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.

Canadian Needs To Know: Frequent Blood Draws Are NOT Necessary For Clomid Induction Cycle

Hello Dr. Ramirez,

I'm currently undergoing cycle monitoring and my RE has not yet been able to pinpoint a reason for our 18 months of infertility (hubby checked out okay and my initial tests - ultrasounds, blood work, saline hysterosonogram - show no problems other than possibly my age being a factor - 35).

I am on my second month now of ovulation induction cycle monitoring. At the clinic I go to (and it appears any of the ones that I have looked into here), they want to do cycle monitoring every single month regardless of whether it is a medicated or natural cycle. He said after this month, we will likely try something like Clomid to produce more eggs and continue with the cycle monitoring.

I could handle the ultrasounds, but the blood work has become such an issue for me I may not be able to continue with treatment. I have to go on CD3 and then daily starting again on CD10 until I ovulate which usually isn't until CD17-19 and then for a progesterone test 7 days post ovulation.

The problem is I have always had small veins that are difficult to get blood from. I've had several of the technicians try and they often try for more than 10 minutes with multiple pokes. I develop massive bruises so the subsequent tests are even worse. They told me I have almost no surface veins and even when they hit one, sometimes no blood comes out of it. They've tried my hand too which is very painful and the last time I was there, they talked to my RE and then they used my foot which also hurt a lot. One of the technicians today said they may have to move onto my groin or neck (but she laughed so I hope she was joking)! I've tried drinking lots of water as well as soaking my hands and arms in hot water without any success.

I talked to my RE and asked if the daily blood work is absolutely necessary each and every cycle and every visit and he said it is required because they need to closely monitor levels. I asked if I could go for the ultrasounds and monitor my LH surge using urine OPK tests and he said they require the blood work because they need to monitor things other than just LH and blood work is a requirement each day an ultrasound is done.

In your opinion is there any other option than all this blood work? I'm almost having panic attacks each day on the way to the clinic (and I've never had panic attacks before) because it gets worse everyday and I don't know how many more months I can deal with this. I'm concerned about future routine blood work as these daily tests are no doubt making my veins worse. At this point I don't want to tell many people about our fertility issues, but my arms make me look like a drug addict as they are covered in bruises.

I'm D. from Ontario, Canada.Thank you for your input.

Answer:

Hello D. from Canada,

I have never heard of such a ridiculous thing! Blood work is not required for simple ovulation induction whether by natural ovulation, Clomid ovulation or even low dose Follistim ovulation. The blood work that is done with IVF is done because the ovaries are being stimulated so strong that we need to make sure that overstimulation or hyperstimulation does not occur. It is NOT required for monitoring. The key to ovulation induction is NOT the blood test results but the number and size of the follicles as seen by ultrasound. Ovulation is timed by the size of the follicle NOT the blood test, and a midluteal progesterone is NOT needed if progeterone supplementation is given and/or ovulation is determined by ultrasound (which is a better method than the progesterone anyways).

I think your doctor, and this clinic, is treating you inappropriately and in essence, torturing you. I would strongly recommend that you change clinics immediately. I find this clinic abhorrent! If you review my blog where I discuss how I do ovulation induction, you will see that there is no mention of any blood tests except for a pregnancy test at the end of the cycle!

In terms of why you are not getting pregnant, if you have not had a laparoscopy then I would recommend that you have one. I often find that in patients that don't seem to have an obvious reason for infertility, that is, the basic workup has been normal, that they often have endometriosis in the pelvis. Endometriosis does not have to be symptomatic to cause infertility.

If you can't find a fertility clinic in Canada that will do the ovulation induction without blood tests, then you should come to my clinic in California. At least I can save you from being tortured. Please seek out the appropriate level and standard of care!

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.

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.

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 Woman TTC Is Concerned: Has Abundant Cervical Mucous & Irregular Cycles

Question:

Hello, I am writing you from Alberta, Canada. I have been doing many searches on the internet to find an answer to my question with no success. I hope that you might be able to help me.

