Women's Health and Fertility

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

noreply@blogger.com (women:s health and fertility) — Fri, 13 May 2022 15:06:00 +0000

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!!

Three IVF Cycles With Immature Eggs: PCOS and HCG Trigger?

noreply@blogger.com (women:s health and fertility) — Mon, 19 Sep 2016 20:16:00 +0000

QUESTION:

Dear Dr. Ramirez,

I'm 39 years old and have done 3 IVFs (in vitro fertilization cycles). During the first two IVFs, half of my eggs were immature. I had 25 retrieved (age 37) the first time, and 16 retrieved (age 38) the next time with 50 percent maturity in both cases. However, I just had an egg retrieval where 15 were retrieved and only 2 eggs were mature. They used generic HCG in this case, and the doc seems to want me to try the transfer the pretty crappy embryos that resulted from this retrieval. He is offering no answers as to why just 2 eggs were mature upon retrieval and the embryo quality was my worst yet.

Does the kind of HCG trigger make a difference? For the second retrieval, I didn't use generic HCG but Novarel. I think I used Ovidrel for the first trigger. Do you think I have a genetic defect and should be tested? I also think I have some of the signs of PCOS (acne and some sideburn hair that I remove), but doctors don't think I have PCOS because I have regular periods and am not overweight. Yet, I've heard many PCOS (polycystic ovarian syndrome) women produce immature eggs. Also think I may be insulin resistant and have heard a connection between this and immature eggs as well.

Would appreciate your insight. Emma from California

ANSWER:

Hello Emma from the U.S. (California),

Egg maturity at the time of retrieval is based on two things: (1) the size of the follicle when triggered and (2) adequate HCG stimulation.

First, let me answer the HCG question. If the HCG is an inadequate dosage or not a quality product, then it is possible that the follicle and consequently the egg within, will not get adequate hormonal stimulation to go through the final maturation phase. Sometimes the egg will not release from the wall and so no egg will be retrieved but otherwise, it would not be mature. In terms of follicle size, it is usually a requirement that the follicle reach a minimum of 16 mm to insure that the egg within has matured. Physiologically, as the follicle grows from FSH stimulation, the egg grows toward maturity. When it reached mature size, the final act is for the HCG or LH which is the physiologic trigger, causes the egg to go through the final phase of maturation and release from the wall. If the follicle is less than 16 mm, an egg could still be retrieved but it would not be mature. This is where the "art" and experience of the physician comes into play. It is his/her decision as to when the optimal time to trigger is. The goal, or what should be the goal, is to trigger when the majority of follicles are of mature size but not let it go on so long that you begin losing the larger follicles. That balance is the key. In my case, I use 50% maturity as my baseline measure, since follicles tend to grow at different rates. That is to say, that I strive to have at least 50% of the retrieved eggs to be mature. In most cases it is much more than that.

You are correct that PCOD patients tend to have a lot of immature eggs but that is because they have so many follicles that result from stimulation. Where a normal woman might produce 15-20 follicles, a PCOD patient will often produce 30-40 follicles. Since they develop at different rates, that leads to different maturity levels. In terms of medication, I favor Ovidrel. In my experience (22 years), I have had cases where the eggs don't mature as a result of Novarel or Generic HCG, so I abandoned them. In addition, Ovidrel is a subcutaneous injection whereas the HCG is intramuscular so, it hurts more.

Good Luck,

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

---------- FOLLOW-UP QUESTION ----------

QUESTION:

Thank you, Dr. Ramirez. There was one more piece of information I forgot to include. Before I started this last cycle, I had been on a three-month dose of lupron. I began stimming exactly three months to the day of my lupron injection, even though I still had hot flashes and only had six follicles to start. Follicles grew from 6 to 8 to 12 the day of the trigger. Normally my number of follicles are in the teens at the beginning of the cycle. I even mentioned this to the doctor and told him that I was still having hot flashes as well. Is it possible that my ovaries were over-suppressed, which resulted in just two immature eggs out of 15?

Thank You,

Emma

Answer:

Hello Again,

Usually the stimulation, if given in adequate dosage, is enough to overcome the Lupton suppression, but I think that your thinking may be right, and that your ovaries may have been suppressed enough so as to not perform as well in the last cycle and the stimulation was not enough to overcome that suppression.

Good Luck,

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

Monterey, California, U.S.A.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

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

noreply@blogger.com (women:s health and fertility) — Wed, 04 Nov 2015 21:25:00 +0000

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

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

Thanks for your time. N2N from California.

Answer:

Hello N2N from California USA,

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

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

Good Luck,

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

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

History of Miscarriages, Now 9 Weeks Pregnant: Continue Progesterone Supplement (Crinone) ?

noreply@blogger.com (women:s health and fertility) — Tue, 18 Aug 2015 16:58:00 +0000

Question:

I'm from the U.S. After a long struggle with secondary infertility and 2 miscarriages, I am pregnant again, 9 weeks along. I'm on supplemental progesterone, Crinone 8% once a day. When can I feel okay about stopping the Crinone? I was supposed to see my doctor in 2 days, but he experienced a family tragedy, and I'm not sure when he'll be back. I think he had talked about stopping the Crinone at 9 or 10 weeks, but I was going to confirm that with him at my appointment, and I have no way of asking now.

Thank you for your time. M. from the U.S.

Answer:

Hello M. from the U.S.,

With your history of two miscarriages, I will usually be very conservative and continue the progesterone until 12 weeks gestational age. However, medically, it would be okay to stop at 10 weeks. By then, the placenta should be fully functional and providing all the hormone necessary to maintain the 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.

**For my readers who are unfamiliar with the use of progesterone to support a pregnancy, here are some additional facts: "Progesterone is essential for the normal functioning of the reproductive system. After ovulation, the corpus luteum (which is the empty follicle from which the egg was released) produces progesterone, which acts on the womb lining and causes it to thicken in preparation for a fertilized egg to implant. This is known as the luteal phase of the menstrual cycle. If an egg implants successfully into the womb, the corpus luteum continues to produce progesterone to maintain the pregnancy until the placenta develops fully. The placenta produces increasing amounts of progesterone until it is fully developed, when it then takes over the production of progesterone to continue to support the pregnancy.

In some women, insufficient progesterone is produced during the luteal phase and this causes problems with implantation of fertilized eggs into the womb lining and maintaining a pregnancy in the early stages. Crinone vaginal gel is used to treat this hormone deficiency. One applicatorful is inserted into the vagina every day, starting either one day after ovulation is known to have occurred, or on day 18 to 21 of the woman's cycle. (Day one is the first day of your period.) The gel is usually continued until the placenta is producing enough progesterone to support the pregnancy.
Crinone vaginal gel is also used to support pregnancy in women having in vitro fertilization (IVF). In this case the gel is used daily, starting after the embryo has been transferred into the womb, for the first 30 days of confirmed pregnancy." www.netdoctor.co.uk/pregnancy/medicines/crinone.html

Conceiving After 45: IVF With Your Own Eggs Or Donor Eggs?

noreply@blogger.com (women:s health and fertility) — Wed, 15 Jul 2015 14:28:00 +0000

Question:

Dr Ramirez,

What are the chances of a 45 year old woman conceiving using IVF with her own eggs? Would it be worth trying or would you recommend using donor eggs? A. from the UK

Answer:

Hello A. from the UK,

There are always exceptions to the rule, however, the chances of pregnancy, even with IVF, are very slim. In the 2012 National summary produced by our Centers for Disease Control (CDC), based on IVF reporting data, the national averages for women >44 years old is 5% pregnancy rate and 2% delivery rate. This, of course, is an average and the statistics can be different for different centers. There have been pregnancies over 44 years old but they are very few. In my center, the oldest patient to get pregnant using her own eggs (as opposed to using donor eggs) was 44 years old.

I tell my patients that only God can determine who will be the exception to the rule, but if you don't try, then you have a 0% from the start. However, if you decide to try, you have to go in with the understanding that your chances are slim. Until you try, you won't know the outcome. If you want a better chance, the donor eggs will be much better.

I have a 45 year old patient contemplating this now who is leaning toward trying at least once because she wants to reassure herself that she has done everything possible to have another child (she has one already). I told her, and you should understand this too, that IVF is not a perfect technology even in young women, and like trying naturally, it can take several tries. So if you want to be absolutely sure that you tried your very best with IVF, then you need to be prepared to try several times.

As to whether or not it is worth it, that is a totally individual decision. The worthiness of something is defined by yourself.

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.

