Infertility Specialist Incompetent: Cancelled IVF Cycle Prematurely

Dear Doctor,

I am 40. I had two missed abortions at 37, both in the ninth week after heart beat was felt. Subsequently I did not conceive and my RE suggested IVF. I have regular 29 day cycle.

My Day 3 FSH is normal. My RE put me on Lupron (0.5cc) from day 17. On day 2 of the period, she started with 600IU of HMG and 0.25 cc of Lupron for 3 days (cd 2-4). On reviewing after on CD 5, she said no follicle and no endometrium growth is seen. She continued the medication for two more days and (cd 5, 6) and examined me cd 7 and said that there are no follicles or endometrium and cancelled the cycle.

I stopped all medications and on cd 12, I checked with a local ultra sound center. The Ultrasound specialist said there are about 12 follicles on both ovaries, the largest being 10mm.

I checked my FSH and E2 on the same day and the FSH was 12.76 and the E2 is 58.00.

On Cd 16 I checked again and the Ultrasound specialist informed me that one follicle is 13 mm and others are still small.

Can I do anything at this stage to get a multiple ovulation in this cycle so that I can try naturally in this cycle (Like one or two doses of clomid or letrozole)?

What do you infer from my endometrial thickness of 10mm though my follicle size is only 13mm.

What is your advice for future IVF cycles? Thanking you in anticipation. R. from India

Answer:

Hello R. from India,

It may be too late to rescue this cycle but if you have any Menopur, you could use it but the dosage would need to be significantly reduced to minimize the number of follicles that grow to ovulatory size. Unfortunately, the reality is that the eggs will not continue to grow and mature if it does not receive enough FSH hormone and will proceed to atrophy (wilt). If your natural FSH production kicks in then you might still have one follicle ovulate as you would in a natural cycle. I guess that is what you will have to hope for.

An endometrial lining of 10 mms is adequate and appropriate for implantation. It is also a sign that you have adequate estrogen levels because endometrial growth is dependent on Estrogen. Did your doctor ever check your estrogen levels?

My second piece of advice is for subsequent cycles. Your age is a factor from this point on so I would advise you to find a competent specialist. Your doctor is incompetent and does not know what she is doing so I would dump her (find a new doctor). It is expected, and usually the case, that there will not be much follicular growth by CD#7 of stimulation. Some people take longer,as you have shown. In IVF cycles, you have to continue to follow the Estradiol levels to see if they are rising, which is proof of follicular growth (stimulation), and measure the follicle. Most people do not have ovulatory sized follicles until CD#10-12.

I often wonder, do doctors in India have to train to be specialists? Your doctor cancelled the cycle prematurely and just wasted your money. I would demand a refund!

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.

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

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


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

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

Best Regards, A. from Ireland

Answer:

Hello A. from Ireland,

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

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

Good Luck,

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

Second IVF Fails Despite Implantation: Thin Lining? Embryo Issue?

Question: Dear Dr. Ramirez,

I am here to seek your advice once again. I just found out my second IVF (in vitro fertilization) attempt finished with a chemical pregnancy. I tested HCG levels at 11dp2dt and it was 19,2 miu/ml (pretty low), and 48h later it was already 4,7 miu/ml.

I am nearly 37yo, have high FSH levels and my antral follicle count was 12 for this past cycle, 8 follicles grew, 6 were collected and 4 eggs retrieved. We got 100% fertilization and we transferred two 8-cell embryos with perfect morphology and no fragmentation.

I think my biggest problem is my endometrium. It is usually very thin. Although I still have 2 frozen embryos from my first IFV, two transfer cycles were cancelled due to thin lining that would never pass 6.9mm. I tried estradiol patches, vaginal estradiol (creme and pills) which resulted in poor endometrial growth (estradiol levels reached 3500pg/ml in one cycle) even after 3 weeks of use. I also tried vaginal viagra, vitamin E, baby aspirin, prednisone, and nothing worked... the endometrium would grow up to 5.5 to 6mm in the first 8-9 days of the cycle and then would take 14-21 days to reach 6.9mm. In one of the cycles it even decreased 1mm in one week.

Before my first IVF I did a hysteroscopy and everything looked fine. I have a couple small intramural fibroids, none projecting into the uterine cavity. I had a big fibroid removed 4 years ago, but it was intramural and the endometrium was not touched during surgery.

So, in my last IVF that turned out as a chemical pregnancy, my endometrium was 7.1mm at the 6th day of stimulation with FSH (Bravelle), which was really encouraging. However, 2.5 days later, it decreased to 6.4mm... Because at that time I already had bid leading follicles, my doctor wanted to triger that night. He then injected into the uterine cavity, using a catheter, 300 ug of filgrastim (G-CSF), since there are two papers from Dr. Gletcher that mention it as a possible treatment for thin lining. My RE explained to me it was experimental and I agreed to try it.

48h latter and on the time of egg retrieval, my endometrium was 7.6mm. Still not ideal, of course, but the best I got in a long time, so my RE advised us to carry on with the transfer (2 beautiful 8-cell embryos).

