Amenorrhea & Secondary Infertility In A 29 Year Old: Needs Evaluation For POF, Thyroid Or Pituitary Disfunction ASAP!

Hi Dr. Ramirez,

I am a 29 yr old healthy female with two daughters, ages 13 & 12. Me and my husband conceived with no problem. I was 16 when we had our first daughter. I started having irregular menstrual cycles when my youngest was 2. We tried to get pregnant again and haven't been able to since then. I have not had a cycle in about 6-7 yrs.

I went to the doctor a few years back, they did blood work, exams, internal ultrasounds and they put me on birth control and hormones, but no period came. I have since stopped going to the doctor and am not taking anything. I am highly concerned on how this is affecting my health. Hoping for your advice.

Thank you, N. from the U.S.

Answer:

Hello N. from the U.S.,

It is highly unusual for you not to have at least one period per year in your age group. I would be worried that you might have a severe ovarian dysfunction like premature ovarian failure (POF or early menopause) or some other hormonal problem with your thyroid or pituitary. You need to undergo an evaluation to find out what is going on.

The problem with not having a period is that you are not producing estrogen. Estrogen is a vital hormone for a woman's body. It impacts many different areas like your bones, skin, heart, brain, vagina. Women who undergo menopause, where they are no longer producing estrogen, have an increased incidence of heart disease, osteoporosis as well as: bone loss, decreased concentration, decreased memory, thinning of the skin, thinning of the hair, vaginal shrinkage and dryness, skin dryness and wrinkling, and accelerated aging. It is one of the most vital hormones in your body. So, if your ovaries are not working and not producing estrogen, or very little estrogen, then you need to go on hormone replacement with something like a birth control pill. If you are interested in getting pregnant, and your ovaries are not menopausal, then you need to take fertility medications to induce your ovaries to ovulate produce and give off an egg.

The bottom line is that you cannot continue like this because it is harmful to your health. You want to stay young for your children and husband, so please go see a Gynecologist as soon as you can.

Sincerely,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Possible Uterine Abnormality Or Immunologic Disorder Causing Four Miscarriages In 32 Year Old: IVF With Surrogate Again?

Question:

Background: I am 32 as is my husband. We had an ectopic pregnancy 10/2005, 8.5 week miscarriage 3/2006, 10 week miscarriage 8/2006, 9 week miscarriage 2/2007 (genetic testing done - female/chromosomally normal), and 9 week miscarriage 8/2007 (male/chromosomally normal).

We had a healthy son via gestational surrogacy with my egg in 2008. During the IVF (in vitro fertilization) procedure for this surrogacy, I only produced 6 eggs and only 1 blastocyte made it to the 5 day transfer as an 8 cell blastocyte. I have Hashimoto's Disease (on medication since 2000), diagnosed with Endometriosis in 2005 (2nd lap in 1/2010 showed it is gone) and diagnosed with Adenomyosis in 1/2010, after which I took Depot Lupron for 4 months.

I have had every genetic test I've heard of and the only issue is one copy of the MTHFR gene. I took 81 ASA and Heperin with my last two pregnancies, and progesteronne with the last four. I even did IVIG with the 5th pregnancy. Two weeks ago I tested my FSH and it was normal. I also had an AMH test and it was 0.2, very low.

My RE has told me that I should try IVF (with me being the carrier) but I'm not sure. I know they are concerned about the number of eggs I have left and the quality of the eggs that are left. What I want to know is if my 2nd through 5th pregnancies could progress to 8-10 weeks with normal hearbeats and the last two we know were chromosomally normal, does this have anything to do with poor egg quality? How could these last two pregnancies test normal but be of poor quality? Is that possible?

Thanks! D. from the U.S.

Answer:

Hello D. from the U.S.,

To answer one of your last questions, since your pregnancies were know to be genetically normal, this is not an indication that you have poor egg quality. Poor egg quality leads to abnormal embryos (genetically) because the chromosomes within are fragile and break during division. It is most likely that you have either an immunologic disorder or a uterine abnormality. The latter might be the case because a surrogate was successful with your eggs.

I don't see any reason for you not to try with your own uterus if you can afford it financially. The only downside is if the uterus is a problem, you will end up miscarrying again and will have spent the money for that IVF cycle. I am not sure that I am convinced that it is a uterine problem, however, because the previous pregnancies progressed as far as they did. I would recommend that you go the gamut with the next in vitro fertilization cycle, using aspirin, heparin and IVIG if you decide to use your own uterus. That may be what it takes. If finances is an issue, then I would recommend that you use a surrogate again.

