Could I Be Infertile Or Am I Still Recovering From Surgery For Endo?

Question:

Hello. I'm a 29 year old female. My husband and I have been trying to conceive for 7 months now. I had a laparoscopy done in June of 2013, due to an ovarian cyst on my right ovary. As the Dr. was doing the procedure, she said that the cyst had already ruptured ( which I didn't even know, or feel) and she found a little bit of endometriosis, which she got rid of as well. My tubes were wide open with no other complications.

 I'm about 2 1/2 months post op, and we still haven't gotten pregnant. I just saw my Obgyn a few days ago for a progesterone test, and it showed I was ovulatory. I was an 8.4. So the next step is to go get another ultrasound to make sure everything is ok inside, followed by some blood work a few days later. He said we'd check for PCOS. I have no symptoms of that. My periods have been pretty regular all my life. My question is why haven't I gotten pregnant? I thought the laparoscopy was suppose to open things up to help a future pregnancy. Could my body still be recovering from the surgery, and that's why I haven't become pregnant?  Or could there possibly be an underlying problem I have. The Dr. didn't really make me feel that comfortable. I asked a lot of questions, yet I still feel I'm unsure about things. I don't know what to think. He said we might start Clomid, but part of me wants to think I'm still recovering. I really hope I don't have any serious problems. I really just want to be blessed with a child, yet it's been so difficult to achieve.

Any advice/help would be greatly appreciated!  P. from Illinois.

Answer:

Hello P. from the U.S.(Illinois),

Infertility is defined as the inability to become pregnant after 12 months of trying so technically you are NOT infertile.

In terms of your surgery, you are way past that and it is not the reason you are not getting pregnant unless scar tissue was formed from the surgery inside the pelvis.

My first recommendation is to find a new doctor.  Preferably, find one that is a specialist in infertility rather than a general Ob/Gyn.  The reason is that you are on the verge of wasting a lot of time and money.  Your doctor is jumping to things without good reason.  For example, saying that you have PCOS when you have regular periods.  PCOS is defined as an ovulation dysfunction and you have to have irregular or absent periods as the prime criteria for the diagnosis.  Also, going straight to Clomid without a full infertility evaluation is a waste of time and money.  It's like prescribing a treatment before you know what you are treating.

My recommendation would be to start with a basic infertility evaluation:

• Cycle day#2 or 3 hormone panel (FSH, LH, Estradiol, TSH, Prolactin)
• HSG

• Hysteroscopy or Hysterosonogram

• Pelvic ultrasound #done#

• Semen analysis

• Cycle day #21 or 22 progesterone #should be 10 or greater#

• End of cycle endometrial biopsy

• Cervical cultures for GC, Chlamydia and Ureaplasma

• Laparoscopy (which you have done)

Once all these are done, then you can discuss and consider treatment options. Since endometriosis was treated, you need to try to get pregnant within one year of the surgery or the endometriosis will return and possibly prevent pregnancy.

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.

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

UAE Patient Tested For Infertility: Clomid or Tamoxifen?

QUESTION:

Hi Doctor,

This is S. from UAE. I would like to have your expert opinion in my case. My infertility workup showed multiple cysts in both ovaries but my hormonal work up was all within range. In addition, I have never missed a period ever in life, my cycles are pretty regular. In spite of this, my gynecologist started a Clomid induction cycle with me and monitored me. I was given Clomid in consecutive months. After reading your blog post about Clomid, I came to a conclusion that my doctor isn't doing right in giving me Clomid, and also, giving it consecutively. I switched doctors, only to recieve Tamoxifen in the subsequent cycle. I am worried. Do I need any kind of ovulation induction at all? Considering my cycles are regular and I had a normal LH/FSH ratio. Can Tamoxifen be followed immediately after Clomid?

ANSWER:

Dear Saman from the U.A.E.,

Glad to see that my blog has been helpful to you all the way in United Arab Emirates! Clomid is not indicated if you are ovulating on your own, but many many doctors use it to boost ovulation thinking that it is a "miracle" fertility drug. If you have been unable to become pregnant, and have had regular cycles, then there is something else, besides ovulation, that is causing the problem. That needs to be found. I am always skeptical when patients tell me "all my fertility tests were normal" without telling me what tests were done. That is because in most of these cases, all the fertility tests were not done, and therefore, the problem has not yet been found.

Tamoxifen has the same mechanism of action as Clomid, namely, it is an estrogen receptor blocker. Your new doctor obviously does not understand these medications. Just like I would not recommend taking Clomid in consecutive cycles because of the estrogen receptor blockage, I would not do that with ANY estrogen receptor blockers, except maybe Femara since it has less effect on the endometrial estrogen receptors. So I alternate cycles with Clomid and Femara. However, again, your new doctor is doing the same mistake and not treating anything specific. He/She needs to find out what the problem is! Ovulation induction is not the answer.

