PCO and other Fertility Related Topics
PCOS (Polycystic Ovaries) and Ovarian Drilling.
Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Androgens, by the way, are the hormones that get changed into estrogens, so androgens are absolutely necessary for normal repoduction, but in PCO the androgens are in excess. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because they do not always work, can cause scar tissue, and there are other alternatives.
There are other ways to stimulate ovulation, including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option.
Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling.
So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin.
What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.
Other PCO Topics
Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.
When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.
Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.
Egg quality clomid vs FSH? Probably similar.
Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.
Sperm Topics:
Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.
Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.
Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.
Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.
Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.
Miscarriage
What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.
Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.
Frozen Embryos
Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.
What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.
General Topics
Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.
Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.
Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.
What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.
How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.
Thanks for reading and don't forget the discalimer posted 5/17/06.
Dr. Licciardi
Some sort of ovarian surgery has been used to treat PCOs for the last 50 years.The surface of the ovary, also called the cortex, is where the eggs are. This is a relatively thin layer covering the ovary. Beneath this layer, in the mid portion of the ovary, is the tissue that makes the androgens. PCO women have higher levels of androgens than women without, and it is possible that these increased levels are what interfere with normal ovulation. Androgens, by the way, are the hormones that get changed into estrogens, so androgens are absolutely necessary for normal repoduction, but in PCO the androgens are in excess. Opening this layer and removing or destroying the inner tissue, either by wedging out a piece of the ovary, or putting in multiple holes using an electrical probe or a laser, changes the hormonal balance of the ovary. It lowers the androgens and and somehow allows for more frequent ovulation. These procedures are not frequently performed because they do not always work, can cause scar tissue, and there are other alternatives.
There are other ways to stimulate ovulation, including clomid and FSH injections. Clomid works to cause ovulation in women with PCO in most but not all cases. FSH works in almost all cases. With FSH injuctions there is a high risk of ovarian hyperstimulation, unless the starting dose is very low. Certainly IVF is also an option.
Now some may ask why get involved with fertility drugs and the cost of monitoring when a simple surgical procedure will do the trick. In the case where the patient cannot afford complex fertility treatments, but can get surgery, the later does make sense. In addition some women just do not want to take any form of fertility medication, so the surgery may be the best thing for them. There can be complications from the laparoscopic surgery including the usual bleeding, infection and injury to internal organs. These are increased as the size of the patient increases, and more severely PCO patient may be more obese. But more specifically, the ovarian wedging or drilling can cause scar tissue and adhesions around the ovary, decreasing the chance of conception even if ovulation normalizes. This is is more common with wedge resection (taking out a wedge) vs. ovarian drilling.
So before surgery is considered, other methods of assisting ovulation need to be employed, such as weight loss, along with medical interventions such as those listed above, with the possible addition of prednisone and or metformin.
What if there is anovulation from PCO and you are having a laparoscopy for another reason such as pelvic pain, lysis of adhesions, endometriosis, or fibroids. Should you have drilling or wedging when the doctor is in there anyway? If the other methods of inducing ovulation are available to you, I would not cut into the ovaries because of the possible scar formation. Plus, wedging or drilling removes or destroys a large number of follicles. Reducing egg number is just something I like to avoid. If, however, you decide the drilling is best for you, the ovarian surgery is an accepted method and may lead to pregnancy rather quickly.
Other PCO Topics
Cysts from Clomid. Clomid makes follicles, which are the fluid filled cysts that contain the eggs. These follicles usually dissolve away 2 weeks ovulation but sometimes, especially when there are more than one, it takes longer than 2 weeks for them to go away. It is really rare that they are there after 4 more weeks. I have not had a patient have a cyst that lasts for months as a result of taking clomid. I have heard of such things, but they must be quite rare. It’s common to use the birth control pill to help make the cysts go away. Clomid causes the follicles to grow by upping the FSH produced by the pituitary. Birth control pills lower FSH levels so the theory kind of makes sense, but no one has really shown going on the pill makes any of these cysts go away any faster.
