QuestionQUESTION: My husband (41) and I (35) are in WI and have been TTC off and on for #2 for the past 3 years. We conceived our son (born 12/2004) after 6 rounds of injections and IUI's. I have hypothalamic ammenorhhea-likely in part due to body fat below 15% (I am genetically very muscular, but of normal body weight). In 2008 I did another 4 rounds of injectable with IUI, but no pregnancy. I took a break, but recently had an increase in my estrogen level due to an Rx change in my seizure drug. I tried clomid again given that this changed and no result. I would like to try another drug- and tamoxifen was mentioned by one specialist, but the one I worked with in the past with the injectable said that if clomid didn't work, neither would any other oral medication. Do you have any thoughts on this. I would love to have another child- but can't afford to go back to the injectable / IUI or IVF.
ANSWER: Hello Dana from the U.S.,
Tamoxifen would not work. It is an site specific estrogen, just like Clomid, which works by blocking the estrogen receptors and tricking the brain into thinking that it is not producing adequate estrogen. The brain (hypothalamus and pituitary) then increase their secretion of FSH to stimulate the ovary to produce more estrogen, which is done through ovulation.
If your estrogen levels are already increased, these drugs do nothing to stimulate more FSH production. In addition, if you have a hypothalamic disorder, FSH is not being produced, which is why you don't ovulate. The ovary can only be stimulated to ovulate with FSH. You have to provide FSH, which is only available by injectable medications.
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: what if the ammenorhea is simply "unexplained"? Does the above response still apply?
AnswerHello Again,
Amenorrhea should not be "unexplained." There must be a reason for it. Hormone blood testing will usually reveal the answer. If the FSH and LH levels are low or nonexistent, then it is pituitary or hypothalamic. If they are normal, then it is ovarian. If it is ovarian, i.e. normal FSH/LH levels, then Clomid might help, but there is a subset of patients with ovarian dysfunction, called PCOD, that do not respond to Clomid. In this case, FSH must be given as an injectable medication to try to stimulate the ovary.
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
