QuestionQUESTION: Hi Dr. Ramirez,
My doctor has me using patches 7-10 days before my menstrual period for an ivf cycle. I have heard estrace tablets 2mg. vaginally are better. I want to try this instead of the patches. How many 2mg. tablets do I insert vaginally? The patches I use are climara 0.025mg/day which I change every other day. My lining is generally on the thin side below 7 but I think the patches or tablets are used to keep the follicles consistent in size before starting injections? Maybe also for lining too? You take off the patches the day you start your injections - do you stop the tablets too?
I have also used it to thicken my lining which has helped a little one 2mg. tablet vaginally in the am and one in the pm. Can you just continue the estrace tablets and increase the dose instead of stopping when you start injections and then starting up again to thicken uterus lining? Can I increase it to 8mg a day to thicken lining? Or does it depend on your estrogen levels? If so what determines if you should increase or decrease?
Thank you,
Christine
ANSWER: Hello Christine from the U.S.,
In general I don't like to comment on the specific protocols that doctors use. Every doctor uses different protocols and there is not an absolutely right way or wrong way. Most of the time it is the doctor's preference. I have to admit I am not sure of the reason for using the estrogen prior to the start of the IVF cycle. Most clinics will precede the IVF cycle with the birth control pill, which has high dose estrogen in it. I don't know if there is any advantage to what you are doing.
Estrogen is used to increase the uterine lining if there is a problem with endometrial thickness. Most of the time the increasing estradiol levels that occur from the increased number of follicles in an IVF cycle are sufficient to form an adequate lining. Occasionally, however, this is not the case. I prefer to use estrogen patches, like Climara because they are easier to use and less messy. Certainly estrogen can be given as a vaginal suppository, vaginal tablet or injection. Mostly it is the doctor's preference. The exact dosage for estrogen supplementation is not determined. Whatever dose works is the basic premise. Estrogen levels (blood) are not useful in this regard. You have to go by endometrial measurements via vaginal ultrasound. The best ways to give estrogen for endometrial development are via the vagina, patches or injections. Oral tablets don't work. Some people believe that the vaginal form is best because the estrogen is in closer proximity to the uterus and therefore can get to the endometrium better. I don't think it matters.
Good Luck,
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
---------- FOLLOW-UP ----------
QUESTION: Thank you for your reply. It is very helpful. I was told that putting me on climara patches 7-10 prior to menstrual period helps to maintain the follicles to a consistent size or keep them all in the same ball park so to speak. So you don't end up having dominant follicles growing too fast so the little ones can't catch up.
I was told by another doctor that he uses estrace tablets vaginally instead of patches before a ivf cycle? It's confusing which is why I wanted to get another expert's opinion.
I wanted to make sure that taking too much estrogen or taking it too early can be harmful to the cycle but according to you reply it seems like it doesn't really matter. I took one 2mg tablet in the morning and one at night which helped to get my lining to 7mm. I will increase it to two 2mg tablets in the morning and two at night to see if it can thicken the uterus lining more. Is this okay? We can find out like you said by endometrial measurements. Lastly when can I start taking the estrace vaginally to thicken my lining? Before I start the injections or when I start the injections? In the past we would wait to late in my opinion, I wouldn't start the estrace until a few days before they trigger me to OV. My doctor says it's still too early and they wait till the very last minute and then have me taking it orally and vaginally and sometimes they have me using viagra suppositories which cost a fortune and did not help.
I just want to know if it's okay to increase the dose and monitor with endometrial measurements to see if it's helping and then also when to start taking them instead of overdosing at the last minute because it's close to procedure?
Thank you again,
Christine
AnswerHello Again,
I disagree with your doctor's explanations about using estrogen before the start of the IVF cycle to even out the follicles. That is nonsense.
I usually will start the estrogen supplementation with the start of the IVF cycle (CD#2) if the reason is to help thicken the endometrial lining due to poor endometrial response. Once the HCG trigger or provera is given, the lining will not continue to grow. The main problem is that it will interfere with the estradiol measurements that are taken to help monitor the ovarian response, because you will have additional estrogen in the system, but that is just something the doctor has to take into consideration. Keep in mind that as the follicles grow, they are producing estrogen and the level rises, so you don't have to add a lot more. There is no such thing as an overdose.
Good Luck,
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
