No Period, Retained Cysts & Fibroids, After IVF Cycle Cancelled: 47 Year Old IVF UK Patient Worried

QUESTION:

I am 47yrs. I had my 6th IVF (in vitro fertilization) cycle in September 2011. The drugs used were climara patches10 days before the cycle began, prednisolene 10mg daily, aspirin 81mg daily, bravelle 6 vials every morning, menopur 2 vials every evening later increased to3 vials and antagoni ganirelix acetate injection. I had 5 follicles before the cycle was abandoned. One on right side 9.5 and four on the left 16, 11, 7.5 and 6. My cycle was abandoned because the follicles didn't grow at same rate and the antagonist may have been administered late.

I have two issues:

1) I have not had a period for about 50 days, though I had spotting and a discharge 10 days after the ivf cycle was abandoned. A vaginal US 2 days ago which indicated that I have multiple large follicle/small cysts ..3 large follicles of 20mm each on left ovary and 1 follicle 4.3 mm on right ovary, endometrial thickness was 9.1mm. Urine peg test was -ve. I am awaiting results Blood tests of hormone levels and peg test. My question is is it normal not to have a period long after after some types ivf cycles.since my period returned to normal 10days after my other 4 previous cycles? Or could the drugs have triggered menopause? Would the 3 large follicle disintegrate eventually?

2) I have 6 uterine fibroids, between 20-28mm, outside the womb. Also, a recent immune blood test revealed that I have a raised Th1:Th2 cytokines ratio of 33.2 and Cd19,Cd5 cells of 13.6. The clinic I attend does not think I should be bothered about these issues since the challenge is for me to produce good quality eggs but I wonder if I should continue ivf treatments. What do you advise? I am writing from UK. With regards, M. from the UlK.

ANSWER:

Hello M. from the U.K.,

It's unfortunate that your cycle had to be cancelled. I had to do the same with a patient of mine this month because the follicles were not growing. It happens with decreased ovarian reserve. You have been quite dedicated to your desire to become pregnant and hopefully your dedication will pay off in the end. As long as your ovaries are still stimulating, then there is a chance, given your age.

In terms of your menses not starting, that is probably because you have the three retained cysts present. They are probably still hormonally active and so there is not the hormone withdrawal that i needed to start the menses. You can either wait it out, or your doctor can prescribe the birth control pill to suppress the cysts.

In terms of the fibroids, they are rather small and should not interfere, but there are some studies showing that fibroids can reduce the chances of pregnancy. I agree that the main hurdle you have is your age and the resultant quality of eggs. But, if you were wanting to do everything possible to increase your chances of pregnancy (short of using donor eggs), then you might want to consider having the fibroids removed prior to another attempt. It is not absolutely necessary, but only an option. In terms of the killer cells, I don't anything more needs to be done.I am impressed that the clinic you are attending is being very aggressive in your treatment, and allowing you to continue to try with your own eggs. That is commendable. Many of the letters I received are from patients whose clinics are not very aggressive.

Follow Up Question:

Many many thanks for your answer. It was amongst my junk mail so I did nt see it earlier. I was very encouraged.

My follow up questions are:

1) How long after an abandoned ivf can I try again? Given that my periods have not started. My clinic had advised that I take the pill for two weeks and then start another ivf cycle immediately on day 2/3. However, I choose to wait for the periods to start naturally and then attempt the following month...that would be about 4 months after the abandoned cycle. I wonder if the drugs may still be in my system now and if it will help provide more good quality eggs if I take the advice of my clinic.

2) Do you think taking intralipids for the immune problems will help? I noticed that it is gaining popularity. I prefer it to the other edications being suggested i.e taking humira jabs for two months prior to the ivf.

3) Surgery to remove the fibrods is not an option for me....however, I learnt that there are other means of shrinking them but since they are small and dont bother me I dont want to interfere with my ivf treatment since time is not on my side.

4) Since, I missed my periods I have been having dull headaches especially when I wake up, my BP has been hoovering around 148/95, increased acne on chin and back and my hair has been falling out alot. Are thse symtoms of the missed periods or the after effect of the stimulation or the side effects of DHEA Supplementation which I have been taking for about 1 year now.

Kindly advise, M.

Follow-Up Answer:

Hello Again,

I think that two weeks after a failed IVF cycle is a little too soon, but my usual minimum waiting time is 4 weeks (1 month). I place the patient right back on the birth control pill once the period starts and prepare for the next cycle. I don't find a need for a "natural" period to occur. Because time is of essence for you, you cannot predict when your ovaries will shut down, I don't recommend that you wait a long period of time.

Intralipids is not indicated for this problem. It will not do anything to help your eggs. It is mainly used for patients that have an immune factor issue. I would opt to leave the fibroids alone unless you wanted to remove all potential obstacles. Fibroids have not proven to be detrimental to IVF unless the fibroid is within the uterine cavity. It could be a side effect of the DHEA which would increase your serum androgens (male hormones). I am not a big fan of using DHEA.

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.