Saturday, December 22, 2012

Sixteen Year Old Does Not Have Her Period Yet: What To Do?

Question: Hi, writing from Califonia!

My name is E. and I am 16 years old, will be 17 on June 9th, 2013. I'm 5'9" and I am overweight, but not terribly obese or anything. I have always been active, and I have been a swimmer since I was 7.

I am wondering if something is wrong with me. I still have not gotten my period. Ever. I just feel so out of place when my friends are all talking about theirs and I just stand there. I don't understand why I haven't gotten it yet. I have pubic hair, I have leg hair, armpit hair, I have breasts, and sometimes I see that my underwear is like a light brown (and it smells weird, but not terrible) but it has never been red.

My Dr. told me that if I don't have it by the time I'm 18 then to come in for some tests.

I just wish so badly that it will have it already. Is there anything I can do? Could this in anyway help the process of it starting?

I heard that drinking lots of green tea can help?

Could it be me being overweight? I am currently in the process of losing weight and I have lost 15lbs so far. I also heard that it might have been because my mom breastfed me for longer? She nursed me until I was 3, not a lot after the first year, she said it was normally just to get me to sleep.

Please help! E. from California.


Hello E. from the U.S.(California,

Since you have secondary sexual characteristics (pubic hair etc.), that means that your ovaries are functioning and producing estrogen. It may just be a matter of time now before the periods start, but it is a little unusual to not have periods by 17 years old. I don't agree with your doctor. This is something you might want to talk to you mother about and urge her to allow you to see a pediatric endocrinologist, adolescent gynecologist or reproductive endocrinologist. These are all specialists with more advanced training in hormones than your regular pediatrician or family practice doctor. A blood test can be done to check your hormones to make sure there is not something amiss. Medicine can also be given to help you start periods, or if your hormones are unbalanced, to help balance them.

Having a hormonal imbalance can cause long term side effects, like facial hair, that is not reversible so I would not recommend doing nothing.

As a side note, don't buy anything on the internet that says it does something medical. Anything that is medically effective has to have FDA approval and then it is sold in a pharmacy or doctor's office. Only non-medical items can be sold via the internet to non-medical people.

Thank you for writing and try to see a specialist soon. 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.

Monday, December 10, 2012

Second IVF Fails Despite Implantation: Thin Lining? Embryo Issue?

Question: Dear Dr. Ramirez,

I am here to seek your advice once again. I just found out my second IVF (in vitro fertilization) attempt finished with a chemical pregnancy. I tested HCG levels at 11dp2dt and it was 19,2 miu/ml (pretty low), and 48h later it was already 4,7 miu/ml.

I am nearly 37yo, have high FSH levels and my antral follicle count was 12 for this past cycle, 8 follicles grew, 6 were collected and 4 eggs retrieved. We got 100% fertilization and we transferred two 8-cell embryos with perfect morphology and no fragmentation.

I think my biggest problem is my endometrium. It is usually very thin. Although I still have 2 frozen embryos from my first IFV, two transfer cycles were cancelled due to thin lining that would never pass 6.9mm. I tried estradiol patches, vaginal estradiol (creme and pills) which resulted in poor endometrial growth (estradiol levels reached 3500pg/ml in one cycle) even after 3 weeks of use. I also tried vaginal viagra, vitamin E, baby aspirin, prednisone, and nothing worked... the endometrium would grow up to 5.5 to 6mm in the first 8-9 days of the cycle and then would take 14-21 days to reach 6.9mm. In one of the cycles it even decreased 1mm in one week.

Before my first IVF I did a hysteroscopy and everything looked fine. I have a couple small intramural fibroids, none projecting into the uterine cavity. I had a big fibroid removed 4 years ago, but it was intramural and the endometrium was not touched during surgery.

So, in my last IVF that turned out as a chemical pregnancy, my endometrium was 7.1mm at the 6th day of stimulation with FSH (Bravelle), which was really encouraging. However, 2.5 days later, it decreased to 6.4mm... Because at that time I already had bid leading follicles, my doctor wanted to triger that night. He then injected into the uterine cavity, using a catheter, 300 ug of filgrastim (G-CSF), since there are two papers from Dr. Gletcher that mention it as a possible treatment for thin lining. My RE explained to me it was experimental and I agreed to try it.

48h latter and on the time of egg retrieval, my endometrium was 7.6mm. Still not ideal, of course, but the best I got in a long time, so my RE advised us to carry on with the transfer (2 beautiful 8-cell embryos).

So my questions are:

1)What is more likely to be the cause of the chemical pregnancy: genetically abnormal embryo or my thin lining?? I know my age is a factor, but I have been taking Coq10 for nearly a year now. My embryos always look good and I have 100% fertilization rate.

2) Also, I wanted to know if it is normal to have a 8-cell embryo at the end of day 2 (I collected the eggs on Mon 9am and the embryos were transferred Wed 6pm).

3) Is it normal for the endometrium decrease during stimulation phase? What could have caused mine to go from 7.1 to 6.4mm in a little over 60h?

3) Do you think I should try filgrastim on my next transfer cycle? I don´t think my body likes synthetic estradiol though, it never responded well... so maybe a natural cycle (in which I usually reach 7mm) with filgrastim could work?

Taking my history into account, what would you recommend for my next FET in order to be suscessful in overcoming thin lining? Should I start to look into surrogacy?

As always, I really appreciate your time and expertise, and most of all the beautiful work you do here at your blog (for which I am a subscriber :)  C. From Brazil

Hello C. from Brazil, Thank you for your kind words and for following my blog! Let me answer your questions in sequence to make it easier.

