37 Year Old TTC With Past History Of Hyperplasia & Endometriosis Is Desperate To Conceive

QUESTION:

Ok, I went to the Gyno in Dec of 2009 because I wasn't getting my period. He sent me for an ultrasound Jan. 2010 and the lining of my uterus was thickened so he did a biopsy which led to my first D&C which was April. I was diagnosed with hyperplasia of the uterus and he said I was producing too much estrogen so he put me on Depo provera.

I got my first shot April 19. 2010 and he told me if I didn't go on the depo shot I would definitely get cancer. I had my second shot July and then I had another D&C September and everything came out good, hardly any tissue. After the D&C the Gyno said he wanted me to stay on the depo till I go through menopause ughh!! I've had three more shots, one in Oct.. one in Dec. and my last shot was March 21, 2011. I want to have a child and in late July I will be 38. My gyno said I could go off the depo shot, so I asked him what if it takes me a year to get pregnant? He said, "You're not allowed to take that long you'll get cancer of the uterus for sure."

I think I need a second opinion & I'm hoping my withdrawal from the depo isn't so horrible. One thing I think you should know is I was diagnosed in my mid 20's with endometriosis and my gyno (back then different doctor) said I didn't have a lot of tissue he also never told me I couldn't conceive, he just said after you have children just get a hysterectomy. I was put on different forms of BC (birth control) over the years and my last form of BC was the NUVA ring. I always had bad cramps w/ my periods so he had me wear the ring continuously. I would wear it for three weeks and take it out and put in a new ring right away to avoid periods, when I was doing that I had break through bleeding all the time & that's where I think all the excess tissue came from with the hyperplasia. I've been on the depo shot for a year and three months then I'm due for my next shot which I don't want.

I'm writing from South Jersey. I only want to have one child! Please tell me what you think. Thank you for all your time. :)

ANSWER:

Hello A. from the U.S.,

First, I don't think you need to worry about the hyperplasia at this point. You have been adequately treated for it. You just need to make sure that you have regular cycles because not shedding the lining at least every three months is what can lead to hyperplasia, and if left untreated the simple hyperplasia can turn into atypical hyperplasia (precancerous) which can then turn into cancer.

I think that pregnancy is a good idea for it and you need to pursue it aggressively! Your age is the number one issue at this point, in terms of getting pregnant. A second issue with getting pregnant is the history of endometriosis. Depo Provera is certainly a good treatment for this disease but endo can recur and can impede pregnancy. Considering your age, I wonder if there are other factors as well since you have never gotten pregnant to date. My recommendation, in general, to patients at 37 years old or older is to strongly consider IVF (in vitro fertilization). Other than age, you don't have an absolute indication for this, unless something else is found wrong, but the chances of pregnancy are so much higher with IVF than any other treatment at your age.

For example, your natural chance of pregnancy is approximately 3% per month or 5% per month with IUI. On the other hand, with IVF it is 69% per month in our clinic, and at least 50% across the country. That is a significant difference. The problem with age is that the majority of eggs that you still have will be of poor quality so the only way to increase your chances to find an egg with good quality is through IVF. You can certainly try with more natural methods but with each month that you fail, your chances are decreasing (it's like chasing your tail).

I would strongly recommend that you go to a good IVF clinic and have a consultation. I know that there are some excellent ones in New Jersey.

Follow-Up Question:

One more question, being on the depo shot for this time period (one year & 3 months) I'm afraid as to how long it will take to get out of my system. Reading posts by women who've been on it much longer than I (like 7-12 yrs.) say it can take 6-18 months to start a normal period & ovulate again. Any suggestions on how to rid the depo from my system when I'm actually due for my next shot? I've read lots of water and excercise.

Thanks again after this no more questions I'm sure you're busier than ever.:) A. from New Jersey.

Follow-Up Answer:

Hello Again,

I don't have any solutions to how to speed up the return of your natural cycles. The Depo can linger for a while but I have never seen it take more than 2-3 months. If you want to start trying for pregnancy sooner, you could undergo ovulation induction and that will get your ovaries to stimulate and ovulate.

You are very welcome to ask your questions and thank you for your patience in waiting for my reply.

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: Dr. Ramirez was very helpful to me I really appreciated his input. Thanks again!!

Could I Be Infertile Or Am I Still Recovering From Surgery For Endo?

Question:

Hello. I'm a 29 year old female. My husband and I have been trying to conceive for 7 months now. I had a laparoscopy done in June of 2013, due to an ovarian cyst on my right ovary. As the Dr. was doing the procedure, she said that the cyst had already ruptured ( which I didn't even know, or feel) and she found a little bit of endometriosis, which she got rid of as well. My tubes were wide open with no other complications.

 I'm about 2 1/2 months post op, and we still haven't gotten pregnant. I just saw my Obgyn a few days ago for a progesterone test, and it showed I was ovulatory. I was an 8.4. So the next step is to go get another ultrasound to make sure everything is ok inside, followed by some blood work a few days later. He said we'd check for PCOS. I have no symptoms of that. My periods have been pretty regular all my life. My question is why haven't I gotten pregnant? I thought the laparoscopy was suppose to open things up to help a future pregnancy. Could my body still be recovering from the surgery, and that's why I haven't become pregnant?  Or could there possibly be an underlying problem I have. The Dr. didn't really make me feel that comfortable. I asked a lot of questions, yet I still feel I'm unsure about things. I don't know what to think. He said we might start Clomid, but part of me wants to think I'm still recovering. I really hope I don't have any serious problems. I really just want to be blessed with a child, yet it's been so difficult to achieve.

Any advice/help would be greatly appreciated!  P. from Illinois.

Answer:

Hello P. from the U.S.(Illinois),

Infertility is defined as the inability to become pregnant after 12 months of trying so technically you are NOT infertile.

In terms of your surgery, you are way past that and it is not the reason you are not getting pregnant unless scar tissue was formed from the surgery inside the pelvis.

