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.

Could I Be Infertile Or Am I Still Recovering From Surgery For Endo?

Question:

Hello. I'm a 29 year old female. My husband and I have been trying to conceive for 7 months now. I had a laparoscopy done in June of 2013, due to an ovarian cyst on my right ovary. As the Dr. was doing the procedure, she said that the cyst had already ruptured ( which I didn't even know, or feel) and she found a little bit of endometriosis, which she got rid of as well. My tubes were wide open with no other complications.

 I'm about 2 1/2 months post op, and we still haven't gotten pregnant. I just saw my Obgyn a few days ago for a progesterone test, and it showed I was ovulatory. I was an 8.4. So the next step is to go get another ultrasound to make sure everything is ok inside, followed by some blood work a few days later. He said we'd check for PCOS. I have no symptoms of that. My periods have been pretty regular all my life. My question is why haven't I gotten pregnant? I thought the laparoscopy was suppose to open things up to help a future pregnancy. Could my body still be recovering from the surgery, and that's why I haven't become pregnant?  Or could there possibly be an underlying problem I have. The Dr. didn't really make me feel that comfortable. I asked a lot of questions, yet I still feel I'm unsure about things. I don't know what to think. He said we might start Clomid, but part of me wants to think I'm still recovering. I really hope I don't have any serious problems. I really just want to be blessed with a child, yet it's been so difficult to achieve.

Any advice/help would be greatly appreciated!  P. from Illinois.

Answer:

Hello P. from the U.S.(Illinois),

Infertility is defined as the inability to become pregnant after 12 months of trying so technically you are NOT infertile.

In terms of your surgery, you are way past that and it is not the reason you are not getting pregnant unless scar tissue was formed from the surgery inside the pelvis.

My first recommendation is to find a new doctor.  Preferably, find one that is a specialist in infertility rather than a general Ob/Gyn.  The reason is that you are on the verge of wasting a lot of time and money.  Your doctor is jumping to things without good reason.  For example, saying that you have PCOS when you have regular periods.  PCOS is defined as an ovulation dysfunction and you have to have irregular or absent periods as the prime criteria for the diagnosis.  Also, going straight to Clomid without a full infertility evaluation is a waste of time and money.  It's like prescribing a treatment before you know what you are treating.

My recommendation would be to start with a basic infertility evaluation:

• Cycle day#2 or 3 hormone panel (FSH, LH, Estradiol, TSH, Prolactin)
• HSG

• Hysteroscopy or Hysterosonogram

• Pelvic ultrasound #done#

• Semen analysis

• Cycle day #21 or 22 progesterone #should be 10 or greater#

• End of cycle endometrial biopsy

• Cervical cultures for GC, Chlamydia and Ureaplasma

• Laparoscopy (which you have done)

Once all these are done, then you can discuss and consider treatment options. Since endometriosis was treated, you need to try to get pregnant within one year of the surgery or the endometriosis will return and possibly prevent pregnancy.

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.

TTC After Surgery For Stage Four Endometriosis

Dear Readers,

As the year draws to a close I want to wish all my readers near and far the very best in their lives as you move forward into 2014. I hope that the blessings of health and peace are with you all and for those of you who continue to struggle with infertility, I can only wish with all my heart that the journey will come to a positive conclusion for you in 2014.

Thank you for following my blog and God Bless.

Edward J. Ramirez, M.D.

 

Question:

Hello,

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why?  I understand surgery can affect ovarian reserve but am looking for better understanding.

What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas?  Thank you.

C. from California

Answer:

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

Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates.  This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding).  In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis.  These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means.  For that reason IVF is the only option.  Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen.  However, statistically speaking these cases are very, very few.

In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming.  For that reason, you can form new endometriomas, despite the previous ones being removed.

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 Suspects She Has Endo: Treat The Pain Or Do IVF?

Question:

Hi there. Hubby and I have been TTC (trying to conceive) for almost 4 years now, with no success. We have been to two different REs, the first performed one HSG (hysterosalpingogram) and we underwent two unsuccessful IUIs (intrauterine insemination). The second ran a lot of tests, told me my eggs were low and wanted to go straight to IVF. In the last couple of years, my menstrual cramps have become unbearable, to the point of awaking me in the middle of the night. I have always had cramps, but nothing like this pain. I also have diarrhea along with my cycle, a yeast infection every month, and terrible seasonal allergies.

Two years ago I had an abdominal myomectomy and at that time, my doctor separated my fallopian tube from my uterus-they had gotten stuck together. I have been reading up on endometriosis and it sounds to me like I may have it. No doctor has ever suggested that I get tested for it. But I seem to have many symptoms of it. Do you think my tube and uterus getting stuck together were a result of undiagnosed endo? Could this be causing our infertility? Thank you for any answers you can provide. Thanks, W. From Virginia.


Answer: Hello W. from the U.S. (Virginia),

It seems that you are smarter than the two RE's that you consulted with. Given this history, you certainly could have endometriosis, and the prior surgery probably made the diagnosis. Endometriosis is one of the major causes of adhesions (scar tissue) formation in the pelvis. It can lead to infertility because it changes the normal anatomy and can prevent an egg from entering the tube. In addition, you have now had an open surgery (myomectomy) which is notorious for causing scar tissue formation as well. These two things on their own would explain your infertility.

At this point you have to make a decision: whether to treat the pelvic pain or get pregnant. Treating the pelvic pain will require additional surgery. Getting pregnant would require IVF, the only option for bypassing an abnormal pelvis. Do not be under the misunderstanding that doing the surgery to diagnose and treat the endometriosis and adhesions will restore your fertility. In fact, the opposite will occur because every surgery leads to further adhesion formation. Only do the surgery if the pain is a significant problem. If pregnancy is the priority, then go straight to IVF. In many cases, getting pregnant will help the endometriosis pain.

Good Luck,

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

Young Woman With Endometriosis & PCOS Fails Five Clomid Cycles: Next Step?

Question:

Dear Doctor,

Hi, I'm from Minnesota. My husband and I have been trying to conceive since August of 2011. I have endometriosis and PCOS (polycystic ovarian syndrome) since finding out when I was around 17 years old, I'm 25 now. I have had five cycles of Clomid that didn't work. I had laparoscopy surgery for this post December, blocked tubes, suck ovaries, scar tissue, cysts and endometriosis. I'm on metformin because that's supposed to help with infertility and PCOS.

I started femara this month. Had 4 follicle on left and 1 on right from ultrasound. I usually ovulated on the 15th day, this time I didn't ovulate so I took the ovidrel shot and had a positive test. Started estrogen and progesterone day 3po. Currently on day 10po. I have cramps on and off.  I was just wondering what my chances of conceiving are and what is the next step if this didn't work this cycle. Any information or insight would be great! K. from Minnesota

Answer:

Hello K. from the U.S. (Minnesota),

Your statistical chances of pregnancy with Stage Four Endometriosis (endometriosis with extensive adhesive disease) and PCOD is probably less than 1% using any natural treatment method (Clomid, Femara or Injectables with intercourse or IUI).  That is because you have an abnormal pelvis and this location is critical for passage of the egg from the ovary to the tube.  Scar tissue, which is like spider webs, can block the egg from entering or reaching the tube.  Endometriosis causes a chronic inflammation of the pelvis which leads to the inflammatory cells attacking and destroying the egg as it exits the ovary to reach the tube. Polycystic ovarian disease is an ovarian dysfunction where the ovaries don't function properly and so there is a resultant hormone imbalance and lack of ovulation.  All of these put together significantly reduces your chances.

See my website for more extensive information and explanation of the options available for both Endometriosis and PCOS. I am convinced that with the proper information patients become empowered to make the right decision about their healthcare and can ascertain if they are receiving the best care.

It is my humble opinion that you are probably not seeing an infertility specialist because a good infertility subspecialist would have told you all this and not done all the treatments you have done.  The treatment of choice is to proceed to IVF so that you can bypass the pelvis completely.

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.

"Infertility Nightmare" After TTC For Seven Years & Two Failed IVFs

QUESTION:

Hi, I was very much hoping you could help me with my infertility nightmare!

Myself - 30 yrs old, AMH: 3 / FSH 9 / ttc 7 years / diagnosed this year with severe endometriosis mostly around my ovaries.

My partner - 39 yrs old - no issues

After trying unsuccessfully naturally for 4 years (tried using ov kits but no signs of ov) I consulted my gp and was referred to our local hospital for 'basic fertility tests'. No issues apparently found and I was diagnosed with 'unexplained infertility'!

I was then given 3 months of clomid and a follow up appointment for 6 months later! Clomid did nothing for me (no ovulation detected on ov kits). My periods were horrendous whilst on this and shortened to 24 days following it. They went back to 28-29 days after a few months.

I was then referred to another hospital for IVF. Again only the basic tests were carried out (blood, semen etc). This was when I was found to have an AMH of 3.

IVF 1 - 0.5 burselin / 4 vials of menopur / gonasi hcg trigger shot / 2x 200mg cyclogest.

Stimmed for 12 days in total - produced 10 eggs of which 5 fertilised. Transferred 1 hatching blast on day 5. Other 4 embryos did not make it to freeze.

Day 3 started to spot pink blood & by day 5 had period. I did have a very strong 'immune reaction' the day after transfer (flu like symptoms which lasted 12 hrs).

My consultant advised he thought the egg quality was to blame causing the early bleed after implantation.

I insisted on further tests and 3 months later has a Hysteroscopy and LAP (laparoscopy). I was then diagnosed with severe endometriosis. I was also given a cervical dilation due to a difficult transfer. I apparently have a small and narrow cervix and a forward tilting uterus.

IVF 2 - 0.5 buserelin / 6 vials of menopur / gonasi hcg shot / 3x 200mg of cyclogest (after my insisting).

Stimmed for 13 days and was very slow to respond this time. Six eggs collected of which 3 fertilised. Two blasts transferred on day 5 (1 more advanced than the other). Day 4 after transfer pink spotting again again developed into period. Felt slightly unwell the day after transfer (but not as intense as the first ivf).

Both IVF's resulted in negatives.

My questions are:

1. What is your opinion on the early bleeds? Do you think it's embryo quality (I don't know there officially grading by the lab). Or is it an immune issue possibly lined to the endo? Or both? My aim next is to have level 1 and 2 immune testing.

2. Do you think the progesterone support is enough? May I possibly also need estrogen support? My doctor does not believe in this!
My aim is to try with DE next time due to my poor response on IVF 2. Do you agree? My main concern is the amount of time I have been infertile plus the 2 failures. I have never achieved a pregnancy yet. Do I have hope in your opinion?

Thank you so much for taking the time to read this.

N. from Ireland

ANSWER: Hello N. from Ireland,

Please note that detailed and comprehensive recommendations cannot be given without review of your medical records. This venue only allows for short and succinct answers so I hope it suffices.

Embryo quality DOES NOT cause post-transfer bleeding. If bleeding occurred, there is probably no way to know exactly what the bleeding was from, however, the first question would be whether or not there was an adequate luteal phase i.e. whether the progesterone you took produced adequate levels. If you took the medication orally, it would not be adequate. The only way to take progesterone with IVF is either vaginally or by injection. Vaginal progesterone can, however, cause some cervical bleeding because of some eroding effects on the cervix. This is not an indication of an immune problem.

Estrogen is required for adequate endometrial formation as manifest by endometrial thickness and a trilaminar pattern on ultrasoud. Estrogen is also required in the implantation phase and is easy to use so many IVF programs do add this to the regimen.

I'm afraid I don't know what you mean by "DE", so cannot comment.

There is always hope. The key is to find the proper treatment, the proper doctor and the proper clinic to make that happen. I tell my patients, "we can get almost anyone pregnant. It is just a matter of what needs to be done to do so." The only sure way to fail is to stop trying.

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

FOLLOW-UP QUESTION:

Hi Dr Ramirez, many thanks for your reply and for taking the time.

Regarding the progesterone I was taking this rectally by Cyclogest pessarie 400mg x3 daily. The reason for taking it rectally is that i tend to suffer from thrush. I'm now wondering whether taking this rectally was not sufficient. I am also concerned I am not maybe absorbing the progesterone enough therefore and I'm now keen to try injections next time.

I do tend to suffer with a shorter luteal phase of 10 days before spotting / bleeding on natural cycles.

I will defiantly suggest using estrogen next time. I can not understand other than a hormone in-balance why i would twice suffer from such an early bleed. My lining on the last scan was found to be 10.9 and of a trilaminar pattern.

'DE' stands for donor eggs. I was advised after my first failure not to try more than 3 times with my own eggs. After my poor response to this cycle and the outcome again I am almost definitely considering trying with donor eggs on my third cycle. I just hope to try and determine any other causes for failure before doing this.

Other than the above and the immune testing the only other issue I'm concerned about was the fact both of my embryo transfers have not been straightforward. Although the second transfer was not as painful as the first, I could still feel the catheter going all the way up into my uterus which was incredibly uncomfortable.

Its such a pity your clinic is far, far away!

Thanks again for your time. If I am to reach a successful outcome in the future I will be to sure to come back and update this to hopefully give other women possible clues to their failures.

N. from Ireland

FOLLOW-UP ANSWER:

Hello Again,

I see no reason why you need to consider Donor eggs. Rather, I think you need to consider changing to a different clinic! Pregnancy rates vary highly from one clinic to another. For example, we have 14 clinics within 100 miles of my center and based on Nationally reported statistics (we are required to report to the Federal Government annually), our clinic has the third highest pregnancy rates within this area. The lowest clinics have rates that are 1/2 of our rate. So where you go makes a difference.

Upon reading your follow-up letter, I saw a significant problem that you have. The embryo transfer is one of the most critical steps, if not the most critical steps, in the IVF treatment process (see my Blog posting on "Step Seven: Embryo Transfer" ). You can have absolutely PERFECT embryos but if they are not transferred appropriately, the cycle will FAIL. The transfer should be a completely PAINLESS procedure and you should not feel a thing. If the catheter touches the back of the uterine cavity or there is bleeding, either of these will cause failure. Maybe that is the main problem? Technique is part of what makes one doctor different from another in terms of pregnancy rates.

I know that I am "far away" but I have had the pleasure of seeing patients from France, Italy, Serbia, Germany, South Korea thus far. Many of these patients tried in local clinics and failed. So, yes it is a 12 hour trip by air, and would definitely cost more for hotel, etc., but if the result is a positive one, would it not be worth it? I'm not trying to induce you to come to my center, but the point I am making is that patients don't have to suffer and endure multiple failures with their local clinic if it is not the best one.

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 once again Dr Ramirez, I was very interested to read your answer & your article regarding embryo transfer & will be taking this up with the hospital on my follow up appointment in the new year. N.

32 Year Old With Two Failed IVF Cycles With Positive Beta's: Chemical Pregnancies?

Question:  Hi Doctor,
I live in Idaho where we only have 1 IVf (in vitro fertilization) clinic, so I don't have the option of a second opinion and can't decide if it's worth the six plus hour drive to find out if anyone else would do anything different so I really appreciate you reading this.

A quick medical run down is my infertility was both blocked tubes which 3 years ago I had opened, since they've been open I developed endometriosis which I had cleared last September. I am 32 years old with no medical issues. I have had 8 failed IUI's before finding the endo and then 4 failed IUI's since clearing it. I did have one pregnancy with the IUI but they thought it was ectopic and it aborted itself. I have just completed my second failed IVF. By the way DH has all "normal" counts and morphs for his samples. Both protocols for meds were the same I took Doxycycline and Medrol right after ER (embryo retrieval) and started Progesterone vaginal inserts day after ET (embryo transfer) and was on prenatals and baby asprin the whole time. Both transfer's were done with guided ultrasound with no complications.

1st IVF-September 2012. 10 eggs,10 matured, 4 embryo's fertilized (no ICSI) 1-six cell, 3-eight cell all grade 2's. Two embryo's transfered, last 2 died on day 6 before making it to blast. First beta was 9, second 32, then on day 11 I started spotting,cramping and clotting. Day 13 beta was 7.

