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.

Follicles Too Big In Clomid Ovulation Induction Cycle

Hello,
I am writing from San Diego, CA.  I was on 100mg Clomid on Cycle Day 3-7, then 2mg estradiol on cd 8-12. I went in for an ultrasound to check follicles on cycle day 13.  My RE said that this was most likely a lost cycle because I had 2 dominant follicles at 26 and 31 mm.  He gave me an HCG trigger because he did not want the follicles to get bigger and become cysts.  My uterine lining was 14 mm, and my RE was happy with that.  My husband and I had intercourse the day of the trigger and the day after, then skipped a day and had intercourse one more time.  

Were the follicles too big?  Do we have any chance of conceiving this cycle?  I have also been feeling cramps since yesterday at 7 days after the trigger.  Is this normal?  

Thanks for your input. L. from San Diego

Answer:

Hello L. from the U.S. (San Diego),

I don't have the ability to foresee the future, and certainly exceptions can occur, however, the follicle sizes were too big.  Usually once the follicle is greater than 24 mms, the egg within is overmature and therefore no longer viable.  Ovulation may occur but that is the main problem.  Also, it is highly likely that these follicles will turn cystic (persist) and have to be suppressed with birth control pills. You need to make sure a baseline ultrasound is done to evaluate for this at the start of your next cycle.

So, statistically and physiologically speaking, this cycle is probably a bust.  Unfortunately, your doctor missed the appropriate point by not doing the ultrasound early enough.  Next cycle he should begin looking at cycle day #9 or 10, which is what I do.  If I'm too early that's okay because nothing is lost and gives me a better idea of follicular development.  If you're too late, as in your cycle, then then cycle is lost; a big price to pay.

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.

Young Woman With Endometriosis & PCOS Fails Five Clomid Cycles: Next Step?

Question:

Dear Doctor,

Hi, I'm from Minnesota. My husband and I have been trying to conceive since August of 2011. I have endometriosis and PCOS (polycystic ovarian syndrome) since finding out when I was around 17 years old, I'm 25 now. I have had five cycles of Clomid that didn't work. I had laparoscopy surgery for this post December, blocked tubes, suck ovaries, scar tissue, cysts and endometriosis. I'm on metformin because that's supposed to help with infertility and PCOS.

I started femara this month. Had 4 follicle on left and 1 on right from ultrasound. I usually ovulated on the 15th day, this time I didn't ovulate so I took the ovidrel shot and had a positive test. Started estrogen and progesterone day 3po. Currently on day 10po. I have cramps on and off.  I was just wondering what my chances of conceiving are and what is the next step if this didn't work this cycle. Any information or insight would be great! K. from Minnesota

Answer:

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

Your statistical chances of pregnancy with Stage Four Endometriosis (endometriosis with extensive adhesive disease) and PCOD is probably less than 1% using any natural treatment method (Clomid, Femara or Injectables with intercourse or IUI).  That is because you have an abnormal pelvis and this location is critical for passage of the egg from the ovary to the tube.  Scar tissue, which is like spider webs, can block the egg from entering or reaching the tube.  Endometriosis causes a chronic inflammation of the pelvis which leads to the inflammatory cells attacking and destroying the egg as it exits the ovary to reach the tube. Polycystic ovarian disease is an ovarian dysfunction where the ovaries don't function properly and so there is a resultant hormone imbalance and lack of ovulation.  All of these put together significantly reduces your chances.

See my website for more extensive information and explanation of the options available for both Endometriosis and PCOS. I am convinced that with the proper information patients become empowered to make the right decision about their healthcare and can ascertain if they are receiving the best care.

It is my humble opinion that you are probably not seeing an infertility specialist because a good infertility subspecialist would have told you all this and not done all the treatments you have done.  The treatment of choice is to proceed to IVF so that you can bypass the pelvis completely.

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.

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

35 Year Old Responds Well To Low Dose Clomid IUI Cycle: NOT A Low Responder!

Question:

Dr. Ramirez,

My husband and I have been infertile for more than 2 years now. We have gone through a wide variety of tests. I have had a polyp removed through operative hysteroscopy and we were asked to try on our own for 3 months afterwards (unsuccessfully). I am 35 years with borderline bad FSH (around 10 on day 3). I have a low antral follicle count (usually around 7 if they can see both ovaries during the ultrasound). We have tried 1 IUI (negative for pregnancy) and I was prescribed 50 mg Clomid on days 3 - 7 for the IUI. I ovulated 3 eggs with this dose and was triggered with an HCG shot when the 3 follicles were between 1.7 - 2.0 and IUI took place approximately 24 and 48 hours after this injection.

I have 2 questions:

1. Is the fact that I developed 3 eggs on Clomid a good or bad sign? My doctor says I will likely be what he calls a poor responder to medications because of my low antral follicle count and IVF may not be more worthwhile than IUI because of this. Does the fact that I got 3 with Clomid mean I might do better with injections then he thinks or are the 2 medications so different that my response to Clomid doesn't indicate anything?

2. What is the purpose of a blood test the day of my second IUI? I have a lot of problems with all the blood work that is required for monitoring due to bad veins (day 3 plus 4 more days of blood tests/ultrasounds before my IUI). I thought when I was triggered that would be my last blood test, but I was told I needed another blood test/ultrasound the day of my second IUI (48 hours post trigger). I asked the nurse if the blood test was essential and she said yes and it is part of the cycle monitoring that all fertility clinics require it so I forced another blood test through my already bruised veins. I understand the ultrasound was to show if the follicles released, but what would the purpose of this blood test be and is it really as essential as they say it is? (I was also on progesterone suppositories 200 mg twice a day following the IUI so I don't think it was to measure progesterone since those were prescribed regardless of the blood results).

