Canadian IVF Cycle Fails: Husband Asks, Try Again?

Question:

Hello Dr. Ramirez and thank you so much for answering these questions.

My wife and I just completed our first IVF (although there was no transfer).  A previous attempt was cancelled due to only a couple follicles (150 Gonal F/150 Menopur).  We had done 2 previous IUIs with Clomid (3 follicles).

My wife is 37 and has very low AMH (0.40), FSH that ranges from 7 to 14 and an AFC of 6 to 14.  My analysis has been normal but we were recommended ICSI as it was unlikely we would get many follicles.  The clinic said they generally like to aim for 2 good ones.

To bring down FSH, my wife used an estrogen patch before her period and had 3 Ganirelix injections.  She then started 300 Gonal F & 150 Menopur on Cycle Day 2.  From Day 9 to 15 she also used Ganirelix. She was told to change the patch every other day and on cycle day 4 stop changing the patch (but it would last 7 days so would still have medication until cycle day 10).

She was slow to respond, not developing any measurable follicles (greater than 1.0) until after 7 nights of stims, but in the end, used the same Gonal/Menopur dosages for 15 nights.  Her AFC had been 14 and when she triggered (with 10,000IU HCG) on night 15 she had 7 follicles (2.2, 3 at 2.0, 1.6, 1.4, 1.0).  On trigger night her e2 was just over 2,500 (I have converted this to the U.S. value - pg/nl). 
 
35 1/2 hours later was retrieval.  They got 4 eggs and had to skip a few on one ovary due to blood vessels. The next day the embryologist called and said they had been able to ICSI 3 of the 4 and as of that morning (day after retrieval) only 1 of the 3 remained.  The next morning (2 days after retrieval) they called to say that embryo failed to divide.  It was the same the next day so there was no transfer.  They didn't have a definite answer as to why but said one of the eggs was soft and they weren't all smooth so it is probably egg quality issues.

Also - up until day 11 of stims her lining had been building well daily (to 1.2 cm).  Over the next 3 consecutive days it got thinner each day (even though e2 was rising) and was 0.9 the day of trigger.  Her lining has never been a problem in any other cycle (natural or medicated - even on Clomid).

We are trying to decide if it is worth it to do another cycle.  Could this be a fluke?  Could the long stim period have compromised egg quality (in addition to her age/FSH/AMH?)  Could ICSI have damaged the eggs at all if they were soft?  Will the blood vessels mean some follicles have to be left in one ovary at every retrieval?

Did the thinning lining indicate anything - coincidentally - when the lining started thinning her own e2 was raising daily quite a bit, but this was the same time the medication from her final estrogen patch would have worn off.  She had a bit of bleeding a few hours before the trigger shot on night 15 and was put on 8 mg/day of estrace the day of retrieval in addition to progesterone because of that. 

I would appreciate your advice.  We would like to try again but I don't want my wife to have to go through another cycle of injections/monitoring/retrieval, etc. if our results would be the same.  She had 12 days of blood tests & ultrasounds between day 2 & 15 and the 12 blood tests made it really hard to find a vein for IV at retrieval which took a couple tries.

We would like to at least make it to transfer before considering other options, but if we can't develop embryos in a lab, we're not sure if we should try again.

Thank you,

T. from Ontario, Canada

Answer:

Hello T.  from Canada,

A lot of the answers you seek are due to technical quality issues and I cannot address that.  Without a thorough review and evaluation of your wife's medical records, I cannot evaluate if I would have done things the same or differently, and whether or not that will make a difference.  Suffice it to say that I am saddened by your results, but at the same time, I am a little leery about some of the embryology outcomes.

Let me just give some information that might help you in your review. 

1.  The dosage of 350/150 is NOT the highest stimulation protocol.  Your wife could go up to the max dosage of 450/150 which might make a difference in the number of follicles recruited. 

2.  Based on the number of follicles formed, she actually stimulated well so the AFC, AMH and FSH may not be valid in predicting her decreased ovarian reserve (which does not predict fertility).

3.  I have not heard of the failure to retrieve due to "veins" or "blood vessels".  There are techniques that can be used to move and manipulate the ovaries to avoid those problems.  I have, however, had patients where I could not retrieve completely because the ovaries moved too much and deep into the pelvis.

4.  I think that ICSI in a 37 year old woman is appropriate and would concur with doing that procedure.  Keep in mind that ICSI is a procedure and "technique and skill" are critical to preventing damage/injury to the embryo.  It has been shown that ICSI done by an embryologist without adequate experience and skill can reduce embryo survival.  That could possibly have been a problem, but certainly inherent egg quality can influence that as well.

