Young Woman TTC Is Concerned: Has Abundant Cervical Mucous & Irregular Cycles

Question:

Hello, I am writing you from Alberta, Canada. I have been doing many searches on the internet to find an answer to my question with no success. I hope that you might be able to help me.

So, I went off BCP (birth control pill) in March 2010 to TTC. (I am 26 and have been on the pill for 7 years.) Since then I have been having a cycle each month (cycles have been ranging 30- 36 days) I have had a cycle last 42 days. And I have had several appointments with my Dr. She said that since my cycles are that long that I "might not be ovulating". This really worried me as it's nothing a woman ttc wants to hear. So I have been watching for the EWCM and each month I barely see any. But there is a bit. Well I am going on day 53 with no period. Last week I had LOTS of EWCM for the entire week. And I mean A LOT of it. More than I have ever seen. I thought I was pregnant because of symptoms but after 2 negatives I know I am not. So this brings me to my question...what does it mean when you have LOTS of EWCM for a whole week? I was having LOTS of cramping so I was thinking my period was going to start but nothing. There was one day which was the worst cramping I have had. I usually cramp a lot when my period starts and the week of ovulation.

Could my body finally have ovulated and the hormones are working out or should I seek more advice from my Doctor? I am waiting for my cycle to start so I can take the clomid she prescribed me. I appreciate any advice you may have for me. I do plan on going back to my Doctor soon but with the Christmas holidays I can't get in to see her til the New Year. I was really curious about all that EWCM. There was sooo much of it and it lasted more than 4 days. Is that a good sign even though it was 45 day of my cycle? My cycles before I went on the pill were usually 32-34 days and very consistent. But the periods were heavier then...lasting 5-6 days. After stopping the pill they were very light and have only lasted 3-4 days.

I apologise for such a long explanation. I just thought I would share my story in case other women have the same issue and question so they can use the answer I receive.

Thank you again and all the Best to you in 2011!

Answer:

Hello C. from Canada, Thank you for wanting to share your concerns with other women who are trying to conceive (ttc). I think that you are putting too much value on cervical mucous. It is an indirect measure of the hormone production in your body. Basically, as the body gets closer to ovulation, the estrogen/estradiol level in your system increases, which in turn converts the cervical mucous to a clear, stretchy, copious mucous. This allows for sperm entry into the uterus and tubes. I am not sure what you are referring to as "EWCM" and because you don't describe the mucous properties so I can't comment on the question regarding having this mucous for multiple days (please be more specific, since descriptions are better than acronyms). The cervix produces all types of mucous and the vagina as well.

Here is a general guideline on what cervical mucous should look like post menses:

Stage 1: Lasting 2 - 3 days Cervical Mucous is sticky or gummy

Stage 2: Lasting 2- 4 days: Cervical Mucous is creamy, milky and lotion like.

Stage 3: Lasting 1-5 days: Egg White Cervical Fluid: It looks like egg whites and is slippery and stretchy. The mucous should be clear, but if there is an odor this may be a sign of an infection, if so, consult with your doctor. Women in their 20's such as yourself can have this type of cervical mucous for up to five days. At this point, women are generally considered to be in their most fertile period.

Stage 4: Dry, Moist or Sticky

Based on the fact that your cycles are irregular, there is evidence that there is some type of ovarian dysfunction going on as well. It could be a lack of ovulation or a hormone imbalance. If it is of ovarian origin (there are other possible causes as well), then the treatment would be to use medication such as Clomid to stimulate the ovary and get it to function normally. But prior to making that assumption, you should have a hormonal evaluation to make sure it is not a problem with your thyroid or pituitary or hypothalamus or other such causes. If it is found to be isolated to the ovaries, then Clomid ovulation induction is appropriate. I would recommend that you look at my blog regarding how Clomid ovulation induction cycles should be done ("How I Do Clomid Induction Cycles"). I hope that helps to answer your questions, good luck!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Young UK Woman Trying To Conceive Has Irregular Cycles, Prior D&C: What Could Be The Problem?

Question:

Good evening, Dr. Ramirez. Thank you for taking the time to read this email.

I am concerned about my periods. Nearly two years ago, I made the difficult choice to have an abortion. Not wishing to go through that again, I chose to have the Depo shot for six months after. However, due to weight gain, I stopped taking it. That was over a year ago.

For the last year, my periods have been coming every two months, but the last one I had scared me. Instead of being red, as was the normal, the blood was brown in most areas and black in others. It lasted seven days, but did not increase in flow, if anything it slowed and thinned towards the end.

I went to see my local doctor, and she told me that I would not get help because I am under 30. My partner and I have been having unprotected sex in the hope for a baby, but to no avail. I cant even work out when I am ovulating.The women in my family have been known to suffer from Polycystic ovaries, especially my sister who is close to me in the gene pool. Is it possible to develop this? I'm so worried and depressed all the time. Please can you help and advise me? I am writing to you from chilly England.

Regards, K. from the United Kingdom.

Answer:

Hello K. from the U.K.,

I can't give you specific advice because I don't have enough information. Certainly if your cycles are irregular, something is going on with the ovaries. There are several levels that have to be checked to find where the problem is. Polycystic ovarian syndrome, or PCO, is an ovarian disorder where the ovaries dysfunction and don't ovulate. That certainly is a possible cause, and probably the most common cause of irregular cycles. Again, without testing it is difficult to know. PCO can be latent for a period of time and then for unknown circumstances, like weight gain, can manifest itself!

In terms of your bleeding, the brown and black blood are nothing to be concerned about. That is old blood that has made its way out of the uterine cavity. It started out red but sat in the cavity for some period of time before making its way out. One concern that I might have, since you are interested in fertility, and because of the bleeding change, is if any damage was done within the uterine cavity from the abortion. Sometimes if the D&C is done too vigorously, scar tissue can form within and prevent the blood from flowing out easily. A procedure called a hysteroscopy would need to be done to evaluate for this.

Regardless of your age, if you have not been able to achieve a pregnancy after one year of trying, you fall into the category of infertility and should see an infertility specialist. They would not only evaluate your for your menstrual irregularity and try to remedy this, but will also evaluate the uterine cavity. So go tell your unhelpful gynecologist that you want to be referred to an infertility specialist!

Good Luck and a very Merry Christmas over there in chilly England!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Helpful, polite and understanding. Everything you want when you need help!

UK Patient Has PCOS, On Clomid For Ovulation: After First Miscarriage, Should She Continue With Clomid Or Start Injectables?

QUESTION:

I was put on 50mg Clomid due to pcos and long cycles (42-43 days). Right away, my cycles reduced to between 26-32 days. I got pregnant on my 3rd cycle of Clomid, then miscarried.

My RE recommends that I go back on Clomid, and would like me to increase my Clomid dose to 100mg so that we can recruit more than 1 egg (since I was only ovulating one egg on the 50mg dose). I will also be taking progesterone this time.

1) Do you recommend that I increase my dose of Clomid to 100mg to recruit more than one egg (even though I was ovulating normally on the 50mg dose)?

2) If the next 3 months of Clomid are unsuccessful, my doctor recommends that I try FSH injections (since I will have been on clomid for a total of 6 consecutive months, including the 3 months before my miscarriage). Do you recommend moving to FSH injections, or staying on the Clomid since it was successful previously?

3) If I cannot get pregnant again during the next 3 months on Clomid, my doctor recommended getting a laparoscopy. Just wondering if you would recommend I proceed with a laparoscopy if I fail to get pregnant again? I feel like I just got pregnant after 3 months of Clomid, so that the procedure seems unnecessary to me. (I have also had bloodwork, SA, and HSG all come back as normal).

Thank you for your advice. Sincerely,S. from the U.K.

ANSWER:

Hello S. from the U.K.,

I am sorry for your miscarriage. Considering your treatment plan, because you responded to 50mg of Clomid previously, you certainly don't need to increase the amount. However, your doctor's strategy is to get you to ovulate more than one egg at a time to increase your chances of pregnancy with each attempt. We call that super-ovulation. With increasing the number of eggs, you certainly will be increasing the chances of a multiple pregnancy. If that is not acceptable then stay with just 50mg.

