 from cycle 5. RE and hubby think I should take a break and try for FET. I and concerned as I don't want to "waste" a cycle insurance will cover on the lower cost option but the meds did really affect me this time and see their point about giving my body a rest. I am at a very reputable clinic in Boston and doc said 4 frozen is a lot due to their strict freezing criteria so am optimistic although obviously embyro age has no advantage. Would FET also be something you would recommend at this point? Fresh cycles are a big logistical challenge as my husband travels 70% of the time.

Also if I go back to fresh cycle is there anything significantly different you would do (btw I am also doing acupuncture). Thank -you in advance for your time. I also want to say I am very grateful for my daughter and don't want to seem selfish but I would really like her to grow up with a sibling. 

J. from Boston

Answer:

Hello J. from the U.S. (Boston),

It sounds like you are in good hands.  Your clinic has accomplished several pregnancies, which is an IVF success.  Keep in mind that IVF can only give you the "opportunity" to become pregnant.  It can't make you pregnant because the last three steps (embryo hatching from its shell, attachment to the endometrial lining, and lining growing around the embryo are natural processes that are in God's hands.  That fact that you got a pregnancy (positive bHCG) shows that those steps occurred.  Continuation of the pregnancy is then based on pregnancy factors and not IVF factors.  Because of your age, your chances of a miscarriage are high due to abnormal embryos.  You've shown that you can get pregnant, and your ovaries stimulate very well.  Now it is just a matter of finding the perfect egg/embryo which will then lead to a successful pregnancy.  I wish all my 38 year olds responded as you do.  So hang in there!

I think I would advise proceeding with the FET cycle before another fresh cycle.  It is a much easier cycle on your body, and some newer studies are showing better pregnancy rates than fresh, probably because of the lack of overstimulation of the endometrial lining.  I don't completely agree that FET is "better" but it certainly gives a good chance.  If they fail, you can certainly try fresh cycles again.  I would advise two FET cycles consecutively.  In fact, I always advise my patients to do an FET cycle, if they have frozens, before trying a fresh cycle again.  You never know. . . the frozen might work.
In terms of additional protocol changes, you are doing everything that I have my patients do in terms of supplemental medications, but I also add low dose heparin (2000 U per day).  Not all RE's agree with this protocol, but it is an accepted protocol for recurrent pregnancy loss so you might want to ask your RE.

Thanks for following my Blog.

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.

Comment: Thank you much for the quick and thoughtful answer. I have several time contemplated seeking a more aggressive clinic despite my comfort level. Your response puts many of my worries at ease. You are truly a huge help to those of us in a constant state of limbo. Thanks again.

 

39 Year Old With Recurrent Chemical Pregnancies

Question:

Hello there! I’m writing to you from Florida. I have recently suffered two miscarriages. One in Oct of 2012 and one in March of this year. Both occurred at about two weeks so very early. I guess the term is chemical pregnancy when it is that early. I don't know how I know I am pregnant so early but I just know. My body is sensitive! I am 39 years old so my Dr. watches me closely and had me do the clomid challenge test to check the fsh which I think tests egg quality. Mine was 7.6. I also had a vaginal ultrasound and everything looks perfect. No fibroids or cysts. Then in March 2013 I got pregnant again and I was immediately sent for an hcg blood test. My hcg levels kept going up and down 241 to 119 over the course of three weeks and it would not leave my system completely so I ended up having to have another ultrasound that found nothing as they were worried about an ectopic pregnancy but did not find a sac or anything. I ended up taking a methotrexate shot.

Finally my levels went back to zero and 6 weeks later I did a complete recurrent miscarriage blood panel test and they found that I tested positive for two copies of the mthfr CT677 gene. I also was out of range for the PAI-1 test which was 51. Everything else was normal. My Dr. put me on foltx and a daily aspirin plus I take my prenatal vitamins and she told me that as soon as I find out I am pregnant again I need to start administering lovenox injections and progesterone suppositories. Right before delivery it would change to heparin. I enjoy reading your blog and appreciate all of your knowledgable answers. I would like to know what your thoughts are about the regimen she has planned for me and if there is anything else I should be doing. I am a bit nervous to try again. We really want to have a baby!  

Thank you, M. from Florida

Answer:

Hello M. from the U.S. (Florida),

The CCCT is to check for ovarian reserve (ability of the ovary to respond to stimulation) and not egg quality.  Thought you should know that.