When should you come off metfomin, at the first pregnancy test or later in the pregnancy? Every doctor has a different idea. There is a prevailing thinking that PCO increases miscarriage rates. But there is at least one good study showing there is no miscarriage difference between women with PCO and women who normally ovulate. Plus there are other OK studies calling into question an association between miscarriage and PCO. However, there are a few studies in literature from outside the US showing metfomin reduces miscarriage rates in women with PCO, plus it reduces some pregnancy complications, including diabetes. This being said, the continuation of metformin during pregnancy is not standard among REs in the US.
Will provera increase your pregnancy rate if you have irregular periods? If you have PCO and have very infrequent periods, strongly consider taking to your doctor about clomid or FSH injections. Provera, except in rare cases, will do nothing to get you to ovulate. Even if you bleed after provera, you probably did not ovulate, you just bled.
Egg quality clomid vs FSH? Probably similar.
Is a clomid cycle that makes 6 follicles any different than an FSH cycle that makes 6follicles? Probably not, providing the clomid has not thinned out the lining of the uterus.
Sperm Topics:
Sperm quality 15 years after a vasectomy? Can really vary. In most cases the sperm is fine. Now if the sperm will be extracted via a needle, even if we consider the sperm quality excellent, we can only extract enough for IVF. But in some cases the sperm quality is lower than expected, but it’s rare that you can’t get a good IVF cycle out of what you find. If there are any changes for the worse, they may be unrelated to the vasectomy.
Can a CT Scan effect sperm? There is more and more discussion about CT radiation exposure every day. However, at this point, there is no evidence that a CT scan effects sperm counts, motility, or functionality in any way.
Should you have icsi with a sperm count of 12 million with 40% motility? This depends on how many sperm are recovered from the sample after rinsing and spinning (I know, sounds like there is a washing machine joke in here somewhere). Sometimes you can recover more than 5 million motile, sometimes only 2 million. Every lab has it’s threshold and will make a decision based on the number of motile sperm recovered. In our lab, 12 million and 40% motility usually means no icsi, but I would need to reserve judgment until we process the sample.
Is frozen sperm for iui less active than fresh? It depends on 2 things. One is the numbers and motility pre thaw. The more you have to start with the more you will have in the end. The second thing is how the sperm survives the freezing. Some really good samples just can’t handle the freezing and thawing. We do not know why this is; there are just differences between men that lead to different freezability. So the talk about frozen sperm is not as good for iui as fresh would only be accurate if post thaw counts or motility are low. Donor sperm has been put to the test. Anytime we freeze sperm we do a post thaw of a very small amount. If the post thaw is bad; bad donor. A good thawed sample is good; the good living sperm have not been weakened. Maybe some dies off, but the survivors are usually good survivors.
Most fertility doctors do not believe in the sperm penetration tests, especially when doing icsi anyway.
Miscarriage
What if you have had miscarriages, then surgery for a septum, and now can’t get pregnant? Start with repeating the HSG and getting a semen analysis. You never know, the septum may still be there, or maybe you developed blocked tubes or even a male factor. Also get the day 3 bloods.
Repeat biochemical pregnancies (yes I still hate that term) require the same workup as for miscarriages.
Frozen Embryos
Re-freezing embryos. There are a few papers showing that embryos can survive being frozen, thawed and then frozen again. Logic dictates that this should not be a first option, but there are cases where it seems like the right thing to do. If you thaw more embryos than you want to transfer, which is commonly done to select the best embryos, and surprisingly all the embryos look great, then refreezing the extras may be a good option.
What if you had a baby from a frozen cycle where 10 embryos were transferred, and you want to get pregnant again but only have 5 left? Even with your 1/10 success rate, 5 is plenty. In fact 5 may be too many.
General Topics
Is an endometrium of 14-16 mm too thick? Providing there is no hidden fibroid, polyp or hyperplasia, that thickness is probably OK. And what about an estrogen level that may be too high? There has always been talk about a too high estrogen level and this goes back to studies in mice. However, I have not see women whose problems are that their estrogen levels are too high. Some women with thin linings are put on estrogen injections or vaginal pills, and it is not uncommon to see levels over 2,000 in a frozen or donor egg cycle. Some women undergoing IVF have estradiol levels 5-10,000 (not a good idea for other reasons), and they have no trouble implanting.
Do I endorse Egg Freezing? I don’t really endorse anything. I am a fan of educating to the best of my ability, and allowing my patients to make informed decisions. Egg freezing is very promising, and some early studies show that is more successful that we thought it would be. But, it is still relatively new and expensive.
