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More Fertility Questions Answered

Courtney has a problem with Clomid and Femara because they make the lining of her uterus very thin. Should she switch? Yes indeed. It’s time for the injections; hopefully you will see a difference.

Anonymous asked about recurrent aneuploidy and miscarriage, PGD and donor egg. Check my blog on PGD. The answer is going to have to come from within, and you understand your obstacles. Even though I am not big on PGD, there are some cases where it should be considered. It may depend on how many miscarriages you have had, your FSH levels and your response to the medications.

Amina has severe anemia and an abnormal uterus and is considering pregnancy. The sickle/thal combo can be very dangerous during pregnancy. You need to sit down with a high risk doctor before you conceive. It’s hard to say what your uterine diagnosis is. If there is a big difference in the sizes of your uteri, it is more likely to be a unicornuate with a rudimentary horn, but this is just a guess. You need an MRI to get all of the facts. And you need the right person (maybe more than one) to read the films.

Jenn is having success taking long term Femara for endometriosis. Your story is giving me and patients important information. Thank you.

Amy M has a short luteal phase and is worried her doctor is not treating it correctly. She is getting Clomid, but not progesterone. I am not worried about your progesterone level of 11. I would concentrate on the length of the luteal phase on Clomid. If you get a 13-14 day luteal phase, you are probably ok. However, I also don’t see a problem with taking progesterone. I don’t know if raising the dose of Clomid will increase the progesterone level.
Sarah 23 asked if the endometrium can be too thick. I have not had problems with a very thick endometrium, providing there are not polyps or hyperplasia. These are things that can make the lining look thicker and could interfere with implantation.

Penny asked about potential problems associated with poor blood flow to the uterus. I don’t do this test; I have not seen any good literature supporting its use.

Jen has an IVF baby, but 3 nice IVF cycle have failed since. She is 35. It sounds to me like the last cycle was fine. It’s hard without seeing all of your records. You need to keep trying. You may not be able to due to finances or other reasons, but if your only barrier is emotional, you must try again. I suspect you are ready to do so, but want to do everything you can in your power to bet it right. Again, I don’t know everything about you, but I have to remain optimistic. It worked once; you make many eggs and get good embryos. Ask about repeating your hysterogram.

Anonymous has bilateral hydrosalpinx and a male factor. If there is some live moving sperm, IVF can work for you. If there are no sperm, you are right, no sense in having your tubes removed. The easiest question is the one about your doctor who is not giving you any information: just get another. There are many doctors out there who can’t wait to see you.

Anonymous asked about Femara. I am sorry but I don’t use it. I just get worried about that one person who takes it while pregnant. If your FSH is high, you know what the deal is. If you want to try it, it will not hurt you, or change you FSH levels. Clomid is not really bad for high FSHers, it is just not very effective, even in young women with normal FSH levels, although of course we use it regularly.

Jill is an excellent responder who has not yet become pregnant. Her doctor is adding metformin. I think this is fine. I did more of the same in the past, but less do lately. I have just started giving less fertility drug instead. I see you will be on less drug and this too should help. I have personal thoughts about long lupron in women with PCO. I think it prolongs the cycle. A no lupron cycle may be 1-2 days shorter, and this may be good for a woman whose estrogen skyrockets. This is just an opinion at this point. Ask your doctor.

Catherine is 40, and has trouble with her health care providers. They aren’t letting her do IVF. Yes you can get pregnant with 4 months of unmonitored Clomid at age 40, but come on let’s get real. Time is the problem. Your odds will be less than 5%, and your odds with FSH iui will be about 10% and your odds with IVF will be higher, although that depends on the success of your IVF clinic.

Thanks for reading and please read disclaimer 5/17/06.

Dr. Licciardi

Polyps

It looks like vacation is over and I have a little catching up to do. I will try to get to as many questions as I can. The first question was about polyps, so here we go.

First a little story. I had a patient whose uterus looked fine on her initial ultrasound and HSG. She started an IVF cycle and lo and behold, a day before her hCG, a couple of polyps were discovered in her uterus. They were just under 1 cm each.

We had a few of options. First we could have canceled the cycle, removed the polyps, and restarted a cycle in another month. The second option was to continue the cycle, freeze the embryos, remove the polyps, and then do the frozen cycle. The third was to do nothing, continue with the retrieval and transfer and see what happens. We did the last, and she became pregnant and delivered twins.

What are polyps? Going back a little, uterus is composed of 2 basic parts, the first being thick outer muscular layer; the myometrium. The second part is the innermost layer made of glands; the endometrium. Most of the endometrium sheds every month with menses. Polyps are little balls, usually round or oval, that are overgrowths of the endometruim. So they grow on the inside of the uterus. They are not shed every cycle, they stick around each month and can get bigger with time. Sometimes I explain they are like skin tags, except inside the uterus. We don’t know what causes them.

Theoretically, they interfere with implantation. How? One possibility is that because the glands are growing in an abnormal way, an embryo may not be able to attach if it tries to stick on top of the polyp. This is probably because the embryo will not be able to receive proper nutrients and blood flow. Also theoretical, a polyp located in one area of the uterus can make even the normal areas inhospitable because the polyp may create a generalized inflammation in all areas of the uterine lining. This inflammation could interfere with any of the many very complicated implantation steps.

Should polyps be removed? It depends what you call a polyp. Some doctors see a little area of irregularity in the uterus, which can be normal, and call it a polyp and want it removed. Most doctors are more reasonable and agree that we don’t know much about small polyps, and we don’t know if they interfere with conception. There are many women with polyps who get pregnant all of the time, but when we have a patient who is not getting pregnant and has a polyp, we at times want it removed.

The smaller a polyps, the less we worry about them. We really don’t have a size chart to tell us what’s too big. In general, polyps less than 5 mm are really small and rarely removed. Polyps 5-10 mm are a little more of a concern, but your doctor may see one of these and not worry. Larger than 1 cm is more significant and more doctors would recommend removal. 2 cm is pretty big; too big.

Most women do not know they have polyps. Occasionally they cause pre menstrual, or post menstrual spotting, sometimes mid cycle bleeding or spotting. Larger polyps can make the period very heavy and long.

So what do we know? We know if there are one or more large polyps, and everything else is normal, women have a good chance of getting pregnant after the polyps are removed. The effect of smaller polpys on infertility is less known. Some women get pregnant after having small polyps removed; some women get pregnant with the polyps in.

Doctors and patients have their breaking point for polyp removal, but the thresholds can be different from case to case and from practice to practice.

Polyps can grow back. Sometimes they are completely removed the first time, and they grow back anyway, or there is a new one that develops. Sometimes the first polyp is not completely removed. Many polyps grow from a stalk, so that if the polyp is removed, but the stalk is not, it is more likely to come back.

This is one reason that a hysteroscopy is mandatory for proper polyp removal. A standard D and C, where the doctor does not actually look in, is not the right surgery, and in many cases leads to failure and a repeat procedure. During this procedure, the doctor scrapes “blindly”, not seeing where the curette (scraper) is going. Here it’s common for the polyps to be pushed aside, but not removed. Looking in with a scope to be sure all of the polyps have been removed, including their stalks, is the way to go. During hysteroscopy the doctor can slide a tiny grabber through a narrow channel in the scope, and target and directly watch the polyp removal.

Can polyps be cancerous? Very very rarely. You can discuss this one with your doctor.

Thanks for reading and please see disclaimer 5/17/06. Dr. Licciardi

References:

  • American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol. 2012 Jan-Feb; 19(1):3-10.
  • Rackow BW, Jorgensen E, Taylor HS. Endometrial polyps affect uterine receptivity. Fertil Steril. 2011 Jun 30; 95(8):2690-2.
  • Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol BW, Mathieu C, D’Hooghe T. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update. 2010 Jan-Feb; 16(1):1-11.
  • Varasteh NN, Neuwirth RS, Levin B, Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol. 1999 Aug; 94(2):168-71.