42 Yr. Old U.K. Patient With Poor Egg Quality, Tubal Damage, Given Troubling News: How To Proceed?

Question:

I am asking this question from the UK.

I am 42 years old, and have recently had a failed IVF cycle. It was my first IVF cycle and I had a low response. I had a total of 3 eggs harvested.

There were 2 from mature follicles and 1 from a small follicle. I know this is a poor response because I was on the maximum amount of drugs. I was on Buserelin 1mg/ml - 0.5ml per day, puregon 300 units and menopur 300 units per day. Not only did I have a poor response but the egg quality was also very poor. The egg from the small follicle burst before the embryologist could perform ICSI on it. The other 2 eggs did not change or develop in anyway when ICSI was performed on them. And ICSI was done because my husband's sperm is low in number and has problems with motility and morphology.

I recently had a follow up session with the fertility specialist and he advised me to not do any more IVFs and to consider egg donation if I want to proceed. And he even went on to say that even if by some miracle I did get pregnant my egg quality is so poor that the child would most probably have serious birth defects. I was so devastated.

My questions are I only had one IVF and the FSH on day 3 was 9.3, so can my doctor tell from one IVF that I have a low egg reserve and all my eggs are of poor quality. I forgot to say that both my tubes are blocked so an IUI wouldn't be useful.

Could it be that on another cycle an IVF might give better results? I have always had regular periods. Could my ovaries just have responded badly the first time and might they respond better to a second IVF? And most importantly, even if by some miracle I get pregnant, does my poor egg quality in this IVF cycle mean that a child would most probably have serious birth defects?

I want to do another IVF cycle. I want to see if a different drug protocol might cause a better result. Please tell me if you think that I should have any hope for a better result or if I must face the brutal truth that there is no hope and I must only consider egg donation.Thank you so much for taking the time to answer my questions.

ANSWER:

Hello P. from the U.K.,

In answer to your questions:

1. Low ovarian reserve (the stimulation response) and low egg quality are two different factors. You had both in this cycle. The elevated FSH of 9.3 is an indication that the ovaries probably will not stimulate very well with maximum stimulation as you did. It does not indicate poor egg quality,however. Your age is more of a factor indicating poor egg quality. As you know, pregnancy rates decrease significantly with increasing age, especially after 35. This is mainly due to poor egg quality. There is no way to correct poor egg quality other than trying to recruit and extract multiple eggs in the hope that a good egg will be present in that group. I don't think that all your eggs are poor quality but certainly the majority (90% or more) are.

2. There have been several studies on poor responders showing that each cycle is unique and yields a different result. So, there is still a chance, that even with one embryo, you could be successful in a subsequent cycle. However, to keep from giving you false hope, the chances would be low so you would need to be prepared for failure and to have to try several attempts. There was recently an article in the New York Times here in the U.S. about a 49 year old woman who conceived and delivered by IVF using her own eggs. I believe she is the oldest in the world to have done so (get pregnant with her own eggs by IVF). However, they were clear to point out that it took her two years of doing IVF to attain that success.

3. I disagree with your doctor's statement that if you got pregnant you would almost certainly have an defective child. Because of your age there is a strong risk for miscarriage or a genetic abnormality such as Down's syndrome. However, abnormal embryos rarely implant or lead to a successful pregnancy. The only reason Down's syndrome gets by is because it is a mild genetic defect (only one chromosome is abnormal). If you get pregnant, and it successfully progresses beyond 8 weeks gestational age, your chances are good of having a normal child. We do recommend genetic testing, however, for those few that are abnormal. Poor egg quality usually leads to an embryo with multiple abnormalities, poor embryonic development and either no pregnancy or an early miscarriage.

4. I don't see any reason why you can't keep trying with your own eggs as I mentioned above. I see miracles happen all the time. However, you have to be prepared for a bad result, and if you can handle that, go ahead and keep trying as long as your ovaries still respond. You can switch to donor eggs at any time and at almost any age (although we tend to limit it to below 50) so that option will always be there. That being said however, I would probably have counseled the same as your doctor because we want you to be successful in the shortest time, least amount of attempts, least amount of emotional cost, and least amount of financial cost.

Follow-Up Question:

Dr. Ramirez,

Hello, it's P. again.

My next question concerns trying to fix my blocked tubes.

I wonder if I should consider a procedure to have one or both of my tubes unblocked. I have read that sometimes a tube can be so scarred that even having a procedure to unblock it doesn't work.

