Fertility Meds

[katespade]

Sorry, this post got long and ramble-y, but I have a lot going through my head right now so here it is:

I saw my GYN on Thursday and we talked about next steps, since I’m still not ovulating regularly.

Is Clomid the only/best med for ovulation issues? I know I’ve seen other meds mentioned here, but that’s the only option she gave me. She said we can start out on a low-ish dose (15mg?), and the only monitoring they’d need to do is an exam at the beginning of each cycle to check for OHSS.

The OHSS thing really freaks me out. Since I only have one ovary, there aren’t really any second chances if something goes wrong. I’m starting to wonder if it’s worth the risk when it’s not like I never ovulate, I just don’t ovulate very often.

Also, is it normal for them to have your SO do a SA before they start you on fertility meds? Are there other tests they usually run, too, on either of you? I’m kind of surprised that they don’t want to do much in the way of hormone level testing for me, especially with my autoimmune disorder and super irregular periods. He’s fine with doing the SA, but I’m worried that we might be missing something that could be fixed without needing Clomid.

I mentioned having her send a referral to my endocrinologist for fertility related testing (because my endo mentioned it as an option at my last appt), and she brushed it off. Should I push harder for that? I have my regular appt with my endo next month, but I don’t think she can talk to me about TTC stuff without a new referral.

Thoughts? Opinions? Insights? Hints? Tips? Hair pats? Anything?

[seeyalater52]

Not to be alarmist, but it doesn’t sound like your GYN knows what they are talking about. They are good at caring for women during pregnancy but very few are experts in getting pregnant.

Clomid and letroxole (femera) are the two oral meds commonly prescribed. Do you have PCOS? Some REs prefer letrozole for women with PCOS and others because it can reduce the likelihood of multiple follicles depending on the dose compared to clomid, which was why I was on it. Clomid can also thin the uterine lining and is generally not recommended for more than about 6 cycles. There are also injectable medications that can be used to induce ovulation but usually that is not a first option.

Yes, your husband should have a sperm analysis. That can help inform next steps, as even though you may assume the issue is on your end due to observable symptoms he may also have contributing factors. You should know that before you start spending money on treatments that may or may not be an appropriate course of action depending on those results.

A lot of infertility is unexplained but at the very least I would expect the normal battery of testing (including a sperm analysis) to get some insight into what the issue might be. Have you had an HSG or saline ultrasound to check your tubes and uterus? Without testing they’re basically just making a decision without all the evidence that ovulation is the only issue which seems like it might not be very helpful.

[seeyalater52]

All of the above goes double since you know you have autoimmune stuff going on.

A billion hair pats. I’m frustrated for you that they’re brushing you off!! I definitely think you should push for a referral. If your GYN refuses to do it you might want to look into seeing another doctor who will, or even taking to your endo about whether they can advocate for the necessity of the referral to your PCP.

[melsamoony]

No real input on meds as I don't have experience with them but in terms of referral there should be no reason your endocrinologist can't discuss reproductive testing at your regularly scheduled appt even without the referral specifying that. Referrals are for insurance purposes and they help give docs a heads up on what to expect to be handling in a new patient. Do you have an HMO insurance? If you have an open access HMO or a straight PPO you can go to any doctor/specialist without a referral.

I agree with seeyalater that it may be time to explore seeing a fertility specialist (re). Your endocrinologist may have a recommendation.

[lo]

I would absolutely see an RE if you can. It seems like all GYNs just prescribe clomid with hardly any testing or monitoring. Even when I was prescribed clomid at the RE, I was still going in for several appointments for bloodwork and u/s. Without that monitoring I would have never known it thinned my lining way too much and then gave me a cyst (which went away but still had to sit a cycle out).

[compassrose]

I think it’s actually extremely common to just start you on clomid or letrazole for a few months and see if that’s successful before doing other expensive or invasive testing.
With your autoimmune issues, you might want further testing, yes, but I actually don’t think it’s a terrible plan to just try letrazole for a couple of months to see if it works for you.

[grover]

My GYN would not prescribe meds and instead referred me to the RE. Even my current OB who delivered DD wouldn't prescribe me femera now.

The RE took both H and my family and personal histories. I had bloodwork (CD3, CD21, and then STD testing), a few ultrasounds at various points in my cycle, a saline sonohystogram, and H had STD testing and two semen analysis. After the results came back unexplained IF, she started me on an IUI cycle (said there wasn't much point in a clomid only cycle) with Femera for 5 days at 5mg and an ovulation trigger shot two days prior to the IUI.

[megstoo]

We just in cycle 1 using clomid. That's what my OB started me with. He wanted to go that route before we go to an RE this way the ground work has already been done and if we do get preg with clomid we've saved the money from seeing an RE to start since insurance doesn't cover anything. We started with clomid 50 and so far I haven't ovulated and I'm on CD 24 right now. After this cycle we'll go up to 100 mg and then finally up to 150 before an RE.

I also don't ovulate on my own but I also have PCOS. Has your OB done any other testing such as the blood work, semen analysis or an HSG?

[katespade]

seeyalater52 - As far as I know, I've never been tested for PCOS. I have had cysts found on ultrasounds in the past, but no one has ever mentioned that as a concern or a need for additional testing. I've also had multiple doctors suspect that I have endometriosis, but haven't reached the point of confirming that through laparoscopy. I've never had an HSG or saline ultrasound, just regular pelvic ultrasounds throughout the years to look at various things, which is how I know I've had cysts in the past and how we found out that I only have one ovary. At my last ultrasound, they were able to confirm that only my right ovary is missing and my uterus appears to be fully intact and correctly shaped (though it is tilted off to the left).

