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Thread: Questions after First IUI w/ Clomid & Ovidrel

  1. #1
    Join Date
    Feb 2009
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    8

    Default Questions after First IUI w/ Clomid & Ovidrel

    Hello,

    I am 34 years old with one successful pregnancy (achieved without trying) in 2005, the result of which is my 3.5 year old son. Under the care of a board certified RE, I had an IUI on 5/26 after taking Clomid CD3-7 and an HCG trigger shot (Ovidrel Sub-Q) on 5/24. At my ultrasound on CD3 I had an antral follicle count of 45 - 26 on the right side and 19 on the left side, and had normal CD3 bloodwork. On 5/23 I had one dominant follicle on the right measuring 18.5 mm and one on the left measuring 15 mm. My lining was "good" according to the ultrasound tech and I was told that my bloodwork showed levels acceptable to trigger (I didn't get the exact numbers). My RE had instructed us to have intercourse the night of the trigger shot and we did. Then, on the morning of the IUI my husband produced his sample at home, and drove the 30 minutes to the RE's office, as instructed. His post-wash count was only 4.1 million. The RE indicated that the chances of success with such a count were very low, but we went ahead anyway.

    We have been put in the "unexplained" category. I have relatively regular cycles (although sometimes on the longer, i.e., 35-40, day side) and appear based on temperature charting and OPKs to ovulate every month. My luteal phase is regularly 12-13 days. I may have "mild PCOS" although my only real symptoms are excess facial hair and difficulty losing weight (I am not obese, just about 10 lbs heavier than I want to be). I had normal CD3 bloodwork, an HSG, endometrial biopsy, post-coital test, and my husband has had 2 sperm analyses. All came back "normal." We have been trying to conceive for 17 cycles, this was our first with any medical assistance from an RE.

    I have a few questions regarding changes we might make if this cycle is not successful:

    1. My husband's last sperm analysis showed the following:

    volume: 6.8ml (>2ml norm)
    Concentration:39 mil (>20 mil norm)
    Motility: 67 % (>50% norm)
    Total motile sperm: 178 (>8 norm)
    Morphology (Kruger): 6% (>15% norm)

    The RE termed this a "normal" sperm analysis despite the low morphology number and explained that the other numbers "make up for it." In February, I put my husband on Pyncogenol (200 mg/day) in addition to the Fertilaid that he is already on in an attempt to improve the morphology. He does not take any other medication and has cut out caffeine, but does still drink alcohol, which I'm trying to get him to eliminate entirely since we had the bad result on the IUI. The RE stated that there were no other supplements or changes he should make to improve the analysis, but that in the future we should abstain from intercourse the day of the trigger shot (and perhaps for up to 5 days before my IUI).

    Do you agree that intercourse on the day of the trigger shot could be part of the problem? Or are we better off getting the "extra exposure" that comes with intercourse close to the HCG trigger, to protect against the possibility that I might ovulate sooner than 36 hours after I get it, which is when the IUIs are scheduled for at my RE's office.

    Also, are there any supplements/vitamins you would recommend that he add to his regimen that might be beneficial?

    Is there a possibility that we would have a better result if he produced the sample at the RE's office? I had heard that it doesn't matter because the sperm has to "sit" for a while anyway to liquefy before they can begin the wash process, but wanted to double check on that. My RE does recommend producing at home, but has rooms available for that purpose if needed.

    How about acupuncture? I have been going 1x per week since January but he has not been at all. I am aware of the studies on improved IVF success after acupuncture in females but am not sure if it can help male infertility problems.

    2. Because I only showed one dominant follicle, is there any use in increasing the Clomid to 100 mg? Or is it the case that if one ovulates at all on Clomid upping the dose won't help? I had abundant cervical mucus while on the Clomid and was told that my lining was good, and also did not experience any troublesome side effects, so am happy to increase the dose if there is any chance of that working. Or, should we consider changing to a different medication for me to increase the number of follicles? With my husband's low morphology (and at the IUI, low count) I am wondering if giving the sperm more "targets" would be helpful.

