Ectopic Pregnancy After IVF

My brother Mike is a real doctor. I mean it. He is a general surgeon in a small town in North Carolina and has not had a full night’s sleep in about 27 years. He is always being called out to the ER to help save someone’s life (or at least remove their appendix) in the middle of the night. The life of a fertility doctor is very different.

Some weeks are more reproductive psychiatry than reproductive endocrinology and emergencies are rare. We have an occasional patient with OHSS in the hospital and once in a while we have an ectopic pregnancy that requires laparoscopy but most of the time there are not a lot of medical surprises. However, among our surprises are the unexpected multiple pregnancy, ectopic pregnancy or heterotopic pregnancy.

Multiple pregnancies are always tricky to predict. Even if you transfer a single embryo, it can split leading to identical twins! Ectopic pregnancies after IVF are rare but not impossible (see below). Heterotopic pregnancies occur when one embryo ends up in the uterus but another one gets stuck in the tube.

Ultimately if you practice reproductive medicine long enough you will see quite a range of unexpected results. Fortunately, most patients do not get OHSS, most patients do not have ectopic pregnancies and most patients do not have heterotopic pregnancies.

So here is today’s Question of the Day from the book that my surgeon brother fell asleep reading: 100 Questions and Answers about Infertility.



55. How can you have an ectopic pregnancy after IVF?

As described in Part 3, an ectopic pregnancy can occur within the section of the fallopian tube that passes through the muscle of the uterus or within the short segment of fallopian tube that remains after surgical removal of the tube. The incidence of ectopic pregnancy following IVF ranges from 0.5 % to 3%, but this figure may be decreasing. For the past several years, embryo transfer has been routinely performed using ultrasound to properly guide the embryo catheter to the optimal uterine location. The exact mechanism responsible for an ectopic pregnancy following an IVF procedure is unknown. Some believe that embryo migration up into the fallopian tubes occurs because of local cellular activity or fluid mechanics present inside the uterus. Sometimes the opening of the fallopian tube in the uterus is dilated because of disease, making it easier for the embryos to enter the tubes.

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More About Stimulation Protocols...and Staying Sane

If you spend any time surfing the websites and bulletin boards concerning infertility, then you will certainly notice that stimulation protocols are discussed by patients all over the web. Some patients complain that their heads are spinning as some of the women posting in cyberspace seem to have physiology PhDs and know all of their estradiol levels and follicle sizes…yadda, yadda, yadda.

I think that informed patients are always the best patients but at some point I also think that you need to trust your RE to make sound decisions. There are many different approaches to IVF and IUI stimulations and one needs to remember that every patient is unique with her own particular history. Don’t be intimidated by the biology and the variety of protocols in use. If one protocol was absolutely superior to all of the others, then don’t you think that everyone would use it?

When a patient comes from another clinic to seek care here I always ask for the stimulation records as there is no better way to pick a protocol than to see how things went in the past. Otherwise, you are flying blind and there is no need not to learn from past experiences.

So ask questions, get sound advice and pick a doctor with a good reputation, a good laboratory and good communication skills. After all that, just hang in there and try not to get overwhelmed by the day to day minutiae of the cycle.

With that in mind here is today’s Question of the Day from the book that should be on your bedside table so you can stop taking Ambien…”100 Questions and Answers About Infertility.”


47. My doctor wants to use Lupron or Antagon during my IUI cycle. What are these drugs, and why do I need them? I thought they were only for IVF.

These medications can be used to prevent premature ovulation—that is, they can delay ovulation until the optimal follicle size has been reached. Premature ovulation during an IUI cycle can be dealt with by simply adjusting the timing of the IUI. These medications are primarily used in patients undergoing IVF rather than IUI. For most patients undergoing treatment with IUI, Lupron and Antagon are rarely necessary. These drugs are not routinely used unless a patient repeatedly experiences a premature LH surge during the treatment cycle. In such cases, these medications can allow for a more optimal
stimulation.

