Ask Dr. Marc: Friendly FSH

Dear Dr. Marc,

I know it is hard answering questions with out seeing all the person’s info. Anyway I am 31 will be 32 next month I have gone through 2 failed IVFs. The reason being my FSH is a 15. The first IVF I had 4 eggs 2 fertilized and 1 made it to day 3 but was very poor. I went to a different clinic for my 2nd. I had 10 eggs 8 were mature 6 fertilized 4 made it to day 3 and 2 made it to day 5. I had one embryo that was a few hours behind and the other was almost a day behind. The doc said they would catch up. Everything was fine up until the embryos didn’t take – then I was told my eggs were no good. With this bit of info is there a chance or should I give up IVF altogether? I am looking for a new clinic now, one that is FSH friendly. I have also read DHEA can aid in helping. Is this something you encourage your patients to take?

Thanks for any insight.

 

Hi friendly FSH,

Let me give you a little background on FSH and then talk about what you can do to improve your chances going forward.

FSH (follicle stimulating hormone) is the primary hormone responsible for human egg stimulation.  FSH originates in the brain and travels to the ovary where it stimulates the egg through follicle growth. A follicle is a small sac of fluid within the ovary; each follicle houses an egg (oocyte).  The normal relationship between the brain and ovary, in terms of FSH, is that the FSH is released in a specific pattern and quantity in the first few days of the menstrual cycle.  The ovary responds through follicle/egg growth and estrogen production.  If the estrogen is produced in the appropriate amount, the brain will recognize the estrogen and will be “satisfied” with the ovarian response subsequently decreasing the amount of FSH it releases.  If the ovary does not respond appropriately, and the brain is not satisfied, then it will release more FSH in an attempt to further stimulate the ovary.  Thus, if the FSH on day 3 of the cycle is low, then the brain is satisfied with the ovarian response; a high level of FSH means that the brain is not satisfied because ovary is less responsive.  Another term used to describe less responsive ovaries is diminished ovarian reserve (DOR).

It is natural for the ovarian reserve to diminish over time.  In fact, menopause is defined by the absence of ovarian reserve and a very high FSH level.  Until menopause however, we spend a great deal of time and effort trying to assess the ovarian reserve because there is a correlation between ovarian reserve and pregnancy rate.

With that being said, FSH is only one way of assessing ovarian reserve.  In my opinion, too much emphasis is placed upon its value.  FSH should be interpreted in the context of the patient’s age, fertility history, antral follicle count and past treatments.  Further, it should never be used as the sole benchmark to determine ones fertility.

In answer to your question, there are a couple things that I think are quite encouraging for you.  First at 32, your oocyte quality should still be pretty good.  In many ways, your age trumps your FSH level!  This is because we know that in two different patients with the same diminished ovarian reserve, the younger patient will always have a greater chance of conceiving.

Next, it appears that your second IVF cycle was significantly better than your first.  This is not totally unexpected because I’m sure that a more appropriate stimulation protocol was used in the second cycle.  My guess is that a third cycle could be even better.

In terms of improving ovarian reserve, I often work in conjunction with an acupuncture practitioner and sometimes utilize DHEA.  The scientific literature for both of these methods is not perfect so you should definitely discuss it with your doctor.

In conclusion, my instinct is to encourage you to try again.  I believe that with the right stimulation protocol, a bit of pre-cycle preparation and a smidgen of good luck, you can be successful.

 

Best,

Dr. Marc

 

A Happy Ending

photo

Even though I don’t always find the time to post as much as I would like to; I love this site.  I love the community that we’ve created.  I love the interactions on the Facebook page.  And I love the stories shared by all of you.  But there is one little thing that is sometimes hard.  Sometimes I find out that old friends, those I knew growing up, are also struggling.  In some ways, the familiarity makes it easier for them to approach me with their stories and questions.  But my heart aches for them in a different way.  While I shed tears for all of you who share your details with me, it really hits close to home when my childhood friends pop up on my radar…simply because of infertility.

Today and old friend shares her story – her happy ending.  After years and years and tests and more tests…after pregnancy and loss and fears and bed rest…after ups and downs and in betweens…she finally has her happy ending.  Truly – I couldn’t be happier.

Please welcome my old friend from Connecticut – I hope her words and story inspire some of you to JUST KEEP SWIMMING.

 

I’m no expert on fertility but I do have my own story and if it makes just one person feel less alone for even just a minute my smile will be a little bigger today. I hope that person is you!

