Natural Cycle IVF Success After Essure

This has been a busy month for patients with prior tubal ligations. Although some patients with a prior tubal ligation will opt for a surgery to reverse their tubal ligation, most will pursue IVF. The data seems to favor IVF over tubal reversal if the patient is over age 37. Of course, other factors also come into play when making this decision. The presence of male factor infertility, the ovarian reserve of the patient, the desire for additional children etc…

More recently those patients seeking sterilization have undergone hysteroscopic sterilization with Essure. Essure is a procedure in which silicone-free inserts made of a polyester fiber, nickel-titanium and stainless steel alloy titanium coils are placed into the fallopian tubes from the uterus during hysteroscopy. The resulting inflammation causes the fallopian tubes to become blocked as they exit the uterus (proximal occlusion). Patients like Essure because the procedure is done hysteroscopically and is therefore less invasive than a traditional tubal ligation performed laparoscopically.

Although there have been a few reports of pregnancies using IVF in patients with Essure inserts in place, none have been in Natural Cycle IVF to my knowledge…until now that is. I have been concerned that the presence of the inserts could decrease implantation rates. Our patient had inserts that were clearly visible on sonogram. She and her husband did not desire stimulated IVF and were much happier with the NC IVF option since no extra embryos would be created. She conceived on her 2nd NC IVF attempt and everything looks great so far on sonogram.

Essure has also been suggested as an option for patients with hydrosalpinges who need surgery to block off the tubes prior to IVF. Although several studies have looked at this option, again the numbers are pretty small but reassuring. I may consider suggesting this option in the future but would still like to see some additional published series that address this question.

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DrG on NBC

This morning one of my favorite patients, Kaet Ruffner, joined me on the Midday Show on NBC channel 4 here in Washington, DC. The topic was the comments that Mr. Gingrich had made concerning oversight of IVF and specifically concern about extra embryos. Of course, there are no extra embryos in Natural Cycle IVF ....one egg, one embryo, one baby. So off we went to NBC to talk about NC-IVF....

View more videos at: http://nbcwashington.com.

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Endometriosis and NC IVF

One thing is true in medicine and that is that you never want to be an interesting patient! Seriously. You should aim to have the condition that your doctor sees all the time and knows exactly what to do. As soon as you start getting a lot of "hmmms" and "wow, that is unusual'" then you may feel free to panic a little bit. Not a lot. Just a little. Because being an interesting patient doesn't preclude a happy outcome! It just means that when you are successful then the medical team feels like they deserve a victory lap. So here is a headline for today's blog about an interesting patient....

NC IVF results in only 2nd pregnancy ever reported in a patient with endometriosis hemorrhagic ascites undergoing IVF!

Ascites is a medical condition in which excess fluid accumulates in the abdomen. Usually we see this in young patients with OHSS. Oncologists see it in patients with cancer. This past year I saw a patient that had recurrent ascites resulting from severe endometriosis. How rare is this condition? Well there have only been 63 reported cases worldwide since 1954 ! That's pretty darn rare.

The patient had first noticed the problem in 2009 and had undergone several procedures to drain the blood fluid that accumulated slowly every day. Lupron dried up the fluid but she came to see me because she wanted to conceive.

We performed a laparoscopy in April 2011 and I was shocked to see how severe the endometriosis was at that time. I thought that it was actually ovarian cancer but the pathology proved it to be endometriosis.

Her options for fertility treatment were limited since we were concerned that the use of fertility drugs could make the whole process a lot worse. Her tubes were very damaged by the endometriosis that was everywhere so she needed IVF…..

Natural Cycle IVF to the rescue! She underwent one cycle of NC IVF. Egg collection was a bit unusual as the ovary was literally floating around in her abdominal fluid but we got a healthy egg, a beautiful embryo and a positive pregnancy test. She is currently almost 12 weeks pregnant and doing great! Another first for NC IVF and Dominion Fertility!

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Question 61. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?

We often have drug reps in the office at lunchtime. As there are only really 4 companies that make pharmaceuticals that are used in fertility we get to know the reps pretty well. This past week we were speaking with a couple of reps about vaginal progesterone in lieu of PIO. The data is very good regarding success with vaginal progesterone but honestly some patients just prefer the shots because the suppositories are so messy.