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Stolen Laptop Returned...Medical Treatment of Endometriosis

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Endometriosis and IVF

Sorry for the large gap between posts but I actually took some vacation and have been paying for it ever since. Usually it takes at least a week to catch up and handle all the questions that have been raised over the previous week. This torture explains why my vacation schedule is pretty sparse!

Once back here at Dominion I was interested in the Grand Rounds lecture given at Inova Fairfax Hospital this past Monday. The topic was the surgical treatment of endometriosis and infertility. Specifically the question of removal of endometriomas was raised and discussed. Basically, there are no good randomized studies so one is left with the choice of doing IVF with an endometrioma just sitting there, or taking a patient to the operating room before IVF. There may be an increased risk of infection after egg collections where an endomtrioma is pierced. However, the absolute risk of infection after egg collection remains very low. Removing the endometrioma removes this risk but may further damage the ovary reducing the egg count… Decisions, decisions…

Ultimately, there is no clear cut answer here so I try to individualize based upon the patient and her history. Hopefully, your RE will do the same.

So after much delay here is today’s Question of the Day from the book that we shamelessly promoted on the Kane Show (click here to hear us on the air) on 99.5 FM here on Tuesday .

37. Does surgery for endometriosis improve pregnancy rates?

Well-designed medical studies clearly show that destroying even small amounts of endometriotic tissue can improve fertility by as much as 50%. In a large Canadian study, the monthly pregnancy rate following surgical treatment of minimal endometriosis rose from 3% to 4.5%. Although this finding represented a 50% improvement in the patients’ monthly chance of pregnancy, it does not compare very favorably with IVF pregnancy rates, which average around 30% for a single treatment cycle.

Nevertheless, because treatment of endometriosis at the time of surgery does improve pregnancy rates, most doctors will destroy the abnormal endometriotic tissue at the time of the diagnostic laparoscopy by using either laser or coagulation techniques. In addition to improving fertility, surgery may often eliminate or improve symptoms of dysmenorrhea and pelvic pain. Ovarian cysts that contain endometriotic tissue may grow quite large. They are often called “chocolate cysts” because of the dark brown fluid found within them, although endometriosis cysts are more correctly referred to as endometriomas.

If left untreated, these growths may destroy part or all of the normal ovarian tissue, including the eggs. Endometriomas must be surgically removed, usually via laparoscopy. Sometimes, however, laparotomy is required. The ultimate choice of which surgery is performed depends on the operative findings and the skill and experience of the surgeon. Medical treatment of endometriomas is insufficient and will not cause these cysts to resolve.

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Fibroids and Fertility

Before I jump into today’s topic I wanted to put a plug in for a local patient information seminar sponsored by RESOLVE. The volunteers at RESOLVE do an outstanding job and this conference (April 12, 2008, 8 am til 5pm at the Bethesda, MD Hyatt Hotel) provides a real resource for patients especially in regards to adoption information. http://www.resolve.org.



Now back to our issue at hand…

Every week it seems that I discuss fibroids with my patients…and it is often a rather complex discussion. Fibroids are extremely common, benign tumors of the uterus. They are found in over 50% of women and can range in size from <1cm>50% inside the cavity may be removed with hysteroscopy but those that are not require laparotomy (bikini incision). I am not a proponent of laparoscopic myomectomy unless the fibroid is on a stem. I believe that the repair is inferior through the laparoscope.

Uterine fibroid embolization is a newer approach that should not be used in fertility patients as the technique leaves a large amount of devascularized (no blood supply) tissue and may thus adversely affect fertility.

So here is today’s Question of the Day.

96. Can fibroids or other uterine problems cause infertility or miscarriage?
Anatomical abnormalities can predispose a woman to preg- nancy loss. In particular, congenital uterine abnormalities such as a uterine septum (fibrous band separating the uterine cavity into two smaller cavities) or a unicornuate uterus (a small malformed uterus that is usually connected to a single fallopian tube) can lead to poor reproductive outcomes. Uterine malformations as a result of prenatal exposure to diethylstilbestrol (DES; see Question 66) can also increase a woman’s risk of a poor pregnancy outcome. The presence of uterine fibroids within or abutting the endometrial cavity has been proposed as a source of pregnancy loss (see Figure 7); the same is true of uterine polyps. Extensive intrauterine adhesions from a previous dilatation and curettage (D&C) procedure may also lead to reduced reproductive success. All of these abnormalities may be amenable to surgical correction, but the decision to pursue surgery requires a careful discussion with your physician.