My husband and I were married in the spring of 2008. About a month before our wedding my dad was diagnosed with cancer. He died almost a year to the day later. I tell you this because it was the main reason we decided to hold off trying to have kids right away. This was a big decision for us since my husband was 37 and I was 33 when we got married. Right after he passed we both decided the time felt right. And so our bumpy road began…

We started trying on our own in 2009 for about  6 months per my OB’s recommendations. I wasn’t sure how the game was going to play out because I went on the pill in college to regulate my periods. After 6 months with very irregular periods and no pregnancies my OB referred me to the “specialist” in their practice. After a  battery of tests I was diagnosed with PCOS. I wasn’t surprised knowing my cycle and family history. The next step was Clomid. I took it and went for my first ultrasound. At that point everything came to an abrupt stop when the ultrasonographer advised me to “stay away from my husband unless I wanted to be the next Octomom on the cover of People Magazine”. Yes, those were her exact words and no, she didn’t have to say them twice. Next stop: a Reproductive Endocronologist.  We got a referral and off we went.

Back to square one. Lots more tests and LOTS more waiting. The next part of the story is pretty monotonous: first IVF cycle- FAIL, second IVF cycle- FAIL, third IVF cycle- FAIL, and yes, the fourth IVF cycle- FAIL. All along I kept thinking there had to be something else wrong with me but my doctor kept saying “we just needed to get it right”. After our fourth cycle failed we decided it was time for a second opinion . So I gathered up my records and we started all over again.

During the first meeting with our new RE he asked what our doctor had said about the septum in my uterus. I’m sorry, the WHAT???!!!  Apparantly the ultrasonographer had written, “question uterine septum” in her notes and our doctor failed to address it. I can’t even begin to explain the amount of anger I felt in that moment. My instincts were right all along; there WAS something else wrong with me.  What an incompetent a**hole!!!! I had been to hell and back over the past 2 years  and it potentially could have been avoided?! After I stopped swearing and wiped my tears  I was able to listen to my new doctor’s plan: remove the uterine septum and try again.  Ok, sounded simple.  Can we do it tomorrow? Of course not.  Didn’t you know that everything in IVF takes twice as long?! Especially for me and my 40 day cycles. So in October 2010 I had my septum removed and then, you guessed it, we had to wait for my uterus to heal. At that point we decided to enjoy the holidays, drink LOTS of wine, do a bunch of skiing and start again after the New Year.

We started our fifth IVF cycle in January and on Valentine’s Day 2012 we found out we were having twins. TWINS! Oh my! Of course we always knew it was a risk, especially when we put two blasotcysts in, but we never thought it would come to fruition. After all, I’d never gotten pregnant before.

Next chapter: the IVF pregnancy. By this time I was what they call Advanced Maternal Age (AMA) or as I call it- OLD … 37 to be exact. I chose a new OB who was high risk since I was now old and carrying twins. All was going great. We were lucky, my husband was self employed so he was able to come to all my appointments. At 12 weeks I had my appointment with my OB in the morning and then my ultrasound in the afternoon. Since I worked in the hospital where my OB was it was easy to schedule things like that. I told my husband to only make the drive for the fun part; the ultrasound. During my appointment with my OB she said she wanted to “take a quick peek” at the babies. Ok, cool with me. I’ll never forget her face when she told me there was only one heartbeat. It’s all kind of a blur after that. After a day or two I picked myself up because Baby A was looking great and I still had a lot to be excited about.

Next stop:  the level 2 ultrasound. Look at all the cute baby parts and it’s a girl! Yay! Then, in walks my OB to tell us there’s a “bright spot” on the heart, also called a cardiac echogenic focus. She said It’s one of the many markers for Downs Syndrome. Are you freaking kidding me?! Is this a joke?! Without any other markers, which we didn’t have, the risk is very low, but there’s still a risk. And then she said because of the demise of Baby B there’s no way we could do the blood test to get the exact risk. Our only option was an amnio, which carries a 1 in 200 risk of miscarriage. Go home and think about it. Cue the tears. These tears were the ones I saved up from the miscarriage when I was trying to be all postiive for Baby A plus the tears of having to make a decision to have an amnio. In other words, there were a lot of them. My husband and I had many conversations about whether to do the amnio  but what it came down to was I could never forgive myself if the amnio was negative and then I had a miscarriage. Altough the risk for that was low, the way things had gone thus far I was convinced that would have been my fate.  So we decided against the amnio and hoped for the best.

Fast forward to week 25. I woke up one morning just not feeling right. I couldn’t put my finger on it but something was just not right. If it hadn’t been Friday I probably would have  blown it off but I lived almost an hour from the hospital and didn’t want to drag myself in on Saturday. So, I waltzed down to the clinic to let them know how I was feeling. They did an internal and hooked me up to the monitor. What do you know, I was in premature labor at 25 weeks. I had just bought myself a full ride to labor and delivery filled with steroids, lots of magnesium and antibiotics. All I kept thinking was after all this I could not have this baby at 25 weeks. It was way too early. She wasn’t cooked enough. Thankfully they were able to stop the labor but I’d be going home to bedrest for the next 15 weeks.

My OB said my ultimate goal was 37 weeks and after that this baby girl could come whenever she was ready. Well 37 weeks came and went and I was still pregnant. Now, I live in New England where we have a few hot months a year so central air conditioning doesn’t exist. At least not in my house. So by 37 weeks, in my hot as hell house, I was past ready to have this baby girl. And sure enough at week 39, in the middle of the night, my water broke. So off we went to the hospital. Here’s the irony of this whole story: after being on bedrest for 15 weeks I had to be induced. Ha! After a much needed epidural and 16 hours of labor, on October 23, 2012, our healthy, beautiful girl, Caroline, was born.