FOLLOW UP QUESTION:

Dear Dr, Thanks a whole lot for your response. It means a lot to me!I need one final querry answered. I have had the following tests:

FSH, LH, TSH, Prolactin, HSG, Fasting Insulin, Testosterone, DHEA Sulphate

All these tests and HSG have come out normal, and HSG shows Bilateral peritoneal spillage. Husband's semen analysis shows 58million/ml and 70% motility. In addition, I have never had any surgery and menstruate regularly every 28days. As I told u before, Clomid induction was done in 2 cycles which just resulted in a single ovum ripening, and was thus abandoned.

I have been adviced to have IUI. Should I go ahead with it? Because I have not had laproscopy, hysteroscopy or endometrial biopsy yet, and there might be reasons for infertility hidden there.....Isn't it better to go straight to IVF? Thank you!

FOLLOW UP ANSWER:

Hello again,

Indeed, based on the tests you have cited we know the following:

1. Your hypothalamic-ovarian pathway is normal (i.e. the ovary is being stimulated properly)
2. Your thyroid, testosterone and adrenal functions are normal.
3. Your fallopian tubes are open.
4. The sperm is normal and has the ability to get to the tube in order to fertilize your egg.

What we don't know is:

1. Is the uterine cavity normal (endometrial cavity) (hysteroscopy)
2. Is the peritoneum normal (where the egg goes through after ovulation) or is there scar tissue or endometriosis (laparoscopy)
3. Are you forming an adequate endometrial lining (endometrial biopsy).

If you wanted to pursue a natural method of getting pregnant (intercourse or IUI), then you will need to do these tests. If you would rather go directly to IVF (which bypasses almost all the steps), then the laparoscopy and endometrial biopsy are not necessary. The hysteroscopy is still needed. Some of my patients do choose to go directly to IVF because it gives you the highest chances of pregnancy. For example, the highest chance of pregnancy with each IUI cycle is 24% (under 35 year old patients), whereas IVF is 76% (at least in my clinic). So ultimately that is your decision. If you want to do things conservatively, that is, be as natural as possible, then IUI would be a reasonable step (it also costs less).

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

Comment: Dr Ramirez's responses are ALWAYS accurate, and prompt....I can't thank him enough for the help he has given this way....IVF at his clinic is definitely on my cards, but hoping I wont need it though :)

U.K. Woman On Clomid For Five Months, Husband With MFI: Periods Are Shorter Now, Why?

Question:

Hi, I have been taking clomid for 5 months because my husband has a low sperm count. I have noticed my periods becoming less and less the last 2 months I have only bleed for 1 day and that was mostly a black/brown color. My periods normally last for a full 7 days. Is this because of the clomid? D. From the U.K.

Answer:

Hello D. from the U.K.,

You should NOT be taking Clomid every month. It leads to a thinning of the endometrial lining because it is an antiestrogen and blocks the estrogen receptors. This is probably why the bleeding has decreased. This lack of adequate uterine lining will prevent implantation.

Secondly, Clomid is NOT a treatment for male infertility if given to the female! I have absolutely no understanding as to why your doctor has prescribed this and not followed you with some type of surveillance to see how you are responding. I would strongly recommend that you look up here in my blog where I discuss how Clomid cycles should be done.

Thirdly, in men that have low sperm counts, they will be treated with Clomid on a daily basis, sometimes to try to increase the count. This works only some of the time. It will take three months to know if it is working or not. If the count gets above 10 Million, then IUI is a treatment option. If it is less than 10 Million then IVF with ICSI is the treatment of choice.

Finally, please make sure that your doctor is an infertility specialist and does ALL levels of infertility treatments, including IVF. Otherwise, you may be wasting your time.

Good Luck,

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

Prior D&C And Infertility: Woman From Barbados Needs A Thorough Infertility Evaluation

Question:

Good Morning All.....My name is D. and I'm from Barbados in the West Indies. Just to give you a bit of background info on myself and hopefully you can make suggestions for me.

I've read the testimonials on the site and I was very touched and moved by the numbers of persons who were able to receive some type of positive assistance regardless of how small of how large.

In 2005 I had an abortion which resulted in me having to have a D&C and I've not been able to get pregnant since. I say not since 2005 because I remember at some point in 2008 having a very faint positive on a pregnancy test but to this day I cant be sure because the next day I did the test again and it was negative ....so I don't know if it was a false positive if it was a true positive or what it was.

In 2007 I saw a fertility specialist and had some tests done. I specifically had the test done where they run the dye through the tubes to see if they are opened and both tubes were opened. At the end of of various consultations the specialist told me that she couldn't find anything wrong and that only thing she could think of was that I had some scar tissue in the cervix area which was blocking the sperm from entering the cervix and travelling on to meet the egg....she said she arrive at that because it was difficult for her to pass the tube to eject the dye through the cervix. She said the only way I would be able to get pregnant is by having and IUI. Now I'm not being forward or anything and I know I'm not a doctor, but the blocked cervix theory is not sitting well with me and it doesn't seem logical at all.

