Young Woman TTC Is Concerned: Has Abundant Cervical Mucous & Irregular Cycles

Question:

Hello, I am writing you from Alberta, Canada. I have been doing many searches on the internet to find an answer to my question with no success. I hope that you might be able to help me.

So, I went off BCP (birth control pill) in March 2010 to TTC. (I am 26 and have been on the pill for 7 years.) Since then I have been having a cycle each month (cycles have been ranging 30- 36 days) I have had a cycle last 42 days. And I have had several appointments with my Dr. She said that since my cycles are that long that I "might not be ovulating". This really worried me as it's nothing a woman ttc wants to hear. So I have been watching for the EWCM and each month I barely see any. But there is a bit. Well I am going on day 53 with no period. Last week I had LOTS of EWCM for the entire week. And I mean A LOT of it. More than I have ever seen. I thought I was pregnant because of symptoms but after 2 negatives I know I am not. So this brings me to my question...what does it mean when you have LOTS of EWCM for a whole week? I was having LOTS of cramping so I was thinking my period was going to start but nothing. There was one day which was the worst cramping I have had. I usually cramp a lot when my period starts and the week of ovulation.

Could my body finally have ovulated and the hormones are working out or should I seek more advice from my Doctor? I am waiting for my cycle to start so I can take the clomid she prescribed me. I appreciate any advice you may have for me. I do plan on going back to my Doctor soon but with the Christmas holidays I can't get in to see her til the New Year. I was really curious about all that EWCM. There was sooo much of it and it lasted more than 4 days. Is that a good sign even though it was 45 day of my cycle? My cycles before I went on the pill were usually 32-34 days and very consistent. But the periods were heavier then...lasting 5-6 days. After stopping the pill they were very light and have only lasted 3-4 days.

I apologise for such a long explanation. I just thought I would share my story in case other women have the same issue and question so they can use the answer I receive.

Thank you again and all the Best to you in 2011!

Answer:

Hello C. from Canada, Thank you for wanting to share your concerns with other women who are trying to conceive (ttc). I think that you are putting too much value on cervical mucous. It is an indirect measure of the hormone production in your body. Basically, as the body gets closer to ovulation, the estrogen/estradiol level in your system increases, which in turn converts the cervical mucous to a clear, stretchy, copious mucous. This allows for sperm entry into the uterus and tubes. I am not sure what you are referring to as "EWCM" and because you don't describe the mucous properties so I can't comment on the question regarding having this mucous for multiple days (please be more specific, since descriptions are better than acronyms). The cervix produces all types of mucous and the vagina as well.

Here is a general guideline on what cervical mucous should look like post menses:

Stage 1: Lasting 2 - 3 days Cervical Mucous is sticky or gummy

Stage 2: Lasting 2- 4 days: Cervical Mucous is creamy, milky and lotion like.

Stage 3: Lasting 1-5 days: Egg White Cervical Fluid: It looks like egg whites and is slippery and stretchy. The mucous should be clear, but if there is an odor this may be a sign of an infection, if so, consult with your doctor. Women in their 20's such as yourself can have this type of cervical mucous for up to five days. At this point, women are generally considered to be in their most fertile period.

Stage 4: Dry, Moist or Sticky

Based on the fact that your cycles are irregular, there is evidence that there is some type of ovarian dysfunction going on as well. It could be a lack of ovulation or a hormone imbalance. If it is of ovarian origin (there are other possible causes as well), then the treatment would be to use medication such as Clomid to stimulate the ovary and get it to function normally. But prior to making that assumption, you should have a hormonal evaluation to make sure it is not a problem with your thyroid or pituitary or hypothalamus or other such causes. If it is found to be isolated to the ovaries, then Clomid ovulation induction is appropriate. I would recommend that you look at my blog regarding how Clomid ovulation induction cycles should be done ("How I Do Clomid Induction Cycles"). I hope that helps to answer your questions, good luck!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Young UK Woman Trying To Conceive Has Irregular Cycles, Prior D&C: What Could Be The Problem?

Question:

Good evening, Dr. Ramirez. Thank you for taking the time to read this email.