If one of my tubes was unblocked and remained so, then I could become pregnant naturally, couldn't I? I know I would still be battling with a poor egg reserve and a lot of eggs that are poor quality because of my age. Do blocked tubes mostly remained blocked even after a tubal opening operation? I am also very overweight, will this make a difference to how easily a surgeon could perform such an operation?

Dr. Ramirez, do you think this could be an option for me? Thank you for answering my questions. It is truly wonderful that you give up your time to help women like myself. God Bless you for your kindness.

Follow-Up Answer:

Hello Again,

Despite what anyone may tell you, tubal damage is NOT repairable or reversible except for two exceptions:

1. The fimbriated end of the tube is blocked by scar tissue that was causes externally, such as by previous surgery or a ruptured appendix.

2. The opening to the tube at the uterus is blocked by mucous, in which case, an HSG can sometimes unblock them and they would function normally.

Anything else that caused tubal damage cannot be fixed, and surgery does not exist for this. In addition, because of your age and ovarian reserve, even if that technology did exist (such as tubal transplantation), your "natural" chances of pregnancy would only be 1% per year of trying. It definitely would not be worth the surgical cost or risks. IVF has a better chance of 25-27% per attempt.

Good luck, P. and don't lose heart!

Sincerely,

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 answered my questions clearly, completely and kindly. He obviously has a genuine desire to help women that find themselves in the terrible position of needing fertility help.

Tubal Reversal Vs. In Vitro Fertilization

Question:

I was diagnosed with PCOS 6 years ago. I had one treatment of Clomid and became pregnant soon after with healthy twin boys. At the time I had decided to get a tubal ligation soon after delivery but now I am regretting the decision I made. Now after so many years I am finally having a very regular menstrual cycle.

My question is, what would be the better option for me: IVF or a reversal of my tubal ligation?

Answer:

Hello, Here are the pros and cons for both options that I usually share with my patients:

*Tubal reversal or reanastamosis

It is a surgical procedure. Some surgeons do it as a large open incision and some as a small incision. Tubal reanastamosis is not covered by private insurance. The large incision will be very expensive ($20,000-$35,000) with a 6-8 week recovery. The small incision can be done as outpatient surgery but will cost $8 - $12,000. Recover will be 4 weeks. The latter surgery is skill-based and should be done by a physician comfortable with a mini-lap procedure to insure success.

The pros are that if the procedure works, you can get pregnant over and over by natural means.

The cons are that it is a surgery, and that success depends on the surgeon, the length of the tube after repair, and the type of tubal ligation that was done. There is an increased risk of a tubal pregnancy (surgical life threatening emergency). Pregnancy rate will vary by age and will be less than the equivalent rate in the normal population. You will need contraception again if you don't want more than one more child. You have to at least try for one year following surgery to get pregnant and determine if the reversal worked. If it hasn't, then the only option left is IVF for an additional cost.

*IVF or in vitro fertilization

IVF is a non-surgical procedure and will cost approximately $15,000 per attempt (which includes the IVF, medications and lab tests). It is sometimes covered by private insurance.

The pro is that it is not surgery, that you will get pregnant with minimal waiting, it is great for those who want one or two more children and that it has a much higher pregnancy rate than trying naturally, especially if you are older. Sometimes you will have enough eggs fertilize that some can be frozen and used for a later frozen embryo transfer, giving you the leisure of deciding to have another child when the time is right. It is not painful to have the eggs retrieved or transferred into the uterus and it is performed as an outpatient procedure.

The con is that it is expensive (as described above), that you have to take injections on a daily basis for a short period of time (although they are not too bad) and that you may have to do it again and again if you want to have more children. It is not a "natural" process since in vitro fertilization is done in an embryology lab.

In closing, nowadays, because IVF pregnancy rates are so much higher, we recommend IVF over tubal reanastamosis. However, the doctors that don't do IVF tend to recommend tubal reversal. The doctors that do both, as I do, tend to recommend IVF because it is better. It is more of a sure thing than the surgery. However, if you are still under the age of 35 and know that you will want to have more children, then the reanastamosis might be the best way to go, assuming that it works. The costs will be about the same, but if it doesn't work, then you have to do IVF. Most of my patients will choose IVF since it has a better chance of success for the money.

Good luck with your decision and whatever you do decide, I wish you success.

Sincerely,

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

Can Tubal Ligation Be Reversed?

Question:

If you have your tubes tied can you have them untied to get pregnant? How is the procedure done and how long does it take and what are the chances of getting pregnant?