My first recommendation is to find a new doctor.  Preferably, find one that is a specialist in infertility rather than a general Ob/Gyn.  The reason is that you are on the verge of wasting a lot of time and money.  Your doctor is jumping to things without good reason.  For example, saying that you have PCOS when you have regular periods.  PCOS is defined as an ovulation dysfunction and you have to have irregular or absent periods as the prime criteria for the diagnosis.  Also, going straight to Clomid without a full infertility evaluation is a waste of time and money.  It's like prescribing a treatment before you know what you are treating.

My recommendation would be to start with a basic infertility evaluation:

• Cycle day#2 or 3 hormone panel (FSH, LH, Estradiol, TSH, Prolactin)
• HSG

• Hysteroscopy or Hysterosonogram

• Pelvic ultrasound #done#

• Semen analysis

• Cycle day #21 or 22 progesterone #should be 10 or greater#

• End of cycle endometrial biopsy

• Cervical cultures for GC, Chlamydia and Ureaplasma

• Laparoscopy (which you have done)

Once all these are done, then you can discuss and consider treatment options. Since endometriosis was treated, you need to try to get pregnant within one year of the surgery or the endometriosis will return and possibly prevent pregnancy.

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.

Woman Suspects She Has Endo: Treat The Pain Or Do IVF?

Question:

Hi there. Hubby and I have been TTC (trying to conceive) for almost 4 years now, with no success. We have been to two different REs, the first performed one HSG (hysterosalpingogram) and we underwent two unsuccessful IUIs (intrauterine insemination). The second ran a lot of tests, told me my eggs were low and wanted to go straight to IVF. In the last couple of years, my menstrual cramps have become unbearable, to the point of awaking me in the middle of the night. I have always had cramps, but nothing like this pain. I also have diarrhea along with my cycle, a yeast infection every month, and terrible seasonal allergies.

Two years ago I had an abdominal myomectomy and at that time, my doctor separated my fallopian tube from my uterus-they had gotten stuck together. I have been reading up on endometriosis and it sounds to me like I may have it. No doctor has ever suggested that I get tested for it. But I seem to have many symptoms of it. Do you think my tube and uterus getting stuck together were a result of undiagnosed endo? Could this be causing our infertility? Thank you for any answers you can provide. Thanks, W. From Virginia.


Answer: Hello W. from the U.S. (Virginia),

It seems that you are smarter than the two RE's that you consulted with. Given this history, you certainly could have endometriosis, and the prior surgery probably made the diagnosis. Endometriosis is one of the major causes of adhesions (scar tissue) formation in the pelvis. It can lead to infertility because it changes the normal anatomy and can prevent an egg from entering the tube. In addition, you have now had an open surgery (myomectomy) which is notorious for causing scar tissue formation as well. These two things on their own would explain your infertility.

At this point you have to make a decision: whether to treat the pelvic pain or get pregnant. Treating the pelvic pain will require additional surgery. Getting pregnant would require IVF, the only option for bypassing an abnormal pelvis. Do not be under the misunderstanding that doing the surgery to diagnose and treat the endometriosis and adhesions will restore your fertility. In fact, the opposite will occur because every surgery leads to further adhesion formation. Only do the surgery if the pain is a significant problem. If pregnancy is the priority, then go straight to IVF. In many cases, getting pregnant will help the endometriosis pain.

Good Luck,

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

Conceiving After The Age Of 40: What Are My Chances?

Question:

Hi. I am 43 and began my quest for motherhood about two years ago. I have been on Clomid and Femara and have tried IUI about 5 times. I most recently tried Follistem and IUI. Last month I was on oral contraceptives because of a cyst and returned this month to discover the cyst was still there AND I had another cyst on the other side. The doc gave the option of aspiration of cysts or to consult to discuss options such as donor eggs.

I have been pregnant once, with no fertility help, about 3 years ago (at 40 yo) which resulted in miscarriage at 8 weeks. We had a heart beat then lost the pregnancy. What are your thoughts about my fertility history and recommendations for an otherwise healthy 43 year old? The cysts are producing estrogen--level was checked. Thank you for your opinion. I am writing from Iowa....thanks! S.

Answer:

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

First you need to understand that you are trying to beat the odds and that statistics is only a reflection of real life, not an exact predictor of it. There are always exceptions. However, we try to make the best decision based on the information that we have.

It is well known and scientifically proven that a woman's fertility decreases with age beginning at 30 years old. This is due to the fact that a woman is born with all the eggs she has for her entire life and those eggs age with her. In addition, she is using up lots of eggs with each cycle so there is also a reduction in the number of eggs available.

We also know that by 40 years old, the remaining eggs will be of poor quality. This leads to a reduction in pregnancy rate or a significant increase in miscarriages, and was probably the reason you miscarried at 40 years old. Your statistical chances of pregnancy with IUI (intra uterine insemination) at 43 years old is less than 0.5% per cycle. This is due to the fact that IUI is still a "natural" treatment method and requires that your body go through the normal steps to achieve pregnancy. As you can see, your chances are not zero, but are pretty slim. (A 20 year old woman has instead a 20% chance of pregnancy per cycle.) At your age, with IVF (in vitro fertilization) using your own eggs, the chances of pregnancy rise to 33% per cycle. Unfortunately, because of pregnancy and miscarriage losses the delivery rate is 13%. It is still significantly better than IUI because most of the steps required are performed by the IVF and only two steps are left to natural processes. With donor eggs and IVF, the chances increase dramatically due to younger and healthier eggs, to 75% with 59% delivering.

Most fertility specialists would recommend donor IVF, but it is a personal choice that you have to make. Most of my older patients want to try at least once with their own eggs and I will give them the chance to try because as I said up above, there are always exceptions!

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.

Can Lubricants Interfere With Getting Pregnant?

