Cystectomy For Grapefruit Size Dermoid Cyst On Ovary

Question:

Hello, I'm writing from Nevada. I went in for an appointment with my MD a few weeks ago after trying to conceive for 1 year. While I was there he did a pap and routine exam as well. In the exam he found my uterus was small or off to the side a bit and wanted me to have an ultra-sound done. When we did this they found a grapefruit-sized dermoid cyst in my left ovary. We're planning on having it surgically removed but I have a few questions.

1. With the size of the cyst is there any chance of keeping a portion of my ovary?

2. If it MUST be removed, is there any possibility of saving my eggs?

3. With a cyst of this size is it wise to do the procedure laparoscopically or should it be done with one large incision?

I have no issue with work and recovery time, I just want it done in the safest way to keep my ovary if possible. I do have another appointment with my MD to discuss this information, just looking for some suggestions or input. Thank you.

Answer:

Hello K. from Nevada,

A skilled gynecologist will usually remove the Dermoid cyst without sacrificing the ovary. Make sure that your's will do that. The procedure is called a cystectomy. There is no reason the ovary should be removed.

The technology for preserving eggs certainly exists, although the pregnancy rates are not as good. However, we do recommend this in women that have cancer since they would otherwise lose the option of getting pregnant with their own eggs. This will have to be done in an IVF center, and must be done BEFORE the surgery, not during or after. The ovary has to be stimulated to grow the eggs so that they can be removed and frozen.

The cystectomy procedure should also be done by a method called laparoscopy, using a scope and small incisions. I do this procedure all the time. If your doc can't do it laparoscopically, then find one that can. This is the best method to preserve your ovary and cause minimal damage so that your fertility is not compromised. Try not to have an open (laparotomy) procedure if you can.

I hope this helps,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

New Zealander Wonders: Does A Cervical Cone Biopsy (LEEP) Lead To An Incompetent Cervix During Pregnancy?

Question:

Hi Doctor,

I'm a 33 year old woman from New Zealand. I recently had a missed miscarriage and D&C (22nd Nov 2009) , then one month later I had another D&C due to infection and retained product. I also had a D&C at age 17 years and a termination at 29 years. I also had a LETZ at 25 years. The doctor has advised me to wait 6 months before getting pregnant again to help my cervix strengthen. He is also saying that I will most probably have an incompetent cervix due to all surgery and the only thing they can do is monitor me during my pregnancy. Is there anything I can do before my pregnancy to help? Are there any tests to see how strong my cervix is?

Will waiting 6 months strengthen my cervix? Do you know of anyone else who has had this many D&C's and a LETZ and still been able to carry to term?

Thanks you so much! I haven't been able to find answers to my questions and I'm feeling very anxious.

Answer:

Hello J. from New Zealand,

Many women have multiple miscarriages requiring D&C, or have multiple abortions. They are not necessarily at increased risk of incompetent cervix. They are at increased risk of uterine adhesions from the multiple D&C's. The risk of incompetent cervix comes from the LETZ procedure because a portion of the cervix is removed. (Briefly: the LETZ procedure removes the entire abnormal area of your cervix with a hot wire loop. The tissue is then sent to Pathology for diagnosis. Some doctors, myself included, refer to this procedure as LEEP-"Loop electro-surgical excision procedure"). That is NOT to say that you are definitely going to have incompetent cervix, only that SOME women that have had cervical cone biopsies or LETZ/LEEP seem to have an increased incidence of cervical incompetence.

I have been doing LEEP for a long time and have never had this problem with my patients. It is a procedure I excel at and enjoy doing. It probably depends on how deep of a cut the Physician makes. There is no way to predict who will have incompetent cervix or not. In some cases, where the cervix is found to be shortened or there is a previous history of incompetent cervix, the doctor will do a cervical cerclage (put a stitch in the cervix), in advance. I would not recommend that in your case. For now, your Ob doctor just needs to keep an eye on things by doing serial ultrasounds to check the cervical length.

In terms of waiting 6 months. There is no reason to do that. There is no such thing as "strengthening the cervix or waiting for the cervix to strengthen". The cervix will be repaired and ready within 6 weeks.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.

Follow-Up Reply:

Thank you so much, Dr.Ramirez,

You have made me feel much better, I had been unable to find any info on this (apart from terrible stories from google) and have been worrying myself sick about it. I will pin your email to the wall and remind myself when I get anxious! Again, thank you so much! J.

Very Weak, One-Day Menstrual Flow - Is There Something Wrong & Will It Affect Fertility?