Both Endometrin and Crinone may prove less annoying to patients who want a shot-free 2ww but these products are also more expensive. I advise the husbands that they do NOT have a vote in this decision unless they are willing to take IM injections themselves. Just because I am driving a new car with the vanity plates CR1NONE should not be taken as evidence that my support of a product is based on anything except a careful review of the medical literature. But seriously, I really do not believe that most doctors are swayed to prescribe a drug just because they got a free pen or because the drug rep is a former cheerleader (although in fact, most drug companies do advertise in Cheerleader magazine according to this NY Times article).

So as we head into a beautiful weekend here in Washington DC here is the latest excerpt from 100 Questions and Answers about Infertility....

61. I had an allergic reaction to the progesterone in oil shots. Does this mean that I cannot do IVF?

Following follicle aspiration, most clinics place patients on progesterone supplementation. The rationale behind the supplemental progesterone is that following egg collection, ovarian hormone production may be impaired because many of the hormone-producing cells are removed at the time of follicle aspiration. In addition, the use of GnRH agonists such as Lupron may diminish ovarian steroid production following egg collection. Progesterone supplementation has evolved over the years to include patients undergoing both stimulated IUI cycles and IVF.

Although many clinics tend to use progesterone-in-oil injections, equivalent pregnancy rates have been reported in patients using only vaginal progesterone supplementation. Allergic reactions to progesterone are infrequent, but switching patients to vaginal progesterone usually resolves the problem.

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Can NC IVF work following a failed stimulated cycle IVF?

When a stimulated cycle IVF fails it is devastating to say the least....all that money, all those shots, all those morning visits, the bloating, the cramping, the PIO shots....yikes, it's a wonder we can convince anyone to try it again. Thank goodness the husbands don't have to go through all that or our business would fold overnight!

So following a failed stimulated IVF it is typical to ask what other options do I have. In cases of poor responders who may have not even made it to retrieval the answer has been "not much." Some of these patients will still conceive on their own, others will try a new protocol (or add DHEAs or human growth hormone or snake oil or miracle grow..). Donor egg or adoption are great options but not every couple will consider these as viable choices. So can NC IVF work in such a setting? "Certainly not," the critics of NC IVF would opine! After all, this approach to IVF is a terrible choice for any patient and how could this approach work in cases where our best treatment has already failed.

Sound logic. However, it just happens to be disproven on a near weekly basis by our patients who pursue NC IVF. Last year I asked what readers wanted from this blog and the majority stated they wanted patient stories so here are 2 vignettes that illustrate the use of NC IVF in patients over 35 with diminished ovarian reserve and failed stimulated cycle IVF!


Patient #1: Bonus baby with NC IVF after being told FSH levels precluded another IVF attempt!


Just received a wonderful email from a lovely couple who traveled all the way from Georgia to do NC IVF here at Dominion. Having had a previous IVF/ICSI baby in 2006 they had returned to their RE for another attempt at IVF. Previously the response to medications had been poor and this time the response was even worse with no retrieval even attempted. Her FSH was 18.9 and they were told that essentially no good options existed in terms of IVF. Fortunately, they had heard about NC IVF and we had a phone consult in April with an IVF attempt in June. Her AMH was <0.16 consistent with diminished ovarian reserve.

Her NC IVF cycle was picture perfect and they ended up with a beautiful early blast for transfer then headed back home. I received the good news that the blood pregnancy test was positive and rising fast. Then came the first shock...it was a twin pregnancy. Yup identical twins. Then came the second shock...the twins were sharing the same sac (in medical terminology they were mono-amniotic, mono-chorionic twins). Then the final shock...there was possibly a third sac.....Fortunately, this last shock turned was not true...there was just a probable blood clot that ultimately went away.

Pregnancy went amazingly well and the girls were delivered at 32 and a half weeks. They spent 2 days in the Intensive Care Nursery and should be home soon. What a great outcome to such a surprising story...one egg, one embryo, TWO healthy babies!


Patient #2: Ongoing pregnancy with NC IVF at 40 with FSH of 17 and AMH of <0.1


Back in 2009 I met DM who was turning 38 and been referred to me by one of my patients who had succeeded with NC IVF after being told donor egg was her only option. We discussed NC IVF versus stimulated IVF and elected to try stimulated IVF. On a MDL flare protocol we got 3 follicles but only one egg and she failed to conceive with transfer of that embryo. I suggested we consider NC IVF rather than pursue additional medicated cycles.

Her first NC IVF cycle resulted in a pregnancy but unfortunately she had a miscarriage. The second NC IVF cycle resulted in a healthy full term baby. She returned this Fall to try again. On day 3 of that third NC IVF attempt her FSH was 17. But we got a nice egg, a beautiful embryo and she conceived again. That makes her 3 for 3 using NC IVF. Currently she had an ongoing pregnancy and here's hoping for another successful outcome.

