37 Year Old TTC With Past History Of Hyperplasia & Endometriosis Is Desperate To Conceive

QUESTION:

Ok, I went to the Gyno in Dec of 2009 because I wasn't getting my period. He sent me for an ultrasound Jan. 2010 and the lining of my uterus was thickened so he did a biopsy which led to my first D&C which was April. I was diagnosed with hyperplasia of the uterus and he said I was producing too much estrogen so he put me on Depo provera.

I got my first shot April 19. 2010 and he told me if I didn't go on the depo shot I would definitely get cancer. I had my second shot July and then I had another D&C September and everything came out good, hardly any tissue. After the D&C the Gyno said he wanted me to stay on the depo till I go through menopause ughh!! I've had three more shots, one in Oct.. one in Dec. and my last shot was March 21, 2011. I want to have a child and in late July I will be 38. My gyno said I could go off the depo shot, so I asked him what if it takes me a year to get pregnant? He said, "You're not allowed to take that long you'll get cancer of the uterus for sure."

I think I need a second opinion & I'm hoping my withdrawal from the depo isn't so horrible. One thing I think you should know is I was diagnosed in my mid 20's with endometriosis and my gyno (back then different doctor) said I didn't have a lot of tissue he also never told me I couldn't conceive, he just said after you have children just get a hysterectomy. I was put on different forms of BC (birth control) over the years and my last form of BC was the NUVA ring. I always had bad cramps w/ my periods so he had me wear the ring continuously. I would wear it for three weeks and take it out and put in a new ring right away to avoid periods, when I was doing that I had break through bleeding all the time & that's where I think all the excess tissue came from with the hyperplasia. I've been on the depo shot for a year and three months then I'm due for my next shot which I don't want.

I'm writing from South Jersey. I only want to have one child! Please tell me what you think. Thank you for all your time. :)

ANSWER:

Hello A. from the U.S.,

First, I don't think you need to worry about the hyperplasia at this point. You have been adequately treated for it. You just need to make sure that you have regular cycles because not shedding the lining at least every three months is what can lead to hyperplasia, and if left untreated the simple hyperplasia can turn into atypical hyperplasia (precancerous) which can then turn into cancer.

I think that pregnancy is a good idea for it and you need to pursue it aggressively! Your age is the number one issue at this point, in terms of getting pregnant. A second issue with getting pregnant is the history of endometriosis. Depo Provera is certainly a good treatment for this disease but endo can recur and can impede pregnancy. Considering your age, I wonder if there are other factors as well since you have never gotten pregnant to date. My recommendation, in general, to patients at 37 years old or older is to strongly consider IVF (in vitro fertilization). Other than age, you don't have an absolute indication for this, unless something else is found wrong, but the chances of pregnancy are so much higher with IVF than any other treatment at your age.

For example, your natural chance of pregnancy is approximately 3% per month or 5% per month with IUI. On the other hand, with IVF it is 69% per month in our clinic, and at least 50% across the country. That is a significant difference. The problem with age is that the majority of eggs that you still have will be of poor quality so the only way to increase your chances to find an egg with good quality is through IVF. You can certainly try with more natural methods but with each month that you fail, your chances are decreasing (it's like chasing your tail).

I would strongly recommend that you go to a good IVF clinic and have a consultation. I know that there are some excellent ones in New Jersey.

Follow-Up Question:

One more question, being on the depo shot for this time period (one year & 3 months) I'm afraid as to how long it will take to get out of my system. Reading posts by women who've been on it much longer than I (like 7-12 yrs.) say it can take 6-18 months to start a normal period & ovulate again. Any suggestions on how to rid the depo from my system when I'm actually due for my next shot? I've read lots of water and excercise.

Thanks again after this no more questions I'm sure you're busier than ever.:) A. from New Jersey.

Follow-Up Answer:

Hello Again,

I don't have any solutions to how to speed up the return of your natural cycles. The Depo can linger for a while but I have never seen it take more than 2-3 months. If you want to start trying for pregnancy sooner, you could undergo ovulation induction and that will get your ovaries to stimulate and ovulate.

You are very welcome to ask your questions and thank you for your patience in waiting for my reply.

Good Luck,

Dr. 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: Dr. Ramirez was very helpful to me I really appreciated his input. Thanks again!!

Woman With Endometriosis Failed IVF Cycle: Poor Egg Quality? Age Issue? PGS?

                                                                                                                                                    

Question:
I am 38 years old from Los Angeles. I just had a failed IVF cycle because my six embryos arrested on Day 5. On Day 3, five were Grade A and one was Grade B. They were 10, 8 and 6 cell. Doctor blames my age for the embryos arresting and basically said my eggs are poor quality. I find this confusing, since they were top ranked on Day 3. I've done one previous failed IVF last year at a different clinic (and still have a frozen Grade B blastocyst from that), but the doctor never blamed my egg quality. My AMH is 2 and other hormone numbers are normal. First IVF, they retrieved 27 eggs. This IVF, they retrieved 16 eggs.

I don't know my fertilization rate  for my most recent IVF because my doctor never told me how many of my eggs were immature, only answering that some of them were. For my first IVF about half the eggs were immature, and I had about a 50 percent fertilization rate. I have endometriosis, which has never been treated. It was discovered 2 1/2 years when I was having a myomectomy, but the doctor didn't remove it, only noting that I had significant ovarian endometriosis but no endometriomas. I've read that endo can affect egg quality or do you think the only issue here is my age, and I should just give up on IVF? My next step is to have a laparoscopy to remove the endometriosis.

Thanks for your time. N2N from California.

Answer:

Hello N2N from California USA,

I think that age has a significant effect on egg quality and that is the issue with age.  More and more eggs become less and less fertile.  There was a study recently that looked at IVF patients that were 37 years old and underwent PGS. PGS, or preimplantation genetic screening, is the proper term for testing for overall chromosomal normalcy in embryos. This involves removing a cell from an IVF embryo to test it for chromosomal abnormalities before transferring the embryo to the uterus.  Only 2 out of every 10 embryos were genetically normal.  So, even if they make it to blastocyst, there is still a chance that the treatment would fail because of abnormal embryos.  In general, there is debate as to whether endometriosis needs to be removed prior to IVF because of a potential effect on pregnancy rates, but there is no clear indication that endometriosis absolutely affects eggs unless there is an endometrioma present and/or the endometriotic fluid contaminates the fluid at retrieval.  If you want to be sure that it is not a factor, a laparoscopy followed by three months of Lupron should take care of that issue, but I'm not sure I would have you do it if you were my patient.  I think you are battling an age issue.

