Ovulation Induction With Follistim Keeps Failing & Estradiol Remains Low

Question:

We are currently TTC our 2nd baby. My daughter who is 2 was conceived on our second cycle of follistim75iu. We are currently on our 4th cycle of Follistim 75iu. Each cycle I'm told my estradiol is low and they end up increasing my dose of Follistim to 150 iu and even by the time I trigger it's still on the low side.

I understand that ideally estradiol should be 200-250per mature follicle. But this cycle it is 110 with follicle sizes of a 14 and a11. So at this point of my cycle what should it be since they are not mature follicles? Also last cycle they had me do hcg booster shots after ovulation because I had a low estradiol (it was 80) 7 days after ovulation the cycle prior. The boosters helped increase my estradiol to 354. My concern is do the boosters really help achieve pregnancy or are they just masking a bigger problem?? Thanks in advance, S. from Pennsylvania, U.S.A.

Answer:

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

There is no fixed protocol when using gonadotropins such as Follistim. Basically, these medications are the hormone FSH which is the hormone that your brain produces to stimulate the ovary to produce a mature follicle for ovulation. If the amount of hormone is insufficient to do this, then it has to be increased and this is usually done on an incremental basis. Please see how I do ovulation inductions here: "Ovulation Induction".

For example, it may be started at 75IU but every three to four days, and estradiol level can be drawn and checked to see if it is increasing. If it is increasing then starting on cycle day #9, an ultrasound is done to evaluate the ovaries and see how many follicles are present, what their sizes are and when to trigger. In your case it sounds like that is not being done. For some reason, your doctor is fixated on keeping the same dosage. I'm not sure I understand why.

You are correct about the estradiol level of a mature follicle. If your follicle does not reach the mature size18-20 mms, then the estradiol level will not reach the appropriate size either. Basically the follicle increases in size by increasing the number of cells. Think of it as a chain of cells in a circle. These cells to increase in size, rather, more cells are added to the chain and each cell produces some estradiol. That is why as the follicle increases, more estradiol is emitted. In order for the follicles to grow more cells, increasing amounts of FSH is required. So, if your doctor stops the dosage at 150IU and it is not enough FSH to stimulate follicular growth, then nothing will happen. He needs to keep increasing the dosage until the follicle grows appropriately. Once the follicle reaches the ovulatory size of 18-24 mms, then ovulation can be triggered with HCG (a substitute for the LH surge you would produce in a natural cycle).

The "HCG booster shots" do nothing to help the estradiol rise. Rather, this was merely a coincidence. The growing follicle causes the increased estradiol. The HCG can be used after ovulation to help prime the enodmetrial lining for ovulation. Some clinics use this instead of progesterone. It is also used to trigger ovulation, as I've mentioned previously.

Based on the information you have given me, I'm wondering if you are seeing the right doctor. Your doctor may be comfortable with using Follistim, but is he really an infertility specialist i.e. have a thorough knowledge of the gonadotropins to use them for IVF (in vitro fertilization) if he has to? There are many Ob/Gyn docs that feel comfortable with ovulation induction and use gonadotropins like Follistim on a protocol basis, but in reality, don't know what they are doing. Could you be in that type of situation? Maybe it is time for a second opinion. The best way to find an infertility specialist is to simply ask the clinic or doctor, "Do you do IVF?".

Good Luck,
Dr. 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.

Ovarian Follicle Size Is Key When Planning For Trigger Shot

Question:

Dear Doctor Ramirez,

I had 3 follicles when I received the trigger shot. 30mm 24mm and not sure what size the 3rd one was. Is the 30mm follicle a good size to have a mature egg to be released?

Thanks, G. from the U.S.

