37 Year Old TTC With Past History Of Hyperplasia & Endometriosis Is Desperate To Conceive

QUESTION:

Ok, I went to the Gyno in Dec of 2009 because I wasn't getting my period. He sent me for an ultrasound Jan. 2010 and the lining of my uterus was thickened so he did a biopsy which led to my first D&C which was April. I was diagnosed with hyperplasia of the uterus and he said I was producing too much estrogen so he put me on Depo provera.

I got my first shot April 19. 2010 and he told me if I didn't go on the depo shot I would definitely get cancer. I had my second shot July and then I had another D&C September and everything came out good, hardly any tissue. After the D&C the Gyno said he wanted me to stay on the depo till I go through menopause ughh!! I've had three more shots, one in Oct.. one in Dec. and my last shot was March 21, 2011. I want to have a child and in late July I will be 38. My gyno said I could go off the depo shot, so I asked him what if it takes me a year to get pregnant? He said, "You're not allowed to take that long you'll get cancer of the uterus for sure."

I think I need a second opinion & I'm hoping my withdrawal from the depo isn't so horrible. One thing I think you should know is I was diagnosed in my mid 20's with endometriosis and my gyno (back then different doctor) said I didn't have a lot of tissue he also never told me I couldn't conceive, he just said after you have children just get a hysterectomy. I was put on different forms of BC (birth control) over the years and my last form of BC was the NUVA ring. I always had bad cramps w/ my periods so he had me wear the ring continuously. I would wear it for three weeks and take it out and put in a new ring right away to avoid periods, when I was doing that I had break through bleeding all the time & that's where I think all the excess tissue came from with the hyperplasia. I've been on the depo shot for a year and three months then I'm due for my next shot which I don't want.

I'm writing from South Jersey. I only want to have one child! Please tell me what you think. Thank you for all your time. :)

ANSWER:

Hello A. from the U.S.,

First, I don't think you need to worry about the hyperplasia at this point. You have been adequately treated for it. You just need to make sure that you have regular cycles because not shedding the lining at least every three months is what can lead to hyperplasia, and if left untreated the simple hyperplasia can turn into atypical hyperplasia (precancerous) which can then turn into cancer.

I think that pregnancy is a good idea for it and you need to pursue it aggressively! Your age is the number one issue at this point, in terms of getting pregnant. A second issue with getting pregnant is the history of endometriosis. Depo Provera is certainly a good treatment for this disease but endo can recur and can impede pregnancy. Considering your age, I wonder if there are other factors as well since you have never gotten pregnant to date. My recommendation, in general, to patients at 37 years old or older is to strongly consider IVF (in vitro fertilization). Other than age, you don't have an absolute indication for this, unless something else is found wrong, but the chances of pregnancy are so much higher with IVF than any other treatment at your age.

For example, your natural chance of pregnancy is approximately 3% per month or 5% per month with IUI. On the other hand, with IVF it is 69% per month in our clinic, and at least 50% across the country. That is a significant difference. The problem with age is that the majority of eggs that you still have will be of poor quality so the only way to increase your chances to find an egg with good quality is through IVF. You can certainly try with more natural methods but with each month that you fail, your chances are decreasing (it's like chasing your tail).

I would strongly recommend that you go to a good IVF clinic and have a consultation. I know that there are some excellent ones in New Jersey.

Follow-Up Question:

One more question, being on the depo shot for this time period (one year & 3 months) I'm afraid as to how long it will take to get out of my system. Reading posts by women who've been on it much longer than I (like 7-12 yrs.) say it can take 6-18 months to start a normal period & ovulate again. Any suggestions on how to rid the depo from my system when I'm actually due for my next shot? I've read lots of water and excercise.

Thanks again after this no more questions I'm sure you're busier than ever.:) A. from New Jersey.

Follow-Up Answer:

Hello Again,

I don't have any solutions to how to speed up the return of your natural cycles. The Depo can linger for a while but I have never seen it take more than 2-3 months. If you want to start trying for pregnancy sooner, you could undergo ovulation induction and that will get your ovaries to stimulate and ovulate.

You are very welcome to ask your questions and thank you for your patience in waiting for my reply.

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

Comment: Dr. Ramirez was very helpful to me I really appreciated his input. Thanks again!!

Recurrent Miscarriages: Is It A Hormonal Issue?

Question:

Dear Dr. Ramirez,

I am writing from Pennsylvania. In 2006, I had two or three miscarriages.  After that, I went to a fertility clinic and had TSH, prolactin, DRVV, and anti-cardiolipin antibodies tested.  All were normal.  I also had progesterone level checked at the very beginning of one of the pregnancies as well as a non-pregnant menstrual cycle after ovulation.  Both were normal.  I had irregular cycles that were anywhere from six to ten weeks apart.  I knew when I ovulated because I got pain in whichever ovary released the egg and always had a luteal phase of 14 days. I also conceived easily.  

 

The doctor felt the lining of my uterus was getting too old to sustain a pregnancy since so much time elapsed between cycles. In February 2007, I conceived on one round of Clomid and carried that child full-term.  I then had two more children in 2009 and 2011 with no help despite still having the same irregular cycles.  My cycles are a little better now and usually five to six weeks apart, but I have had three miscarriages again in September 2012, December 2013 and June 2014.  All the miscarriages I ever had were missed abortions with embryo development ending between week 5 and 6 with the exception of the most recent which ended at 11 weeks 5 days despite fetus having a strong heartbeat and normal looking development.  Since a drop in progesterone causes shedding of the lining of the uterus, is it safe to assume that since my miscarriages were not spontaneous that progesterone was not an issue?  Could other hormones be issues or was chromosomal defect the likely issue all these times? 

Thank you for your time. Sincerely, M. from Pennsylvania

Answer:

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

There are basically five known causes of recurrent miscarriages from the following abnormalities: genetic, anatomic, immunologic, hormonal and infectious.  When a woman has had two or three miscarriages, she automatically has earned the diagnosis of "recurrent pregnancy loss" and as such, needs to undergo a thorough evaluation of these elements.  The most common cause of miscarriages is genetic abnormalities and is responsible for 85% of miscarriages in women over 35 years old.  A recent study showed this cause to be less in younger women.  Genetic abnormalities can be caused from an inherited disorder or a spontaneous disorder, whereby the egg makes a genetic error when it is dividing leading to an abnormal embryo.  Most of these pregnancies will end before 12 weeks gestational age.