I know these are tough decisions but your young age, the positives that you have had, in addition to the child you have already had via surrogate two years ago, make your chances for another pregnancy very likely.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

American In The UK Taking Clomid & Has Thin Uterine Lining: Needs A Specialist

Question:

Hi Dr. Ramirez,

I will try to keep this as concise as possible. I am very healthy, slim and 29 years old, and have never had issues with my periods. My husband (29 years also) and I conceived on our first try last year, but unfortunately had a missed M/C at 12 wks (fetus stopped growing at 8 wks). Tests confirmed non-recurring genetic abnormality. After the D&C I had only spotting, until 5 days after when I had a very heavy bleed with large clots lasting only one day. Then I got my first period 6 weeks later. The 3 subsequent cycles were 42-45 days.

Pelvic ultrasound revealed PCOS, hormone levels were all normal, including thyroid. Lining on this ultrasound was only 5.5 on day 40, just before I started my period. I have just completed one round of 50 mg Clomid unmonitored due to travel, and BBT shows clear ovulation on day 18 with 12 day luteal phase. This cycle I have had my first follicle tracking on day 11 which showed dominant follicle at 15 mm, but lining of only 4 mm. My questions are:

1. Could the thin lining be due to problems from the D&C?

2. My gyn prescribed Progesterone pessaries for the second half of this cycle to help thicken the lining- is this the appropriate treatment?

3. When should I consider seeing a fertility specialist?

Thank you for your time- I am writing from London. M.

Answer:

Hello M. from the U.K.,

A thin lining could certainly be due to an over-vigorous D&C, leading to scarring in the uterus. This is called Asherman's syndrome. A procedure called hysteroscopy can be done to evaluate the uterus cavity for this. However, that being said, it is not very common to develop this with D&Cs. The more common possibility is a thin lining due to the use of Clomid.

Clomid is an estrogen receptor blocker and so blocks estrogen receptors at the endometrium (uterine lining). For that reason, many patients have to use extra estrogen given vaginally in order to overcome the blockage from the Clomid, or they use a different medication such as Femara or injectables.

Progesterone is NOT the hormone that thickens the uterine lining. Endometrial thickening and priming is dependent on ESTROGEN in the first half of the cycle. The fact that your doc told you the wrong info makes me skeptical that he/she clearly understands the physiology of this treatment. So, I think you should go see a fertility specialist instead. Without proper estrogen priming, the uterine lining will not be ready for implantation. The progesterone, which is given after ovulation, is to convert the endometrial lining to develop the "pinopodes" that are necessary for implantation. (See diagram up above, the "pinopodes" are small finger-like protrusions in the endometrium) Without the proper priming, the pinopodes will not develop.

Good Luck and keep trying, you should succeed with the right treatment path,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you Dr. Ramirez! I am very grateful to have your opinion, which confirmed to me that I need to see a specialist. As an American living abroad, it can be daunting to find the same quality of health care that we take for granted in the US. Again, I really appreciate your help.

TTC For Seven Years & Dealing With Male Factor Infertility: Do We Do IUI or IVF?

Question:

My hubby and I have been trying to conceive for 7 yrs. One specialist told us only IVF (in vitro fertilization)would work, but a second opinion told us IUI (intra uterine insemination) would work.

He has a count of 9mill and motility of 60%. I'm perfectly fine, my eggs and tubes are good all blood work came back good, and I have conceived in the past and have a son.What are our chances with conceiving using IUI and how many attempts do you think will be needed? Any additional advice would be greatly appreciated. Thanks, S. from the U.S.

Answer:

Hello S. from the U.S.,

If you are under the age of 35 years old, then I think that IUI would be an option for you. The sperm findings are abnormal, but there is a small chance. Your chances of pregnancy under the age of 35 would be 20-24% per cycle, and I would not recommend more than 4 attempts. Your best option is IVF with ICSI (intra cytoplasmic sperm injection). In general, if the count is less than 10 million, ICSI/IVF is the recommendation. You have to bear in mind that only 60% of the 9 million are sperm that can fertilize the egg (3.6 million). That is way lower than the normal required for natural pregnancy (20 million is required).

