Question:
Hi Dr. Ramirez,
I am writing from Philadelphia, PA and am 39 years old. I have had 9 pregnancies, 7 miscarriages and 2 live births. Since my last child I have had 4 miscarriages and two of the pregnancies I got pregnant with clomid (100mg a day, days 2-6).
I recently switched doctors and the new one recommended IVF with genetic testing because three of my misses were confirmed chromosonal abnormailites - but nothing else has ever been found wrong and I do have two perfectly healthy children. Well, I decided I don't want to do IVF and just take my chances of getting a "good egg" (although the last 4 weren't, I'm still hopeful that one will be). O.k, now for the question... this new doctor wants me to take 250mg of clomid days 4,5,6 and then 200mg days 7 and 8. Why more than double the dose when the lower dose got me pregnant before? Is this safe? necessary? When I call, the nurse says they want to increase my chances, but clomid doesn't effect egg quality does it? Thank you for any advice, thoughts, you can offer.
Answer:
Hello J. from the U.S.,
I am very sorry to hear about all your losses, but your age is the culprit. That is what I call the "age related egg factor". As the woman ages, the quality of her eggs decline and so there is an increased risk of abnormal embryos leading to pregnancy failure or miscarriages. IVF is recommended because we are able to get multiple eggs at the same time. With the increased number of eggs, there is a higher chance of getting a good egg that will lead to a healthy pregnancy.
PGD (pre implantation genetic diagnosis/screening) does not necessarily need to be done. In fact, I am not a big proponent of PGD if this were the only reason. I believe that the poor quality eggs will not work with IVF (i.e. not progress to viable embryos in the petri dish) and if a pregnancy ensues from the good embryos the chances are higher that it will be normal. If you absolutely want to make sure that only genetically normal embryos are transferred then PGS will be required. But then, you would have to do IVF, which you have opted not to.
The reason your doc is recommending high dose Clomid is to increase the number of eggs that you ovulate. Clomid is not the best drug for this but it is the least expensive. Using injectable medications is better but a lot more expensive. That is the only reason for using high dose Clomid in your case. By increasing the number of eggs ovulated, he is hoping that one of the eggs ovulated with be a good quality egg, just like we are trying to do with IVF. However, it may take several attempts, and you may still have miscarriages, whereas IVF would work faster and your chances of a successful pregnancy are higher.
To address your last question, Clomid will not affect the egg quality. That is already inherent in the egg. Perseverance is key in your case. I believe in letting my patients decide how they want to progress with their treatment path. You will need to keep trying, but it may take many cycles. If the miscarriages and heartbreak continue, and you truly wish to have another child, then you may have to consider in vitro fertilization.
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.
