Dear Dr Ramirez
I'm writing to you from Australia. I hope you don't mind but this will be a little long because I'm a little 'interesting' according to doctors over here.
I started getting natural periods around the age of 13. I continued to get them until I was 17, all very normal. Some discomfort but nothing beyond that. I was on the pill from 17 to 27 on and off again. Anytime I was off the pill my natural period commenced without an issue. In September 2007 I went off the pill and we used other protection until May 2008. During this time my period was normal. In May 2008 I fell pregnant naturally on our first try. My pregnancy and birth were all normal. I gave birth in February 2009 and breastfeed until May where I was given Domperidone to assist with low milk supply for 3 weeks after that time I completely stopped breastfeeding #in June 2009#. Initial blood tests were taken by my GP in October 2009 showing the following results
FSH 5 u/l
LH 3 u/l
Oestradiol 83 pmol/l
Progesterone <0.5 nmol/l
My GP suggested waiting for my natural cycle to return but this hadn't occurred by 2010 so he referred me to an OBGYN. She used noresthesterone to induce withdrawal bleeds in April 2010, June 2010 and August 2010. No natural cycle occurred. She referred me to an IVF specialist in September 2010 who did two monitored clomid cycles #1 without trigger which resulted in no ovulation# and 1 with a trigger but no luteal support which resulted in no pregnancy. His suggestion was to wait again for natural cycle to occur.
We returned to the IVF specialist in August 2011 as I still had not had a natural cycle. He did two AMH tests showing 4.9 and 5.1. He suggested IVF, which we completed in October 2011. He used 375IU of FSH and 19 eggs were collected. I had a blastocyst transfer but did not conceive and they were unable to freeze any blastocysts. I had a second IVF cycle in January 2012 with a lower dose of FSH was used #300IU# but they collected 24 eggs. Only 1 blastocyst was transferred which did not result in pregnancy and no others were able to freeze.
In March 2012 we asked to do a monitored clomid cycle #100mg# with trigger and progesterone support and this resulted in a pregnancy. Normal pregnancy and birth occurred in December 2012.
In January 2013 low milk supply occurred again and I was put on Domperidone for 6 months while breasfeeding. I completely stopped breastfeeding 1/6/2013. No natural cycle commenced. In late July 2013 bloods were taken with the following results
Oestradiol 91 pmol/l
We tried to mimic the clomid cycle that resulted in pregnancy in October 2013 but in this instance my body did not respond to the clomid at all.
I have recently had bloods taken in February 2014.
Oestradiol 143 pmol/l
Testosterone 0.2 nmol/l
Notes. I have not had a natural period since April 2008 and I fell pregnant naturally and easily in May 2008.
I have had a CT scan in 2010 which came back normal.
My questions are
1. Have you seen results like this and do you know what they indicate?
2. We would like to have another child, do you think this is possible with these results?
3. Do you think this is the start of early menopause?
Thanks so much for taking the time Dr, I know its long winded.
Hello Lisa from Australia,
The blood tests, which mainly are checking the hypothalamus, are normal and therefore the problem is localized in the ovary i.e. an ovarian dysfunction. Considering that you had so many follicles and eggs retrieved in the last IVF cycle, I would suspect that you have an ovarian dysfunction disorder called Polycystic Ovarian Disease. The hallmark of this problem is irregular or absent menstrual cycles with normal hypothalamic function. There are other signs but you don't need to have them all. You only need two and the increased yield on ovarian stimulation meets the criteria for the second.
Before jumping to that conclusion, however, two other blood tests need to be done to check the Pituitary, which could also interfere with ovulation, and that is a Prolactin and TSH level.
I am a little worried about the IVF center that you are attending. I know that Australia has some of the best IVF centers, but what makes me worried is that despite a high egg yield, embryo development was quite poor. Considering that you have been fertile multiple times, I'm wonder if this might indicate a laboratory problem. It could indicate an egg problem, but since I don't have your age, I can't comment on that. If you are less than 35 years old then there should not be an egg issue.
In terms of treatment, I think you should try ovulation induction with either timed intercourse or IUI using injectable medications such as Follistim. You've shown you can get pregnant by natural means so this should work since I think that ovulation may be the problem. Also, since you are very sensitive to the injectable medications, your doctor needs to be very careful with this stimulation so that you don't have too many follicles.
Finally, you are NOT in early menopause. If the ovulation induction with intercourse or IUI doesn't work then I would suggest returning to IVF, but seek out a different clinic.
Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com
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