Ask Dr. Marc: Unicornuate Uterus

Dr. Marc,

 

My name is Kristin, I am 31 and my husband Aaron is 39 (he has a 16 year old daughter from a previous marriage). I am currently seeing a fertility specialist and recently had cycle day three testing, ultrasound and an HSG. Upon completion it was determined that I have Diminished Ovarian Reserve and a Unicornuate Uterus on my left side (one Fallopian tube that is completely healthy on my left side as well as a good looking uterus on my left side, both ovaries, although, are small). My husband had a sperm analysis done as well and his Count/Motility/Volume were more than double the normal range. So we now know that the infertility issues are due to my body alone. We have discussed our options with our Dr and have decided to go ahead with medicated IUI cycles starting in May 2013 although our Dr thinks IVF is a better option. We cannot afford to do IVF at this time, IUI is far more cost effective for us. My question is how likely am I to conceive from IUI. My Dr only gave me a 2% chance of conceiving naturally, 5% with medicated IUI and 30% with IVF each cycle. Is that accurate? Or is it possible my chances may be higher given that my husband has exceptional sperm and even though I do have DOR I am still fairly young?

 

I appreciate your taking the time to answer my question. Thank you in advance.

 

Sincerely,

 

Kristin

 

Hi Kristin,

As I see it, there are a few issues to discuss.

First, I think it is important to recognize that infertility is NEVER due to one partner alone. Remember that making a baby is a team effort.  Just because one partner’s tests are normal and the others are not, does not necessarily mean that one person is at fault or responsible.  Further, remember that women have many more variables at play in this situation.  Men only have to have a few normal sperm; women need normal tubes, ovaries and uterus not to mention the hormonal environment for the 9 months of pregnancy!  It really is a lot, so don’t get down on yourself!

Second, the unicornuate uterus represents abnormal embryonic development.  The prognosis of a unicornuate uterus can range from poor to good, but it depends on how small the uterus is.  From your letter, it sounds like your uterus is of decent size so as not to be too much of a problem.  One thing I would recommend however, is that your doctor evaluate your kidneys.  The kidneys and uterus form at near the same time and is not uncommon for women with a uterine abnormality to also have a renal (kidney) abnormality.

Third, the diminished ovarian reserve (DOR) is a bigger deal.  I am not sure what your doctor is basing the DOR on, but it is probably the most important factor facing you.  The medication should help with this and the fact that you are young is also a positive!

Fourth, the fact that your husband’s semen analysis is normal is a good thing, but it doesn’t trump the other factors.

As far as numbers, I’d say your doctor is pretty accurate.  Maybe your chance is 5-15% with medicated IUI, but it really depends on your response to the medication.

The bottom line is that doing something will increase your chance over doing nothing.  If you could easily afford IVF that would be great, however if you cannot, then IUI is a reasonable way to go.

 

Good luck!

 

Dr. K

 

 

As I Wait

Today on Share Your Story, Whitney, shares her long journey toward pregnancy.  Whitney is no stranger to the waiting game, and knows a thing or two about saving up to make your family dreams come true.  What strikes me most about Whitney is that, despite the long and exhausting struggle, she manages to find the positive and remain grateful for what is good in her life.  Very inspiring, indeed.  You can catch Whitney over at There She Goes

It is November 6, 2012 and the world is waiting to find out who the next President of the United States is, I on the other hand am waiting to see if my period shows up. This is the life of any woman, who wants a child, and this has been my life for the last 3 years; this is my story.

 

I always knew that I wanted children. I could never explain it, I did not come from a big family, in fact I was an only child, but I always babysat and was a nanny in college, and I remember feeling so happy people would tell me what I wonderful mother I would make someday.

 

I never thought that at 21 I would meet the love of my life and then be married by 22. At 23, I held a positive pregnancy test in my hand and felt true joy, only to watch it slip away days later. At first we were optimistic, I remember my husband telling me that he had a feeling that “you will be really good at getting pregnant”, but as months went by we started to realize that this might be a little harder then we thought.

 

Months turned into a year, and I tried to be patient. We moved to Orange County my husband threw himself into law school and I graduated college, still no baby.

 

The tests were done and advice was given, “just give it more time,” “try to relax”, “go on a trip” not to mention all of the other weird advice “keep a pillow under your hips,” “keep your legs up for 20 minutes” …like anyone can do that? Clomid was given and taken, two years and still no baby.

 

When people talk about the cost of infertility they often don’t think about young students who are working as hard as they can to pay the rent and saving their pennies so they can do one round of IUI. And putting it off month after month, watching couples around you have their first and then second child.

