Hi Doctor,

Your website is very nice and it helped me to learn more about these treatments….success stories really gives me hope…

I took clomid for 5 cycles but ovulated only once and didnt get pregnant. I had an ultrasound after the 3rd cycle and found a cyst on the right ovary. As the cyst was small they continued with the clomid for two more rounds. But I didnt ovulate. So my RE changed my treatment plan.

I took prometrium for 10 days and got periods after stopping it. I had my baseline ultrasound on cycle day three. Again they found a cyst on my right ovary and they put me on BCP for 11 days. On 12th day I had another ultrasound but the cyst was still there of the same size. So my RE said it might be the same cyst that I had 4 months back .RE said either it might be cyst hanging out on the ovary or on fallopian tube. I had an HSG earlier and my tubes are clear.

RE said this cyst won’t get affected by the stimulation. So she told me to start on the follistim.

I am confused now , because I stopped BCP and RE didn’t wait for the periods to come. She asked me to start on the follistim on the third day after I stopped the BCP.

Is this correct? Should I wait for the periods to come before starting the follistim? If I don’t wait will I get periods while I am on follistim?

It would be a great help if you could answer my question. Thanks in advance.

Annie

Dear Annie,

I can’t give an answer as to what is the best treatment for you, because there are a lot of things that I don’t know about your case. However, I can address a few general topics. As you may already know, the reason that we do ultrasounds prior to starting ovarian stimulation is to check for cysts. There are functional cysts and non-functional cysts. Functional cysts could react to the stimulation medications and end up growing. Since they are out of sync with the cycle, their continued growth would end up lowering the success chances of the cycle in many ways. For example, they could grow and cause the release of LH before the follicles have time to mature. There is also the fear that the stimulation might make the cysts grow so abnormally large as to risk of a lot of other problems (ruptured cyst, ovarian torsion). A non-functional cyst, on the other hand, will not grow in response to the stimulation. Non-functional cysts are inert. The problem is…you can’t tell a functional cyst from a non-functional cyst the first time you see it. You can only figure it out by seeing what it does over the course of time.

As far as not waiting for a period after starting the BCPs before starting stimulation, you have a very valid point. I usually wait for a period so that the old lueteinized lining is shed. BCPs make the lining post-ovulatory, so that it would not be receptive to implantation. You should discuss with your RE why she chose not to wait for a period. She might have a good reason.

Dear Dr , I have been through each and every section of your website and it
is really very informative for people like us who sometimes wish to know ,
why this treatment , what would it do? It has really encouraged me to ask my
RE politely about various things and treatments she suggests.

My goal is not to make extra work for my colleagues , but there are certainly times in which part of being an RE is communicating with patients and not just being an egg and sperm engineer. I personally get a lot of satisfaction from teaching, not just teaching medical students, but also teaching my patients and my blog readers.

There is this one thing about which I’ll like an opinion from you. I’ll
try to be brief but explanatory about my history , please advise me , I
really need your advice.

My Problems - TTC for 3.5 years now, I am 29 now.
- Irregular periods(since the age of 21, was on provera to get my periods)
- Married at age 25(BCP for 6 months)
- Detected with PCOS, Insulin resistance and hypothyroidism(currently on
metformin 1500 mg, synthroid 50mg) after 6 months of marriage
- Vaginismus - to top all the above problems , I have this, I sometimes
want to run away from this truth but I just cannot , my brain just does not
let my husband in and I don’t know whether we have ever had a successful
intercourse. I had a surgery to remove the hymen which the doctors thought
might be causing pain. I have been able to get all vaginal ultrasounds and
IUIs but I still can’t let him in. I just can’t state my helplesness and
wish somebody could understand it.

Infertility problems are divided into problems of sperm, eggs and anatomy. You haven’t mentioned sperm yet, but the irregular menses suggest an egg problem and the fact that you can’t effectively have sex creates an anatomical problem. Over the course of my practice, I have encountered quite a few married couples who never have sex. There are obviously many emotional implications in addition to the fertility implications. Dyspareunia is the medical term for painful sexual intercourse. This is further divided into deep dyspareunia and superficial dyspareunia depending on if the pain is felt deep in the pelvis or on the skin and surface. Vaginismus is a case of superficial dyspareunia. Your case, while severe is not as severe as those women who can’t even get ultrasounds.

I have been working on my above problems, I started with an aggressive
approach this year when my RE said that inseminations will overcome the
vaginismus factor. I have had 3 IUIs , 2 IUIs with clomid cycles and one
with Injectables. In both the clomid cycles , I had good mature follicles
always on my right ovary on cycle day 18 . The first cycle , I had 3 that
measured 2.1, 1.8 and 1.7 but my lining was only 0.5 cms. Next cycle with
clomid on my right ovary I had only one mature follicle on day 17 of 1.9 cm
and my lining was agin a 0.6. My RE said that clomid is causing the thin
lining and moved me to Injectables with the low dose of 75 IU. I had 5 good
follicles this time on cd12 and they were 1.9, 1.8, 1.8, 1.6, 1.5 and my
lining was 1.07 cms.I had the HCG shot at 12:00 in the night and went for
IUI at 9:30 on cd14.My doctor said the chances are very high and I was
started on progesterone on cd14 itself and on CD21 the progesterone levels
came as 38.3 but I wasn’t pregnant.

