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


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.


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.

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 😉





Low dose vs High dose stims-what is the best approach for DOR and does it really make a difference?

In the Facebook groups I am an administrator of (the Low AMH, the TTC over 35 and the TTC over 40) not one week passes without someone complaining a high dose stimulation cycle failed her and she was directed towards donor eggs.

Obviously, it comes a time in the fertile life of every woman, when her eggs will no longer be good. And when the body really can’t deliver anymore, the science can’t do much about it. But until this happens, the vast majority of women I come into contact with (virtually) prefer to exhaust every possibility of using their own eggs.

As I have mentioned it before, and many of you already know first hand, IVF works by narrowing down the chances to finding the better egg. This being said, the more eggs you produce, the better chances you have for success. This is why some clinics turn off clients with low AMH and diminished ovarian reserve, for fear this clients won’t be able to respond well enough to treatments, to produce enough eggs to ensure a positive outcome-this resulting in negatively affecting their success rates. Those clinics will probably serve you the donor egg speech even without considering treating you.

There are of course other clinics, the majority of them actually, who really believe they can do well, and take you in. They treat you just like they treat their “fertile”patients (let us not forget for a moment that IVF was initially conceived to overcome male fertility issues and tubal problems) and therefore they try to make you produce as many eggs as possible, cause the more eggs the merrier with IVF, right?

Even more than that, they will have the tendency to give you higher doses then they use for their “fertile” patients, because they know your DOR makes your ovaries pretty lazy, and they believe higher doses of stims compensate for your ovaries’ lack of reactivity. This was indeed the approach several years ago. Since then, lots of studies have been performed and facts have proven otherwise.

What I am going to tell you next, is my own personal experience…

I started my IVF adventure in March 2014, on my 40’th anniversary. My RE was one of the most appreciated REs at the American Hospital in Paris, and I just loved his calm and poise, and the patience with which he answered all our questions. All my tests were perfect, except for my AMH who came back at 0.5 only to throw me into a black despair. Little did I know about AMH  back then, or that I shouldn’t pay too much attention to it. I had gotten pregnant precisely 10 months ago, naturally, like I always did, on the first month trying. Unfortunately and very unfairly if I may say so, I lost our little boy at 16 weeks because of an incompetent cervix (that I later corrected through surgery in USA).

My RE told me the same story most of your REs tell you: your AMH is low, we have to be pretty agressive in order to make the most of these ovaries of yours….He started me on an agonist, a French kind of Lupron, and high doses of Gonal-450 if I recall well. My AFC was (and still is to this day, 3 years later) between 9 and 11 on CD3. As the days went by and my retrieval approached, I could see my follicles disappearing: 11 became 8, then 6, then 4…eventually that cycle we got 3 eggs…To say I was disappointed would be a huge understatement. We converted to IUI and when I asked him what the heckity heck happened, he shrugged and told me morosely: “Your AMH is 0.5, what did you expect?” Yeah, I wanted to kick him…

But I didn’t, and when I got a BFN, I went to see him again, and I asked him how did he prefer to proceed for the next cycle? Should we try an antagonist protocol? (You see, in the meantime I had discovered fertility groups, I started to read studies, articles, and educate myself-my journalistic self forbad me to act like sheep and pushed me into finding out the “truth”, my truth.) He replied contemptuously “Oh, but the antagonist protocol is such a bullshit, I don’t believe in it, I only do this protocol and it works so well for my patients”. I knew then it was time for us to part…I don’t believe in making the same mistake twice, on purpose. And I left…

For another famous French clinic, a public one this time. Horrible conditions (you, my American readers won’t understand this but believe me-horrible conditions, lol) fantastic doctor. I was pretty impressed by his CV until he told me “You are in the best hands, I am the best in France, you will NE-VER find another RE better than me in this country”…..ughhhhhhhhhhhhhh…ok………But I stayed…4 IVF (high dose and local anaesthesia only for retrieval) and 1 IUI later, still BFN, not even a chemical. I would like to give him this though: he tried! He changed protocols every cycle. We did Gonal, Pergoveris, Menopur, Puregon. We did testosterone priming (the worst for me, 2 AFC instead of my usual over 9) estrogen priming (he was the first RE  to ever use this protocol, he invented it)….We did everything!!! The only thing we didn’t do was low dose. Whatever he did, I was on 450 FSH and some 150 LH and the best results I ever got with him were 3 lousy eggs, with a 100% fertilisation rate, giving me 3 lousy embryos. One day, I went to see him and I told him I am willing to leave him and go to London to a clinic I have heard did low dose IF he didn’t accept to do the low dose protocol another RE in NY gave me over the phone, after having sent her all my medical records. He said sure, sure, we will do whatever you want, just know that this protocol is “counterproductive” and you will never get more eggs than that. He therefore prescribed me the usual 450 Puregon and the 150 Menopur the freaking same protocol we had done the previous month. I just couldn’t try to reason him anymore, so I left.