It is not unusual for good looking day #3 embryos to not make it to blastocyst.  In one of my patients recently, we had 12 embryos that were good quality (grade 1 or 2, 6-8 cells) on Day #3.  We cultured all of them and only 6 made it to blastocyst.  The rest arrested before Day #5.  So, your doctor is probably correct that this failure was due to egg quality.  That is what you are battling.  The bottom line is that IVF is trying to help you find the one or two good eggs that are still remaining in the ovary and it will just take time.  If you want it to go faster, then you need to move to donor eggs to improve the egg quality, but if you want a genetic child, then you need to resolve that it may take several attempts.  Unfortunately, there are no technologies yet, that can improve egg quality.  Only repetition is the option.  As long as your ovaries still respond well to stimulation, so that we can get a lot of eggs at retrieval, then you have a good chance of being successful if you hang in there.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com 

Monterey, California, U.S.A.

Conceiving After 45: IVF With Your Own Eggs Or Donor Eggs?

Question:

Dr Ramirez,

What are the chances of a 45 year old woman conceiving using IVF with her own eggs? Would it be worth trying or would you recommend using donor eggs? A. from the UK

Answer:

Hello A. from the UK,

There are always exceptions to the rule, however, the chances of pregnancy, even with IVF, are very slim.  In the 2012 National summary produced by our Centers for Disease Control (CDC), based on IVF reporting data, the national averages for women >44 years old is 5% pregnancy rate and 2% delivery rate.  This, of course, is an average and the statistics can be different for different centers.  There have been pregnancies over 44 years old but they are very few.  In my center, the oldest patient to get pregnant using her own eggs (as opposed to using donor eggs) was 44 years old.

I tell my patients that only God can determine who will be the exception to the rule, but if you don't try, then you have a 0% from the start.  However, if you decide to try, you have to go in with the understanding that your chances are slim.  Until you try, you won't know the outcome.  If you want a better chance, the donor eggs will be much better.

I have a 45 year old patient contemplating this now who is leaning toward trying at least once because she wants to reassure herself that she has done everything possible to have another child (she has one already).  I told her, and you should understand this too, that IVF is not a perfect technology even in young women, and like trying naturally, it can take several tries.  So if you want to be absolutely sure that you tried your very best with IVF, then you need to be prepared to try several times.

As to whether or not it is worth it, that is a totally individual decision.  The worthiness of something is defined by yourself.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com 

Monterey, California, U.S.A.

 

 

Fertility At 40 After Having Had Children Earlier In Life: Is It Still Good?

Question:

Hello. I just turned 40 years old. I am healthy. I had 1 miscarriage in my early 30s. I waited a few years to conceive after that and conceived two children back to back in the first month of trying so I am hoping my fertility is still good. Obviously Im reproductively old and there is an issue of egg quality. Is it always better to try to conceive naturally. We are worried about chromosomal disorders. I had testing done at a fertility clinic. My AFC was 14, my FSH was 6 point something and my AMH was 5 point something. Can you help me interpret this? Again, is it always better to try to conceive naturally? Thanks!!! S. from the U.S.

Answer:

Hello S. from the U.S.,

Having had children previously does extend your fertility in my opinion so although you are "reproductively old", you may still be quite fertile.

The tests mentioned, AFC, FSH and AMH are all INDIRECT measures of ovarian function and NOT fertility or egg quality.  They give us an idea of how well the ovaries will respond to stimulation, which statistically can increase or decrease your chances of success.  In older women, the more eggs you get in an IVF cycle, the higher the chances of finding a good egg because there are fewer good eggs with increasing age.  That is all that those tests reveal.

In terms of what may be the best way to get pregnant, certainly trying natural has significant advantages: it is more fun and pleasurable, it costs less.  The disadvantages are: there is an increased risk of genetic disorders (based on your age), it may not work, and there is a higher risk of miscarriage.  So, in terms of whether to try naturally or go with a technological means, it depends completely on your personal preference and goals.  Unless you want to do something like genetic testing of embryos for normality or sex selection or want to increase your chance of pregnancy in the shortest possible period, then I would recommend that you try naturally for at least 6 months.   If not successful by that point, then I would recommend that you consider proceeding directly to IVF, which is the recommendation if you say yes to either of the previous criteria.  The downsides of IVF are: cost, not fun, unnatural and it's a medical procedure.  The upside is it is more efficient (higher chance of pregnancy per attempt, you can genetically test the embryos to minimize the risk of miscarriage or genetically abnormal child and you can achieve pregnancy faster.  Because your ovarian testing is so good (more like a 20 year old), you are a very good candidate for IVF and I would probably give you a high chance of success per attempt (50-60%) in a good IVF center.

 

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

 

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.

 

42 Year Old TTC With Endometriomas And Low Antral Follicle Count

Hi Dr. Ramirez,

Not sure what to do.  I met the love of my life later in life and we just started trying to conceive, I am 42 years old.  We really want to have a child, but not so sure about donor eggs .  I have never been pregnant or attempted to get pregnant before. Six months ago my AFC=3, FSH=6.3, E2=117.  My results today were AFC=0, FSH=1.4, and E2=252 and two endometriomas that appear to be growing.  Could the endometriomas have caused the change in numbers?  If so, would removing them increase my chances of becoming pregnant?  I've read that surgery reduces the ovarian reserve which is not a good thing so I'm confused as to what to do.  I've also had a hard time figuring out which doctors would be gentle/skillful and not remove any unnecessary ovarian reserve, this could be crucial in my situation.  I would like to do IVF (in vitro fertilization) but the clinic I've gone to is not willing to discuss it due to the change in numbers.  Are there any clinics that will work with my numbers and the endometriomas?  We want to give it our best shot, it would mean so much for us to have a baby together.

My pelvic transvaginal ultrasound results were: 

FINDINGS: The uterus is normal in size measuring 7.9 x 3.9 x 4.6 cm.  No fibroids or other myometrial abnormalities are visualized.  The double layer endometrial thickness is normal measuring 7mm. No focal endometrial abnormality or endometrial cavity fluid is seen.

Right ovary is enlarged.  The right ovary measures 6.1 x 4.4 x 6.1 cm.  Homogeneous hypoechoic structure in the right ovary measures 5.1 x 3.9 x 5.7 cm previously 3.9 x 2.6 x 3.8 cm (on 18Nov2012 ultrasound).  The left ovary measures 4.2 x 2.5 x 3.9 cm. Hypoechoic structure in the left ovary measures 3.6 x 2.5 x 3.2 cm previously 2.0 x 2.0 x 2.4 cm (on 18Nov2012 ultrasound). No abnormal free fluid is seen.

