PCOS Patient Taking Natural Progesterone Cream For Cycles: NPC Does Not Help You To Ovulate, Only Regulates Cycle

Question:

Hi,

I have long cycles and was recently diagnosed with PCOS. Prior to my diagnosis I have tried everything under the sun to regulate them and help me to ovulate. Vitex, Evening Primrose Oil, Dr John Lee's Shutdown, (in which Natural Progesterone Cream is applied for CD's 5-26, then stopped) a couple unmedicated cycles, soy isoflavones, currently on 1000mg/day of Metformin and the ONLY cycles I had "normal" cycle length with ovulation, is when I took NPC (25mg/BID) from CD's 5-26 (or til Aunt Flow) I know normally NPC should suppress ovulation, but instead for me it helps me ovulate. Why would that be? I cannot make sense of it at all, but am impressed that this is all it took.

I recently had an appointment with my dr, who actually told me that the NPC would do me no good in the beginning of my cycle and I should stop the NPC and start BCP's for a while to help get my cycles regulated again.

Thank you,

L. from Oregon

Answer:

Hello L. from Oregon,

Natural progesterone cream (NPC) will NOT get you to ovulate, but will help to keep you regular. In fact, you don't need to take it as many days as you are taking if all you want is to have a period on a regular basis. All you have to do is use it on CD#16-25 (10 days). When you withdraw the progesterone, you will have a period, because that is what happens in the luteal phase of the cycle. The progesterone is working directly on the endometrial lining and causing it to "luteinize" which is why withdrawal of the hormone causes it to breakdown and bleed. We use other forms of "natural" progesterone such as prometrium, Crinone, Procheive, Endometrin and Provera to accomplish the same task. But the progesterone does nothing to the ovary so ovulation does not occur. In large enough doses of progesterone, as that contained in birth control pills, it will cause a suppression of ovarian function.

The birth control pill is only a treatment to regulate your cycles. If a woman with PCOS is not intending to become pregnant, then the treatment of choice is to use the birth control pill. On the other hand, if your goal is to start ovulating, because you want to get pregnant, then as a woman with PCOS you need to use a medication that will induce the ovaries to ovulate such as Clomid, Femara or injectable medications.

I hope this helps to explain things,

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.

Do Not Measure BBT For Ovulation When You Are Sick

QUESTION:

Hi, I came down with a mild case of shingles (no pain, just itching) last week. I have had a high BBT (I am tracking my BBT for ovulation and luteal phase) for the past 13 days now (my BBT went up a couple days before I developed a rash). Can having even a mild case effect my BBT? I have been checking my temp through out the day too and it doesn't look like I have a fever. Just trying to make sure my high BBT is actually from ovulating. How long can a luteal phase last? Thanks.

ANSWER:

Hello Cathy from the U.S.,

Any inflammation or disease can cause a reaction in your body and elevate your temperature. A BBT would not be valid during that period.

As I have said in a previous posting, I would not analyze the temperature chart so closely anyways. It is not that accurate. Many factors, such as your shingles, 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.

To answer your last question: The luteal phase is usually 14 days.

Sorry about your shingles, I have had it and it is not a pleasant condition at all!!!

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.

30 Yr Old With Very High FSH Levels Getting Poor Advice From Her Doctor: Has Ovarian Resistance & Possible Future POF

QUESTION:

Dear Dr. Ramirez,

I am 30 years old and recently started trying to conceive. My periods have always been regular and I always been ovulating on day 13. But I still could not succeed after 2 /3 attempt. I did all the blood tests, pelvic ultrasound. My husband did his semen analysis and everything came out OK. I had an FSH 28.5 and LH 81.9 on day 13 (ovulation time) and then again I did the test on Day 1 with an FSH 10.48 and LH 4.72 and again i did on day 4 FSH 8.72 and LH 14.42. Recently my day 3 FSH was 11.54 and LH 4.18. My doctor has prescribed me to take tablet Duoluton L for 3 months.

What is surprising to me is that all my FSH and LH ranges are within the reference range given in the lab test report and more over I have regular periods which start on every 26th day and I am ovulating (which i check through ovulation test kit). I have a normal height and weight, no excessive body hair etc. Why is my doctor considering me a patient of PCOD?

Is my LH and FSH proportion so bad that I have to take these tablets for 03 months?

Please advise, thanking you, Sarika from India.

ANSWER:

Hello Sarika from India,

I'm afraid to say that based on your description, your doctor does not know what she is doing. Sorry to be so blunt. FSH and LH levels only make sense if drawn on cycle day # 2 or 3. We do not draw them at other times in the cycle because the levels can vary. Therefore, the standard is CD# 2 or 3 only.What they tell you, if interpreted by someone who knows what they are doing, is how the ovaries are functioning. The FSH and LH are hormones that the pituitary sends to stimulate the ovary. If the ovary is picking up the hormones correctly, then the levels are low. If not, the levels are high. This is on cycle day # 2 or 3 only.

Your ovaries are functioning correctly as evidenced by regular menstrual cycles. This means that you are ovulating, and based on your cycle day # 3 FSH/LH levels, your ovary is NOT menopausal nor PCOD. However, the worrisome thing is that your FSH level is high (11.54). This is a sign of "ovarian resistance" which means that the ovaries are tending toward menopause, although they have not reached that level yet (> 20). We interpret it as shortening the amount of time you have for ovarian function, therefore we approach this situation more aggressively. I recommend IVF in these patients because we don't want to waste time. There is a disorder called "premature ovarian failure" or POF, whereby a young woman (less than 40) enters menopause early. That is what I would fear with you. So don't waste time. Go see a fertility specialist!!

Follow-Up Question:

Thanks a lot for picking my question! It helped me a lot to understand what's been going wrong for a long time. In the mean time I did my follicular study today (i.e. Day 5) and it showed two follicles in the left ovary : F1 - 18.5mm (dominant follicle) and F2 5.0 mm. So I thought of giving one more try this month also. Is that OK? Or this also indicate that I am moving towards "premature ovarian failure"? Also in the report it is written "Minimal free fluid in Pouch of Douglas". What does this mean? Please help me more with this.

I will be always grateful to you Dr. Ramirez for giving so much information. Regards, Sarika

Follow-Up Answer:

Hello,

If your ovary is functioning, then you should continue to try to get pregnant. Don't give up. You are not in premature ovarian failure yet. Also, the fluid found on ultrasound is a normal finding.

You are wise to question what is going on, please consider switching over to a fertility specialist as I mentioned above! Good luck with your procedures!

Regards,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, USA

37 Yr. Old IVF Patient With Decreased Ovarian Reserve or DOR: Continue Trying Or Use Donor Eggs?

Question:

Hi there,

I have just turned 37 years old and this year have been through two IVF cycles both of which were abandoned prior to egg collection due to lack of response to the drugs (only 2 follicles matured and they would only go ahead with 4 min). My consultant has diagnosed low ovarian reserve (DOR, decreased ovarian reserve) without further testing. My FSH level was 7.5 in October when the cycles began and I have not been tested since (they wanted to but I was going on holiday so they used my previous result).

The first IVF converted to IUI but did not work. The next month I fell pregnant naturally but miscarried (very early so was probably a clinical pregnancy). The second cycle we did not convert to IUI as my consultant wanted to wait until I developed a LH surge and then we would have gone to IUI but I didn't surge (probably due to my poor body having had so many drugs!). Anyway, now I am left feeling very down about the whole thing and I think the next meeting I have with the consultant will be the donor egg discussion. I just wanted to know whether you agree with all of this or whether I should try something else first?

Please ask if you need more details but I seem to be rambling on here. Thank you!

Answer:

Dear Adrienne,

Thank you for your question.

You diagnosis of decreased ovarian reserve or DOR is based on the poor response to stimulation during your IVF cycles. We call that "poor responder." Despite a relatively low FSH level, your ovaries did not respond well. This could also be dependent on the amount of medication that you received. I presume you received a high protocol? I go up to 600IU per day with my poor responder patients. Some physicians will not use this high a dose, however.

There are differing philosophies regarding whether or not to proceed with the IVF cycle if there are only a few follicles. Some physicians, like yours, will cancel the cycle if there are not sufficient numbers. I, on the other hand, always complete the cycle. I have had many pregnancies with only 1 egg/embryo. In a natural cycle you only ovulate one egg anyway. IVF is definitely more efficient at achieving pregnancy than a natural method such as IUI so I proceed. I think it gives the patient a better chance for pregnancy. I have heard that in the states where IVF benefits are mandated, such as in Massachusetts, the physicians will cancel because there is a limit on the number of IVF cycles that can be done. In this case it is not the patient's best interest that is being served but economics. That is the problem with government regulations.

Certainly, if your doctor has determined that because you are a poor responder you should not continue trying on your own, then donor eggs is the only option. It is really your choice as to what is the best option for you. I think that each individual has to be emotionally and psychologically ready to go to donor eggs. That is, you have to have resolved that you cannot do it with your own eggs. When my patients have not reached this point, I allow them to continue trying on their own (with their own eggs). You see, my feeling is that I am here to HELP patients achieve their goal, not to dictate what they should or should not do. I don't want to force them into a choice that they are not prepared for or want (some IVF clinics do mandate the choice).

I hope this answers your questions.

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.

Kuwaiti Woman Asks: How To Thicken My Endometrium Lining?

Question:

Hi Dr. Ramirez,

I feel am really blessed to find someone very expert and caring like you :)

This is N. from Kuwait, I am very concerned about my endo thickness (was between 6.5 to 7.9 on CD14). On the other hand, I don’t want to take medicine that may harm me. The dr. is giving me Duphaston and Progyluton. The Norgestrel is combined with Estradiol valerate in one pill that comes in medicine call Progyluton (I don’t know if you know it). 11 white tablets each containing Estradiol valerate and 10 light brown tablets to be taken from CD16, each containing Estradiol valerate and Norgestrel). You have said previously that the Norgestrel is not used in the USA to treat endos.

What about the Duphaston which is Dydrogesterone 10 mg- Orally – 2 times a day from CD14? Should I take it Vaginally? Does it hurt? What do you suggest? Should I take natural Progesterone instead of the Duphaston? If yes, would you please give me name of the medicine?

Unfortunately it seems there are not that good doctors over here, they are RE and Gyno. This is the 3rd doc. The 2nd doc believes that clomid will increase the endo because it produces eggs; and she sees endo thickness 7 or 8 mm is not bad!!! Dr. Ramirez, If you don’t mind to give me Online Consultancy and I will PAY for it (I can call). Write me a prescription with what should I take and when and how? For example estrace from CDx to CDx, and then XXX medicine from CDxx. (I can order them online)

I know that it sounds weird, but with the globalization and the existence of internet the behaviors and habits are changing. I will go to the doctor on CD14 (or whenever you think is the best) to do the ultrasound and then will let you know about the size of eggs, endo and so on :)

Thank you!

Answer:

Hello N. from Kuwait,

The Duphaston can be used vaginally. Progesterone is important to help with implantation. I would NOT recommend the Progyluton. It is used from hormone replacement therapy and cycle control. It is not used in infertility because of the Norgestrel. Although the Estradiol component is okay, and necessary to increase the uterine lining, the Norgestrel (progesterone) will compete with the estrogen and keep the lining thin. With this combination women don't usually have periods, which is the reason why it is used for menopausal hormone replacement therapy. In fertility cycles, the first half of the cycle needs to have unopposed estrogen stimulation so that the lining will grow. Then once ovulation occurs, the progesterone is introduced to help the lining convert to a luteal phase lining so that implantation can occur.

Your proposal for an internet consultancy is interesting, I will send you an email. I'll have to think about that one. In terms of your supplementation, I use the following protocol:

1. I use the estrogen patch for estrogen supplementation such as the Climara patch. I use two 0.1 mg Climara patches beginning at the start of the cycle and continuing until the pregnancy test. If it is positive, then I continue it until you are 10 weeks pregnant.

2. For progesterone, I use a product called Endometrin 100 mg vaginal tablets. You place 1 vaginally twice per day beginning on cycle day # 16, or beginning with the HCG injection if you use an HCG trigger for ovulation. You would then continue this until the pregnancy test or 10 weeks gestational age if you get pregnant. Other forms of progesterone that you can use in the same way are Prometrium 100 mg or Crinone/Procheive 8% cream.

If you look up my blog regarding how I do Clomid ovulation inductions, it will give you directions on how I recommend doing Clomid cycles. Normally, as the follicles are stimulated and grow, they produce increasing amounts of estrogen. This then goes to the uterine lining and increases it. The problem with Clomid, however, is the way it works. It blocks estrogen receptors in the reproductive system and tricks the brain into thinking that it is not producing enough estrogen. So the brain responds by increasing the amount of stimulation of the ovary, hence ovulation is stimulated or multiple eggs are stimulated. By blocking the receptors, however, it can cause the uterine lining (endometrium) to no grow sufficiently.

Don't stress too much over all this, please take your time and copy these instructions. Take the time to discuss this thoroughly with your physician and 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.

32 Year Old Canadian With Multiple Miscarriages: Do Not Despair! You Can Conceive!

Question:

Dear Dr.Ramirez,

I am a 32 years old and my husband is 34. We have been trying for a baby since July 2008. In early 2009 we conceived and were over the moon. An early dating u/s at 6 weeks showed a heartbeat but sadly I started bleeding 2 days later and naturally lost the pregnancy.

