QuestionHello. I really need some advice. I'm 34 and have 2 children. My husband and I would like another child. We went to the ob to discuss and found out I have endometriosis stage one, one fully blocked tube and my cycles are sometimes 20 day. I did have a laparoscopy and hcg to find all that out. They cleaned up a bunch of scar tissue and found that my ovaries and other tube look really good. So my dr. started me on a round of clomid with no luck. He wasn't really able to give me a whole lot of answers so I went and saw a fertility specialist that put me through a bunch of tests only to find out that my ob was right on track. So now I'm at a loss on what to do. Do I go back to my OB and stick it out with him? Also do I try clomid for a few cycles or should I go right to IUI. I should also mention I had an issue with cervical mucus while on the clomid so I was concerned the sperm weren't able to get to where they needed to go. My financial situation is limited. And my OB was willing to code my visits to endometriosis so they would be covered.
Any advice would be greatly appreciated.
Danielle
AnswerHello Danielle,
So, based on what you told me, you have two definite problems: endometriosis and tubal blockage, and one potential problem: age (decreased natural fertility rate). The fact that you have two previous children is a very good sign and will help your chances.
I am surprised that the infertility specialist did not give you recommendations, but you have several options. The choices are going to depend on the risks, finances and chances of pregnancy. Since it cannot be known at what point your tube because blocked, I would assume that it has been since your last child, only because you didn't have trouble getting pregnant before. With any tubal blockage, or disease, we have to make an assumption. That is, whether or not the remaining open tube is normal or not. The most common reason for tubal blockage is some type of infection or inflammation that caused scar tissue formation within the tube. This infection or inflammatory event will usually course through both tubes, but the results are not often even. So in your case, one tube is completely blocked whereas the other is not. The other tube could be completely normal or injured, and therefore open but not functional. There could also be scar tissue within it that cannot be seen, which could lead to a tubal pregnancy. This problem could be the major reason why you have not gotten pregnant yet. If you assume the tube is normal and functioning normally, then you have the option of using a "natural" treatment method such as Clomid with timed intercourse or IUI (intrauterine insemination). However, if you assume that the tube is injured, and the reason for your infertility, then the only option is IVF to bypass the tubes.
Endometriosis is also a factor, however, stage I endometriosis has not been found to completely correlate with infertility. In my experience, any stage of endometriosis can lead to fertility problems. You have undergone treatment by laparoscopy, so if this were the only reason for your lack of fertility, then you would have a 6 month-1 year window of opportunity to get pregnant before the endometriosis returns. Once it returns, you are back to where you were. Some docs will treat with an endometriosis/estrogen blocking medication such as Lupron for a 3 month period. This is to get rid of any microscopic endometriosis that is certainly there and was not seen on laparoscopy. Then they would follow with aggressive fertility treatment such as IUI to give you the best chances of a natural pregnancy. The alternative to this is to bypass the pelvis where the endometriosis lies, which can be done with IVF.
Age is really not a significant factor until you are 35 years old. Since I don't have your birth date, I put this risk in as well. Your natural chances of fertility at 30 years old is 16% per month or 60% per year. At 35 it changes to 7% per month and 30% per year. With IUI, the chances are a maximum of 24% per month. With IVF it is 60-79% per month until 35 years old.
I think that you need to speak to your fertility specialist and continue with him/her in order to have the highest chances of pregnancy. Of course that will be the expensive way to go. If your Gynecologist feels comfortable with infertility, and can render treatments including IUI, then you could always do that with him/her, especially if he/she will code it for endometriosis instead of infertility. However, word of caution, if your chart is ever requested and audited by your insurance company, and the mention of infertility is in the note, they will charge you and your doctor for all the visits and treatments going all the way back to the first mention of infertility.
I think that you should try IUI for up to four cycles. If you don't become spontaneously pregnant by that means, then move to IVF from there.
Good Luck,
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