I am concerned about my periods. Nearly two years ago, I made the difficult choice to have an abortion. Not wishing to go through that again, I chose to have the Depo shot for six months after. However, due to weight gain, I stopped taking it. That was over a year ago.

For the last year, my periods have been coming every two months, but the last one I had scared me. Instead of being red, as was the normal, the blood was brown in most areas and black in others. It lasted seven days, but did not increase in flow, if anything it slowed and thinned towards the end.

I went to see my local doctor, and she told me that I would not get help because I am under 30. My partner and I have been having unprotected sex in the hope for a baby, but to no avail. I cant even work out when I am ovulating.The women in my family have been known to suffer from Polycystic ovaries, especially my sister who is close to me in the gene pool. Is it possible to develop this? I'm so worried and depressed all the time. Please can you help and advise me? I am writing to you from chilly England.

Regards, K. from the United Kingdom.

Answer:

Hello K. from the U.K.,

I can't give you specific advice because I don't have enough information. Certainly if your cycles are irregular, something is going on with the ovaries. There are several levels that have to be checked to find where the problem is. Polycystic ovarian syndrome, or PCO, is an ovarian disorder where the ovaries dysfunction and don't ovulate. That certainly is a possible cause, and probably the most common cause of irregular cycles. Again, without testing it is difficult to know. PCO can be latent for a period of time and then for unknown circumstances, like weight gain, can manifest itself!

In terms of your bleeding, the brown and black blood are nothing to be concerned about. That is old blood that has made its way out of the uterine cavity. It started out red but sat in the cavity for some period of time before making its way out. One concern that I might have, since you are interested in fertility, and because of the bleeding change, is if any damage was done within the uterine cavity from the abortion. Sometimes if the D&C is done too vigorously, scar tissue can form within and prevent the blood from flowing out easily. A procedure called a hysteroscopy would need to be done to evaluate for this.

Regardless of your age, if you have not been able to achieve a pregnancy after one year of trying, you fall into the category of infertility and should see an infertility specialist. They would not only evaluate your for your menstrual irregularity and try to remedy this, but will also evaluate the uterine cavity. So go tell your unhelpful gynecologist that you want to be referred to an infertility specialist!

Good Luck and a very Merry Christmas over there in chilly England!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Monterey, California, U.S.A.

Comment: Helpful, polite and understanding. Everything you want when you need help!

UK Patient Has PCOS, On Clomid For Ovulation: After First Miscarriage, Should She Continue With Clomid Or Start Injectables?

QUESTION:

I was put on 50mg Clomid due to pcos and long cycles (42-43 days). Right away, my cycles reduced to between 26-32 days. I got pregnant on my 3rd cycle of Clomid, then miscarried.

My RE recommends that I go back on Clomid, and would like me to increase my Clomid dose to 100mg so that we can recruit more than 1 egg (since I was only ovulating one egg on the 50mg dose). I will also be taking progesterone this time.

1) Do you recommend that I increase my dose of Clomid to 100mg to recruit more than one egg (even though I was ovulating normally on the 50mg dose)?

2) If the next 3 months of Clomid are unsuccessful, my doctor recommends that I try FSH injections (since I will have been on clomid for a total of 6 consecutive months, including the 3 months before my miscarriage). Do you recommend moving to FSH injections, or staying on the Clomid since it was successful previously?

3) If I cannot get pregnant again during the next 3 months on Clomid, my doctor recommended getting a laparoscopy. Just wondering if you would recommend I proceed with a laparoscopy if I fail to get pregnant again? I feel like I just got pregnant after 3 months of Clomid, so that the procedure seems unnecessary to me. (I have also had bloodwork, SA, and HSG all come back as normal).

Thank you for your advice. Sincerely,S. from the U.K.

ANSWER:

Hello S. from the U.K.,

I am sorry for your miscarriage. Considering your treatment plan, because you responded to 50mg of Clomid previously, you certainly don't need to increase the amount. However, your doctor's strategy is to get you to ovulate more than one egg at a time to increase your chances of pregnancy with each attempt. We call that super-ovulation. With increasing the number of eggs, you certainly will be increasing the chances of a multiple pregnancy. If that is not acceptable then stay with just 50mg.