Two months later we conceived again and my doctor suggested progesterone supplements. At the 7 1/2 week u/s the baby had an extremely slow heart rate and passed one week later. I had another natural m/c.

After the second miscarriage we decided to go to a Fertility Clinic and do a full work up. Everything came back perfect. Good FSH (5.9 & 6.8), AFC count of 20, normal karyotypes, no autoimmune or blood clotting issues. All other hormones were great as well including husbands DNA sperm test.

We decided to try agian with the aid of a low dose fertility drug (puregon) and timed intercourse. I got pregnant that first cycle this January. All of early ultrasounds were perfect but sadly we found out the baby had a large cystic hygoma and T21 at 12 weeks. I just had my D&E and am totally devastated.

Could we really have such bad luck? Or is there something else going on like poor egg quality at my age? What would you recommend we try for next time?

Your response is much appreciated. D. from Canada

Answer:

Hello D. from Canada,

Despite the fact that you had three losses, I am not sure that you can bunch them together. For one thing, the last loss was due to a congenital anomaly. It was not technically a miscarriage. I presume that you doctor checked chromosomes in both you and your husband to make sure that you are not passing something along. If that is the case, and it was normal, then the congenital anomaly was just chance, as was the miscarriages.

The most common reason for miscarriage is spontaneous genetic defects. That means that when the egg was dividing, there was chromosomal breakage and so the embryo developed abnormally. In most cases, the body detects the abnormal embryo/fetus and stops the pregnancy leading to a miscarriage. It is known that most patients with multiple miscarriages will eventually be successful, so one piece of advice is to not give up. Certainly, getting pregnant is not an issue for you. Also, because you are still young, it is unlikely that you have "bad" eggs or poor egg quality. That is usually an age related phenomenon.

I know that it is emotionally draining and an absolute heartbreak to go through all these losses. But you will eventually be successful if you keep trying, so, not to belittle the losses, but it might help if you think of these as practice runs for the real thing. Also, in addition, to the progesterone supplements with each cycle, you might want to add low dose aspirin and folic acid to the regimen. Hopefully, the next pregnancy will be the good one.

Good Luck and God Bless,

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: Dear Dr.Ramirez, Thank-you so much for your prompt and informative response. My husband and I will certainly try again in the future after we take some time to heal emotionally. Your answer has given me much hope ! Also, yes we had our karyotypes checked and we do not have any genetic/inheritable issues. All of those tests were normal. I pray for a healthy baby soon.

Welcome To "IComLeavWe" Participants: A Unique Infertility Blog Roll Event!

Welcome to those who are participating in this very interesting Infertility Blogger's event, thanks to the hard work and dedication of Melissa, the author and blogger extraordinaire of "Stirrup Queens". It is the first time that I, an infertility specialist, will be participating in this sort of activity and I'm not quite sure if I am up to it schedule-wise...I am definitely going to have to tackle those comments with my cup of coffee at 6 am! I look forward to visiting many of the blogs listed by Melissa and seeing how infertility has affected so many of you out there.

I hope you won't mind if I quote some of you from time to time on my Facebook page (Edward J Ramirez) or our center's Facebook fan page (Monterey Bay IVF) simply to give inspiration and support to all the other women & men out there who are struggling along with you in their family building quest. I invite you to follow me here & on Facebook, where there is almost daily posting and links to relevant information regarding reproductive endocrinology and assisted reproductive technologies.

I also hope that you find my blog interesting. It is largely made up of questions and answers from patients all over the world. I receive many in my role as an infertility specialist volunteer advisor on the About.com's All Expert's site and some of the more interesting ones (that are not designated private) are published here. As you can see, some things in the IF field are the same and some aspects, especially concerning treatment protocol, can be very different between countries, clinics and cultures. Scroll down to the index to find the topic that interests you or concerns you most!

For those of you who don't have the slightest idea of what I am talking about, simply click on the blue link at the top right corner of my blog page and it will take you to the Stirrup Queen's site (or www.stirrup-queens.com/2008/06/icomleavwe ), where you will see many other blogs about infertility that you might like to visit.

Thank you for taking the time to visit and good luck to all of you!

Edward J. Ramirez, MD

Secondary Infertility, High Responder PCO Patient: Why Did I Fail Two IVF Cycles?

Question:

Hi, I am 28 years old and my husband and I have a naturally conceived 3 year old son. We are dealing with secondary infertility. We have gone through 2 IVF cycles.

1st IVF/ICSI cycle-21 eggs--11 fertilized (70% fert. rate)--transferred 2 great 8 cell embryos. None to freeze. Negative result

2nd IVF/ICSI cycle

19 eggs--(85% fert. rate)--8 embryos on day 3

1-8 cell grade 1 (best)

2-8 cell grade

21-8 cell grade

32-7 cell grade

22-5 cell grade 2

No transfer because of lining issues. Did one FET--ended in a chemical pregnancy.

My question--do I have poor egg quality? Lab results said some eggs were abnormal, with thicker zona. Any hope to go through IVF again?

I'm from Fargo, ND. Thanks in advance!

Answer:

Hello M. from North Dakota,

From the number of eggs retrieved, I presume you also had a high number of follicles (>20). That indicates that you are responding like a PCO patient, or have PCOD. Studies have shown that there is a decrease in pregnancy rates with PCO patients, probably due to a high number of immature eggs retrieved. It also seems to affect egg quality. That is not because you have abnormal eggs, it is probably because the PCO causes an inefficiency in egg maturation.I would not give up hope. In fact, I would encourage you to continue trying because you will be successful. It may take some more tries, and hopefully, your doctor will adjust your protocol to try to reduce your stimulation. It would be better to have fewer follicles with good eggs than lots of follicles with poor eggs.

By the way, I just had a patient from your end of the country, Montana, that previously went to a clinic in Washington state and had two failed IVF cycles. She was a secondary infertility patient as well. Well, the change in weather or location or clinic did the trick because she became pregnant with one attempt, and with twins. Infertility Physicians and clinics are not all equal. That may have a bearing on your success as well. I am worried about the fact that despite all the eggs, your embryo quality rate and number to freeze were so low. That might also indicate a laboratory issue.

In any case, don't give up hope. You will eventually be successful.

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: Thank you for your insight! Very much appreciated! :)

44 Year Old Trying IVF For A Baby For The First Time: Can I Use My Own Eggs?

Question:

Dear Dr. Ramirez,

WOW!!!! I am so glad I found this site. You have given lots of great information that is very straight forward. Thank you for that. There are many sites out there and the more you read, the more unreasonable they sound. Here is my question: I am 44 years old, never had kids, and now I want to start a family, and I live in Florida. I did the Fallopean tube test (yes they are clear)and here are the results of my blood work from Jan. 2010 and March 31, 2010: 1st test=FSH 17.59, AMH=0.32, Estradoil=35,March test: FSH=5.1, estradoil=142, AMH=0.2. My RE said I had a few follicles. He STRONGLY recommends donor eggs. He did advised if I want to try Ovidrel and try for natural pregnany he said to go for it, however he said he does not believe with my results I will be successful and he thinks I am wasting my time.

My question: Is it a waste of time to try fertility drugs? Would I be wasting my time begging him to try and retrieve some of my eggs? He never even suggested that. He came highly recommended and I really don't know what to do. I would really like to try my eggs first instead of paying $40,000.00 the first time around for donor eggs. You have seen your share of patients and I am asking you if you had a client at age 44 with these results, would you make ANY attempt to use her own eggs?

I thank you very much for reading my question and I look forward to seeing your opinion.

Sincerely, S. from the U.S.

Answer:

Hello S. from the U.S.,

You have a dilemma that is shared by many these days. I keep seeing the average age of my patients increasing. There are two factors to consider with your results. First, the variations in results, namely the FSH levels, are natural occurrences as a woman ages. Some would attribute these to a "pre-menopausal" stage, where the ovary starts to show some fluctuations. We worry when the fSH level is above 10, and especially if it is above 15 (menopause is a level of 20), because it is a sign that the ovary may not respond to stimulation well, despite normal function. It doesn't mean that you can't retrieve eggs, or that you can't get pregnant with your own eggs, it only means that if you go through an IVF stimulation, you may not get very many eggs. In fact, you may not have any embryos to transfer at all.

Of course, this can vary from cycle to cycle, as your tests have shown, and studies confirm that, because of this variation, even poor responders or low responders, still have the opportunity to become pregnant. Because of this, I don't deny my patients the opportunity to try, or to at least have the comfort that they tried. Remember, the bottom line is that it only takes ONE good egg/embryo to become pregnant. The difficulty is finding or getting that one good egg and as a woman ages, that one good egg becomes more and more scarce. That is the second factor, that I call the "age related egg factor." Egg quality deteriorates with time, leading to less and less good eggs, hence lower and lower pregnancy rates. IVF tries to overcome this factor by stimulating the ovary harder to get more eggs out in the hope that there will be a good egg in the group. It is merely a chance and statistical issue based on numbers. For example, if you were rolling a dice and you wanted the number two. It can take several rolls before you get the number two but eventually you get it. IVF is, in a sense, rolling the dice to find that good egg because the ovaries give us whatever eggs they are going to give. We cannot tell them what eggs to give us. However, if the ovaries don't stimulate well and you don't get lots of eggs out, then your chances of finding that good egg diminishes. In my example it would be the same as if you were only able to roll the dice two or three times, then the chances of getting the number two go down statistically. Then, you may never get the number two.

What your doctor advises is because he doesn't want you to spend lots of money and see you fail. He wants you to have the best chances of pregnancy in the fewest attempts, and so, he recommends donor eggs. On the other hand, many of my older patients don't want to give up the hope of having a genetic child or don't want to have tried at least once with their own eggs. So I justify it to myself, that I have given the best counsel that I could, but my role is to help my patients achieve what they want in the best way that I can. If what they need is to try multiple times with their own eggs or convince themselves that they gave it their best efforts, then so be it. I am not there to tell them what to do. I only advise and am their advocate.

There IS a pregnancy rate at 44 years old, albeit a low one. It is NOT zero, so there is an opportunity to become pregnant. I have not had a pregnancy over the age of 43 in a woman using her own eggs, but have had many many patients try. I look forward to the first patient that becomes the exception to the rule for me, just as the 43 year old patient I had recently did! So, you do have a chance, just know that multiple tries with your own eggs will cost a lot more than one try with donor eggs, and your chances of pregnancy are significantly lower, but not zero. Ultimately, YOU have to make the choice. The New York Post reported last year of a woman that delivered a child conceived at 49 years old using her own eggs, but she had to try IVF many, many times over two years. I strongly admire her perseverance, but most patients cannot afford that nor have the emotional energy or resilience to do that. Only YOU know if you do or not.

I hope this helps, and 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.

38 Year Old TTC'r With Factor V Lieden, MTHFR, High BMI, High FSH & Good Embryos Has Done 3 IVF Cycles: I'd Throw In The Kitchen Sink!

Question:

I am a 38 yo female in the Northeast US. I started menstruating when I was 10 yo and due to irregular (too frequent) and heavy periods, went on BCP's at age 15 thru 35 - after stopping BCP's, my periods are very regular. We started TTC 3 years ago, and after no success, initial tests showed my H had good sperm count but low motility. We started w/ an RE in Jan 09. For me, my problem areas are age, high BMI, hypothyroid (well controlled) and + for MTHFR (Methylenetetrahydrofolate reductase) & Factor 5 Leiden. No PCOS, no endometriosis, tubes are open, endometrial lining develops well, FSH 9.

We were advised to go right to IVF to increase our chances of conception. IVF#1 5/09 Lupron/Gonal F protocol - 13 retrieved, 7 fertilized, 3 day transfer of 3 embryos - all Grade 2 (8, 7, 6 cells), resulted in pregnancy that ended in m/c at 8 weeks due to triploidy. IVF#2 8/09 Lupron Flare protocol - 13 retrieved, 2 fertilized, 3 day transfer of 2 embryos - Grade 2 (6 & 5 cell) BFN. Dec 09 - had a d&c and a month of antibiotics & estrace to prepare for IVF. IVF #3 1/10 w/ acupuncture, Lupron/Gonal F/Menopur - 13 retrieved, 5 fertilized, 3 day transfer of 3 embryos - all Grade 1 (8 cells) another BFN. All IVF's had ISCI and last 2 w/Assisted Hatching and no embryos made it to freeze. My E2 levels were consistent for all 3 - always between 1900-2300. My meds are always prenatal vits, folgard, baby asa, and levoxyl (thyroid). Lovenox only during pregnancy. My RE says that my age is the problem & that although I respond well and fertilize well, my eggs are of poor quality and arrest several days after transfer. I have no more covered IVF's, but do have 6 IUI's. His recommendation was to try 4 IUI's and if I do not get pregnant, to move onto other options, like DE (donor eggs).

My questions:

1. Do you agree with this diagnosis? Would it be worth trying another IVF with another RE? I have been very happy w/ my experience w/ this group.

2. I've read about Natural Killer cells & antibodies & immunology treatments - my RE says the studies do not support this type of treatment and this will not help. Do you agree?

3. I've had my first IUI on 3/31 and am awaiting a beta on 4/13. Do you think trying several IUI's is worth it or are the chances of success so low that I am wasting my time?

4. Is moving onto Donor Eggs my best next step?

Thank you so much for taking the time to read and reply. I really enjoy reading your answers on this site. A. from the U.S.A.

Answer:

Hello Alyssa from the U.S.,

1. In reviewing your history, out of three IVF cycles, you were successful with one (the first one), but in each, you stimulated well, had a good number of eggs retrieved and, except for the second cycle, had decent embryos. So that means that your ovaries are functioning well and stimulating well despite your high FSH level, and you seem to make good embryos. Of course, since embryos are rated only based on how they look, we cannot know if they are normal or not. Your first pregnancy was genetically abnormal and that is the "age factor" i.e. poor quality eggs leading to abnormal embryos. It is possible that the embryos in cycles #2 and 3 were genetically abnormal as well and that is the reason they did not implant. So, I agree that egg quality might be the issue, leading to imperfect embryos. That is the hurdle that you need to overcome and is totally based on your age. You may not necessarily need to change doctors, but it just may take more tries to become pregnant, since the majority of your eggs are not good quality and the goal is to get a good one.

However, pregnancy rates do vary by physician and protocols, and that could possibly make a difference. For instance, I do not use the Long (lupron) protocol or flare protocol. I use a combination (Ganerelix (antagonist) + Follistim + Menopur) protocol. That could possibly make a difference in your stimulation and the number of eggs retrieved, thereby increasing the chances of finding a good egg. Also, a lot of it is just luck of the draw, so to speak. Each cycle is unique and has the potential to yield a different outcome.

2. You have a +MTHFR and Factor V Leidin. That puts you at increased risk immunologically. For that reason, low dose aspirin, Medrol, and possibly Heparin or Lovenox, might make a difference and would be a good idea. I automatically place my failed patients on this protocol. My reasoning is that, despite the studies showing no value to this regimen, it is like stress reduction, acupuncture or any number of other adjuncts that have not been clinically proven in that, it doesn't hurt and it might help. The American Society of Reproductive Medicine does not advocate the use of immunological therapies, so your RE is correct. However, if you keep failing multiple times and that is something you want to try, then go for it. Basically I throw the kitchen sink in to try to overcome the failures. So, what's the harm?

3. If your IUI is positive, great. If negative, then you need to understand that you are doing them because you have the benefit and not because it is a better treatment. It is not. It certainly has a chance of working that is better than trying naturally, but that chance is not that good. At 38 yo, the chances are about 7-10% per cycle, which is much less than the 60+% with IVF per cycle. But, that doesn't mean it can't work. The goal would be to make sure that you are ovulating as least three eggs with each cycle. It should preferably be 5. Use injectables if you have to. It is the ovulation of multiple eggs that increases the pregnancy rate with IUI.

4. Donor eggs is certainly an option and an option that you will have until you are 50 years old. It certainly gives you the best chances of success because it eliminates the egg factor and reduces the risk of miscarriage. It's your ace in the pocket. Whether or not to proceed with it at this time is your personal decision. Because your ovaries stimulate well, there is still the opportunity for you to get pregnant with your own eggs. There should still be some good ones left inside. It will just be a matter of time. But, if you would rather not keep trying until you find that good egg, and increase your chances of success in the shortest time, then donor eggs would be the logical option. There was a report in the NY Times about a patient who is now the oldest patient to get pregnant successfully with her own eggs at age 49. She was very persistent and dedicated to being successful, and it took her two years of doing IVF.

I hope this helps, you have the potential to get that one good embryo & it may only be a matter of time and changing up the treatment protocol a bit. I find it heartening that you are willing to stay open to all possibilities, so I know you will succeed!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.comMonterey, California, U.S.A.

How I Do Clomid Induction Cycles...A Controlled Cycle Approach

Dear Readers,

Recently, I received a private question regarding the use of Clomid in a natural ovulation cycle. This 31 year old patient has been seeing an OB/Gyn for her infertility evaluation and treatment. She has gone through eight failed natural cycles, "diligently" using ovulation charts and opk's. After seeing her doctor, she was put on Clomid. "My first appointment, she never asked me what specific day I was ovulating, just ordered the blood work. Thus, I scheduled the second appointment to assert my concern. She proceeded to prescribe me 50mg of Clomid on days 5-9." Unfortunately, this patient failed with her first cycle using Clomid and is unsure how to proceed.

I know that there are many of you out there with similar concerns, so I have decided to publish my response to her question by outlining my Clomid timed ovulation protocol. As an infertility specialist and an Ob/Gyn, this is the approach that has yielded success for me with patients like the one above.

Her closing concerns mirror many others I have received in the past: "What would be your advice for me at this point in the process? Should I be patient and continue with Clomid and not be concerned with late ovulation? Should I go to a different ob-gyn or assert myself more with my current Dr? Or, should I go to a fertility specialist?".

Answer:

Hello J. from the U.S.,

First, let me explain how I do Clomid ovulation induction cycles, which is the way that I recommend. I DO NOT recommend just taking clomid and trying to time intercourse on your own (noninterventional method), which is what a lot of OB/GYN's like to do.

1. Patient calls with onset of period or within the first five days of onset. She is scheduled to be seen within the first five days of the cycle.

2. Patient comes in for a baseline ultrasound to evaluate for the presence of an ovarian cyst. Ovarian cysts are a contraindication to using fertility medications and will interfere with the cycle. The cyst may just get bigger and ovulation will not be accomplished.

3. Treatment calendar is made up showing when everything is going to happen, approximately.

4. Patient stops having intercourse on cycle day #10.

5. Patient returns on cycle day #10, 11 or 12 for vaginal ultrasound to check for: whether she is responding to that dose of Clomid as manifest by multiple growing follicles, how many follicles are growing and if the follicular size is appropriate for ovulation. Serial daily or every other day ultrasounds are done until the ovulatory follicle(s) reach the appropriate size of 18-24 mms.

6. Once the follicles reach the appropriate size, HCG is given to trigger ovulation.

7. If a timed intercourse cycle, the patient begins intercourse the next day for four consecutive days, only one ejaculation per day. If an IUI cycle, the patient has an IUI the next day and following day.

8. Vaginal progesterone is then started either on the 5th day after trigger if a timed intercourse cycle, or the day after the second IUI, and continued until the pregnancy test.

9. Blood pregnancy test is done two weeks after the trigger and the progesterone is NOT stopped until this result is negative. If positive, it is continued until 10 weeks gestational age. We DO NOT wait for onset of menses, because often it will not come if progesterone is taken.

