Why Do I Need HCG Injections After Ovulation During IUI Cycle?

Question:

Dr. Ramirez,

My husband and I have been trying to start our family for a few years. I have been pregnant and miscarried 3 times, but is has been over a year and a half since my last miscarriage. I am seeing a Reproductive Endocrinologist and their diagnosis for not getting pregnant again is unexplained infertility. We have are trying the IUI process now using Letrozole and I have also been given a prescription to do HCG injections on days 3, 6, and 9 past my LH surge. I am not finding very much information about using HCG after ovulation. I know their reasoning is to supplement my progesterone... but not sure why then, they don't just use progesterone? Please help!

Thank you! G. from Colorado

Answer:

Hello G. from the U.S. (Colorado),

HCG (human chorionic gonadotropin) injections can be used to support the luteal phase in place of progesterone and there is nothing wrong with that protocol. Most don't use that method because you have to take it as injections and the medication is considerably more expensive. There are many progesterone alternatives such as Crinone, Endometrin, Prometrium that can be used vaginally as a supplement. You should ask your doctor why they don't just use a progesterone supplement.

The other question to ask is "what are they treating or trying to achieve"? Do they suspect that your miscarriages are due to a luteal phase defect i.e. decreased progesterone? In that case testing by an end of cycle endometrial biopsy for dating and/or b-integrin would have diagnosed luteal phase defect and your diagnosis would not be "unexplained infertility." I am not a strong believer in "unexplained infertility" as a real entity. I think it is more like undiagnosed infertility. The cause just has not been found because either a test has not been done to find it or doesn't exist. Often we find that many of these cases of fertilization failures or defects with the sperm (found at the time of IVF) or endometriosis found on laparoscopy. Sometimes age is the problem as well leading to poor embryo quality.

Your question is a good one and you should ask your doctor. Be sure they explain everything to you!

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

Comment: Thank you so much... for all of your information and quick response! I will follow up with my doctor.

Inadequate Luteal Phase Support In IVF Cycle Can Cause Bleeding & Failure

Hello Dr. Edward,

Thank you in advance for your answer! I'm from Paraguay. I just went through my second IVF-ICSI and both times I started bleeding 7-8 days after day 3 transfer, just when implantation should be occurring. Do I have an implantation problem? Are there any tests I should do? What should be done to prevent this early bleeding? I'll appreciate your expert opinion on this!

Here are the details of the case:

He: 38, had testicular cancer 6 years ago (unilateral orchiectomy and radiotherapy), very low count, morphology and motility. Now healthy, treated autoinmune hypothyroidism, BMI 26.

She: 34, no known fertility concerns, healthy, BMI 27.

Went directly for IVF-ICSI due to male factor.1st IVF/ICSI: 12 eggs, 6 fertilized, 3 transfered (day 3, 2x 8 cell + 1x 7 cell, fair quality), none to freeze. Long agonist protocol: suppressed with BCP + Lupron, stimulated with Menopur + Puregon, triggered with HCG, after ER Dostinex (8 days), anti-inflammatories and antibiotics (3 days), luteal support with Prometrium. Early bleeding 8dp3dt: BFN.2nd IVF/ICSI: 14 eggs, 8 fertilized, 3 transferred (day 3, 1x 9 cell + 1x 8 cell + 1x 7 cell, good quality), 4 frozen. Same protocol, added Estrace and more Prometrium for luteal support. Early bleeding 7dp3dt: BFN. Thank you!

Answer:

Hello E. from Paraguay,

Thanks for the information. You don't mention how much Prometrium you used in your cycles but I think that may be the problem. I think you may have inadequate luteal phase support i.e not enough progesterone. Certainly prometrium should be adequate to cover the luteal phase, and many studies have shown that vaginal progesterone only is adequate, but the dosage has to be adequate as well. I think the minimum used should be 100mg three times per day. In my practice, because I don't want patients to not get pregnant or lose a pregnancy because of inadequate progesterone, I use both injectable progesterone 50mg per day and vaginal progesterone (I use Endometrin) 100 mg per day. That is what I would recommend for you. You should not be having bleeding that soon after embryo transfer.

Protocols and technique are what distinguishes IVF centers and their respective pregnancy rates. So, that is what you need to carefully evaluate.

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 Importance Of Choosing A Qualified Infertility Specialist: 41 Year Old Patient Losing Time

(If the blog radio program turns on, please go to my October 1st post & pause it! I will be keeping the show up for the month of Oct.)

Question:

I have started evaluation with a RE at the beginning of August. I have so far been diagnosed as having low progesterone and not ovulating properly. I am just turned 41 and had a miscarriage at age 38 at 9 weeks.

My Dr said if my problem is only hormonal, it is an easy fix. He had me on prometrium for 10 days and now I go back for another ultrasound at the end of my menstrual cycle. I know other people have been put on Clomid with the prometrium. I just wondered what would be his justification or reason behind only giving me prometrium. I asked the nurse and she the prometrium was to help me ovulate. I am curious, I think my doctor is fabulous. I just want another opinion. Thanks! M. from the U.S.