IMPRESSION:  Normal uterus. No uterine fibroids are seen.  Homogeneous hypoechoic structures in both ovaries, increased in size since 18Nov2012.  Findings most likely represent endometriomas.

Thank you so much for any advice you can give us. L. from Virginia

Answer:

Hello L. from Virginia,

First, I think that your blood testing is incorrect.  The reason is that the FSH test is only valid if done right at the beginning of the cycle, generally cycle day#2 or 3.  I suspect that the test was not correct because your estradiol was above 100 in both tests. This shows that the ovaries were not at rest i.e. not in the early phase.

Second, I am sure that you can find a clinic or doctor that is compassionate enough to allow you to try IVF (in vitro fertilization) with your own eggs, but that will be with a complete understanding of your chances.  For example, I don't have a blanket policy to not allow patients to try as long as they understand the risks and chances.

Third, you have to understand the major problems you are facing and the impact that has on your chances.  The first major problem is your age.  This is what we call the "age related egg factor".  This basically means that because of a woman's age, the quality of her eggs decreases so that the majority are no longer viable.  As a result, the pregnancy rate decreases and the risk of miscarriage due to genetic abnormalities increases. Even with IVF your chances will be decreased, BUT they will much better than trying naturally! The second major problem is Stage IV Endometriosis.  When you have endometriomas, that automatically makes it stage four, which is severe endometriosis.  As a consequence, IVF is the treatment of choice.  You can, and probably should, try to find a very good gynecologist to remove the endometriomas laparoscopically, with specific instructions to NOT remove any ovarian capsule tissue (that is the layer that has the eggs).  That will help to give you the best chances of pregnancy.  However, it is not an absolute necessity. Third, you have a decreased antral follicle count (AFC), which is supposed to represent the number of follicles available, but frankly, I don't rely on that too much.

You can achieve pregnancy if you go about it with an open mind and choose a good clinic. For more information on endometriosis and infertility, as well as other age-related factors please see these pages: “Endometriosis” and “Age Factors” in my website’s section on Understanding Infertility.

Good Luck,

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

40 Year Old TTC After Termination Of Trisomy Pregnancy

Hello, Doctor.


I am a 40 YO who has never had any trouble conceiving. I've been pregnant seven times. I had a child when I was 37; all went fine.

My husband and I are TTC (trying to conceive). GYN did an AMU (.86) a year ago. He said there was little hope. Nevertheless, I was pregnant in January, but the CVS @ 11 weeks revealed a double trisomy (13/21). We terminated the pregnancy.

Beginning with that particular pregnancy I have experienced pronounced pg symptoms within days of fertilization. They are symptoms I would expect to arise @ 6 weeks. I have had these symptoms each month when my husband and I try (with the exception of one month). My assumption is that I am experiencing hormone surges, but I have my period on time, and I have not had a positive urine test. I have tried a "control month" of abstiinence, and there were no symptoms. Also, no symptoms one other month (although we had tried).

I had a hormone panel on day 3 of my cycle, and another when I had begun to experience the nausea, tenderness, food aversion, fatigue, etc. GYN reported that the baseline was totally normal (FSH 3 and all other #s in range). The second test indicated that levels had changed, but still in normal range and not consistent with pregnancy. He has no explanation for these symptoms U/S's have been clear. No cysts or fibroids.

I did not experience these symptoms with my daughter or any other pregnancy.

I began taking lamictal in 09 150mg daily and .5 Klonopin daily. The addition of these meds and age are the only variables. My dx is Bipolar 1. I have found no research that supports either medication as interfering with implantation. The genetic counselor said the meds are a nonissue.

I have wondered if perhaps the procedure with the trisomy situation has harmed me somehow. My GYN said I never should have been able to implant an egg so defective.

So it seems, now, I will continue to experience these incredibly uncomfortable symptoms every time I fertilize an egg although my prospects for implantation seem dismal. I get all the bad stuff and hope for a good result that doesn't materialize.

Any words of wisdom would be appreciated.  Thanks, S. from California

Answer:

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

Your symptoms are confusing and not easily explained. First, you cannot tell whether or not fertilization takes place. That occurs within the embryo and nothing within the body is changed at that point. You would not have symptoms. It is possible that the symptoms you are having are "hormonal shifts" or physiologically the result of the rise in progesterone in the luteal phase. Why would you be more sensitive to this now than before? I can't clearly explain that but you are also older now than you were before so maybe that had something to do with it. Normally, the pregnancy symptoms don't begin until weeks after implantation occurs, so it is unusual. But the progesterone is the culprit for PMS (premenstrual syndrome) which does have some of the symptoms that you describe. I don't think it was the D&E (dilation and evacuation).

Your doctor is right and wrong about the trisomy. It is well known that age is a significant factor and leads to increased numbers of embryos with chromosomal abnormalities. This leads to infertility and increased miscarriage rates. In most cases of complex or multiple abnormalities, the embryo never gets to the point of implantation. But if the defect is not significant enough, as in trisomies, implantation can occur but then most will end in miscarriage. Few will continue to the point where genetic testing finds the abnormality but they do occur.

As you continue to attempt pregnancy you have to remember these facts. Due to your age, it will be more difficult for you to get pregnant, you have an increased risk of miscarriages and an increased risk of abnormal embryos. Aside from your one successful pregnancy, you note that you have had six that miscarried which is troublesome. You have what we call "secondary infertility". Since there is no technology that can change the quality of your eggs, the only way to increase the chances of a successful pregnancy in older patients (over 35 years old), is to increase the number of eggs that have the opportunity to implant. This is done by increasing the number of eggs that ovulate (superovulation) or through IVF (even higher numbers of eggs). In addition, with IVF, genetic testing can be done on the eggs to eliminate the ones that are genetically abnormal so that only normal embryos are transferred. This is just food for thought.

I hope I was able to ease your concerns.

Good Luck,

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

40 Year Old UK Woman Trying IVF After Implantation Failures: Assisted Hatching & PGD?

PGD

QUESTION:
dear doctor ramirez, i am so glad to find you on this website and would very much appreciate your help. I will try to give you some background.

i have had 3 failed iui, then found problems with my fallopian tubes which led to bilateral salpingectomy, myomectomy, adhesiolysis and cornual tubal occlusion, left ovarian cystectomy, i also have fitz hugh curtis syndrome.


so then after recovery from the above op i had

one fresh ivf cycle - 18 follicles, 14 eggs collected, 8 fertilised, 3 day transfer of 2 embryos(8 cell, grade 2)on 18/10, started bleeding 30/10

fet - 19/3. 2 embryos transferred (5 cell grade 2 & 7 cell

grade 1-) Negative test 4/4

fet - 9/8. 2 embryos transfered (6 cell grade 3/3 & 3 cell grade 4/4) Negative test 24/8

on each occassion as you can see i had 2 embryos put back (blastacysts on the last fet) and all failed at implantation stage. these were in 2006 & 2007.

now in june 2012 i have started my ivf journey again. so far:

low amh result (i am 40 in october)

2 new fibroids found on ultrasound, advised to proceed anyway

down regulation extended 1 week as lining not thin enough

stim injections all went to plan

15 follicles (2 v large suspected to be cysts)

10 eggs retreived

7 fertilised

7 made it to blast but one left to perish as structure wasnt great.