My questions
1) Is one IUI enough for me, knowing my situation that aur love making is
not successful , should we go for 2 IUIs in one cycle and if 2 what should
be the timings of them?

This type of detailed variation is an individual choice between the RE and the patient. There is no clear data showing that two IUI’s are that much better than just one. The timing of IUI’s is also a personal judgment call. Many RE’s don’t time it down to the hour, but just schedule it sometime either 1, 2 and/or 3 days after the hCG shot. I like IN GENERAL, to do the IUI about 40 hours after the hCG shot, but it varies especially in patients who have had previous IUI’s in which case you can go back and see what they have done in the past, so as to fine tune the plan for future cycles.

2) can inseminations truly overcome the vaginsimus factor, if so , why do
doctors say to make love that night and the following night ?

IUI’s get the sperm deep inside the uterus. For patients with vaginismus, the sperm often doesn’t even get into the vagina. So, yes, IUI’s are mechanically very effective for overcoming the vaginismus factor. I’m not sure what you mean in your second question. We don’t typically tell that to our IUI patients.

3) Also, I think that I took the HCG shot quite late at night(As in one of
your case studies you said it should be 35 hrs prior to iUI). Please tell me
when should the HCG shot be taken and when should the IUIs be done to have
most chances?

Again, refer to my answer to question #1. It is not set in stone. By the way, please point out where exactly did I said 35 hours for IUI. It might be a mistake. Or are you sure I wasn’t referring to IVF? In that case, it is indeed about 35 hours between hCG and egg retrieval.

3)Also, my RE didn’t do a HSG for me and she wants to do it this cycle, can
I do an HSG and an IUI in the same cycle? Also, as they say HSG improves
fertility , is that true , would that really help?

Yes, it’s possible and often done to have an HSG and an IUI in the same cycle. The drawback is if the HSG shows both tubes to be blocked, then you’ve wasted the ovarian stimulation. In some patients, an HSG does improve pregnancy, both through natural intercourse and through IUI. The thought is that the dye flushes debris and "junk" out of the tubes making them cleaner than ever.

4)If due to vaginismus my chances are very low with IUI,should I just move
to IVF ?

If your only problem is vaginismus, then IUI should overcome it. Bear in mind you might have other problems, such as egg quality issues, if you truly do have PCOS, as you suggested. In general, if the tubes are open, my patients undergo 1-3 cycles of IUI before going on to IVF, but there are so many factors to consider that you had best leave the recommendation up to your own RE.

Thanks
Pia

Dear Dr.

Eve

Dear Eve,

The whole concept of natural cycle IVF might sound good on paper, especially the way you presented it, but there is one huge catch! It would be feasible if the three-month process you have described really constitutes one IVF cycle. In that case, the balance of cost and success rate would be very good. However, the big problem is that what you have described is not ONE IVF cycle, but rather THREE IVF cycles, so now the cost becomes astronomical in comparsion to one good stimulated IVF cycle.

The success of IVF depends a lot on how many eggs you can get. So let’s take an example. Let’s suppose that an IVF cycle without ICSI costs about $9000 and the medications cost about $3000.

For a healthy 32-year old such as yourself, let’s assume that you will make an average of 13 eggs with mild to moderate stimulation and 1-2 eggs with a no-stim or Clomid-stim cycle. So let’s compare the yield.

One Conventional Stimulated IVF
COST = $12000.  Yield = 13 eggs.

One Natural IVF Cycle
COST = $9000. Yield = 2 eggs.

Two Natural IVF Cycles
COST = $18000. Yield = 4 eggs.

Three Natural IVF Cycles
COST = $27000. Yield = 6 eggs.

Now some say there might be a difference in egg quality between stimulated eggs vs natural cycle eggs, but this is so controversial as to having some people on both sides of the argument. Some would argue that eggs from stimulated cycles are BETTER than eggs from natural cycles and others would argue the opposite.

In either case, unless the disparity were huge, you’re still looking for all practical purposes that a conventional stimulated IVF cycle will still give you the best value for your money.

We can also look at the common sense assertion that things that work tend to be more popular. You would just ask yourself, if natural cycle IVF is so much better than stimulated IVF, then why are more than 95%+ cycles in this country done with stimulation rather than without?

Thanks for the great question. Whatever decision you make, I hope there is a baby in your future very soon!