I do not recommend moving to FSH injections yet. They certainly have a place but since you have gotten pregnant with Clomid before, I would just increase the Clomid dose. You can go up to 250 mg of Clomid. 3 months also seems like a short time frame for the trial unless you are over 35 years old. Then you might want to proceed more aggressively.

If you move up to the injections then I would also recommend that you add IUI in order to increase your chances even more. I don't recommend a laparoscopy at this time because I don't see a reason for it. I keep in mind that you were successful already with Clomid which shows that everything your body needs to do in order to achieve pregnancy can occur. The pregnancy re-sets the time frame. Now you just need to go back to the same plan and keep trying!

Follow Up Question:

Dr. Ramirez,

Thank you for your prompt reply. It is extremely helpful. I just have a few follow-up questions:

I mentioned previously that I was on Clomid for 3 months and got pregnant on the 3rd month (and miscarried). I have now been on Clomid for another 2 months since the miscarriage and not gotten pregnant yet. So I will be starting my 6th consecutive month of Clomid this month.

You recommended I continue with Clomid at a higher dose (rather than move straight to the FSH injections), since Clomid worked for me before.

1) Could please tell me what is the longest period that I can safely be on Clomid for? [I keep reading that one is only supposed to be on Clomid for a limit of 6 consecutive months. I am going to be starting my 6th consecutive month of Clomid this month]

2) I also keep reading about two negative effects that can occur with continuous use of Clomid. One is thinned lining (my lining has been fine so far). The second effect I have read about is hostile cervical mucus.

My RE said she is willing to do a post-coital test to check on cervical mucus if I want one, but that she does not consider it a reliable test. So my question is - how am I supposed to know if my cervical mucus is being affected by the Clomid? Also, since I am now entering my 6th month of Clomid use, should I consider taking an estrogen supplement which can possibly improve cervical mucus? Thank you very much for your advice. Regards,S.

Follow Up Answer:

Hello Again, When I answered your previous question, I was not implying that I agreed with continuous Clomid cycles. I do not. Because of the "antiestrogenic" effects of Clomid, I do not use Clomid on a continuous monthly basis. I alternate with Femara, but if that is not used, then Clomid should be used on an every-other month basis so as not to block the estrogen receptors, for exactly the reasons you indicated. Yet, as I stated above, your pregnancy reset the time frame.

In terms of the maximum number of months to use Clomid, there is no rule that says that Clomid needs to be stopped after a certain number of months. However, if pregnancy does not occur, then you should move on to the next level of treatment after six months. In your case, since you became pregnant, that reset the count. Because fertility treatments cannot control the pregnancy, and can only give you the opportunity to become pregnant, that is where treatment success ends. So you are now on your second cycle of Clomid, not your 5th.

Certainly if you want to move to the higher level of treatments such as Follistim, there is no reason that you should not. I only suggested the Clomid because it is less expensive, easier to use and worked for you before.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

37 Yr Old Failed Two IVF Cycles, Has Frozen Embies And Husband With Slow Swimmers: What Would You Suggest?

Question:

I just failed my second IVF (in vitro fertilization) procedure. I am 37 years old living in the Bay Area. My husband has slow swimmers and not great morphology either. We used ICSI (intra cytoplasmic sperm injection) with both IVF procedures.

The first cycle I had 8 eggs, 6 fertilized and only two made it for transfer. The second cycle I had nine retrieved, 8 fertilized and we transferred two embryos on day 3, one an 8 cell and one a nine cell. We were able to freeze 3 embryos, not of as high quality. I believe the frozen embryos are 5 and 6 cells. I am planning to use the frozen embryos, but it seems like a lost cause as the quality of the embryos are not as good as the fresh ones that were transferred. I am doing acupuncture treatments as well.

Any advice would be most helpful. L. from San Francisco, California

Answer:

Hello L. from the U.S.,

I am sorry to hear of your failures, but IVF is certainly the best treatment for you based on your husband's problem and your age.

Without reviewing your IVF records, I cannot give you any specific information regarding your cycles or chances. Keep in mind that each IVF center uses different protocols and methods and pregnancy rates vary. For example, my pregnancy rate in your age group with ICSI is 56% per attempt with 41% continuing pregnancies. Pregnancy rates are very dependent on the stimulation, how many mature eggs are retrieved, embryo development and transfer technique. In addition, in your age group, having failed one IVF cycle already, I would have placed back all four embryos, even though the lesser celled ones were not as good quality. There is no utility to freezing them, and the prognosis with those embryos is not good as you already know. The success rate of a frozen embryo transfer cycles with good embryos is approximately 30%. Your best chance, once you have tried with the frozens if you choose, is to keep trying with fresh embryos.

In my protocol, I would probably place you at the max stimulation protocol, add low dose aspirin, low dose heparin, medrol and increased progesterone with the next cycle. Acupuncture certainly does not hurt and I would recommend that you continue it. On a side note, when my wife & I went through IVF she was 37 like you. We also did ICSI. She had 14 eggs retrieved, eight fertilized, and we ended up with one nine cell, one eight cell and the other two 5 cell. After conferring with her RE, (she was under the care of my colleague at the time) we decided to transfer all four. She became pregnant with a singleton, our daughter, who is now a healthy young teenager (her baby picture is on the Doctor's Background page of my blog). Needless to say, we did not regret our decision :)

Good Luck on your journey, I will keep my fingers crossed for you both!

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

Monterey, California

Patient With Short Luteal Phase Has Spotting With Progesterone Suppositories, Is This Normal?

QUESTION:

Dr. Ramirez, I am hoping that you can help answer some questions for me as I am feeling confused and hopeless...I am 30 years old and I am trying to concieve. I was on the birth control pill for 9 years and stopped taking it in June. I have been charting my Basal Body Temps and discovered that I have a short luteal phase--

I begin spotting 9 days after ovulation and start my period the following day making my luteal phase 9-10 days. My period is very light-- only lasting a few days. I have been taking Vitamin B6 supplements and my doctor started me on Crinone Progesterone Suppositories this month. I began 3 days after ovulation and am taking 90mg once per day.

Yesterday, 9 days into my luteal phase, I began spotting very lightly when wiping. This was very discouraging as I usually begin spotting on day 9 before starting the suppositories. I was convinced that I was starting my period as I had in previous months and that this was not implantation spotting due to the coincidence of the spotting on day 9.

However, now on day 10, I am wondering if I gave up hope too soon. The spotting is still VERY scant and does not seem to be increasing as in previous months. Also, the actual flow of the bleeding seems a little different than previous months. Upon intially wiping, there is no blood on the toilet paper. After wiping a couple of times, a very small amount of red blood appears on the toilet paper. In fact, as I continue to wipe, the bleeding seems to increase with each wipe. Also, it does not resemble my usual spotting (blood mixed with a wet discharge) but just small amounts of blood smears. The flow only appears when wiping.

Should the progesterone suppositories have increased my luteal phase count at least a little bit? It's very discouraging to think that there was no increase at all. If my period is beginning, does this mean that it is not a progesterone issue? What else could cause a Luteal Phase Defect? Can your period begin while you are taking the suppositories? I read online that your period will not begin until you stop taking the progesterone? However, I have also read conflicting info as well.

Could this be "break-through bleeding"? Is this common with suppositories? Could you explain what this is? Does this sound like implantation spotting? I called my Dr. and she said to stay on the progesterone for a few more days and see if my period does start. She has admitted that she is not too familiar with LPD isues and has referred me to a Reproductive Endocrinologist however the earliest appointment I could get is March. I am feeling really confused and discouraged. Any help, guidance or suggestions would be greatly appreciated! Also, I did take a pregnancy test today and it was negative but realize that it may have been too early. I am writing from Massachusetts.

ANSWER:

Hello D. from Massachusetts,

I have found that vaginal spotting is very common with the use of Crinone in my IVF patients, so I don't think you need to worry about it. Supplemental progesterone is the appropriate treatment for suspected luteal phase defect. A pregnancy test will be required because your natural period will not occur if you are on supplemental progesterone. The incident that causes the withdrawal bleed (your period) to occur is the abrupt drop of progesterone in your system if a pregnancy has not occurred. Therefore, I would recommend a scheduled serum bHCG at 14 days after ovulation. If it is negative, then stop the progesterone but don't stop until you have that result.