Answer:

Hello M. from the U.S.,

I am glad that you wrote to me because your case disturbs me. You may like your doctor but he is wasting your time. If what you say is correct, neither he nor his nurse know what they are doing and they are leading you in the wrong direction!

If you ovulate correctly, then the progesterone level should be in the normal range. When that does not occur, it is called a "luteal phase defect" and the progesterone is used to help the endometrial lining of the uterus to convert correctly and support implantation. It DOES NOT cause you to ovulate. However, if your ovulation is not correct i.e. you are not ovulating, which would also lead to a low progesterone, then the treatment is to use a fertility medication to get the ovaries to ovulate properly, thereby correcting the problem.

There is another very very large issue, however, and that is that you are 41 years old. Did your "RE" talk to you about the age effects on your fertility? Did he tell you that your chances of a spontaneous natural pregnancy are only 1% per month or slightly less than 10% per year? Did he tell you that you may be wasting your time and possibly losing your ability to have a genetic child if you don't proceed in a more aggressive manner?

If your "fabulous" doctor is indeed an RE, then he should be very concerned about the impact of your age on your fertility and time. He would not be wasting your time with fruitless treatments like prometrium. He would be doing a more aggressive treatments like IUI (intra uterine insemination) or in vitro fertilization, IVF (preferred). Also, if he is indeed an RE, he would be doing IVF in his clinic. Does he? If not, then he may not be an RE at all.

My recommendation would be for you to go see a real infertility specialist, preferably one that does IVF, so that you can be counseled appropriately. I recently had a consult with a patient who, like you, went to a doctor that said that she was a fertility specialist. She was with this doctor from 36 years old to 45 years old. She was never referred to see a real infertility specialist, and so now, her only option is to use donor eggs with IVF. If she would have come to me sooner, we might have been able to get her pregnant using her own eggs. Please don't make that mistake!

Good Luck and keep asking those questions!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Positive Beta But I Missed Dose Of Prometrium, Now Spotting: Am I Miscarrying?

Hello Dr. Ramirez,

I am on prometrium 200mg/1morning and 2evening. I forgot evening dose on my 12th dpo. Experienced spotting and pencil line blood in mucus next 3 days. Since I forgot to take the prometruim could I be miscarrying? Today it's 16dpo and my beta came back + but at 77. Thanks! M. from the U.S.A.

Answer:

Hello M. from the U.S.,

It is unlikely that this missed dose would cause you to miscarry. Remember, the progesterone you are taking (prometrium) is a supplement and not the only source of progesterone. Your ovary, or follicle that you ovulated from, becomes a corpus luteum cyst and is the natural source of progesterone to support implantation and an early pregnancy. Once the placental develops, it takes over the production of progesterone.

The number for your first bHCG is fine. It should double approximately every other day (48 hrs) and the trend gives a good indication of how the pregnancy is progressing until an ultrasound can be done at 6 weeks gestational age. The actual amount of rise of the bHCG is at least 80% so if it doesn't double completely, don't be worried as long as it is going up.

Good Luck and don't worry too much,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you so much for the information! I appreciate the advice. I am actually moving to santa clara county and will see if it is feasible to use Dr. Ramirez as my physician!

Prometrium Vs. Endometrim For Luteal Phase Support In IVF

Question:

Dear Dr. Ramirez,

I've written to you before about luteal phase bleeding. We've tried 3 IUI's, but my husband's morphology has been consistently 0%, so we are moving on to IVF with ICSI.

My RE has me on a long protocol (BCP, Synarel, Puregon, Repronex). My main concern is luteal phase support. My RE plans to have me on 200mg of Prometrium PV TID starting the evening of retrieval... During my last natural cycle I tried this dose of Prometrium and I still had some breakthrough bleeding (but not everyday). Do you think that this is sufficient luteal phase support for someone with a history of luteal bleeding? My RE is doing a hysteroscopy next week to rule out other causes.

Thank-you for your time, L. from Canada

29yo, secondary infertility

Answer:

Hello L. from Canada,

The dosage of prometrium that your doctor has prescribed is certainly adequate for luteal phase support but is not the mainstay with IVF treatments. The gold standard is injectable progesterone 50 mg per day starting on the day of the retrieval. The alternatives that have been studied with IVF are Endometrin 100 mg vaginally three times per day or Crinone 8%/Prochieve 8% vaginally each morning. I double up and use the progesterone injection and the Endometrin or Crinone together to make sure that I have adequate progesterone coverage. So, prometrium can be used but is not the medication of choice with IVF. It is the cheapest alternative however.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank-you Dr. Ramirez! My RE has given me the option of using Endometrin (just recently approved in Canada) so I will use your advice.