I really appreciate you providing this service and if we do decide to travel for treatment, California will be our choice. Thanks again, A. from British Columbia

Answer:

Hello A. from Canada (British Columbia),

The fact that you responded well to low dose Clomid is very, very reassuring and I completely disagree with your doctor's opinion. FSH levels and Antral counts are indirect measures of ovarian response but not absolute. In other words, studies have shown that these numbers can vary from cycle to cycle and so the response can vary from cycle to cycle. Besides, an FSH level of 10 is not necessarily that bad. Sure, we prefer the level to be 7 or less, but it is much better than a level of 12 or greater, which I often see. Even these patients do respond to stimulation albeit only a few follicles.

So, considering that you responded well to Clomid, low dose Clomid no less, is more of an indication that you are NOT a low responder. A low responder would have only one follicle despite high dose (250mg) of Clomid. One thing these two levels do tell you, however, is that you may not have as much time to work with as you would have thought. You will need to use your time wisely and strongly consider a more aggressive approach (such as IVF). I would not recommend more than 4 IUI attempts. If that does no work (which is the number where most patients will be pregnant), then you have to go to IVF.

In terms of your second question regarding the blood test, I have absolutely no idea why it is being done. It must be something specific to your doctor. You will have to ask him. Now, I do an ultrasound after each IUI so that I can see if ovulation has occurred. That way I know that the timing was good. Since I don't know what test they did or what it could be, I can't try to explain why they would do it. It can't or shouldn't be a progesterone level, which is what we often use to determine if ovulation occurred, but that test is not valid if progesterone supplementation is given.

Thank you for your question and consideration...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.

Trying To Conceive After Surgery For Cysts & Endometriosis: Do A Clomid Induction Cycle?

Question:

Hi from Wisconsin!
My husband and I have been trying to conceive our third child. My youngest will be turning three in a couple of months. They were conceived quickly with no issues. About a year ago, I was advised to have surgery to remove what looked liked a "complex ovarian cyst" that was causing intense pain. I was on birth control pills at the time. I was told everything else looked good at the time of surgery and I experienced heavy bleeding afterwards for about a week. A year later I was still having pain in that area, so a different MD did surgery and removed an adhesion between my tube and ovary, a small amount of endometroisis, and paratubular cysts everything was located on the same side as my surgery. My tubes were open.

I am about 3 months from the surgery and on our fifth month of ttc and have been having really light periods (which I have always had, so I was surprised by the endo) that start/stop and have brownish spotting in the beginning. I was told it means I am not ovulating. I am doing a progesterone test later this week to see if I am. I did get a positive OPK on day 14 this month and my periods are pretty regular occurring every 28-30 days. Clomid was suggested for my next cycle, which I am nervous about trying. I am 33 and my husband has a normal semen analysis (one of the motility numbers was lower 37% but they said because his total motile sperm number was above 57 million they said it was fine).

Do the light periods have anything do to with not getting pregnant? I also get a lot of white sticky discharge after the egg white mucus and a few days after the OPK positive, is this also a sign something is not working? Will Clomid help me? If I am ovulating will it just increase the number of available eggs? For the next cycle an ultrasound and HCG trigger were also suggested. This is all so frustrating! When asked my MD told me I had a reasonably good chance of getting pregnant on my own but I am worried about being on a time crunch, especially since no endo was seen a year before.
Thank you for your advise. S. from Wisconsin.

Answer:

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

Usually the amount of flow with a period is proportional to the amount of endometrial lining produced. The endometrial lining is produced or grown with increasing amounts of estrogen that occurs in the first two weeks of the cycle. This is called the "proliferative phase" for proliferation/growth of the endometrium. As a targeted follicle grows, it produces more and more estrogen. So, the fact that your periods are very light is a little worrisome in terms of the possibility that there is inadequate estrogen production. If you are ovulating then adequate estrogen should be produced, so maybe there is an ovarian dysfunction going on. I cannot be sure without additional information or testing. Clomid may help this by inducing the ovary to function more normally and increase the estrogen production by increasing the number of follicles that progress to ovulation. Clomid increases pregnancy rates by increasing the number of eggs ovulate in women that are already ovulating normally. This treatment is called "superovulation.".

With clomid ovulation induction cycles, I am a strong advocate of ultrasound surveillance or monitoring. This allows us to evaluate how you are responding to a particular dosage of medication, since there are varying dosages that can be used and people respond differently, how many follicles are being developed, so that you don't ovulate too many eggs and significantly increase your chances of a super-multiple gestation, when the follicle is at the appropriate size to trigger ovulation with HCG and to time intercourse or IUI so that it is at the closest time to ovulation (ovulation cannot be predicted completely).

You are correct about the timeline for your endometriosis. I tell my patients that they basically have a 6 month window of opportunity after their endometriosis treatment. With each cycle, new endometriosis is being produced and some endometriosis that was at a microscopic stage is growing. Eventually, you will return to the pre-surgery state which may be preventing pregnancy. For that reason, I too recommend a more aggressive timeline and aggressive approach to treatment such as superovulation with timed intercourse or IUI.

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 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.

Canadian Is Nine Weeks Pregnant, Has Enlarged Yolk Sac And No Fetal Pole: Is There A Problem?

Question:

Hi Dr Ramirez,

I was prescribed Clomid this cycle and am now pregnant. I am currently 9 weeks along. I went for an ultrasound at 8 weeks, 1 day pregnant and my measurements indicated that I was 8 weeks, 6 days pregnant. There was no fetal pole found. The yolk sac is measuring 8.6 mm. I am doing HCG/progesterone testing every other day -- so far all levels are within range. I am going for a follow up ultrasound at 10 weeks pregnant. Is the enlarged yolk sac a bad sign, even though my measurements and bloodwork are good?

Thanks, E. from Canada.

Answer:

Hello E. from Canada,

Assuming that your dates are correct, the yolk sac size is not a problem but the fact that there was no fetal pole or fetal heart motion at 8 weeks is bad. Usually by 6.5 weeks gestational age, a fetal pole and heart beat can be detected. This is seen for sure by 8 weeks. An empty gestational sac is called a "blighted ovum" and basically means that the sac developed but the fetus did not. You should not have to wait until 10 weeks gestational age to make the diagnosis. Your doctor should make that diagnosis already and recommend treatment.

