Monday, May 30, 2011

UAE Patient Tested For Infertility: Clomid or Tamoxifen?


Hi Doctor,

This is S. from UAE. I would like to have your expert opinion in my case. My infertility workup showed multiple cysts in both ovaries but my hormonal work up was all within range. In addition, I have never missed a period ever in life, my cycles are pretty regular. In spite of this, my gynecologist started a Clomid induction cycle with me and monitored me. I was given Clomid in consecutive months. After reading your blog post about Clomid, I came to a conclusion that my doctor isn't doing right in giving me Clomid, and also, giving it consecutively. I switched doctors, only to recieve Tamoxifen in the subsequent cycle. I am worried. Do I need any kind of ovulation induction at all? Considering my cycles are regular and I had a normal LH/FSH ratio. Can Tamoxifen be followed immediately after Clomid?


Dear Saman from the U.A.E.,

Glad to see that my blog has been helpful to you all the way in United Arab Emirates! Clomid is not indicated if you are ovulating on your own, but many many doctors use it to boost ovulation thinking that it is a "miracle" fertility drug. If you have been unable to become pregnant, and have had regular cycles, then there is something else, besides ovulation, that is causing the problem. That needs to be found. I am always skeptical when patients tell me "all my fertility tests were normal" without telling me what tests were done. That is because in most of these cases, all the fertility tests were not done, and therefore, the problem has not yet been found.

Tamoxifen has the same mechanism of action as Clomid, namely, it is an estrogen receptor blocker. Your new doctor obviously does not understand these medications. Just like I would not recommend taking Clomid in consecutive cycles because of the estrogen receptor blockage, I would not do that with ANY estrogen receptor blockers, except maybe Femara since it has less effect on the endometrial estrogen receptors. So I alternate cycles with Clomid and Femara. However, again, your new doctor is doing the same mistake and not treating anything specific. He/She needs to find out what the problem is! Ovulation induction is not the answer.


Dear Dr, Thanks a whole lot for your response. It means a lot to me!I need one final querry answered. I have had the following tests:

FSH, LH, TSH, Prolactin, HSG, Fasting Insulin, Testosterone, DHEA Sulphate

All these tests and HSG have come out normal, and HSG shows Bilateral peritoneal spillage. Husband's semen analysis shows 58million/ml and 70% motility. In addition, I have never had any surgery and menstruate regularly every 28days. As I told u before, Clomid induction was done in 2 cycles which just resulted in a single ovum ripening, and was thus abandoned.

I have been adviced to have IUI. Should I go ahead with it? Because I have not had laproscopy, hysteroscopy or endometrial biopsy yet, and there might be reasons for infertility hidden there.....Isn't it better to go straight to IVF? Thank you!


Hello again,

Indeed, based on the tests you have cited we know the following:

1. Your hypothalamic-ovarian pathway is normal (i.e. the ovary is being stimulated properly)
2. Your thyroid, testosterone and adrenal functions are normal.
3. Your fallopian tubes are open.
4. The sperm is normal and has the ability to get to the tube in order to fertilize your egg.

What we don't know is:

1. Is the uterine cavity normal (endometrial cavity) (hysteroscopy)
2. Is the peritoneum normal (where the egg goes through after ovulation) or is there scar tissue or endometriosis (laparoscopy)
3. Are you forming an adequate endometrial lining (endometrial biopsy).

If you wanted to pursue a natural method of getting pregnant (intercourse or IUI), then you will need to do these tests. If you would rather go directly to IVF (which bypasses almost all the steps), then the laparoscopy and endometrial biopsy are not necessary. The hysteroscopy is still needed. Some of my patients do choose to go directly to IVF because it gives you the highest chances of pregnancy. For example, the highest chance of pregnancy with each IUI cycle is 24% (under 35 year old patients), whereas IVF is 76% (at least in my clinic). So ultimately that is your decision. If you want to do things conservatively, that is, be as natural as possible, then IUI would be a reasonable step (it also costs less).

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

Comment: Dr Ramirez's responses are ALWAYS accurate, and prompt....I can't thank him enough for the help he has given this way....IVF at his clinic is definitely on my cards, but hoping I wont need it though :)

Tuesday, May 24, 2011

Clomid Protocol In Depth: Dosage, Specific Indications & Period Of Use

Hello Doctor,

Your willingness to answer fertility questions is admirable. Let me say, "Thank you!"

I've been trying to find specific information on your blog regarding clomid protocol and I simply cannot find what I'm looking for. I do find questions and answers regarding clomid, but not specific information on how and when to use it, for how many months etc. Do you have a specific link perhaps? Thank you again, J. in the USA


Hello J. from California,

Actually the answers to those questions are in the blog but are within the body of the answers. I don't think I have one entire blog post that goes over the specific indications or period of use. You can look at my website for more information as well: "Ovulation Induction".

I will endeavour to explain as much as I can here:

Clomid is one of many medications that are used to induce ovulation. In most cases it is used for patients that have an ovulation disorder, i.e. don't ovulate spontaneously or have a hormonal imbalance leading due to an ovulation disorder. Clomid is an estrogen that blocks the estrogen receptor and induces the brain to increase the FSh output thereby stimulating the ovaries harder. Some doctors will also use Clomid, and other fertility medications, to "superovulate" the ovaries. That is to increase the number of eggs that the ovaries give off so that the chances that an egg with reach, enter and get fertilized will be increased. Unfortunately, many doctors use this as their "magic pill approach" to infertility and will prescribe it without doing an infertility evaluation or determining whether or not it is indicated.

In my blog, I go over how the Clomid is given and how I recommend doing a Clomid ovulation induction. But as a basic method, Clomid can be given in doses ranging from 50mg per day to 250mg per day (1-5 tablets). It is taken orally once per day for a five day period. Most Physicians will give it between cycle day #3-7, 4-8 or 5-9, with cycle day #1 being the first day of the period. It should be taken at approximately the same time of day each day but the specific time is not critical. Most textbooks will state that you should start with the lowest dose of Clomid and increase the dosage in 50mg increments per month if the patient does not respond to that dose. Many doctors blunder by increasing the dosage anyway if the patient does not get pregnant in that month, thinking that a higher dose increases the chances of fertility. That is not true! It only risks increasing the number of eggs that the patient ovulates and therefore the higher chances of a multiple pregnancy.

In essence the lowest ovulatory dosage should be used, so that if a patient responds to 50 mg with ovulation, then you stay at that dose. If ovulation does not occur, then it is increased by 50 mg. I don't quite follow this method because as you can see, if the patient does not respond to dosages less than 250mg, then you have wasted four months finding that out. Instead, my experience has shown me that it is better to be more aggressive and quicker in finding the dose that the patient responds to or to know whether she will respond at all. For example, the most common patients that require ovulation induction are PCO patients. I don't start at 50 mg. Rather, I start at 150mg then proceed to 250 mg if they don't respond. If they don't respond to 250mg, then I know that we have to move to stronger meds. This is because most PCO patients will require high dose Clomid or will not respond to Clomid so I want to find out as soon as possible. In a patient being superovulated, you have to use doses lower than 150mg because these patients are already ovulating. I use superovulation mainly in older ovulatory patients (over 35 years old) because I know that one problem they are facing is an egg quality issue and increasing the number of eggs does in fact increase their chances. I will often strive to get them to ovulate up to 5 eggs per cycle. Finally, I don't recommend more than 6 ovulatory cycles of Clomid. If you have not achieved pregnancy by then, then there is something else going on and so you have to move to a more aggressive treatment plan.

I hope that this answers your questions.

Good luck,

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

Friday, May 20, 2011

Canadian Needs To Know: Frequent Blood Draws Are NOT Necessary For Clomid Induction Cycle

Hello Dr. Ramirez,

I'm currently undergoing cycle monitoring and my RE has not yet been able to pinpoint a reason for our 18 months of infertility (hubby checked out okay and my initial tests - ultrasounds, blood work, saline hysterosonogram - show no problems other than possibly my age being a factor - 35).