PCOS Patient Taking Natural Progesterone Cream For Cycles: NPC Does Not Help You To Ovulate, Only Regulates Cycle

Question:

Hi,

I have long cycles and was recently diagnosed with PCOS. Prior to my diagnosis I have tried everything under the sun to regulate them and help me to ovulate. Vitex, Evening Primrose Oil, Dr John Lee's Shutdown, (in which Natural Progesterone Cream is applied for CD's 5-26, then stopped) a couple unmedicated cycles, soy isoflavones, currently on 1000mg/day of Metformin and the ONLY cycles I had "normal" cycle length with ovulation, is when I took NPC (25mg/BID) from CD's 5-26 (or til Aunt Flow) I know normally NPC should suppress ovulation, but instead for me it helps me ovulate. Why would that be? I cannot make sense of it at all, but am impressed that this is all it took.

I recently had an appointment with my dr, who actually told me that the NPC would do me no good in the beginning of my cycle and I should stop the NPC and start BCP's for a while to help get my cycles regulated again.

Thank you,

L. from Oregon

Answer:

Hello L. from Oregon,

Natural progesterone cream (NPC) will NOT get you to ovulate, but will help to keep you regular. In fact, you don't need to take it as many days as you are taking if all you want is to have a period on a regular basis. All you have to do is use it on CD#16-25 (10 days). When you withdraw the progesterone, you will have a period, because that is what happens in the luteal phase of the cycle. The progesterone is working directly on the endometrial lining and causing it to "luteinize" which is why withdrawal of the hormone causes it to breakdown and bleed. We use other forms of "natural" progesterone such as prometrium, Crinone, Procheive, Endometrin and Provera to accomplish the same task. But the progesterone does nothing to the ovary so ovulation does not occur. In large enough doses of progesterone, as that contained in birth control pills, it will cause a suppression of ovarian function.

The birth control pill is only a treatment to regulate your cycles. If a woman with PCOS is not intending to become pregnant, then the treatment of choice is to use the birth control pill. On the other hand, if your goal is to start ovulating, because you want to get pregnant, then as a woman with PCOS you need to use a medication that will induce the ovaries to ovulate such as Clomid, Femara or injectable medications.

I hope this helps to explain things,

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 for Pregnancy. . . Thank You! Success at last!

QUESTION: I have been trying to get pregnant for 7months. My period is regular every 26 days. Ultrasound and sperm tests indicate normalcy. I was given Clostilbegyt 50mg to take on day 2-6 and Provera for 10 days fron day 16. Does this sound correct? Won't Provera induce a period and stop me from getting pregnent. Oh I'm 33.

ANSWER: Hello,　
　
I hate to see these type of questions because it shows that the doctor you are seeing is not treating you appropriately. Have you had all the infertility testing done? Hysterosalpingogram, Hormone testing, Hysteroscopy, Laparaoscopy, Midluteal phase progesterone level. If not, then you shouldn't be jumping to Clomiphene. For one, if you have regular periods, ovulation is not the problem, although you may have a hormone problem as manifest by a short menstrual cycle. The only other reason is to try "something" since there doesn't seem to be a reason for your infertility. Many general docs give Clomid because they can, and not for any good reason, thinking that because it is a "fertility drug" it will help you to get pregnant. That is incorrect thinking. It should only be used for a specific reason i.e. it is treating a specific disorder.　
　
Technically, if you are under 35 years old, you would not be considered to have an infertility problem yet, because you have only been trying for 7 months. We don't consider a person to have an infertility problem until they have not been able to become pregnant for over one year. If you are over 35 then we shorten that time line. In women under 35 years old, it takes 8-12 months for the majority to achieve pregnancy naturally. So you may just need to keep trying on your own for a while longer. If your cycles are 26 days, then you are ovulating around day # 12, so you should start having intercourse on day # 10 for 5 consecutive days.　
　
Provera is not used with fertility because it is a "synthetic" progeterone. We only use natural progesterones like Prometrium, Endometrin, Progesterone in oil, when augmenting the luteal phase for fertility treatments. That is what me suspect that your doc doesn't have all the knowledge required for your treatment.
　
Sincerely,
　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
　　
---------- FOLLOW-UP ----------
QUESTION: Great news, I am now 6 weeks pregnant after following your advice. However, before I got pregnant I had a yeast infection for almost three months. My doctor gave me Canesten tablets and inserts and that did not work.It eased the symptoms for two days and then they returned. She then gave me Flagyl tablets for both my husband and I for ten and five days respectively ( 3 tabs per day). I was also given Klion to insert every night for ten days. That last dose of medication was a nightmare as it caused severe pain and irritation, I stopped after five days. Now I'm still having some irrtiation and itching and extremely painful sex on penetration and afterwards. My new doc gave me Travogen cream and it has helped a little with the itching but sex is still painful. Is this normal? Is it that I may have something more serious? Can this affect my pregnancy? I'm really worried.... please advise me!

Answer:
Hello Rhonda from Trinidad-Tobago,
　
Congratulations!!! :) :)
　
If you have symptoms, then you need to be checked and have cultures done. It may be a simple yeast infection that can be treated easily, or something else. Don't go the trial and error route like your doctor did previously. Have the cultures done so that he/she knows exactly what to treat, especially since you are pregnant. There are some medications that you don't want to take at this time. Sex should not be painful, but since you are newly pregnant, you might want to avoid sex until you are further along (12 weeks gestational age).
　　
Sincerely,
　　
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/