2 fantastic blasts put back after using embryoscope which i was told had started collapsing which was explained as a very good development.

4 frozen.

so, 2 put back in and progesterone pessaries used one morning & 1 night.

day 5 post transfer sign of period.

evening of day 6 post transfer period definately started with heavy bleeding & clots, continued until today (day 9pt) flow seems to be slowing down.

negative test today 9dpt

clinic advised me to continue with pessaries and re-test on saturday (day 11 pt)
theres the background for you, so here are my questions:

1. why am i failing at implantation stage every time?

doctor says it just nature but i cannot help feeling something else could be wrong and i am running out of time

2. is there any kind of contraception or other medication that i could use to stop producing eggs, thus preserving the small reserve i have left?

3. what tests can i have done to rule out ANY other problems? ie immunology, uterine probs, endometrium probs?

4. fibroids-what should i do have them removed or is there any medication available that may shrink them before my next fet

5. assisted hatching-could this help?

6. pgd (preimplatation genetic diagnosis)?

7. having read my history but you advise i do????

if need be i will pay for any tests that they wont complete at my clinic. i feel if i can rule all other possible problems out then i can admit that yes it is in gods hands and just a matter of keep trying but at the moment i feel what if there is something else that is being overlooked?

many thanks for your help in advance doctor.

as you can see i am getting pretty desperate now!

lisa, uk

ANSWER:

Hello Lisa from the U.K.,

The term "Implantation failure" means that the last two steps of the reproductive process did not occur. These last two steps are natural steps and we do not have the technology to make them happen. That is why IVF is not a perfect technology. Once the embryo is placed into the uterus, the embryo has to hatch out of its shell and attach to the endometrial ining. Then the endometrial has to engulf the embryo (implantation). So either of these two steps could have been the source of failure. In addition, it is well know that pregnancy rates will vary from doctor to doctor and clinic to clinic because the transfer technique can play a significant role.

In your previous cycles, your embryo quality was poor. I am not surprised that they failed. In this last cycle, despite having good blastocysts, there is still a potential deficiency that they have. This is because of your age, or what I refer to as the "age related egg factor." We know that as the eggs age, the internal structures of the egg become more debilitated and so less likely to thrive. One of these deficits is the chromosomal structures are more brittle and can lead to chromosomal abnormalities as the cell is dividing. Without doing genetic testing, these cannot be detected. Even chromosomally abnormal embryos can turn into good looking embryos but not necessarily into pregnancies. That is another possible source of failure. IVF helps to overcome this problem by increasing the number of eggs retrieved and therefore, statistically, increases the chances of finding the perfect egg. But that does not occur every time. You will have to keep trying in the hopes of finding the perfect egg eventually. The good thing is that your ovaries are still very responsive (you don't have decreased ovarian reserve and stimulate well), which gives you a good chance.

In terms of your other questions, I would not do anything with the fibroids, any birth control pill can stop your ovaries from going through the ovulatory cycles and hopefully preserve your eggs and I can't think of any other testing. Without thoroughly reviewing your medical record, however, it is difficult for me to give you specific advice.

I would recommend assisted hatching as this has been shown to increase pregnancy rates in older patients. I would also recommend that you scrutinize your clinic, because of all the failures. Pregnancy rates can be very clinic and doctor dependent. You should try to find one that has good pregnancy rates for your age group. I am getting a 57% pregnancy rate in 40 year olds and many of the clinics in the U.S. are getting similar results. I would also recommend that you consider transferring more than two embryos (we allow up to 4 in 40 year olds).

You faith in God will help you through this, and eventually it will happen. You may have to change course at some point and look at a different approach, but your faith will get you to that dream of having a child. When I complete my embryo transfers, I say a prayer with each of my patients and ask God to bless my couple with fruit of the womb and grant their wish for a child. I am confident that he will do so as He wills it.

Good Luck

FOLLOW-UP QUESTION:
hi doctor

thank you so very much for your speedy and detailed response, it has set my mind at rest on a lot of points. it is interesting to be told that the quality of the embryos on our cycle a few years ago were of poor quality. although that is sad, at least now i can accept that maybe that is why we failed on those 3 occassions. i had been under the impression that the embryos were good quality, particularly on the first fresh cycle after egg collection.

i have read lots on assisted hatching and am glad you agree this may be a way forward for us.

can i please just take a few more minutes of your time to clarify my point on pgd & other test (point 3&6)

When you mention checking the quality of the eggs/embryos were you suggesting asking our clinic to go ahead with pgd for our next fet?

also what is your opinion on other testing such as Natural Killer cells, immunology, uterine/endo probs? Which of these or any other tests would you suggest i rule out before going ahead with our fet?

also you mention my ovarian reserve being good but i was under the impression that the AMH test i had done suggested i was on the bottom level in terms of my remaining eggs? this has confused me slightly?

thank you in advance.

many many many thanks for you time again. Lisa

FOLLOW-UP ANSWER:

Hello Again,

There are pros and cons about using PGS. It can help to identify embryos that are chromosomally abnormal so that you can be more selective in the ones that you transfer. The downside is that there is a decrease in pregnancy rates, probably because of the impact of the biopsy on the embryo.

I check certain immunologic testing on my patients that fail two or more IVF cycles. The tests I choose do not include natural killer cells because I don't believe in that concept as a source of implantation failure. Despite this testing, I also automatically place my patients on low dose aspirin, low dose heparin and medrol, as well as, increase the progesterone supplementation. The latter is the treatment for patients that have endometrial biopsy for beta integrins and find that they are deficient. I figure, why waste money on doing the test and just cover any ways, since increasing the progesterone is the treatment.

Remember that AMH is an "indirect" test for ovarian reserve and does not necessarily predict how you will respond. Your have already shown good response so it is not an issue.

Good Luck,

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

How Can I Overcome Implantation Failure After Failing Multiple Fresh & Frozen Cycles?

