QuestionQUESTION: Hi. I am writing from Raleigh, NC. I was diagnosed with endomitriosis in 2009, and at that time had an emdometrioma, dermoid, amd simple cyct removed from my ovaries. I had my 3rd lap on June 6, 2012. My husband and I have been TTC for a total of (around) 20 months (14 cycles in 2008-2009, 7 cycles in 2011-2012). all my lab work is normal, tubes are clear, and dh has normal sperm.
My dr (obgyn, not fertility spec.) said "I don't think that clomid or femera would be a total waste of time... but your best chances to get pregnant are probably going to be IVF. If I were you I would try 3 or 4 rounds of clomid..." Well, that confuses me. I know that if I were to SOMEHOW get pregnant with clomid it would save me a TON of money. But I don't want to waste a lot of time doing treatments that just aren't going to work. I have Stage 4 endo, and very damaged ovaries... but, my dr said "your tubes are clear though." Well, what good does clear tubes do me if the egg never releases, or is too hard for a sperm to penetrate? I am still young at 30 and dh is 36.
What would you recommend going forward.
Thanks from NC.
ANSWER: Hello Anna May from the U.S. (North Carolina),
I think your doctor is trying to give you options but in reality is telling you that IVF is the best choice. Most of us do not like making decisions for our patients but prefer to help them have the facts to make their own decision. Technically speaking, if you have stage IV endometriosis, then IVF is the treatment of choice. Of course there are exceptions to that rule but 99% of patients in that category are not going to get pregnant by natural means. The problem, as you pointed out, is not a tubal patency issue, rather it is a pelvic issue. In the normal processes your body goes through to get pregnant (refer to my blog for more comprehensive information), the third step is for the egg to pass through the pelvis to get to the tube. That is the space behind the uterus where the fimbria of the tubes lie. If there is endometriosis or severe scar tissue there, this can prevent the egg from getting or finding the tube. Endometriosis can cause inflammation in the pelvis and the inflammatory cells can destroy the egg. Severe endometriosis (stage IV) causes severe scar tissue around the tube, ovaries and pelvis preventing movement of the egg (think of scar tissue like having spider webs within the pelvis). So, you can either have more surgery to try to clean out the pelvis of the scar tissue, which does not work well, or you can bypass the pelvis by doing IVF.
Many young women in your age group have to do IVF because that is their best or only choice. You are not alone. It is unfortunate that you can't use a more natural and less expensive method but that also is not your fault. Your body has already dealt the cards for you. In the past, before IVF, you remained childless for your life unless you adopted. At least now, we have the technology to give you a pretty good chance of having your own child. Now you just need to find a good clinic that has good success rates for your age group and go for it.
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 additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf
---------- FOLLOW-UP ----------
QUESTION: Hello. Thank you so much for your response. I have finally had my post op and my dr recommends Lupron + add back... I get very mixed reviews about this. I think the recommendation from him is 3-6 months and then doing clomid for 3 months, and then moving into IVF. It just seems like a lot of wasted time. He is also not a board certified RE. I am going to get a second opinion from an RE about the whole thing. What would you recommend to your own patient?
Again, thank you for your opinion!
Anna
AnswerHello Again,
First let me say that "Board Certification" does not make you a better or more knowledgeable doctor. It just means that you passed a test. With RE, you can't take the test unless you have training at an American accredited Fellowship. Not all infertility specialists go that way. Some do it the Apprenticeship method, but then they can't take the Boards to prove their knowledge. I know plenty of bad fellowship trained and board certified RE's, but the advantage of that credential in the U.S. (European doctors do not have such a thing as Board certification or fellowships. They still use the apprenticeship method)is that you know the doctor had additional training in that specialty area and MOST general Ob/Gyn's get inadequate training in infertility in their residency training programs.
You doctor has given you appropriate advice, but ultimately it is your choice. The standard would be to do 3-6 months of Lupron if the purpose was to try a more Natural treatment method, such as ovulation induction with intercourse or IUI. Some specialists do recommend Lupron prior to IVF cycles as well if there is severe endometriosis or an endometrioma. Usually that duration is 3 months. Based on your previous history, I think I would lean more toward IVF and not require the Lupron, but ultimately it is your decision how you want to proceed. At 30, you have some time before your fertility is significantly decreased (35 years old), so it is more a personal preference as to how quickly you want to get pregnant, how natural you want it to be, and how much money you can afford.
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 additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf
