QuestionDr Ramirez,
I wrote to you once before and you kindly helped me. I am a 38 year old woman who has lost about 140 pounds. This has given me a very low leptin level. I suspect I have hypothalamic amenorrhea, but that diagnosis has not been confirmed yet by my RE. I have to take T3 because my body apparently doesn't convert T4 to T3 well. I also have very low levels of both progesterone and estrogen. If I recall correctly, my day 10 Clomid challenge FSH level was fairly low--about 5.7 I believe. (I have asked my RE for a diagnosis and hope to receive one by the end of December.) My cycles became erratic/nonexistent last March. I usually have to force them with progesterone.
My question is what are typical causes and remedies for HCG trigger failure; that is, when a woman takes 5 days of 100mg Clomid then injects Follistim (or Repronex) on day 11 then HCG on day 14, what could be preventing ovulation from occurring and would a slightly different regimen of injections likely help? (When I wrote you before, you were unsure that I hadn't ovulated with this regimen. I can now confirm that at least twice I have not ovulated. My day 21 progesterone after my last attempt was .8--very low and proof that I did not ovulate.) I'm concerned that at my age I have no time to waste. I fear my situation might be unusual because it has surprised both my OBGYN and my current RE. I also can't find any references to it online. Is my failure to ovulate after HCG really atypical and should I, therefore, consider going 300 miles away to a larger city where I might find a more specialized RE?
Any ideas about what I may be facing would be helpful. The wait for appointments with my current RE is always over a month and I worry we may not have time enough together to solve my problem before it's too late.
Thank you,
Ella
AnswerHello Ella,
You don't mention if your doctor actually checked to see if you had follicles that were ready to ovulate. Usually, I start vaginal ultrasounds on cycle day # 10 and do them as often as needed until the dominant follicle(s) are the appropriate size to ovulate (18-24 mms). At that point the HCG is given. If it is given on a calendar method (without monitoring), it is basically a shot in the dark. It is not known if there are even follicles ready to ovulate. If there are no follicles prepared to ovulate, then ovulation won't occur. If there are follicles ready to ovulate, then ovulation should occur as long as the HCG is of good quality. To not do so has never been seen in the past. However, I guess there can always be exceptions. If your doctor did do ultrasounds to monitor and did the HCG when the follicles were the appropriate size, AND you did not ovulate, that is very very unusual, and the only conclusion I can draw is that the HCG that you used was bad.
I agree that based on your age, your time is running out. I would proceed directly to IVF and forget these easy, and low probability, methods. Your chances of pregnancy with ovulation induction and intercourse or ovulation induction and IUI are less than 10 per cycle (actually 3 per cycle with intercourse and 7 per cycle with IUI). IVF is the treatment of choice.
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.