The recommended testing is as follows:

Genetic: wife and husband chromosomal analysis, saliva DNA analysis

Anatomic: diagnostic hysteroscopy, pelvic ultrasound, end cycle endometrial biopsy for dating and b-Integrin

Immunologic: Complete antiphospholipid antibodies, natural killer cells, Factor V Leiden, MTHFR, Antinuclear antibodies, Lupus anticoagulant, anti-Thyroid antibodies

Hormonal: FSH, LH, TSH, Prolactin, Estradiol, Mid-luteal Progesterone

Infectious: GC, Chlamydia, Ureaplasma/Mycoplasma, Toxoplasmosis

Age is probably the most common major cause which leads to an increase in genetic abnormalities.  Since you don't mention your age, that could be part of the problem if you are over 35 years old.  The good news is that most women with recurrent miscarriage will eventually have a successful pregnancy.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

 

Could I Be Infertile Or Am I Still Recovering From Surgery For Endo?

Question:

Hello. I'm a 29 year old female. My husband and I have been trying to conceive for 7 months now. I had a laparoscopy done in June of 2013, due to an ovarian cyst on my right ovary. As the Dr. was doing the procedure, she said that the cyst had already ruptured ( which I didn't even know, or feel) and she found a little bit of endometriosis, which she got rid of as well. My tubes were wide open with no other complications.

 I'm about 2 1/2 months post op, and we still haven't gotten pregnant. I just saw my Obgyn a few days ago for a progesterone test, and it showed I was ovulatory. I was an 8.4. So the next step is to go get another ultrasound to make sure everything is ok inside, followed by some blood work a few days later. He said we'd check for PCOS. I have no symptoms of that. My periods have been pretty regular all my life. My question is why haven't I gotten pregnant? I thought the laparoscopy was suppose to open things up to help a future pregnancy. Could my body still be recovering from the surgery, and that's why I haven't become pregnant?  Or could there possibly be an underlying problem I have. The Dr. didn't really make me feel that comfortable. I asked a lot of questions, yet I still feel I'm unsure about things. I don't know what to think. He said we might start Clomid, but part of me wants to think I'm still recovering. I really hope I don't have any serious problems. I really just want to be blessed with a child, yet it's been so difficult to achieve.

Any advice/help would be greatly appreciated!  P. from Illinois.

Answer:

Hello P. from the U.S.(Illinois),

Infertility is defined as the inability to become pregnant after 12 months of trying so technically you are NOT infertile.

In terms of your surgery, you are way past that and it is not the reason you are not getting pregnant unless scar tissue was formed from the surgery inside the pelvis.

My first recommendation is to find a new doctor.  Preferably, find one that is a specialist in infertility rather than a general Ob/Gyn.  The reason is that you are on the verge of wasting a lot of time and money.  Your doctor is jumping to things without good reason.  For example, saying that you have PCOS when you have regular periods.  PCOS is defined as an ovulation dysfunction and you have to have irregular or absent periods as the prime criteria for the diagnosis.  Also, going straight to Clomid without a full infertility evaluation is a waste of time and money.  It's like prescribing a treatment before you know what you are treating.

My recommendation would be to start with a basic infertility evaluation:

• Cycle day#2 or 3 hormone panel (FSH, LH, Estradiol, TSH, Prolactin)
• HSG

• Hysteroscopy or Hysterosonogram

• Pelvic ultrasound #done#

• Semen analysis

• Cycle day #21 or 22 progesterone #should be 10 or greater#

• End of cycle endometrial biopsy

• Cervical cultures for GC, Chlamydia and Ureaplasma

• Laparoscopy (which you have done)

Once all these are done, then you can discuss and consider treatment options. Since endometriosis was treated, you need to try to get pregnant within one year of the surgery or the endometriosis will return and possibly prevent pregnancy.

Good Luck,

Dr. 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.

TTC After Surgery For Stage Four Endometriosis

Dear Readers,

As the year draws to a close I want to wish all my readers near and far the very best in their lives as you move forward into 2014. I hope that the blessings of health and peace are with you all and for those of you who continue to struggle with infertility, I can only wish with all my heart that the journey will come to a positive conclusion for you in 2014.

Thank you for following my blog and God Bless.

Edward J. Ramirez, M.D.

 

Question:

Hello,

I was diagnosed with stage 4 endometriosis in 2011 (26 yrs old) after a laparoscopy found a large endometrioma. I've never had painful periods prior so that diagnosis was surprising to me.I then grew back another large endometrioma and had my 2nd lap in June 2013. I am now 29 and have been TTC (trying to conceive) since my surgery in June. I was told to try naturally for the 1st 6 months. I am now on my 7th cycle and beginning to look into other options. I have seen that with stage 4 endo the treatment of choice is IVF over trying clomid / IUI. Can you explain why?  I understand surgery can affect ovarian reserve but am looking for better understanding.

What would you recommend my next steps be? How aggressive should I be in getting pregnant right away since I only had a two years between surgeries was regrowth or large endometriomas?  Thank you.

C. from California

Answer:

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

Unfortunately, Stage 3 and 4 endometriosis have been found to significantly decrease fertility rates.  This is because endometriosis cause a chronic inflammation of the pelvis that recruits inflammatory cells and these cells attack and destroy the eggs when ovulation occurs (this of course is putting is very simply for ease of understanding).  In stage 4 endometriosis, severe adhesions or scar tissue formation occurs in the pelvis.  These adhesions are like spider webs so that when the egg exits the ovary and moves into the pelvis, prior to finding the tube, the eggs get caught in these spiker webs or the webs block the tubes so that the egg never gets into the tube where fertilization takes place.

Because of this, the only way to achieve pregnancy is to bypass the tubes, which you cannot do by natural means.  For that reason IVF is the only option.  Now, even I have had patients with stage 4 endometriosis get pregnant, and as a Catholic I believe in miracles, and so don't doubt that this can happen.  However, statistically speaking these cases are very, very few.

In terms of the recurrence of endometriosis or endometriomas, this is a chronic disease and new implants are continuously forming.  For that reason, you can form new endometriomas, despite the previous ones being removed.

Good Luck,

Dr. 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.