[katespade]

compassrose - Is letrazole the same thing as Clomid? If not, is there a notable difference between the two?

[compassrose]

Feb 12, 2018 12:22:31 GMT -5 katespade said:

compassrose - Is letrazole the same thing as Clomid? If not, is there a notable difference between the two?

No, letrazole is the generic for Femara, which is very similar to Clomid, but they have different success rates for different issues. Some doctors prefer one over the other, but you can't be on either one for more than 6 months. 

[somersault72]

I did one round of Clomid, and 2 rounds of Femara (lowest dose for both). My OB prefers Femara because she says it makes your lining thicker. Also, people tend to have more side effects on Clomid, although I didn't have any with either one. My doctor also would not do more than 3 medicated cycles before moving on to IUI because she said your chances go down after 3 medicated cycles.

As far as PCOS, your ovary should have signs on it on ultrasound, (we call it the "string of pearls" sign), but bloodwork can also help confirm a diagnosis. We will NOT typically see endometriosis on an ultrasound.

Did they say anything about monitoring you on Clomid? You should have an ultrasound to see if you have any follicles as well as document the sizes of said follicles.

Finally, if you are unhappy with the care you are receiving, I would certainly not hesitate to look for another doctor. You should not be feeling blown off by your doctor. Big, big hugs to you.

[larzhope]

I can't echo the recommendations enough to go see an RE. My gynecologist was not very knowledgeable about fertility issues. I don't think you should do the clomid without monitoring (as others have referenced). My RE basically said the reason monitoring is so important is because they essentially guess at a dose to start you off with, and if your body produces too many follicles, they don't want you to have timed intercourse that month because the risk of multiples is much higher - and no one wants to be octomom

As far as Clomid vs. Femara (letrozole) - my RE gave me the choice and clearly outlined the pros and cons. As somersault72 mentioned, Clomid is known to have crappy side effects (mood swings, irritability, and thinning of your lining) where as Femara the side effects are less. The kicker is that Femara is not traditionally a fertility med - it's indicated to treat breast cancer, so my RE was very upfront about that - the "side effects" just happen to mimic the primary intention of Clomid. I chose Femara and was very lucky the first cycle, despite us all (me, H and the RE) not thinking it would work. My RE believes you can try anything up to 6 cycles and then switch, but obviously some RE's would have you move on more quickly (and thankfully, the Femara was incredibly inexpensive for me - I think I paid $3, but I know typically it is about $30 for a month's supply, so I was willing to give it more time).

Lots of different options though - you can do Femara/clomid with timed intercourse, Femara/clomid with a trigger shot + timed intercourse (our successful method), or the meds with an IUI, along with a bunch of other combinations I'm not listing here/not aware of. That's why it's so important to have a fertility expert, imo guiding you, especially since you have PCOS/endo.

[swiftlyirun]

Chiming in a little late here, but thought I’d offer my 2cents since I’ve had 2 pregnancies with PCOS and anovulation.

DH and I TTC for over a year and after no success saw a RE. The RE quickly diagnosed me with PCOS. Despite what some may tell you, there is no clear way or test to diagnose every case of PCOS. My only symptom was anovulation and some cysts on my ovaries. However, I wasn’t overweight, no random hair growth, or “string of pearls”. My RE is literally one of the best in the country and his words were something to the effect of, if you don’t ovulate, you can’t get pregnant so pretty much everything else is a moot point right now. DH did do a sperm analysis, which is important because there is no point in putting you on meds right away if there is a sperm issue also. Also, an HSG could shed light on any blockage you might have in your ovaries.

All that being said, I did a two cycles of fermara with OB before going to the RE but ultimately moved quickly to the RE because being closely monitored was important to me. I had to wait several cycles with RE because I had a large cyst on one of my ovaries which ended up having to be surgically removed. I’m so glad I chose to move to the RE as the monitoring they did identified the cyst which easily could have been overstimulated with another round of fermara or clomid (initial rounds likely caused it in the first place) and burst causing further damage. I ended up conceiving shorlty after surgery with Clomid.

For my current pregnancy I needed Clomid again and a HCG trigger shot. I went straight to the RE when we decided to TTC #2 on the recommendation of my OB.

If I were you, I’d consult with an RE if possible.

[thoseareradishes]

A typical fertility workup includes CD3 blood work, an HSG, an SA, an ultrasound, and sometimes blood work ~7DPO. Once all the results are in, you make a plan about what to do. Without testing, you don't know the full picture about what's going on - what dose of meds? Are your tubes clear? Are the sperm all good?

There is this cavalier attitude (not you, in general, especially with OBs apparently) about fertility meds that I never understood. For instance, what if you went to the doctor and said you were thirsty all the time and they just put you on insulin for a few months because they assumed you have diabetes, without any testing or monitoring? Nobody would think that's okay. But it's done with fertility meds all the time.

I'd see an RE, get a full workup, and go for there.

[pickel]

My OBGYN put me on Femara (2.5mg) last month and upped it to 5 mg this month. We ended up making an appointment with a RE because we were both a little uncomfortable with fertility meds and no monitoring, and we seemed to be heading that way anyway. My OBGYN waits until three failed cycles before getting a SA done. Which to me, seems like a lot of wasted time, and also, like you said, what if the problem is something that doesn't require a fertility med. I did not get a referral from my OBGYN for the RE, we just went. Since I'm already CD 8, the RE didn't do any testing but will if need be next cycle (FSH and Estradiol). I thought a RE would be really hard to get into and stressful, but we got in within a week and it was pretty laid back. I also feel a TON better knowing that they will be monitoring me from here on out and that there is a plan in place moving forward.