QUESTION:
Hi Doctor,
This is S. from UAE. I would like to have your expert opinion in my case. My infertility workup showed multiple cysts in both ovaries but my hormonal work up was all within range. In addition, I have never missed a period ever in life, my cycles are pretty regular. In spite of this, my gynecologist started a Clomid induction cycle with me and monitored me. I was given Clomid in consecutive months. After reading your blog post about Clomid, I came to a conclusion that my doctor isn't doing right in giving me Clomid, and also, giving it consecutively. I switched doctors, only to recieve Tamoxifen in the subsequent cycle. I am worried. Do I need any kind of ovulation induction at all? Considering my cycles are regular and I had a normal LH/FSH ratio. Can Tamoxifen be followed immediately after Clomid?
ANSWER:
Dear Saman from the U.A.E.,
Glad to see that my blog has been helpful to you all the way in United Arab Emirates! Clomid is not indicated if you are ovulating on your own, but many many doctors use it to boost ovulation thinking that it is a "miracle" fertility drug. If you have been unable to become pregnant, and have had regular cycles, then there is something else, besides ovulation, that is causing the problem. That needs to be found. I am always skeptical when patients tell me "all my fertility tests were normal" without telling me what tests were done. That is because in most of these cases, all the fertility tests were not done, and therefore, the problem has not yet been found.
Tamoxifen has the same mechanism of action as Clomid, namely, it is an estrogen receptor blocker. Your new doctor obviously does not understand these medications. Just like I would not recommend taking Clomid in consecutive cycles because of the estrogen receptor blockage, I would not do that with ANY estrogen receptor blockers, except maybe Femara since it has less effect on the endometrial estrogen receptors. So I alternate cycles with Clomid and Femara. However, again, your new doctor is doing the same mistake and not treating anything specific. He/She needs to find out what the problem is! Ovulation induction is not the answer.
FOLLOW UP QUESTION:
Dear Dr, Thanks a whole lot for your response. It means a lot to me!I need one final querry answered. I have had the following tests:
FSH, LH, TSH, Prolactin, HSG, Fasting Insulin, Testosterone, DHEA Sulphate
All these tests and HSG have come out normal, and HSG shows Bilateral peritoneal spillage. Husband's semen analysis shows 58million/ml and 70% motility. In addition, I have never had any surgery and menstruate regularly every 28days. As I told u before, Clomid induction was done in 2 cycles which just resulted in a single ovum ripening, and was thus abandoned.
I have been adviced to have IUI. Should I go ahead with it? Because I have not had laproscopy, hysteroscopy or endometrial biopsy yet, and there might be reasons for infertility hidden there.....Isn't it better to go straight to IVF? Thank you!
FOLLOW UP ANSWER:
Hello again,
Indeed, based on the tests you have cited we know the following:
1. Your hypothalamic-ovarian pathway is normal (i.e. the ovary is being stimulated properly)
2. Your thyroid, testosterone and adrenal functions are normal.
3. Your fallopian tubes are open.
4. The sperm is normal and has the ability to get to the tube in order to fertilize your egg.
What we don't know is:
1. Is the uterine cavity normal (endometrial cavity) (hysteroscopy)
2. Is the peritoneum normal (where the egg goes through after ovulation) or is there scar tissue or endometriosis (laparoscopy)
3. Are you forming an adequate endometrial lining (endometrial biopsy).
If you wanted to pursue a natural method of getting pregnant (intercourse or IUI), then you will need to do these tests. If you would rather go directly to IVF (which bypasses almost all the steps), then the laparoscopy and endometrial biopsy are not necessary. The hysteroscopy is still needed. Some of my patients do choose to go directly to IVF because it gives you the highest chances of pregnancy. For example, the highest chance of pregnancy with each IUI cycle is 24% (under 35 year old patients), whereas IVF is 76% (at least in my clinic). So ultimately that is your decision. If you want to do things conservatively, that is, be as natural as possible, then IUI would be a reasonable step (it also costs less).
Good Luck,
Dr. 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.
Comment: Dr Ramirez's responses are ALWAYS accurate, and prompt....I can't thank him enough for the help he has given this way....IVF at his clinic is definitely on my cards, but hoping I wont need it though :)
