IVF Patient's Early BetaHCG Levels Show Drop In Estrogen

Question:

On January 12th, I discovered I was pregnant following IVF. My HCG numbers have been excellent. However, on January 21st I learned that my estrogen levels had dropped to 259 (from 400 on Jan 15). My progesterone and HCG continued to do well (HCG 569 on Jan 15, 3616 on Jan 21st). My Doctor has indicated that I should plan a D&C imminently as the pregnancy is unlikely to be viable.

Would you share this view? How significant is an estrogen drop? Thank you.

Answer:

Thank you for your question.

In the early pregnancy, less than 6 weeks gestational age, estrogen is derived almost completely from the ovary. Placental estrogen production has not started. Based on your first BHCG, I estimated that you are less than 6 weeks gestational age (assuming your BHCG was drawn at 8-10 weeks post transfer). If that is the case, and you are not taking exogenous estrogen (from another source), then the drop is concerning because it is an essential hormone of pregnancy.

Your doctor might want to consider adding estrogen in some form. Estrogen alone is not sufficient to diagnose an impending miscarriage. If all three hormones are dropping, then that would be significant. I would continue to follow the BHCG levels, which is the most sensitive to make that diagnosis.

In such an early pregnancy, a D&C is generally not required. Good luck and hang in there!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Primary Amenorrhea In 32 Year Old

Question:

I am 32 years old and never had a period. My mom took me to the doctor when I was 20 yrs old and they did an ultrasound of my abdomen which showed no cysts in the ovaries and a hormone test which showed that my FSH and LH levels were low. The TSH was normal.

A genetics test confirmed that I am xx. I used the contraceptive pill and had a bleeding. I have always had excess hair growth since puberty and acne issues. Do you think something is seriously wrong with me or I should just let things stay the way they are?

Answer:

There is absolutely something wrong, and it should have been taken care of a long time ago. Without specific laboratory information I cannot tell you what the problem is, but you have some type of ovarian dysfunction. In other words, your ovaries are not working. The bad part of this is that you are probably estrogen deficient. Estrogen is the female hormone and is important for many different parts of your body. As a consequence, you have an elevation in the male hormone, testosterone, because your ovary is not making estrogen. If you keep up like this you could suffer the following consequences: increased facial and body hair, loss of head hair (male pattern baldness), increased acne, deepening of the voice, obesity, diabetes, osteoporosis, increased heart disease.

The reason for the birth control pill was to give you the female hormones that you need and block the male hormone production. If you are not planning on getting pregnant, then you need to go back on the birth control pill. I would recommend that you go on Yasmin or Yaz, which blocks the male hormone better. Bottom line is that you need to see an Endocrinologist or Reproductive endocrinologist.

Good luck and be sure to follow through with my advice!

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

ELONVA, A New Sustained Follicle Stimulant Just Approved In Europe!

Dear Readers,

I just read a news release from the big drug manufacturer Merck that they have been approved by the European Commission to market a new drug for IVF patients that will make their lives remarkably easier! It is a sustained release follicle stimulating hormone called Elonva, the first of it's kind! Whereas women undergoing IVF now have to have daily subcutaneous injections of FSH, with Elonva they will only have to have a subcutaneous injection ONCE a week. This is a significant improvement, thanks to the Organon division of Merck pharmaceuticals.

From what I have read in their press release, this new long-acting FSH lasts for 7 days. It has to be used with an antagonist so that doctors that already use antagonist protocols will have an easier time adapting to the new regimen. Those that use the long protocol will be less amenable to use it because they will have to get comfortable with two new meds. It will replace the first 7 days of injections required by currently available medications. Hopefully, the cost of medication will be equivalent or less, but for sure patients will appreciate the reduced number of injections! I can't wait for an FSH/LH equivalent for my mixed protocols. I hope the FDA approves it ASAP for U.S.A. use. Otherwise, I might have to take a lot of trips to Europe :-)

See the following link to get more information: http://bit.ly/cQpXn5

Here's hoping for a quick release for our patients in the United States!

Edward Ramirez, MD, FACOG

Executive Medical Director

Fertility & Gynecology Center

Monterey Bay IVF

http://www.montereybayivf.com/

I Had An Ectopic, Can I Get Pregnant With Only One Fallopian Tube?

Question:

Hello, I am from India and I hope you would be able to help me.

I had an ectopic pregnancy 3 months back wherein I had to undergo laparoscopic surgery to remove my right fallopian tube where the fertilized egg had embedded.

Both my ovaries are intact.I didn't have any fertility issues before conceiving. My question is whether it is possible for left fallopian tube to collect the eggs released by right ovary? Also, I wanted to check with you whether the ovaries release eggs in alternate months. In your opinion, approximately how long it might take for me to conceive the next time?

Please help me with these questions!

Answer:

In answer to your questions, yes, it is possible for an egg that is ovulated from the right side to enter through the left tube.

That is because no matter what side the egg ovulates from, it falls into a space in the middle, called the culdesac, where the end of the tubes are usually hanging. Eggs are released randomly from the ovaries. They do not alternate. The problem that you have is that you had an ectopic pregnancy. This is usually caused by scar tissue within the fallopian tube. The egg/embryo gets stuck on this scar tissue and cannot advance, therefore, it implants there. If you have scar tissue on one side, you are at risk for having scar tissue on the opposite side because usually the inflammation that affects one tube, also affects the other tube (that is where the scar tissue came from). For that reason, you are at increased risk of another ectopic on the opposite side.

Your chances of getting pregnant are still the same, despite only having one tube, but you have a 30-50% chance of an ectopic. The treatment that I would recommend at this point would be to consider IVF so that the tubes can be bypassed.

I hope you succeed in your efforts to become pregnant and that you keep in mind the risk involved with trying to get pregnant naturally with your past medical history.

Sincerely,

Edward Ramirez, MD, FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
Monterey, CA

Patient Had Laparoscopic Ovarian Drilling & Damaged Tubes, What To Do Next?

Question:

I am from the United Arab Emirates. I had problems with my periods earlier since beginning of my teenage, like the absence of periods for years. Then I started taking contraceptive pills for regularizing my periods but it didn't help me. After that I thought it would be ok after I got married but then I didn't get pregnant for 1 year. After that, I had Laparoscopic ovarian drilling done.

I take no medicine till now after the surgery I got my period twice on my own 28 days difference but on the 3rd month I didn't get my periods at all. I thought I got pregnant then but I had blood tests done twice but it showed me negative. Before the surgery I had taken injectables, Clomid and what not, but it didn't help me ovulate actually. Both of my tubes were blocked but now after the surgery one of them is working. The doctor said I have less hormone & right now I am on primolute to get periods. So after consuming primolute for 10 days when should I expect my periods???? and what has to be done for my hormones???

