QuestionHello, I am 25 years old and my husband and I have been trying to get pregnant for over 2 years now. When I was around 15 or so I was diagnosed with PCOS, so I have always known that getting pregnant was going to be a little bit more difficult. We started taking Metformin ER 750mg 3x daily, and did 2 rounds of Clomid, first with 50mg then second with 100mg. With each cycle of Clomid I would never recieve a period and had to be put on Provera. I started a cycle of follistim 150 units IM on cycle days 3-9. After 3 injections my E2 level was 98 and I had 14 follicles all under 10mm. After 6 injections my E2 level was 95 and I had 21 follicles all under 10mm. I had my HSG that day also which was normal. My dose was then increased to 225 units IM, after 3 injections at 225 my E2 level was 94 and I had 22 follicles all under 10mm. At this point my doctor stopped the medications and had me start some provera, he wants me to come in and discussion our options. I guess my question is what are the options at this point?
Answer
Dr. R
Hello Jennifer from the U.S.
I am a little dismayed at the treatment protocol you are using. You are at very very high risk for either a super-multiple pregnancy if you ovulate too many eggs or hyperstimulation syndrome if you respond too strongly. I am a little skeptical of whether or not you are in appropriate hands. Is your doctor a fertility specialist? Does he do IVF?
The problem with PCOD patients is that their ovaries are somewhat resistant to Clomid and very sensitive to the injectable gonadotropins (Follistim, Gonal-f, Menopur, Pergonal, Repronex). For this reason, they must be used very very carefully in PCOD patients. Because of this sensitivity, and the high likelihood of forming multiple follicles, most (80%) of PCOD patients have to proceed to IVF to safely complete a cycle.
I have been successful with some alternative protocols, however. One is to use Clomid at its maximum dose of 250 mg per day for 5 days. If that does not work, then another medication called Femara can be tried using 2.5-7.5 mg per day for 5 days. Then if that does not work, I use a combination protocol with Clomid 250mg for five days followed by Follistim 75IU per day until ovulation is accomplished. By the way, Follistim is a subcutaneous, not IM, injection. This latter protocol has been working well for me in most patients. You should not ovulate more than three follicles (16 mm or greater) if you are using a "natural" technique such as intercourse or IUI. That is how the quintuplets, sextuplets and septuplets are formed.
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 and twitter with me at @montereybayivf.