"How In Vitro Fertilization Works" Video from TED-Ed

noreply@blogger.com (women:s health and fertility) — Tue, 14 Jul 2015 16:33:00 +0000

Dear Readers,
I recently found this nicely animated video on In Vitro Fertilization created on the new TED-Ed platform. You might find this a good way to not only inform yourself but also friends and family who might have trouble understanding the fertilization process.

"Infertility affects 1 in 8 couples worldwide. But in the last 40 years, more than 5 million babies have been born using in vitro fertilization (IVF). How does it work? Nassim Assefi and Brian A. Levine detail the science behind making a baby in a lab."

Lesson by Nassim Assefi and Brian A. Levine, animation by Kozmonot Animation Studio.

As always, I am open to questions regarding this complex but important assisted reproductive technology, IVF.

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.

Upcoming Frozen Embryo Transfer #4: Do I Transfer 1, 2 or 3????

noreply@blogger.com (women:s health and fertility) — Thu, 02 Oct 2014 14:26:00 +0000

Question:

Hello,

I have a son via FET. I have now had three cycles of FET total. The first did not work, the second we got my son, and this last one worked- however I had a miscarriage at 6.5 weeks pregnant. I now have 4 embryos left frozen and am starting my next IVF cycle. They are frozen in vials of 2 each. I am so concerned if only one survives: do I only implant only one and pray it works, or do I thaw the last two we have and implant all 3? I obviously want the ultimate outcome: a pregnancy.

My doctor is NO help when I ask what he recommends. I am scared to only implant one. Yet I am scared to use all of them in this one last attempt we have. Is only implanting one pointless? Can you give me a recommendation on what is best if this situation were to happen on the day of transfer? The transfer is only a couple weeks away so I am so nervous.

Thank-you so much.

S. from Illinois. Nervous mom!!!!!!!

Answer:

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

Since you haven't given me your age, I can't give you specific recommendations but will have to answer your question in more general terms. Also, another significant piece that would help answer the question is whether your embryos were frozen on day#3 (cleaved) or day#5 (blastocyst).

We always consider age when counseling patients on the number to transfer because this affects the quality of the embryos and therefore their chances of implantation. Of course, the younger you are, the higher your chances of implantation and pregnancy per embryo. Because the technology has gotten so much better over the years, pregnancy rates have gone up and we have realized a problem; namely, an increase in multiples, especially those over twins. As a consequence, every IVF Physician is wary of putting to many back for fear of getting too many in return. As a result, the American Society for Reproductive medicine and the Society for Assisted reproduction, its subgroup, have produced recommendations or guidelines for transfer. these of course are dependent on the age and the stage of development. Their recommendations are as follows:

Cleaved embryos:
35 35-37 38-40 40 years old

Favorable 1-2 2 3 5+

Unfavorable 2 3 4 5+

Blastocyst

Favorable 1 2 2 3

Unfavorable 2 2 3 3

I have my patient sign a counseling for that they have been informed regarding these guidelines and either choose to follow them or choose a different number. I do let my patients decide within reason. Because you have gotten pregnant with these embryos before, that would be an additional piece of information making me more cautious.

So here's the decision. Unless you are over 35, I would recommend no more than 2 if they are blastocysts. If these are cleaved embryos, then I would recommend 2-3. But, the risk is of getting multiple implantations leading to at least twins. With blastocysts and transferring 2, my twin rate is 56%. With cleaved and transferring 3, my twin rate is 35%. Are you willing to take the risk of having twins? The pregnancy is harder and there is an increased risk of fetal loss. If you are not willing to take the risk of twins then you would only transfer 1 no matter what stage. If you are not willing to take the risk of triplets, then you would not transfer more than 2. I do not recommend triplets. The fetal loss rate can be as high as 50%. The down side of transferring less than 2 is a decrease in pregnancy rates per cycle, but not necessarily over all. It make take more attempts to get pregnant doing single embryo transfer.

I hope this gives you the information you needed to help with the decision.

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.

Recurrent Miscarriages: Is It A Hormonal Issue?

noreply@blogger.com (women:s health and fertility) — Thu, 21 Aug 2014 14:32:00 +0000

Question:

Dear Dr. Ramirez,

I am writing from Pennsylvania. In 2006, I had two or three miscarriages. After that, I went to a fertility clinic and had TSH, prolactin, DRVV, and anti-cardiolipin antibodies tested. All were normal. I also had progesterone level checked at the very beginning of one of the pregnancies as well as a non-pregnant menstrual cycle after ovulation. Both were normal. I had irregular cycles that were anywhere from six to ten weeks apart. I knew when I ovulated because I got pain in whichever ovary released the egg and always had a luteal phase of 14 days. I also conceived easily.

The doctor felt the lining of my uterus was getting too old to sustain a pregnancy since so much time elapsed between cycles. In February 2007, I conceived on one round of Clomid and carried that child full-term. I then had two more children in 2009 and 2011 with no help despite still having the same irregular cycles. My cycles are a little better now and usually five to six weeks apart, but I have had three miscarriages again in September 2012, December 2013 and June 2014. All the miscarriages I ever had were missed abortions with embryo development ending between week 5 and 6 with the exception of the most recent which ended at 11 weeks 5 days despite fetus having a strong heartbeat and normal looking development. Since a drop in progesterone causes shedding of the lining of the uterus, is it safe to assume that since my miscarriages were not spontaneous that progesterone was not an issue? Could other hormones be issues or was chromosomal defect the likely issue all these times?

Thank you for your time. Sincerely, M. from Pennsylvania

Answer:

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

There are basically five known causes of recurrent miscarriages from the following abnormalities: genetic, anatomic, immunologic, hormonal and infectious. When a woman has had two or three miscarriages, she automatically has earned the diagnosis of "recurrent pregnancy loss" and as such, needs to undergo a thorough evaluation of these elements. The most common cause of miscarriages is genetic abnormalities and is responsible for 85% of miscarriages in women over 35 years old. A recent study showed this cause to be less in younger women. Genetic abnormalities can be caused from an inherited disorder or a spontaneous disorder, whereby the egg makes a genetic error when it is dividing leading to an abnormal embryo. Most of these pregnancies will end before 12 weeks gestational age.

The recommended testing is as follows:

Genetic: wife and husband chromosomal analysis, saliva DNA analysis

Anatomic: diagnostic hysteroscopy, pelvic ultrasound, end cycle endometrial biopsy for dating and b-Integrin

Immunologic: Complete antiphospholipid antibodies, natural killer cells, Factor V Leiden, MTHFR, Antinuclear antibodies, Lupus anticoagulant, anti-Thyroid antibodies

Hormonal: FSH, LH, TSH, Prolactin, Estradiol, Mid-luteal Progesterone

Infectious: GC, Chlamydia, Ureaplasma/Mycoplasma, Toxoplasmosis

Age is probably the most common major cause which leads to an increase in genetic abnormalities. Since you don't mention your age, that could be part of the problem if you are over 35 years old. The good news is that most women with recurrent miscarriage will eventually have a successful 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

REQUEST FOR HELP FROM MY READERS

noreply@blogger.com (women:s health and fertility) — Mon, 02 Jun 2014 14:26:00 +0000

Dear Readers,

It has been a while since I last posted to this blog, and to my readers I apologize. Things have been quite busy, hectic and stressful this year. As you know, we are still in a recession here in the U.S. (not officially of course) which has placed a great deal of stress on my practice. Although I have continued to answer questions that come in daily in the comment sections, posting in this blog is one of my duties that I have neglected. I'll strive to do better from here on out!

This post is a little different and a little off subject, but something important that I want to request from my readers. Yes, instead of you asking something from me, I'm asking something from you this time. As you know, the internet has become the biggest driving force for information and patients also use this to choose their doctors or clinics. This is a good thing, as anyone who has ever looked for a doctor, plumber, contractor, etc. realizes, but at the same time, the current sites that rate are flawed and often unreliable which make it a bad thing. It also can be used as a weapon against competitors. This latter point is something that I've only recently come to realize. I usually don't pay any attention to the rating sites, such as "Yelp" but just by chance, while looking for something else, I came upon it and saw some ratings of me "Edward J. Ramirez MD". My overall rating was a 2 (out of 5) based on four reviews, three of which were terrible! Interestingly, all three were within 1 week of each other so I decided to see if I could recognize who these "former patients" were and figure out why they hated me. The site had the first name and the initial of the last names listed so I thought I would look them up using that criteria. I have electronic medical records so it is not a difficult thing to do. I also had the time period (April 2014) to help with the search. Interestingly, I could not find any patients with the first names and last name initials to match these three patients. I also found the exact same texts in reviews on two other review sites! What I concluded is that these three "patients" were not actual patients but could only have been staff from a competing clinic that is trying to drive patients away from me by using these review sites. Why do I suspect a competitor? Because each of the reviews mention going to a "bigger Bay area clinic or another doctor". Of course they wouldn't state the clinic or doctor by name because that would them reveal who was placing these malicious reviews.

