Woman With Secondary Infertility & Possible Blocked Tube: Misdiagnosed? Surgery? What To Do?

Question:

I had an HSG (hysterosalpingogram) in November. The dye flowed freely through my left tube, which appeared normal and healthy.  However, the dye would not enter my right tube until after the radiologist had me get on my right and then left side. The dye then went into the tube and appeared to flow freely, but then it stopped abruptly mid way in the tube.The visible part of the tube appeared normal and healthy.  My RE told me that it is extremely rare for a woman to have a blocked tube in the middle of the tube unless she's had her tubes tied and that it was possible I was just born with half a tube.

I recently had a laparoscopy in June to get more info about the cause of my infertility and to attempt to repair the right tube. The dye again flowed freely in the left tube. My doctor inspected the right tube, and found that it appeared to be completely normal and healthy in every respect. However, again, the dye entered the right tube and stopped mid way. 

After the surgery, my doctor told me that I had no endometriosis or adhesions of any kind. She also told me that I had no evidence of any tubal disease or previous infection in my pelvic cavity.  The only abnormalities that were found were a large paratubal cyst that had wrapped around my good left tube (the cyst was successfully removed), and a small polyp during the hysteroscopy (also removed).  I also have never had any other surgeries or ectopic pregnancies. 

My RE told me she had no idea what was blocking the tube, but not to worry about it because research shows that having one healthy tube does not really decrease your chances that much for Clomid/IUI or timed intercourse.  Still, it's very frustrating to me because I thought that laparoscopy was 100% method for diagnosing the cause of a blocked tube, but I have no more info about the cause of blocked tube than when I started.

I am 38 and my FSH and AMH values are excellent, and my hubby passed his sperm analysis. I have a 2 year old that was conceived after 8 months and we have been trying for #2 for 1.5 years.  Although I understand that having just one tube should not affect my chances that much, I am still concerned because at this point, it is our only known issue.    

My questions are:  1. What could have caused the blockage in my tube?  2. Is it possible that the tube is not actually blocked but is not flowing for some other reason (I've heard about false diagnoses of blocked tubes due to preferential flow or not enough dye being used)?  3.  Is there any other way to find out what is blocking my tube?  4.  Is it worth it to pursue surgery to repair the tube like I've seen for women who undergo tubal reversal surgery?  

Thank you! C. from Atlanta

Answer:

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

To answer your questions in order:

1.  The most common cause of a mid-tubal blockage, that is not from prior surgery, is an internal tubal infection.  Many of the bacteria that cause this type of scarring can do so without any type of symptom.  A laparoscopy would not be able to find this type of injury and, other than the HSG, there is no way to examine the inside of the tubes.

2.  It is possible that there was tubal "spasm" causing the tube to appear blocked, but I doubt it because the Radiologist was able to get the dye to flow down part of the tube.  However, if you think that it my not be an accurate test, then I would recommend that you have another one, but have your doctor specifically request that they pay most attention to the right tube i.e. do the test so that the dye preferably goes down the right side.  Remember, fluid will always go down the side of least resistance.

3.  There is no other testing that can be done to examine the tube.  Scope technology is still not small enough.

4.  NO.  Such surgery can cause pelvic scar tissue and impair your fertility more.

First, I think you need to consider ALL the factors involved in your fertility potential.  Yes, it is possible to get pregnant naturally (intercourse or IUI) with one normal tube, but there is no way to prevent the egg from going into the tube that is blocked, so your chances are actually decreased. 

Second, you are 38 years old which means that your natural chances of pregnancy are already reduced significantly down to 3-5% per month (15% per year), which is further reduced if you add the tubal problem. Even with IUI your max chance of pregnancy based on your age is only about 7-10% per month not considering the tubal issue. The fact that you have been pregnant before is a positive factor and increases your success with assisted reproduction. If you want that second child right away and if you were my patient, I would strongly urge you to consider IVF. 

