Diagnosis: Infertility Caused By Endometriosis
by Royalyne

What Endometriosis Means and Its Impact on Fertility

Endometriosis is a condition in which endometrial tissue (the tissue that lines your uterus during your cycle and is shed during menstruation) occurs outside of the uterus. It can be found pretty much anywhere inside your pelvic cavity: fallopian tubes, ovaries, bladder, bowel, etc. The adhesions can cause varying levels of pain during menstruation or intercourse, from no pain at all to debilitating pain. As the adhesions grow they can impact thetissues they are on. Endometrial adhesions on the ovaries can cause endometrial cysts (called endometrioma). Adhesions on the bladder or bowel can infiltrate and obstruct. Adhesions on the fallopian tubes can infiltrate or constrict and result in scar tissue forming. In addition, scar tissue on the fallopian tube can prevent eggs from passing into the uterus to implant (which can lead to an ectopic pregnancy). Endometrioma can affect ovulation and scar tissue on the uterus can prevent implantation or lead to miscarriage and premature labor.

There are varying levels of endometriosis, from level 1 which usually causes no symptoms to level 4 which can seriously impede fertility.

Diagnostic Process

Endometriosis cannot be seen on ultrasound or diagnosed with blood testsor pap smears. The only way to diagnose endometriosis is to undergo laparoscopic surgery. During the surgery, a small incision is made in the abdomen for a tiny camera and a second incision is made to facilitate a tube used to pump air into the abdomen. Inflating the abdomen allows more space and a better view of tissues. During surgery the adhesions can be removed.

Treatment Options

Many doctors will also recommend Lupron injections. Lupron basically “kills” the adhesions by halting the growth for 6 months. Endometriosis is also controlled with birth control pills. Birth control pills can be used to treat symptoms or to prevent/control a reoccurrence after surgery.

Personal Experience

My endometriosis was level 4, affecting one ovary with a large endometrioma. The endometrioma pulled that ovary down and behind my uterus and twisted the fallopian tube. There was also a small adhesion to my bladder. I had debilitating pain during menstruation–it was so bad that I couldn’t walk and often vomited from the extreme pain which was not reduced by any OTC or prescription painkiller. My laparoscopic surgery lasted over 3 hours (I was scheduled for 1 hour of OR time) to remove all the adhesions and re-anchor my ovary where it belonged. I had spent 5 years on triphasic birth control pills, which kept me symptom-free for the duration. I chose against Lupron because I didn’t feel the side effects were worth it for me.

Natural Miscarriage
by Lisa Blogger

First of all, if you’re reading this for advice, I am very sorry that you’re going through this. I’ve had two natural miscarriages, one at 8 weeks with a blighted ovum and one at 9 weeks with an embryo measuring only 6 weeks. I am not an expert on this by any means, and I do realize that every experience is different, but hopefully this will be of some help.

Pregnancy losses that occur prior to 20 weeks are called a miscarriage. While some pregnancy losses necessitate the use of a D & C, other pregnancies end without medical intervention or assistance. This write up is for a natural miscarriage.

Why You May Have a Natural Miscarriage (rather than using medical intervention)

Some doctors will take a “wait and see” approach once there is an indication of a potentially failing pregnancy, particularly if it is a first pregnancy. Other doctors are inclined to suggest natural miscarriage rather than a D&C due to the potential for post-D&C complications (scarring, for example, or if you are not good with anesthesia). If there is a possibility that you are off on your ovulation calculations, many doctors will not suggest a D&C until a second ultrasound a week later confirms that the pregnancy is not just progressing slower than expected.

What You Can Expect

While both of my natural miscarriages were different, there were also similarities. Both times, spotting was my indication that something was wrong, followed in both cases by an ultrasound that confirmed we were likely going to lose the pregnancy. After the ultrasound, things moved rather quickly the first time (I miscarried that evening), but more slowly the second (it took three days to complete).

In most cases, bleeding will begin to increase first. Cramps will begin, often mild but will intensify as the miscarriage progresses. My first miscarriage felt almost like what I’ve heard labor pains feel like, in that there was a rhythmic pattern to them and they were very intense at the end. When I was in the midst of one, it helped immensely to have a microwavable heating pad wrapped around my lower abdomen, and it was almost necessary that I was up and walking — sitting still seemed to make the cramps worse. Also — and this may sound odd — but I somehow knew when I was going to pass a clot or tissue, because I had the urge to go sit on the toilet. As a result I did not bleed as much on a pad as some people might.

