Wednesday, September 29, 2010

37 Yr. Old Australian Woman With Complex Hyperplasia With Atypia Does Not Want Hysterectomy: Wants To Conceive


I am a 37 yr old woman who has been trying to get pregnant since I was 16. I have never fallen pregnant that I know of. I have had a Laparoscopy to see if i have a blockage in my tubes-there was not. Last year I had mid cycle bleeding for a few months & went to doctors who did a LLETZ procedure and found I had complex hyperplasia with atpia. I was told to have a hysterectomy, but declined & said I would like to see if I can get pregnant through a Natropath here in Australia, because she has a 87% success rate of clients falling pregnant.

The findings from my last hysterscopy, dilation & curetteage & polypectomy were, cervix healthy, consistent with previous LLETZ. Uterus bulky 8 week size, cavity 10cms, endometrial polyp and hyperplastic endometrium, both ostia seen, Adenexa NAD.

What does all this mean? Could I still fall pregnant?. Can I die from having complex hyperplasia with atpia? Do I really need to have a hysterectomy or can it be left until after I fall pregnant? I am so confused & very distressed that I may never have children of my own. I have asked my surgeon that performed the lasts LLETZ procedure and all he said was he wants me to have a hysterectomy, I don't want to have one, because I think he is being a little knife happy. What would you suggest? Thank you. D. From Australia


Hello D. from Australia,

Complex hyperplasia with atypia is an endometrial diagnosis and not a cervical diagnosis. It is a worrisome diagnosis because of the possibility that it could develop into a uterine cancer. It needs to be treated and in a woman who wants to maintain her fertility potential, is usually treated with depo provera injections for a 6 month period. Rebiopsy is then done to make sure that it is resolved. This diagnosis does NOT require a hysterectomy necessarily. If it is successfully treated with progesterone, that is all that is required. Another possible treatment option is D&C to clear the endometrial tissue. I would not simply ignore it.

At your age, if you want pregnancy and have never been able to achieve it, you should be under the care of an infertility specialist, who is also a gynecologist and should be able to care for both problems. I do not know of any physician in anywhere in the world who can claim an 87% pregnancy rate. If that were indeed true, people would be flocking to see her from all over the world and forsaking us infertility specialists! NO treatment is that good, and such a claim is highly suspicious. I hope you do not waste your time because age is a critical factor for you and your chances are decreasing rapidly.

Good Luck,

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

Comment: Thank you so much for giving me a direct answer. The surgeon I had wouldn't give me a direct answer.You have been very helpful. I have been to the Monash Ivf Clinic but there findings after all the tests were that I have unexplained infertility, which is very frustrating, That is why I thought I would try a natropath. But I still have my fingers crossed that one day I will have a baby. Thank you again.

Friday, September 24, 2010

"Ask The Fertility Specialist About PCOS & Your Fertility" on PCOS Challenge BlogTalk Radio Show

I will be interviewed by Sasha Ottey next week on her hour-long internet radio show and I cordially invite you to tune in to what will be an interesting discussion on PCOS and how it affects women who are trying to conceive. To quote the show's host, Sasha Ottey: "It is estimated that more than 1 in 10 women are afflicted with Polycystic Ovarian Syndrome (PCOS), yet most people are uninformed about it and have no idea that such a condition exists. Women with PCOS experience a combination of symptoms that can lead to serious conditions such as heart disease, diabetes, and infertility. In fact, PCOS is a leading cause of infertility in women." Ms. Ottey is the founder of PCOS Challenge, with a very popular website as well as a television series on PCOS that will be airing this fall. has a wealth of information as well as forums for support...well worth visiting!

The show will air on Wednesday, September 29th at 3 pm PST, 6pm EST on . You can access the internet radio show's main page by clicking here: PCOS Challenge's main page . You can sign up to attend, send in your questions or simply call in when the show is in progress with any questions you may have and I will try to answer them!

Looking forward to hearing from some of you!