If you wait too long, then a D&C (surgery) would be required to clear the uterus. At an earlier stage it can be done using medication alone. I should not be the one to be the bearer of bad news so I am sorry that this answer is not reassuring. You need to talk with your doctor right away and don't let them put you off or avoid the issue, like they seem to be doing.

Take care and good luck,

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

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.

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.

4 Weeks Pregnant, Hypothyroid, At 43 After Clomid Cycle: How Are My Levels? What To Do If I Miscarry?

Question:
Hello, I’m in California.

I just found out I’m pregnant, about 4weeks 4days. I had my first beta; it was only 18 at 14 dpo and 24 at 15 dpo. I took another yesterday at 17 dpo, but I won’t know the results until tomorrow. Either way, a very poor prognosis for a viable pregnancy.

I know I should just wait until tomorrow, but I want another opinion. This is an agonizing waiting period – I feel like I don’t know if I’m coming or going. This is the 5th or 6th time I’ve been pregnant, but I’ve never had a pregnancy like this, where I have no symptoms whatsoever. I can unhappily handle a miscarriage, but I do NOT want it to turn out to be ectopic, which is what I fear the lack of symptoms means.

Question 1:
I am on Crinone 8% 1/day. Would that “mask” a miscarriage? I know it won’t stop a miscarriage, but what I’m trying to find out is if the progesterone will stop the bleeding I would have if I were to miscarry? Will I not start bleeding until I stop using the Crinone? (Which I’m not going to do until I find out for sure what’s going on.)

It turns out that my TSH is high, about 5.7. And from what I understand, that number may actually have been higher prior to pregnancy. I should have been medicated for this problem before getting pregnant, but the multitude of doctors I’ve been to never had me get this test done, as a matter of a fact, I actually added this test to the beta lab slip myself.

Question 2:
I have been told that the rate of early miscarriage is high in women with untreated hypothyroidism – IF they can get pregnant at all. Do you have any information on this?

I am going to ask to be put on thyroid medication tomorrow at my appointment. Is there a specific medication that I should be on while trying to get pregnant that is more effective for fertility and safer for a growing fetus?

I am assuming an upcoming miscarriage (I’m a realist). I am also 43, so I literally do not have a second to spare. I got pregnant on my first round of 50mg Clomid (I also added Soy Isoflavones and Black Cohosh), which says to me that I was either previously not ovulating – or my follicles were not rupturing (exact 30 day cycles). If/when I miscarry I will immediately begin trying again.

Question 3:
Should I try the Clomid again because it worked, or try something a bit stronger, injectables with an IUI perhaps?

Question 4:
Can I use fertility drugs immediately after miscarrying, i.e. before I get another period? I know that often a woman will conceive immediately after a miscarriage.

Thank you so much for your help. I wish you weren’t so far away, it would take me about three hours each way to get to you! J. from California

Answer:

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

The reason you are not feeling any pregnancy symptoms at this time is because the bHCG levels are still very low. The symptoms may come on if the levels risk over time but not all patients have pregnancy symptoms even with normal pregnancies.

The fact that the levels are increasing is a good sign. They cannot be interpreted in less than 48 hr intervals so I don't know why your doctor ordered them that way. Basically the bHCG should increase by 80% in 48 hrs. If the next level is still going up, I would continue to follow them. I caution against drawing any conclusions based on these results. They are a guide only.

Your TSH level is indeed elevated and is an indication of hypothyroidism. That means that you need thyroid supplementation. I would recommend that you see an endocrinologist or reproductive endocrinologist to have this done.

The fact that you got pregnant on Clomid is a very, very good sign! It shows that you have the ability to get pregnant! However, your obstacle is the "age factor" i.e. decreased egg quality and viability due to age. You certainly got very lucky on your first Clomid cycle but I would not expect that each time. Your natural chances of pregnancy per month (Clomid, injectables and IUI fall into this category) is approximately 0.2% per month. Using fertility medications to increase the number of eggs that you ovulate is the only way to increase your chances per month. If you are determined to continue the natural pathway, then I would strongly recommend injectables with a closely monitored cycle. Ideally, you should be going directly to IVF to give you the highest chances per attempt of 33%.

You will not be able to go directly into another ovulation inductions cycle after the miscarriage. You will need the miscarriage to resolve completely, as determined by following the bHCG's. Once this has resolved, then you can induce ovulation.

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.

UAE Patient Tested For Infertility: Clomid or Tamoxifen?

QUESTION:

Hi Doctor,

This is S. from UAE. I would like to have your expert opinion in my case. My infertility workup showed multiple cysts in both ovaries but my hormonal work up was all within range. In addition, I have never missed a period ever in life, my cycles are pretty regular. In spite of this, my gynecologist started a Clomid induction cycle with me and monitored me. I was given Clomid in consecutive months. After reading your blog post about Clomid, I came to a conclusion that my doctor isn't doing right in giving me Clomid, and also, giving it consecutively. I switched doctors, only to recieve Tamoxifen in the subsequent cycle. I am worried. Do I need any kind of ovulation induction at all? Considering my cycles are regular and I had a normal LH/FSH ratio. Can Tamoxifen be followed immediately after Clomid?

ANSWER:

Dear Saman from the U.A.E.,

Glad to see that my blog has been helpful to you all the way in United Arab Emirates! Clomid is not indicated if you are ovulating on your own, but many many doctors use it to boost ovulation thinking that it is a "miracle" fertility drug. If you have been unable to become pregnant, and have had regular cycles, then there is something else, besides ovulation, that is causing the problem. That needs to be found. I am always skeptical when patients tell me "all my fertility tests were normal" without telling me what tests were done. That is because in most of these cases, all the fertility tests were not done, and therefore, the problem has not yet been found.

Tamoxifen has the same mechanism of action as Clomid, namely, it is an estrogen receptor blocker. Your new doctor obviously does not understand these medications. Just like I would not recommend taking Clomid in consecutive cycles because of the estrogen receptor blockage, I would not do that with ANY estrogen receptor blockers, except maybe Femara since it has less effect on the endometrial estrogen receptors. So I alternate cycles with Clomid and Femara. However, again, your new doctor is doing the same mistake and not treating anything specific. He/She needs to find out what the problem is! Ovulation induction is not the answer.