Many of you, my readers/followers, have never met me and don't know me personally. However, from my writing, I hope that you can see my devotion to patients and to treating them properly and respectfully. My consultations are 1+ hours long, and I don't limit the number of questions, how much time spent with the patients or tell the patient what to do. I also give my patients my email address in order to have almost immediate access to me for additional questions. I always try to make sure that the patient(s) understand everything that I have explained fully and clearly, even drawing diagrams and giving handouts regarding the topics. At the end of the consult, I give each patient a "consultation diagnosis and treatment" summary with a written explanation of their options. As you have read here in this blog, I believe that patients should be given options and should understand the pros/cons, risks/benefits, approximate costs and approximate pregnancy rates for each option; and I believe that this is a personal problem that they need to decide for themselves. Each patient has different priorities and needs and therefore, the decision will be different for each. As such I DO NOT TELL PATIENTS WHAT TO DO! I give them options. My role, as I explain to each new patient, is to be their consultant, adviser, advocate and therapist to help them reach their goal. I am here to help them to the best of my abilities via the path that they choose, even if it is against my recommended path. Some patients can't afford IVF so prefer to try IUI or prefer it because it is more natural, whereas other patients want to be pregnant immediately so want to bypass the easy treatments like ovulation induction or IUI and go straight to IVF. I believe that is THEIR choice, not mine. I'm there to help them in whichever path they choose.

So as you can see, when reviews show up that state that "I don't spend time answering questions" or "push them into IVF" or "don't explain things to them", you can bet that it is NOT a real patient writing that review, because that is exactly the opposite of what I really do.

After these many years of writing these blogs, answering questions through All Experts and responding to questions in the comments on this blog, I am asking for assistance from you, my readers and followers. The best way to overcome these false reviews is to put REAL reviews on these sites. If you have found me to be helpful to you, despite the fact that you have never seen or met me, but you feel that I've spent time on your questions, given you proper and reliable answers, given you hope, or helped you understand what you are going through, I would greatly appreciate it if you would call up one of these rating sites like YELP and put in a good word for me. Give me a rating that you feel I deserve and comments that you feel reflect what you feel about me. In this way, not only will you be helping me, but more importantly, you will be giving potential patients searching for a doctor a VALID review upon which to base their opinion and choices. I hope that you will go to a review site (type in Edward J. Ramirez MD or Fertility and Gynecology Center or Monterey Bay IVF or all three) and file a review of your experience in return for the information, response or advice that I have given you.

I would greatly appreciate your help in this matter.

Edward J. Ramirez, M.D.
Monterey Bay IVF
Monterey, California

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

noreply@blogger.com (women:s health and fertility) — Thu, 23 Jan 2014 14:37:00 +0000

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.

TTC After Surgery For Stage Four Endometriosis

noreply@blogger.com (women:s health and fertility) — Sat, 21 Dec 2013 13:42:00 +0000

Dear Readers,

As the year draws to a close I want to wish all my readers near and far the very best in their lives as you move forward into 2014. I hope that the blessings of health and peace are with you all and for those of you who continue to struggle with infertility, I can only wish with all my heart that the journey will come to a positive conclusion for you in 2014.

Thank you for following my blog and God Bless.

Edward J. Ramirez, M.D.

Question:

Hello,

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why? I understand surgery can affect ovarian reserve but am looking for better understanding.

What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas? Thank you.

C. from California

Answer:

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

Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates. This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding). In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis. These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means. For that reason IVF is the only option. Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen. However, statistically speaking these cases are very, very few.

In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming. For that reason, you can form new endometriomas, despite the previous ones being removed.

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.

Fertility At 40 After Having Had Children Earlier In Life: Is It Still Good?

noreply@blogger.com (women:s health and fertility) — Sat, 07 Dec 2013 16:34:00 +0000

Question:

Hello. I just turned 40 years old. I am healthy. I had 1 miscarriage in my early 30s. I waited a few years to conceive after that and conceived two children back to back in the first month of trying so I am hoping my fertility is still good. Obviously Im reproductively old and there is an issue of egg quality. Is it always better to try to conceive naturally. We are worried about chromosomal disorders. I had testing done at a fertility clinic. My AFC was 14, my FSH was 6 point something and my AMH was 5 point something. Can you help me interpret this? Again, is it always better to try to conceive naturally? Thanks!!! S. from the U.S.

Answer:

Hello S. from the U.S.,

Having had children previously does extend your fertility in my opinion so although you are "reproductively old", you may still be quite fertile.

The tests mentioned, AFC, FSH and AMH are all INDIRECT measures of ovarian function and NOT fertility or egg quality. They give us an idea of how well the ovaries will respond to stimulation, which statistically can increase or decrease your chances of success. In older women, the more eggs you get in an IVF cycle, the higher the chances of finding a good egg because there are fewer good eggs with increasing age. That is all that those tests reveal.

In terms of what may be the best way to get pregnant, certainly trying natural has significant advantages: it is more fun and pleasurable, it costs less. The disadvantages are: there is an increased risk of genetic disorders (based on your age), it may not work, and there is a higher risk of miscarriage. So, in terms of whether to try naturally or go with a technological means, it depends completely on your personal preference and goals. Unless you want to do something like genetic testing of embryos for normality or sex selection or want to increase your chance of pregnancy in the shortest possible period, then I would recommend that you try naturally for at least 6 months. If not successful by that point, then I would recommend that you consider proceeding directly to IVF, which is the recommendation if you say yes to either of the previous criteria. The downsides of IVF are: cost, not fun, unnatural and it's a medical procedure. The upside is it is more efficient (higher chance of pregnancy per attempt, you can genetically test the embryos to minimize the risk of miscarriage or genetically abnormal child and you can achieve pregnancy faster. Because your ovarian testing is so good (more like a 20 year old), you are a very good candidate for IVF and I would probably give you a high chance of success per attempt (50-60%) in a good IVF center.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

Poor Responder Needs To Know IVF Is Not All About Numbers: It 's About One Good Embryo

noreply@blogger.com (women:s health and fertility) — Tue, 29 Oct 2013 14:37:00 +0000

Question:

Hi Dr. Ramirez,

My name is A. and I am writing from Michigan. I am 33 years old and have DOR with an AMH of <.16, Hashimoto’s and positive ANA’s. I am on day 10 of stims for IVF #2 and responding poorly compared to our first attempt. I am hoping you could answer a few questions regarding the cause of the diminished response (compared to the first) and also give your opinion regarding canceling the cycle.

IVF #1 (March 2013):

BCP suppression 5 weeks

225 iu Bravelle, 150 iu Menopur, Ganirelix days 8-10. Stimmed for 10 days.

Day 5 of stims: 6 follies: 9-10 mm, E2 301

Day 10 of stims: 7 follies: 19-21 mm, E2 724

Retrieved 8 eggs, 6 mature, 4 fertilized with ICSI, 2 transferred (grade B’s, no frag), none to freeze.

IVF #2 (in progress):

BCP suppression 4 weeks

225 iu Bravelle, 225 iu Menopur, Ganirelix added day 8 of stims.

Day 7 of stims: 6 follies: 12, 12, 9, 9, 9, 9 mm, E2 243

Day 10 of stims: 4 follies: 15, 14, 11, 10 mm, E2 495

There are five factors that have changed since the first cycle. 1) Menopur was increased by 75 iu. 2) Ganirelix was introduced when follies were smaller at just 12 mm. 3) Slightly less time on BCP suppression; less one week 4) Added Methylprednisolone 16 mg. 5) Discontinued DHEA 50 mg and Myo-Inositol 2 g.

What could be causing the poorer response, loss of follicles and slow growth? Is there anything that can be done to speed up growth and/or catch up the 10 and 11? Does the slow growth speak to poor egg quality?

I am okay with going to retrieval with so few follicles as I realize I have DOR and cannot expect a normal response. However, with having had a better response previously, would you recommend canceling at this point? Why?

This is such a stressful time for us, so I greatly appreciate your attention and feedback.

A. from Michigan

Answer:

Hello A. from the U.S. (Michigan),

First, you should know that ovaries can and will respond differently with each cycle regardless of the protocol used. That is to say that even poor responders will respond better or worst from one cycle to the next.

