High Dosage Of Clomid For A "Good Egg": Why Double The Dose? Will It Affect Egg Quality?

Question:

Hi Dr. Ramirez,

I am writing from Philadelphia, PA and am 39 years old. I have had 9 pregnancies, 7 miscarriages and 2 live births. Since my last child I have had 4 miscarriages and two of the pregnancies I got pregnant with clomid (100mg a day, days 2-6).

I recently switched doctors and the new one recommended IVF with genetic testing because three of my misses were confirmed chromosonal abnormailites - but nothing else has ever been found wrong and I do have two perfectly healthy children. Well, I decided I don't want to do IVF and just take my chances of getting a "good egg" (although the last 4 weren't, I'm still hopeful that one will be). O.k, now for the question... this new doctor wants me to take 250mg of clomid days 4,5,6 and then 200mg days 7 and 8. Why more than double the dose when the lower dose got me pregnant before? Is this safe? necessary? When I call, the nurse says they want to increase my chances, but clomid doesn't effect egg quality does it? Thank you for any advice, thoughts, you can offer.

Answer:

Hello J. from the U.S.,

I am very sorry to hear about all your losses, but your age is the culprit. That is what I call the "age related egg factor". As the woman ages, the quality of her eggs decline and so there is an increased risk of abnormal embryos leading to pregnancy failure or miscarriages. IVF is recommended because we are able to get multiple eggs at the same time. With the increased number of eggs, there is a higher chance of getting a good egg that will lead to a healthy pregnancy.

PGD (pre implantation genetic diagnosis/screening) does not necessarily need to be done. In fact, I am not a big proponent of PGD if this were the only reason. I believe that the poor quality eggs will not work with IVF (i.e. not progress to viable embryos in the petri dish) and if a pregnancy ensues from the good embryos the chances are higher that it will be normal. If you absolutely want to make sure that only genetically normal embryos are transferred then PGS will be required. But then, you would have to do IVF, which you have opted not to.

The reason your doc is recommending high dose Clomid is to increase the number of eggs that you ovulate. Clomid is not the best drug for this but it is the least expensive. Using injectable medications is better but a lot more expensive. That is the only reason for using high dose Clomid in your case. By increasing the number of eggs ovulated, he is hoping that one of the eggs ovulated with be a good quality egg, just like we are trying to do with IVF. However, it may take several attempts, and you may still have miscarriages, whereas IVF would work faster and your chances of a successful pregnancy are higher.

To address your last question, Clomid will not affect the egg quality. That is already inherent in the egg. Perseverance is key in your case. I believe in letting my patients decide how they want to progress with their treatment path. You will need to keep trying, but it may take many cycles. If the miscarriages and heartbreak continue, and you truly wish to have another child, then you may have to consider in vitro fertilization.

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.

42 Year Old UK Woman With Irregular Periods, Hot Flashes: Is She Perimenopausal? Can She Still Get Pregnant?

Question:

I am 42 years old and have had irregular periods for about the last 10 months, also hot flushes, etc. I have had blood tests at my doctors which showed I have started early menopause. How do I know if I am still producing any eggs and if so could I become pregnant? Is there anything I could do to help in getting pregnant or is this not going to be possible? Thank you, S. from the U.K.

Answer:

Hi S. from the U.K.,

The term "early menopause" is actually a misnomer. There is no way to tell if a woman is entering menopause until it actually happens. That is to say, a woman can be in the perimenopausal period, diagnosed by changes such as irregular cycles, mood changes, hot flashes, insomnia, etc., for years (5-10 yrs) before she actually goes into the menopause. During the peri-menopausal period, the ovary is starting to dysfunction as it leads into menopause, where it shuts down. During this "perimenopausal period" the ovary still ovulates, but often in an irregular fashion. Therefore, pregnancy can still occur. However, the chances are low, and some of the times that you ovulate, and egg is not given off i.e. the follicle is empty.

Some doctors will define "perimenopause" if the cycle day #2 FSH level is greater than 10 (between 10-20), but this actually is a measure of ovarian reserve and does not tell you if menopause is coming soon or not.