I spoke to two other specialists and they too do not agree with the assessment. I have a regular 26day cycle EVERY month without fail and testing ovulation sticks shows me a surge around day 10-11 every month. The only thing is that my period has gone over the years form 5 days to perhaps 3 at times with clotting and dark blood or brown blood at time.....other that that it is like clockwork every month.. It doesn't make sense that blood and clots would be able to pass through the cervix and sperm cannot pass through the same opening.

I'm of Christian Faith and I've put the entire situation in God's hands but I think can also prepare my body for when he decides to bless me. I keep thinking that perhaps herbs or something can help I don't know what to do really. I've been married now for 1 and a 1/2 years and we've been trying since 2008 but nothing. I was thinking about the Fertility Cleanse and wonder if you think that would be a good first step, if not I welcome any thoughts you may have Thank you so much for your time and please have a blessed day.

Answer:

Hello D. from the West Indies,

Thank you for your kind comments. Now, what your doctor is referring to when she talks about "scar tissue in the cervix" is probably cervical stenosis. Many women who have never had children can have a small narrow cervix. We call that stenosis. You are correct in that the blood can pass through this, so sperm should as well. Cervical stenosis is NOT a reason for infertility, but IUI will definitely help this issue.

A D&C, dilation and curettage, can lead to scar tissue formation within the uterus which is called "Asherman's Syndrome". The only way to clearly identify this is to undergo a procedure called a hysteroscopy. This is where a small scope is passed into the uterus to look inside the cavity. Scar tissue can be readily seen and if present, can be removed at the time. But this is a difficult problem because often the scar tissue will return and several hysteroscopies with removal of the scar tissue may be needed.

There are other possible causes of infertility that you may not have had checked. For instance, have you had a laparoscopy? It is a surgical procedure whereby a scope is passed into the abdomen via the umbilicus in order to examine the pelvis. The pelvis is important because this is where the egg needs to pass through after ovulation (leaving the ovary) in order to get to the tube. Abnormalities such as endometriosis or pelvic adhesions can prevent the egg from getting to the tube. In addition, has your husband had a semen analysis done? Have you had a end of cycle endometrial biopsy to check to see that the uterine lining (endometrium) is forming correctly? These are just some examples of fertility testing. Lastly, you have not mentioned your age. Advanced age (over 35 yo) can play a role in egg abnormalities.

If you have had all this testing and still nothing has been found, then you would be categorized as an "unexplained infertility". This just means that we have not found a cause, and the most likely reason is because we don't have the technology to find the cause. Many of these patients have to resort to IVF (In Vitro Fertilization) in order to achieve pregnancy because there might be a sperm-egg fertilization problem (which you cannot test for). If your doctor is a fertility specialist, then she should be able to map out a treatment plan for you. Before resorting to alternative treatments that may not work, please go over some of the suggestions I made with your doctor.

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: I was kind of skeptical in looking for a response.Like most online Q&A I expected a vague response at best and I expected the doctor to be as short as possible considering he wasnt being paid but I was pleasantly surprised with Dr Ramirez...he was great and I got more info from him than I did with my own doctor... Thank you so much Dr Ramirez and may God bless you as you seek to help others :)

Stage IV Endometriosis Patient Trying To Conceive: More Time, More Surgery or IVF?

Question:

I was diagnosed 4 years ago with stage IV endo after having it excised during a lap. I had a Mirena IUD inserted during surgery and just had it removed a few months ago because I am ready to have a baby. I am very regular (26 or 28 days) and ovulation predictor tests show that I am ovulating on day 12 or 14.

Five cycles later we are not pregnant. I feel my ovaries pinch a few days before my period and am back to having pretty bad menstrual cramps (though not as bad as before the surgery). I have read a lot of your responses and see that IVF (in vitro fertilization) is your advice for stage IV endo. Do you think I am ovulating normally and what do you think my next step should be? I have a doctors appointment and am very nervous that he is going to suggest another laparoscopy!

Thank you in advance for your time. M. from the U.S.

Answer:

Hi M. from the U.S.A.,

Thank you for reading my responses. Technically, you have not tried for pregnancy long enough to suspect that a problem exists. We do not define infertility until a woman under 36 has been trying for at least 12 months because it takes most women in that age group 8-12 months to achieve pregnancy naturally. If you are 36 or older, then 6 months would be the limit.

Certainly because of the history of stage IV endometriosis, you have a significant impairment to your natural fertility. Mirena helped, but it is not perfect. There is no treatment to eradicate endometriosis completely, and so it is highly probable that endometriosis is still present in the pelvis. In addition, stage IV endometriosis implies that there has been significant damage to your pelvis and it is not normal i.e. pelvic adhesions, inflammation, destruction of the normal anatomy. These will impair your natural chances for pregnancy. For that reason, in many of these patients, but not all, IVF will be required to get pregnant. I have had some spontaneous pregnancies in stage IV endometriosis patients but they are few.