I do not recommend moving to FSH injections yet. They certainly have a place but since you have gotten pregnant with Clomid before, I would just increase the Clomid dose. You can go up to 250 mg of Clomid. 3 months also seems like a short time frame for the trial unless you are over 35 years old. Then you might want to proceed more aggressively.

If you move up to the injections then I would also recommend that you add IUI in order to increase your chances even more. I don't recommend a laparoscopy at this time because I don't see a reason for it. I keep in mind that you were successful already with Clomid which shows that everything your body needs to do in order to achieve pregnancy can occur. The pregnancy re-sets the time frame. Now you just need to go back to the same plan and keep trying!

Follow Up Question:

Dr. Ramirez,

Thank you for your prompt reply. It is extremely helpful. I just have a few follow-up questions:

I mentioned previously that I was on Clomid for 3 months and got pregnant on the 3rd month (and miscarried). I have now been on Clomid for another 2 months since the miscarriage and not gotten pregnant yet. So I will be starting my 6th consecutive month of Clomid this month.

You recommended I continue with Clomid at a higher dose (rather than move straight to the FSH injections), since Clomid worked for me before.

1) Could please tell me what is the longest period that I can safely be on Clomid for? [I keep reading that one is only supposed to be on Clomid for a limit of 6 consecutive months. I am going to be starting my 6th consecutive month of Clomid this month]

2) I also keep reading about two negative effects that can occur with continuous use of Clomid. One is thinned lining (my lining has been fine so far). The second effect I have read about is hostile cervical mucus.

My RE said she is willing to do a post-coital test to check on cervical mucus if I want one, but that she does not consider it a reliable test. So my question is - how am I supposed to know if my cervical mucus is being affected by the Clomid? Also, since I am now entering my 6th month of Clomid use, should I consider taking an estrogen supplement which can possibly improve cervical mucus? Thank you very much for your advice. Regards,S.

Follow Up Answer:

Hello Again, When I answered your previous question, I was not implying that I agreed with continuous Clomid cycles. I do not. Because of the "antiestrogenic" effects of Clomid, I do not use Clomid on a continuous monthly basis. I alternate with Femara, but if that is not used, then Clomid should be used on an every-other month basis so as not to block the estrogen receptors, for exactly the reasons you indicated. Yet, as I stated above, your pregnancy reset the time frame.

In terms of the maximum number of months to use Clomid, there is no rule that says that Clomid needs to be stopped after a certain number of months. However, if pregnancy does not occur, then you should move on to the next level of treatment after six months. In your case, since you became pregnant, that reset the count. Because fertility treatments cannot control the pregnancy, and can only give you the opportunity to become pregnant, that is where treatment success ends. So you are now on your second cycle of Clomid, not your 5th.

Certainly if you want to move to the higher level of treatments such as Follistim, there is no reason that you should not. I only suggested the Clomid because it is less expensive, easier to use and worked for you before.

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.

37 Yr Old Failed Two IVF Cycles, Has Frozen Embies And Husband With Slow Swimmers: What Would You Suggest?

Question:

I just failed my second IVF (in vitro fertilization) procedure. I am 37 years old living in the Bay Area. My husband has slow swimmers and not great morphology either. We used ICSI (intra cytoplasmic sperm injection) with both IVF procedures.

The first cycle I had 8 eggs, 6 fertilized and only two made it for transfer. The second cycle I had nine retrieved, 8 fertilized and we transferred two embryos on day 3, one an 8 cell and one a nine cell. We were able to freeze 3 embryos, not of as high quality. I believe the frozen embryos are 5 and 6 cells. I am planning to use the frozen embryos, but it seems like a lost cause as the quality of the embryos are not as good as the fresh ones that were transferred. I am doing acupuncture treatments as well.

Any advice would be most helpful. L. from San Francisco, California

Answer:

Hello L. from the U.S.,

I am sorry to hear of your failures, but IVF is certainly the best treatment for you based on your husband's problem and your age.

