I came across your website and decided to contact you just to get a second opinion. Hopefully you can help. I am 25 yrs old, married for two years and have been trying to conceive for the past 5-6 months. Once we decided to have a baby, I started reading a lot online and decided to see an obgyn while trying to conceive that way we weren’t just “wasting” our time. (I know, I’m very impatient)! My ovaries, uterus, etc have been checked and everything seems to be fine. I believe I have ovulation issues. Although I have ovulated on my own in the past (positive opk and confirmation from blood test), I do not believe I have ovulated in the past few months. My obgyn wanted to do an endometrial biopsy but I didn’t agree with that for some reason. She also stated that I don’t have PCOS. The impatient person that I am, I decided to seek a fertility specialist since insurance covered it. So last month I went to a very well known specialist here in New York. After tests and consultation, she advised me to start on 50mg of Clomid (days 3-7) and monitoring of follicles. I really liked the fact that I was being monitored.
Well I went for ultrasound on CD 10 and there were 4 follicles (3 on my left ovary, 1 on my right) ranging from 8-10mm and uterus lining was at 6.2. Then I went again on CD 13 (yesterday) and found that the follicles have barely grown from last visit – not even 1mm. My uterus lining was 7.5, which she said was good based on the size of the follicles…? We also did bloodwork to check estrogen level which unfortunately indicated that it had decreased since last visit (from 67 to 55). Right away my dr. decided to prescribe Provera and to start that right away rather than waiting for the follicles to mature which she didn’t think was happening. Additionally, she wants me to start on 100mg (increased form 50mg) and start that next cycle…obviously depending on my next visit on cycle day 3. She also stated that maybe we might consider Metformin (?) but the blood result will be available tomorrow (Monday). I don’t have diabetes but I’m just afraid that all these medications might affect my body.
My questions to you are the following:
1. Do you think I would have eventually ovulated?
2. Do you think it’s already too soon to increase the dosage of Clomid?
3. Is it true that Clomid on days 3-7 increases more follicles VS. Clomid on 5-9 gives mature follicles? Should I be taking it on CD 5-9 since I didn’t have mature follicles?
4. Would you have recommended an endometrial biopsy as my 1st obgyn did?
5. How do you feel about the Metformin?
6. Is there possibility that my tube(s) can be blocked at this age? I’m very reluctant to do HSG at this point. There wouldn’t be any connection b/w tubes and ovulation, right?
7. Would you recommend something different after reading my story?
Also, just additional information…One of the main reasons I decided to go to a doctor initially in July 2007 was because I had abnormal 3 week bleeding. This is the first time that’s ever happened and it wasn’t a miscarriage or anything. That’s when my obgyn prescribed Provera to restart my cycle and then in August I did ovulate on my own. She concluded that the bleeding might have been due to stress and travelling. Also, from July to October, I have gained about 10 lbs. Maybe because I’ve been stressing about this whole TTC thing…not sure.
I have been reading thru both of your websites and there’s helpful information that I really appreciate. I’ve learned a lot from reading your articles and real stories. I know you have an extremely busy schedule and this might be just another story but any advice would be greatly appreciated! 
I look forward to hearing from you soon.
Thank you kindly,
Sara
Thanks for the detailed email. I think our readers will benefit from many of the issues you raise. I will try to address most of the ones you mentioned if you promise not to take it as an official “second opinion” or as being specific medical advice to YOU only. Without knowing your medical situation in greater detail and without examining you, there’s no safe way I can advise what is right for you specifically. However, I’d have to say that your RE and I appear to have similar approaches. If you stick with her and discuss things with her, you’re probably going to be in good shape.
