Stage IV Endometriosis Patient Trying To Conceive: More Time, More Surgery or IVF?

Question:

I was diagnosed 4 years ago with stage IV endo after having it excised during a lap. I had a Mirena IUD inserted during surgery and just had it removed a few months ago because I am ready to have a baby. I am very regular (26 or 28 days) and ovulation predictor tests show that I am ovulating on day 12 or 14.

Five cycles later we are not pregnant. I feel my ovaries pinch a few days before my period and am back to having pretty bad menstrual cramps (though not as bad as before the surgery). I have read a lot of your responses and see that IVF (in vitro fertilization) is your advice for stage IV endo. Do you think I am ovulating normally and what do you think my next step should be? I have a doctors appointment and am very nervous that he is going to suggest another laparoscopy!

Thank you in advance for your time. M. from the U.S.

Answer:

Hi M. from the U.S.A.,

Thank you for reading my responses. Technically, you have not tried for pregnancy long enough to suspect that a problem exists. We do not define infertility until a woman under 36 has been trying for at least 12 months because it takes most women in that age group 8-12 months to achieve pregnancy naturally. If you are 36 or older, then 6 months would be the limit.

Certainly because of the history of stage IV endometriosis, you have a significant impairment to your natural fertility. Mirena helped, but it is not perfect. There is no treatment to eradicate endometriosis completely, and so it is highly probable that endometriosis is still present in the pelvis. In addition, stage IV endometriosis implies that there has been significant damage to your pelvis and it is not normal i.e. pelvic adhesions, inflammation, destruction of the normal anatomy. These will impair your natural chances for pregnancy. For that reason, in many of these patients, but not all, IVF will be required to get pregnant. I have had some spontaneous pregnancies in stage IV endometriosis patients but they are few.

Let's say after six months or one year, you still cannot get pregnant (depending on your age), you will need to pursue other options. Knowing that you have Stage IV endo, additional surgery will NOT help. You may want to go straight to IVF and avoid the surgery. That is what I would recommend. Many gynecologists will recommend the surgery because that is all they can do, they don't do IVF. They would rather do something in their power than do nothing. Instead, a good gynecologist will refer you to a fertility specialist that does IVF for at least a consultation. A good infertility specialist will probably explain that the pelvis, an essential part of your anatomy for achieving a natural pregnancy, is a hostile place for the egg. Therefore, the treatment of choice is to avoid the pelvis which is what occurs with IVF.

Good Luck on your journey and don't hesitate to write again with any other questions,

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: Thank you so much, you have quelled much of my anxiety. The scariest part about facing fertility problems is all the unknowns and the waiting. I appreciate your help.

Stage 2 Endometriosis Patient: Life & Fertility After Lupron?

Question:

Hi. My name is B. I am 26 and I live in Mississippi. I was diagnosed with Stage 2 Endo in June of 2009. Within 4 months of the lap (performed in June) I was already experiencing high levels of pain during urination, bowel movements and intercourse. My doctor had previously recommended Lupron, but I had declined so I went on continuous birth control. I still had high amounts of pain on a regular basis. I decided to do the treatment after the pain returned so quickly.

While on the shots, I didn't experience nearly as many hot flashes as I had expected and I only gained about 12 -15 lbs. I had my last shot about 27 days ago (3.75mg) and I want to know what I can expect.

When should I start having a cycle again? Also, I have had some mild-moderate pain during the last 3 months of my treatment and occasionally what felt like menstrual cramps. My doctor said he thought it was probably scar tissue.

Any thoughts on the pain I experienced during the second half of my treatment? Any thoughts on my statistical time frame for the possibility of having a family vs. infertility. My boyfriend is very cynical and doesn't believe my best chance at a family is within the next two years. How adamant should I be about going for it considering my circumstances? Thank you!

Answer:

Hello B. from Mississippi, let me answer your questions in sequence:

1. In general, the normal cycle will resume within 3 months of the last month of Lupron injections. That means, give yourself three months after the one month from the injection.

2. I can't explain the pain that you had in the last 3 months of treatment. Scar tissue is a possibility but the symptom is so nonspecific that I can't give a more definite answer.

3. In general, I advise patients to begin trying for pregnancy immediately after completing a Lupron treatment because there is a 6 month window before the endometriosis will return and inhibit fertility. If you are not in the position to try for pregnancy right away, then you should follow the Lupron with some type of prophylactic treatment to prevent the immediate return of the endometriosis. I recommend Depo provera but if you don't want to take this, then a low estrogen dose, high progesterone birth control pill is second best. Do not use a high dose estrogen pill (30mcg or greater) because the estrogen feeds the endometriosis. Again, Depo provera is my preference.

4. Lastly, I hope you don't mind this piece of advice: You should never insist on having a child with a partner. It needs to be a mutually acceptable proposition. Having a child is a life-changing event. You want your situation to be stable before then.

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.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV

Very Confused Woman With PCOS & Endo, Who Is Anovulatory: TTC & Not Getting The Right Treatment

Question:

I was recently diagnosed with PCOS, (after many years of suffering with endo also) and we've been TTC for 2 years. I have been taking 1,000mg/day of Metformin to help control the insulin resistance. I have long anovulatory cycles and was recently seen by my doctor who wants to put me on Ortho-tri-cyclen to help get my cycles back under control. She said that women with PCOS have too little of estrogen and that is why I am anovulatory.

I have always learned that women with PCOS are estrogen dominant, so now I'm very confused. Which is it? Also, will I see ANY benefit from the birth control pills, after I stop taking them? Will it help to make me ovulate? I have not ovulated since November, which of course makes it difficult to TTC without that important factor.

Thank you in advance. L. from the U.S.A.

Answer:

Hi L. from the U.S.,

First, you are taking an inadequate dose of Metformin, if you have been found to have insulin resistance. The recommended dose is 1500 mg per day.

Secondly, your current doctor is incorrect in that OCP's (birth control pill) is only a treatment to regulate the cycles. If a woman with PCOS is not intending to become pregnant, then the treatment of choice is to use the birth control pill. This is the recommendation that medical doctors in my field will give you. That is mainly because the pill/patch/ring are made of estrogen and progesterone and override your ovaries. It will do nothing for your fertility. Also, the reason why you are anovulatory is because PCOS (polycystic ovarian syndrome) is an ovarian dysfunction that leads to low estrogen, high testosterone levels. It is NOT the other way around.

Once you stop the OCP's you will go back to your normal anovulatory cycles. If you want to get pregnant with PCOS, you need to use a medication that will induce the ovaries to ovulate such as Clomid, Femara or injectable medications. I would recommend that you see a fertility specialist, who understands this problem better and won't waste your time, so that you can get pregnant in the shortest period of time. My job, as an infertility specialist, is to try to get my PCOS patients pregnant. The goal is to get them to ovulate! We use fertility drugs such as the ones mentioned above for this purpose, but it varies as to how a patient responds to these medications. The "fertility drug" is actually stimulating the ovary to ovulate.

Also, keep in mind that endometriosis is also a cause for infertility so in essence, you have two problems that are preventing you from getting pregnant.

Please read further on PCOS in some of my earlier blog posts. There is one in particular with a link to a radio interview that I did on the subject. See the February blog post: http://womenshealthandfertility.blogspot.com/2010/02/interview-on-pcos-challenge-talk-radio.html

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.