Question:

Hi there. I was wondering if you can tell me if using a lubricant like KY sensitive Jelly can hurt your chances of getting pregnant. My husband and I just started using it a few months ago and we have been trying to conceive. I just read online that it can be toxic to sperm. Does this mean that you cannot get pregnant at all while using the lubricant or that it just lowers your chances? We will stop using it if we don't get pregnant this month. Thank you. J. from New York

Answer:

Hello J. from the U.S. (New York),

The rule of thumb is that lubricants like KY can interfere with sperm mobility and therefore also the ability to achieve pregnancy. Some lubricants can kill sperm but it depends completely on the formulation. Johnson and Johnson does make a version that is compatible with attempting pregnancy and there are other companies that produce "fertility-friendly" lubricants as well. You have to look specifically for one that states that it is compatible with trying for pregnancy. Some alternate brands you might want to look at are "Pre-Seed" or "Conceive Plus".

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.

37 Year Old Fails 3 Clomid Cycles & 2 IUI's: What Should She Do Next?

Question:

Dear Dr. Ramirez: thank you for your great service!

I just turned 37 years old and have been ttc for 1 year already. My cycles all my life have been like clockwork (ovulating on day 13 in a 26day cycle). After charting and some blood tests during the early months of ttc, I realized I had low progesterone. I was put on suppositories and after another 6 months of no success, I was put on 50mg Clomid. That's when my cycle was completely thrown off. On Clomid cycle #1, I ovulated on day 19 (much later than normal), on Clomid cycle #2, I ovulated on day 14. Both cycles were followed by unsuccessful IUIs (intra uterine inseminations). On Clomid cycle #3, I ovulated on day 11, so we missed it and didn't do IUI. On cycle #4, I ovulated on day 10 and I did two back-to back IUI (again unsuccessful). My lining is fine, there are no cysts and all my blood work on all hormone levels is good within healthy normal levels. In fact my hormone levels were normal when I tested during my natural cycle before taking Clomid. Only progesterone was low and the suppositories didn't provide enough (day 21 showed 12 only), so 2 months ago I was put on PIO and that works like magic (level was 33 and 36 on day 21).

I read in on your blog that women who ovulate on their own shouldn't take clomid, which may REDUCE their chances of getting pregnant. Did we undertake the wrong treatment? Again, until I started clomid, you could set your watch by my cycle and I could check my ovulation using the monitor. After taking Clomid, my monitor cannot register any hormone changes and peak ovulation anymore. I was told that given my age the next thing to do is move to a more aggressive treatment (injectables), but if I was so regular and ovulating on my own, why do i need the injectables?

The fertility center never did an ultrasound to see how mature my follicles are during my natural cycle (they did this only when I was on Clomid), so my inclination is to get off clomid and try a natural cycle for a few more months again and ask them to see if my follicles are large enough. Would you think that's wise or shall I move to more aggressive treatments? My husband's sperm count varies from 25mil to 100mil during the IUI cycles. He also had average motility of 90%. Semen analysis also indicated 80% morphology.

Thank you kindly for any advice you may be able to offer. L. R. from Lancaster, PA

Answer:

Hello L. from the U.S. (Pennsylvania),

The main problem, and only problem that you have identified, is your age. I call this the age related egg factor. This means that the eggs have aged and have decreased in quality and viability. A study was done to look at embryos created at 37 years old and did genetic testing on those embryos and found that only 20% were normal, a reflection of egg quality. So that is the hill that you are trying to overcome.

In this case, the use of fertility medications is to achieve "superovulation" not ovulation. The main use of Clomid is to induce ovulation in women that are not ovulating but in older women, the goal is to increase the number of eggs that you ovulate to increase the chances that you will ovulate a good egg. In my patients over 35, my goal is to get them to ovulate 3-5 eggs per cycle. In my blog what I am referring to is the tendency for general docs (family practice and Ob/Gyn's) who automatically place an infertility patient on Clomid without finding out the root cause of their infertility, as if Clomid were some magic drug. They are misusing the medication.

In your case, because you stated that you are at a fertility center, I presume that you have undergone an infertility evaluation and nothing was found except for your age, so superovulation would be a reasonable first step. I also don't recommend consecutive Clomid cycles because Clomid works by blocking estrogen receptors and too much Clomid with block the estrogen receptors that are necessary for fertility, such as tubal motility, endometrial lining development and cervical mucous production. In that case repetitive Clomid cycles can lead to infertility by blocking these receptors.

Because of your age, I do believe that you need to pursue an aggressive treatment plan. I usually do not recommend more than 4 IUI cycles as part of an aggressive treatment plan because studies have shown that most patients will get pregnant within four attempts and pregnancy rates decrease dramatically after four. Keep in mind that at your age, your pregnancy rate per IUI cycle is only 12%. But if you want to continue to try IUI, then it is reasonable to try with injectables, although these meds are a lot more expensive, for two more carefully monitored and timed cycles. Then if that is not successful, I would strongly encourage you to proceed to IVF.

By carefully monitoring, I mean that ultrasound screening should begin at cycle day #9 the proceed from there depending on the size of the follicles. The closer you get to ovulatory size, the more frequent the ultrasounds will be. HCG should be given to trigger the ovulation. IUI's should be done at 24 and 48 hrs after the HCG trigger and then the progesterone is started the day following the second IUI and continued until the bHCG. Progesterone should be given as a vaginal suppository 2-3 times per day depending on the formulation.


Good Luck and thank you for reading my blog!

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.

The Wrong Way To Do A Clomid Induction Cycle

Question:

Hi. My Doctor prescribed me provera to induce a period and then clomid to induce ovulation. She told me that monthly I am supposed to take provera from the first of the month through the tenth of the month and then once my period comes i'm supposed to take Clomid from day 5-9.

So here it is, May 13th and it is day two of my cyle which means I will take Clomid May 16th-20th. Am i supposed to automatically take the Provera again on the 1st of June? That just doesn't sound right to me. Please help me understand this. C. from Nevada

Answer:

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

You are wiser than your doctor, which means you are seeing the WRONG doctor. She is not correct on the proper method to do a Clomid ovulation induction cycle. I would recommend that you look up my blog and review how I recommend doing Clomid cycles. I think you will be shocked once you compare it to what your doctor prescribed!