 

And now we are waiting. After two doctors, two semen analyses, one HSG, and a million ultrasounds all we know is this:  We are young and healthy and there seems to be no reason why we cannot conceive a child. The only diagnosis that we have been given is that I might have a slight resistance to insulin, and a very mild form of PCOS, but I have no typical symptoms.

 

Full of excitement we counted out every dollar and paid for the one round of IUI. Clomid 100mg twice a day. Ultrasounds stated that I responded very well, took the HCG trigger and released three eggs. IUI went perfectly and now we wait.

 

During this whole process I have tried to be optimistic, and not angry. But there were times when it seemed like the whole world was pregnant and I wasn’t. When family members who didn’t know about our struggle would complain about their pregnancy, and how they didn’t really want children anyway.

 

I know that one day my husband and I will hold our child in our arms, I know that child will be worth every negative pregnancy test that I have taken, it will be worth all of the ovulation kits I bought, and all of the crazy drugs we have been on. That child will be the answer to all of our prayers and hopes and dreams.

I have found comfort in my sweet friends who know of my struggle, how have encouraged me and make me find the humor in infertility. I have found comfort in the stories from the old testament of Rachael, Sarah and Rebekkah. I have tried to smile and nod when people tell me “just relax and it will happen.” I have tried my best to be supportive when friends and family have babies even though it hurts a little. Sometimes I get so angry I want to break something, then I remember “Thine adversity shall be but a small moment. And then, if thou endure it well, God shall exalt thee on high; thou shalt triumph over all thy foes.”

I have come to accept that things do not happen on my timing but on the Lords. I don’t know how long the road to our child will be. But I do know that the Lord has plans for me and my family. I know that one day hopefully soon I will look into the eyes of my child.

But until that day I will try my best to be content with the blessings that I have already been given. A husband who loves me, who is kind and supportive, a safe home, a job, food to eat, rockin abs, a sweet puppy who I suspect might be better then some children. And the assurance that good things come to those who wait and that I have so much more than I could ever have imagined. These are the things that I suspect we all think about as we wait…

Thanks, Whitney.  Every story told helps another someone along the way…

Ask Dr. Marc: Weight Gain and Infertility Treatments

Dear Dr. Marc,

Nice to meet you my name is Marianella.  I live in Costa Rica and I have 34 years, almost 35. My case is not like the other cases. I have a son…for IA…after he was born I decide to get pregnant and went for 6 IAS…nothing happen, so the Dr. send me to the fertility specialist… He made me a laparoscopy…clean on fallopian tube and he told me I had endometriosis.. I (2 focus) we did with him 2 IAs more…and nothing.

Desperate, I stop the treatments. I gain 27 pounds in this 2-year process… and I am losing weight since I decided it to stop. The Dr. told me not to let go the birth control pills and maybe do a FIV. Right now I am not in position of invest…my husband lose his job…and is really hard to find another one.

In all my IAs I had 2-4 eggs 18-25, most of them break …other made cyst..

So my question:
What can I do more? Is the FIV an option for me? Or the TIFG? Can I have option to get natural pregnant??? Is my weight affecting me?

 

Hola Marianella,

I am sorry that you have had such a string of bad luck; hopefully we can straighten some things out and get you on the right tract for the future.  Lets address things one at a time:

1. The fact that you became pregnant through insemination (AI as you said) previously, bodes well for you now.  Importantly, we need to figure out why insemination worked for you in the past.  Was there an issue with your husband’s sperm?  If so, that issue may now be worse.  Just because they have used his sperm for inseminations recently, does not mean that they have performed a complete evaluation of the sperm.  You should have your husband’s sperm evaluated completely.

2. Your history of endometriosis is important.  We know that endometriosis can contribute to infertility.  Although it sounds like your endometriosis was not severe in the past (only 2 focuses) it may have progressed.  With your history, it may justify another laparoscopy, or at least an HSG (hysterosalpingogram) to be sure that your tubes are still open.  I would do this before any more treatment.

3. Weight can be an issue.  We know that it is harder to get pregnant for women who are significantly over or under weight.  Ideally your BMI should be between 20 and 30.  To check your BMI you can go to (www.nhlbisupport.com/bmi/).

4. IVF is the best bet for you now.  After 6 inseminations with 4 to 8 eggs each time, you have exhausted the usefulness of insemination.  As for cost, IVF is more expensive than IUI, but it is not more expensive than multiple IUIs.  From that point of view, it is probably more cost effective to not do any more IUI and save up for IVF.

5. Natural pregnancy is always a possibility!  To that end I want to share a story of one of my recent patients.  She had gone through multiple IUIs over a 2-year period and never conceived.  Subsequently, the couple resigned themselves to IVF and took off a year to save up enough money.  She was supposed to come in this month with her period to start medication but her period never came!!! Low and behold, she was pregnant!!

