Question:
Hi Dr. Ramirez,
I am writing to you as I am now desperate with our situation and hoping to get some push from someone who is knowledgeable in this field. I am 34 and my husband is 40. No kids from both sides. We've been TTC for 2.5 years now. When we started, our bloodwork both came back normal as per my family doctor although he mentioned that my ANA (anti nuclear antibodies) is out of the normal but he said he's not sure if it has something to do with fertility or not and he'll leave it up to our RE to decide. My ANA is positive 2+ speckled pattern.
I've always been regular with a 26-29 day cycle. We first visited our RE in April 2011 and he said I should go for additional bloodwork which I did and came back normal. So he said I am generally healthy, no weight or smoking problems. My husband didn't smoke too. I also did BBT (basal body temperature) charting and my RE confirmed that I am ovulating regularly. I went for an HSG (hystergosalpingogram) in June 2011 and they said they can't get the fluid to get into my cervix or uterus so they considered me blocked.
I went for laparoscopy on July 2011 and my RE told me that I have stage 2 endometriosis but he was able to clear it out and my left tube is open while the right is still blocked. He said we only need 1 tube to get pregnant so he prescribed me with Clomid in August and did a scan at cd 12 and he saw 2 mature follicles in my left ovary. We didn't get pregnant that month so I went for another month of Clomid but I noticed that month, I didn't get the cervical mucus that I usually have during my fertile days. I told my RE so in October he switched me to femara and had another HSG done. He said he unblocked my right tube so I am perfectly healthy. We did another scan at CD 12 and my RE confirmed that I have 2 mature follicles, one from each side so he said I should get pregnant pretty soon. He gave me 2 more prescriptions of femara and told me not to come back to him until Feb 2012 or when I am pregnant. I am now in my final dose of my femara and really desperate :(. While taking femara I didn't notice my cervical mucus coming back to normal. I think it was the same case as with clomid. I am dry during my fertile periods so I started using preseed in November.
Now my questions are, what do you think are the other options that we can take besides IVF? I've never tested positive in a test since we started TTC. I've never taken birth control pills in my entire life. Do you think my positive 2+ ANA has something to do with our infertility? My RE seems to ignore it and I am not too sure if I still have to remind him about it. What do you think about the fertilaid supplements? I am just in a desperate mood now so I think I am taking any chances. Any advice on the next steps to take?
Sorry for the long post. I would really appreciate your reply on this. I hope you had a fantastic holidays!
Here's my husband's numbers:Volume 3.5 mlpH 7.6Motility 50%Speed 4Count 48 million/mlMorphology 80% normal. I don't have some of my bloodwork numbers so I cannot post but my RE said it looks ok. Thanks in advance for your reply. F. from Canada
Answer:
Hello F. from Canada,
First let me say that you should not feel "desperate" at this time. You have plenty of time to work with because you are young, and options open to you. You are just beginning your journey so you just have to accept your situation and move forward through it, do what must be done and look forward to your eventual success.
It is worrisome to me that you only have one tube open. Why is there a tubal problem at all? Could this imply that although the tube is open that it is not functional i.e. that there is internal damage? If the tube is not functional then natural pregnancy cannot occur as the tube is an essential part of the process required to become pregnant by natural means.
The second problem you have is the endometriosis. Endometriosis, even if treated surgically, can still be present in microscopic form. It is surmised that this ectopic tissue, i.e. tissue that is not supposed to be present in the pelvis, causes a low level inflammatory reaction that that interfere with the egg in its travel from ovary to tube and therefore prevent pregnancy from occurring. One consideration would be to undergo a 3 month treatment with Lupron in order to get rid of any microscopic residual endometriosis followed by aggressive treatment to achieve pregnancy.
The alternative is IVF to bypass the pelvis altogether. Yes, Clomid and Femara (to a lesser extent) can block estrogen receptors and therefore lead to reductions in cervical mucous and endometrial thickness (that is how they work..they trick the pain into thinking it is not making enough estrogen so that it stimulates the ovary harder, which in turn makes more estrogen). These are side effects. These can be treated by giving vaginal estrogen tablets.
I don't think that the ANA is having any affect on your lack of pregnancy at this time. But, you could take an 81 mg tablet of aspirin daily to help overcome this. It's an easy treatment. (For my readers information, an ANA test detects antinuclear antibodies in your blood. Normally your immune system makes antibodies to help you fight infection. In contrast, antinuclear antibodies often attack your body's own tissues — specifically targeting each cell's nucleus. But some people have positive ANA tests and are perfectly healthy.)
I am not a proponent of fertiliaid. I think the product is just preying on people like you who are desperate and will try anything. I don't think that it helps.
In terms of other options, if the simple ovulation induction with Clomid, Femara or injectables is not successful, and I would not recommend continuing with this strategy if no pregnancy occurs within 6 months, then the next level of treatment is IUI. I would not recommend more than 4 attempts at IUI. If all the above don't work, then you should move to IVF.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