Third, you have to decide which of two assumptions are correct: the tube was blocked from a prior bacteria, which probably went to the opposite tube as well but did not cause blockage, but did cause damage vs the blocked tube was the only injury and the opposite tube is therefore normal.  If the open tube is injured, which cannot be proven but is possible, it may not be functioning normally despite being open.  Keep in mind that fluid can pass through even the smallest opening.  In that case, you will not be able to get pregnant naturally and so IVF would be the treatment of choice.  Because of your age, I would make the assumption that the tube is damaged (mainly because you have not been able to get pregnant naturally when you were able to previously) and therefore recommend IVF.  It is the most successful and expedient treatment option for you. 

If your doctor wants to waste time and try something less like ovulation induction or IUI, that is fine as you understand that the risk you are taking is losing the opportunity to get pregnant with your own eggs and more time passes. I hope this second opinion is useful to you.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

 

40 Year Old TTC After Termination Of Trisomy Pregnancy

Hello, Doctor.


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

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

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

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

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

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

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

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

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

Answer:

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

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

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

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

I hope I was able to ease your concerns.

Good Luck,

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

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.

Will Removing Blocked Fallopian Tube Help This Patient Conceive?

Question:

Hi again Dr Ramirez, it's K. in NY.

I have written in the past about my multiple miscarriages/chemical pregnancies. I tested positive for the MTHFR mutation this past fall. I had a miscarriage at 9 weeks in August, which you believed was most likely due to a virus I contracted. I have followed up with a new specialist recently, and received some new information today.

First of all, my right tube is definitely blocked (although most of my miscarriages/chemical pregnancies resulted from ovulating on the right) We are led to believe that I most likely had a few early ectopic pregnancies. The specialist today suggested that I undergo surgery to remove the right tube completely. I am not sure how I feel about this, as surgery for any procedure is risky. Do you feel that having the tube removed would increase my odds of becoming pregnant? I am willing to do it if it makes sense, but hate to do it "just because". I am not sure if research supports this practice or if it doesn't really make a difference in the long run.

The second piece to this scenario is that my husband was diagnosed with a translocation between chromosomes 11 and 13 (46xy,t(11;13)(q21;14)). IVF (in vitro fertilization) was suggested to us, but we do not have the money for this and it is not an option unfortunately. Our Dr prefers to remove the tube and discuss fertility meds and other options after that point. While it explains many of our losses, I am curious if you have any other treatment suggestions. We have two healthy children that we had no difficulty conceiving. I have taken femara multiple times (pregnancy x1) and progesterone. We have not tried IUI, but were wondering if it would be of any benefit. I am just confused with all of this new information as to how to proceed conservatively. I am willing to take meds and try IUI, but I would rather not have surgery at this time unless there is a strong link between increased fertility and tube removal. Also, if we continue with meds and u/s, is there a point in being aggressive on months where I ovulate on the right?

We are just looking for the best path to take and I am hoping that you have some input to help us make an informed decision. Obviously this journey gets more difficult with every diagnosis. Thank you for your time.

Answer:
Hello K. from the U.S.(New York),

So sorry about your secondary infetility problems. To begin, there are no studies to either validate or invalidate the recommendation to remove a nonfunctioning tube unless it is blocked at the fimbriated end (called a hydrosalpinx). In that case, it has been shown to decrease pregnancies via IVF and is thought to impair implantation. It is recomnended to remove or separate the tube from the uterus. However, your doctor's recommendation is not unreasonable. Considering that it is not predictable as to which tube the egg will go into, each month you have a 50/50 chance that the egg will get picked up by the wrong/damage tube, and therefore will not get pregnant. In addition, you are risking ectopic pregnancy should the sperm get through on that side. I think that removing the tube might give you a better chance at getting pregnant because that only leaves one tube where the egg can go, and it does not matter which side the egg is ovulated from. They all go into the culdesac where the tubes lie.

In terms of your husband's translocation, that certainly can be a cause for miscarriages, just as your postive MTHFR can be a cause. There are no real good solutions for his problem other than doing PGS (preimplatation genetic screening) in conjuction with IVF. You'll just have to take your chances. I am not sure that IUI will offer you any more than trying as you have been, but statistically it does give a slightly increased chance of pregnancy if 2-3 eggs are ovulated at a time. That's the only advantage.