There are gynecologists out there that are well versed in infertility treatments. You don't necessarily have to see an RE for your level of care. You might want to call around and see if you can find one so you don't have to wait so long to undergo proper treatment. However, be very careful because there are many general Ob/Gyn's that say they do infertility that know very little and don't render proper care. You might want to ask them specifically how they diagnose and treat luteal phase defect. You also might want to find one that does IUI treatments, and avoid the ones that don't do this level of care.

Follow Up Question:

Thank you so much for your quick response! This was very helpful. It is encouraging to know that spotting is common when using Crinone. From your response, it sounds like my period will not start until I stop taking the progesterone. Do you feel confident that given the info that I provided that it is not my period starting and just due to the progesterone? Is this "break-through bleeding?"Also, do you think 90 mg once per day is adequate? I read about women taking the supplements 2 times per day. Again, thank you for any help you can provide and for your timely feedback. I appreciate your advice re: the RE as well. March seems like it will never get here!!

Follow Up Answer:

Hello Again,
I am confident that this bleeding is not your period, but keep in mind that there are always exceptions. It is most likely breakthrough bleeding as I explained previously. Crinone has been extensively studies for use in infertility and once per day is adequate.

I am happy to have helped clear up some of your fears. Good luck with your treatment and don't hesitate to write again!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

Can Progesterone Be Given With Clomid Induction? PCO Patient With 3 Failed Cycles Wants To Know...

Question:
I'm 31, never pregnant. Dx PCOS, receiving metformin 1500 mg a day. Three cycles with clomid with no ovulation. HSG normal, husband semen analysis OK. Now going through second cycle of IUI (intra uterine insemination), ovulation stimulated with Gonal F and triggered with ovidrel.

First cycle progesterone level on day 3 after second IUI was low (2.3), so I asked the doctors why they can not prescribe progesterone to improve luteal phase and make implantation more possible, and they told me they do it only with IVF. Is this Ok? What I mean is, why don't give progesterone if the level is low, and it is know than low progesterone impairs implantation and also increases risk of miscarriage in first trimester? Please give me some advice, or some reference articles where to read about this (scientific articles to support my request) Thank you! S. from Arkansas

Answer:

Hello S. from the U.S.,

You have a very valid question and you should ask your doctor why they don't give progesterone after intra-uterine insemination. I'm sure there are many articles on the web that you could find that advise this technique. There is absolutely no reason not to give progesterone after IUI or even after simple ovulation induction.

However, I think that your thinking may be incorrect, however. If the ovulation induction were proceeding correctly, and ovulation occurs, then the hormones should be corrected and there should be a normal luteal phase. Usually a mid-luteal progesterone is not to see if there is adequate progesterone for implantation, but to see if ovulation in fact took place because if it did not, the progesterone would be low. So you see, rising progesterone levels occur from ovulation. If the progesterone is low, that is an indication that ovulation did not take place and replacing progesterone would not have anything to help i.e. no implantation would occur any way.

I have to wonder about the protocol that your doctor is using, and I would suggest that you look at my blog under how I do clomid induction cycles. One specific technique that I use is to follow the follicle(s) with the ultrasound to determine when ovulation is going to occur. That way, I can better time the insemination. I also give an HCG trigger. Then I start progesterone the day after the second IUI (I do two IUI's per cycle) for luteal phase support. This is mainly because progesterone is an easy medication to use, is not expensive and has no adverse reactions/side effects/harm to the pregnancy. It can only help and increased progesterone is one of the main stays for the treatment of implantation failure due to inadequate b-integrin levels.

Maybe you should ask your doctor why he uses it for IVF and not for IUI? The reason to use it should be the same.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

37 Yr. Old Malaysian Woman Gets Chemical Pregnancy With First IVF: How Did Her First Cycle Look And What Are Her Chances With The Second?

Question:

Dear Doc, I would appreciate an opinion on this current IVF cycle I'm on and my previous failed cycle. I'm 37. My period is regular ie 28-32 day cycles. This is my second IVF. I started suprefact on day 21, 40 units for 13 days, 15 units from the 14th day onwards. 300 iu Gonal F on the 16th day for 4 consecutive days now. I will be seeing my RE tomorrow. My period came on the 10th day I was on Suprefact, 30 days after my previous period.

My first IVF also started on day 21, I was on suprefact for 14 days @ 40units. I started puregon 350iu on the 15th day-was on 350iu for 11 days, 250iu on the 12th day and 225 on the 13th day; suprefact was at 15 units. 13 eggs retrieved, 9 fertilised but only 4 left on the 3rd day when the transfer was done. 13dp 3dt my HCG was 375. At 18dp 3dt, my HCG was 2065. I was bleeding lightly post transfer and when the time came for the ultrasound, no sac was found and my hcg level had dropped to 117-end of my BFP. What do you think my chances are for this second cycle? I would appreciate any advise you might have. A. from K.L., Malaysia

Answer:

Hello A. from Malaysia,

Thank you for writing me all the way from Kuala Lumpur! Let me comment on the information that you have given me. The first IVF cycle looked pretty good except that the embryo development was poor. If 9 eggs fertilized, you should have had 9 embryos formed. Despite this, you were able to get pregnant, which proves that this treatment plan (IVF or in vitro fertilization) can work for you. The miscarriage has nothing to do with the IVF. Once the pregnancy occurred, it becomes an independent entity and will either progress or miscarry on its own. In your case, a chemical pregnancy occurred leading to a miscarriage. Most miscarriages occur because of spontaneous genetic/chromosomal abnormalities that occur at the time of cell division. Because the embryo was abnormal, a fetus did not develop, thus leading to the miscarriage. This was probably due to the "age factor."

As a woman ages, more and more of her eggs become weakened/debilitated leading to abnormal embryo formation. Therefore the miscarriage rate increases. Keep in mind that IVF can only give you the opportunity to get pregnant. Whether or not implantation and pregnancy occur are up to your body's and the embryo's natural processes. We do not have the technology to make that happen. It has to happen on its own. So the fact that those processes occurred is a very good sign :) and all you need now is to get a good and healthy embryo into position. Then you'll have a successful pregnancy.

I'm glad to see that you are now in another IVF cycle. Since you had a chemical pregnancy, I am confident that you can achieve pregnancy eventually. Because of your age, it will just require persistence on your part.

Good Luck on your second cycle,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Woman Underwent Medical Miscarriage 8 Months Ago & Had Continuous Spotting, No BFP Yet: Should She Be Concerned?

Question:

Hello, I am a 29 year old female from Pennsylvania. My husband (also 29) and I started trying to conceive last year. We got pregnant on our 2nd month trying, and were very excited. At my first ultrasound, there was only a yolk & gestational sack, which showed growth only until 5w5d. I should have been much further along. I opted for medical management, offered by my doctor, to force the miscarriage. I took a mix of Mifepristone & Misoprostol - 4 pills were inserted vaginally, 24 hours after I'd taken the first pill orally.

The miscarriage began right away, and took days to complete. After 7 days, I went to my doctor for a checkup where she deemed the miscarriage complete with no side effects. I had spotting for months, which my doctor said was normal, and my period resumed in 4 weeks. Since then, we have tried for 8 months to get pregnant, with no luck. We track my cycles through BBT & OPK's, and it ranges now. I used to be regular, now I ovulate anywhere from day 11 to day 18. But I do ovulate every month. My period ranges from day 24 to day 29, depending on when I ovulated. My luteal phase went from 14 days pre-miscarriage to about 11-12 days post miscarriage. Are these cycle changes potentially a bad sign, or can they be normal?

My doctor does not seem concerned at all. She's run blood work, and done an internal ultrasound (last month) and said everything looks fine. She said that a medical miscarriage cannot cause scar tissue or block tubes. Is this true? I find it hard to believe because it was so painful w/so much bleeding. So my major concern is that my miscarriage caused me to become infertile. Is this something you have heard of? Is there a chance of scar tissue if I never had surgery, had no infections, and have never had an infection or any problems before my miscarriage? My husband has had all the male tests run as well, and they have said his tests are perfect.

