U.K. Patient with Inactive Pituitary and History of Bulimia Trying To Conceive

Question:

Dear Dr Ramirez,first of all I would like to thank you for taking the time to read my question. I'll give you a brief history of my problem. I have a history of anorexia/bulimia which became very serious when I was 18, I lost around 20 kilos of weight in under two months when I was 19 and since then have not had my periods. I am now 27 (will be turning 28 in three months). I also developed bilateral, simple, unilocular ovarian cysts that were removed through laporoscopy when I was 23.

I am 99.99% cured of my eating disorder now, my weight and BMI is normal, but my estradiol levels are extremely low (around 40 whereas they should be around 400 (?) at my age?). All other causes of secondary amenorrhea have been ruled out, I have been thoroughly checked and there is no problem with my ovaries, fallopian tubes or uterus, and the hormonal levels show an inactive/hypoactive pituitary.

It might help to add here, when I was about 24, I had an attack of ventricular fibrillation due to low potassium levels because of all the purgeing. The blood supply to my brain was compromised for about 5 - 10 minutes (if not more). I was wondering if that might have affected my pituitary in some way. I recently got a bone density scan done and I have developed osteopenia, because of the low estrogen levels for so long.

From age 19/20 to 25/26 I have been on and off of contraceptive pills, which were being prescribed to me first to deal with the ovarian cysts, and after the removal of the cysts, as HRT, but at that time my weight and BMI were below normal.I have recently brought my weight to normal (my BMI had been around 18 since last year, and I have brought it to 20 - 21 just recently after being told by my doctor to do so)and I have been put on Prempak C as HRT (one month ago) after being off of any contraceptive pills or anything for more than a year.

My questions are:

1) Will this HRT with Prempak C help awaken my pituitary? so that my periods might become regular on their own? Or will I be on HRT for life?

2) Will I regain my bone density with the help of this treatment?

3) I am married now and we are trying to conceive, could you please tell me what the risks involved would be? I mean will my low bone density be a problem? Will I be able to sustain the pregnancy with my inactive pituitary? Will my condition affect the health of my child?

Thank you so much for your time and consideration. Kindest Regards.

Answer:

I am glad to hear that you are almost cured of your eating disorder. As you know, the worst outcome is death from such a disorder.

The decreased oxygen insult could certainly have affected your pituitary, causing it to become inactive. We have seen similar cases after hemorrhage from childbirth. If that is the case, your FSH and LH levels will be almost 0. You would have what is called hypogonadotropic hypogonadism i.e. the ovarian function would be low because of low pituitary stimulation. In that case, you will need to receive pituitary hormones for the ovary, thyroid and adrenal in order to have a normal body function. If you have normal thyroid and adrenal function now, then you do not have this disorder, only an ovarian dysfunction. Female hormone levels must be checked on the 2nd or 3rd day of the menstrual cycle in order to find the baseline because the levels vary during the cycle. The estrogen level that you report is within the normal limits. 400 is not a normal findings unless you are undergoing fertility treatments. The peak estradiol level in the mid-cycle is around 200-250. If the anorexia was the cause of your lack of ovarian function, then with return of your body to normal, that should return your ovarian function. If it does not, then there could be an inherent ovarian dysfunction as well.

I do not believe in bone density tests. I have NEVER seen a woman have a normal test. Everyone, has osteopenia based on these tests, so I can't give a lot of credibility to the results. That being said, however (my bias#, if you have a lack of estrogen production, you can certainly develop osteoporosis, as well as other problems. For that reason, it is important to have estrogen replacement therapy if you are not producing it on your own. The easiest and best method for a young woman under 45 yo is to use the birth control pill. Menopausal hormone replacement therapy, like what you are taking, is NOT made for young woman and does not give sufficient estrogen for your increased metabolic requirements. The birth control pill is better because it has an increased amount of estrogen.

If you are trying for pregnancy, that is another issue and should take precedent. Of course, you cannot be on the birth control pill if you are trying for pregnancy. Getting your weight up to normal is a good start. If ovarian function does not return on its own, then you will need medication to induce ovulation. Without ovulation, you cannot get pregnant using your own eggs. In that case, you need to see a reproductive endocrinologist to diagnose what needs to be treated (pituitary or ovary) and place you on the correct regimen and hormonal supplementation. Once your pregnancy gets past 8 weeks gestational age, the placenta will produce the hormones that it needs, so you will no longer require the supplements. Your child's health and well being will be independent of this treatment.