If this is not the way that your doctor is using Clomid, then he/she is not treating you appropriately in my opinion, and you should find someone who will. Usually a fertility specialist is the appropriate choice, but there are many general Ob/Gyn's who do fertility well. The purpose of Clomid in your case, is to get your ovaries to function normally. Usually that will regulate your ovulatory cycles and you will ovulate by cycle day # 14. Clomid often shortens the follicular phase (first two weeks), if an appropriate dose is used. Clomid can be given in doses from 50 mg to 250 mg. The doctor has to find what the lowest appropriate dose is and that is done by trial and error. Without checking with the ultrasound, he/she can't know how you are responding. In clomid cycles you don't want more than 5 ovulatory sized follicles. Also, you don't want to do consecutive months with Clomid because it blocks estrogen receptors and can lead to poor endometrial lining and poor cervical mucous. Clomid is one of the most misused drugs in the U.S.

Sorry for the mass of information, but I hope this will give you what you need to know to make an appropriate informed decision.

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.

Husband Has Prostate Cancer & Has Banked Sperm: How Many "Straws" Of Sperm Are Needed For IVF?

Question:

My husband has prostate cancer and was referred for sperm banking. He's ready to start hormone treatment but the lab techs don't know if he's stored enough sperm. They said to ask our doctor, but as we're not under a fertillity specialist yet no one seems to know.

He has 43 or 48 straws stored from 3 banks (can't remember which they said). Is this enough? How many cycles of IVF might this equate to? I think motility was lower than average.

Thanks. S. From Germany

Answer:

Hello S. from Germany,

Only one "straw" of sperm is required per IVF cycle, and I would doubt that you would need to do IVF 43-48 times. It is safe to say you have banked enough sperm.

Sperm is usually washed and frozen in alloquats of 0.3-0.5 ml each. I presume that is what your sperm bank did. With that amount, you will have to do ICSI with your IVF cycle and so you would only need enough sperm for the number of eggs that are retrieved.

Good Luck to you and your husband,

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.

Very Confused Woman With PCOS & Endo, Who Is Anovulatory: TTC & Not Getting The Right Treatment

Question:

I was recently diagnosed with PCOS, (after many years of suffering with endo also) and we've been TTC for 2 years. I have been taking 1,000mg/day of Metformin to help control the insulin resistance. I have long anovulatory cycles and was recently seen by my doctor who wants to put me on Ortho-tri-cyclen to help get my cycles back under control. She said that women with PCOS have too little of estrogen and that is why I am anovulatory.

I have always learned that women with PCOS are estrogen dominant, so now I'm very confused. Which is it? Also, will I see ANY benefit from the birth control pills, after I stop taking them? Will it help to make me ovulate? I have not ovulated since November, which of course makes it difficult to TTC without that important factor.

Thank you in advance. L. from the U.S.A.

Answer:

Hi L. from the U.S.,

First, you are taking an inadequate dose of Metformin, if you have been found to have insulin resistance. The recommended dose is 1500 mg per day.

Secondly, your current doctor is incorrect in that OCP's (birth control pill) is only a treatment to regulate the cycles. If a woman with PCOS is 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 will do nothing for your fertility. Also, the reason why you are anovulatory is because PCOS (polycystic ovarian syndrome) is an ovarian dysfunction that leads to low estrogen, high testosterone levels. It is NOT the other way around.

Once you stop the OCP's you will go back to your normal anovulatory cycles. If you want to get pregnant with PCOS, you need to use a medication that will induce the ovaries to ovulate such as Clomid, Femara or injectable medications. I would recommend that you see a fertility specialist, who understands this problem better and won't waste your time, so that you can get pregnant in the shortest period of time. My job, as an infertility specialist, is to try to get my PCOS patients pregnant. The goal is to get them to ovulate! We use fertility drugs such as the ones mentioned above for this purpose, but it varies as to how a patient responds to these medications. The "fertility drug" is actually stimulating the ovary to ovulate.

Also, keep in mind that endometriosis is also a cause for infertility so in essence, you have two problems that are preventing you from getting pregnant.

Please read further on PCOS in some of my earlier blog posts. There is one in particular with a link to a radio interview that I did on the subject. See the February blog post: http://womenshealthandfertility.blogspot.com/2010/02/interview-on-pcos-challenge-talk-radio.html

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.

A Random Question: Two Guys, Two Sperm, One Egg = An Embryo With Two Fathers?

Dear Readers...sometimes I get some very interesting questions and this one is no exception. It did bring up an interesting point that perhaps some of you don't realize...

Question:

A Random Question...

So this does not pertain to my life AT ALL but i was just curious, if a girl has sex with two guys at once, and she got pregnant would the child have both males genes? I'm sorry that was a really odd question but it has had me wondering about it for a while.

Thanks!! Oh, and I'm from South Carolina

Answer:

Hello,

No. Only ONE sperm can fertilize an egg (basic biology).

The egg will allow only one sperm to fertilize it. If, by chance, two sperm enter the egg at the same time the results are a triploidy embryo which results in a miscarriage. There was a very odd case in 2005 of a possible triploidy embryo making it to a successful pregnancy & delivery although the result was "semi-identical twins", one with a genetic abnormality. You can read a link to this case on Time's online site: http://bit.ly/9cEZWD . As the physician interviewed for the piece said, never say never in medicine and science.

Suffice to say, "if" you were ever to encounter this kind of complication, you do not need to worry about the embryo having two fathers.

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.

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U.K. Patient Has One More Question: How Would I Go About Egg Donation?

Question:

Dr. Ramirez,

I see that having an operation to fix my tubes would be useless.

My last question concerns egg donation-If I decide (after 1 or more IVFs) that my only option is to try egg donation could you please tell me what I should be considering when I choose a clinic. I have heard that in Valencia, Spain there is a clinic that is connected with the local university and only uses young women, mostly students, to donate eggs after they have been thoroughly screened. Have you heard of this particular clinic? I understand that you cannot recommend a particular clinic.

Most importantly, what should I be making sure is involved in the egg donation operation? Is there anything I can do to ensure that I have a better chance of success?

I can't thank you enough for all your advice. Sincerely, P. from the U.K.

Answer:

Hello again,

I cannot give any information regarding the clinic in Spain, as I have no contacts in that country. I have heard of an organization recently called Global IVF & I think it might be a good place to start (http://www.globalivf.com/).

In terms of finding a clinic, you would need to find a good IVF center. It is one that does an adequate number of IVF cycles per year with good published results. You should in particular examine the Donor IVF pregnancy rates. In the U.S., these rates are over 60% per cycle.

