Young Woman With Endometriosis & PCOS Fails Five Clomid Cycles: Next Step?

Question:

Dear Doctor,

Hi, I'm from Minnesota. My husband and I have been trying to conceive since August of 2011. I have endometriosis and PCOS (polycystic ovarian syndrome) since finding out when I was around 17 years old, I'm 25 now. I have had five cycles of Clomid that didn't work. I had laparoscopy surgery for this post December, blocked tubes, suck ovaries, scar tissue, cysts and endometriosis. I'm on metformin because that's supposed to help with infertility and PCOS.

I started femara this month. Had 4 follicle on left and 1 on right from ultrasound. I usually ovulated on the 15th day, this time I didn't ovulate so I took the ovidrel shot and had a positive test. Started estrogen and progesterone day 3po. Currently on day 10po. I have cramps on and off.  I was just wondering what my chances of conceiving are and what is the next step if this didn't work this cycle. Any information or insight would be great! K. from Minnesota

Answer:

Hello K. from the U.S. (Minnesota),

Your statistical chances of pregnancy with Stage Four Endometriosis (endometriosis with extensive adhesive disease) and PCOD is probably less than 1% using any natural treatment method (Clomid, Femara or Injectables with intercourse or IUI).  That is because you have an abnormal pelvis and this location is critical for passage of the egg from the ovary to the tube.  Scar tissue, which is like spider webs, can block the egg from entering or reaching the tube.  Endometriosis causes a chronic inflammation of the pelvis which leads to the inflammatory cells attacking and destroying the egg as it exits the ovary to reach the tube. Polycystic ovarian disease is an ovarian dysfunction where the ovaries don't function properly and so there is a resultant hormone imbalance and lack of ovulation.  All of these put together significantly reduces your chances.

See my website for more extensive information and explanation of the options available for both Endometriosis and PCOS. I am convinced that with the proper information patients become empowered to make the right decision about their healthcare and can ascertain if they are receiving the best care.

It is my humble opinion that you are probably not seeing an infertility specialist because a good infertility subspecialist would have told you all this and not done all the treatments you have done.  The treatment of choice is to proceed to IVF so that you can bypass the pelvis completely.

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.

Patient On Metformin To Prevent Miscarriage: Is It Necessary?

Question:

HI Dr. Ramirez,

Sorry to keep this up about the Metformin, but you have been so helpful in the past...thought I would try your take on this.

I talked with my Doc about low dose heparin, and he told me that he does not prescribe this unless tested and confirmed thrombophilia is present, which he says I do not have. He would really like me to take the metformin. I have had one chemical pregnancy and one 9 week miscarriage and am currently 5 weeks pregnant. I took his advice and so far have taken 5 pills. I am extremely nauseated, which I know is from the Metformin as a few hours after it started. I REALLY DO NOT want to take this stuff after just recovering from OHSS. IS there any greater risk of miscarriage stopping now that I've started, and is there a greater risk of miscarriage if I don't take this med. I would love your thoughts on metformin and PCOS. Many sites are saying it really helps in the early stages of pregnancy for PCOS women to stay pregnant.

Thanks so much for your time....once again! C. from Canada

Answer:

Hello C. from Canada,

Metformin does nothing to help with a continuation of pregnancy and does not need to be continued once pregnant unless it was prescribed for diabetes. It is a pregnancy category B medication so is safe in pregnancy if your doctor insists that you continue it. If you were my patient, you would not be on it now. Metformin, given to help some PCO patients ovulate, is for that specific reason only. Once pregnant, the Metformin has done its job and is no longer required. If it is causing side effects, which it usually does, then I think I would recommend that you stop. There are absolutely NO recent studies that show that continuation of Metformin in PCO patients helps the pregnancy to survive or continue. Pregnancies continue or miscarry for many other reasons. Your doctor is mistaken but since he is the doctor you have chosen for your care, you have to decide if you are going to abide by his recommendations or not.

By the way, based on his comment about heparin, it is clear to me that he doesn't understand its use in recurrent miscarriage patients or infertility patients. It is obvious that he is not a specialist in that field. Please see my section on "Recurrent Pregnancy Loss".

P.S. Regardless of what many sites may be saying on the internet, you are wise to ask the advice of a medical professional.