The biggest problem, however, is if the ovary is dysfunctioning, the hormones are out of balance and so, the steps following ovulation sometimes are out of synchrony so that pregnancy does not occur, and due to age, the ovulated eggs are often of very poor quality such that fertilization does not occur, or an abnormal embryo is formed that does not go to implantation or that the abnormal embryo leads to miscarriage. For these and other reasons, the chances of a successful pregnancy decline.

If you are contemplating pregnancy at this point, and have not entered menopause, then you have to worry that time is not on your side. That is to say, your time is short to achieve the pregnancy. Therefore, you need to proceed aggressively and with haste. For that reason, I recommend to my patients to do IVF. It has the highest chances of getting you pregnant in the shortest period of time. Trying by natural means, simple intercourse, ovulation induction with intercourse or IUI, will take much time, and you may lose your window of opportunity to use your own eggs.

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.

Prior D&C And Infertility: Woman From Barbados Needs A Thorough Infertility Evaluation

Question:

Good Morning All.....My name is D. and I'm from Barbados in the West Indies. Just to give you a bit of background info on myself and hopefully you can make suggestions for me.

I've read the testimonials on the site and I was very touched and moved by the numbers of persons who were able to receive some type of positive assistance regardless of how small of how large.

In 2005 I had an abortion which resulted in me having to have a D&C and I've not been able to get pregnant since. I say not since 2005 because I remember at some point in 2008 having a very faint positive on a pregnancy test but to this day I cant be sure because the next day I did the test again and it was negative ....so I don't know if it was a false positive if it was a true positive or what it was.

In 2007 I saw a fertility specialist and had some tests done. I specifically had the test done where they run the dye through the tubes to see if they are opened and both tubes were opened. At the end of of various consultations the specialist told me that she couldn't find anything wrong and that only thing she could think of was that I had some scar tissue in the cervix area which was blocking the sperm from entering the cervix and travelling on to meet the egg....she said she arrive at that because it was difficult for her to pass the tube to eject the dye through the cervix. She said the only way I would be able to get pregnant is by having and IUI. Now I'm not being forward or anything and I know I'm not a doctor, but the blocked cervix theory is not sitting well with me and it doesn't seem logical at all.

I spoke to two other specialists and they too do not agree with the assessment. I have a regular 26day cycle EVERY month without fail and testing ovulation sticks shows me a surge around day 10-11 every month. The only thing is that my period has gone over the years form 5 days to perhaps 3 at times with clotting and dark blood or brown blood at time.....other that that it is like clockwork every month.. It doesn't make sense that blood and clots would be able to pass through the cervix and sperm cannot pass through the same opening.

I'm of Christian Faith and I've put the entire situation in God's hands but I think can also prepare my body for when he decides to bless me. I keep thinking that perhaps herbs or something can help I don't know what to do really. I've been married now for 1 and a 1/2 years and we've been trying since 2008 but nothing. I was thinking about the Fertility Cleanse and wonder if you think that would be a good first step, if not I welcome any thoughts you may have Thank you so much for your time and please have a blessed day.

Answer:

Hello D. from the West Indies,

Thank you for your kind comments. Now, what your doctor is referring to when she talks about "scar tissue in the cervix" is probably cervical stenosis. Many women who have never had children can have a small narrow cervix. We call that stenosis. You are correct in that the blood can pass through this, so sperm should as well. Cervical stenosis is NOT a reason for infertility, but IUI will definitely help this issue.

A D&C, dilation and curettage, can lead to scar tissue formation within the uterus which is called "Asherman's Syndrome". The only way to clearly identify this is to undergo a procedure called a hysteroscopy. This is where a small scope is passed into the uterus to look inside the cavity. Scar tissue can be readily seen and if present, can be removed at the time. But this is a difficult problem because often the scar tissue will return and several hysteroscopies with removal of the scar tissue may be needed.

There are other possible causes of infertility that you may not have had checked. For instance, have you had a laparoscopy? It is a surgical procedure whereby a scope is passed into the abdomen via the umbilicus in order to examine the pelvis. The pelvis is important because this is where the egg needs to pass through after ovulation (leaving the ovary) in order to get to the tube. Abnormalities such as endometriosis or pelvic adhesions can prevent the egg from getting to the tube. In addition, has your husband had a semen analysis done? Have you had a end of cycle endometrial biopsy to check to see that the uterine lining (endometrium) is forming correctly? These are just some examples of fertility testing. Lastly, you have not mentioned your age. Advanced age (over 35 yo) can play a role in egg abnormalities.