In most cases where the semen analysis is abnormal, that is an indication that there is a problem with sperm function. After all, it only takes one good sperm to achieve fertilization but for some reason, studies have shown that if there is a severe abnormality in the semen analysis, the sperm have difficulty or lack the ability to fertilize the egg. That is how & why ICSI was developed (see my website for further explanation http://bit.ly/9AdrJc ) . So far, over 10,000 babies have been born with this technique from men who were otherwise considered hopelessly sterile, whose sperm are weak or too few to effectively fertilize an egg. These ICSI/IVF babies have long been proven to be physically, mentally and genetically completely normal, no matter how poor the sperm of the father. If I were your doc, I would have recommended IVF/ICSI as your best treatment option, but would allow a trial of IUI if that is what you wanted to do.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Australian Woman Has Possible Semen Allergy & Yeast Infection or Thrush

Question:

Ever since my partner and I have been having unprotected sex, I have been having a severe reaction straight after he ejaculates in me. It happens almost immediately with swelling internally and externally, burning, and pain for at least the next two hours. If I wash myself quickly sometimes this can help but if I'm too late then the pain continues. Recently I went to the doctor and the possibilities were "thrush, acidity or allergy". I was positive for thrush and commenced treatment. I reacted to the 7 day treatment of miconazole nitrate 2% in a very similar way to the semen. It also made the thrush ten times worse. The same occurred with clotrimazole once only cream and with Nystatin 100,000 i.u 14 day treatment cream (which I stopped at day 4) and then I tried the once tablet fluconazole 150mg which I developed a dry taste in my mouth and then a metal taste and severe abdominal cramping. All these side effects lasted for two weeks at a time. The thrush finally cleared with the tablet.

After having sex again the problem was still there. I then tried taking fexofenadine hydrochloride 180mg tablet half an hour before sex and this reduced the pain from 7/10 compared to 10/10 but the problem was still there. With the acidity part we both tried drinking only water, this didn't change anything. I'm getting married in November and I'm worried. Is there anything we can do? What tests can we get done to determine if I have an allergy to semen? Should I get a referral to a gynecologist? and how can I stop the pain? and if I get thrush again what options do I have left? C. from Australia

Answer:

Hello C. from Australia,

It is not very common but women can develop an allergy to semen, since it is a protein (medically known as "seminal plasma hypersensitivity"). It is a difficult problem to treat. Basically, you need to use a condom to avoid the contact with the semen. Sometimes, if enough time passes without contact with the semen, the allergy will resolve. Fungal infections (yeast infection) are the most common vaginal infections that women can have. You should be cultured for other bacteria as well to make sure that the symptoms you are having are NOT due to a different type of bacterial infection, and was due to the yeast. I am surprised that you had such a reaction to each of the vaginal medications used. That makes me think that there is something else going on and not a yeast infection. It is also possible that with all the inflammation your vagina is going through, it just has not had any time to heal.

So, I would recommend a natural treatment for the prevention of yeast, which is to use plain yogurt, mix it in a douche bottle (buy a douching kit from the store but DON"T use the vinegar solution given) with half/half water. Then use this to irrigate the vagina 2-3 times per week. This will increase the vaginal bacteria called lactobacillus, which will help to prevent yeast infections.

I would also recommend that you try intercourse with a condom and see if you get any type of vaginal irritation or reaction (unfortunately, when you will eventually try to get pregnant this method will be counter-productive). If you don't, then it is most likely that you have a semen allergy. If you do, then it is unlikely that you have a semen allergy but have something else going on. You should then make sure that your gynecologist does a vaginal culture. If it does look like you have an allergy to semen (the symptoms only occur with ejaculation in the vagina), then you may have to see an allergist to see if there is a way to desensitize you to your husband's semen. Your husband should also see a Urologist to have the semen checked and make sure that it is the correct pH. If it is not, and is more acidic, he may have something going on that needs treatment. It usually is best to see a male fertility specialist rather than a general urologist but there aren't very many so that may be harder. You may also need to be placed on a antihistamine and vaginal steroid to be taken before intercourse to reduce the inflammatory/allergic reaction.

If and when you decide to try to have children, and you do indeed have severe seminal plasma hypersensitivity, then you may have to resort to intra-uterine insemination or IVF. Going this route will allow the semen to be washed free of semen proteins making pregnancy possible by preventing an allergic reaction.

Sorry I can't give more specific information. I hope this will give you some guidance.

Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

Comment: Thank you so much for your reply. It is slowly becoming more clearer to me in how to go forward with my allergy to semen. In reply to your note, I do not get any symptoms of irritation when using a condom. I can find some relief in this method at least. And I'm glad to hear of a way to prevent the thrush. Your information has been in depth and very helpful.

A Positive BHCG But Now Bleeding Two Weeks After Embryo Transfer: Am I Miscarrying?