So, I went off BCP (birth control pill) in March 2010 to TTC. (I am 26 and have been on the pill for 7 years.) Since then I have been having a cycle each month (cycles have been ranging 30- 36 days) I have had a cycle last 42 days. And I have had several appointments with my Dr. She said that since my cycles are that long that I "might not be ovulating". This really worried me as it's nothing a woman ttc wants to hear. So I have been watching for the EWCM and each month I barely see any. But there is a bit. Well I am going on day 53 with no period. Last week I had LOTS of EWCM for the entire week. And I mean A LOT of it. More than I have ever seen. I thought I was pregnant because of symptoms but after 2 negatives I know I am not. So this brings me to my question...what does it mean when you have LOTS of EWCM for a whole week? I was having LOTS of cramping so I was thinking my period was going to start but nothing. There was one day which was the worst cramping I have had. I usually cramp a lot when my period starts and the week of ovulation.

Could my body finally have ovulated and the hormones are working out or should I seek more advice from my Doctor? I am waiting for my cycle to start so I can take the clomid she prescribed me. I appreciate any advice you may have for me. I do plan on going back to my Doctor soon but with the Christmas holidays I can't get in to see her til the New Year. I was really curious about all that EWCM. There was sooo much of it and it lasted more than 4 days. Is that a good sign even though it was 45 day of my cycle? My cycles before I went on the pill were usually 32-34 days and very consistent. But the periods were heavier then...lasting 5-6 days. After stopping the pill they were very light and have only lasted 3-4 days.

I apologise for such a long explanation. I just thought I would share my story in case other women have the same issue and question so they can use the answer I receive.

Thank you again and all the Best to you in 2011!

Answer:

Hello C. from Canada, Thank you for wanting to share your concerns with other women who are trying to conceive (ttc). I think that you are putting too much value on cervical mucous. It is an indirect measure of the hormone production in your body. Basically, as the body gets closer to ovulation, the estrogen/estradiol level in your system increases, which in turn converts the cervical mucous to a clear, stretchy, copious mucous. This allows for sperm entry into the uterus and tubes. I am not sure what you are referring to as "EWCM" and because you don't describe the mucous properties so I can't comment on the question regarding having this mucous for multiple days (please be more specific, since descriptions are better than acronyms). The cervix produces all types of mucous and the vagina as well.

Here is a general guideline on what cervical mucous should look like post menses:

Stage 1: Lasting 2 - 3 days Cervical Mucous is sticky or gummy

Stage 2: Lasting 2- 4 days: Cervical Mucous is creamy, milky and lotion like.

Stage 3: Lasting 1-5 days: Egg White Cervical Fluid: It looks like egg whites and is slippery and stretchy. The mucous should be clear, but if there is an odor this may be a sign of an infection, if so, consult with your doctor. Women in their 20's such as yourself can have this type of cervical mucous for up to five days. At this point, women are generally considered to be in their most fertile period.

Stage 4: Dry, Moist or Sticky

Based on the fact that your cycles are irregular, there is evidence that there is some type of ovarian dysfunction going on as well. It could be a lack of ovulation or a hormone imbalance. If it is of ovarian origin (there are other possible causes as well), then the treatment would be to use medication such as Clomid to stimulate the ovary and get it to function normally. But prior to making that assumption, you should have a hormonal evaluation to make sure it is not a problem with your thyroid or pituitary or hypothalamus or other such causes. If it is found to be isolated to the ovaries, then Clomid ovulation induction is appropriate. I would recommend that you look at my blog regarding how Clomid ovulation induction cycles should be done ("How I Do Clomid Induction Cycles"). I hope that helps to answer your questions, 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.

UK Patient Has PCOS, On Clomid For Ovulation: After First Miscarriage, Should She Continue With Clomid Or Start Injectables?

QUESTION:

I was put on 50mg Clomid due to pcos and long cycles (42-43 days). Right away, my cycles reduced to between 26-32 days. I got pregnant on my 3rd cycle of Clomid, then miscarried.

My RE recommends that I go back on Clomid, and would like me to increase my Clomid dose to 100mg so that we can recruit more than 1 egg (since I was only ovulating one egg on the 50mg dose). I will also be taking progesterone this time.

1) Do you recommend that I increase my dose of Clomid to 100mg to recruit more than one egg (even though I was ovulating normally on the 50mg dose)?

2) If the next 3 months of Clomid are unsuccessful, my doctor recommends that I try FSH injections (since I will have been on clomid for a total of 6 consecutive months, including the 3 months before my miscarriage). Do you recommend moving to FSH injections, or staying on the Clomid since it was successful previously?