I am on my second month now of ovulation induction cycle monitoring. At the clinic I go to (and it appears any of the ones that I have looked into here), they want to do cycle monitoring every single month regardless of whether it is a medicated or natural cycle. He said after this month, we will likely try something like Clomid to produce more eggs and continue with the cycle monitoring.

I could handle the ultrasounds, but the blood work has become such an issue for me I may not be able to continue with treatment. I have to go on CD3 and then daily starting again on CD10 until I ovulate which usually isn't until CD17-19 and then for a progesterone test 7 days post ovulation.

The problem is I have always had small veins that are difficult to get blood from. I've had several of the technicians try and they often try for more than 10 minutes with multiple pokes. I develop massive bruises so the subsequent tests are even worse. They told me I have almost no surface veins and even when they hit one, sometimes no blood comes out of it. They've tried my hand too which is very painful and the last time I was there, they talked to my RE and then they used my foot which also hurt a lot. One of the technicians today said they may have to move onto my groin or neck (but she laughed so I hope she was joking)! I've tried drinking lots of water as well as soaking my hands and arms in hot water without any success.

I talked to my RE and asked if the daily blood work is absolutely necessary each and every cycle and every visit and he said it is required because they need to closely monitor levels. I asked if I could go for the ultrasounds and monitor my LH surge using urine OPK tests and he said they require the blood work because they need to monitor things other than just LH and blood work is a requirement each day an ultrasound is done.

In your opinion is there any other option than all this blood work? I'm almost having panic attacks each day on the way to the clinic (and I've never had panic attacks before) because it gets worse everyday and I don't know how many more months I can deal with this. I'm concerned about future routine blood work as these daily tests are no doubt making my veins worse. At this point I don't want to tell many people about our fertility issues, but my arms make me look like a drug addict as they are covered in bruises.

I'm D. from Ontario, Canada.Thank you for your input.


Hello D. from Canada,

I have never heard of such a ridiculous thing! Blood work is not required for simple ovulation induction whether by natural ovulation, Clomid ovulation or even low dose Follistim ovulation. The blood work that is done with IVF is done because the ovaries are being stimulated so strong that we need to make sure that overstimulation or hyperstimulation does not occur. It is NOT required for monitoring. The key to ovulation induction is NOT the blood test results but the number and size of the follicles as seen by ultrasound. Ovulation is timed by the size of the follicle NOT the blood test, and a midluteal progesterone is NOT needed if progeterone supplementation is given and/or ovulation is determined by ultrasound (which is a better method than the progesterone anyways).

I think your doctor, and this clinic, is treating you inappropriately and in essence, torturing you. I would strongly recommend that you change clinics immediately. I find this clinic abhorrent! If you review my blog where I discuss how I do ovulation induction, you will see that there is no mention of any blood tests except for a pregnancy test at the end of the cycle!

In terms of why you are not getting pregnant, if you have not had a laparoscopy then I would recommend that you have one. I often find that in patients that don't seem to have an obvious reason for infertility, that is, the basic workup has been normal, that they often have endometriosis in the pelvis. Endometriosis does not have to be symptomatic to cause infertility.

If you can't find a fertility clinic in Canada that will do the ovulation induction without blood tests, then you should come to my clinic in California. At least I can save you from being tortured. Please seek out the appropriate level and standard of care!

Good Luck,

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

Wednesday, May 18, 2011

The Wrong Way To Do A Clomid Induction Cycle


Hi. My Doctor prescribed me provera to induce a period and then clomid to induce ovulation. She told me that monthly I am supposed to take provera from the first of the month through the tenth of the month and then once my period comes i'm supposed to take Clomid from day 5-9.

So here it is, May 13th and it is day two of my cyle which means I will take Clomid May 16th-20th. Am i supposed to automatically take the Provera again on the 1st of June? That just doesn't sound right to me. Please help me understand this. C. from Nevada


Hello C. from the U.S. (Nevada),

You are wiser than your doctor, which means you are seeing the WRONG doctor. She is not correct on the proper method to do a Clomid ovulation induction cycle. I would recommend that you look up my blog and review how I recommend doing Clomid cycles. I think you will be shocked once you compare it to what your doctor prescribed!