If you have had all this testing and still nothing has been found, then you would be categorized as an "unexplained infertility". This just means that we have not found a cause, and the most likely reason is because we don't have the technology to find the cause. Many of these patients have to resort to IVF (In Vitro Fertilization) in order to achieve pregnancy because there might be a sperm-egg fertilization problem (which you cannot test for). If your doctor is a fertility specialist, then she should be able to map out a treatment plan for you. Before resorting to alternative treatments that may not work, please go over some of the suggestions I made with your doctor.

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.

Comment: I was kind of skeptical in looking for a response.Like most online Q&A I expected a vague response at best and I expected the doctor to be as short as possible considering he wasnt being paid but I was pleasantly surprised with Dr Ramirez...he was great and I got more info from him than I did with my own doctor... Thank you so much Dr Ramirez and may God bless you as you seek to help others :)

Stage IV Endometriosis Patient Trying To Conceive: More Time, More Surgery or IVF?

Question:

I was diagnosed 4 years ago with stage IV endo after having it excised during a lap. I had a Mirena IUD inserted during surgery and just had it removed a few months ago because I am ready to have a baby. I am very regular (26 or 28 days) and ovulation predictor tests show that I am ovulating on day 12 or 14.

Five cycles later we are not pregnant. I feel my ovaries pinch a few days before my period and am back to having pretty bad menstrual cramps (though not as bad as before the surgery). I have read a lot of your responses and see that IVF (in vitro fertilization) is your advice for stage IV endo. Do you think I am ovulating normally and what do you think my next step should be? I have a doctors appointment and am very nervous that he is going to suggest another laparoscopy!

Thank you in advance for your time. M. from the U.S.

Answer:

Hi M. from the U.S.A.,

Thank you for reading my responses. Technically, you have not tried for pregnancy long enough to suspect that a problem exists. We do not define infertility until a woman under 36 has been trying for at least 12 months because it takes most women in that age group 8-12 months to achieve pregnancy naturally. If you are 36 or older, then 6 months would be the limit.

Certainly because of the history of stage IV endometriosis, you have a significant impairment to your natural fertility. Mirena helped, but it is not perfect. There is no treatment to eradicate endometriosis completely, and so it is highly probable that endometriosis is still present in the pelvis. In addition, stage IV endometriosis implies that there has been significant damage to your pelvis and it is not normal i.e. pelvic adhesions, inflammation, destruction of the normal anatomy. These will impair your natural chances for pregnancy. For that reason, in many of these patients, but not all, IVF will be required to get pregnant. I have had some spontaneous pregnancies in stage IV endometriosis patients but they are few.

Let's say after six months or one year, you still cannot get pregnant (depending on your age), you will need to pursue other options. Knowing that you have Stage IV endo, additional surgery will NOT help. You may want to go straight to IVF and avoid the surgery. That is what I would recommend. Many gynecologists will recommend the surgery because that is all they can do, they don't do IVF. They would rather do something in their power than do nothing. Instead, a good gynecologist will refer you to a fertility specialist that does IVF for at least a consultation. A good infertility specialist will probably explain that the pelvis, an essential part of your anatomy for achieving a natural pregnancy, is a hostile place for the egg. Therefore, the treatment of choice is to avoid the pelvis which is what occurs with IVF.

Good Luck on your journey and don't hesitate to write again with any other 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.

Comment: Thank you so much, you have quelled much of my anxiety. The scariest part about facing fertility problems is all the unknowns and the waiting. I appreciate your help.

43 Yr Old With High FSH Of 30 Asks: Is There A Way To Lower It?

Question:

Dear Dr. Ramirez,

First, thank you very much for taking the time to answer so many questions. Your column has been an important part of my education on IVF.

I am writing from Cincinnati, OH. I am 43 years old and am considering IVF. I just learnt that my FSH is 30, substantially above the cutoff rate for my fertility clinic (their cutoff is 10). Are there any options other than donor eggs? Is there a way to lower FSH? Would love to get your perspective. Thank you. S.