Let's say after six months or one year, you still cannot get pregnant (depending on your age), you will need to pursue other options. Knowing that you have Stage IV endo, additional surgery will NOT help. You may want to go straight to IVF and avoid the surgery. That is what I would recommend. Many gynecologists will recommend the surgery because that is all they can do, they don't do IVF. They would rather do something in their power than do nothing. Instead, a good gynecologist will refer you to a fertility specialist that does IVF for at least a consultation. A good infertility specialist will probably explain that the pelvis, an essential part of your anatomy for achieving a natural pregnancy, is a hostile place for the egg. Therefore, the treatment of choice is to avoid the pelvis which is what occurs with IVF.

Good Luck on your journey and don't hesitate to write again with any other 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.

Comment: Thank you so much, you have quelled much of my anxiety. The scariest part about facing fertility problems is all the unknowns and the waiting. I appreciate your help.

Trying To Conceive For One Year: Clomid Vs. Laparoscopy?

(If the blog radio program comes on, you can pause it by going to my Oct. 1st post. I will be keeping the show up for the month of October.)

Question:

Hi. I've been trying to conceive for about a year and my doctor and I are ready to take a more aggressive approach. We have generally discussed both clomid and laparoscopy as next steps in the coming months. I am wondering if you can give some advice as to the order of trying clomid first or having a laparoscopy first.

My sister and aunt both had endometriosis so I expect that could be the culprit. I personally lean towards having the laparoscopy first, but I want to understand which is usually recommended. Thank you. V. from the U.S.

Answer:

Hello V. from the U.S.,

In order for you to achieve pregnancy, if you have been having trouble, you have to find the reason so that you can get the appropriate treatment. The term "fertility treatment" or "fertility drug" is a misnomer. The treatment has to treat the problem. There is nothing that makes your more "fertile" no matter what the problem.

Clomid is a fertility medication only in that it is used to treat infertility. In actuality, it is an ovulation inducing drug. That is, it gets the ovary to ovulate if the ovary is not already ovulating. Doctors use this medication in women that ovulate also to increase the number of eggs they ovulate so that there is a higher chance for one of the eggs to reach and enter the tube (because that does not happen every time).

Laparoscopy is a surgical procedure that is used as an infertility test. It is part of the infertility evaluation because it is the only method to assess if there are any pelvic abnormalities. This is important because the third step of the body's process to achieve pregnancy (brains sends FSH/LH to ovary > ovary grows follicle and matures an egg > ovary ovulates and egg enters pelvis > egg has to get to tube . . .) is for the ovulated egg to pass through the pelvis and get into the tube. If there is anything within the pelvis, like scar tissue or an inflammatory disease like endometriosis, then then egg may not make it to the tube (endometriosis causes inflammation that can destroy the egg).

I presume that you have had a complete infertility evaluation prior to your doctor's recommendation to use Clomid or do laparoscopy? I dislike it when general Ob/Gyn doctors jump to unnecessary conclusions such as go directly to Clomid or laparoscopy without making sure that is what is needed. Clomid is used for ovulation problems or in conjunction with IUI (if there is a sperm problem). Laparoscopy is done if all the other preliminary tests are normal, or if there is an increased chance of having endometriosis such as severe menstrual cramping or pelvic pain or pain with intercourse. It is usually one of the last tests to be done. Is that where you are?

These are the things that need to be considered and if you see the right fertility specialist, it is more likely that the appropriate things will be done to help you to become pregnant. If you see the wrong person, then you might just be wasting your time.

If you give me more detailed and specific information (such as your age and what tests have been done), then I would be able to give you my recommendations on what needs to be done next.

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.

Woman With Chronic BV Asks: "Will Simply Taking Birth Control Pills, Then Going Off, Cure My Infertility?"

Question:

Hello. My partner and I have been together for 3 years and have not been able to conceive. He has a daughter from another relationship. We are pretty sure I'm the problem. I was told by a gyno that with some people to treat infertility they are put on the pill and taken off and then they see if they can get pregnant. Is this true? If so how long should I go on the pill. Also I have chronic bv (bacterial vaginosis) could this contribute to infertility?

I was on birth control 5 years ago... I've taken the pill patch and nuva ring. Since I got off we haven't used protection ever and have never gotten pregnant. I have pretty regular periods. They are off no more then 3 days at the most.

Thank you! R. from the U.S.

Answer:

Hello R. from the U.S.,

The answer to your first question is absolutely NO. That is a wives tale propagated by Gynecologists that don't know better.