My doctor will not put me on a fertility drug or run an HSG, as she said it is simply stress causing me to not get pregnant again. Is there anything you think I am misinformed about, or anything you recommend I do different? I am concerned that I took a really scary medication that did damage to me. Thank you so much for your help! J. from Pennsylvania

Answer:

Hello J. from the U.S.,

In general, a medical induction of miscarriage should not lead to scar tissue formation within the uterine cavity (known as Asherman's syndrome). This syndrome is usually a result of over-scraping of the uterus at the time of a D&C. However, if not all the products from the pregnancy were discharged, as can happen from time to time, then the resultant inflammation caused from the retained tissue can prevent pregnancy. It would be the same mechanism as an IUD. By checking you, I presume that your doc did an ultrasound and the cavity looked completely empty. To be absolutely sure, a hysterosonogram or hysteroscopy can be done. If the cavity is normal, then your current fertility issue is not due to the miscarriage.

The fact that you got pregnant easily before shows that your body does have the ability to get pregnant. We don't consider a woman to have an infertility problem until she has been trying for at least one year without success. At that point, an infertility evaluation should be done. I never never tell my patients that they are not getting pregnant because of "stress." Sure stress can impact the chances of pregnancy, but it is not significant enough to be a birth control device, so not good enough to be the cause of pregnancy failure or infertility. It is a patronizing remark. More than likely, you just haven't been as lucky this go around as you were the first time. Because you got pregnant so easily, you are assuming that you will again. But in fact, the average woman under the age of 30 will take 8-12 months to get pregnant naturally. So you still have to give yourself a chance.

The BBT's and ovulation predictor kits is ONLY to help you predict when ovulation is about to occur. They DO NOT say when ovulation has occurred. There is no way to know that. They also cannot be used to diagnose a short luteal phase, known as luteal phase defect. This has to be done by endometrial biopsy dating. The fact that there is a little variation in your cycles does not indicate irregularity. Cycles can vary +/- 7 days normally.

I understand and sympathize with your concern, but also advise you to keep it in perspective. Give yourself a chance for your body to do what it needs to do without undue pressure on yourself or your husband. Then if it does not happen in a few months (which would make it over a year of trying for you both), then insist on an infertility evaluation. At this point, evaluation and/or treatment might be premature.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

41 Yr. Old South African Woman Fails IVF: Needs Higher Stim Protocol, Menopur Dose Too Low

Question:

Hi Dr Ramirez,

I am 41 (42 in March) and have just come through a failed IVF cycle (our 1st attempt). I'm not sure what my FSH levels are but know that I only have 4 and 5 antral follicles left and an AMH of 0.94.

I was put on an 11 day course of 5 amps of menopur a day. I produced 4 eggs, 2 of which fertilised. On day three I had a 6 cell and a 10 cell (neither of which were fragmented) and so the transfer went ahead. Neither took and our result was negative.

I have a 13 month old daughter that we conceived naturally so am reluctant (at this stage) to use a donor egg. The reason we have to go the IVF route is that I have severe Ashermans Syndrome as a result of bad placente accreta from my pregnancy. We are therefore using the services of a surrogate.

I understand that the odds are against us but if we have the means do you think it is worth another attampt or two with my own eggs, and are there any other protocols which may produce a better egg result?

Thanks, M. from Johannesburg, South Africa.

Answer:

Hello M. from South Africa,

As you well understand, IVF pregnancy rates are very dependent on the age effect on eggs. As a woman ages, more and more of her eggs become debilitated leading to poor quality or abnormal embryos. This is the most likely reason for failure after the age of 40 years old. If you absolutely want to have a genetic child, then the only option you have is to continue trying as many times as it takes to be successful. The only things that may stop that plan are if you run out of money (i.e. cannot afford to continue) or the quality of the embryos is consistently poor. Otherwise, persistence can sometimes yield success.

There is a fairly good pregnancy rate at 41-42. In our clinic it is 55% pregnancy/32% deliveries. Miscarriages are increased because of the higher chance of genetically abnormal embryos. The oldest pregnancy to date in a woman using her own eggs was 49 years old in the U.S., but it took her 2 years of trying. Since you have been able to conceive about two years ago, there is already evidence that you do have good eggs. In your case there is the added factor of using a surrogate, but I assume you have selected one that has had successful pregnancies.

In terms of your protocol, every clinic is different and every doctor is different and prescribes/uses different protocols. It does not mean that one is better than the other. In my opinion, however, your protocol is too low for your age. In order to increase the chances of finding a good egg, a lot more eggs need to be recruited and retrieved. 5 amps of Menopur is only 375IU of FSH. As an example, my highest protocol, which is pretty consistent with other clinics in the U.S., uses 450IU of Follistim (pure FSH) + 150IU of Menopur (FSH/LH) for a total of 600IU per day. The bottom line is that the clinic you are working with and their protocol is highly influential on your outcome. You should check and see what their 41-42 year old pregnancy and delivery rates are, then compare them to other clinics. You may find that another clinic is better than the one you are attending.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thanks very much! It was great to receive such a quick and informative response.

High Dosage Of Clomid For A "Good Egg": Why Double The Dose? Will It Affect Egg Quality?

Question:

Hi Dr. Ramirez,

I am writing from Philadelphia, PA and am 39 years old. I have had 9 pregnancies, 7 miscarriages and 2 live births. Since my last child I have had 4 miscarriages and two of the pregnancies I got pregnant with clomid (100mg a day, days 2-6).

I recently switched doctors and the new one recommended IVF with genetic testing because three of my misses were confirmed chromosonal abnormailites - but nothing else has ever been found wrong and I do have two perfectly healthy children. Well, I decided I don't want to do IVF and just take my chances of getting a "good egg" (although the last 4 weren't, I'm still hopeful that one will be). O.k, now for the question... this new doctor wants me to take 250mg of clomid days 4,5,6 and then 200mg days 7 and 8. Why more than double the dose when the lower dose got me pregnant before? Is this safe? necessary? When I call, the nurse says they want to increase my chances, but clomid doesn't effect egg quality does it? Thank you for any advice, thoughts, you can offer.

Answer:

Hello J. from the U.S.,

I am very sorry to hear about all your losses, but your age is the culprit. That is what I call the "age related egg factor". As the woman ages, the quality of her eggs decline and so there is an increased risk of abnormal embryos leading to pregnancy failure or miscarriages. IVF is recommended because we are able to get multiple eggs at the same time. With the increased number of eggs, there is a higher chance of getting a good egg that will lead to a healthy pregnancy.

PGD (pre implantation genetic diagnosis/screening) does not necessarily need to be done. In fact, I am not a big proponent of PGD if this were the only reason. I believe that the poor quality eggs will not work with IVF (i.e. not progress to viable embryos in the petri dish) and if a pregnancy ensues from the good embryos the chances are higher that it will be normal. If you absolutely want to make sure that only genetically normal embryos are transferred then PGS will be required. But then, you would have to do IVF, which you have opted not to.

The reason your doc is recommending high dose Clomid is to increase the number of eggs that you ovulate. Clomid is not the best drug for this but it is the least expensive. Using injectable medications is better but a lot more expensive. That is the only reason for using high dose Clomid in your case. By increasing the number of eggs ovulated, he is hoping that one of the eggs ovulated with be a good quality egg, just like we are trying to do with IVF. However, it may take several attempts, and you may still have miscarriages, whereas IVF would work faster and your chances of a successful pregnancy are higher.

To address your last question, Clomid will not affect the egg quality. That is already inherent in the egg. Perseverance is key in your case. I believe in letting my patients decide how they want to progress with their treatment path. You will need to keep trying, but it may take many cycles. If the miscarriages and heartbreak continue, and you truly wish to have another child, then you may have to consider in vitro fertilization.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

42 Year Old UK Woman With Irregular Periods, Hot Flashes: Is She Perimenopausal? Can She Still Get Pregnant?

Question:

I am 42 years old and have had irregular periods for about the last 10 months, also hot flushes, etc. I have had blood tests at my doctors which showed I have started early menopause. How do I know if I am still producing any eggs and if so could I become pregnant? Is there anything I could do to help in getting pregnant or is this not going to be possible? Thank you, S. from the U.K.