The point is that you should not give up Marianella! Formulate a long-term treatment plan, save up for IVF and while you are getting prepared for the treatment, continue trying the old fashioned way!

Good luck,

Pura Vida,

Dr. Marc

 

 

Share Your Story: Just Stop Trying and It Will Happen

Today I want to introduce you to Tracy.  Tracy has been on the infertility roller coaster for quite some time.  Her ability to keep her spirits up and cheer for others along the way is truly inspiring.  She began blogging as a form of catharsis, but quickly realized that if we all stick together we can help each other along the way.  Did I mention that she’s also funny?  With the tagline, “Barren and blogging.  Don’t be jealous”, you know you’ll find some humor along the way!  You can find her over at Just Stop Trying and It Will Happen.  Please show her some love and support here today as she shares her story with all of you.

My infertility story began about three and a half years ago.  The husband and I were newly married, and eager to start a family.  We let things go for a couple of months, not really trying to try.  When nothing happened after about six months, and my two closest friends who had been married within a few months of me were expecting their first babies, I started to get frustrated.

I escalated to ovulation predictor kits, and learned a lot more about my body.  After a few unsuccessful months of that, I escalated again to taking my basal body temperature every morning.

Every month brought disappointment, frustration, and jealousy over others’ ability to produce children at will.  I peed on more things than I can count, and that has yet to end.

After we had been actively trying for about 18 months, I went to my new ob-gyn and asked for advice.  She asked me to show her on a calendar how often the husband and I were having sex, told me that was not adequate, and told me to have sex every other day.  If nothing happened within a year, I was to report back to her for further treatment.

At this point, I was 29.  My clock had been ticking for a while… I was ready.  Not in a year.  Now.

I made an appointment with a new ob-gyn that day, and saw her the next week.  She ordered a whole barrage of blood work for me, a a semen analysis for the husband, and sent me for an HSG to be sure my fallopian tubes were not blocked.

After everything came back normal, I was officially diagnosed with unexplained infertility.  I like to call it Invisible Infertility.  Ugh.

I started a two month stint on the entry-level dosage of Clomid, and found that despite the side effects, the meds helped me to see a more clear ovulation occurring on my BBT chart and with the OPKs.  Since I was prescribed the meds through my ob-gyn, I was not able to be monitored aside from a blood test at the beginning and end of each month.

When the second month of Clomid was unsuccessful, the very kind ob-gyn advised that I see a reproductive endocrinologist.  I made the appointment, and waited the three excruciating months for the consultation.

The meeting was brief.  We talked about my testing, medical history, and knowledge of the conception process.  In the end, my insurance would not cover much of anything, and we opted to try more medicated cycles.  I started what would be a six month Femara and Ovidrel diet, along with monitoring ultrasounds and blood work.

When the November 2011 cycle came to an unfortunate, but not unexpected conclusion, the husband and I decided to take the holidays off to enjoy being unmedicated for a bit.

In January 2012, I heard a radio advertisement offering a clinical study for women with unexplained infertility.  I figured I’d call and check it out… I mean, what could it hurt, right?  So I called.

After a series of questions over the phone, I was invited up for some preliminary blood work and to fill out some paperwork.  I found out about a week after the call that I’d been accepted into the study, and would receive four fully-funded IUI cycles, complete with medication and monitoring for my participation in the study.

I was randomized for medication at the beginning of February, and of the three options (Clomid, Femara, and Menopur), I was chosen for the pills.  I’m still not quite sure which pills, and I won’t officially know until after the study concludes.  I have a sneaking suspicion that it’s Clomid, however, based entirely on the horrendous hot flashes and night sweats.  I also get an HCG trigger 36 hours before my IUI, and I follow the IUI with Prometrium.

Last cycle was tough.  We not only got news of a very close family member who is expecting their first child, but we also suffered a chemical pregnancy after what was the most promising cycle I’ve ever had.  It was a very hard time for us, but I didn’t want to lose momentum and opted to continue onto the next cycle.

I am currently waiting to start monitoring for my thrid IUI cycle, and expect the procedure itself to take place early next week.

Come ooooooooon, lucky number three!!

So that’s my story so far.  I started blogging for catharsis, and through that process have met some of the most amazing, caring, supportive people in my life.  I hope to inspire others to share their stories as well, and to ask questions about the treatment process, the emotional toll, and how we cope with the stress month after month.

Above all else though, I hope to be a mother.  One of these days, it’s bound to happen, right?  :)

Thank you, Tracy.  Sending you lots of support and pregnant thoughts!