FOLLOW UP QUESTION:

Dear Dr, Thanks a whole lot for your response. It means a lot to me!I need one final querry answered. I have had the following tests:

FSH, LH, TSH, Prolactin, HSG, Fasting Insulin, Testosterone, DHEA Sulphate

All these tests and HSG have come out normal, and HSG shows Bilateral peritoneal spillage. Husband's semen analysis shows 58million/ml and 70% motility. In addition, I have never had any surgery and menstruate regularly every 28days. As I told u before, Clomid induction was done in 2 cycles which just resulted in a single ovum ripening, and was thus abandoned.

I have been adviced to have IUI. Should I go ahead with it? Because I have not had laproscopy, hysteroscopy or endometrial biopsy yet, and there might be reasons for infertility hidden there.....Isn't it better to go straight to IVF? Thank you!

FOLLOW UP ANSWER:

Hello again,

Indeed, based on the tests you have cited we know the following:

1. Your hypothalamic-ovarian pathway is normal (i.e. the ovary is being stimulated properly)
2. Your thyroid, testosterone and adrenal functions are normal.
3. Your fallopian tubes are open.
4. The sperm is normal and has the ability to get to the tube in order to fertilize your egg.

What we don't know is:

1. Is the uterine cavity normal (endometrial cavity) (hysteroscopy)
2. Is the peritoneum normal (where the egg goes through after ovulation) or is there scar tissue or endometriosis (laparoscopy)
3. Are you forming an adequate endometrial lining (endometrial biopsy).

If you wanted to pursue a natural method of getting pregnant (intercourse or IUI), then you will need to do these tests. If you would rather go directly to IVF (which bypasses almost all the steps), then the laparoscopy and endometrial biopsy are not necessary. The hysteroscopy is still needed. Some of my patients do choose to go directly to IVF because it gives you the highest chances of pregnancy. For example, the highest chance of pregnancy with each IUI cycle is 24% (under 35 year old patients), whereas IVF is 76% (at least in my clinic). So ultimately that is your decision. If you want to do things conservatively, that is, be as natural as possible, then IUI would be a reasonable step (it also costs less).

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: Dr Ramirez's responses are ALWAYS accurate, and prompt....I can't thank him enough for the help he has given this way....IVF at his clinic is definitely on my cards, but hoping I wont need it though :)

Clomid Protocol In Depth: Dosage, Specific Indications & Period Of Use

Hello Doctor,

Your willingness to answer fertility questions is admirable. Let me say, "Thank you!"

I've been trying to find specific information on your blog regarding clomid protocol and I simply cannot find what I'm looking for. I do find questions and answers regarding clomid, but not specific information on how and when to use it, for how many months etc. Do you have a specific link perhaps? Thank you again, J. in the USA

Answer:

Hello J. from California,

Actually the answers to those questions are in the blog but are within the body of the answers. I don't think I have one entire blog post that goes over the specific indications or period of use. You can look at my website for more information as well: "Ovulation Induction".

I will endeavour to explain as much as I can here:

Clomid is one of many medications that are used to induce ovulation. In most cases it is used for patients that have an ovulation disorder, i.e. don't ovulate spontaneously or have a hormonal imbalance leading due to an ovulation disorder. Clomid is an estrogen that blocks the estrogen receptor and induces the brain to increase the FSh output thereby stimulating the ovaries harder. Some doctors will also use Clomid, and other fertility medications, to "superovulate" the ovaries. That is to increase the number of eggs that the ovaries give off so that the chances that an egg with reach, enter and get fertilized will be increased. Unfortunately, many doctors use this as their "magic pill approach" to infertility and will prescribe it without doing an infertility evaluation or determining whether or not it is indicated.

In my blog, I go over how the Clomid is given and how I recommend doing a Clomid ovulation induction. But as a basic method, Clomid can be given in doses ranging from 50mg per day to 250mg per day (1-5 tablets). It is taken orally once per day for a five day period. Most Physicians will give it between cycle day #3-7, 4-8 or 5-9, with cycle day #1 being the first day of the period. It should be taken at approximately the same time of day each day but the specific time is not critical. Most textbooks will state that you should start with the lowest dose of Clomid and increase the dosage in 50mg increments per month if the patient does not respond to that dose. Many doctors blunder by increasing the dosage anyway if the patient does not get pregnant in that month, thinking that a higher dose increases the chances of fertility. That is not true! It only risks increasing the number of eggs that the patient ovulates and therefore the higher chances of a multiple pregnancy.

In essence the lowest ovulatory dosage should be used, so that if a patient responds to 50 mg with ovulation, then you stay at that dose. If ovulation does not occur, then it is increased by 50 mg. I don't quite follow this method because as you can see, if the patient does not respond to dosages less than 250mg, then you have wasted four months finding that out. Instead, my experience has shown me that it is better to be more aggressive and quicker in finding the dose that the patient responds to or to know whether she will respond at all. For example, the most common patients that require ovulation induction are PCO patients. I don't start at 50 mg. Rather, I start at 150mg then proceed to 250 mg if they don't respond. If they don't respond to 250mg, then I know that we have to move to stronger meds. This is because most PCO patients will require high dose Clomid or will not respond to Clomid so I want to find out as soon as possible. In a patient being superovulated, you have to use doses lower than 150mg because these patients are already ovulating. I use superovulation mainly in older ovulatory patients (over 35 years old) because I know that one problem they are facing is an egg quality issue and increasing the number of eggs does in fact increase their chances. I will often strive to get them to ovulate up to 5 eggs per cycle. Finally, I don't recommend more than 6 ovulatory cycles of Clomid. If you have not achieved pregnancy by then, then there is something else going on and so you have to move to a more aggressive treatment plan.

I hope that this answers your questions.

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.

The Wrong Way To Do A Clomid Induction Cycle

Question:

Hi. My Doctor prescribed me provera to induce a period and then clomid to induce ovulation. She told me that monthly I am supposed to take provera from the first of the month through the tenth of the month and then once my period comes i'm supposed to take Clomid from day 5-9.

So here it is, May 13th and it is day two of my cyle which means I will take Clomid May 16th-20th. Am i supposed to automatically take the Provera again on the 1st of June? That just doesn't sound right to me. Please help me understand this. C. from Nevada

Answer:

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

You are wiser than your doctor, which means you are seeing the WRONG doctor. She is not correct on the proper method to do a Clomid ovulation induction cycle. I would recommend that you look up my blog and review how I recommend doing Clomid cycles. I think you will be shocked once you compare it to what your doctor prescribed!

First, Clomid cycles should be monitored for three reasons: (1) to see whether you are responding to that dose of Clomid (there are five dosages that can be used). (2) to see how many follicles are developing so that you don't have too many and (3) to determine when ovulation is going to occur so that you can time your intercourse properly.

The "autopilot" method of Clomid ovulation induction is not correct and shows that your doctor has a very limited knowledge of this treatment and infertility in general. I would strongly recommend that you go see a fertility specialist so that you don't waste your time.

Many doctors will use a progesterone supplement with Clomid cycles in order to support implantation and the early pregnancy. Clomid often can induce a luteal phase defect. However, Provera is NOT the drug used because it is a synthetic progesterone. Instead, a natural progesterone like Prometrium is used and a pregnancy test is done at the end of the cycle to determine whether or not your are pregnant so that you can stop the medication and have a period. If there is a luteal phase defect and you stop the progesterone prematurely, that could induce a miscarriage due to inadequate progesterone support. Does that make sense? So you can see why your doctors orders are all wrong.

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.

Mini-IVF In A Woman Over 40 Years Old

Question:

I am from Canada and will turn 42 in a few weeks. I am trying to conceive my second baby after already having a baby boy with a previous IVF cycle. My first cycle for baby number two was unsuccessful. It consisted of Lupron from day 21 then Gonal F and Repronex. This was not successful as they retrieved only 5 eggs from fourteen follicles. All five fertilized but only 1 made it to the 5 day transfer. This cycle my RE has me on Clomid from day 3 to 7 with Gonal F and Menapur starting on day 7. I will be taking Cetrotide at some point. I have tried to find this protocol on the web and couldn't find it anywhere. I will be taking 100 mg of Clomid, 150 Gonal F and 75 Menopur. It seems like these amounts appear to be very low. I am so worried that this protocol does not seem very aggressive. Do you have any experience with this type of protocol for someone with my age?? I assume that egg quality is the issue. My FSH is low after three months of DHEA. Thank you, S. from Canada

Answer:

Hello S. from Canada,

The protocol you are using is a "mini-IVF" protocol and mainly used to help reduce the cost of medications. It is probably reasonable in a young woman that responds well to stimulation, because the Clomid will be adequate to recruit sufficient follicles, but I think it is not appropriate for you at your age. 

(Readers: Since the writing of this blog post there has been a Yale University study published in April 2012 showing that Mini-IVF is highly overrated and results in lower pregnancy rates as well as take home baby rates. See article "Mini IVF Yields Mini Success" and the study brief  "A case-control pilot study of low-intensity IVF in good-prognosis patients".)


This is a very low protocol. You would be at high risk of having a minimal stimulation and very few follicles. In truth, I can't believe your RE is planning this. Since you didn't give me the amount of medications you used on the first cycle, I can't tell whether you were adequately stimulated or not, but if you were my patient (and keep in mind that protocols vary widely amount doctors and no one protocol is better than another), I would be stimulating you aggressively with a high dosage. Namely 450IU Follistim and 150IU Menopur (or Repronex) in a continuous dosage.

In terms of your previous cycle, you had fourteen follicles and that is a very respectable number. I am worried about the fact that only 5 eggs were retrieved. Without looking at your records, I cannot know for sure, but I am inclined to think that you were probably triggered (with HCG) a little too early. If the eggs within do not have time to begin maturing, they do not release from the follicle wall and don't get retrieved. I expect to have at least a 60% retrieval rate in my clinic, so that would mean that you should have gotten at least 8 eggs retrieved. Since all 5 of your eggs fertilized, that means that they were all mature, which is a good maturity rate. The lack of development was due to the "age factor", which is the decline in egg quality that occurs with age. I would NOT have taken them to blastocyst, as that puts them through an unnecessary extra step, and instead, would have opted to transfer all at D#3. I believe the uterus is a better incubator than the laboratory.

Because of your age, keep in mind that it is going to be harder to become pregnant, but not impossible. Since your ovaries are still responding well, you still have the opportunity to become pregnant with your own eggs. You will just have to be resigned to having to go through several attempts to become successful. The only alternative is donor eggs, and you will always have that option as it takes away your age as a factor.

Follow-up Question:

Thank you so much for your response. As predicted the cycle was a bust. I had four follicles only and at one point they decreased in size (after my Cetrotide shot) I have been told that my lead follicle that reached 1.4 (which is when I was instructed to take my Cetrotide) may of been a cyst that they saw on day three. Anyway, I have a couple of questions about my upcoming cycle. So far I have had two awful cycles when taking Cetrotide. My first cycle before conceiving my son my Estrogen dropped significantly after Cetrotide. Do you think I should do another cycle with Cetrotide or do you think I should go back to Lupron?? Is it possible to just start Lupron the same day as my injections instead of going back to CD21.

I am at a loss as what would be the best plan for me given my age. As far as medication amount, you were accurate that I was on 450 of Lupron and 150 of Repronex. I believe the cycle that I had my son my Lupron was stopped as soon as I started my medication but he doesn't seem to be wanting to do that. Could you please give me advice on what protocol would be best given my age?? Thanks

Follow-up Answer:
Hello Again,
If you are going to use Lupron, then you have to start from CD21 of the preceding cycle. It is called the "long protocol". I would not recommend it in you.