So here I sit writing to you. I’m not going to lie; it wasn’t easy. It was 4 years of heartbreak and physical pain. There were so many days I cried thinking it was never going to happen. All my friends were having their second and third kids and I was still trying to have one. There were lots of pity parties in my house and if you wanted to come you’d better bring red wine, and lots of it! It got to the point where friends didn’t know what to say to me anymore so they stopped saying anything at all. There were many days I felt like my husband and I were on an island and I wondered where all my friends went. I felt like they just didn’t understand.

I certainly don’t have all the answers. I can tell you that when I wake up to my beautiful girl smiling at me every morning I know it was all worth it. I equate it to labor amnesia; I remember it was horribly painful but I don’t remember the pain I felt when there was a hole in my heart. Only that it was there. Perhaps that’s what will make me do it all over again….someday.

It will all feel like too much sometimes because it just is. And on those days when you feel so alone try to remember that you’re not. Sometimes the most comforting words come from someone you’ve never met through blogs. So stay strong, trust your instincts and forgive yourself for whatever it is you’re feeling. You can do it.

Thank you, my sweet friend.  May motherhood be all that you hoped for and then some.  xoxoxoxo

Pin It

This and THAT

 

Our very own Dr. Marc sent me the original link to this very powerful story.  I cried when I read it.  Then I waited two days, read it again, and cried just a little bit more.  Meet Terry.  She’s strong, insightful, and a fighter.  She blogs over at Terrilox.  This post was originally posted on Terrilox on November 19, 2012 and is reprinted with permission.  Warning:  Tissues required.

At the begin­ning of Novem­ber I signed off of Facebook.

It was my way of retreat­ing from the empty, shal­low, judge­ment spew­ing from my news feed.

I have always been too sen­si­tive, and on Novem­ber 4th I deter­mined I was way too sen­si­tive even for Facebook.

In real­ity, I did actu­ally have a lot of work to do, and after remov­ing Face­book from all of my devices, the Face­book Anx­i­ety went away.  How­ever, two weeks in, I real­ized I needed to con­nect with some­one I was only con­nected to on Face­book, and my Face­book boy­cott ended, with­out nearly as much fan­fare as it had started.

I only talk about Face­book, because in writ­ing this blog about this and THAT — I real­ized my retreat had so lit­tle to do with Face­book and more to do with a retreat into myself and away from the world.

I woke up last Fri­day ambiva­lent about the fact that I had signed up for a yoga retreat. All I could think was, “I am not in the mood for forced inter­ac­tion with strangers, even strangers that do yoga. If we get in a cir­cle and start shar­ing any­thing, I might die. Why did I say yes to shar­ing a room with strangers? How am I going to sur­vive this?”

The ques­tions were swirling.

As I loaded my lug­gage, I flashed back to when I was four and my mother left me at day­care for the first time. I was trau­ma­tized. My mother had dared to send me into a room of strange lit­tle chil­dren. Fri­day morn­ing, as I was hug­ging my hus­band good­bye, I felt like I was head­ing to day­care, only this time I was 43-years old, I was dri­ving and pay­ing for it myself.

It had been eight years since my last yoga retreat. It was an entirely dif­fer­ent per­son ago. Would Terry ver­sion 4.3 be able to han­dle this?

Anx­i­ety Rising.

To act out even fur­ther, I stopped at Taco Bell for a bur­rito and a Dr. Pep­per.  Just the way to kick-off my healthy, heart-opening week­end. Eat­ing crap in an act of com­plete defi­ance.  Terry ver­sion 3.3 would have bought a pack of cig­a­rettes, so I con­sid­ered this progress.

There was no traf­fic. The music blar­ing from the radio was punc­tur­ing my armor.  Coun­try music can do that like no other music can.  I started to relax.  I credit part of this to the Dr. Pep­per, which I have always believed has med­i­c­i­nal prop­er­ties hid­den in those 23, prob­a­bly com­pletely unnat­ural flavors.

The music played on.  It was as if God was play­ing DJ on The High­way at Sir­ius XM, care­fully build­ing a playlist in an effort to reach my taco-bell-eating-dr-pepper-drinking-why-the-hell-am-i– doing-this-soul.

I’m a tough nut to crack in the God depart­ment. We’ve had a life­long love-hate rela­tion­ship, but some­how I always real­ize if He was not around I would have no one to dis­cuss all of the things no one else in my life wants to lis­ten to — most espe­cially me. I know some peo­ple call God the Uni­verse or even like to think of Him as Her, and I say, what­ever works for you — but for me, there is some­thing com­fort­ing about a grandfatherly-type fel­low with white hair and a long beard, sit­ting on a heav­enly throne.

