QuestionQUESTION: Dear Dr Ramirez
I am writing out of sheer desperation (as a guess a lot of people are when they contact you). I live in Australia. Thank you in advance for your kind assistance and for reading my LONG story. I have been attempting to have a baby for almost 3 years. I am now 36.5 years old.
I first became pregnant in Jan 2009. The pregnancy ended at 6.5wks after seeing a fetal hb of 104bpm. It turned out to be a cornual ectopic but the pregnancy ended in missed miscarriage before any adverse outcome (other than excrutiating cramps). In fact it was only discovered to be cornual after the first D&C. The first D&C left the entire pregnancy behind and after a week of agony and bleeding I had a repeat D&C... the next month I developed Ashermans or stenosis of the cervix (?) which my Ob/Gyn 'skewered' open when my first period after the 2nd D&C refluxed into my peritoneum. (Ouch)
Amazingly, the following month I conceived again...but miscarried naturally at 5.5 weeks.
Then...later in 2009 I became pregnant for a third time. During my first obstetric appointment at 10.5 weeks we discovered I had my third (missed) miscarriage with the baby measuring 8.5 weeks ( a strong hb was seen at 7wk - tests revealed turner syndrome). This was a new doctor. He performed a D&C that day, perforated my uterus, let me haemorrhage for 18 hours and refused me antibiotics. I ended up being transfused 3 bags of blood nearly 24 hours later after lying in agony with blood again in my peritoneum....and of course because he wouldn't allow me to have antibiotics I ended up in hospital for 2 weeks with peritonitis and endometritis resulting in surgery to wash my tummy out...
Fast forward nearly 2 years and I have been unable to conceive since. I had 'reconstructive' surgery (with a fabulous doctor I love) in my pelvis to remove severe adhesions which has been unsuccessful. My tubes apparently are patent but with the scarring are worse than useless. I have had 4 IUIs and now 4 IVFs. I have also during this time been diagnosed as being in premature ovarian failure (possibly because of my Hashimotos and/or possibly because of the infection). I have had to have a 'fresh' cycle with each IVF because I never end up with any embryos to freeze. Also, despite having between 9-13 eggs collected each of the four times I only end up with 1 to transfer.
So. Today. I discovered the fourth IVF HAS worked after all, sort of! I am now 20dpo (20 days post retrieval). Two compacting 8 cell embryos were transferred (my best so far). But on the day my period would have been due it showed up with a vengeance. It was more like 2 periods at once with clots and everything and lasted 5 days, so naturally I thought that the IVF had failed yet again. Until this morning as per the instructions from the clinic I was to do a preg test regardless of any bleeding. It was positive. Where the heck is this little embryo? I'm thinking its in my tube. I did a beta hcg blood test immediately and it has returned at only 159 which for 20dpo I think is ridiculously low.
What is going on? Why can't I catch a break? I can't even sue the doctor who took my ability to conceive on my own. All my tests are NORMAL except the AMH which is 9.8 and day 3 FSH is 20. I do however have an IgA and IgM deficiency which results in lots of minor viral infections. Also I have mild Von Willebrands which means that I have a hemoperitoneum and have to be admitted overnight for monitoring and pain control (internal bleeding HURTS) with each oocyte retrieval.
In my previous IVFs we've tried prednisone, doxycycline, asprin, and this last time IVIG ($2000).
So this is where I'm currently at. Writing to a stranger, heartbroken, lost and a little bit pregnant. One thing I can count on is that as with every other pregnancy it is going to come out of my body one way or another...and probably with a lot of physical pain and emotional suffering.
This leads me to my specific question. Because of my bleeding disorder and hemoperitoneums after each oocyte retrieval, I end up with several hundred milliliters of blood in my peritoneum. Considering my tubes are clear (although not functional) do you think it's possible that the blood is refluxing down into my uterine cavity and killing my embryos? My current Gyn says this is not possible, but I really am not so sure. The reason I am wondering this is because during this last retrieval the anesthetist used DDAVP which greatly reduced the amount of bleeding and, coincidentally, this is the first time I've had somewhat of a success with implantation (regardless of where the implantation is at this stage).
I look forward to hearing your opinion. In Australia adoption is NOT an option unless you are rich, nor is surrogacy. It's up to me to grow my own child and as you can see I need all the help I can get. (Ironically my identical twin sister has two beautiful girls and has become pregnant with a viable pregnancy two days after my embryo transfer).
I so hope I have some good luck sometime....before I''m bankrupt - emotionally, physically and financially.
Thanks again for your time
Anne
ANSWER: Hello Anne from Australia,
Thank you for writing to this stranger and I hope I can adequately answer some of your questions.
First, I am doubtful of the diagnosis of "premature ovarian failure" if you are getting 9-13 eggs with your IVF attempts. By definition, "premature ovarian failure" means that your ovaries are no longer functioning and you are essentially in menopause. With this condition, your ovaries cannot be stimulated and no eggs would be retrieved. You mention an FSH of 20, but I'm afraid that this result does not make sense considering the fairly good stimulation you are getting with IVF.
In terms of your question regarding your peritoneal blood getting into the tube and migrating backward into your uterus, I'm afraid that is an impossibility and I agree with your Ob/Gyn doc. This cannot be the source of your current bleeding. I don't know what the exact cause is at this time. We'll have to wait and see. You should have serial (every other day) bHCG's done to follow the progress of the pregnancy and make sure they are rising appropriately. Once the level is above 2500, you should have an ultrasound to confirm an intrauterine pregnancy and rule out an ectopic (you are at risk for this).
You certainly present a difficult case, but not an impossible one. You should be treated with DDAVP with your egg retrievals because of your Von Willebrand's disease. Without reviewing your medical records carefully, I cannot give you any specific advice. I do think that IVF is the way for you to go, and I hope and pray that you will be successful. One thing I think you might strongly consider, is to use a surrogate. I understand that you cannot do that in Australia, but you can go elsewhere. We, and I, have had patients from other countries specifically for that reason. Before you run out of financial resources, that may be an option you might want to consider. I am not saying that you need to do that now, but you may have to eventually. Considering your medical issues, that might be the safest way to go as well.
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
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QUESTION: Thank you so much for your reply. I feel more comfortable now about the blood not tracking back down my tubes (I was thinking I was going to ask for my tubes to be removed if that were the case).
Since I wrote my first HCG was 159, it then fell to 118 so I've just wasted another $12K. I am definately considering surrogacy and the laws in Australia have just changed (only in July) to allow altruistic surrogacy. My 46year old non-menopausal sister is very keen to do it for me. Is she too old? She's in great health otherwise. The funny thing about this whole saga is that I have an identical twin sister with the exact same health issues who has two beautiful healthy girls and is now pregnant with her third... Poor me!
Thanks again for your help, it's a rare and kind Specialist who is so giving of time and knowledge without a hint of arrogance. All the best for you.
Anne
AnswerHello Again,
Sorry for the delay. This is my IVF week and it has been very busy.
If your sister is in good health, then she can certainly act as your surrogate. Age is not an issue. She just needs to have a healthy uterus and uterine cavity. Pregnancy is difficult in older women so she needs to be prepared for that. The body is not as resilient as when a woman is younger. She has a slightly increased risk of pregnancy complications such as diabetes or preeclampsia and requiring a c-section delivery, but that is only statistical and not a prediction.
Sorry to hear about your loss.
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