I'm sorry for the long reply, and the short reply. I cannot cover all the topic in detail because it would take too much space. What you have is a complex issue, but easy to treat if you are in the right hands. Don't worry.

Follow-up Question:

Dear Dr Ramirez,

I'm extremely thankful for your detailed response, I feel very comforted as well that you understand my situation and also that I understand it better now myself too!

I just wanted to tell you that my FSH and LH is within normal range, so I'm glad it's not hypogonadotropic hypogonadism, which I guess is good news.

Secondly, I'm very happy that it's no big deal that my come density scan showed osteopenia as you say bone density scans are not accurate, but my aunt also got hers done, she's a young 53 yo and her scan showed normal come density. But I feel fine really, no bone pains or anything.

Could you please tell me further that with normal weight and normal eating habits, how long it might take for my normal cycles to start on their own? And if there is anything further that I can do or discuss with doctors here to help me get better?

Thank you very much again.

Follow-up Answer:

Hello Again,

Good to hear that your FSH and LH are normal. Then, we can assume it's an ovarian dysfunction. Normally, I would expect your periods to resume within 4-6 months of achieving a normal weight, but to speed things up, you could go directly to ovulation induction (if you're trying for pregnancy or the birth control pill for three months to kick start your ovary).

Sincerely,

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 Treated Without Appropriate Testing Equals One Confused Patient & Poor Results

Question:

Hello, I am writing from somewhere in the United States. My husband (35) and I (30) tried to get pregnant for about 13 months with no luck. After initial bloodwork where everything looked good except for slightly elevated testosterone, my doctor put me on Femara. I did day 3 bloodwork to check FSH, which was normal, and then took 2 pills a day for 5 days and checked my progesterone on day 21. It was 0.5. So we decide to do another round of Femara. Both times I had to take provera to start my period. After doing the exact same thing with this round, my progesterone was still 0.5. We discussed that injections would be the next option.

I guess my question is did I do enough before moving to injections? And also I feel like I need to have an ultrasound before doing anything else to check my ovaries, look for blockage in my tubes, etc. Should I request an ultrasound to check for those things or is that something that the specialist will do anyway before starting injections? I just don't want to do the injections unless they are absolutely neccessary. BTW-My doc has finally referred me to an infertility specialist.

Answer:

Your story is one that I don't like to hear because I think you have been mismanaged. You should have undergone a infertility evaluation before starting any medications/treatment, but I know that a LOT of general Ob/Gyn's and Family Practicioners like to go straight to a trial of treatment. A basic infertility evaluation is:

1. Cycle day#2/3 hormone panel

2. Hysterosalpingogram - check tubes

3. Hysteroscopy or Hysterosonogram - check uterine cavity

4. Laparoscopy - check pelvis (optional at the beginning#5. cycle day#21 progesterone level

6. Cycle day#26 endometrial biopsy - check endometrial development

7. Semen analysis

8. Pelvic ultrasound

9. Cervical cultures

Before moving further into treatment, especially injectables, I would recommend that you have the above testing done.

However, if you are going to go directly to treatment, you might want to try high dose Clomid #150-250 mg# first before injectables. Many patients will not respond to Femara but will respond to Clomid. Also, a proper ovulation induction cycle with Clomid, Femara or injectables will use the ultrasound at the beginning of the cycle, before starting medication, to make sure there are no ovarian cysts and get a baseline, then starting from day# 9 or 10, to evaluate the ovaries for #1# response to medication, #2# how many follicles are growing and #3) when to give HCG to stimulate ovulation. This also will help to know when to have intercourse or insemination.

Hopefully, your infertility specialist will advise you better than your previous doc.

Follow-Up Question:

Thank you so much for your response! You confirmed what I was thinking. I plan to request everything you listed in your steps 1-9 when I see the specialist. So I know what I'm talking about when I see the doctor, what is the reason for the pelvic ultrasound, cervical cultures, and checking the uterine cavity?

Also, I failed to mention in my first question that when I went off the pill I had normal periods for 2-4 months and then it started getting longer and longer in between periods (30-50 days). Then this past July 6 I had my last period and haven't had one since (except when taking povera for that purpose). I first started having my period at 13 and from age 13-19 had perfectly normal periods. I went on bc at 19 and stayed on them until right before my 29th birthday, and of course had very regular periods during that time. So I know that it looks like basically I'm just not ovulating, but any ideas on what else might be going on? I know it could be lots of things, but I'm just worried and seeking as many answers as I can before seeing the specialist next week.

