AboutEdward Joseph Ramirez, MD, FACOG Expertise I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.
Experience I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 15 years.
Organizations American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society
Publications American Journal of Obstetrics and Gynecology
Education/Credentials Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco
Question I have been diagnosed with PCOS for 2 years. I conceived my son naturally 7 years ago. My husband and I began trying right before I was diagnosed. I stopped BCP and didn't menstruate or ovulate for a year and a half. I have to take progesterone in order to mimic a period. We were referred to a RE by my OBGYN. Never tried Clomid, or IUI, and were told we needed to go straight to IVF. We did 2 fresh cycles, first was a 3 day transfer and moderate OHSS, failed. None of our 19 frozen embryos made it to blast. Second fresh IVF attempt, retrieved 16 eggs, 12 fertilized and arrested on day 5 never making it to early blast stage. My RE said the embryos turned "grainy". What does/would cause the embryos to become grainy?? Would it be worth it to try Clomid/hCG/natural conception or go directly to Follistim/hCG/IUI as RE wants to do?? It seems we have already invested so much money in this process and Follistim isn't cheap!!! Can you give me any reason to skip the Clomid?? Sometimes I wonder if my RE is looking at her income rather than our outcome, it seems crazy to spend the money on Follistim/IUI if we have a remote chance of conceiving with Clomid?? Any suggestions or advice would be greatly appreciated. Any lab values of question could definitely be answered.
Answer Hello Alicia,
Thanks for your question. In defense of your RE, 85% of patients with PCOS, eventually have to go to IVF because they don't respond to Clomid. That is why we usually recommend it. However, you are an exception in that you went straight without trying Clomid first. I usually will try Clomid or Latrezole (Femara), just in case you are in the 15% that do respond. Sometimes I have to go up to high dose clomid (250mg) but it does work. If you have never tried Clomid, you certainly could give it a try. I don't know why you would need the IUI, however, if there are no sperm problems. Doing a timed intercourse cycle with Clomid will at least see how you respond, and I wouldn't use any less dose that 250 mg to start, and save you cost. If you don't respond, then you know you have to go to Follistim.
The problem with Follistim/IUI in a PCOS patient is that you will probably respond too strongly and have too many follicles to complete the cycle. With IUI we can't control how many eggs get into the uterus, and therefore, restrict the number of ovulatory eggs to 3-5, depending on your age. (3 for younger than 36, 5 for older). As you have found out, your ovaries are very sensitive to this medication, hence the hyperstimulation syndrome. Doing IUI doesn't change that. That is the reason we recommend going to IVF with PCOS patients. They end up spending time and money on cycles that can't be completed.
One option I will do with my PCOS patients is a combination of Clomid + Follistim. I use Clomid on days #3-7 and 75 IU of Follistim for days # 8-11. Often this will get two or three follicles to mature without getting 20.
I was a little surprised to read about your IVF outcomes, however. Definitely, not good because PCOS patients tend to do very well with this treatment. Because they have sooo many eggs, they tend to have many to choose from and freeze. I can't explain what happened to you without reviewing all your records. "Grainy" is a term that refers to the amount of fragmentation within the embryos. Unless, the fragmentation is high (70% or greater), it usually doesn't have an influence on pregnancy rates. Often, fragmentation is a sign of "Old" eggs. What is your age? We tend to see that more often in women over the age of 36. The fact that they didn't make it to Blastocyst is either because the eggs were not good enough, or the culture media/lab technique wasn't good enough. The fact that the second cycle showed arrent on day # 5 may lead to the latter conclusion rather than the former.
If you were my patients, I would probably recommend IVF again, but if you wanted to try a Clomid cycle, then I would try a Clomid 250 mg/timed intercourse cycle first, then if you response, a Clomid 250mg + Follistim/timed intercourse cycle. If no response to the second cycle, then you would be convinced that IVF is the only remaining option and try again. Those two cycles would only cost you $1000 apiece.
Another option would be to proceed with IVF but try a different clinic if you've lost confidence in this one. Doctors are different you know and different clinics have different experience, outcome and protocols. For instance, it has been at least 10 years since I had an OHSS patient because of the specific protocol that I use, and I know not all clinics use the same protocol.
I hope this helps.
Sincerely,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
