When Is Surgery The Right Option For Infertility?

September 11, 2007 - Tuesday
5:11 PM to (EST)
Guest Speakers: Charles March, MD

Categories
Endometriosis • Infertility • IUI • IVF • PCOS • Pregnancy Loss

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Corey_Whelan	Hi early birds! Hi Dr. March, welcome. I'm Corey Whelan, Director of Development for The AFA and your chat moderator tonight. We are SO LUCKY to have Charles March, MD, of California Fertility Parnters with us this evening. Dr. March is one of the most respected voices in reproductive medicine and Ob/Gyn today. Tonight, we will be discussing surgery and infertility.
Corey_Whelan	Our chat can begin whenever you guys are ready. Mcoleman, Woodigit, please don't be shy. You know that the chat room fills up quickly so please ask your questions now.
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Corey_Whelan	Dr. March, can you tell us a little bit about what types of surgery are common for infertility treatment?
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Corey_Whelan	Welcome everyone. Please feel free to ask your questions of Dr. March.
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charles_march_md	Laparosocpic and hysterosocpic surgery can correct congenital abnormalities of the uterus, scarring inside the uterus from a prior D & C, fibroids on the interior of the uterus. scarring of the fallopian tubes, tual blockage at either the uterine or tubal sides and scaqrring fro endometriosis
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mcoleman	I am about to have my second laparoscopy. The first time they did cauterization and now they will laser. the first time they found only a little endometriosis. Now I'm w/ another doctor and since I'm hesitant to do IVF, he suggests we do the scope again and back to inseminations, of which I've had 6 so far. Is this normal? Will the surgery make a difference? Will the surgery only be good for so long then I may need a third? I have had no other problems other than infertility, but the only cause seems to be poor ovulation.
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charles_march_md	If the interval between procedures is brief and if the prior cauterization procedure was complete, it is unlikely that you have much endo remaining. AFter 6 inseminations, it's time to move on. More issue may be operative and perhaps IVF is a better alternative at present.
frances1	Age 34 with no obvious problems on workup. Husband has no problems on workup. We have tried to get pregnant with natural conception for 1 1/2 years. I was then put on clomid for 8 months with natural attempt at conception monitoring my ovulation (which seemed regular) and then one clomid cycle with iui. A new physician - reproductive endocronologist has recommended a laparoscopy to see if I have endometriosis. I have no symptoms whatsover. My periods are regular, no pain, light bleeding. Or he will give me an iui but not with clomid or injectables. I am frustrated as to which direction I should go...what do you recommend?
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frances1	I also had a hysteroscopy that showed no blockage and FSH, Estradiol testing that was normal
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vla136	good evening everyone
charles_march_md	If your HSG is normal and you are without symptoms , the chance of finding much via laparosocpy is small. Cloimid beyond three months is rarely scessful. I would recommend 3 cyccle of injectable s+ IUI and then moving to either laparoscopy or IVF.
vla136	Dr. March : what are success rates for a bilateral spermatic vein ligation?
charles_march_md	Hysteroscopy can visualize the tubal openings but CANNOT PROVE TUBAL PATENCY.
krisinva	Dr March, are you familiar with surgery to unclog blocked seminal ducts? My husband just had this surgery 1.5 weeks ago. His Urologist said that we have a strong chance of getting pregnant on our own now, but my RE said that we'll probably still need IUI. What is your opinion?
frances1	I don't undertand what you mean by if my HSG is normal...thank you.
purple	my re found a durmoid cyst on one of my ovaries.. will removing this improve my fertility.. i have pcos
charles_march_md	Both semen quality and pregnancy rates improve. Broad figures for the former are 65% and 40% for the latter (without meds, IUI, IVF, etc) are 40%. However, is male hormores are abnormal r if there any testicalr atrophy, success rates fall dramatically.
charles_march_md	WAs an HSG (x-ray of the interior of the uterus and fallopian tubes) performed?