Woman Suspects She Has Endo: Treat The Pain Or Do IVF?

Question:

Hi there. Hubby and I have been TTC (trying to conceive) for almost 4 years now, with no success. We have been to two different REs, the first performed one HSG (hysterosalpingogram) and we underwent two unsuccessful IUIs (intrauterine insemination). The second ran a lot of tests, told me my eggs were low and wanted to go straight to IVF. In the last couple of years, my menstrual cramps have become unbearable, to the point of awaking me in the middle of the night. I have always had cramps, but nothing like this pain. I also have diarrhea along with my cycle, a yeast infection every month, and terrible seasonal allergies.

Two years ago I had an abdominal myomectomy and at that time, my doctor separated my fallopian tube from my uterus-they had gotten stuck together. I have been reading up on endometriosis and it sounds to me like I may have it. No doctor has ever suggested that I get tested for it. But I seem to have many symptoms of it. Do you think my tube and uterus getting stuck together were a result of undiagnosed endo? Could this be causing our infertility? Thank you for any answers you can provide. Thanks, W. From Virginia.


Answer: Hello W. from the U.S. (Virginia),

It seems that you are smarter than the two RE's that you consulted with. Given this history, you certainly could have endometriosis, and the prior surgery probably made the diagnosis. Endometriosis is one of the major causes of adhesions (scar tissue) formation in the pelvis. It can lead to infertility because it changes the normal anatomy and can prevent an egg from entering the tube. In addition, you have now had an open surgery (myomectomy) which is notorious for causing scar tissue formation as well. These two things on their own would explain your infertility.

At this point you have to make a decision: whether to treat the pelvic pain or get pregnant. Treating the pelvic pain will require additional surgery. Getting pregnant would require IVF, the only option for bypassing an abnormal pelvis. Do not be under the misunderstanding that doing the surgery to diagnose and treat the endometriosis and adhesions will restore your fertility. In fact, the opposite will occur because every surgery leads to further adhesion formation. Only do the surgery if the pain is a significant problem. If pregnancy is the priority, then go straight to IVF. In many cases, getting pregnant will help the endometriosis pain.

Good Luck,

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

"Infertility Nightmare" After TTC For Seven Years & Two Failed IVFs

QUESTION:

Hi, I was very much hoping you could help me with my infertility nightmare!

Myself - 30 yrs old, AMH: 3 / FSH 9 / ttc 7 years / diagnosed this year with severe endometriosis mostly around my ovaries.

My partner - 39 yrs old - no issues

After trying unsuccessfully naturally for 4 years (tried using ov kits but no signs of ov) I consulted my gp and was referred to our local hospital for 'basic fertility tests'. No issues apparently found and I was diagnosed with 'unexplained infertility'!

I was then given 3 months of clomid and a follow up appointment for 6 months later! Clomid did nothing for me (no ovulation detected on ov kits). My periods were horrendous whilst on this and shortened to 24 days following it. They went back to 28-29 days after a few months.

I was then referred to another hospital for IVF. Again only the basic tests were carried out (blood, semen etc). This was when I was found to have an AMH of 3.

IVF 1 - 0.5 burselin / 4 vials of menopur / gonasi hcg trigger shot / 2x 200mg cyclogest.

Stimmed for 12 days in total - produced 10 eggs of which 5 fertilised. Transferred 1 hatching blast on day 5. Other 4 embryos did not make it to freeze.

Day 3 started to spot pink blood & by day 5 had period. I did have a very strong 'immune reaction' the day after transfer (flu like symptoms which lasted 12 hrs).

My consultant advised he thought the egg quality was to blame causing the early bleed after implantation.

I insisted on further tests and 3 months later has a Hysteroscopy and LAP (laparoscopy). I was then diagnosed with severe endometriosis. I was also given a cervical dilation due to a difficult transfer. I apparently have a small and narrow cervix and a forward tilting uterus.

IVF 2 - 0.5 buserelin / 6 vials of menopur / gonasi hcg shot / 3x 200mg of cyclogest (after my insisting).

Stimmed for 13 days and was very slow to respond this time. Six eggs collected of which 3 fertilised. Two blasts transferred on day 5 (1 more advanced than the other). Day 4 after transfer pink spotting again again developed into period. Felt slightly unwell the day after transfer (but not as intense as the first ivf).

Both IVF's resulted in negatives.

My questions are:

1. What is your opinion on the early bleeds? Do you think it's embryo quality (I don't know there officially grading by the lab). Or is it an immune issue possibly lined to the endo? Or both? My aim next is to have level 1 and 2 immune testing.

2. Do you think the progesterone support is enough? May I possibly also need estrogen support? My doctor does not believe in this!
My aim is to try with DE next time due to my poor response on IVF 2. Do you agree? My main concern is the amount of time I have been infertile plus the 2 failures. I have never achieved a pregnancy yet. Do I have hope in your opinion?

Thank you so much for taking the time to read this.

N. from Ireland

ANSWER: Hello N. from Ireland,

Please note that detailed and comprehensive recommendations cannot be given without review of your medical records. This venue only allows for short and succinct answers so I hope it suffices.

Embryo quality DOES NOT cause post-transfer bleeding. If bleeding occurred, there is probably no way to know exactly what the bleeding was from, however, the first question would be whether or not there was an adequate luteal phase i.e. whether the progesterone you took produced adequate levels. If you took the medication orally, it would not be adequate. The only way to take progesterone with IVF is either vaginally or by injection. Vaginal progesterone can, however, cause some cervical bleeding because of some eroding effects on the cervix. This is not an indication of an immune problem.

Estrogen is required for adequate endometrial formation as manifest by endometrial thickness and a trilaminar pattern on ultrasoud. Estrogen is also required in the implantation phase and is easy to use so many IVF programs do add this to the regimen.

I'm afraid I don't know what you mean by "DE", so cannot comment.

There is always hope. The key is to find the proper treatment, the proper doctor and the proper clinic to make that happen. I tell my patients, "we can get almost anyone pregnant. It is just a matter of what needs to be done to do so." The only sure way to fail is to stop trying.

Good Luck, Dr. Edward J. Ramirez, M.D., FACOG

FOLLOW-UP QUESTION:

Hi Dr Ramirez, many thanks for your reply and for taking the time.