Question:

Hello. I did an IVF transfer June 24th, was told it was a beautiful transfer of 3 beautiful embryos. This past Tuesday, July 6th, I got a positive result, however doc told me to be cautiously optimistic as it could be a chemical pregnancy because my level was 33. The next morning I woke up to cramps and started brown (old blood like) spotting, which is kind of weird for me to be honest. My cautious optimism diminishes to despair. Called doc, told me it was normal and had to wait. Retested 48 hrs later (yesterday) and it was 60, so it nearly doubled! Which was a big shocker...I was really expecting it to go down. But yeah, right?

This morning, July 10th, I woke up to heavier spotting and an actual clot like thing (which kind of looked like a massive amount of my Crinone gel). Mostly brown blood with a little red now, but mostly when I wipe after going to the bathroom (sorry TMI). They say it could be a number of things, irritation from the progesterone gel, passing of one of the embryos, or just normal pregnancy symptoms. I think they are miscarry symptoms. I go back for blood draw Monday and I am just beside myself. I am normally a pretty together person but this has turned me upside down as I feel like I'm on an emotional roller coaster. One day I think I am dealing with a m/c and then we get news that my hcg doubles. This bleeding after my embryo transfer worries me.

I guess what I'm asking is should I look at the doubling as good news or could it be my levels haven't caught up with what will happen? Could I be passing one or two embryos while one implants? Is a m/c imminent in your opinion? Any help would be most appreciated. Thank you in advance. D. from the U.S.

Answer:

Hello D. from the U.S.,

First, let me answer your last question. Based on your symptoms and bHCG levels, you CANNOT make a diagnosis of imminent miscarriage. It can go either way, but I tend to focus on the good side.

The bHCG levels doubled as they were supposed to. I generally follow them every 48 hrs for the first four levels, but your doctor has a different protocol. As long as they continue to rise and approximately double (they don't have to double exactly), then we wait and see how things go. There is only a limited amount of information that you can gather from this blood test. If they are going up, you are pregnant and things are looking good. If they plateau or drop then things are not good. One cannot necessarily predict the outcome based on the levels.

Second, I would totally disregard the spotting that you are having, and not worry unless it is bright red blood that flows like a period. Anything less than that can be "normal" at this point. Bleeding after embryo transfer is more common than you think. We see this very, very often. . . in almost 90% of our IVF patients using Crinone. In fact, there have been studies showing increased spotting with vaginal progesterones like Crinone. It is thought that the progesterone makes the cervix more prone to oozing from the surface. In any case, this type of spotting with Crinone is very common.

Not much can be known about the pregnancy at this very early point, except that you are pregnant! Now, despite the worry, you have to wait and see how things progress. Try to be optimistic and keep the stress level down. I would not assume that you are destined for a miscarriage or are miscarrying yet. It can still go either way. Whatever is destined to happen, will happen and we don't have the power to change that at this point. We can only hope and pray for the best. By the way, it is never "TMI" (too much information), rather, all the information you can provide is appreciated by a physician.

The very best of luck to you both, my thoughts are with you. Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF
Monterey, California
www.montereybayivf.com

Prometrium Vs. Endometrim For Luteal Phase Support In IVF

Question:

Dear Dr. Ramirez,

I've written to you before about luteal phase bleeding. We've tried 3 IUI's, but my husband's morphology has been consistently 0%, so we are moving on to IVF with ICSI.

My RE has me on a long protocol (BCP, Synarel, Puregon, Repronex). My main concern is luteal phase support. My RE plans to have me on 200mg of Prometrium PV TID starting the evening of retrieval... During my last natural cycle I tried this dose of Prometrium and I still had some breakthrough bleeding (but not everyday). Do you think that this is sufficient luteal phase support for someone with a history of luteal bleeding? My RE is doing a hysteroscopy next week to rule out other causes.

Thank-you for your time, L. from Canada

29yo, secondary infertility

Answer:

Hello L. from Canada,

The dosage of prometrium that your doctor has prescribed is certainly adequate for luteal phase support but is not the mainstay with IVF treatments. The gold standard is injectable progesterone 50 mg per day starting on the day of the retrieval. The alternatives that have been studied with IVF are Endometrin 100 mg vaginally three times per day or Crinone 8%/Prochieve 8% vaginally each morning. I double up and use the progesterone injection and the Endometrin or Crinone together to make sure that I have adequate progesterone coverage. So, prometrium can be used but is not the medication of choice with IVF. It is the cheapest alternative however.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank-you Dr. Ramirez! My RE has given me the option of using Endometrin (just recently approved in Canada) so I will use your advice.