3) If I cannot get pregnant again during the next 3 months on Clomid, my doctor recommended getting a laparoscopy. Just wondering if you would recommend I proceed with a laparoscopy if I fail to get pregnant again? I feel like I just got pregnant after 3 months of Clomid, so that the procedure seems unnecessary to me. (I have also had bloodwork, SA, and HSG all come back as normal).

Thank you for your advice. Sincerely,S. from the U.K.

ANSWER:

Hello S. from the U.K.,

I am sorry for your miscarriage. Considering your treatment plan, because you responded to 50mg of Clomid previously, you certainly don't need to increase the amount. However, your doctor's strategy is to get you to ovulate more than one egg at a time to increase your chances of pregnancy with each attempt. We call that super-ovulation. With increasing the number of eggs, you certainly will be increasing the chances of a multiple pregnancy. If that is not acceptable then stay with just 50mg.

I do not recommend moving to FSH injections yet. They certainly have a place but since you have gotten pregnant with Clomid before, I would just increase the Clomid dose. You can go up to 250 mg of Clomid. 3 months also seems like a short time frame for the trial unless you are over 35 years old. Then you might want to proceed more aggressively.

If you move up to the injections then I would also recommend that you add IUI in order to increase your chances even more. I don't recommend a laparoscopy at this time because I don't see a reason for it. I keep in mind that you were successful already with Clomid which shows that everything your body needs to do in order to achieve pregnancy can occur. The pregnancy re-sets the time frame. Now you just need to go back to the same plan and keep trying!

Follow Up Question:

Dr. Ramirez,

Thank you for your prompt reply. It is extremely helpful. I just have a few follow-up questions:

I mentioned previously that I was on Clomid for 3 months and got pregnant on the 3rd month (and miscarried). I have now been on Clomid for another 2 months since the miscarriage and not gotten pregnant yet. So I will be starting my 6th consecutive month of Clomid this month.

You recommended I continue with Clomid at a higher dose (rather than move straight to the FSH injections), since Clomid worked for me before.

1) Could please tell me what is the longest period that I can safely be on Clomid for? [I keep reading that one is only supposed to be on Clomid for a limit of 6 consecutive months. I am going to be starting my 6th consecutive month of Clomid this month]

2) I also keep reading about two negative effects that can occur with continuous use of Clomid. One is thinned lining (my lining has been fine so far). The second effect I have read about is hostile cervical mucus.

My RE said she is willing to do a post-coital test to check on cervical mucus if I want one, but that she does not consider it a reliable test. So my question is - how am I supposed to know if my cervical mucus is being affected by the Clomid? Also, since I am now entering my 6th month of Clomid use, should I consider taking an estrogen supplement which can possibly improve cervical mucus? Thank you very much for your advice. Regards,S.

Follow Up Answer:

Hello Again, When I answered your previous question, I was not implying that I agreed with continuous Clomid cycles. I do not. Because of the "antiestrogenic" effects of Clomid, I do not use Clomid on a continuous monthly basis. I alternate with Femara, but if that is not used, then Clomid should be used on an every-other month basis so as not to block the estrogen receptors, for exactly the reasons you indicated. Yet, as I stated above, your pregnancy reset the time frame.

In terms of the maximum number of months to use Clomid, there is no rule that says that Clomid needs to be stopped after a certain number of months. However, if pregnancy does not occur, then you should move on to the next level of treatment after six months. In your case, since you became pregnant, that reset the count. Because fertility treatments cannot control the pregnancy, and can only give you the opportunity to become pregnant, that is where treatment success ends. So you are now on your second cycle of Clomid, not your 5th.

Certainly if you want to move to the higher level of treatments such as Follistim, there is no reason that you should not. I only suggested the Clomid because it is less expensive, easier to use and worked for you before.

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.

Can Progesterone Be Given With Clomid Induction? PCO Patient With 3 Failed Cycles Wants To Know...

Question:
I'm 31, never pregnant. Dx PCOS, receiving metformin 1500 mg a day. Three cycles with clomid with no ovulation. HSG normal, husband semen analysis OK. Now going through second cycle of IUI (intra uterine insemination), ovulation stimulated with Gonal F and triggered with ovidrel.