5.  Embryo quality (based on external features) are certainly based on inherent egg quality and that decreases with age.  However, that does not mean that all the eggs are bad.  Studies have shown that at 37 years old, 2 of 10 embryos formed will be normal.  The trick is to find the two good ones.  That may take several attempts or you would have the option of moving to donor eggs.  Since you have never completed an IVF cycle, you certainly have not tested whether or not it will work.

6.  Finally, I don't think I have ever had a patient that needed 12 blood tests during an IVF cycle.  The maximum I've had was 7.  Keep in mind that IVF success rates are highly variable between clinics and doctors.  Even in the U.S., rates are highly variable as compiled by the CDC.  I'm sure they vary greatly in Canada as well.  Based on what you have told me in your review, I can't help but be a little skeptical of the level of care you are receiving, but again, I can't draw any conclusions without a careful review of your records.

Good Luck,

Dr. Edward J. Ramirez, M.D. F.A.C.O.G.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Programwww.montereybayivf.com

Comment: Thank you very much for your quick and helpful response.

 

Off The Pill After 12 Years, No Period: Trying To Conceive, What Can I Do?

Question:

Dr. Ramirez,
I was on the pill for 12 years, and stopped taking it back in September of 2012 to try and conceive. I did not have a period for over 3 months, so I went to the doctor who gave me a progesterone injection. About a week later, I had light bleeding for one day. A month later, I had the same light bleeding for one day. Five weeks later, I had nothing.

I went back to the doctor and got another injection. Two days later I had light spotting and nothing else. Is this considered a cycle? I am suppose to start Clomid on day five, but I am worried that the progesterone is not working for me and that the absence of my period is something else. Also, is there any difference in results if I were to take Provera instead? I am 30 years old, and really want to start having children. Should I try the Provera or just go on to an infertility specialist? I am so impatient and ready to get started, but very frustrated. Please help! L. from Tennessee

Answer:

Hi Lisa from the U.S. (Tennessee),

Obviously your current doctor is wasting your time (and has done so three times), so I would recommend that you go see a fertility specialist. Not only will you have an appropriate evaluation done to see why your ovaries are not working, but you'll get the appropriate treatment and get pregnant in the shortest time period.

Basically, progesterone injections and Provera (progesterone) accomplish the same thing, which is to induce a withdrawal bleed. So, using Provera won't make any difference. The reason the bleed wasn't much is because you probably did not have much of an endometrial lining formed. In that case, the light bleed would be the first day of the cycle and the counting of the cycle days would start from then. However, before starting the Clomid, a baseline ultrasound is usually done to confirm that you are on your period, as evidenced by a thinned lining, and that there are no cysts in the ovaries that might prevent ovulation. Having a cyst in the ovary is a contraindication to using Clomid or any other fertility drug.

Good Luck,

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

42 Year Old TTC With Endometriomas And Low Antral Follicle Count

Hi Dr. Ramirez,

Not sure what to do.  I met the love of my life later in life and we just started trying to conceive, I am 42 years old.  We really want to have a child, but not so sure about donor eggs .  I have never been pregnant or attempted to get pregnant before. Six months ago my AFC=3, FSH=6.3, E2=117.  My results today were AFC=0, FSH=1.4, and E2=252 and two endometriomas that appear to be growing.  Could the endometriomas have caused the change in numbers?  If so, would removing them increase my chances of becoming pregnant?  I've read that surgery reduces the ovarian reserve which is not a good thing so I'm confused as to what to do.  I've also had a hard time figuring out which doctors would be gentle/skillful and not remove any unnecessary ovarian reserve, this could be crucial in my situation.  I would like to do IVF (in vitro fertilization) but the clinic I've gone to is not willing to discuss it due to the change in numbers.  Are there any clinics that will work with my numbers and the endometriomas?  We want to give it our best shot, it would mean so much for us to have a baby together.

My pelvic transvaginal ultrasound results were: 

FINDINGS: The uterus is normal in size measuring 7.9 x 3.9 x 4.6 cm.  No fibroids or other myometrial abnormalities are visualized.  The double layer endometrial thickness is normal measuring 7mm. No focal endometrial abnormality or endometrial cavity fluid is seen.