Let’s start off the month with some questions…

Hi, i am glad to come across this website and am glad to find it very resourceful.

thks,
MI
MALAYSIA

Dear Mi,
I’ll try my best to address this topic, even though the answer might not apply to you directly. There is a physical difference between doing an embryo transfer and doing IUI. With IUI, the goal is to get the sperm sample into the uterus. Of course, this sample is in the form of a liquid, so if we inject into at some place shallow, the laws of physics governing fluids will cause the liquid to travel deeper in response to differences in pressure. An embryo transfer, on the other hand, must be done precisely. Imagine the difference between going to a parked car that had it’s window rolled down a crack and using a garden hose to flood the interior of the car with water. That’s sort of like an IUI. Now imagine being given the assignment of taking a drop of water and placing it precisely at the top of the steering wheel at the 12:00 position. That is more like an embryo transfer.

Sometimes, when an IUI is difficult, we can’t get the catheter to physically go all the way in. However, when we inject the sperm, often it will just continue to travel deeper on its own, ultimately winding up where we want it anyway. I do an ultrasound right after each IUI, partly to look for ovulation and partly to document where the sperm is. You are correct in assuming that sometimes, inserting the catheter only part way is a problem. This is because of the possibility that a lot of the sperm will leak out rather than go deeper. This is the reason to try and get the sample deeper.

One thing to remember is this. Although a tight cervix is one reason for a tough IUI, it’s not the only reason. Sometimes, the cervix is not tight, but just very twisted. One way to overcome this is to use a different catheter. In my practice, I have a whole armamentarium of different catheters of different stiffness, different "memory" ability, different slipperiness and different size. We also use Teflon dilators, if needed. Ask your doctor if he is sure that your cervix is tight and not just tortuous.

Instead of addressing the specific technique that your RE has advised (dilating the cervix ahead of time), I just urge you to make a judgment call of your level of confidence that you personally have in your RE’s ability to get the IUI done optimally. This is developed through candid conversation with your doctor, asking for his/her rationale in choice of strategy. Do not be shy to question your doctor. It is your right as a patient. But please, do it politely.

Best of luck. And sorry, but I don’t know of anybody in Malaysia whom I would especially recommend.

hi
i am 30yrs old and had a ectopic pregnancy 18 days ago, my husband and i had sex last night and this morning i took a ovulation test with a store bought kit, just to see what it would say, and it says iam ovulating, IS THIS POSSIBLE????? COULD I GRT PREGNANT, PLEASE HELP

CHRISTINA

Dear Christina,

Sorry to hear of your unfortunate outcome. Assuming that 18 days ago, you had surgery to remove the ectopic (or the tube), your hCG levels would have quickly dropped to zero and your next cycle could have started immediately. In that case, it is feasible to be surging and ready to ovulate within 12 days. If you took Methotrexate to address your ectopic, it’s not recommended that you be trying to get pregnant again so soon, However, if your treatment was purely surgical, then you can confirm with your doctor if it’s OK to be trying this early.

Remember, it’s possible to ovulate before your first period. This especially applies to girls who are reaching puberty and women who have delivered a baby. In the first scenario, a misguided teenage girl who has not had her first period unwisely decides to have unprotected sex, thinking that she can’t possibly get pregnant, but learns that she is wrong. In the second scenario, a woman has a baby and has not resumed her period yet. She thinks it’s impossible to get pregnant until her first period, so she just keeps waiting for it to come. She then notices her belly growing and goes to the doctor who tells her the news that she is pregnant again. In your case, assuming this is indeed your first ovulation after the ectopic, you do have a chance to get pregnant. However, if you don’t, then you can expect a period within two weeks. Please check with your doctor to make sure that the ectopic is completely resolved. Sometimes when you have a salpingostomy instead of a salpingectomy (ie dig out the ectopic rather than removing the whole tube), there is enough tissue left behind that it begins to grow again! This is rare, but potentially very dangerous.

Best wishes!

Dear Dr.
I’am 35 with a beautiful 19 month old daughter that took me 3 months to conceive and my husband and I have tried for a second child for one year and no luck, we are now seeing a endocrinologist here in Michigan named Dr.___. I have concluded my first IUI with a low dose of 50mg of Clomid and all my blood work came back great, two great follies, I ovulate naturally but my husband is 38 and has a sperm motility problem with a high sperm count, washed sperm was 7 million. No luck conceiving with the first IUI and now they want me to do a second IUI with injectables. One year before I conceived my daughter I had a chocolate cyst and emdometrosis removed, could this be a problem again for me and keep me from conceiving another child? If yes, could the IUI and the stronger meds help to combat this problem? Is it true that the endometrosis goes into remission after a birth? Please help, I feel that time is not on our side because we are getting older and all of the procedures are draining our savings, our insurance only pays for ultrasounds which helps but we are still out almost $3,000, we wouldn’t mind if it will work. What are your thoughts about our situation.
Thank you for your time and I look forward to hearing back from you.
THERESA
MICHIGAN

Dear Theresa,

You seem to have an intelligent and accurate grasp of your situation. Remember that human beings are not computers and as such, do not behave in absolutes. As long as the tubes are open, you MIGHT be able to get pregnant on your own, you MIGHT be able to get pregnant with Clomid + IUI, you MIGHT be able to get pregnant with injectables + IUI and you might be able to get pregnant with IVF. Each succeedingly advanced form of treatment gives you higher odds. Trying to decide when to continue the same treatment vs when to go on to the next step is as difficult as trying to call the correct play in football game. Likewise, it is subject to a lot of second-guessing. Had you gotten pregnant with the Clomid IUI just now, then that would have been judged to be the right call. If you get pregnant with the upcoming injectable + IUI cycle, then you will be very glad that you didn’t jump right away to IVF. If, however, you do 3 more cycles of IUI with injectables and nothing happens, then you’ll look back and wish that you had done IVF sooner. There are many factors to consider in deciding now between another IUI cycle vs IVF. I discussed this in a previous post, but I’ll repeat them here.

• COST DIFFERENCE: Some people have full insurance coverage for IVF. So for them, the cost of IVF and IUI are the same — zero. Many of these people choose to go straight to IVF because they can pregnant faster at no cost. On the other extreme, some have full coverage for IUI, but no coverage for IVF. These patient usually ask me to keep trying as many IUI’s as possible. There are also many people who have worked hard for many years and therefore have great financial resources. Most of these will choose to do IVF fairly early.
• PAST TREATMENT FAILURE: All other things being equal, someone who has never tried either IUI nor IVF would be better off with IUI as compared to someone who has already failed IUI eight times, for example.
• TUBAL DIAGNOSIS: All other things being equal, someone with known tubal problems or with endometriosis would be better off trying fewer IUI cycles than someone with no tubal problems.
• SPERM DIAGNOSIS: All other things being equal, someone with low counts or unproven fertility would be better off trying fewer IUI cycles than someone with great sperm and proven fertility.
• PERSONAL SENSE OF URGENCY: Those who have more patience and are not desperate to get pregnant "this very month" can try more IUI cycles than someone who is insistent on absolutely getting pregnant right away. A lot of this has to do with age also. Someone younger has more time to play with, so may try more IUI cycles before going to IVF. Someone older would be wise to consider IVF sooner than later.

To further answer your questions, YES, it’s possible that endometriosis could be lowering your chances of getting pregnant naturally and even lowering your chances of success with IUI. YES, injectables + IUI is a legit way to try and overcome the problems of endometriosis. YES, many women experience a decrease in their endometriosis after pregnancy, as manifest by disappearance ( or lessening ) of pain and disappearance ( or lessening ) of implants.

Discuss all these factors with your RE. I hope you make the right decision. It’s a tough judgment call and I can’t possibly know everything about you as compared to if you were my patient that I saw on a regular basis. Therefore, I can’t make your decision for you. However, I hope the general guidelines get you thinking in the right direction. Good luck!

Dear Dr. ,

ELIZABETH
Johnson City, TN

Dear Elizabeth,

I certainly hope your husband is OK and continues to stay healthy after his chemotherapy. It was so wise of you to freeze his sperm ahead of time. Those two vials are precious and should be used very wisely. Bear in mind the possibility that his sperm could naturally return to normal or at least to some detectable levels. If so, then it’s not quite as worrisome. I’ve known patients whose husbands froze their sperm before chemo. Then before we could plan out their treatment, they end up getting pregnant on their own. So it might be worthwhile to do a semen analysis, say four months or so after the final treatment to see what we’re dealing with. There might be a pleasant surprise.

It’s expected that five months after going off BCPs, the periods should return to the pattern they showed prior to starting the BCPs. A day 3 FSH of 8.2 with a E2 of 91 is a little higher than expected in someone so young, but it’s not something that would send me into a panic. However, short of a grizzly bear rapidly headed my way, there is not much that sends me into a panic nowadays. You should look into OTHER possibilities that your periods have not returned. Instead of just looking at the hardware (the ovaries themselves) investigate the software (hormonal programming of the ovaries). Without knowing more about you, such as your BMI and medical history, I can’t tell you directly what to investigate, but some potential testing would include your thyroid function, prolactin level and the possibility of PCOS.

If it turns out that all these are normal and we are left only with the FSH and E2 as suspects, then realize that there are many other ways to estimate someone’s ovarian age. I wrote it all up last year on a post for my old blog.

Taken literally, your question of "Do I need to be concerned about my levels?" is one I can’t answer, because nobody can judge whether someone should worry about something or not. That is a personal choice. A better way to focus our energy is to ask "Given my D3 FSH and estradiol and all my other relevant clinical information, how should that guide my actions?". I know it’s picky of me to say things this way, but I hope you see my point.