First cycle progesterone level on day 3 after second IUI was low (2.3), so I asked the doctors why they can not prescribe progesterone to improve luteal phase and make implantation more possible, and they told me they do it only with IVF. Is this Ok? What I mean is, why don't give progesterone if the level is low, and it is know than low progesterone impairs implantation and also increases risk of miscarriage in first trimester? Please give me some advice, or some reference articles where to read about this (scientific articles to support my request) Thank you! S. from Arkansas

Answer:

Hello S. from the U.S.,

You have a very valid question and you should ask your doctor why they don't give progesterone after intra-uterine insemination. I'm sure there are many articles on the web that you could find that advise this technique. There is absolutely no reason not to give progesterone after IUI or even after simple ovulation induction.

However, I think that your thinking may be incorrect, however. If the ovulation induction were proceeding correctly, and ovulation occurs, then the hormones should be corrected and there should be a normal luteal phase. Usually a mid-luteal progesterone is not to see if there is adequate progesterone for implantation, but to see if ovulation in fact took place because if it did not, the progesterone would be low. So you see, rising progesterone levels occur from ovulation. If the progesterone is low, that is an indication that ovulation did not take place and replacing progesterone would not have anything to help i.e. no implantation would occur any way.

I have to wonder about the protocol that your doctor is using, and I would suggest that you look at my blog under how I do clomid induction cycles. One specific technique that I use is to follow the follicle(s) with the ultrasound to determine when ovulation is going to occur. That way, I can better time the insemination. I also give an HCG trigger. Then I start progesterone the day after the second IUI (I do two IUI's per cycle) for luteal phase support. This is mainly because progesterone is an easy medication to use, is not expensive and has no adverse reactions/side effects/harm to the pregnancy. It can only help and increased progesterone is one of the main stays for the treatment of implantation failure due to inadequate b-integrin levels.

Maybe you should ask your doctor why he uses it for IVF and not for IUI? The reason to use it should be the same.

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.

Canadian Wonders If Progesterone Is Needed for Clomid & IUI Cycles: YES!

QUESTION:

I am trying to conceive and I have had 3 rounds of Clomid (100mg) by itself with no success. I have also now done round 4 with IUI. With the IUI cycle, my doctor told me to take 100mg Progesterone 2xday, intervaginally, and 2mg of estrace 2xday. My question is this...should I have been given Progesterone with the first 3x of Clomid?

I have heard Clomid lowers the progesterone levels and mine was only 7 to start with. I have also had a history of lots of ovarian cysts which has been explained to me as one of the possible reasons I haven't conceived again...because cysts indicate being estrogen dominant.

With this in mind, I have looked up estrace and it is contraindicated in pregnancy...so now I am confused. Why am I being prescribed a med that is contraindicated in pregnancy, when that is what I am trying to achieve, and why if I am already high in estrogen?

I am confused and wonder if I should only be taking the Progesterone....Help! A. from Canada

ANSWER:

Hello A. from Canada,

Practically ALL medications state that they are contraindicated in pregnancy (for legal issues). In actuality, if you read all the fine print, it says to consult your doctor. Both estrogen and progesterone are required for pregnancy to occur. The estrogen is required to prime the endometrium for implantation and the progesterone both converts the endometrium for implantation and supports the pregnancy. They are both used in fertility treatments, and have been for many many years. No problems so far! So, you don't need to worry about using them.

However, I am not sure that you need the estrogen supplementation, especially in the luteal phase (after ovulation). It is usually required in the proliferative (endometrial proliferation in preparation for implantation) phase. The progesterone is required in the luteal phase (after ovulation).

I use progesterone, but not necessarily estrogen, in ALL my Clomid cycles. Clomid is an estrogen receptor blocker and so extra estrogen might be require in the first half of the cycle to make sure that a proper endometrial lining is developed, but that is not always the case. On the other hand, often Clomid with cause a lack of progesterone production, and progesterone is such a benign and easy supplement to use that I don't risk not having enough.

From what you have briefly described, I am not sure that you are in the best hands for this treatment. I know Canada limits the availability of specialists, but you might want to see a fertility specialist. I would recommend that you look up my blog, under "how I do Clomid cycles" and it will describe my recommendations for a proper Clomid induction cycle with or without insemination.

Good Luck and stay informed!

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.

41 Yr. Old Iranian Woman With Mixed FSH Results: Remember, FSH Levels Are Not A Measure Of Your Fertility, They Are A Measure Of Ovarian Function!