Depend­ing on the con­ver­sa­tion, I fluc­tu­ate between that and some­one who looks just like George Burns.

My sun­roof was open. Rain or no rain, I always love the sun­roof open when I can see the ocean.  The ocean was now in view.

Kenny Ches­ney was singing El Cer­rito Place — it was blar­ing through the speak­ers.  I found myself singing louder with each verse, as rain poured though the sunroof.

Some­one said they might have seen you, where the ocean meets the land

So I’ve been out here all night lookin’ for your foot­prints in the sand
Did you hear the ocean singing, baby did you sing along
While you danced out in the water, to some ol’ for­got­ten song

Were you even here at all?

I’ve been lookin’ for you, baby. I’ve been lookin’ for you baby. I’ve been lookin’ for you baby all night long … 

Tears were stream­ing down my cheeks by the end of the song. It’s an absolutely beau­ti­ful song, but it was more than that. As the final note of El Cer­rito Place played out, I heard a song inside my own head.

“De-Da-De-Da-De-Do”

The tears mul­ti­ply and become sobs. My grand­mother was in the car. Per­haps she was only in my mind, but the song and the voice was so dis­tinct it was as if she was there.

I sud­denly remem­bered I was sup­posed to bring some­thing for the altar at the yoga retreat. I had planned to bring some­thing that reminded me of her. I for­got. Or per­haps I just did not want to remember.

I miss her every sin­gle day, often to the point of intense sob­bing, usu­ally in the shower.  No one in my young life was more awe­some to me than my Maw­maw (except pos­si­bly Donny Osmond in third grade), and I always knew she thought I was equally as fan­tas­tic. Every kid should be made to feel that absolutely perfect.

I never real­ized until Maw­maw was phys­i­cally gone how large the hole in my heart had grown in her absence from my life while she was still here on earth. I hope she knows how impor­tant she was to me, with the way it all ended for her, I will never be cer­tain. I know that is part of what makes remem­ber­ing so painful. But on Fri­day, in the car, my spunky Maw­maw was singing her favorite made up song and I silenced the radio long enough to sing along with her. Out loud, with the sun­roof open, as the driz­zle set­tled on my steer­ing wheel.

I arrived at El Cap­i­tan Canyon at exactly 3:00.

After releas­ing so much in the car on the drive up, I was feel­ing slightly more open to the week­end. Actu­ally, I was feel­ing a lot more open, but still scared to death. As long as I did not have to talk about THAT.  Let’s keep THAT in the box.  Locked.

I was sched­uled to share the cabin with Tatyana (some­one I did know) and two women I did not. I was the first one in our cabin and I had two glo­ri­ous hours of alone time, read­ing and tak­ing it all in. I could not have asked for a bet­ter transition.

Our first yoga class was at 5:00. We started with a writ­ing exer­cise. All I could think was,“Thank God we are not shar­ing in a circle.”

I started writ­ing down every­one I was grate­ful for in my life. My hus­band. My par­ents. My in-laws. Ellen. Chaz. Heidi. Selma. Dr. Kalan. Tatyana. Maw­maw. Bob. Memom. GranGran.

The list filled three columns. I had so many peo­ple to be grate­ful for, so why was I still feel­ing so incred­i­bly sorry for myself? I hate weak­ness.  I hate whin­ing. I was feel­ing like a weak-willed whiner.  It’s no way to start a week­end like this.

In my first down dog the tears started to roll. I knew there was no way I was going to get through this week­end with­out fac­ing THAT, but not tonight. Not now.

The tears sub­sided and turned into sweat. I was slightly pissed off at my inabil­ity to fool myself.

The pulse of THAT grew stronger.

After din­ner, Tatyana and I finally met our other cabin mates, Mar­sha and Laura. They were great. Easy. We all sat around the cabin, drink­ing wine and talk­ing. I was able to hold back shar­ing any­thing at first, but Mar­sha and Laura were talk­ing about their children.

Yes, THAT.

Chil­dren.

No, I don’t have any. I can’t have any of my own. My eggs are too old. Iron­i­cally, I’ve never felt phys­i­cally bet­ter or stronger, despite the fact that I drank a Dr. Pep­per this after­noon. This is one rea­son I am quite cer­tain God is a man, a woman never would have made us like this.

My hid­ing ended when some­one asked me directly about THAT.

“Do you have children?”

I spoke softly on the bot­tom bunk bed. I have been try­ing nat­u­rally and via IVF.  No suc­cess. Our next step is donor eggs. I choked up and noth­ing came out. Just tears.

Will they ever stop?

When I talk about THAT, my soul feels as bar­ren as my womb. I feel empty. I feel incom­plete. I feel like a bad wife. A washed up celebrity from the 70’s. A woman who needs to be returned. Expired. My hus­band does not put this on me, I do. I feel uncer­tain of what the hell I am doing here if not to pass a part of myself on. What is the fuck­ing point?  How did this hap­pen? There has never been a prob­lem I could not solve until now.  How did an only child who wanted Eight is Enough (I used to name all eight of them) get to be 43 years old and childless?

