QuestionQUESTION: hi, i am a 27 year old from australia. have been trying to conceive for 15 months now. began seeing a fertility specialist in february and was soon diagnosed with polycystic ovaries. i also have elevated androstenedione (19.1 nmol/L) and elevated testosterone (2.8 nmol/L). each transvaginal ultrasound i have been to i have approx 30 small follicles on each ovary. doesnt seem to be a lining problem-seems to reach about 9-10mm at ovulation. i am not overwieght (62kg at 5 feet 5 inches tall), exercise regularly and do not have insulin issues. i was put on clomiphene citrate 50mg and hcg injections x4 (5000 x 1, 1500 x3)the first cycle. ovulated 1 main egg on day 17 with estrogen at 1300-no luck. 2nd try they put me on clomid 75 and the hcg injections, one main egg, ovulated day 17, estrogen 2500, progesterone 2. i fell pregnant but had a chemical pregnancy. third time was clomd 75 again-ended up with 3 large eggs and estrogen 2900-cancelled cycle but we still tried without the hcg injections (no luck). 4th try was clomid 50 (and hcg injections), 2 eggs, estrogen 2000 and progesterone 1.9 at ovulation. still no luck-estrogen levels were not as good so they are trying me on puregon with iui this time. i have been on puregon 25 for 7 days and my estrogen levels at day 8 were 302, day 10 they dropped to 291 and my dose has now been upped to puregon 50. my husband and i discovered through all the testing that was done on us that we both had chlamydia-i presume for about 6 years-have both been cured since.
husbands sperm is 400 000 000 with average motility, however it is abnormally viscous. my husband is a marijuana user though and wont give it up as he believes it is not having any effect on him. i also have a retroverted uterus. a few questions i guess... do i have polycystic ovarian syndrome or just polycystic ovaries? is my treatment along the lines with what you would do? i am losing hope of falling pregnant as time goes on (not to mention the expense of it all), what are my chances of falling pregnant soon? is there anything i could do to help my situation? the more information the better!
ANSWER: Hello Krystal from Australia,
Based on the information that you gave me, I cannot be sure if you are a PCOD patient or not. Did you have irregular menstrual cycles prior? An elevated androgen testing and PCO-type ovaries would certainly qualify you for PCOD. You would not have the syndrome unless you had other problems such as elevated insulin, diabetes, hirsuitism, etc.
Your doc is certainly using a low dose of Clomid, for a PCO patient. I usually will start at 150 mg per day and increase to 250mg if there is no or minimal response. With ovulation induction and natural intercourse cycles, I prefer to try to cause three eggs to ovulate. I will only cancel a cycle if there are more than that. Since you are responding to low dose Clomid, it is unlikely that you are PCOD, or maybe a very mild version (there is a wide variety of PCO). If a patient does not respond to high dose Clomid (250mg), then I move to a combination protocol whereby I use 250 of Clomid on CD#3-7 then injectables such as Follistim from cD#8 on. You would continue until the lead follicle reaches 20-22 mms, then would receive a trigger shot of HCG (Ovidrel) to stimulate ovulation. You would then either have intercourse for the next four days or have IUI's for the next two. I would recommend that you check out my blog where I wrote about how I do Clomid cycles.
The injectables, Puregon, is a stronger and more direct ovarian stimulation method. I would expect that you would respond to that but the worry would be that you would over-respond. PCO patients tend to be more sensitive to the injectable medications. Some will have to go to IVF because of this. They tend to produce 15-30 follicles with the injections and only IVF can extract the eggs so that the cycle can be completed. Otherwise, the cycle would have to be cancelled. If your doc is a fertility specialist, then he should be able to counsel you regarding this. IVF might be the best way to go. Also, since you have not had any other testing, maybe there is something else going on that is preventing pregnancy besides ovulation? With a history of Chlamydia exposure, it is possible that the fallopian tubes have been affected. Did they check to see if the tubes are open? If they haven't then you might want to have that done before proceeding further (and you might want to consider seeing a different fertility specialist).
