41 Yr. Old South African Woman Fails IVF: Needs Higher Stim Protocol, Menopur Dose Too Low

Question:

Hi Dr Ramirez,

I am 41 (42 in March) and have just come through a failed IVF cycle (our 1st attempt). I'm not sure what my FSH levels are but know that I only have 4 and 5 antral follicles left and an AMH of 0.94.

I was put on an 11 day course of 5 amps of menopur a day. I produced 4 eggs, 2 of which fertilised. On day three I had a 6 cell and a 10 cell (neither of which were fragmented) and so the transfer went ahead. Neither took and our result was negative.

I have a 13 month old daughter that we conceived naturally so am reluctant (at this stage) to use a donor egg. The reason we have to go the IVF route is that I have severe Ashermans Syndrome as a result of bad placente accreta from my pregnancy. We are therefore using the services of a surrogate.

I understand that the odds are against us but if we have the means do you think it is worth another attampt or two with my own eggs, and are there any other protocols which may produce a better egg result?

Thanks, M. from Johannesburg, South Africa.

Answer:

Hello M. from South Africa,

As you well understand, IVF pregnancy rates are very dependent on the age effect on eggs. As a woman ages, more and more of her eggs become debilitated leading to poor quality or abnormal embryos. This is the most likely reason for failure after the age of 40 years old. If you absolutely want to have a genetic child, then the only option you have is to continue trying as many times as it takes to be successful. The only things that may stop that plan are if you run out of money (i.e. cannot afford to continue) or the quality of the embryos is consistently poor. Otherwise, persistence can sometimes yield success.

There is a fairly good pregnancy rate at 41-42. In our clinic it is 55% pregnancy/32% deliveries. Miscarriages are increased because of the higher chance of genetically abnormal embryos. The oldest pregnancy to date in a woman using her own eggs was 49 years old in the U.S., but it took her 2 years of trying. Since you have been able to conceive about two years ago, there is already evidence that you do have good eggs. In your case there is the added factor of using a surrogate, but I assume you have selected one that has had successful pregnancies.

In terms of your protocol, every clinic is different and every doctor is different and prescribes/uses different protocols. It does not mean that one is better than the other. In my opinion, however, your protocol is too low for your age. In order to increase the chances of finding a good egg, a lot more eggs need to be recruited and retrieved. 5 amps of Menopur is only 375IU of FSH. As an example, my highest protocol, which is pretty consistent with other clinics in the U.S., uses 450IU of Follistim (pure FSH) + 150IU of Menopur (FSH/LH) for a total of 600IU per day. The bottom line is that the clinic you are working with and their protocol is highly influential on your outcome. You should check and see what their 41-42 year old pregnancy and delivery rates are, then compare them to other clinics. You may find that another clinic is better than the one you are attending.

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.

Comment: Thanks very much! It was great to receive such a quick and informative response.

Prior D&C And Infertility: Woman From Barbados Needs A Thorough Infertility Evaluation

Question:

Good Morning All.....My name is D. and I'm from Barbados in the West Indies. Just to give you a bit of background info on myself and hopefully you can make suggestions for me.

I've read the testimonials on the site and I was very touched and moved by the numbers of persons who were able to receive some type of positive assistance regardless of how small of how large.

In 2005 I had an abortion which resulted in me having to have a D&C and I've not been able to get pregnant since. I say not since 2005 because I remember at some point in 2008 having a very faint positive on a pregnancy test but to this day I cant be sure because the next day I did the test again and it was negative ....so I don't know if it was a false positive if it was a true positive or what it was.

In 2007 I saw a fertility specialist and had some tests done. I specifically had the test done where they run the dye through the tubes to see if they are opened and both tubes were opened. At the end of of various consultations the specialist told me that she couldn't find anything wrong and that only thing she could think of was that I had some scar tissue in the cervix area which was blocking the sperm from entering the cervix and travelling on to meet the egg....she said she arrive at that because it was difficult for her to pass the tube to eject the dye through the cervix. She said the only way I would be able to get pregnant is by having and IUI. Now I'm not being forward or anything and I know I'm not a doctor, but the blocked cervix theory is not sitting well with me and it doesn't seem logical at all.

I spoke to two other specialists and they too do not agree with the assessment. I have a regular 26day cycle EVERY month without fail and testing ovulation sticks shows me a surge around day 10-11 every month. The only thing is that my period has gone over the years form 5 days to perhaps 3 at times with clotting and dark blood or brown blood at time.....other that that it is like clockwork every month.. It doesn't make sense that blood and clots would be able to pass through the cervix and sperm cannot pass through the same opening.

I'm of Christian Faith and I've put the entire situation in God's hands but I think can also prepare my body for when he decides to bless me. I keep thinking that perhaps herbs or something can help I don't know what to do really. I've been married now for 1 and a 1/2 years and we've been trying since 2008 but nothing. I was thinking about the Fertility Cleanse and wonder if you think that would be a good first step, if not I welcome any thoughts you may have Thank you so much for your time and please have a blessed day.

Answer:

Hello D. from the West Indies,

Thank you for your kind comments. Now, what your doctor is referring to when she talks about "scar tissue in the cervix" is probably cervical stenosis. Many women who have never had children can have a small narrow cervix. We call that stenosis. You are correct in that the blood can pass through this, so sperm should as well. Cervical stenosis is NOT a reason for infertility, but IUI will definitely help this issue.

A D&C, dilation and curettage, can lead to scar tissue formation within the uterus which is called "Asherman's Syndrome". The only way to clearly identify this is to undergo a procedure called a hysteroscopy. This is where a small scope is passed into the uterus to look inside the cavity. Scar tissue can be readily seen and if present, can be removed at the time. But this is a difficult problem because often the scar tissue will return and several hysteroscopies with removal of the scar tissue may be needed.

