Woman With Endometriosis Failed IVF Cycle: Poor Egg Quality? Age Issue? PGS?

                                                                                                                                                    

Question:
I am 38 years old from Los Angeles. I just had a failed IVF cycle because my six embryos arrested on Day 5. On Day 3, five were Grade A and one was Grade B. They were 10, 8 and 6 cell. Doctor blames my age for the embryos arresting and basically said my eggs are poor quality. I find this confusing, since they were top ranked on Day 3. I've done one previous failed IVF last year at a different clinic (and still have a frozen Grade B blastocyst from that), but the doctor never blamed my egg quality. My AMH is 2 and other hormone numbers are normal. First IVF, they retrieved 27 eggs. This IVF, they retrieved 16 eggs.

I don't know my fertilization rate  for my most recent IVF because my doctor never told me how many of my eggs were immature, only answering that some of them were. For my first IVF about half the eggs were immature, and I had about a 50 percent fertilization rate. I have endometriosis, which has never been treated. It was discovered 2 1/2 years when I was having a myomectomy, but the doctor didn't remove it, only noting that I had significant ovarian endometriosis but no endometriomas. I've read that endo can affect egg quality or do you think the only issue here is my age, and I should just give up on IVF? My next step is to have a laparoscopy to remove the endometriosis.

Thanks for your time. N2N from California.

Answer:

Hello N2N from California USA,

I think that age has a significant effect on egg quality and that is the issue with age.  More and more eggs become less and less fertile.  There was a study recently that looked at IVF patients that were 37 years old and underwent PGS. PGS, or preimplantation genetic screening, is the proper term for testing for overall chromosomal normalcy in embryos. This involves removing a cell from an IVF embryo to test it for chromosomal abnormalities before transferring the embryo to the uterus.  Only 2 out of every 10 embryos were genetically normal.  So, even if they make it to blastocyst, there is still a chance that the treatment would fail because of abnormal embryos.  In general, there is debate as to whether endometriosis needs to be removed prior to IVF because of a potential effect on pregnancy rates, but there is no clear indication that endometriosis absolutely affects eggs unless there is an endometrioma present and/or the endometriotic fluid contaminates the fluid at retrieval.  If you want to be sure that it is not a factor, a laparoscopy followed by three months of Lupron should take care of that issue, but I'm not sure I would have you do it if you were my patient.  I think you are battling an age issue.

It is not unusual for good looking day #3 embryos to not make it to blastocyst.  In one of my patients recently, we had 12 embryos that were good quality (grade 1 or 2, 6-8 cells) on Day #3.  We cultured all of them and only 6 made it to blastocyst.  The rest arrested before Day #5.  So, your doctor is probably correct that this failure was due to egg quality.  That is what you are battling.  The bottom line is that IVF is trying to help you find the one or two good eggs that are still remaining in the ovary and it will just take time.  If you want it to go faster, then you need to move to donor eggs to improve the egg quality, but if you want a genetic child, then you need to resolve that it may take several attempts.  Unfortunately, there are no technologies yet, that can improve egg quality.  Only repetition is the option.  As long as your ovaries still respond well to stimulation, so that we can get a lot of eggs at retrieval, then you have a good chance of being successful if you hang in there.

Good Luck,

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

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com 

Monterey, California, U.S.A.

Atypia Is NOT An Absolute Indication For Hysterectomy

Question:

Hi Dr. Ramirez,

I'm a Canadian, temporarily living in South Africa. Greetings from Pretoria!

I'm 44 yrs old, diagnosed with PCOS at age 33, on metformin 500mg 2/day since then. I've got about 45 pounds to lose and have been slowly and steadily losing pounds since May (5 kg). I've never been able to get pregnant and throughout my 20s and early 30s, I went months without menstruation. Weight came on very quickly. I exercise regularly.

My new gyne here found a myoma in my uterus in August during my yearly exam. I had bleeding between periods almost every day for a few months. Some days it was spotting; other days it was heavier. The myoma was removed hysteroscopically and examined. The biopsy of the tumour shows atypical cells and the lab report summarizes the microscopy as "these features are most suggestive of an adenomyomatous (endometrial) polyp with focal atypia against the background of a proliferative endometrium."

I understand I need to remove my uterus.The doctor can do the surgery vaginally. Is uterus removal the best course of action? What can I do to prepare my body for no uterus? And Is there anything I can do to protect my ovaries going forward?

Thanks for your help in advance. S. from South Africa

Answer:

Hello S. from Canada and South Africa,

Atypia is NOT a absolute indication for hysterectomy, so no, you don't necessarily need to have your uterus removed. Atypia is not cancer, it is a pre-cancerous finding. It is possible that the only area of atypia was already removed, which then would have solved the problem. A repeat D&C should be done to evaluate the rest of the endometrial tissue. Also you should be cycles for three months then rechecked again by endometrial biopsy or D&C. If there is no abnormality found, then no other testing or treatment needs to be done other than keep you cycling on the birth control pill.

However, if you want you uterus out, and that is understandable, it is certainly a option for you and a vaginal hysterectomy would be fine. Make sure that your doctor keeps the ovaries intact i.e. does not remove them. You still need them to produce adequate hormone that your body needs. It's your choice. Make sure your doctor understands and is told that you want to keep your ovaries. There is absolutely no reason to have them removed.

Thank you for your question all the way from South Aftrica, addressing a problem that many women around the world face as well.

Good luck,

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

Comment: Thank you Dr. Ramirez! Very timely and useful.