One suggestion is to get the truth about your husband’s CURRENT sperm status. As I said earlier, a good time to test is four months after the final chemo treatment. Remember that sperm takes 74 days to develop, so any toxic injury could leave its mark for as long as that time. If there is sperm detected, that is cause for celebration. If there is none, then I would think twice about wasting one of two vials on just a simple IUI cycle, even with Letrozole. By the way, while there was a time in the past where I tried Leterozole as an alternative to Clomid, I now have almost stopped using Letrozole all together. The data is limited, but there have been reports of at least 12 women who took Letrozole DURING PREGNANCY inadvertently. Out of those, two delivered their children with birth defects and two lost their pregnancies. A larger study looked at Letrozole use prior to pregnancy and the birth defect risk was found to be similar to baseline, so opinions are mixed. Since Clomid has been in use for a much longer time, I feel safer using it, mainly out of fear of giving it to someone who is already pregnant. There might be some specific cases in patients who don’t respond as well to Clomid where Letrozole is worth the risk, but in general, I now stick with Clomid. You might want to discuss with your RE why the choice of Letrozole. An even bigger question is this. If the two remaining vials of sperm are so precious, why even risk them on IUI as opposed to saving them for IVF? (Especially if one vial is used in an unsuccessful IUI and only one vial remains)

Back to the issue of your ovarian aging, the most revealing information about your ovaries will surface once you begin stimulation. If you make a lot of eggs and get pregnant, then the whole FSH issue would be put to rest. So if you are physically, emotionally and financially ready to be parents, then get started now. Your FSH level of 8.2 cannot reliably predict what will happen. You could be fine and not go into menopause until age 49, or you could be menopausal within a year. The test does not say for sure one way or another, although my first guess is that you’ll be fine even for another 10 years. I hope this information helps guide you in your next conversation with your RE. Good luck and thanks for your question!

Hi there Dr!

VIRA
Chicago, IL

Dear VIRA,

The situation you describe is a common one. We have somebody with over a year of infertility, despite regular periods. A workup has been done. Treatment has been tried. But still, there is no pregnancy yet. What are the options at this point. Let’s break it down logically.

Should we do more testing?
What do we know with respect to the three factors that contribute to infertility? SPERM problems. EGG problems. ANATOMICAL problems.
You share that your RE has evaluated your husband’s sperm and has told you that he has "perfect counts".
Because you are doing monitored cycles, we are getting a good idea of your ovulation.
You also share that you have had an HSG and that it came out great.
With this limited information, I agree with your RE’s decision not to pursue any further advanced testing at this point.

Another IUI vs IVF?
This is always a tough decision. There are many factors to consider.
COST DIFFERENCE: Some people have full insurance coverage for IVF. So for them, the cost of IVF and IUI are the same — zero. Many of these people choose to go straight to IVF because they can pregnant faster at no cost. On the other extreme, some have full coverage for IUI, but no coverage for IVF. These patient usually ask me to keep trying as many IUI’s as possible. There are also many people who have worked hard for many years and therefore have great financial resources. Most of these will choose to do IVF fairly early.
PAST TREATMENT FAILURE: All other things being equal, someone who has never tried either IUI nor IVF would be better off with IUI as compared to someone who has already failed IUI eight times, for example.
TUBAL DIAGNOSIS: All other things being equal, someone with known tubal problems or with endometriosis would be better off trying fewer IUI cycles than someone with no tubal problems.
SPERM DIAGNOSIS: All other things being equal, someone with low counts or unproven fertility would be better off trying fewer IUI cycles than someone with great sperm and proven fertility.
PERSONAL SENSE OF URGENCY: Those who have more patience and are not desperate to get pregnant "this very month" can try more IUI cycles than someone who is insistent on absolutely getting pregnant right away. A lot of this has to do with age also. Someone younger has more time to play with, so may try more IUI cycles before going to IVF. Someone older would be wise to consider IVF sooner than later.

Conservative stimulation vs Aggressive stimulation?
You bring up a very good question. How many eggs should you be trying to get? The answer to this also depends on many factors.
PREVIOUS TREATMENT FAILURE: For patients in their first IUI cycle, it’s generally better to be conservative, because you never know how powerful treatment can be. For patients who have failed IUI many times with many eggs in total, it’s less dangerous to have multiple eggs, so one can afford to be more aggressive. For example, it’s almost impossible for someone to fail with 2 eggs, fail with 2 eggs, fail with 3 eggs and fail again with 3 eggs and then, in the next cycle, when they have 5 eggs, all of a sudden get quadruplets. However, while still rare, it’s more likely for someone who has never tried any treatment to get 5 eggs in the first try and wind up with triplets or quadruplets. In your case, VIRA, after failing one year of trying on your own, three cycles of Clomid with her OB, 3 Clomid/IUI cycles and one injectable/IUI cycle, you have demonstrated that you are at less risk of having higher order multiple gestation as compared to someone who has never failed any treatment.
TOLERANCE FOR MULTIPLES: I have some patients who are absolutely against the idea of twins and want to avoid them as much as possible, even if it means taking much longer to achieve pregnancy. For them, I would recommend a conservative stimulation. On the other extreme, there are those who WANT twins and who are willing to take up to a 10% risk of triplets! For those, once I am convinced they know what they are saying, I would be willing to be more aggressive.
AGE: In younger patients, I’m more hesitant to give a strong stimulation. For older patients, I’m much more willing to stimulate aggressively.

Is there anything non-medical I should be doing to help increase my chances?
These would fall under the area of quitting smoking, reducing stress and optimizing body weight towards a BMI of 21-24.