Regarding the BV: Chronic vaginal infections can certainly kill the sperm, thereby preventing pregnancy. When you have Bacterial Vaginosis, there are changes to the acid environment of your vagina. Many factors can contribute to BV including: use of highly scented soaps, douches and bubble baths; use of an IUD or the coil; or because of certain types of sexual acts. It can also happen when the pH level of the vagina alters during the menstrual cycle. But it can also happen without any of these factors in place. It is, after all, the most common form of odorless bacterial discharge.

Bacterial Vaginosis is easily treated with antibiotics, like metronidazole or clindamycin. Women who are trying to become pregnant should be treated with an oral antibiotic. In fact, the Center for Disease Control recommends that all women receive some form of treatment for the condition because there is some evidence that chronic bacterial vaginosis could lead to pelvic inflammatory disease. With chronic, unresolved BV, the solution would be to do intrauterine insemination (IUI), to bypass the bacteria.

My recommendation is to see a fertility specialist. You are at the point where you need to undergo an infertility evaluation and your Gyno is not going to be able to help. Since your partner has had children before, you could assume that he is fertile, but you never know. Things change with time. Also, you don't seem to have any obvious reason, other than the BV, as to why you are not getting pregnant so the only way to find out what the problem is, is to have an evaluation. Once this is done and the problem(s) found, an appropriate treatment can be provided for you to achieve pregnancy.

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.

Amenorrhea & Secondary Infertility In A 29 Year Old: Needs Evaluation For POF, Thyroid Or Pituitary Disfunction ASAP!

Hi Dr. Ramirez,

I am a 29 yr old healthy female with two daughters, ages 13 & 12. Me and my husband conceived with no problem. I was 16 when we had our first daughter. I started having irregular menstrual cycles when my youngest was 2. We tried to get pregnant again and haven't been able to since then. I have not had a cycle in about 6-7 yrs.

I went to the doctor a few years back, they did blood work, exams, internal ultrasounds and they put me on birth control and hormones, but no period came. I have since stopped going to the doctor and am not taking anything. I am highly concerned on how this is affecting my health. Hoping for your advice.

Thank you, N. from the U.S.

Answer:

Hello N. from the U.S.,

It is highly unusual for you not to have at least one period per year in your age group. I would be worried that you might have a severe ovarian dysfunction like premature ovarian failure (POF or early menopause) or some other hormonal problem with your thyroid or pituitary. You need to undergo an evaluation to find out what is going on.

The problem with not having a period is that you are not producing estrogen. Estrogen is a vital hormone for a woman's body. It impacts many different areas like your bones, skin, heart, brain, vagina. Women who undergo menopause, where they are no longer producing estrogen, have an increased incidence of heart disease, osteoporosis as well as: bone loss, decreased concentration, decreased memory, thinning of the skin, thinning of the hair, vaginal shrinkage and dryness, skin dryness and wrinkling, and accelerated aging. It is one of the most vital hormones in your body. So, if your ovaries are not working and not producing estrogen, or very little estrogen, then you need to go on hormone replacement with something like a birth control pill. If you are interested in getting pregnant, and your ovaries are not menopausal, then you need to take fertility medications to induce your ovaries to ovulate produce and give off an egg.

The bottom line is that you cannot continue like this because it is harmful to your health. You want to stay young for your children and husband, so please go see a Gynecologist as soon as you can.

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.

Overweight Woman Trying To Conceive Has Irregular Periods And Multiple Miscarriages

Question:

Hi Dr. Ramirez,

I read your blog and I love it! I learned a lot reading all your archives, so I wanted to come to you for advice about my situation.

I am 24 years old and my husband is 26. When I was 21, I was told that I have problems ovulating because my cycles were just a week of spotting after 2-6 months of nothing. My OB/GYN says that I don't ovulate due to my obesity, so I have never had any tests to check for PCOS or anything else. I am working on losing weight, but it has been a slow process. I do menstruate when given progesterone supplements, typically within hours of finishing my 10th day of 200 mg Prometrium. I also have hypothyroidism (and a strong family history of the same), but it is under control with 50 mcg levothyroxine; my most recent TSH, in January, was 1.7. I also have a family history of lupus, but do not have lupus myself.

In July 2008, I got pregnant while on Sprintec and miscarried at 5w2d, then went back on Sprintec. In October 2009, I got pregnant in my first month off Sprintec and miscarried at 5w4d, then went back on Sprintec. In February 2010, I got pregnant again in my first month off Sprintec but had a chemical pregnancy (bleeding started at 4w2d). Additionally, just from knowing my typical pregnancy symptoms in retrospect, I suspect that I might also have had a chemical while on Sprintec in April 2009, but I did not test because I was taking active pills three months at a time so I did not have a period to miss.

I have been taking OPKs twice daily (12 hours apart) since the chemical but have not ovulated; in fact, I rarely if ever see a second line at all on the tests. My OB/GYN said I can start Clomid at any time, but he is unwilling to do any testing regarding the losses until I have another miscarriage. My husband and I do not want to try to conceive again until we have tried to get an explanation for our losses.