There are other possible causes of infertility that you may not have had checked. For instance, have you had a laparoscopy? It is a surgical procedure whereby a scope is passed into the abdomen via the umbilicus in order to examine the pelvis. The pelvis is important because this is where the egg needs to pass through after ovulation (leaving the ovary) in order to get to the tube. Abnormalities such as endometriosis or pelvic adhesions can prevent the egg from getting to the tube. In addition, has your husband had a semen analysis done? Have you had a end of cycle endometrial biopsy to check to see that the uterine lining (endometrium) is forming correctly? These are just some examples of fertility testing. Lastly, you have not mentioned your age. Advanced age (over 35 yo) can play a role in egg abnormalities.

If you have had all this testing and still nothing has been found, then you would be categorized as an "unexplained infertility". This just means that we have not found a cause, and the most likely reason is because we don't have the technology to find the cause. Many of these patients have to resort to IVF (In Vitro Fertilization) in order to achieve pregnancy because there might be a sperm-egg fertilization problem (which you cannot test for). If your doctor is a fertility specialist, then she should be able to map out a treatment plan for you. Before resorting to alternative treatments that may not work, please go over some of the suggestions I made with your doctor.

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.

Comment: I was kind of skeptical in looking for a response.Like most online Q&A I expected a vague response at best and I expected the doctor to be as short as possible considering he wasnt being paid but I was pleasantly surprised with Dr Ramirez...he was great and I got more info from him than I did with my own doctor... Thank you so much Dr Ramirez and may God bless you as you seek to help others :)

Serious Post-Partum Accreta, a D&C & Now No Period...Asherman's Syndrome?

Question:

I am a healthy 28 year old who has never had any reproductive issues. I gave birth to a healthy baby in the spring of 2008. She was my third. At birth, I heard the doctor say, "Hmmm, funky placenta." The nurse looked and agreed. I later found out that it was "lobulated", but that was normal.

I went home after 1 day and all was well. Exactly 2 weeks later, when I was laying the baby down in her bassinet after a 3:00 am feeding - something "burst" and it felt like a a bucket of liquid was dumped between my legs. I had stopped the postpartum bleeding a few days earlier, and that had been light without clots the whole time.

All of a sudden it was like a faucet of bright red blood. I ran to the bathroom and was shocked by the sight of the gushing blood. I sat on a pile of towels on the floor and tried to stop the flow. The ambulance came and rushed me to the ER (30 min away). The doctor there decided that I had retained a piece of placenta and a D&C was to be done. No big deal, 30 min. procedure.
I woke up 5.5 hours later with my doctor at my bedside with a very serious look on his face. It turns out that I had accreta and they had to perform a very aggressive D&C. They could not even do a hysterectomy because I had no blood to spare. I lost 4.5 L in the OR alone. He said that he's not sure how the bleeding finally stopped, or how I lived. He had never experienced placenta accreta, nor had any of the docs in the clinic.

Anyway, after a few days in the ICU, I went home and everything has been great.

EXCEPT...it has been 6.5 months since my D&C and I have not had any period - not one drop. I was birth control pills for 3 months and nothing. So, I went off them a few months ago. Nothing. My hormone levels were checked and I had borderline hyperthydroidism, which at my most recent test seems to be correcting itself. My doc thinks this is the reason for my lack of menses.
However, I do not. I am thinking Asherman's Syndrome. He has not examined me at all since the procedure. I feel that a "borderline" hyper-thyroid (w/o symptoms) would not cause a complete stop to my period. It's hard to put in words, but I can feel a kind of crampiness or pressure in my abdomen (not a period kind). Some sexual positions are uncomfortable or painful. And the last time sex was painful, there was a spot of bright red when I wiped. And that was it. So, new blood. It seems to me that would signify something with my cervix...maybe scar tissue?

I am afraid that the hyper-thyroid will mask the true problem. I am not worried about future fertility, but more about my health in general.

What is your opinion?

Answer:

Hello,

You are wise beyond your years, and maybe even smarter than your doctor. It sounds clearly like Asherman's Syndrome. Let me say first, that it is amazing that you are still alive, and still have your uterus at that. What you went through is a very scary event and in many cases, fatal. Whatever your docs did, they did well, and saved your life. Be very appreciative of that.

There are two possibilities for the lack of menstruation. One is Asherman's Syndrome. This is a situation where the aggressive D&C causes scar tissue formation in the uterus. As a result, the uterine lining is unable to form and hence there is nothing to slough at the end of the month (no period). This is how endometrial ablation works to stop bleeding. The only worry I would have in this scenario, is that your cervical os (outlet) is blocked, in which case you could be having some bleeding, but it is staying within the uterus. The reason for this suspicion are the symptoms of cramping and uterine tenderness. Basically, because the uterus can stretch , it will continue to fill and fill and fill. This is called "hematometria". The easiest way to make this diagnosis is with a vaginal ultrasound. To make the diagnosis of Asherman's syndrome, you need to have a procedure called a hysteroscopy. This is where a small scope is passed into the uterine cavity to examine it. If the cervix is blocked, dilating the cervix in preparation for the hysteroscopy will open it up and the blood will be able to be discharged. If you used the birth control pill and didn't bleed, then the uterus has to be highly suspected because the birth control pill works directly on the uterine lining.

The second possibility is that excessive vaginal bleeding postpartum can lead to a pituitary dysfunction, leading to the lack of hormone production. This would result in the loss of menstruation (panhypopituitarism). That is checked for by hormone testing. If the hormones are all normal, then this diagnosis is ruled out.

I hope this answers your questions and gives you some information to take to your doctor. Please make an appointment to see him soon!

Good luck,

Edward J. Ramirez, M.D.,FACOG
Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf