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.

Previous Ectopic, Left Salpingectomy, Painful HSG: Can I Still Get Pregnant?

Question:

Dear Dr. Ramirez,

Approximately 8 years ago, after the birth of my first child, I had an IUD (copper T) inserted. About 6 months later, I lost the thread,and went back to the medical practice for it to be removed and replaced, but was told that losing the thread wasn't a threat. Anyway, 2 more months later, I had an ectopic pregnancy which ruptured my left fallopian tube and resulted in an emergency salpingectomy...... the entire tube was removed (about 7 cm).

Fast forward 8 years, I am ready to have another child, however an HSG (hysterosalpingogram) revealed proximal blockage to my right tube. I was in an immense amount of pain during this procedure.....that I cried. I am not convinced that the results of the HSG are accurate because of the pain (similar to labor pains)that I felt. Also because the ectopic was due to a foreign object, I don't feel that there should be anything wrong with my right tube. Anyway, my questions are as follows and I really appreciate your time:

1. Since the IUD was the cause of my ectopic pregnancy, would I be considered a high risk for another ectopic (assuming my right tube is not blocked#?

2. Based on the pain that I was in, could the proximal blockage be a result of a tubal spasm? What are the stats on false hsg readings for proximal blockage?

3. Is it possible that a left salpingectomy could result in scar tissue blocking the remaining right tube?

4. And finally, my uterus and ovaries (I still have both) are healthy per the scan. There is evidence of scarring from my previous c-section. How feasible is it for my right tube to pick up an egg from my left ovary as I usually feel ovulation cramping on my left?

Thank you very much in anticipation. E. (age 35),USA

Answer:

Hello E. from the U.S.,

You cannot be sure that the IUD was the cause of the ectopic. That would be a false assumption. Certainly having an IUD in place can increase the risk of an ectopic but intrauterine pregnancies also occur with IUD's in place. The IUD does not block the tube, it creates a hostile bed for implantation of the embryo. Ectopic pregnancies mostly occur because of fine adhesions within the tube which prevent the embryo from migrating into the uterus. As a result, the embryo implants there. The most common reason for these adhesions are from some form of inflammatory event in the past, often a sub-clinical (no symptoms) infection by a bacteria. Chlamydia is the most common form but some studies also point to multiple different bacteria. In any case, this infection gets into the tube, causes the tubal lining to become inflamed thereby resulting in scar tissue formation. It is possible that this inflammation is was led to the blockage of the right tube, whereas the left tube was only partially blocked, hence the ectopic.

In terms of the pain with the HSG, yes, it could mean that you had tubal spasm but the more likely source was that because the tube is blocked, the increased pressure or pushing by the doc caused increased stretching of the uterus and hence increased pain. I would have to look up the statistics for false readings on HSG, but it is low and so HSG is the gold standard for the diagnosis of tubal blockage. I am sure there is some false positive or false negative readings, however.

If the surgery was performed without incident, a salpingectomy on the left should not cause blockage of the right tube at its entrance. Any pelvic surgery could lead to scar tissue formation within the pelvis and lead to blockage at the end of the tube, however (your previous c-section).

If the right tube is normal at the fimbriated end, and there are no adhesions within the pelvis, then there is a good chance of egg pickup even if ovulation is from the opposite side. The reason is that the egg from one side of the ovary does not necessarily go directly to the tube on that side. The opening to the tube is not that close to the ovary. In fact, the egg falls into a pool of fluid within the culdesac, a space behind the uterus, where the tube lies and through fluid motion, gets to the tube. So pregnancy can and have occurred in patients with a functioning ovary on one side and a normal tube, without an ovary, on the opposite side.

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: Dear Dr. Ramirez, Thank you very much for your response. You are very knowledgeable and I feel very enlightened. Again, many thanks, E.

32 Year Old Has Multiple Miscarriages With Secondary Infertility On Clomid With No Success: Should She See An RE?

Question:

I am 32 and writing from Texas. We are trying to have our 4th child. In Jan. 2010 I had a miscarriage at 7 weeks and subsequent D&C. It took 2 months for my cycles to even begin. Then I was put on Clomid 50mg days 5-9 for 4 cycles. I was monitored with progesterone blood checks, 14th day ultrasounds, hcg shots, and checking for over-stimulation. I ovulated every time (with a progesterone level of 27) and the doctor said my follicles and lining looked good. However, I am not pregnant and it has been 6 months since the miscarriage! My first child was conceived with clomid the 1st time.

Why is the clomid not working for me? Has it changed the cervical mucus and lining? Do other women struggle to become pregnant after a miscarriage too? The last two times that I conceived (3rd child and miscarriage) I became pregnant naturally the 1st effort made. Does miscarriage change your fertility? Should I not have clomid??

My doctor wants to take a break and then come back later and 'blow out' my tubes. Is this necessary? Do I need a different regime of medicine? I feel as though I am out of luck since the clomid did not help in conception. Should I see an RE (reproductive endocrinologist) soon?

Thank you for helping! I feel overwhelmed and just want to bring this baby into our lives. L. from Texas

Answer:

Hello L. from Texas,

I think the easiest way to answer your questions is to take them individually one at a time:

1. Since you are stimulating with the Clomid (and I presume you are ovulating more than one egg per cycle because that is the purpose of Clomid), you are responding to the Clomid. I don't know why your doc even put you on the Clomid since you were able to get pregnant on your own before. Any idea? All Clomid will do is increase the number of eggs you ovulate. It does nothing else. The body still has to go through the 9 step natural process for a pregnancy to occur. It is NOT a magic drug.

2. Clomid at high doses can change the endometrial lining causing it to thin because it is an estrogen receptor blocker and similarly change the cervical mucous. Often a Clomid cycle will have to be supplemented with estrogen if this is the case, or changed to a different medication such as Femara. The lining can easily be seen and measured by ultrasound.

3 Miscarriage is very common. It has been reported that the miscarriage rate is as high as 40% of pregnancies. This includes women who have late periods that don't even realize that they are pregnant. Statistically, 85% of women that have miscarriages will go on to have a successful pregnancy so you shouldn't worry. Your previous miscarriage does not worsen you chances of getting pregnant unless you had a major complication from it such as hemorrhage or uterine rupture.

4. The procedure to "blow out" your tubes is actually called an HSG (hysterosalpingogram). It is the test that we use to see if the tubes are open. Sometimes women will form a mucous plug in the tubes thereby inhibiting sperm passage. The HSG can push out this mucous plug and open it. It is worthwhile to make sure that the tubes are open but I would not count on it for anything else. It does hurt by the way.

5. I think that if you want the expertise of a specialist in infertility, and feel you are not getting it with your current doc, then an RE (reproductive endocrinologist) would certainly be more specialized and have more knowledge. You might want to consider that. It would be the same as going to see a Cardiologist for your heart instead of being treated by your Family practice doc. The basic knowledge of a specialist and the treatments they can offer are greater.

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.

Three Miscarriages and HSG Shows Blocked Tubes

Question:

Dear Dr. Ramirez,

I have had three miscarriages in the last couple years and have been to two fertility clinics. I have had $8,500 dollars worth of tests done and all the male testing. I was told that my tubes are blocked by one doctor and the other one says that there is no way that they can just one day unblock. I was but on meformin and told that I have pcos. I read on pcos and it said that with Clomid a pregnancy is possible. What is your opinion on this?

Answer:

Thank you for your questions. You've thrown quite a lot of different things at me.

There are several issues that you have brought up. Let me see if I can answer them one at a time and give you the information that you are requesting:

1. Three miscarriages-There is an almost 40% chance of miscarriage with every pregnancy. Most are caused by a spontaneous chromosomal abnormality that occurs when the egg is dividing into an embryo. These usually lead to miscarriage within the first 8 weeks of the pregnancy. These patients will eventually be successful. A small percentage of recurrent miscarriages occur because of uterine abnormalities, hormonal abnormalities, immunological abnormalities, infectious diseases and health events like diabetes.

2. Blocked tube - Blocked tubes are evaluated by a test called an HSG (hysterosalopingogram). It is an x-ray test whereby a dye is injected into the tubes and xrays are taken as the dye flows through. If it doesn't flow through one or both tubes then that shows that the tubes are blocked. Once blocked, it is always blocked but there is an exception. Sometimes, the tube will be blocked by a mucus plug at the opening of the tube. In general, it is one side only. With increased pressure at the time of the HSG, this mucus plug can be pushed out and the tube opened. If this is the case, the HSG "helps" in clearing the tube and allowing for a natural pregnancy to occur. If pregnancy does not occur then this could not be done and that tube is probably blocked by scar tissue. The problem with one tube blocked is that the incident that caused the blockage was probably an inflammation or infection in the past, usually caused by a bacteria. These usually pass through both tubes but it affected one tube more than the other, so that one tube is blocked. That does not preclude damage in the other tube, however. As you know, it takes a very small hole to allow fluid, like the dye, to flow through. I usually counsel my patients to assume that the other tube is damaged. The inner structure can be damaged and render the tube non-functional even without it being blocked. Therefore, with any blockage, I counseled that IVF (In Vitro Fertilization) is probably the best option.

3. PCOS - I have explained this pretty extensively in past questions. Please refer to some of my previous blog posts. But to summarize for you, PCO is a disorder of the ovaries whereby ovulation does not occur. For this reason, fertility medications are required to stimulate the ovary to ovulate. Clomid is one of those medications that is used but does not work on all PCO patients. Metformin only is useful in PCO patients that have an elevated insulin level. So it does not work in over 50% of PCO patients.

I hope this answers your questions.

Follow-up Question:

If you don't mind, I was also told that when I had the HSG done that because I was in a lot of pain that my tubes could have contracted and acted like they were blocked. Is the possible? I have been pregnant 3 times and 2 of them were on Clomid alone. Is it possible that Clomid together with metformin would work?

Follow-up Answer:

Hello Again,

HSG's are generally painful, especially if the tubes are blocked. That is because they are increasing the pressure to see if the dye will flow through. Increased pain does not indicate tubal spasm, however, tubal spasm can prevent the dye from flowing through. We see this most often when injecting dye at the time of a laparoscopy. It is uncommon to see tubal spasm in both tubes, however. If you are concerned that you may have had tubal spams, then you should have the test repeated to confirm.

If the tubes are blocked, legitimately and not due to tubal spasm, then Clomid and/or metformin will not help. If the sperm and egg cannot get together, then fertilization cannot occur, and hence, pregnancy will not ensue. If the HSG result was due to tubal spasm, then it is possible they could help, so the tubes are the key element in this. Try to clear these issues with your specialist and proceed according to his/her recommendations. Good luck!

Sincerely,

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.

Trying for Pregnancy. . . Thank You! Success at last!

QUESTION: I have been trying to get pregnant for 7months. My period is regular every 26 days. Ultrasound and sperm tests indicate normalcy. I was given Clostilbegyt 50mg to take on day 2-6 and Provera for 10 days fron day 16. Does this sound correct? Won't Provera induce a period and stop me from getting pregnent. Oh I'm 33.

ANSWER: Hello,　
　
I hate to see these type of questions because it shows that the doctor you are seeing is not treating you appropriately. Have you had all the infertility testing done? Hysterosalpingogram, Hormone testing, Hysteroscopy, Laparaoscopy, Midluteal phase progesterone level. If not, then you shouldn't be jumping to Clomiphene. For one, if you have regular periods, ovulation is not the problem, although you may have a hormone problem as manifest by a short menstrual cycle. The only other reason is to try "something" since there doesn't seem to be a reason for your infertility. Many general docs give Clomid because they can, and not for any good reason, thinking that because it is a "fertility drug" it will help you to get pregnant. That is incorrect thinking. It should only be used for a specific reason i.e. it is treating a specific disorder.　
　
Technically, if you are under 35 years old, you would not be considered to have an infertility problem yet, because you have only been trying for 7 months. We don't consider a person to have an infertility problem until they have not been able to become pregnant for over one year. If you are over 35 then we shorten that time line. In women under 35 years old, it takes 8-12 months for the majority to achieve pregnancy naturally. So you may just need to keep trying on your own for a while longer. If your cycles are 26 days, then you are ovulating around day # 12, so you should start having intercourse on day # 10 for 5 consecutive days.　
　
Provera is not used with fertility because it is a "synthetic" progeterone. We only use natural progesterones like Prometrium, Endometrin, Progesterone in oil, when augmenting the luteal phase for fertility treatments. That is what me suspect that your doc doesn't have all the knowledge required for your treatment.
　
Sincerely,
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
　　
---------- FOLLOW-UP ----------
QUESTION: Great news, I am now 6 weeks pregnant after following your advice. However, before I got pregnant I had a yeast infection for almost three months. My doctor gave me Canesten tablets and inserts and that did not work.It eased the symptoms for two days and then they returned. She then gave me Flagyl tablets for both my husband and I for ten and five days respectively ( 3 tabs per day). I was also given Klion to insert every night for ten days. That last dose of medication was a nightmare as it caused severe pain and irritation, I stopped after five days. Now I'm still having some irrtiation and itching and extremely painful sex on penetration and afterwards. My new doc gave me Travogen cream and it has helped a little with the itching but sex is still painful. Is this normal? Is it that I may have something more serious? Can this affect my pregnancy? I'm really worried.... please advise me!

Answer:
Hello Rhonda from Trinidad-Tobago,
　
Congratulations!!! :) :)
　
If you have symptoms, then you need to be checked and have cultures done. It may be a simple yeast infection that can be treated easily, or something else. Don't go the trial and error route like your doctor did previously. Have the cultures done so that he/she knows exactly what to treat, especially since you are pregnant. There are some medications that you don't want to take at this time. Sex should not be painful, but since you are newly pregnant, you might want to avoid sex until you are further along (12 weeks gestational age).
　　
Sincerely,
　　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/