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Question
Hi Dr. Ramirez!

1. Would using vaginal estrogen 1mg 1/day cause a huge increase in fertile (egg white) cervical mucus?

2. Can I wait to trigger with hCG until I get my LH surge? I normally have a very short LH surge, sometimes having a positive OPK for only an hour or two. Is this a problem? Is it too short to cause the follicle to rupture? I realize that OPK’s are measuring the amount of LH in my urine, which isn't an exact science. But if the LH surge isn't long enough to trigger the rupture, wouldn't the hCG trigger increase the chances of the rupture happening? Are there any negatives to using the trigger?

3. Are estrogen and progesterone supplementation required with Femara and an hCG trigger? And in a natural, non-medicated cycle would they be helpful?

4. I had a 7dpo (days post ovulation# progesterone level of about 7.5. #It may actually have been 5-9dpo.) This was on a very low step-up dose of Femara. I was told this was way too low. I was also told that anything over 5 means there was some form of ovulation, so that’s confusing. What does that mean?

Thank you so much for your generous help.

Janet

Answer
Hello Janet from the U.S. (California),

First, I hope that with all this talk of medications you are under the care of a Physician.

Estrogen is the hormone that causes the change in cervical mucous to allow the sperm to swim up into the uterus and tube.  Adding estrogen does not make it better if your natural estrogen is already doing its job but does help if it is not.

In terms of your questions, the natural "trigger" for ovulation is the LH surge.  If you detect an LH surge then ovulation should occur.  Certainly you could add HCG to that without any negative consequences, and that is done all the time with ovulation induction cycles.  However, in a natural cycle it is not absolutely necessary.  I use the HCG to make sure that there is adequate stimulation to induce ovulation.

I use progesterone supplementation in ALL my ovulation induction cycles.  Again, because medications such as Clomid are estrogen blockers and can induce a luteal phase defect.  In addition, I would hate to lose a pregnancy due to luteal phase defect when it can be treated so easily.  I don't routinely use estrogen unless I think the endometrial lining is too thin and therefore needed to increase it.  

Both explanations given are incorrect.  There is no such thing as "some form of ovulation."  There is either ovulation or no ovulation.  If the mid-luteal (7 dpo) progesterone is 10 or above, this is evidence of ovulation.  Less than 10 means that ovulation probably did not occur.  Just for your info, I have NEVER heard of a "low dose step up" femara protocol.  Are you sure you are seeing the right kind of doctor?  Femara, like Clomid is given in several doses (2.5, 5.0, 7.5 mg) for five days.  It is not raised or lowered as this does nothing.  It is not like injectable medications which are used for a longer period of time.

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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