Regarding the progesterone I was taking this rectally by Cyclogest pessarie 400mg x3 daily. The reason for taking it rectally is that i tend to suffer from thrush. I'm now wondering whether taking this rectally was not sufficient. I am also concerned I am not maybe absorbing the progesterone enough therefore and I'm now keen to try injections next time.

I do tend to suffer with a shorter luteal phase of 10 days before spotting / bleeding on natural cycles.

I will defiantly suggest using estrogen next time. I can not understand other than a hormone in-balance why i would twice suffer from such an early bleed. My lining on the last scan was found to be 10.9 and of a trilaminar pattern.

'DE' stands for donor eggs. I was advised after my first failure not to try more than 3 times with my own eggs. After my poor response to this cycle and the outcome again I am almost definitely considering trying with donor eggs on my third cycle. I just hope to try and determine any other causes for failure before doing this.

Other than the above and the immune testing the only other issue I'm concerned about was the fact both of my embryo transfers have not been straightforward. Although the second transfer was not as painful as the first, I could still feel the catheter going all the way up into my uterus which was incredibly uncomfortable.

Its such a pity your clinic is far, far away!

Thanks again for your time. If I am to reach a successful outcome in the future I will be to sure to come back and update this to hopefully give other women possible clues to their failures.

N. from Ireland

FOLLOW-UP ANSWER:

Hello Again,

I see no reason why you need to consider Donor eggs. Rather, I think you need to consider changing to a different clinic! Pregnancy rates vary highly from one clinic to another. For example, we have 14 clinics within 100 miles of my center and based on Nationally reported statistics (we are required to report to the Federal Government annually), our clinic has the third highest pregnancy rates within this area. The lowest clinics have rates that are 1/2 of our rate. So where you go makes a difference.

Upon reading your follow-up letter, I saw a significant problem that you have. The embryo transfer is one of the most critical steps, if not the most critical steps, in the IVF treatment process (see my Blog posting on "Step Seven: Embryo Transfer" ). You can have absolutely PERFECT embryos but if they are not transferred appropriately, the cycle will FAIL. The transfer should be a completely PAINLESS procedure and you should not feel a thing. If the catheter touches the back of the uterine cavity or there is bleeding, either of these will cause failure. Maybe that is the main problem? Technique is part of what makes one doctor different from another in terms of pregnancy rates.

I know that I am "far away" but I have had the pleasure of seeing patients from France, Italy, Serbia, Germany, South Korea thus far. Many of these patients tried in local clinics and failed. So, yes it is a 12 hour trip by air, and would definitely cost more for hotel, etc., but if the result is a positive one, would it not be worth it? I'm not trying to induce you to come to my center, but the point I am making is that patients don't have to suffer and endure multiple failures with their local clinic if it is not the best one.

Good Luck,

Dr. 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.

Comment: Thank you once again Dr Ramirez, I was very interested to read your answer & your article regarding embryo transfer & will be taking this up with the hospital on my follow up appointment in the new year. N.

Woman With History Of Endometriosis Wishes Baby #2

March is "Endometriosis Awarness Month" and I thought it would be appropriate to post this recent question from a woman who had endo and succeeded to have her child six months ago. For those of you who wish more information on this reproductive immunologic disease that affects millions worldwide you might begin by visiting the Endometriosis Research Center website.

Question:

Dear Dr. Ramirez,

My beautiful baby boy- now 6 months old- was conceived via IUI (after more than 2 years of trying, painful laser ablation of my endometriosis, 4 rounds of clomid, and two tries with IUI). I have endometriosis. I also happen to have an AMH level of .8-- quite low for age 31, but my FSH and other levels have been perfectly healthy and age appropriate. My fertility specialist urged me not to wait to try for a 2nd baby (given my AMH and the likelihood of my endometriosis returning after pregnancy). So now that my son is 6 months old, and I fear I am beginning to feel some of the painful twinges of endometriosis returning, I am wondering when I should start getting serious about another IUI for baby #2.

I am still breastfeeding (hope to continue for maybe another 6 mo) and my period has not yet returned. While becoming pregnant right now feels a little hard to imagine, given the demands of having an infant, my husband and I DO want a 2nd child, and would like a chance to have another of our own. Is it reasonable/recommended to wait until my period returns (and is normal) before getting serious about this? Or, must I take sooner action? What about breastfeeding-- would breastfeeding interfere (hormonally) with the chance of IUI success/pregnancy? I am trying to temper not feeling quite ready to be pregnant again with not wanting to miss my chance to grow our family... what do you suggest??

So very sincerely appreciated, K. from Atlanta, GA

Answer:

Hello K. from the U.S. (Georgia),

First of all, AMH is an indirect test of the ovary and NOT an absolute. It is used in conjunction with cycle day #2 or 3 FSH and an ultrasonic antral follicle count. So, I would not assume that your time is limited if the FSH and AFC are normal but the AMH is decreased. It is not that critical. Now, it is a little worrisome that your level would be low at your age, so time needs to be kept in mind. But the timeline is not days or months but probably years. For example, I would not wait until you are 35 years old where your age will then start to become an issue as well.

In terms of when to try next, I think you can wait until you have finished breastfeeding, since it would interfere with conception.While you are breastfeeding the ovaries are at rest and not functioning any way so you don't have to rush. In some women, in fact, pregnancy seems to clear up their endometriosis temporarily, so you may have time to conceive after you stop breast-feeding and your period returns. I have had patients like you who have had endometriosis and needed assisted reproductive help for their first baby, who then went on to have baby number 2 & even 3 without the need of further IUI's or IVF.

Congratulations and enjoy your baby!

Dr. 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.

Woman Wonders: Natural FET Cycle Vs. Controlled FET Cycle?

Question:

Dr. Ramirez, I have some embryos frozen. I have adenomyois and endo and chronic endometritis diagnosed.

Have done antibiotic treatment with uterine lavages and IVs.

After depot lupron treatment, is it better to do a natural FET (frozen embryo transfer) or medicated FET. Since it takes about 2-3 months to wait for period to arrive is it better to do a medicated FET? I am concerned about medicated FET as the last time I did a medicated FET I had fluid in the uterus although nearer to transfer it disappeared and I did go on to transfer although BFN (big fat negative).