Edward J. Ramirez, MD

Thursday, September 23, 2010

200 Blog Posts!!!! All About Infertility & Women's Health Issues...With More To Come!

Well, with the last post I have made it to two hundred blog posts since I began in 2008! I have to admit, I started out rather slow but picked up speed when I fell into the format that I now use. Although I have posted overviews on subjects ranging from PCOS to what to expect from an Infertility Evaluation, I've found that the most popular blog posts involve trying to put a patient's mind at ease. By posting mainly questions that I receive from women and men across the country and around the world, I feel that I can address some of the most pressing and prevalent issues in reproductive health. It has been a pleasure interacting with many of you out there through your comments as well!

Smiley Face My blog followers now number over 300 and there are a number of you that burn our feed as well...which definitely encourages me to keep going! Thank you for your interest & loyalty!

As I did back when I reached my 100th post, I would like to list the ten most popular blog posts to date (a statistic available from the StatCounter app):

1. "Bleeding After Embryo Transfer"

2. "The Difference Between PCOD and PCOS, Fear of Birth Control Protocol"

3. "Off Depo Provera But Still No Period, What's Wrong?"

4. "30 Year Old With Very High FSH Levels Getting Poor Advice From Her Doctor: Has Ovarian Resistance & Possible Future POF"

5. "IVF Implantation Failure"

6. "Post IVF Transfer Pain: Implantation Pain Or Ectopic?"

7. "What FET Protocol Do You Use For Difficult PCOS Patients? UK Patient Asks

8. "Three Miscarriages And HSG Shows Blocked Tubes"

9. "Estrogen Patches Vs. Estrogen Injections: Which Is Better For Pregnancy Success?"

10. "Clomid Protocol Not Working"

It also always amazes me to see where my visitors come from! This reveals, most of all, how the subject of infertility can span cultures and continents. I have many, many great readers from the United States, Canada & the U.K....but we get occasional visitors from some interesting places including most recently:

Jülich, Germany
Surabaya, Indonesia
Camberwell, Australia
Osaka, Japan
Hanzinelle, Belgium
Hyderabad, India
Doha, Qatar
Kampala, Uganda
Tronheim, Norway
Kuala Lumpur, Malaysia

It is always my personal pleasure and privilege to assist my readers in whatever way I can, given the limits of the written word and the distance from which you communicate. I am always available to give general responses via this blog and's All Experts Site. Please keep in mind, though, that the information provided in this blog is not meant to be a medical opinion about your specific case. The problems of every patient are unique and should be addressed by their physician in a face-to-face conversation and thorough work-up. You are welcome to bring up questions about my postings with your doctor. However, no one should assume that this blog is a source of medical care. I believe that reading it might offer some insights into medicine that might not otherwise be available in the general media.

Best and warmest regards,

Edward J. Ramirez, MD, FACOG
Monterey Bay IVF
Monterey, CA

Monday, September 20, 2010

High Prolactin Levels Can Interfere With A Successful IVF Cycle



I'm 28 years old and had the first cycle of ICSI done a month ago. The reason for ICSI was that my husband has a very low sperm count and motility. My test date was 26th August and I started bleeding on the 24th of Aug. I went for a beta hcg which was 4.73.

I had a high prolactin level (35) for which I was given Dopergin (Bromocriptine) until Embryo transfer which was on the 12th of Aug. I was not told to continue it and I was stupid enough not to ask about it. I had 3 Grade A embroys transferred but there was no implantation. I had my prolactin test done on the 25th of Aug and it was 48.

My question is, could the high prolactin have been a reason for implantation failure? I'm not trying to play a blaming game but I need to know if this could've been avoided particulary as have nine day 2 frozen embryos and I plan on going for FET after my next cycle in September.

Thank you. A. from Spain


Hello A. from Spain,

It is our protocol in the U.S. to check all the hormones prior to starting any infertility treatment cycle. This is so that we can eliminate anything that might interfere with the success of the IVF cycle. Of course, we check other things as well, and thus, have the highest pregnancy rates in the world. Traditionally, prolactin levels were measured in ng/ml, and normal prolactin levels in women are less than 20 ng/ml. (The new units now are pmol/l and to convert you need to multiply by 44. This means a normal level is less than 700 pmol/l.)

Since your prolactin was found to be elevated prior to the IVF cycle, and 35 is not very elevated, you were been placed on the Bromocriptine ahead of time in order to get the level back to normal prior to starting the cycle. There is no question that an elevated prolactin level can interfere with fertility.

My recommendation would be to get your level back to normal prior to your FET cycle!


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

Sunday, September 19, 2010

Canadian Wonders If Progesterone Is Needed for Clomid & IUI Cycles: YES!


I am trying to conceive and I have had 3 rounds of Clomid (100mg) by itself with no success. I have also now done round 4 with IUI. With the IUI cycle, my doctor told me to take 100mg Progesterone 2xday, intervaginally, and 2mg of estrace 2xday. My question is this...should I have been given Progesterone with the first 3x of Clomid?

I have heard Clomid lowers the progesterone levels and mine was only 7 to start with. I have also had a history of lots of ovarian cysts which has been explained to me as one of the possible reasons I haven't conceived again...because cysts indicate being estrogen dominant.

With this in mind, I have looked up estrace and it is contraindicated in now I am confused. Why am I being prescribed a med that is contraindicated in pregnancy, when that is what I am trying to achieve, and why if I am already high in estrogen?

I am confused and wonder if I should only be taking the Progesterone....Help! A. from Canada


Hello A. from Canada,

Practically ALL medications state that they are contraindicated in pregnancy (for legal issues). In actuality, if you read all the fine print, it says to consult your doctor. Both estrogen and progesterone are required for pregnancy to occur. The estrogen is required to prime the endometrium for implantation and the progesterone both converts the endometrium for implantation and supports the pregnancy. They are both used in fertility treatments, and have been for many many years. No problems so far! So, you don't need to worry about using them.

However, I am not sure that you need the estrogen supplementation, especially in the luteal phase (after ovulation). It is usually required in the proliferative (endometrial proliferation in preparation for implantation) phase. The progesterone is required in the luteal phase (after ovulation).

I use progesterone, but not necessarily estrogen, in ALL my Clomid cycles. Clomid is an estrogen receptor blocker and so extra estrogen might be require in the first half of the cycle to make sure that a proper endometrial lining is developed, but that is not always the case. On the other hand, often Clomid with cause a lack of progesterone production, and progesterone is such a benign and easy supplement to use that I don't risk not having enough.

From what you have briefly described, I am not sure that you are in the best hands for this treatment. I know Canada limits the availability of specialists, but you might want to see a fertility specialist. I would recommend that you look up my blog, under "how I do Clomid cycles" and it will describe my recommendations for a proper Clomid induction cycle with or without insemination.

Good Luck and stay informed!

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

Saturday, September 18, 2010

Excercise Induced Amenorrhea Leads To Poor Health & Infertility

QUESTION: I have been over exercising for about 10 years now. I get my period fine on birth control pills but when off birth control, I do not get it. I have been off it now for 6 months because the pills are expensive. Is this harmless not to get my period because of over exercising? I got a scan back in June and my gyno ruled out polycystic ovarian disorder. Since I know it's from the exercising and don't want to cut back, could this cause a problem with my fertility? What if I wanted to get pregnant right now? Would that even be possible? Thank you. N. from the U.S.


Hello N. from the U.S.,

If in fact the reason why you are not getting a period is because you have "exercise induced amenorrhea", that is the result of a dysfunction of the hypothalamus. It is detrimental to your health because, you are not forming the hormones that your body needs. The purpose of the birth control pill was not mainly to have a period, it is not needed in a person who is not making a uterine lining, but the birth control pill gives you the essential hormone estrogen. In addition, the hypothalamus is important for production of other hormones as well including thyroid hormone.

In terms of your fertility, your ovaries will be shut down so that you will have difficulty getting pregnant unless you decrease your exercising so that you have normal ovarian function (have natural periods) or you use fertility medications to replace the hormones the hypothalamus is not producing, to stimulate the ovaries to ovulate.

So, I know that you are an exercise junkie, but keep in mind that instead of making you more healthy, it may actually be more detrimental to your health in many ways, including achieving pregnancy.

Follow-up Question:

You mentioned the hypothalamus being important for the production of hormones including the thyroid, well I have an underactive thyroid and have been taking Levoxyl for at least 5 years now. Is this giving me the hormones I need? Also, I explained not getting my period to my OBGYN and after a scan of my area, he told me nothing was wrong. Why do you think he would say that when he knows of my period problems?

Follow-Up Answer:

Hi Again,

Adequate levels of thyroid hormone is measured by a blood test. We usually use TSH. If your thyroid replacement is adequate, the TSH levels should be in the normal range.

A vaginal ultrasound is only for anatomical abnormalities. It can see the ovaries and uterus, but cannot diagnose ovulation or hormonal problems. That is done by other testing as mentioned previously. If your doc only checks you out by doing an ultrasound, he is inadequately evaluating you for menstrual problems. Most menstrual problems are caused by hormonal problems, as mentioned previously. At least by the ultrasound you know that your ovaries, tubes and uterus are normal, but you don't know anything more than that. So from that point of view, anatomically nothing is wrong, but that is only anatomically. I would suggest you find a better doctor!

Good Luck,

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

Thursday, September 16, 2010

Woman With Hypogonadotropic Hypogonadism Needs FSH, LH and Hormones To Get Pregnant With IUI


Dear Sir, I have hypogonadotropic hypogonadism. I am trying to get pregnant and did IUI twice, but did not succeed. I was injected with GMH 150. I had to take around 26 injection to develop my follicles and then had to be injected with HCG for ovulation. My E2 level was 2250 and 4 big follicle. After IUI my doctor gave me only progestrone support. My question is that " is there no need of any other hormone medication as my body don't produce any hormone"? After fertilization can egg produce enough hormone which need for proper implantation. Can taking so many injections for stimulating the ovary affect the ovary or uterus in future? M. from India


Hello M. from India,

In order to get you pregnant, you need to take supplemental FSH and LH (such a Menopur) and then when the follicle is appropriate size (18-22 mms), HCG is given to trigger ovulation. Progesterone supplementation is then started 3-4 days after the HCG to support implantation. You also have to consider that since this is a "natural" treatment, and most normal women don't get pregnant immediately when they begin trying for pregnancy (it usually takes 8-12 months of trying), this treatment is just making you into a normal ovulatory woman and so it may take several tries as well.

Finally, you have to make sure that you are taking thyroid hormone and adrenal hormone (cortisol), as well so that all your hormones are normal. If you don't, that could affect your ability to become pregnant. It sounds like your doc is doing the proper thing so you should trust in him/her, and ask him/her the same question.

Follow-Up Question:

Hello Dr., Good news. After HMG therapy and IUI, now I'm pregnant. 3rd month is going on, right now I am taking progestrone support only. I want to know in future will breast milk produce naturally or I have to take any hormone replacement for that. Will my baby affect because of my diseases? Thank you!

Follow-Up Answer:

Hello Again,

The pregnancy takes over hormone production, so you should not have problems producing breast milk. Your disease should not affect your baby unless it is due to some sort of congenital/genetic disease that is passed to your child.


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

Sunday, September 12, 2010

Woman With Chronic BV Asks: "Will Simply Taking Birth Control Pills, Then Going Off, Cure My Infertility?"


Hello. My partner and I have been together for 3 years and have not been able to conceive. He has a daughter from another relationship. We are pretty sure I'm the problem. I was told by a gyno that with some people to treat infertility they are put on the pill and taken off and then they see if they can get pregnant. Is this true? If so how long should I go on the pill. Also I have chronic bv (bacterial vaginosis) could this contribute to infertility?

I was on birth control 5 years ago... I've taken the pill patch and nuva ring. Since I got off we haven't used protection ever and have never gotten pregnant. I have pretty regular periods. They are off no more then 3 days at the most.

Thank you! R. from the U.S.


Hello R. from the U.S.,

The answer to your first question is absolutely NO. That is a wives tale propagated by Gynecologists that don't know better.

Regarding the BV: Chronic vaginal infections can certainly kill the sperm, thereby preventing pregnancy. When you have Bacterial Vaginosis, there are changes to the acid environment of your vagina. Many factors can contribute to BV including: use of highly scented soaps, douches and bubble baths; use of an IUD or the coil; or because of certain types of sexual acts. It can also happen when the pH level of the vagina alters during the menstrual cycle. But it can also happen without any of these factors in place. It is, after all, the most common form of odorless bacterial discharge.

Bacterial Vaginosis is easily treated with antibiotics, like metronidazole or clindamycin. Women who are trying to become pregnant should be treated with an oral antibiotic. In fact, the Center for Disease Control recommends that all women receive some form of treatment for the condition because there is some evidence that chronic bacterial vaginosis could lead to pelvic inflammatory disease. With chronic, unresolved BV, the solution would be to do intrauterine insemination (IUI), to bypass the bacteria.

My recommendation is to see a fertility specialist. You are at the point where you need to undergo an infertility evaluation and your Gyno is not going to be able to help. Since your partner has had children before, you could assume that he is fertile, but you never know. Things change with time. Also, you don't seem to have any obvious reason, other than the BV, as to why you are not getting pregnant so the only way to find out what the problem is, is to have an evaluation. Once this is done and the problem(s) found, an appropriate treatment can be provided for you to achieve pregnancy.

Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

Saturday, September 11, 2010

"What FET Protocol Do You Use For Difficult PCOS Patients?" UK Patient Asks

Dear Dr Ramirez,

Firstly, thank you so much in advance for taking the time to read my question.

Brief History: Dx with PCOS at 17 y/o. HSG clear. My husband has severe m/f, so our only chance of conceiving is through IVF with ICSI. On my fresh cycle in 2008, I had 30 eggs retrieved and due to OHSS, couldn't have an Embryo Transfer. We had 13 embryos, all of which were frozen at the 2PN stage. I have gone through six FET cycles since, but only got to transfer three times, b/c the drugs used to suppress my ovaries (ProstapSR, Buserelin, Synarel) have actually stimulated my ovaries, leading to OHSS a further three times!

My treatment is in the UK and I cannot switch clinics b/c a) my treatment is free and b) since it's free I can't choose where to have my IVF/FET's. The Drs at my clinic have put their heads together to try to come up with an individualized protocol for me, since I keep suffering these rare responses to the suppression meds. I am naturally frightened and sceptical about this new protocol since it hasn't been tried and tested in the UK as yet (but apparently it has in other countries with good success for challenging PCOS patients).

The new protocol would not involve the usual suppression medications. On day 3 of my period, I would inject a long acting Cetrotide shot (sub-q) and also commence 6mg Progynova (estradiol valerate). On Day 5, I would commence daily Cetrotide shots, whilst continuing daily with the Progynova. All in all, this protocol should only take around 13days, then I would commence Progesterone, 3-4days before Embryo Transfer. I am terrified of hyperstimulating again. Is this likely to happen with the Cetrotide at all? Have you had any PCOS patients who have ever responded like I have to suppression medications?

If you were my Dr (I wish you were :D ), what protocol would you suggest for a FET? It may be helpful to add that I have always been a slim PCOSer (BMI 21) and have an AMH of 98.5. I also got pg on our first FET with twins, which I sadly miscarried at 8 weeks. My subsequent two transfers resulted in a negative beta. Thank you so much for reading and for any input you may be able to give! G. from the U.K.


Hello G. from the U.K.,

I have never heard of such as thing as OHSS with an FET cycle. I'll have to do some research on that and see if that actually happens. If not, your docs might want to write your case up as an unusual case. Since you have been using GnRH "agonists (stimulators)" in your previous cycles, it sounds like maybe the dosages were not high enough to suppress the hypothalamus (which is what they are supposed to do and prevent ovarian function), but instead stimulated FSH production and ovarian stimulation leading to the OHSS.

I think the change to an "antagonist" is certainly the best way to go. I converted to using the antagonist, Cetrotide and now Ganerelix, over 5 years ago (mainly because it is less injections). I have not used it with an FET cycle (because it is more expensive), but it can work just as well with the protocol you have outlined. The antagonist will definitely suppress any ovarian function, so you should not be able to mount an OHSS response. This is definitely a good plan.