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.

Secondary Infertility: Decreased Ovarian Reserve And Low Morphology May Be The Culprits

Hello,

I just turned 33 and I have one beautiful 18 mo little girl who is the love of my life. She was conceived on our 3rd iui using 5mg of Femara. My husband has low morphology (6%) and I have no regular periods. We both exercise / eat as we should and have no other health issues. We are considered unexplained infertility.

For the past 6mos we have been trying to conceive. I just had a large polyp removed and my fsh levels were tested. 2 1/2 years ago they were 7.0. 6 weeks ago they were 12.1. We are trying to figure out what to do next. We definitely want another child (And we would be open to 3). My questions are:

1) What do you recommend for medication? Is Femera a good starting point? Should we use the same dosage or higher?

2) Should we try an IUI or go straight to IVF?

3) Are there any "rules of thumb" for why FSH increases and how quickly it increases? I've heard stress can impact it. Thanks in advance for your help. C. from Washington State

Answer:

Hello C. from the U.S.,

Congratulations on achieving your first baby relatively easily. You do not have "unexplained" infertility as you have two reasons: sperm abnormality/low motility and irregular periods (ovulation dysfunction). Those are reasons enough to prevent spontaneous pregnancies.

In terms of your FSH level, I have to presume that it was drawn on cycle day #2 or 3, because that is the proper time to do this test and the only way that it an be interpreted. If it was, the elevated FSh level of 12.1 is not a good finding. This is called "decreased ovarian reserve", which basically means that your ovaries will be more resistant and less productive if stimulated with fertility medications. It is not an indication of ovarian function, but is somewhat of a time clock. Once the FSH level reaches 15, most IVF clinics will require you to use donor eggs. When it reaches 20, it means you are in menopause, which in your young age would be classified as premature ovarian failure. So from a time perspective, that means you don't have a lot of time to waste.

Certainly IUI is an option for you, and somewhat reasonable since it worked before. The FSH level will have no bearing on its chances of success. Chances of success depends on age and the sperm problem. If you wanted to do IUI first, I would limit it to no more than 4 attempts. You can use Femara, Clomid or injectables for these attempts and even alternate them, but don't waste a lot of time. Keep in mind that the chances of pregnancy with IUI in your age group is 20% per attempt. By four attempts you should be pregnant, otherwise the statistical chances drop dramatically after that.

If the IUI's fail, then you need to progress aggressively and quickly, especially if you want to have more than one more child. In that case I would recommend proceeding to IVF with ICSI. This will give you a 74% chance of pregnancy per attempt in my clinic (and is the treatment level that most infertility specialists would recommend with an FSH level above 10. Most would recommend not even to try the IUI).

I can't tell you why the fSH is elevated. That is an unknown.

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.

Secondary Infertility Patient With Seven Miscarriages: Cannot Afford IVF

Question:

Hello-I am 33 and have a healthy 3 1/2 year old daughter who was conceived naturally. I have had 7 miscarriages (1 before my daughter and 6 consecutive since her birth). I have had 4 chemicals, 2 confirmed blighted ovums and 1 xxx69..this one had a heartbeat and all hormones were great, heart stopped at 8 weeks and did a karyotype on fetal tissue.

I've been to an RE and have had the following tests: Karyotype, HSG, Day 3 Hormone Panel, Clotting Disorder Panel, ultrasound to measure lining of uterus and to check for any abnormalities...all results are "normal". I have also supplemented with progesterone after a positive pregnancy test as well, my LP is usually 11-12 days. My hubby has only had a karyotype and he is "normal" as well. The RE said that our XXX69 was more than likely due to a mutated sperm containing an entire extra set of chromosomes. He has recommended we do IVF (in vitro fertilization) with PGD (pre genetic determination).