Thanks so much

Follow-Up Answer:

Without the right tests I cannot comment on your irregular periods. I'm sure the infertility specialist will do a proper evaluation. Each test evaluates for the specific steps in the process your body goes through in order to get pregnant.

1. Ultrasound - to look for ovarian cysts, tumors, uterine fibroids, enlarged tubes or other structural abnormalities in the pelvis.

2. Cervical cultures - check to make sure you don't have any STD's or bacteria that might affect/kill the sperm.

3. Hysteroscopy - the uterine cavity is the critical place where implantation takes place. It needs to be completely normal.

You have to undergo the testing I mentioned previously to find out why your ovaries may not be working properly, hence probably, the irregular periods. It could be an ovarian problem, pituitary problem, thryoid problem, hypothalamic problem, etc. Your specialist will work with you to figure things out.

Good Luck and be sure to always take a pad of paper along for your question & answers while you progress with your evaluation.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

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

Patient From India With 2 Ovarian Cysts For 5 Years: Cystectomy or Ovarian Wedge Resection

Question:

Hi, doc.

I have 2 cysts of size 2-3 cm on my rt ovary since last 5-6 years. My gynae has advised for analysis and removal of the cysts laparoscopically. I would like to know which is the best procedure for the same and wedge recesection is good or any other procedures are now available for this.

I am 26 years old , and I'm writing from India. Thanks for ur help. Regards.

Answer:

Hello and thank you for your question.

Certainly if these cysts have been there for the past 5-6 years, they should be removed! I would have done that years ago. It is most likely that these are benign tumors of some form.

However, the only way to be sure is to remove them and analyze them pathologically. Laparoscopy is the best way for removal if done by a doctor with experience. I would only recommend removing the cysts (cystectomy), not wedge resection or removal of the ovaries. The latter two will affect your ability to become pregnant in the future by increasing the chances of scar tissue formation. The benefit of laparoscopy, as opposed to laparotomy (open procedure) is that there is much less scar tissue formation.

I hope this answers your questions.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Post IVF Transfer Pain: Implantation Pain or Ectopic?

Question:

My wife says that she was experiencing sharp pain yesterday (10 days after FET) on the area near right side of her stomach. She experienced the pain only yesterday and that was during a 3 mile walk. Today she says she feels some pressure near the right ovaries.

I'm concerned. Could you please let me know your suggestions? Thank you.

Answer:

Thank you for your question. This could be normal, but the main concern would be an implantation that occurs in the tubes called an ectopic pregnancy. I wouldn't jump to this conclusion but it is a possibility. This could also be what we typically call "implantation" pain. Please see my overview of what happens after the IVF transfer including pain and bleeding here: "After Your IVF Procedure".

Let me go into more detail regarding both possibilities.

All patients with infertility are at increased risk for an ectopic, even with IVF. The incidence is low but it occurs. At 10 days post transfer I usually have done my pregnancy test. This can give a better idea of how the pregnancy is doing and whether or not an ultrasound will show anything. Generally, the BHCG level has to be over 3000 to see a pregnancy in the uterus and if it is not there with that level, then an ectopic pregnancy as to be assumed. At only 10 days post transfer, it is unlikely to be an ectopic, however. These usually do not become symptomatic until 6-8 weeks of the pregnancy. At this point, it is probably not anything serious.

Pregnancy can also induce other kinds of pains and discomforts. We call them implantation pain or growing pain. Sometimes women tell us that they "feel" a sharp pain within a week or two post transfer. I cannot discount that sometimes the women who complain of this pain (and I have IUI patients who tell me the same) do have a positive pregnancy test. Another possibility on the right side, of course, would be appendicitis. You can still get other illnesses despite trying for pregnancy. However, appendicitis, is progressive and does not come and go. Once the pain started it would progressively get worst. That doesn't fit your wife's scenario. Without further evaluation it is hard to know what is going on. You should probably bring this up with your doctor.

As a side note, if your wife is actively trying to get pregnant using IVF or FET, then I would not recommend a 3 mile walk right now. She should limit her activity to more sedate activities. A short normal walk would be fine, but power walks are not recommended as are heavy exercises like aerobics, karate, gymnastics, running, etc.

Good luck with your cycle and I hope that this will be a success!

Sincerely,

Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

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

Question:

I have PCOS and I've started IVF (in vitro fertilization). I have concerns because I don't really understand what is going on. They say they want my estrogen level up and that it is going in the right direction but they keep increasing my medication. Why? How can I tell if it is working?