Good luck,

Dr. 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.

New 2011 Study Questions Routine Metformin Use In All PCO Patients

Dear Readers,

A recent study published in the medical journal "Clinical Endocrinology" Frans S., Clinical Endocrinology. [Oxf], 2011; 74:148-151, brings into question the routine use of Metformin in PCO (polycystic ovary) patients. The study showed a small improvement for ovulation but not clearly better than weight loss. It also showed no improvement in pregnancy outcomes, except in patients with diabetes. It showed no benefit or improvement in hirsuitism, acne or hair loss resulting from PCO (polycystic ovary). Alone, it showed no improvement in pregnancy rates but did show some improvement in combination with Clomiphene (Clomid), yet there was no increase in the live birth rate. The authors therefore concluded that there was no real evidence to draw any conclusions regarding Metformin’s treatment in PCO, and that its only benefits may be in patients with diabetes or impaired glucose tolerance.

As you have seen through reading my blog, PCO (polycystic ovaries) is a very common problem among infertility patients. I have participated in numerous posts, have had several on-line, television and radio discussions regarding this problem, and I have given my opinion regarding the diagnosis, management and treatment options associated with this problem. One of the main problems that I face, almost on a daily basis within the medical community, is the mistreatment of PCO patients with Metformin. I see this commonly done by second tier providers such as Nurse practitioners and Physician Assistants, as well as, Physician providers such as Family Medicine practitioners and general Ob/Gyns. Many of these providers have mistakenly latched onto Metformin as the ultimate drug for the treatment of PCO, much the same as they have latched unto Clomid is the ultimate treatment for infertility. As a result, they automatically treat all suspected PCO patients with Metformin. This practice is unfounded and this recent study shows that treating all PCO patients with Metformin may be misguided. In fact, it brings into question whether there is any benefit at all.

I would not say or conclude that there is no benefit, but there is selective benefit. There are certainly studies that show benefit in a sub-population of PCO patients, just as this study shows benefit in patients with impaired glucose tolerance. These are patients that have been found to have an elevated insulin level or diabetes from insulin resistance. Not diabetics who do not produce insulin. Decreasing this level, either through weight loss or Metformin, will often return the ovary to normal function in these patients, or make their ovaries more responsive to fertility medications.

But clearly, it does not benefit all PCO patients and therefore should be selectively used, not, as many of these aforementioned providers do, used for all PCO patients. There is not a good way to know exactly which patients will respond or not respond to this medication, but here are three requirements that I abide by.\:

*First, a fasting insulin level should be taken to see if it is elevated. If not, then skip the Metformin.

*Secondly, if Metformin is going to work, it can take several months, some authors state 6-8 months, to see if there is any effect. The effect should be noticed by resumption of normal ovarian function i.e. regular menstrual cycles or decrease of the fasting insulin levels.

*Thirdly, a minimum dosage of 1500 mg per day is required. I have seen some patients taking only 500 mg. That is a total waste. If you are going to use this medication then you have to use it in the clinically effective dose.

The exact cause of PCOS is not understood. Some thought it was elevated insulin, but that clearly is not the case in all patients. Some thought it was increased weight, but that also is not the cause. It is clearly some inherent pathway within the ovary that is dyfunctioning, and it is clear that there are many forms of this disorder. It may be a multi-factorial condition where there is not one presentation or one treatment. In is imperative that patients and Physicians understand this and not latch onto one treatment modality for all. Treatments have to be specific to the patient.

Which brings me to my final point regarding the patient-doctor relationship:

This is exactly why Medicine can never be dictated by a cookbook method. People are all different, present differently and must be treated differently. We call that the art of medicine, and this is what makes some doctors better or worse than others, makes some doctors decide to specialize, an option which, unfortunately, is quickly disappearing from medicine as we look to less trained and less costly practitioners.

Edward J. Ramirez, MD, FACOG
Medical Director
The Fertility & Gynecology Center
Monterey Bay IVF
http://www.montereybayivf.com/

PCOS Challenge Radio Show Summary: Everything You Wanted To Know About PCOS, Fertility, Menopause, Pregnancy & More!

Dear Readers,
On September 29th I was interviewed by Sasha Ottey of PCOS Challenge on her BlogTalkRadio program, for an episode titled: "Ask The Fertility Specialist About PCOS And Your Fertility". I was pleasantly surprised at how quickly the one-hour interview went. It was basically a question/answer format (like my blog ). It was interesting to see how many questions I received from Sasha and her listeners that not only covered PCOS but many, many other issues that relate to women's reproductive health. For more in depth information on PCOS and infertility please see: Polycystic Ovarian Syndrome.

I will attempt to give you some idea of the many different issues that were brought up during this very enlightening hour! I can't list them all, but if any of the topics that I list below interest you, please listen to the radio show through the widget below!

Listen to internet radio with PCOSChallenge com on Blog Talk Radio

• "What is the difference between a normal menstrual cycle and one that is PCOS?" With an abnormal menstrual cycle you can develop abnormalities in your endometrial lining.
• "What are the top reasons for infertility?" Probably PCOS is the number one cause for infertility that I see, with tubal factors and age factors coming in close seconds.
• "While overweight PCOS patients are told to lose weight, lean PCOS patients are at a loss as to what to do?" I go in depth on Clomid, Femara and the injectables that might be the treatment path for "lean" PCO patients.
• "What is the difference between ovarian reserve and ovarian resistance?" With ovarian reserve you need to evaluate your FSH levels and AMH and tends to come with age, but ovarian resistance has to do with how the ovary responds to fertility medications.
• "How long do you need to wait to try for pregnancy again after you have a miscarriage?" Surprisingly, recent studies have shown that trying as soon as possible will actually increase your chances of pregnancy. You must wait until you resume your normal menstrual cycle, though.
• "What about patients that are insulin resistance and overweight, will changing their diet and losing weight help with their fertility?" This will work in a majority of patients, but some of these patients will have to go on Metformin, and possibly ovulation inducing medication.
• "I am a very heavy-bleeder during my period and are there any options besides a hysterectomy?" You need to establish first whether you want to get pregnant in the future, in which case you want to preserve your uterus. You should find out why you have the bleeding. It could be an ovarian disfunction or perhaps caused by fibroids or polyps which can be removed. Otherwise, if you don't want to get pregnant you can opt to have a D&C, bcp, Mirena, endometrial ablation, or a hysterectomy.
• "When can I expect to see or hear the heartbeat in early pregnancy?" By the seventh week you should expect to see something.
• "Can you have menopause and PCO?" Once you become menopausal PCO is not an issue anymore, you have a hormonal imbalance because your ovaries are not functioning anymore. There are treatments for menopause, including estrogen replacement therapy for the first five years.
• "What is Metformin and Spironolactone?" Metformin is an insulin blocker, while Spironolactone is a diuretic used with PCO patients that have hirsuitism as well.
• "How do you treat nausea in pregnancy?" There is a great drug out there now that I use with all my patients, including those who have just had surgery, called "Zofran". It is safe for pregnant patients.
  
  Not all the topics we covered are listed above...so tune in if you want to hear me discuss these issues and more in depth! Thank you, Sasha, for the opportunity to share this knowledge with your listeners!
  
  Edward Ramirez, MD, FACOG
  Monterey Bay IVF
  www.montereybayivf.com

36 Year Old With 3 Miscarriages On Prometrim Using OPK : Continue With Calendar Method or Go For An Infertiity Consult?

Question:

Hi, My name is R. I am 36 years old living in Atlanta GA. My husband is 41 we do not have any kids and would like to have a baby.

In the past I have had 3 miscarriages. prior to my miscarriages, I had a hystersalpinogram(sp) when I was in my early 20's unblocking both of my tubes. Recently I had been diagnosed with Pcos and placed on Metformin 750mg 2x a day, although I have always had a regular period lasting only 3 days but it comes like clockwork every 28 days. So now let me bring you up to date. Today 08/15/2010 I had detected my LH surge via clearblue ovulation kit. But last month my doctor recommended the Clearblue ovulation test and prescribed me Prometrium.

I do not understand why I was prescribed the medication and 2 I am confused as to when to take it, the bottle says to take 3 days after ovulation, when is that? I just detected the LH surge so when should I begin taking it? In the meantime, shouldn't me and my husband be having intercourse to try and conceive? The Prometrium is a 30 count, so should I take the medication starting day 3 until its all gone? I am so confused and excited, I have never used the ovulation predictor and so I am surprised that I see this happy face, what should I do next? Beside sit and worry!

