QuestionHi Dr. Ramirez,
I've read through many of your posts and found them helpful and really informative, so I was hoping that you might give us your insight into my situation. I've just turned 38, and my husband is just 40, and we've been trying to conceive since February of 2009. I've had 2 pregnancies, a confirmed ovarian (left) ectopic in 12/09 and an early miscarriage in 3/10. My first pregnancy I conceived approximately 2 weeks after my HSG in 10/09 where they found that it appeared my tubes were blocked with mucus. One tube cleared with the HSG, and the other tube cleared fine during my laproscopic surgery in early 11/09. My lap surgery was found to be completely normal, no endo, etc. We sought the help of a specialist due to our ages after not conceiving after 6 months post early miscarriage. I have never had a D&C. All miscarriage/ectopic passed naturally (w/the exception of the methotrexate shot to resolve EP). My cycles are generally 28-32 days w/an average luteal phase of 15 days, I usually ovulate on cd 12-15. I'm in excellent health, exercise, eat well, 120lbs and 5'2" tall.
My cd3 labs came back normal in 9/10; FSH was 5.8, Estradiol was 39.7, TSH was .97. Progesterone 7dpo draws prior to seeing a specialist were generally 14-31 (high). My husband's sperm analysis came back normal (#'s and morph), but low volume. In 10/10, I started my first IUI/injectable cycle (150 iu/day Gonal-F, Ovidrel (trigger) and 100 Progesterone/Estrogen suppository 2 days post final IUI. By cd9, my Estradiol was 1070 and I had 7 follicles (2 @ 19.5 & 18, and 4 b/t 13.5-16.5). My lining was 6.3 at time of trigger shot. Result was negative for that cycle. My December cycle, we followed the same protocol, but added oral Estrace beginning cd8. I stimulated even faster than the October cycle, and my Estradiol was 1178 on cd7. I went in for an ultrasound on cd8, and had 6 follicles (3 @ 18.5, 18&17.5, and 3 @ 16 (2)&16.5), but my lining was again only 6.3. My RE decided to wait to trigger me until the next day, but I ended up surging that night, and I was instructed to give myself the trigger shot that night. I went in for the IUI's the next 2 days. Since I started the Estrace on the day I triggered, we won't know how my lining responded to it.
It seems that my main problem is age and thin lining. Is there anything I can do to optimize my chances of a successful pregnancy? What can I do to delay ovulation so that my lining can have a chance to catch up? It seems that I stimulate too fast, what can be done about that, and why is this happening? What does that mean in regards to my future w/fertility treatments (IUI's & possibly IVF)? Is it possible that my tubes are plugged with mucus again? I'm anxious to get pregnant as continuing w/hormone treatments for an extended time is probably not recommended given that my identical twin sister has a history of estrogen-related breast cancer (we are brca negative). Any insight would be greatly appreciated.
Lisa
Northern California
AnswerHello Lisa from the U.S.,
There is no question that you have the ability to get pregnant, as proven by your prior two pregnancies. However, time has now passed such that more and more of your eggs will be reduced in quality. That is one of the big stumbling blocks and a problem with attempting pregnancy by a "natural" treatment method (IUI). I see from your stims that you responding well to the stimulation and that is a good sign. It shows that your ovaries are functioning well, which increases your chances of pregnancy with your own eggs. maturing several eggs at at time is the only way to over-come the "age factor". I also see from how many follicles that you had, that your doc was not worried about a multiple gestation because of your age. Usually we do not allow the trigger when there are more than 3 potential ovulatory sized follicles (>16 mms). I think that you are going through a lot of trouble and expense (especially medications) for a maximal pregnancy rate of 7-10% per cycle with IUI. I am not sure that I would recommend that treatment plan, but treatments have to be tailored to the patient's desires and I presume you want to try by a natural method.
The quick response of the follicles is a product of the medications that you are using. Your ovaries respond readily and quickly to the stimulation. That is why they are ready sooner. That is not necessarily a problem, however. The thin lining does not have anything to do with the rapidity of stimulatory response. The estradiol levels are more than sufficient to have developed an adequate lining (usually an E2 over 100 is enough to develop the proper lining).
I personally do not think that oral Estrace is adequate to supplement for development of the endometrial lining. For one, most of it is lost in the pass through the liver, and secondly the estrace dosage is not adequate. My preference would be estrogen patches, such as Climara, or estrogen suppositories, or estrogen gel. In addition, I use 4 times the dosage that these products come in (remember that these products are made for menopausal hormone replacement therapy and are fairly low dose). These delivery methods have been shown to be better for delivery to the uterine lining (especially the vaginal form). Estrace can be used vaginally.
If you presented to me for consultation, I would probably recommend IVF as the treatment of choice simply because of your age. It is the only effective treatment method to overcome the age factor. However, that does not mean that IUI won't work. It just has a less chance and may take longer, and meanwhile, your chances are declining even with IVF. I think you are at the point that you need to move forward more aggressively.
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