Share Your Story: One LoCo Mommy

This week on Share Your Story, meet Diane.  Known on Twitter as One LoCo Mommy, Diane blogs over at One LoCo Mommy.  There was nothing easy about her journey to parenthood, including a substantial amount of pain.  After months of trying without any luck, Diane finally saw a specialist.  It was then that she learned that she really only had a 1-2% chance of conceiving each month.  And so she started infertility treatments.  Today she shares her story with us.  “It’s So Hard When It Doesn’t Come Easy” originally appeared on The Invisible Disability on April 26, 2012.

It’s So Hard When It Doesn’t Come Easy

Byline:  One LoCo Mommy

This morning, after putting Mayita back down in her crib from yet another waking, I stumbled back to bed. Unfortunately I couldn’t get back to sleep. Thoughts kept rolling through my mind (like, preparing for her birthday party, why is my credit card bill so damn high, etc.) when I suddenly realized that I missed a BIG anniversary.

Five years ago, on April 23rd, 2007, I walked into an nondescript office building. It was a day we were waiting for a long time. It was the day of my Intrauterine Insemination procedure, otherwise known as an IUI.

It was a long, frustrating and painful lead-up to that day. We were trying for a year and a half.  We were doing all the “right” things. I had bought “Taking Charge of Your Fertility”. I measured my basal body temp every single morning and charted. I even had a subscription to an online site that would take my temps and pretty much told me the right time to…well…try.

I exercised, limited my caffeine and alcohol intake, and definitely tried to negotiate with “the big man upstairs”. I bought  books and then more books. I scoured the Internet for resources. I went to online sites and found other women like me trying to learn some magic trick to getting pregnant.

And, every month, like clockwork, there was the disappointment. The crying. And, because I havedysmenorrhea, I was in extreme pain (because the Pill actually helps regulate that). I was not a pleasant person during these times.

Inevitably, we would buck up and look forward to the next month with optimism. That maybe “this” was THE month.

But it was never THE month. And so it went on. We had to dodge questions from family and friends. We always had a smile and joked that our dog was, “our child” but yet it still hurt. When family members and friends announced their upcoming joys we were crushed. We would hold the babies in our arms, devastated that we hadn’t been the “lucky” ones.

I finally saw my OB again, and other tests were run. We discovered what we had suspected all along – that we were dealing with infertility. Most likely, we were looking at IVF for a shot of becoming pregnant. Even now, I remember how far my heart fell when I heard all those words. But yet, it was strangely reassuring because now there was something new to explore. We knew what was going on now.

We got our referral to a Reproductive Endocrinologist (RE). After reviewing our initial results, the doctor explained that we had about…oh…1-2% chance of getting pregnant every month. Well, with those odds, no wonder we were failing miserably. The doctor continued by telling us that maybe an IVF wasn’t the avenue we should pursue. Instead, we should try an IUI, with Clomid and injectibles. As he put it, “create as many targets as possible for the little buggers.”

So we went through more tests and blood work. I had to get an hysterosalpingogram (HSG). And while the majority of women only have slight pain or cramping, I was not one of those. The poor techs were not sure what to do with my sharp breathing and yelps. Happily they were able to report that my reproductive system was clear as a bell.  I’ll take that as a compliment.

We had to go to a class to learn how to use the injectibles. Rather, Husband had to learn and I had to make sure that I wasn’t going to freak out about the thought of Husband giving me shots.

When we finally straightened out the insurance (and let me just say, we were extremely lucky my insurance covered this) we were able to “officially” start Round 1. That meant more blood work, and then I got to experience the transvaginal ultrasound. This is what I commonly joked to as the “dildo cam”. I took the Clomid on cue every day and then, on the designated days, Husband did his duty and poked me with the injectibles. He did very well and I was proud of him.

I had to have another ultrasound to monitor my follicle development and when the time was right, we scheduled the IUI. I had many viable follicles that were ripe for insemination. Woot. The actual procedure itself did not take long at all, was nowhere near as painful as the HSG (thank GOD) and I was able to go right back to work. With a little secret, of course.

And, so we waited anxiously. For two whole weeks. I obeyed my RE doctor and nurse who said not to test early. I didn’t want to have a false negative (or positive). In order to get an accurate result, a Beta Pregnancy Test was best. Which meant more blood work.

I never told y’all that I hate getting my blood drawn, right? I mean I actually will pass out. I was actually advised to not donate blood because I couldn’t last two minutes. But I put on my big girl panties for the chance to become a mom. I had to.