First, Clomid cycles should be monitored for three reasons: (1) to see whether you are responding to that dose of Clomid (there are five dosages that can be used). (2) to see how many follicles are developing so that you don't have too many and (3) to determine when ovulation is going to occur so that you can time your intercourse properly.

The "autopilot" method of Clomid ovulation induction is not correct and shows that your doctor has a very limited knowledge of this treatment and infertility in general. I would strongly recommend that you go see a fertility specialist so that you don't waste your time.

Many doctors will use a progesterone supplement with Clomid cycles in order to support implantation and the early pregnancy. Clomid often can induce a luteal phase defect. However, Provera is NOT the drug used because it is a synthetic progesterone. Instead, a natural progesterone like Prometrium is used and a pregnancy test is done at the end of the cycle to determine whether or not your are pregnant so that you can stop the medication and have a period. If there is a luteal phase defect and you stop the progesterone prematurely, that could induce a miscarriage due to inadequate progesterone support. Does that make sense? So you can see why your doctors orders are all wrong.

Good Luck,

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

Saturday, May 14, 2011

The Family Act of 2011 Needs Your Support!

Dear Readers and Followers in the U.S.A.,

I am taking the time this morning to blog about an important piece of legislation for Infertility patients that needs a co-sponsor in the Senate. This legislation was introduced by Senator Gillibrand of New York and proposes a tax credit for those who undergo assisted reproductive treatments. Here is the gist of the legislation and what you can do to help pasted from the Facebook page "The Family Act of 2011" (please visit & like, FB members!):

On May 12, 2011, legislation was introduced into Congress that, if passed, will establish a tax credit to improve access to medical treatment for infertility, which affects millions of people in the United States i. This important legislation could help those who might not otherwise be able to have children, build families of their own through in vitro fertilization (IVF) if indicated as a course of action.

The Family Act of 2011 is the first tax credit introduced in Congress to support those seeking to build a family through medical treatment for infertility. It was introduced to the Senate by Senator Kirsten Gillibrand (D-NY) in an effort to reduce the considerable cost barriers that infertile couples face.

The American Society of Reproductive Medicine (ASRM) lists the average price of one in vitro fertilization (IVF) cycle in the U.S. to be $12,400.i For the majority of patients seeking treatment for infertility, costs for assisted reproductive technology, such as IVF, are paid for-out-of-pocket and not a covered benefit under group or individual health insurance policies. Only 15 states have passed laws requiring that insurance policies cover or offer to cover some level of infertility treatment.

With new U.S. healthcare costs continually rising and new coverage mandates in place as a result of the new healthcare reform law, it is more important than ever to establish tax and economic policies that are supportive of families.

If you would like to contact your Congressman to voice your support of the Family Act, go to

About the Family Act:

Tax payers who have been diagnosed as infertile by a licensed physician and for whom the indicated course of treatment is to undergo IVF treatment would be able to claim a tax credit
Eligible treatments include medical procedures, laboratory procedures, professional charges and other necessary costs when a patient undergoes IVF treatments

The maximum credit amount available to eligible tax payers would be $13,360

The credit would be available to taxpayers that have an adjusted gross income of less than $182,500 and phases out for those whose incomes reach $222,520

There is a 50/50 cost share inherent in the credit so eligible tax payers may claim the credit for up to one half of their expenses

**To quote the Association's website bulletin: "ASRM has endorsed this measure and encourages its members to call their two Senators in Washington to urge that they co-sponsor this legislation. You can locate contact information for your Senators at or connect via the US Capitol switchboard at 202-225-3121."

Thank you very much and let's keep our fingers crossed that this will go through!!!