These are the never-ending ques­tions run­ning through my mind.

This is why God and I have a love hate relationship.

Sleep was wel­come. Any­thing to escape all of THAT.

We woke up at 7:00am on Sat­ur­day for break­fast. Yoga was from 9:30–11:30. I hit the mat again. Feel­ing stronger. No tears. As long as I did not have to look any­one in the eye and speak, I could get through it.

When class ended, we were get­ting ready to head to lunch and some­one asks if we can intro­duce our­selves. I think to myself, “Please, God, no. Just let me eat lunch. Let me wal­low in my own crap. No sharing.”

God is George Burns.  He is laugh­ing. I am sit­ting in a cir­cle. Petrified.

As the cir­cle opens up I hear very lit­tle, except every time some­one men­tions THAT. Chil­dren. The word is mock­ing me. When it’s my turn, I intro­duce myself. I talk about where I take yoga. I say it’s been a really hor­ri­ble year, I am try­ing to be grate­ful and I start to cry. I pass the Kleenex box. I could get noth­ing else out.

I could feel it stuck between my shoul­der blades, right behind my heart.  Burning.

My heart. My bro­ken heart.

Tatyana hugs me and whis­pers, “You will be a Mom. I know it.” In that moment, I am grateful.

After lunch all I could do was sleep until it was time for breath work at 3:30. Breath work. Am I breath­ing? I keep ask­ing myself.

Before we start the breath work there is more shar­ing. At this point, I am just going with the flow. A sweet young woman named Hay­ley comes and sits on my mat. With­out real­iz­ing it, I am shar­ing again. It turns out her step-mother had infer­til­ity issues in her early 40’s — but she ended up get­ting all the way to 50 with­out a child. She had recently started a foun­da­tion to help women in this sit­u­a­tion to adopt older children.

My eyes glaze over when I hear this. Will I be one of those women? I want to ask about the foun­da­tion, but I can’t. I am not there yet. I am not ready to give up, despite the hope­less­ness I feel inside.

I retreat unable to accept the pos­si­bil­ity that I will not carry a child. I am pro­cess­ing the idea of donor eggs right now, but when I hear about this foun­da­tion, I think — what if I am child­less at 50?

I lie down and start breathing.

In-in-out.

In-in-out.

This goes on for a long time. I am dizzy. I am cry­ing. The pain behind my heart is burn­ing. I have to stop and lift my neck, try­ing to release it.

The instruc­tor asks us to think about our own per­sonal sym­bol. Mine was a Tiger. Maw­maw always called me Tige, short for Tigeroo.

Today I was not think­ing of Terry the tiger cub, but Terry the Mama Tiger.

As the breath is puls­ing through my body, warm­ing my hands, my toes, and yes, even my heart … For the first time since this jour­ney began, the THAT starts to scatter.

I was not child­less.  I was not barren.

These few moments of allow­ing myself to open to the pos­si­bil­ity starts to fill the hole in my heart.

I kept flash­ing back to this video I saw on YouTube of a real Mama Tiger tak­ing care of baby piglets as fiercely as if they were her own. If a Mama Tiger can take care of an entirely dif­fer­ent species as if they were hers then I can fully open my heart to donor eggs.

Not as a last resort, not as the end of the line, not as the result of a fail­ure — but as a gift from God via a self­less young woman.  A mitzvah.

Breathe deeply.

After breath work we had Yin Yoga with Ellen. Ellen was the rea­son I was on this retreat at all, really.  End­ing the day with her class was good for me.  I felt open, vul­ner­a­ble and safe.

The burn­ing behind my heart was dis­si­pat­ing.  Was I finally let­ting go?

Some­times peo­ple come into your life at just the right moment.  Iron­i­cally, she came into my life because of Chaz.  I love how the world works some­times.  As crap­tas­tic as 2012 had been, I can’t imag­ine it had I not had Ellen guid­ing me through it on the mat.

The evening ended with a Thanks­giv­ing din­ner in the rain.  I was so incred­i­bly grate­ful for the rain.  I felt cleansed.  Scrubbed clean, ready to fin­ish the year unafraid to talk about THAT.

Sun­day morn­ing was the final yoga class of the week­end.  I held noth­ing back.  I was just so incred­i­bly grate­ful.  It was a great feel­ing to have four days before Thanksgiving.

I drive home full of grat­i­tude.  I was glad I dropped myself off at that day­care full of strangers.  I was ready to see my hus­band, feel­ing much lighter than when I left on Friday.

My sun­roof was open while blar­ing The High­way.  I am singing Kid Rock, Tim McGraw, Sug­ar­land, Kenny Ches­ney, George Strait and so many more at the top of my lungs for 115 miles. This is some­thing I can only do alone in the car, my hus­band would rather poke out his own eyes than lis­ten to Kenny Ches­ney or Sug­ar­land. I would rather poke out my own eyes than lis­ten to sports on the radio. We gen­er­ally com­pro­mise on a good mix of 70s and 80s with some Sina­tra and Willie thrown in for good mea­sure. It works for us.