First, Clomid cycles should be monitored for three reasons: (1) to see whether you are responding to that dose of Clomid (there are five dosages that can be used). (2) to see how many follicles are developing so that you don't have too many and (3) to determine when ovulation is going to occur so that you can time your intercourse properly.

The "autopilot" method of Clomid ovulation induction is not correct and shows that your doctor has a very limited knowledge of this treatment and infertility in general. I would strongly recommend that you go see a fertility specialist so that you don't waste your time.

Many doctors will use a progesterone supplement with Clomid cycles in order to support implantation and the early pregnancy. Clomid often can induce a luteal phase defect. However, Provera is NOT the drug used because it is a synthetic progesterone. Instead, a natural progesterone like Prometrium is used and a pregnancy test is done at the end of the cycle to determine whether or not your are pregnant so that you can stop the medication and have a period. If there is a luteal phase defect and you stop the progesterone prematurely, that could induce a miscarriage due to inadequate progesterone support. Does that make sense? So you can see why your doctors orders are all wrong.

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.

Canadian TTC Wants To Know When Is The Best Time To Use A Pregnancy Test Kit

Question:

My husband and I are trying to get pregnant with our second baby, I got pregnant very easily with my now three year old son. As of right now I am 8 days post ovulation. I have been using 10 miu pregnancy tests which have all come up negative the last three days.

I have two questions I hope that is okay. My first one is what is the average day for a positive pregnancy test using 10 miu tests? My second question is if I am experiencing ALL of my usual pms symptoms does that mean I am likely not pregnant? Thanks so much! L. from Canada

Answer:

Hello L. from Canada,

You'll have to wait at least 10-14 days to check a home urine pregnancy test. At 8 days post-ovulation (assuming that is when it occurred because there is no way to know for sure), entrance into the uterus is just occurring for the embryo and implantation has not yet occurred. Keep in mind that an ovulation predictor kit does NOT tell you when ovulation occurs but the range of when it will occur. There is no way to know when it occurs exactly.

PMS symptoms are usually due to the increased progesterone levels in the luteal phase and not an indicator of a lack of a pregnancy. You'll just have to wait and see.

Also keep in mind that despite the fact that you got pregnant easily the first time, it takes the average woman 8 months to get pregnant and 85% will achieve pregnancy by one year of trying. So, in fact, you have not tried for a long enough period of time to worry. :)

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 you so much! I feel much better that you have answered my questions, and I now know I do not need to worry.

Norwegian Patient With Arcuate Uterus & PCOS Wants To Know: Is IUI A Good Option?

Question:

Hi, I wrote before. I have an arcuate uterus and polycystic ovaries. My hormonal results were fine as well as my test for cervical cancer. My husband and I have decided to go for artificial insemination since we have been trying to have a baby for 4 years. I have never gotten pregnant. My question will I qualify for that and what does the whole process involve? Is it less expensive than in-vitro? Thank you, N. from Norway

Answer:

Hello N. from Norway,

IUI (intrauterine insemination) is certainly an option for you, especially if you have been found to be completely normal except for ovulation, the polycystic ovarian syndrome. (As far as the "arcuate" configuration to your uterus, this is generally considered a normal variant and does NOT cause infertility, do not be concerned with that.) Because IUI is a "natural" treatment method, meaning your body has to go through all its natural steps to achieve pregnancy, each of these natural steps have to work properly to get pregnant. Therefore, it can take several IUI attempts to achieve pregnancy, just as it would take several months of trying normally for a regular couple. The pregnancy rates are age dependent and range from 3%-24%. The maximum pregnancy rate is 24% in a woman under the age of 30. It decreases from there due to age factors.

The basic problem with PCOS (polycystic ovarian syndrome) is that the ovary does not function correctly and therefore does not ovulate on a regular basis. Therefore, any infertility treatment that you do will require that you take fertility medications in order to induce the ovaries to ovulate. With IUI the goal is to get you to ovulate three eggs per month (that is what increases the pregnancy chances). Ultrasound is then used to gauge your progess and time when the insemination should be performed. Basically, when the ovulatory follicles reach appropriate ovulatory size (18-24 mms), then a trigger such as HCG is given to trigger ovulation. I do two IUI's at 24 and 48 hrs from trigger but some clinics will only do 1 IUI at 32-26 hrs. There are pros and cons of each and I believe that two IUI's are better despite the fact that studies have shown that they are equivalent (I'm not sure that the studies were good enought to show a difference). IUI cost tends to be much much less than IVF because there is less technology used. If you don't achieve pregnancy by four attempts, then the pregnancy rates decrease dramatically so it is recommended to proceed to IVF from there.

One of the difficulties with PCOS patients is that there ovaries are very difficult to stimulate, so that many (80-85%) end up proceeding to IVF. With the simple meds such as Clomiphene or Letrozole, many PCOS patients do not stimulate at all despite the highest dosages, whereas, with the injectables (gonal-f, Follistim, Bravelle, Menopur), they tend to stimulate too much and produce too many eggs necessitating cancellation of the cycle. With natural treatments like IUI we don't allow more than three ovulatory sized follicles because we cannot control how many get to the uterus, which would increase the risk of a super-multiple such as 5, 6 or 8 implanting. This is a situation you most certainly would want to avoid!

I hope this gives you the information that you desired. Thank you for writing me from Norway!

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.

Young Woman TTC Is Concerned: Has Abundant Cervical Mucous & Irregular Cycles

Question:

Hello, I am writing you from Alberta, Canada. I have been doing many searches on the internet to find an answer to my question with no success. I hope that you might be able to help me.

