Friday, February 25, 2011

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


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
Monterey, California, U.S.A.

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

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