So my questions are:

1)What is more likely to be the cause of the chemical pregnancy: genetically abnormal embryo or my thin lining?? I know my age is a factor, but I have been taking Coq10 for nearly a year now. My embryos always look good and I have 100% fertilization rate.

2) Also, I wanted to know if it is normal to have a 8-cell embryo at the end of day 2 (I collected the eggs on Mon 9am and the embryos were transferred Wed 6pm).

3) Is it normal for the endometrium decrease during stimulation phase? What could have caused mine to go from 7.1 to 6.4mm in a little over 60h?

3) Do you think I should try filgrastim on my next transfer cycle? I don´t think my body likes synthetic estradiol though, it never responded well... so maybe a natural cycle (in which I usually reach 7mm) with filgrastim could work?

Taking my history into account, what would you recommend for my next FET in order to be suscessful in overcoming thin lining? Should I start to look into surrogacy?

As always, I really appreciate your time and expertise, and most of all the beautiful work you do here at your blog (for which I am a subscriber :)  C. From Brazil

Answer:
Hello C. from Brazil, Thank you for your kind words and for following my blog! Let me answer your questions in sequence to make it easier.

1. If endometrial thickness were the problem, implantation would not have occurred. Technically, the minimum endometrial thickness required is 6.5 mms so your lining was adequate for implantation to occur, which did happen. The miscarriage was most likely a genetic issue considering your age. Unfortunately, we do not have a technology to evaluate internal egg quality nor change the quality. Keep in mind that the CoQ 10 study was in mice and not humans so we don't know if that will work or not.

2. An 8-cell embryo on D#2 is not normal. That is a rapidly dividing embryo and may indicate that it is genetically abnormal, as has been found on preimplantation genetic studies in the past. Division rate is one of the criteria I use to evaluate embryos, in addition to the external quality.

3. The endometrium does not decrease. The difference in widths are variations in ultrasound measurements. Because we are dealing with mms, the difference between 7.1 and 6.4 (0.6) is within the margin of error and not significant.

4. I cannot comment regarding the "filgrastim" as I am not familiar with this medication or its usage. I would recommend that you consider the frozen embryo transfer in a natural, unmedicated cycle, but I would follow a natural cycle without transfer first to evaluate if your body growth the endometrium to adequate width. Then if it does, I would schedule to make do the transfer in the next cycle. I would still use supplemental hormones after the transfer, namely progesterone to help support implantation and the early pregnancy.

5. If the FET fails, despite everything that has been done, the only other recommendation I could make, if you are still going to try your own eggs, is to have preimplantation genetic screening done (trophectoderm biopsy) on a Day #5 embryo. Some studies have shown increased pregnancy rates in older patients when embryos are screened for normal genetics. That will at least give you an indication on the genetic health of the embryos you are making and whether or not you should consider donor eggs. I would only recommend surrogacy if you are absolutely sure that you cannot get implantation and in your case, you've had implantation. I think it might be more of an embryo issue.

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.

Egyptian Fails One Fresh & One Frozen IVF Cycle: Advice On How To Improve Lining Thickness

Question:

Hi, I am 28 years old, married since 3 years, trying to get pregnant since 2 years. I had ectopic pregnancy since 15 months which ended by right laparoscopic salpingectomy. Then I tried clomid for 3 cycles, HMG induction for 2 cycles and I tried fresh IVF (in vitro fertilization) with long protocol.

I took 1 amp menogone , 1 amp fostimon 75 mg, 1 amp fostimon 150 mg/d. there was 36 mature follicles , all fertilized well, then 4 good embryos were transferred on 3rd day but ended badly on 5th week by blighted ovum.

Then I tried frozen embryo transfer by thawing the embryos and let them grow to the blastocyst stage. We got 14 good blastocyst from 19 embryos, then 2 hatched blastocysts were transferred. I took estrogen valereate 6 tab/d till endometrium thickness 8cm, then progesterone supp 800 mg/ d , aspirin 75 mg/d. but again a negative BHCG on due time.

Some history:

a) semen analysis is good with no abnormal forms or motlity
b) patent left tube by hysterosalpigogram
c) history of endometriosis discovered during laparoscopic salpingectomy.
d) good hormonal profile FSH, LH, TSH, prolactin, anti-phospholipid tests

Now I am planning to repeat but I still have 12 frozen blastocysts, but I need your advise because we thawed the 3rd day embryos from the first ivf , then let them grow till the blastocyst stage , then did the transfer the last time , then refreezed them again.

My question:

I am undergoing a new frozen cycle now. I take 6 tablets oral estrogen valereate/ day, 200mg sildenafil (viagra) vaginally/ day and vitamin e, aspirin, and after the endometrium reached 8.5 mm thickness on the 10th day stimulation, it decreased on the 13th day to 6 mm although I still take the same dose with no discontinuation, sure of the expiry date.

What is your explanation please, and what can I do to prevent cancellation of the cycle? If I continued the same dose is there any hope for restoration the thickness?