I use the antagonist protocol almost exclusively in my practice. The problem that I see from what you told me is that you started the Cetrotide too early. If you do that, you suppress the follicle growth and get what you saw. The antagonist (Cetrotide or Ganerelix) should only be started when the follicles have reached 16-17 mms. The rule of thumb is that at least 30% of the follicles should be this size. I will sometimes wait until the lead follicle is 18mms if the other follicles are not sufficient enough size. With that, I do see an estradiol drop so I don't pay attention to it much any more. I think it is showing a decrease in activity of the smaller follicles that have been stunted. Using the antagonist is where the art of medicine comes into play because there are no hard and fast rules. It is very dependent on the experience and judgement of your doctor.

As I mentioned previously, if you were my patient, I would use the antagonist Cetrotride, not Lupron,and use the highest protocol of 450IU Follistim and 150IU Menopur continuously (no adjustments).
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.

U.K. Woman On Clomid For Five Months, Husband With MFI: Periods Are Shorter Now, Why?

Question:

Hi, I have been taking clomid for 5 months because my husband has a low sperm count. I have noticed my periods becoming less and less the last 2 months I have only bleed for 1 day and that was mostly a black/brown color. My periods normally last for a full 7 days. Is this because of the clomid? D. From the U.K.

Answer:

Hello D. from the U.K.,

You should NOT be taking Clomid every month. It leads to a thinning of the endometrial lining because it is an antiestrogen and blocks the estrogen receptors. This is probably why the bleeding has decreased. This lack of adequate uterine lining will prevent implantation.

Secondly, Clomid is NOT a treatment for male infertility if given to the female! I have absolutely no understanding as to why your doctor has prescribed this and not followed you with some type of surveillance to see how you are responding. I would strongly recommend that you look up here in my blog where I discuss how Clomid cycles should be done.

Thirdly, in men that have low sperm counts, they will be treated with Clomid on a daily basis, sometimes to try to increase the count. This works only some of the time. It will take three months to know if it is working or not. If the count gets above 10 Million, then IUI is a treatment option. If it is less than 10 Million then IVF with ICSI is the treatment of choice.

Finally, please make sure that your doctor is an infertility specialist and does ALL levels of infertility treatments, including IVF. Otherwise, you may be wasting your time.

Good Luck,

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

Young Canadian With Endometriosis: Will Have Six Month Window For TTC Post Surgery

Question:

Hi, I’m from Calgary, Alberta in Canada. I am 33 and my husband is 30, we are both healthy and we’ve been TTC unsuccessfully for 19 cycles. I have never been pregnant. We have been tested at the fertility clinic and told that there is no obvious reason why we shouldn't’t be able to conceive. I had blood work to check my hormone levels, an ultrasound to check my follicles and an HSG to make sure my tubes were open, my husband had a SA done and it showed good numbers and motility. He does have some antibodies, but less than 50%.

All that being said, I contracted chlamydia about 14 years ago, but it was treated quickly (I believe within 1-2 months). I have also been experiencing some symptoms of endo since going off the BC pill so I am a candidate for the laparoscopic surgery. The doctor said I could also try clomid or clomid with assisted insemination. I’m looking for additional guidance on how to proceed. Given that I have symptoms of endo, would you recommend that I proceed with the surgery before trying clomid or even IVF?

Thanks. J. from Canada

Answer:

Hello J from Canada,

You pose an interesting question and the answer will be based on personal desires.

Given that your infertility evaluation has been negative thus far, and you are only 33 years old, if you want to attempt pregnancy by natural means (intercourse or IUI), then you should proceed with the laparoscopy. This is the only method that can diagnose endometriosis. It can be treated at the time surgically and then followed with a 3 month course of medication (Lupron depot) to eradicate any microscopic endometriosis. You will then be free to try on your own or with IUI for the next six months. That is the window of opportunity. If the laparoscopy shows that the endometriosis is stage 3 or 4, then IVF would be indicated.

Certainly if you decide to proceed with trying by natural mean after the laparoscopy, I would recommend an aggressive treatment plan because you need to try to get pregnant within six months. After six months there is a high chance that the endometriosis will return and you will be back to square one. By aggressive natural means, I mean ovulation induction with Clomid, Femara or injectables and either timed intercourse or IUI.

If you don't want to do the laparoscopy, then the best option would be to proceed with IVF. That is the decision that my wife and I made when we faced a similar point in our infertility evaluation and treatment. This is because IVF will bypass any endometriosis and you won't have to undertake the pain or risks of surgery. But, it is the most expensive way to go.

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.

After Failing IVF Three Times 45 Yr Old Wonders, Higher Stim or Lower Stim? Use BCP?: I Recommend A High Stim Mixed Protocol & BCP

Question:

Hi Dr. Ramirez,

I am 44 turning 45 this June. I have had 3 failed IVFs - 1 didn't go beyond retrieval because I pre-ovulated so no eggs to retrieve. My recent failed ivf cycle I had 3 follicles 19mm, 18mm and 16.5mm. The biggest follicle had no egg, the second largest had a degenerative cell and the third an immature egg. I took 300 iu's of follistim and 1 vial of menopur increased to two mid cycle.

Can taking too little or too much meds (follistim/menopur) cause this outcome?

We are trying a gentler dose and using follistim instead of gonal f. My first few cycles I was taking 600 iu's of gonal f and 150 iu;s of menopur. They had me doing this protocol for months and I started to respond poorly to it. I insisted on changing the meds or trying a gentler dose.

We interviewed with a new doctor here and his approach is less is more, less meds and get better quality vs. quantity eggs. And is it true that the smaller follicles esp. women my age will have bad eggs? My last cycle debunked that whole theory because the dominant follicle or the two largest didn't have any eggs. The smallest follicle did have an egg but it was immature.

I know that on the average I produce 5-8 follicles per cycle. I think it's important to save as many of the follicles we can, we can't afford not to even if they have bad eggs in them. I am not young and producing 20 follicles. How much do you recommend women my age take in meds (follistim/menopur)? The new doctor wanted to put me on 150iu's of follistim every other day or maybe everyday? That did not seem enough? He only wants to stimulate the dominant follicle or larger follicles. I don't want to take so little that it doesn't stimulate enough or take too much that I can get overstimulated and not respond well. I know my body and I am very sensitive to the drugs. I have also used micro-dose lupron and I responded poorly to it.