Our insurance doesn't cover ANY fertility, so that is really not an option for us.The RE wanted to me to try a monitored clomid cycle as a plan "B". In doing some research, I just don't think clomid will help with unknown recurrent pregnancy loss...what is your opinion? I "O" just fine without any meds. What else would you recommend? I am in excellent shape, eat organic whole foods, don't consume any alcohol or caffeine..

I take prenatals and fish oil daily. Do you think that all my miscarriages could be a sperm issue? I'm really at a loss....what do you think our chances are of having another healthy child without doing IVF/PGD? Thanks, S. from Maryland.

Answer:

Hello S. from Maryland,

I am sorry for your losses. You certainly have recurrent abortion as a diagnosis, but the exact cause is unknown. Granted that the fetal tissue from the last miscarriage showed a genetic abnormality, but if your husband's genetic testing was normal, then I would not expect that all the miscarriages were for the same reason. I would think that it is more likely to be a spontaneous genetic abnormality occurring with division of the embryo. Hopefully that is the case because that means that there is still a good chance of having a normal pregnancy. If the problem is a sperm abnormality causing a genetic problem, then there is very little that can be done to change that other than using donor sperm.

One alternative would be to try IUI (intra uterine insemination), since the sperm will be washed and the best sperm will be made available for fertilization. There is no guarantee with this but it is an option. Your RE is correct in that the only way to make sure that a normal embryo is available for implantation is to do preimplantation genetic screening with IVF. Since you cannot do IVF, then the only option is to continue to try and hope/pray for the best. I do not think you need to do Clomid either. It doesn't help with this problem. The good thing is that you are still young and have time to keep trying. Hopefully with continued trying, you will be successful.

If you were my patient, I think I would add low dose aspirin 81mg per day, PNV with folic acid, Medrol 16 mg per day, progesterone supplementation in the luteal phase (Crinone or Endometrin) and low dose heparin 2000 unit injections twice per day with each cycle. These are more to cover the immunologic causes of miscarriage, but have been shown in numerous studies to help. Since we cannot be sure exactly why the previous miscarriages occurred and can't conclude that it is ONLY a genetic problem, I would favor covering those bases.

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.

Right After A Cancelled IVF Cycle, Try Naturally Or IUI?

Question:

Dear Dr. Ramirez,

I write to you from Los Angeles, California. I am 38 and just started an IVF (in vitro fertilization) cycle after two FETs (frozen embryo transfers) that did not take. Those embryos from the FET were from an IVF I did when I was 36 that resulted in my wonderful son. I am on Bravelle and went in for my first ultrasound and they saw only two developing maturing follicles, one on each side, that were outpacing all the rest. Previously, they had seen about five on each side. My doctor has cancelled this cycle but recommended continuing on the Bravelle for two more nights and then trigger ovulation and timed intercourse. My questions is, should I do IUI instead of just timing intercourse? I know that my chances are very low of conceiving anyway, but my feeling is that if we are paying for the meds and these ultrasounds, that perhaps we should optimize our chances, even though they are very low. The doctor was trying to minimize our costs and suggested timed intercourse instead of the IUI.

I am hoping that these two years that have passed since my son was born haven't led me to be a 'poor responder.' The doctor said that sometimes this happens and that we can try a fresh ivf cycle next month and he would increase the amount of the stimulation drugs.Any thoughts on IUI versus timed intercourse or anything else?

Answer:

Hello S. from California,

I don't recommend canceling IVF cycles normally because you never know if the perfect egg is in one of those follicles. In addition, despite the fact that two have outgrown the others, that does not mean you can't get mature eggs from the other follicles. There have been studies that have retrieved mature eggs from follicles as small as 10 mm. So even if there is only one follicle, I like to give it the best chance that we can. I know that this is a more expensive way to go, but I've had numerous pregnancies from just one follicle. Bear in mind that IVF has a significantly higher pregnancy rate, even with only one egg, than any other method at your age, per cycle. In my center it would be 70% pregnancy with 40% continuing with IVF vs 7-10% with IUI.