Please answer me because I am frustrated and breakhearted.

N. from Egypt

Answer:

 Hello N. from Egypt,

This is a protocol question, which I do not answer because protocols can vary widely and there is not only one way to do things. That being said, there is some general information that I can provide.

First, keep in mind that you have been pregnant with IVF and so can get pregnant again. IVF only gives you the opportunity to become pregnant, it cannot make you pregnant because there are still some natural steps that must occur on their own. Studies have shown that if you have gotten pregnant in the past, your chances of getting pregnant with IVF are higher. Also keep in mind that, just like trying to get pregnant on your own each month, it does not always work. Sometimes it can take several attempts before it is successful.

Second, it is well documented by studies that the best way to deliver hormones for IVF is either by injection, by patches or by vaginal delivery. Oral tablets can be used vaginally (you just push them to the very back). This helps with maximum absorption of the hormone and delivery to the uterus. Oral intake has been shown to be the worst way to give hormones for IVF because most of it is lost when it passes through the liver. I personally use patches, which most US doctors use, but tablets used vaginally is also a good option.

I would not necessarily cancel the cycle, because time can be taken to develop the endometrial lining further. It is only finalized once the progesterone is started. That is what determines the timing of the transfer, which for a blastocyst, should be on the 6th day after starting the progesterone. If you have not started the progesterone yet, you can keep using an increased amount of estrogen to get the lining to 9 mms.

Good Luck,

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

Can I Thicken Endometrium With Estrogen?

Question:

Dear Dr. Ramirez,

I´m 35 years old (will be 36 in Feb). I have been trying to get pregnant for 2 years (had a miscarriage a year ago). After going to a reproductive clinic, I´ve tried Clomid for 2 cycles with no success, an it really thinned up my endometrium, which usually wasn´t very thick (7-8mm). So my RE recommended to change to Menopur in the next cycle and do a IUI (My husband´s Kruger morphology is 5% - lab reference 4% all the rest is good). This current cycle (no meds) she did an sonogram on me on day 12 (my last period, which followed the Clomid treatment, was only 21 days longer and she wanted to check me for cysts). I had a 20mm follicle and several smaller ones, but my endometrium although trilaminar was only 7mm. For all I have been reading 7mm is not optimal thickness, although my doctor seems to think it´s ok and there´s no need to do anything.

So I was wondering how can I prime it before ovulation? Will taking estrogen help? Will it interfere with ovulation? What are the cycle days you normally recommend your patients to take it and what is the dosage?

Thanks for your time. I really appreciate it. C. from Brazil

Answer:

Hello C. from Brazil,

Yes, you can use estrogen in addition to the Menopur. I use it as an estrogen patch (Climara 0.2 mg per week up to 0.4 mg) or vaginal tablet (FemHRT, Estrace 1 mg up to 4 mg per day). As the follicles grow, they produce more and more estrogen so that should help as well. 7 mm is the minimum size needed, but ideally it should be 9 mms.

In terms of treatment, keep in mind that you have three problems going on. My opinion is that the more problems there are, the higher the treatment level you need to use. The problems identified are: (1) thin endometrial lining, (2) age factor (going on 36yo) and (3) severe male factor. Because of the age and SEVERE male factor, I would advise IVF with ICSI as the treatment of choice. The sperm may not have the ability to fertilize the egg naturally and so ICSI is required. This can only be done with IVF. IVF is also the only treatment that helps to increase pregnancy rates related to age, which is an egg problem, by increasing the number of eggs available to fertilize.

Follow-Up Question:

Thanks for answering my question, Dr. Ramirez.

When would I start taking the estradiol, cd1 and go up to ovulation? I´d like to know so I can talk to my doctor about it.

Also, now I am really concerned about the severe male factor. Is a 5% Kruger morphology that bad even if the sperm concentration is high (85 million/ml) and they show good motility (>70%)? For the IUI procedure, after swim up test and washes, can the doctor choose only the sperm that have good morphology? I´ve read that some doctors think that the Kruger method is really too strict and based on it, most males would be called fertile. What´s your opinion on that? Is there any treatment for sperm morphology (my husband is 37yo)?Thanks again for your valuable time and input! C. from Brazil

Follow-Up Answer:

Hello Again,

1. The estradiol patch or vaginal suppository would begin with CD#1 or 2.

2. If only 5% of the sperm are anatomically normal (morphology), even with an 85 Million count that means only 3.2 Million are available to actually fertilize the sperm (85 Million x 75% motility = 63.75 Million motile x 5% = 3.2 Million). This is inadequate for natural fertility. In addition, when there are sperm abnormalities, there is a high chance that there could be a defect in its ability to fertilize, and there is no test for that other than with IVF. For that reason ICSI is recommended. The embryologist will only take anatomically normal forward swimming sperm for the ICSI (if they are good embryologists).

3. I somewhat agree with the opinion regarding Kruger, but the decision has to be made based on the information that you have. Even 5% normal morphology is pretty low using Kruger.4. Unfortunately, other than ICSI there is no good treatment methods available to change morphology. There are two products that he can try, which are basically vitamins, called Proxeed and Fertility Blend. These can be purchased via the internet. He would need to use them for 3 months minimum. He can then repeat the semen analysis and see if this helps at all.

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 again Dr. Ramirez. I wish I was still living in the US to go to your clinic :)

Canadian With Recurring Ovarian Cysts And Thick Endometrial Lining: Does She Go On The Birth Control Pill?

QUESTION:

I'm 28 years old and have recently been referred to an OBGYN for recurring ovarian cysts. My most recent pelvic ultrasound suggests that I may also have a slightly thicker than usual uterine lining. My new OBGYN has prescribed a birth control pill (Alesse-21) for paroxysmal but intense pain associated with the cysts, as well as to thin out the lining of the uterus. I havent filled the prescription yet, as I am trying to learn more about its indications prior to doing so. My OBGYN instructed me to take the pills everyday for three months, then take one week off, during which I should get my period. I am supposed to continue on this schedule for at least one year. She did not explain WHY I should take the pills for three MONTHS, then one week off, as opposed to the usual three WEEKS on and one week off. Can you suggest any reason she would perscribe the medication in this way?

Further, I am expected to have a hysterosonogram next month. I was instructed to call in on the first day of my July period in order to schedule the appointment, as they need to make sure that the uterine lining is at its thinnest for the test. However, I will not be having a period next month because I will on the birth control pill (for three months straight). Therefore, does it matter when I schedule the hystersonogram? If I start taking the pills on the first day of my period this month (June), will the lining of my uterus be thin enough at ANY time in July, or should I wait a certain amount of time before scheduling the test?

Finally, I hope to eventually get pregnant. If I thin the lining of my uterus now, and control the growth of the ovarian cysts, does this increase my chances of getting pregnant once I stop the pill?I would really appreciate some knowledgeable guidance. I thank you in advance for your assistance.

Sincerely, M. from Ontario, Canada

Answer:

Hello M. from Canada,

Without reviewing your medical records it will be difficult for me to know exactly what your doctor is thinking and planning. It would be a good idea for you to ask her directly to explain the treatment plan in detail.

If you were found to have an ovarian cyst, there are many types of cysts. The most common type of cyst is a physiologic ovarian cyst and treatment with the birth control pill will help it to go away. However, this should take no more than one month. If the cyst does not resolve after one month on the pill, then there is a likelihood that this is some form of tumor (mostly benign forms) and so surgery will then be required to remove the cyst/tumor.

If the endometrial lining is thickened, there is the possibility of a disorder called "endometrial hyperplasia." Some forms of this can be atypical or precancerous so an endometrial biopsy is indicated. If the biopsy is negative for cancer, then it can be treated with the birth control pill to thin the lining. However, this treatment is NOT done until after a biopsy is taken because you DON'T want to use the birth control pill if precancerous cells or cancerous cells are present in the endometrium. With the birth control pill it can take 1-3 months to thin the lining but the standard treatment is to have a period each month so that the lining can be shed and NOT to use the every 3 month sequence. That sequence is only used for people that need contraception and don't want to have a period every month. So, again this does not make any sense to me.

In terms of the sonohysterogram, once you are on the birth control pill for at least one month, the lining should be thin enough to have it done at any time.

In terms of your fertility, this treatment plan does not work for or against your chances for pregnancy unless you have an endometrial cancer that is missed and then requires a hysterectomy.

I would urge you to speak with your doctor.

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: You have given me a lot to think about. Thank you for being so thorough in your response. As this doctor of mine seemed to be heading in her own direction with this treatment as opposed to offering any alternatives or discussing the possible risks (as you have outlined here), I am very much inclined to seek a second opinion from another OBGYN. Thanks again for your outstanding assistance.

32 Year Old Has Multiple Miscarriages With Secondary Infertility On Clomid With No Success: Should She See An RE?

Question:

I am 32 and writing from Texas. We are trying to have our 4th child. In Jan. 2010 I had a miscarriage at 7 weeks and subsequent D&C. It took 2 months for my cycles to even begin. Then I was put on Clomid 50mg days 5-9 for 4 cycles. I was monitored with progesterone blood checks, 14th day ultrasounds, hcg shots, and checking for over-stimulation. I ovulated every time (with a progesterone level of 27) and the doctor said my follicles and lining looked good. However, I am not pregnant and it has been 6 months since the miscarriage! My first child was conceived with clomid the 1st time.

Why is the clomid not working for me? Has it changed the cervical mucus and lining? Do other women struggle to become pregnant after a miscarriage too? The last two times that I conceived (3rd child and miscarriage) I became pregnant naturally the 1st effort made. Does miscarriage change your fertility? Should I not have clomid??

My doctor wants to take a break and then come back later and 'blow out' my tubes. Is this necessary? Do I need a different regime of medicine? I feel as though I am out of luck since the clomid did not help in conception. Should I see an RE (reproductive endocrinologist) soon?

Thank you for helping! I feel overwhelmed and just want to bring this baby into our lives. L. from Texas

Answer:

Hello L. from Texas,

I think the easiest way to answer your questions is to take them individually one at a time:

1. Since you are stimulating with the Clomid (and I presume you are ovulating more than one egg per cycle because that is the purpose of Clomid), you are responding to the Clomid. I don't know why your doc even put you on the Clomid since you were able to get pregnant on your own before. Any idea? All Clomid will do is increase the number of eggs you ovulate. It does nothing else. The body still has to go through the 9 step natural process for a pregnancy to occur. It is NOT a magic drug.

2. Clomid at high doses can change the endometrial lining causing it to thin because it is an estrogen receptor blocker and similarly change the cervical mucous. Often a Clomid cycle will have to be supplemented with estrogen if this is the case, or changed to a different medication such as Femara. The lining can easily be seen and measured by ultrasound.

3 Miscarriage is very common. It has been reported that the miscarriage rate is as high as 40% of pregnancies. This includes women who have late periods that don't even realize that they are pregnant. Statistically, 85% of women that have miscarriages will go on to have a successful pregnancy so you shouldn't worry. Your previous miscarriage does not worsen you chances of getting pregnant unless you had a major complication from it such as hemorrhage or uterine rupture.

4. The procedure to "blow out" your tubes is actually called an HSG (hysterosalpingogram). It is the test that we use to see if the tubes are open. Sometimes women will form a mucous plug in the tubes thereby inhibiting sperm passage. The HSG can push out this mucous plug and open it. It is worthwhile to make sure that the tubes are open but I would not count on it for anything else. It does hurt by the way.

5. I think that if you want the expertise of a specialist in infertility, and feel you are not getting it with your current doc, then an RE (reproductive endocrinologist) would certainly be more specialized and have more knowledge. You might want to consider that. It would be the same as going to see a Cardiologist for your heart instead of being treated by your Family practice doc. The basic knowledge of a specialist and the treatments they can offer are greater.

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.

American In The UK Taking Clomid & Has Thin Uterine Lining: Needs A Specialist

Question:

Hi Dr. Ramirez,

I will try to keep this as concise as possible. I am very healthy, slim and 29 years old, and have never had issues with my periods. My husband (29 years also) and I conceived on our first try last year, but unfortunately had a missed M/C at 12 wks (fetus stopped growing at 8 wks). Tests confirmed non-recurring genetic abnormality. After the D&C I had only spotting, until 5 days after when I had a very heavy bleed with large clots lasting only one day. Then I got my first period 6 weeks later. The 3 subsequent cycles were 42-45 days.

Pelvic ultrasound revealed PCOS, hormone levels were all normal, including thyroid. Lining on this ultrasound was only 5.5 on day 40, just before I started my period. I have just completed one round of 50 mg Clomid unmonitored due to travel, and BBT shows clear ovulation on day 18 with 12 day luteal phase. This cycle I have had my first follicle tracking on day 11 which showed dominant follicle at 15 mm, but lining of only 4 mm. My questions are:

1. Could the thin lining be due to problems from the D&C?

2. My gyn prescribed Progesterone pessaries for the second half of this cycle to help thicken the lining- is this the appropriate treatment?

3. When should I consider seeing a fertility specialist?

Thank you for your time- I am writing from London. M.

Answer:

Hello M. from the U.K.,

A thin lining could certainly be due to an over-vigorous D&C, leading to scarring in the uterus. This is called Asherman's syndrome. A procedure called hysteroscopy can be done to evaluate the uterus cavity for this. However, that being said, it is not very common to develop this with D&Cs. The more common possibility is a thin lining due to the use of Clomid.

Clomid is an estrogen receptor blocker and so blocks estrogen receptors at the endometrium (uterine lining). For that reason, many patients have to use extra estrogen given vaginally in order to overcome the blockage from the Clomid, or they use a different medication such as Femara or injectables.

Progesterone is NOT the hormone that thickens the uterine lining. Endometrial thickening and priming is dependent on ESTROGEN in the first half of the cycle. The fact that your doc told you the wrong info makes me skeptical that he/she clearly understands the physiology of this treatment. So, I think you should go see a fertility specialist instead. Without proper estrogen priming, the uterine lining will not be ready for implantation. The progesterone, which is given after ovulation, is to convert the endometrial lining to develop the "pinopodes" that are necessary for implantation. (See diagram up above, the "pinopodes" are small finger-like protrusions in the endometrium) Without the proper priming, the pinopodes will not develop.

Good Luck and keep trying, you should succeed with the right treatment path,

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! I am very grateful to have your opinion, which confirmed to me that I need to see a specialist. As an American living abroad, it can be daunting to find the same quality of health care that we take for granted in the US. Again, I really appreciate your help.

Kuwaiti Woman Asks: How To Thicken My Endometrium Lining?

Question:

Hi Dr. Ramirez,

I feel am really blessed to find someone very expert and caring like you :)

This is N. from Kuwait, I am very concerned about my endo thickness (was between 6.5 to 7.9 on CD14). On the other hand, I don’t want to take medicine that may harm me. The dr. is giving me Duphaston and Progyluton. The Norgestrel is combined with Estradiol valerate in one pill that comes in medicine call Progyluton (I don’t know if you know it). 11 white tablets each containing Estradiol valerate and 10 light brown tablets to be taken from CD16, each containing Estradiol valerate and Norgestrel). You have said previously that the Norgestrel is not used in the USA to treat endos.

What about the Duphaston which is Dydrogesterone 10 mg- Orally – 2 times a day from CD14? Should I take it Vaginally? Does it hurt? What do you suggest? Should I take natural Progesterone instead of the Duphaston? If yes, would you please give me name of the medicine?

Unfortunately it seems there are not that good doctors over here, they are RE and Gyno. This is the 3rd doc. The 2nd doc believes that clomid will increase the endo because it produces eggs; and she sees endo thickness 7 or 8 mm is not bad!!! Dr. Ramirez, If you don’t mind to give me Online Consultancy and I will PAY for it (I can call). Write me a prescription with what should I take and when and how? For example estrace from CDx to CDx, and then XXX medicine from CDxx. (I can order them online)

I know that it sounds weird, but with the globalization and the existence of internet the behaviors and habits are changing. I will go to the doctor on CD14 (or whenever you think is the best) to do the ultrasound and then will let you know about the size of eggs, endo and so on :)

Thank you!

Answer:

Hello N. from Kuwait,

The Duphaston can be used vaginally. Progesterone is important to help with implantation. I would NOT recommend the Progyluton. It is used from hormone replacement therapy and cycle control. It is not used in infertility because of the Norgestrel. Although the Estradiol component is okay, and necessary to increase the uterine lining, the Norgestrel (progesterone) will compete with the estrogen and keep the lining thin. With this combination women don't usually have periods, which is the reason why it is used for menopausal hormone replacement therapy. In fertility cycles, the first half of the cycle needs to have unopposed estrogen stimulation so that the lining will grow. Then once ovulation occurs, the progesterone is introduced to help the lining convert to a luteal phase lining so that implantation can occur.

Your proposal for an internet consultancy is interesting, I will send you an email. I'll have to think about that one. In terms of your supplementation, I use the following protocol:

1. I use the estrogen patch for estrogen supplementation such as the Climara patch. I use two 0.1 mg Climara patches beginning at the start of the cycle and continuing until the pregnancy test. If it is positive, then I continue it until you are 10 weeks pregnant.

2. For progesterone, I use a product called Endometrin 100 mg vaginal tablets. You place 1 vaginally twice per day beginning on cycle day # 16, or beginning with the HCG injection if you use an HCG trigger for ovulation. You would then continue this until the pregnancy test or 10 weeks gestational age if you get pregnant. Other forms of progesterone that you can use in the same way are Prometrium 100 mg or Crinone/Procheive 8% cream.

If you look up my blog regarding how I do Clomid ovulation inductions, it will give you directions on how I recommend doing Clomid cycles. Normally, as the follicles are stimulated and grow, they produce increasing amounts of estrogen. This then goes to the uterine lining and increases it. The problem with Clomid, however, is the way it works. It blocks estrogen receptors in the reproductive system and tricks the brain into thinking that it is not producing enough estrogen. So the brain responds by increasing the amount of stimulation of the ovary, hence ovulation is stimulated or multiple eggs are stimulated. By blocking the receptors, however, it can cause the uterine lining (endometrium) to no grow sufficiently.

Don't stress too much over all this, please take your time and copy these instructions. Take the time to discuss this thoroughly with your physician and good luck!

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.

Very Weak, One-Day Menstrual Flow - Is There Something Wrong & Will It Affect Fertility?

Question:

I am a 26 year old female and for the past few months I have been having very weak periods that often last no longer than a single day. They are so weak that I don't need to use tampons and pantyliner will suffice. They are however extremely regular and fall every 30 days. I came off the pill last year and for after a few months my periods returned to normal. It is in the past 6 months or so that they have become so weak that they are causing me concern. A few years ago, I had a big cyst on my right ovary and late treatment meant it twisted and resulted in me having to have one ovary removed along with the cyst. I have researched possible reasons for weak periods and polycystic ovaries seem to be one of the main explanations. However I do not have any of the other symptoms usually associated with this condition and I am not over- weight.

I am extremely concerned of the implication my weak periods may have on future fertility but when I have taken my concerns to my GP he has dismissed them. I was hoping you could maybe give me some possible reasons as to why this may be happening.

Many thanks for your time. K. from the U.K.

Answer:

Hello K. from the U.K.,

The amount of bleeding a woman has with her periods is dependent on the amount of tissue there is to slough. That is, the thickness of the endometrial lining. Even if the amount is small, at this point it would not be of concern. The amount of bleeding will vary from person to person and cycle to cycle. As long as your cycles are regular, that is the important part. Certainly if the endometrium is not developing adequately, that could impair implantation of the embryo and your fertility. But, I doubt that would be the case. I would not worry about this at this point in time. Just wait and see what happens when you begin trying for pregnancy. If you have difficulty, then testing and evaluation will be done to see if the endometrium is not developing adequately. If that is the case, then supplemental hormone can be given.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

New IVF Patient Mixed Up Suppositories & Took Progesterone Early - What Now?

Question:

Hello Doctor,

I am one day before fresh embryo transfer and I'm really worried. I'm currently on my first IVF. Two days before my egg retrieval last week I was instructed to use Clindamycin suppository at night for 3 nights last night being the day of my egg retrieval. Well, I mixed up the suppository bags and inserted 50 mg of Prog suppositories for first 2 nights instead of Clindamycin. I didn't realize this mistake till the day of my egg retrieval. So I ended using 2 Prog suppositories for 2 nights before my egg retrieval.

I told my doctor and he said this is a problem in that my uterus was exposed to progesterone too early therefore lining is not optimal for transfer...and that we need to freeze my embryos and do a frozen embryo transfer next month! I was just devastated to hear the news and asked for any alternatives. To make the long story short we are going ahead with a fresh single embryo transfer tomorrow with hopes that not too much damage was done. Given my history what are the chances of me actually getting pregnant? Would it take a miracle?

R. from the U.S.

Answer:

Hello R. from the U.S.,

Keep in mind that miracles do happen.

I'm afraid that I agree with your doctor's response. Progesterone converts the endometrium from its growing state to its implantation phase. If the endometrium is out of phase with the embryo, then implantation will not occur. There is a very small (2 day) window for implantation. It is likely that the progesterone changed the internal architecture (cellular structure) of the endometrium, which will make it inhospitable to the embryo and implantation will not occur. But there is no way to know that for sure. You will just have to wait and see.

If you want to be absolutely sure, then you should postpone the transfer and freeze the embryos. Then do a frozen embryo transfer the next month. If you don't mind risking an embryo, then given it a try. I normally prescribe antibiotics on the day of the retrieval, but all clinics have their own protocols specific to how the physician prefers to tweek their cycles. Like I said at the beginning, miracles do happen.

I'm sorry and stay positive!

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.

The Difference Between PCOD and PCOS, Fear of Birth Control Pill Protocol

Question:

Hi, thank you very much for your help in advance. I am 22 years old and not sexually active. I had my first period may be at about 16 yrs. of age. My period was always relatively irregular and it was normal for me to miss 2 to 4 months (4 months usually happened once a year in the spring). I have gone to a gynecologist several times and after the exams all have told me that I have irregular hormonal levels and should take birth control pills. As I have heard many times that such pills are bad for my health, I refused to follow that advice. The problem which greatly concerns me is that I now have not had a period for about 6 months (last time was in March).

I am very worried and will go to the doctor, however, I would appreciate your opinion as well. I have a good figure, good eating habits, no excessive stress. What could this be? If this is PCOS would it have significant negative effects on my ability to get pregnant? Are hormonal pills really bad (weight gain, hair growth, adaptation of the body to constant supplements)? Could this be due to my lack of sexual experience/activity? If so, is this a problem? Is there a "body cleansing" pill that I could take to induce a period and see how things go without significant negative effects? Do you think that traditional Chinese medicine could be of help? In short, what is you opinion on this? I would appreciate as much detail as possible.

Thank you for taking the time to answer my questions.

Answer:

From your history, it sounds like you have PCOD (polycystic ovarian disease). This has not become the syndrome (PCOS) yet because the disease eventually turns into PCOS (polycystic ovarian syndrome) when it manifests by increased weight gain (obesity), excessive hair growth, increased male hormone, decreased voice, hair loss (male pattern loss), diabetes. This disorder is due to a dysfunction of the ovary, whereby the ovary does not process the FSH and LH from the brain appropriately so that ovulation does not occur. If the ovulatory process does not occur, the hormone precursors do not go down the estrogen/progesterone pathway to make those hormones and instead go down the testosterone pathway, leading to excess testosterone. This leads to the manifestations explained above. These are long term changes and occur slowly. They are not reversible, so you don't want to go down that road.

The other problem with not having a period regularly is that the endometrial lining can thicken leading to several problems: hemorrhagic bleeding when you do have a period requiring hospitalization and transfusion, a precancerous state and endometrial cancer. You also don't want to go down that road. Another problem is that with the lack of estrogen in your body, you can suffer other long-term consequences such as a very dry vagina, vaginal shrinkage, inadequate lubrication with intercourse, shrinking of the breasts, increased heart disease, bone loss, dryness of the skin.

If you are not intending to become pregnant, then the treatment of choice is to use the birth control pill. This is the recommendation that medical doctors in my field will give you. That is mainly because the pill/patch/ring are made of estrogen and progesterone and override your ovaries. It basically puts your ovaries at rest and gives you the hormones your body needs. Several studies have shown long term benefits from the pill including a significant decrease in ovarian cancer if used for greater than 7 years. I also believe that it helps to preserve your fertility longer because the ovary is quiescent. The things you heard that are "bad" about the pill are wives tales and not true. The one truth is that you may not be able to become pregnant after stopping the pill, but that is because you will go back to the way you were prior, which is not conducive to pregnancy because you are not ovulatory. So, my recommendation is to go on the pill.

In terms of sexual activity. The value of sex, if you are not trying to get pregnant, is for recreation. Because it feels good or gives other good feelings. It is not a physiologic requirement, so don't feel compelled to have sex just because you have to. It should be fun.

I cannot comment regarding Chinese medicine, as I have no knowledge of this subject. I have recommended acupuncture for my infertility IVF patients as a complimentary part of my protocol and have seen improved pregnancy results.

I hope this gives you the information that you were looking for.

Follow-up question:

I wonder if I can take up a bit more of your time by asking a follow-up question.

From what I understand, birth control pills do not treat the problem, they simply override it, for lack of a better term. At this stage in my life, I am not looking to become pregnant; however, this is a natural progression in life. As such the question is as follows: If I can't become pregnant without taking the pill due to the absence or scarcity of the ovulation process, and the pill while restoring that process, will be acting as a contraceptive, what are my options?

One of my concerns about the pill is that by taking it I will be decreasing the possibility of having natural period, as my body will become used to constant supplements. Consequently, my chances of ever becoming pregnant suddenly become almost null. As for sexual activity, I certainly understand the value thereof, I have been told, however, that sexually activity will stimulate the production of the hormones which are missing in my body. This was the assertion the validity of which I was looking to confirm. From what I understand, that belief is erroneous. Is that correct?

Furthermore, I was a bit unclear as to why you believe that I have not yet developed a "syndrome". You also mentioned that the pill will prolong my fertility. Are you then suggesting that I will likely lose fertility at some point due to PCOD?

Again, thank you for your time and assistance!

Follow-up answer:

Hello Again,

The answer to your first question is that the pill will not inhibit your ability to become pregnant in the future. As you said, it overrides the ovary and puts it into a quiescent state. The active state returns after stopping the pill and you will return to where you were previously. That is, if you are not ovulating prior to the pill, you will still not ovulate after stopping the pill. Your body will not "become used to constant supplements" so you don't need to worry about that.

Sometimes, being on the pill causes the ovary to straighten itself out and I have had patients get pregnant immediately upon stopping the pill (the opposite reaction to what you are thinking.)Sexual activity has no influence on the regular hormones in your body. You can have many sexual encounters per day and your hormones and ovaries would still be abnormal from the PCOD. Of course, you will be exhausted every day too. :) Just kidding!

From how you described yourself in your first question, you do not seem to be exhibiting the "classic" symptoms of hirsuitism, weight gain etc. that manifest themselves with PCOS. That is why I am assuming that you have PCOD. I have had many patients that are PCOD with no symptoms whatsoever. To diagnose latent PCO you need to see an infertility specialist who will ultrasound you during your cycle to determine whether you are overproducing follicles.

Lastly, you will lose your fertility potential with increasing age, not because of PCOD. At age 30 the pregnancy rate is 85% per year, 35 PR is 30% per year, 40 yo PR is 10% per year.

Hope all this makes sense and answers your questions.

Sincerely,

Edward J. Ramirez, M.D.

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Estrogen Supplement For Thin Lining

Question:

Hello, I am from Canada and I have been seeing a fertility specialist since January 2009. My husband and I have been TTC for 1.5 years and experienced a miscarriage in September 2008, when I had a D&C. My lining has never been above 4.5 mm and is normally about 2-3mm thick. I have been put on 8 mg Estrace daily for the past 2.5 weeks. Ultrasound today showed no change in thickness, and suppression of the follicle size. What is your experience with thin lining and pregnancy success Is there anything else that you would suggest for me to do to thicken my lining?

Answer:

Did you use the Estrace orally or vaginally? If you have not tried it vaginally, that is a more efficient delivery method for the endometrial lining. Orally is the worst. The second best would be estrogen patches.

If you are using them vaginally and your lining is still not developing, that is a problem. It should be getting to a minimal width of 9 mms. Did you have a hysteroscopy to make sure you didn't have scar tissue after the D&C? That could be a cause of a thin lining that doesn't respond to estrogen. Most people will form an adequate lining with estrogen supplementation, so you would be a rare entity. If the hysteroscopy shows evidence of scar tissue then you must proceed to have that removed prior to starting any infertility treatments. It is difficult to do, so you must find a competent specialist to do it who will then schedule an operative hysteroscopy as an outpatient surgical procedure.

I have seen in the literature, reports of people trying nitroglycerine tabs vaginally, Levitra and Viagra to increase blood flow to the uterus and thereby try to increase the lining. They have not worked universally.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

www.montereybayivf.com