mcoleman	So if the scope and IUI are not successful, that must mean that probably the tubes aren't picking up the eggs. Would IVF or GIFT be the only other options?
vla136	what is testicular atrophy?
frances1	oh, yes, sorry. It was normal.
krisinva	Thank you for those numbers, they definitely give me hope. I know his hormone levels are normal, he's had the bloodwork done. I'm not sure about testicular atrophy...would that include a varicocele?
charles_march_md	Small dermoids do not pose a problem with respect to infertility and or pregnancy. However, if your PCOS requires fertility meds, removal is advisable frior to ovarian stimulatin
charles_march_md	Tetsticular atrophy is a decrease in the size and softening of the testicle. His urologist can make that determination.
purple	thank u dr charles.. my treatment will require fertility meds this is probably why my re wants it removed
krisinva	My husband does have a varicocele, however we have been pregnant twice, both times before the blockage. Both the Urologist and my RE don't seem to think that the varicocele is preventing us from getting pregnant.
purple	how soon after it's removal will i be able to begin meds?
vla136	if the bilateral ligation was done 3 weeks ago, when will we see improvements in his sperm?
charles_march_md	IVF would also cover issues such as fertilization failure which cannot be assessed .
frances1	So, would back to back IUI without medication be a good option as that is the one I am being given. Anything to help improve my results with this? Thank you.
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charles_march_md	If the intercval between pregnancy and now is brief and if the semen quality has not deteriorated, I agree that the varicocoele is not an issue.
charles_march_md	Ovarian stimulation could begin two months after ovarian surgery.
charles_march_md	4-6 mos after varicocoelectomy, improvement should be noted.
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charles_march_md	IUI without stimulation makes little sense unless I am missing something.
vla136	if I also have PCOS, would be make more sense to go straight to IVF even with the variococoelectomy or should I wait 4-6 months and try naturally or IUI?
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krisinva	Thank you Dr. March. The problem is that we don't have an SA pre-fertility issues to compare. We got pregnant with our 2.5 yr old son right away, got pregnant again about 2 years ago, but I miscarried that baby at 20 weeks (placental abruption). What numbers on an SA point to seminal quality decline? He's had poor motility and morphology, however the Urologist was confident that once the blockage was removed, volume would increase, significantly increasing the other numbers. Do you agree?
purple	do you know of any cases where fertility increased after ovarian surgery
charles_march_md	Ovarian stimulation and IUI would make sense if semen quality improves--I would use a maximum of three cycles before IVF.
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charles_march_md	If his semen quality is significantly decreased, surgery makes sense
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krisinva	Okay, thank you. I appreciate all of your advice.
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charles_march_md	Only laparoscopic "ovarian drilling" in anovulatoiry patients has been shown to improvesovulation and fertility rates as well as removal of ovarian endometriomas.
vla136	when is ovarian drilling deemed necessary?
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charles_march_md	Basically for failed clomiphene therapy in anovulatory patients who wish to avoid injectable meds
tonya	Hello Dr. March, I'm 34 hubby 37 trying for 3 years have used 11 months of clomid new RE states no problems with any of the boodwork, SA or reserve. Should I do a few IUI without meds or go ahead with Lapo to determine if I have endo? I do not have any symptoms of endo. Lapo is not covered by ins and is very expensive.
vla136	I did respond to clomid but not as high as injectables...should I consider ovarian drilling?
charles_march_md	Eleven mos of Clomid?-STOP! If laparosocpy not covered, 3 mos of injectables-IUI and then make the BIG decision--laparosocpy or IVF.
charles_march_md	Ovarian drilling carries with it a high chance of ovarian scarring--I would avoid and stick with injectables.
vla136	Thanks Dr. March
purple	how many sa should one have to diagnose low sperm count
tonya	Thank you Dr. March
charles_march_md	2-3 over a three month period. Remeber motility and morphology are very important parameters
purple	the motility and morphology was fine the count was extremely low though.. 800,000 the 1x and 1,000,000 the 2x.. they performed the tests within 2 weeks of one another
charles_march_md	If none of the ejaculate "missed the cup", he should be evaluated by a reproductive urologist.