By the way my age is 21 and my height is 162 cm and have been married for 1 and half years . My husband's semen was tested and they said that it's normal. Thank you very much!

Answer:

It sounds like you have PCOD (polycystic ovarian disease). Ovarian drilling is a very, very old fashioned treatment for PCOD. It is a procedure whereby a laparoscope is inserted into the abdomen and a needle, electrode or laser is used to make holes (yes, holes) in the capsule of the ovary. In the past, it was used as the mainstay treatment for PCOS, and in some cases was successful in getting the ovaries to function normally, at least for a short while. But, it does not work in all cases, and the problem is that damage to the ovary can induce scar tissue around the ovary, tubes and pelvis, thereby rendering the patient infertile by obstructing movement of the egg to the tube. Contemporary fertility surgery preaches minimal tissue damage to prevent or reduce scar tissue formation. This procedure contradicts this philosophy, did not work in most cases and, in some cases, made the fertility problem worse. We don't use it very much in the U.S. any more, and I cannot recommend it.

You have two problems in regards to your fertility: (

Number One: because of the PCOD you don't ovulate and Number 2: you have a tubal problem.

First, let me deal with the tubal problem. In reality, there are NO surgeries that can correct a tubal problem. Surgery can be used to open the ends of the tubes, but the major damage is usually within the tube and this cannot be repaired. The fallopian tubes are not just pipes. Opening them is not enough. They are working organs with muscle layers and small hairlike cilia that help to move the egg and sperm together. Because this damage cannot be repaired, the only realistic treatment option is to proceed with IVF "in vitro fertilization". This allows us to bypass the tubes.

The second problem is PCOD. In this case the ovaries are difficult to ovulate safely (only allowing 2-3 eggs to ovulate). For that reason, the majority of PCOD women have to proceed with IVF. This is because we can extract all the eggs and control the number that are put back in. This is necessary because PCOD patients tend to over-respond to injectable medication, which is the only medication that will work to stimulate most PCOD ovaries. Clomid usually doesn't work.

So my recommendation is to see a fertility specialist and undergo IVF. The primolute is a progesterone, I believe, and is only being used to induce a period. It is not doing anything else.

Follow-Up Question:

So what do you say doctor, just Laparoscopic ovarian drilling and Clomid will not work after getting my periods thru primolute? I am waiting for my periods to come and so I can start with clomid and injections. This is the first clomid cycle after my surgery? Well, what I think is let me wait and see and then next we will go for IVF.

Follow-Up Answer:

Hello Again,

There is a good chance that the Clomid might stimulate your ovaries to ovulate. The ovarian drilling can sometimes make the ovaries more receptive to this medication. However, the chances are not good. The biggest problem that you have is a tubal problem. Because Clomid with either timed intercourse or IUI rely completely on the fact that there has to be normal tubes, if they are not, that is what will prevent you from getting pregnant.

In any case, miracles do happen and you may be the exception to the rule! So as long as you don't mind trying the Clomid, then it is okay to try.

Good Luck.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Pelvic Pain Proper Diagnosis and Treatment Needed

Question:

I have been married almost two years and I have not been able to get pregnant. I have noticed a clear mucus on the tissue when I go to the bathroom. I went to the clinic because of pelvic pain and the nurse told me that she does not see any signs of an infection but gave me doxicyclin and metronodazol for 1 or 2 weeks. She told me that she noticed a lot of cervical mucus. I had also had the same pain issue 5 months prior and was given doxicyclin then by a different doctor whom also said that she did not see an infection but because I recently had an IUD taken out there might be a little bug in there bothering me. I had an IUD removed in Jan/07. I was in for about 3 months. I was not comfortable with the idea of this foreign thing inside me all the time. I feel a sharp pain and discomfort during sex and also I am shocked that I have not been pregnant yet.

I already have one son who was induced a week past due date, and I have been pregnant a few times after but terminated those. I have never seen this heavy clear mucus before. What is it, and why do I keep having this pelvic pain? My weight has also ballooned up 70 pounds in the last 3 years, and I am under a lot of stress. I feel exhausted all of the time and can barely walk up a flight of stairs without taking a break. I am currently at 220pnds and I am 5"8 tall. I hope you can shed some light on my concerns. Thanks.

Answer:

One of the problems seeing a nurse practitioner is that because they have a limited knowledge base, they treat indiscriminately. As in your example, the nurse practitioner did not detect an infection, yet treated you with two antibiotics. She is essentially covering you for two types of infections. That of course, is improper medical treatment.

I am surprised no one has suggested a pelvic ultrasound. If the pelvic examination was not remarkable, then that would be the next step in your evaluation. You may have a cyst or tumor. Some cysts and tumors express increased amounts of estrogen, which could be why you have an abundance of clear mucous. Clear mucous is usually not due to an infection but due to hormones. I would request a pelvic ultrasound. If the ultrasound does not reveal anything, then you should consider a laparoscopy, which is an outpatient surgery to look into your abdomen and examine the pelvis. Considering your fertile history in the past, and now no pregnancy but pelvic pain, there is a high possibility that you may have developed endometriosis or scar tissue. These entities can cause pain and inhibit fertility.

Finally, your weight is the issue for the remainder of your symptoms. Your ideal weight is 140 lbs. Your are carrying an extra 80 pounds which causes you and your muscles to have to work harder. I would bet that the difficulty going up the stairs is partly due to this and partly due to being out of shape. There have been studies showing that increased weight also decreases fertility, so you may want to use this a a reason to exercise and lose weight.

I hope this answers your questions. Start by insisting on seeing a physician and go from there.

Good luck!

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

The Difference Between PCOD and PCOS, Fear of Birth Control Pill Protocol

Question:

Hi, thank you very much for your help in advance. I am 22 years old and not sexually active. I had my first period may be at about 16 yrs. of age. My period was always relatively irregular and it was normal for me to miss 2 to 4 months (4 months usually happened once a year in the spring). I have gone to a gynecologist several times and after the exams all have told me that I have irregular hormonal levels and should take birth control pills. As I have heard many times that such pills are bad for my health, I refused to follow that advice. The problem which greatly concerns me is that I now have not had a period for about 6 months (last time was in March).

I am very worried and will go to the doctor, however, I would appreciate your opinion as well. I have a good figure, good eating habits, no excessive stress. What could this be? If this is PCOS would it have significant negative effects on my ability to get pregnant? Are hormonal pills really bad (weight gain, hair growth, adaptation of the body to constant supplements)? Could this be due to my lack of sexual experience/activity? If so, is this a problem? Is there a "body cleansing" pill that I could take to induce a period and see how things go without significant negative effects? Do you think that traditional Chinese medicine could be of help? In short, what is you opinion on this? I would appreciate as much detail as possible.

Thank you for taking the time to answer my questions.

Answer:

From your history, it sounds like you have PCOD (polycystic ovarian disease). This has not become the syndrome (PCOS) yet because the disease eventually turns into PCOS (polycystic ovarian syndrome) when it manifests by increased weight gain (obesity), excessive hair growth, increased male hormone, decreased voice, hair loss (male pattern loss), diabetes. This disorder is due to a dysfunction of the ovary, whereby the ovary does not process the FSH and LH from the brain appropriately so that ovulation does not occur. If the ovulatory process does not occur, the hormone precursors do not go down the estrogen/progesterone pathway to make those hormones and instead go down the testosterone pathway, leading to excess testosterone. This leads to the manifestations explained above. These are long term changes and occur slowly. They are not reversible, so you don't want to go down that road.

The other problem with not having a period regularly is that the endometrial lining can thicken leading to several problems: hemorrhagic bleeding when you do have a period requiring hospitalization and transfusion, a precancerous state and endometrial cancer. You also don't want to go down that road. Another problem is that with the lack of estrogen in your body, you can suffer other long-term consequences such as a very dry vagina, vaginal shrinkage, inadequate lubrication with intercourse, shrinking of the breasts, increased heart disease, bone loss, dryness of the skin.

If you are not intending to become pregnant, then the treatment of choice is to use the birth control pill. This is the recommendation that medical doctors in my field will give you. That is mainly because the pill/patch/ring are made of estrogen and progesterone and override your ovaries. It basically puts your ovaries at rest and gives you the hormones your body needs. Several studies have shown long term benefits from the pill including a significant decrease in ovarian cancer if used for greater than 7 years. I also believe that it helps to preserve your fertility longer because the ovary is quiescent. The things you heard that are "bad" about the pill are wives tales and not true. The one truth is that you may not be able to become pregnant after stopping the pill, but that is because you will go back to the way you were prior, which is not conducive to pregnancy because you are not ovulatory. So, my recommendation is to go on the pill.

In terms of sexual activity. The value of sex, if you are not trying to get pregnant, is for recreation. Because it feels good or gives other good feelings. It is not a physiologic requirement, so don't feel compelled to have sex just because you have to. It should be fun.

I cannot comment regarding Chinese medicine, as I have no knowledge of this subject. I have recommended acupuncture for my infertility IVF patients as a complimentary part of my protocol and have seen improved pregnancy results.

I hope this gives you the information that you were looking for.

Follow-up question:

I wonder if I can take up a bit more of your time by asking a follow-up question.

From what I understand, birth control pills do not treat the problem, they simply override it, for lack of a better term. At this stage in my life, I am not looking to become pregnant; however, this is a natural progression in life. As such the question is as follows: If I can't become pregnant without taking the pill due to the absence or scarcity of the ovulation process, and the pill while restoring that process, will be acting as a contraceptive, what are my options?

One of my concerns about the pill is that by taking it I will be decreasing the possibility of having natural period, as my body will become used to constant supplements. Consequently, my chances of ever becoming pregnant suddenly become almost null. As for sexual activity, I certainly understand the value thereof, I have been told, however, that sexually activity will stimulate the production of the hormones which are missing in my body. This was the assertion the validity of which I was looking to confirm. From what I understand, that belief is erroneous. Is that correct?

Furthermore, I was a bit unclear as to why you believe that I have not yet developed a "syndrome". You also mentioned that the pill will prolong my fertility. Are you then suggesting that I will likely lose fertility at some point due to PCOD?

Again, thank you for your time and assistance!

Follow-up answer:

Hello Again,

The answer to your first question is that the pill will not inhibit your ability to become pregnant in the future. As you said, it overrides the ovary and puts it into a quiescent state. The active state returns after stopping the pill and you will return to where you were previously. That is, if you are not ovulating prior to the pill, you will still not ovulate after stopping the pill. Your body will not "become used to constant supplements" so you don't need to worry about that.

Sometimes, being on the pill causes the ovary to straighten itself out and I have had patients get pregnant immediately upon stopping the pill (the opposite reaction to what you are thinking.)Sexual activity has no influence on the regular hormones in your body. You can have many sexual encounters per day and your hormones and ovaries would still be abnormal from the PCOD. Of course, you will be exhausted every day too. :) Just kidding!

From how you described yourself in your first question, you do not seem to be exhibiting the "classic" symptoms of hirsuitism, weight gain etc. that manifest themselves with PCOS. That is why I am assuming that you have PCOD. I have had many patients that are PCOD with no symptoms whatsoever. To diagnose latent PCO you need to see an infertility specialist who will ultrasound you during your cycle to determine whether you are overproducing follicles.

Lastly, you will lose your fertility potential with increasing age, not because of PCOD. At age 30 the pregnancy rate is 85% per year, 35 PR is 30% per year, 40 yo PR is 10% per year.

Hope all this makes sense and answers your questions.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Using BBT chart and Ovulation Predictor Kit while on Clomid

Question:

First, thank you for your time. It is awesome that you would offer your advice on line.

I am on Clomid 150mg. I show on my BBT chart that I ovulated on cd 17. My temps stayed above the coverline till 7 DPO and again today on 8 DPO it is still low. All of the research I find says that implantation dip is only a single day, but that my temp should drop of between 10-16 days to start menstruation.

Here is the link to the website where I get my BBT chart. http://www.fertilityfriend.com

Thank you for your time.

Answer:

Thank you for your question, I try to give as good advice that I can considering the limiting factors, which of course include not being able to talk to you at length and in person.

I would not analyze the temperature chart so closely. It is not that accurate. Many factors can influence the temperature. It is only useful to see if there is a rise in the mid-cycle, which is an indirect measurement of the LH surge, indicating ovulation is going to occur. If you are going to continue using the chart, use it only for that indication i.e. timing of intercourse, and nothing else.

Another option, which I think is more accurate but more expensive is the ovulation predictor kit or OPK. However, with this kit you also cannot evaluate the luteal phase. The only way to evaluate the luteal phase is to do an endometrial biopsy. You will need to begin infertility testing for that.

Follow-Up Question:

One more question. My cycles are very irregular I take progestrone to start before the clomid. When do you recommend taking the home pregnancy test?

Thank you for your time.

Follow-Up Answer:

You are going through a lot of effort that is not very efficient.

The way that I do Clomid cycles is I follow my patients using the Ultrasound starting from day # 10 of the Clomid cycle. This allows me to see if the patient is responding to the dose that I prescribed, count how many potential ovulatory follicles there are so that there are not too many, and to time when intercourse should occur. I also use HCG to trigger the ovulation. With this method, the cycle is done more efficiently. I then do a pregnancy test two weeks later. It is programmed. There is no guessing. If your doctor is not doing it this way, then you are probably not seeing the right person or specialist. This is the correct way.

If you don't have a choice, then you have to go by the calendar method which is based on your period. Cycle day # 1 is the day your period starts. Begin intercourse on cycle day # 13-17, once per day, only one ejaculation per day. Do a pregnancy test on cycle day # 28 and repeat on cycle day # 30. If it is positive, then have a blood pregnancy test done on those days.

I hope this helps. Good Luck!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Three Miscarriages and HSG Shows Blocked Tubes

Question:

Dear Dr. Ramirez,

I have had three miscarriages in the last couple years and have been to two fertility clinics. I have had $8,500 dollars worth of tests done and all the male testing. I was told that my tubes are blocked by one doctor and the other one says that there is no way that they can just one day unblock. I was but on meformin and told that I have pcos. I read on pcos and it said that with Clomid a pregnancy is possible. What is your opinion on this?

Answer:

Thank you for your questions. You've thrown quite a lot of different things at me.

There are several issues that you have brought up. Let me see if I can answer them one at a time and give you the information that you are requesting:

1. Three miscarriages-There is an almost 40% chance of miscarriage with every pregnancy. Most are caused by a spontaneous chromosomal abnormality that occurs when the egg is dividing into an embryo. These usually lead to miscarriage within the first 8 weeks of the pregnancy. These patients will eventually be successful. A small percentage of recurrent miscarriages occur because of uterine abnormalities, hormonal abnormalities, immunological abnormalities, infectious diseases and health events like diabetes.

2. Blocked tube - Blocked tubes are evaluated by a test called an HSG (hysterosalopingogram). It is an x-ray test whereby a dye is injected into the tubes and xrays are taken as the dye flows through. If it doesn't flow through one or both tubes then that shows that the tubes are blocked. Once blocked, it is always blocked but there is an exception. Sometimes, the tube will be blocked by a mucus plug at the opening of the tube. In general, it is one side only. With increased pressure at the time of the HSG, this mucus plug can be pushed out and the tube opened. If this is the case, the HSG "helps" in clearing the tube and allowing for a natural pregnancy to occur. If pregnancy does not occur then this could not be done and that tube is probably blocked by scar tissue. The problem with one tube blocked is that the incident that caused the blockage was probably an inflammation or infection in the past, usually caused by a bacteria. These usually pass through both tubes but it affected one tube more than the other, so that one tube is blocked. That does not preclude damage in the other tube, however. As you know, it takes a very small hole to allow fluid, like the dye, to flow through. I usually counsel my patients to assume that the other tube is damaged. The inner structure can be damaged and render the tube non-functional even without it being blocked. Therefore, with any blockage, I counseled that IVF (In Vitro Fertilization) is probably the best option.

3. PCOS - I have explained this pretty extensively in past questions. Please refer to some of my previous blog posts. But to summarize for you, PCO is a disorder of the ovaries whereby ovulation does not occur. For this reason, fertility medications are required to stimulate the ovary to ovulate. Clomid is one of those medications that is used but does not work on all PCO patients. Metformin only is useful in PCO patients that have an elevated insulin level. So it does not work in over 50% of PCO patients.

I hope this answers your questions.

Follow-up Question:

If you don't mind, I was also told that when I had the HSG done that because I was in a lot of pain that my tubes could have contracted and acted like they were blocked. Is the possible? I have been pregnant 3 times and 2 of them were on Clomid alone. Is it possible that Clomid together with metformin would work?

Follow-up Answer:

Hello Again,

HSG's are generally painful, especially if the tubes are blocked. That is because they are increasing the pressure to see if the dye will flow through. Increased pain does not indicate tubal spasm, however, tubal spasm can prevent the dye from flowing through. We see this most often when injecting dye at the time of a laparoscopy. It is uncommon to see tubal spasm in both tubes, however. If you are concerned that you may have had tubal spams, then you should have the test repeated to confirm.

If the tubes are blocked, legitimately and not due to tubal spasm, then Clomid and/or metformin will not help. If the sperm and egg cannot get together, then fertilization cannot occur, and hence, pregnancy will not ensue. If the HSG result was due to tubal spasm, then it is possible they could help, so the tubes are the key element in this. Try to clear these issues with your specialist and proceed according to his/her recommendations. Good luck!

Sincerely,

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.

19 Year Old With Very Irregular Periods May Have PCOD

Question:

I am a 19 year old female (obviously). I had my first period when I was approximately 11 years old and for the first three to four months I had a regular cycle. After that period of time my cycle became irregular (which is in no way odd for someone of that age), being that I would menstruate every other month rather than every single month. After approximately 4 to 5 months of this my menstruation stopped completely. Over the course of the next 3 years I would have a period perhaps once every 5 to 6 months, and there would never be any mood swings, cramping, bloating, or overly heavy flow. The intervals between menstruation began to increase from there, lengthening to 8 months between periods (give or take two months).

This month and last month, however, I have had my period. Two months in a row after almost 13 months without anything. This past month, however, I have experienced severe cramping and moodiness. I know that it is not uncommon for cramping to occur after a prolonged period of time without menstruation, but the fact that I was incapacitated and in bed for two days was unbelievable to me.

I have had no problem developing secondary sexual characteristics, which would probably be signals of a pituitary or other glandular disorder. I am not obese, nor am I incredibly tall or short, which, from what I have gathered, excludes most thyroid issues.

I have no health insurance at current. During the course of my teenage years I would occasionally see an MD for various checkups, and I would bring up the matter of my irregularity. Every doctor I has ever seen has sloughed off the issue as probably having to do with "stress". This answer does nothing to satisfy me, as it seems like a knee-jerk reaction because they were either at a loss or because I could not afford whatever tests might actually tell me.

My worry, for quite some time now, has been the question of fertility. I have no actual plans to have children at any point in the near future, and I am not (nor have I ever been) sexually active. However, I need to know if I even CAN have children, for my own piece of mind. I know that without an examination, there's only so much you can tell me, but any information on what you might think is amiss would be greatly appreciated.

Answer:

Thank you for your question. For a 19 year old, your writing is incredibly sophisticated and impressive. You seem to be well educated. Most women do not know about "secondary sexual characteristics" or how the "pituitary or other glands" affect their cycles. Bravo to you for this knowledge.

Your irregular period is far from normal. There is a very common disorder, which you seem to be alluding to, called polycystic ovarian syndrome or PCOS. This is an ovarian dysfunction disorder caused by the ovary not processing the pituitary hormones correctly, leading to the lack of ovulation. Without ovulation, there is no subsequent menses, assuming you are not pregnant. We know that this disorder begins in the teen years in many women. So the doctor's previous explanations of "this is normal for your age group", is incorrect. There are problems that occur from PCOD in the long term such as increased weight gain, diabetes, increased facial and body hair growth, excessive bleeding episodes, irregular bleeding, endometrial cancer and infertility. Because of this, we DO NOT recommend continuing with the irregular cycles.

In women that are not attempting pregnancy, we use the birth control pill protocol to over-ride the ovaries and keep a normal cycle. This gives the essential female hormones, estrogen and progesterone, that your ovaries are not producing, and that you are lacking, because of the lack of ovulatory cycles. When you decide to become pregnant, this has to be substituted with ovulation inducing fertility drugs. PCOD is a clinical diagnosis, and although we do hormone testing to check the thyroid, pituitary and other hormones, it is not a diagnosis made by these lab tests. From your description of your symptoms, you probably suffer from it. If you do further internet searching, you will come upon a description of patients that have this disorder, that you do not fit. However, keep in mind that there are variations on this theme and even normal appearing females can have a milder form of the disorder. Not all patients are hairy and obese :).

In terms of your future pregnancy, bravo for getting through your teen years without having had a sexual experience. When you do contemplate getting pregnant, I do not see any reason that you would be unable to become pregnant, except for your ovulatory disorder. Assuming that this is corrected with fertility drugs, you should have a pregnancy rate commensurate with your age group. I have had many PCOS patients that get pregnant with the proper protocol , though sometimes they need more than one try before they get their cycle exactly right.

I would advise you to seek another opinion with this information in hand, preferably a good OB/Gyn.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Failed IUI In 38 yr old - Inadequate Protocol & Advice

Question:

I'm 38 and my menstrual cycles became erratic after an abdominoplasty removed approximately 1.2kg from my stomach area this past January. I am trying now to become pregnant and have undergone my first intra-uterine insemination (IUI), which failed.

I've had to use Provera twice to start my cycle after it went over forty days. Recently my OBGYN had me take Clomid on days 3-7 then Repronex on day 9. An U/S on day 12 revealed that I had a 20mm follicle so I was given a hCG trigger then had an IUI the next day. A later U/S revealed that the follicle was still there and that the hCG trigger apparently hadn't caused ovulation. Do you have any information on possible reasons why the trigger failed or whether it would be worth my time and money to try this same process again given this first failure?

Thank you very much for your time.

Answer:

Thank you for your question. It is not possible to know if ovulation actually occurred or not. We presume, based on the ultrasound that if the follicle disappears, then ovulation occurred. However, even an ovulatory follicle can reaccumulate with fluid, as we often see after IVF. So, it does depend on when the ultrasound was done. I always do two back-to-back IUI's on my patients. With each IUI, I look with the ultrasound again to see if ovulation occurred. It is generally good at seeing that ovulation occurred because it is within a very short time period that I am looking. In your case, because the ultrasound was done later, it is not accurate. In addition, some people will ovulate later than expected after the HCG injection. Remember, once the HCG is given, people will ovulate within 24-52 hours. I want my patients to succeed, and if that means doing the IUI on a Saturday & Sunday, in order to guarantee this success, then we come in on the weekend.

There is no reason to think that this treatment plan will not be effective, unless there is something else preventing you from becoming pregnant other than ovulation. From your history, the clomid is giving you the chance of getting pregnant with each cycle and you should continue. I would not recommend more than four cycles, however, because statistically, the chances for pregnancy decrease significantly after four cycles. I would also increase your Clomid dose and/or Repronex dose to try to get you to ovulate up to five eggs per cycle.

One thing that needs to be mentioned is the impact of age on your fertility. You certainly can get pregnant with IUI but it is not the best option. At 38 yo, the chances of pregnancy per IUI cycle is 5-10%. Because of this, we generally recommend proceeding with IVF after the age of 36yo. With IVF, in a good program, you can have a 52% chance of pregnancy per cycle. Because of your age, I would limit the number of IUI cycles to three or less. If your OB/GYN cannot get you to form at least 3-5 follicles, then IUI should be abandoned. It is not significantly increasing your chances. You should also have a cycle day # 2 or 3 FSH level done. If it is 7.0 or above, then I would go straight to IVF. You are looking at time passing, which is affecting your chances even with IVF.

Good luck and don't hesistate to query your Ob/Gyn regarding his success rates with IUI's.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF

www.montereybayivf.com

Testicular Biopsy To Determine Absence of Sperm Prior To TESE & IVF

Question:

Dear Dr. Ramirez,

My husband was born with exstrophy of the urinary bladder (in 1965 before some of the advances in that area), and as a result has had numerous surgeries, etc. He believes he used to have normal ejaculation before a major surgery in 1990; he does not now (none at all). A number of years ago (before we were married), he had a fertility test that involved opening the testicles (I don't remember what it was called), but the doctor failed to find sperm. His current urologist thinks he should give it another try. Which leads to my questions:

1. Is it likely to succeed (my husband said it was extremely painful)?

2. If they do find some sperm, do we need to be ready for IVF immediately? (This is a big issue for us, since IVF is much more expensive than something like IUI with donor sperm, so we'd need to save up for a while. Also, I don't want to have to take fertility drugs unless absolutely necessary, which would be the case with IVF.)

Thank you so much. I've gotten a lot out of reading your answers to other questions.

Answer:

Thank you for the compliment and for your question.

I think that the testicular biopsy would be a good thing to do. The Urologist needs to make sure that all quadrants of the testicle are biopsied to check for sperm. Of course, if the first biopsy shows sperm then he doesn't need to continue further. Because of this, it would be best that an andrologist, a sub-specialist urologist who treats male infertility and sexual disfunction, were present to examine the sperm immediately. It is not necessary for the test, but can avoid all the extra biopsies.

The biopsy is important because this is going to determine if sperm can be harvested from your husband's testicles, which can then be used to inject into your eggs via IVF. That would lead to a genetic child for your husband. Since testicular sperm is not the same (i.e. not activated) as sperm that is ejaculated, it cannot be used in conjunction with an IUI. You would need to do IVF with TESE and ICSI, which can be expensive, so you have to decide if it is important for you to have a child with your husband's genetics. If it is not important, certainly IUI with donor sperm is cheaper.

Fertility drugs are given with IVF to maximize the number of eggs that are retrieved and fertilizable. This is necessary because not all the eggs that a woman has are good eggs. There are no known long-term side effects, problems or complications with taking the fertility drugs, so you don't need to worry about that. The biggest problem is the cost, and the fact that they are injections.

Finally, you don't need to proceed with IVF immediately after the testicular biopsy is done. The testicle can be rebiopsied at the time of the egg retrieval. In fact, they need to coincide. We usually do the TESE under conscious sedation so that it is more comfortable for our patients, because we use conscious sedation for the egg retrieval as well.

I hope that helps. Good Luck to you and your husband.

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

More On Luteal Phase Defect

After the January 10th Q & A regarding Luteal Phase Defect while on Clomid, I received another question which I would like to include to further enlighten those who struggle with this problem and are not receiving an adequate explanation or treatment for it..

Question:

Hi Dr. Ramirez, My question is that I have a LP (luteal phase) of 8 days. I ovulate on day 23. I always spot beginning of cycle, mid cycle and after cycle for 2-4 days. I started taking 100mg of B6 vitamins last month and progesterone cream immediately after ovulation. Last month, I began spotting two days post-O (I stopped the cream at that time).

The problem is my spotting has increased (menstruation CD 1-9, spotting CD 10, 11, 15-18, 25-31 and menstruating during new CD 1-10). What can I do about this? I am taking my BBT (temps are elevated post-O, I am also taking OPKs so I know I am ovulating. My Dr has done pelvic u/s (ultrasound), ovarian u/s, etc. everything is normal, so are hormone levels. Is there anything I can do on my own to increase my chances of conception? Or is there anything I can bring to my Dr.'s attention? Help! Thx..

Answer:

Thank you for your question. I would like to explain a little about what the luteal phase is before addressing your concerns. The luteal phase is one of the most exact parts of a woman's cycle, if she is ovulatory. It is the second half of the menstrual cycle after ovulation. The corpus luteum secretes progesterone which prepares the endometrium for the implantation of an embryo. A normal luteal phase is 14 days. However, there is a disorder of the luteal phase whereby this part is short. It is called a luteal phase defect. It sounds like you may have a luteal phase defect, which is cuased by hormonal asynchrony. Hence the abnormal bleeding. The uterine lining (endometrium) is very dependant on appropriate hormonal synchrony to keep it stable. If it is unstable, it breaks apart, hence the bleeding at odd times during the month.

The luteal phase can be supported by using supplemental progesterone. It is generally used beginning on cycle day #16 and extending for two weeks. Of course, a pregnancy test will have to be done because the period may be suppressed. If it is positive, you continue the progesterone until 10 - 12 weeks gestational age.

However, based on your scenario, LPD is not the only problem. You may actually need to go an an ovulation induction protocol with Clomid, Latrezole or Gonadotropins in addition to the progesterone supplementation. These medications will help your ovary to perform normally and synchronize the hormonal situation. It may also alleviate the luteal phase defect.

I hope this helps!

Edward J. Ramirez, MD, FACOG

Executive Medical Director

Fertility and Gynecology Center

Monterey Bay IVF

http://www.montereybayivf.com/

Monterey, CA

Luteal Phase Defect While On Clomid For Timed Intercourse Cycle

Question:


Hi. I am 26 years old and have been trying to conceive for 2 years now. So far my infertility is unexplained. All tests have yielded normal results. My husband's sperm analysis was normal in all categories. Count was 170mil although he did have moderate sperm aggregation (clumping) which I was told should not be an issue since its moderate and there were plenty more sperm doing the right thing. While I do ovulate and have a period on a frequent basis it is not on a 28 day cycle, in fact my cycle lengths range from 26 days to 35 and go up and down from month to month.

I just finished my first round of Clomid. Ultrasound at day 12 indicated one good follicle, my lining was good. At day 21 my progesterone was 22.5. I did ovulate. However, my period was only 1 day in length with a 2nd day of spotting. Normally, I have 2 days of moderate bleeding and then 1-2 days of spotting. Is it normal to have a shorter menses with Clomid?

Also, my cycle was only 27 days. I had a confirmed sugar at day 14. I believe I ovulated on day 16. It has apparently also caused a shorter luteal phase. Is that normal? I was under the impression it would lengthen my cycle. My menses came 6 days after my 21 day progesterone showed 22.5. Is that too sudden of a drop in hormone?

Answer:

Hello. Yes, very often Clomid will shorten a cycle. I am concerned, however, that you had a short luteal phase. This should not be the case, but can happen with Clomid. We call it a "luteal phase defect". If this is the case, it could impair implantation leading to failure or loss of the pregnancy. For this reason, I always add and recommend adding progesterone from day 16. It is an easy thing to do and does not have side effects. The only problem is that it will inhibit a spontaneous period if you don't get pregnant, so a pregnancy test will need to be scheduled.

I also recommend ultrasound surveillance when doing Clomid cycles. Most non-fertility specialists will not do this, as in your cycle. It is the best way to monitor progress and lets you know how many follicles are about to be ovulated. HCG can be given to stimulate ovulation (which also helps with the luteal phase) and helps to time your intercourse best. You should ask your doctor to do this. If he/she looks at you curiously, and without understanding, then you need to find a real fertility specialist. Also, only 4-6 cycles of Clomid are recommended by ASRM and reproductive specialists, after that you need to look at other options.

I hope this answers your question.

Sincerely,

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 Gestational Sac After IVF

Question:

Hello, Dr. Ramirez,

Does In Vitro increase the odds of an empty gestation sac? I am 6 weeks pregnant and had an ultrasound with no heart beat detected. I bled just before the ultrasound but there was no bleeding before that.

Two frozen embryos were implanted but only one sac is visible on the ultrasound after the bleeding. The sac is round and empty. What do you think?

Answer:

Hello,

I'm sorry about the news. The answer to your question is no, IVF does not increase the risk of genetic abnormalities in the fetus. An empty gestational sac is due to the lack of development of the fetus. That occurred AFTER implantation, and therefore, after the IVF. It probably occurred due to a genetic defect in the embryo that implanted. It is considered a form of miscarriage, which can occur in up to 40% of pregnancies whether natural or IVF.

Many women who get pregnant naturally are not aware that they are even pregnant before they "lose" the pregnancy. Because we test and ultrasound IVF patients soon after transferring the embryos, they have the opportunity to learn if their pregnancy is proceeding or not proceeding earlier than most. This is not necessarily a bad thing, since actions can be taken to prevent miscarrying in subsequent IVF cycles.

Good luck and keep trying!

