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 Good afternoon,
My husband and I have been trying to conceive for over 4 years. We were successful without medication once in June 2008 which resulted in a miscarriage at 14 weeks ( I had some type of blood borne infection that sent me into labor, I was told it was a fluke and very rare) I am now 40 and my husband is 36. We have both been tested and all appears to be normal. My diagnosis is unexplained infertility.
I am currently on injectable medication and we are timing our intercourse. My husband is opposed to IUI or IVF for religious reasons. This is my 4th cycle. The first was unsuccessful and we ended up taking a break due to an upcoming trip to Italy. We restarted in July and this cycle produced too many follicles (8) with a very high E2 level (2000) and the cycle had to be cancelled. The next cycle was better with 4 follicles and E2 levels around 900 before triggering and was also unsuccessful. This cycle I am on CD7 and after 4 nights of stimming, I had very little follicle growth (1 maybe 2 follicles) but my E2 level is 462. So they are lowering my meds from 150 Gonal-F, 75 Menopur and 5 Lupron to 75 Gonal F, 75 Menopur and 5 Lupron for the next 2 nights and then only Lupron the 3rd night.I go back after the 3rd night for further evaluation.
My concern is the lack of much follicle development for this cycle. Every other cycle I have had 3 or 4 good sized follicles and E2 levels in the 500-600 range. Is the high E2 level with little follicle growth indicative of a low reserve of follicles? I'm confused and losing hope. Are these feelings unwarranted or is this something to be concerned about? Any insight or thoughts would be greatly appreciated!
Thanks for your time.
Answer Hello Deanna from the U.S.,
Your infertility is not necessarily "unexplained". You have the "age factor" working against you. That is enough to make it difficult for you to get pregnant. For that reason, the increased stimulation and increased number of eggs ovulated is an advantage and will raise your pregnancy rates. Keep in mind, however, that since you are still using a "natural" method, your chances of pregnancy are only slightly higher than your natural chances, which is approximately 1% per month. So with stimulation you may be increasing it to 2% per month.
In most cases of IUI, we try to limit the number of eggs that will ovulate to 3-4, as your doctor has been doing. However, in my older patients, I will increase that up to 7 because the chances of very low that all 7 will get to the tube, become fertilized and create normal embryos that can implant. Certainly the best method for getting pregnant at your age is to use IVF, but I understand that this is not an option.
Ovarian function and stimulation will vary from cycle to cycle. That is the reason this cycle was less than the last. I don't understand, however, why your doc is decreasing your meds. That does not seem to be right to me as well. You'll have to ask him to explain it. The E2 level is a reflection of follicle growth. It will increase from increasing follicles and/or increasing number of follicles. Basically each follicle produces estradiol and as it increases in size, it produces more. I could explain it at the biological level, but that would take way too much space. Also if you have more follicles, you have more estradiol. The average estradiol level at ovulation for one follicle is 150-200.
Good Luck. I hope that answered your questions.
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