1. If endometrial thickness were the problem, implantation would not have occurred. Technically, the minimum endometrial thickness required is 6.5 mms so your lining was adequate for implantation to occur, which did happen. The miscarriage was most likely a genetic issue considering your age. Unfortunately, we do not have a technology to evaluate internal egg quality nor change the quality. Keep in mind that the CoQ 10 study was in mice and not humans so we don't know if that will work or not.

2. An 8-cell embryo on D#2 is not normal. That is a rapidly dividing embryo and may indicate that it is genetically abnormal, as has been found on preimplantation genetic studies in the past. Division rate is one of the criteria I use to evaluate embryos, in addition to the external quality.

3. The endometrium does not decrease. The difference in widths are variations in ultrasound measurements. Because we are dealing with mms, the difference between 7.1 and 6.4 (0.6) is within the margin of error and not significant.

4. I cannot comment regarding the "filgrastim" as I am not familiar with this medication or its usage. I would recommend that you consider the frozen embryo transfer in a natural, unmedicated cycle, but I would follow a natural cycle without transfer first to evaluate if your body growth the endometrium to adequate width. Then if it does, I would schedule to make do the transfer in the next cycle. I would still use supplemental hormones after the transfer, namely progesterone to help support implantation and the early pregnancy.

5. If the FET fails, despite everything that has been done, the only other recommendation I could make, if you are still going to try your own eggs, is to have preimplantation genetic screening done (trophectoderm biopsy) on a Day #5 embryo. Some studies have shown increased pregnancy rates in older patients when embryos are screened for normal genetics. That will at least give you an indication on the genetic health of the embryos you are making and whether or not you should consider donor eggs. I would only recommend surrogacy if you are absolutely sure that you cannot get implantation and in your case, you've had implantation. I think it might be more of an embryo issue.

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.

Sunday, December 2, 2012

40 Year Old TTC After Termination Of Trisomy Pregnancy

Hello, Doctor.

I am a 40 YO who has never had any trouble conceiving. I've been pregnant seven times. I had a child when I was 37; all went fine.

My husband and I are TTC (trying to conceive). GYN did an AMU (.86) a year ago. He said there was little hope. Nevertheless, I was pregnant in January, but the CVS @ 11 weeks revealed a double trisomy (13/21). We terminated the pregnancy.

Beginning with that particular pregnancy I have experienced pronounced pg symptoms within days of fertilization. They are symptoms I would expect to arise @ 6 weeks. I have had these symptoms each month when my husband and I try (with the exception of one month). My assumption is that I am experiencing hormone surges, but I have my period on time, and I have not had a positive urine test. I have tried a "control month" of abstiinence, and there were no symptoms. Also, no symptoms one other month (although we had tried).

I had a hormone panel on day 3 of my cycle, and another when I had begun to experience the nausea, tenderness, food aversion, fatigue, etc. GYN reported that the baseline was totally normal (FSH 3 and all other #s in range). The second test indicated that levels had changed, but still in normal range and not consistent with pregnancy. He has no explanation for these symptoms U/S's have been clear. No cysts or fibroids.

I did not experience these symptoms with my daughter or any other pregnancy.

I began taking lamictal in 09 150mg daily and .5 Klonopin daily. The addition of these meds and age are the only variables. My dx is Bipolar 1. I have found no research that supports either medication as interfering with implantation. The genetic counselor said the meds are a nonissue.

I have wondered if perhaps the procedure with the trisomy situation has harmed me somehow. My GYN said I never should have been able to implant an egg so defective.

So it seems, now, I will continue to experience these incredibly uncomfortable symptoms every time I fertilize an egg although my prospects for implantation seem dismal. I get all the bad stuff and hope for a good result that doesn't materialize.

Any words of wisdom would be appreciated.  Thanks, S. from California


Hello S. from the U.S. (California),

Your symptoms are confusing and not easily explained. First, you cannot tell whether or not fertilization takes place. That occurs within the embryo and nothing within the body is changed at that point. You would not have symptoms. It is possible that the symptoms you are having are "hormonal shifts" or physiologically the result of the rise in progesterone in the luteal phase. Why would you be more sensitive to this now than before? I can't clearly explain that but you are also older now than you were before so maybe that had something to do with it. Normally, the pregnancy symptoms don't begin until weeks after implantation occurs, so it is unusual. But the progesterone is the culprit for PMS (premenstrual syndrome) which does have some of the symptoms that you describe. I don't think it was the D&E (dilation and evacuation).

Your doctor is right and wrong about the trisomy. It is well known that age is a significant factor and leads to increased numbers of embryos with chromosomal abnormalities. This leads to infertility and increased miscarriage rates. In most cases of complex or multiple abnormalities, the embryo never gets to the point of implantation. But if the defect is not significant enough, as in trisomies, implantation can occur but then most will end in miscarriage. Few will continue to the point where genetic testing finds the abnormality but they do occur.

As you continue to attempt pregnancy you have to remember these facts. Due to your age, it will be more difficult for you to get pregnant, you have an increased risk of miscarriages and an increased risk of abnormal embryos. Aside from your one successful pregnancy, you note that you have had six that miscarried which is troublesome. You have what we call "secondary infertility". Since there is no technology that can change the quality of your eggs, the only way to increase the chances of a successful pregnancy in older patients (over 35 years old), is to increase the number of eggs that have the opportunity to implant. This is done by increasing the number of eggs that ovulate (superovulation) or through IVF (even higher numbers of eggs). In addition, with IVF, genetic testing can be done on the eggs to eliminate the ones that are genetically abnormal so that only normal embryos are transferred. This is just food for thought.

I hope I was able to ease your concerns.

Good Luck,

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


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