Sincerely,

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

30 Yr. Old TTC'r With Elevated Estradiol Levels- May Be Physiological Cyst

Question:

I am 30 years old and have been trying to get pregnant for 3 years. I have had 4 cycles of Clomid including 3 cycles of IUI. I ovulate on my own, have regular painless periods, and no apparent endometriosis. HSG shows clear tubes.

Bloodwork done 7 months before shows estradiol, FSH and progesterone within the normal range. My husband who is 32 has low sperm motility (about 47%) and morphology shows 71% abnormal sperm heads. We decided to go ahead with IVF+ICSI and since my RE thought I may not need to supress my ovaries too much, I was on birth control pills for only 2 weeks starting in the luteal phase. For my baseline appointment and bloodwork they discovered that I had elevated levels of estrogen (about 190) so I was called in after 4 days.

I did my second set of bloodwork today (had taken my lupron shot before going in) and my level was 185 which they thought was still high so they have canceled my IVF this month. Since I live in a small town and we have just one RE I have been scheduled for November. I am very disappointed and I wonder what went wrong. Can you please help me understand why the levels went so high.

Answer:

Hello, to answer your question as best I can without being able to evaluate your condition myself, an elevated Estradiol level is an indication of ovarian hormone production. The ovary needs to be down regulated prior to starting the stimulation medications. Usually a persistent elevated Estradiol occurs because there is a persistent cyst present in the ovary.

This cyst is producing the estrogen. If then continued the cycle, you would not stimulate well, and pregnancy would not ensue. I would have cancelled the cycle as well. I'm sorry that you have to wait until November, however.

I presume that your RE put you back on OCP's so technically you would be ready to start the cycle in September.

Follow Up Question:

Thank you so much Dr.Ramirez, however I have not been diagnosed with PCOS and my ovary did not seem to have a cyst during any ultrasounds. I was always told that the ovaries looked great and the lining was great.

Do you think it might have been missed?? :-( I have been reading on the internet and came across an article about how a weak liver can not filter the estrogens. I have had malaria thrice and maybe the meds I took made my liver weak? I have also worked in a research lab and handles a lot of teratogenic material..do you think that might have affected something?

I know I sound paranoid, but it's the first time I have had a test report that was not normal.

Follow Up Answer:

The cyst I was referring to is a physiologic cyst, not the cysts of PCOS. If there was no cyst at the time of your baseline ultrasound, then something is producing estrogen. There are very few things that produce estrogen. It is not from your history of malaria. The liver has to be in failure before it significantly affects the processing of hormones and medications. You would know if you were in liver failure!

Your history of working with teratogenic materials would also have no impact. Something else is producing hormones. You might want to ask your doc what it could be. Hormones can only be produced from hormone producing structures and the ovary is the only structure that produces estrogen. You are not taking estrogen from another source such as medication are you? The only non-ovarian source would be certain types of tumors.

If the estrogen level goes down after your course of birth control pills, then that would rule out any type of tumor. In that case you should be good to go.

Good Luck!

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

No Period, Low BMI Can Equal Hypoganodotropic Hypogonadism

Question:

I'm a 27 year old woman. I'm not pregnant. I went off the pill 7 months ago, and have not had a period since, though I had light spotting in response to a progesterone challenge. I'm about to be evaluated for PCOS, but I have a hard time believing this is what I have.

I have always been thin, and in the past I was told this was why I did not menstruate when I tried to go off the pill. I have made the effort to gain a little weight and my BMI is about 19 now. I work out regularly, though not more than 50 minutes a day. I have no family history of PCOS, diabetes or insulin resistance.

In the past 7 months I have developed benign PVC's of my heart, and have had a mild increase in facial hair and hair around my navel (this is why they think I might have PCOS).

My question is, are there any other conditions that might cause my symptoms that I should be aware of when I go to have the blood tests? Should I be tested for premature ovarian failure and hyperprolactinemia as well?

Thank you so much!

Answer:

Thank you for your question.

Your history does not quite fit PCOS. The most likely diagnosis is hypoganodotropic hypogonadism. It is a long name for saying that your brain is probably not stimulating the ovary. It is likely due to a lack of adequate body fat. Not premature ovarian failure. Since you had a little response to the Provera challenge, that shows that you are making a little estrogen, but the increase in hair growth is consistent with an elevation of the male hormone testosterone. If the ovary is not stimulated to ovulate, it does not produce estrogen and the available hormone precursors go to make testosterone.

Body fat is important because it is the chemical basis for the production of all hormones. If the body fat is too low, because of excessive exercise or anorexia or bulimia, the brain shuts down the production of FSH and LH. This leads to a lack of stimulation of the ovary, hence the above result.

This diagnosis can be made with blood testing. You should be tested for FSH, LH, Prolactin, TSH, Estradiol and Testosterone. This would test all the possible sources of your lack of menstruation. They will probably find that your FSH and LH are very low. Your thyroid may also be out of sync because of the same problem. TSH is the preliminary test for thyroid function.

It would be best if you could get your BMI up above 20, and increase your body fat content.

I hope this helps.

Sincerely,

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

Monterey, California, U.S.A.

Tubal Reversal Vs. In Vitro Fertilization

Question:

I was diagnosed with PCOS 6 years ago. I had one treatment of Clomid and became pregnant soon after with healthy twin boys. At the time I had decided to get a tubal ligation soon after delivery but now I am regretting the decision I made. Now after so many years I am finally having a very regular menstrual cycle.

My question is, what would be the better option for me: IVF or a reversal of my tubal ligation?

Answer:

Hello, Here are the pros and cons for both options that I usually share with my patients:

*Tubal reversal or reanastamosis

It is a surgical procedure. Some surgeons do it as a large open incision and some as a small incision. Tubal reanastamosis is not covered by private insurance. The large incision will be very expensive ($20,000-$35,000) with a 6-8 week recovery. The small incision can be done as outpatient surgery but will cost $8 - $12,000. Recover will be 4 weeks. The latter surgery is skill-based and should be done by a physician comfortable with a mini-lap procedure to insure success.

The pros are that if the procedure works, you can get pregnant over and over by natural means.

The cons are that it is a surgery, and that success depends on the surgeon, the length of the tube after repair, and the type of tubal ligation that was done. There is an increased risk of a tubal pregnancy (surgical life threatening emergency). Pregnancy rate will vary by age and will be less than the equivalent rate in the normal population. You will need contraception again if you don't want more than one more child. You have to at least try for one year following surgery to get pregnant and determine if the reversal worked. If it hasn't, then the only option left is IVF for an additional cost.

*IVF or in vitro fertilization

IVF is a non-surgical procedure and will cost approximately $15,000 per attempt (which includes the IVF, medications and lab tests). It is sometimes covered by private insurance.