Vira, as I said earlier, your dilemma is a common one and very vulnerable to second-guessing. Now that you have failed so many IUI’s, you are wondering if you should have done more aggressive stimulation in those past cycles. If you go ahead and do two injectable/IUI cycles with an aggressive dose and still don’t get pregnant, you will have wished that you had gone straight to IVF. However, if you get pregnant on your next IUI, you will be so glad that you didn’t do IVF. Such is the nature of the art of medicine. Thank you for your email and good luck!

Hi
I found this site when i was searching google site for my questions.This
site is wonderful with good information.I too want to ask some questions.I
will explain my situations.
This is a very lengthy mail.Please make time to read this and answer my
questions.I will be very thankful to u.

MADHAVI
Helsinki, Finland

Dear Madhavi,

Thank you for sharing your story. Your doubt and disappointment are understandable. However, in my judgment, based only on what you have revealed, your chances of ever having a baby are quite good.

I will summarize what you’ve revealed to us so far, but bear in mind there are some key bits of information that you either left out completely or for which you have been vague. Email is not the optimal form of communication for this, but let’s try our best.

When I work on seeing the big picture for someone’s fertility, I focus on three areas which most of the regular readers already know and those are SPERM, EGGS and ANATOMY. You mention nothing of your husband’s sperm, but with the two pregnancies you have described, we might assume that the sperm is OK. Your eggs have produced two pregnancies (even if they were an ectopic and a biochemical), so that is promising. Your age is even more promising. This brings us to your big problem — your anatomy. From what you said, your HSG showed that your left tube was open. Can we assume you mean that your right tube is absent or blocked then? If, so that leaves you with a realistic chance of getting pregnant ONLY IF you ovulate from the good side.

Now going back to the ovulation issue, your periods are not every 28 days on your own. The fact that naturally, they are every 32-35 days means you will have fewer ovulations per year than average. Also, half of your ovulations are essentially wasted because they will be on the right side where the tube is blocked / absent / disconnected. We don’t know for sure whether or not you ovulate on your own. We do know that you have ovulated at least twice using a combination of Clomid and hCG (Pregnyl and Pubergen are both hCG. Just different brands). Your descriptions of your ultrasound findings are very good. It seems everything went as expected with respect to the sizes of the follicles.

Now let’s look at your specific questions:
1.As i got Ectopic Pregnancy once will i be able to have normal pregnancy
again?
A woman who has at least one open tube can usually still have a normal pregnancy. Most pregnancies that occur are normal rather than ectopic. This is true even for women who already had an ectopic.
2.In my case will egg releases only if i take that injection? Without that
is it not possible??
This question is not answerable, because I have no way of knowing, without doing further monitoring whether you can release an egg on your own or not. I would venture to guess that you CAN ovulate on your own without the trigger injection, but the chances of ovulation are MORE CONSISTENT if you take the injection. In other words, some months you might and some months you might not. But it is not that important anymore. Remember that the best questions to ask focus on WHAT DECISIONS TO MAKE, which is what we will discuss shortly.
3.Even if I take that injection i think my chances of getting pregnant is
good only if my left follicle gets matured. Am I right?
As I said earlier, if your right tube is truly blocked or missing, then the chances of pregnancy are terrible UNLESS you have ovulation on the good side (the left side), so I would agree with you there.
4.My doc is asking to try one more cycle of clomid and then start the
injections treatment.Shall I do that or shall I start injections treatment
in this cycle itself?
This is the type of question I find most practical. You have many choices. You can try naturally, on your own. You can try Clomid again. You can move up to taking injectables. With each advancement, costs go up, but chances also go up. So the choice is individualized depending on the balance between how great your sense of urgency vs how great is your preference to save money. I always thought medical care was free in Scandinavia. Isn’t it? If so, have you considered just going on to IVF?
5.I am very depressed thinking about this all the time I have a big doubt
that will I become pregnant and have a baby?
Your feelings are very normal. However, don’t forget that with IVF, your chances of getting pregnant should be very very high.
6.Please suggest me which treatment is better based on ur opinion in my
case.
This is best discussed with your doctor. I still have incompletely information. Some things that would be considered in making the decision are as follows:
What exactly does the HSG film show? Is the uterine cavity normal? Is it confirmed that the left tube is open and the right tube is not? How brisk is the spillage from the left side. Is it just a small trickle? Or is there a large amount of dye spillage?
What other ovuations problems might you have? Do you have a healthy BMI (below 25)?
How much will it cost you to do IVF? How much will it cost you to do IUI?

For most couples in your situation, I would probably offer at least one aggressive IUI cycle with injectable stimulation, trying to get 2 or 3 eggs to grow on the good side. (It doesn’t matter how many grow on the bad side). Then, if there is still no pregnancy, I would give serious consideration to going on to IVF. Your age is on your side and gives you many options. If you were 40, I’d probably suggest IVF sooner than later.

Thanks for sharing your story. We all wish you the best. Feel free to give us an update on your progress!