Answer:

Hello G. from the U.S.,

I'm sorry to say but those follicle sizes are way too big. The trigger should be given when the follicle is between 18-23 mms. Once larger than that, the egg becomes over mature and non-viable. In some cases the follicle will not ovulate and be retained as a retained physiologic cyst. This type of situation generally occurs when patients are seeing the wrong type of doctor. I would advise that you consider seeking out a specialist in infertility or at least an ob/gyn who knows how to monitor your cycle properly so that you trigger at the correct time.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

The Importance Of Choosing A Qualified Infertility Specialist: 41 Year Old Patient Losing Time

(If the blog radio program turns on, please go to my October 1st post & pause it! I will be keeping the show up for the month of Oct.)

Question:

I have started evaluation with a RE at the beginning of August. I have so far been diagnosed as having low progesterone and not ovulating properly. I am just turned 41 and had a miscarriage at age 38 at 9 weeks.

My Dr said if my problem is only hormonal, it is an easy fix. He had me on prometrium for 10 days and now I go back for another ultrasound at the end of my menstrual cycle. I know other people have been put on Clomid with the prometrium. I just wondered what would be his justification or reason behind only giving me prometrium. I asked the nurse and she the prometrium was to help me ovulate. I am curious, I think my doctor is fabulous. I just want another opinion. Thanks! M. from the U.S.

Answer:

Hello M. from the U.S.,

I am glad that you wrote to me because your case disturbs me. You may like your doctor but he is wasting your time. If what you say is correct, neither he nor his nurse know what they are doing and they are leading you in the wrong direction!

If you ovulate correctly, then the progesterone level should be in the normal range. When that does not occur, it is called a "luteal phase defect" and the progesterone is used to help the endometrial lining of the uterus to convert correctly and support implantation. It DOES NOT cause you to ovulate. However, if your ovulation is not correct i.e. you are not ovulating, which would also lead to a low progesterone, then the treatment is to use a fertility medication to get the ovaries to ovulate properly, thereby correcting the problem.

There is another very very large issue, however, and that is that you are 41 years old. Did your "RE" talk to you about the age effects on your fertility? Did he tell you that your chances of a spontaneous natural pregnancy are only 1% per month or slightly less than 10% per year? Did he tell you that you may be wasting your time and possibly losing your ability to have a genetic child if you don't proceed in a more aggressive manner?

If your "fabulous" doctor is indeed an RE, then he should be very concerned about the impact of your age on your fertility and time. He would not be wasting your time with fruitless treatments like prometrium. He would be doing a more aggressive treatments like IUI (intra uterine insemination) or in vitro fertilization, IVF (preferred). Also, if he is indeed an RE, he would be doing IVF in his clinic. Does he? If not, then he may not be an RE at all.

My recommendation would be for you to go see a real infertility specialist, preferably one that does IVF, so that you can be counseled appropriately. I recently had a consult with a patient who, like you, went to a doctor that said that she was a fertility specialist. She was with this doctor from 36 years old to 45 years old. She was never referred to see a real infertility specialist, and so now, her only option is to use donor eggs with IVF. If she would have come to me sooner, we might have been able to get her pregnant using her own eggs. Please don't make that mistake!

Good Luck and keep asking those questions!

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.

Woman With Chronic BV Asks: "Will Simply Taking Birth Control Pills, Then Going Off, Cure My Infertility?"

Question:

Hello. My partner and I have been together for 3 years and have not been able to conceive. He has a daughter from another relationship. We are pretty sure I'm the problem. I was told by a gyno that with some people to treat infertility they are put on the pill and taken off and then they see if they can get pregnant. Is this true? If so how long should I go on the pill. Also I have chronic bv (bacterial vaginosis) could this contribute to infertility?

I was on birth control 5 years ago... I've taken the pill patch and nuva ring. Since I got off we haven't used protection ever and have never gotten pregnant. I have pretty regular periods. They are off no more then 3 days at the most.

Thank you! R. from the U.S.

Answer:

Hello R. from the U.S.,

The answer to your first question is absolutely NO. That is a wives tale propagated by Gynecologists that don't know better.