Overweight Woman Trying To Conceive Has Irregular Periods And Multiple Miscarriages

Question:

Hi Dr. Ramirez,

I read your blog and I love it! I learned a lot reading all your archives, so I wanted to come to you for advice about my situation.

I am 24 years old and my husband is 26. When I was 21, I was told that I have problems ovulating because my cycles were just a week of spotting after 2-6 months of nothing. My OB/GYN says that I don't ovulate due to my obesity, so I have never had any tests to check for PCOS or anything else. I am working on losing weight, but it has been a slow process. I do menstruate when given progesterone supplements, typically within hours of finishing my 10th day of 200 mg Prometrium. I also have hypothyroidism (and a strong family history of the same), but it is under control with 50 mcg levothyroxine; my most recent TSH, in January, was 1.7. I also have a family history of lupus, but do not have lupus myself.

In July 2008, I got pregnant while on Sprintec and miscarried at 5w2d, then went back on Sprintec. In October 2009, I got pregnant in my first month off Sprintec and miscarried at 5w4d, then went back on Sprintec. In February 2010, I got pregnant again in my first month off Sprintec but had a chemical pregnancy (bleeding started at 4w2d). Additionally, just from knowing my typical pregnancy symptoms in retrospect, I suspect that I might also have had a chemical while on Sprintec in April 2009, but I did not test because I was taking active pills three months at a time so I did not have a period to miss.

I have been taking OPKs twice daily (12 hours apart) since the chemical but have not ovulated; in fact, I rarely if ever see a second line at all on the tests. My OB/GYN said I can start Clomid at any time, but he is unwilling to do any testing regarding the losses until I have another miscarriage. My husband and I do not want to try to conceive again until we have tried to get an explanation for our losses.

I actually have a few questions. One, is there a reason I seem to ovulate only when I have recently been on hormonal birth control? Is it a down-regulation thing like women have before their IVF cycles? Two, is it possible that just taking Clomid might allow us to make it out of the first trimester? Three, in your opinion, is it time to move to an RE even though we have not yet been trying for a year (the only one in South Dakota is more than 200 miles away from our home)? And four, what sort of tests would an RE want us to do regarding my pregnancy losses?Thank you so very much for your time and consideration.

You provide a wonderful service, and if I'm ever in California I'd love to become a patient!

Answer:

Hello B. from South Dakota,

Thank you for reading my blog and your kind comments. I hope the information was useful.

It certainly sounds like you have an ovulation problem, and Clomid would be an appropriate treatment. However, because you have had three miscarriages, you also have the problem of recurrent miscarriage. Both of these problems would fall into the infertility category and an infertility specialist would be the best person for you to see. That way, both problems can be managed, rather than just the ovulation problem as your current doctor suggests. Regarding your weight, I have had infertility patients who are overweight and still achieve a pregnancy. There are other issues that need to be addressed that take precedence over your weight.

Let me answer your questions specifically in order:

1. I find it interesting that you were able to ovulate on the birth control pill. I'm not sure that I can explain this. Most likely, the birth control pill caused an FSH/LH burst that led to ovulation. It usually suppresses FSH/LH discharge, which is how it works.

2. Clomid will certainly help you to ovulate, at the appropriate dosage, and may correct any hormonal problems if that is the cause of your miscarriages. I would not bet on it, however. Rather, I treat ALL my infertility patients will supplemental progesterone in order to help prevent any miscarriages caused by hormonal problems. In addition, with a patient with recurrent miscarriages like yourself, I would add low dose aspirin 81 mg per day beginning at the start of the menstrual cycle, medrol 16 mg per day beginning at the start of the cycle and tapering to 8 mg per day after ovulation, then stop with the pregnancy test and heparin 2000U injections twice per day beginning at the start of the cycle. Lovenox could be substituted for this as well. An RE is the most knowledgeable with this problem and protocol.

3. I answered the question regarding the RE above, but I would recommend that you see one because of the ovulatory dysfunction and recurrent miscarriages.

4. Recurrent miscarriage evaluation includes: Hysteroscopy, pelvic ultrasound, blood tests for antiphospholipid antibody (full screen), ANA, Lupus anticoagulant, Leidin factor V, RPR, Toxoplasmosis, Chromosomal analysis in you and your husband, hormone panel.

Good Luck,

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you so much! I plan to see if my current clinic can run the panels, then follow up with a specialist.