2nd IVF-November 2012. 21 eggs, 18 matured, 13 fertilized with ICSI, 1-eight cell grade 1, 6-eight cell grade 2, 4-seven cell grade 2, 1-nine cell grade 2, 1-two cell grade 3. Transfered 2 embryo's back (one was hatching) and cryopreserved 6. Beta test 1 was only a 3 and then the second beta nothing improved. I started bleeding day 11 again.

I have not yet met with my RE but I am trying to gather all the info I can before meeting with her. This last fresh cycle will have been the last one that I think I will do just because the stress on my body of being on meds off and on for 3 years now I think is too much. So the 6 frozen are very important to me to use wisely. I read that you said a chemical pregnancy is not an implantation problem so does that mean that you think it would be a problem with the embyo's? My RE felt last time that there was no need for genetic testing and that my endo was not an issue. I'm just lost as to what my next step should be, what to test for or what I should do with my remaining embryo's (gestational carrier or gamble with them). Thank you again for your time, your blog's have been so much help for me while searching for answers. M. from Idaho, U.S.A.

Answer:

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

Once you get a positive bHCG, that means that implantation occurred. To be more specific, it means that after the embryo was transferred into the endometrial cavity (the limit of what IVF can do), the embryo progressed in its development, hatched out of its shell, attached to the endometrial lining and the lining grew and enclosed the embryo. These last steps are all natural steps that we do not have the technology to make happen. They have to happen on their own. The take away message from this is the knowledge that you can achieve a pregnancy with IVF. The ensuing problem, of miscarriage, is a pregnancy issue. Whether or not the embryo progresses to developing a successful pregnancy and ultimately a normal and healthy baby is based on the pregnancy alone.

Miscarriage is a more common occurrence than people think. We know that up to 50% of pregnancies can end in a miscarriage, many of which are chemical pregnancies like you had. In most cases of early miscarriage, the reason is because of an abnormal embryo, meaning the embryo had some sort of genetic abnormality. In most of these cases, it is a spontaneous abnormality that occurred at the time of embryo division and not something that you carry. But just to make sure, you and your husband might want to undergo genetic testing if you have not already done so.

One other thing I noticed is that your embryo quality, based on its external appearance because we don't have the technology to know the internal quality, was not optimal for someone your age. This could be related to an inherent problem with the eggs, sperm or lab conditions. In a woman under the age of 35, I would expect most of the embryos to be 8 cell, grade 1 embryos. Genetic testing in the embryos, PGS, is an option but I too would not have recommended it in your age group. In addition, PGS may do some harm to the embryo thereby reducing your pregnancy chances. You'll need to discuss this further with your doctor.

I don't think that any of this has to do with your endometriosis, which is not an issue with IVF.

Ultimately, because you have achieved chemical pregnancies, you have to keep in mind that the IVF can work. Now it is just a matter or time, or more specifically, a matter of getting the perfect embryo. That will take continuing to try and ultimately I am confident you will be successful. It is unfortunate that you only have one option for an IVF clinic in your area because pregnancy rates vary highly from clinic to clinic. That may be another option i.e. travelling to another clinic. We call that distance IVF where patients travel to another state to have the IVF done. It is easily coordinated and arranged so you don't have to limit yourself to one option only. There is more that can be said or advised, but a thorough review of your medical records would be required.

Good Luck,

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

Comment: I was amazed at the timely response and all the information given. I feel confident that the Dr. is giving a knowledgable response as well as very honest without pushing his own clinic which was comforting. Thank you again for your time.

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.

Trying To Conceive After Surgery For Cysts & Endometriosis: Do A Clomid Induction Cycle?

Question:

Hi from Wisconsin!
My husband and I have been trying to conceive our third child. My youngest will be turning three in a couple of months. They were conceived quickly with no issues. About a year ago, I was advised to have surgery to remove what looked liked a "complex ovarian cyst" that was causing intense pain. I was on birth control pills at the time. I was told everything else looked good at the time of surgery and I experienced heavy bleeding afterwards for about a week. A year later I was still having pain in that area, so a different MD did surgery and removed an adhesion between my tube and ovary, a small amount of endometroisis, and paratubular cysts everything was located on the same side as my surgery. My tubes were open.

I am about 3 months from the surgery and on our fifth month of ttc and have been having really light periods (which I have always had, so I was surprised by the endo) that start/stop and have brownish spotting in the beginning. I was told it means I am not ovulating. I am doing a progesterone test later this week to see if I am. I did get a positive OPK on day 14 this month and my periods are pretty regular occurring every 28-30 days. Clomid was suggested for my next cycle, which I am nervous about trying. I am 33 and my husband has a normal semen analysis (one of the motility numbers was lower 37% but they said because his total motile sperm number was above 57 million they said it was fine).

Do the light periods have anything do to with not getting pregnant? I also get a lot of white sticky discharge after the egg white mucus and a few days after the OPK positive, is this also a sign something is not working? Will Clomid help me? If I am ovulating will it just increase the number of available eggs? For the next cycle an ultrasound and HCG trigger were also suggested. This is all so frustrating! When asked my MD told me I had a reasonably good chance of getting pregnant on my own but I am worried about being on a time crunch, especially since no endo was seen a year before.
Thank you for your advise. S. from Wisconsin.