Regarding the BV: Chronic vaginal infections can certainly kill the sperm, thereby preventing pregnancy. When you have Bacterial Vaginosis, there are changes to the acid environment of your vagina. Many factors can contribute to BV including: use of highly scented soaps, douches and bubble baths; use of an IUD or the coil; or because of certain types of sexual acts. It can also happen when the pH level of the vagina alters during the menstrual cycle. But it can also happen without any of these factors in place. It is, after all, the most common form of odorless bacterial discharge.

Bacterial Vaginosis is easily treated with antibiotics, like metronidazole or clindamycin. Women who are trying to become pregnant should be treated with an oral antibiotic. In fact, the Center for Disease Control recommends that all women receive some form of treatment for the condition because there is some evidence that chronic bacterial vaginosis could lead to pelvic inflammatory disease. With chronic, unresolved BV, the solution would be to do intrauterine insemination (IUI), to bypass the bacteria.

My recommendation is to see a fertility specialist. You are at the point where you need to undergo an infertility evaluation and your Gyno is not going to be able to help. Since your partner has had children before, you could assume that he is fertile, but you never know. Things change with time. Also, you don't seem to have any obvious reason, other than the BV, as to why you are not getting pregnant so the only way to find out what the problem is, is to have an evaluation. Once this is done and the problem(s) found, an appropriate treatment can be provided for you to achieve pregnancy.

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.

36 Year Old With 3 Miscarriages On Prometrim Using OPK : Continue With Calendar Method or Go For An Infertiity Consult?

Question:

Hi, My name is R. I am 36 years old living in Atlanta GA. My husband is 41 we do not have any kids and would like to have a baby.

In the past I have had 3 miscarriages. prior to my miscarriages, I had a hystersalpinogram(sp) when I was in my early 20's unblocking both of my tubes. Recently I had been diagnosed with Pcos and placed on Metformin 750mg 2x a day, although I have always had a regular period lasting only 3 days but it comes like clockwork every 28 days. So now let me bring you up to date. Today 08/15/2010 I had detected my LH surge via clearblue ovulation kit. But last month my doctor recommended the Clearblue ovulation test and prescribed me Prometrium.

I do not understand why I was prescribed the medication and 2 I am confused as to when to take it, the bottle says to take 3 days after ovulation, when is that? I just detected the LH surge so when should I begin taking it? In the meantime, shouldn't me and my husband be having intercourse to try and conceive? The Prometrium is a 30 count, so should I take the medication starting day 3 until its all gone? I am so confused and excited, I have never used the ovulation predictor and so I am surprised that I see this happy face, what should I do next? Beside sit and worry!

Thanks for your answer, I am anxiously awaiting to hear back from you.

Answer:

Dear R. from Georgia.,

I don't know why you have the diagnosis of PCO if you have very regular cycles, but there is a variant of PCO that you would fit into. You would not need to take Metformin, however. Did your doctor check an insulin level or how did he decide to put you on Metformin?

In terms of timing your ovulation, that is good but if you want to save yourself money, since you have such a regular cycle, the calendar method would work just as well. If using the OPK, when it turns positive, you begin intercourse (on that day#, once per day for four consecutive days #only one ejaculation per episode). With the calendar method, mark you calendar on the first day of your period then count each days in sequence. Stop having intercourse on cycle day #10 then on CD#13 begin having intercourse once per day for four consecutive days as explained above. In both cases, start the Prometrium on CD#16 and use it twice per day. Because this will suppress your menses, you will need to do a pregnancy test around CD#30.

You know, I need to emphasize that time is a critical factor in your case. I presume you have been trying for pregnancy for a while, so you & your husband really should see an infertility specialist. Your age, the miscarriages, previously blocked tubes and possible PCO diagnosis all indicate that it may be necessary. The specialist will lead you in the right direction, doing the tests that need to be done before starting an arbitrary treatment plan, and be the most efficient in helping you to get pregnant. Sometimes it may only take doing one Intra Uterine Insemination. With each year, your pregnancy rates are decreasing, even with the highest level of treatment, which is IVF, so don't waste time.