Your site is fantastic. I have searched many infertility sites and there is nothing else like it. I have a question that I would respect your opinion on, please.
Recently, i found out that my FSH is high (20.4). My fertility doctor says that this is the reason for my infertility and it means my eggs are getting bad.  I also went to see a Chinese medicine specialist. She says I need to get a full evaluation and then she can come up with a formula of herbs that will definitely lower my FSH. I don’t really trust her. She’s not even Asian! What can I do to lower my FSH? Is there no hope for me?

Angel
Larkspur CA

Dear Angel,
I’m sorry to hear about the bad news that your doctor gave you. Since I don’t even know some very basic and crucial pieces of information, such as your age, I don’t have enough clues to directly comment about your specific situation. However, you do bring up a very popular topic, namely that of FSH values, so I will be glad to tell a little story about the significance of FSH.

FSH is the abbreviation for FOLLICLE-STIMULATING HORMONE. It is a substance created from part of the brain called the pituitary gland. In a young, healthy woman, a small wave of FSH released at the beginning of the cycle will get her follicles to start developing for that month. Why only a small amount? Because a young fertile woman’s ovaries are very sensitive. They don’t need much to get them going. After getting just a tiny whiff of FSH, they will start to do their thing. As the follicles do their thing, they start to grow bigger AND they will produce another hormone called estradiol. The news that estradiol is rising goes back up to the pituitary and tells it the good news that "OK, things are moving along just fine. You can ease up on the FSH production. Thank you very much. Talk to you later." The FSH factory supervisor gets this message and tells the production crew to slow down, get some rest and wait until next cycle. In physiological terms, this is known as NEGATIVE FEEDBACK, which is not a bad thing here, unlike the way it is when you’re talking about your EBay rating.

In a woman who is 45, the follicles are few in number and poor in quality, so a different scene plays out. The story begins the same way. At the beginning of the cycle, the pituitary faithfully sends out pulses of FSH and waits for a negative feedback estradiol signal from the follicles that will tell the pituitary to rest again. However, because the follicles are bad, they won’t develop as vigorously, if they even develop at all. So while the follicles struggle to grow and develop in a healthy manner, they will not send out a strong estradiol signal. Meanwhile, the pituitary starts to get a little nervous. "Hmm, it’s been several days and we still haven’t heard back from the follicles. Maybe they need a little more juice." The pituitary then makes the decision to crank up the FSH production and the FSH level goes up a bit. If the follicles eventually respond to this new increase of FSH, then the estradiol signal will arrive and the pituitary crew will breathe a sigh of relief. However, in a worst case scenario (for example if the woman is completely menopausal or if her ovaries have both been surgically removed), then the pituitary is in for a big surprise. The estradiol signal will never come. So what happens is the pituitary will frantically shift into panic mode, going full power and pouring out tons of FSH. The FSH levels will skyrocket!

This second scenario doesn’t just happen in 45 year-olds. It can also happen in some younger women whose ovaries for some reason or other are behaving much older than they really are. This is a condition, known as diminished ovarian reserve or in an extreme situation where the follicles have completely shut down, it is known as PREMATURE OVARIAN FAILURE.

So when your RE checks your FSH level, he is screening to see if your pituitary is overworking itself. If the FSH level is high, it typically means that the follicles are fewer in number and/or lower in quality. The elevated FSH is the INDICATOR of the bad news. It is NOT THE CAUSE of the bad news.

So the concept of trying to lower your FSH, as that herbalist suggests, is downright silly. It won’t solve your problem. It’s actually easy to lower you FSH. Can you guess how? That’s right. If you just give someone a high dose of estrogen through pills, injections or a patch, that will give the pituitary the signal it has been waiting, albeit a fake signal. The pituitary will then ease up on the FSH production. But you haven’t achieved anything helpful. The follicles are still as poor as they always were.

Think of it like this. You are happily driving your car when all of a sudden, a bright red warning light starts flashing telling you that the engine is overheating. Trying to lower the FSH would be like taking a wire cutter and cutting the wire that powers the warning light. The light will go off and you will longer see the bad news. However, that doesn’t change the fact that something is very wrong with the engine.

In general, FSH levels over 10 IU/L are a little bit concerning. If they are over 12 IU/L, it’s definitely a predictor of poor follicle function. And if it’s over 20, it’s almost for sure that something is seriously wrong with the follicles. I will share that I’ve had patients with FSH levels over 20 who eventually got pregnant with their own eggs, but those cases are so rare that they are distinctly memorable. But it’s not entirely without hope.

So now that you understand this, I hope that you don’t let anyone mislead you. As for your Chinese medicine provider not being Asian, you shouldn’t let that alone prejudice you against her. I once took martial arts from a non-Asian master and he’s definitely someone not to mess with.

I found your website from someone who posted about it on the bulleting boards and I can’t stop reading it!
I took Clomid once and it made me ovulate but not get pregnant. My doctors says that it was successful because before Clomid I didn’t even ovulate. She told me that the chance of getting pregnant each time I ovulate is 20%. Why is it only 20% and what can I do to make it 100%? Does that make sense?

