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

Primary Amenorrhea In 32 Year Old

Question:

I am 32 years old and never had a period. My mom took me to the doctor when I was 20 yrs old and they did an ultrasound of my abdomen which showed no cysts in the ovaries and a hormone test which showed that my FSH and LH levels were low. The TSH was normal.

A genetics test confirmed that I am xx. I used the contraceptive pill and had a bleeding. I have always had excess hair growth since puberty and acne issues. Do you think something is seriously wrong with me or I should just let things stay the way they are?

Answer:

There is absolutely something wrong, and it should have been taken care of a long time ago. Without specific laboratory information I cannot tell you what the problem is, but you have some type of ovarian dysfunction. In other words, your ovaries are not working. The bad part of this is that you are probably estrogen deficient. Estrogen is the female hormone and is important for many different parts of your body. As a consequence, you have an elevation in the male hormone, testosterone, because your ovary is not making estrogen. If you keep up like this you could suffer the following consequences: increased facial and body hair, loss of head hair (male pattern baldness), increased acne, deepening of the voice, obesity, diabetes, osteoporosis, increased heart disease.

The reason for the birth control pill was to give you the female hormones that you need and block the male hormone production. If you are not planning on getting pregnant, then you need to go back on the birth control pill. I would recommend that you go on Yasmin or Yaz, which blocks the male hormone better. Bottom line is that you need to see an Endocrinologist or Reproductive endocrinologist.

Good luck and be sure to follow through with my advice!

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