I actually have a few questions. One, is there a reason I seem to ovulate only when I have recently been on hormonal birth control? Is it a down-regulation thing like women have before their IVF cycles? Two, is it possible that just taking Clomid might allow us to make it out of the first trimester? Three, in your opinion, is it time to move to an RE even though we have not yet been trying for a year (the only one in South Dakota is more than 200 miles away from our home)? And four, what sort of tests would an RE want us to do regarding my pregnancy losses?Thank you so very much for your time and consideration.

You provide a wonderful service, and if I'm ever in California I'd love to become a patient!

Answer:

Hello B. from South Dakota,

Thank you for reading my blog and your kind comments. I hope the information was useful.

It certainly sounds like you have an ovulation problem, and Clomid would be an appropriate treatment. However, because you have had three miscarriages, you also have the problem of recurrent miscarriage. Both of these problems would fall into the infertility category and an infertility specialist would be the best person for you to see. That way, both problems can be managed, rather than just the ovulation problem as your current doctor suggests. Regarding your weight, I have had infertility patients who are overweight and still achieve a pregnancy. There are other issues that need to be addressed that take precedence over your weight.

Let me answer your questions specifically in order:

1. I find it interesting that you were able to ovulate on the birth control pill. I'm not sure that I can explain this. Most likely, the birth control pill caused an FSH/LH burst that led to ovulation. It usually suppresses FSH/LH discharge, which is how it works.

2. Clomid will certainly help you to ovulate, at the appropriate dosage, and may correct any hormonal problems if that is the cause of your miscarriages. I would not bet on it, however. Rather, I treat ALL my infertility patients will supplemental progesterone in order to help prevent any miscarriages caused by hormonal problems. In addition, with a patient with recurrent miscarriages like yourself, I would add low dose aspirin 81 mg per day beginning at the start of the menstrual cycle, medrol 16 mg per day beginning at the start of the cycle and tapering to 8 mg per day after ovulation, then stop with the pregnancy test and heparin 2000U injections twice per day beginning at the start of the cycle. Lovenox could be substituted for this as well. An RE is the most knowledgeable with this problem and protocol.

3. I answered the question regarding the RE above, but I would recommend that you see one because of the ovulatory dysfunction and recurrent miscarriages.

4. Recurrent miscarriage evaluation includes: Hysteroscopy, pelvic ultrasound, blood tests for antiphospholipid antibody (full screen), ANA, Lupus anticoagulant, Leidin factor V, RPR, Toxoplasmosis, Chromosomal analysis in you and your husband, hormone panel.

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 so much! I plan to see if my current clinic can run the panels, then follow up with a specialist.

Off Depo Provera But Still No Period, What's Wrong?

Question:

Hello, I am 30 years old and was on the Depo-Provera shot for 3 years during which time I did not have a single period. I had my last shot in January 2008 and still have not had a period. My husband and I would like to start a family in the next 2-3 years and I am getting increasingly worried that this will not be possible. I am also suffering from very bad vaginal dryness (could this be related?)

I am currently doing some voluntary work in Argentina now and it is difficult to see an English speaking doctor. Is there something I can do to help my self in the short-term or should I consider returning home to seek medical advice?

Answer:

Hello T. from Argentina,

I am surprised that you can't find an English speaking doctor in Argentina. Maybe you should look for a Reproductive specialist specifically as most of them do speak English. If you still can't find one, then you should return to the U.S. for consultation.

Certainly, something is not working correctly which is preventing the ovary from ovulating, hence no periods. This is not due to the Depo Provera, since it does not last this long. It can delay periods for 1-3 months but not usually longer. There is something else going on and you need to undergo evaluation. The vaginal dryness is because you are probably not producing estrogen, which occurs with ovulation, and the vaginal gland is estrogen dependent. You don't want this to go on much longer because the vagina will actually begin to shrink and intercourse will be difficult and painful.

In order to get pregnant, depending on the cause of the problem, you need a treatment that will get you ovulating again. There are various options, but it depends on the cause. In the meantime, you might want to consider going on the birth control pill in order to get you cycling again (it overrides the ovaries so is not correcting the problem), which will give you estrogen. Many parts of your body require estrogen. You should be able to get this from a non-English speaking doctor while you plan to return to the U.S. for consultation.

Thank you for writing and good luck!

Sincerely,

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

Infertility Treated Without Appropriate Testing Equals One Confused Patient & Poor Results

Question:

Hello, I am writing from somewhere in the United States. My husband (35) and I (30) tried to get pregnant for about 13 months with no luck. After initial bloodwork where everything looked good except for slightly elevated testosterone, my doctor put me on Femara. I did day 3 bloodwork to check FSH, which was normal, and then took 2 pills a day for 5 days and checked my progesterone on day 21. It was 0.5. So we decide to do another round of Femara. Both times I had to take provera to start my period. After doing the exact same thing with this round, my progesterone was still 0.5. We discussed that injections would be the next option.

