Infertility/Fertility/superovulation

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Question
QUESTION: Hello DR.EDWARD JOSEPH RAMIREZ;
  
        MY name is Aliya .I am trying to conceive.I am 37yrs old.my F.S.H is 10.29mIu/ml.I have a regular menstrual cycle lasting for 5 days.I have done ovulation study and timed intercourse in 3 natural cycles .I  conceived in the third cycle but had a miscarriage at 2months2wks.'
       Then I had two cycles on letroz 2.5mg taken on day2 to day6 ,which resulted in only one follicle.IN both the letroz cycle the follicle grew very fast and to a very big size
      
 
     NATURAL CYCL    LETROZ 2.5MG[day2-day6]
     folli size       folli size
    
DAY 10   18m.m         22m.m
DAY 11   19m,m         25m.m
DAY 12   21m.m         28m.m[H.C.G inj]
DAY 13   21m.m         Ruptured
DAY 14   RUPTURED
         
     ENDOMETRIUM at the time of rupture in natural cycle was 9.5m.m and in letroz cycle
it was 11m.m.
     Due to certain problems we cannot afford I.V.F now.so the doctor has advised I.U.Iafter taking clomid 100m.g  from day4 to day8 .She says this will help in getting 2-3
follicles and the follicles will not overgrow as happened in letroz cycle.
       
       Sir,is it true that clomid 100mg taken on day 4-8 will give multiple follicles and the follicle will not overgrow as happened on letroz. my menses last for 5days .
         
         THANK YOU,  
         Aliya

ANSWER: Hello Aliya from India,

I'm not sure what your doctor is explaining to you.  Basically Letrozole cycles should be done the exact same way as Clomid cycles.  If ultrasound is used to evaluate the growth of the follicle, as your doctor did, then once it reaches 20 mms, ovulation should be triggered with HCG.  That way the follicle does not go cystic like yours did.  IN addition, the goal with any superovulation cycle is for the patient to have at least three ovulatory follicles but in a patient over 36 years old, I generally try for 5.  Letrozole can be used in doses from 2.5 mg to 7.5 mg.  Clomid can be used in doses from 50 mg to 250 mg.  

I know you can't afford IVF, as many patients have this problem, but you should know that with IUI, your chances of pregnancy at 37 years old is 10-12% per cycle.  With an elevated FSH over 10, there is a worry that your ovaries are growing more resistant, which means that even IVF may not be successful in getting lots of follicles because you have ovarian resistance or decreased ovarian reserve.  Time is therefore critical.  Once the ovaries don't respond to stimulation (usually an FSH level of 15 or greater), you may have to use donor eggs.  

With your age and FSh level in consideration, I would strongly recommend that you try to proceed to IVF.

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.Your advise means a lot to me.As per your advise as soon as we can afford ivf we will go for it but right now since we donnot want to waste any cycle so in my next cycle we are planning to shift to clomid after having done two cycles of letroz 2.5.As I have mentioned on letroz 2.5 i had a single follicle only which grew very
big {28m.m}on day 12 on letroz 2.5 taken on day2 to day 6.SIR please advise whether i should start with clomid 100mg or any other dose
 for superovulation so that i get multiple follicles and on which
days of cycle clomid is taken. my fsh is 10miu/ml.I am 37 yrs old.
         
         THANK YOU
         Aliya

ANSWER: Hello Again,

1 follicle is NOT a response to superovulation.  A natural cycle produces one follicle.  The purpose of superovulation is to have more than one follicle.  

In terms of your follicle of 28 mms on CD#12, the problem is that your doctor waited too long to do the initial scan.  In the Clomid cycle, he/she might want to start the ultrasounds on CD#9.  I would also recommend starting with 150 mg of Clomid.  Because of your age, I would not worry about having too many follicles.  In fact, if you have five ovulatory sized follicles that would probably be optimal considering that only 2 of 10 embryos formed will be normal.  If the 150 mg of Clomid is not that effective, then I would jump straight to 250 mg.  If that still does not stimulate well, which I would expect because your baseline FSH is high which means you have ovarian resistance, then the injectable medications would be your only option.  That leads you to IVF.

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 again for your reply.I have one last query.Earlier we were planning iui with clomid but today my doctor told me that she is going on a vacation .sir please suggest if i can take clomid 150mg and plan timed intercourse with ovulation study as i have conceived earlier in a natural cycle but miscarried.
    Sir also tell me whether i should take clomid 150mg on days2-6 or days4-8 for superovulation.I have a 27-28 day cycle which last for 5 days.
         THANK YOU

Answer
Hello,

I'm sorry but I do not provide medical treatment via the internet.  That needs to be done under the direction of a doctor.  I do not recommend that you take Clomid on your own.

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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