Right ovary is enlarged.  The right ovary measures 6.1 x 4.4 x 6.1 cm.  Homogeneous hypoechoic structure in the right ovary measures 5.1 x 3.9 x 5.7 cm previously 3.9 x 2.6 x 3.8 cm (on 18Nov2012 ultrasound).  The left ovary measures 4.2 x 2.5 x 3.9 cm. Hypoechoic structure in the left ovary measures 3.6 x 2.5 x 3.2 cm previously 2.0 x 2.0 x 2.4 cm (on 18Nov2012 ultrasound). No abnormal free fluid is seen.

IMPRESSION:  Normal uterus. No uterine fibroids are seen.  Homogeneous hypoechoic structures in both ovaries, increased in size since 18Nov2012.  Findings most likely represent endometriomas.

Thank you so much for any advice you can give us. L. from Virginia

Answer:

Hello L. from Virginia,

First, I think that your blood testing is incorrect.  The reason is that the FSH test is only valid if done right at the beginning of the cycle, generally cycle day#2 or 3.  I suspect that the test was not correct because your estradiol was above 100 in both tests. This shows that the ovaries were not at rest i.e. not in the early phase.

Second, I am sure that you can find a clinic or doctor that is compassionate enough to allow you to try IVF (in vitro fertilization) with your own eggs, but that will be with a complete understanding of your chances.  For example, I don't have a blanket policy to not allow patients to try as long as they understand the risks and chances.

Third, you have to understand the major problems you are facing and the impact that has on your chances.  The first major problem is your age.  This is what we call the "age related egg factor".  This basically means that because of a woman's age, the quality of her eggs decreases so that the majority are no longer viable.  As a result, the pregnancy rate decreases and the risk of miscarriage due to genetic abnormalities increases. Even with IVF your chances will be decreased, BUT they will much better than trying naturally! The second major problem is Stage IV Endometriosis.  When you have endometriomas, that automatically makes it stage four, which is severe endometriosis.  As a consequence, IVF is the treatment of choice.  You can, and probably should, try to find a very good gynecologist to remove the endometriomas laparoscopically, with specific instructions to NOT remove any ovarian capsule tissue (that is the layer that has the eggs).  That will help to give you the best chances of pregnancy.  However, it is not an absolute necessity. Third, you have a decreased antral follicle count (AFC), which is supposed to represent the number of follicles available, but frankly, I don't rely on that too much.

You can achieve pregnancy if you go about it with an open mind and choose a good clinic. For more information on endometriosis and infertility, as well as other age-related factors please see these pages: “Endometriosis” and “Age Factors” in my website’s section on Understanding Infertility.

Good Luck,

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

What Kind Of Estrogen For Endometrin Priming & Luteal Phase Support?

Question:
Hi there, I'm in Ireland and having egg donation treatment in Spain. I've had several unsuccessful cycles and am now finding that my endometrium is not as thick as it used to be. When my period begins, I take 6mg of Meriestra orally. I was interested to read an earlier answer of yours to question "thin endometrium causing ivf failure" that said "Vaginal is better because the hormone goes directly to the endometrium without having to go through the liver first (first pass), where most of the estrogen is removed, when taken orally."


Should i go back to my clinic and question the oral administration of the drug? In earlier cycles I was applying patches to my body.

Thanks in advance for any guidance you can offer and I understand it would be general advice rather than a medical opinion.

Best Regards, A. from Ireland

Answer:

Hello A. from Ireland,

Thank you for reading some of my previous answers. Multiple studies have shown that oral estrogen for endometrial priming and luteal phase support are the least effective method. For that reason, it has become the standard of care to use either injectables, patches, vaginal gels or vaginal tablets. I think this is something you should query your doctors about. If your lining is not developing adequately in an egg donor cycle, it may be because you are not getting adequate estrogen.

Your doctors should be evaluating this thickness prior to deciding whether or not to proceed with the transfer. If you were my patient, I would not do the transfer if your endometrial lining was inadequate. In that situation, I would freeze the embryos and plan a frozen embryo transfer at a later date, in a cycle where the lining is adequate.

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.

Recurrent Pregnancy Loss: 5 Miscarriages Since 2009

Question:

Hello Dr. Ramirez,

My husband and I have been trying to conceive since 2007. I have PCOS (polycystic ovarian syndrome) and I have had 5 miscarriages, first one in April 2009 at 10 weeks and the others at 6 weeks. I've also lost a baby due to an incompetent cervix at 6 months. My most recent miscarriage was last month after an IFV cycle at 6 weeks. I was on baby aspirin, progesterone shot, metformin and Estrace. My fertility specialist was not able to say why I am having these recurrent miscarriages. My doctor has done blood work and all standard testing.