Answer:

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

Usually the amount of flow with a period is proportional to the amount of endometrial lining produced. The endometrial lining is produced or grown with increasing amounts of estrogen that occurs in the first two weeks of the cycle. This is called the "proliferative phase" for proliferation/growth of the endometrium. As a targeted follicle grows, it produces more and more estrogen. So, the fact that your periods are very light is a little worrisome in terms of the possibility that there is inadequate estrogen production. If you are ovulating then adequate estrogen should be produced, so maybe there is an ovarian dysfunction going on. I cannot be sure without additional information or testing. Clomid may help this by inducing the ovary to function more normally and increase the estrogen production by increasing the number of follicles that progress to ovulation. Clomid increases pregnancy rates by increasing the number of eggs ovulate in women that are already ovulating normally. This treatment is called "superovulation.".

With clomid ovulation induction cycles, I am a strong advocate of ultrasound surveillance or monitoring. This allows us to evaluate how you are responding to a particular dosage of medication, since there are varying dosages that can be used and people respond differently, how many follicles are being developed, so that you don't ovulate too many eggs and significantly increase your chances of a super-multiple gestation, when the follicle is at the appropriate size to trigger ovulation with HCG and to time intercourse or IUI so that it is at the closest time to ovulation (ovulation cannot be predicted completely).

You are correct about the timeline for your endometriosis. I tell my patients that they basically have a 6 month window of opportunity after their endometriosis treatment. With each cycle, new endometriosis is being produced and some endometriosis that was at a microscopic stage is growing. Eventually, you will return to the pre-surgery state which may be preventing pregnancy. For that reason, I too recommend a more aggressive timeline and aggressive approach to treatment such as superovulation with timed intercourse or IUI.

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 History Of Endometriosis Wishes Baby #2

March is "Endometriosis Awarness Month" and I thought it would be appropriate to post this recent question from a woman who had endo and succeeded to have her child six months ago. For those of you who wish more information on this reproductive immunologic disease that affects millions worldwide you might begin by visiting the Endometriosis Research Center website.

Question:

Dear Dr. Ramirez,

My beautiful baby boy- now 6 months old- was conceived via IUI (after more than 2 years of trying, painful laser ablation of my endometriosis, 4 rounds of clomid, and two tries with IUI). I have endometriosis. I also happen to have an AMH level of .8-- quite low for age 31, but my FSH and other levels have been perfectly healthy and age appropriate. My fertility specialist urged me not to wait to try for a 2nd baby (given my AMH and the likelihood of my endometriosis returning after pregnancy). So now that my son is 6 months old, and I fear I am beginning to feel some of the painful twinges of endometriosis returning, I am wondering when I should start getting serious about another IUI for baby #2.

I am still breastfeeding (hope to continue for maybe another 6 mo) and my period has not yet returned. While becoming pregnant right now feels a little hard to imagine, given the demands of having an infant, my husband and I DO want a 2nd child, and would like a chance to have another of our own. Is it reasonable/recommended to wait until my period returns (and is normal) before getting serious about this? Or, must I take sooner action? What about breastfeeding-- would breastfeeding interfere (hormonally) with the chance of IUI success/pregnancy? I am trying to temper not feeling quite ready to be pregnant again with not wanting to miss my chance to grow our family... what do you suggest??

So very sincerely appreciated, K. from Atlanta, GA

Answer:

Hello K. from the U.S. (Georgia),

First of all, AMH is an indirect test of the ovary and NOT an absolute. It is used in conjunction with cycle day #2 or 3 FSH and an ultrasonic antral follicle count. So, I would not assume that your time is limited if the FSH and AFC are normal but the AMH is decreased. It is not that critical. Now, it is a little worrisome that your level would be low at your age, so time needs to be kept in mind. But the timeline is not days or months but probably years. For example, I would not wait until you are 35 years old where your age will then start to become an issue as well.

In terms of when to try next, I think you can wait until you have finished breastfeeding, since it would interfere with conception.While you are breastfeeding the ovaries are at rest and not functioning any way so you don't have to rush. In some women, in fact, pregnancy seems to clear up their endometriosis temporarily, so you may have time to conceive after you stop breast-feeding and your period returns. I have had patients like you who have had endometriosis and needed assisted reproductive help for their first baby, who then went on to have baby number 2 & even 3 without the need of further IUI's or IVF.

Congratulations and enjoy your baby!

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.

34 Year Old With One Tube, Endometriosis, Abnormal ANA: What TTC Strategy Do You Recommend?

Question:

Hi Dr. Ramirez,

I am writing to you as I am now desperate with our situation and hoping to get some push from someone who is knowledgeable in this field. I am 34 and my husband is 40. No kids from both sides. We've been TTC for 2.5 years now. When we started, our bloodwork both came back normal as per my family doctor although he mentioned that my ANA (anti nuclear antibodies) is out of the normal but he said he's not sure if it has something to do with fertility or not and he'll leave it up to our RE to decide. My ANA is positive 2+ speckled pattern.

I've always been regular with a 26-29 day cycle. We first visited our RE in April 2011 and he said I should go for additional bloodwork which I did and came back normal. So he said I am generally healthy, no weight or smoking problems. My husband didn't smoke too. I also did BBT (basal body temperature) charting and my RE confirmed that I am ovulating regularly. I went for an HSG (hystergosalpingogram) in June 2011 and they said they can't get the fluid to get into my cervix or uterus so they considered me blocked.