Question:

Hi! I am 41, with a 22-day cycle. I got married 8 months ago and had a miscariage at very early months (1st month). Then, my doctor prescribed me clomid and letrozol which resulted in production of several eggs. however, I did not get pregnant.My last FSH test result at 21th day was 4.7, while its level at 3rd day (i.e. four days later than my FSH test at 21th day) was 35.5!

I am too much worried about this high level of FSH. What are your recommendations for FSH reduction and get pregnant?

thanks! M. from Iran.

Answer:

Hello M. from Iran,

I am surprised but glad that you are able to search the web, since many of us believe your government has tighter controls. Let me clear something up first of all. The FSH level is only valid for interpretation if it is done on cycle day #2 or 3. I would recommend that you have it repeated because the results you cited don't make sense. The FSH is a measure of ovarian function (or ovarian resistance). This is mainly important to determine how well the ovaries will respond to stimulation. It is NOT a measure of fertility.

However, if the CD#3 FSH level of 35.5 were correct, that would indicate that you are in menopause and your ovaries would be shut down. You would no longer be having periods and you would have menopausal symptoms such as hot flashes. Your ovaries would not respond to stimulation with Clomid or Femara. Yet, you mention that you were able to "produce several eggs" while on Clomid. That is why I don't think that your FSH level is correct.

From a fertility point of view, we want the FSH level to be less than 7. It is of some concern when it is between 7-10, which indicates that there may be less time for the ovaries than we suspected and that the ovaries might be more resistant that expected, and it is of great concern in the level is greater than 10 because that means there is significant ovarian resistance and a shorter time line. Once the level is 15 or greater, most fertility specialists will recommend using donor eggs.

The biggest hurdle that you are facing, in addition to ovarian function, is your age. Your chances of pregnancy with simple Clomid treatments is 2% per month of trying and with IUI is 5% per month of trying. I would not recommend this at your age. I think that time is of the essence, so that you don't lose the possibility of having a genetic child. For that reason I would recommend a more aggressive treatment plan, which would be to proceed directly to IVF. That would give you a 50% chance of pregnancy per month.

Good Luck and thank you for your question,

Edward J. Ramirez, M.D., FACOG
Executive Medical DirectorThe Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Twitter with me at @montereybayivf, and follow me on Facebook at http://bit.ly/9Iw9oV

PCO Patient With Complex Hyperplasia Trying To Conceive: Needs To Lose Weight & Begin Clomid Protocol

Question:

Dr. Ramirez, I am 31 years old my husband is 40. We have been trying to conceive for about 3 years. I have taken Clomid about 4 different times. I have only had about 5 or 6 periods on my own in my entire life. I went to my OBGYN who put me on provera to get me to bleed then take 50mg clomid to start with. She told me that I had PCOS. In Dec of 2009 I hemorrhaged and had to have 4 units of blood. My OBGYN sent me to a oncologist who diagnosed me in Jan with complex hyperplasia with atypia and a well differentiated adenocarcinoma. They said I needed to have a hysterectomy but I want a baby really bad. They said we would have to try to reverse the condition first. They started me out on Megace then changed to Provera 15 mg a day for 1 month. I have had 3 d&c's. My last vaginal ultrasound showed everything was clear but my lining was very thin. My OBGYN stated that I could try clomid again and she put me on birth control pills which she said would help to make my lining thicker. She told me to take Nortrel birth control pills to start my period. I was on 100 mg of clomid but didn't ovulate. I haven't had a test done to check my husbands sperm because I know that I do have a problem and the test for him is too expensive. But I will have to have it done if I eventually start to ovulate and still do not get pregnant.

My OBGYN just started me on another cycle of the birth control pills and then 250mg of clomid. On the first cycle of 100 mg of clomid, I stopped taking the birth control pills when I started to bleed. Then I took the clomid on day three of bleeding. Was this wrong? Should I have kept taking the birth control pills even though I had started bleeding? I only had 2 left in the pack. I was just confused and was afraid that this might have been something to keep me from ovulating. Do you think that even though I have had the complex hyperplasia with atypia and the cancer that I can still possibly get pregnant? I also was wondering if my OBGYN said everything looked clear and I don't have the hyperplasia anymore then why can't I ovulate and get pregnant?

