Question:
Hi again Dr Ramirez, it's K. in NY.
I have written in the past about my multiple miscarriages/chemical pregnancies. I tested positive for the MTHFR mutation this past fall. I had a miscarriage at 9 weeks in August, which you believed was most likely due to a virus I contracted. I have followed up with a new specialist recently, and received some new information today.
First of all, my right tube is definitely blocked (although most of my miscarriages/chemical pregnancies resulted from ovulating on the right) We are led to believe that I most likely had a few early ectopic pregnancies. The specialist today suggested that I undergo surgery to remove the right tube completely. I am not sure how I feel about this, as surgery for any procedure is risky. Do you feel that having the tube removed would increase my odds of becoming pregnant? I am willing to do it if it makes sense, but hate to do it "just because". I am not sure if research supports this practice or if it doesn't really make a difference in the long run.
The second piece to this scenario is that my husband was diagnosed with a translocation between chromosomes 11 and 13 (46xy,t(11;13)(q21;14)). IVF (in vitro fertilization) was suggested to us, but we do not have the money for this and it is not an option unfortunately. Our Dr prefers to remove the tube and discuss fertility meds and other options after that point. While it explains many of our losses, I am curious if you have any other treatment suggestions. We have two healthy children that we had no difficulty conceiving. I have taken femara multiple times (pregnancy x1) and progesterone. We have not tried IUI, but were wondering if it would be of any benefit. I am just confused with all of this new information as to how to proceed conservatively. I am willing to take meds and try IUI, but I would rather not have surgery at this time unless there is a strong link between increased fertility and tube removal. Also, if we continue with meds and u/s, is there a point in being aggressive on months where I ovulate on the right?
We are just looking for the best path to take and I am hoping that you have some input to help us make an informed decision. Obviously this journey gets more difficult with every diagnosis. Thank you for your time.
Answer:
Hello K. from the U.S.(New York),
So sorry about your secondary infetility problems. To begin, there are no studies to either validate or invalidate the recommendation to remove a nonfunctioning tube unless it is blocked at the fimpiated end (called a hydrosalpinx). In that case, it has been shown to decrease pregnancies via IVF and is thought to impair implantation. It is recomnended to remove or separate the tube from the uterus. However, your doctor's recommendation is not unreasonable. Considering that it is not predictable as to which tube the egg will go into, each month you have a 50/50 chance that the egg will get picked up by the wrong/damage tube, and therefore will not get pregnant. In addition, you are risking ectopic pregnancy should the sperm get through on that side. I think that removing the tube might give you a better chance at getting pregnant because that only leaves one tube where the egg can go, and it does not matter which side the egg is ovulated from. They all go into the culdesac where the tubes lie.
In terms of your husband's translocation, that certainly can be a cause for miscarriages, just as your postive MTHFR can be a cause. There are no real good solutions for his problem other than doing PGS (preimplatation genetic screening) in conjuction with IVF. You'll just have to take your chances. I am not sure that IUI will offer you any more than trying as you have been, but statistically it does give a slightly increased chance of pregnancy if 2-3 eggs are ovulated at a time. That's the only advantage.
Good Luck,
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.