Thanks for your answer, I am anxiously awaiting to hear back from you.

Answer:

Dear R. from Georgia.,

I don't know why you have the diagnosis of PCO if you have very regular cycles, but there is a variant of PCO that you would fit into. You would not need to take Metformin, however. Did your doctor check an insulin level or how did he decide to put you on Metformin?

In terms of timing your ovulation, that is good but if you want to save yourself money, since you have such a regular cycle, the calendar method would work just as well. If using the OPK, when it turns positive, you begin intercourse (on that day#, once per day for four consecutive days #only one ejaculation per episode). With the calendar method, mark you calendar on the first day of your period then count each days in sequence. Stop having intercourse on cycle day #10 then on CD#13 begin having intercourse once per day for four consecutive days as explained above. In both cases, start the Prometrium on CD#16 and use it twice per day. Because this will suppress your menses, you will need to do a pregnancy test around CD#30.

You know, I need to emphasize that time is a critical factor in your case. I presume you have been trying for pregnancy for a while, so you & your husband really should see an infertility specialist. Your age, the miscarriages, previously blocked tubes and possible PCO diagnosis all indicate that it may be necessary. The specialist will lead you in the right direction, doing the tests that need to be done before starting an arbitrary treatment plan, and be the most efficient in helping you to get pregnant. Sometimes it may only take doing one Intra Uterine Insemination. With each year, your pregnancy rates are decreasing, even with the highest level of treatment, which is IVF, so don't waste time.

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.

Very Confused Woman With PCOS & Endo, Who Is Anovulatory: TTC & Not Getting The Right Treatment

Question:

I was recently diagnosed with PCOS, (after many years of suffering with endo also) and we've been TTC for 2 years. I have been taking 1,000mg/day of Metformin to help control the insulin resistance. I have long anovulatory cycles and was recently seen by my doctor who wants to put me on Ortho-tri-cyclen to help get my cycles back under control. She said that women with PCOS have too little of estrogen and that is why I am anovulatory.

I have always learned that women with PCOS are estrogen dominant, so now I'm very confused. Which is it? Also, will I see ANY benefit from the birth control pills, after I stop taking them? Will it help to make me ovulate? I have not ovulated since November, which of course makes it difficult to TTC without that important factor.

Thank you in advance. L. from the U.S.A.

Answer:

Hi L. from the U.S.,

First, you are taking an inadequate dose of Metformin, if you have been found to have insulin resistance. The recommended dose is 1500 mg per day.

Secondly, your current doctor is incorrect in that OCP's (birth control pill) is only a treatment to regulate the cycles. If a woman with PCOS is 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 will do nothing for your fertility. Also, the reason why you are anovulatory is because PCOS (polycystic ovarian syndrome) is an ovarian dysfunction that leads to low estrogen, high testosterone levels. It is NOT the other way around.

Once you stop the OCP's you will go back to your normal anovulatory cycles. If you want to get pregnant with PCOS, you need to use a medication that will induce the ovaries to ovulate such as Clomid, Femara or injectable medications. I would recommend that you see a fertility specialist, who understands this problem better and won't waste your time, so that you can get pregnant in the shortest period of time. My job, as an infertility specialist, is to try to get my PCOS patients pregnant. The goal is to get them to ovulate! We use fertility drugs such as the ones mentioned above for this purpose, but it varies as to how a patient responds to these medications. The "fertility drug" is actually stimulating the ovary to ovulate.

Also, keep in mind that endometriosis is also a cause for infertility so in essence, you have two problems that are preventing you from getting pregnant.

Please read further on PCOS in some of my earlier blog posts. There is one in particular with a link to a radio interview that I did on the subject. See the February blog post: http://womenshealthandfertility.blogspot.com/2010/02/interview-on-pcos-challenge-talk-radio.html

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.

Injectables with IVF - Is Metformin Indicated?