My RE seems to want to wait for a period before transfer but would not that waste 2-3 months since you said the endo can return in 6 months? Will the cycle be regular and as in ovulation or will it be not regular when I do FET. At the moment my cycles are regular. I have also heard of high dose progesteone treatments treating endo and adeno. Can you explain how this works?

I am confused what to do as we have limited embryos and want to do everything as possible as once the embryos are used up we are done.

Thank you. R. from Rhode Island

Answer:

Hello R. from the U.S. (Rhode Island),

Your RE should have explained that one of the critical steps in getting pregnant, natural or with IVF, is the state of the uterine lining at the time the embryo reaches it for implantation. We know that there is a very limited time that the embryo can implant and the endometrial lining has to be in a very specific and correct microscopic state for implantation to occur. This is where timing is absolutely essential. If you miss this "implantation window", then it will fail.

Conceivably you could do this with a natural cycle, but then there is a wider margin of error because we don't know exactly what the timing is or what is going on microscopically in the uterus. For this reason, we do not do this in FET cycles. FET cycles are always done as a controlled and programmed cycle. With this protocol, you can have a period induced artificially with medication and then start the cycle, but most clinics will want their patients to be on the birth control pill for at least two weeks period to the FET cycle in order to suppress the ovaries, which then allow complete control of the FET cycle.

If this is in fact gong to be your last attempts at getting pregnant, then I would make absolutely certain that you are in the best clinic that you can be in and that it will give you the highest chances of success. A good clinic would be able to answer these questions and make sure everything is clearly laid out.

Finally, in terms of progesterone treatment with endometriosis and adenomyosis, progesterone has suppressive action or counteracts estrogen in estrogen receptors. AS you probably know, endometriosis/adenomyosis are stimulated by estrogen and therefore, will be somewhat suppressed by progesterone. However, there is still some small amount of stimulation so progesterone is not the perfect treatment. Estrogen receptor blockers such as Lupron are better at suppressing endometriosis. Progesterone is used mainly to slow down the recurrence of the endometriosis after they have been treated with surgery or Lupron.

Good Luck,

Dr. 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.

39 Yr Old TTC With Previous Miscarriage: Clomid Vs. Gonadotropins? Flare Vs. Antagonist Protocol?

Question:

Dear Doctor,

I am from India. I am 39. I had two missed abortions at 36 and 37 both in the eighth week and after the heart beat was felt.After leaving a gap of four months I have been trying to conceive naturally for 14 months without any result.

Subsequently I started Clomid 100 mg (day 3-7) at the advice of doctor.I did 3 cycles with Clomid out of which I got two follicles of ovulatory size (more than 18mm) in two of the cycles and one follicle (20mm) in one of the cycles.I did not conceive. My FSH and other hormones are normal.

I consulted a IVF specialist who examined me and said that my ovary volume is good and said that she will go for two cycles of IUI, if they are not successful she will go for IVF.

In my first cycle of IUI, the doctor did a trans-vaginal ultra sound on day 2 and gave the following medications from day 2 to day 5 (1) Suprefact 10 markings in the insulin syringe with 100 markings (BD 100 mark syringe) (between 1 to 2 pm daily)(2) GMH (human menopausal Gonadotropins (FSH+LH)) 225 IU (between 7-9 pm daily)

On day 6 she checked and told me that there is no response and the follicles have not grown.She changed the medication to GMH 375 IU per day on day 6 and day7 (between 7-9 pm daily) (She stopped Suprefact)

On day 8, she checked and told me that the follicles have not grown and advised cancellation of the cycle.Further she said that my follicles are not good enough for future trials of IVF or IUI and advised IVF with donor egg.

I asked her how I could get two ovulatory sized follicles (above 18mm) with Clomid in two of my three monitored cycles but nothing in this cycle and she is ruling out the possibility of the future trials. Her answer was that with Clomid or Letrozole even empty follicles grow and give a false impression that the follicles are growing and ovulating. But with Gonadotropins only follicles with good eggs will grow and that is the reason why my follicles did not grow with Gonadotropins. Is the above statement about Clomid and Gonadotropins correct. I will be grateful for your answer. R. from India

Answer:

Hello R. from India,

The simple answer is "NO. Her explanation is NOT correct." The gonadotropins are more effective than Clomid or Letrozole in recruiting and growing follicles because it IS the hormone the brain sends to the ovary for that purpose. Clomid and Letrozole work by an indirect method to cause the brain to increse its FSH output.

Also, she is NOT correct that gonadotropins only grow "good" follicles whereas Clomid grows "false" follicles. This explanation is made up and not scientific at all. In fact, no such thing exists. Sorry.I am not sure why your doctor cancelled your cycle. If the CD#8 ultrasound (which is early) or Estradiol level are showing a low response, the proper protocol is to continue going. Sometimes the follicle can grow slower. I have had patients get up to 21 days before ovulation occurs. In addition, the FSH should be increased if the stimulation is slow. I do not expect to have ovulatory sized follicles until at least CD#12.

I agree with you that since you stimulated with Clomid previously, you should readily stimulate with Gonadotropins as well. Maybe you should find a new IVF specialist. One thing to keep in mind, however, although your chances are still good at 39 years old, your previous miscarriage show what part of the problem is, which is that the eggs have aged and more and more of them are not of good quality. As a result, there is a higher chance of abnormal embryos which increases the miscarriage rate. IVF should help that because it increases the amount of eggs that are retrieved which in turn increases the possibility of finding an egg that is still good quality. You probably will need a high dose protocol using up to 600IU of FSH. IVF is definitely the way to go!

Follow-Up Question:

Dear Doctor,Thanks for your kind advice.The IVF specialist said the protocol given to me is the flare protocol meant for poor responders. Is that so? Then I do not understand why I did not respond to the protocol.

During my Clomid cycles my follicles reach ovulatory size by day 12. Do you think the poor response in the Gonadotropins cycle could be due the Suprefact Injection which was given from day 2 to day 5 along with Gonadotropins? Also kindly advise if it is necessary to add Suprefact or lupron early in the cycle or giving only FSH will help. Besides doctors here give Gonadotropins (FSH+LH) not Recombinant FSH. Is it better to give Recombinant FSH?

Kindly advise. R.

