QuestionQUESTION: Hi, my name is Natalia and I am currently in Brazil. I am forty years old and have done all immune tests, hystersalpinogram,and everything is good except for a cyst on one of my ovaries which my doctors felt is not a problem until now. I have undergone four fresh cycles of ivf. I am a low responder to medications , produced on an average 9 eggs. However, I have all had grade 1 embryos, all 8 cells to do a 3 day transfer. Since my husband has a low sperm count we had ICSI done on all attempts. The first three times we ended up having 3 excellent quality embryos transferred but was all BFN. Our last attempt was done in Brazil, last month. I was on Bravelle, Menopur, Orgalutran for 8 days and produced six eggs. One was not mature and from the five, four made it to the 8 cell stage again without fragmentation. My RE transferred all four to maximise my chances since he didn't think it made sense to freeze just one. Two days prior to my HCG test I did a HPT which was semi faint but very visible. However, when I did my HCG it came back negative. It is really difficult since now my RE thinks that I should now have surgery to remove the cyst. He believes that this is probably the reason why I am not being successful. I don't know if I should just do acupunture and try again or do the surgery. Please advise!
ANSWER: Hello Natalia from Brazil,
It sounds like despite your age your ovaries are doing pretty well. You may not have a lot of eggs and embryos, but you have sufficient numbers. In a 40 year old, I would put up to 7 embryos to increase the chances of pregnancy! Also, your embryos have looked good which is a big plus as well. I cannot tell you why your cycles have not worked. There are too many other possible sources of the failure.
In terms of the cyst, I can't address this question without seeing the ultrasound to see what kind of cyst is present. Whether or not to remove the cyst depends on what kind of cyst is suspected. However, whatever this cyst is, I do not think that it is the reason that prevents your IVF from being successful. If the cyst has been there all this time and not gone away, the worry is that it could be some form of an ovarian tumor. That reason alone would cause me to recommend that it be removed laparoscopically. This is irregardless of the fertility issues. A persistent cyst is a different problem. So the doctor has to decide whether this cyst is at high risk of being a tumor or if it is a physiologic cyst that will resolve on its own or an endoetriotic cyst, which does not need to be addressed at this time.
In my practice, if a patient has failed IVF more than once, I have a special protocol that I use with my patients. This protocol is not necessarily a universally accepted protocol, but many clinics use it as well. I won't advise you on this because you are depending on your doctor to do what he/she thinks is the best and his/her approach may be completely different. I don't like to interfere with another doctors approach or decisions. But, that is what distinguishes one doctor and one clinic from another. We are not all the same and so pregnancy rates vary widely.
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: Hi, this is Natalia and I am just wondering if a woman's fertility gets a little boost after an ivf cycle. Is a woman's chances of conceiving naturally increased within the next month or two. If not, then how long should I wait before attempting another cycle. My doctor recommends two months.
ANSWER: Hello Again,
There was a study recently that showed that after a miscarriage, the chances of pregnancy are increased for the following six months and decreases with each momth from the point of resolution of the miscarriage. No one has studied whether this holds true with IVF, but I have seen patients get pregnant soon after IVF seemingly because whatever was preventing them from getting pregnant prior to the IVF cycle (except for anatomical problems), is temporarily fixed. Who knows for sure?
With IVF, however, it is mandated that the ovaries have a rest period for at least one month because of the increased stimulation. For that reason, the fastest you can do IVF is every other month. There is no reason to have to wait two months except it might be more convenient for your doctor's schedule. In consideration of your age, I would recommend that you attempt IVF as frequently as possible. Time is not on your side.
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: Thanks for the feedback,highly appreciated. Today I had a consultation with my doctor who is now highly recommending that I do an uplift uterus procedure since it is retroverted. He also wants to remove the fibroid at the same time. According to him there was no problems with the last cycle which I did with him since he said that all four embryos were grade A's and the culture medium was also perfect. Even the transfer of the embryos was a smooth procedure so he is now thinking that after four attempts at ivf with excellent embryos and no sucess that the uterus maybe not too receptive because of the position. He explained that sometimes women go on to conceive naturally after this surgery is performed. My RE also claimed that it's a short procedure that normally takes 1-11/2 hours and the healing process is about a month. What are
your views on the recent developments in my case and what do you advise?
AnswerHello Again
Of course you have to determine and only you know how much you trust your doctor's opinion. I have no doubt that he is giving you his best opinion. My opinion would be totally different.
Because he puts so much emphasis on the position of the uterus, which usually does not have any impact on IVF success rates, I am wondering if, in fact, that position made it difficult for him to transfer the embryos. If that were the case, the embryo transfer may be the reason for the failure. My teacher taught me that you can have the absolute best and most perfect embryos, but if you don't get them into the uterus properly, the IVF cycle will fail. In any case, position of the uterus is NOT a significant issue and I therefore could not and would not recommend that procedure.
Now, the fibroid, if large enough or in the wrong position, could affect one's chances of success with IVF. Therefore, if you have failed numerous times and cannot find any other reason (ie you have excluded problems with the transfer) then it might be reasonable to remove the fibroid prior to another attempt.
Another option would be to seek out a different clinic and doctor all together. Remember, every clinic and doctor is different and success rates vary widely. Again, you are the only one that can know and trust your doctor's expertise.
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