Edward Ramirez, MD
Monterey Bay IVF

Tuesday, May 10, 2011

Mini-IVF In A Woman Over 40 Years Old


I am from Canada and will turn 42 in a few weeks. I am trying to conceive my second baby after already having a baby boy with a previous IVF cycle. My first cycle for baby number two was unsuccessful. It consisted of Lupron from day 21 then Gonal F and Repronex. This was not successful as they retrieved only 5 eggs from fourteen follicles. All five fertilized but only 1 made it to the 5 day transfer. This cycle my RE has me on Clomid from day 3 to 7 with Gonal F and Menapur starting on day 7. I will be taking Cetrotide at some point. I have tried to find this protocol on the web and couldn't find it anywhere. I will be taking 100 mg of Clomid, 150 Gonal F and 75 Menopur. It seems like these amounts appear to be very low. I am so worried that this protocol does not seem very aggressive. Do you have any experience with this type of protocol for someone with my age?? I assume that egg quality is the issue. My FSH is low after three months of DHEA. Thank you, S. from Canada


Hello S. from Canada,

The protocol you are using is a "mini-IVF" protocol and mainly used to help reduce the cost of medications. It is probably reasonable in a young woman that responds well to stimulation, because the Clomid will be adequate to recruit sufficient follicles, but I think it is not appropriate for you at your age. 

(Readers: Since the writing of this blog post there has been a Yale University study published in April 2012 showing that Mini-IVF is highly overrated and results in lower pregnancy rates as well as take home baby rates. See article "Mini IVF Yields Mini Success" and the study brief  "A case-control pilot study of low-intensity IVF in good-prognosis patients".)

This is a very low protocol. You would be at high risk of having a minimal stimulation and very few follicles. In truth, I can't believe your RE is planning this. Since you didn't give me the amount of medications you used on the first cycle, I can't tell whether you were adequately stimulated or not, but if you were my patient (and keep in mind that protocols vary widely amount doctors and no one protocol is better than another), I would be stimulating you aggressively with a high dosage. Namely 450IU Follistim and 150IU Menopur (or Repronex) in a continuous dosage.

In terms of your previous cycle, you had fourteen follicles and that is a very respectable number. I am worried about the fact that only 5 eggs were retrieved. Without looking at your records, I cannot know for sure, but I am inclined to think that you were probably triggered (with HCG) a little too early. If the eggs within do not have time to begin maturing, they do not release from the follicle wall and don't get retrieved. I expect to have at least a 60% retrieval rate in my clinic, so that would mean that you should have gotten at least 8 eggs retrieved. Since all 5 of your eggs fertilized, that means that they were all mature, which is a good maturity rate. The lack of development was due to the "age factor", which is the decline in egg quality that occurs with age. I would NOT have taken them to blastocyst, as that puts them through an unnecessary extra step, and instead, would have opted to transfer all at D#3. I believe the uterus is a better incubator than the laboratory.

Because of your age, keep in mind that it is going to be harder to become pregnant, but not impossible. Since your ovaries are still responding well, you still have the opportunity to become pregnant with your own eggs. You will just have to be resigned to having to go through several attempts to become successful. The only alternative is donor eggs, and you will always have that option as it takes away your age as a factor.

Follow-up Question:

Thank you so much for your response. As predicted the cycle was a bust. I had four follicles only and at one point they decreased in size (after my Cetrotide shot) I have been told that my lead follicle that reached 1.4 (which is when I was instructed to take my Cetrotide) may of been a cyst that they saw on day three. Anyway, I have a couple of questions about my upcoming cycle. So far I have had two awful cycles when taking Cetrotide. My first cycle before conceiving my son my Estrogen dropped significantly after Cetrotide. Do you think I should do another cycle with Cetrotide or do you think I should go back to Lupron?? Is it possible to just start Lupron the same day as my injections instead of going back to CD21.

I am at a loss as what would be the best plan for me given my age. As far as medication amount, you were accurate that I was on 450 of Lupron and 150 of Repronex. I believe the cycle that I had my son my Lupron was stopped as soon as I started my medication but he doesn't seem to be wanting to do that. Could you please give me advice on what protocol would be best given my age?? Thanks

Follow-up Answer:
Hello Again,
If you are going to use Lupron, then you have to start from CD21 of the preceding cycle. It is called the "long protocol". I would not recommend it in you.

