QuestionQUESTION: Hello!
I've been seeing my RE for about 2 years now. My husband and I have gone through all of the testing and everything has come back okay. I did have surgery in 2001 & had to have my right ovary and fallopian tube removed due to a torsion. We started out with Clomid and that didn't work well for me. My RE told me that I wasn't responding as quickly as he would've liked. I tried 3 or 4 cycles of that, my highest dosage being 150mg. We then moved on to Follistim with back to back IUIs. I've done 3 cycles of that and haven't had any luck. The first two cycles I only ended up with 1 follicle each time. Then I had to take a month off due to a cyst. This past month I actually ended up with 2 follicles, which was a great surprise. This cycle didn't work out either. I'm on CD1 right now. With the Follistim, I was on it for a quite a few days before my follicle(s) were mature enough. In 3 cycles I went through 12 boxes of 300iu vials. I'm not sure if that's a lot of medication in comparison to others. My RE has always told me that my best chance of conceiving would be to just do IVF. That's not really an option for us right now, because our insurance doesn't have any IVF coverage. Here's where I'm at right now. I've met my yearly max amount for injectable medications already and I only have 2 boxes of Follistim left. I won't be getting any more medication until January 2010, because my husband and I feel it is too expensive to pay out of pocket for it. I'm meeting with my RE on Thursday to discuss where we go from here, but I was looking for another opinion. I don't want to stop my treatments until January. Do we have any other options other than to pay out of pocket for Follistim or do IVF? Could I do a combination cycle with my last 2 boxes of Follistim & Clomid? Could I try Clomid @ a higher dosage than 150mg & see if that works by itself? I just don't want to give up. It's just really frustrating that IVF is basically my last option. If you could give me any advice or insight, I would greatly appreciate it! A little background info on me... I'm 25 and my husband is 29. My RE put me on Metformin in March 2009, because he thinks I'm slightly insulin resistant. My fasting glucose was 94 and my fasting insulin was 19. Both higher end of normal. He started me out on 1500mg and then increased to 2500mg in June 2009. I had another bloodtest come back with a fasting glucose at 86 and my fasting insulin was 30! I just had another bloodtest done a couple of weeks ago and we're going to discuss the results @ my appointment on Thursday. My fasting glucose was 86 and my fasting insulin was 25.9. I'm wondering too, if the Metformin is actually helping me? It doesn't seem to be. No PCOS though. My husband and I have conceived once before, but it ended in a miscarriage @ 8 weeks. This was in 2003.
Thank you for your time!
Laura
Dr. Ramirez
ANSWER: Hello Laura from the U.S.,
Thanks for the extensive information. I am surprised that you are having such problems at your age. For one, it is possible that the previous surgery has causes scar tissue formation within your pelvis preventing the egg from reaching the tube. That may be the basis for your problem. Secondly, your insulin levels don't seem right if you are on 2500 mg of Metformin. I would not have put you on it to begin with. That may be a little over-kill. Thirdly, you are not responding to the Follistim adequately. You should be forming at least 3 follicles per IUI cycle to maximize your chances of pregnancy. If you are forming only one follicle, then you hare not doing much more that what would occur in a natural cycle without the medication. You need to be ovulating 2-3 eggs per cycle to increase your chances with IUI. Your dosage is probably not adequate. What was your cycle day # 2 or 3 FSH level? Was it above 10? This is an indication that you may have some "ovarian resistance", which means that your ovary is not readily taking up the follistim (FSH). If this is the case, you may have a limited and shorter reproductive time period, so should consider a more aggressive tact.
In light of all this, I think that IVF is the best treatment option for you. I know that it is very expensive, and most insurances don't cover it, but you have several reasons for it. If you want to continue with IUI, and medication cost is an issue, then you might want to try a combination of Clomid plus Follistim. This has been shown to work well, and is less cost because the Clomid costs less and less follistim is used. Talk to your doctor about that. You could use Clomid up to 250 mg. Another alternative would be to try a similar medication called Femara.
