Expert: Edward Joseph Ramirez, MD, FACOG - 9/20/2008

Question
QUESTION: Hello,
For an IVF cycle, can using a Gonal F pen that was first used for injections over a month ago cause it not to work?  Also, I have a 5 cm endometrioma on one ovary.  Will this influence my egg retrieval or will they work around that when they go to retrieve the eggs?  Thank you.

ANSWER: Hello Sarah,

If you refrigerated the remaining Gonal-f pen, and it has not passed its expiration date, then it should still be good.

There have been some studies showing that an endometrioma can reduce the pregnancy rate with IVF cycles.  However, I have done patients with endoetriomas present and have been successful, just as many centers have.  Therefore, it is not an absolute contraindication, meaning, you don't necessarily have to go through the surgery to remove it.  On the other hand, if you don't want to take any chances and make sure that everything is in order prior to doing the IVF cycle, then you should have it removed.

The problem with the endometrioma is that the fluid within it is very embryotoxic (kills embryos).  The doctor will have to be very careful not to puncture or aspirate it, and if he does, he will need to change the needle prior to proceeding with aspirating the remainder of the follicles.  Your doctor should have discussed this with you, including your options.

I hope that answers your questions.

Edward J. Ramirez, M.D.
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.

---------- FOLLOW-UP ----------

QUESTION: What is the average number of follicles that you like to see prior to going to egg retrieval and what size do they need to be?  Thanks again!

Answer
Hello Again,

With IVF I like to see as many follicles as I can with a total number less than 25.  Over 25 increases the chance of ovarian hyperstimulation syndrome.  However, this number will vary from patient to patient because of their age and ovarian function.  

Some IVF clinics do have a minimum number that they will go forward with.  I do not.  I will proceed even if I only have one.  You never know if that is the perfect egg that will lead to the perfect embryo and a subsequent pregnancy.  I have had many pregnancies with only one egg.  Besides, nature does it all the time.

I prefer my leading follicles to be 20-22 mm at the time of HCG trigger.  I like to see 3-4 leading follicles, not just one or two.  I also use the other sizes to determine the trigger because sometimes you can have a few that are growing fast and the rest are small which will lead to lots of immature eggs.  This is where experience comes in to play.  I know that some clinics will use 17-18 mm.

Thanks for the question.

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com

Monterey, California, U.S.A.