Both husband and wife diagnosed with hypothyroidism. It’s possible, but get a second opinion just to be sure. Some doctors over diagnose thyroid problems in everyone.
What if you had some questions about your luteal phase, so you were placed on progesterone but are still not pregnant? Don’t wait long. Talk to your doctor about starting clomid because it too is a treatment for luteal phase defect, and it may up your odds of getting pregnant as well.
How long do you need to be on OCP’s prior to an IVF cycle? In reality, you don’t need to be on them at all. One exception is the OCP microdose (also called microflare) IVF protocol. Here the recipe calls for ocps. But for all others, ocps are not necessary. Many programs use them to time the cycle. This means the program wants you to start on a certain day to time the retrieval/transfer. Or they want you to start in a certain week because they may have lab personal coming from the outside for a specified number of days. If you are relatively young and a good responder, the length of time on the pill probably does not matter. However if you are a marginal or poor responder, pill use, especially prolonged, could lower your egg production further.
Thanks for reading and don't forget the discalimer posted 5/17/06.
Dr. Licciardi
posted by Dr. Licciardi at 11:09 AM
21 Comments:
What are your thoughts on, and experience with, embryo donation?
What about lots of abnormal bleeding through the luteal phase? All bloodwork and u/s are normal, no hsg abnormalities, and medicated cycles with prog support clear this up... but still not pregnant. Would you do a laproscopy before proceeding to IVF? Any other tests I should ask for?
thanks for the "sperm topic" info... good information in there!
is a wedge/drilling too late at 44 - pcos, metformin, lap band and gained huge amount of weight. thought starting to be premenapausal - on kliogest and primulut n - having terrible sweats on top of hyperhydrosis - bw not premenapausal. assume that is from the hormones?
This comment has been removed by the author.
Thank you for all your work on educating us and answering all our questions!!
That said- I have a question. :)
Have you ever heard of testicles being 'homogenous' (the tissue) during a MTESA/Testicular biopsy?
My husband had this yesterday, and the urologist said that there were zero sperm seen. They sent a biopsy for pathology etc.
Can any meds change this? Clomid..or something? I can't find any literature on this anywhere.
Thanks!
My question - Husband and I have been trying to get pregnanct for almost 3 years. it has taken us about 3-5 months to get pregnant, but the pregnancies all resulted in an early loss at 6 weeks, 2 chemical pregnancies, and a blighted ovum. i am currently on my second cycle of clomid even though i ovulate on my own and have a normal cycle (varies 28-30 days) and a 14 day luteal phase. this clomid is to help boost egg quality. i am 34, husband is 32. i am just afraid that since there are no guarantees, we're just going to experience another loss. all recurrent pregnancy loss testing came back NORMAL. HSG normal, semen analysis, stellar. next month, because our timing was not good this month, we'll persue IUI. any recommendations to help boost our odds?
Thank you for your thoughts on PCOS. I'm 37 years old, overweight, have PCOS and have been TTC for about 6 cycles now. I have ovulated on my own every cycle when not on BCP since I started metformin over 6 years ago. I've been charting for about a year and have had several cycles monitored by my RE and I typically ovulate on day 15 with a 13-14 day LP. My HSG is clear, all ultrasounds show everything is working normally with my cycles and I've tried 2 cycles of 50mg Clomid without getting pregnant. I only had 1 follicle ovulate in each of those two cycles. My husband (28 yo) is going in for his semen analysis soon,and obviously that's an important piece of knowledge. Here's my problem....we have no fertility coverage so everything is out of pocket. Assuming the SA comes back normal, is it crazy to keep trying on our own? My RE would just keep moving me forward, injectibles, IUI, IVF fairly rapidly because of my age. Which I understand. But because of the costs, with everything checking out normal for me despite the PCOS, assuming the SA is normal as well, shouldn't we have a fairly good chance to conceive on our own or could the PCOS be reducing egg quality even though I ovulate regularly?
Thank you.
My name is Maria. I'm forty three years old. I have been a daycare teacher for twenty two years. I love children. I've always wanted to be a Mother. I have a special devotion to the Blessed Mother and the Rosary. For years I prayed the rosary to meet a good Catholic gentleman and for us to be blessed with children. Several years later I met my husband on a Catholic Singles website. My husband Ed and I were married on June 16th, 2007 (The Feast of the Immaculate Heart of Mary).
