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

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.

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.

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/