Follow-Up Answer:

Hello Again,

I do not like to comment on protocol specifics because there is no one way to do things. Please keep that in mind as I answer your questions. The "flare" protocol is one type of protocol used to stimulate the ovaries with IVF. It has no advantage over other protocols, but sometimes is used in patients that are designated as "poor responders". Studies have not shown it to be any better. I personally do not use the flare protocol. My preference is to use an antogonist protocol so that there is no suppression of the ovaries during the initial recruit phase, but I am in the minority in terms of centers that use this type of protocol.

In terms of your stimulation, I still think that a higher amount of medication may be warranted.

Both Suprefact and Lupron are medications called "gonadotropin agonists" and what they do is suppress the brain from producing FSH and LH.Gonadotropins are either pure FSH, pure LH or mixed FSH/LH. This is the name for that class of medications. Some IVF clinics only use FSH, some will use a mixed protocol of FSH and FSH/LH. Examples are Follistim (pure FSH) and Menopur (FSH/LH). My preference is the mixed protocol but many clinics will use FSH only protocols and some will use only the mixed FSH/LH medications. Studies have not show a necessary benefit of any of these protocols so they cannot be compared or criticized. Each doctor and/or clinic has their preferences. The most important aspect is how much FSH is being given because FSH (follicle stimulating hormone) is the hormone that stimulates follicle growth in the ovaries. Also, Natural vs Recombinant forms are equal. There is no difference.

Wishing you good luck with your TTC journey,

Dr. 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.

PCOS Patient In India On Clomid: Needs To "Rest" Ovaries & No Ovarian Drilling!

Question:

Hi, I am G. from India. I am 26 yr old and I have PCOS. My LH level (14) is high on day 2. I am trying to conceive now. My gynae suggested me with clomid 100 mg from day 2 to day 7 and hmg 75 on day 2, 3 and 4. After seeing a developing follicle in my right ovary through ultrasound, I was injected with hmg 75 on day 8, 10 and 12. I had 2 eggs with 18 mm measurement on day 14. Then I was administered with hcg 10000 to release those eggs. Me and my husband was asked to have intercourse for 4 days and I was prescribed with progesterone supplement (400 mg) from day 15 for 10 days. In spite of all this, I didn’t get pregnant last month. My husband (age 28) has got healthy sperms. What could be the reason for this failure?

My gynae is suggesting for IUI (intra uterine insemination) this month. How long can I go about with this treatment? Will I succeed in conceiving if I get this kind of eggs in the following month? My gynae also suggests that she has to do a laproscopic drilling if I fail 1 IUI.

Please advice. Thanks in advance.

Answer:

Hello G. from India,

First, you need to understand that fertility treatments are not magic. They don't work 100% of the time. What they do is attempt to restore your reproductive system back to normal, which in your case is to get your ovary to ovulate. For more, in depth information on PCOS please see: Polycystic Ovarian Syndrome.It looks like your doctor did a very good job of treating you in this cycle. She was able to get you to ovulate (probably two eggs) and you had intercourse at the appropriate time. In addition, she supplemented you with progesterone as I would have recommended. Now you need to do that repetitively, just as if you were trying for pregnancy naturally. If you or any woman were trying on their own, they would give up after only one try or wonder why they didn't get pregnant after one try, would they?

The only caveat is that because you stimulated the ovary, you need to skip a cycle in between to give the ovary a rest. You should go on the birth control pill that month to make sure that you have a period in a timely fashion, so you don't have to wait for your natural period to begin. Then you do the same cycle again I would recommend that you continue trying this for 4-6 cycles. Then if it does not work, you can consider other treatments. But, keep in mind that you are assuming that the only problem is PCO. If you have done a complete infertility evaluation, there could be other reasons why the treatment did not work. For that reason, you might want to do an evaluation before moving up to higher levels of treatment. I don't think IUI is an appropriate suggestion at this time. I also DO NOT recommend laparoscopic drilling under any circumstances!

Remember, what you are doing is a "natural" treatment method and your chances of pregnancy, at your age, is 18-20% per month. A normal woman (not using fertility treatments) can take 8-12 months to achieve pregnancy. So, just like someone trying naturally, you have to give yourself time. Don't let your doctor push you into more expensive treatments that you don't yet need.

Good luck,
Dr. 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.

Comment: Thank you so much for your advise, doctor. I am confident that I am moving in the right path now. So as u said I shall try this treatment for 4-6 cycles. Thanks for your time.

Can Lubricants Interfere With Getting Pregnant?

Question:

Hi there. I was wondering if you can tell me if using a lubricant like KY sensitive Jelly can hurt your chances of getting pregnant. My husband and I just started using it a few months ago and we have been trying to conceive. I just read online that it can be toxic to sperm. Does this mean that you cannot get pregnant at all while using the lubricant or that it just lowers your chances? We will stop using it if we don't get pregnant this month. Thank you. J. from New York

Answer:

Hello J. from the U.S. (New York),

The rule of thumb is that lubricants like KY can interfere with sperm mobility and therefore also the ability to achieve pregnancy. Some lubricants can kill sperm but it depends completely on the formulation. Johnson and Johnson does make a version that is compatible with attempting pregnancy and there are other companies that produce "fertility-friendly" lubricants as well. You have to look specifically for one that states that it is compatible with trying for pregnancy. Some alternate brands you might want to look at are "Pre-Seed" or "Conceive Plus".

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.

37 Year Old Fails 3 Clomid Cycles & 2 IUI's: What Should She Do Next?

Question:

Dear Dr. Ramirez: thank you for your great service!

I just turned 37 years old and have been ttc for 1 year already. My cycles all my life have been like clockwork (ovulating on day 13 in a 26day cycle). After charting and some blood tests during the early months of ttc, I realized I had low progesterone. I was put on suppositories and after another 6 months of no success, I was put on 50mg Clomid. That's when my cycle was completely thrown off. On Clomid cycle #1, I ovulated on day 19 (much later than normal), on Clomid cycle #2, I ovulated on day 14. Both cycles were followed by unsuccessful IUIs (intra uterine inseminations). On Clomid cycle #3, I ovulated on day 11, so we missed it and didn't do IUI. On cycle #4, I ovulated on day 10 and I did two back-to back IUI (again unsuccessful). My lining is fine, there are no cysts and all my blood work on all hormone levels is good within healthy normal levels. In fact my hormone levels were normal when I tested during my natural cycle before taking Clomid. Only progesterone was low and the suppositories didn't provide enough (day 21 showed 12 only), so 2 months ago I was put on PIO and that works like magic (level was 33 and 36 on day 21).