What protocol do you at your clinic use on women my age? My recent baseline fsh is 8.6, E2 is 30 and my AMH 0.27. It started low and increased up to 0.7 taking dhea and in the last few months started to decrease. I have no other issues other than my age and thyroid disease but it's under control. Do you change dosage depending on blood levels, number and size of follicles? The doctors I went to never did that.

Do you use clomid or birth control pills? I am not fond of either of them but I have heard and read that if you are on clomid you third ivf cycle will be successful? I prefer to use estrace or patches over the birth control pill to suppress. Why do clinics use birth control pills? I have read clomid was found to give cancer to lab rats?

Your help is greatly appreciated. I don't have time to waste anymore.

Thank you, C. from New York

Answer:

Hello C. from New York,

In general I don't comment on specific protocols because each doctor has their personal preferences and there are none that are perfect or better than others. However, I don't think I like your new doctor's recommendations or protocols and I'll explain why.

The biggest hurdle that you are facing is an age related decline in egg quality AND a decreased ovarian reserve. There is nothing that can be done about the egg quality but the goal with IVF is to increase the number of eggs recruited and available in the hope that a good egg is still present and we can find it. So, the protocol is always to try to stimulate an increased number of follicles and hopefully eggs.

I have read studies where the argument is if you use a natural cycle (no stimulation or decreased stim cycle), the egg quality will be better, but I believe that to be nonsense. Why would decreasing the number of follicles or relying on a natural cycle (only one follicle) produce better eggs? That is illogical. The quality of the eggs are already predetermined. Stimulation or lack thereof does not influence its quality. Again, I believe that the only way to overcome the age factor is to try to get the maximum number of eggs out at a time. For this I use a high protocol or mixed protocol that is 450IU of follistim and 150IU of Menopur. I also Do Not Use Lupron (called the long protocol) because I think it is inhibiting the ovaries too much at the time of follicle recruitment. Instead I use an antagonist protocol where the antagonist is given for only 1-3 days.

The only time I will decrease the amount of medication is if the patient has gone through one or two IVF cycles and still the number of follicles encountered or eggs retrieved are few. I decrease the protocol because I don't want her to spend lots of money on medications if the increased amount is really not doing too much. The ovaries do get to a point where they won't stimulate much despite increased dosage of medications. Unfortunately, your ovaries sound like they are there already. Again, the reason for doing this is to reduce the cost of medications.

I do alter my dosages as the cycle goes on, but only if I am starting from a lower dose and the patient is not stimulating, in which case I increase the dosage, or if I start on a higher dosage protocol and she is stimulating too strongly, in which case I decrease the dosage. Other than that, the dosage stays the same for most of the cycle without alterations.

I would not even consider Clomid for an IVF cycle. Some clinics do again to decrease the cost of medications but multiple studies show that the injectables are superior to Clomid.

Finally, in terms of the birth control pill, I do use it. Several studies have shown a better response if preceded by birth control pills. It suppresses the ovaries in the cycle preceding the IVF cycle and there may be a rebound effect so that the ovaries stimulate better. Estrogen does not suppress the ovaries unless given in very high amounts such as with the birth control pill. I have read of clinics trying to do IVF after a natural "unsuppressed" cycle, but I don't think it makes much difference. The other reason to use the birth control pill is that it allows us to take control of your cycle so that we can be sure that timing is correct. Timing is absolutely critical with IVF. There is a very small window of opportunity for the embryo to implant and if you miss it, then the cycle will fail. Also, using the birth control pill helps with scheduling if you batch patients (put them in the same group).

I think it is meritorious that you are trying to achieve pregnancy with your own eggs at 45 years old, but you have to understand that pregnancies rarely occur after 43 even with IVF unless donor eggs are used. However, I always remind my patient that the oldest woman to achieve pregnancy through IVF using her own eggs was 49 years old. It did take her two years of doing IVF, so persistence can count if you can afford it and want to wait that long to have a child. But you also have to be realistic and not let your expectations be too high. I hope that your journey will go well nonetheless, and that you achieve your goal of having a child.

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.

Secondary Infertility With Miscarriage And Possible Luteal Phase Defect: Is Clomid OK?

QUESTION:

Hi Dr. Ramirez. Here I am writing again. I previously emailed you, I had a miscarriage in Feb 2010, at about 7 weeks. I have a 4 year old and a 3 year old, conceived the first month I tried with both. I also got pregnant the first time with the miscarried pregnancy. Since March I have been trying to get pregnant and nothing has happened. I have been getting my period every 25-27 days, and the last 2 months I have been doing BBT charting so I am pretty sure I am ovulating. I had hormonal blood work done in June and another estrodial draw in July and all were within normal range, Although the estrodial was a little low.

I had an HSG procedure last month; normal tubes and uterus. Now we have to have my husband's sperm checked. It has been 8 months now and for the last 6 weeks I have been having acupuncture/taking chinese herbs, to strengthen my uterus and help me relax. I have told you before that my periods are shorter and lighter since the loss, the tend to start and stop and the flow is very limited. My obgyn has now suggested that I start a low dose clomid to see if that will help me.

I have read your blog and I understand that you do not agree with clomid for people that already ovulate on their own. I am wondering if you think I should see a specialist. Also, since I have started charting I have noted that my cycle last month was just 25 days, and from the temp drop indicating ovulation to the start of my next period was only 9 days (luteal phase). This month the luteal phase was 11 days. My obgyn said that the way they would help that would also be through clomid. I thought, from reading your blog that progestorone is only suggested. If I start the clomid, do you think I should also ask for estrogen since my period is so short.

I am trying to relax doctor, but I am worried that I won't be able to get pregnant again. I am 31 years old. My husband is 38. Thanks in advance for your time and advice. J. from the U.S.

ANSWER: Hello Again,

Thank you for following my blog.