I went for laparoscopy on July 2011 and my RE told me that I have stage 2 endometriosis but he was able to clear it out and my left tube is open while the right is still blocked. He said we only need 1 tube to get pregnant so he prescribed me with Clomid in August and did a scan at cd 12 and he saw 2 mature follicles in my left ovary. We didn't get pregnant that month so I went for another month of Clomid but I noticed that month, I didn't get the cervical mucus that I usually have during my fertile days. I told my RE so in October he switched me to femara and had another HSG done. He said he unblocked my right tube so I am perfectly healthy. We did another scan at CD 12 and my RE confirmed that I have 2 mature follicles, one from each side so he said I should get pregnant pretty soon. He gave me 2 more prescriptions of femara and told me not to come back to him until Feb 2012 or when I am pregnant. I am now in my final dose of my femara and really desperate :(. While taking femara I didn't notice my cervical mucus coming back to normal. I think it was the same case as with clomid. I am dry during my fertile periods so I started using preseed in November.

Now my questions are, what do you think are the other options that we can take besides IVF? I've never tested positive in a test since we started TTC. I've never taken birth control pills in my entire life. Do you think my positive 2+ ANA has something to do with our infertility? My RE seems to ignore it and I am not too sure if I still have to remind him about it. What do you think about the fertilaid supplements? I am just in a desperate mood now so I think I am taking any chances. Any advice on the next steps to take?

Sorry for the long post. I would really appreciate your reply on this. I hope you had a fantastic holidays!

Here's my husband's numbers:Volume 3.5 mlpH 7.6Motility 50%Speed 4Count 48 million/mlMorphology 80% normal. I don't have some of my bloodwork numbers so I cannot post but my RE said it looks ok. Thanks in advance for your reply. F. from Canada

Answer:

Hello F. from Canada,

First let me say that you should not feel "desperate" at this time. You have plenty of time to work with because you are young, and options open to you. You are just beginning your journey so you just have to accept your situation and move forward through it, do what must be done and look forward to your eventual success.

It is worrisome to me that you only have one tube open. Why is there a tubal problem at all? Could this imply that although the tube is open that it is not functional i.e. that there is internal damage? If the tube is not functional then natural pregnancy cannot occur as the tube is an essential part of the process required to become pregnant by natural means.

The second problem you have is the endometriosis. Endometriosis, even if treated surgically, can still be present in microscopic form. It is surmised that this ectopic tissue, i.e. tissue that is not supposed to be present in the pelvis, causes a low level inflammatory reaction that that interfere with the egg in its travel from ovary to tube and therefore prevent pregnancy from occurring. One consideration would be to undergo a 3 month treatment with Lupron in order to get rid of any microscopic residual endometriosis followed by aggressive treatment to achieve pregnancy.

The alternative is IVF to bypass the pelvis altogether. Yes, Clomid and Femara (to a lesser extent) can block estrogen receptors and therefore lead to reductions in cervical mucous and endometrial thickness (that is how they work..they trick the brain into thinking it is not making enough estrogen so that it stimulates the ovary harder, which in turn makes more estrogen). These are side effects. These can be treated by giving vaginal estrogen tablets.

I don't think that the ANA is having any affect on your lack of pregnancy at this time. But, you could take an 81 mg tablet of aspirin daily to help overcome this. It's an easy treatment. (For my readers information, an ANA test detects antinuclear antibodies in your blood. Normally your immune system makes antibodies to help you fight infection. In contrast, antinuclear antibodies often attack your body's own tissues — specifically targeting each cell's nucleus. But some people have positive ANA tests and are perfectly healthy.)

I am not a proponent of fertiliaid. I think the product is just preying on people like you who are desperate and will try anything. I don't think that it helps.

In terms of other options, if the simple ovulation induction with Clomid, Femara or injectables is not successful, and I would not recommend continuing with this strategy if no pregnancy occurs within 6 months, then the next level of treatment is IUI. I would not recommend more than 4 attempts at IUI. If all the above don't work, then you should move to IVF.

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.

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.

Canadian Needs To Know: Frequent Blood Draws Are NOT Necessary For Clomid Induction Cycle

Hello Dr. Ramirez,

I'm currently undergoing cycle monitoring and my RE has not yet been able to pinpoint a reason for our 18 months of infertility (hubby checked out okay and my initial tests - ultrasounds, blood work, saline hysterosonogram - show no problems other than possibly my age being a factor - 35).

I am on my second month now of ovulation induction cycle monitoring. At the clinic I go to (and it appears any of the ones that I have looked into here), they want to do cycle monitoring every single month regardless of whether it is a medicated or natural cycle. He said after this month, we will likely try something like Clomid to produce more eggs and continue with the cycle monitoring.

I could handle the ultrasounds, but the blood work has become such an issue for me I may not be able to continue with treatment. I have to go on CD3 and then daily starting again on CD10 until I ovulate which usually isn't until CD17-19 and then for a progesterone test 7 days post ovulation.

The problem is I have always had small veins that are difficult to get blood from. I've had several of the technicians try and they often try for more than 10 minutes with multiple pokes. I develop massive bruises so the subsequent tests are even worse. They told me I have almost no surface veins and even when they hit one, sometimes no blood comes out of it. They've tried my hand too which is very painful and the last time I was there, they talked to my RE and then they used my foot which also hurt a lot. One of the technicians today said they may have to move onto my groin or neck (but she laughed so I hope she was joking)! I've tried drinking lots of water as well as soaking my hands and arms in hot water without any success.

I talked to my RE and asked if the daily blood work is absolutely necessary each and every cycle and every visit and he said it is required because they need to closely monitor levels. I asked if I could go for the ultrasounds and monitor my LH surge using urine OPK tests and he said they require the blood work because they need to monitor things other than just LH and blood work is a requirement each day an ultrasound is done.

