Hello Dr.

I’ve been on two cycles of clomid (50mg/100mg) but the follicles never matured =(. I haven’t been diagnosed with PCOS and have ovulated on my own in the past. My RE did blood work on cd10, 12, 14 and my estrogen levels were 55, 57, 65 and then 54. What could be the reasons the follicles weren’t maturing and what causes the estrogen level to remain low. I understand estrogen level has to be above 200+.

Thanks for your help.

Jen
Orlando, FL

Monitoring of Clomid cycles is helpful because even if you don’t get pregnant, it’s helpful to know if you’re at least ovulating. To monitor with blood tests rather than ultrasounds offers little advantage, unless of course, the capability of doing ultrasound is not available. I’m not sure if in this case, there were ultrasound exams done in addition to the estradiol tests, but it doesn’t matter. The obvious conclusion is that even with the Clomid, the follicles are not developing. Clomid works by raising your own natural release of FSH (Follicle-Stimulating Hormone) from your pituitary gland (a small organ that hangs from your brain). For some people, this small boost in FSH is enough to get the follicles growing. For others, it’s not enough. This is a common problem. So what is there to do?

Some possible approaches to help achieve ovluation when you get to this point are:

• INCREASING THE CLOMID DOSE: I personally don’t favor this approach. I don’t remember the last time I had someone who didn’t do anything on 100mg and then went on to ovulate and get pregnant with just a higher dose of Clomid.
• ADDING OR COMPLETELY SWITCHING OVER TO INJECTABLE MEDICATIONS: This is a popular tactic and works well. The danger is that sometimes, it works too well and you end up with so many follicles that you get twins (or more). The other drawback is that it is more expensive than Clomid. However, I will repeat that it works very well.
• LOOKING FOR OTHER CAUSES: If someone is not developing follicles on Clomid, it would make sense to look at other issues such as an underactive thyroid, elevated prolactin, elevated male hormones or worst of all, diminished ovarian reserve.
• TREATMENT OF INSULIN RESISTANCE USING METFORMIN: If patients show clues suggestive of insulin resistance (unexplained weight gain, chronically feeling tired, strong carbs or sugar cravings, family history of diabetes, preferential distribution of fat around the waist, extreme post-meal sleepiness, or documented high insulin to glucose ratio on challenge testing), then metformin can not only help them ovulate, it can help them get healthier.
• NORMALIZATION OF BMI: This goes along with the concept of getting healther. A good target of BMI is between 21-23. I’ve had patients who successfully lost weight and then started to respond to the Clomid, or in some extreme cases, started to ovulate on their own and get pregnant, even without Clomid. To figure your BMI, you can use this online calculator.

Jen, it is good that you have ovulated on your own before. However, if you don’t ovulate more consistently, you will fall into the situation where on months that you DO ovulate, you have a chance of getting pregnant. But, on the months that you fail to ovluate, all you end up doing is wasting one more month of your reproductive years. I’m curious what test results your doctor has found that rule out insuiln resistance. A lot of times, if you just test fasting levels rather than checking challenged levels using a glucose drink to stimulate insulin activity, you will easily miss a diagnosis of insulin resistance. As you can see, there are still many options you can take at this point. Have a good discussion with your doctor regarding which of these tactics to try next. And let us know as soon as you succeed. Good luck!

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