Question:
Hello Dr. Ramirez!
I am 38 and trying to conceive my 2nd child. I did 2 rounds of IVF at 35 and had a healthy daughter at age 36. We just went through another round of IVF and got pregnant, however it ended up in a miscarriage at 10 weeks. We can't afford another IVF so we're trying a few rounds of IUI with Clomid 100 mg. I'm now going for my second round.
My issues are stemmed from a ruptured appendix at 16 which left one of my fallopian tubes badly scarred. I did have a laparoscopy and had that one closed and my other one is totally open. In all the testing for my IVF, everything came back good..."for my age". My husband has a fantastic motility and count, so there's no issues there. My questions are:
1. My RE says that follicle growth is completely random and that they do not alternate sides every month. What are your thoughts on this? I hate to waste the time and money if the follicles grow on the bad side.
2. Have you seen much success with clomid/IUI at my age? Everything is totally normal with me and my husband. We eat good, (I was a smoker from 16-30 but haven't smoked in 8 years) and I rarely drink.
3. If this doesn't work, any suggestions on where to go from here?
BTW, I'm writing from Milwaukee! Thanks!
Answer:
Hello L. from the U.S. (Wisconsin),
First of all, it is wonderful that you were able to already have one child via IVF! This is encouraging.
1. Yes, your RE is correct that it does not alternate but is random. Also, your assumption that the side that it ovulates on is the side where it enters the tube is not correct. In fact, the ovary, being three dimensional, can have a follicle rupture at any part of its surface, even the side that is opposite where the tube is located. So how then does it get to the tube? Well, when the ovary ovulates the fluid surrounding the egg rushes out taking the egg with it and flow down-hill into a space called the culdesac. The culdesac is like a little bowl. The fluid collects here and then with simple fluid motion, it moves around. In normal anatomy, the end of the tube that picks up the egg, called the fimpia, is located in the culdesac, so it you are lucky, the egg contacts the fimpia of one tube and is pought into the tube (like an elevator) where it meets the sperm. This is why a woman who only has one tube on one side and one ovary on the opposite side can get pregnant.
2. Pregnancy rates at 38 years old are around 5% per cycle, which is not very good but it is not zero.The pregnancy rates are less with Clomid than IVF because you and your body still need to go through the 9 step process to achieve a pregnancy whereas with IVF, steps 1-7 are done by the IVF procedure and there is only two steps left to contend with.
3. Monterey, California :) I'm only kidding. You have already shown that IVF can work. The reason that you miscarried is because the empyo was probably abnormal, which is a risk that you have because of your egg. The goal is to eventually get a perfect egg that will give you a perfect and healthy baby. That is probably just a matter of time. The only alternative, which gives you a higher chance for pregnancy per cycle and less chance of a miscarriage, is using donor eggs. But you can do that at any age, so I would try again with IVF if you are not successful with your Clomid cycles, although I understand that finances are an issue. You don't have much time, though. If you do manage another IVF cycle and it fails, then you can always do donor eggs. I recently had a patient who tried IVF in her early 40's, miscarried then failed, and then gave up. At 55 she decided she wanted to try again and went with donor eggs. She now has a beautiful daughter. With donor eggs, your age is not a significant factor.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A