In your case, I can make several observations which may be helpful to you:

1. Despite a low AMH, you have responded pretty well with each cycle. You had 14 follicles and 10 in the second. This is not a sign of a poor responder. Poor responders tend to have less than 10 total follicles. In addition, your stimulation was not that high, so I would say you are a pretty average (normal) responder.

2. As mentioned, your stimulation protocol was in the mid-range (375 IU and 450 IU). The max protocol that most clinics use is up to 600 IU (450 FSH + 150 FSH/LH (menopur). So in terms of stimulation, you have lots of room to improve.

3. You mentioned starting Ganerelix when the follicles were 12 mms. That is way too soon in my opinion. Based on European studies and over 10 years of use by myself, I do not start Ganerelix until the lead follicles are at least 16 mms and preferably when the 30% or more are between 16-18 mms. The purpose of Ganerelix is to prevent premature ovulation so I hold it until the very latest that I can to allow the follicles to develop without suppression. Starting too early will lead the smaller follicles to stop growing.

None of this implies low egg quality or poor outcome. It is part of the "art" of assisted reproduction and what distinguishes one doctor or clinic from another. Bottom line is that IVF is not all about numbers. It is about getting at last one good embryo to attach and lead to a pregnancy. For that reason, even if there are fewer follicles I recommend that you keep going just in case the perfect embryo is in this group.

Good Luck,

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

After Failing 3 IVF, Reader Has Pregnancy Success After Writing To Me

noreply@blogger.com (women:s health and fertility) — Tue, 15 Oct 2013 16:30:00 +0000

Dear Readers, Sometimes I get great news from one of the many couples I help on AllExperts.com and this is one I would like to share with you. Over a year ago I began corresponding with this woman regarding her failed IVF cycles. Her original questions appear right after the good news I received from her a few days ago. Makes it all worthwhile :)

October 7, 2013

Comment: Dr. Ramirez helped me conceive from across the country thanks to his blog. We've never met and my husband and I credit him with the birth of our healthy baby boy. When my RE rejected our suggestions, Dr. Ramirez provided facts that played a major role in our "self" treatment which was to try naturally with baby aspirin. More doctors should provide online guidance and provide proven medical facts and suggestions to help those of us who are skeptical of patient forums.

July 2012

Question:

Hello Dr. Ramirez,

I am writing from the United States. I have been TTC for 2 years. I began RE treatment 6 months after trying to conceive naturally at 34 yrs old. I am 36 now. I have failed 6 Intra Uterine Inseminations and Three IVF (in vitro fertilization) cycles. Below are the details: (for privacy purposes I have omitted the precise details of each cycle…except for the transfer details)

First IVF: 7 mature eggs, All ICSI 1 fertilized, transferred 4 cell Grade AB on day 3

Second IVF: 17 mature eggs, 9 fertilized, transferred 2 Grade AA on Day 3, one made it to blast and freeze (poor quality)

Third IVF - 18 mature eggs, 14 fertilized, 9 made it to blast, transferred 2 Grade AA, froze 6 good quality blasts ranging from Grades AA - BB

I never had a positive beta or urine test. I've done all the preliminary testing, water sono, bloodwork, HSG, etc. everything is normal. My husband’s tests and sperm are also normal.

I asked about immunology testing and Doctor said there is nothing to support that treating it helps.

I don't believe the early bleeding is normal. My luteal phase naturally is about 11 days long. Dr said the PIO is plenty for me and would not recommend increasing it.

I asked about baby aspirin and heparin. They said baby aspirin is ok, but heparin can be dangerous. I've read in your posts that you recommend that if there is one IVF failure.

Is there harm in taking heparin? I don't know what else to do to make them implant. What are your thoughts considering my history? I do not want to transfer any frozens unless the protocol is changed. I feel like continuing the same PIO / medrol protocol is setting me up for failure again. I appreciate your advice. Thank you!

Answer:

Hello,

Since you have had decent embryos to transfer in at least two of your three IVF cycles, this would be regarded as implantation failure. Thanks for reading my posts. I also discuss these issues in my blog.

Your doctor is right in that the correct general opinion, kind of like being politically correct, is that the studies do not show any benefit to treating for immunologic problems in IVF. However, it remains to be seen and depends which studies you prefer to believe. There are certainly studies that show that immunology plays a role in miscarriages and some studies that show immunological treatments help with IVF. I don't think it can be discounted completely but at the same time, don't believe in every treatment that is offered.

I certainly advocate low dose aspirin, low dose medrol and low dose heparin in my patients that fail two cycles of IVF for no clear reason. I have had many be successful thereafter with that protocol, which I have been using for the past 18 years. There is NO danger in using low dose heparin. Full dose heparin is another matter.

I think that the dilemma you now face is whether to continue with this doctor or not. If you want more, such as using the protocol mentioned, then you'll probably have to find a doctor that will provide that to you. I certainly think your doctor needs to reevaluate and consider what else he/she can do since what is being done so far has failed.

You certainly can always fly out to California. :) For an FET cycle, you would only need to be here for one day.

Good Luck,

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

Follow-Up Question:

Hello again,

We consulted with our RE again regarding the transfer and he suggested doing nothing differently and chalked it up to bad embryo genetics. Again he reiterated no baby aspirin so we pleaded for him to do immunologic testing, cytogenetics (on us) and blood clotting work ups to which he agreed.

Everything came back normal, including cytogenetics on my husband, with the exception of my protein s free antigen level. It was 151 and regarded as "high" by the lab that ran it. He referred me to a hematologist who ran protein s activity testing which thankfully came back normal. He said a high level protein s is not concerning and that only a low level would be.

So here we are again with his recommendation of transferring with the same protocol. I asked again how about baby aspirin and he remained firm on "no". I told him 3 doctors, including one at his practice, the hematologist and an online doctor i have emailed have said there is no harm in using it along with my friends who have used it with no pre-existing blood clotting disorders and went on to have successful IVFs.

He said taking baby aspirin with no blood clotting problem can cause more complications than help. He said it can interfere with the growth of the placenta. Is this true? So far he is the only doctor that has said no to baby aspirin including the doctors of everybody I know who has gone through ivf unexplained.

Are there any facts you know of with baby aspirin and placental defects?

Again, I truly appreciate your knowledge and advice and thank you for your responses. There should be more doctors like you who help others online with honest, professional opinions!

Follow –Up Answer:

Hello Again,

There are no studies that show any adverse affects of low dose aspirin on embryo or placental development. In fact, and either you or he can look this up in any Infertility textbook, low dose aspirin is an approved and advocated treatment for recurrent pregnancy loss (now why would they endorse it if it caused placental problems?). We have extrapolated its use in failed IVF with the same idea that it increases blood flow to the implantation site and reduces the formation of micro-clots in the tiny vessels supplying the implantation site. There is no way to test for these.

Since this doctor is not willing to work with you on this very simple and innocuous treatment, which may or may not help, I think you should seriously re-consider using him.

Good Luck,

Edward J. Ramirez, M.D.

Follow-Up Question:

QUESTION: Hello again

Have you noticed this email is more than nine months after your last reply?

Our RE did not budge again on the baby aspirin so we decided to wait on the next transfer and try naturally with baby aspirin.

That month I became pregnant for the first time. I went to my RE and he confirmed it with blood though the levels were low and I was bleeding and he did not offer progesterone cream. He said he doubted the pregnancy was due to the baby aspirin. At 5 weeks I miscarried, and although it was sad, I was elated at the fact that I did get pregnant. So we tried again naturally the following cycle with baby aspirin (2 weeks after miscarriage) and what do you know?

I got pregnant again. I went back to RE and he confirmed with a blood test. I started bleeding again so he suggested progesterone cream. I told him we did the baby aspirin thing again and if I should continue taking it and he said YES!

He followed my progress until 2 months and referred me to my obgyn to monitor the pregnancy. I continued the progesterone cream until the end of the 3 months and continued taking baby aspirin until 37 weeks. Yes, 37 weeks.

Our healthy baby boy was born at 41 weeks, weighing 9lbs, 4oz and measuring 20.5 inches.

If I did not read your blog, he would not exist. My husband and I attribute his existence to your blog and cannot thank you enough. Please continue your public advisement as it made our dreams come true.

Thank you!!!!!!

Follow-up Answer:

Hello,

I am absolutely delighted for you. Congratulations :) I'm saddened to see that you had to prescribe a therapy for yourself, but glad that it might have done the trick. No one will ever know for sure if it helped or not and what the mechanism is, but it seems to help many people with your type of history. I now put all my infertility patients on low dose aspirin from the beginning, IVF or not. Another possible factor is that you tried soon after your miscarriage--studies show that there is a higher chance of pregnancy after a miscarriage.

