Expert: Wendy Zwickl - 3/23/2004

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I am currently on my third cycle of clomid. The first month, I took 100mg CD 5-10, and also took 500mg QD metformin. I do not have PCOS or any type of insulin resistance. That cycle, only one dominant follicle formed. No luck. Next month, I again took 100mg clomid cd 5-10 and DID NOT take the metformin as my RE said. That time, I had 9 follicles... thought for sure I'd get pregnant with multiples in fact. No luck again. This cycle, I am doing the same 100mg clomid CD 5-10, and again added the metformin of 500mg QD along with it. I am nervous though because this time, I'm not having any of the side effects of the clomid taking effect, such as the bloating and abdominal pain I had last month, which signaled to me that it was working. Can metformin make clomid less effective? Other than that, nothing else is different between all the cycles. I appreciate your advice. Thank you.
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CC,

I am curious as to why you are taking Metformin if you do not have PCOS. Is it so that you can avoid having the FSH shot? Have you had annovulatory cycles previous to this? Is this primary or secondary IF? Also, have you had a post coital test during a Clomid cycle to determine if Clomid makes your CM hostile to sperm? What was your primary diagnosis? If you have not had a post coital test, I recommend asking for one. We did several Clomid cycles before finding out about the hostile CM, my RE said that it was very common. I will wait for more info from you.
Thanks,
Wendy

Wendy, thank you for your prompt reply... to answer your questions, my doctor (who used to be the head of the fertility dept. at our largest hospital, so I hope he knows what he's doing) has had clinical experience in putting annovulatory women on metforming, whether they have PCOS or IR, or not.  I didn't feel right about it, but listened to him.  The reason for my annovulation is that I used to suffer from an eating disorder and was too thin to have a period.  I have since gained 20lb and am at a healthy weight, but my periods have not returned normally.  The clomid did WONDERFUL last month for me... 9 developed follicles!  This time though, I'm not having any of the same feelings of bloating and such.  I'm worried it's not working, and this is my final round with it, according to this dr.  I have never had a post coital test, only bloodwork for estraidol and an ultrasound.  I feel like I should seek another RE.  Advice?  
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CC,
I did not have the pain/bloating with every Clomid cycle. I had good results with them all, though. So you may still have good follicles. I gather from your initial email that you did not tell the RE that you didn't take the Met with the second cycle, but that it was prescribed. Did you tell the RE after the cycle that you didn't take the Met? I still think that you may need a post coital test. I did 4 cycles before I did one, then to find out that the CM was killing the sperm! I was so disappointed in my doc. But it was a local GP, so...That is when I went to an RE. But for you, I would at the very least ask your RE whether you need this test, and if not, why he doesn't think so. I was also underweight and had no regular cycle for years. But I did not do Metformin, and it was never even mentioned for me. There must be some underlying reason that your RE wants to do Metformin. I think that you should call his office and ask to speak with him, or speak with him on your follicle check coming up. This is your right as a patient to be told these things. People are getting more info over the internet and from books these days, and docs are going to have to learn that we will not just be treated by them no questions asked. Here is what to do: write a list of all the questions you want answered. Definitly ask why you are on the Met. Also make sure to ask about the post coital test--why you don't need one if he says that you don't. Make sure you ask about why the Clomid seemed to work better when you didn't take the Met (regardless of the fact that you didn't conceive), this may require you to divulge the fact that you didn't take the Met if he doesn't already know. Write everthing down, questions and answers, so you don't forget when he starts explaining things to you, what other questions you have. I also recommend a book, "The Unofficial Guide to Overcoming Infertility", by  Joan, Ph.D. Liebmann-Smith, Jacqueline Nardi Egan, and John J. Stangel.
Sweetie, don't allow your RE to run over you, if you feel you would be better off switching, if his answers don't jibe with what you feel, the you should switch. You are paying for his service, don't forget. You are (or should be) your own best advocate. Good luck, and I would love to hear how it goes for you.