Question:

I am a 26 year old female and for the past few months I have been having very weak periods that often last no longer than a single day. They are so weak that I don't need to use tampons and pantyliner will suffice. They are however extremely regular and fall every 30 days. I came off the pill last year and for after a few months my periods returned to normal. It is in the past 6 months or so that they have become so weak that they are causing me concern. A few years ago, I had a big cyst on my right ovary and late treatment meant it twisted and resulted in me having to have one ovary removed along with the cyst. I have researched possible reasons for weak periods and polycystic ovaries seem to be one of the main explanations. However I do not have any of the other symptoms usually associated with this condition and I am not over- weight.

I am extremely concerned of the implication my weak periods may have on future fertility but when I have taken my concerns to my GP he has dismissed them. I was hoping you could maybe give me some possible reasons as to why this may be happening.

Many thanks for your time. K. from the U.K.

Answer:

Hello K. from the U.K.,

The amount of bleeding a woman has with her periods is dependent on the amount of tissue there is to slough. That is, the thickness of the endometrial lining. Even if the amount is small, at this point it would not be of concern. The amount of bleeding will vary from person to person and cycle to cycle. As long as your cycles are regular, that is the important part. Certainly if the endometrium is not developing adequately, that could impair implantation of the embryo and your fertility. But, I doubt that would be the case. I would not worry about this at this point in time. Just wait and see what happens when you begin trying for pregnancy. If you have difficulty, then testing and evaluation will be done to see if the endometrium is not developing adequately. If that is the case, then supplemental hormone can be given.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Poor Embryo Quality: Donor Eggs Vs. Change Protocol Vs. Change Centers

Question:

I have undergone 3 IVF cycles without success in Canada. First IVF using long protocol, failed to stim and the cycle was cancelled. Subsequent 2 IVF cycles were done in flare protocol.

Of the flare cycles, first one was using Gonal F (450IU) and Luveris, we got 18 eggs, 13 mature, all 13 fertilized, but on day 3 only 2 had divided to 6-8 cells. All others arrested at 2-4 cells. Transferred 2 back with assisted hatching, but failed.

Second flare cycle was using Menopur (375IU), 13 eggs retreived, 8 mature, all 8 fertilized, but on day 3 only 2 were good enough to transfer, one that had started compacting, another at 8 cell, both were transferred back with assisted hatching, but failed again. All others divided will odd cells (3-5) and arrested on day 3. After the 3rd cycle, doctors suspect the egg quality to be very poor and advice us to use donor eggs. All blood/hormone tests are normal, left fallopian tube is blocked at fimbral end. I'm now 33, never been pregnant. My husband's results are normal.

Is this indeed due to poor egg quality? Is there any treatment available to improve egg quality? Is there any other IVF protocol that we can try that might give better results?Any advice based on your extensive experience is greatly appreciated.

Answer:

Dear S. from Canada,

Based on the information you gave me, you certainly did stimulate well in your second and third cycles. One option is to use a combination protocol with Gonal-f and menopur, and the antogonist (ganerelix or cetrotide), instead of lupron flare protocol. That may help with egg development and quality. There have been several studies showing the benefit of the combination protocol. The antagonist allows the ovary to stimulate and develop the eggs without being suppressed, as occurs with lupron. You'll have to ask your docs if they feel comfortable using an antagonist protocol.

There is no direct way to improve egg quality after fertilization. However, eggs/embryos are very sensitive to their environment i.e. laboratory quality. Any airborne gas or contaminant can effect them.

For example, in 2007 I had terrible pregnancy rates. In review, we found that in this year, the building where I had previously had my offices & center had gotten several new tenants and was doing a lot of remodeling. The air flow system in that building was not isolated and the air shared throughout all the offices. We had a very good Hepa filter in the lab but it could not isolate the air effectively with the huge change in parameters. Luckily, in early 2008 we moved our center to a new building where we are the only tenants. I was able to build my lab using the latest technology and air flow recommendations. My under 35 pregnancy rate went from 27% in 2007 immediately to 74%. The only difference was the air quality and control. Our lab is now in an isolated part of the building and does not share airflow with any other part of the office. Environmental controls and air flow have been studied and written about extensively in the IVF literature.

Certainly, if you are consistently having poor embryos, then the only alternative would be donor eggs. But before I would draw that conclusion, you might want to try a different center. Another experience I had was a patient who moved from Washington D.C. to California. She had gone through two IVF cycles there and, like you, had poor embryo quality and also was recommended to undergo donor IVF. But because her husband's job location changed, they moved here and she presented to me. Like you, she was young and I counseled that she should continue trying with her own eggs, at least two more times. Well, in her first cycle with me, she had three excellent quality embryos and became pregnant with twins (all three were transferred). It just goes to show not only that a different center could have a different outcome, but because we know that each cycle is unique, the outcome could be different from just having a different set of eggs and embryos.