I read in on your blog that women who ovulate on their own shouldn't take clomid, which may REDUCE their chances of getting pregnant. Did we undertake the wrong treatment? Again, until I started clomid, you could set your watch by my cycle and I could check my ovulation using the monitor. After taking Clomid, my monitor cannot register any hormone changes and peak ovulation anymore. I was told that given my age the next thing to do is move to a more aggressive treatment (injectables), but if I was so regular and ovulating on my own, why do i need the injectables?

The fertility center never did an ultrasound to see how mature my follicles are during my natural cycle (they did this only when I was on Clomid), so my inclination is to get off clomid and try a natural cycle for a few more months again and ask them to see if my follicles are large enough. Would you think that's wise or shall I move to more aggressive treatments? My husband's sperm count varies from 25mil to 100mil during the IUI cycles. He also had average motility of 90%. Semen analysis also indicated 80% morphology.

Thank you kindly for any advice you may be able to offer. L. R. from Lancaster, PA

Answer:

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

The main problem, and only problem that you have identified, is your age. I call this the age related egg factor. This means that the eggs have aged and have decreased in quality and viability. A study was done to look at embryos created at 37 years old and did genetic testing on those embryos and found that only 20% were normal, a reflection of egg quality. So that is the hill that you are trying to overcome.

In this case, the use of fertility medications is to achieve "superovulation" not ovulation. The main use of Clomid is to induce ovulation in women that are not ovulating but in older women, the goal is to increase the number of eggs that you ovulate to increase the chances that you will ovulate a good egg. In my patients over 35, my goal is to get them to ovulate 3-5 eggs per cycle. In my blog what I am referring to is the tendency for general docs (family practice and Ob/Gyn's) who automatically place an infertility patient on Clomid without finding out the root cause of their infertility, as if Clomid were some magic drug. They are misusing the medication.

In your case, because you stated that you are at a fertility center, I presume that you have undergone an infertility evaluation and nothing was found except for your age, so superovulation would be a reasonable first step. I also don't recommend consecutive Clomid cycles because Clomid works by blocking estrogen receptors and too much Clomid with block the estrogen receptors that are necessary for fertility, such as tubal motility, endometrial lining development and cervical mucous production. In that case repetitive Clomid cycles can lead to infertility by blocking these receptors.

Because of your age, I do believe that you need to pursue an aggressive treatment plan. I usually do not recommend more than 4 IUI cycles as part of an aggressive treatment plan because studies have shown that most patients will get pregnant within four attempts and pregnancy rates decrease dramatically after four. Keep in mind that at your age, your pregnancy rate per IUI cycle is only 12%. But if you want to continue to try IUI, then it is reasonable to try with injectables, although these meds are a lot more expensive, for two more carefully monitored and timed cycles. Then if that is not successful, I would strongly encourage you to proceed to IVF.

By carefully monitoring, I mean that ultrasound screening should begin at cycle day #9 the proceed from there depending on the size of the follicles. The closer you get to ovulatory size, the more frequent the ultrasounds will be. HCG should be given to trigger the ovulation. IUI's should be done at 24 and 48 hrs after the HCG trigger and then the progesterone is started the day following the second IUI and continued until the bHCG. Progesterone should be given as a vaginal suppository 2-3 times per day depending on the formulation.


Good Luck and thank you for reading my blog!

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.

Right After A Cancelled IVF Cycle, Try Naturally Or IUI?

Question:

Dear Dr. Ramirez,

I write to you from Los Angeles, California. I am 38 and just started an IVF (in vitro fertilization) cycle after two FETs (frozen embryo transfers) that did not take. Those embryos from the FET were from an IVF I did when I was 36 that resulted in my wonderful son. I am on Bravelle and went in for my first ultrasound and they saw only two developing maturing follicles, one on each side, that were outpacing all the rest. Previously, they had seen about five on each side. My doctor has cancelled this cycle but recommended continuing on the Bravelle for two more nights and then trigger ovulation and timed intercourse. My questions is, should I do IUI instead of just timing intercourse? I know that my chances are very low of conceiving anyway, but my feeling is that if we are paying for the meds and these ultrasounds, that perhaps we should optimize our chances, even though they are very low. The doctor was trying to minimize our costs and suggested timed intercourse instead of the IUI.

I am hoping that these two years that have passed since my son was born haven't led me to be a 'poor responder.' The doctor said that sometimes this happens and that we can try a fresh ivf cycle next month and he would increase the amount of the stimulation drugs.Any thoughts on IUI versus timed intercourse or anything else?

Answer:

Hello S. from California,

I don't recommend canceling IVF cycles normally because you never know if the perfect egg is in one of those follicles. In addition, despite the fact that two have outgrown the others, that does not mean you can't get mature eggs from the other follicles. There have been studies that have retrieved mature eggs from follicles as small as 10 mm. So even if there is only one follicle, I like to give it the best chance that we can. I know that this is a more expensive way to go, but I've had numerous pregnancies from just one follicle. Bear in mind that IVF has a significantly higher pregnancy rate, even with only one egg, than any other method at your age, per cycle. In my center it would be 70% pregnancy with 40% continuing with IVF vs 7-10% with IUI.

That is because, if you image how the natural cycle process works, it takes 10 steps for your body to accomplish a pregnancy:
(1)Brain sends FSH to stimulate the ovary to grow follicle
(2) Ovary grows follicle
(3) Follicle ruptures out of ovary (ovulation)
(4) egg is pulled into the culdesac with the fluid from the follicle and finds (or has to find) tube within 12-24 hrs
(5)Egg is picked up by the fimbria of the tube
(6) Sperm and Egg meet within the tube and fertilization occurs
(7) Egg travels down the tube and divides into blastocyst
(8) Embryo enters uterine cavity
(9)Embryo hatches and exits from its shell
(10) Inner mass attaches to the uterine lining and the lining grows around the embryo (implantation)

With IVF, steps 1-8 are accomplished for you and only two steps left up to chance/nature/God, whereas with IUI, only steps 1 and 2 are accomplished for you. The rest occurs naturally.

