Secondary Infertility With Miscarriage And Possible Luteal Phase Defect: Is Clomid OK?

QUESTION:

Hi Dr. Ramirez. Here I am writing again. I previously emailed you, I had a miscarriage in Feb 2010, at about 7 weeks. I have a 4 year old and a 3 year old, conceived the first month I tried with both. I also got pregnant the first time with the miscarried pregnancy. Since March I have been trying to get pregnant and nothing has happened. I have been getting my period every 25-27 days, and the last 2 months I have been doing BBT charting so I am pretty sure I am ovulating. I had hormonal blood work done in June and another estrodial draw in July and all were within normal range, Although the estrodial was a little low.

I had an HSG procedure last month; normal tubes and uterus. Now we have to have my husband's sperm checked. It has been 8 months now and for the last 6 weeks I have been having acupuncture/taking chinese herbs, to strengthen my uterus and help me relax. I have told you before that my periods are shorter and lighter since the loss, the tend to start and stop and the flow is very limited. My obgyn has now suggested that I start a low dose clomid to see if that will help me.

I have read your blog and I understand that you do not agree with clomid for people that already ovulate on their own. I am wondering if you think I should see a specialist. Also, since I have started charting I have noted that my cycle last month was just 25 days, and from the temp drop indicating ovulation to the start of my next period was only 9 days (luteal phase). This month the luteal phase was 11 days. My obgyn said that the way they would help that would also be through clomid. I thought, from reading your blog that progestorone is only suggested. If I start the clomid, do you think I should also ask for estrogen since my period is so short.

I am trying to relax doctor, but I am worried that I won't be able to get pregnant again. I am 31 years old. My husband is 38. Thanks in advance for your time and advice. J. from the U.S.

ANSWER: Hello Again,

Thank you for following my blog.

I think you misunderstood a little. I don't disagree with ovulating patients using Clomid, I just don't like docs who turn to that immediately in ovulating patients without having done a full infertility evaluation. There certainly is a place and time to use Clomid in ovulating patients, and we call that "super-ovulation". I use this especially is older patients to help them ovulate more than one egg at a time to increase there chances because as a woman ages, more and more of her eggs are debilitated and poor quality. By increasing the number ovulated, you increase the chances of getting a good egg.

In your case, even though you are ovulating, your luteal phase is too short. It is likely that you have a luteal phase defect. Your doctor is correct that Clomid can correct a luteal phase defect, although not always. What it does is correct the ovulatory-hormonal problem that is leading to the LPD. In addition, by getting you to ovulate more than one egg, it increases your chances for a pregnancy with each cycle. But, because it doesn't always correct the LPD, the treatment of choice would be supplemental progesterone such as Crinone, Procheive, Prometrium or Endometrin. You would start that after ovulation.

If you continue to fail to conceive, my recommendation would be to see a fertility specialist, instead of undergoing treatment that is more of a "shotgun" treatment. That way you don't waste too much time. But if you want to try some low dose Clomid with your current doc, that would be okay too. The advantage you have is that you are still young. If the low dose Clomid does not work, or your doc is not doing the cycles correctly, then definitely go see a fertility specialist.

I don't think you need supplemental estrogen.

Follow Up Question (Sometimes Great Things Happen When You Least Expect!):

Hi Dr. Ramirez,

I just wanted to repost and thank you so much for all your help and advice in taking the time to answer my questions over the last several months.Your answers to my questions and that of many others have always been honest, reassuring and optimistic. I never got to take the clomid, I was supposed to start January 2011, but with prescription in hand, I instead bought a HPT and I am now 10 weeks pregnant! So yes, a bit more patience and relaxation helped...9 months after my miscarriage I am pregnant. I saw the heartbeat at 6 weeks 7 days and again at 9 weeks 3 days, so I know we are not in the clear yet but we are headed to 12 weeks!

My OBGYN said that once you see the heartbeat, there's a low chance of loss. I am also taking prometrium (spelling) progesterone by mouth. My levels were good in the beginning, but my doc is just being safe with me. Is around 10 weeks gestation the time you have your patients stop taking them? Just wondering what your protocol was.

Thanks again! Keeping my fingers crossed that everything will go smoothly this time around!

J. from the U.S.

Follow Up Answer:

Hello Again,

Thank you for the kind words and CONGRATULATIONS! Once the pregnancy reaches 8 weeks and the size is appropriate for dates and the heart rate at 120 or higher, the chances of a miscarriage drop to 5% (from 40%). So, you are in a very good position for this pregnancy to keep going.