Thank you!

Answer:

The term "tied" is actually a misnomer. Basically, all tubal ligation procedures damage a portion of the tube causing the canal to be blocked off. There are various methods and the ability to repair them varies depending on the method. The methods are:

Post-partum tubal ligation (tubes are tied in two places and the tube removed in between). The ends are then cauterized.

Laparoscopic tubal ligation done through a scope. The tubes can be burned, clipped or a ring placed. The clip method yields the best reversal and burning and cutting the least successful reversal.

In addition, there has to be sufficient normal tube present for the tube to function (4 cms). If the fimbria is damaged (fimbriectomy) then this is absolutely not reversable. Most physician do a laparoscopy first to evaluate whether or not the tubes can be reversed before doing the reversal procedure.

Because the tubes are damaged, the chances for pregnancy are reduced and the chances depend on your age. As an infertility specialist and gynecologic surgeon, I can perform microscopic tubal reconstruction. Regardless of age, a complete evaluation is done to eliminate the possibility of other infertility factors. Some of those factors may include: maternal age, surgical risk, and ectopic pregnancy risk. See my page on "Microscopic Tubal Reconstruction".


I do not recommend tubal reversal surgery in patients over the age of 35.

A viable alternative is In Vitro Fertilization, which has a much higher chance of pregnancy per month of trying. Most fertility specialists do not do reversal anymore for this reason. For the same cost, IVF is better and is not a surgery, which means less risk. Cost wise, both are approximately the same and range from $8000-15,000. I hope this answers your question.

Sincerely,

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.

Hydrosalpinges and Miscarriages

Question:
I am 34 years old, writing from Australia. I have had one child (3 years old) and two miscarriages. The first miscarriage (embryo stopped growing 6.5 weeks) on Jan. 09, the second Nov. 09 (9.5 weeks). Just before I became pregnant with the most recent one, I found out I had bilateral hydrosalpinges that showed up on the transvaginal ultrasound.

We were considering having surgery to remove the fallopian tubes ( on the advice of an IVF specialist) then start IVF, when suddenly we found out we were pregnant. Unfortunately, at 9.5 weeks I had a miscarriage.

We are awaiting results of tissue testing to determine if chromosomal abnormality exists. We are also booked in for a repeat ultrasound.

1. Does having bilateral hydrosalpinges cause you to miscarry at 10 weeks pregnant? If so, by how much (i.e. what %)? Gyn says they do not make you miscarry but more likely to not allow implantation.

2. Would the preferred option be to clip them, or just remove them and commence IVF even though I have gotten pregnant naturally? Or would the best option be to give it one more go naturally?

Any other advice would be appreciated.

Answer:

Hello,

You present a very interesting scenario because women with hydrosalpinges usually cannot get pregnant. The reason is because the cause of the hydrosalpinges is a tubal infection that caused the damage to the tubes. Not only did it cause the tube to be obstructed, but it even usually leads to damage of the inner lining of the tube that is important for egg and sperm transport. Therefore the recommendation is to proceed with IVF. Your case negates that thinking.

Hydrosalpinges can lead to non-implantation, and by the same mechanism, miscarriage. It is thought that the hydrosalpinx has inflammatory fluid within that migrates back into the uterus. Several studies have found decreased pregnancy rates in IVF when hydrosalpinges are present. That is why it is recommended to clip the tubes or remove them prior to IVF. This inflammatory fluid causes a mild inflammation of the uterine lining causing the lack of implantation. If implantation were to occur, I would expect that the same inflammation could lead to the death of the embryo from a mild amnionitis. That, however, is theoretical.

Because you have shown that you are the exception to the rule, you have two options. You can have a laparoscopy and have the tubes opened (salpingoplasty) or you can have the tubes clipped/removed. If the tubes are opened, you have the opportunity to become pregnant naturally, like you showed that you could. It would allow the fluid to escape into the abdomen, thereby reducing the chances of backflow into the uterus. However, if there is tubal damage within, you are at increased risk of a tubal pregnancy called an ectopic pregnancy. That can be life threatening if it ruptures and you hemorrhage. The second option, which then requires IVF is certainly the safer option, but the more expensive option. You need to discuss these two options with your docs.

If I were counseling you, I would almost be inclined to recommend the former (tubal repair) as long as you were completely aware of the risk of ectopic and willing to take that chance. I would then watch you very closely if you were to become pregnant to rule out the ectopic at the beginning of your pregnancy.

I hope that this answers your questions.

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