In your opinion is there any other option than all this blood work? I'm almost having panic attacks each day on the way to the clinic (and I've never had panic attacks before) because it gets worse everyday and I don't know how many more months I can deal with this. I'm concerned about future routine blood work as these daily tests are no doubt making my veins worse. At this point I don't want to tell many people about our fertility issues, but my arms make me look like a drug addict as they are covered in bruises.

I'm D. from Ontario, Canada.Thank you for your input.

Answer:

Hello D. from Canada,

I have never heard of such a ridiculous thing! Blood work is not required for simple ovulation induction whether by natural ovulation, Clomid ovulation or even low dose Follistim ovulation. The blood work that is done with IVF is done because the ovaries are being stimulated so strong that we need to make sure that overstimulation or hyperstimulation does not occur. It is NOT required for monitoring. The key to ovulation induction is NOT the blood test results but the number and size of the follicles as seen by ultrasound. Ovulation is timed by the size of the follicle NOT the blood test, and a midluteal progesterone is NOT needed if progeterone supplementation is given and/or ovulation is determined by ultrasound (which is a better method than the progesterone anyways).

I think your doctor, and this clinic, is treating you inappropriately and in essence, torturing you. I would strongly recommend that you change clinics immediately. I find this clinic abhorrent! If you review my blog where I discuss how I do ovulation induction, you will see that there is no mention of any blood tests except for a pregnancy test at the end of the cycle!

In terms of why you are not getting pregnant, if you have not had a laparoscopy then I would recommend that you have one. I often find that in patients that don't seem to have an obvious reason for infertility, that is, the basic workup has been normal, that they often have endometriosis in the pelvis. Endometriosis does not have to be symptomatic to cause infertility.

If you can't find a fertility clinic in Canada that will do the ovulation induction without blood tests, then you should come to my clinic in California. At least I can save you from being tortured. Please seek out the appropriate level and standard of care!

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.

Young Canadian With Endometriosis: Will Have Six Month Window For TTC Post Surgery

Question:

Hi, I’m from Calgary, Alberta in Canada. I am 33 and my husband is 30, we are both healthy and we’ve been TTC unsuccessfully for 19 cycles. I have never been pregnant. We have been tested at the fertility clinic and told that there is no obvious reason why we shouldn't’t be able to conceive. I had blood work to check my hormone levels, an ultrasound to check my follicles and an HSG to make sure my tubes were open, my husband had a SA done and it showed good numbers and motility. He does have some antibodies, but less than 50%.

All that being said, I contracted chlamydia about 14 years ago, but it was treated quickly (I believe within 1-2 months). I have also been experiencing some symptoms of endo since going off the BC pill so I am a candidate for the laparoscopic surgery. The doctor said I could also try clomid or clomid with assisted insemination. I’m looking for additional guidance on how to proceed. Given that I have symptoms of endo, would you recommend that I proceed with the surgery before trying clomid or even IVF?

Thanks. J. from Canada

Answer:

Hello J from Canada,

You pose an interesting question and the answer will be based on personal desires.

Given that your infertility evaluation has been negative thus far, and you are only 33 years old, if you want to attempt pregnancy by natural means (intercourse or IUI), then you should proceed with the laparoscopy. This is the only method that can diagnose endometriosis. It can be treated at the time surgically and then followed with a 3 month course of medication (Lupron depot) to eradicate any microscopic endometriosis. You will then be free to try on your own or with IUI for the next six months. That is the window of opportunity. If the laparoscopy shows that the endometriosis is stage 3 or 4, then IVF would be indicated.

Certainly if you decide to proceed with trying by natural mean after the laparoscopy, I would recommend an aggressive treatment plan because you need to try to get pregnant within six months. After six months there is a high chance that the endometriosis will return and you will be back to square one. By aggressive natural means, I mean ovulation induction with Clomid, Femara or injectables and either timed intercourse or IUI.

If you don't want to do the laparoscopy, then the best option would be to proceed with IVF. That is the decision that my wife and I made when we faced a similar point in our infertility evaluation and treatment. This is because IVF will bypass any endometriosis and you won't have to undertake the pain or risks of surgery. But, it is the most expensive way to go.

Good Luck,

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.

Indian Woman TTC For 3 Years, Has Endo: Danazole Or Lupron Therapy?

Question:

I am tryiong to concieve last 3 years. I did on 6 January 2011 report as follows:

H-Lap, D&C/ PT(HPE) done

Hysteroscopy--Ut cavity regular canal narmal B/L ostia seen.

Laproscopy-- Ut normal size. retroverted congestion, Small Seedling fibroid, both ovaries are normal size and healthy.

Both Tubes Patents and healthy.

B/L adhesions, Endometriotic patches seen on both sides.

Now i completed 2 months course with DANAZOLE (200) which i am taking daily twice, only one month left. after laparascopy on 6 jan my period come after 21 days i.e. on 27 of Jany and i started Danazole Therapy on 17 of Jan. but still my periods not come almost 18 days left.

I asked the doctor she said some women concieve with Danazole also and some may not, so first complete the course of one month then try to concieve with Letrofil and all medicine.

But now i am thinking i dont want to waste time so instead of continue with Danazole i want to take LUPRON Depo Injection. Please guide me is it right ? Or good for me altough its expensive,. Please tell me should i take only one injection of Lupron or more than one becoze already i completed 2 months course with Danazole. Also, when my period expected and when should i try to concieve doctor, i m very much crazy about child.