I went back to my obgyn and we did the low dose protocol – IUI, bam, 5 follicles.  It was a huge surprise for both of us. She considered that I respond too well and in case I wanted to do another cycle (that IUI cycle was still BFN) I would be better off doing IVF. She spoke to my first RE and she asked him would he accept performing IVF with my protocol  next time? He said yes! We did it in April and we got….8 eggs. 6 fertilised, 4 embryos, 3 were pretty poor quality and were transferred on day 3, and one was kept growing but it arrested later that day.

BFN yet again. But my actual (and ex first RE, lol) changed the tune. He was so super amazed by the wonders this low dose protocol did for me, that he wrote it down. Where he once told me my AMH was so low I had nothing to hope for, now he is very optimistic we can make this work and it is worth trying despite me being 43 now. He put me on Inositol (I am also taking Ubiquinol, Vitamin D, Folic Acid, Zinc and L Arginine) and he wants me to try again in September, to see if over 3 months of supplements intake managed to positively impact the quality of my embryos. Which is exactly what we will do.

This journey, as well as the experiences of so many of you out there who did much better on low dose (or even natural IVF cycles) made me think of a comparison between cars. Take a Lamborghini and a Fiat 500. Both brand new. The Lamborghini can go up to 200 miles per hour, The Fiat only to 120 per hour. If you push the pedal of the Lamborghini you can definitely make it ride up to 200 miles per hour, and she will. But there is no point pushing the pedal of the Fiat to try and make it ride at 200 miles per hour too. She won’t be able to. Because all she can do is 120. And forcing her to go to 200 won’t actually make her go to 200. But what can happen is she can break. It’s the same for us. Pushing huge doses of stims into ovaries able to produce a certain quantity of eggs  won’t necessarily make them produce more eggs. Hence the “bad response” we hear about all the time. More often than not, DOR patients see their ovaries block and don’t function ok on high stims. While a gentler approach, a milder stimulation, gives them better results.

This has not been discovered only by us, patients, but it has become a trend lately in the medical world. Studies have been performed that have proven mild stimulation and in some cases even natural IVF (that is no stims at all, just one egg retrieved) work better for DOR patients, aka “bad responders”. Some REs will tell you live pregnancy rates are low for natural and low dose IVF – and they are, when you compare them to the high rates of normal responders. But when you compare them to the results bad responders have after failing cycles on high doses, you will find that something is still better than  nothing. There are more and more clinics offering this low dose approach. One of them is CreateHealth in London who exclusively treats patients with diminished ovarian reserve. There are others too, and if you have come across one, I would ask you to comment with the name and location, in order to help other ladies.

Whatever protocol you and your RE choose, just keep in mind that IVF is really trial and error. It is pretty rare for an IVF patient to be successful on the first cycle, and this is even truer in the case of  poor responders. Therefore, if your first IVF cycle fails, do not despair. Chances are you will have learned a lesson and you will know what and how to do better next time. And know that unless you try, you cannot really know how you will respond, either to low doses or high doses. The most important thing is to have the luck to come across a doctor who knows DOR, who is familiar with both approaches not only the aggressive one, and who is willing to work with and for you, to get you the best outcome. And that would be a baby 🙂

Meanwhile, you might want to take a look at these recent studies, giving hope to us, poor responders who might want to use the milder approach versus the aggressive one.

Comparison of IVF Outcomes between Minimal Stimulation and High-Dose Stimulation for Patients with Poor Ovarian Reserve


Natural IVF cycles may be desirable for women with repeated failures by stimulated IVF cycles