In any case, there are several issues you have brought up and questions that correspond. One is whether you should do IUI vs try naturally right after a cancelled IVF cycle. Statistically, IUI has a better chance of pregnancy than pregnancy (7-10% vs 5%), so for that reason alone, I would go with IUI. I would recommend following the exact same protocol as you would of with IVF except that retrieval and transfer will not occur. I would do the same progesterone supplementation.

The other issue is regarding your stimulation. It is obvious that you were not stimulated with the max protocol if you doctor commented that they are going to increase it. You may have a decrease in response but without getting maximum stimulation, you don't know that for sure. So, you may not be a poor responder. You just did not get stimulated adequately.

The good news is that you have had one successful pregnancy. It is a good thing that you are pursuing having the second at 38 yr.s, before you become much older and the rate of success drops dramatically.

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.

Infertility Bloggers Offer A Great Support Network!

Dear Readers:

I would like to refer you to some of the blogs that I follow that I consider worthwhile. Some of these ladies are still going through IF, some have finally achieved the pregnancy that they have been hoping for, some are going the adoption route & all are infertility advocates. I admire them for being willing to share their infertility journey publicly. They all welcome your comments & laments. Here are some: http://www.thefertilityblogs.com/ (a collection of bloggers), http://www.pouringoutmyinsides.blogspot.com/ , http://www.infertilityoverachievers.com/ , http://www.fromiftowhen.com/(in her 2ww period now), http://www.roadtohappilyeverafter.com/ (PCOS w/6 IUI's now pregnant), http://www.fertilitychick.blogspot.com/ (one of my fav's...on a break from IF treatments) and of course, one of the most popular blogs out there, the very funny, sometimes heart-breakingly so, http://www.999reasonstolaugh.com/ .

Another great resource: A few months ago I participated in Melissa, "The Stirrup Queen's", very rewarding "ICLW " infertility blogroll (http://www.stirrup-queens.com/2010/08/icomleavwe-august-2010/). On her website you will find a links this month to 166 blogs !!! Melissa has been blogging since 2006. To quote her: "Blogging is a conversation and comments should be honoured and encouraged. I like to say that comments are the new hug–a way of saying hello, giving comfort, leaving congratulations." In addition to Stirrup Queens, she also writes the daily Lost and Found (LFCA).

If you have a blog that you want to add to my list...please leave a comment & I will add it! Good luck on all your journeys, and remember:

"All of life is a journey; which paths we take, what we look back on, and what we look forward to is up to us. We determine our destination, what kind of road we will take to get there, and how happy we are when we get there." from A Little Book of Happiness

Edward Ramirez, MD

Infertility Blogger...& Friend

Husband In Oman Concerned With Wife's First Miscarriage: Should She Have A D&C? When Should We TTC Again?

Question:

Good Day! My wife is 25, we have been trying to conceive from last three years. She got pregnant as well last march, we have gone for the checkup at 6th week and could see the heartbeat at 90bpm and was asked to have a follow up after two weeks. When we were for checkup we found it as a missed carriage (sp. miscarriage) due to no cardiac activity and eventually we have to go for the D&C procedure.

Now my concern is that, how far and the success rate /time to get pregnant after a D&C procedure? Since we have been trying so hard to get one and finally got disappointed, we are very eager to get the next soon...Please reply me, K. from Oman.

Answer:

Hello K. from Oman,

The good news is that your wife got pregnant! That tells you that your body can do all the steps necessary to achieve pregnancy naturally. That is a big step because most people with infertility don't know what is going wrong. This also means that she should be able to get pregnant again.

My recommendation is NOT to do a D & C, wait up to four weeks to see if your wife will miscarry naturally and if she doesn't ask for a "medical miscarriage". This is where we use a combination of medications to induce the miscarriage. There is always the danger that an over-vigorous D&C could lead to scar tissue formation called "Asherman's syndrome." Of course, if a "medical miscarriage" is not available where you are, then the only option is a D & C.

Once the miscarriage occurs or D & C, then your doctor should follow the blood pregnancy hormone levels until they go down to "0". At that point, it will take 4-6 weeks for your wife to have another period. Once she has this, you can begin trying for pregnancy again. There is no need to wait any longer than the start of your wife's period, which an indication that her ovaries have begun functioning again.

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.

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

Secondary Amenorrhea...Low Estrogen?

Question:

Hi! I'm writing from the UK and hoping I can finally get some answers!
I had my last depo provera in Dec 2008. This ran out in March, and I had a light menstrual bleed in April but nothing since. It is now November!

My husband and I are wanting to conceive so in July we went to my GP and I was given Noresthisterone, 3 times a day for 10 days. I did NOT get a withdrawal bleed. I had some blood tests done, and I was told by a lucum doc that they were all normal. But in my opinion he didn't look sure, as he kept looking at them.

I have read that if you don't get a withdrawal bleed it could be due to low estrogen. Do you think this could be the case with me? And if it is, what would be the next step? I am desperate for my menstrual cycle to return so we can start to conceive.

Can you give me any advice, or anything that I could ask my doctor about? Many thanks!

Answer:

Hello,

You are correct in that if you do not get a withdrawal bleed after progesterone (Norethindrone), then that indicates that the uterus was not primed i.e. you did not have estrogen aboard to create an adequate uterine lining. Hormone testing would be the first check. Unfortunately, the FSH, LH test needs to be interpreted, not just checked against the laboratories normal and abnormal. A woman cna have an abnormal level but be within the normal limits for the laboratory testing results. For example, the FSH level could be 35, indicating ovarian failure or menopause, yet this is within normal testing limits. The reason this is important, is because if the FSH level is elevated, that indicates that you ovaries have shut down. An example of this occurring at a young age is called premature ovarian failure. In this case, you will be unable to become pregnant naturally, and without using an egg donor. I am not saying that is what you have, but the hormone test is very important to know where you stand.

Most likely, you have an ovarian dysfunction, whereby the ovary is not working correctly so that you are not ovulating and not producing estrogen. This is the most common reason. The FSH and LH levels would be normal and less than 20. In this case, you will need fertility medications to stimulate the ovaries to ovulate so that you can become pregnant.

I would recommend that you see a fertility specialist if you can. He/She will be able to make the diagnosis and recommend an appropriate treatment. A GP cannot do those and does not have the appropriate knowledge base to help you.

Sincerely,

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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