In that moment I was grate­ful to have my own time, with my own music.

Through­out the week­end, Chaz had asked us to take a video diary of our expe­ri­ence.  I tried, but it was too scary.

So I write.

A lit­tle of this, a lot of THAT.

As I was dri­ving away from El Cap­i­tan Canyon, I looked to my left and there was Hay­ley.  Our eyes met and she made a curve over her own belly to sym­bol­ize preg­nancy and mouthed, “good luck.”

I was really grate­ful and for the first time in a long time, I felt open to any and all possibilities.

The Mama Tiger was ready to receive her cubs, how­ever George Burns wants to man­i­fest them.

 

Ask Dr. Marc: C-Section Scars

Dear Dr. Marc,

I am 30 years of age, have had my first child naturally (after one try!) at the age of 26.  For that birth, I ended up have an emergency cesarean due to preeclampsia at 38 ½ weeks.  In seeking answers for our inability to fall pregnant after a year, it was found that I have fluid in my uterus from my c-sec scar which is there throughout my cycle and I also have a very low AMH for my age (only 3.5).  In determining this I have had a laparoscopy, an attempted hysteroscopy and a successful hysteroscopy (different Dr).  I also had a HCG where they found my tubes were fine.  We have done IUI once and two cycles of IVF.  My husband’s sperm has also been tested and is fine.  I have had very few eggs from each cycle, but have managed to have two day 5 blastocysts the first time and 3 blastocysts the second cycle.  I miscarried two weeks after the transfer with the first cycle and got a negative from the second cycle.

My question is have you come across someone with fluid throughout their cycle from a c-sec scar before and have they successfully fallen pregnant?  My specialist is lovely but I don’t know that he has come across this before.  My low AMH also complicates matters.  With the IVF, he aspirated the fluid out of the uterus before transferring the embryos but I have my doubts as to whether implantation is possible because won’t the fluid just come back again and prevent implantation?

Thanks,

Trying for number 2

 

Hi Trying for number 2,

Your situation is quite interesting and somewhat unique.  First let’s talk about how a caesarian section is performed.  In most C-sections a horizontal incision is made in the lower (closest to the vagina) part of the uterus.  Importantly, the scar on a woman’s abdomen has nothing to do with the type of scar that is made on the uterus.  Through this horizontal uterine incision, which is about 10 centimeters in diameter, the doctor can access the baby and placenta and remove them from the uterus.  Following delivery of the placenta, the uterine incision is normally repaired with at least 2 layers of stitches.   In the vast majority of cases, this repair is quite strong and has no significant impact on the structure or function of the uterus.  In fact, many women are able to have normal vaginal deliveries after having a C-Section, this is called a VBAC (vaginal birth after caesarian).

 

 

In some circumstances however, the C-section repair is less than perfect and can affect future pregnancies.  It is important to know that this does not mean that your doctor made a mistake.  There are simply many factors that go into the healing of a C-section scar.  For you, it seems that these factors may have combined to cause there to be fluid in your uterus.

The fluid may be due to a gland that healed within the scar and secretes mucus into the uterus.  Alternatively, there could be a channel that allows fluid to flow into the uterus from the outside.  Either way, the best step to further explore the scar is a hysteroscopy and laparoscopy.  If there is a structural abnormality responsible for the fluid, then it should be identifiable and treatable through hysteroscopy and laparoscopy.

Moreover, some amount of fluid is normal in the uterus.  The uterus is full of glands and they produce mucus that is critical to the health of the uterine environment.  It is possible that you simply make more mucus than normal and that it has nothing to do with your C-section scar.

This brings us to the other issue, which is ovarian reserve.  We know that as we get older, each of our eggs is somewhat less likely to go on to become a baby.  The significance of age is different for each of us and unfortunately, some women experience decreased ovarian reserve earlier than others.  30 years of age is relatively young in the world of fertility, but some women do notice diminished ovarian reserve at 30.  I suspect that if you are not making many eggs per cycle, this is the case with you.  The good news is that although you do not make many eggs, the ones you do make seem to be of good quality.  Ultimately, this means that your prognosis good.

My advice to you is to have another doctor review the operative report from your surgery.  If the C-section scar was visualized and appeared normal, then there is not much more that can be done surgically.  At that point I would focus on the next IVF cycle and making it as optimal as possible.  It would be reasonable to remove any extra mucus from the uterus prior to transferring embryos.  Alternatively, a frozen embryo transfer may be beneficial because the uterus tends to produce less mucus during a frozen cycle.

In conclusion, my feeling is that the mucus is less important than embryo quality and quantity.  Hopefully it is just a matter of getting the right embryo in place and then nature will take care of the rest!

Good Luck!