Answer:

Dear T.,

Thank you for your question and thank you for the very long history. You are certainly faced with a dilemma. However, you are not the first to have this problem and oncologists are very aware of what they need to do. After the Megace treatment, you should have had another D&C to make sure that the cancer was resolved. If you have not had that resolution, then that has to be done first. You don't want to be pregnant with cancer, and have that shorten your life with your new child. Also, the Megace treatment is only for very early stage cancers. If it is more advanced then do not delay the hysterectomy. They can preserve (not remove) your ovaries so that you can use a surrogate to achieve pregnancy. There have already been great successes with frozen ovarian tissue as well as frozen eggs. Do what is going to be the best for your child in the long term.

It sounds like your OB/GYN is proceeding correctly, however, you probably need to see an infertility subspecialist. If you do not respond to the 250 of Clomid, that is the maximum dose. It is time to move on, especially since time is not your friend. You should have had a basic evaluation, which included a semen analysis, before starting treatment. You don't want to waste time and energy if a Clomid-intercourse cycle is not going to work.

In terms of the birth control pill, you were correct is stopping the pill and not finishing it since your period started early. That is the key for starting the Clomid cycle.

In terms of getting pregnant, PCO is a complex but not insurmountable problem and is very common. However, most of these patients do not respond to the easy medications (Clomid, Latrezole) and have to move into the more complicated injectable medications. For that reason, I advise seeing a fertility specialist, not a general OB/GYN. In addition, you want to get pregnant as soon as possible, so that your cancer does not return. You may want to consider a treatment plan that is going to get you pregnant the efficiently.

Follow-up Question:

Dr. Ramirez, I did have the D&C after the megace and Provera treatment and it showed that I no longer had the complex hyperplasia with atypia or the cancer. They let me start the fertility medicine again. I am on the Nortrel birth control pills now and when I start my period I will be starting the 250mg of clomid. My husband hasn't had the semen test done yet because we do know that I can't ovulate so it is definitely a problem of mine right now. I just couldn't afford to have the test done for him. I don't think that I can see a infertility subspecialist because my insurance won't cover it. I wouldn't be able to afford it.

I was just curious if you thought that as long as the complex hyperplasia with atypia and the cancer are gone if I should be able to ovulate and get pregnant. I started out at 262 in December when I hemorrhaged and I am now 234. I am losing weight but find that I am staying pretty much at the same weight and can't lose anymore. I also have thyroid problems and I'm on Levothyroxine. I appreciate your help. Thank you!

Follow-up Answer:

Hi Again T.,

I'm glad to hear that the complex hyperplasia and cancer are gone! That buys you time. However, as I explained earlier, you will need to be cycled, so don't go any prolonged period of time without having a period.

I think you can safely assume that part of your infertility problem is the lack of ovulation. It is most likely that you have a disorder called polycystic ovarian syndrome. Your increased weight is contributing to the problem, and the PCO also causes you to increase weight. You should try to get your weight down as much as possible, close to your ideal weight. This by itself may induce your ovaries to begin ovulating on its own.

You also need to make sure that your Thyroid problem is under control and the levels are normal. This too can decrease your chances.Since financially you can't progress beyond Clomid at this point, it is certainly okay to continue trying Clomid. However, 250 mg is the maximum dose and many PCO patients do not respond to this dosage or clomid at all. In that case, you will have to go to the injectable medications, which are much more expensive, and you will definitely have to see a fertility specialist for that level of treatment.

Good luck and don't give up! It's possible that your fertility specialist may have various financial plans in place that will make it affordable for you and your husband to pursue treatment, as our center does.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

41 Year Old With High FSH, High Estradiol - Can I Still Get Pregnant?

Question:

Dear Dr. Ramirez,

I am forty-one year old professional woman living in OH, and I desperately want another child (I have a 16 year-old and a five year-old that were conceived with no problem at all). Before trying to conceive this time, my dr. ran day 3 FSH and estradiol testing, with an FSH result of 15.9 and an estradiol result of 207.

What does all of this mean for me? I've heard that I should take Clomid to stimulate ovulation, but since Clomid raises the FSH, isn't that counterproductive? How does Femara work? Is there any hope for me without donor eggs?

Thank you so much, M.

Answer:

Hello M. from Ohio,

First of all, thank you for your questions. They have relevancy with a topic which I have addressed lately, which is how to approach infertility at +40 and beyond.