Without reviewing your IVF records, I cannot give you any specific information regarding your cycles or chances. Keep in mind that each IVF center uses different protocols and methods and pregnancy rates vary. For example, my pregnancy rate in your age group with ICSI is 56% per attempt with 41% continuing pregnancies. Pregnancy rates are very dependent on the stimulation, how many mature eggs are retrieved, embryo development and transfer technique. In addition, in your age group, having failed one IVF cycle already, I would have placed back all four embryos, even though the lesser celled ones were not as good quality. There is no utility to freezing them, and the prognosis with those embryos is not good as you already know. The success rate of a frozen embryo transfer cycles with good embryos is approximately 30%. Your best chance, once you have tried with the frozens if you choose, is to keep trying with fresh embryos.

In my protocol, I would probably place you at the max stimulation protocol, add low dose aspirin, low dose heparin, medrol and increased progesterone with the next cycle. Acupuncture certainly does not hurt and I would recommend that you continue it. On a side note, when my wife & I went through IVF she was 37 like you. We also did ICSI. She had 14 eggs retrieved, eight fertilized, and we ended up with one nine cell, one eight cell and the other two 5 cell. After conferring with her RE, (she was under the care of my colleague at the time) we decided to transfer all four. She became pregnant with a singleton, our daughter, who is now a healthy young teenager (her baby picture is on the Doctor's Background page of my blog). Needless to say, we did not regret our decision :)

Good Luck on your journey, I will keep my fingers crossed for you both!

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

Monterey, California

Patient With Short Luteal Phase Has Spotting With Progesterone Suppositories, Is This Normal?

QUESTION:

Dr. Ramirez, I am hoping that you can help answer some questions for me as I am feeling confused and hopeless...I am 30 years old and I am trying to concieve. I was on the birth control pill for 9 years and stopped taking it in June. I have been charting my Basal Body Temps and discovered that I have a short luteal phase--

I begin spotting 9 days after ovulation and start my period the following day making my luteal phase 9-10 days. My period is very light-- only lasting a few days. I have been taking Vitamin B6 supplements and my doctor started me on Crinone Progesterone Suppositories this month. I began 3 days after ovulation and am taking 90mg once per day.

Yesterday, 9 days into my luteal phase, I began spotting very lightly when wiping. This was very discouraging as I usually begin spotting on day 9 before starting the suppositories. I was convinced that I was starting my period as I had in previous months and that this was not implantation spotting due to the coincidence of the spotting on day 9.

However, now on day 10, I am wondering if I gave up hope too soon. The spotting is still VERY scant and does not seem to be increasing as in previous months. Also, the actual flow of the bleeding seems a little different than previous months. Upon intially wiping, there is no blood on the toilet paper. After wiping a couple of times, a very small amount of red blood appears on the toilet paper. In fact, as I continue to wipe, the bleeding seems to increase with each wipe. Also, it does not resemble my usual spotting (blood mixed with a wet discharge) but just small amounts of blood smears. The flow only appears when wiping.

Should the progesterone suppositories have increased my luteal phase count at least a little bit? It's very discouraging to think that there was no increase at all. If my period is beginning, does this mean that it is not a progesterone issue? What else could cause a Luteal Phase Defect? Can your period begin while you are taking the suppositories? I read online that your period will not begin until you stop taking the progesterone? However, I have also read conflicting info as well.

Could this be "break-through bleeding"? Is this common with suppositories? Could you explain what this is? Does this sound like implantation spotting? I called my Dr. and she said to stay on the progesterone for a few more days and see if my period does start. She has admitted that she is not too familiar with LPD isues and has referred me to a Reproductive Endocrinologist however the earliest appointment I could get is March. I am feeling really confused and discouraged. Any help, guidance or suggestions would be greatly appreciated! Also, I did take a pregnancy test today and it was negative but realize that it may have been too early. I am writing from Massachusetts.

