Infertility/Fertility/clomid and fluctuating prolactin
Hi Dr. Ramirez,
I'm 35, and writing from Indiana. I'd like to give you some background before I ask some questions.
I have suffered from chronic migraines since I'm 20,but apart from that, I am a healthy person. I always had regular periods (24-25 days long), normal bleeding, no pain at all, except for my breasts that get really sore 10 days before my period comes.
The problem started two years ago when I moved to the US. I stopped having my periods (for 3 months) and the Dr run some blood tests. It turned that my prolactin level was high: 47 ug/ml. Because of my migraine history, I was tested for a prolactinome but my MRI came normal. Two weeks later my period came back (without any medication) but I stopped having it again for another 3 months. Because my Dr. didn't prescribe anything, I started taking vitex fruit and 2 weeks after my period came back and started to be normal again!!!! By this time my prolactin was tested again and it was 4.9 ug/ml.
After this, I started having my period normally, but now my cycle is 27-29 days long.
The problem is that my husband and I have been TTC for the last 7 months without success. For over 6 months I charted my BBT and tested for ovulation with OPK and according to these I ovulated every month with a luteal phase of 12-13 days.
We had an appointment with a FACOG and we had some tests done: my husband sperm check came back normal and I had an HSG that was also normal too. My blood work at CD 5 was normal (FSH: 7.2mIU/ml, LH: 2.8 mIU/ml, Estradiol: 93pg/ml) except for my prolactin (45.6ug/ml), high again. The Dr. made me repeat the test one month later (CD3)and this time is was normal again (7.6 ug/ml). I didn't fast for any of my blood works (Dr. said it wasn't necessary)...They both were done in the morning after I drunk some tea, but while the blood extraction for the first test was done within one hour I woke up, the second test was done after 2 hours.
So now, because everything look "normal", the Dr. indicated to start a clomid cycle, but I have my concerns about this...Is this a good idea??? The prolactin fluctuation shouldn't be a problem?? If I ovulate by myself, what's the point of taking clomid??? Should be my progesterone tested??? I also think that my hormone levels are not totally normal (LH/FSH ratio is pretty away from 1), but if the prolactin was high this could be affecting my other results..is this correct???
Hello Pio from the U.S. (Indiana),
First, let me explain that prolactin is a very fluctuant hormone in that it goes up and down depending on many factors such as eating, stress, hormonal cycle, time of the day. For that reason, an elevated prolactin is always repeated and is supposed to be done fasting (because eating affects the level). If the repeat level is normal, then it is not a problem. Certainly and continuously elevated prolactin can affect pregnancy rates, but that is not what you have. Whether it was from the tea or not, I don't think you have a prolactin problem.
Second, technically you have not been trying long enough to be classified as having an infertility problem. It takes the average woman under 30 years old, 8-12 months to conceive. So I think the evaluation may have been a little premature but it's good information to know.
Thirdly, in a patient with regular ovulatory cycles, the purpose of clomid, or any fertility medication for that matter, is for "superovulation". That is, to increase the number of eggs that you ovulate per month and thereby increase the chances that one of the eggs will make it to the tube, get fertilized and proceed to implantation/pregnancy. However, such cycles need to be done correctly and not haphazardly. That is, they should be monitored with ultrasound to make sure that (1) you are responding to that dose (there are five dosage levels for Clomid), (2) make sure you are not producing too many follicles and therefore won't ovulate more than 3 at a time and (3) timing when ovulation occurs so that you can have intercourse at the appropriate time. If you look at my blog, I have written extensively about how Clomid cycles are done.
Finally, if you are second guessing your doctor then you are seeing the wrong doctor! You should have enough confidence in your doctor's knowledge and expertise to not have to question the recommendations. I would recommend that you find a competent doctor that you feel that you can trust.
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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