That is because, if you image how the natural cycle process works, it takes 10 steps for your body to accomplish a pregnancy:
(1)Brain sends FSH to stimulate the ovary to grow follicle
(2) Ovary grows follicle
(3) Follicle ruptures out of ovary (ovulation)
(4) egg is pulled into the culdesac with the fluid from the follicle and finds (or has to find) tube within 12-24 hrs
(5)Egg is picked up by the fimbria of the tube
(6) Sperm and Egg meet within the tube and fertilization occurs
(7) Egg travels down the tube and divides into blastocyst
(8) Embryo enters uterine cavity
(9)Embryo hatches and exits from its shell
(10) Inner mass attaches to the uterine lining and the lining grows around the embryo (implantation)

With IVF, steps 1-8 are accomplished for you and only two steps left up to chance/nature/God, whereas with IUI, only steps 1 and 2 are accomplished for you. The rest occurs naturally.

In any case, there are several issues you have brought up and questions that correspond. One is whether you should do IUI vs try naturally right after a cancelled IVF cycle. Statistically, IUI has a better chance of pregnancy than pregnancy (7-10% vs 5%), so for that reason alone, I would go with IUI. I would recommend following the exact same protocol as you would of with IVF except that retrieval and transfer will not occur. I would do the same progesterone supplementation.

The other issue is regarding your stimulation. It is obvious that you were not stimulated with the max protocol if you doctor commented that they are going to increase it. You may have a decrease in response but without getting maximum stimulation, you don't know that for sure. So, you may not be a poor responder. You just did not get stimulated adequately.

The good news is that you have had one successful pregnancy. It is a good thing that you are pursuing having the second at 38 yr.s, before you become much older and the rate of success drops dramatically.

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.

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

Question:

Hi Dr Ramirez,

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

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

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

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

Thanks, M. from Johannesburg, South Africa.

Answer:

Hello M. from South Africa,

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

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

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

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

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

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.

Secondary Infertility, High Responder PCO Patient: Why Did I Fail Two IVF Cycles?

Question:

Hi, I am 28 years old and my husband and I have a naturally conceived 3 year old son. We are dealing with secondary infertility. We have gone through 2 IVF cycles.

1st IVF/ICSI cycle-21 eggs--11 fertilized (70% fert. rate)--transferred 2 great 8 cell embryos. None to freeze. Negative result

2nd IVF/ICSI cycle

19 eggs--(85% fert. rate)--8 embryos on day 3

1-8 cell grade 1 (best)

2-8 cell grade

21-8 cell grade

32-7 cell grade

22-5 cell grade 2

No transfer because of lining issues. Did one FET--ended in a chemical pregnancy.

My question--do I have poor egg quality? Lab results said some eggs were abnormal, with thicker zona. Any hope to go through IVF again?

I'm from Fargo, ND. Thanks in advance!

Answer:

Hello M. from North Dakota,

From the number of eggs retrieved, I presume you also had a high number of follicles (>20). That indicates that you are responding like a PCO patient, or have PCOD. Studies have shown that there is a decrease in pregnancy rates with PCO patients, probably due to a high number of immature eggs retrieved. It also seems to affect egg quality. That is not because you have abnormal eggs, it is probably because the PCO causes an inefficiency in egg maturation.I would not give up hope. In fact, I would encourage you to continue trying because you will be successful. It may take some more tries, and hopefully, your doctor will adjust your protocol to try to reduce your stimulation. It would be better to have fewer follicles with good eggs than lots of follicles with poor eggs.

By the way, I just had a patient from your end of the country, Montana, that previously went to a clinic in Washington state and had two failed IVF cycles. She was a secondary infertility patient as well. Well, the change in weather or location or clinic did the trick because she became pregnant with one attempt, and with twins. Infertility Physicians and clinics are not all equal. That may have a bearing on your success as well. I am worried about the fact that despite all the eggs, your embryo quality rate and number to freeze were so low. That might also indicate a laboratory issue.

In any case, don't give up hope. You will eventually be successful.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you for your insight! Very much appreciated! :)