Dear Dr Ramirez,

I'm a 43 years old female (from Australia) and for the last 2 years have been unsuccessful with IVF (in vitro fertilization) after 3 stimulated cycles and 10 Embryo transfers. I produce a good number of eggs (approx 18) with a stimulated cycle of 300iU/day of Gonal F. This egg number usually decreases at each stage; eg of 19 eggs, 13 are mature to fertilise, 6 fertilise and finally 1 or 2 reach day 5 blastocysts which can be transferred or frozen. All frozen eggs have always thawed well and transferred.

The pattern each cycle is similar however I'm finding that in this latest cycle only one embryo was transferred and the 2 remaining did not reach an acceptable stage for freezing. Implantation has always failed, even with the use of progesterone pessaries after transfer. I've also tried implanting 2 embryos with no positive result.

My specialist has resigned to the fact that my eggs are not of good quality due to my age. No testing on this has been suggested.

In terms of health I have PCO's and have a BMI of 30 (90kgs). I find it difficult to lose the weight which has been gradually gained in the last 8 years, have mild anxiety on the odd morning upon waking and trouble getting quality sleep 2 -3 nights per week. At times I suffer from low mood but put it down to the drugs and loss of hope. But I pull though with the support from family but use no medication. I do take a prenatal multivitamin 150mg of CoenzQ10 and fish oil. In your experience are there other treatments that could be explored for recurring implantation failure? Thank you, S. from Australia

Answer:

Hello S. from Australia,

Based on your embryo development and transfer of at least one good blastocyst, the cause of your failures is not determinable. We classify this as implantation failure but in reality there are two steps that have to occur naturally after the embryo is transferred. These are embryo hatching and attaching to the uterine wall and the endometrium growing around the attached embryo (implantation). We have no way to confirm that these steps are occurring. For that reason, there are no specific therapies to overcome failure at this point, but there are many suggestions for things to try. I say "things to try" because these are not proven remedies either. Also keep in mind that IVF success is not only dependent on embryo quality/normality and endometrial processes, but also on the doctor's transfer technique.

I think that what I would do if you were my patient is:

(1) Abandon the blastocyst transfer. Blastocyst culturing does not guarantee a quality embryo or success. Laboratory techniques, media, etc are not perfect. I wholly believe that the uterus is a better culture media and environment than the lab. Also, some embryos that might be the normal and healthy ones may not develop to blastocyst, as has been shown by numerous studies looking at preimplantation genetic screening.

(2) You could consider PGS to determine which embryos are genetically normal, and therefore have the highest chances for success.

(3) I empirically add low dose aspiring 81 mg per day, Medrol (Prednisone) 16 mg per day and Heparin 2000 Units twice per day starting at the beginning of the IVF cycle in my patients that have had repetitive failures. This is a formula that has been proven to decrease recurrent miscarriages with the thought that adequate micro blood flow and immunological factors may be leading to failure. I also increase my progesterone supplementation by using both injectable and vaginal supplementation, and add estrogen supplementation after the transfer by patch. Acupuncture has also been found to increase success in some studies, possibly by increasing blood flow or by reducing stress. All of these latter treatments are, as I said earlier, unproven. We call it "throwing the kitchen sink in" which basically means trying everything under the sun.

Finally, if you really suspect that it is an embryo problem, then donor embryos would be the remaining option, or you could consider using a surrogate if you think your embryos are okay but the uterus is not hospitable (my presumption is that a diagnostic hysteroscopy was already done to make sure of this).

Keep trying and good luck,

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

Monterey, California, U.S.A.

Conceiving After The Age Of 40: What Are My Chances?

Question:

Hi. I am 43 and began my quest for motherhood about two years ago. I have been on Clomid and Femara and have tried IUI about 5 times. I most recently tried Follistem and IUI. Last month I was on oral contraceptives because of a cyst and returned this month to discover the cyst was still there AND I had another cyst on the other side. The doc gave the option of aspiration of cysts or to consult to discuss options such as donor eggs.

I have been pregnant once, with no fertility help, about 3 years ago (at 40 yo) which resulted in miscarriage at 8 weeks. We had a heart beat then lost the pregnancy. What are your thoughts about my fertility history and recommendations for an otherwise healthy 43 year old? The cysts are producing estrogen--level was checked. Thank you for your opinion. I am writing from Iowa....thanks! S.

Answer:

Hello S. from the U.S. (Iowa),

First you need to understand that you are trying to beat the odds and that statistics is only a reflection of real life, not an exact predictor of it. There are always exceptions. However, we try to make the best decision based on the information that we have.

It is well known and scientifically proven that a woman's fertility decreases with age beginning at 30 years old. This is due to the fact that a woman is born with all the eggs she has for her entire life and those eggs age with her. In addition, she is using up lots of eggs with each cycle so there is also a reduction in the number of eggs available.

We also know that by 40 years old, the remaining eggs will be of poor quality. This leads to a reduction in pregnancy rate or a significant increase in miscarriages, and was probably the reason you miscarried at 40 years old. Your statistical chances of pregnancy with IUI (intra uterine insemination) at 43 years old is less than 0.5% per cycle. This is due to the fact that IUI is still a "natural" treatment method and requires that your body go through the normal steps to achieve pregnancy. As you can see, your chances are not zero, but are pretty slim. (A 20 year old woman has instead a 20% chance of pregnancy per cycle.) At your age, with IVF (in vitro fertilization) using your own eggs, the chances of pregnancy rise to 33% per cycle. Unfortunately, because of pregnancy and miscarriage losses the delivery rate is 13%. It is still significantly better than IUI because most of the steps required are performed by the IVF and only two steps are left to natural processes. With donor eggs and IVF, the chances increase dramatically due to younger and healthier eggs, to 75% with 59% delivering.

Most fertility specialists would recommend donor IVF, but it is a personal choice that you have to make. Most of my older patients want to try at least once with their own eggs and I will give them the chance to try because as I said up above, there are always exceptions!

Good Luck,

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

40 Yr Old Wonders: Should I Use Donor Eggs After Failing Five IUIs?

Question:

Dear Dr. Ramirez,

I would like your opinion on whether I should move on to donor eggs. I am 40 yr and I have 5 failed IUI (intra uterine inseminations), 3 of the IUI was with Menopur injections. The last IUI, my RE (reproductive endocrinologist) prescribed 22 vials where I used 3 vials for 7 days. Each IUI, I have one matured follicle whether its clomid, clomid combo injections or injections only.

