Expert: Edward Joseph Ramirez, MD, FACOG - 10/7/2008

Question
I am 30 yrs old and my husband and I have been trying to get pregnant for 4 yrs. Our first roadblock was endometrosis, which was removed. Then my husband was treated for a varcoucle which was fixed and as of the last visit it hadnt returned. We tryed IUI 3times..no success. My husband was deployed for a year and know he has returned and we are trying again! I had laporscopy again sept 4 2008, which revealed alot of scar tissue close to my left tube, no endometrosis and my tubes were open. I started clomid sept 26 for 5 days. I went in for an ultrasound on day 9 (oct2) and had a mature follicule. She gave me a HCG shot and we tryed at home on our own for the next 3 days (we are stationed in Germany, no IUI) she then wanted me start progestrone 100mg oct 6. Now I wait. I guess my questions to you are was me getting an hcg shot on day 9 too early even though i had a mature follicule? Also why exactly am I on progestrone?
Through all of the trying I feel as though they are missing something..very simple, like they arent taking the time to sit and study my case, anything you would suggest that I can look into? Oh my fsh levels as of last year were at an 11. Also Im on synthroid .05mg.
I know this is alot to ask for, I just appreciate you taking the time to review my questions. thank you

Answer
Hello Kristy,

I think that because you are in the military, and the military does not offer more that IUI, that is the only course that your doctor can take.  It sounds like she is doing it correctly.  With Clomid, I prefer to look with the ultrasound starting on cycle day # 10 and follow until the follicle (s) are the correct size (>18 mms).  I then give HCG to trigger ovulation and have my patient either have intercourse for the next four consecutive days or do IUI's the next day and day after (I belive in the two IUI school of thought).  If your follicle was the correct size, then the HCG shot was given at the appropriate time.  I also use progesterone, as your doctor has prescribed.

I only recommend four IUI attempts.  If no pregnancy ensues, then IVF is recommended.  That is based on the studies that have shown that most pregnancies will occur within four IUI attempts.  After that, the pregnancy rate drops significantly, therefore the recommendation to proceed with IVF.

Endometriosis is a strange and not completely understood disease.  We are not sure exactly why it prevents pregnancy.  I believe that it causes a low level inflammation in the pelvis, which kills the egg upon ovulation, because that is where the egg goes after it leaves the ovary and before it reaches the tube.  Scar tissue (adhesions) can also prevent movement of the egg.  Many patients with endometriosis end up proceeding with IVF to bypass the hostile pelvis.

You need to be sure that your Thyroid is normal also, because this can impact your fertility and prevent pregnancy too.

I hope this answers your questions.

Sincerely,

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.