Answer:

Hi S. from the U.K.,

The term "early menopause" is actually a misnomer. There is no way to tell if a woman is entering menopause until it actually happens. That is to say, a woman can be in the perimenopausal period, diagnosed by changes such as irregular cycles, mood changes, hot flashes, insomnia, etc., for years (5-10 yrs) before she actually goes into the menopause. During the peri-menopausal period, the ovary is starting to dysfunction as it leads into menopause, where it shuts down. During this "perimenopausal period" the ovary still ovulates, but often in an irregular fashion. Therefore, pregnancy can still occur. However, the chances are low, and some of the times that you ovulate, and egg is not given off i.e. the follicle is empty.

Some doctors will define "perimenopause" if the cycle day #2 FSH level is greater than 10 (between 10-20), but this actually is a measure of ovarian reserve and does not tell you if menopause is coming soon or not.

The biggest problem, however, is if the ovary is dysfunctioning, the hormones are out of balance and so, the steps following ovulation sometimes are out of synchrony so that pregnancy does not occur, and due to age, the ovulated eggs are often of very poor quality such that fertilization does not occur, or an abnormal embryo is formed that does not go to implantation or that the abnormal embryo leads to miscarriage. For these and other reasons, the chances of a successful pregnancy decline.

If you are contemplating pregnancy at this point, and have not entered menopause, then you have to worry that time is not on your side. That is to say, your time is short to achieve the pregnancy. Therefore, you need to proceed aggressively and with haste. For that reason, I recommend to my patients to do IVF. It has the highest chances of getting you pregnant in the shortest period of time. Trying by natural means, simple intercourse, ovulation induction with intercourse or IUI, will take much time, and you may lose your window of opportunity to use your own eggs.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Prior D&C And Infertility: Woman From Barbados Needs A Thorough Infertility Evaluation

Question:

Good Morning All.....My name is D. and I'm from Barbados in the West Indies. Just to give you a bit of background info on myself and hopefully you can make suggestions for me.

I've read the testimonials on the site and I was very touched and moved by the numbers of persons who were able to receive some type of positive assistance regardless of how small of how large.

In 2005 I had an abortion which resulted in me having to have a D&C and I've not been able to get pregnant since. I say not since 2005 because I remember at some point in 2008 having a very faint positive on a pregnancy test but to this day I cant be sure because the next day I did the test again and it was negative ....so I don't know if it was a false positive if it was a true positive or what it was.

In 2007 I saw a fertility specialist and had some tests done. I specifically had the test done where they run the dye through the tubes to see if they are opened and both tubes were opened. At the end of of various consultations the specialist told me that she couldn't find anything wrong and that only thing she could think of was that I had some scar tissue in the cervix area which was blocking the sperm from entering the cervix and travelling on to meet the egg....she said she arrive at that because it was difficult for her to pass the tube to eject the dye through the cervix. She said the only way I would be able to get pregnant is by having and IUI. Now I'm not being forward or anything and I know I'm not a doctor, but the blocked cervix theory is not sitting well with me and it doesn't seem logical at all.

I spoke to two other specialists and they too do not agree with the assessment. I have a regular 26day cycle EVERY month without fail and testing ovulation sticks shows me a surge around day 10-11 every month. The only thing is that my period has gone over the years form 5 days to perhaps 3 at times with clotting and dark blood or brown blood at time.....other that that it is like clockwork every month.. It doesn't make sense that blood and clots would be able to pass through the cervix and sperm cannot pass through the same opening.

I'm of Christian Faith and I've put the entire situation in God's hands but I think can also prepare my body for when he decides to bless me. I keep thinking that perhaps herbs or something can help I don't know what to do really. I've been married now for 1 and a 1/2 years and we've been trying since 2008 but nothing. I was thinking about the Fertility Cleanse and wonder if you think that would be a good first step, if not I welcome any thoughts you may have Thank you so much for your time and please have a blessed day.

Answer:

Hello D. from the West Indies,

Thank you for your kind comments. Now, what your doctor is referring to when she talks about "scar tissue in the cervix" is probably cervical stenosis. Many women who have never had children can have a small narrow cervix. We call that stenosis. You are correct in that the blood can pass through this, so sperm should as well. Cervical stenosis is NOT a reason for infertility, but IUI will definitely help this issue.

A D&C, dilation and curettage, can lead to scar tissue formation within the uterus which is called "Asherman's Syndrome". The only way to clearly identify this is to undergo a procedure called a hysteroscopy. This is where a small scope is passed into the uterus to look inside the cavity. Scar tissue can be readily seen and if present, can be removed at the time. But this is a difficult problem because often the scar tissue will return and several hysteroscopies with removal of the scar tissue may be needed.

There are other possible causes of infertility that you may not have had checked. For instance, have you had a laparoscopy? It is a surgical procedure whereby a scope is passed into the abdomen via the umbilicus in order to examine the pelvis. The pelvis is important because this is where the egg needs to pass through after ovulation (leaving the ovary) in order to get to the tube. Abnormalities such as endometriosis or pelvic adhesions can prevent the egg from getting to the tube. In addition, has your husband had a semen analysis done? Have you had a end of cycle endometrial biopsy to check to see that the uterine lining (endometrium) is forming correctly? These are just some examples of fertility testing. Lastly, you have not mentioned your age. Advanced age (over 35 yo) can play a role in egg abnormalities.

If you have had all this testing and still nothing has been found, then you would be categorized as an "unexplained infertility". This just means that we have not found a cause, and the most likely reason is because we don't have the technology to find the cause. Many of these patients have to resort to IVF (In Vitro Fertilization) in order to achieve pregnancy because there might be a sperm-egg fertilization problem (which you cannot test for). If your doctor is a fertility specialist, then she should be able to map out a treatment plan for you. Before resorting to alternative treatments that may not work, please go over some of the suggestions I made with your doctor.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: I was kind of skeptical in looking for a response.Like most online Q&A I expected a vague response at best and I expected the doctor to be as short as possible considering he wasnt being paid but I was pleasantly surprised with Dr Ramirez...he was great and I got more info from him than I did with my own doctor... Thank you so much Dr Ramirez and may God bless you as you seek to help others :)

Stage IV Endometriosis Patient Trying To Conceive: More Time, More Surgery or IVF?

Question:

I was diagnosed 4 years ago with stage IV endo after having it excised during a lap. I had a Mirena IUD inserted during surgery and just had it removed a few months ago because I am ready to have a baby. I am very regular (26 or 28 days) and ovulation predictor tests show that I am ovulating on day 12 or 14.

Five cycles later we are not pregnant. I feel my ovaries pinch a few days before my period and am back to having pretty bad menstrual cramps (though not as bad as before the surgery). I have read a lot of your responses and see that IVF (in vitro fertilization) is your advice for stage IV endo. Do you think I am ovulating normally and what do you think my next step should be? I have a doctors appointment and am very nervous that he is going to suggest another laparoscopy!

Thank you in advance for your time. M. from the U.S.

Answer:

Hi M. from the U.S.A.,

Thank you for reading my responses. Technically, you have not tried for pregnancy long enough to suspect that a problem exists. We do not define infertility until a woman under 36 has been trying for at least 12 months because it takes most women in that age group 8-12 months to achieve pregnancy naturally. If you are 36 or older, then 6 months would be the limit.

Certainly because of the history of stage IV endometriosis, you have a significant impairment to your natural fertility. Mirena helped, but it is not perfect. There is no treatment to eradicate endometriosis completely, and so it is highly probable that endometriosis is still present in the pelvis. In addition, stage IV endometriosis implies that there has been significant damage to your pelvis and it is not normal i.e. pelvic adhesions, inflammation, destruction of the normal anatomy. These will impair your natural chances for pregnancy. For that reason, in many of these patients, but not all, IVF will be required to get pregnant. I have had some spontaneous pregnancies in stage IV endometriosis patients but they are few.

Let's say after six months or one year, you still cannot get pregnant (depending on your age), you will need to pursue other options. Knowing that you have Stage IV endo, additional surgery will NOT help. You may want to go straight to IVF and avoid the surgery. That is what I would recommend. Many gynecologists will recommend the surgery because that is all they can do, they don't do IVF. They would rather do something in their power than do nothing. Instead, a good gynecologist will refer you to a fertility specialist that does IVF for at least a consultation. A good infertility specialist will probably explain that the pelvis, an essential part of your anatomy for achieving a natural pregnancy, is a hostile place for the egg. Therefore, the treatment of choice is to avoid the pelvis which is what occurs with IVF.

