Young Canadian With Hydrosalpinx And Endometriosis Complicating IVF Cycle

Question:
Hello Dr. Ramirez,

I am 27 years old and last year stage 4 endometriosis was discovered and I had 2 large cysts removed from both my ovaries, one was 12cm and and the other was 5cm. My left ovary is almost completely gone and both my tubes are not functional. My hormones as far as I know it are normal and my antral follicle count is 8.

My first IVF with ICSI (my husband has blood in his semen due to unknown reasons) was last November with an antagonist estrogen priming protocol. I had 10 eggs retrieved, 5 mature, 3 fertilized, and ended up with 1 good quality day 3 embryo to put back. The cycle ended with a chemical pregnancy. I was on 400 puregon and 75 repronex.

I did my second IVF cycle with ICSI this month on the exact same protocol. They saw 11 follicles before my retrieval and 6 was retrieved, but none fertilized at all. My RE said that egg quality was very poor and may not suggest another cycle for me.

My questions are:
1. Is my endo the cause of bad eggs?

2. Will changing the protocol help better egg quality?

3. They noticed 2 small cysts on a recent ultrasound, and also a hydrosalphinx on the left. Would it help to have another surgery?

4. Do I have any hope in becoming pregnant with my own eggs?
Thank you so much for your information!

Thanks... A. from Canada

Answer:

Hello A. from Canada (Ontario),

I don't think that endometriosis is causing the egg problem, but that is certainly debatable. There are some studies showing better results if the IVF cycle is preceded by 3 months of Lupron depot in stage 3 and 4 endometriosis. There is definitely an effect if there are endometriomas that are penetrated at the time of egg retrieval. These endometriosis debris has been found to be detrimental to egg quality. Because of that, I am very careful to avoid the endometrioma at the time of retrieval, or if it is penetrated, I replace the needle and tubing before continuing.

In terms of protocol, you certainly seem to be stimulating well, which is the goal of the protocol and there are many variations that can be used. Each doctor has their own preferences. There is not one protocol that is better than another. However, I would probably use a stronger protocol if you were my patient (you are currently using a 475 combination protocol# such as a 600 IU combination protocol #450 FSH + 150 FSH/LH (Menopur)). Changing the protocol will not improve egg quality, but having more eggs may help with getting more embryos to work with.

If you have a hydrosalpinx, you definitely need to have that surgically removed or excised from the uterus. Numerous studies have shown a reduction in pregnancy rates with IVF by 50% if a hydrosalpinx is present. In the U.S. it is now considered the standard of care. The cysts are not an issue.

I am always hopeful for my patients, in terms of your last question, even those that have a minimal chance because they are way too old. I see exceptions all the time and believe in miracles.You are only 27 years old. Your chances should be much much better and I am leery of the results you have had thus far. Frankly, it doesn't make sense to me, but I would have to review your medical records to see what might be going on. At your age, you should not have an egg quality issue and fertilization should be at least 60%. In my clinic, your age group has a 76% chance of pregnancy per attempt. That makes me worried about the quality of the clinic you are going to. You may want to seek a second opinion.

Good luck and don't hesitate to keep me updated,

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.

TTC Patient Needs Aggressive Approach After Laparoscopy For Endometrioma or "Chocolate Cyst"

Question:

Hi, I have been trying to conceive since 1 year. I am 29 yrs old,and a professional with busy working schedules. I recently got myself investigated and found that my FSH levels r 7.09 and LH levels 3.0, AMH levels 3.29.

I have undergone 2 ovulation induction cycles which showed normal ovulation but I have a tendency towards cyst formation. HSG is normal. My antral follicle count is 6 and 4 in both ovaries. Kindly opine if i should undergo IUI cycles with clomiphene or with gonadotropins or should I directly go ahead with IVF cycle?

I am worried as my FSH levels are on the higher side and also my FSH:LH ratio is >2:1.

I recently underwent a hysterolaproscopy and was found to have a small chocolate cyst of 1cm in one ovary that was removed with cyst wall and spot on the other ovary along with few spots in the P.O.D that were fulgerated. Rest of findings were normal....no adhesions, healthy tubes with free spill and good uterine cavity.

From what I have learnt, endometriotic ovaries have a poor ovarian reserve and chances of recurrence of endometriosis is also high. My FSH values are already in the upper range.So what do you suggest i should go for? What sort of induction should I undergo?

Thank you. S. from India

Answer:

Hello, S. from India,

First, let me reassure you that your lab tests, including FSH level, are all normal.

More important were the findings after your laparoscopy. With an endometriotic cyst present (chocolate cyst or endometrioma), we would automatically classify you has having stage 3 endometriosis. Studies have shown that stage 3 and 4 endometriosis affect fertility. Normally, with these stages IVF would be the recommended treatment of choice. But considering that you are young, there are some lesser options that you can try.

First, let me point out that your diagnosis is "Endometriosis" as the cause of your infertility. It has been treated by laparoscopy thus far. However, we know that if there is visible endometriosis present on a laparoscopy, then microscopic endometriosis exists as well.