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
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QUESTION: further to our discussion regarding my PCOS. once we decided to go off the pill my periods were irregular. i thought it was just due to being on the pill for 10 years but they never returned to normal. some cycles would be 80 days long, some would be 35. i do have a little more hair on my chin than i would think normal for a female, so if you put that together with the multiple follicles on my ovaries, elevated androgens and irregular periods i guess i do have PCOS. i have also had the HSC test to see if my fallopian tubes were ok-they were fine.
i have now got to ovulation stage (first time using puragon), managed to get one follicle to develop (took a while though-im day 21 now)-its at 18mm with a lining of 11mm, many smalls but nothing over 8mm. should be given HCG trigger injection today or tomorrow and will have IUI done with 3 follow up injections over 9 days. we are hoping this will work or we might have to take your advice and go to IVF. how many cycles would you advise of Puragon with IUI and HCG injections? my clinic has told me to expect a success rate of 15%. is this accurate? it seems so low.
ANSWER: Hello Again,
Yes, I agree that based on the information you have provided, you definitely have PCOD.
I usually like to wait until the follicle is at least 20mms and also try for at least 3 ovulatory sized (>16 mms) in each cycle. I will usually do an IUI at approximately 24 hrs and 48 hrs. Then progesterone will start the day after the second IUI. Yes, HCG injections can be used instead of progesterone but vaginal progesterone (vaginal form) is easier to use. Your chances of pregnancy per cycle, based on your age, is 20-24% per cycle if you are ovulating 3 follicles. If only ovulating 1 follicle, then your chances are no better than what a normal person your age would have, which is 18% per cycle. The PR that your clinic gave you might be their pregnancy rate with IUI (clinic specific).
I usually will tell my patients to try no more than 4 IUI cycles (successful cycles with proven ovulation and good timing). If it does not work at that point, studies have shown that the statistical chances of pregnancy drop pretty drastically (because most that get pregnant by IUI will do so by 4 attempts), so at that point I recommend proceeding to IVF.
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
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QUESTION: thanks for that information. here in australia we have much stricter guidelines in regards to infertility. my fertility specialist has told me im only allowed to do two iui's before having to go to ivf. and i cant just go straight to ivf as we have laws to make sure people try all other methods before it becomes invasive.
i have a question about PCOS/PCOD... if my fertility specialist has got me ovulating using medication (puragon this time), is there anything else that would be hampering my efforts to become pregnant? since i dont have insulin/weight issues and i am ovulating on the meds do i have the same chance of falling pregnant as a normal person now? or do the elevated androgens play a part in my infertility? my current understanding is that PCOS is affecting my ovulation-if i fix that shouldn't i have the same chance as anyone else?
also a question about progesterone.... i have just ovulated-was given HCG trigger injection on the 23rd august, had iui done 24th august. by night time on the 26th my nipples had become very sore which i know has something to do with the surge of progesterone. my question is-do the sore nipples indicate i am currently ovulating or does it indicate that i have already ovulated-thus getting a surge of progesterone?
also-what sort of exercise do you recommend for me? i am usually an active person who runs and fast walks 4-5 times a week. i have stopped running for the 2 week wait to give myself the best chance of implantation but i still fast walk which gets my heart rate up. i am finding that puragon has increased my weight significantly-probably have put on 4kg's in the last 2 weeks. can i run or should i just keep to the walking?
AnswerHello Again,
You are correct that if you are ovulating on the medication, then your PCOS is being treated appropriately and you should have the same chances of pregnancy as anyone trying normally. Keep in mind that a young woman that ovulates normally, typically will take 8-12 months to get pregnant, statistically. So like a normal person, if all that is done is to restore ovulation, it may take several tries for you to be successful.
I don't know of any relationship with "sore nipples" and progesterone levels or ovulation. Breast in general certainly get more sensitive/uncomfortable with the rise in progesterone, however.
You can do stretching exercises, low impact exercises such as walking and biking, but want to avoid any exercise that is "aerobic" and causes a sharp rise in your heart rate. This aerobic exerercise is robbing oxygen from the uterus.
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
