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Infertility/Fertility/clomid +follitropin superovulation

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QUESTION: Hello sir,
     
    my name is seema.I am 36 yrs old.I conceived in a natural cycle in aug 2012.I was given follitropin 75u{follimon} on day6 and day8 but unfortunately had a miscarriage after
cardiac activity was seen at 7 weeks.This cycle my doctor has advised superovulation with a combination of clomid 150mg + follitropin 75u + timed intercourse .please tell how a
combination cycle is done?
    I am scared that such a high dose of clomid will turn the crvical mucous hostile for sperms and will also affect the uterine lining but my doctor is saying tablet robitussin from day 1o to day 16 will help in keeping the mucous fertile.

ANSWER: Hello Seema from India,

Combination therapy with Clomid+gonadotropic (follistropin) is a common treatment protocol and often used in patients that do not respond to Clomid alone.  It is not necessarily better than Clomid alone, so if you responded to Clomid previously, you don't necessarily need to add the follitropin.

Basically, in the combination protocol, Clomid is first taken for 5 days as usually then starting the 6th day, the follitropin begins on a daily basis.  You continue this until the follicle(s# reach mature size (16-24 mms) an then trigger with HCG.

150 mg of Clomid is NOT high dose, it is a middle dose.  The highest dose of Clomid is 250mg per day.  Yes, with continuous use, Clomid can cause thinning of the endometrial lining because it is an estrogen receptor blocker.  For that reason, I do not recommend using Clomid on a monthly basis, but on an every other month basis or alternate with Femara.  That problem does not exist with the injectables.  Although Robitussin will help to thin out the cervical mucous, it does nothing for the endometrial lining.  I don't think it is necessary, but that is up to your doctor.

You describe getting pregnant on follitropin, which by the way is NOT a "natural cycle" because you used fertility medication, although it does rely on the natural process to achieve pregnancy.  This basically means that you have the ability to achieve pregnancy by natural means (using a natural treatment method like super ovulation).  So it would be worth continuing on that path.

The way that you can screen whether your doctor is a fertility subspecialist or not is to simply as if he/she does IVF.  Only infertility subspecialists do IVF because it requires additional training.

Good Luck,

Dr. 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.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate



---------- FOLLOW-UP ----------

QUESTION: Hello sir,
     
   THANKS for your reply. As i mentioned earlier i will be going through a combination cycle with clomid 100mg[day3-7]+follitropin[highly purified FSH] 75u[day8 and 9]+timed intercourse .I have taken clomid on day3 to 7. On my day7 i had  TVS since the doctor was not going to be available on day8.ON day 7at 8pm tvs showed two follicles of size9by8
and 12by11.so now my doctor is saying that i do not need fsh injection.BUT as i am 36 yrs old .my fsh is 10.without clomid also i ovulate regularly.I am afraid that without fsh only one follicle will grow whereas our goal is superovulation to increase chances of
conception.SIR i have conceived earlier on FSH inj taken on day 6 and day 8[without clomid]but miscarried after cardiac activity was seen at 7 wks.
Please advise.
 
         THANK YOU

Answer
Hello,

A follicle of 8.5 mms and 11.5 mms mean diameter does not indicate whether the follicles will continue to grow or whether or not there will be two follicles to ovulate.  They are too early in the follicle development.  The ultrsound should be repeated, or should have been repeated, after 3 days to see what the growth was, and I would certainly have continued with the Follistim as orginally planned.  Are you sure your doctor understands exactly what he/she is doing?

Good Luck,

Dr. 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.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate

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Edward 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 19 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, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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