QuestionGood afternoon! I am 37 y/o, trying to conceive with donor sperm (from Oregon), with a h/o of PCOS. I have almost always been able to catch my LH surge on CD 13. I am a little concerned about my CD 21 Progesterone level: 9.3. Am I correct in believing that this is a little low? Would I benefit from supplemental Progesterone? My CD FSH was 7, which, from what I can ascertain, is normal, I believe. I will be having an HSG this coming week, and have been told that if one of the fallopian tubes is blocked (which is suspected), than she'll start me on Clomid to induce ovulation from both side. If the HSG is favorable, than I will be having my IUI about 7 days later. My concern is, if one tube is blocked, it will be too late in my cycle to start Clomid. My provider is not an RE, she is an OBGYN doctor. Any information or advice you can provide would be greatly appreciated. Thank you in advance. :) Veronica
AnswerHello Veronica,
If I can be so bold, I would recommend that you see an infertility subspecialist or RE. The reason is because, I am a little leery of the comments made by your OB/GYN, and because of your age. As you know, age is a significant factor in getting pregnant and you should have a clear, concise, and well thought out treatment plan. You don't have one.
First, the good news is that your ovarian reserve (fSH level) is still very good which means that your ovaries will stimulate well. The bad news is that your OB/GYN doctor has not done an infertility evaluation and is embarking on a treatment plan empirically. When time is of essence, as in my older patients, and they elect not to pursue IVF (which bypasses most of the natural steps), then I think that a basic infertility evaluation is essential so that we don't waste time. That is, we don't do Clomid cycles if they are not going to work because of tubal blockage or other major problems.
That being said, my approach would be as follows: I would recommend an HSG to confirm that the tubes are open. If one or both are blocked, then I would recommend IVF. Generally, if one tube is blocked that indicates that there was some event in the past that caused damage to the tube. Whatever this was also affected the other tube but not enough to cause full blockage. However, it can still be damaged. Therefore, the only way to bypass this problem would be IVF.
If the tubes are open, and there are no other problems, I would recommend 3-4 cycles of IUI. Not more than four! Statistically, if there is not a pregnancy resulting after four attempts, then the chances of pregnancy are dismal and you should proceed with IVF. I ALWAYS use Clomid with my IUI cycles, otherwise, it is just like trying naturally. Your pregnancy rates trying naturally is only 5 per cycle. With the Clomid, to increase the number of eggs that you ovulate, you can boos that to 10-12 per cycle. Unfortunately, many PCOD patients do not respond to Clomid (up to 250mg per day) and have to proceed to IVF (85). Not using Clomid or Laterzole or Gonadotropins with the IUI is essentially a waste of your precious time.
Finally, ALL IUI cycles should be supported with progesterone supplementation as either an injection or vaginal suppository. I prefer the letter using either Endometrin, Crinone or Procheive. Lack of implantation or miscarriage can occur from a luteal phase defect (inadequate progesterone in the luteal phase), and that would be a tragedy because we can supplement progesterone. This is the other reason that I am leery of your doctor. It is such a simple thing to do, not costly, and immensely beneficial. There is not reason to withhold it.
I do not mean to be pompous in my opinion regarding her doctor, and don't necessarily exclude general OB/GYN doctors from doing infertility. Many are well trained, and as long as they have the knowledge base, can do it well. However, I have to go with the recommendations of my colleagues, which is that when a woman is over the age of 36, she would be sent directly to a reproductive specialist. We, and I, often get patients in their 39th and 40th years that have been doing unending Clomid or IUI cycles with their general OB/GYN's, and now come to us for rescue. Unfortunately, at that point, it becomes very difficult to achieve success. For example, at age 37, in my program, you have a 52% chance of pregnancy per IVf cycle. At 40, it drops to 27%. So don't wait too long.
I hope that this helps. Good luck.
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.