One of the IUI resulted in pregnancy but I miscarried at 7 weeks 4 days in 2011 at age 39. Previous to my 5 IUIs, I was able to conceive naturally and got pregnant but miscarried at almost 10 weeks in 2010 at age 38. My FSH is 12 in 2012 but was 20 in 2010. My amy level was 0.5 in early 2011 and 0.25 in feb 2012. I have not tried IVF (in vitro fertilization) yet but I would like to know if the different protocol will make any difference producing more matured follicle. My RE doctor states that he needs at least 3 matured follicle to transfer, if there is not one, the cycle will get cancel and change to IUI. I have already find a donor but i found myself going back and forth to see if its worth going to a IVF cycle or not.

Please help! Thank you, D. from Texas

Answer:

Hello D. from the U.S. (Texas),

I think I would have recommended IVF back when you were 38 years old. In general, if a patient is 37 years old or older, I strongly recommend IVF rather than IUI. The main reason is that the chances of pregnancy with IUI at 37 is 5-10% per cycle vs 60% for IVF. In addition, seeing that your FSH level was already elevated at 12, that would have made a strong argument that time was critical so I would not have wasted it on a low yield treatment plan. But that is "spilled milk" as they say.

Now, you have two things going against you in terms of trying with your own eggs. One is that you are 40 years old so your chances of pregnancy are decreased, but still around 50% per attempt. More critical is that your FSH level is very very high and your AMH level is low. These are not good and indicate that the ovaries would probably not stimulate well. Sure, it only takes one good embryo to achieve pregnancy, which is what I tell my patients, but at the same time, the only way to increase your chances because of your eggs is to try to get a lot of eggs (it is know that the number of good eggs decreases with age). If only a few eggs are retrieved, then the chances of having a good egg, decreases. By the way, I don't agree with your doctor's policy to change to IUI if you have less than three follicles. IVF is clearly better than IUI because more of the steps are accomplished, bringing you closer to implantation, whereas IUI requires that your body go through ALL the steps naturally. In addition, I and many others in the assisted reproductive speciality have experiences with only one embryo leading to a pregnancy. Why give up IVF when it is your best option in such a cycle?

However, given your age, FSH level and AMH, I think that if you are willing to consider donor eggs, that is now the best way to go. I do let my patients try IVF despite these adverse factors because many desire to try at least once with their own eggs before giving that up. If you can afford it, that is an option. But you should clearly understand and be prepared for a failure and be ready to go to IVF with donor eggs.

Thank you for writing and good luck,

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

38 Year Old With One Fallopian Tube: Miscarriage With 2nd IVF

Question:

Hello Dr. Ramirez!

I am 38 and trying to conceive my 2nd child. I did 2 rounds of IVF at 35 and had a healthy daughter at age 36. We just went through another round of IVF and got pregnant, however it ended up in a miscarriage at 10 weeks. We can't afford another IVF so we're trying a few rounds of IUI with Clomid 100 mg. I'm now going for my second round.

My issues are stemmed from a ruptured appendix at 16 which left one of my fallopian tubes badly scarred. I did have a laparoscopy and had that one closed and my other one is totally open. In all the testing for my IVF, everything came back good..."for my age". My husband has a fantastic motility and count, so there's no issues there. My questions are:

1. My RE says that follicle growth is completely random and that they do not alternate sides every month. What are your thoughts on this? I hate to waste the time and money if the follicles grow on the bad side.

2. Have you seen much success with clomid/IUI at my age? Everything is totally normal with me and my husband. We eat good, (I was a smoker from 16-30 but haven't smoked in 8 years) and I rarely drink.

3. If this doesn't work, any suggestions on where to go from here?

BTW, I'm writing from Milwaukee! Thanks!

Answer:

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

First of all, it is wonderful that you were able to already have one child via IVF! This is encouraging.

1. Yes, your RE is correct that it does not alternate but is random. Also, your assumption that the side that it ovulates on is the side where it enters the tube is not correct. In fact, the ovary, being three dimensional, can have a follicle rupture at any part of its surface, even the side that is opposite where the tube is located. So how then does it get to the tube? Well, when the ovary ovulates the fluid surrounding the egg rushes out taking the egg with it and flow down-hill into a space called the culdesac. The culdesac is like a little bowl. The fluid collects here and then with simple fluid motion, it moves around. In normal anatomy, the end of the tube that picks up the egg, called the fimbria, is located in the culdesac, so it you are lucky, the egg contacts the fimbria of one tube and is brought into the tube (like an elevator) where it meets the sperm. This is why a woman who only has one tube on one side and one ovary on the opposite side can get pregnant.

2. Pregnancy rates at 38 years old are around 5% per cycle, which is not very good but it is not zero.The pregnancy rates are less with Clomid than IVF because you and your body still need to go through the 9 step process to achieve a pregnancy whereas with IVF, steps 1-7 are done by the IVF procedure and there is only two steps left to contend with.

3. Monterey, California :) I'm only kidding. You have already shown that IVF can work. The reason that you miscarried is because the embryo was probably abnormal, which is a risk that you have because of your egg. The goal is to eventually get a perfect egg that will give you a perfect and healthy baby. That is probably just a matter of time. The only alternative, which gives you a higher chance for pregnancy per cycle and less chance of a miscarriage, is using donor eggs. But you can do that at any age, so I would try again with IVF if you are not successful with your Clomid cycles, although I understand that finances are an issue. You don't have much time, though. If you do manage another IVF cycle and it fails, then you can always do donor eggs. I recently had a patient who tried IVF in her early 40's, miscarried then failed, and then gave up. At 55 she decided she wanted to try again and went with donor eggs. She now has a beautiful daughter. With donor eggs, your age is not a significant factor.

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

39 Yr Old TTC With Previous Miscarriage: Clomid Vs. Gonadotropins? Flare Vs. Antagonist Protocol?

Question:

Dear Doctor,

I am from India. I am 39. I had two missed abortions at 36 and 37 both in the eighth week and after the heart beat was felt.After leaving a gap of four months I have been trying to conceive naturally for 14 months without any result.

Subsequently I started Clomid 100 mg (day 3-7) at the advice of doctor.I did 3 cycles with Clomid out of which I got two follicles of ovulatory size (more than 18mm) in two of the cycles and one follicle (20mm) in one of the cycles.I did not conceive. My FSH and other hormones are normal.

I consulted a IVF specialist who examined me and said that my ovary volume is good and said that she will go for two cycles of IUI, if they are not successful she will go for IVF.

In my first cycle of IUI, the doctor did a trans-vaginal ultra sound on day 2 and gave the following medications from day 2 to day 5 (1) Suprefact 10 markings in the insulin syringe with 100 markings (BD 100 mark syringe) (between 1 to 2 pm daily)(2) GMH (human menopausal Gonadotropins (FSH+LH)) 225 IU (between 7-9 pm daily)

On day 6 she checked and told me that there is no response and the follicles have not grown.She changed the medication to GMH 375 IU per day on day 6 and day7 (between 7-9 pm daily) (She stopped Suprefact)

On day 8, she checked and told me that the follicles have not grown and advised cancellation of the cycle.Further she said that my follicles are not good enough for future trials of IVF or IUI and advised IVF with donor egg.