It sounds like your Ob/Gyn doctor is well versed in the evaluation and treatment of recurrent pregnancy loss, which makes her a little better than the average Ob/Gyn doc.  One thing to keep in mind, however, is that you have the "age factor" which means that your eggs are old and debilitated and therefore have a propensity to forming abnormal embryos.  In most cases these embryos will not continue and lead to a miscarriage (especially before 8 weeks gestational age).  The age factor is the main factor that you are trying to overcome.  There is no treatment that can make eggs better.  The good news is that your ovaries are still functioning well, and you know that you can get pregnant.  Now it is just a matter of getting a perfect egg.

The increased folic acid, low dose aspirin, low dose heparin or lovenox and progesterone supplementation are all reasonable and acceptable treatments for recurrent pregnancy loss. What I would recommend is that the heparin/lovenox start immediately with the start of your period, NOT once you become pregnant.  It should already be in your system when implantation occurs to help with increased blood flow at the implantation site, and decrease the immune response to the embryo.  Starting after pregnancy would defeat the purpose.

Based on your age, I would agree with the above regimen, add CoQ10 600 mg per day (found to help with egg quality in mice.  No human studies yet but it can't hurt) and strongly recommend that you consider IVF rather than continuing to try naturally.  I know that you are able to get pregnant naturally, and it may eventually happen, but the only way to increase your chances of success (overcome the age factor) is to increase the number of eggs and embryos you have to choose from.  With IVF, you have a better chance of finding the perfect egg.  I explain it to my patients with the following analogy: imagine that you have a bucket of blue balls and a few red balls. There are mostly blue balls and only 4-5 red balls.  The red balls represent your good quality eggs and the blue balls the poor quality eggs.  These balls are all mixed up together and you lift the bucket above your head so that you can't see inside.  Now you have several options.  You can take one ball out at a time (like you would in a naturally ovulatory cycle) whereby you will eventually get a red ball, but you can see that it will take a long while; or you can take out a handful of balls out at a time (like using superovulation with fertility drugs); or you can dump out a bunch of balls at a time (like doing IVF).  You can see that the latter method is the fastest for getting to a red ball.  That is why IVF (in vitro fertilization) is the recommended treatment.  With a red ball (good quality egg) not only will you get pregnant, but you will have a successful pregnancy because a normal embryo will develop.

Sorry for the extremely long explanation, but I hope my answer has been clear.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVFwww.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.

 

How To Reduce The Risk Of OHSS

Question:

Hello,

I have been able to get pregnant naturally, but due to my kidney disease was not able to carry to term.  I have about 50 percent kidney function due to mild segmental mesangial sclerorsis.  I'm planning on pursuing surrogacy and would like to know what you would recommend for cycling treatment to reduce to the risk of OHSS (ovarian hyperstimulation syndrome) during the stimulation process?

Thank you, R. from California

Answer:

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

First, I would choose a good IVF clinic.  OHSS is mostly due to overstimulation.  You'll want a doctor that is cautious, has a protocol to reduce the chances of developing OHSS and watches his patients carefully.

Second, OHSS tends to be most common in patients with PCOS where the ovaries are very sensitive to the stimulation.  If you don't have PCOS, then the chances of developing this problem are lower.

Third, patients at risk for OHSS get less medication than patients not at risk.  That is because their ovaries are so sensitive that they don't need much stimulation, and in fact, you don't want to stimulate them too strongly.  So a low dose FSH only or FSH/LH protocol is used.  I also don't use the "long protocol" in patients at risk for OHSS.  The long protocol is using Lupron injections starting from the luteal phase of the preceding cycle.  I use the antagonist protocol (the antagonist is to prevent spontaneous ovulation by suppressing the ovaries) which then allows me to trigger with Lupron instead of HCG (such as Ovidrel).

Finally, the estradiol levels and close monitoring of follicular growth are required so find a physician/clinic that works closely with their patients.  A large "factory" type of clinic is probably not a good choice. See this article regarding an American egg donor who underwent an IVF cycle through a Canadian clinic in 2011 to get an idea of the worst case scenario:  http://news.nationalpost.com/2013/03/28/kylee-gilman-sues-toronto-fertility-doctor/

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.