I use the antagonist protocol almost exclusively in my practice. The problem that I see from what you told me is that you started the Cetrotide too early. If you do that, you suppress the follicle growth and get what you saw. The antagonist (Cetrotide or Ganerelix) should only be started when the follicles have reached 16-17 mms. The rule of thumb is that at least 30% of the follicles should be this size. I will sometimes wait until the lead follicle is 18mms if the other follicles are not sufficient enough size. With that, I do see an estradiol drop so I don't pay attention to it much any more. I think it is showing a decrease in activity of the smaller follicles that have been stunted. Using the antagonist is where the art of medicine comes into play because there are no hard and fast rules. It is very dependent on the experience and judgement of your doctor.

As I mentioned previously, if you were my patient, I would use the antagonist Cetrotride, not Lupron,and use the highest protocol of 450IU Follistim and 150IU Menopur continuously (no adjustments).
Good Luck,

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

Wednesday, May 4, 2011

40 Year Old IVF Patient In Vietnam On Low Protocol Fails First Cycle: Has Many Questions, Concerns


Dear Dr. Ramirez,
My name is A. from Vietnam, 40 years old by end of March 2011. Just give you some information about me regarding Infertility/IVF. My menstruation cycles are different every month: 28 days in Feb, 26 days in March and 31 days in April. So, average: 26 days. Period in March was especially longer; maybe it was caused by hormone therapy in March. My FSH on March 6 ( of period) was 10.6mIU/mL and AMH on April 9 was 0.8ng/mL.

I started my first IVF cycle on March 6 2011 (2. day of period) and ended it with 2 embryos transferred on March 22. Unfortunately, it failed. On March 6, I got 1 Decapeptyl 0.1mg. However, I reacted allergic to this and the doctor stopped Decapetyl and gave me 2 days later on March 8: 1x Gonal F 300 i.u. each day and for 8 days until March 15. One day later on March 16, I got Pregnyl at 8.30pm. 2 day later on March 18 at 8.30am, I had my egg retrieval. 6 eggs were collected and 4 were fertilized. On Day 3 after retrieval at 8C stage I had 2xnormal embryos with grade 1, 1x embryo with grade 2 and 1 embryos with Monosomy 21. On day 4, 2 embryos were transferred. My husband semen test result shows 25% normal form (morphology) with total live count of 341 million sp/vol and has anti-sperm antibody. So, I used IVF, ICSI and PGD (for down’s syndrome) in March.

For the next IVF: One clinic suggested to give me on the of my menstruation 1x300 i.u. Gonal-F mornings and 1x 150IU Menopur nights for 4 days first. Based on the follicle count and size in the ovaries, they will decide on further dose. They are likely to follow a step-down protocol. They will not use any drugs like Decapeptyl this time.

Another clinic suggested to give me on the 2nd day of my menstruation 1x300 i.u. Gonal-F for 5 days and will see based on the ultrasound result.

Could you please kindly answer my following questions and tell me what would you do differently?

1. Do I need birth control pills? Why or why not? I think I need it, because my monthly cycles are different. So, with the birth control pills, the embryos will be implanted on time. What do you think?.

2. Which dosage and drugs would you use except for the 2 dosages of 2 clinics?. Which dosage of these 2 clinics does make more sense to you? Which one will give me more eggs with good quality? Last IVF, I just had 6 eggs, 4 fertilized and just 2 healthy embryos transferred at the end. As I know, I need 3 embryos for my age.. Do I need such kind of drugs like Decapeptyl? Why or why not?.

3. On which day would you start the IVF (2. or 3.Day of period)? Why?.

4. Will acupuncture and Chinese herbs support the success of IVF? Or will it be contra productive? If recommended: before or before and during the IVF? I am taking prenatal multi vitamin and 400mcg folic acid. Do the unfreezing eggs have the worse quality compared to fresh eggs?

5. Was the embryos’ transfer late (at the Murola stage) last time? Should it be transferred earlier this time at 8C stage? I will not use PGD this time. Did I have enough eggs (6 eggs last IVF) at my age? Do I need to increase them next time? Does one embryo have 9% success rate for women at 40?

Thank you very much for your time. Best wishes.