ANSWER:

Hello D. from Massachusetts,

I have found that vaginal spotting is very common with the use of Crinone in my IVF patients, so I don't think you need to worry about it. Supplemental progesterone is the appropriate treatment for suspected luteal phase defect. A pregnancy test will be required because your natural period will not occur if you are on supplemental progesterone. The incident that causes the withdrawal bleed (your period) to occur is the abrupt drop of progesterone in your system if a pregnancy has not occurred. Therefore, I would recommend a scheduled serum bHCG at 14 days after ovulation. If it is negative, then stop the progesterone but don't stop until you have that result.

There are gynecologists out there that are well versed in infertility treatments. You don't necessarily have to see an RE for your level of care. You might want to call around and see if you can find one so you don't have to wait so long to undergo proper treatment. However, be very careful because there are many general Ob/Gyn's that say they do infertility that know very little and don't render proper care. You might want to ask them specifically how they diagnose and treat luteal phase defect. You also might want to find one that does IUI treatments, and avoid the ones that don't do this level of care.

Follow Up Question:

Thank you so much for your quick response! This was very helpful. It is encouraging to know that spotting is common when using Crinone. From your response, it sounds like my period will not start until I stop taking the progesterone. Do you feel confident that given the info that I provided that it is not my period starting and just due to the progesterone? Is this "break-through bleeding?"Also, do you think 90 mg once per day is adequate? I read about women taking the supplements 2 times per day. Again, thank you for any help you can provide and for your timely feedback. I appreciate your advice re: the RE as well. March seems like it will never get here!!

Follow Up Answer:

Hello Again,
I am confident that this bleeding is not your period, but keep in mind that there are always exceptions. It is most likely breakthrough bleeding as I explained previously. Crinone has been extensively studies for use in infertility and once per day is adequate.

I am happy to have helped clear up some of your fears. Good luck with your treatment and don't hesitate to write again!

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.

Can Progesterone Be Given With Clomid Induction? PCO Patient With 3 Failed Cycles Wants To Know...

Question:
I'm 31, never pregnant. Dx PCOS, receiving metformin 1500 mg a day. Three cycles with clomid with no ovulation. HSG normal, husband semen analysis OK. Now going through second cycle of IUI (intra uterine insemination), ovulation stimulated with Gonal F and triggered with ovidrel.

First cycle progesterone level on day 3 after second IUI was low (2.3), so I asked the doctors why they can not prescribe progesterone to improve luteal phase and make implantation more possible, and they told me they do it only with IVF. Is this Ok? What I mean is, why don't give progesterone if the level is low, and it is know than low progesterone impairs implantation and also increases risk of miscarriage in first trimester? Please give me some advice, or some reference articles where to read about this (scientific articles to support my request) Thank you! S. from Arkansas

Answer:

Hello S. from the U.S.,

You have a very valid question and you should ask your doctor why they don't give progesterone after intra-uterine insemination. I'm sure there are many articles on the web that you could find that advise this technique. There is absolutely no reason not to give progesterone after IUI or even after simple ovulation induction.

However, I think that your thinking may be incorrect, however. If the ovulation induction were proceeding correctly, and ovulation occurs, then the hormones should be corrected and there should be a normal luteal phase. Usually a mid-luteal progesterone is not to see if there is adequate progesterone for implantation, but to see if ovulation in fact took place because if it did not, the progesterone would be low. So you see, rising progesterone levels occur from ovulation. If the progesterone is low, that is an indication that ovulation did not take place and replacing progesterone would not have anything to help i.e. no implantation would occur any way.

I have to wonder about the protocol that your doctor is using, and I would suggest that you look at my blog under how I do clomid induction cycles. One specific technique that I use is to follow the follicle(s) with the ultrasound to determine when ovulation is going to occur. That way, I can better time the insemination. I also give an HCG trigger. Then I start progesterone the day after the second IUI (I do two IUI's per cycle) for luteal phase support. This is mainly because progesterone is an easy medication to use, is not expensive and has no adverse reactions/side effects/harm to the pregnancy. It can only help and increased progesterone is one of the main stays for the treatment of implantation failure due to inadequate b-integrin levels.

Maybe you should ask your doctor why he uses it for IVF and not for IUI? The reason to use it should be the same.

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.