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.

100 POSTS!!! And More To Come!

Dear, faithful readers and new visitors!

Since I started blogging about Women's Health & Fertility back in 2008, I didn't realize how much I would enjoy communicating through the huge network that we call the internet! Back then, I thought it would be enough to post general articles regarding infertility and gynecology. At about the same time, I decided to become a volunteer expert on About.com's All Experts Infertility site. There, I began receiving questions from all over the world regarding women's and men's infertility as well as gynecological issues. I had to limit my questions there to five a day because they were coming in too fast, and those who know me know that I like take my time with some questions and be thorough with my answers. To date, I have answered 1,685 questions from around the world.

I soon realized that this may be the way to go with my blog format. I saw that the same problem that plagued a reader in Copenhagen was also relevant to a reader in Australia or here, in the United States. I decided to change my format and began to post Q & A's from my blog readers as well as some of the more interesting ones that I receive on the All Expert's site (always with the person's permission, of course). It is always a pleasure to see where the people who ask me questions come from but more surprising to me, with over 8ooo page views in the last few months alone, where all my visitors come from! Now I am on Twitter, Facebook, and Networked Blogs as well, meeting more people who are involved in the ART field as well as gaining new followers, all of which makes me feel more connected and proud of what I do as an infertility specialist.

Since I added the visitor statistics widget to the blog a few months ago, it's been amazing to see how many people actually visit the blog. (Prior to installing the widget, I thought no one did!) Here are some statistics that might interest you:

My top ten popular blog entries to date:

"Bleeding After Embryo Transfer"

"Secondary Amenorrhea...Low Estrogen?"

"PCOS Patient Beginning IVF Treatment.What Questions Should She Ask Her Doctor?"

"Empty Follicle Syndrome"

"Post IVF Transfer Pain:Implantation Pain or Ectopic?"

"Three Miscarriages and HSG Shows Blocked Tubes"

"Estrogen Supplement For Thin Lining"

"No Period, Low BMI Can Equal Hypoganodotropic Hypogonadism"

"Prolactin Level and Clomid for 30 Year Old TTC'r"

"ELONVA, A New Sustained Follicle Stimulant Just Approved In Europe!"

Recent Visitors From Far & Wide:

Mumbai, India

Perth, Australia

Parma, Italy

Pound Ridge, New York

Gdansk, Poland

Sofia, Bulgaria

Cairo, Egypt

Zagreb, Croatia

Krefeld, Germany

Kamloops, Canada

Rotterdam, Netherlands

Exeter, United Kingdom

Budapest, Hungary

Bursa, Turkey

Sligo, Ireland

Kritianstad, Sweden

Rehovot, Israel

.....To name a few!!! Thank you to all of you for following my blog. I want to commend each and every one of you for taking action with your health issues and for seeking out the right kind of information that will possibly make a difference in your lives and the lives of those whom you love. It is my personal pleasure and privilege to assist you in whatever way I can, given the limits of the written word and the distance from which you communicate.

I am always available to give general responses via this blog & the All Experts Site. I am also available as a Personal Physician Email Consultant for more complicated, in depth responses to your concerns.

Regards to you all,

Edward J. Ramirez, MD, FACOG

The Fertility & Gynecology Center

Monterey Bay IVF

ejrmd@montereybayivf.com

Too Many Rounds of Clomid Will Inhibit Pregnancy

Question:

I have been trying to conceive for two years. So far, I have done 12 total cycles of clomid. We hare having issues getting my follicles mature. I am now taking metformin daily, dexamethasone on CD 1-14, and clomid on days 3-9. I have ultrasounds on CD 14 and usually find immature follicles.

I am wondering, do all these meds seem excessive? All these meds are making me crazy! At what point should conceiving be considered not possible?