Question:

Hello-I am from the US and I am 33 years old. My husband is 34. We have been trying for almost a year and saw an RE. I was told I have a fibroid that I am having removed laparoscopically the end of March. I was told by my doctor that since my huband's sperm is below where it needs to be (both count and motility) that I can begin IVF (in vitro fertilization) with injectable treatments about 2 cycles after the surgery. Which drugs are used? She mentioned ICSI (intracytoplasmic sperm injection) also. Will I have side effects from these injectable medications and if so what will they possibly be?

She also mentioned my possibly taking Metformin to try to enhance the IVF to work. I have heard mixed reviews on this medication actually working and was wondering what your take is on it. Can you please advise? I have heard of some unpleasant side effects from Metformin/Glucophage so I am not sure what to do.

What is the chance of IVF or IVF with ICSI to work? She said around 50% which I believe is much better than the 20% chance it would be which we were told if it would happen naturally. Is this true? I have had an ultrasound with saline and an HSG with dye- both came back fine other than the fibroid. I have been put on Synthroid to regulate my thyroid which I was told was slightly elevated. I am also on the birth control pill until I have the surgery to remove the fibroid the end of next month. I have had several blood tests testing my FSH, LH, Prolactin, Estradoil, glucose, etc all which have been normal results. Any additional info. you could provide would be appreciated.

Thanks!- S.

Answer:

Hello S.,

Let me answer your questions sequentially to make it easier:

1. Lots of different medications are used with IVF cycles. This is a question best answered by your doctor, or her IVf coordinator. Each doctor has different protocols, depending on their preferences and how they are trained. The main medications are called gonadotropins and are synthetic versions of the FSH and LH that your brain produces to stimulate the ovary to ovulate. We give higher dosages of these medications in order to make the ovary produce/prepare more that one egg. The goal with IVF, in order to maximize the chances of pregnancy, is to get more than one egg out. Preferably 10-20. This is because not every egg is a good egg.

2. Most women tolerate these medications very well since they are essentially the same as the hormones your body produces. Of course, all medications have side effects and each person is different and can react differently to each medication. The biggest side effect of these stimulation drugs is that the ovaries will enlarge and become tender because so many eggs are being recruited. In addition, some patients will feel bloated. If the ovaries are stimulated too strongly, or the ovaries respond too strongly, you can develop an illness called "hyperstimulation syndrome." This is a very serious and dangerous problem that has to be prevented and managed appropriately. If you have PCO, which I suspect you might have since your doctor recommended Metformin, you are at increased risk for hyperstimulation syndrome. You need to discuss this with your doctor and ask her what she does to prevent this. There are methods that we use to prevent this from occurring such as using lower dosage protocols, close monitoring of blood levels, coasting or drifting if necessary, antagonist protocol, triggering with Lupron instead of HCG.3. Metformin is only indicated in 30-40% of patients that have PCOD. It is NOT indicated in all patients AND, it takes 6-8 months to work so starting it with an IVF cycle is not appropriate. I would not recommend it unless you have been found to have insulin resistance by blood testing.

4. In terms of IVF working, you have a 50-70% chance of pregnancy with each IVF cycle in your age group. You should ask you doctor what her statistic is. Pregnancy rates do vary depending on the clinic and the doctor, so be sure to check both out.5. With a severe sperm disorder, the chances of pregnancy would be much less than 20%. Your natural chances of pregnancy at your age, if there were absolutely no problems, would be about 15% per month of trying. With the sperm problem it would drop it to less than 10%. That is why IVF is the treatment of choice. With IVF and ICSI, we had a 75% pregnancy rate per transfer in 2009. Most clinics are reaching that level as well.

I hope this information helps. Be sure to ask lots of questions. You will be paying a lot of money for this treatment and you should make sure you have had ALL your questions answered to your satisfaction. This type of procedure is like shopping at Saks 5th Avenue. You should demand and get the highest level of service!

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.