So, I went off BCP (birth control pill) in March 2010 to TTC. (I am 26 and have been on the pill for 7 years.) Since then I have been having a cycle each month (cycles have been ranging 30- 36 days) I have had a cycle last 42 days. And I have had several appointments with my Dr. She said that since my cycles are that long that I "might not be ovulating". This really worried me as it's nothing a woman ttc wants to hear. So I have been watching for the EWCM and each month I barely see any. But there is a bit. Well I am going on day 53 with no period. Last week I had LOTS of EWCM for the entire week. And I mean A LOT of it. More than I have ever seen. I thought I was pregnant because of symptoms but after 2 negatives I know I am not. So this brings me to my question...what does it mean when you have LOTS of EWCM for a whole week? I was having LOTS of cramping so I was thinking my period was going to start but nothing. There was one day which was the worst cramping I have had. I usually cramp a lot when my period starts and the week of ovulation.

Could my body finally have ovulated and the hormones are working out or should I seek more advice from my Doctor? I am waiting for my cycle to start so I can take the clomid she prescribed me. I appreciate any advice you may have for me. I do plan on going back to my Doctor soon but with the Christmas holidays I can't get in to see her til the New Year. I was really curious about all that EWCM. There was sooo much of it and it lasted more than 4 days. Is that a good sign even though it was 45 day of my cycle? My cycles before I went on the pill were usually 32-34 days and very consistent. But the periods were heavier then...lasting 5-6 days. After stopping the pill they were very light and have only lasted 3-4 days.

I apologise for such a long explanation. I just thought I would share my story in case other women have the same issue and question so they can use the answer I receive.

Thank you again and all the Best to you in 2011!

Answer:

Hello C. from Canada, Thank you for wanting to share your concerns with other women who are trying to conceive (ttc). I think that you are putting too much value on cervical mucous. It is an indirect measure of the hormone production in your body. Basically, as the body gets closer to ovulation, the estrogen/estradiol level in your system increases, which in turn converts the cervical mucous to a clear, stretchy, copious mucous. This allows for sperm entry into the uterus and tubes. I am not sure what you are referring to as "EWCM" and because you don't describe the mucous properties so I can't comment on the question regarding having this mucous for multiple days (please be more specific, since descriptions are better than acronyms). The cervix produces all types of mucous and the vagina as well.

Here is a general guideline on what cervical mucous should look like post menses:

Stage 1: Lasting 2 - 3 days Cervical Mucous is sticky or gummy

Stage 2: Lasting 2- 4 days: Cervical Mucous is creamy, milky and lotion like.

Stage 3: Lasting 1-5 days: Egg White Cervical Fluid: It looks like egg whites and is slippery and stretchy. The mucous should be clear, but if there is an odor this may be a sign of an infection, if so, consult with your doctor. Women in their 20's such as yourself can have this type of cervical mucous for up to five days. At this point, women are generally considered to be in their most fertile period.

Stage 4: Dry, Moist or Sticky

Based on the fact that your cycles are irregular, there is evidence that there is some type of ovarian dysfunction going on as well. It could be a lack of ovulation or a hormone imbalance. If it is of ovarian origin (there are other possible causes as well), then the treatment would be to use medication such as Clomid to stimulate the ovary and get it to function normally. But prior to making that assumption, you should have a hormonal evaluation to make sure it is not a problem with your thyroid or pituitary or hypothalamus or other such causes. If it is found to be isolated to the ovaries, then Clomid ovulation induction is appropriate. I would recommend that you look at my blog regarding how Clomid ovulation induction cycles should be done ("How I Do Clomid Induction Cycles"). I hope that helps to answer your questions, good luck!

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 UK Woman With Irregular Periods, Hot Flashes: Is She Perimenopausal? Can She Still Get Pregnant?

Question:

I am 42 years old and have had irregular periods for about the last 10 months, also hot flushes, etc. I have had blood tests at my doctors which showed I have started early menopause. How do I know if I am still producing any eggs and if so could I become pregnant? Is there anything I could do to help in getting pregnant or is this not going to be possible? Thank you, S. from the U.K.

Answer:

Hi S. from the U.K.,

The term "early menopause" is actually a misnomer. There is no way to tell if a woman is entering menopause until it actually happens. That is to say, a woman can be in the perimenopausal period, diagnosed by changes such as irregular cycles, mood changes, hot flashes, insomnia, etc., for years (5-10 yrs) before she actually goes into the menopause. During the peri-menopausal period, the ovary is starting to dysfunction as it leads into menopause, where it shuts down. During this "perimenopausal period" the ovary still ovulates, but often in an irregular fashion. Therefore, pregnancy can still occur. However, the chances are low, and some of the times that you ovulate, and egg is not given off i.e. the follicle is empty.

Some doctors will define "perimenopause" if the cycle day #2 FSH level is greater than 10 (between 10-20), but this actually is a measure of ovarian reserve and does not tell you if menopause is coming soon or not.

The biggest problem, however, is if the ovary is dysfunctioning, the hormones are out of balance and so, the steps following ovulation sometimes are out of synchrony so that pregnancy does not occur, and due to age, the ovulated eggs are often of very poor quality such that fertilization does not occur, or an abnormal embryo is formed that does not go to implantation or that the abnormal embryo leads to miscarriage. For these and other reasons, the chances of a successful pregnancy decline.

If you are contemplating pregnancy at this point, and have not entered menopause, then you have to worry that time is not on your side. That is to say, your time is short to achieve the pregnancy. Therefore, you need to proceed aggressively and with haste. For that reason, I recommend to my patients to do IVF. It has the highest chances of getting you pregnant in the shortest period of time. Trying by natural means, simple intercourse, ovulation induction with intercourse or IUI, will take much time, and you may lose your window of opportunity to use your own eggs.

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.

Trying To Conceive For One Year: Clomid Vs. Laparoscopy?

(If the blog radio program comes on, you can pause it by going to my Oct. 1st post. I will be keeping the show up for the month of October.)

Question:

Hi. I've been trying to conceive for about a year and my doctor and I are ready to take a more aggressive approach. We have generally discussed both clomid and laparoscopy as next steps in the coming months. I am wondering if you can give some advice as to the order of trying clomid first or having a laparoscopy first.

My sister and aunt both had endometriosis so I expect that could be the culprit. I personally lean towards having the laparoscopy first, but I want to understand which is usually recommended. Thank you. V. from the U.S.

