QuestionQUESTION: Hello, Dr.
I am from New Jersey , USA.
I have 2 questions for you.
I was diagnosed with stage 4 endometriosis in January of 2009. The surgeon removed all my endo in the operating room,
Since the surgery I've been having nightsweats in the morning. From what I read from the internet, it can be due to the high estrogen level in my blood.. I have 1.5cm cyst on my left ovary)
Somehow the doctors I have seen so far don't know what is causing this.
1)What is the cause of my nightsweats?(I have it almost every morning)
My hormone levels were taken several times.
FSH=3.84 E2=92.3? in JULY 2009
FSH=10.4 E2=52 in October 2009
AMH=1.4 in November 2009
I tried IVF in October 2009 and failed.
I had only 1 immatrue oocyte at the retrieval even though on the ultrasound there were at least big 6-7 follicles. The doctor who retrieved the egg said the others could be chocolate cysts not real eggs.
My RE used an antagonist protocol for IVF in October 2009. I had to take estradiol tablets for a week in the luteal phase just before the actual cycle.
Now I changed my RE, and She said she'll try something flare? protocol.
This will take 2 months and I will have to start with estradiol patch for a week before the cycle.
Isn't this almost similar to the antagonist protocol I tried before?
How come the RE'S give me extra? estrogen when they know that I have endometriosis?
Wouldn't it make my cyst( 1.5cm cyst on my left ovary) grow bigger when they do this?
2)Will this micro flare? protocol work for me?
ANSWER: Hello Joy from the U.S.,
Night sweats can be from multiple causes such as Decreased Estrogen (menopause or ovarian dysfunction) or thyroid problems or cardiac problems.
In terms of your subsequent questions, there is some confusion. You had two FSH levels drawn, one was 3.84 and the other 10.4. Were these done on cycle day# 2 or 3? because that is when they need to done to interpret them correctly. From a fertility perspective, we want the FSH level to be less than 7 on cycle day #2 or 3. When it is higher, that signifies that the ovaries are "resistant" which means that they will not respond well to stimulation because they are not going to pick up the hormone adequately. As a woman ages, her ovaries become more and more resistant, but this can occur in younger ages as well. That may explain why you did not have very many follicles. Endometriosis does not and will not affect your response to stimulation. The problem with increasing estrogen is that endometriosis thrives and grows from estrogen, so that it can cause a recurrence of the endometriosis. Your first FSH level was actually very good and would indicate good ovarian response. In fact, you would probably not need too much medication (low protocol).
Without having all the details of your IVF cycle, I cannot answer questions to it specifically, but your yield was very low. There could be multiple reasons for this.
I presume your new RE is going to try the "flare" protocol because you are a poor responder, low ovarian response. The flare is only another technique that is used to try to increase the egg yield, and is something different to try but has not shown any additional benefit is current studies.
The antagonist protocol just means that an antagonist is used to suppress the ovaries instead of an agonist. The ovaries are suppressed so that they don't spontaneously ovulate or function on their own, so that the cycle can be better programmed, the ovaries can respond to stimulation better and don't short-circuit the stimulation. In addition, we don't want the ovaries to ovulate before we have the chance to retrieve the eggs. There is no difference between using an antagonist or agonist, in general, except there are less injections with the antagonist (3-4 vs 21). Antagonists are medications such as Ganerelix or Cetrotide and Agonist is Lupron.
I would advise that you not worry so much about your endometriosis. IVF is the treatment of choice and bypasses the endometriosis. If you become pregnant, pregnancy is a GREAT treatment for endometriosis so that is the goal. Your first cycle did not do very well because of the poor stimulation (which could be due to not enough medications) and low retrieval number. The fact that the egg was immature could be because the egg was not given enough time to mature ie. you were triggered too soon. So, I would advise that you keep trying. Studies show good cumulative pregnancy rates if a patient keeps trying, even in older women.
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 facebook and twitter with me at @montereybayivf
---------- FOLLOW-UP ----------
QUESTION: Hello. Dr.
This is Joy again, I am 32 years old.
I have normal TSH result.
FSH=3.84 E2=92 were taken before the IVF on day 3 of my period.(I had the nightsweats that morning)
FSH=10.4 E2=52 were taken after the IVF on day 2 of period.(I didn't have the nightsweats this day)
There are only about 5 days that I don't have nightsweats in a month.
I thought if the estadiol is higher than 80,in my case 92 the FSH=3.84 was false negative, no??
My egg retrieval was done on the 15th day of my period.
I was triggered on day 14th.<queston #1-Was I triggered too soon?>
My numbers from the stimulation report are as follow:
E2=2256
P4=2.20
bHCG=223
RIGHT ovary-two 10mm,
-one 15mm
LEFT ovary-three 10mm
-two 13mm
-one 15mm
-two 17mm
-three 20mm
only yielding 1 oocyte-all the others are empty follicles or chocolate cysts???
From these numbers, <question #2-Was I stimulated long enough?>
My another concern is that I had the papsmear done last month.
My nurse told me there were abnormal cells found but no HPV virus.
She said to repeat the papsmear in 6 months.
In the meantime, they said to go for another IVF cycle.
The papsmear was normal 6 months before the Jan 2009 surgery.
I had the laparotomy to cut the part of the colon-rectal endo &laparoscopy then.
Also I had the hysteroscopy to remove some polyps in uterus August 2009.
<question #3-Do you think l have the inflammation from the surgeries thus causing abnormal cells in papsmear?>
Thank you in advance for your reply.
AnswerHello Again,
#1 and #2. The date of trigger is based on the largest follicles. Your largest follicles were 20 mms, which is a sufficient size. However, you had a lot of follicles that were less than 16mm which will usually yield immature eggs and no fertilization. Every doctor is different, so you have to take this response as only one opinion. I would have waiting another day or two to allow the smaller follicles to get a little bigger in order to have the most number of mature eggs as possible.
#3. Inflammation and abnormalities inside the abdomen/pelvis do not cause abnormalities on the outside, so your abnormal pap smear was not due to the endometriosis or surgeries. It was due to something irritating the cervix. These could be vaginal infections, tampons, intercourse or anything, basically, that can irritate the cervix. I don't think you need to worry about this at this time.
Based on the second elevated FSH level of 10.4, you would be considered a low responder. We always use the highest FSH level to determine stimulation protocols. You don't mention how much medications you used, but your stimulation seemed to be pretty good. If my count is correct, you had 14 follicles which is a good number. It is very unusual that you had such a low egg yield. In any case, that means that your ovary was stimulated enough with the medications you used, although there is room for an increase in medications. I don't see any advantage or reason to apply the flare protocol in this case. I think the antagonist is better because the preceding Lupron (prior to the cycle) may actually suppress your ovaries too much and lead to a lower yield.
Remember, these are just my opinions and each doctor will be different. That is part of what makes doctors, clinics and pregnancy rates different.
Sincerely,
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 facebook and twitter with me at @montereybayivf
