What happens when anovulation treatments don't work?
March 2, 2015 12:58 AM Subscribe
What's next when Femara/Clomid fails?
We've been trying to conceive for 10 months now. I had been taking birth control pills (most recently, Seasonale) since I was 16. I'm 34 now (and was 33 when we started trying). I remember having regular cycles when I was a teenager.
When my periods didn't resume on schedule after quitting BCP, I went to the obstetrician I planned to see for my pregnancy, and she took me seriously -- after three months without a cycle, she tested me thoroughly and started me on Provera.
All of my test results were normal: ovarian reserves, thyroid (I take Synthroid), prolactin (even though I'm taking antipsychotics and apparently high prolactin is a common side effect), whatever else they tested. I do not have PCOS.
The Provera failed to start a cycle. We tried a few more times, but we eventually started Femara, after testing my husband's semen and finding everything fine there. My doctor prefers Femara because of concerns about my lining. I mentioned Clomid in the post because I thought it had better name recognition.
I've now had four rounds of Femara. The last three appear to have done something:
- in November, I had my first positive OPK, but my progesterone tested five days later was low, and my period started a week later. No mid-cycle ultrasound because the right day fell on a weekend.
- in January, mid-cycle ultrasound revealed my first-ever dominant follicle. After I didn't get a positive OPK within the next few days, we did an Ovidrel shot. Five days later, still low progesterone, and my period started a little bit later.
- in February, mid-cycle ultrasound revealed no dominant follicles. I still had a miraculous positive OPK. That was last week. I get my progesterone checked tomorrow.
My hopes are low for this cycle -- I had a raging UTI and was running a fever and started taking antibiotics right around the time of the supposed ovulation. But we had so much sex, I can't imagine we would have missed the egg if there was one.
The doctor says we can try an IUI next, or we can go straight to a specialist. The IUI seems strange because our semen is good -- the problem is that I don't ovulate even when medicated. That's what they say the low progesterone means. And I'm curious what else the specialist can do. Do we go straight to IVF and even stronger drugs? What's wrong with me anyway? All the doctor can tell me is that sometimes it takes a while for the body to return to normal after stopping BCP.
There's no history of infertility in my family that I know of. My sister got pregnant on accident. My mother had us when she was over 35, so I guess things look good for me to be an older mother.
I'm bipolar and take Abilify, Wellbutrin, and Synthroid (for mood regulation and fatigue -- my thyroid labs have always been in the normal range). My psychiatrist says going off the meds would be worse for my pregnancy than staying on them, and my obstetrician agrees. I'm grasping at straws here though -- what if they're part of the problem?
What should we do? Do you have a success story? I'm desperate to get pregnant before I turn 35.
We've been trying to conceive for 10 months now. I had been taking birth control pills (most recently, Seasonale) since I was 16. I'm 34 now (and was 33 when we started trying). I remember having regular cycles when I was a teenager.
When my periods didn't resume on schedule after quitting BCP, I went to the obstetrician I planned to see for my pregnancy, and she took me seriously -- after three months without a cycle, she tested me thoroughly and started me on Provera.
All of my test results were normal: ovarian reserves, thyroid (I take Synthroid), prolactin (even though I'm taking antipsychotics and apparently high prolactin is a common side effect), whatever else they tested. I do not have PCOS.
The Provera failed to start a cycle. We tried a few more times, but we eventually started Femara, after testing my husband's semen and finding everything fine there. My doctor prefers Femara because of concerns about my lining. I mentioned Clomid in the post because I thought it had better name recognition.
I've now had four rounds of Femara. The last three appear to have done something:
- in November, I had my first positive OPK, but my progesterone tested five days later was low, and my period started a week later. No mid-cycle ultrasound because the right day fell on a weekend.
- in January, mid-cycle ultrasound revealed my first-ever dominant follicle. After I didn't get a positive OPK within the next few days, we did an Ovidrel shot. Five days later, still low progesterone, and my period started a little bit later.
- in February, mid-cycle ultrasound revealed no dominant follicles. I still had a miraculous positive OPK. That was last week. I get my progesterone checked tomorrow.
My hopes are low for this cycle -- I had a raging UTI and was running a fever and started taking antibiotics right around the time of the supposed ovulation. But we had so much sex, I can't imagine we would have missed the egg if there was one.