Again this demonstrates the limitation of ovarian reserve testing when applied to NC IVF. When one eliminates the use of fertility drugs all bets are off when it comes to ovarian reserve. Makes our job difficult since patients assume that diminished ovarian reserve = poor egg quality and the relationship just isn't that simple!

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IUI vs IVF...The FASTT Trial

Frequently I am asked about IUI compared to IVF and specifically about NC IVF compared with IUI. Although IUI can be successful, there are clear limitations to an IUI. First of all, unless pregnancy occurs an IUI does little to explain why a couple has failed to conceive.

Could the tube have failed to catch an egg(s)?
Could the sperm have failed to find an egg(s)?
Could the sperm have failed to fertilize an egg(s)?
Could the fertilized egg(s) have failed to grow?
Could the embryo(s) have failed to make it to the uterus and failed to implant?

The answer to all of these questions following a failed IUI is "we don't know."

This is the reason that IVF is a powerful diagnostic as well as therapeutic tool. It is so difficult to counsel a patient undergoing a stimulated IUI cycle with multiple dominant follicles. On the one hand you have to say "well, there are 6 good follicles so we could end up with 0-6 babies..." Then when it fails (which is more often than it succeeds) you have to say "well, we really have no idea why it didn't work." Very frustrating indeed.

The FASTT Trial aimed to look at the impact of omitting FSH/IUI for patients with unexplained infertility who were <40 years old. Its results clearly demonstrated the superiority of IVF first compared with FSH/IUI then IVF if FSH/IUI were unsuccessful. I think that NC IVF is also superior to IUI. Perhaps the comparable option would be CC/IUI but I think that NC IVF is likely superior to even FSH/IUI in cases where a couple has no previous pregnancies or there is possible male factor or possible tubal factor or endometriosis. Since many patients do not have a laparoscopy these days, it could be that many of them have an element of tubal disease or endometriosis and clearly IVF would be superior in these patients.


So for those wanting to conceive FAST.....think about the results of the FASTT trial and give strong consideration to IVF. It is not the only option but it may be the best option...whether it is NC IVF or stimulated cycle IVF.

Good luck.

DrG

A randomized clinical trial to evaluate optimal treatment for unexplained infertility: the fast track and standard treatment (FASTT) trial. Fertil Steril. 2010 Aug;94(3):888-99. Reindollar et al.

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Here comes 2012!!

Happy New Year! (belated)

Good grief, somehow I have failed to post for nearly 6 weeks….How is this possible? Beats me but I am hoping to make up for it in 2012. This past year was full of ups and downs. I am hopeful that 2012 will be a little bit less of a roller coaster ride for the world economy. Last weekend I was camping (yes, in a tent) with the Boy Scouts at the USNA Jambo at Annapolis. It was pretty chilly at night and I may indeed be getting too old to sleep outside in a tent when all standing water freezes solid…Be that as it may, I was so impressed by the young men and women at the Naval Academy. What a great education and what outstanding young people…it gives me hope for the future that I rarely feel when reading about 20 somethings living in their parents' basement playing X Box 15 hours a day and transforming slowly into Jabba the Hut. So last weekend I was too busy to work on the blog.

I did get a week off as well just after Christmas and then there was an avalanche of charts to deal with upon my return. Still not sure where all my time went. I have no recollection of being abducted by space aliens so who knows how i managed to neglect the blog so long but there you have it.

There are still numerous chapters left to cover from our book. There are some very interesting cases from our clinic to share (with no identifying info) and there are some clinical questions that I really want to discuss.

As we start this New Year of 2012 I would also like to address those who wish to post a question or comment.

First of all, when you post a comment it goes to my Inbox before it gets posted to the site. Thus, don't fret if you fail to see your well constructed post appear with a single mouse click. I was getting so many posts about Viagra that I had to change my settings with Google so all posts had to be approved by me before they are posted to the blog.

Secondly, it would be nice for those who post comments to enter some sort of screen name. I get tired of replying to Anonymous #1, #2, #3 etc etc. No salesman will call. No email spam will be sent. I just think that if you are asking for an opinion then you can at least share some sort of name with me…even if it is totally unrelated to your real name.

Finally, if you are dying to read my opinion on a particular issue then please post it as a comment to this post and I will try to cover it this year. Medical issues are preferred but I can certainly weigh in on my favorite DC Pizza restaurant or why my wife hatesd Tom Brady and the New England Patriots and other matters of critical importance….

Happy New Year to all!

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