IVF After A Myomectomy & Low Ovarian Reserve

Question:

Hello, Dr. Ramirez,

D. from VA here! I wrote to you a few weeks ago concerning my RE wanting to freeze my eggs, give me a myomectomy, then do implantation. You didn't understand why he wanted to do things in that order, and neither did I. He thought that my fibroids were blocking my left tube, and I also have hostile cervical mucus and low ovarian reserve. I want to thank you for your response to my question, it really made me think about things. I am having a myomectomy in a few weeks (by my gyno) and decided to hold off on any aspect of the IVF until later in the year, when I was fully recovered from the myomectomy (and had saved up some more money.) I do have a couple of questions.

First, is it a good idea to put off having the IVF, given all of my problems? Especially the low ovarian reserve. Part of me is hoping that by doing the myomectomy, I'll improve my chances of being able to get pregnant naturally. But because of the low reserve, I'm afraid if I wait too long I will have missed any chance of conceiving. Question #2: is there anything that can be done to improve cervical mucus? Or is the best option to bypass it with the IVF? Is intratubal insemination a good option? Thank you for any answers you can give me!

Answer:

Hello D. from the U.S. (Virginia),

Low ovarian reserve is an indication that your ovaries might not stimulate well with the fertility medications and so less eggs will be retrieved. That is its ONLY implication. It does not mean that you cannot get pregnant or cannot get pregnant on your own. It is only important for IVF. Now, if you have to do IVF for specific indicated reasons, such as tubal blockage or sperm problems etc, then you will want to do it sooner than later because your ovaries might get to the point where they will not stimulate at all and that will decreased your chances of success with IVF.

In terms of your fibroids, it is not that uncommon for a patient to become spontaneously pregnant after a myomectomy. I am sure that every fertility doctor has had patients like this. As long as your ovaries are functioning then you have that possibility. Low ovarian reserve has nothing to do with spontaneous ovulation.

In terms of cervical mucous, if you are trying naturally (non-IVF), then you can try Robitussin taken daily to help thin the cervix or you can proceed to IUI (intrauterine insemination) where the sperm is injected into the uterus and thereby bypasses the cervix (there is no such thing as intratubal insemination).

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.

Chances Of Pregnancy After Myomectomy: With Or Without IVF

(If the blog radio program turns on, go to the Oct. 1st blog post and pause it...I will be keeping the show up for the month of October.)

Question:

Dear Doctor,

Hello. I am writing from Atlanta, GA. I wrote once before (concerning my dermoid - thank you for the information!) and was hoping you would consider a second question. Much like everyone else here, I've had a complicated TTC journey.

April - laparoscopic dermoid removal from right ovary. Ovary was not removed but is small and has not produced follicles since (despite being on letrozole).

July - HSG. Right tube open. Left tube did not spill dye. Proximal block. No history of STDs or infections, thinking maybe it's scar tissue from surgery?

Sept - Large fibroid (~4cm) found on US (significantly distorts the uterine cavity). RE recommends abdominal myomectomy before moving forward with IVF. I also have a uterine polyp (~5mm) that will need to be removed at the same time (if possible) or during a 3rd surgery.

I am 36 years old and have never been pregnant. While on letrozole I produced 2 eggs the first month and 1 egg the second month. However, we are open to the use of donor embryos. My question is, what do you think is the risk of a complication from abdominal myomectomy (during the initial surgery or during a resulting pregnancy) and what is the probability of achieving a pregnancy after such a procedure? I am feeling discouraged given that there are issues with my ovaries, tubes, and uterus, and want to have a clear understanding of the potential for complications versus the potential for pregnancy if I move forward with the surgery.Thank you again for your time, J from Georgia

Answer:

Hello J from Atlanta,

Basically at this point you have two choices: you could attempt IVF without the myomectomy or have the myomectomy first before IVF.

The studies are controversial regarding the influence of fibroids on pregnancy rates in IVF. Some show that any fibroid can reduce the PR, whereas others show that only the ones that enter the uterine cavity do. In my experience, if the myoma is very large and takes up a good portion of the uterine muscle, it seems to impact fertility. I have had many patients get pregnant spontaneously after a myomectomy in those cases, or achieve pregnancy with IVF after they failed previous cycles. What I counsel my patient is that the studies are not clear and so the decision is really whether you not you want to do everything you can to maximize your chances with IVF or do you want to try the IVF without the surgery and take the risk. It is a toss up. I will go with whichever choice my patient makes. Neither option is a guarantee anyways. I have had patients that do the myomectomy and still fail with IVF, for whatever reason.

I cannot give you specific statistics regarding the chances of pregnancy with or without myomectomy because the mixed findings in the studies that have been done. In general, the current recommendation by ASRM is that only fibroids that invade into the uterine cavity need to be removed (because they can interfere with implantation) and 4 cms is not a large fibroid. I would consider 7 or larger to be a large fibroid. In some hands, this 4 cm fibroid can be removed laparoscopically. I also prefer to do the procedure as an open procedure, but that is because of a lack of experience removing deep fibroids laparoscopically. If you don't want the open procedure, then you might want to investigate and find someone that does these laparoscopically and has a lot of experience (the experience is the key in this procedure). That will allow for less pain and a quicker recovery. In either procedure, you won't be able to do the IVF for at least 8 weeks after the date of the surgery.

Good Luck on your journey...it is good that you are leaving yourself open to other options too!

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! Your knowledge and kindness are invaluable.