    3. Is there any utility in having his sperm analysis re-done before the next cycle? It has been over 3 months since the last one, and they did not measure morphology at the IUI, so that is a big unknown.

    4. Finally, how many IUIs would you recommend before moving on to IVF, particularly if my husband's count does not improve? If it matters, I am 34 and will turn 35 this July, so I feel my clock ticking and know that the IVF success rates go down after 35. I believe my insurance company will cover IVF only after 3 unsuccessful IUIs, but if it is likely to make a big difference in success possibility to move more quickly than that, we are open to the possibility. At the same time, if I had IUIs in May, June, and July, conceivably I could do IVF in August or September, so just 2-3 months past my 35th birthday.

    Thanks for any thoughts you might have.

  2. #2
    Join Date
    Feb 2009
    Posts
    8

    Default

    Hi Dr. Roseff, just bumping this up in case it was missed, I know the site was down for a few days after I posted. Thanks for any insight on my questions.

    Hope

  3. #3
    Join Date
    Sep 2008
    Posts
    851

    Default

    Hi,

    Sorry I didn't see this until today, due to the site being down:

    1. My husband's last sperm analysis showed the following:

    volume: 6.8ml (>2ml norm)
    Concentration:39 mil (>20 mil norm)
    Motility: 67 % (>50% norm)
    Total motile sperm: 178 (>8 norm)
    Morphology (Kruger): 6% (>15% norm)

    The RE termed this a "normal" sperm analysis despite the low morphology number and explained that the other numbers "make up for it." In February, I put my husband on Pyncogenol (200 mg/day) in addition to the Fertilaid that he is already on in an attempt to improve the morphology. He does not take any other medication and has cut out caffeine, but does still drink alcohol, which I'm trying to get him to eliminate entirely since we had the bad result on the IUI. The RE stated that there were no other supplements or changes he should make to improve the analysis, but that in the future we should abstain from intercourse the day of the trigger shot (and perhaps for up to 5 days before my IUI).

    Do you agree that intercourse on the day of the trigger shot could be part of the problem? Or are we better off getting the "extra exposure" that comes with intercourse close to the HCG trigger, to protect against the possibility that I might ovulate sooner than 36 hours after I get it, which is when the IUIs are scheduled for at my RE's office.
    ==> Intercourse the night before IUI can definitely lower the sperm count. We discourage this....


    Also, are there any supplements/vitamins you would recommend that he add to his regimen that might be beneficial?
    ==> With all due respect to your RE, I think a Kruger morphology of 6% is low and warrants follow-up (varicocele? etc.). Sounds like you have him on good supplements (did you get the Pycnogenol data from me?).

    Is there a possibility that we would have a better result if he produced the sample at the RE's office? I had heard that it doesn't matter because the sperm has to "sit" for a while anyway to liquefy before they can begin the wash process, but wanted to double check on that. My RE does recommend producing at home, but has rooms available for that purpose if needed.

    How about acupuncture? I have been going 1x per week since January but he has not been at all. I am aware of the studies on improved IVF success after acupuncture in females but am not sure if it can help male infertility problems.
    ==> All of my patients are referred to a phenomenal acupuncturist we work with, and she's BOARD CERTIFIED in fertility acupuncture. Is yours?

