Infertility/Fertility/IVF & Endometriosis


Hi Dr Ramirez,

I'm writing to you from Australia and would really appreciate your opinion. Im 30 years old (started IVF at 28) initially for Male factor infertility (husband had an testicular cancer as a teen resulting in an orchidectomy- surgery only), but after the 4 fresh cycles I have done, the last one queried empty follicles (detailed below) I have now sought another specialist. This specialist has found moderate endometriosis, not on the ovaries, mainly around the bowel and behind the uterus, which he has now been removed. My AMH is also normal at 27.7.

My questions are do you think subsequent IVF cycles will show an improvement, and perhaps better egg quality, following the endometriosis removal? Do you think there may be a trigger problem? Do you think the endo combined with dhea could have something to do with the last terrible cycle?

I really appreciated your time and look forward to your response. Many thanks, Kylie.

Cycle 1 - ISCI Long Down Regulation

-   Syneral BD, 112.5IU Gonal F
-   12 days stimulation
-   Trigger day 12 Ovidrel 250mcg E2 at trigger 13 700
-   Follicles ≥ 16mm at trigger = 9

-   EPU 7 collected 4 mature , 2 immature, 1 not quite mature
-   Day 1 3 fertilised, Day 2 Transfer of 2 embryos (1 x 2 cell, 1 x 3cell)
-   Negative Beta, Nil Freeze

Cycle 2 -ISCI Long Down Regulation

-   Syneral BD, 116.6IU Puregon
-   12 Days stimulation
-   Trigger day 12 Ovidrel 250mcg, E2 at trigger 6501, Follicles ≥ 16mm at trigger = 6

-   EPU 8 collected, 5 mature, 1 needing polar bodies, 2 immature, Day 1 4 fertilised, Day 2 Transfer 1 embryo (1 x 4 cell)
-   Negative Beta, Nil Freeze

Cycle 3 ISCI Antagonist

-   OCP 21 days
-   DHEA 7 weeks prior to EPU
-   133.3 Puregon for 7 days, 150 IU Puregon for 5 days
-   12 Days stimulation, Orgalutron started day 7
-   Trigger day 12 Ovidrel 250mcg, E2 at trigger 3600 , Follicles ≥ 16mm at trigger = 9

-   EPU 6 collected 6 mature
-   Day 1 4 fertilised, Day 2 2 x 2PN, 1 x 2pn disappeared, 1 x divided, Day 3 1 x 3 cell, 2 x 4 cell, Day 5 3 Blastocysts, transfer 1 blastocyst
-   2 blastocysts frozen , Negative Beta

Cycle Frozen Medicated Cycle

-   Transfer 2 x blastocysts
-   Positive Beta of 7  - 12dp5dt, beta 14 15dp5dt
-   Chemical pregnancy

Cycle 5 ISCI Antagonist

-   OCP 24 days
-   DHEA 12 weeks prior to EPU
-   150iu Puregon
-   10 days stimulation. Orgalutron started day 7
-   E2 stimulation day 6- 1333.3
-   E2 stimulation day 9 4129, Trigger day 10 Ovidrel 250 mcg,Follicles ≥ 16mm day before trigger = 9

-   EPU 1 mature collected (poor quality)
-   Day 1 1 fertilised
-   Day 2 divided with fragmentations, Nil transfer, Nil frozen

Hello Kylie from Australia,

At 30 years old, you should have a 60-70% chance of pregnancy per IVF cycle, and cumulatively should have an 86% success rate after two attempts and 92% by three attempts.  I am sincerely worried that you've been working with a bad clinic.  It does not make sense to me that you would have bad egg quality at your very young age, and so I worry that something else is going on, such as poor medical technique, expertise or laboratory quality.  I only say this because your age group should have the very highest chances of success, and in the U.S. clinics are compared by using patients under age 35 as the "gold standard."  These patients should have the highest pregnancy rates.  For example, in my clinic the pregnancy rate is 73% in patients under 35 years old with the cumulative success rates as I've mentioned.

Endometriosis does not affect IVF pregnancy rates but does affect natural rates.  This is because the endometriosis is a pelvic disease only, and does not affect the ovaries internally or the uterine cavity.  IVF is the treatment of choice for stage 3 and 4 endometriosis simply because it removes the eggs from a hostile environment i.e. bypasses the pelvis.  I don't know why your doctor felt compelled to treat the endometriosis surgically.  Some clinics, not mine however, will treat patients with Lupron for 3 months preceding an IVF cycle to reduce the inflammatory reaction that might be present.  The only time surgery would be indicated is if there is a large endometrioma in the ovary.

Looking over your experience I am saddened at the result and am sincerely worried about the quality of the clinic you've been going to.  In this last cycle, your peak E2 was higher than I usually will go (because of the increased risk of OHSS), but it was adequate, and 9 follicles of at least 16 mms is an adequate number, although on the low side (I try to get 10-15 follicles), but the retrieval data is horrendous.  It makes no sense that only 1 mature egg was retrieved.  That is a very poor retrieval rate, and my worry would be that you ovulated before the retrieval was done.  Without reviewing your medical records more closely there is no way for me to know if that was the case.

My final recommendation would be to go to a different clinic for any subsequent IVF cycles.

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, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

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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