I thank you for the compliment :) and wish that you could be my patient as well. For many reasons, such as the fact that some like you can get IVF for free where they live, patients feel that they are stuck in the clinic near their home. This cannot be further from the truth. I have a patient from Serbia and South Korea in my IVF cycle this month. I have patients come from out-of-state, one from as far as Montana, which is like the difference between the UK and Poland. You can travel to the best center to do your IVF, thereby saving you years of frustration & grief. I had one patient who failed five times at a Los Angeles center only to succeed the first time with us. It is not that difficult to do or arrange IVF afar. There are additional costs involved, which is the biggest factor, but heck, you could plan a vacation at the same time. The IF community calls this "Reproductive Tourism" or "Cross-Border IVF", I believe.

An IVF cycle can be done so that you only have to come here for the minimum necessary time, which for an FET cycle would be 1 week or less or 10 days for a fresh cycle. Also, remember the old adage, "you get what you pay for." Free cycles are all well and good, but as you mentioned above, you are stuck with one center, one protocol, one embryology lab (and there quality can differ greatly), governmental restrictions and that is unfortunate. In the U.S., particularly in California, we have few restrictions and can do embryo donation, donor egg, donor sperm, frozen eggs, surrogacy, and are given leeway on the number of embryos we can implant. I wish that I could just outfit a 747 jet with an IVF clinic and jet all over the world where patients want to see me. I think that would be fun as well :D !!!

Good Luck,

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

Friday, September 10, 2010

Possible PCO Patient Adjusting IVF Antagonist Protocol For Fear Of OHSS: Decrease Gonal-F Dosage?


I am about to start my first IVF protocol (today is CD2). I am concerned about the recombinant FSH dosage prescribed and would like your opinion regarding appropriate dosage. I believe I am at higher risk for OHSS for several reasons (described below), however my recent ultrasounds are not showing definitive signs of PCO. Here is the protocol prescribed by my doc:

No pre-cycle BCPs (they make me very ill)
CD2: gonal-f 225
CD3: gonal-f 225
CD4: gonal-f 150
CD5: gonal-f 150
ultrasound on day 6
addition dosing determined following this ultrasound
Gonarilex to prevent premature ovulation

I called the doctor today because I was nervous about taking the first two days of 225IU gonal because of the risk of OHSS. After very little discussion, he switched me to 150IU for 4 days.

The difference between 225 and 150 is a big change. I wonder if I will get good results with a dosage that is this low. What is your opinion? I feel like there might be some sort of middle ground that is more appropriate? I would appreciate any thoughts. I would like to get the "best" results without complications of OHSS.

I believe I am at higher risk for OHSS than the normal woman for many reasons:

1) my ultrasound yesterday (on CD1) shows 9 follicles on right and 16 on left
2) I responded well to low doses of gonadotropins (6 IUI cycles some with letrozol/femera at 5mg/day?, others with clomid at 25mg/day all cycles gave 3-5 mature follicles on CD12),
3)I am petite (5'2", 100 lb.s)
4) in 2006 a doctor told me I had PCOS based on ultrasound results, a history of severe PMS, and moderate acne(two additional doctors I consulted with gave no diagnosis - I am not hairy or pear-shaped)
5) cancelled IUI due to elevated estrogen associated with a small complex cyst on cd2 (and another very uncomfotable IUI cycle when a different OBGYN proceeded with an IUI when I had a cyst at the start of my cycle).
6) grandma had type 2 diabetes
7)early male baldness runs in my family.


Hello J. from the U.S.,

First of all, I have to caution you about trying to second guess your doctor. Sometimes that may not be good. I would presume that your doctor had a logical reason for selecting your protocol.