Putting on the big girl panties worked. My Beta levels were high. I was pregnant. Round 2 of the Beta test, then the ultrasound proved it. There was a tiny heartbeat going strong. Mere months later, Mayor Bee entered our lives. And we won the Battle of Infertility.

And for all the frustration, sadness, and worthlessness I felt during that long journey, holding that little precious baby made it all melt away. It was all worth it.

Thank you, Diane, for your words, your strength, and for sharing your happy ending.  A little bit of hope goes a very long way.  Now head on over and pay Diane a visit.
One LoCo Mommy

Ask Dr. Marc: Success with IUI

Dear Dr. Marc,

It looks like we will be doing our 3rd attempt at an IUI. The first one we tried, I was on 50mg of Clomid for 5 days and then a trigger shot of Orvidrel. I didn’t respond well to the Clomid so the 2nd attempt we did Femera. I am not sure what we will try this time for medication, but my husband and I decided this will be the final attempt at IUI before we try IVF.

So my question is, do you have any advice on what we can do to help increase the success of the IUI? I have been doing acupuncture weekly and I have definitely seen a difference with that. However, do you have any other advice?

Any advice or tips you have would be much appreciated.

Thanks,

C

 

Hi C,

The IUI is an important part of basic fertility treatment.   For a select population of patients, it represents an increased chance for success over timed intercourse.  With that being said, an IUI under the best circumstances is only successful about 20-25% of the time.  For many couples, success is considerably lower than that.  Now, this does not mean that IUIs are a waste of time, but it is important to have proper expectations.

One of the strategies to improve success with IUI is to increase the number of oocytes (eggs) ovulated.  Remember, just because an oocyte is ovulated does not mean it will enter the fallopian tube.  By releasing more than one egg, the chance that at least one egg enters the tube increases.  Additionally, the more eggs present in the tube, the more likely that one will become fertilized.

As I’m sure you can imagine, the downside to this approach is risk for multiple pregnancy.  In fact, IUI with gonadotropin injection is the largest source of triplets and quads.  (John and Kate plus 8 did IUI)

As far as your specific case, it would be reasonable to try one more IUI, but this time with injectable medication.  You will be monitored very closely during this process and if you develop too many follicles, the cycle should be canceled.

Additionally, if you have not yet had an HSG, it would be a good idea.  The HSG will confirm that your tubes are open, plus there is a small but real increased chance for pregnancy in the 2 months following an HSG.

Good luck,

Dr. Marc

Ask Dr. Marc: Cycle Conversions

Dear Doctor Marc,

I am in the middle of a cycle now and we’re faced with more decisions. For our first, we did 9 rounds of IUI (started with just clomid, progressed to combo clomid and follistim, then only follistim to conceive).

We’re on our third round of IUIs this time around (on max dose of follistim) and are considering converting this round to an IVF cycle due to the risk of hyperstimulation. Just yesterday I had 6 follicles in the 9-11 mm range and today we had 19 in the 11-13 range! We’ve never done IVF so I’m slightly nervous about the conversion, especially the down time after retrieval and transfer with chasing another little one around.

Here are a few more details: estrogen in low 900s, can’t convert cycle because our clinic isn’t in an IVF cycle at the moment, monitoring again tomorrow morning, lower follistim dosage to 25 iu for tonight and possibly take Luperon tomorrow depending on lab work. Doc doesn’t think we have an overly average number of fully mature follicles but we are concerned about high order multiples and other risks (hyper-stimulation, etc).

Is conversion a good option?

L.

Dear L.,

Converting an IUI cycle to IVF is a very reasonable option in certain circumstances.  In fact, I can think of a couple patients, in particular, who have benefited greatly from this option.  In addition, the fact that you have completed so many IUIs indicates to me that it is probably time to move on to IVF anyway.  With that being said, there are a few factors you would want to be in order before converting up to IVF.

1. Your lead follicles should not be too big:  If the largest follicles are too big, the smaller follicles may not have time to catch up.  This could result in a lower number of eggs for IVF and potentially could affect your chance for success.  If there are indeed 19 follicles in the 11-13mm range, this does not seem to be a problem.

2. Endometrial lining:  Sometimes an IUI cycle that is converted to IVF may be a very long cycle (greater than 14 days).  Very long cycles can result in overstimulation of the endometrium, which could negatively affect your chances.   You doctor can get a sense of your lining by measuring it on ultrasound.

3. Timing: There are a multitude of variables which go into an IVF cycle.  Coordinating these variables is one of the most important jobs of an IVF center.  If your center is not prepared to coordinate an IVF cycle at this time, then you definitely want to wait until they are ready.

The bottom line is that conversion to IVF can be an excellent option, but it should only be used in properly selected patients.

Good luck,

Doctor Marc