I'm shocked and a little disappointed that your Ob doctor allowed you to go post-dates (41+ weeks) because that posed significant risk to the baby such as a fetal demise, fetal distress, etc. I NEVER let my infertility or IVF patients go past 40 weeks. The sooner the baby was out the safer it was at that point.

Thank you for reading my blog and using this service (AllExperts) as well. I do it in tribute to the task and gifts that God has given me, which is a part of the love he has for us. Your baby is also a gift from God for you to treasure and teach of his ways. Devote your love to this son and shower him with Goodness so that when he grows up, he will shower others with goodness as well, and thereby contribute toward making this world a better place. It is not often that I get feedback of successes attributed to my writings, but know that your feedback reinforces my dedication to this task.

Congratulations!

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.

Protect Your Fertility!

noreply@blogger.com (women:s health and fertility) — Sun, 29 Sep 2013 15:45:00 +0000

Dear Readers,
The American Society of Reproductive Medicine has launched a campaign with the aim of educating women on how to protect their fertility by avoiding certain risk factors. The Society has made available a number of fact sheets, graphics and brochures that are all downloadable on their "Protect Your Fertility" page. At our center we also offer the ability to extend the fertility of a woman by either freezing her eggs or her embryos. See "Fertility Preservation" for more information.

Check out the selection of fact sheets, infographics and a brochure on the ASRM page, including:

"Advancing Age Decreases Your Ability To Have Children"
"Smoking and Infertility"
"Protect Your Fertility Brochure"
"Impact of Age on Female Fertility"
"Practicing Safe Sex Now Protects Your Ability To Have Children Later"

To quote ASRM: "At the risk of sounding like your high school health teacher, the decisions you make today really can impact your fertility and ability to have kids later. That's why it's so important to learn how to take care of your body. After all, there's a huge difference between choosing not to have kids and physically being unable to conceive if and when you want to."

Be proactive about your fertility health!

Edward J. Ramirez, M.D., F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

Follicles Too Big In Clomid Ovulation Induction Cycle

noreply@blogger.com (women:s health and fertility) — Mon, 16 Sep 2013 14:19:00 +0000

Hello,
I am writing from San Diego, CA. I was on 100mg Clomid on Cycle Day 3-7, then 2mg estradiol on cd 8-12. I went in for an ultrasound to check follicles on cycle day 13. My RE said that this was most likely a lost cycle because I had 2 dominant follicles at 26 and 31 mm. He gave me an HCG trigger because he did not want the follicles to get bigger and become cysts. My uterine lining was 14 mm, and my RE was happy with that. My husband and I had intercourse the day of the trigger and the day after, then skipped a day and had intercourse one more time.

Were the follicles too big? Do we have any chance of conceiving this cycle? I have also been feeling cramps since yesterday at 7 days after the trigger. Is this normal?

Thanks for your input. L. from San Diego

Answer:

Hello L. from the U.S. (San Diego),

I don't have the ability to foresee the future, and certainly exceptions can occur, however, the follicle sizes were too big. Usually once the follicle is greater than 24 mms, the egg within is overmature and therefore no longer viable. Ovulation may occur but that is the main problem. Also, it is highly likely that these follicles will turn cystic (persist) and have to be suppressed with birth control pills. You need to make sure a baseline ultrasound is done to evaluate for this at the start of your next cycle.

So, statistically and physiologically speaking, this cycle is probably a bust. Unfortunately, your doctor missed the appropriate point by not doing the ultrasound early enough. Next cycle he should begin looking at cycle day #9 or 10, which is what I do. If I'm too early that's okay because nothing is lost and gives me a better idea of follicular development. If you're too late, as in your cycle, then then cycle is lost; a big price to pay.

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.

Similar IVF Protocol But Different Results: Why?

noreply@blogger.com (women:s health and fertility) — Sat, 31 Aug 2013 13:24:00 +0000

Question:

Hi Dr. Ramirez,

I'm back again with a question about my recent IVF (second one). This IVF (in vitro fertilization) cycle we did the same protocol as last time (antagonist) but started off at a higher dose of Gonal-f based on my response last cycle. This cycle we started off at 300iu gonal-f and 75iu menopur whereas last cycle we started with 225iu gonal f and 75 IU menopur but had to increase to 300 IU gonal f after day 4 showed an E2 of only 90. Both cycles I started out with similar AFCs of 10 and 12 at suppression check. My usual AFC is between 16-20. Last cycle it seemed that I recruited more follies along the way and ended up with an E2 of 3030 and 23 eggs retrieved (17 of which were mature based on icsi and conventional fert rates as we did 50/50 split fertilization). This cycle my E2 was 2100 at trigger and they retrieved 12 eggs (still waiting on fert report today but we are doing all conventional fertilization).

My question is why did I have such a different response this cycle given that we started off at a higher dose this cycle compared to last? Last cycle we went up from 225iu gonal to 300 IU gonal at day 4 and stayed there until trigger. this cycle we started at 300iu gonal and stayed there until we added ganirelex on day 7. At that point my E2 stalled and do they increased my gonal f to 375iu gonal f and kept me there until trigger.

As always thanks for your advice/insight. S. from the U.S.A.

Answer:

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

The human body is not a consistent nor predictable structure so I can't explain why your response is different. I have always explained to patients that have low response to stims that the ovaries can react differently each cycle and your experience is a case in point. That being said, I would not have increased your dosage since your stimulation was so good the previous time and you bordered on entering OHSS territory. In any case, IVF is not a contest where the person with the highest number of follicles or eggs wins the prize. The goal is to find 1 or 2 perfect eggs that will lead to perfect embryos and a successful pregnancy. So despite the fact that you stimulated less, that might be a better thing. Bottom line is you only need one good one. Also, there have been some studies showing that when a patient stimulates hard with lots of follicles, sometimes the egg quality suffers and the pregnancy rate drops. This is especially true in PCO patients. In those patients, our preference is to stimulate less and get fewer follicles.

So, in any case, as the saying goes: "I don't think you should sweat the nitty gritty" i.e the fine details. Hope for the one perfect one. That is the goal.

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.

Is A Tubal Reversal A Good Option For Me?

noreply@blogger.com (women:s health and fertility) — Thu, 22 Aug 2013 16:36:00 +0000

QUESTION:

I am a 33 year old mother of two. My children are 11 and nearly 10 years old. After the birth of my second child in 2003 I had surgery to prevent further pregnancies. (I was in an unhappy marriage and only 23, and couldn't see myself ever getting out with 2 children.) The doctor was reluctant, because I was so young, but he decided to go ahead and perform the sterilization surgery. My tubes are not cut or clipped or burnt, they just have little clips on them to prevent the egg from passing through. But just as many people predicted, now I regret the decision.

I am divorced, my children are growing up, and I am in a wonderful relationship with a man who has no children of his own but would very much like to have one. Barring infertility issues on his part, is there much hope of us being able to reverse my tubal and conceive a child of our own? I don't have any other medical issues. I am healthy and active, average healthy weight, non-smoking, non-drinking...same for him. He is 39 and I'll be 34 this year, so we feel like the clock is ticking on any opportunity for another child. Can this surgery be done, what are the odds of conception afterwards, what factors do I need to consider, how long do you need to wait after the surgery before trying to conceive. And what is the average cost?? I appreciate any answers you can give me on the matter.

Thank-you! K. from Kentucky

ANSWER:

Hello K. from the U.S. (Kentucky),

The type of tubal ligation that you have is the best to reverse because the majority of the tube is kept intact and there is minimal damage to adjacent tubes. Also, considering you are young still, a tubal reversal would be a good option in your case. A good and experienced gynecologist or reproductive specialist can do the reversal either by laparoscopy (using a scope and little incisions) or by a mini-laparotomy (a small incision above the pubic bone. You would want to find a surgeon who is well experienced in this and does them a lot to get the best chances for success.

I have had a patient who went to North Carolina to have hers done by a doc who only does reversals. The risks for this procedure are the same risks as for any surgery (infection, bleeding, general anesthesia, injury to adjacent structures, failure) but this is not considered a major surgery, but rather should be an outpatient (same day) surgery. In terms of success, those rates can vary widely so I can't give you an exact number. A good surgeon will have an 80% success rate in patients under 35 years old after 1 year of trying. If a pregnancy does not occur within 1 year, then the procedure probably has failed.