Good Luck on your journey and don't hesitate to write again with any other questions,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you so much, you have quelled much of my anxiety. The scariest part about facing fertility problems is all the unknowns and the waiting. I appreciate your help.

43 Yr Old With High FSH Of 30 Asks: Is There A Way To Lower It?

Question:

Dear Dr. Ramirez,

First, thank you very much for taking the time to answer so many questions. Your column has been an important part of my education on IVF.

I am writing from Cincinnati, OH. I am 43 years old and am considering IVF. I just learnt that my FSH is 30, substantially above the cutoff rate for my fertility clinic (their cutoff is 10). Are there any options other than donor eggs? Is there a way to lower FSH? Would love to get your perspective. Thank you. S.

Answer:

Hello S. from the U.S.,

I'm assuming, of course, that your FSH levels were accurately tested. The FSH level is only valid for interpretation if it is done on cycle day #2 or 3. The FSH is a measure of ovarian function (or ovarian resistance). This is mainly important to determine how well the ovaries will respond to stimulation. It is NOT a measure of fertility. However, if the CD#3 FSH level of 30 is correct, that would indicate that you are perimenopausal and your ovaries would be shutting down. You would no longer be having periods and you would have menopausal symptoms such as hot flashes. Is this the case?

If so, unfortunately, with an elevated FSH of 30 you are not eligible for any other treatments other than donor eggs. I'm sorry but there is no way to revive the ovaries at this time. I see on the web that there are many lay people claiming that there are "natural" alternatives like acupressure that can help lower your FSH levels. This is simply not true!

Please see my previous post:"41 Yr Old With High FSH, High Estradiol..." where I go into greater detail regarding this distressing issue. Remember, there are many paths you can take to motherhood and from my experience as an infertility specialist, all those paths can bring happiness.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

When Should An IUD Be Removed In Order To Get Pregnant?

Question:

Hi, I am a pretty healthy 25 year old woman with two children ages 5 and 3. I am writing from Washington, DC. I currently have a copper IUD as birthcontrol. I have had it in for a little more than three years now (since I had my youngest child). My husband and I are thinking about having another baby and I would really like for the baby to be born in March, April, or May 2012. As far as I know the copper IUD shouldn't affect my ability of getting pregnant after I have my doctor remove it and I didn't have any problems getting pregnant with my other two kids.

My question is during what month should I have my IUD removed in order to get pregnant and give birth during these months. And should I have the IUD removed before or after I get my period that month? Y. from the U.S.

Answer:

Hello Y. from the U.S.,

I usually will recommend that the IUD be pulled when you are on your period. Because there is flow, the uterine cavity is more expanded and removing the IUD is easier at that time. You can then begin trying for pregnancy with that month. So, if March 2012 is the earliest you want to have your baby then you can begin trying in July 2011. You can remove the IUD with your period nearest July (end of June or beginning of July).

Good Luck!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

U.K. Patient Concerned About ICSI And Husband's Diabetes: Will There Be Abnormal Embryos?

Question:
Dear Dr. Ramirez,

My husband had a semen analysis result and he had Moderate Oligospermia and Severe Asthenospermia (only 4% normal progressive). It has been suggested that we would require ICSI IVF, however my husband also has Type 1 diabetes. I have read that his sperm cells might have DNA damage and to use such sperm in ICSI could result in an unhealthy child prone to cancer. None of the professionals I have spoken to in this early stage have made any reference to the implications of my husband being diabetic and it is causing me concern.

I was hoping that you could clarify how sperm are tested for DNA damage and if it could be used in conjunction with ICSI. Also, does non-ICSI IVF avoid the risks of DNA damaged sperm cells? Would they be filtered out by natural processes? Thanks, L. from the U.K.

Answer:

Hello L. from the U.K.,

Sperm can only undergo DNA testing apart from IVF/ICSI because the sperm tested are essentially destroyed. There is not method to test the sperm prior to ICSI at the time of IVF. There is also no way to test the resultant embryos from DNA damage, but testing for genetics is possible.

There have been some studies, mainly out of Europe and using small homogeneous numbers (homogeneous meaning that everyone tested was of the same racial type such as Sweden), that showed the possibility of fetal abnormalities with ICSI. However, that has been unproven and IVF with ICSI has been around for almost 20 years. In the U.S., where the population is more diverse, studies have not shown any type of abnormalities, so the tests that were done previously in Europe might have some type of population/genetic weakness.

The fact that your husband has diabetes might explain why his semen analysis was abnormal (due to reduced blood flow in the testicles). This should not affect the embryos formed with ICSI, however. In general, the embryologist performing ICSI chooses the healthiest swimming and formed sperm for injection. There should be plenty to choose from. The embryos that might be abnormal generally do not progress, and therefore are not implanted.

Hope this helps to set your mind at ease!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Thank you for your response. It has really put my mind at ease. It is very difficult to find a small amount of information that could have a massive impact on your children and it not seeming to be acknowledged. Regards, L.

Four Weeks Post First IVF & Positive BHCG: Not Rising Adequately & Possible Ectopic

Question:

Hi Dr. R. -

I am 39 years old and we have male factor infertility. In our first completed IVF cycle we had 27 eggs retrieved, 20 good, 14 fertilized, and 3 - day 5 blasts transferred. I had a very light implantation bleed and a positive Hcg at day 14 post retrieval.

1st Hcg 132 14 days post retrieval (this was 2 days early as I had to go out of town)

2nd Hcg 183 19 days post (this was a few days late since I was out of town)

3rd Hcg 278 21 days post (also requested a progest test which was 119 or so, can't remember exact #).

4th Hcg 479 23 days post

Had a u/s 23 days post which showed nothing other than very large ovaries. I understand the data on Hcg doubling but am curious about the 10-20% of women who do not have doubling - not a lot of literature on these patients. My RE said there is zero chance of the pregnancy progressing and said it was a chemical pregnancy and would monitor for an eptopic, I was advised to stop progesterone supps. Also, I had preg symptoms day 12-18 post but they have become less this past week. I have had no bleeding or cramping during the entire process. Any thoughts on my prognosis would be appreciated. Are my levels just too low and too slow?

One other question, my ovaries are "as big as grapefruits", is the only option to wait until they resolve and how long can that expect to take? Again, I am 4.5 wks post retrieval.

Thank you! J. from the U.S.A.

Answer:

Hello J. from the U.S.,

The minimum requirement for HCG rising in a normal pregnancy is an 80% rise, not 100% (doubling). However, your bHCG's have not been rising adequately. For example, the first bhCG at 132 should have risen to 238. The fact that your bHCG's are not rising adequately means that it is unlikely to be a normal progressing pregnancy, but you are still pregnant. In addition, an ectopic (tubal) pregnancy cannot be ruled out yet because the level is not high enough to see a pregnancy in the uterus. The level generally has to be above 2500. It is wise to keep a close eye on your situation.

The ovarian size is due to the increased stimulation you received. It will take up to two weeks to resolve in size from the cessation of the pregnancy. Remember, even though your first cycle has not been successful, you and your husband were able to go through all the steps needed to accomplish IVF, with some good embryos to transfer. I hope that you will consider trying again.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Empty Follicle Syndrome In 40 Year Old Attributed To Age Factor

Question:

Hello Doctor,

I am from Cuba but I live in Miami. I am 40 y/o now. I had my first IVF cycle at 39 that failed, back in July. I started 2nd round in Sept.- Oct. but it was just cancelled due to empty follies. It is possible that I have no more eggs in my ovaries?

I have another theory but I am not an expert and I don't know if it is possible to be true. The first step was taking birth control pill. I took them for 21 days. After that I had NO PERIOD. I did have symptoms "as if" my period was there (cramping, pain) but no bleeding. I did an ultrasound but the endometrium was not big enough to shed. At day 7 after the last pill, my Dr. told me to start the stimulation for IVF anyways. There were 6 follies formed but empty. What do you think? Could this (bcp) be the cause for no eggs retrieved? Thank you very much. I am very frustrated. T. from Florida

Answer:

Hello T. from Florida,

We tend to see a higher incidence of "empty follicle syndrome" with increasing age. This is indeed because there are fewer and fewer eggs left. However, no eggs at the time of retrieval is not related to having used the birth control pill and not having a period. There are other reasons, besides age, where no follicles are retrieved as well.