Answer:

Hello V. from the U.S.,

In order for you to achieve pregnancy, if you have been having trouble, you have to find the reason so that you can get the appropriate treatment. The term "fertility treatment" or "fertility drug" is a misnomer. The treatment has to treat the problem. There is nothing that makes your more "fertile" no matter what the problem.

Clomid is a fertility medication only in that it is used to treat infertility. In actuality, it is an ovulation inducing drug. That is, it gets the ovary to ovulate if the ovary is not already ovulating. Doctors use this medication in women that ovulate also to increase the number of eggs they ovulate so that there is a higher chance for one of the eggs to reach and enter the tube (because that does not happen every time).

Laparoscopy is a surgical procedure that is used as an infertility test. It is part of the infertility evaluation because it is the only method to assess if there are any pelvic abnormalities. This is important because the third step of the body's process to achieve pregnancy (brains sends FSH/LH to ovary > ovary grows follicle and matures an egg > ovary ovulates and egg enters pelvis > egg has to get to tube . . .) is for the ovulated egg to pass through the pelvis and get into the tube. If there is anything within the pelvis, like scar tissue or an inflammatory disease like endometriosis, then then egg may not make it to the tube (endometriosis causes inflammation that can destroy the egg).

I presume that you have had a complete infertility evaluation prior to your doctor's recommendation to use Clomid or do laparoscopy? I dislike it when general Ob/Gyn doctors jump to unnecessary conclusions such as go directly to Clomid or laparoscopy without making sure that is what is needed. Clomid is used for ovulation problems or in conjunction with IUI (if there is a sperm problem). Laparoscopy is done if all the other preliminary tests are normal, or if there is an increased chance of having endometriosis such as severe menstrual cramping or pelvic pain or pain with intercourse. It is usually one of the last tests to be done. Is that where you are?

These are the things that need to be considered and if you see the right fertility specialist, it is more likely that the appropriate things will be done to help you to become pregnant. If you see the wrong person, then you might just be wasting your time.

If you give me more detailed and specific information (such as your age and what tests have been done), then I would be able to give you my recommendations on what needs to be done next.

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.

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.

Male Factor Infertility -- IVF Cycle FET Positive But Ended With Miscarriage: Should I Seek A Second Opinion?

Question:

Dr. Ramirez,

My husband and I are a 29yo healthy couple with male factor infertility. Motility is less than 1%, morphology is about 25-30%, and count is pretty low-normal. There are no female issues. We have done 2 IVF/ICSI cycles and one FET (frozen embryo transfer). The first IVF (in vitro fertilization) cycle, I was mildly hyperstimmed. The egg quality wasn't great, and we had about a 50% fertilization rate. We transferred 2 grade A embryos that did not result in pregnancy. No embryos made it to day 5. IVF #2 was much better and had an 80% fertilization rate. 2 day-3 grade A embryos were transferred, but there was no implantation. There were 2 day-6 blasts that were frozen. Both were starting to hatch upon thawing, and the FET resulted in a singleton pregnancy with a heartbeat at about 7 weeks. Unfortunately, I miscarried (no heartbeat) at 8 weeks.

My question to you is when should I seek a second opinion? We had planned on obtaining a 2nd opinion if the FET was unsuccessful, but we feel like technically it was successful. We like the place we go to right now and feel that they are familiar with us. We are planning to do IVF #3 in the near future and are torn as to whether we should stay here or move on. If we stay with the current practice, we will not be changing the protocol since it was successful last time. Although it has been suggested, we are not ready to use donor sperm since we were able to grow 2 blasts and achieve a pregnancy. We are located in Missouri.

Thanks in advance for your time.

Answer:

Hello L. from Missouri,

I agree with your statement that technically the FET was successful. In fact, the FET cycle WAS successful. Remember, IVF can only give you the opportunity to become pregnant. It cannot MAKE you pregnant because the last two steps in the natural process, embryo hatching and implantation, are NATURAL steps and we don't have the technology to make that happen. So, the fact that an embryo did those two steps and the pregnancy went to 7 weeks is a success. And, it is a very good sign because it now shows that what you are doing can work!

I would not give up on that clinic yet. In fact, pregnancy rates with FET are lower than fresh cycles, so a success with an FET is good. They deserve the credit. Now that they have stimulated you twice, know how you react, etc., they are hopefully in a good position to build on that the next cycle. You have to give them some credit for that.

Overall, I would hang in there. You've proven that it can work. Whether or not the pregnancy continues is solely and completely dependent on the embryo. It was probably an abnormal embryo. Now, you just need to get a good one there and you'll go all the way. Don't look back, just look forward. You should now be more encouraged than before because you know that it can work. It is just a matter of time!

On a personal note, I have a patient that I was able to get pregnant on her first try at the age of 36 and she had a beautiful child. She just came back to me for her second child at 39 (worse chances statistically) and became pregnant again, but it was an abnormal pregnancy and ended in a miscarriage. I found out today, that she is planning to transfer to another clinic because they have a "special" research program going on that gives patients a significant discount. You can't believe how heart broken and how I feel rejected by this. I put my heart and soul into my patients, and they get the best care that they can receive. I know that logically the cost is a significant issue, and this is what is driving the patient, but having gotten so close to a success, when we have been successful before, is difficult for me. That is what your clinic will think too. They'll ask themselves, "why is she leaving when we were successful under less odds?"

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

Comment: Dr. Ramirez clearly stated his opinion and seemed to have genuine answers. I appreciate his advice and his providing this service

Young PCOD Patient With Tubal Blockage Unable To Conceive: Surgery or IVF?

Question:

I'm really searching for some advice. I was diagnosed with PCOS (not insulin resistant) this month (after four years of "maybe yes") as well as finding out I have a blocked fallopian tube.

I'm seeing an IVF specialist who recommended having hysteroscopy and laparoscopy surgery to clear the blockage and determine if there is scar tissue or endometriosis that can be fixed. I've suffered from very heavy irregular periods for the last 4 years.

