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

QUESTION:

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 pregnancy...so 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

ANSWER:

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
www.montereybayivf.com
Monterey, California, U.S.A.

Estrogen Supplement For Thin Lining

Question:

Hello, I am from Canada and I have been seeing a fertility specialist since January 2009. My husband and I have been TTC for 1.5 years and experienced a miscarriage in September 2008, when I had a D&C. My lining has never been above 4.5 mm and is normally about 2-3mm thick. I have been put on 8 mg Estrace daily for the past 2.5 weeks. Ultrasound today showed no change in thickness, and suppression of the follicle size. What is your experience with thin lining and pregnancy success Is there anything else that you would suggest for me to do to thicken my lining?

Answer:

Did you use the Estrace orally or vaginally? If you have not tried it vaginally, that is a more efficient delivery method for the endometrial lining. Orally is the worst. The second best would be estrogen patches.

If you are using them vaginally and your lining is still not developing, that is a problem. It should be getting to a minimal width of 9 mms. Did you have a hysteroscopy to make sure you didn't have scar tissue after the D&C? That could be a cause of a thin lining that doesn't respond to estrogen. Most people will form an adequate lining with estrogen supplementation, so you would be a rare entity. If the hysteroscopy shows evidence of scar tissue then you must proceed to have that removed prior to starting any infertility treatments. It is difficult to do, so you must find a competent specialist to do it who will then schedule an operative hysteroscopy as an outpatient surgical procedure.

I have seen in the literature, reports of people trying nitroglycerine tabs vaginally, Levitra and Viagra to increase blood flow to the uterus and thereby try to increase the lining. They have not worked universally.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com