I asked her how I could get two ovulatory sized follicles (above 18mm) with Clomid in two of my three monitored cycles but nothing in this cycle and she is ruling out the possibility of the future trials. Her answer was that with Clomid or Letrozole even empty follicles grow and give a false impression that the follicles are growing and ovulating. But with Gonadotropins only follicles with good eggs will grow and that is the reason why my follicles did not grow with Gonadotropins. Is the above statement about Clomid and Gonadotropins correct. I will be grateful for your answer. R. from India

Answer:

Hello R. from India,

The simple answer is "NO. Her explanation is NOT correct." The gonadotropins are more effective than Clomid or Letrozole in recruiting and growing follicles because it IS the hormone the brain sends to the ovary for that purpose. Clomid and Letrozole work by an indirect method to cause the brain to increse its FSH output.

Also, she is NOT correct that gonadotropins only grow "good" follicles whereas Clomid grows "false" follicles. This explanation is made up and not scientific at all. In fact, no such thing exists. Sorry.I am not sure why your doctor cancelled your cycle. If the CD#8 ultrasound (which is early) or Estradiol level are showing a low response, the proper protocol is to continue going. Sometimes the follicle can grow slower. I have had patients get up to 21 days before ovulation occurs. In addition, the FSH should be increased if the stimulation is slow. I do not expect to have ovulatory sized follicles until at least CD#12.

I agree with you that since you stimulated with Clomid previously, you should readily stimulate with Gonadotropins as well. Maybe you should find a new IVF specialist. One thing to keep in mind, however, although your chances are still good at 39 years old, your previous miscarriage show what part of the problem is, which is that the eggs have aged and more and more of them are not of good quality. As a result, there is a higher chance of abnormal embryos which increases the miscarriage rate. IVF should help that because it increases the amount of eggs that are retrieved which in turn increases the possibility of finding an egg that is still good quality. You probably will need a high dose protocol using up to 600IU of FSH. IVF is definitely the way to go!

Follow-Up Question:

Dear Doctor,Thanks for your kind advice.The IVF specialist said the protocol given to me is the flare protocol meant for poor responders. Is that so? Then I do not understand why I did not respond to the protocol.

During my Clomid cycles my follicles reach ovulatory size by day 12. Do you think the poor response in the Gonadotropins cycle could be due the Suprefact Injection which was given from day 2 to day 5 along with Gonadotropins? Also kindly advise if it is necessary to add Suprefact or lupron early in the cycle or giving only FSH will help. Besides doctors here give Gonadotropins (FSH+LH) not Recombinant FSH. Is it better to give Recombinant FSH?

Kindly advise. R.

Follow-Up Answer:

Hello Again,

I do not like to comment on protocol specifics because there is no one way to do things. Please keep that in mind as I answer your questions. The "flare" protocol is one type of protocol used to stimulate the ovaries with IVF. It has no advantage over other protocols, but sometimes is used in patients that are designated as "poor responders". Studies have not shown it to be any better. I personally do not use the flare protocol. My preference is to use an antogonist protocol so that there is no suppression of the ovaries during the initial recruit phase, but I am in the minority in terms of centers that use this type of protocol.

In terms of your stimulation, I still think that a higher amount of medication may be warranted.

Both Suprefact and Lupron are medications called "gonadotropin agonists" and what they do is suppress the brain from producing FSH and LH.Gonadotropins are either pure FSH, pure LH or mixed FSH/LH. This is the name for that class of medications. Some IVF clinics only use FSH, some will use a mixed protocol of FSH and FSH/LH. Examples are Follistim (pure FSH) and Menopur (FSH/LH). My preference is the mixed protocol but many clinics will use FSH only protocols and some will use only the mixed FSH/LH medications. Studies have not show a necessary benefit of any of these protocols so they cannot be compared or criticized. Each doctor and/or clinic has their preferences. The most important aspect is how much FSH is being given because FSH (follicle stimulating hormone) is the hormone that stimulates follicle growth in the ovaries. Also, Natural vs Recombinant forms are equal. There is no difference.

Wishing you good luck with your TTC journey,

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

Can I Thicken Endometrium With Estrogen?

Question:

Dear Dr. Ramirez,

I´m 35 years old (will be 36 in Feb). I have been trying to get pregnant for 2 years (had a miscarriage a year ago). After going to a reproductive clinic, I´ve tried Clomid for 2 cycles with no success, an it really thinned up my endometrium, which usually wasn´t very thick (7-8mm). So my RE recommended to change to Menopur in the next cycle and do a IUI (My husband´s Kruger morphology is 5% - lab reference 4% all the rest is good). This current cycle (no meds) she did an sonogram on me on day 12 (my last period, which followed the Clomid treatment, was only 21 days longer and she wanted to check me for cysts). I had a 20mm follicle and several smaller ones, but my endometrium although trilaminar was only 7mm. For all I have been reading 7mm is not optimal thickness, although my doctor seems to think it´s ok and there´s no need to do anything.

So I was wondering how can I prime it before ovulation? Will taking estrogen help? Will it interfere with ovulation? What are the cycle days you normally recommend your patients to take it and what is the dosage?

Thanks for your time. I really appreciate it. C. from Brazil

Answer:

Hello C. from Brazil,

Yes, you can use estrogen in addition to the Menopur. I use it as an estrogen patch (Climara 0.2 mg per week up to 0.4 mg) or vaginal tablet (FemHRT, Estrace 1 mg up to 4 mg per day). As the follicles grow, they produce more and more estrogen so that should help as well. 7 mm is the minimum size needed, but ideally it should be 9 mms.

In terms of treatment, keep in mind that you have three problems going on. My opinion is that the more problems there are, the higher the treatment level you need to use. The problems identified are: (1) thin endometrial lining, (2) age factor (going on 36yo) and (3) severe male factor. Because of the age and SEVERE male factor, I would advise IVF with ICSI as the treatment of choice. The sperm may not have the ability to fertilize the egg naturally and so ICSI is required. This can only be done with IVF. IVF is also the only treatment that helps to increase pregnancy rates related to age, which is an egg problem, by increasing the number of eggs available to fertilize.

Follow-Up Question:

Thanks for answering my question, Dr. Ramirez.

When would I start taking the estradiol, cd1 and go up to ovulation? I´d like to know so I can talk to my doctor about it.