I hope this helps,

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.

New IVF Patient Mixed Up Suppositories & Took Progesterone Early - What Now?

Question:

Hello Doctor,

I am one day before fresh embryo transfer and I'm really worried. I'm currently on my first IVF. Two days before my egg retrieval last week I was instructed to use Clindamycin suppository at night for 3 nights last night being the day of my egg retrieval. Well, I mixed up the suppository bags and inserted 50 mg of Prog suppositories for first 2 nights instead of Clindamycin. I didn't realize this mistake till the day of my egg retrieval. So I ended using 2 Prog suppositories for 2 nights before my egg retrieval.

I told my doctor and he said this is a problem in that my uterus was exposed to progesterone too early therefore lining is not optimal for transfer...and that we need to freeze my embryos and do a frozen embryo transfer next month! I was just devastated to hear the news and asked for any alternatives. To make the long story short we are going ahead with a fresh single embryo transfer tomorrow with hopes that not too much damage was done. Given my history what are the chances of me actually getting pregnant? Would it take a miracle?

R. from the U.S.

Answer:

Hello R. from the U.S.,

Keep in mind that miracles do happen.

I'm afraid that I agree with your doctor's response. Progesterone converts the endometrium from its growing state to its implantation phase. If the endometrium is out of phase with the embryo, then implantation will not occur. There is a very small (2 day) window for implantation. It is likely that the progesterone changed the internal architecture (cellular structure) of the endometrium, which will make it inhospitable to the embryo and implantation will not occur. But there is no way to know that for sure. You will just have to wait and see.

If you want to be absolutely sure, then you should postpone the transfer and freeze the embryos. Then do a frozen embryo transfer the next month. If you don't mind risking an embryo, then given it a try. I normally prescribe antibiotics on the day of the retrieval, but all clinics have their own protocols specific to how the physician prefers to tweek their cycles. Like I said at the beginning, miracles do happen.

I'm sorry and stay positive!

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.

More Questions Regarding IVF and ICSI: Can I Have Twins, SET, And Other Post Retrieval And Transfer Questions

Question:

Hello again, this is S. with some follow-up questions from my earlier email.

Thanks for answering my questions. I have a few more. I know that obviously it depends upon the number of viable eggs removed during egg retrieval for IVF with ICSI but how many of the eggs would they try to fertilize and use at a time? How does it work with the frozen embryos? What are the chances of twins or triplets with this type of procedure? Can I decide if I want twins if I have more than 1 egg that is ready? After the egg is fertilized and put back do I have to be off of my feet for a time? How long does it take for the process to take place?

Sorry I'm just really unclear about all of this. Do I have to go back for ultrasounds afterwards and if so how often do I have follow up appts? Thanks again!

Answer:

Hello S.,

You're welcome to follow up with additional questions any time. I probably did not address the ICSI (intracytoplasmic sperm injection) question you had in your first email. With ICSI, all mature eggs are injected since not all with fertilize. If they only took a few and did ICSI, which I understand some clinics will do, that could impair the number of embryos you have to work with if they don't fertilize.

These are then allowed to divide over a 3-5 day period. An appropriate number is then chosen to transfer. That number is decided between you and your doctor. With frozen embryo transfers, the embryos are thawed, allowed to expand, and if they survive, are transferred. Usually the number thawed are the number transferred because re-freezing is not necessarily a good thing.

If three embryos are transferred, the risk of twins is about 35% and triplets less than 10%. This risk declines as the number of embryos transferred decreases. Because of the high pregnancy rates these days, many clinics have moved to doing a single embryo transfer, or SET, in order to minimize the risk of twins or more. This is based on new recommendations that have come out from the American Society for Reproductive Medicine and the Society for Advanced Reproductive Technology. There has been strong political pressure for IVF centers to reduce the incidence of a multiple gestation (twins or more). If you want twins, then you have to discuss this with your doctor and see if that is something the doctor feels comfortable with. Depending on your age, either two or three embryos would be transferred to try to achieve twins.

Once the embryos are transferred, you do not have to "rest" for any period of time. I have my patients do light activity for three days after the transfer to allow for implantation to take place, but I do not want them to be at bedrest. From that point it is a natural process and is the same that your body would go through if you were trying on your own.