Donors can be obtained from three sources: (1) someone you know or find, like a sibling, friend, acquaintance, etc., (2) a donor registered with the IVF clinic or (3) through a donor agency. Usually the costs increase from source 1 to 3. Almost all clinics or agency recruit donors that are under the age of 33, so I would not consider one older that that age, unless it were someone you personally knew, like a sister. In addition, if the donor had proven fertility such as a previous pregnancy, or previous successful donor IVF cycle, then that would be preferential as well. In the US, we have strict rules regarding eligibility and medical history for donors. They are extensively tested to make sure that they don't have any transmittable diseases or genetic diseases. I don't know about Spain.

In the US, donors are usually selected by the recipient, and not by the clinic. I have had information from other European couples that they have to choose the donor the clinic provides, and have no choice. In the U.S., the donors have a full profile, including pictures for you to choose from. Many patients like to choose someone with the same characteristics, background, education, etc. However, the more criteria you have, the more difficult it becomes to find an appropriate donor.

I hope that gives you the information that you need.

Good Luck, your questions are all relevant ones and I hope you continue to inquire of your physicians as much as you need to!

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 Yr. Old U.K. Patient With Poor Egg Quality, Tubal Damage, Given Troubling News: How To Proceed?

Question:

I am asking this question from the UK.

I am 42 years old, and have recently had a failed IVF cycle. It was my first IVF cycle and I had a low response. I had a total of 3 eggs harvested.

There were 2 from mature follicles and 1 from a small follicle. I know this is a poor response because I was on the maximum amount of drugs. I was on Buserelin 1mg/ml - 0.5ml per day, puregon 300 units and menopur 300 units per day. Not only did I have a poor response but the egg quality was also very poor. The egg from the small follicle burst before the embryologist could perform ICSI on it. The other 2 eggs did not change or develop in anyway when ICSI was performed on them. And ICSI was done because my husband's sperm is low in number and has problems with motility and morphology.

I recently had a follow up session with the fertility specialist and he advised me to not do any more IVFs and to consider egg donation if I want to proceed. And he even went on to say that even if by some miracle I did get pregnant my egg quality is so poor that the child would most probably have serious birth defects. I was so devastated.

My questions are I only had one IVF and the FSH on day 3 was 9.3, so can my doctor tell from one IVF that I have a low egg reserve and all my eggs are of poor quality. I forgot to say that both my tubes are blocked so an IUI wouldn't be useful.

Could it be that on another cycle an IVF might give better results? I have always had regular periods. Could my ovaries just have responded badly the first time and might they respond better to a second IVF? And most importantly, even if by some miracle I get pregnant, does my poor egg quality in this IVF cycle mean that a child would most probably have serious birth defects?

I want to do another IVF cycle. I want to see if a different drug protocol might cause a better result. Please tell me if you think that I should have any hope for a better result or if I must face the brutal truth that there is no hope and I must only consider egg donation.Thank you so much for taking the time to answer my questions.

ANSWER:

Hello P. from the U.K.,

In answer to your questions:

1. Low ovarian reserve (the stimulation response) and low egg quality are two different factors. You had both in this cycle. The elevated FSH of 9.3 is an indication that the ovaries probably will not stimulate very well with maximum stimulation as you did. It does not indicate poor egg quality,however. Your age is more of a factor indicating poor egg quality. As you know, pregnancy rates decrease significantly with increasing age, especially after 35. This is mainly due to poor egg quality. There is no way to correct poor egg quality other than trying to recruit and extract multiple eggs in the hope that a good egg will be present in that group. I don't think that all your eggs are poor quality but certainly the majority (90% or more) are.

2. There have been several studies on poor responders showing that each cycle is unique and yields a different result. So, there is still a chance, that even with one embryo, you could be successful in a subsequent cycle. However, to keep from giving you false hope, the chances would be low so you would need to be prepared for failure and to have to try several attempts. There was recently an article in the New York Times here in the U.S. about a 49 year old woman who conceived and delivered by IVF using her own eggs. I believe she is the oldest in the world to have done so (get pregnant with her own eggs by IVF). However, they were clear to point out that it took her two years of doing IVF to attain that success.

3. I disagree with your doctor's statement that if you got pregnant you would almost certainly have an defective child. Because of your age there is a strong risk for miscarriage or a genetic abnormality such as Down's syndrome. However, abnormal embryos rarely implant or lead to a successful pregnancy. The only reason Down's syndrome gets by is because it is a mild genetic defect (only one chromosome is abnormal). If you get pregnant, and it successfully progresses beyond 8 weeks gestational age, your chances are good of having a normal child. We do recommend genetic testing, however, for those few that are abnormal. Poor egg quality usually leads to an embryo with multiple abnormalities, poor embryonic development and either no pregnancy or an early miscarriage.

4. I don't see any reason why you can't keep trying with your own eggs as I mentioned above. I see miracles happen all the time. However, you have to be prepared for a bad result, and if you can handle that, go ahead and keep trying as long as your ovaries still respond. You can switch to donor eggs at any time and at almost any age (although we tend to limit it to below 50) so that option will always be there. That being said however, I would probably have counseled the same as your doctor because we want you to be successful in the shortest time, least amount of attempts, least amount of emotional cost, and least amount of financial cost.

Follow-Up Question:

Dr. Ramirez,

Hello, it's P. again.

My next question concerns trying to fix my blocked tubes.

I wonder if I should consider a procedure to have one or both of my tubes unblocked. I have read that sometimes a tube can be so scarred that even having a procedure to unblock it doesn't work.

If one of my tubes was unblocked and remained so, then I could become pregnant naturally, couldn't I? I know I would still be battling with a poor egg reserve and a lot of eggs that are poor quality because of my age. Do blocked tubes mostly remained blocked even after a tubal opening operation? I am also very overweight, will this make a difference to how easily a surgeon could perform such an operation?

Dr. Ramirez, do you think this could be an option for me? Thank you for answering my questions. It is truly wonderful that you give up your time to help women like myself. God Bless you for your kindness.

Follow-Up Answer:

Hello Again,

Despite what anyone may tell you, tubal damage is NOT repairable or reversible except for two exceptions:

1. The fimbriated end of the tube is blocked by scar tissue that was causes externally, such as by previous surgery or a ruptured appendix.

2. The opening to the tube at the uterus is blocked by mucous, in which case, an HSG can sometimes unblock them and they would function normally.

Anything else that caused tubal damage cannot be fixed, and surgery does not exist for this. In addition, because of your age and ovarian reserve, even if that technology did exist (such as tubal transplantation), your "natural" chances of pregnancy would only be 1% per year of trying. It definitely would not be worth the surgical cost or risks. IVF has a better chance of 25-27% per attempt.

Good luck, P. and don't lose heart!

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.

Comment:
Dr. Ramirez answered my questions clearly, completely and kindly. He obviously has a genuine desire to help women that find themselves in the terrible position of needing fertility help.

