QuestionHello Dr Ramirez,
I'm 38 and my menstrual cycles became erratic after an abdominoplasty removed approximately 1.2kg from my stomach area this past January. I've had to use Provera twice to start my cycle after it went over forty days. Recently my OBGYN had me take Clomid on days 3-7 then Repronex on day 9. An U/S on day 12 revealed that I had a 20mm follicle so I was given a hCG trigger then had an IUI the next day. A later U/S revealed that the follicle was still there and that the hCG trigger apparently hadn't caused ovulation. Do you have any information on possible reasons why the trigger failed or whether it would be worth my time and money to try this same process again given this first failure? Thank you very much for your time.
Kind Regards,
Ella
AnswerHello Ella,
Thank you for your question. It is not possible to know if ovulation actually occurred or not. We presume, based on the ultrasound that if the follicle disappears, then ovulation occurred. However, even an ovulatory follicle can reaccumulate with fluid, as we often see after IVF. So, it does depend on when the ultrasound was done. I generally do two IUI's per month. With each IUI, I look with the ultrasound again to see if ovulation occurred. It is generally good at seeing that ovulation occurred because it is within a very short time period that I am looking. In your case, because the ultrasound was done later, it is not accurate. In addition, some people will ovulate later than expected after the HCG injection. Remember, once the HCG is given, people will ovulate within 24-52 hours.
There is not reason to think that this treatment plan will not be effective, unless there is something else preventing you from becoming pregnant other than ovulation. From you history, the clomid is giving you the chance of getting pregnant with each cycle and you should continue. I would not recommend more than four cycles, however, because statistically, the chances for pregnancy decrease significantly after four cycles. I would also increase your Clomid dose and/or Repronex dose to try to get you to ovulate up to five eggs per cycle.
One thing we did not talk about is the impact of age on your fertility. You certainly can get pregnant with IUI but it is not the best option. At 38 yo, the chances of pregnancy per IUI cycle is 5-10%. Because of this, we generally recommend proceeding with IVF after the age of 36yo. With IVF, in a good program, you can have a 52% chance of pregnancy per cycle. Because of your age, I would limit the number of IUI cycles to three or less. If you OB/GYN cannot get you to form at least 3-5 follicles, then IUI should be abandoned. It is not significantly increasing your chances. You should also have a cycle day # 2 or 3 FSH level done. If it is 7.0 or above, then I would go straight to IVF. You are looking time, which is affecting your chances even with IVF.
I hope this helps.
Sincerely,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF program
www.montereybayivf.com
Monterey, California, U.S.A.