I think you misunderstood a little. I don't disagree with ovulating patients using Clomid, I just don't like docs who turn to that immediately in ovulating patients without having done a full infertility evaluation. There certainly is a place and time to use Clomid in ovulating patients, and we call that "super-ovulation". I use this especially is older patients to help them ovulate more than one egg at a time to increase there chances because as a woman ages, more and more of her eggs are debilitated and poor quality. By increasing the number ovulated, you increase the chances of getting a good egg.

In your case, even though you are ovulating, your luteal phase is too short. It is likely that you have a luteal phase defect. Your doctor is correct that Clomid can correct a luteal phase defect, although not always. What it does is correct the ovulatory-hormonal problem that is leading to the LPD. In addition, by getting you to ovulate more than one egg, it increases your chances for a pregnancy with each cycle. But, because it doesn't always correct the LPD, the treatment of choice would be supplemental progesterone such as Crinone, Procheive, Prometrium or Endometrin. You would start that after ovulation.

If you continue to fail to conceive, my recommendation would be to see a fertility specialist, instead of undergoing treatment that is more of a "shotgun" treatment. That way you don't waste too much time. But if you want to try some low dose Clomid with your current doc, that would be okay too. The advantage you have is that you are still young. If the low dose Clomid does not work, or your doc is not doing the cycles correctly, then definitely go see a fertility specialist.

I don't think you need supplemental estrogen.

Follow Up Question (Sometimes Great Things Happen When You Least Expect!):

Hi Dr. Ramirez,

I just wanted to repost and thank you so much for all your help and advice in taking the time to answer my questions over the last several months.Your answers to my questions and that of many others have always been honest, reassuring and optimistic. I never got to take the clomid, I was supposed to start January 2011, but with prescription in hand, I instead bought a HPT and I am now 10 weeks pregnant! So yes, a bit more patience and relaxation helped...9 months after my miscarriage I am pregnant. I saw the heartbeat at 6 weeks 7 days and again at 9 weeks 3 days, so I know we are not in the clear yet but we are headed to 12 weeks!

My OBGYN said that once you see the heartbeat, there's a low chance of loss. I am also taking prometrium (spelling) progesterone by mouth. My levels were good in the beginning, but my doc is just being safe with me. Is around 10 weeks gestation the time you have your patients stop taking them? Just wondering what your protocol was.

Thanks again! Keeping my fingers crossed that everything will go smoothly this time around!

J. from the U.S.

Follow Up Answer:

Hello Again,

Thank you for the kind words and CONGRATULATIONS! Once the pregnancy reaches 8 weeks and the size is appropriate for dates and the heart rate at 120 or higher, the chances of a miscarriage drop to 5% (from 40%). So, you are in a very good position for this pregnancy to keep going.

One thought: Studies have shown that progesterone (prometrium) orally does not help with luteal support. Too much of the chemical is lost in the liver. For that reason it is usually used vaginally. I usually will stop it at exactly 10 weeks gestational age, but some clinics will keep going until 12 weeks. By 10 weeks, the placenta has taken over so it doesn't do much. I think the extra time is for peace of mind.

Good luck with the pregnancy and congratulations again.

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: Excellent source of information from Dr. Ramirez. Highly value his thoughts and advice!

Norwegian Patient With Arcuate Uterus & PCOS Wants To Know: Is IUI A Good Option?

Question:

Hi, I wrote before. I have an arcuate uterus and polycystic ovaries. My hormonal results were fine as well as my test for cervical cancer. My husband and I have decided to go for artificial insemination since we have been trying to have a baby for 4 years. I have never gotten pregnant. My question will I qualify for that and what does the whole process involve? Is it less expensive than in-vitro? Thank you, N. from Norway

Answer:

Hello N. from Norway,

IUI (intrauterine insemination) is certainly an option for you, especially if you have been found to be completely normal except for ovulation, the polycystic ovarian syndrome. (As far as the "arcuate" configuration to your uterus, this is generally considered a normal variant and does NOT cause infertility, do not be concerned with that.) Because IUI is a "natural" treatment method, meaning your body has to go through all its natural steps to achieve pregnancy, each of these natural steps have to work properly to get pregnant. Therefore, it can take several IUI attempts to achieve pregnancy, just as it would take several months of trying normally for a regular couple. The pregnancy rates are age dependent and range from 3%-24%. The maximum pregnancy rate is 24% in a woman under the age of 30. It decreases from there due to age factors.

The basic problem with PCOS (polycystic ovarian syndrome) is that the ovary does not function correctly and therefore does not ovulate on a regular basis. Therefore, any infertility treatment that you do will require that you take fertility medications in order to induce the ovaries to ovulate. With IUI the goal is to get you to ovulate three eggs per month (that is what increases the pregnancy chances). Ultrasound is then used to gauge your progess and time when the insemination should be performed. Basically, when the ovulatory follicles reach appropriate ovulatory size (18-24 mms), then a trigger such as HCG is given to trigger ovulation. I do two IUI's at 24 and 48 hrs from trigger but some clinics will only do 1 IUI at 32-26 hrs. There are pros and cons of each and I believe that two IUI's are better despite the fact that studies have shown that they are equivalent (I'm not sure that the studies were good enought to show a difference). IUI cost tends to be much much less than IVF because there is less technology used. If you don't achieve pregnancy by four attempts, then the pregnancy rates decrease dramatically so it is recommended to proceed to IVF from there.

One of the difficulties with PCOS patients is that there ovaries are very difficult to stimulate, so that many (80-85%) end up proceeding to IVF. With the simple meds such as Clomiphene or Letrozole, many PCOS patients do not stimulate at all despite the highest dosages, whereas, with the injectables (gonal-f, Follistim, Bravelle, Menopur), they tend to stimulate too much and produce too many eggs necessitating cancellation of the cycle. With natural treatments like IUI we don't allow more than three ovulatory sized follicles because we cannot control how many get to the uterus, which would increase the risk of a super-multiple such as 5, 6 or 8 implanting. This is a situation you most certainly would want to avoid!

I hope this gives you the information that you desired. Thank you for writing me from Norway!

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.