    2. Because I only showed one dominant follicle, is there any use in increasing the Clomid to 100 mg? Or is it the case that if one ovulates at all on Clomid upping the dose won't help? I had abundant cervical mucus while on the Clomid and was told that my lining was good, and also did not experience any troublesome side effects, so am happy to increase the dose if there is any chance of that working. Or, should we consider changing to a different medication for me to increase the number of follicles? With my husband's low morphology (and at the IUI, low count) I am wondering if giving the sperm more "targets" would be helpful.
    ==> Clomid is designed to help women who don't normally/regularly ovulate an egg to ovulate. If a woman DOES ovulate normally on her own, then taking Clomid can potentially work AGAINST her! Here's an excerpt from a paper I wrote several years ago for INCIID:

    Clomiphene is usually started at a dose of 50 mg (one tablet) per day for five days per menstrual cycle, beginning on the third, fourth, or fifth day of the cycle. Starting the drug earlier tends to induce ovulation somewhat sooner in the cycle, and may also increase the odds of developing more than one egg. It’s crucial to be monitored while taking clomiphene (rather than simply going home and taking it month after month), so as to determine if it’s doing a proper job. If you ovulate on a particular dose of clomiphene, there’s generally no benefit to increasing the dosage on a subsequent menstrual cycle.

    This medicine can also have some adverse effects on your fertility, and it would be beneficial to assure these haven’t occurred. Possible negative effects of clomiphene that can interfere with getting and/or staying pregnant include, but aren’t limited to:


    • Decreased or “hostile” cervical mucus
    • Thin uterine (endometrial) lining
    • Disordered uterine lining at a microscopic level


    Your doctor can check your mucus around the time of ovulation if intercourse is planned, or intrauterine insemination (IUI) can be scheduled to “bypass” potential mucus problems and optimize the odds of becoming pregnant. A sonogram can be done to assure the uterine lining isn’t too thin, and an endometrial biopsy can be performed to check the endometrium at a microscopic level to assure it has properly developed for pregnancy implantation and maintenance.

    One final note on clomiphene – As I mentioned earlier, it’s generally not a true fertility drug. There are clear indications for it, and if you’re a clomiphene “candidate” it works quite well. But, if you don’t “need” this medicine, then it can potentially work against you by preventing you from getting pregnant or causing a miscarriage. If you don’t “need” clomiphene , it can potentially “throw a wrench into your works” by interfering with your pituitary hormones, creating poor cervical mucus, thinning out your uterine lining, and creating an environment that’s not conducive to getting or staying pregnant. So, who should not take clomiphene? If you fulfill the following criteria, then you may want to question whether you should be taking this medicine:


    • Regular menstrual cycles every 26-32 days
    • Documented or presumed monthly ovulation
    • Normal peak progesterone blood level seven days after ovulation
    • Normal luteal phase length


    3. Is there any utility in having his sperm analysis re-done before the next cycle? It has been over 3 months since the last one, and they did not measure morphology at the IUI, so that is a big unknown.
    ==> Probably.

    4. Finally, how many IUIs would you recommend before moving on to IVF, particularly if my husband's count does not improve? If it matters, I am 34 and will turn 35 this July, so I feel my clock ticking and know that the IVF success rates go down after 35. I believe my insurance company will cover IVF only after 3 unsuccessful IUIs, but if it is likely to make a big difference in success possibility to move more quickly than that, we are open to the possibility. At the same time, if I had IUIs in May, June, and July, conceivably I could do IVF in August or September, so just 2-3 months past my 35th birthday.
    ==> Most of my IUI patients who will conceive via IUI do so within an average of 3 unmedicated cycles.

    I hope this helps, and I hope your RE is Board Certified!
    Dr. Roseff in Wellington, Florida
    Dr. Roseff - South Florida Institute for Reproductive Medicine - Boca Raton, FL
    PERSONALIZED/SUCCESSFUL Specialty care....

    As you’re not my patient, information herein may be incomplete/inaccurate & I can't be responsible for your actions. This is for educational purposes & should never be used to replace information & care rendered by your own doctor. No part of this message may be reproduced, printed, or posted elsewhere without express written authorization of Dr. Roseff or INCIID.

