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Infertility/Fertility/Endometriomas and zero antral follicles


Hi Dr. Ramirez,
Not sure what to do.  I met the love of my life later in life and we just started trying to conceive, I am 42 years old.  We really want to have a child, but not so sure about donor eggs .  I have never been pregnant or attempted to get pregnant before. Six months ago my AFC=3, FSH=6.3, E2=117.  My results today were AFC=0, FSH=1.4, and E2=252 and two endometriomas that appear to be growing.  Could the endometriomas have caused the change in numbers?  If so, would removing them increase my chances of becoming pregnant?  I've read that surgery reduces the ovarian reserve which is not a good thing so I'm confused as to what to do.  I've also had a hard time figuring out which doctors would be gentle/skillful and not remove any unnecessary ovarian reserve, this could be crucial in my situation.  I would like to do IVF but the clinic I've gone to is not wiling to discuss it due to the change in numbers.  Are there any clinics that will work with my numbers and the endometriomas?  We want to give it our best shot, it would mean so much for us to have a baby together.
My pelvic transvaginal ultrasound results were:  
The results were:
FINDINGS: The uterus is normal in size measuring 7.9 x 3.9 x 4.6 cm.  No fibroids or other myometrial abnormalities are visualized.  The double layer endometrial thickness is normal measuring 7mm. No focal endometrial abnormality or endometrial cavity fluid is seen.
Right ovary is enlarged.  The right ovary measures 6.1 x 4.4 x 6.1 cm.  Homogeneous hypoechoic structure in the right ovary measures 5.1 x 3.9 x 5.7 cm previously 3.9 x 2.6 x 3.8 cm (on 18Nov2012 ultrasound).  The left ovary measures 4.2 x 2.5 x 3.9 cm. Hypoechoic structure in the left ovary measures 3.6 x 2.5 x 3.2 cm previously 2.0 x 2.0 x 2.4 cm (on 18Nov2012 ultrasound). No abnormal free fluid is seen.
IMPRESSION:  Normal uterus. No uterine fibroids are seen.  Homogeneous hypoechoic structures in both ovaries, increased in size since 18Nov2012.  Findings most likely represent endometriomas.
Thank you so much for any advice you can give us.

Hello Linea from Virginia,

First, I think that your blood testing is incorrect.  The reason is that the FSH test is only valid if done right at the beginning of the cycle, generally cycle day#2 or 3.  I suspect that the test was not correct because your estradiol was above 100 in both test.  This shows that the ovaries were not at rest i.e. not in the early phase.

Second, I am sure that you can find a clinic or doctor that is compassionate enough to allow you to try IVF with your own eggs, but that will be with a complete understanding of your chances.  For example, I don't have a blanket policy to not allow patients to try as long as they understand the risks and chances.

Third, you have to understand the major problems you are facing and the impact that has on your chances.  The first major problem is your age.  This is what we call the "age related egg factor".  This basically means that because of a woman's age, the quality of her eggs decreases so that the majority are no longer viable.  As a result, the pregnancy rate decreases and the risk of miscarriage due to genetic abnormalities increases. Even with IVF your chances will be decreased, BUT they will much better than trying naturally! The second major problem is stage four endometriosis.  When you have endometriomas, that automatically makes the stage, stage four, which is severe endometriosis.  As a consequence, IVF is the treatment of choice.  You can, and probably should, try to find a very good gynecologist do remove the endometriomas laparoscopically, with specific instructions to NOT remove any ovarian capsule tissue (that is the layer that has the eggs).  That will help to give you the best chances of pregnancy.  However, it is not an absolute necessity.  Third, you have a decreased antral follicle count, which is supposed to represent the number of follicles available, but frankly, I don't rely on that too much.

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.

for additional information check out my blog at check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate


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Edward Joseph Ramirez, MD, FACOG


I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.


I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, California Medical Association, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists

American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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