Dear Doctor .......Secondary infertility By Paula Hovell on April 15, 2014

Dear Doctor,

I got pregnant with my first son on the second month that we tried, he is 2 ½. Now that we are ready for number 2, we are struggling; I guess they call this secondary infertility. Here is some background information. I came off of birth control in December 2012 and we actively started to try to conceive. Around May, I began taking data on my cycles, when I got a positive/negative on my ovulation kits, etc. I noticed that I would spot for about 3 to 5 days prior to my period starting. I went to my OB in October and they checked the following:

Oct 2013: Progesterone level: all was good; progesterone was around 16.

Nov 2013: Post Coital test: great results; sperm was getting to where it needed to go. HSG test: tubes were clear; I think they found a small polyp near the ovary. Started taking Progesterone prescribed by my doctor after a positive ovulation test (even though my levels were good)

Dec 2013: Hysteroscopy: uterus lining looked good. Semen analysis-My husband got an A+ in all areas including volume, count, motility.

January 15^th: Began Clomid on day 5, (we had sex every other day around this time)

January 27^th: Started progesterone again

February 15^th: Started acupuncture (I’ll try anything that doesn’t hurt!)

February 16th and 17^th: started spotting again

Question: When I went to my doctor yesterday (Feb 19th), she said to come in on Friday and if my cyst is gone, “we’ll call it day 5” and start another round of Clomid. Are we just “shooting in the dark” by “calling this day 5” or is this okay? I feel like my cycle is so messed up at this point with the cyst. I trust my doctor but just want a second opinion. Also, she said something along the lines of “if you would have come in on Monday, January 27th, I would have been able to tell when your next cycle was.” I’m not sure what she meant and although I have several years of higher education, I’m so intimidated when I go in to see her.

Thank you so much for taking the time to answer my questions. Just writing this out has been cathartic. Thank you again,

Trying

Hi Trying for # 2,

Thanks for all the information, I like that you are on top of the details! Let’s go through some of the information you provided, and try to answer your questions.

1. Spotting before your period begins:

I hear this observation quite commonly from women trying to conceive. There are several possible explanations. First, it can be evidence of inadequate progesterone production from the ovary. It sounds like you checked the levels and they were okay, none the less, progesterone supplementation is a good idea.

Second, it could represent a polyp or fibroid in your uterus. There may have been evidence of this on your HSG, but it should have been resolved by the hysteroscopy (surgery with a camera placed in the uterus). I’d follow-up with your doctor to see if a polyp was identified.

Third, it could represent “implantation spotting”. Some patients notice that they have spotting before a positive pregnancy test. It might be worthwhile to check an early pregnancy blood test to make sure that you are not missing an early biochemical (only detectable by blood test) pregnancy.

2. Sperm:

It is great that your husband got an “A+” on his semen analysis, but you only mentioned that they checked the volume, motility and count. It is critically important that they also check the sperm morphology (shape). Morphology is actually the best predictive factor in terms of fertility. Also you mentioned the post coital test, I’m glad it was normal, but it is important for people to know that the post coital test is an antiquated test which provides very little predictive or useful information in terms of chance for pregnancy. I do not use it in my practice.

3. Clomid:

Clomid is a pill that causes the body to produce more than 1 egg each month. It reasonable starting point to increase your chance for conception, but the truth is that its benefit is quite small for couples with unexplained infertility (where all tests on the sperm, ovaries, uterus and tubes are normal). Further, clomid without an insemination (IUI) is barely better than no treatment at all. Thus, if you decide to continue with clomid, I would definitely add an intrauterine insemination. If it does not work, I’d consider moving on the other medicine like fertility shots (injectable gonadotropins).

4. Age and ovarian reserve:

The one detail you didn’t provide was your age. Age is the single most important factor when considering your chance for success. As we get older, our egg supply (ovarian reserve) diminishes. This is directly related to our chance for conception. The methods we have to check your ovarian reserve include blood tests like the FSH, estradiol and AMH levels (FSH and estradiol should be checked on the 2^nd or 3^rd day of your cycle) as well as an ultrasound measurement of the follicles in your ovaries. This is called the antral follicle count. These tests should be considered to help you judge how aggressive you need to be in your treatments.

5. Intimidation:

You mentioned feeling intimidated by your doctor; this is a REALLY important detail. I feel that clear open communication between doctor and patient is critical to success. You should consider addressing this issue with your doctor. Tell her how you feel, if she is not receptive and understanding, you might be better served by a doctor who is better at communication and doesn’t intimidate you.

6. The cysts and timing of cycle:

Cysts and spotting can make it difficult to figure out exactly where one is in their cycle. As long as the uterus and ovaries are synchronized on ultrasound and the hormone levels (estrogen and FSH) are okay, you can start medicine as if it is day 5, even if it is not officially day 5.

Good luck Trying, I believe with the right guidance and a little work, you will be successful and be able to conceive again.

Warmly,

Your Doctors @ The Center for Fertility and Gynecology