The cramps will be the worst while you are passing tissue or large clots. After this occurs, the cramping will subside and the bleeding will begin to taper off, although this may still take a day or so. Your doctor will likely want to schedule a series of betas to make sure that your levels are dropping to zero (some doctors will only test to <5). Problems That May Arise and Ways to Troubleshoot

If you are bleeding so much that you are soaking a pad in an hour or less, you should go to the emergency room, as this could indicate hemorraging or other problems. Have someone drive you — rapid blood loss could cause you to faint or pass out. It is possible that you will still need to have a D&C if there is retained tissue; a sign of this may be that you are still bleeding heavily after most of the tissue has passed. Your doctor will most likely want to do an ultrasound or at least a repeat beta to see whether your levels are not dropping off.

Personal Tips

If you have seen your doctor for an ultrasound or other diagnosis prior to the miscarriage, try to remember to ask your doctor what their recommendations are and for a script for pain medicine if you think you’ll need it. I know that it’s an emotional time, but try to make sure you are looking out for your body as well. I was distraught the day of our ultrasound and was given no advice on what would be considered an emergency, when to call the doctor, or whether it was safe to take Advil or something stronger. Luckily I had online friends and resources that could tell me some of the things I describe here. When I was still reading loss message boards, I’ve seen many people ask whether they should try to get a tissue sample to their doctor for chromosomal testing. There are a few problems with that with a natural miscarriage, mainly that by the time you would be able to get the sample to your doctor it would likely be unusable, not to mention collection/storage and the emotional aspect of doing this.

I was extremely calm during my miscarriages, but extremely emotional afterwards. Be sure that you take some time for yourself if at all possible and just allow yourself to feel whatever you feel. It will help with the grieving process if you do not try to resume “normal” life immediately.

Questions When Choosing a Reproductive Endocrinologist (RE)
by Cara

The best type of patient is a prepared patient! I was both excited and anxious for my first appointment with my RE. I find I function best when I know what to expect and I stay calm if I am organized. In order to help you through this potentially nerve-wracking first experience, I have prepared a list of tips, questions and expectations for your first appointment with your RE. If you are not satisfied with the answers from the first RE and clinic that you visit, I urge you to keep looking for one that is a better fit.

Tips for your first appointment:

• Bring your list of questions with you
• If possible, have someone accompany you to the appointment–2 sets of ears are better than one
• Take notes during the consultation
• Bring relevant medical records: surgeries, recent pap test, list of medications
• Bring copies of any fertility work up you or your partner have had completed with the OB
• Bring list of concerns/observations about your cycle. If you have a month or two before your first appointment, try charting your basal body temperature
• Do not leave your appointment until all your questions are answered to your satisfaction!

Questions, Questions and more Questions!

About the Clinic

• How long has this clinic been in business?
• What are your office hours?
• What procedures are performed on the weekend?
• Are the Clinic and Lab open 365 days a year?
• How much work should I expect to miss?
• Do you provide pre-natal care? If not when will I be released to an OB?

About Communication

• Who is the case manager?
• Who is available if I call with questions?
• Can I leave a message for my RE? Can I email my RE directly?
• How long will I wait to receive a return call/email?
• Is there a number for off-hours problems?

About the Reproductive Endocrinologist (RE)

• Where did you earn you degree?
• What is your training in infertility? Are you board certified as a reproductive endocrinologist?
• What hospital are you affiliated with?
• Will I always get to see you?
• If not, how many REs are part of the group?
• Will I always see the same nurse?
• Will all my treatment and procedures be performed by you?
• How often will I get to meet with you face to face?
• How open are you to discussing information that I have learned about from other sources?
• Do you recommend counseling?
• Do you have a counselor on staff? If not, can you refer me to one?
• What books do you recommend reading?
• What is your view on alternative treatments (acupuncture, TCM, vitamins)?

About Initial Evaluation

• What tests do you perform to evaluate me/us?
• How long will it take to diagnose my/our problem?
• What specific tests would you recommend to diagnose my infertility?
• How long will you wait from the time of diagnosis to starting treatment?
• What do you see as our first step in treatment?
• If that fails to produce a positive, where do you see us moving next?