Hello A. from Vietnam,

It is interesting for me to see that IVF is being done in Vietnam, proving that this is a procedure that spans the world. Keep in mind that protocols used are highly variable between clinics and doctors. No one protocol is better than another so the recommendations I give are based on my knowledge, experience and preferences.

I always use the birth control pill preceding an IVF cycle. I believe the studies that show better response to stimulation by using the BCP. In addition, it causes the ovaries to essential shut down so that they will be more responsive to the stimulation and so that the follicles will start out somewhat evenly when the stimulation is started.

One thing I noticed about the protocols you have been on is the fact that they are low dose protocols. My highest protocol is a total of 600IU of FSH and I prefer a "mixed" protocol using pure FSH and an FSH/LH mixed compound. The preferred medications I use are Follistim (pure FSH) and Menopur (FSH/LH) in an approximately 2:1 ratio. So, my highest protocol, which is what I would use with you, is Follistim 450IU and Menopur 150IU taken every evening. My highest protocol is a continuous protocol, meaning you stay at the same dose all the way through, but it will really depend on your stimulation. Sometimes, if the patient stimulates more strongly than expected, I will drop the dose but most patients with an elevated FSH like yours (decreased ovarian reserve) will stay at the same dose. I do think that you were understimulated and the number of eggs retrieved and resultant embryos was low. In your age group I would prefer to have 4-6 embryos to transfer.

I cannot comment on the two clinic's protocols specifically, as I mentioned earlier. I can only give you my opinion regarding the protocol that I use.

In my center, I start the IVF cycle on an arbitrary day called "cycle day #2" irregardless of when your period actually starts on that cycle. This is because having used the birth control pill, I am in total control of the cycle and don't have to rely on the natural cycle timing.

I do recommend acupuncture as some studies have shown it to be beneficial with IVF.

I do think that the transfer should have been on D#5 post retrieval if PGS was done (blastocyst) but if PGS is not going to be done, then D#3 is better because I believe the uterus to be a better culture environment that the lab. Frozen embryos tend to have a decreased pregnancy rate, mainly because the best embryos are used to do the fresh transfer and the second best left to freeze. Also, the freeze/thaw have a little effect on the embryos but if done right, this should not be significant.

Finally, pregnancy rates are highly variable between doctors, clinics and countries. I cannot compare them exactly. In my center, your chances of pregnancy per cycle is 70% with 60% continuing. The U.S. does tend to have higher pregnancy rates than most other countries. At 41 years old, this decreases to 47% pregnancy and 29% continuing. Since we batch pregnancy rates into a 38-40 yo category, the rate I gave for 40 years old might be a little higher than it should be.

"Chúc may mắn"....Good luck on your next cycle!

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

Sunday, May 1, 2011

How To Interpret Positive BHCG Levels After IVF: When Will You Know For Sure?


My question is about beta levels, and how to interpret what they indicate.This is my first IVF / first pregnancy, so this is a constant learning process.

1st Beta at 14 dpo (11 days past 3 day transfer) was 158.
2nd Beta at 18 dpo was 704.
3rd Beta at 21 dpo was only 1537.

My beta levels started off doubling, but then slowed considerably.I have an ultrasound upcoming next week, but not sure what to expect at this point. I am feeling very concerned about this change, and not sure if it still falls into normal range or is a valid cause for concern. Should I request a 4th beta? Can an ultrasound at 5 1/2 weeks provide a definitive answer to the viability of a pregnancy?

Thank you so much for your answer! C. from New York


Hello C. from the U.S.,

Absolute values of the bHCG cannot be interpreted (although many people try to). bHCG's are evaluated based on their trend i.e. up/down and double every other day (actually it only needs to increase by 80%). I would caution you on trying to interpret how things are going by your bHCG levels unless they drop precipitously. The ultrasound will give you a better idea of how things are proceeding.

Viability cannot be established at 5-1/2 weeks. It is too early. That ultrasound is mainly to rule out an ectopic (tubal) pregnancy. Viability is established at 7-8 weeks gestational age.

You have a positive pregnancy test, which is a good thing! Now all you can do is wait and see how it progresses.

Good Luck,

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


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