Tuesday, June 15, 2010

The U.S. Open Arrives In Monterey...

Just wanted to welcome golf's U.S. Open to our area. For those of you who don't know where I am, I am in Monterey, California where the U.S. Open is being played this week at Pebble Beach Lodge and Golf resort. My office is 15 minutes away. Not only is this area a golf mecca, but it is a secluded travel location where many of the wealthy and celebrity come to get away. We are next door to Pebble Beach, Carmel, Monterey and Big Sur.

For patients it is a relaxing, peaceful, private and tranquil setting, more conducive to avert the stresses of infertility treatments. As you watch the U.S. Open this week, and think, "boy what a beautiful place", I hope that you'll think of us, and one day plan to come visit us and our beautiful location. I will even treat you to a round of golf at our nearby Laguna Seca Golf Ranch!


  1. Hi Dr. Ramirez,
    I recently stumbled upon your blog and think it is wonderful that you donate your time to answer questions and share your wisdom on the facets of infertility.
    I was hoping you can advise me on my upcoming in vitro. I am a 35 year old who has been trying to conceive for almost 2 years. 5 Iui's latter (first 3 w/clomid and last two with Gonal-F) we were ready for IVF. Unfortunately with my elevated FSH (13.7 was my first ever reading, for my clomid challenge test it was 10 and then 14.9) and very low AMH (.4), I only produced 3 follicles (on almost 400 iu of gonal-f and microdose lupron 20/20) and so that cycle was converted to an IUI. Per my RE for my next cycle (day 21), I will be taking 2mg of estradiol (estrace?) vaginally 2x a day. I remember he called it luteal phase estradiol. He is hoping this will prevent me from producing dominate follicles like the first ivf attempt.
    My first question is, is it safe to try naturally for this cycle? Against my doctor's instructions to NOT try naturally, I could not let a month go to waste and so we did. It just does not make sense to me that after an IVF cycle, I would have taken vivelle patches which is estrogen. Why would my doctor say its not safe for the fetus if I should get pregnant on this cycle, not know yet and be taking estradiol vaginally? Should I fess up?
    My next protocol is: estradial on day 21 on the cycle prior, no microdose lupron, just higher FSH and ganerilex towards the end. I was told they will likely have me take clomid too. Is that a common protocol to take clomid and Gonal-F ? I know in the past I made 3-4 follicles on just clomid for my IUI's. I think the doctor feels my response was decent with the clomid.
    Any advise you can provide will be GREATLY appreciated. As a side note, my husband is watching the Pebble Beach golf tournament :D. Its on his bucket list to play there while my bucket list is to have a baby. Perhaps someday we may find our way to Monterray!


  2. Hello Kari,

    The elevated FSH, positive Clomid challenge test and low AMH, are all measures of ovarian reserve. That is it shows that the ovary has a high level of resistance already and will not sitmulate well. It also means that your timeline is shorter than expected so you need to try to get the first pregnancy as soon as possible. Every year that passes will affect your ovarian function and once it shuts down (FSH >15) you will lose the option to get pregnant with your own eggs. That is the signficance of those measurements. That does not mean that you cannot get pregnant with your own eggs, however. It is NOT a measure of egg quality and your age is the major determinant of egg quality. At 35 the majority of your eggs should be of good quality. For that reason, in my hands I would not have cancelled your first cycle. Even with only a few follicles, we cannot know if the perfect embryo is in that group and you would only have transferred two embryos anyways and we would only have needed one to implant. I NEVER give up on an IVF cycle for that reason.

    I try to make it a policy to not critique protocols of other clinics because each clinic, and each Physician, has their own protocols and their own preferences. That is what makes us different. Some clinics are more aggressive, some are less, some are more experienced with particular kinds of cases and some not. There is not perfect or only way to do things. In my case, I am more aggressive with my patients that have decreased ovarian reserve. That is, I treat them with high doses and NEVER use the long protocol (lupron preceding the start of the cycle like you did). The long protocol, in my mind, suppresses the ovaries too much. Instead, I use an antagonist protocol (generelix, cetrotide), like you doc is planning for your second cycle. That leaves the ovary un-suppressed for the majority of the cycle, and hopefully allows it to recruit more follices. I also use a high combination protocol (450IU FSH and 150IU FSH/LH). I specifically use Follistim and Menopur, but there are other forms of this as well.

    I am to admit that I don't see a reason to use Clomid. In fact, I would think that Clomid would be detrimental because it does not stimulate the ovary as well, and tends to block vital estrogen receptors, such as those in the endometrial lining. I would counsel against that.

    I don't know the reason for the estradiol preceding your IVF cycle. That is a new one for me. But don't worry if you tried naturally. It is okay and the estrogen won't affect the fetus (that's why we use it in IVF cycles.

    Well, this answer has gone for too long and I appologize. I would welcome you to my clinic in Monterey, and you husband could then take care of two things in the same trip. We are a golf mecca and there are many more courses than just Pebble Beach. If you decide to come this way, and your husband wants to play Pebble, let me know and I will try to set it up for you. I might even join him! :)

    Good luck.



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