So, how does Femara work? Well, FSH stands for Follicle Stimulating Hormone. It is the hormone that the pituitary (brain) produces to stimulate the ovary to grow and ovulate an egg. Think of the ovary as a ball with lots of holes in it (sort of like a practice golf wiffle ball). Imagine this ball at the end of your blood vessel and the holes let the FSH in. When the FSH reaches the inside, the ovulatory process is stimulated. Now, imagine the same ball with much less holes because over time the holes have blocked off. So now less of the FSH is entering the ball and stays in the blood stream. That is your cycle day# 2 or 3 level. If the ovary is picking up a lot of the fSH, the level is low, but if it is picking up less, the fSH is high. When then level reaches 20, that signifies that the ovary is not picking up the fSH anymore, which is menopause. From a fertility point of view, we want the fSH to be less than 10. When it is higher than 10, that signifies "ovarian resistance", which simply means that if we stimulated the ovary with fSH (fertility medications), the ovary will not respond very well i.e. not increase the number of eggs that it ovulates.

The main purpose of fertility drugs, in someone who is ovulatory, is to increase the number of eggs that are ovulated in order to increase the chances that one egg will find and get into the tube to be fertilized, etc. So if the ovary is "resistant" to being stimulated, then more eggs will not be ovulated or available to be retrieved (as in IVF). When the fSH level is 15 or above, as yours is, that is significant ovarian resistance and very close to menopause. It is very, very unlikely that we would get more than one egg, if any at all, which means that the IVF cycle would be wasted. Here's the catch: That doesn't mean it won't work, after all, it only takes one good egg and one good embryo to become pregnant (and I have had several of these types of patients), but merely that the chances are less. For this reason, many IVF clinics use an fSH of 15 as their cutoff for a patient to use their own egg. However, it is not an absolute and the choice is ultimately yours.

Regarding your question re Clomid/Femara. Clomid and Femara work by stimulating the ovary indirectly. They are both estrogen receptor blockers, and in doing so, trick the brain into thinking that it is not producing enough estrogen (which occurs from the ovulation process in the ovary). As a result, the brain increases the amount of fSH in the blood to stimulate the ovary. As you can see, if you have ovarian resistance already, meaning that the ovary will not pick up more fSH anyways, then using Clomid or Femara will not help. In fact, using high dose injectable fSH won't do much either. Finally, the way that IVF helps with the age factor, what I call the "age related egg factor", is by stimulating the ovary to get lots of eggs out at a time. The assumption is that there are still some good eggs left in the ovary. By taking many, many eggs out at a time, we are hoping that we will have a good egg in that group, and thereby increase the chances of pregnancy. We do not have the technology to make eggs better. If we can't get a lot of eggs out at a time, then then IVF is helping a little more than trying naturally but not by much. I still think that IVF is better, however, than trying naturally because more of the process required to become pregnant is accomplished with IVF, whereas your natural process is less exact.

I have had and have patients will high FSH levels, such as yours, attempting IVF. Again, it is your choice, and my role is to be your advisor, not your parent. Most patients want to try at least once, to convince themselves that they gave their best effort. Also, as I mentioned previously, I have had some successes with only one egg. One can make a good argument for not using fertility stimulation in these cases, since a natural cycle will produce one egg on its own if the ovary is still functioning normally, however, we can't know that until we try, so I still use high dose stimulation. By the way, having such a high estradiol level on cycle day#3 does not make sense. The estradiol should be at its lowest level. Having a high level like that means that something else is producing estrogen, such as a cyst, or that the timing of the test is wrong. Therefore, I would recommend that you repeat the test after another natural cycle.

I know this is a long answer, but I hope it gave you some relevant information.

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.

Follow-up comment: Thank you so much for your honest and clear answer. You did not have to put so much time into answering by question, and I truly appreciate it that my question was important enough to you for you to do so.

Using BBT chart and Ovulation Predictor Kit while on Clomid

Question:

First, thank you for your time. It is awesome that you would offer your advice on line.

I am on Clomid 150mg. I show on my BBT chart that I ovulated on cd 17. My temps stayed above the coverline till 7 DPO and again today on 8 DPO it is still low. All of the research I find says that implantation dip is only a single day, but that my temp should drop of between 10-16 days to start menstruation.

Here is the link to the website where I get my BBT chart. http://www.fertilityfriend.com

Thank you for your time.

Answer:

Thank you for your question, I try to give as good advice that I can considering the limiting factors, which of course include not being able to talk to you at length and in person.