Thank you. S. From India

Answer:

Hello S. from India,

Danazol is a medication that is given for the treatment of endometriosis. It inhibits estrogen production and therefore ovarian function. Because of this ovulation will usually be inhibited and pregnancy is not possible. It will also cause you to not have periods. Sometimes you will get breakthrough (irregular) bleeding in the first cycle but by the second and third cycle, the periods will stop.

Lupron is another similar medication. It is slightly chemically different but does the same thing. I like the Lupron because it has less side effects than Danazol. Danazol is really an older treatment. We rarely use that anymore in the U.S. Instead, Lupron depot can be given as a 3.75 mg monthly dose for three months or an 11.25 mg single dose that lasts for three months.

Once you finish the three month therapy of either of these medications, you can begin trying for pregnancy. I would recommend aggressive treatment with either ovulation induction and IUI or IVF. You will have about a 6 month window before the endometriosis will return again. Endometriosis is usually given a stage from 1-4. If you have stage 3 or 4 endometriosis, you should go directly to IVF as the treatment of choice. If it is stage 1or 2, then IUI would be appropriate.

Good luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Grading Of Embryos At Blastocyst: How Does It Reflect Implantation Rates?

Question:

My husband and I recently went through our first IVF. We have been trying for 2.5 years to get pregnant and have done 6 failed IUIs. We have stage 2 endometriosis that was cleared out by a laparoscopy last Fall. Aside from that we are unexplained infertility. We retrieved 10 eggs and 9 fertilized naturally. We transferred 2 blastocysts on Day 5 that were graded 2BB and 3BB at transfer. We had 5 others that made it to freeze on day 6.

I have been a little stressed out about the quality of the blastocysts. I know that 4AA is the highest. Will our blastocyst quality impact implantation rates? R. from the U.S.

Answer:

Hello R. from the U.S.,

The answer to your question is yes and no. It is ambiguous because grading does not necessarily predict whether implantation, pregnancy or a successful delivery will take place. I have often been surprised when I get a pregnancy from embryos that are "graded" as poor quality. I have also seen cases where when we do genetic testing called PGS (preimplantation genetic screening) the test results reveal that the good quality embryos are abnormal and the real bad one is normal! So I don't think you can say that the way your blastocyst are graded will necessarily have any impact on their ability to implant.

At this point in time, we do not have the technology to evaluate embryos fully to know which ones will implant and which ones won't. As far as I'm concerned, all embryos have the potential to implant and lead to a successful pregnancy. In my opinion, only God knows for sure. It is a good sign that you had embryos to transfer and freeze...Good luck with your transfer results!

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.

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

Question:

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

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

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

Answer:

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

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

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

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

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

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

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

Trying To Conceive For One Year: Clomid Vs. Laparoscopy?

(If the blog radio program comes on, you can pause it by going to my Oct. 1st post. I will be keeping the show up for the month of October.)

Question:

Hi. I've been trying to conceive for about a year and my doctor and I are ready to take a more aggressive approach. We have generally discussed both clomid and laparoscopy as next steps in the coming months. I am wondering if you can give some advice as to the order of trying clomid first or having a laparoscopy first.

My sister and aunt both had endometriosis so I expect that could be the culprit. I personally lean towards having the laparoscopy first, but I want to understand which is usually recommended. Thank you. V. from the U.S.

Answer:

Hello V. from the U.S.,

In order for you to achieve pregnancy, if you have been having trouble, you have to find the reason so that you can get the appropriate treatment. The term "fertility treatment" or "fertility drug" is a misnomer. The treatment has to treat the problem. There is nothing that makes your more "fertile" no matter what the problem.

Clomid is a fertility medication only in that it is used to treat infertility. In actuality, it is an ovulation inducing drug. That is, it gets the ovary to ovulate if the ovary is not already ovulating. Doctors use this medication in women that ovulate also to increase the number of eggs they ovulate so that there is a higher chance for one of the eggs to reach and enter the tube (because that does not happen every time).

Laparoscopy is a surgical procedure that is used as an infertility test. It is part of the infertility evaluation because it is the only method to assess if there are any pelvic abnormalities. This is important because the third step of the body's process to achieve pregnancy (brains sends FSH/LH to ovary > ovary grows follicle and matures an egg > ovary ovulates and egg enters pelvis > egg has to get to tube . . .) is for the ovulated egg to pass through the pelvis and get into the tube. If there is anything within the pelvis, like scar tissue or an inflammatory disease like endometriosis, then then egg may not make it to the tube (endometriosis causes inflammation that can destroy the egg).

I presume that you have had a complete infertility evaluation prior to your doctor's recommendation to use Clomid or do laparoscopy? I dislike it when general Ob/Gyn doctors jump to unnecessary conclusions such as go directly to Clomid or laparoscopy without making sure that is what is needed. Clomid is used for ovulation problems or in conjunction with IUI (if there is a sperm problem). Laparoscopy is done if all the other preliminary tests are normal, or if there is an increased chance of having endometriosis such as severe menstrual cramping or pelvic pain or pain with intercourse. It is usually one of the last tests to be done. Is that where you are?

These are the things that need to be considered and if you see the right fertility specialist, it is more likely that the appropriate things will be done to help you to become pregnant. If you see the wrong person, then you might just be wasting your time.

If you give me more detailed and specific information (such as your age and what tests have been done), then I would be able to give you my recommendations on what needs to be done next.

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.