I have started since January 22nd. Is it normal to continue and what questions do I ask my doctor to see if my chances remain good?

Answer:

Thank you for your question, it's always good to know exactly what is going on so don't hesitate to ask your doctor as many questions as you can. Take a pad of paper with you and write down the answers if you need to.

Let me begin with our protocol at our clinic for patients such as yourself. With PCOS patients we have to be very careful because if you over-respond, you could develop and illness called ovarian hyperstimulation syndrome (OHSS). Many IVF programs use a protocol called a "step-up" protocol whereby you start on a lower dose and it is slowly increased based on your estradiol levels and ovarian response. They should be doing ultrasounds at the same time to see how many follicles are growing and what size the are. Once it looks like you are stimulating, the dose is usually kept constant until the follicles reach the appropriate size for retrieval (18-24 mms).

If you started on the 22nd of January, your cycle is definitely going kind of slow. Most patients will respond within 10-16 days. I would presume you are getting closer.

If your doctor is not explaining these things, then you need to be more insistant that you want an explanation at each visit. Most doctors, or their respective nurses, will then explain how things are going and what the goal and timeline is. We can usually predict, within a day or two, when you will be ready to retrieve.

What you should ask is:

1. How am I doing?

2. Am I responding to this dose or protocol? Are my follicles increasing?

3. How many growing follicles do I have?

4. When are you expecting me to be ready to retrieve? Transfer? Explain that you need to plan the date.

5. What if I have too many follicles? Will you cancel me? Do you Coast? Will you trigger with HCG or Lupron? (Lupron is what I use because it has a shorter duration of action and has been shown to decrease the incidence of OHSS if there are too many follicles and the estradiol is too high (over 4000).

6. What is my estradiol level? (the goal is to have a level of 2000-4000 at the point that the follicles are ready for retrieval. If the estradiol level is over 4000, then the risk for OHSS is higher).

I hope this gives you enough questions to ask for now. Keep informed and stay in touch! Good luck!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

44 Yr. Old Has Clomid Challenge Test

Question:

Hi Dr. Ramirez,

I'm 44 yrs. old and recently had a clomiphene citrate challenge test with two ultrasounds. I took 100 mg. of Clomiphene Citrate from days 5-9.

The results are as follows: Before Clomiphene Citrate: FSH 5.5, Estradiol 131, with a baseline vaginal ultrasound showing one follicular at 4.2mm in right ovary(I believe) and endometrial lining 4.39, could not locate left ovary. Then, after taking last cc pill another blood test on 11/14 showing FSH of 27.6 and Estradiol of 90. Then, another ultrasound on 11/16 showing two follicles, 10.0 mm, 10.2 mm, in right ovary and 6mm in left ovary, with endometrial lining of 8.2 mm.

What are my options? Should I pursue taking HCG shots or other fertility drugs using my own eggs? Should I pursue donor eggs? My sister is willing to donate her eggs, she recently had a normal, healthy baby boy 10 months ago and she is 41 years old. Thank you in advance for your answers.

Answer:

Thank you for your question.

The purpose of the Clomid challenge test is to evaluate if the ovaries will respond well to stimulation. The Clomid is used for stimulation. A "positive" test is when there is an elevation of the FSH level on cycle day# 11. This shows that there is significant resistance to stimulation and the ovary will probably not stimulate well. The only way to overcome the "age" factor is to get lots of eggs from the ovary. If only a few eggs are retrieved, then the chances for success decrease significantly. Your ovaries are still working, which means that you can be stimulated to get a few (1-3) eggs, but the chances for pregnancy are not good. I do have patients try this but it is with this clear understanding. Most patients do want to try at least once on their own. As I tell them, there are always exceptions to the rule and you only need one good egg, so from an emotional and psychological point of view, it might be worth the try. Expect the worst, however.

Donor eggs is probably your best chance for pregnancy from a statistical point of view. Although your sister was recently successful, she is not the best donor candidate. IVF pregnancy rates are very dependent on the eggs retrieved. If you are going to use a donor, you want the best eggs that you can get. For that reason, we recommend donors that are under the age of 35 years old. The other problem with older eggs is the risk of genetic abnormalities, such as Down's syndrome. You would have a risk of 1:50 for this syndrome with your sister's eggs. I am sure that both you and she would be crushed if that happened. Therefore, I would recommend that you consider an anonymous donor under the age of 35.

I hope this helps,

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com