Interview on PCOS Challenge Talk Radio Part Two: Insulin Resistance, The Metformin Myth and Infertility

Again, it was a pleasure being interviewed by Sasha Ottey of http://www.pcoschallenge.com/ on her radio show. We covered a lot of ground, although I probably could have gone on for another hour since this is such an important subject for many of you PCOS sufferers out there. You can still listen to the show in it's entirety at http://www.blogtalkradio.com/rss/tag/pcos.rss. We left off in the last blog at defining the characteristics of a typical woman who suffers from polycystic ovarian syndrome. I would now like to touch upon one of the hot topics of the PCOS community:

Insulin Resistance In PCOS Patients

Sasha and I went over how PCOS treatment protocols need to be tailored to the specific individual. There is no "one size fits all" with this particular syndrome. One of the most important points that was brought up during the show was the question of insulin resistance in PCOS patients. There has been a lot of press coverage regarding "insulin resistance" as being the main cause of polycystic ovarian syndrome. This has led to many, many women being misdiagnosed and mismanaged. As a result, there has been a tendency to automatically prescribe Metformin (Glocophage). In reality, only 30-40% of these women have insulin resistance, and only those patients will have some response. Some will resume normal ovulatory function, and others will become more respondent to fertility medications. It will take 6-8 months to see if the medication works and a minimum dosage of 1500mg per day is required.

When is it appropriate to go this route with a patient? The patient must be evaluated for insulin resistance. This is going to be manifest by an elevated fasting insulin blood test, or abnormal glucose tolerance, that is, when the fasting glucose is elevated, a glucose tolerance test is positive or there is a diagnosis of diabetes. In these cases, the insulin level may be low or normal because the long-standing resistance has caused the pancreas to stop secreting insulin. If a patient is not insulin resistant then Metformin or similar medications are not indicated.

Non-Insulin Resistant PCOS Patients

For non-insulin resistant patients the treatment varies,depending on whether a patient is trying for pregnancy or not. For those who are not trying to get pregnant, the dominant male hormones have to be suppressed, female hormone needs to be increased and the patient needs to have regular cycles. This is done through the use of birth control pills because it does all of the above. My preference is a new pill called Yasmin or the lower dosage version, Yaz, because its progesterone, drospirenone, blocks testosterone receptors and so has a stronger effect in lowering the testosterone effects of PCOS. This also replaces the female hormone so that the person does not suffer the long-term effects from a lack of estrogen.

A Tough Journey To Pregnancy

For those women who have PCOS and want to get pregnant the journey gets a little tougher. My job, as an infertility specialist, is to try to get my PCOS patients pregnant. The goal is to get them to ovulate! We use fertility drugs for this purpose, but it varies as to how a patient responds to these medications. The "fertility drug" is actually stimulating the ovary to ovulate.

The first drug we use is Clomid, but it has to be used in higher dosages than normal because of the ovarian resistance that PCO patients have to Clomid. I use it from 150 mg to 250 mg. Another similar medication called Femara (Letrozole)can also be tried. Some Clomid resistant patients will respond to Letrozole. In the patients that do not respond to either of these medications, I use a combination protocol.

Briefly, it entails starting with Clomid or Femara then adding injectable fertility drugs like Follistim, Gonal-f or Bravelle. This "boosts" the Clomid or Femara effect to stimulate a few follicles to grow. The problem with going straight to the injectables is that most PCO ovaries will have a hyper or exaggerated response to the medication, because these ovaries are more sensitive to these drugs, causing the formation and/or ovulation of 10 or more follicles. When that happens the cycle is often converted to an IVF cycle in order to prevent a super-multiple pregnancy to occur, or the cycle is cancelled. With the combination protocol we are trying to give the patient the opportunity to get pregnant using a natural means such as intercourse or IUI. Of course it may take several attempts before pregnancy occurs, since the body has to go through many steps to become pregnant naturally. The medication is just trying to make the ovaries act like normal ovaries.

We have been pretty successful at getting some of our patients pregnant with this protocol. Keep in mind, most PCOS patients are young with fertile eggs. It can be merely a matter of persistance with them, of trial and error with their treatment until success is hopefully soon achieved. But, just like national statistics show that up to 80% of PCOS patients have to progress to IVF, we also see a high number of patients having to go in that direction. The combination protocol is just one option to try to achieve pregnancy through an easier means.

Lastly, Sasha asked me if patients come to me for "damage control"....not only for OHSS (as I blogged on February 20th) but for recurrent miscarriages. It is not really "damage control" but recurrent failures, or looking for a different option. I have seen many, many patients that have been put on Metformin and/or Clomid for long periods of time and not get pregnant. Many of these patients have just been given a prescription with multiple refills and told to take that for 6-8 months. They never get checked to see if they are even responding to that dosage. In some the dosage is slowly increased up to 150 mg but again they are not checked, by ultrasound, to see if they are responding. So, when they come to me, we have to take a more aggressive tact, and the patient gets to the protocol that will lead to success.