The pro is that it is not surgery, that you will get pregnant with minimal waiting, it is great for those who want one or two more children and that it has a much higher pregnancy rate than trying naturally, especially if you are older. Sometimes you will have enough eggs fertilize that some can be frozen and used for a later frozen embryo transfer, giving you the leisure of deciding to have another child when the time is right. It is not painful to have the eggs retrieved or transferred into the uterus and it is performed as an outpatient procedure.

The con is that it is expensive (as described above), that you have to take injections on a daily basis for a short period of time (although they are not too bad) and that you may have to do it again and again if you want to have more children. It is not a "natural" process since in vitro fertilization is done in an embryology lab.

In closing, nowadays, because IVF pregnancy rates are so much higher, we recommend IVF over tubal reanastamosis. However, the doctors that don't do IVF tend to recommend tubal reversal. The doctors that do both, as I do, tend to recommend IVF because it is better. It is more of a sure thing than the surgery. However, if you are still under the age of 35 and know that you will want to have more children, then the reanastamosis might be the best way to go, assuming that it works. The costs will be about the same, but if it doesn't work, then you have to do IVF. Most of my patients will choose IVF since it has a better chance of success for the money.

Good luck with your decision and whatever you do decide, I wish you success.

Sincerely,

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

29 Yr. Old IVF Patient Told She Has "Bad Eggs", Husband Has Balanced Translocation

Question:

A bit of history...2 miscarriages in the last 2 years. We were referred to an RE who did testing and found that my husband has a balanced translocation. We were advised to do IVF with PGD - I had no apparent problems. Our IVF cycle resulted in 10 eggs, 7 fertilized, 3 made it to day 3 for pgd and stopped dividing later that day. The PGD revealed very abnormal embryos with multiple trisomies and some chromosomes with only 1 copy.

The dr said I must have bad eggs - he indicated he was very surprised because all my levels were normal and I'm only 29. he has suggested donor eggs. I'm wondering if I should try another protocol or just go along with the donor eggs. I feel like I'm too young to have bad eggs but since no embryos lived there must be something wrong right?

Any advice would be greatly appreciated!

Answer:

Your history is a little odd, because for someone your age, I would have expected a better outcome in terms of the number of embryos to test. It is most likely that the abnormal embryos are coming from your husband. Not you. I think, unless finances is a problem, I would continue trying. You will eventually have a good embryo, and hopefully, a subsequent cycle will give you more embryos to test. You were not stimulated very strongly and could be. Because of the poor embryo development, I would try to get you to produce 15-20 eggs. That will probably require more medications. PGD can be done to check the embryos with subsequent cycles to see if they are chromosomally normal or not. Keep in mind though, that recent studies have shown decreased pregnancy rates with PGD, probably due to embryo injury or affects from removing one of the blastomeres. In other words, you may harm a potentially "good egg".

If you go another 2-3 tries and still no normal embryos, then I would suggest you consider donor sperm with IUI. You could do IVF but that would be much more expensive. I would think that if you persist in having abnormal embryos it is because of the abnormal sperm. That is why I suggest donor sperm. If you are dead set on having a genetic child from your husband, then you will just have to keep trying using IVF.

I don't agree that your outcome in the first cycle is a sign of bad "eggs", especially at your age.

Good luck and try to keep in mind that you do have options.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

E2 Levels Falling While On Follistim, Why? PCOS Patient Asks...

Question:

Hi, I am a 29/f with PCOS, secondary amenorrhea, non-IR, normal weight. We've done Follistim + Ovidrel + IUI 3 times and it never worked. Upon HCG administration my E2 was around 500 never higher. My RE works at a superbusy teaching hospital clinic.

This cycle we are doing the same thing with injectables. My E2 dropped from 400 to 60 but my follicles are still growing (dose never changed). Why is this? I tried doing some research and journal articles indicate that this is correlated to poor outcomes even in IVF. I also think that I have no LH in my body because before the cycles on Follistim my test line on the OPK's would be half as dark as the control, now I see absolutely no test line on all the days prior to HCG trigger.

Answer:

If the E2 drops despite the follistim, that is an indication that the follicle is either not growing or deteriorating. It is the growing follicle that produces the estradiol. You are correct, this heralds a poorer prognosis. It is possible that you may need some LH in addition to the FSH (follistim).

You should discuss this with your doc. Keep in mind that it is difficult to get a PCOS (polycystic ovarian syndrome) patient to stimulate normally, and at a low rate with injectables. Most will overstimulate and produce too many follicles which necessitates that the cycle be cancelled.

For this reason, 85% of PCOS patients will eventually need to use IVF (in vitro fertilization) to be successful. It is the only way that we can control the number of embryos transferred into the uterus despite the ovaries over stimulating. At your age, your chances at succeeding at IVF with a positive pregnancy are very high and it is possible that there would be embryos to freeze as well for a future (cheaper) frozen embryo transfer if you would wish to have more children.

Good Luck!

Sincerely,

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.

Too Many Rounds of Clomid Will Inhibit Pregnancy

Question:

I have been trying to conceive for two years. So far, I have done 12 total cycles of clomid. We hare having issues getting my follicles mature. I am now taking metformin daily, dexamethasone on CD 1-14, and clomid on days 3-9. I have ultrasounds on CD 14 and usually find immature follicles.

I am wondering, do all these meds seem excessive? All these meds are making me crazy! At what point should conceiving be considered not possible?

Answer:

Thank you for your question. You have already exceeded the number of cycles on Clomid (clomiphene) that is recommended by ASRM (American Society of Reproductive Medicine) and fertility experts. You need to move to something else. I presume you are seeing a General Ob/Gyn for your treatments. Find a fertility sub-specialist and transfer your care. At this point, you should be moving to IUI or IVF, and certainly the gonadotropins. NO MORE CLOMID.

It is this type of prolonged Clomid treatments that get Infertility specialists upset with general OB/GYN docs. All that are strictly recommended are 4-6 cycles at the most. Clomid will inhibit pregnancy after too many consecutive cycles. It works by blocking the estrogen receptors and tricking the brain into thinking it is not making enough estrogen. The brain then stimulates the ovaries harder. After a while, the Clomid will block all the estrogen receptors, which are required to produce adequate cervical mucous, adequate uterine lining and tubal motility. So in essence, it will be preventing pregnancy.

In terms of getting pregnant, it depends on many factors. I tell my patients that I can get anyone pregnant. The difference is what I have to do to get them pregnant. So, you have lots of other options. However, if you don't get out of your current situation with your current doctor, then you will be wasting a lot of time, just as you already have.

Good luck and keep trying, only not in this manner.

Sincerely,

Edward J. Ramirez, M.D.Executive

Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California

www.montereybayivf.com