For infertility patients, I recommend a 3-6 month course of Lupron depot therapy to get rid of any residual endometriosis before moving forward with any treatment. This medication will put you in a semi-menopausal state for the duration of the treatment but there will not be any long term effects. You can then begin treatment immediately thereafter. Because endometriosis will return within six months after ending this treatment, I would recommend that you proceed with a more aggressive treatment such as insemination. I would recommend four attempts, using Clomid 150mg or higher to have 2-3 ovulatory sized follicles per cycle, alternating with Femara 5.0-7.5 mg since you don't want to take Clomid in consecutive months (it can lead to poor endometrial lining formation and prevent pregnancy, among other things).

If you don't achieve pregnancy by four good IUI cycles, then I would proceed directly to IVF.

The alternative would be to go directly to IVF, in which case, it is not absolutely necessary to take the Lupron treatment, although some docs still will do this. IVF bypasses the pelvis and takes the eggs out of this hostile environment. It is the preferred treatment for stage 3 or 4 endometriosis. It will also be the fastest way for you to get pregnant.

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.

Woman With Stage 4 Endo Worries About Endometrioma: Will Not Interfere With IVF, Can Be Excised At A Later Date

Question:

I am 28 years old & TTC for a while. Diagnosed with stage 4 endo in Dec. 09. I was told to do 6 months of lupron, then another laparascopy from an ob-gyn. I got a second opinion from a fertility doctor in may 09 after not getting pregnant naturally with the assistance of acupuncture and herbs. He said I could do another lap, or start on fertility drugs. I chose to start on clomid 50 mg CD 5-9. I do have a 2mm cyst on my left ovary and am concerned about the cyst growing.

Is Clomid something recommended for someone with stage 4 endometriosis trying to conceive? I asked my doc if the cyst posed a problem and he said if it was larger then he would be concerned, but he said given the size it's not an issue. Well, if the clomid causes the cyst to grow, then that scares me. Not sure if I should consult another fertility doctor? K. from the U.S.

Answer:

Hello K. from the U.S.,

In general, if a patient has stage 3 or 4 endometriosis, then the treatment of choice is IVF. The reason is because the endometriosis, despite the laparoscopy and Lupron, causes the pelvis to be inflamed and is hostile to the egg. Basically the egg gets destroyed before it can make it into the tube. This is not 100% of cases, however. I have had patients with stage 4 endometriosis that become pregnant naturally. How they did it, I cannot explain, but they are definitely the exceptions to the rule. In general, natural pregnancy is very, very difficulty with stage 4. Therefore, if you consulted me, I would recommend IVF to you.

The cyst you had (2 mms) is a normal follicle and technically NOT a cyst. We don't worry about cysts unless they are 2 cms (20mms) or more. The clomid will cause a follicle or follicles to grow. That is what it is supposed to do. Those follicles contain the eggs and they have to grow to 24 mms in order to ovulate and for the egg within to mature.

Because you are young, your doc is probably thinking that you could try something easier for a few tries to see if you might be one of the exceptions to the rule. That is why he is suggesting Clomid. Then if that doesn't work, he might suggest IVF. I would recommend that you talk with him/her again and ask if he/she thinks the Clomid has a good chance of working and what treatment would be the best treatment in light of the severe endometriosis. He/She might change their opinion then. I don't think you need to consult another fertility doctor because you just consulted me. I hope I gave you the information you needed.

Follow-Up Question:

Thank you Dr. Ramirez! You did clarify things for me. I'm sorry I meant to put 2cm cyst, I don't know why I put 2mm. I was told it was a chocolate cyst when I had my laparoscopy in Dec. The ob/gyn said he drained it. It was 4cm then, and now by June it has grown to 2cm again. I guess that is the reason I have been feeling the pain again. Can endometrial cysts dissolve on their own? If not, if it continues to grow does that pose any risk to getting pregnant if my tubes are open, and if I succeed in natural pregnancy could the cyst create a problem during pregnancy?

I just don't know if I should have another laparoscopy so soon. Is 6-7 months too soon? Thank you for any insight on this issue.

Follow-Up Answer:

Hello Again,

The cyst that you have is called an Endometrioma. It is an endometriotic cyst or tumor. Draining it is not sufficient because the endometriosis is still located within the cyst and it will refill as it has done in your case. It should have been excised (cystectomy) at the time of the laparoscopy. It will not interfere with your ovarian function and will not interfere with an IVF treatment. Its presence, however, means that endometriosis and scar tissue are still present and an issue, which reduces the chances of a natural pregnancy (as I explained previously).

If you were lucky enough to become pregnant naturally despite the endometriosis, then pregnancy is a good treatment for endometriosis, and the endometriosis will not complicate the pregnancy. Neither will the endometrioma as long as it does not get too big or does not twist on itself (torsion). If needed, it can be removed during pregnancy.

Six to seven months for another laparoscopy is not too soon. We usually will do a second-look laparoscopy within 4 weeks if we are worried about recurrent scar tissue formation. My advice would be either to have another laparoscopy and this time make sure the cyst is removed, then proceed to IVF or proceed to IVF directly without the laparoscopy. My wife had an endometrioma at the time that we did our IVF which they were able to drain at the time of egg retrieval. It did not interfere and her cycle was successful.

