PCO Patient With Complex Hyperplasia Trying To Conceive: Needs To Lose Weight & Begin Clomid Protocol

Question:

Dr. Ramirez, I am 31 years old my husband is 40. We have been trying to conceive for about 3 years. I have taken Clomid about 4 different times. I have only had about 5 or 6 periods on my own in my entire life. I went to my OBGYN who put me on provera to get me to bleed then take 50mg clomid to start with. She told me that I had PCOS. In Dec of 2009 I hemorrhaged and had to have 4 units of blood. My OBGYN sent me to a oncologist who diagnosed me in Jan with complex hyperplasia with atypia and a well differentiated adenocarcinoma. They said I needed to have a hysterectomy but I want a baby really bad. They said we would have to try to reverse the condition first. They started me out on Megace then changed to Provera 15 mg a day for 1 month. I have had 3 d&c's. My last vaginal ultrasound showed everything was clear but my lining was very thin. My OBGYN stated that I could try clomid again and she put me on birth control pills which she said would help to make my lining thicker. She told me to take Nortrel birth control pills to start my period. I was on 100 mg of clomid but didn't ovulate. I haven't had a test done to check my husbands sperm because I know that I do have a problem and the test for him is too expensive. But I will have to have it done if I eventually start to ovulate and still do not get pregnant.

My OBGYN just started me on another cycle of the birth control pills and then 250mg of clomid. On the first cycle of 100 mg of clomid, I stopped taking the birth control pills when I started to bleed. Then I took the clomid on day three of bleeding. Was this wrong? Should I have kept taking the birth control pills even though I had started bleeding? I only had 2 left in the pack. I was just confused and was afraid that this might have been something to keep me from ovulating. Do you think that even though I have had the complex hyperplasia with atypia and the cancer that I can still possibly get pregnant? I also was wondering if my OBGYN said everything looked clear and I don't have the hyperplasia anymore then why can't I ovulate and get pregnant?

Answer:

Dear T.,

Thank you for your question and thank you for the very long history. You are certainly faced with a dilemma. However, you are not the first to have this problem and oncologists are very aware of what they need to do. After the Megace treatment, you should have had another D&C to make sure that the cancer was resolved. If you have not had that resolution, then that has to be done first. You don't want to be pregnant with cancer, and have that shorten your life with your new child. Also, the Megace treatment is only for very early stage cancers. If it is more advanced then do not delay the hysterectomy. They can preserve (not remove) your ovaries so that you can use a surrogate to achieve pregnancy. There have already been great successes with frozen ovarian tissue as well as frozen eggs. Do what is going to be the best for your child in the long term.

It sounds like your OB/GYN is proceeding correctly, however, you probably need to see an infertility subspecialist. If you do not respond to the 250 of Clomid, that is the maximum dose. It is time to move on, especially since time is not your friend. You should have had a basic evaluation, which included a semen analysis, before starting treatment. You don't want to waste time and energy if a Clomid-intercourse cycle is not going to work.

In terms of the birth control pill, you were correct is stopping the pill and not finishing it since your period started early. That is the key for starting the Clomid cycle.

In terms of getting pregnant, PCO is a complex but not insurmountable problem and is very common. However, most of these patients do not respond to the easy medications (Clomid, Latrezole) and have to move into the more complicated injectable medications. For that reason, I advise seeing a fertility specialist, not a general OB/GYN. In addition, you want to get pregnant as soon as possible, so that your cancer does not return. You may want to consider a treatment plan that is going to get you pregnant the efficiently.

Follow-up Question:

Dr. Ramirez, I did have the D&C after the megace and Provera treatment and it showed that I no longer had the complex hyperplasia with atypia or the cancer. They let me start the fertility medicine again. I am on the Nortrel birth control pills now and when I start my period I will be starting the 250mg of clomid. My husband hasn't had the semen test done yet because we do know that I can't ovulate so it is definitely a problem of mine right now. I just couldn't afford to have the test done for him. I don't think that I can see a infertility subspecialist because my insurance won't cover it. I wouldn't be able to afford it.

I was just curious if you thought that as long as the complex hyperplasia with atypia and the cancer are gone if I should be able to ovulate and get pregnant. I started out at 262 in December when I hemorrhaged and I am now 234. I am losing weight but find that I am staying pretty much at the same weight and can't lose anymore. I also have thyroid problems and I'm on Levothyroxine. I appreciate your help. Thank you!

Follow-up Answer:

Hi Again T.,

I'm glad to hear that the complex hyperplasia and cancer are gone! That buys you time. However, as I explained earlier, you will need to be cycled, so don't go any prolonged period of time without having a period.

I think you can safely assume that part of your infertility problem is the lack of ovulation. It is most likely that you have a disorder called polycystic ovarian syndrome. Your increased weight is contributing to the problem, and the PCO also causes you to increase weight. You should try to get your weight down as much as possible, close to your ideal weight. This by itself may induce your ovaries to begin ovulating on its own.

You also need to make sure that your Thyroid problem is under control and the levels are normal. This too can decrease your chances.Since financially you can't progress beyond Clomid at this point, it is certainly okay to continue trying Clomid. However, 250 mg is the maximum dose and many PCO patients do not respond to this dosage or clomid at all. In that case, you will have to go to the injectable medications, which are much more expensive, and you will definitely have to see a fertility specialist for that level of treatment.

Good luck and don't give up! It's possible that your fertility specialist may have various financial plans in place that will make it affordable for you and your husband to pursue treatment, as our center does.

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.