ROBERTA, Alabama

Dear Roberta,

Clomid works its very best when it is given to women who normally do not ovulate on their own, but then end up ovulating while on the Clomid. It is not as helpful when given to women who already ovulate on their own. Remember that the average woman with normal fertility does not always get pregnant every single month. In fact, the monthly odds of getting pregnant are about 20-25%. If you are a woman who does NOT ovulate on your own, but is fortunate enough to respond to Clomid, then it is an approximate, but fair estimate that the Clomid now has converted you from having zero chance of pregnancy that month (had you not ovulated) to having a normal chance, provided that the sperm and tubes do not contribute any problems, and that normal chance is about 20-25% in most cases.

The question of why normal fertile women or women who respond to Clomid do not have a 100% chance of conceiving with each ovulation is a good one.

One way to look at it is to realize that few things in life are 100%. This is not purely a philosophical answer, but rather one based on reality. If you have normal vision, normal hand-eye coordination and normal arm strength, then you have the capability to wad up a piece of paper and throw it into the wastepaper basket across the room. You can probably succeed on a fairly regular basis, tossing it in every few tries, but you can NOT do it 100% of the time.

Now let’s consider what has to happen in order to get a successful conception. First of all, you must have ovulation. But even assuming that you do ovulate, the egg, which explodes out of the ovary into the general area of the Fallopian tube now has to be lucky enough to be scooped up by the tube. This does not always happen. On my old blog, I posted a description of how egg pickup by the tubes can be compared to the actions of a swimming pool sweeper. So, if the egg is successfully picked up, then it may or may not encounter a sperm. Even if sex occurs within the correct window period, the egg is microscopic and the few sperm that reach its general neighborhood may still not collide with it. Even if the sperm does hit the egg, it may not have the strength left, so to speak, to successfully fertilize it. And even if the sperm and egg do result in a fertilized embryo, that particular sperm or that particular egg may not have perfectly normal DNA. Without perfectly normal DNA, the embryo will stop growing and fail to implant. With all that can go wrong, it is a wonder that pregnancy occurs naturally at all, but it does. And it does so about 20-25% of the time.

Your doctor is on the right track. However, if you still don’t get pregnant after ovulating several times on the Clomid, then it’s time to look at stronger ways of getting the job done, such as IUI or even IVF. Remember that even though something is only 20% and not 100%, if it’s done enough times it will eventually succeed. Thank you for your question. 

Hello!  Your website is great.  It is so informative and helpful.  i was
wondering if you could give me some insight……

KIM, North Carolina

Dear Kim,

Let’s look at the big picture. It has been nine months since you went off the OCPs. While we would love it if you had regular ovulatory cycles, the harsh fact, based on the detailed information that you provide about your cycles,  is that you don’t , at least not on a consistent basis.  Your RE has chosen Clomid as the first line treatment for you. Let’s assume that you have had your thyroid and prolactin checked already. The goal is straighforward at present. GIVE CLOMID. MONITOR to see if ovulation occurs.

I have to admit I don’t quite understand what the 45 and 55 mean. I can’t imagine that your RE counted 45 and 55 small follicles in your ovaries. I’m wondering if you meant that he saw a very large 45mm follicle. That wouldn’t quite make sense either, because if you had 45mm and 55mm follicles, your E2 (estradiol) would be expected to be higher than 69 pg/ml. In any case, to answer your specific questions, some RE’s will start patients on Clomid and if there is no response, they will add injectables. I have never tried to give a higher dose of Clomid within the same cycle. It doesn’t mean that it won’t work, but time will tell. Again, it’s a good thing that you are being monitored so we will at least know what’s going on.

As for what the chances are that it will make you ovulate, at this point, the decision has already been made, so we should just be patient and see what the monitoring shows. After something is done and committed, I try to minimize thinking about what the chances are, but instead focus on carefully tracking what DOES happen. Having said that, I’ll venture a guess that someone who does nothing on Clomid 100mg, will probably not do much on Clomid 150mg givin within the same cycle.

As for whether or not you have PCOS, the smartest things would be to get more information before answering that. There are several questions I need to know before venturing an opinion. I will agree with you that you being so slender would make it atypical for you to have it. BUT there are exceptions. If you haven’t already read this story, you might find it interesting.

So what if Clomid doesn’t work? Your RE knows more about you than I do, so I would defer to him/her. My general approach is to start with some investigation into the causes of the poor ovulation. This starts out with better understading the patients lifestyle (nutrition, stress level, exercise, overall wellness). This might then include checking TSH, prolactin and insulin resistance. Another factor that influences the choice of letrozole vs injectables is the patient’s preference. Is this someone who begs to avoid needles if at all possible and wants to go as conservatively as she can? Or is this someone who is determined to get pregnant as quickly as possible? Most of my patients go on to injectables rather than try letrozole.

Thanks for the question. Feel free to leave a comment with an update on your story. Good luck!

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!