I was told that if I chose not to go with the surgery the next step will probably be IVF. I thought IVF was a little extreme, completely skipping over Clomid and other fertility drugs. I know it's possible to get pregnant with one working tube, and I really don't want to do surgery unless it's absolutely necessary. I've been told by family I should get a second opinion, that sometimes surgeries are recommended when it's not really needed, because of money, etc. My Dr office did tell me I have excellent health insurance coverage. I don't think that's the case but it just seems like 2 extreme methods. I'm at one of the best fertility clinics in South Florida and feel like they should know better than me.

I'm 26 and not overweight (I lost 40 pounds 3.5 years ago), I've been off birth control for 5 years, and we've actively been Trying to conceive for over 8 months. My husband's sperm count is great. I used ovulation kits for 3 months but was never able to get a positive result. Is surgery the only way to tell if I have endometriosis?Would it be more beneficial to have the surgery then to start IVF without it?Is it usual to skip all other fertility medications in situations like mine and just use IVF? Is this a situation that you would recommend getting a second opinion?

Any advice you can shed is greatly appreciated.

Thank you, S. from Palm Beach County, FL

Answer:

Hello S. from Florida,

I guess I can be your second opinion. As you have described, you have two problems thus far: PCOD and tubal blockage. Certainly if PCOD were the only problem, ovulation induction with Clomid, Femara or injectables would be an option and could be combined with intercourse or IUI. However, keep in mind that most PCOD patients do not respond well to these medications and many (up to 85%) end up having to go to IVF because of this. However, if this were the only problem, then you would have more options.

Tubal blockage is another problem. The more problems you have, the worst the prognosis for achieving a natural pregnancy and the more you need to consider IVF. Tubal blockage by itself is enough to consider IVF, however. You don't describe where the tube is blocked but the only situation where surgery might help with tubal blockage is if it is blocked at the very end AND there has been no internal tubal damage, such as is caused by endometriosis. If the tube is blocked anywhere along the tube, it cannot be repaired and surgery would therefore not be indicated. The most common cause of tubal blockage is some form of inflammatory disease that ascended into the tube via the vagina and uterus. Because both tubes open to the uterus, this inflammation/infection problem got into both tubes but affected them unevenly such that only one tube is completely blocked. That does not mean that the other tube is normal, however. It could mean that the other tube was affected and damaged but did not scar enough to block completely. Usually when I see one side blocked, I make the assumption that the other tube is also not functional based on the fact that if it were, the patient would probably have achieved pregnancy on their own. Considering how long you have been trying, that makes me suspicious that the open tube is not functional. In that case, the ONLY treatment option is IVF because that is the only way to bypass the tubes. Remember that the internal part of the tube cannot be repaired and repair of the tube at the very end of the tube does not work well (1% pregnancy rate).

So, now, if you combine these two problems, then you can see that IVF is the treatment of choice for you. In that case, why have the surgery? Any other problems found, like endometriosis, will just be additional reason to do IVF. It does not affect your IVF chances. The only reason to have a laparoscopy if you are considering IVF is if the tube is swollen with fluid, called a hydrosalpinx, in which case that tube either needs to be removed or severed from the uterus to prevent the fluid within from leaking into the uterus. Studies have found that IVF pregnancy rates decrease by 50% when a hydrosalpinx is present. The only other reason is if you had any kind of ovarian mass or cyst. That would need to be removed prior to IVF as well. Remember, the treatment has to treat and overcome the problems.

Just choosing a treatment arbitrarily, like fertility medications, does not necessarily overcome all the problems present.

I hope that answers your questions.

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

Progesterone Supplement For Luteal Phase Defect

Question:

Hello Dr. Ramirez,

I am turning 34 later this month and have been trying to get pregnant for the past 4 months. I never have any spotting during the first half of my cycle, but have had light spotting usually for 3 - 5 days before my period starts (as long as I can remember except when I was on the pill). About 7 years ago my doctor did some tests and sent me for an ultrasound and when he found nothing wrong, put me on the pill to regulate this. I stopped using the pill about 3 years ago and have lived with the light spotting (starts very, very light and gets a bit heavier each day until my real period starts - usually starts on Day 27 to 32 of my cycle).

Over the last 4 months, I've been recording basal body temperatures while trying to get pregnant. I've noticed my temperature only stays high for about 8 days. It drops usually on the 9th day and the day after that very light spotting starts. After doing my own research, I'm concerned that I may have a luteal phase defect and need some sort of progesterone to help get/maintain a pregnancy. I went to my doctor and he said I would need to try for a year regularly before determining I have a fertility problem and he doesn't think testing is necessary yet even thought I think my temperature readings and spotting indicate there may be a problem. I understand it may take a while to get pregnant, but if there is a possibility of a problem that could be helped with progesterone, I would rather find out now than wait until next year when I'll be almost 35. Especially if I do need a referral to a specialist at some point, it could be a 6 month wait to get an appointment.

Does it sound like I may have a problem (hopefully treatable) or should I continue trying for another 6 or 8 months before undergoing any testing?

Thank you very much for your help, L. from Canada

Answer:

Hello L. from Canada,

I have had many letters from Canadians lamenting the fact that their Physicians are uncooperative and it is a long wait to see a specialist. You certainly have not tried long enough on your own to warrant an infertility evaluation, but I am surprised that you doc won't give you progesterone supplements. It is such a simple thing with no side effects and potentially helpful.

Yes, the BBT findings and pre-menstrual spotting are consistent with LPD. The diagnosis is made with an end cycle endometrial biopsy for dating. Since your doctor won't do that, we can make the assumption and you should go on progesterone supplements. There are many sources of natural progesterone. I believe you can even get natural progesterone creams in health food stores. I will usually prescribe the pharmaceutical versions such as Prometrium, Endometrin, Crinone or Prochieve. You have to take them starting from day #16, but the problem is that the supplementation may prevent your natural menses from starting because it is the dropping of the hormones that leads to a menses. So, you would have to do a pregnancy test to see if you are pregnant then stop the meds if you are not (you would continue them if you are).