I guess my question is did I do enough before moving to injections? And also I feel like I need to have an ultrasound before doing anything else to check my ovaries, look for blockage in my tubes, etc. Should I request an ultrasound to check for those things or is that something that the specialist will do anyway before starting injections? I just don't want to do the injections unless they are absolutely neccessary. BTW-My doc has finally referred me to an infertility specialist.

Answer:

Your story is one that I don't like to hear because I think you have been mismanaged. You should have undergone a infertility evaluation before starting any medications/treatment, but I know that a LOT of general Ob/Gyn's and Family Practicioners like to go straight to a trial of treatment. A basic infertility evaluation is:

1. Cycle day#2/3 hormone panel

2. Hysterosalpingogram - check tubes

3. Hysteroscopy or Hysterosonogram - check uterine cavity

4. Laparoscopy - check pelvis (optional at the beginning#5. cycle day#21 progesterone level

6. Cycle day#26 endometrial biopsy - check endometrial development

7. Semen analysis

8. Pelvic ultrasound

9. Cervical cultures

Before moving further into treatment, especially injectables, I would recommend that you have the above testing done.

However, if you are going to go directly to treatment, you might want to try high dose Clomid #150-250 mg# first before injectables. Many patients will not respond to Femara but will respond to Clomid. Also, a proper ovulation induction cycle with Clomid, Femara or injectables will use the ultrasound at the beginning of the cycle, before starting medication, to make sure there are no ovarian cysts and get a baseline, then starting from day# 9 or 10, to evaluate the ovaries for #1# response to medication, #2# how many follicles are growing and #3) when to give HCG to stimulate ovulation. This also will help to know when to have intercourse or insemination.

Hopefully, your infertility specialist will advise you better than your previous doc.

Follow-Up Question:

Thank you so much for your response! You confirmed what I was thinking. I plan to request everything you listed in your steps 1-9 when I see the specialist. So I know what I'm talking about when I see the doctor, what is the reason for the pelvic ultrasound, cervical cultures, and checking the uterine cavity?

Also, I failed to mention in my first question that when I went off the pill I had normal periods for 2-4 months and then it started getting longer and longer in between periods (30-50 days). Then this past July 6 I had my last period and haven't had one since (except when taking povera for that purpose). I first started having my period at 13 and from age 13-19 had perfectly normal periods. I went on bc at 19 and stayed on them until right before my 29th birthday, and of course had very regular periods during that time. So I know that it looks like basically I'm just not ovulating, but any ideas on what else might be going on? I know it could be lots of things, but I'm just worried and seeking as many answers as I can before seeing the specialist next week.

Thanks so much

Follow-Up Answer:

Without the right tests I cannot comment on your irregular periods. I'm sure the infertility specialist will do a proper evaluation. Each test evaluates for the specific steps in the process your body goes through in order to get pregnant.

1. Ultrasound - to look for ovarian cysts, tumors, uterine fibroids, enlarged tubes or other structural abnormalities in the pelvis.

2. Cervical cultures - check to make sure you don't have any STD's or bacteria that might affect/kill the sperm.

3. Hysteroscopy - the uterine cavity is the critical place where implantation takes place. It needs to be completely normal.

You have to undergo the testing I mentioned previously to find out why your ovaries may not be working properly, hence probably, the irregular periods. It could be an ovarian problem, pituitary problem, thryoid problem, hypothalamic problem, etc. Your specialist will work with you to figure things out.

Good Luck and be sure to always take a pad of paper along for your question & answers while you progress with your evaluation.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

www.montereybayivf.com

Too Many Rounds of Clomid Will Inhibit Pregnancy

Question:

I have been trying to conceive for two years. So far, I have done 12 total cycles of clomid. We hare having issues getting my follicles mature. I am now taking metformin daily, dexamethasone on CD 1-14, and clomid on days 3-9. I have ultrasounds on CD 14 and usually find immature follicles.

I am wondering, do all these meds seem excessive? All these meds are making me crazy! At what point should conceiving be considered not possible?

Answer:

Thank you for your question. You have already exceeded the number of cycles on Clomid (clomiphene) that is recommended by ASRM (American Society of Reproductive Medicine) and fertility experts. You need to move to something else. I presume you are seeing a General Ob/Gyn for your treatments. Find a fertility sub-specialist and transfer your care. At this point, you should be moving to IUI or IVF, and certainly the gonadotropins. NO MORE CLOMID.

It is this type of prolonged Clomid treatments that get Infertility specialists upset with general OB/GYN docs. All that are strictly recommended are 4-6 cycles at the most. Clomid will inhibit pregnancy after too many consecutive cycles. It works by blocking the estrogen receptors and tricking the brain into thinking it is not making enough estrogen. The brain then stimulates the ovaries harder. After a while, the Clomid will block all the estrogen receptors, which are required to produce adequate cervical mucous, adequate uterine lining and tubal motility. So in essence, it will be preventing pregnancy.