You were originally scheduled to be on a 3 down protocol (75IU x 3 for two days then decrease). That is a standard protocol and is on the low side. Because of your concern, your doc decreased you to 150IU and will make adjustments based on the response. The only down side to the lower protocol is that you may not recruit as many follicles as the higher dose, but there is no way to know this when it is the very first cycle. In most cases we determine the protocol based on an educated guess. The adjustment at CD#6 is still early enough to increase the dosage and recruit more follicles if necessary, and if you are indeed a PCO, then you will already have an increased number of follicles and the decreased dosage will be safer for you.

I am glad to see that your doc is using the "antagonist" protocol with ganerelix. I am a firm believer in this medication and its ability to decrease the risks of OHSS. With the antagonist, instead of using HCG to trigger ovulation, Lupron can be used to trigger and because of its shorter half-life, the risk of OHSS is dramatically reduced. This is the protocol I use with my PCOD patients to reduce their risk, in addition to careful monitoring, lowered FSH dosage, Drifting (if necessary) and Coasting (if necessary). My goal is to keep the Estradiol level less than 4000 at the time of trigger. With this protocol, I have had no incidence of OHSS in my center for the past 5 years. Most the reasons that you gave for being PCOD are not valid criteria, but my concern would be the same as yours based on the high number of antral follicles seen on ultrasound. I treat patients as a PCO patient if they have PCO-appearing ovaries even if they don't meet the strict criteria for PCO. And, I find that they do stimulate like a PCO ie have a high number of follicles (>25).

In your case, I think that being safe is better than being sorry and the lower dose is probably the way to go. I call your new protocol a 2up protocol and it is a standard protocol that I use with my PCO patients. I check estradiols at CD#5, however, and adjust from there.

Good Luck,

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

Monterey, California, U.S.A.

Tuesday, September 7, 2010

Positive Beta But I Missed Dose Of Prometrium, Now Spotting: Am I Miscarrying?

Hello Dr. Ramirez,

I am on prometrium 200mg/1morning and 2evening. I forgot evening dose on my 12th dpo. Experienced spotting and pencil line blood in mucus next 3 days. Since I forgot to take the prometruim could I be miscarrying? Today it's 16dpo and my beta came back + but at 77. Thanks! M. from the U.S.A.


Hello M. from the U.S.,

It is unlikely that this missed dose would cause you to miscarry. Remember, the progesterone you are taking (prometrium) is a supplement and not the only source of progesterone. Your ovary, or follicle that you ovulated from, becomes a corpus luteum cyst and is the natural source of progesterone to support implantation and an early pregnancy. Once the placental develops, it takes over the production of progesterone.

The number for your first bHCG is fine. It should double approximately every other day (48 hrs) and the trend gives a good indication of how the pregnancy is progressing until an ultrasound can be done at 6 weeks gestational age. The actual amount of rise of the bHCG is at least 80% so if it doesn't double completely, don't be worried as long as it is going up.

Good Luck and don't worry too much,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
Comment: Thank you so much for the information! I appreciate the advice. I am actually moving to santa clara county and will see if it is feasible to use Dr. Ramirez as my physician!

Sunday, September 5, 2010

The Fertility Chase: PCOS - Polycystic Ovarian Syndrome and Fertility

Back in May 2010, we were privileged to make a movie with The Fertility Chase which aired on the We Network. This short, 7 minute movie is an intimate look at how PCOS, polycystic ovarian syndrome, has affected two women who happen to be patients of our center. They frankly discuss their frustrations and pain over their struggle with infertility. We are grateful to them for having the courage to step forward to talk about this distressing syndrome with the hope of letting others know that they are not alone and that there is hope. In addition, you will have the opportunity to meet me! Perhaps my brief overview of this syndrome will clear up some misconceptions and pave the way for those of you who are struggling with this disorder to begin to formulate a treatment path that will aid in bringing resolution to your problem.

One moving quote from the movie by our patient, Brandi: "...Being a family doesn't mean you have to have children. You're a family when you're a daughter, you're a family when you're a wife, and you don't have to have children to be a family. It's been comforting to know that, hey, I'm not the only one..."

September is PCOS Awareness Month. Other worthwhile sites to look at for more information include: PCOS Challenge, founded by Sasha Ottey ( and the PCOS Association, founded by Christine DeZarn (


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