I hope with these last couple of blogs and through the radio show, that I was able to help clarify some of the issues regarding Polycystic Ovarian Syndrome, as well as debunk some of the myths surrounding this difficult illness.


Thank you!

Three Miscarriages and HSG Shows Blocked Tubes

Question:

Dear Dr. Ramirez,

I have had three miscarriages in the last couple years and have been to two fertility clinics. I have had $8,500 dollars worth of tests done and all the male testing. I was told that my tubes are blocked by one doctor and the other one says that there is no way that they can just one day unblock. I was but on meformin and told that I have pcos. I read on pcos and it said that with Clomid a pregnancy is possible. What is your opinion on this?

Answer:

Thank you for your questions. You've thrown quite a lot of different things at me.

There are several issues that you have brought up. Let me see if I can answer them one at a time and give you the information that you are requesting:

1. Three miscarriages-There is an almost 40% chance of miscarriage with every pregnancy. Most are caused by a spontaneous chromosomal abnormality that occurs when the egg is dividing into an embryo. These usually lead to miscarriage within the first 8 weeks of the pregnancy. These patients will eventually be successful. A small percentage of recurrent miscarriages occur because of uterine abnormalities, hormonal abnormalities, immunological abnormalities, infectious diseases and health events like diabetes.

2. Blocked tube - Blocked tubes are evaluated by a test called an HSG (hysterosalopingogram). It is an x-ray test whereby a dye is injected into the tubes and xrays are taken as the dye flows through. If it doesn't flow through one or both tubes then that shows that the tubes are blocked. Once blocked, it is always blocked but there is an exception. Sometimes, the tube will be blocked by a mucus plug at the opening of the tube. In general, it is one side only. With increased pressure at the time of the HSG, this mucus plug can be pushed out and the tube opened. If this is the case, the HSG "helps" in clearing the tube and allowing for a natural pregnancy to occur. If pregnancy does not occur then this could not be done and that tube is probably blocked by scar tissue. The problem with one tube blocked is that the incident that caused the blockage was probably an inflammation or infection in the past, usually caused by a bacteria. These usually pass through both tubes but it affected one tube more than the other, so that one tube is blocked. That does not preclude damage in the other tube, however. As you know, it takes a very small hole to allow fluid, like the dye, to flow through. I usually counsel my patients to assume that the other tube is damaged. The inner structure can be damaged and render the tube non-functional even without it being blocked. Therefore, with any blockage, I counseled that IVF (In Vitro Fertilization) is probably the best option.

3. PCOS - I have explained this pretty extensively in past questions. Please refer to some of my previous blog posts. But to summarize for you, PCO is a disorder of the ovaries whereby ovulation does not occur. For this reason, fertility medications are required to stimulate the ovary to ovulate. Clomid is one of those medications that is used but does not work on all PCO patients. Metformin only is useful in PCO patients that have an elevated insulin level. So it does not work in over 50% of PCO patients.

I hope this answers your questions.

Follow-up Question:

If you don't mind, I was also told that when I had the HSG done that because I was in a lot of pain that my tubes could have contracted and acted like they were blocked. Is the possible? I have been pregnant 3 times and 2 of them were on Clomid alone. Is it possible that Clomid together with metformin would work?

Follow-up Answer:

Hello Again,

HSG's are generally painful, especially if the tubes are blocked. That is because they are increasing the pressure to see if the dye will flow through. Increased pain does not indicate tubal spasm, however, tubal spasm can prevent the dye from flowing through. We see this most often when injecting dye at the time of a laparoscopy. It is uncommon to see tubal spasm in both tubes, however. If you are concerned that you may have had tubal spams, then you should have the test repeated to confirm.

If the tubes are blocked, legitimately and not due to tubal spasm, then Clomid and/or metformin will not help. If the sperm and egg cannot get together, then fertilization cannot occur, and hence, pregnancy will not ensue. If the HSG result was due to tubal spasm, then it is possible they could help, so the tubes are the key element in this. Try to clear these issues with your specialist and proceed according to his/her recommendations. 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.