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PCO and other Fertility Related Topics

Posted May 13 2010 8:09am
PCOS 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. 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 the do not always work. Plus are alternative 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
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