Infertility/Fertility/If success rate

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Question
Hi Dr I am 29 and have severe pcos. Never been pregnant.  I had five iui's ovulated four times and had no pregnancy.  I weigh  110kg but that has not interfered with my ovulation as each cycle I had 4 mature follicles and ovulated on my own. I have a High AMH level of 22. Are there any additional tests I can do before moving on to ivf. Tests that might determine what the problem could bee?
Many thanks

Answer
Hello Nicky from South Africa,

At this point you have two options:(1) do a complete infertility evaluation if you have not already done one or (2) proceed to IVF.  The basic infertility evaluation involves tests that check each of the 10 steps that the body requires to get pregnant.  The advantage of this is that you might be able to find out what else is preventing you from getting pregnant and maybe, if this is fixed, you would get pregnant by natural means.  The tests are:
1.  Hormone panel (FSH, LH, Estradiol, TSH, Prolactin)
2.  Hysterosalpingogram (HSG) - check tubes
3.  Hysteroscopy or Hysterosonogram - check uterine cavity
4.  Pelvic ultrasound - check pelvic gross anatomy
5.  Mid Luteal Progesterone
6.  End cycle endometrial biopsy (check for adequate formation of endometrial lining for implantation)
7.  Semen analysis
8.  Laparoscopy - check internal pelvic anatomy

Since you are known to have PCOD and ovulate with fertility medications, you probably could eliminate the hormone panel, mid luteal progesterone and endometrial biopsy.  The latter two would require supplementation with progesterone, which I do with all my fertlity treatments.

However, the alternative is to consider IVF.  It is known that statistically, most pregnancies will occur within 4 attempts.  After that, the pregnancy rate plummets because that is an indication that there probably is something else going on.  For that reason, most specialists will recommend moving to IVF after four IUI attempts have failed since IVF is the only treatment that can overcome most other problems.  This would be one INSTEAD of doing the testing mentioned.  Keep in mind that IUI is the highest NATURAL treatment option and the only other treatment left is IUI, and it may only help you find out what is going on but not necessarily help you to get pregnant.

I hope that gives you the information for making your treatment strategy.

Good Luck,

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

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com 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.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

Infertility/Fertility

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Edward Joseph Ramirez, MD, FACOG

Expertise

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.

Experience

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.

Organizations
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

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

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

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