QuestionDear Doctor Ramirez,
I'm glad that you are back from vacation. I have been waiting to talk to you.
My history:-
I have a regular 26 day menstrual cycle. Im 33 years old. Im trying to conceive since the past 6 months. I have a cyst of 17mm since few months. Even though I have a cyst, my other follicle develops and ruptures usually at size 24mm around day 13.
Occasionally it happens that the other follicle also forms into a cyst and then passes away during periods, but not the earlier cyst, it still remains.
My gynac has put me on a contraceptive pill for the cyst to disappear for the past 2 months. Her next plan of action is to start clomid 25 for me from day 2 of my periods next month, irrespective of the cyst being there or not. Then give an HCG shot of 5000 or 10,000 and then an IUI.
Please help on the following:-
a. Is her treatment / advise appropriate. I want a opinion from you doctor, please.
b. Is the cyst causing this late rupture. (if 24mm is a late rupture). Or do you think I must be having LH problem.
c. Will clomid form more cysts or will the HCG shot take care of that problem by rupturing all follicles.
d. Will the HCG shot rupture the cyst as well. If it so happens, what repercussions will it have.
Please help doctor.
Thank you doctor,
Shamita
AnswerHello Shamita from India,
Since the cyst has not disappeared, it is possible that it is not an ovarian cyst but a peri-ovarian cyst. This is a very common benign cyst located just below or next to the ovary. It is of no concern. However, the only way to know that for sure is to look with a laparoscope into the abdomen and remove it for biopsy. In most cases, a persistent ovarian cyst can be distinguished from a peri-ovarian cyst. A good ultrasonographer can tell the difference. If it is the latter, then no surgery or biopsy is required.
Whether or not to do IUI depends on the cause of your infertility. What is your cause? If you have only been trying for the past 6 months then you have not been trying long enough. Therefore, I would not recommend any treatment at this time. In the U.S. we recommend that a woman under the age of 35 years old, try for at least 1 year. 85% will take up to 1 year to get pregnant. If you have been unable to become pregnant after 1 year of trying, then you should undergo a basic infertility evaluation first before moving to a treatment. Going directly to a treatment, such as your doctor has suggested, is inappropriate. Besides, IUI is the second level of treatment. The first level would be ovulation induction with Clomid or Femara and timed intercourse.
Ovulatory follicles have to reach a size of 18-24 mms to ovulation (rupture). 24 mms is the usual size at the time of ovulation so your ovary is functioning just fine. In a woman that is already ovulating, adding a fertility medication will increase the number of eggs that ovulate. HCG is give in order to make sure that the follicle ovulates in case your body does not mount its normal LH surge. We always add that with fertility treatments to make sure that the opportunity to get pregnant is increased. The HCG will do nothing if the cyst you have is a peri-ovarian cyst.
You are right to be wary of your doctor's recommendations. I certainly don't agree with them.
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