I have had several cases of EFS in my career (16 years) of doing IVF and in some cases they were in younger women, so the age factor did not apply. Those younger cases I attributed to a lack of adequate HCG triggering. I used to use a generic HCG, and it is possible that either the medication was not stored correctly and lost its efficacy, or it was not injected properly, or it was a bad batch of medicine. For that reason, I switched to Ovidrel, which is what I still use. I have not had a case of EFS in a young woman since. I still do see older women that have no eggs retrieved, however, and that is the age factor. Nothing can be done about the age factor except continuing to try in the hopes that (1) the next cycle will yield some eggs and (2) there will be a good one in the group.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Marathon Runner Has Amenorrhea And Is Trying To Conceive: May Need Gonadotropins

Question:

Hi, I am a 25 year old, PhD student and I am a competitive marathoner. My husband and I would like to get pregnant over the next 8 months. I was on the pill until last April, when I went off the pill. I had been on the pill for nine years and my cycle was regular before I went on the pill. During the years I was taking the pill my cycle was fairly regular, light and short in duration, but still regular. I have not had a period since I went off the pill 6 months ago. I am 5 7' and about 108lbs.

I have met with my Dr and she suggested that I go on the pill for a month so I can at least have my period to shed my uterine wall. Then she said if my period does not stick around I may need to gain a bit of body fat. I have also done blood work to make sure there are no other issues. Do you think that I will have to gain weight before I can get pregnant? Or can I just cut back on my training and lose some muscle mass and avoid gaining weight? Also can I get pregnant with my period being absent? Thanks! A. from Canada

Answer:

Hello A. from Canada,

The problem with competitive runners is that they lose a tremendous amount of body fat and so cannot produce hormones. They develop a disorder called hypogonadotropin hypogonadism. For this reason, they do not cycle normally. The birth control pill artificially takes over ovarian function and so you have an artificial period, but it is not because the ovaries are working. Having stopped the BCP (birth control pill), you are now at your normal state and your ovaries are not working. This is the reason your doctor recommended that you gain fat weight. Hormones are made from cholesterol. It is the chemical basis for all hormones. Unless you gain fat weight, you will not ovulate naturally and so will be unable to get pregnant.

I would not recommend another course of BCP's at this time, however. You can wait and see if you get a period, which you only need to have every three months at a minimum, and if it does not occur by itself, then you can take progesterone for 5 days to start the period. That way you will have the opportunity to become pregnant should ovulation occur.

The only other option for getting you pregnant would be to give you the hormones that your brain is not making to stimulate the ovaries. This is a medication called a gonadotropin. We would use a medicine called Menopur that is FSH and LH hormone. These hormones stimulate the ovaries to ovulate. You cannot use Clomid or Femara because the hypothalamus needs to be working for these to work and yours is not working.

Although there are many reasons for primary & secondary amenorrhea (absence of menstruation), I believe yours is due to your pattern of exercise and has a good chance of being corrected. See the Mayo Clinic website for more information: "Amenorrhea: Causes".

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Patient Runs Risk Of High Multiples With 7 Mature Follicles In IUI Cycle

Question:
I am on my 7th IUI cycle (a miscarriage on the 4th attempt). This month I have 7 follicles mature and ready to go. I am 36 years old. We would gladly welcome twins or even triplets.

What is the risk of higher order? A. From the U.S.A.

Answer:

Hello A. from the U.S.,

I would not continue the cycle with 7 ovulatory sized follicles (>15 mms) because of the risk of a super-multiple gestation (>2). I cannot give you a statistical risk as that number does not exist, but I would expect the risk to be high. Keep in mind that even twins are a high risk pregnancy and should not be taken lightly! I had an IVF patient this week who was pregnant with twins that just lost both at 23 weeks due to premature labor and delivery. It is heartbreaking. That is why we try not to have twins and definitely, try not to have triplets.

I will allow up to 5 mature follicles at 36 years old, but no more than that. Some RE's will not allow more than 3. I don't think you should take that chance.

You did not say if you are seeing an Ob/Gyn or an RE. I would like to comment on the fact that this is your 7th IUI (intra uterine insemination) cycle...I would hope that you have had a thorough infertility evaluation. One very simple reason that many women fail their IUI's is that their tubes are blocked. I can't tell you how many patients I have seen that have done multiple cycles of Clomid and IUI's who end up having this problem. If you have had a complete workup and you still fail, at 36 y.o. I would only have had you try 4 to 5 IUI cycles. At this point I would be counseling you regarding a more advanced fertility procedure, IVF (in vitro fertilization). Time is not on your side after the age of 35 as fertility begins to decline rapidly.

See my blog post: "Tips On How To Increase Your Fertility" for more information.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Trying To Conceive For One Year: Clomid Vs. Laparoscopy?

(If the blog radio program comes on, you can pause it by going to my Oct. 1st post. I will be keeping the show up for the month of October.)

Question:

Hi. I've been trying to conceive for about a year and my doctor and I are ready to take a more aggressive approach. We have generally discussed both clomid and laparoscopy as next steps in the coming months. I am wondering if you can give some advice as to the order of trying clomid first or having a laparoscopy first.

My sister and aunt both had endometriosis so I expect that could be the culprit. I personally lean towards having the laparoscopy first, but I want to understand which is usually recommended. Thank you. V. from the U.S.

Answer:

Hello V. from the U.S.,

In order for you to achieve pregnancy, if you have been having trouble, you have to find the reason so that you can get the appropriate treatment. The term "fertility treatment" or "fertility drug" is a misnomer. The treatment has to treat the problem. There is nothing that makes your more "fertile" no matter what the problem.

Clomid is a fertility medication only in that it is used to treat infertility. In actuality, it is an ovulation inducing drug. That is, it gets the ovary to ovulate if the ovary is not already ovulating. Doctors use this medication in women that ovulate also to increase the number of eggs they ovulate so that there is a higher chance for one of the eggs to reach and enter the tube (because that does not happen every time).

Laparoscopy is a surgical procedure that is used as an infertility test. It is part of the infertility evaluation because it is the only method to assess if there are any pelvic abnormalities. This is important because the third step of the body's process to achieve pregnancy (brains sends FSH/LH to ovary > ovary grows follicle and matures an egg > ovary ovulates and egg enters pelvis > egg has to get to tube . . .) is for the ovulated egg to pass through the pelvis and get into the tube. If there is anything within the pelvis, like scar tissue or an inflammatory disease like endometriosis, then then egg may not make it to the tube (endometriosis causes inflammation that can destroy the egg).

I presume that you have had a complete infertility evaluation prior to your doctor's recommendation to use Clomid or do laparoscopy? I dislike it when general Ob/Gyn doctors jump to unnecessary conclusions such as go directly to Clomid or laparoscopy without making sure that is what is needed. Clomid is used for ovulation problems or in conjunction with IUI (if there is a sperm problem). Laparoscopy is done if all the other preliminary tests are normal, or if there is an increased chance of having endometriosis such as severe menstrual cramping or pelvic pain or pain with intercourse. It is usually one of the last tests to be done. Is that where you are?

These are the things that need to be considered and if you see the right fertility specialist, it is more likely that the appropriate things will be done to help you to become pregnant. If you see the wrong person, then you might just be wasting your time.

If you give me more detailed and specific information (such as your age and what tests have been done), then I would be able to give you my recommendations on what needs to be done next.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

The Importance Of Choosing A Qualified Infertility Specialist: 41 Year Old Patient Losing Time

(If the blog radio program turns on, please go to my October 1st post & pause it! I will be keeping the show up for the month of Oct.)

Question:

I have started evaluation with a RE at the beginning of August. I have so far been diagnosed as having low progesterone and not ovulating properly. I am just turned 41 and had a miscarriage at age 38 at 9 weeks.

My Dr said if my problem is only hormonal, it is an easy fix. He had me on prometrium for 10 days and now I go back for another ultrasound at the end of my menstrual cycle. I know other people have been put on Clomid with the prometrium. I just wondered what would be his justification or reason behind only giving me prometrium. I asked the nurse and she the prometrium was to help me ovulate. I am curious, I think my doctor is fabulous. I just want another opinion. Thanks! M. from the U.S.

Answer:

Hello M. from the U.S.,

I am glad that you wrote to me because your case disturbs me. You may like your doctor but he is wasting your time. If what you say is correct, neither he nor his nurse know what they are doing and they are leading you in the wrong direction!

If you ovulate correctly, then the progesterone level should be in the normal range. When that does not occur, it is called a "luteal phase defect" and the progesterone is used to help the endometrial lining of the uterus to convert correctly and support implantation. It DOES NOT cause you to ovulate. However, if your ovulation is not correct i.e. you are not ovulating, which would also lead to a low progesterone, then the treatment is to use a fertility medication to get the ovaries to ovulate properly, thereby correcting the problem.

There is another very very large issue, however, and that is that you are 41 years old. Did your "RE" talk to you about the age effects on your fertility? Did he tell you that your chances of a spontaneous natural pregnancy are only 1% per month or slightly less than 10% per year? Did he tell you that you may be wasting your time and possibly losing your ability to have a genetic child if you don't proceed in a more aggressive manner?

If your "fabulous" doctor is indeed an RE, then he should be very concerned about the impact of your age on your fertility and time. He would not be wasting your time with fruitless treatments like prometrium. He would be doing a more aggressive treatments like IUI (intra uterine insemination) or in vitro fertilization, IVF (preferred). Also, if he is indeed an RE, he would be doing IVF in his clinic. Does he? If not, then he may not be an RE at all.

My recommendation would be for you to go see a real infertility specialist, preferably one that does IVF, so that you can be counseled appropriately. I recently had a consult with a patient who, like you, went to a doctor that said that she was a fertility specialist. She was with this doctor from 36 years old to 45 years old. She was never referred to see a real infertility specialist, and so now, her only option is to use donor eggs with IVF. If she would have come to me sooner, we might have been able to get her pregnant using her own eggs. Please don't make that mistake!

Good Luck and keep asking those questions!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Faith Salie Comes Out On Her Choice To Undergo Egg Freezing

(If the blog radio program comes on, please go to the Oct. 1st blog & pause it. I will be keeping the show up for the month of October.)

Dear Readers,

For those of you who missed this, Faith Salie, a multi-talented American writer, television and radio host decided to "come out" regarding her decision to freeze her eggs. Her experience was filmed and shown on CBS's Sunday Morning Show on October 10th. Her slightly tongue-in-cheek account has a powerful message, nonetheless, and that is, "Choice". Now, young women do have a choice to prolong their fertility. It is not inexpensive but those who never had this choice and are now faced with undergoing multiple IVF cycles or using donor eggs would probably be the ones to tell you that they wished they would have had this opportunity. The development of better ART to freeze and thaw has made egg freezing a reality, a viable option for women like Faith Salie.

As she put it in her piece for CBS:

"Let’s talk eggs.

Not the ones on your breakfast plate. No, the ones I have frozen at the NYU Fertility Center.I want to talk about egg freezing, because I don’t think enough young-ish women know about it. I even made a video diary of my eggs-perience, in which I chose to shoot myself up with fertility drugs, visit my doctor twice a day for bloodwork and ultrasounds, and check myself into the hospital for the big retrieval.

I knew two things: I really, really want to have a baby; and I really, really don’t know who should be the father. Now I know a third thing: The option to freeze one’s eggs is just about the most empowering choice a single woman who knows she wants to be a mother can make."

Guest Blogger Mindy Berkson: Building The Foundation For Surrogacy Brick By Brick

(If the blog radio program comes on, please go to the Oct. 1st blog & pause it. I will be keeping the show up for the month of October.)

Dear Readers:

Mindy Berkson is visiting my blog once again with an excellent guest post on surrogacy. For many, surrogacy is the only option. Recently, I had a patient who had an emergency hysterectomy after the birth of her first child. She was grief-stricken at the prospect of not having the ability to have another child until she decided upon surrogacy as an option. The whole process went forward without a hitch, with her and her husband undergoing IVF at our center with a surrogate they had found through a reputable agency. Her gestational carrier is now pregnant and will be delivering soon.

This is a complicated process and one in which Ms. Berkson has a wealth of experience as an infertility consultant. One of the first in the country to work with infertile couples on a case-by-case basis, she is both professional and compassionate when guiding her clients through what can be a very difficult and emotional treatment path. See the end of the blog post for more information on Lotus Blossum Consulting.

Building The Foundation For Surrogacy Brick By Brick

With so many moving parts to surrogacy it is no wonder the process can be overwhelming. Learning to be your own best advocate, effectively planning financially, physically and financially help you maximize your chances of success and minimize your financial expenditure.

The first step in building the foundation is preparing to pay for treatment and the ancillary costs associated with surrogacy. Finances are specific to individual circumstances. Sometimes savings are available, often the sale of portfolio items are used to fund treatment. A third popular option are various borrowing opportunities. All of the above should be discussed with a tax professional and or financial planner in the context of your individualized circumstances. It is also vital to plan and prepare for multiple treatment cycles. In my experience balancing hope with caution is what helps my clients to approach treatment with clear expectations and realistic parameters.

The second step in building the foundation is to identify the fertility center, the Reproductive Endocrinologist and the Embryologist who have above national average success rates for the type of treatment you are exploring as well as a specialty in treating your specific diagnosis.

The next resource is identifying the right donor and/or surrogate. Seeking ideal criteria in a perfect stranger is often a very intimate process. There is always some level of risk in the decision making process. Being your own best advocate is helpful in mitigating and or eliminating potential stumbling blocks. Identifying a candidate on line can be risky since they are not screened and you will not have the benefits of a third party to act as an intermediary. On the other hand, it is necessary to be aware of onerous contracts with recruiting agencies.

The fourth brick in the foundation is understanding the legal terrain and how it affects your specific situation. Surrogate friendly states vary across the country. Surrogate friendly means that parentage can be achieved at some future point after birth. But from state to state this varies greatly. Some states require pre birth orders to get intended parents names on the birth certificate after the birth and other states require a formal adoption after the surrogate delivers. Other states are favorable in getting intended parents names on the birth certificate at birth, as long as one parent is biologically related to the child. Furthermore, often how the embryos are created, and with whose biological material is relevant to the big picture. Thus, the individualized situation can and does impact the selection of a surrogate candidate from state to state. Finally, selecting a surrogate with like-minded intentions for the term of the pregnancy is essential.

There is still more to consider. Most health insurance policies have exclusions for surrogates. Therefore, it is essential to analyze policy alternatives that may help you to save thousands of dollars in the future. Some states offer maternity policies, other states offer nothing. Disability and complications only polices can often be purchased to offset financial risk. But it is the gap analysis performed by the licensed insurance agent that can help uncover what is best for your given situation, the surrogate, the state where she will deliver, and how these factors impact your individual risk adversity given your personal financial situation.

Another extremely important and often overlooked resource in family building is estate planning. Prior to surrogates going to embryo transfer it is essential to engage an estate planner to draft directives and desires and prepare effectively for any unforeseen circumstances. This provides the most protections for all involved parties.

Building the foundation for treatment is essential. Knowing all available options, researching the viability of each options, interviewing several reproductive specialists to determine if you are in the right place are all very relevant and key factors to consider before patients begin the journey.

When making educated decisions to pursue treatment options, I encourage my clients to take into consideration all the facts. Because making informed medical decisions is the best way to maximize their chances of success and minimize their financial expenditure.

As one of the first infertility consultancies in the United States, Lotus Blossom Consulting, LLC was founded by Mindy Berkson in 2005. With more than a decade of experience at physician’s offices, and egg donor and surrogacy agencies, Berkson assists individuals working through the often-challenging roadblocks of infertility, by providing the best information and resources available to them from around the world – all in one location.

Lotus Blossom Consulting works with individuals on a case-by-case basis, taking into consideration clients’ emotional, physical and financial infertility issues and then develops an individualized, comprehensive plan, to help clients make informed decisions and pull together a team of unbiased professionals to accomplish a treatment cycle. Mindy is a sought-after infertility expert and has appeared on countless media programs and speaker panels educating audiences on the topic of infertility, egg banking and surrogacy. For more information about Lotus Blossom Consulting, LLC, call toll free (877) 881-2685, email mindy@lotusblossomconsulting.com or visit the web at www.lotusblossomconsulting.com or www.infertilityconsultant.com.