Answer:

Hello S. from the U.S.,

I'm assuming, of course, that your FSH levels were accurately tested. The FSH level is only valid for interpretation if it is done on cycle day #2 or 3. The FSH is a measure of ovarian function (or ovarian resistance). This is mainly important to determine how well the ovaries will respond to stimulation. It is NOT a measure of fertility. However, if the CD#3 FSH level of 30 is correct, that would indicate that you are perimenopausal and your ovaries would be shutting down. You would no longer be having periods and you would have menopausal symptoms such as hot flashes. Is this the case?

If so, unfortunately, with an elevated FSH of 30 you are not eligible for any other treatments other than donor eggs. I'm sorry but there is no way to revive the ovaries at this time. I see on the web that there are many lay people claiming that there are "natural" alternatives like acupressure that can help lower your FSH levels. This is simply not true!

Please see my previous post:"41 Yr Old With High FSH, High Estradiol..." where I go into greater detail regarding this distressing issue. Remember, there are many paths you can take to motherhood and from my experience as an infertility specialist, all those paths can bring happiness.

Good Luck,

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.

When Should An IUD Be Removed In Order To Get Pregnant?

Question:

Hi, I am a pretty healthy 25 year old woman with two children ages 5 and 3. I am writing from Washington, DC. I currently have a copper IUD as birthcontrol. I have had it in for a little more than three years now (since I had my youngest child). My husband and I are thinking about having another baby and I would really like for the baby to be born in March, April, or May 2012. As far as I know the copper IUD shouldn't affect my ability of getting pregnant after I have my doctor remove it and I didn't have any problems getting pregnant with my other two kids.

My question is during what month should I have my IUD removed in order to get pregnant and give birth during these months. And should I have the IUD removed before or after I get my period that month? Y. from the U.S.

Answer:

Hello Y. from the U.S.,

I usually will recommend that the IUD be pulled when you are on your period. Because there is flow, the uterine cavity is more expanded and removing the IUD is easier at that time. You can then begin trying for pregnancy with that month. So, if March 2012 is the earliest you want to have your baby then you can begin trying in July 2011. You can remove the IUD with your period nearest July (end of June or beginning of July).

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.

U.K. Patient Concerned About ICSI And Husband's Diabetes: Will There Be Abnormal Embryos?

Question:
Dear Dr. Ramirez,

My husband had a semen analysis result and he had Moderate Oligospermia and Severe Asthenospermia (only 4% normal progressive). It has been suggested that we would require ICSI IVF, however my husband also has Type 1 diabetes. I have read that his sperm cells might have DNA damage and to use such sperm in ICSI could result in an unhealthy child prone to cancer. None of the professionals I have spoken to in this early stage have made any reference to the implications of my husband being diabetic and it is causing me concern.

I was hoping that you could clarify how sperm are tested for DNA damage and if it could be used in conjunction with ICSI. Also, does non-ICSI IVF avoid the risks of DNA damaged sperm cells? Would they be filtered out by natural processes? Thanks, L. from the U.K.

Answer:

Hello L. from the U.K.,

Sperm can only undergo DNA testing apart from IVF/ICSI because the sperm tested are essentially destroyed. There is not method to test the sperm prior to ICSI at the time of IVF. There is also no way to test the resultant embryos from DNA damage, but testing for genetics is possible.

There have been some studies, mainly out of Europe and using small homogeneous numbers (homogeneous meaning that everyone tested was of the same racial type such as Sweden), that showed the possibility of fetal abnormalities with ICSI. However, that has been unproven and IVF with ICSI has been around for almost 20 years. In the U.S., where the population is more diverse, studies have not shown any type of abnormalities, so the tests that were done previously in Europe might have some type of population/genetic weakness.

The fact that your husband has diabetes might explain why his semen analysis was abnormal (due to reduced blood flow in the testicles). This should not affect the embryos formed with ICSI, however. In general, the embryologist performing ICSI chooses the healthiest swimming and formed sperm for injection. There should be plenty to choose from. The embryos that might be abnormal generally do not progress, and therefore are not implanted.

Hope this helps to set your mind at ease!

Good Luck,

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 for your response. It has really put my mind at ease. It is very difficult to find a small amount of information that could have a massive impact on your children and it not seeming to be acknowledged. Regards, L.