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.

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 :)

Estrogen Patches Vs. Estrogen Injections: Which Is Better For Pregnancy Success?

Question:

I have four frozen embryos which I would like to have transferred. My question is what has a better success rate with prepping the uterus, the Vivelle dot 0.1mg patches vs. the delestrogen injections? I had a baby two years ago from a donor egg and how they prepped me was with the delestrogen. I have since moved away from that IVF Clinic who used this protocol. I have recently consulted with a different clinic where I presently live and they would rather use the patches.

This makes me wary since I am not sure if this will hinder my success rate. Please advise.

Thank you. B. from the United States

Answer:

Hello B. from the U.S.,

There is no difference in pregnancy rates between these two forms of estrogen. Any estrogen can be used. Some clinics will use oral tablets, others will use vaginal suppositories, in addition to the patches or injections. The key is to make sure that enough estrogen is being delivered to form an adequate uterine lining. Certainly protocols can vary, and it is the specifics of the protocols that are important i.e. are they using enough estrogen with the patches vs the injections. Without looking at the two protocols, I cannot tell you if the patch protocol is adequate. You would have to send them to me in order for me to review them and give an opinion on those specifics.

Keep in mind that frozen embryo transfers have a lower pregnancy rate than fresh transfers, so that may affect your chances of pregnancy. The rates are roughly 50% less (30% vs 60%). Let me hear from you if you have further questions.

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, USA