About Treatment and Procedures

• Will my treatment be individualized or will you follow set protocols?
• What procedures do you perform at your clinic?
• Which do you perform on-site? Which in a hospital?
• How will you proceed if we have unexplained infertility?
• Do you monitor while on Clomid?
• What kind of monitoring should I expect for other types of medicated cycles?
• During a treatment cycle, how often will I have to come into the clinic?
• What are your office hours for different procedures (ie: Blood tests, ultrasounds)
• If we go to IUI or IVF, can I bring in sperm sample or does it have to be produced in the clinic?
• How long do you stick with a particular treatment before moving forward?

About the Lab

• Do you have a Donor Egg and Donor Sperm programme?
• Do you do Blastocyst transfers?
• Do you do Assisted Hatching?
• Do you do Intracytoplasmic Sperm Injections (ICSI)?
• Do you do Pre-implantation Genetic Diagnosis (PGD)?
• How long do blood tests and other results take to receive? What is the procedure for getting the results?

About Expenses

• Do you have a price list? Can you run through it with me?
• Do your fees include the medications? Injection Instruction?
• Is it possible to set up payment plans?
• Will my insurance pay for the testing and/or treatments?
• Will your clinic help me determine what my insurance will cover?

About Success

• May I contact any of your patients who have had similar treatments?
• What are your statistics for couples with our diagnosis?
• What are your live birth statistics for different procedures?
• How do your statistics stack up against national averages?
• What would account for these differences?

What you might expect from your first RE appointment:
You can expect your first appointment to last from an hour to two hours. You will meet with the RE and your primary care nurse. The RE will ask you about your medical history as well as your sexual history. Check your embarrassment at the door! The more honest you are with your doctor, the quicker he may be able to arrive at a diagnosis and treatment plan. Whenever I feel myself getting embarrassed about something, I think: no matter how weird/abnormal this seems to me, the doctor has certainly seen worse!

At your first appointment your RE will probably order blood tests to check for the following diseases: Rubella (female only), Chlamydia (female only), HIV antibody, Hepatitis B surface antigen, Hepatitis C antibody, RPR (syphilis).

Depending on where a woman is in her cycle, your RE may also take blood to check the following: Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), Estradiol, Progesterone, Prolactin, Free T3, Free Thyroxine (T4), Total Testosterone, DHEAS, Androstenedione.

For women, the RE may also wish to perform a vaginal ultrasound to look for any abnormalities, measure ovarian volume and look at antral follicles. The RE will probably order a Hysterosalpingogram (HSG) to be done between days 7 and 10 of the next cycle.

Men may also do a semen analysis, even if they have done one or two before. Be prepared: abstain from sex 3-5 days before your appointment! If the man has had previous semen analyses with abnormal results, the RE may refer him to a urologist. The urologist will order blood work to look at hormone levels, and he may recommend a testicular ultrasound.

IVF (FET or Frozen Embryo Transfer)
by Bea

Why Would You Be Having An FET?

1. Because you had extra embryos left after your fresh transfer cycle. There is a limit to how many embryos can or should be transferred at one time. This limit will vary from patient to patient, for both personal and medical reasons, and also according to the laws and guidelines in your region of the globe. Extra embryos of good enough quality can be frozen for later use. This cuts down the amount of drugs and treatment you need to have to achieve a pregnancy.

2. Because, although you made nice embryos, your fresh transfer was cancelled. This may be the case if you are at risk for ovarian hyperstimulation syndrome.

3. Because you are using donor embryos (which will usually be frozen).

What Can You Expect?

1. First, your specialist will decide on a protocol. In some cases, there is a clear reason for choosing one protocol over another – a post-menopausal woman, for example, will most certainly be prescribed a HRT protocol (see below). Other cases rely on a review of many factors, including cause of infertility, clinician and patient preference, and response to previous protocols. In other words, it’s very complicated and frankly, half the time it’s either hard to know what is best in advance, or it will make little difference to your chances of success either way.