Wendy, you are wonderful for taking time to email women like me... thank you!  What a service!  :-)  Ok, I have to back track for a moment and tell you that I realized that on my first cycle of clomid, I DID not take metformin.  I had started taking it about two months prior to my first try with clomid, but stopped taking it 20 days before I actually started the clomid dosing.  That was the cycle that produced one follicle, remember?  Ok, so my question about metformin and clomid is a moot point for me now, since I never took it while taking clomid like I thought, but I have a new question...  I just returned home from my u/s, on CD 11.  I had three small follicles (largest measured 9mm) on my left ovary, and one on my right.  So there are more than the first cycle, less than the second cycle I tried.  My question, do ALL women produce several follicles to have only one mature, or am I (hopefully) at an advantage because I have more?  Also, how much do they grow per day?  1.5mm?  While on clomid I have about 33 day cycles, so I probably won't ovulate for another 10 days or so, if I'm calculating right.  I just wonder what "normal" women, not on fertility drugs would see if they ahd an u/s.  Also, is there anything I can do to help the growth of the follicles until o?  

I so much appreciate your attentiveness and advice and am making a list of questions for the RE.  I know for a fact that the only reason he prescribed metformin was because he has had success with it clinically.  Believe me, I ask LOTS of questions... I am a pharmaceutical drug rep, so I try to know the ins and outs of all meds, especially ones I'm taking!!!  Thanks again, Wendy!

Colleen
Answer -
Colleen,

Good for you! I am glad that you are writing them down. I always MEAN to ask, but get sidetracked and found that if I didn't write them down, I invariably forgot the most important ones!

A normal woman would see, early in her cycle, several small follicles on either or both ovaries. As they grow, one (rarely two or more) grows faster than the others and when this 'dominant follicle' hits a certain size, I think it is near 24mm..., You ovulate and all the other, smaller ones get re-absorbed. They can sometimes still be there, residual on the ovary, even through repressed IVF cycles (I had this happen once, but it doesn't hurt anything on a frozen embryo cycle).
The dominant follicle should grow at a rate of 1-2 mm a day.
You should really read this page: http://www.squ.edu.om/mj/Archive/Jan2000/Min_stim/
as it describes another protocol, Minimum Stimulataion Protocol, that is used after Clomid cycles (not that I am jinxing you, but you may want to read anyway.)and before going to IVF. It has follicle growth rates that are comparable to Clomid, from everything I have read.
I don't think that there is anything that you can do to speed the growth along. You may try the Robitussin trick to give you more abundant CM, if that seems less than normal. But if you have hostile CM, then it would not help that.
I would love it if you wanted to email me personally. I don't know if you can see my email on my profile or not, but if you can't let me know.
Wendy

Thank you, Wendy, as always!  I would love to email you personally... but you're right, your email address doesn't show.  If you would like to send me an email, so I then have your address, that would be great.  You can see my address, right?

I had the phone call from the RE nurse yesterday.  She said that I have poly cystic ovaries, which is so false!  She isn't the brightest, I must admit.  I DO NOT HAVE PCOS!!!  I have been emailing a new RE in my area who immediately said that due to my history of anorexia, it sounds like I have hypothalamic amenorrhea.  I researched it, and that is EXACTLY what I have.  I have ruined the balance of hormones in my hypothalamus!  Usually, you need injections for fertility, rarely does clomid work, so I've wasted months!!!  I'm so angry.  I'm also worried about the damage (irreverisble?) I've done to my reproductive system by having anorexia.  I want a child...

I go into see my current RE again on Thursday for another u/s to see if any follicles grew, but I also made an appt. for next THursday, April 1, to see the new RE, who gave me the right prognosis first time, over email!!!  I'm amazed.  :-)

I very much appreciate your "expertise" from your personal experiences.  I look forward to getting that email from you so we can continue to correspond.  Thanks!

COlleen

Answer
Colleen, I cannot see your email, either. That is great for protection of both parties, but not so good if you want to start a regular correspondence! Here is what I will do...I will give you the address to my secondary email (the one I use for junk mail and contests), and when you write me, I will answer from my primary email address, that way you can put it in your address book. Anybody can look back at my answered questions, so it will not be good for either of us to put our primary email form. I don't worry about this other address, when I enter contests, they always sell your addy to a bazillion companies. Here it is: wendywx@gci.net. I look forward to hearing from you.
I am glad that you were able to find an RE who recognized your particular problem. Will chat (via email!) with you soon.
Wendy