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QUESTION: Hi there, I'm in Ireland and having egg donation treatment in Spain. I've had several unsuccessful cycles and am now finding that my endometrium is not as thick as it used to be. When my period begins, I take 6mg of Meriestra orally. I was interested to read an earlier answer of yours to question "thin endometrium causing ivf failure" that said "Vaginal is better because the hormone goes directly to the endometrium without having to go through the liver first (first pass), where most of the estrogen is removed, when taken orally."
Should i go back to my clinic and question the oral administration of the drug? In earlier cycles I was applying patches to my body.

Thanks in advance for any guidance you can offer and I understand it would be general advice rather than a medical opinion.

Best Regards
Angie

ANSWER: Hello Angie from Ireland,

Thank you for reading some of my previous answers.  I would also recommend that you look at my blog where I go into these subjects more extensively.

Multiple studies have shown that oral estrogen for endometrial priming and luteal phase support are the least effective method.  For that reason, it has become the standard of care to use either injectables, patches, vaginal gels or vaginal tablets.  I think this is something you should query your doctors about.  If your lining is not developing adequately in an egg donor cycle, it may be because you are not getting adequate estrogen.  Your doctors should be evaluating this thickness prior to deciding whether or not to proceed with the transfer.  If you were my patient, I would not do the transfer if your endometrial lining was inadequate.  In that situation, I would freeze the embryos and plan a frozen embryo transfer at a later date, in a cycle where the lining is adequate.

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: Hi Dr Ramirez, thank you so much for your reply. Do you think there would be any connection between taking the Meriestra orally and the fact that every second cycle, I have begun to bleed around day 15 while taking the Meriestra - both times just as we were preparing for transfer.

Apologies if this is a random question but I've been on the IVF journey for a long long time and everything that could happen has happened. I'm getting near the end now and want to do anything I can to try and make this work. I am now 48 years old.

Kind regards
Angie

Answer
Hi Angie,

Bleeding in the cycle often results from premature sloughing of the endometrial lining and that is caused when the lining begins to retract.  This retraction is caused from inadequate estrogen levels, which is why the period occurs when there is no pregnancy; basically the estrogen level plummets and so the lining sloughs (period bleeding).

The problem with taking oral estrogen is that most of the estrogen is deactivated by the liver.  This is called the "first pass" effect and is a function of the liver.  That is why oral medications tend to be higher doses than vaginal.  As a result, less estrogen is delivered to the blood stream and even less to the uterine lining, one of the many structures receiving the estrogen.  THAT is why it is recommended to use estrogen either by injection, by patch, gel or vaginally.

If you have luteal phase bleeding, the problem is that it could mean that the lining is NOT adequate and so implantation is thwarted.

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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