My hubby Ed and I will be celebrating our third anniversary on June 16th. We have been trying to conceive for almost three years without being able to get pregnant once. It has been very frustrating. There has been a lot of tears. Two years ago I was diagnosed with endometriosis stage four. I never knew I had this. I've now had two surgeries. But still it seems I am unable to get pregnant. I think I've tried almost everything to try to get pregnant - I've lost weight, tried to exercise, taken vitamins, ect. Nothing seems to work for me.
The thought of never having a child to hold breaks my heart. I've been in tears over this for a long time. My heart and arms ache to have a child. The problem is, hubby and I do not enough money right now to be able to adopt. This also breaks my heart. It seems the only way I can become a Mother is by going the adoption route and we do not make enough money on our own to be able to afford it.
Every day I hope and pray for the gift of a child. Every month we try to conceive and hope and pray it will happen, but every month we end up so disappointed. I want to be a Mommy so much. Adoption seems to be the only way we can become parents. Hubby and I are heartbroken over this.
May God Bless you and everyone here!
Love,
Maria Therese In Mass :)
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How do you know if you have PCO? I am 31, and over weight (about 300lbs). I have recently started taking Provera to get my period, then Clomid days 3-7 to attempt ovulation. 50 mg of clomid didnt help me ovulate, 100 mg didnt work, and this month I will be going up to 150. I know 250 is the max to prescribe...what if I still don't ovulate? What is the next step? I want to be a mother so badly, but won't consider adoption at this time. Where do I go from here?
I am 31, DH is 33, TTC for 3 years. Unexplained infertility. We are seeing an RE and she is now suggesting IVF...
I have Hypothyroidism but my levels are under control. DH's sperm is fine - we were told his density is thick and his sperm are slow so he started taking some supplements- still not pregnant. We've tried clomid, femara, follistim with IUI (4 cycles) and no success. I do have a low progesterone deficiency so I used Ovidrell one week after IUI. Can you sugges anything or what are your initial reactions?
Thanks,
MG
I am so glad I found this blog, my husband and I are starting the fertility treatments to start with IUI's. This is such great and helpful information.
Hi doctor, my first IVF i retrieved only 3 mature eggs and 2 were fertilized normally. for my 2nd one I retrieved 8 mature eggs but only 1 was fertilized normally by ICSI. feeling terrible.. what could be the reason? any possibility that there was a problem with the lab?
Also how could one get more mature eggs? i got only 3/7 and 8/13 from my two cycles. anything could be improved with the protocol?
thank you very much!
This comment has been removed by a blog administrator.
i am 39 yrs old, with one miscarriage at 38. two failed iui's, one failed ivf with 3 embryos. positive ana titer 80. my question is this: i want to be as aggressive as possible going forward. should i request an endometrial biopsy, a hysterosalpingogram (this was never done on me, but i was told the tubes looked open on the sonohysterogram), or immunological tests?
phase defect other than Clomid? I am 33 and been trying to conceive for 13 months. I've done 2 rounds of Clomid, HCG shot, IUI, then progesterone suppositories. I have two rounds left before we need to go to IVF (which we can't afford right now). My eggs, his sperm, etc has tested fine except that, without fail, I start my period 11 days after I get a positive OPK. Is there anything else that we can try?
I noticed that people are looking for advice regarding fertility. I recently came across Zen Jen who has a rather popular Fertility Bracelet. It's been purchased by several public figures and worked. There's a few videos about it at her site.
Here's a link to the bracelet page of her store.
Link
If you enter 2010 in the coupon code box you can get a $20.10 discount on your purchase until 2011!!
Best of luck!
My experience with embryo donation was very frustrating, can you recommend another alternative ?
very nice information you shared with us ..
I'm really impressed that you have lots of information about reproduction,Birth Control and pregnancy.i may believe that you also want to know about Tubal Reversal.if tubal ligation then look on mybabydoc.com ..
Thanks for sharing
Fertility Treatments Can Be Stressful but also very rewarding should you be lucky enough to have success. Research your Infertility Clinic thoroughly prior to making a final decision on who you will use.
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