The doctor says we can try an IUI next, or we can go straight to a specialist. The IUI seems strange because our semen is good -- the problem is that I don't ovulate even when medicated. That's what they say the low progesterone means. And I'm curious what else the specialist can do. Do we go straight to IVF and even stronger drugs? What's wrong with me anyway? All the doctor can tell me is that sometimes it takes a while for the body to return to normal after stopping BCP.
There's no history of infertility in my family that I know of. My sister got pregnant on accident. My mother had us when she was over 35, so I guess things look good for me to be an older mother.
I'm bipolar and take Abilify, Wellbutrin, and Synthroid (for mood regulation and fatigue -- my thyroid labs have always been in the normal range). My psychiatrist says going off the meds would be worse for my pregnancy than staying on them, and my obstetrician agrees. I'm grasping at straws here though -- what if they're part of the problem?
What should we do? Do you have a success story? I'm desperate to get pregnant before I turn 35.
Not a doctor, but it seems like you're really stressing about this, and the "raging UTI" that you're still having sex through was a red flag to me. If you're pretty sure there's no egg, then there's no point in having tons of (probably uncomfortable?) sex. One bout would be enough to conceive if you get lucky and there's an egg there. Maybe tone down the sexual frequency during your fertile window and just do it a few times? That might at least help with the stress.
posted by permiechickie at 4:54 AM on March 2, 2015 [1 favorite]
posted by permiechickie at 4:54 AM on March 2, 2015 [1 favorite]
This was me.... I have PCOS and do not ovulate. After going the Clomid route, and being sure that my tubes were open, a round of Follistim was all I needed to get a healthy egg to develop. The first pregnancy happened "the old fashioned way", the second was with an IUI since that was the fertility clinic's procedure when using follicle stimulating drugs. Some women just need a little more boost to get the ovaries moving. Best of luck....
posted by pearlybob at 5:22 AM on March 2, 2015
posted by pearlybob at 5:22 AM on March 2, 2015
Disregard this advice if you think it would just add to your stress, but have you thought about basal body temperature charting instead of just relying on OPKs? It might make you feel more in control of the process.
The book that is most recommended is Taking Charge of your Fertility and it is a great resource.
posted by lydhre at 5:33 AM on March 2, 2015 [3 favorites]
The book that is most recommended is Taking Charge of your Fertility and it is a great resource.
posted by lydhre at 5:33 AM on March 2, 2015 [3 favorites]
Start working with a reproductive endocrinologist. Although your OB sounds better than most in that she's taking your concerns seriously, regular OB's do not have the level of expertise that you need when dealing with this issue. There is a support group called RESOLVE that is a good starting point for finding good RE's in your area. Feel free to memail me if you have questions about selecting a good doc.
posted by vignettist at 5:51 AM on March 2, 2015 [2 favorites]
posted by vignettist at 5:51 AM on March 2, 2015 [2 favorites]
It's awesome that you've had such a supportive and proactive doctor so far.
But now it's time to go to a well-reviewed RE - Reproductive Endocrinologist. This is what they do. They are up on the latest science, they see tons of women having reproductive health stuff exactly like this, and they have so so so much experience with precisely this situation.
posted by barnone at 5:58 AM on March 2, 2015
But now it's time to go to a well-reviewed RE - Reproductive Endocrinologist. This is what they do. They are up on the latest science, they see tons of women having reproductive health stuff exactly like this, and they have so so so much experience with precisely this situation.
posted by barnone at 5:58 AM on March 2, 2015
Lots of RE's are also working with acupuncturists; I'd find one of those as assisted reproductive techniques tend to have higher success rates when coupled with specialized acupuncture treatment.
posted by quince at 10:18 AM on March 2, 2015
posted by quince at 10:18 AM on March 2, 2015
When Clomid didn't work for me (I don't think I ovulated all the time on it, either) I was referred to an RE and we did Follistim (an injectable), monitoring through cycle (timed bloodwork and ultrasound), then an ovulation trigger shot followed by IUI. Nothing wrong with the sperm, but my RE thought it best to get the best egg and best sperm in the best position. First try with that resulted in my older son. Second time around we tried a similar protocol for almost a year with only a chemical pregnancy to show for it, and the month after that happened I got pregnant the old fashioned way. I second the suggestion for Taking Charge of Your Fertility, and I would say if you're looking at IUI, it's probably specialist time.
posted by percolatrix at 11:41 AM on March 2, 2015
posted by percolatrix at 11:41 AM on March 2, 2015
An-ovulation can be the result of any number of things - body weight, stress, etc.