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IVF Stimulation Protocols...cooking eggs with DrG

Many of the questions that I answer on the INCIID bulletin board revolve around issues of stimulation. High responders, low responders, unusual responders…you name it. Of course, making pronouncements on cycles that I have never seen, from clinics that I have never heard of and with REs that I personally have never met represents a difficult proposition.

IVF is really an art on some level and we need to carefully pick stimulation protocols and make trigger shot decisions after careful consideration of all the data. We sometimes really agonize over these decisions and that is why we prefer to do our own sonograms so we can get a real feel for whether the follicles are ready….and yet sometime it just doesn’t work out the way you thought that it would….

So after much delay, here is another question from the book that every fertility patient should buy or borrow or steal (OK, not steal) although we have yet to see a dime from our publisher…


62. Which types of drug protocols are used in IVF, and how is the most appropriate protocol selected?

Although several drugs and protocols are available to stimulate the ovaries to produce extra eggs for IVF, most clinics The first method, called luteal suppression, involves suppression of the ovaries using a GnRH-analog (Lupron) during the luteal phase of the menstrual cycle preceding the planned IVF treatment cycle. Once the ovaries are suppressed, ovarian
stimulation is accomplished with daily injections of gonadotropins (e.g., Gonal-F, Follistim).



In the second method, called flare stimulation, the woman does not take any medications until the second day of her menstrual cycle. At that time, a microdose (most commonly) of Lupron is used to “flare” the pituitary gland and induce it to release its store of FSH and LH. Simultaneously, gonadotropins are started, producing a “one–two punch” in terms of ovarian stimulation. Premature ovulation of the eggs rarely occurs despite the low dose of GnRH agonist utilized in this protocol.

A third, more recent option is GnRH-antagonist stimulation, in which GnRH antagonists are added later in the stimulation to prevent premature ovulation. In this method, the gonadotropins are started on cycle day 2 of a normal menstrual period. Once the follicles have reached a specific size (usually 12 to 14 mm), the woman begins the GnRH-antagonist medication, which almost instantaneously prevents the pituitary gland from generating an LH surge.

Some reproductive endocrinologists prescribe oral contraceptive pills to their female patients prior to beginning the actual ovarian stimulation drugs, but this practice varies between patients and fertility clinics. We have found that the use of birth control pills often results in oversuppression of the ovaries and cycle cancellation except in those patients known to be high responders (women with PCOS, in particular).

The type of protocol selected for any patient (i.e., luteal suppression, flare stimulation or GnRH antagonist) depends on the individual patient and the philosophy of the fertility clinic. Factors that may influence the type of stimulation protocol selected include the patient’s age, her day 3 hormone levels, her follicle antral count as determined by ultrasound, and her previous responses to any other attempts at ovarian stimulation.

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Trust me, I'm a doctor...

Trust is at the heart of the doctor-patient relationship. You, the patient, put your trust in me to make the correct treatment recommendations, and I, the doctor, trust that you are being honest with me regarding your history, symptoms, insurance issues etc.

Patients will sometimes ask me to use non-fertility codes during their care in order to get their insurance to cover a particular visit or procedure. This request is known as insurance fraud and I explain that although I am sympathetic to their situation, I am not willing to go to the "big house" on their behalf.

The problem is that doctors may differ in their philosophy, approach and personality. There may be multiple acceptable options for each couple and it takes time to discuss all options as one works towards making a decision.

So how do you know that you can trust the advice that you are getting? First, consider the source. What is your physician's training background...how long has he/she been in practice...does he/she look as young as Doogie Howser (I used to get that a lot but not anymore)....and what services does your doctor offer (full range of fertility treatments; no IVF; only IVF; no Donor Egg etc etc).

Then when you can no longer figure out where to go you can always ask if your RE ever worked as a camp counselor at a Boy Scout Camp...


Have a great weekend!

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