QuestionThank you so much for taking the time...here's my history:
TTC for 3 years, I'm 36 years old
Ovulate on day 17, been charting basal temp. for 2 years and seem to always ovulate plus there is very recognizable cervical mucus each month. Luteal phase is 12 days on average, sometimes it's less (8, 10 or 11 days), only once was it 14 days, and twice 13 days.
Got all hormones tested and was perfect.
Had HSG Sept 2009 and tubes were great, started 100mg clomid one month on and one month off November 2009, started accupuncture Jan 2010, got pregnant March 2010 on a month I took clomid plus doing intensive accumpuncture treatments (had miscarriage at 4 weeks), had laparoscopy Aug 2010 and found stage III endometriosis and chocolate cyst on my right ovary, doctor cauterized all the endo and the chocolate cyst, she felt great about cleaning up the endo and they also put dye through my tubes during the laparoscopy and said they were great.
Period is odd, brown discharge 3 days before period then 2 days of heavy menses, then 2 more days of lighter brown discharge. I thought this might get better after surgery but it seems to be the same (2 periods since laparoscopy).
Obviously, since I've learned that I have endometriosis, I feel that is the main reason why I cannot conceive. However, since I have conceived before (even before my laparoscopy) I worry that my luteal phase is also the problem. I was told clomid can help regulate the luteal phase. I've also heard that progesterone cream can help the luteal phase but that isn't prescribed often in Canada. My doctor has told me that for the first 6 months after my laparoscopy that I have an increased chance of conceiving, but because of the 2 day period and brown discharge, and short luteal phase it makes me wonder if I conceive that it will implant. I just took clomid last month with no luck and I have one clomid left for next month.
Do you feel that I may have a luteal phase problem? Should I be focusing on correcting it with clomid, or something else? Is it possible that implantation or conception can occur with odd periods like mine?
Thank you for your time, I really appreciate it. I think it's wonderful that you take the time to answer questions for everyone on your forum.
P.S. I do wish that I had gotten my laparoscopy prior to going on Clomid...Just thought I'd add that in case anyone is ever wondering what route to go first.
Gina from Nova Scotia
AnswerHello Gina from Canada,
It sounds like you could have a luteal phase defect based on a short luteal phase. The test for this would be an end cycle (CD#26,27 or 28) endometrial biopsy taken just before your menses. This would confirm whether the endometrium is in phase or out of phase in its development. But it is not absolutely necessary to have this test. I would just treat for LPD which is with progesterone. Yes, Clomid can help a luteal phase defect by correcting the hormone output, but that was not your problem to begin with. In your case, the Clomid is just supplementing the natural hormones to get you to ovulate more than one egg per month (superovulation). Clomid can also cause a luteal phase defect through its natural mechanism of action. So, I and most infertility specialists will treat with progesterone supplementation in any fertility treatment. We use a vaginal progesterone such as Crinone or Endometrin. These are specifically formulated for fertility. You certainly can use a progesterone cream, purchases OTC, but I would not know what dose would be adequate. I would recommend that you ask your doctor that is giving the Clomid, to prescribe one of the two progesterones I've suggested.
Keep in mind that you now have another factor preventing pregnancy in addition to the endometriosis, and that is your age. You have a reduced fertility due to reduced egg quality. For that reason, you need to be more aggressive in your approach to pregnancy. You have gotten pregnant once before, which shows that you can get pregnant and your body can do what it needs to, but this pregnancy took a long time to achieve and did not continue. Miscarriages are mostly due to spontaneous chromosomal abnormalities resulting from chromosomal breakages at the time of egg division and is a characteristic of old eggs. I call this the age related egg factor. The only treatment to overcome this factor is IVF where a high number of eggs are removed which gives you an increased chance of obtaining a good egg. With natural treatments such as Clomid and intercourse or Clomid and IUI, we have to limit the number of eggs ovulated because of the higher risk of a multiple pregnancy due to the lack of our ability to control how many eggs/embryos implant.
Also keep in mind that your endometriosis has not been treated completely so there is still some there. The visible endometriosis and endometrioma was removed surgically, but it is known that microscopic endometriosis is still present. Further treatment with a medication such as Lupron or Femara would have been required to get rid of the micro-endometriosis. In stage III and IV patients (you actually had stage IV because of the endometrioma), I usually will treat with Lupron for 3 months unless my patient is proceeding directly to IVF. IVF is again the treatment of choice for stage III and stage IV endometriosis because it allows the eggs to bypass the "hostile environment" in the pelvis.
I hope this helps you with your decision making.
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
