Infertility

A FRIEND LIKE CLOMID MIGHT NOT BE THE FRIEND YOU NEED (Especially if you’re over 35)

I have been lazy lately…lazy to write, lazy to start the new IVF cycle that would be my last (or so I promise myself) but there’s this Clomid topic coming up so often lately, in all three Facebook groups I am administering, and I just have to say something about it.

Me and my big mouth, y’all…

So what is Clomid? It is a medicine that works as an “anti-estrogen” i.e it tricks your brain into believing your estrogen levels are low. The brain (the pituitary gland, to be precise) then releases more of your natural FSH in order to make your follicles grow.

Clomid was synthetized in 1956 and approved for use in the USA in 1967. Due to it being cheap and easy to use it has been a first line treatment for decades now. It has been considered to be a revolution in the treatment of female infertility and the cornerstone of the assisted medical reproduction treatments.

Sure enough, medicine advanced since the 60s, many other stimulation medicines have been invented and proven efficient, yet somehow Clomid still has this aura of “inoffensive worth a try, fit for a first step” solution.

Lately, less and less reproductive endocrinologists use it, especially if you are over 35, but it is still the med of choice for many OBGYNs.

My own OBGYN prescribed it to me, at the beginning of my secondary infertility journey. And I was happy: Clomid was gonna make me a baby, yaaay!

Two cycles and a 2.9 mm thick lining later, it was obvious Clomid was not the Prince Charming I thought it was.

Now let’s get one thing straight: I adore my OBGYN – she is the most caring and sweet doctor I have ever met and she has amazing bedside manners. And she knows a lot of things and is very competent. But infertility is not her job. That’s why REs exist.

And when I went to see my first RE I understood a few things about Clomid:

  1. It dramatically thins lining in some individuals, and for some of the less lucky, this damage may be permanent.
  2. It may trigger a rapid response in stimulation and by the time your follicle is “grown” your lining is left behind incapable of catching up.
  3. It dries up your cervical mucus making it harder for sperm to swim up your uterus and into your tubes
  4. It causes cysts that stubbornly refuse to ovulate in spite of trigger administration and this may impact your future cycles.
  5. It has some nasty side effects that I will not linger on too much, but will just mention: hot flashes, headaches, visual problems, mood swings.

Lately, more and more data shows that Clomid is a bad idea for older women. Dr Sher has a very concise and documented article that I suggest you read, if you are over 35 and about to take Clomid. Not only does he recommend the use of Clomid exclusively for younger women with a normal ovarian reserve, capable to override the anti-estrogenic effects of this drug, but he also points out that used for more than 3 cycles, Clomid starts to act like a … contraceptive, no doubt by thinning the lining and drying out the cervical mucus. The link is below

http://haveababy.com/fertility-information/ivf-authority/clomiphene-for-women-over-35-bad-idea

 

There are tons and tons of women out there who swear by Clomid, and will tell you it is the best choice. Surely, had it worked for me on my two months of trying, I would have sworn on it too!

But it has not. And with a 22 mm follicle on cd 8, and a lining of 2.9 at trigger, it could have never worked. Moreover, even when I stopped Clomid, my lining stayed thin. For 6 whole months it never grew thicker than 6 mm, despite the Vitamin E, the vaginal estrogen, the acupuncture, the warm baths, the femoral massage, the red raspberry tea, the castor oil packs. I was sure I was doomed and I would be one of those who never recover after Clomid.

Actually, as Dr Sher very well explains in another article, Clomid can be very useful and of assistance, if administered to the right persons. Unfortunately for older women with diminished ovarian reserve and/or a tendency of producing cysts, Clomid might work against them.

 

https://haveababy.com/fertility-information/ivf-authority/clomiphene-citrate-clomid-how-it-works-who-should-use-it

 

So what is there to be done if we cannot afford injectables, but still need a boost to ovulate?

For me, injectables were better. In terms of response, obviously, but also better for my lining.

But in between my many IVF cycles, I had to have some breaks. Having become a sort of infertility junkie (as in what hormones should we do this month to improve our chances) I considered one monthly egg was not going to be enough so I might as well try something. And I tried Letrozole, commonly known as Femara. Two nice eggs, plump lining, cervical mucus not so much, but Hey! that’s me, hello Preseed! And a great estrogen level value at trigger. Basically, Femara got me the same result as some of my high-dose stims, on less money, a bit of headache for a side effect and zero bruises around my navel. Now could a girl ask for more than that?

You will even find below a comparative study between the two, mostly in terms of side effects. Interesting read.

http://online.liebertpub.com/doi/abs/10.1089/gyn.2012.0033

I am no doctor and my aim is not to dissuade you from using Clomid and asking your doctors for Femara. Or for anything else, for that matter.

But it has struck me as crazy that there are doctors out there who prescribe Clomid in huge doses, and for much more than 5 days. Doctors that allow their patients to do several back to back cycles with Clomid (one lady was at her 7th!!!). Ever since I started this journey, and now that I am continuing it here on the blog, in front of you, my mantra has been “Know your body, educate yourself, do not follow blindly”.