Answer:

Thank you for your question. You have already exceeded the number of cycles on Clomid (clomiphene) that is recommended by ASRM (American Society of Reproductive Medicine) and fertility experts. You need to move to something else. I presume you are seeing a General Ob/Gyn for your treatments. Find a fertility sub-specialist and transfer your care. At this point, you should be moving to IUI or IVF, and certainly the gonadotropins. NO MORE CLOMID.

It is this type of prolonged Clomid treatments that get Infertility specialists upset with general OB/GYN docs. All that are strictly recommended are 4-6 cycles at the most. Clomid will inhibit pregnancy after too many consecutive cycles. It works by blocking the estrogen receptors and tricking the brain into thinking it is not making enough estrogen. The brain then stimulates the ovaries harder. After a while, the Clomid will block all the estrogen receptors, which are required to produce adequate cervical mucous, adequate uterine lining and tubal motility. So in essence, it will be preventing pregnancy.

In terms of getting pregnant, it depends on many factors. I tell my patients that I can get anyone pregnant. The difference is what I have to do to get them pregnant. So, you have lots of other options. However, if you don't get out of your current situation with your current doctor, then you will be wasting a lot of time, just as you already have.

Good luck and keep trying, only not in this manner.

Sincerely,

Edward J. Ramirez, M.D.Executive

Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California

www.montereybayivf.com

THE INFERTILITY PATIENT AND THE INSURANCE COMPANY...THE ODD COUPLE.

Here is some advice regarding getting coverage for infertility testing. Consumers need to keep in mind that medical insurance companies are not your advocates. They make their money by keeping the premiums that you have paid, if you don't use them. Therefore, their goal is to keep as much of your money as they can (profit); and they have been doing a good job of it. Evaluation of their stock and company perfomance show that they are one of the best businesses to invest in because, despite a recession, they continue to make lots of money. That being said, here is one way that insurance companies shortchange infertility patients.

As many infertility patients know, once they determine that they have been unable to become pregnant, they need to undergo an evaluation. Also, patients undergoing higher level treatments, such as in vitro fertilization, are required to undergo testing as mandated by the FDA and CDC. In most cases, these tests are general health screening tests and not specifically infertility tests. They are tests such as infectious disease testing, hepatitis, AIDS, hormone testing, pelvic ultrasounds, etc. These are tests that are done for many reasons and for many diagnoses, not specifically or only for infertility. Coding requirements mandate that the most specific diagnosis is used when billing. Infertility, is not a very specific diagnosis. In most instances, there is a diagnosis that is a more specific illness, which as a consequence of their effect, can lead to or cause infertility. These are illnesses such as:

• irregular menstrual cycles


• polycystic ovarian syndrome


• sexually transmitted disease screening


• abnormal bleeding, endometriosis


• uterine fibroids, etc.

Make sure that your doctor or clinic is using the most specific diagnosis that they can.

In terms of insurance coverage, if you do not have infertility coverage, then insurance companies will not pay for infertility services. As mentioned above, many of the tests, if coded with the specific illness, are not infertility codes. Therefore, these tests should be covered. However, many, if not most, insurance companies will automatically flag your account if there is ANY reference to infertility. They then will deny all claims that can be related to infertility testing or treatment thereafter, including general health tests. Remember, their goal is to not pay for as much as possible and this is one way that they get away from paying for tests. Keep an eye on your EOB's, the statements you receive from your insurer that tells what they covered and did not cover. Also, check your test requisitions too and ask what diagnostic code they used. If they used an infertility code, ask if there is a more specific diagnosis code pertaining to your condition that they can use. Then if the lab test is denied, YOU need to contact your insurance company and file an appeal. It should be done in writing and keep all records of your attempts. Do not rely on the doctor's office to do this for you. Remember, you are the insurance company's client, NOT the doctor. You have more leverage than they do. Ultimately, if the insurance company denies a justified claim, that you have repeatedly appealed, you can go to the next level of appeal, which is the Commissioner of Insurance for your State and file a complaint.