- CANCELLING CYCLES: I’m sorry that your cycle was cancelled. I can probably write an entire post on the topic of cancelling cycles. When an RE initiates a stimulation cycle and prescribes ovulation medications, it is with the good INTENTION of growing a suitable number of quality follicles that month. Just because it’s the right intention doesn’t mean the ovaries will necessarily cooperate. As you astutely noted, proper monitoring is very nice to do, because it gives you the peace of mind of knowing exactly what’s going on. And in your case, it tipped off your RE to the fact that your ovaries weren’t responding this month. Whenever the ovaries don’t respond quite the way we like, we have to make a decision. Should we push it and see if eventually something develops or should we cut our losses and regroup. It’s a judgment call! Pretend you started a business, for example. Let’s say you opened a restaurant with the intention of packing it in with happy diners every night. However, after a year, you still have very few patrons showing up each night. You have to decide whether to stick with it, despite losing more money every month and hope things turn around or you can throw in the towel. The same applies to cancelling a cycle. You can make two types of mistakes. You can give up on a cycle too early and miss out on eggs that would have eventually shown up the next visit. OR you can make the mistake of getting sucked into the never-ending void of a drawn-out eggless cycle, thereby wasting a fortune in medication. Now in the case described above, because it’s a Clomid cycle and not an injectable cycle, there is no additional expenditure of medications. But based on the fact that it was already day 13 and still nothing had grown to the critical threshold of 13mm (which is a rough cutoff I use to distinguish between follicles that will go on to do well vs those that will fizzle out) AND based on the additional clue that your E2 was actually dropping instead of rising, I likely would have cancelled you as well. Remember. Even though you weren’t wasting additional medication each day, you WERE wasting your precious time.
- INCREASING THE DOSAGE: The minimal starting dose of Clomid is usually 50mg daily. If someone fails to make eggs with that, it doesn’t usually faze me. There’s plenty of room for improvement. Bear in mind that with respect to a first time Clomid cycle, there is a difference between failing to get pregnant and failing to ovulate at all. If on 50mg, someone makes eggs, but fails to get pregnant, there is a reasonable for sticking with the same dosage and trying one more time. However, if they completely fail to ovulate (as can be determined best by doing close monitoring), then it makes less sense to do the same thing over again.
- STARTING CLOMID ON D3 VS D5: Even among RE’s, there is general disagreement regarding the concept that starting earlier gives more follicles and starting later gives better-quality follicles. I don’t think the answer is clear cut and in the grand scale of things, it is not a critical difference when we’re talking about a relatively low-level form of treatment like taking Clomid.
- ENDOMETRIAL BIOPSY: EMB’s are very useful when used to screen for endometrial cancer. When used for infertility, it’s just a way to inflict torture on patients you don’t like. (In case you have no sense of humor and can’t recognize a joke, please ignore the previous sentence). During one of our round table dinners this past year, I remember a joking discussion on EMB’s with the consensus that out of the RE’s present, none of us did EMB’s any more. I personally have never done an EMB in my practice other than to occasionally screen for cancer in older patients with abnormal bleeding.
- METFORMIN: When you ask me how I feel about metformin, I KNOW I can write 10+ pages about it. I am definitely going to be inspired to write volumes about it at some other time. Suffice it to say that there are many patients that I put on metformin and many patients that I don’t put on metformin. As for the suitability for you in particular, I leave that decision up to your RE. If you were my patient and we had a nice one-hour chat and I got to evaluate you more completely, then I could better render an opinion on your case. But even with what you have told me, I can’t say more for sure. Sorry
. - WHEN TO DO AN HSG: The answer to this question is similar to the metformin question. It depends. In some patients, I do an HSG right away. In others, I push it back for later. Without going into detail, some factors that influence how soon I do an HSG include risk factors for blocked tubes (previous surgery, previous STD’s, painful periods), the suspicion of other fertility factors, patient’s aversion to discomfort, costs, and the exact history of failed attempts at treatment. Bear in mind that nothing is a perfect predictor. You can have an patient with painful periods and previous Chlamydia and a previous ovarian cyst surgery who ends up with a pristinely clean HSG result, just as you can have a perfectly healthy patient with no risk factors who ends up showing blocked tubes on HSG. You mention your age as a factor, but in reality, that’s not a good predictor of someone’s tubal status. I will answer your other question and say you are correct, for the most part, tubal status and ovulatory status are independent factors and don’t influence each other directly. You can have blocked tubes and ovulate great or you can have fantastic tubes and not make eggs. The two are separate issues.
Sara, thanks again for your well-written letter. I know that other readers appreciate your taking time to share. Good luck in your quest! Be thankful you have a good RE there in New York. Perhaps I know her.
