seeking advice-Crohn's disease

[Lori229]

Hi Dr. Roseff,

My husband and I have been ttc for four years and recently sought the help of a fertility specialist. We are on our third treatment cycle and I am looking for some advice on where to proceed from here if it is unsuccessful.

Here is a little background info: I am 39 years old with Crohn's disease (likely in remission) and have had two surgeries for rectovaginal fistula (2006 and 2009). The past 6 months I have noticed and increasing amount of blood in my stool at the beginning of my cycle which my doctor believes may be from bowel endometriosis.

We are on our third cycle of treatments which included Femara, Follistim and Ovidrel along with IUI. It appears that I have responded well to all of the treatments and my husband's sperm count has been good.

I'm not sure at what point we need to consider other options. The analytical side of me is searching for a reason as to why we can't conceive. I guess the next step would be IVF, but my Dr. is also concerned about egg retrieval considering the history of fistulas.

I guess I have three questions: Do you think the possible bowel endo could be causing infertility and is it something I should be concerned about? Are there other options besides IVF? If we do opt for IFV, is it too risky to consider using my own eggs?


Thanks for your help!

[Scott Roseff MD]

Hi,

Was your bowel endo confirmed via colonoscopy or endoscopy?

Why are you adding Femara to the Follistim rather than doing a straight, injectables cycle?

Women with bowel endo typically have extensive, invasive endo. If that's someone's case, then extensive endo can significantly lower the odds of conception with IUI (but not usually with IVF).

IF you do IVF, ask your RE if you might be a candidate for laparoscopic egg retrieval. Ask your gastroenterologist if he/she thinks the RV fistula(s) would be a problem for a transvaginal egg retrieval.

What was your last cycle day 3 FSH/E2? How long ago were they checked? AMH? Antral follicle count?

Dr. Roseff in FL

[Lori229]

Thanks for the reply.

The bowel endo has not been confirmed. My last colonoscopy was in April and nothing was found. Coincidentally, it was two weeks later at the start of my cycle that I started noticing the blood. At first it was dismissed as blood from a biopsy site during my colonoscopy, but I have had increasing amounts of blood at the beginning of my cycle every month since (large clots).

The Ferara along with the Follistim is what was recommended by my doctor. I assumed it to be common treatment? However, this month we are only doing the Follistim (10 injections).

My estradiol this cycle was 261. As far as the others, I am not sure exactly what they were to be honest. I know that everything was in range according to my doctor. I will get my exact numbers when I go for my ultrasound tomorrow.

[Scott Roseff MD]

If endometriosis is not seen on colonoscopy or endoscopy, it's concerning to me that someone would say GI bleeding is due to bowel endometriosis.

I'm hoping you didn't mean to say your estradiol level was 261 pg/ml on the third day of your menstrual cycle (CD3)....

Dr. Roseff in Florida

[Lori229]

He only suggested that bowel endo was a possibility. He said that it may not have been seen on the colonoscopy because it was the middle of my cycle. At that time, there was very little blood. Six months later, the amount of blood has increased significantly. It comes in the form of large, mucousy clots and long thin strands of blood encasing the stool. But it is only at the start of my cycle. Any thoughts on what else it could be?

I feel like this is an issue I should get resolved, but I'm not sure where to turn. I have not seen my GI doctor since my after my colonoscopy when I first told him about the blood. He waved it off because my colonoscopy was clean. My GYN also brushed it off and my RE also does not seem to be concerned. So I feel like I am over-reacting. Should I be concerned?

Also, the E2 level of 261 was day 5 after 3 Follistim injections. Sorry for the confusion there.