QuestionQUESTION: Dear Dr. Ramirez,
I am taking clomiphene to strengthen my ovulation (I have a luteal phase defect and secondary infertility). I some questions for you about clomiphene.
This is my 4th cycle on clomiphene 50mg d3-7. I have ovulated on days 18, 19, 20, and 16 (current cycle). The cycle where I ovulated on day 18, I conceived and miscarried at 5 weeks. I have read that clomiphene can cause an overdeveloped egg due to increased LH levels, especially if ovulation occurs after day 16. Would you change the ovulation protocol for a woman who ovulates late on clomiphene? Would a dose increase improve ovulation? Would letrozole be a better option?
I haven't been able to find any statistics for women who miscarry during a clomiphene cycle. Are they still likely to succeed with clomiphene, or do they usually need alternative treatments?
Thank you for your time and expertise.
Laura
28yo, secondary infertility
blood tests, HSG, US, SA all normal
ANSWER: Hello Laura from Canada,
Clomiphene will not cause an underdeveloped egg, but it can cause ovulation to occur more rapidly but not necessarily. There are some women who respond more slowly, especially if the Clomid dose is inadequate. Clomid will not cause increased chances of miscarriage, however, it can reduce implantation rates, because it can cause the uterine lining to be thinned. This occurs especially if you take Clomid in consecutive cycles. It is best to take it every other month or alternate with Letrozole, which has less effect on the uterine lining. I would also recommend a progesterone supplement starting after ovulation to reduce the incidence of luteal phase defect, and help with implantation and maintenance of the pregnancy.
With your very young age, and having become pregnant already, you have a very good chance of achieving a pregnancy. You just have to hand in there.
Sincerely,
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 facebook and twitter with me at @montereybayivf
---------- FOLLOW-UP ----------
QUESTION: Hi again Dr Ramirez,
Thank-you for your answer. My follow up question is in light of some new information. My husband's SA wasn't normal after all. The concentration was 40mil/mL however, both motility and morphology were abnormal. I don't remember to what degree.
My OB said that this is likely our fertility issue and not my luteal phase defect (10-12d LP with 5d spotting). While I do believe that my LP is playing a role, does it make sense for me to continue with clomiphene (I've just started my 3rd clomiphene cycle post m/c)? We have a healthy 2 year old together and we conceived but miscarried 4 months ago. Does this mean that we may succeed on our own, or is IVF with ICSI our only chance?
I did ask my OB to refer me to a RE. My husband and I are both 28.
Thanks for your help.
Laura
AnswerHello Again,
In 30% of infertility cases, the contributing factor is both from the male and female. That seems to be the case with you. However, LPD is easily treated with Clomiphene and Progesterone. I would continue with these medications. However, IUI or IVF may be indicated depending on how bad the sperm findings are. I just answered a question from a patient regarding what sperm parameters are for IUI and for IVF. You should read through it. It was just before your question. If you go to see an RE, he/she could probably clear things up for you. At the minimum, with the sperm abnormalities, you need to pair the Clomiphene ovulation induction with IUI IVF is best if the abnormalities are severe because there is probably a functional component as well i.e. the sperm have decreased ability to fertilize the egg.
Merry Christmas and Happy Holiday,
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 facebook and twitter with me at @montereybayivf