For now, I would recommend that since none of this is easily obtainable for you, you should continue trying on your own for the next six months. If you should become pregnant, the pregnancy will produce the hormones that you require via the corpus luteum cyst that forms from ovulation.

Follow-up Question:

Thank you. I really appreciate your response and think I will go to a walk in clinic next month to at least get a day 21 progesterone test to have some idea of my levels.

I started taking a B50 complex vitamin this month as some women have reported B6 helps with the luteal phase (contains 50 mg of B1, B2, B3, B6, Pantothenic Acid, Choline and Inositol; 50 mcg of B12 and Biotin; and 0.4 mg of Folate.) Would there be any known problems with these vitamins if I were to become pregnant? I am also taking a prenatal vitamin that contains very low amounts of the above noted vitamins (except for Folate which is 1 mg in the pre-natal). Again, thank you very much for your help. It is very much appreciated.

Answer:

Hello Again,

It is okay to continue those vitamins for now, but discontinue them should you become pregnant and stick with the prenatal vitamin only.

Good luck with your treatment!

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.

Patient Had Laparoscopic Ovarian Drilling & Damaged Tubes, What To Do Next?

Question:

I am from the United Arab Emirates. I had problems with my periods earlier since beginning of my teenage, like the absence of periods for years. Then I started taking contraceptive pills for regularizing my periods but it didn't help me. After that I thought it would be ok after I got married but then I didn't get pregnant for 1 year. After that, I had Laparoscopic ovarian drilling done.

I take no medicine till now after the surgery I got my period twice on my own 28 days difference but on the 3rd month I didn't get my periods at all. I thought I got pregnant then but I had blood tests done twice but it showed me negative. Before the surgery I had taken injectables, Clomid and what not, but it didn't help me ovulate actually. Both of my tubes were blocked but now after the surgery one of them is working. The doctor said I have less hormone & right now I am on primolute to get periods. So after consuming primolute for 10 days when should I expect my periods???? and what has to be done for my hormones???

By the way my age is 21 and my height is 162 cm and have been married for 1 and half years . My husband's semen was tested and they said that it's normal. Thank you very much!

Answer:

It sounds like you have PCOD (polycystic ovarian disease). Ovarian drilling is a very, very old fashioned treatment for PCOD. It is a procedure whereby a laparoscope is inserted into the abdomen and a needle, electrode or laser is used to make holes (yes, holes) in the capsule of the ovary. In the past, it was used as the mainstay treatment for PCOS, and in some cases was successful in getting the ovaries to function normally, at least for a short while. But, it does not work in all cases, and the problem is that damage to the ovary can induce scar tissue around the ovary, tubes and pelvis, thereby rendering the patient infertile by obstructing movement of the egg to the tube. Contemporary fertility surgery preaches minimal tissue damage to prevent or reduce scar tissue formation. This procedure contradicts this philosophy, did not work in most cases and, in some cases, made the fertility problem worse. We don't use it very much in the U.S. any more, and I cannot recommend it.

You have two problems in regards to your fertility: (

Number One: because of the PCOD you don't ovulate and Number 2: you have a tubal problem.

First, let me deal with the tubal problem. In reality, there are NO surgeries that can correct a tubal problem. Surgery can be used to open the ends of the tubes, but the major damage is usually within the tube and this cannot be repaired. The fallopian tubes are not just pipes. Opening them is not enough. They are working organs with muscle layers and small hairlike cilia that help to move the egg and sperm together. Because this damage cannot be repaired, the only realistic treatment option is to proceed with IVF "in vitro fertilization". This allows us to bypass the tubes.

The second problem is PCOD. In this case the ovaries are difficult to ovulate safely (only allowing 2-3 eggs to ovulate). For that reason, the majority of PCOD women have to proceed with IVF. This is because we can extract all the eggs and control the number that are put back in. This is necessary because PCOD patients tend to over-respond to injectable medication, which is the only medication that will work to stimulate most PCOD ovaries. Clomid usually doesn't work.

So my recommendation is to see a fertility specialist and undergo IVF. The primolute is a progesterone, I believe, and is only being used to induce a period. It is not doing anything else.

Follow-Up Question:

So what do you say doctor, just Laparoscopic ovarian drilling and Clomid will not work after getting my periods thru primolute? I am waiting for my periods to come and so I can start with clomid and injections. This is the first clomid cycle after my surgery? Well, what I think is let me wait and see and then next we will go for IVF.

Follow-Up Answer:

Hello Again,

There is a good chance that the Clomid might stimulate your ovaries to ovulate. The ovarian drilling can sometimes make the ovaries more receptive to this medication. However, the chances are not good. The biggest problem that you have is a tubal problem. Because Clomid with either timed intercourse or IUI rely completely on the fact that there has to be normal tubes, if they are not, that is what will prevent you from getting pregnant.

In any case, miracles do happen and you may be the exception to the rule! So as long as you don't mind trying the Clomid, then it is okay to try.

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/

TTC And Using Ovulation Kit

Here is a fairly common question that I get on the All Experts site having to do with ovulation kits...

Hi Doc,

I have a 25 day cycle and my period usually lasts 3 to 4 days. When do you think I would ovulate? When should I start testing with the ovulation kit?

Thanks in advance.

Hello,

Thank you for your question. Generally the second half of the cycle is the most constant. It is 14 days from the onset of menses. So, if your cycles are 25 days, then you are most likely ovulating around cycle day #11. Your fertile period would then be CD# 9-13. Those are the days I would recommend intercourse. You should stop intercourse on CD#7 and wait until CD#9 to start. Have intercourse once per day on those days, only one ejaculation per day. Start using your ovulation kit on CD #9 (counting back 16 days from the end of your average cycle).

Hope this helps and good luck!

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

Check me out on Facebook http://www.facebook.com/home.php#/ejramirez1?ref=profile and Twitter with me at @montereybayivf.