QuestionQUESTION: Hi Dr. Ramirez, my question is that I have a LP of 8 days. I ovulate on day 23. I always spot beginning of cycle, mid cycle and after cycle for 2-4 days. I started taking 100mg of B6 vitamins last month and progesterone cream immediately after ovulation. Last month, I began spotting two days post-O (I stopped the cream at that time). The problem is my spotting has increased (menstruation CD1-9, spotting CD 10,11, 15-18, 25-31 and menstruating during new CD 1-10). What can I do about this? I am taking my BBT (temps are elevated post-O, I am also taking OPKs so I know I am ovulating. My Dr has done pelvic u/s, ovarian u/s, etc. everything is normal, so are hormone levels. Is there anything I can do on my own to increase my chances of conception? Or is there anything I can bring to my Dr.'s attention? Help! Thx.
ANSWER: Dear Nathalie,
Thank you for your question. Where are you writing from?
The luteal phase is one of the most exact parts of a woman's cycle, if she is ovulatory. However, there is a disorder of the luteal phase whereby this part is short. It is called a luteal phase defect. A normal luteal phase is 14 days. It sounds like you may have a Luteal phase defect, which is caused by hormonal asynchrony. Hence the abnormal bleeding. The uterine lining (endometrium) is very dependent on appropriate hormonal synchrony to keep it stable. It is is unstable, it breaks apart, hence the bleeding.
The luteal phase can be supported by using supplemental progesterone. It is generally used beginning on cycle day # 16 and extending for two weeks. Of course, a pregnancy test will have to be done because the period may be suppressed. If it is positive, you continue the progesterone until 10-12 weeks gestational age.
However, based on your scenario, LPD is not the only problem. You may actually need to go on an ovulation induction protocol with Clomid, Latrezole or Gonadotropins in addition the the progesterone supplementation. These medications will help your ovary to perform normally and synchronize the hormonal situation. It may also alleviate the LPD.
I hope this helps,
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
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QUESTION: Thank you for your answer Dr. Ramirez. I just want to say that what you do for women online who have unanswered questions is so helpful. Thank you. I am 32 years old and I am writing from Toronto, Ontario, Canada.
This month the interim bleeding has gone down (CD 1-9 menstruation; CD10-11 spotting; CD16-17 light spotting). I ovulated on CD23. Today is CD25 and I have light pink spotting (creamy). This seems to be the case every month. I will likely spot until CD 31 when I will get my period.
I wanted to know what are the differences between Clomid, Latrezole or Gonadotropins and what is the likelihood of success that women having using these drugs? What is the procedure associated with these drugs (ie. how much do you take and for how long before success is usually achieved?)Also, I have an appointment with a fertility specialist on Sept 8. Should I stop taking my B6 vitamins? Would they interfere with an ovulation induction protocol? I look forward to your answer. Thank you!
ANSWER: Dear Nathalie,
I thought I answered this question and sent it but it may have gotten lost somehow. So if this is redundant, sorry.
The spotting/bleeding throughout the cycle is not normal and has to be evaluated further. I would discuss this with your Gynecologist. It could be due to hormonal abnormalities or other possible abnormalities.
In terms of the medication, it would take too long for me to give you a complete detailed answer so let me summarize as follows:
Clomid and Latrezole are estrogen receptor blockers. They trick the brain into thinking it is not producing enough estrogen so that the brain sends down the hormone FSH to stimulate the ovary further. The ovary is where estrogen is produced. It is in pill form and easier to use. It is not as strong as the injectables, however. I generally use these drugs with timed intercourse cycles and inseminations, in order to keep the costs down.
The Gonadotropins are injectable hormones. They are the same hormones that the brain produces to stimulate the ovary. So they are stimulating directly, rather than indirectly like Clomid/Latrezole. They are used mainly with the higher treatments like IVF because they are very strong. The incidence of multiples would be too high if used with IUI or timed intercourse.
Success rates are not dependent on the medications. Rather, it is more dependent on the treatment that is being used and the patients age. Timed intercourse has a pregnancy rate of 1-18% per month. IUI has a rate of 1-24% per month. IVF has a pregnancy rate of 23-63% per month.
I hope that answers your questions.
Edward J. Ramirez, M.D.
Executive Medical Director
The Fertility and Gyencology Center
Monterey Bay IVF Program
www.montereybayivf.com
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QUESTION: Hi Dr. Ramirez! Welcome back from vacation! I hope you had a wonderful time off!
So, just to update you, you were right about the above. I am now on Gonal-F (150 units) from CD3 to ovulation date which winds up being on CD 15 and 16 (IUI took place on both those days). My first IUI took place in January and was unsuccessful. At the time, I has also been prescribed progesterone suppositories 100mg that I was taking daily after the IUI. They apparently didn't work because I started spotting 6 DPO (my doctor says I was a "non-absorber" and that the injections would no doubt work next time). A pregnancy test later confirmed that I was not pregnant.
I have since had my second IUI done this month (April 23 and 24 which was CD 15 and CD 16). This month I am taking progesterone injectibles (1 cc every morning at the same time). At 7DPO I noticed some yellow CM (my doctor said it was likely hormone related and nothing to worry about). On 8DPO it turned to brown spotting which continued until 10 DPO when I started bleeding heavily (new blood) for approximately 10 minutes (the blood contained large clots) and then reduced to spotting/very very light flow immediately thereafter. I am now 12 DPO and am concerned. I am still lightly bleeding. I have a pregnancy test scheduled for tomorrow and will be meeting with my doctor on Friday to discuss this.
My questions to you are:
1. What could be causing this early spotting/sudden heavy blood flow?
2. If it is related to the progesterone, is it possible that the injections are not working?
2. Is it possible that I am pregnant despite the spotting/blood loss?
3. What are the things I can do to fix this problem and is it in any way related to my not being able to get pregnant?
4. What kind of questions should I ask or things should I discuss with my doctor on Friday?
5. What should the next step be in my quest to conceive?
I feel lost. I have no idea what is going on with my body. HELP!
Thanks so much. Looking forward to hearing from you soon.
:)
AnswerHello Again,
These are certainly good questions and should be discussed with your doc. I do not want to over-ride him/her.
1. The exact source/cause of the bleeding is unknown. It could be from many factors including the progesterone.
2. It is possible the amount of progesterone you are using is still not adequate.
3. It is possible that you have an early pregnancy, even with this bleeding. We see a lot of bleeding in the early first trimester with our IVF patients so it is not uncommon.
4. The fix will depend on the cause. Since there is not clear cause (at least not to me), I cannot recommend a specific remedy. Increasing the progesterone to 100 mg or adding suppositories to the injection might be an option. By the way, we usually prescribe 300mg of progesterone per day in the suppository form (100 mg three times per day).
5. All these questions are good ones. Ask them.
6. You need to continue with the current treatment plan for at least four IUI cycles. If that does not work, then proceed with IVF.
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.