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purple	thank u dr march.. he had his first appointment about a month ago and the bloodwork came back ok and he had an ultrasound today and we should know those results by next week
charles_march_md	Hopefully the semen analyses have been done at a "dedicated" facility. Most general hospital labs cannot assess morphology well.
purple	i'm not really sure.. is it possible that the morphology could have come back better than it really is?
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Corey_Whelan	Welcome diedlesree and westgirl. Please feel free to post your questions for Dr. March.
charles_march_md	No the other way, hospital labs tend to call sperm of almost any appearance "normal". Unfortunately most techs have little experience/training in sperm morphology.
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Corey_Whelan	Guys, we have around 15 minutes left to spend together tonight.
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Corey_Whelan	Hi Anitet, welcome.
anitet1	good evening
Corey_Whelan	We have around 11 minutes left to our chat, so please don't wait to ask your questions of Dr. Charles March. Dr. March, if people wish to reach you, what is the telephone number at California Fertility Partners? And also, where are your offices located?
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charles_march_md	310-828-4008. The office is in west Los Angeles, less that a mile west of the 405 Freeway on Wilshire Blvd. We have our own dedicated lab (semen, jormones, etc) and our own operting room
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frances1	do numerous surgeries hurt future pregnancy attempts. 2 miscarriages with d&c's, 3 laps, with laser surgery, hormone therapy, fibroid removal, attempted myomectomy.
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charles_march_md	The procedures tend to be fertility-promoting, but all can lead to scar formatioon which heads us in the opposite direction. I don't understand "attempted" myomectomy
woodigit	I had an IVF last Oct. that ended in very early miscarriage. I had no embryos left. I responded very well with stims. The only problem was that my right ovary moved around too much and they couldn't get anything from that ovary. The Doctor said that I could have another lap and sew my ovary to something so it wouldn't move around. Have you every heard of a surgery for this? I had already had 2 laps. 1 to open both tubes and the second to remove one tube that turned into a hydro.
nikilott	I know time is almost up, but I have a question about ovarian drilling.....
nikilott	What are the chances of success versus the risk factors
charles_march_md	Usually a very mobile ovary can be "braced" by an assistant with a hand of the abdomen. Ovarian suturing can compromise ovarian blood supply. I'd need more details to support that recommendation
charles_march_md	If you can use injectable fertility drugs, I'd prefer those to ovarian drilling
nikilott	ok, thanks
Corey_Whelan	guys, in case you're not aware, the transcript of this chat will be up on line in about a week. You can reference it at will. And if you're not AFA members, of course you should join and support the organization. I think we have time for one or two more questions and then we need to let Dr. March go!
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hoping	i am having a lap after 2 failed ivf's. a second opinion says to just do the frozen transfer instead, no lap. does the lap. help to discover endometriosis?
charles_march_md	Yes, but I'd go with the FET
hoping	because of risk factors of the lap?
charles_march_md	Yes AND because a bit of endo will not affect an FET adversely
frances1	turned out to be adenomyosis instead of fibroid
frances1	so myomectomy was not really performed
charles_march_md	OK, adenomyosis is a tough one and can impact fertility in a more negative way than fibroids and complete removal is very difficult
Corey_Whelan	folks, I'm sorry to say that it's 9:00, and our chat is officially over. The hour goes very quickly! I want to thank Dr. March for his time tonight, you were great! Thanks for the info. And thanks to all of you for asking your questions. When you ask, we all learn.
krisinva	Thank you Dr. March!
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charles_march_md	Goodnight ladies, I hope that I was able to help in some way
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When Is Surgery The Right Option For Infertility?

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