One thought: Studies have shown that progesterone (prometrium) orally does not help with luteal support. Too much of the chemical is lost in the liver. For that reason it is usually used vaginally. I usually will stop it at exactly 10 weeks gestational age, but some clinics will keep going until 12 weeks. By 10 weeks, the placenta has taken over so it doesn't do much. I think the extra time is for peace of mind.

Good luck with the pregnancy and congratulations 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.

Comment: Excellent source of information from Dr. Ramirez. Highly value his thoughts and advice!

HCG Trigger Shot Must Be Timed With Ultrasound Surveillance NOT With Calendar Dating When Doing IUI

Question:

I am writing from Hawaii with several questions. We will be undergoing our first IUI soon. The background is the following: I am 36 years old with no fertility factors. We decided to seek out fertility help because my husband, also 36, has an ejaculatory issue. I have been using Follistim AQ for the past 10 days and have two more days to go. My doctor instructed me to use my hCg shot at 11pm the night before my IUI. My first question is this, with only a 13 hour window between my hCg shot and IUI is this optimal? I have read that 36 hours is best.

Also, my normal cycle length is 26-27 days, I will be inseminated on day 16, will I still follow my normal cycle and expect to see my period on day 26? Should I ask my specialist for Progesterone supplements? I had 5 decent sized follicles 5 days ago, all between 10 and 12mm. Today during my ultrasound only 2 follicles were visible, one at 14mm and one at 15mm. I have been using a ClearBlue Easy fertility monitor, which said 3 days ago I was reaching peak fertility. Is it possible I already ovulated one or more egg? Thank you so much for your time. My doctor is a good doctor, but very busy and I often don't formulate my questions until after I have left the office. Mahalo! H. from Hawaii

Answer:

Hello H. from Hawaii,

First, let me say that I am a little skeptical of your doctor, based on your questions.

The optimal size for a follicle at ovulation is 18-20 mms. Using Follistim, your cycle should not be timed based on a calendar, but on the growth and size of your folllicles. In addition, at your age, the maximum number of ovulatory follicles should be no more than 3 because of the significant increased risk of a super-multiple if there is more than 3. So, the proper way to do this is daily ultrasound, if necessary, as your follicles reach closer to the 18 mm point. Once the follicle is 18 mm (my personal preference is 20mms), then the HCG shot is given and the IUI is done at 36 hours if only one IUI is done or at 24 and 48 hrs if two are done (My preference is the two IUI protocol).

The times don't have to be exact. The sperm just needs to be there reasonably close to ovulation and precede ovulation. Since it cannot be known exactly when ovulation occurs and it is know that it can take up to 12 hours for the egg to find and enter the tube, exact timing cannot be done. In general, follicles grow at 2mms per day but this can vary as well. That is why close ultrasound surveillance needs to be done as you get closer. If your doctor solely uses a calendar date, such as cycle day #16, there is a possibility of missing ovulation, which essentially dooms this cycle. In any case, based on a 27 day cycle (and counting backwards), you would ovulate at around cycle day #13 not #16.

I ALWAYS supplement with progesterone. It is an easy thing to do and there is no downside risks. If you have inadequate stimulation of progesterone in the luteal phase, you risk non-implantation and/or early miscarriage. I hate to take that chance when I can cover the risk by adding a little progesterone. I have written extensively regarding timing and doing IUI's in my blog. I would recommend you review that material and discuss your concerns with your physician.

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.

Doctor Cancels IVF Cycle Despite Follies Being Present: Can Patient Go On To Do A "Natural" IVF Cycle?

HI-
This is a pretty simple question - started IVF cycle with micro-dose lupron after 10 days on the pill (for the dr.s convenience) Follistem and menopur. I stimmed for 4 days then cancelled due to only having 3 follicles and low E2.

My question is, my period is due soon. Can I jump right in and re-start the process? This go around will be a "natural" cycle. I respond much better when it correlates to my body's natural timing. We have an issue with age and I hate to put it off another whole month.

Thank you! A. From Illinois

Answer:

Hello A. from the U.S.,

First let me say that using the birth control pill is NOT just for the doctor's convenience. After many many years of doing IVF worldwide, it has been shown to help increase the chances of success and helps to control the ovary better. Timing is critical with IVF so it especially helps with timing.

Yes, natural cycle IVF can be done and there are some (a minority) of specialists that think this works better in low responder or older patients. But if that were the thinking then why cancel a cycle? I am not one of those "believers" and I don't cancel cycles. Even if I have only one follicle, there is no way for me to know that that one follicle doesn't have the perfect egg that only comes up once every several months. Why should I waste the opportunity? I have had many pregnancies with only one follicle and one egg.

You certainly can go directly into another cycle using your natural period as the start point. You will need to check with your doctor about that, but physiologically there is not reason to not do that except if a persistent cyst is present. Sometimes, if ovulation has not occurred, you can have a persistent cyst that will cause dysfunctional bleeding and trick you into thinking that you are having a natural period. It just needs to be checked for at the beginning (CD#2) of the cycle.

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.

Alaskan Worried After First Miscarriage: Was The Cause Low Progesterone? No!

Question:

Hello, I am writing to you from a remote community in Alaska,

We have a clinic and Doctors here but, no hospital or specialists, so I am glad to have found your site and hope to receive an answer to my concern. I suffered a miscarriage on Jan 10th at 8 weeks. For the year leading up to my pregnancy I had mid cycle bleeding starting around 7 DPO. I now believe that I bled and lost my pregnancy due to low progesterone.

My MD here in town tested my levels on days 10-12-14 post ovulation and the results were 7.8 - 17.9 - 20. She says these are all normal and I can try again, but everything I see online says the numbers are in fact low and supplements should be started after I ovulate next. I also have been BBT charting and my temp drops to pre ov levels within 2 days of the ovulation spike and stays low. Do you see a low progesterone issue here and would you recommend suppositories? Please respond as I am so confused and somewhat upset that the info I am getting from my Doc. does not match the info on the web. Thank you so very much for taking the time to consider this.

I appreciate it more than you know. S. From Alaska, USA

Answer:

Hello S. from Alaska,

Thank you for writing me with your concerns. Progesterone levels measured at the mid-luteal phase do not make the diagnosis of luteal phase defect. They are mainly used to confirm ovulation. Any level above 10 confirms ovulation if the test is done in the mid-luteal phase (CD#20-22). In order to make a diagnosis of luteal phase defect, an endometrial biopsy would need to be taken at the end of the cycle to check for endometrial dating. This is usually done around CD#26-28 (before your period starts).

Progesterone is such a simple treatment with no side effects and much benefit that I do not see any harm from using it after ovulation. We certainly use it with every type of fertility treatment that we give. There are two that are made specifically for infertility treatment called Crinone and Endometrin. Another one that is used is called Prometrium but is not specifically for infertility use. You would start the supplementation on cycle day #16 and continue until a pregnancy test is done at the end of the month. Do not stop the medication until a pregnancy test is done and do not wait for a period because the progesterone will likely prevent that from occurring. If you are pregnant then you would continue it until you are 10 weeks gestational age.

Now with all that being said, a lack of progesterone is NOT the reason why you miscarried. The placenta takes over progesterone production at the 6th week so a luteal phase defect or lack of progesterone would not cause a miscarriage at that point. It is usually earlier. The most common reason for a miscarriage in the first trimester is a spontaneous chromosomal defect that occurred at the time of embryo division. This led to an abnormal embryo, which the body detected and stopped. It is most likely that you will have a successful pregnancy subsequently.

You have to take the information you find on the web with a very large grain of salt, and don't try to micro-interpret what may or may not have happened or is happening. Since you were able to get pregnant naturally before, you chances of a successful pregnancy are high. We don't worry about recurrent miscarriages until there have been at least three consecutive miscarriages. Keep trying!

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

42 yo U.K. Woman, SWF, Low FSH, Low LH, High TSH, No Periods For 16 Years: What Is Wrong? What Are Her Reproductive Options?

Question:

Dear Doctor, I am a single, white female, aged 42. I have high prolactin and started having no periods at age 26 following cessation of pill. There has been no return of periods despite shrinking of prolactinoma found. Many consultants scratched their heads over the years. I am now using HRT (hormone replacement therapy) to guard against osteoporosis.

I have been told I would just need a little help conceiving, clomide maybe. I went off HRT for 6 months whilst exploring potential IVF (in vitro fertilization) clinics using donor sperm. I looked at adoption but did not proceed as few babies for single white people in the UK. Had ORT (ovarian reserve test) at clinic. FSH at 0.8. e2 under 44. AMH low at 0.83. tsh normal/borderline at 4.36. It was suggested that I get tested for response with gonatrophins, then if follicles appear I can try with donor eggs. Donor eggs and sperm may be a bit too far for me.

Any thoughts? Feels like end of road for me. But as clinic is going to seek advice from endocrinologists, I thought I would start to ask wider. Thank you! J. from the U.K.

Answer:

Hello J.from the U.K.,

There are several problems that you report. Let me take them one at a time.

You mentioned that you hve not had periods since the age of 26 and now your are 42 years old. There must be some explanation for that and the only explanation I can see is that your FSH level is very very low (0.8). I presume the LH (lutenizing hormone) level is similarly low. We call that "hypogonadotrophic hypogonadism". It means that your hypothalamus is dysfunctioning and not producing adequate FSH (follicle stimulating hormone) to stimulate the ovaries to work. The treatment for a woman that wants pregnancy is to give FSH and LH (Menopur or Repronex) to stimulate the ovaries to work. This can be done with a reproductive endocrinologist, not a medical endocrinologist, also known as an infertility subspecialist.

Secondly, I noticed that your TSH (thyroid stimulating hormone) level, albeit is within the normal limits, is higher than we like to see it. In general, and U.S. endocrinologists have now adjusted their tolerances as well, we like to see the TSH at less than 2.2. So your thyroid is functioning but it is a little hypothyroid. A little thryoid replacement hormone (synthroid) would probably help to bring that down.

Thirdly, I presume that your prolactin levels are normal now? If not, then need to be treated to get them down to less than 20.

Now, let's talk about your options to get pregnant assuming all the above findings. The one very significant problem that you have, in addition to those above, is your age. At 42 years old, your natural chances for pregnancy have diminished significantly. For example, a 26 year old would have an 85% chance of pregnancy per year. A 42 year old has a 1% chance of pregnancy per year. Therefore, as a single, white female, you need to think outside the envelope of getting pregnant by natural means i.e. just having intercourse or injecting sperm (IUI). IVF will be the treatment of choice, and the medications used to stimulate your eggs will be FSH and LH so that covers the hypothalamic problem.

You might want to consider a gonadotropin stimulation test (trial of using the meds to see if your ovaries respond), but that is not necessary. If you enter the IVF cycle path and your ovaries don't stimulate, then you just cancel the cycle, so the IVF cycle will be test enough. At 42 years old, in my clinic, your chances of pregnancy would be 44% per cycle. That's significantly better than your natural chances. You certainly have the option of using donor eggs. Because donor eggs are taken from a younger woman, and pregnancy rates are dependent on the age of the eggs, you will have a greater chance of pregnancy no matter what age you are as long as your uterus is normal. That means the chances of pregnancy would be the same at 42 as at 45 years old. So that is a backup option that you will always have. If you wanted the best chances for pregnancy, then donor eggs would give you a 60-79% chance of pregnancy per attempt. In the U.S., we do allow donor egg cycles in single women.

So I hope that gives you some food for thought. I have written more extensively on this subject in my blog so you might want to use the search bar to look up more information.

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.

Canadian TTC Wants To Know When Is The Best Time To Use A Pregnancy Test Kit

Question:

My husband and I are trying to get pregnant with our second baby, I got pregnant very easily with my now three year old son. As of right now I am 8 days post ovulation. I have been using 10 miu pregnancy tests which have all come up negative the last three days.

I have two questions I hope that is okay. My first one is what is the average day for a positive pregnancy test using 10 miu tests? My second question is if I am experiencing ALL of my usual pms symptoms does that mean I am likely not pregnant? Thanks so much! L. from Canada

Answer:

Hello L. from Canada,

You'll have to wait at least 10-14 days to check a home urine pregnancy test. At 8 days post-ovulation (assuming that is when it occurred because there is no way to know for sure), entrance into the uterus is just occurring for the embryo and implantation has not yet occurred. Keep in mind that an ovulation predictor kit does NOT tell you when ovulation occurs but the range of when it will occur. There is no way to know when it occurs exactly.

PMS symptoms are usually due to the increased progesterone levels in the luteal phase and not an indicator of a lack of a pregnancy. You'll just have to wait and see.

Also keep in mind that despite the fact that you got pregnant easily the first time, it takes the average woman 8 months to get pregnant and 85% will achieve pregnancy by one year of trying. So, in fact, you have not tried for a long enough period of time to worry. :)

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: Thanks you so much! I feel much better that you have answered my questions, and I now know I do not need to worry.