Have you had a hysterosalpingogram done (it's such a shitty, but good test to be done)? These are the reasons it's a good idea to see an RE. Just as you sometimes need to see an ophthalmologist instead of an optometrist.
I did Clomid for several cycles and it did nothing. We did move on to stronger drugs and with both my pregnancies, and it was the second IUI that worked each time. Why jump straight to IVF? You will to end up with the stronger drugs and a much bigger investment (financially and emotionally) when there's a chance won't don't have to.
Good luck!
posted by dancinglamb at 11:49 AM on March 2, 2015
Have you had a hysterosalpingogram done (it's such a shitty, but good test to be done)? These are the reasons it's a good idea to see an RE. Just as you sometimes need to see an ophthalmologist instead of an optometrist.
I did Clomid for several cycles and it did nothing. We did move on to stronger drugs and with both my pregnancies, and it was the second IUI that worked each time. Why jump straight to IVF? You will to end up with the stronger drugs and a much bigger investment (financially and emotionally) when there's a chance won't don't have to.
Good luck!
posted by dancinglamb at 11:49 AM on March 2, 2015
Because of your age, I would go straight to a specialist. Time is a factor here. I have a similar story - normal lab work, normal ovarian reserve, PCOS panel negative...I just don't ovulate. I still don't know why because we stopped testing once I got pregnant on Clomid.
Is trying Clomid a possibility? You could always try one or two rounds (with your current doctor's blessing, of course) while waiting to see the specialist. I know it took me three months to get in to a specialist here, and in the waiting time, I became pregnant. Perhaps your body would respond better to the Clomid - possibly something to discuss with your care provider?
Also, how are you using your OPKs? You should be taking one test every 12 hours all around and through your anticipated fertile window. Some people have a very short LH surge, and if you only test once a day, you can miss it. Also, follow the directions to the letter! If you decide to start taking your BBT, it needs to be taken with a basal body thermometer at exactly the same time each morning. The book others have recommended (Taking Charge of Your Fertility) is excellent, but speaking as someone who doesn't ovulate, it's not as useful to us as it is to others. And it's frustrating when you feel like you have no fertility of which to take charge - I know it was for me.
As far as sex, it's a misconception (ugh, pardon the pun) that you need to have ALL THE SEX to become pregnant. Your male partner needs time to regenerate sperm. Having sex more than once a day, if that happens to be something you're doing, results in fewer sperm being released with each ejaculation - not what you want. Sperm can live for up to 5 days - having sex once every other day is fine. Of course, discuss all this with your doctor.
I became pregnant after 14 months of trying and after 2 rounds of Clomid, however, I was a bit younger when I began trying. I think it's great that you took action as soon as you did and that you realize time is an issue.
You don't ask this, but I think while you're waiting to get in to see a specialist, you and your partner should decide where your boundaries are as far as treatments and trying. How long will you try? Are you open to any treatment? Are you open to using donor eggs? We decided our "hard line" was IVF - we were willing to try anything up to that point, but were not interested in IVF (or comparable procedures).
posted by pecanpies at 2:10 PM on March 2, 2015
Is trying Clomid a possibility? You could always try one or two rounds (with your current doctor's blessing, of course) while waiting to see the specialist. I know it took me three months to get in to a specialist here, and in the waiting time, I became pregnant. Perhaps your body would respond better to the Clomid - possibly something to discuss with your care provider?
Also, how are you using your OPKs? You should be taking one test every 12 hours all around and through your anticipated fertile window. Some people have a very short LH surge, and if you only test once a day, you can miss it. Also, follow the directions to the letter! If you decide to start taking your BBT, it needs to be taken with a basal body thermometer at exactly the same time each morning. The book others have recommended (Taking Charge of Your Fertility) is excellent, but speaking as someone who doesn't ovulate, it's not as useful to us as it is to others. And it's frustrating when you feel like you have no fertility of which to take charge - I know it was for me.