Basically, with a tubal reversal, all you are doing is attempting to restore your natural fertility rate. This rate is very age dependent. Your chances of natural pregnancy at 25 years old was 85% per year whereas at 35 it will be 30% per year because your eggs have aged. So, keep these statistics in mind. The alternative to a tubal reversal, and with a higher likelihood of success is In Vitro Fertilization, but the down side is you would have to do this every time you wanted a child from this point on. With a reversal, you could continue to have children by natural means if you wanted more than one. Cost wise, tubal reversal will vary depending on the doctor, the clinic and whether or not it is done in an outpatient surgery center or hospital. The cheapest I have seen is about $6000 and is done in an outpatient surgery center. Hospital performed reversals will be $15,000-18,000. I hope that gives you the information you needed.

Good Luck,

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

Monterey, California, U.S.A.

Comment: Thank you so much, once again. Armed with the information you provided, we can now move forward! I feel like I got lucky having my question go to such a knowledgeable and open volunteer!

Secondary Amenorrhea: A Description, Not A Diagnosis

noreply@blogger.com (women:s health and fertility) — Sat, 10 Aug 2013 14:59:00 +0000

Question:

Hello Dr. Ramirez,

I'm 20 and 293 pounds. I have had Secondary Amenorrhea for close to 4 years now. It is apparently being caused by my weight. I'm not planning to TTC for at least another 12 or 13 years. I don't hate babies but it's not just a good time on the emotional or financial level to have them. If I'm able to get down to a decent weight and get rid of this disease, What are my chances of getting pregnant when it's time for me to TTC???

There's a history of Diabetes in my family and I haven't had a asthma attack since I was 8.My mom had thyroid disease before I was born but I don't think that's genetic. But I don't have any other diseases than the SA at the current moment and my hormone levels were just fine at my last doctor appt which was last October. I've been on progesterone more than I count and it gets me a period but I want to have it without the help of drugs. Is there some kind of natural cure to SA??

I know that it seems a bit silly to ask about this NOW but I'm not getting any real answers about this disease from my OB. Everytime I asked my OB about this, she would tell me not to worry about it or brings a therapist in the room to basically tell me that I'm crazy.

She's since moved her practice out of state and I have a new OB that I'll start seeing very soon. But how in the hell am I crazy for wanting to be proactive about my own health?? I'm sorry for the language but I'm just so fed up about this and at my wits end.

I know that I'm not producing eggs right now but what else could this be doing to my body?? Do I have a reason to be concerned about it besides the obvious infertility scare?? If I do get rid of this disease, Is there some kind of leftover side effect that could cause me to get Ovarian Cancer in the future??

I don't have these answers and I need to know what's going on. Please help me clear at least some of this up.

Thank You. D. R. from Michigan.

Answer:

Hello D. R. from the U.S. (Michigan),

Good riddance to your previous Ob doctor! "Secondary Amenorrhea" is a description of a problem and NOT a diagnosis. It just means that you used to have periods and now you don't. It doesn't explain the cause. The most common reason for old women to have secondary amenorrhea is menopause. The most common reason for young women to have secondary amenorrhea is pregnancy. However, a close second is an ovarian disorder called "Polycystic ovarian disease." This diagnosis is manifested by irregular or rare natural menstrual cycles and at least one of the following findings: ovaries that look like PCO ovaries on ultrasound, inverted FSH/LH ratio, obesity, hirsuitism (increased facial hair), elevated testosterone levels, diabetes, elevate insulin levels signifying insulin resistance. I think that you have PCOD but without a thorough endocrine evaluation, I cannot say for sure.

With this disorder, you have a hormonal imbalance and that needs to be corrected. The most simple way to do that is to use a low androgen birth control pill such as Yaz. Once you are ready for pregnancy, then you will have to use fertility medications, which actually do not increase your fertility but induce your ovaries to ovulate, so that you can give off an egg to get pregnant. You need to see a COMPETENT gynecologist or a reproductive endocrinologist to be evaluated and treated correctly!

You may want to see a more detailed explanation of Polycystic Ovarian Disease on my website.

Glad you wrote! Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

Woman With Secondary Infertility & Possible Blocked Tube: Misdiagnosed? Surgery? What To Do?

noreply@blogger.com (women:s health and fertility) — Mon, 15 Jul 2013 16:52:00 +0000

Question:

I had an HSG (hysterosalpingogram) in November. The dye flowed freely through my left tube, which appeared normal and healthy. However, the dye would not enter my right tube until after the radiologist had me get on my right and then left side. The dye then went into the tube and appeared to flow freely, but then it stopped abruptly mid way in the tube.The visible part of the tube appeared normal and healthy. My RE told me that it is extremely rare for a woman to have a blocked tube in the middle of the tube unless she's had her tubes tied and that it was possible I was just born with half a tube.

I recently had a laparoscopy in June to get more info about the cause of my infertility and to attempt to repair the right tube. The dye again flowed freely in the left tube. My doctor inspected the right tube, and found that it appeared to be completely normal and healthy in every respect. However, again, the dye entered the right tube and stopped mid way.

After the surgery, my doctor told me that I had no endometriosis or adhesions of any kind. She also told me that I had no evidence of any tubal disease or previous infection in my pelvic cavity. The only abnormalities that were found were a large paratubal cyst that had wrapped around my good left tube (the cyst was successfully removed), and a small polyp during the hysteroscopy (also removed). I also have never had any other surgeries or ectopic pregnancies.

My RE told me she had no idea what was blocking the tube, but not to worry about it because research shows that having one healthy tube does not really decrease your chances that much for Clomid/IUI or timed intercourse. Still, it's very frustrating to me because I thought that laparoscopy was 100% method for diagnosing the cause of a blocked tube, but I have no more info about the cause of blocked tube than when I started.

I am 38 and my FSH and AMH values are excellent, and my hubby passed his sperm analysis. I have a 2 year old that was conceived after 8 months and we have been trying for #2 for 1.5 years. Although I understand that having just one tube should not affect my chances that much, I am still concerned because at this point, it is our only known issue.

My questions are: 1. What could have caused the blockage in my tube? 2. Is it possible that the tube is not actually blocked but is not flowing for some other reason (I've heard about false diagnoses of blocked tubes due to preferential flow or not enough dye being used)? 3. Is there any other way to find out what is blocking my tube? 4. Is it worth it to pursue surgery to repair the tube like I've seen for women who undergo tubal reversal surgery?

Thank you! C. from Atlanta

Answer:

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

To answer your questions in order:

1. The most common cause of a mid-tubal blockage, that is not from prior surgery, is an internal tubal infection. Many of the bacteria that cause this type of scarring can do so without any type of symptom. A laparoscopy would not be able to find this type of injury and, other than the HSG, there is no way to examine the inside of the tubes.

2. It is possible that there was tubal "spasm" causing the tube to appear blocked, but I doubt it because the Radiologist was able to get the dye to flow down part of the tube. However, if you think that it my not be an accurate test, then I would recommend that you have another one, but have your doctor specifically request that they pay most attention to the right tube i.e. do the test so that the dye preferably goes down the right side. Remember, fluid will always go down the side of least resistance.

3. There is no other testing that can be done to examine the tube. Scope technology is still not small enough.

4. NO. Such surgery can cause pelvic scar tissue and impair your fertility more.

First, I think you need to consider ALL the factors involved in your fertility potential. Yes, it is possible to get pregnant naturally (intercourse or IUI) with one normal tube, but there is no way to prevent the egg from going into the tube that is blocked, so your chances are actually decreased.

Second, you are 38 years old which means that your natural chances of pregnancy are already reduced significantly down to 3-5% per month (15% per year), which is further reduced if you add the tubal problem. Even with IUI your max chance of pregnancy based on your age is only about 7-10% per month not considering the tubal issue. The fact that you have been pregnant before is a positive factor and increases your success with assisted reproduction. If you want that second child right away and if you were my patient, I would strongly urge you to consider IVF.

Third, you have to decide which of two assumptions are correct: the tube was blocked from a prior bacteria, which probably went to the opposite tube as well but did not cause blockage, but did cause damage vs the blocked tube was the only injury and the opposite tube is therefore normal. If the open tube is injured, which cannot be proven but is possible, it may not be functioning normally despite being open. Keep in mind that fluid can pass through even the smallest opening. In that case, you will not be able to get pregnant naturally and so IVF would be the treatment of choice. Because of your age, I would make the assumption that the tube is damaged (mainly because you have not been able to get pregnant naturally when you were able to previously) and therefore recommend IVF. It is the most successful and expedient treatment option for you.