Also, now I am really concerned about the severe male factor. Is a 5% Kruger morphology that bad even if the sperm concentration is high (85 million/ml) and they show good motility (>70%)? For the IUI procedure, after swim up test and washes, can the doctor choose only the sperm that have good morphology? I´ve read that some doctors think that the Kruger method is really too strict and based on it, most males would be called fertile. What´s your opinion on that? Is there any treatment for sperm morphology (my husband is 37yo)?Thanks again for your valuable time and input! C. from Brazil

Follow-Up Answer:

Hello Again,

1. The estradiol patch or vaginal suppository would begin with CD#1 or 2.

2. If only 5% of the sperm are anatomically normal (morphology), even with an 85 Million count that means only 3.2 Million are available to actually fertilize the sperm (85 Million x 75% motility = 63.75 Million motile x 5% = 3.2 Million). This is inadequate for natural fertility. In addition, when there are sperm abnormalities, there is a high chance that there could be a defect in its ability to fertilize, and there is no test for that other than with IVF. For that reason ICSI is recommended. The embryologist will only take anatomically normal forward swimming sperm for the ICSI (if they are good embryologists).

3. I somewhat agree with the opinion regarding Kruger, but the decision has to be made based on the information that you have. Even 5% normal morphology is pretty low using Kruger.4. Unfortunately, other than ICSI there is no good treatment methods available to change morphology. There are two products that he can try, which are basically vitamins, called Proxeed and Fertility Blend. These can be purchased via the internet. He would need to use them for 3 months minimum. He can then repeat the semen analysis and see if this helps at all.

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

Comment: Thank you again Dr. Ramirez. I wish I was still living in the US to go to your clinic :)

No Period, Retained Cysts & Fibroids, After IVF Cycle Cancelled: 47 Year Old IVF UK Patient Worried

QUESTION:

I am 47yrs. I had my 6th IVF (in vitro fertilization) cycle in September 2011. The drugs used were climara patches10 days before the cycle began, prednisolene 10mg daily, aspirin 81mg daily, bravelle 6 vials every morning, menopur 2 vials every evening later increased to3 vials and antagoni ganirelix acetate injection. I had 5 follicles before the cycle was abandoned. One on right side 9.5 and four on the left 16, 11, 7.5 and 6. My cycle was abandoned because the follicles didn't grow at same rate and the antagonist may have been administered late.

I have two issues:

1) I have not had a period for about 50 days, though I had spotting and a discharge 10 days after the ivf cycle was abandoned. A vaginal US 2 days ago which indicated that I have multiple large follicle/small cysts ..3 large follicles of 20mm each on left ovary and 1 follicle 4.3 mm on right ovary, endometrial thickness was 9.1mm. Urine peg test was -ve. I am awaiting results Blood tests of hormone levels and peg test. My question is is it normal not to have a period long after after some types ivf cycles.since my period returned to normal 10days after my other 4 previous cycles? Or could the drugs have triggered menopause? Would the 3 large follicle disintegrate eventually?

2) I have 6 uterine fibroids, between 20-28mm, outside the womb. Also, a recent immune blood test revealed that I have a raised Th1:Th2 cytokines ratio of 33.2 and Cd19,Cd5 cells of 13.6. The clinic I attend does not think I should be bothered about these issues since the challenge is for me to produce good quality eggs but I wonder if I should continue ivf treatments. What do you advise? I am writing from UK. With regards, M. from the UlK.

ANSWER:

Hello M. from the U.K.,

It's unfortunate that your cycle had to be cancelled. I had to do the same with a patient of mine this month because the follicles were not growing. It happens with decreased ovarian reserve. You have been quite dedicated to your desire to become pregnant and hopefully your dedication will pay off in the end. As long as your ovaries are still stimulating, then there is a chance, given your age.

In terms of your menses not starting, that is probably because you have the three retained cysts present. They are probably still hormonally active and so there is not the hormone withdrawal that i needed to start the menses. You can either wait it out, or your doctor can prescribe the birth control pill to suppress the cysts.

In terms of the fibroids, they are rather small and should not interfere, but there are some studies showing that fibroids can reduce the chances of pregnancy. I agree that the main hurdle you have is your age and the resultant quality of eggs. But, if you were wanting to do everything possible to increase your chances of pregnancy (short of using donor eggs), then you might want to consider having the fibroids removed prior to another attempt. It is not absolutely necessary, but only an option. In terms of the killer cells, I don't anything more needs to be done.I am impressed that the clinic you are attending is being very aggressive in your treatment, and allowing you to continue to try with your own eggs. That is commendable. Many of the letters I received are from patients whose clinics are not very aggressive.

Follow Up Question:

Many many thanks for your answer. It was amongst my junk mail so I did nt see it earlier. I was very encouraged.

My follow up questions are:

1) How long after an abandoned ivf can I try again? Given that my periods have not started. My clinic had advised that I take the pill for two weeks and then start another ivf cycle immediately on day 2/3. However, I choose to wait for the periods to start naturally and then attempt the following month...that would be about 4 months after the abandoned cycle. I wonder if the drugs may still be in my system now and if it will help provide more good quality eggs if I take the advice of my clinic.

2) Do you think taking intralipids for the immune problems will help? I noticed that it is gaining popularity. I prefer it to the other edications being suggested i.e taking humira jabs for two months prior to the ivf.

3) Surgery to remove the fibrods is not an option for me....however, I learnt that there are other means of shrinking them but since they are small and dont bother me I dont want to interfere with my ivf treatment since time is not on my side.

4) Since, I missed my periods I have been having dull headaches especially when I wake up, my BP has been hoovering around 148/95, increased acne on chin and back and my hair has been falling out alot. Are thse symtoms of the missed periods or the after effect of the stimulation or the side effects of DHEA Supplementation which I have been taking for about 1 year now.

Kindly advise, M.

Follow-Up Answer:

Hello Again,

I think that two weeks after a failed IVF cycle is a little too soon, but my usual minimum waiting time is 4 weeks (1 month). I place the patient right back on the birth control pill once the period starts and prepare for the next cycle. I don't find a need for a "natural" period to occur. Because time is of essence for you, you cannot predict when your ovaries will shut down, I don't recommend that you wait a long period of time.

Intralipids is not indicated for this problem. It will not do anything to help your eggs. It is mainly used for patients that have an immune factor issue. I would opt to leave the fibroids alone unless you wanted to remove all potential obstacles. Fibroids have not proven to be detrimental to IVF unless the fibroid is within the uterine cavity. It could be a side effect of the DHEA which would increase your serum androgens (male hormones). I am not a big fan of using DHEA.

Good Luck,

Dr. 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.