I would not analyze the temperature chart so closely. It is not that accurate. Many factors can influence the temperature. It is only useful to see if there is a rise in the mid-cycle, which is an indirect measurement of the LH surge, indicating ovulation is going to occur. If you are going to continue using the chart, use it only for that indication i.e. timing of intercourse, and nothing else.

Another option, which I think is more accurate but more expensive is the ovulation predictor kit or OPK. However, with this kit you also cannot evaluate the luteal phase. The only way to evaluate the luteal phase is to do an endometrial biopsy. You will need to begin infertility testing for that.

Follow-Up Question:

One more question. My cycles are very irregular I take progestrone to start before the clomid. When do you recommend taking the home pregnancy test?

Thank you for your time.

Follow-Up Answer:

You are going through a lot of effort that is not very efficient.

The way that I do Clomid cycles is I follow my patients using the Ultrasound starting from day # 10 of the Clomid cycle. This allows me to see if the patient is responding to the dose that I prescribed, count how many potential ovulatory follicles there are so that there are not too many, and to time when intercourse should occur. I also use HCG to trigger the ovulation. With this method, the cycle is done more efficiently. I then do a pregnancy test two weeks later. It is programmed. There is no guessing. If your doctor is not doing it this way, then you are probably not seeing the right person or specialist. This is the correct way.

If you don't have a choice, then you have to go by the calendar method which is based on your period. Cycle day # 1 is the day your period starts. Begin intercourse on cycle day # 13-17, once per day, only one ejaculation per day. Do a pregnancy test on cycle day # 28 and repeat on cycle day # 30. If it is positive, then have a blood pregnancy test done on those days.

I hope this helps. Good Luck!

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Clomid Protocol Not Working

Question:

Hello!

First of all, thank you for being available to answer questions for all of us. I have taken Clomid twice now. The first month I took it I was on 50mg 5-9 and I ovulated on cd 21 with a progesterone level of 19. I have 33 day cycles. The second cycle I was on 100mg 5-9 and I used my Clear Blue Easy monitor and it never peaked just stayed on high. Then I had my progesterone test and it was only 7. But then my OB gave me 100mg again for the next month. Shouldn't I still be on 50mg if that worked better??

I am also thinking about taking the 50mg days 3-7 instead of 5-9 since it is my last month being able to take it according to my OB. On top of the Clomid, she also gave me Estrace (not sure if that is spelled right) to take days 8-12 and Prochieve to take days 16-28. So if I take the Clomid days 3-7 do I take the other meds on different days?? Also, a little background, I have one child conceived naturally, I am overweight but don't have PCOS and don't have blocked tubes (I was tested for both). If there is any way you can help me with my situation it would be very helpful!

Thanks again!

Answer:

Hello,

Although the Clomid worked the first cycle, I too would have increased it to 100mg to get your cycles more normal and shorter. It is possible that the Clomid at 50mg was barely effective, and worked by luck only. That would explain why the 100mg did not work.

I also do not advocate the method your doctor is using. I am a firm believer in the ultrasound surveillance to evaluate whether or not the medication is working, how many follicles there are and to time ovulation. That is a lot more information that your doctor is getting. I also automatically use progesterone with my Clomid cycles to help implantation and support the pregnancy. Sometimes, Clomid can also cause the uterine lining to be thinned, however, your doctor should be checking this with an ultrasound rather than treating empirically, as I've mentioned before.

Finally, whether you take Clomid on days 3-7 or 5-9 does not make any difference in stimulation.

My protocol is as follows with Clomid:

1. Cycle day 2-5: Baseline ultrasound to rule out residual ovarian cyst, give Clomid calendar and prescription.

2. Stop recreational intercourse on CD #10.

3. Start ultrasound surveillance on CD #11 and continue as frequently as needed to determine when the follicle is appropriate size for ovulation. This also rules out a super-multiple (three or more) pregnancy potential. If there are more than three follicles, we cancel the cycle and prevent pregnancy.

4. When the lead follicle reaches 20-22mms, HCG (Ovidrel) is given to stimulate ovulation.

5. Have intercourse daily, once per day, one ejaculation per day beginning the day after HCG, for four consecutive days.

6. Start progesterone five days after HCG and take daily until the pregnancy test.

7. Do pregnancy test (serum) in two weeks.

I hope this helps. Please discuss your situation with your OB and get a second opinion if necessary.

Edward J. Ramirez, M.D.,FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

Check me out on Facebook and Twitter with me at @montereybayivf