At the basic end, you have the natural FET. You are monitored for ovulation and lining thickness, and embryo transfer is scheduled for several days after ovulation. The exact timing will depend on the age of the embryos at transfer. If you have frozen the embryos at day two, transfer will happen two days after ovulation. If you have frozen the embryos at day five, transfer will happen five days after ovulation, and so on. The idea is to mimic the natural process as closely as possible. As in the natural situation, the timing doesn’t have to be ultra-precise, with studies showing there is up to twenty-four hours leeway.

A natural cycle may be used with or without some form of luteal phase support. Commonly you will be given two or three hCG injections and/or progesterone supplements (pessary-style or injections). Again, protocols for luteal phase support vary wildly, sometimes starting before transfer, sometimes the day of transfer, some continuing until beta (and perhaps beyond if your test is positive), and others continuing only for a set number of days, no matter what.

If you don’t ovulate reliably on your own, your specialist may use an ovulation induction (OI) protocol, in which ovulation of a single follicle is induced (usually using FSH injections). You will either be monitored for a natural LH surge, or triggered with an hCG injection. Transfer and luteal phase support happens as per a natural protocol.

Hormone replacement therapy (HRT) protocols are favoured by some specialists, and for some patients. These use hormone tablets, patches, pessaries or injections to mimic the natural cycle, plus or minus a GnRH agonist/antagonist to shut off your body’s natural control. The simplest and most common protocol seems to be oestrogen tablets until the lining is thick and ready, followed by progesterone supplements, with transfer happening near the beginning of the “luteal” (progesterone) phase.

2. Prior to transfer, your embryo will be thawed out. Fifty to eighty percent of embryos survive the thaw. By thawing the day before transfer, the lab ensures plenty of time to thaw extra embryos if need be. It also gives a chance to see if the embryo will resume growth after thawing – those that don’t are very unlikely to survive inside the uterus.

It’s also possible to thaw a batch of embryos and grow them for a few days prior to transfer–for example, if you have decided to grow day two embryos to blast. An embryo can be thawed, grown, and re-thawed providing it remains of good enough quality.

3. The transfer itself is exactly like a fresh transfer. The procedure is similar to an IUI (which feels a bit like a pap smear) except it is performed in the hospital for easy access to the laboratory where embryos are kept and thawed, instead of in the doctor’s rooms. You are usually given a short period of rest, and your doctor will let you know if there are any other instructions. Some doctors prefer you to rest for a day or more, just on the off-chance this helps, although numerous studies show no benefit to restricting your normal activities for more than twenty minutes after the transfer is done.

Problems That May Arise And Ways To Trouble Shoot

1. Problems with giving medication. Please see trouble-shooting suggestions under subcutaneous injections, intramuscular injections or progesterone.

2. Cysts and other nasties. If a cyst is discovered at the beginning of your cycle, your doctor may want to treat it before going ahead with transfer.

3. Ovulation is not happening or the lining is not thickening. Most of the time, your specialist will simply prescribe extra drugs and continue monitoring. If the problem is severe, your cycle may be cancelled and a new protocol put in place for next time.

4. It’s a natural cycle and ovulation is missed. Your cycle will be cancelled and you will be monitored more closely next time, or placed onto a medicated cycle for greater control.

5. Embryos do not survive the thaw. From personal experience, it is possible to thaw four embryos, one by one, in the twenty-four hours prior to transfer, and almost certainly more, depending on how quickly each succumbs. This is, of course, wrenching in its own way, but as long as there are embryos left, you will not need to worry about your cycle being cancelled.

If none of your embryos survive the thaw, it’s possible to start a full cycle straight away. For example, if you usually start sniffing or around day 21 or so of the cycle prior to EPU, you can start your drugs within a week of your cancelled transfer day.

6. Unusual spotting in the middle of your cyle. If it’s happening in your luteal phase, your specialist may prescribe extra drugs to support the lining. If it happens prior to transfer, your cycle may be cancelled pending investigation – depending on the opinion of your specialist. Unusual spotting is very common, not always explanable or treatable, and can happen even in successful cycles. Having said that, please report it to your doctor immediately.

Personal Tips

A frozen embryo transfer is easier, physically and emotionally, than a full cycle. As you can see, problems do sometimes arise, but most people find things go fairly smoothly until beta day – so please try not to let the above list panic you! There is often some trial and error involved in finding the best protocol for your body. Good luck – and yes, FETs do work for many people!

IVF (fresh cycle)
by Serenity

Why would you be doing In-Vitro Fertilization (IVF)?