In terms of getting pregnant, it depends on many factors. I tell my patients that I can get anyone pregnant. The difference is what I have to do to get them pregnant. So, you have lots of other options. However, if you don't get out of your current situation with your current doctor, then you will be wasting a lot of time, just as you already have.

Good luck and keep trying, only not in this manner.

Sincerely,

Edward J. Ramirez, M.D.Executive

Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California

www.montereybayivf.com

INFERTILITY EVALUATION ABC'S

I thought I would share my approach to the infertility evaluation. I have seen many patients referred to me, who have not undergone a complete infertility evaluation. Many physicians approach this haphazardly, checking some things but not others. Like other disease states, in order to find the diagnosis, all the different possiblities must be ruled out. In 30% of cases, there is more than one problem, and in 30% of cases it involves both the man and women. Therefore all these systems must be checked. There are basically 9 steps that are required to become pregnant. These steps are a sequence of events, such that, if there is a disturbance in any part of the sequence, then the entire process fails. These steps are 1. Brain sends signals (FSH hormone) to the ovary to begin the ovulation process, and the Ovary begins the maturation of the egg > 2. Ovulation occurs where the egg is expelled from the ovary into the culdesac > 3. The egg has to find the fimbria of the tube. > 4. The egg enters the tube where the sperm needs to be waiting, such that, the sperm needs to have proceeded from the vagina into the cervix, into the uterus then into the tube. > 5. The sperm has to fertilize the egg. > 6. The egg begins developing and dividing and passes through the tube (7-days). > 7. The formed embryo now enters into the uterus. > 8. The embryo has to hatch. > 9. the embryo has to implant into the lining of the uterus. The infertility evaluation that is recommended, checks each one of these steps and I've listed them with the respective step in the sequence:


1. Hormone levels on cycle day # 2 or 3. This is to test to see if the hormone levels, that the brain is producing, are normal at the start of the cycle. This can also give an indication of how the ovary is functioning and able to be stimulated. If the FSH level is elevated, it could indicate that the ovary is already beginning to slow down and/or approaching menopause. If the FSH is elevated, some physicians will proceed with a Clomid challenge test to see if the ovary is past the point where it can be stimulated by fertility medications. The only way to see if the ovary is maturing an egg is to do an ultrasound, in sequence, and see if a growing ovarian follicle is present. This is not usually done as part of the basic infertility evaluation.

2. Mid-luteal progesterone test on cycle day # 20-22. The progesterone level is increased when ovulation occurs, so this in an indirect test of ovulation.

3. Laparoscopy. Any abnormalities in the culdesac, the part of the female pelvis where the egg passes through and where the fimbriated end of the fallopian tubes sit, such as endometriosis or adhesions or tubal abnormalities, can affect the eggs ability to be picked up by the tube. The only test for this is laparoscopy, where a scope is inserted through the belly button to look inside.

4. Hysterosalpingogram. Sperm and egg get together in the fallopian tube. A hysterosalpingogram (HSG) is done to test if the tube is open. This is an x-ray test where a dye is injected into the uterus and passes through the tubes. X-rays are taken in various intervals to confirm that the dye passes into the pelvis.

5. Semen Analysis. We do not have a test to see if fertilization can occur. Therefore, we test the sperm as an indirect method to assess its potential. This is done with a semen analysis. In this analysis we test for the number of sperm, the number of sperm that are swimming (motility)-which is also a measure of the number of live sperm, and the number of normally formed sperm (morphology). This is not just a test of numbers. It is an indirect indication of sperm function. If there is an abnormality then this may indicate that the sperm may not be able to fertilize an egg. The only way to assess if your husband's sperm can fertilize your egg is to remove your eggs and put them together with his sperm, then see what happens. That cannot be done without in vitro fertilization.

6. There is no test for this step, but the HSG indirectly gives evidence that the tube is open and the egg has the potential to pass through.

7. Hysteroscopy. The uterine cavity is tested by a procedure called a hysteroscopy. In this test, a scope is passed through the cervix and the uterine cavity is visualized directly to make sure it is normal. I do this test in my office but most gynecologists do this test in a surgery center.

8. There is no test for this step.

9. An endometrial biopsy is done at the end of the cycle, just before onset of menses, usually cycle day # 26-28. The biopsy tells us if the uterine lining is developed adequately for implantation.

10. Pelvic ultrasound. I do one additional test, which is a pelvic ultrasound. This allows me to assess the uterus, especially the muscle layer and anatomy, the ovaries to rule out cysts and tumors, and if there are any adnexal abnormalities (the areas around the ovaries). Sometimes a dilated tube can be seen.