Word of Caution! I am NOT advocating that you commit fraud. If there is no other diagnosis or illness that applies to your test, and infertility is the only diagnosis that can be used, then that is the correct diagnosis. In that case, the insurance company has the right to deny the claim. Do Not ask your doctor to lie about your condition by using another diagnosis code. Both you and your doctor can be criminally liable if you commit fraud. Remember, honesty is your greatest weapon when dealing with the insurance companies. They are required to be honest with you as well. If you are not honest, you have nothing to stand on to refute their denial. If you are, and your claim is legitimate, then the insurance company has to accept your claim. You are paying them for the services they have promised to provide. Be a wise and diligent consumer and make sure they are providing you with all the services you are entitled to.

CHOOSING A FERTILITY SPECIALIST

I've often been asked by patients, when and how to choose a fertility specialist. The question they have is whether to stay with their current OB/GYN physician or seek out an infertility specialist. First, if you are undergoing some evaluation and possibly treatment by a Family Practice physician or General practitioner, you're in the wrong hands. Your doctor may feel he or she can do infertility, and may have had some exposure to infertility in their training, but it was hardly enough for them to be evaluating and/or treating infertility patients. I have even had patients that were under the care of physician assistants and nurse practitioners! These are the wrong providers for your problem. Speciality care should be done by a specialist, an OB/GYN physician, Infertility specialist or Reproductive Endocrinologist, not a general practitioner. See "Infertility Evaluation" for more information.

The easy answer to the question is seek out the physician that you feel you need to see. If you want a basic level of evaluation and treatment, or want minimal intervention, then most OB/GYN physicians have adequate training and knowledge of infertility to help you. However, this varies among OB/GYN docs so make sure your doc has this knowledge. One good way of screening is to simply ask what levels of treatment they provide: Clomid ovulation induction, Gonadotropin ovulation induction or Insemination (artificial insemination)? I would choose a doc that can do at least insemination. If they don't do that, then their training and knowledge is probably not adequate for your needs. The problem with docs that only do a little, is they tend to get stuck in the little that they can do and are slow to refer you to a higher level of care. For example, a doc that can only do Clomid ovulation induction, but not insemination, tends to treat their patients for months with just Clomid, often without even doing a complete infertility evaluation to see if this is the best treatment. Clomid ovulation induction should probably not be done for more than 6 months. If your doc gives you a prescription for Clomid, that is a year's supply, and says call me if you miss your period, then you need to find another doctor. Or, if you go to your doctor with your infertility problem and the doctor sends you away with a Clomid prescription before even suggesting an infertility evaluation, then that is another sign that you need to seek out a different doctor. As a consequence, you end up losing valuable time, and money. A good OB/GYN and Infertility specialist will lay out a clear and concise plan for evaluation and treatment, and give a defined timeline for each.

However, that being said, you may also want to avoid the clinic that provides only IVF, because they will not offer other choices of evaluation or treatment. If you are just starting your infertility care and evaluation, that may be the wrong choice for you. Many large IVF clinics are like that. They only provide IVF. You want an infertility specialist that offers IVF, in addition to, a broader level of evaluation and care. Find someone who can provide all levels of infertility evaluation and treatment.

So, when should you seek a specialist? The answer is when you feel you need a specialist. For some that will be right from the start, when you realize you are not getting pregnant. For others, that will not be until they have exhausted their options with their Ob/Gyn doctors. My advice is this: if you are under 35 years old, then either a well-trained Ob/Gyn doc or an infertility specialist will do, depending on your problem. If you decide to go to an Ob/Gyn doc, then do not spend more than 6 months on a treatment plan. If it doesn't work by that time, then it's time to move on. If you are over 35, then you should go directly to see an infertility specialist, because time is working against you. Also, if you have tubal blockage, stage 3 or 4 endometriosis, a very bad semen analysis or failed four IUI's, then you should see an infertility sub-specialist directly.