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

Endometriosis surgery or Pregnancy?

Question:

I'm 35 yrs old from California. Never had kids and planning on having one, hopefully soon! My husband and I have been trying to conceive for approx. a year with no luck. So the frustration (and old age), has led me to see a doctor. A month ago, ultrasound has shown that I’ve 2 cysts on my left ovary (sizes: 2.1cm and 2.5cm) and so I've been diagnosed with endometriosis (endometrioma). According to my doctor, is severe stage (didn’t specify level) Usually, I have no pain during my periods. Since my priority is having a baby, my doctor gave me the choice of either having the surgery first and then try to conceive, or try to get pregnant first (by using fertility aid, for like 3 months) and then go for the surgery. And that’s my dilemma.

1. What are my chances of conceiving with endo? He said that the endo will melt away if I get pregnant so I’m having a hard time deciding.

2. Will my chances of conceiving decrease after the surgery? Also, I’m worried about:

3. type of surgery: According to my doctor, he’ll not perform a laparoscopy (which is more common and recovery is faster), but a traditional incision surgery. I wonder why? I believe it’s the size of my cysts? Or maybe the cysts are not benign? (He said they were benign!) although there was something unusual about the cysts : they were still present on my ovary when I was having my period. He said they shouldn’t be showing on the ultrasound during that time.

4. will the surgery damage/deteriorate /affect my reproductive system?

5. Time. I’m going to be 36 early next year and the chances of conceiving will decrease if I do surgery firstPlease advise!!! Time is sensitive and I cannot come to a decision, I’m so confused!

Here’s some extra info that might help: I’m 5’3, 115 lbs. Every visit, I have a close to high blood pressure (135/90). On my 3rd menst.day, test showed FSH of 8.9 (which is close to bad) and around ovulation my estradiol was bad: 128.0. However, I ovulated by myself and size of egg was OK. My husband sperm test was good.I don’t know if stress can affect the results of my blood test, but I was going through some difficult times since I was diagnosed with endo (lost my job and my father had a terrible accident, all happening within 2 weeks)I appreciate your help and I thank you so very much in advance.
Answer:

Hello Sarah from California,

Prior to answering your questions specifically, I would strongly recommend that you go have a consult with a fertility specialist. I think that you can be counseled better that way. I am presuming that your doctor gave you the diagnosis of stage IV endometriosis (severe) based on the presence of the presumed endometriomas. This was seen on ultrasound but not based on a laparoscopic evaluation. Endometriosis can only be staged by laparoscopy and endometriomas can only be diagnosed by tissue biopsy obtained from laparoscopy. That being said, there is a high likelihood that your doctor is right since endometriomas have a certain look on ultrasound and the presence of endometriomas usually means severe scar tissue formation in the pelvis, which is stage IV endometriosis. However, that is all a presumption before the fact (as attorney's like to say).

In answer to your questions:
1. 20% of patients with infertility have endometriosis (1 in 5). Most of these patients will conceive, although the method will vary. There is no specific statistic for endometriosis. Studies have shown no relationship between stage I and II endometriosis and infertility, but there is definite reduction of fertility with stage III or IV. If you have stage III or IV endometriosis, IVF is the treatment of choice because the pelvis has been severely altered.

2. Your chances of conceiving can increase after endometriosis has been removed surgically and if you are treated with medication for a 3-6 month period after. However, this is very dependent on the type of surgery you will have. From the type that you say your doctor advises, there is a high risk that the surgery itself may compromise your fertility by increased scar tissue production and damage to your ovaries and tubes.

3. I would NOT recommend the type of surgery that your doctor recommends if it is for fertility. He is probably assuming that there is going to be severe scar tissue formation in the abdomen and the only way that he can remove the "masses" is through an open procedure. However, I usually will approach this by laparoscopy first to see if it is possible to remove by this less invasive and less destructive method. If it is not possible laparoscopically, then I schedule for an open procedure at a later date. The problem with the open procedure, other than the increased risks, hospital days and recuperation, is that it can be a more complicated procedure leading to more tissue destruction, scar tissue formation and the possible removal of the ovary. If you would consider proceeding directly to IVF, then the removal of the endometriosis is not required. However, as I mentioned previously, you cannot know what the masses are until you obtain tissue and that can only be tested after their removal. So that may be the indication for the surgery.

4. Yes, as mentioned above.

5. Your age is a significant issue because fertility decreases with age. With the combination of age and endometriosis (severe), I would strongly recommend that you consider going directly to IVF as the treatment of choice. This way, the surgery does not need to be done. You doctor is correct in saying that pregnancy is a great treatment for endometriosis. However, you have to become pregnant first and endometriosis interferes with this. Endometriosis causes the pelvis to become a hostile environment for the egg. IVF is best because we remove the eggs directly and take them out of the hostile environment. Endometriosis does not affect the inside of the uterus (uterine cavity).

I hope this helps,Sincerely,

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