As far as sex, it's a misconception (ugh, pardon the pun) that you need to have ALL THE SEX to become pregnant. Your male partner needs time to regenerate sperm. Having sex more than once a day, if that happens to be something you're doing, results in fewer sperm being released with each ejaculation - not what you want. Sperm can live for up to 5 days - having sex once every other day is fine. Of course, discuss all this with your doctor.
I became pregnant after 14 months of trying and after 2 rounds of Clomid, however, I was a bit younger when I began trying. I think it's great that you took action as soon as you did and that you realize time is an issue.
You don't ask this, but I think while you're waiting to get in to see a specialist, you and your partner should decide where your boundaries are as far as treatments and trying. How long will you try? Are you open to any treatment? Are you open to using donor eggs? We decided our "hard line" was IVF - we were willing to try anything up to that point, but were not interested in IVF (or comparable procedures).
posted by pecanpies at 2:10 PM on March 2, 2015
Your OB sounds better than most, but you need to go directly to a reproductive endocrinologist. You are probably going to kick yourself for not going sooner, but please don't - you didn't know!
IUI can help even if the semen is good because it allows you to bypass cervical mucus, and anything to make things easier for the process to happen is good when you have infertility issues. Infertility can be multifactorial, you don't know that anovulation is the only problem. A lot of people have 'unexplained' infertility so there are clearly other causes of infertility that medical science does not understand well yet and cannot test for or treat. IUIs are used for anyone with infertility, not just people with known male factor issues.
Your REI doctor will lay out the potential next steps they recommend to you. You may need to have more workup done, like a hysterosalpingogram or a saline sonogram or other testing. They may review the testing you have had done and come to different conclusions. For example, my regular OB ran all the labs that yours did and didn't give me any diagnosis, but when I went to an REI, they showed me the results and that there were abnormal labs that actually did indicate PCOS, which apparently my OB had missed. You can go directly to IVF after trying Clomid/Femara if you want to, but there are other options which your REI may present to you including repeating meds but with IUI and better monitoring (including trigger shot), and injectable medications - injectables are similar to IVF except that you don't actually do the IVF procedure. An injectables cycle requires close monitoring including ultrasound and blood work checks, and it carries a higher risk of multiples, particularly higher order multiples like triplets. Some people prefer to use IVF because you can guarantee that you only transfer 1 or 2 follicles which helps to limit risk of multiples.
When I was in your situation (except I had also done a few IUIs with the meds too), I trusted in my REI and went with the injectables cycle, because she promised me we would use an extremely conservative protocol to try to minimize risk of multiples. That cycle resulted in my beautiful daughter. Best of luck to you and feel free to MeMail me with any other Qs.
posted by treehorn+bunny at 5:23 PM on March 2, 2015 [1 favorite]
IUI can help even if the semen is good because it allows you to bypass cervical mucus, and anything to make things easier for the process to happen is good when you have infertility issues. Infertility can be multifactorial, you don't know that anovulation is the only problem. A lot of people have 'unexplained' infertility so there are clearly other causes of infertility that medical science does not understand well yet and cannot test for or treat. IUIs are used for anyone with infertility, not just people with known male factor issues.
Your REI doctor will lay out the potential next steps they recommend to you. You may need to have more workup done, like a hysterosalpingogram or a saline sonogram or other testing. They may review the testing you have had done and come to different conclusions. For example, my regular OB ran all the labs that yours did and didn't give me any diagnosis, but when I went to an REI, they showed me the results and that there were abnormal labs that actually did indicate PCOS, which apparently my OB had missed. You can go directly to IVF after trying Clomid/Femara if you want to, but there are other options which your REI may present to you including repeating meds but with IUI and better monitoring (including trigger shot), and injectable medications - injectables are similar to IVF except that you don't actually do the IVF procedure. An injectables cycle requires close monitoring including ultrasound and blood work checks, and it carries a higher risk of multiples, particularly higher order multiples like triplets. Some people prefer to use IVF because you can guarantee that you only transfer 1 or 2 follicles which helps to limit risk of multiples.
When I was in your situation (except I had also done a few IUIs with the meds too), I trusted in my REI and went with the injectables cycle, because she promised me we would use an extremely conservative protocol to try to minimize risk of multiples. That cycle resulted in my beautiful daughter. Best of luck to you and feel free to MeMail me with any other Qs.
posted by treehorn+bunny at 5:23 PM on March 2, 2015 [1 favorite]
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