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

 

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Infertility, Ivf

Priming protocols-what with and who for?

I am going to address a very debated topic and one of huge interest for those who carry the tags DOR or POF and need ovarian stimulation for assisted reproduction.

The way IVF works, we all know the more eggs we make, the better it is. And this because in vitro fertilisation is all about narrowing down the chances to finding the best egg(s). It is a matter of logic because more eggs retrieved will give us more fertilised eggs, hence higher chances of pregnancy. Also, women who respond better to stimulation protocols usually have a better egg quality (PCOS do not enter in this category of better egg quality, we will discuss this later on). Last but not least, “the more eggs the merrier” principle has also financial connotations. With prices so high for stimulation meds, monitoring, retrieval and laboratory, you’re far better off paying thousands and thousands for ten eggs than for one.

While women over 35 and those under 35 but dealing with POF and DOR might be worse responders than the fertile population generally is, lots of protocols have been invented and experienced over the years, some of them with great results and quite encouraging pregnancy rates. One of the approaches is that of using luteal phase adjuvants, hoping to create a better environment for the follicles and preparing the ovaries for the following stimulation cycle.

BIRTH CONTROL – By far the most used approach before a medicated cycle. Its main purpose is to give your ovaries a rest, and give them the chance to start the next cycle with a clean slate. Useful for reducing cysts, it also comes, unfortunately, with a bad side effect: the dreaded suppression. BC pretreatment in IVF protocols establishes an estrogenic environment and increases sex hormone-binding globulin levels while decreasing follicular androgen levels. But by putting the ovaries to sleep the risk is they might not wake up well enough… Sometimes, we end up with a lower antral follicle number, and we are facing the need of stimulating for a longer period of time, and with higher doses of stims, which might in turn, affect egg quality for older patients.

Here is a very interesting study, where  even young egg donors have experienced lower AMH levels and lower numbers of oocytes after being put on birth control.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637242/

If in the case of a young donor, having  5 eggs retrieved  instead of 10 might not make much of a difference, because donors are chosen to be young and healthy, therefore having a great egg quality, things are quite different with us, older women, where quality as well as quantity might be a problem.

TESTOSTERONE PRIMING- Relatively new,  and controversial. If you listen to Dr Sher, a very famous and respected Reproduction Endocrinologist, you should run away from testosterone exposure, especially if you are not very young anymore. If you listen to me, LOL, my biggest failure of a cycle was the one I primed with testosterone gel. While I usually would have an antral follicle count of 9-10, one week of testosterone gel reduced my AFC to a whopping 2 (two), and thats what I got until the end of stims, when I told my RE there is no way I am going to waste an IVF cycle on two eggs, and converted to IUI. Even he himself later admitted that testosterone priming was a mistake in my case (I was 41 at the time, this might have been a reason) and he is known to be a very stubborn and proud one…And it was no coincidence: all the other cycles I ever did (and we are talking 12 with full protocol, my afc was never under 8)

This being said, there are many studies out there who scientifically prove testosterone priming works for many low responders. If you read this analysis of several studies (https://http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4061182/) you will see the mean age of the patients was 36-37, so there….probably that’s the key, being younger is better for testosterone priming. I personally guess there is no way of knowing until you try.

Oh, and most important: I grew no beard during the treatment, neither did I engage in violent exchanges with people in pubs 😛

ESTROGEN PRIMING– It avoids the suppressive effect of BCP on the ovaries. In addition, the use of estrogen during the pretreatment cycle prevents premature recruitment of follicles that can reduce the number of follicles available for stimulation. Studies have shown that this protocol allows more gradual and coordinated growth of follicles resulting in improvement of embryo quality and quantity. For me this has been the only way I could avoid the growth of the horrible LEAD follicle, the scarecrow of IVF…I personally took estrace pills, but patches are used with the same success.

You might want to read this study https://www.ncbi.nlm.nih.gov/m/pubmed/22160464/ and also this analysis of several studies https://www.ncbi.nlm.nih.gov/pubmed/23887073

I believe it is essential to have a doctor you really trust. I, for one, could not trust any doctor who insults my intelligence by imagining that in this age and time I have no ways of gathering enough information as to educate myself on matters concerning my health and my life. Would this auto-education give me a medical degree? Obviously not! And I do not pretend it does. What it does give me, is at least basic knowledge, so useful in understanding where I stand, and if the direction I am heading to is the good one. It gave me the power of standing up and saying NO, when I knew for a fact that the approach I was suggested would be wrong for me (I wish I knew what I know now, when I was suggested the testosterone priming…) It gave me the power to fight me RE for the estrogen priming protocol, that as an anecdote he himself invented, but not so much used afterwards, for fear of oversupression. I fought him and he gave in, and later admitted I was right. It also gave me the power to say NO to him for yet another high dose stimulation protocol, and when he wouldn’t give in and would insist low dose is “counterproductive” for low responders (sic!) I would say bye to him, and find another RE who was willing to try on me my estrogen priming low dose protocol. And we got 8 eggs, instead of my usual 2-3.

I don’t know if it is my journalistic background, or maybe just me being a stubborn Aries, but I am a strong believer in the “Knowledge is power” part, as much as it might sound  like a cliche.

Apparently you believe so too, or else you wouldn’t be here, trying to find out more ❤

Sources: NCBI