  4. #4
    Join Date
    Feb 2009
    Posts
    8

    Default

    Thank you so much Dr. Roseff. To answer your questions --

    First, yes, my RE is board certified, although your responses give me some reason to question (which I will do, thanks to this tremendous resource)! As to your other questions:

    Regarding intercourse before IUI -- Sounds like you agree with my RE's recommendation not to have intercourse the day of the trigger for my next IUI -- given my husband's sperm parameters I don't understand why we were instructed to do so this time, but other than complaining it seems like that is water under the bridge. We certainly won't do that again! What period of abstinence, in your view, is preferable? 3 days? 5 days? I have read that longer than that can be problematic.

    Regarding my husband's sperm parameters -- He had an ultrasound to check for a varicocle after his first sperm analysis (which showed lower count than the one I quoted and during which morpholgy wasn't measured) and was told that he does not have one. So, I'm not sure what else could be causing the issues. If there are other tests that can be run I'd appreciate you letting me know. And yes, I found the pyncogenol info on this board and am familiar with your study. I'm going to ask about a repeat sperm analysis as well.

    Regarding acupuncture -- My acupuncturist is board certified in fertility acupuncture. After talking with her, my husband is going to start treatments with her asap to see if she can improve his parameters as well as continuing to work with me.

    Regarding Clomid -- I am aware of the issues with Clomid in women who ovulate regularly but was told by my RE and insurance company that it was the "first line" of treatment they recommend (and the insurance company will not cover anything else until at least one unsuccessful Clomid cycle). My RE said he never recommends Clomid without IUI due to potential mucus issues, and so I had an IUI this past month while on the drug (I also did not notice a reduction in mucus, seemed to have quite a bit). My lining was checked by ultrasound prior to the IUI and I was told it was acceptable, and I've been on progesterone supplements to build it further since the day after the IUI. I did have an endometrial biopsy BEFORE starting Clomid and that was normal, but I'm guessing irrelevant after being on Clomid. My RE does not routinely perform those as part of a work-up (I had mine done while under the care of my OB) or after a Clomid cycle, but I will discuss the matter with him.

    Related to the Clomid, my question is more about whether - aside from potential downsides you identify - increasing the Clomid dose in someone who already ovulates (or ovulated on 50 mg) might cause an increase in the number of eggs or otherwise improve one's chances of conceiving? And also what drugs (if any) you might recommend as a second step if I am able to move onto something else combined with timed intercourse or IUI? Femara (I believe not FDA approved for fertility which concerns me)? Gonal F? Others?

    Regarding moving onto IVF -- Thanks, I think my personal limit is 3 cycles of IUI, I'm just trying to figure out if I should push for changes to the protocol (other than the period of abstinence) or move that up to 1 or 2. Sounds like if it doesn't work in 3 it's not worth anymore, so that meshes with what my RE said and what I think right now too.

    Thank you again for your prior answers, and anything further you can share on the above would be much appreciated!

  5. #5
    Join Date
    Sep 2008
    Posts
    851

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    My patients typically abstain for 2-3 days.

    I don't usually use Clomid in women who ovulate, so asking if I would increase the dose is a moot question. Injectable fertility drugs (like Follistim), in my opinion, are the only "true fertility drugs" we have....

    Glad this helped!
    Dr. Roseff in FL
    Dr. Roseff - South Florida Institute for Reproductive Medicine - Boca Raton, FL
    PERSONALIZED/SUCCESSFUL Specialty care....

    As you’re not my patient, information herein may be incomplete/inaccurate & I can't be responsible for your actions. This is for educational purposes & should never be used to replace information & care rendered by your own doctor. No part of this message may be reproduced, printed, or posted elsewhere without express written authorization of Dr. Roseff or INCIID.

  6. #6
    Join Date
    Feb 2016
    Posts
    2

    Default

    After talking with her, my husband is going to start treatments with her asap to see if she can improve his parameters as well as continuing to work with me.????


    Ali

  7. #7
    Join Date
    Feb 2016
    Posts
    2

    Default

    I don't usually use Clomid in women who ovulate, so asking if I would increase the dose is a moot question. Injectable fertility drugs (like Follistim), in my opinion, are the only "true fertility drugs" we have....


    == Solitaire ==

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