After numerous IUI cycles we went ahead with IVF which also led to a miscarriage. I still have four embryos left and don't want to pursue with another IVF cycle until I can get some answers as to what might have gone wrong or what I can do to change the outcome. Do you have any suggestions for me? Any feedback is greatly appreciated. N. from Canada

Answer:

Hello N. from Canada,

I am sorry for all your losses! The incompetent cervix is something that can easily be handled with your next  pregnancy by doing a cerclage (either a TVC or a TAC by the 16th week of gestation--a TAC can also be done pre-pregnancy). But you need to achieve and hold that next pregnancy. First, let me say that you should also read my website page where I have written extensively regarding evaluation of Recurrent Pregnancy Loss (RPL) and a possible protocol for treating this problem. Anyone who has miscarried three times or more needs to have this type of comprehensive evaluation. Some of the possible reasons you may be miscarrying include:

• Genetic/Chromosomal Causes (you don't state your age, but that could be factor)
• Polyps, Fibroids & Uterine Disorders
• Hematologic Disorders
• Hormonal (you have PCOS, so your cycle day 9 & 10 LH needs to be checked )
• Infectious, Genetic & Immune Factors

With a diagnosis of "Recurrent pregnancy loss", there is a protocol that is usually followed to evaluate for the possible causes. As stated above, this includes genetic testing (both you and your husband), immunological testing, infectious disease testing, anatomical testing, hematologic testing and hormonal testing. It is quite an extensive array of tests and can take up to two months.This is what should be done BEFORE you proceed with any more IVF cycles. The treatment will then depend on what is found. In some cases, for those with genetic causes, IVF with PGD (preimplantation genetic diagnosis) can be done to test the embryos for viability and chromosomal abherrations.

What is good is that you are able to ovulate, that your eggs fertilize and that you have been able to get pregnant. It is very difficult to go through as many miscarriages as you have and I hope that with proper evaluation you will be able to deliver a beautiful, healthy child in the near future.

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.

"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.

Sixteen Year Old Does Not Have Her Period Yet: What To Do?

Question: Hi, writing from Califonia!

My name is E. and I am 16 years old, will be 17 on June 9th, 2013. I'm 5'9" and I am overweight, but not terribly obese or anything. I have always been active, and I have been a swimmer since I was 7.

I am wondering if something is wrong with me. I still have not gotten my period. Ever. I just feel so out of place when my friends are all talking about theirs and I just stand there. I don't understand why I haven't gotten it yet. I have pubic hair, I have leg hair, armpit hair, I have breasts, and sometimes I see that my underwear is like a light brown (and it smells weird, but not terrible) but it has never been red.

My Dr. told me that if I don't have it by the time I'm 18 then to come in for some tests.

I just wish so badly that it will have it already. Is there anything I can do? Could this in anyway help the process of it starting?

http://www.amazon.com/gp/product/B0009ETA6M/ref=ox_sc_act_title_1?ie=UTF8&smid=ATVPDKIKX0DER

I heard that drinking lots of green tea can help?

Could it be me being overweight? I am currently in the process of losing weight and I have lost 15lbs so far. I also heard that it might have been because my mom breastfed me for longer? She nursed me until I was 3, not a lot after the first year, she said it was normally just to get me to sleep.

Please help! E. from California.

Answer:

Hello E. from the U.S.(California,

Since you have secondary sexual characteristics (pubic hair etc.), that means that your ovaries are functioning and producing estrogen. It may just be a matter of time now before the periods start, but it is a little unusual to not have periods by 17 years old. I don't agree with your doctor. This is something you might want to talk to you mother about and urge her to allow you to see a pediatric endocrinologist, adolescent gynecologist or reproductive endocrinologist. These are all specialists with more advanced training in hormones than your regular pediatrician or family practice doctor. A blood test can be done to check your hormones to make sure there is not something amiss. Medicine can also be given to help you start periods, or if your hormones are unbalanced, to help balance them.

Having a hormonal imbalance can cause long term side effects, like facial hair, that is not reversible so I would not recommend doing nothing.

As a side note, don't buy anything on the internet that says it does something medical. Anything that is medically effective has to have FDA approval and then it is sold in a pharmacy or doctor's office. Only non-medical items can be sold via the internet to non-medical people.

Thank you for writing and try to see a specialist soon. 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.