If your doctor wants to waste time and try something less like ovulation induction or IUI, that is fine as you understand that the risk you are taking is losing the opportunity to get pregnant with your own eggs and more time passes. I hope this second opinion is useful to you.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

Finally Pregnant After Multiple Miscarriages: "I Am A Nervous Wreck!"

noreply@blogger.com (women:s health and fertility) — Sat, 06 Jul 2013 16:11:00 +0000

Hello Dr. Ramirez,

I've written you in the past regarding my fertility challenges and your responses have been very encouraging. In my last, I discussed how I'd experienced an early loss in March after our first IVF attempt. You encouraged me to be strong and keep trying that my chances were good. You were right. I waited until my next cycle began and started a more simple IUI cycle again with just Follistim injections. My first miscarriage in April 2012 after IUI with Femara/GonalF was caused by trisomy 3. I found studies that said use of Femara in some women could increase the chances of aneuploidy. This time we tried without the Femara and I have become pregnant again.

I have gone through the complete RPL panel-DNA analysis, autoimmune, alloimmune, thyroid, hysteroscopy, etc. Everything has been normal. I believe the second miscarriage, because it began just 16 days after embryo transfer, was due to my body being weak (I was very sick during stimulation and had a lap/hysteroscopy/cystectomy 3 weeks before I started stimulants). I am 32, maybe borderline diminishing reserve (last AMH was .9), but otherwise nothing really bad with me.

So I am currently past 9 weeks. My betas doubled and were actually in the higher end of the ranges for weeks along. I did a viability ultrasound at 5 weeks and could see the heartbeat. Embryo measured exactly the right size. At 7 weeks we could hear the heartbeat at 174. RE saw me again at 8 weeks and said I looked good, released me to my OBGYN, said most women miscarry between 7-8 weeks. I've had no spotting or cramping. OBGYN is letting me do weekly scans until I'm through my first trimester. Heartbeat has stayed in the 170 range. Growth is continuing. Last ultrasound at 9 weeks showed the baby kicking its legs.

Here's the thing - I'm a nervous wreck. I'm terrified of something going wrong again. I am fighting to follow reason rather than fear but it is so hard. I have hardly any symptoms certainly none of the "noticeable" ones which means most of the time I don't feel like I'm pregnant. My last HCG was only at 102,900 when it was checked at 8.5 weeks, which I felt was low for where it had been but I know it slows down. My progesterone in the beginning was all the way up to 75 and is now holding at 30 (I had cysts leftover from after the IUI, made 3 follicles).
The statistics are all over the place. Some say less than 5% when heartbeat is detected but that can jump to 20% if you've had prior losses. I read it's even less once you enter the fetal stage past 8.5 weeks.

I feel stupid for asking but your answers are thoughtful. What do you think my chances are of carrying this baby to term? What would you say my change of miscarriage is? And why in the world do I hardly feel anything? I'm a little tired in the evenings and I pee in the middle of the night with crazy dreams, breasts are bigger but not sore, no nausea, etc. But hardly anything to notice. Thank you so much for your time. L. from Indiana

Answer:

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

CONGRATULATIONS :) Like your RE, I release my patients at 8 1/2 weeks gestational age because the risk of miscarriage is minimal. Statistics show that the risk of miscarriage is up to 50% prior to 8 weeks gestational age and then decreases to 5% up to 12 weeks gestation. So you are now at 5% risk but the fact that all the signs have been good, is very encouraging and I would not worry about miscarrying. At this point, the only risk of a miscarriage would be if there is a major genetic abnormality, and this would be a baby that you wouldn't want to go to term any way. You should certainly consider genetic testing early to check on that. There is now a blood screening test that can be done at an early stage.

In my experience, and as evidenced by the data, most patients will have a successful pregnancy and delivery at this point. The fact that you "don't feel any different" with this pregnancy is irrelevant. Every pregnancy is different and different people experience pregnancy differently. Some have pregnancy symptoms and some have none. You may be one of the lucky ones that doesn't have to suffer with the "morning sickness" or other such symptoms. For now, pray that all continues to go well and thank God for the blessing.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

38 Year Old Has Five Failed Fresh IVF Cycles But Has Frozen Embies: Should She Try FET?

noreply@blogger.com (women:s health and fertility) — Sun, 23 Jun 2013 15:29:00 +0000

Question:

Hello - I have been reading you blogs for some time now and am so thankful that you take the time you do with such thoughtful answers.

I am 38 and husband is 41. My history is as follows: 2009 wasted time on clomid prescribed by my obstetrician, 2010 saw RE (reproductive endocrinologist) and began the real journey. Major issue is male factor morphology but I suspect with my age quality may be issue too.

In 2010 we had 2 Fresh IVF (in vitro fertilization) cycles, first was a failure 3 eggs collected, thankfully 3 fertilized and implanted 2 (1 frozen) but no pregnancy, cycle 2 doubled my stim meds to 300 gonal f and 150 repronex, collected 13 eggs but transferred 2 "decent" but beta was very low around 70 the pregnancy continued to around 11 weeks saw heartbeat but clearly there was issues as the size kept loosing ground until miscarriage and D&E. Cycle 3 same meds, 13 eggs, transferred 2 on day 5 and then arrived my beautiful baby girl delivered 12/29/2011. Fast forward to 2013 where I have done two more fresh cycles same protocol, birth control, 10 lupron, to 5 lupron when stimming, retrievals after 9-10 days of stims. Cycle 4 resulted in collecting 20 eggs, 2 "decent" transferred on day 5 (blastocyst and morula) very low beta resulted in loss about a week later. Cycle 5 same protocol except menopur instead of repronex, collected 18 eggs, 14 fertilized and transferred 2 blastocysts on day 5. This was a negative. BTW all cycles are ICSI and included medrol, baby aspirin, antibiotics, vivelle patches and progesterone in oil injections.

My question is what are your thoughts on FET (frozen embryo transfer). I have 4 frozen embryos 1 from cycle 1, 1 from cycle 4 and 2 from cycle 5. RE and hubby think I should take a break and try for FET. I and concerned as I don't want to "waste" a cycle insurance will cover on the lower cost option but the meds did really affect me this time and see their point about giving my body a rest. I am at a very reputable clinic in Boston and doc said 4 frozen is a lot due to their strict freezing criteria so am optimistic although obviously embyro age has no advantage. Would FET also be something you would recommend at this point? Fresh cycles are a big logistical challenge as my husband travels 70% of the time.

Also if I go back to fresh cycle is there anything significantly different you would do (btw I am also doing acupuncture). Thank -you in advance for your time. I also want to say I am very grateful for my daughter and don't want to seem selfish but I would really like her to grow up with a sibling.

J. from Boston

Answer:

Hello J. from the U.S. (Boston),

It sounds like you are in good hands. Your clinic has accomplished several pregnancies, which is an IVF success. Keep in mind that IVF can only give you the "opportunity" to become pregnant. It can't make you pregnant because the last three steps (embryo hatching from its shell, attachment to the endometrial lining, and lining growing around the embryo are natural processes that are in God's hands. That fact that you got a pregnancy (positive bHCG) shows that those steps occurred. Continuation of the pregnancy is then based on pregnancy factors and not IVF factors. Because of your age, your chances of a miscarriage are high due to abnormal embryos. You've shown that you can get pregnant, and your ovaries stimulate very well. Now it is just a matter of finding the perfect egg/embryo which will then lead to a successful pregnancy. I wish all my 38 year olds responded as you do. So hang in there!

I think I would advise proceeding with the FET cycle before another fresh cycle. It is a much easier cycle on your body, and some newer studies are showing better pregnancy rates than fresh, probably because of the lack of overstimulation of the endometrial lining. I don't completely agree that FET is "better" but it certainly gives a good chance. If they fail, you can certainly try fresh cycles again. I would advise two FET cycles consecutively. In fact, I always advise my patients to do an FET cycle, if they have frozens, before trying a fresh cycle again. You never know. . . the frozen might work.
In terms of additional protocol changes, you are doing everything that I have my patients do in terms of supplemental medications, but I also add low dose heparin (2000 U per day). Not all RE's agree with this protocol, but it is an accepted protocol for recurrent pregnancy loss so you might want to ask your RE.

Thanks for following my Blog.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVF

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Thank you much for the quick and thoughtful answer. I have several time contemplated seeking a more aggressive clinic despite my comfort level. Your response puts many of my worries at ease. You are truly a huge help to those of us in a constant state of limbo. Thanks again.

