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.

You Can Do IVF With A Low AMH !

Question:

Hello Dr. Ramirez,

I am 36 and have been unable to conceive for 3 years. The diagnosis we have been given is diminished ovarian reserve. I have tried 3 IUIs (intra uterine insemination) with clomid. Each time I ovulated only 1 egg (I already ovulate on my own). I decided to move on to IVF. I went to a new clinic because they have very high success rates (30% higher than my current clinic). Over the last year, my antral follicle count has only been between 6 - 8. FSH has been between 7.6 to 9.5 (my very first cycle a year ago it was 12.5, but that was tested on day 4, so I'm hoping that made a bit of a difference). Estrogen is always low on day 3, so my FSH is not artificially suppressed. The new RE insisted on an AMH test (my previous clinic offered it, but I declined as it is not covered by insurance and wouldn't have changed my treatment plan - only possibly caused more worry - my previous clinic was okay with my decision).The AMH test came back with very bad results (2.4 pmol/L - I understand there are 2 units for measuring this and for pmol/L this is very low). The new RE says there is no point doing IVF with that AMH result. He said my chances of success are less than 2%. He said you usually get half the number of eggs of your AMH (so I would be lucky to get 1). He would only do IUI with injectables if I wanted to, but recommends I move straight to donor eggs based on the AMH test.

I am wondering if the new clinic has such great results because they exclude patients from IVF that may not respond so well OR if the doctor really does know what he is talking about and I would just be throwing money away. Obviously, I would prefer to have a chance at a biological child and wanted to move to IVF ASAP. In your opinion, should I visit another clinic that would allow me to do IVF (understanding with low AFC and low AMH, my results may not be positive) or do you think this doctor is right and it would be a waste of time to try my own eggs and move to donor eggs immediately. I know donor eggs would have a better success rate, but there is not a time limit on this option (as there is on my own eggs) so that could be a future option. Thank you very much for your time, L. from Toronto, Canada

Answer:

Dear L. in Toronto

It always angers me when Doctors draw these type of conclusions. A recent study that I read showed that despite a low AMH number or an elevated FSH, there is still a pregnancy rate of about 20%. What that basically shows, as I have always argued, is that it only takes ONE good egg to be successful. When a woman tries on her own naturally each month, she only has one egg to work with. I often get letters from patients whose doctor has cancelled their cycle because they only have 1-3 follicles. But, what if the perfect egg was in one of those follicles? FSH levels and AMH are only indirect measures of ovarian function. They are NOT measures of egg quality or your chances of pregnancy. Please see more on AMH here: Understanding Infertility: Age Factors.

Naturally, part of the statistical chances with IVF occurs from being able to get many eggs to work with i.e. more eggs increases the statistical chances. Imagine that you have a dice and want the number 6. If you only have one dice, you have a 1 of 6 chance. Two dices double your chances, three dices etc. So with IVF, since we can't predict if the egg that is retrieved will be the perfect egg, and because we don't want to have to do this over and over again due to cost, we want to have lots of eggs. But that doesn't necessarily mean it won't work if you have fewer than is ideal. It might take more than one try (statistically). But, as I ALWAYS tell my patients, who are usually older than you, it only takes one good egg to be successful.You might want to find a clinic that is more willing to work with you instead of make decisions for you. I can see that you are good at analyzing the situation and I am confident that you will make the right decision.

Good luck and don't give up!

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

Follow-Up To This Post:

Please scroll down to November 6, 2013 to see this writer's good news and how by persevering she conceived with a low AMH :)!

"I am the one that originally submitted this question to you and I want to thank you for being positive as even with the low AMH we did end up getting pregnant and are currently 4 months away from meeting our 'miracle' baby."