I hope this helps,
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 and join me on twitter at @monteeybayivf.com
---------- FOLLOW-UP ----------
QUESTION: Dr. Ramirez,
I would like to thank you for getting back to me so quickly! I really appreciated your feedback.
I went to see my RE yesterday and we discussed our possible options from here. He told me that he would like to see me do 2 more round of Follistim and if those don't work then we should sit down and talk about IVF. I told him that I didn't want to do anymore Follistim cycles until January when my insurance would cover more of the cost. I asked him about the Follistim/Clomid cycle and he said that doesn't really work that well. He said something about how that's an older treatment or something. I asked him if we could do a higher dose of Clomid and he told me that he would do whatever wanted, but he thinks the Clomid isn't going to work. Seeing as I didn't respond very well to it before. He put me on 150mg for 7 days. I was pretty upset @ our appointment. It's hard to hear that we're almost at the end of this journey. I told him I wanted to exhaust all of my resources before I even consider IVF. He told me honestly that we've just about exhausted all of our other options. He also told me to keep taking the Metformin, which I don't agree with. I asked for my FSH level and it was 5.1. Is that good?
I also have another question for you, if you wouldn't mind answering it. I had a laparoscopic surgery done in April 2009. It was a failure. My RE told me that it was mainly due to me being overweight. I think it had to with the inflation of my abdomen. I'm not really clear on the reason though. I was really nervous for that surgery to begin with & my RE told me that he tried and tried, but finally gave up. He said he knew how nervous I was and decided not to continue. I was discussing all of my options with my husband last night and I told me that I want to ask my RE if he would agree to this idea that I have. I want to try to lose as much weight as I can by January and if I've reached my goal then have my RE do another laparoscopic surgery. We have no idea if anything is in my pelvic area preventing me from getting pregnant at this point. Then if he finds nothing, we'll consider IVF. Not before that though. Because what if he does find something and we can get pregnant without having to go the IVF route. I figure if I wait until January, then if we need to do the IVF my insurance company will cover the needed medication. Do you think this is a good idea? I wanted to ask my RE about it yesterday, but we just didn't have the time.
Thanks again for your time!
Laura
AnswerHello Again,
My personal belief is that the most important relationship between a patient and Physician is trust. If there is no trust, then it is not an appropriate relationship. I will usually dismiss patients from my practice if I feel that this trust is missing or compromised. I want my patients to trust me completely. Based on your visits, I wonder if this might be an issue with your doctor.
You seem to be looking for alternatives to IVF. I don't have a problem with that, but your doctor seems reticent. I think you need to emphasize that you want to try everything that you can up to IVF, and he should comply. You, after all, have the ultimate say in what is done. In my previous letter I advised that IVF might be the best treatment option for you. But it is not the only one and I would not "force" you into it if you don't want it. That only leads to bad feelings for everyone, and suboptimal results. I think that your plan is reasonable.
Clomid/Follistim combination therapy is not "old", and there are many recent papers. In fact, there was even a recent paper from Isreal using a repeat Clomid dosage if the initial 5 days was not adequate. They checked by ultrasound on day #10 and if no follicular development, repeated the Clomid at a higher dose. I use Clomid 250mg for five days (3-7 or 5-9) then Follistim 75IU daily after that until there is follicular development. The Follistim can be increased as necessary every three to four days until there is a result.
I don't think the repeat laparoscopy is unreasonable, but you might want to change docs for that procedure. I have done "obese" patients, and in my 24 years of practice, have never "failed" to perform a laparoscopy. It sounds like he had problems getting in with the first trocar, otherwise, he would have completed the procedure. I have had cases where I got in but could not see anything inside because of severe scar tissue, or that the excessive fat prevented good insufflation of the abdomen, preventing the examination, but I have never failed to get in. I use a trocar, called Optiview, that allows me to look with the scope and camera as I am inserting the first trocar. It is not a blind insertion.
These are just things for you to think about and consider. I don't want to get between you and your doctor. You have to discuss these issues with him and make your decisions.
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.
