Sunday, February 7, 2010

Infertility Treated Without Appropriate Testing Equals One Confused Patient & Poor Results


Hello, I am writing from somewhere in the United States. My husband (35) and I (30) tried to get pregnant for about 13 months with no luck. After initial bloodwork where everything looked good except for slightly elevated testosterone, my doctor put me on Femara. I did day 3 bloodwork to check FSH, which was normal, and then took 2 pills a day for 5 days and checked my progesterone on day 21. It was 0.5. So we decide to do another round of Femara. Both times I had to take provera to start my period. After doing the exact same thing with this round, my progesterone was still 0.5. We discussed that injections would be the next option.

I guess my question is did I do enough before moving to injections? And also I feel like I need to have an ultrasound before doing anything else to check my ovaries, look for blockage in my tubes, etc. Should I request an ultrasound to check for those things or is that something that the specialist will do anyway before starting injections? I just don't want to do the injections unless they are absolutely neccessary. BTW-My doc has finally referred me to an infertility specialist.


Your story is one that I don't like to hear because I think you have been mismanaged. You should have undergone a infertility evaluation before starting any medications/treatment, but I know that a LOT of general Ob/Gyn's and Family Practicioners like to go straight to a trial of treatment. A basic infertility evaluation is:

1. Cycle day#2/3 hormone panel
2. Hysterosalpingogram - check tubes
3. Hysteroscopy or Hysterosonogram - check uterine cavity
4. Laparoscopy - check pelvis (optional at the beginning#5. cycle day#21 progesterone level
6. Cycle day#26 endometrial biopsy - check endometrial development
7. Semen analysis
8. Pelvic ultrasound
9. Cervical cultures
Before moving further into treatment, especially injectables, I would recommend that you have the above testing done.

However, if you are going to go directly to treatment, you might want to try high dose Clomid #150-250 mg# first before injectables. Many patients will not respond to Femara but will respond to Clomid. Also, a proper ovulation induction cycle with Clomid, Femara or injectables will use the ultrasound at the beginning of the cycle, before starting medication, to make sure there are no ovarian cysts and get a baseline, then starting from day# 9 or 10, to evaluate the ovaries for #1# response to medication, #2# how many follicles are growing and #3) when to give HCG to stimulate ovulation. This also will help to know when to have intercourse or insemination.

Hopefully, your infertility specialist will advise you better than your previous doc.

Follow-Up Question:
Thank you so much for your response! You confirmed what I was thinking. I plan to request everything you listed in your steps 1-9 when I see the specialist. So I know what I'm talking about when I see the doctor, what is the reason for the pelvic ultrasound, cervical cultures, and checking the uterine cavity?

Also, I failed to mention in my first question that when I went off the pill I had normal periods for 2-4 months and then it started getting longer and longer in between periods (30-50 days). Then this past July 6 I had my last period and haven't had one since (except when taking povera for that purpose). I first started having my period at 13 and from age 13-19 had perfectly normal periods. I went on bc at 19 and stayed on them until right before my 29th birthday, and of course had very regular periods during that time. So I know that it looks like basically I'm just not ovulating, but any ideas on what else might be going on? I know it could be lots of things, but I'm just worried and seeking as many answers as I can before seeing the specialist next week.

Thanks so much

Follow-Up Answer:

Without the right tests I cannot comment on your irregular periods. I'm sure the infertility specialist will do a proper evaluation. Each test evaluates for the specific steps in the process your body goes through in order to get pregnant.

1. Ultrasound - to look for ovarian cysts, tumors, uterine fibroids, enlarged tubes or other structural abnormalities in the pelvis.

2. Cervical cultures - check to make sure you don't have any STD's or bacteria that might affect/kill the sperm.

3. Hysteroscopy - the uterine cavity is the critical place where implantation takes place. It needs to be completely normal.

You have to undergo the testing I mentioned previously to find out why your ovaries may not be working properly, hence probably, the irregular periods. It could be an ovarian problem, pituitary problem, thryoid problem, hypothalamic problem, etc. Your specialist will work with you to figure things out.

Good Luck and be sure to always take a pad of paper along for your question & answers while you progress with your evaluation.

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


  1. Hi Dr Ramirez,

    I wonder if you think I have been mismanaged too? I am 30yo Australian and have been undergoing fertility treatment for 12 months. We have one son who is nearly 3 and was conceived naturally after 6 months (I saw a naturopath who increased my luteal phase from 9 days to 12 days). I have been unable to conceive another child since then apart from another pregnancy 1.5 years ago which was terminated for conjoined twins.

    So, all initial blood work on day 2 came back normal, HSG result normal, chromosone tests came back normal, husbands sperm count & chromosone tests is great (as well as the other things they test in the sperm tests). Only problem is 8-9 day luteal phase coupled with 25-35 day periods. Tried 3 goes at clomid 25mg (ovulated well with one egg), then two goes at 25mg clomid with IUI. Fresh ivf on long protocol with 150 gonal-f, nearly cancelled due to poor response (but got 7 eggs in the end, 6 fertilitsed) and was able to transfer 2 excellent day 2 embies. Next was FET, grew the remaining 4 out to blast, 2 made it and were transferred.

    My luteal phase support consist of 2 prog pess a day and 3 spaced out pregnyl injections.

    Going to see a new FS soon and was wondering what I should be asking for in terms of more testing (maybe a lap?) and change in protocol? I'm classed as an 'easy' case but it seems something is missing from the puzzle!

  2. Hi Sarah,

    Well you certainly have been through an ordeal thus far. I am surprised considering that you have been pregnant previously. I would have considered you to be easy as well.

    I am surprised also that you went to IVF so quickly, because I don't think your Clomid attempts and Clomid/IUI attempts were adequate. The doses were too low and the yield too low as well. With IUI you want to have 3 ovulatory sized follicles at the time of IUI. In any case, that is in the past.

    I would have expected the IVF to work. Certainly sometime is not right, but I cannot tell you what it is. The IVf cycle should have taken care of any hormone problems by supplementation. It also would have taken care of any undiagnosed pelvic problems, like endometriosis, because the process occurs mainly outside of the body. In some cases, IVF success is in God's or nature's hands or is just luck. I would recommend that you continue on this treatment plan, and hopefully they will stimulate your ovaries a little harder to retrieve more eggs to work with. In my failed IVF patients I also add aspirin 81 mg per day, medrol 15 mg per day and Heparin 2000IU twice per day. This regimen is to reduce the chances of decrease blood flow at the implantation site (through micro clots) and reduces the immune system. It has worked for some patients in the past, although studies have not verified its efficacy. I also advocate trying accupuncture with the cycle as well.

    Overall I think you have a good chance at success. Going to a different clinic might be a good choice as well since pregnancy rates are very dependent on the Physician doint the transfer (everything can be perfect but if the transfer is not done well, it will fail.)

    Good Luck



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