Dr. Marc

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: Murphy Lives Here

Merryl Polak is the author of Murphy Lives Here, a story about her struggle with the pursuit of motherhood. After struggling with infertility for almost 9 years, she is finally a mother and now has a lot to say about that topic!

 

When the birth parents might change their mind…

 

My heart sank before she even uttered the next sentence, which was; “The birth parents were not ready to sign the papers today.”

 

Although the previous nights had been sleepless due to a child in need of food and diaper changes, this night was sleepless for additional reasons. William and I kept staring at each other with complete despair. We watched the clock tick by all night and the following morning. We barely moved and we did not eat. We tried to memorize every detail of the beautiful baby in front of us fearing the worst, but William assured me that the birth parents would never renege on all of the promises they made not only to us, but also to the baby girl before us.

 

“They don’t have a pot to piss in,” he reassured me. “They don’t have jobs, they don’t have cars, and they don’t have any financial way of providing for her. They want more for her, that is why they pursued adoption in the first place and nothing has changed.”

 

As true as that statement was, financial security was not the only requirement to parent. Of course, as true as that statement was, anyone pursuing adoption would not be considered without stable financial resources. This is what angered me. Adoptive parents have to prove that they are capable of raising a child in a million ways, but biological parents never had to prove a thing. Adoptive parents were insignificant and retained no rights. People who are loving and kindhearted and financially stable who for whatever reason cannot procreate are punished multiple times.

 

They are punished with infertility. Perhaps they pursue IVF or other invasive treatments like we did, which punishes an infertile couple’s wallet, and in my case, physical health. If that fails, as it did so many times in our case, they must jump through hoops to be approved for adoption. Even when that is over, someone must actually choose them as being worthy to parent their child. And still, when you think you have jumped every hurdle, birth parents have to stick to their word and still follow through and allow you to raise their biological child.

 

I found myself contemplating, what was the magic of genetics? Somehow, being genetically tied to someone gave a person superior parenting rights. For this, I have no explanation. Whatever the reasons are, they seem misguided. Perhaps it is because of the position I sit in, but perhaps, it is because it is also true…

 

Merryl has a happy ending to share…but you’ll have to visit her blog and pick up her book to get to the end of this story.  And don’t forget to find her on Facebook!

Ask Dr. Marc: Estrace Priming

Dear Dr. Marc,

I’m currently on Estrace 2mg twice daily as part of an Estrace priming protocol.  My FSH went from 6.7 in 2010 to 17 last month (wah).  Even though I’ve done this, gotten pregnant and have a gorgeous little girl I am still nervous as hell to do this again.  I don’t know much about Estrace priming, can’t seem to find any good info on it and am wondering if anyone else has done it and maybe Dr. Marc can comment.  I know it’s for poor responders like me but not sure the rationale (even though I’m a pharmacist – a DOCTOR of pharmacy – I become very dumb when it comes to hormones and infertility and endocrinology).

Thanks!

 

Hi Estrace priming,

It is amazing how years of training can disappear in an instant, once a clinical situation become personal!

The rationale behind Estrace priming is based on sound physiology in and works quite nicely for some patients.  The bottom line is that the estrogen prevents your body from recruiting follicles too early (a common problem as ovarian reserve declines).  By limiting early recruitment, there are more follicles available at the beginning of your stimulation.  Additionally, the follicles tend to be better synchronized.  Therefore, they should all be ready at the same time and hopefully give you more high quality embryos.

Without going into too much detail, there are several hormones which participate in the communication between your brain and ovary.  One of those hormones, inhibin, acts to suppress (or inhibit) the release of FSH from your brain in the last week of the cycle.  As ovarian reserve declines, the production of inhibin in that last week of the cycle also declines.  This decline allows your brain to start releasing FSH earlier than it normally would.  The FSH then stimulates the ovary in the last week of the preceding cycle, and by the time the third day of the next cycle comes around, there is already a follicle or 2 that is bigger than the rest.  We call this dys-synchrony and it is one of the reasons, of lower egg yield in low responders.

With estrace priming, the estrogen pills, which also suppress FSH release, essentially replace the inhibin.  Theoretically, if the estrogen suppresses FSH, then the follicles should all be the same size when your period begins.  IF the follicles are all the same size when stimulation begins, there is a better chance that they will grow at the same rate and be ready at the same time.

I hope that is clear.  If not, rest assured that estrace priming is a safe and relatively effective technique that can help with egg yield.

Good Luck,

Dr. Marc

Pin It

Share Your Story: Liz

Today I want to introduce you to Liz, who won her battle with infertility after three rounds of IVF (all of which occurred while she was busy working on the historic final season of The Oprah Winfrey Show…can you even imagine the stress?)  Liz found comfort in a small group of women she found when she dared to reach out for a little support.  She was the last in her group to get pregnant…but her friends never left her side.  I love this story, and I know you will too.  Liz now blogs about her happy ending (among other things) over at Posie Pie Productions, so be sure to find here there.

