Infertility/Fertility/Secondary amenorrhea

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QUESTION: Dear Dr Ramirez

Firstly, many thanks for taking the time to read my question. I have been an avid follower of your blog for nearly 3 years.

Apologies if this is a little long winded but my history is a little complex.

I am 34 years old I have never had properly regular menstrual cycles. Shortly after menarche (age 14) I developed an eating disorder which I suspect disrupted things. I used the combined pill from age 18-31. When I came off the pill to try to conceive, I had no periods for 6 months. Blood tests revealed normal fsh and lh, normal thyroid hormones but low estradiol. My ovaries had a polycystic apppearance with many antral follicles. Tubes were fine so I was given clomid which gave me 5 ovulatory cycles but no pregnancy. I underwent a cycle of ivf which produced 10 mature eggs, 9 of which fertilised and 6 of which went to blastocyst. I transferred 1 grade A blast with no pregnancy and we were able to freeze the remaining 5 blasts. This was an antagonist protocol andI stimmed for 12 days on 150IU of FSH. My concern is that my estradiol levels were much lower than the number of mature eggs that were retrieved and barely rose after cetrotide was administered. I was very lucky to get pregnant naturally the following month and gave birth to my beautiful little boy in December 2012. I breastfed him up until the end of May and have not resumed menstrual cycles. I have been suffering from hot flashes and brain fog  and was very worried that I could be experiencing premature ovarian failure which prompted me to get more blood tests. My FSH was 5.1, LH 2 and estradiol very low at 71pmol (20 pgml). Thyroid and iron levels were normal. Do you think I could still have POF with these hormone levels? If not, what could be causing the low estrogen and hot flashes? I am a normal weight and run for 30 minutes twice a week. I am hoping to try for another child soon but am not ready to do another IVF cycle yet. I would like to get my periods back as I am worried about the long term consequences for my health. So I guess I am wondering

1) what are my options other than IVF at this stage?
2) Does the low estradiol during IVF lower my chances with a frozen embryo transfer
3) what is the likely cause of my current low e2?

I so appreciate everything you are doing for people like me navigating the confusing and distressing world of infertility.

Best Wishes

Laura from the uk

ANSWER: Hello Laura from the UK,

First, you are NOT in premature ovarian failure which is proven by your FSH and LH levels.  Your ovaries may not be functioning normally, but they have not stopped.  The FSH and LH would be very high if you had POF.

The IVF result was good considering that you required very little stimulation.  I wouldn't worry about the estradiol level.  The result of the number of eggs, number of mature eggs, fertilization and number of good embryos formed is the most important part of the IVF cycle.  

By the way, if you still have frozen embryos from your first IVF cycle, you should try to use those first before you proceed with another fresh IVF cycle.  The cost should be minimal and the chances of pregnancy should be pretty good.

Now addressing your questions in sequence:
1.  Since you got pregnant on your own, how about trying ovulation induction with timed intercourse rather than IVF?
2.  AS mentioned the low estradiol at the previous IVF cycle is unimportant at this point.
3.  Your E2 level is not low.  If the blood was drawn on cycle day #2 or 3 as it needs to be to properly evaluate the hormone levels, the estradiol is supposed to be at the lowest point.  The FSH and LH are the important markers.

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: Dear Dr Ramirez

Many thanks for taking the time to answer my question. It is reassuring that you are not too concerned  about my estradiol levels during IVF. I think we will attempt a FET if no success by the beginning of next year.

I just wanted to clarify that my recent e2, LH and FSH was done on a random day as I am not getting any periods. I stopped breastfeeding in May and do not understand why my cycles have not resumed. Do you any ideas what the cause of this could be?

Once again, thank you for sharing your time and expertise. Is is much appreciated.

Laura (UK)

Answer
Hello Again,

Has your breast milk stopped flowing?  Basically the physiology is that the hormone prolactin is what causes the formation of breast milk.  Until this level gets down to normal, it can interfere with the other hormones, including follicle stimulating hormone, which are all produced in the pituitary.  However, since it has only been 8 weeks or so since you stopped breastfeeding, this may not be abnormal.  If you are concerned, you certainly can ask your doctor to check your levels.  Otherwise, I would just wait.  Also, keep in mind that you are susceptible to getting pregnant.  Ovarian function will occur before you have your first period.  In fact, the way the physiology works, the ovary will reset, ovulation will occur, and if you don't get pregnant, then you will have the period. Therefore, a pregnancy test needs to be checked as well.

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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