And even if at the end of the day you decide together with your doctor that Clomid is the solution for you, at least you would have made this decision knowing your cards, aware of risks, and watching out for bad side effects that might negatively impact your outcome.

After all, we all want one and the same thing: to arrive at the end of this infertility road if not with success, at least with the conviction of having tried everything and having fought to improve our chances.

Although I have to agree success is sweeter. And I wish it for you as I wish it for myself 😉

 

Sources:

http://www.haveababy.com

http://www.liebertpub.com

 

Advertisements
Infertility

The CD 3 tests-how important and what do they predict?

If you are familiar with fertility treatments or  if you just had an assessment of your ovarian reserve because you are trying to conceive, the term “3 day tests” rings a bell to you.

Day 3 testing (can also be done and day 2 or 4) consists of bloodwork used to measure hormone levels (FSH, Estrogen, Progesterone, LH) and a scan, meant to measure the number and size of your Antral Follicles. Your AMH level can be measured anytime and if you need to have it measured more than once, it is preferred to do so using the same laboratory, because measurement scales vary for every lab.

E2 (Estrogen) is the main female reproductive hormone, it is being secreted by the ovary and helps to stimulate follicle growth and prepare the lining for implantation, in case conception occurs. The majority of the fertility clinics would want you to have an E2 level under 50 (some under 80) on your day 3. Too high an estrogen level on this day might suggest you have a cyst producing estrogen, in which case stimulation might not be advised. Feeding it stimulation meds, the cyst might not only “eat up” the meds destined for your other normal sized antrals, but also grow and grow until it bursts. A too low estrogen level is not ideal either, suggesting diminished ovarian reserve and possibly  peri/premenopause. Also, very important, when your Estrogen levels are high, the value of the FSH is artificially lowered.

FSH (Follicle-stimulating hormone) as the name tells us, is the hormone that stimulates the ovary to make the eggs grow. Released by the brain, the FSH tends to get higher and higher as we age, and our ovaries struggle more and more to produce an egg. The ideal FSH level is under 10, the lower the better. Some clinics would accept you for fertility treatments with an FSH under 15, but there are tons of studies out there showing success rates diminish seriously as 3 day FSH levels increase. That might explain why older women with high FSH have better chances getting pregnant naturally than with IVF treatments. This being said, if you need help to procreate, there are lots of clinics who offer natural IVF for women with high FSH-meaning no meds, egg retrieval for possibly just one egg, and fertilisation as needed (normal or ICSI, IMSI etc)

LH (Luteinising hormone) helps mature the follicle and eventually, when an LH surge occurs in the end of the follicular phase, helps the release of the mature follicle. The ideal level is under 7 mIU/ml with a ratio LH:FSH of 1:1. An LH much higher than the FSH might be an indication of PCOS (Polycystic Ovary Syndrome).

P4 (Progesterone) should remain low during the follicular phase (under 1ng/ml) and rise after ovulation, as proof the ovary released the egg. The low limit used as indicator for ovulation at 7dpo is 5, but the higher the better. Some women with low progesterone might need progesterone supplementation in order to maintain pregnancy.

AMH (Anti Mullerian Hormone) is a free circulating hormone released by the small antral follicles present in your ovaries, and it is used to assess your ovarian reserve, as in “how many eggs do you still have”. Taken alone, it doesn’t amount for much, and it is far more reliable when discussed in conjunction with the other day 3 levels, and most important, with the day 3 scan. Also, it is important to know that the AMH level has been proven to be artificially lowered by low Vitamin D levels.

Ovarian ultrasound/scan: it is meant to count and measure the antral follicles. The antral follicles are small follicles (between 2-10 mm) found in your ovaries at the beginning of the follicular phase. They are an extremely important and very useful assessment of the way your body might respond to fertility treatments. Each antral contains an immature egg that might develop and ovulate. During natural cycles, the body recruits what is thought to be the best follicle, and makes it grow and eventually ovulate once the Estrogen level is high enough (200-600 E2 level/mature follicle) and the LH surge occurs. In stimulated cycles, all antrals have potential to grow, and even sometimes, some more follicles pop up during stims.

Those are the main tests performed during the day 3 assessment. The list is not exhaustive, though. Depending on your clinic and your health issues, you might have your prolactin and thyroid levels checked, or any other test your doctor might consider appropriate.

Unfortunately, there are some clinics who perform this testing once a year, and consider it available in subsequent cycles. Whether for logistic or financial reasons, this is bad. Hormones fluctuate every God given month, and once you have your period, they are reset and you start the new month with a clean slate. It is possible to have an FSH of 6 in January, and an FSH of 14 the next month, and you surely won’t have the same response to meds during those two months if you are to cycle. Hence the importance of demanding those 3 day tests at the beginning of each and every cycle using stimulation meds, to spare you the heartbreak, the false expectations and yes, the waste of money.

In a future article I will bring to your attention a list of supplements with great effects on your fertility, and the links to the medical studies that attest it.