 

The Benefits of Having Internet Friends

Byline: Liz Kozak

Almost two years ago, I was starting the process of IVF and was feeling totally scared. I didn’t know anyone else that had ever done it, I had a million questions, and I wanted a buddy or two who knew what it was like to walk in these particular shoes. So I did something scary– I reached out.

Online.

I posted a message on a message board at BabyCenter asking if anyone else out there was also about to begin the process. And something awesome happened: I met five other women all across the country, all in the same boat, who my husband named– in no particular order– Upper East Side, Bloomington, Texas, Oklahoma and Portland. Some of his geography was a little off, but I guess it helped him keep them straight.

We communicated daily for the next several weeks about the injections, the side effects, how our egg retrievals went, how our husbands were dealing with things, how WE were dealing with things. And then, something not-so-awesome-happened:

ALL FIVE OF THEM GOT PREGNANT.

Except me.

In real life, that would have been a real friendship test. In the internet-friend world, it would have been easy for me to retreat. But it was too late. We were all in too deep and cared too much, and they knew almost exactly what I was going through. I stayed in the group. And six months later when I finally DID get pregnant after two more tries, these five women were the first people I told. After two years, they are no longer my internet friends– they’re my REAL friends (even though I’ve only met one in person).

This week marks the 1st birthday of the first babies (twins!) that were born out of our merry little band of mothers. Six women; eight babies. I was so lucky to find them, and it turns out they might have actually literally helped me get pregnant. Harvard-led research indicates that women experiencing infertility are more likely to conceive if they participate in a stress-reducing program, such as a support group. So if you found out that having a baby is going to be tough for you, I encourage you to reach out and talk to other women in the same baby-boat.

Epilogue: We’re all still very much in contact and have taken our relationship to the next level… Facebook.

Doesn’t this story just warm your heart?  Introduce yourself to Liz in the comments…you never know…she just might help YOU get there too.  Support matters.

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

Share Your Story: Jessica

Byline: Jessica Blanco-Busam

Jessica wrote this story on April 23, 2012.  The next morning, she had two embryos transferred.  One didn’t make it through the thawing, and she is waiting for results on the second.  Please send Jessica good thoughts while she waits for news.

This is my first time sharing my story in a public forum. It’s funny, because tomorrow will be my final attempt at getting pregnant for the second time.

After many years of painful periods and hearing from my doctor that I had a low pain threshold, I convinced her to do an exploratory laparoscopy. She tried to assure me that everything would be okay. Unfortunately, I knew better. It turned out I had stage IV endometriosis: scarring all the way up to my diaphragm and down to my intestines, bladder, rectum, you name it. I was 26 years old and luckily, happily married. My husband and I knew our plan to wait until 30 wouldn’t do anymore. We had to try immediately and we were told IVF was the way to go.

I switched doctors, got on lupron to improve my chances, had another surgery where my appendix and one fallopian tube were removed, and then went through my first cycle. I almost quit right in the middle of the transfer because the doctor could not get the catheter into my uterus and was causing me such indescribable pain (talk about messed up anatomy and too much scarring).

It failed, but I was blessed enough to get pregnant on my second try. Complications lead to a c-section during which my doctor said the endometriosis was even more extensive than before. How that happened after being period-free for 10 months is beyond me. I guess I’m just lucky that way.

In 2011 we knew it was time to try again. Our son deserved to have a brother or sister. My doctor said I would need a laparotomy instead of a laparoscopy to give me a fighting chance at getting pregnant again. That February, I had the surgery. He had to get an oncologist in on the surgery because the damage was more severe than he could handle. He did the best he could but said a hysterectomy was my best shot at ever helping the endometriosis. Basically, good luck getting pregnant again.

We failed 3 times: we had an FET, then an IVF cycle, then another IVF cycle. Each time my body did worse and worse with the meds: OHSS, painful and difficult transfers, you name it. I looked like and felt like the walking dead.

I was a miserable human being, truly a shadow of my former self. It was beginning to wear on me – and on my marriage.

My husband and I had the talk. We decided this FET would be our last attempt. My son needs me, my husband needs me, my students need me. My life will not revolve around failed attempts to get pregnant and 14 day periods during which I’m on codeine for the first 3 days just to be able to walk and hopefully make it to work. I pray that tomorrow 1 or more of my 3 embryos will thaw and that I will get pregnant. Of course it’s a stretch – a huge one given my history with this horrible disease.

As sad as it is, I know it probably won’t result in a pregnancy. But the finality of it all, the fact that a hysterectomy is in my future at the age of 30, gives me hope. I can move on. I can get that “quality of life” I’ve longed for, for so many years. And I have my miracle baby and he is amazing. That’s my story. I’m not sure if it’ll help anyone at all, but maybe it will.

Jessica- you are incredibly brave to share this story with others.  Please leave Jessica good thoughts in the comment form.  You do not need to be a blogger to leave a comment, you just need a name and an email address.  And be sure to join us over in the Forum, where we are already sharing stories and providing support.