In terms of your last two questions, these are answers that you should be getting directly from your IVF center. You pay them a lot of money for this procedure and they should be giving you almost royal treatment. If they are not, then you should demand it. The IVF process is a three week process, basically mimicking your natural process. The ovaries are stimulated, which takes 10-12 days, the eggs are retrieved at the mid-cycle and allowed to fertilized, then they are allowed to grow in culture for 3-5 days, then they are transferred back into the uterus. 8-10 days later a pregnancy test is done, which usually coincides with the end of the month if you started at the beginning of the month. (You should check out my website and I have an outline of the IVF process.) In the first 10-12 days, ultrasound and blood tests are done periodically to evaluate how you are responding, how many follicles you have, how big the follicles are and when to trigger for the retrieval. These ultrasounds can be done daily, every other day or farther apart depending on how big the follicles are and how close you are to the trigger day (generally as you get closer, the appointments get closer). The egg retrieval is usually done two days after the trigger (35-36 hours from the trigger injection) then the transfer is done 3-5 days after that.

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.

Injectables with IVF - Is Metformin Indicated?

Question:

Hello-I am from the US and I am 33 years old. My husband is 34. We have been trying for almost a year and saw an RE. I was told I have a fibroid that I am having removed laparoscopically the end of March. I was told by my doctor that since my huband's sperm is below where it needs to be (both count and motility) that I can begin IVF (in vitro fertilization) with injectable treatments about 2 cycles after the surgery. Which drugs are used? She mentioned ICSI (intracytoplasmic sperm injection) also. Will I have side effects from these injectable medications and if so what will they possibly be?

She also mentioned my possibly taking Metformin to try to enhance the IVF to work. I have heard mixed reviews on this medication actually working and was wondering what your take is on it. Can you please advise? I have heard of some unpleasant side effects from Metformin/Glucophage so I am not sure what to do.

What is the chance of IVF or IVF with ICSI to work? She said around 50% which I believe is much better than the 20% chance it would be which we were told if it would happen naturally. Is this true? I have had an ultrasound with saline and an HSG with dye- both came back fine other than the fibroid. I have been put on Synthroid to regulate my thyroid which I was told was slightly elevated. I am also on the birth control pill until I have the surgery to remove the fibroid the end of next month. I have had several blood tests testing my FSH, LH, Prolactin, Estradoil, glucose, etc all which have been normal results. Any additional info. you could provide would be appreciated.

Thanks!- S.

Answer:

Hello S.,

Let me answer your questions sequentially to make it easier:

1. Lots of different medications are used with IVF cycles. This is a question best answered by your doctor, or her IVf coordinator. Each doctor has different protocols, depending on their preferences and how they are trained. The main medications are called gonadotropins and are synthetic versions of the FSH and LH that your brain produces to stimulate the ovary to ovulate. We give higher dosages of these medications in order to make the ovary produce/prepare more that one egg. The goal with IVF, in order to maximize the chances of pregnancy, is to get more than one egg out. Preferably 10-20. This is because not every egg is a good egg.

2. Most women tolerate these medications very well since they are essentially the same as the hormones your body produces. Of course, all medications have side effects and each person is different and can react differently to each medication. The biggest side effect of these stimulation drugs is that the ovaries will enlarge and become tender because so many eggs are being recruited. In addition, some patients will feel bloated. If the ovaries are stimulated too strongly, or the ovaries respond too strongly, you can develop an illness called "hyperstimulation syndrome." This is a very serious and dangerous problem that has to be prevented and managed appropriately. If you have PCO, which I suspect you might have since your doctor recommended Metformin, you are at increased risk for hyperstimulation syndrome. You need to discuss this with your doctor and ask her what she does to prevent this. There are methods that we use to prevent this from occurring such as using lower dosage protocols, close monitoring of blood levels, coasting or drifting if necessary, antagonist protocol, triggering with Lupron instead of HCG.3. Metformin is only indicated in 30-40% of patients that have PCOD. It is NOT indicated in all patients AND, it takes 6-8 months to work so starting it with an IVF cycle is not appropriate. I would not recommend it unless you have been found to have insulin resistance by blood testing.

4. In terms of IVF working, you have a 50-70% chance of pregnancy with each IVF cycle in your age group. You should ask you doctor what her statistic is. Pregnancy rates do vary depending on the clinic and the doctor, so be sure to check both out.5. With a severe sperm disorder, the chances of pregnancy would be much less than 20%. Your natural chances of pregnancy at your age, if there were absolutely no problems, would be about 15% per month of trying. With the sperm problem it would drop it to less than 10%. That is why IVF is the treatment of choice. With IVF and ICSI, we had a 75% pregnancy rate per transfer in 2009. Most clinics are reaching that level as well.

I hope this information helps. Be sure to ask lots of questions. You will be paying a lot of money for this treatment and you should make sure you have had ALL your questions answered to your satisfaction. This type of procedure is like shopping at Saks 5th Avenue. You should demand and get the highest level of service!

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.