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.

42 Year Old TTC With Endometriomas And Low Antral Follicle Count

Hi Dr. Ramirez,

Not sure what to do.  I met the love of my life later in life and we just started trying to conceive, I am 42 years old.  We really want to have a child, but not so sure about donor eggs .  I have never been pregnant or attempted to get pregnant before. Six months ago my AFC=3, FSH=6.3, E2=117.  My results today were AFC=0, FSH=1.4, and E2=252 and two endometriomas that appear to be growing.  Could the endometriomas have caused the change in numbers?  If so, would removing them increase my chances of becoming pregnant?  I've read that surgery reduces the ovarian reserve which is not a good thing so I'm confused as to what to do.  I've also had a hard time figuring out which doctors would be gentle/skillful and not remove any unnecessary ovarian reserve, this could be crucial in my situation.  I would like to do IVF (in vitro fertilization) but the clinic I've gone to is not willing to discuss it due to the change in numbers.  Are there any clinics that will work with my numbers and the endometriomas?  We want to give it our best shot, it would mean so much for us to have a baby together.

My pelvic transvaginal ultrasound results were: 

FINDINGS: The uterus is normal in size measuring 7.9 x 3.9 x 4.6 cm.  No fibroids or other myometrial abnormalities are visualized.  The double layer endometrial thickness is normal measuring 7mm. No focal endometrial abnormality or endometrial cavity fluid is seen.

Right ovary is enlarged.  The right ovary measures 6.1 x 4.4 x 6.1 cm.  Homogeneous hypoechoic structure in the right ovary measures 5.1 x 3.9 x 5.7 cm previously 3.9 x 2.6 x 3.8 cm (on 18Nov2012 ultrasound).  The left ovary measures 4.2 x 2.5 x 3.9 cm. Hypoechoic structure in the left ovary measures 3.6 x 2.5 x 3.2 cm previously 2.0 x 2.0 x 2.4 cm (on 18Nov2012 ultrasound). No abnormal free fluid is seen.

IMPRESSION:  Normal uterus. No uterine fibroids are seen.  Homogeneous hypoechoic structures in both ovaries, increased in size since 18Nov2012.  Findings most likely represent endometriomas.

Thank you so much for any advice you can give us. L. from Virginia

Answer:

Hello L. from Virginia,

First, I think that your blood testing is incorrect.  The reason is that the FSH test is only valid if done right at the beginning of the cycle, generally cycle day#2 or 3.  I suspect that the test was not correct because your estradiol was above 100 in both tests. This shows that the ovaries were not at rest i.e. not in the early phase.

Second, I am sure that you can find a clinic or doctor that is compassionate enough to allow you to try IVF (in vitro fertilization) with your own eggs, but that will be with a complete understanding of your chances.  For example, I don't have a blanket policy to not allow patients to try as long as they understand the risks and chances.

Third, you have to understand the major problems you are facing and the impact that has on your chances.  The first major problem is your age.  This is what we call the "age related egg factor".  This basically means that because of a woman's age, the quality of her eggs decreases so that the majority are no longer viable.  As a result, the pregnancy rate decreases and the risk of miscarriage due to genetic abnormalities increases. Even with IVF your chances will be decreased, BUT they will much better than trying naturally! The second major problem is Stage IV Endometriosis.  When you have endometriomas, that automatically makes it stage four, which is severe endometriosis.  As a consequence, IVF is the treatment of choice.  You can, and probably should, try to find a very good gynecologist to remove the endometriomas laparoscopically, with specific instructions to NOT remove any ovarian capsule tissue (that is the layer that has the eggs).  That will help to give you the best chances of pregnancy.  However, it is not an absolute necessity. Third, you have a decreased antral follicle count (AFC), which is supposed to represent the number of follicles available, but frankly, I don't rely on that too much.

You can achieve pregnancy if you go about it with an open mind and choose a good clinic. For more information on endometriosis and infertility, as well as other age-related factors please see these pages: “Endometriosis” and “Age Factors” in my website’s section on Understanding Infertility.

Good Luck,

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

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.

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.

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

Question:

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

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

Answer:

Hello K. from the U.S.,

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

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

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

Follow-Up Question:

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

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

Follow-Up Answer:

Hello Again,

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

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

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

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Twitter with me at @montereybayivf and follow me on Facebook at http://bit.ly/9Iw9oV

South African Had Surgery for Stage 4 Endometriosis - Now What?

Question:

Hi, doc, I'm 30yrs old and recently had laparascopic surgery. I was diagnosed with stage iv endometriosis, most of it was removed. My fiance also has fertility issues. He was diagnosed with anti sperm antibodies. We are desperate to conceive and will meet our doctor next week to discuss our options. I would love your opinion on this matter?

Thank you, Regards from South Africa.

Answer:

Dear M. from South Africa,

Stage IV endometriosis is the worst stage that you can have. This has definitely been shown to impair fertility via natural means. The problem is that the endometriosis has now impaired the pelvis and this is the path that the egg must take in order to reach the tube. Both the scar tissue formed from the endometriosis and surgery, and the inflammation caused by the endometriosis will interfere with the egg.

Most women with stage III or IV will not get pregnant naturally and will need to go directly to IVF. To these women I first recommend trying naturally after surgery for a 6 month period. You can either try on your own or with IUI, it doesn't really make that much of a difference. Most RE's would treat with Lupron or Letrozole after the laparoscopy for three months to remove any residual endometriosis prior to starting with a treatment.

Since your problem is combined with your partner's problem, then you have two major strikes against you. That would definitely make me strongly recommend IVF as the treatment of choice. That is not to say that you could not get pregnant without IVF. I have had a patient with stage four endometriosis that became pregnant spontaneously. However, the statistical chances of pregnancy is 1% or less.

Thank you for your question and good luck!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com