IVF Poor Responder With Endometriosis And Nightsweats

Question:

Hello, Dr.

I am from New Jersey , USA. and I have 2 questions for you.

I was diagnosed with stage 4 endometriosis in January of 2009. The surgeon removed all my endo in the operating room. Since the surgery I've been having nightsweats in the morning. From what I read from the internet, it can be due to the high estrogen level in my blood. I have 1.5cm cyst on my left ovary). Somehow the doctors I have seen so far don't know what is causing this.

1)What is the cause of my nightsweats?(I have it almost every morning)

My hormone levels were taken several times.

FSH=3.84 E2=92.3? in JULY 2009

FSH=10.4 E2=52 in October 2009

AMH=1.4 in November 2009

I tried IVF in October 2009 and failed.

I had only 1 immatrue oocyte at the retrieval even though on the ultrasound there were at least big 6-7 follicles. The doctor who retrieved the egg said the others could be chocolate cysts not real eggs. My RE used an antagonist protocol for IVF in October 2009. I had to take estradiol tablets for a week in the luteal phase just before the actual cycle.

Now I changed my RE, and she said she'll try something "flare protocol". This will take 2 months and I will have to start with estradiol patch for a week before the cycle. Isn't this almost similar to the antagonist protocol I tried before? How come the RE'S give me extra estrogen when they know that I have endometriosis? Wouldn't it make my cyst( 1.5cm cyst on my left ovary) grow bigger when they do this?

2)Will this micro flare protocol work for me? Thank you!

ANSWER:

Hello J. from the New Jersey,

First of all, "night sweats" can be from multiple causes such as decreased estrogen (menopause or ovarian dysfunction) or thyroid problems or cardiac problems.

In terms of your subsequent questions, there is some confusion. You had two FSH levels drawn, one was 3.84 and the other 10.4. Were these done on cycle day# 2 or 3 because that is when they need to done to interpret them correctly. From a fertility perspective, we want the FSH level to be less than 7 on cycle day #2 or 3. When it is higher, that signifies that the ovaries are "resistant" which means that they will not respond well to stimulation because they are not going to pick up the hormone adequately. As a woman ages, her ovaries become more and more resistant, but this can occur in younger ages as well. That may explain why you did not have very many follicles. Endometriosis does not and will not affect your response to stimulation. The problem with increasing estrogen is that endometriosis thrives and grows from estrogen, so that it can cause a recurrence of the endometriosis. Your first FSH level was actually very good and would indicate good ovarian response. In fact, you would probably not need too much medication (low protocol). Without having all the details of your IVF cycle, I cannot answer questions to it specifically, but your yield was very low. There could be multiple reasons for this.

I presume your new RE is going to try the "flare" protocol because you are a poor responder, low ovarian response. The flare is only another technique that is used to try to increase the egg yield, and is something different to try but has not shown any additional benefit is current studies. The antagonist protocol just means that an antagonist is used to suppress the ovaries instead of an agonist. The ovaries are suppressed so that they don't spontaneously ovulate or function on their own, so that the cycle can be better programmed, the ovaries can respond to stimulation better and don't short-circuit the stimulation. In addition, we don't want the ovaries to ovulate before we have the chance to retrieve the eggs. There is no difference between using an antagonist or agonist, in general, except there are less injections with the antagonist (3-4 vs 21). Antagonists are medications such as Ganerelix or Cetrotide and Agonist is Lupron.

I would advise that you not worry so much about your endometriosis. IVF is the treatment of choice and bypasses the endometriosis. If you become pregnant, pregnancy is a GREAT treatment for endometriosis so that is the goal. Quite often, Endo pain decreases dramatically after a successful pregnancy.

Your first cycle did not do very well because of the poor stimulation (which could be due to not enough medications) and low retrieval number. The fact that the egg was immature could be because the egg was not given enough time to mature ie. you were triggered too soon. So, I would advise that you keep trying. Your RE will adjust your protocol to give you the best chance of success. Studies show good cumulative pregnancy rates if a patient keeps trying, even in older women.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

U.K. Infertility Patient Had Four Fibroids Removed, Now Has Pain Upon Ovulation - Ovarian Adhesions?

Question:

Hi Dr. Ramirez,

I am a 28 year old lady who has been trying to conceive for 18 months. I had an ectopic pregnancy last June, but thank God both tubes are still intact as I was diagnosed early.

I decided to have a laparoscopy in February 2010 to find out what is wrong and my doc took out 4 fibroids and I also had mild adhesions to the right ovary but apart from that the tubes and the uterus looked healthy. But since the laparoscopy, I have been having this unbearable ovulation pain on the right side which I never experienced before. It lasts for 3-4 days. The pain is very uncomfortable and right hand side of the abdomen is very sore and tender. It feels exactly like the pain I had when I had the ectopic.

My question is could the adhesions be back on the right ovary already? If so, if they were mild before the lap, is it possible they got worse after the lap? Also, would the laparoscopy affect the functioning of the ovary as I have been having abnormal basal body temperature since the lap.Lastly, is it possible to ovulate from the same ovary every month, as I don't think I am ovulating from the left ovary at all?

Is my only chance of conceiving IVF?

Many thanks in advance for your suggestions. Regards, B. from the U.K.

Answer:

Hello B. from the U.K.,

Yes, adhesions can return and usually return within 24 hours. Also, any surgery, including laparoscopy, can result in adhesion formation. Normally, when you ovulate, your ovaries swell thereby "moving". Unfortunately, the adhesions may be fixing the ovary in place causing you to have uncomfortable pain. I would not expect the laparoscopy to affect your ovarian function if the ovary was not damaged in any way or its blood flow affected.

Yes, it is possible to ovulate from the same ovary every month.

My opinion is that you have tubal disease that was probably caused by some type of event, like an infection in the past. That usually leads to internal tubal damage and scar tissue formation. If significant enough, you can also get scar tissue within the pelvis and around the ovary and tubes. The main problem is that if there is damage within the tube, it cannot be fixed. These internal adhesions are probably what caused the embryo to get stuck in the tube, leading to the ectopic. Certainly patients that have had ectopics before do subsequently have normal pregnancies, but there is no way to know which category you will fall into. With the combination of problems, ectopic and peri-tubal adhesions, I would expect that your natural chances of pregnancy are low, in which case, IVF would be the treatment of choice. That is how I would advise you in my clinic. You could certainly continue trying with a more natural method such as ovulation induction with timed intercourse or ovulation induction with IUI. You need to be seen right away if you get pregnant because of your increased risk of recurrent ectopic.

If you don't get pregnant after a period of time, I would set it at 6 months or no more than 4 IUI attempts, then I would proceed directly to IVF.

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.