IVF essentially means “fertilization outside the body.” People undergoing IVF can have the following diagnoses:

Blocked, damaged, or inoperable Fallopian tubes
Male factor infertility (low count, abnormal morphology, etc)
Women with endometriosis
Unexplained infertility
Immunological issues

In general, an IVF cycle consists of a phase where you will suppress your body’s tendency to ovulate with a GnRh agonist subcutaneous medication such as Lupron, then use a follicle-stimulating medication such as Follitism or Repronex to super-stimulate your ovaries into producing a number of eggs. When you have a number of mature follicles, you’ll “trigger” with a shot of HcG, and exactly 36 hours from that shot, your doctor will extract them in a retrieval which is usually done under general anesthesia. From there, embryologists will take the mature eggs and fertilize them with sperm. Transfers of the resulting embryos (6-8 cells) or blastocysts (multiple cells) take place either three (embryos) or five (blastocysts) days after the retrieval. Any excess embryos or blastocysts from the procedure can be cryo-preserved (frozen) for future frozen embryo transfers (FET).

What you can expect

In general, an IVF cycle involves a lot of needles – depending on your protocol, the agonist repression, follicle-stimulation, and trigger medications are delivered via subcutaneous injections. There are some agonists that can be delivered in an inhaler form – you “sniff” the agonist once or twice a day. But generally you will be required to give yourself daily injections.

When you begin your follicle-stimulating medications, too, you can expect ultrasounds and blood draws every other day and/or every day leading up to the retrieval. Additionally, as you get closer to the retrieval, you might become a little bloated and uncomfortable from the extra eggs that are developing in your ovaries.

For the retrieval, like any other procedure under general anesthesia you will be advised not to eat or drink after midnight. When the procedure is over you may feel some pain from the egg extraction and/or nausea from the anesthesia.

And because a doctor is surgically removing the egg from your follicles, there is no corpus luteum to generate progesterone. So after the transfer, you might also be required to have someone give you daily progesterone-in-oil (PIO) intramuscular injections, depending on your protocol (if you’re lucky like I was, you’ll just get the prometrium suppositories instead).

There are a host of potential side effects of the medications you’ll take during IVF cycle. During the repression phase, you may be prescribed birth control pills, which might cause headaches and PMS-type symptoms. In the stimulation phase, you might feel physically uncomfortable and have headaches (I had massive migraines with my Gonal-F until they reduced my dosage). After the retrieval, expect to stay home from work for a few days – you will be bloated and at least a little sore.

Problems that might arise

The biggest issue that might arise is Ovarian Hyper-Stimulation Syndrome (OHSS), where the follicles after the retrieval fill with fluid and leak into the abdominal cavity and into the chest. Symptoms of OHSS include rapid weight gain (2lbs or more per day), inability to urinate, fullness/bloating in your abdomen, and/or a shortness of breath. Mild OHSS will resolve itself in a few days, though if you get pregnant it might take longer. But moderate and severe OHSS can be life-threatening, though fairly rare – less than 1% of patients end up with OHSS this severe.
However, your doctor will monitor your estradiol levels (E2) via bloodwork just before the retrieval. Levels over 5000 are generally not recommended – if this is the case your doctor may have you “coast” (i.e. skip your injections) for a day to decrease your levels.

Personal tips

Take things a day at a time. I was totally overwhelmed with the number of needles and medication I needed for our IVF cycle at first, so I just focused on what I needed to do that day. Before I knew it my medicines were almost gone.

If you can’t do the injections yourself, have your husband do them. I have no issue with needles and did my own injections. However, most women seem to prefer it if their husbands do their injections, and it’s a nice way to keep him involved.

If you do your injection slowly, chances are you won’t bruise. I found that when I rushed my injections I ended up giving myself a bruise. Slower is better.

Drink plenty of Gatorade after the retrieval to replenish your electrolytes. The more fluid you drink, the better chance you’ll have at healing more quickly.

It takes longer than you’d expect to recover from the retrieval. Granted, my E2 was at 5178 when I triggered, so I had a moderate case of OHSS, complete with a burst follicle. But I couldn’t walk far at all for about 5 days after the retrieval, so I stayed home pretty much for an entire week. Just be prepared that you’re going to be uncomfortable and might need to stay home and rest up.