39 Year Old With Recurrent Chemical Pregnancies

noreply@blogger.com (women:s health and fertility) — Mon, 17 Jun 2013 12:59:00 +0000

Question:

Hello there! I’m writing to you from Florida. I have recently suffered two miscarriages. One in Oct of 2012 and one in March of this year. Both occurred at about two weeks so very early. I guess the term is chemical pregnancy when it is that early. I don't know how I know I am pregnant so early but I just know. My body is sensitive! I am 39 years old so my Dr. watches me closely and had me do the clomid challenge test to check the fsh which I think tests egg quality. Mine was 7.6. I also had a vaginal ultrasound and everything looks perfect. No fibroids or cysts. Then in March 2013 I got pregnant again and I was immediately sent for an hcg blood test. My hcg levels kept going up and down 241 to 119 over the course of three weeks and it would not leave my system completely so I ended up having to have another ultrasound that found nothing as they were worried about an ectopic pregnancy but did not find a sac or anything. I ended up taking a methotrexate shot.

Finally my levels went back to zero and 6 weeks later I did a complete recurrent miscarriage blood panel test and they found that I tested positive for two copies of the mthfr CT677 gene. I also was out of range for the PAI-1 test which was 51. Everything else was normal. My Dr. put me on foltx and a daily aspirin plus I take my prenatal vitamins and she told me that as soon as I find out I am pregnant again I need to start administering lovenox injections and progesterone suppositories. Right before delivery it would change to heparin. I enjoy reading your blog and appreciate all of your knowledgable answers. I would like to know what your thoughts are about the regimen she has planned for me and if there is anything else I should be doing. I am a bit nervous to try again. We really want to have a baby!

Thank you, M. from Florida

Answer:

Hello M. from the U.S. (Florida),

The CCCT is to check for ovarian reserve (ability of the ovary to respond to stimulation) and not egg quality. Thought you should know that.

It sounds like your Ob/Gyn doctor is well versed in the evaluation and treatment of recurrent pregnancy loss, which makes her a little better than the average Ob/Gyn doc. One thing to keep in mind, however, is that you have the "age factor" which means that your eggs are old and debilitated and therefore have a propensity to forming abnormal embryos. In most cases these embryos will not continue and lead to a miscarriage (especially before 8 weeks gestational age). The age factor is the main factor that you are trying to overcome. There is no treatment that can make eggs better. The good news is that your ovaries are still functioning well, and you know that you can get pregnant. Now it is just a matter of getting a perfect egg.

The increased folic acid, low dose aspirin, low dose heparin or lovenox and progesterone supplementation are all reasonable and acceptable treatments for recurrent pregnancy loss. What I would recommend is that the heparin/lovenox start immediately with the start of your period, NOT once you become pregnant. It should already be in your system when implantation occurs to help with increased blood flow at the implantation site, and decrease the immune response to the embryo. Starting after pregnancy would defeat the purpose.

Based on your age, I would agree with the above regimen, add CoQ10 600 mg per day (found to help with egg quality in mice. No human studies yet but it can't hurt) and strongly recommend that you consider IVF rather than continuing to try naturally. I know that you are able to get pregnant naturally, and it may eventually happen, but the only way to increase your chances of success (overcome the age factor) is to increase the number of eggs and embryos you have to choose from. With IVF, you have a better chance of finding the perfect egg. I explain it to my patients with the following analogy: imagine that you have a bucket of blue balls and a few red balls. There are mostly blue balls and only 4-5 red balls. The red balls represent your good quality eggs and the blue balls the poor quality eggs. These balls are all mixed up together and you lift the bucket above your head so that you can't see inside. Now you have several options. You can take one ball out at a time (like you would in a naturally ovulatory cycle) whereby you will eventually get a red ball, but you can see that it will take a long while; or you can take out a handful of balls out at a time (like using superovulation with fertility drugs); or you can dump out a bunch of balls at a time (like doing IVF). You can see that the latter method is the fastest for getting to a red ball. That is why IVF (in vitro fertilization) is the recommended treatment. With a red ball (good quality egg) not only will you get pregnant, but you will have a successful pregnancy because a normal embryo will develop.

Sorry for the extremely long explanation, but I hope my answer has been clear.

Good Luck,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility And Gynecology Center
Monterey Bay IVFwww.montereybayivf.com

Monterey, California, U.S.A.

36 Yr. Old Has Repeated Implantation Failure With Great Embryos...What's Wrong?

noreply@blogger.com (women:s health and fertility) — Mon, 27 May 2013 14:20:00 +0000

Question:

Dear Dr,

We have just had our 4th failed IVF (in vitro fertilization).

Our history. I am 36, my husband is 39. 1st pregnancy was in 2009 after 3 IuI's (intra uterine insemination) and clomid, but had to terminate at 15 weeks due to large enphaloceale (was a random genetic mutation)and my 2nd pregnancy with IUI was a success with a full term healthy baby boy.

Started with IuI's for 2nd child in 2011! We had 10 IuI's and now 4 IVF's. Each IVF has been with icsi (intracytoplasmic sperm injection) and this time we had Embryo hatching. Last 3 transfers were 3 top grade 8 cell embryos each time on day 3. I am not a great responder and only ever have 5-7 eggs, of which usually 4 fertilise.

I have had all the immunity checks done, my husbands sperm dna damage is within normal, fertilisation rate is good. My ovarian reserve was also checked and the level was 1.0- My specialist said that he wasn't overly worried about the reserve for my age. I have had a hysteroscopy and all normal. I have been on various drug protocols and this last one was the long Lupron cycle with menapur.

We are just not sure what to do next? Do we keep going, as my doctors are very positive and we have the finances. Are my doctors missing something? Is there anything else we can do to improve our chances. I am on DHEA and Royal Jelly, and my hubby is also on supplements.

I am writing from CapeTown, South Africa.

Thank you for your consideration, R.

Answer:

Hello R. from South Africa,

The exact cause of your failure cannot be known as there are still four steps your embryo has to go through in order to produce a pregnancy: embryo has to develop to blastocyst, the blastocyst has to hatch our of its shell, it then has to attach to the uterine lining and the lining has to grow around it. As of now, there is no technology that can make this happen. "Assisted hatching" is just making a defect in the shell so that the embryo can exit (hatch) more easily.

Something I always worry about when I have patients tell me they have failed multiple cycles despite good embryos, is the quality of the final step of the IVF process, which is the transfer. You can have the absolute best and perfect embryos but if the transfer technique is not done well, then it will fail. This has been shown by numerous studies. Since you have been going to the same clinic, I wonder if that is not the problem, in which case, I would recommend that you seek out a different clinic.

One thing that I do with my patients that is not universally accepted but done by many of us, is to use a recurrent miscarriage protocol to reduce the immune system, thinking that a heightened immune system might be at fault. For this regimen I add low dose heparin or lovenox, medrol, low dose aspirin, extra estrogen and extra progesterone (both injectable and vaginal). I don't think that DHEA does anything so I don't use it.

At 36 years old, I have a 66% pregnancy rate in my clinic. By two to three attempts with good 8 cell embryos, you should already be pregnant. Your rate should especially be increased over other 36 year olds since you have been pregnant before. For these reasons, I think the fault may lie in your clinic and not in you or your husband.

Good luck in your journey to have a second child,

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

Monterey, California, U.S.A.

Is A Big IVF Clinic Better Than A Small One?

noreply@blogger.com (women:s health and fertility) — Sun, 19 May 2013 14:08:00 +0000

Question:

Hello,

I am writing from Japan and want to ask that can big, crowded clinics be good or are small ones always good? Which is a worst choice...I'm very confused actually....like the crowded one has all the plus points, it is experienced, and cost is little bit lower than other. The big one has the pioneer in begining the IVF (in vitro fertilization) in Japan, the other has good success rates but only opened 6 yrs back...I'm totally confused!

How many cycles should a clinic do per year and what can I use to make my decision?

Please help ! H. from Tokyo

Answer:

Hello H. from Tokyo,

I run a smaller, low volume clinic and have better pregnancy rates that they large ones in my area, including the ones at Stanford University and the University of California, San Francisco. I feel that I give better more personalized care because I am caring for them personally and completely. I don't have other people doing what I should be doing. The biggest disadvantage of a very large clinic is that it is a factory and depersonalized. IVF should be a personal and intimate procedure, NOT a mechanical one. So, of course I have a bias. I would not recommend a small clinic that has a poor pregnancy rate, but if it has a good pregnancy rate, I think that is the better place to go. I don't care how big and famous the larger clinic is or how many cycles they do, if it were me and my wife doing this I would want a clinic where the doctor is going to give us personalized attention the entire way, including personally do the retrieval and transfer procedures. I know that at the larger clinic in Japan you will rarely if EVER get to see the "famous" doctor, so what good is it to go there? The smaller clinic will probably give you a better experience even though it is at a slightly higher cost.

In the U.S., people prefer to go to clinics where they get one on one personalized care, not where they are treated as another number.

幸運 ... Good Luck!

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

Monterey, California, U.S.A.