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More on Polycystic Ovaries

Please start off by going back to the archived blogs from 7/06/06 and 7/22/06. These will update you with the basics of cysts and polycystic ovaries.
So let’s say you were told you have PCO, or Polycystic Ovaries, and you want to get pregnant. What are your next steps?
The first steps have to do with further diagnostics. You don’t ovulate and getting you to ovulate is probably all you need to get pregnant. Clomid may be all you need. Do you need to do any other tests before you start the Clomid? Probably not but you may. It is common for women to have more than one fertility problem. Some women with PCO also have blocked tubes (totally unrelated to having PCO) or a low sperm count. And some have other hormonal issues.
The basic things to check are your prolactin, thyroid and 17 hydroxyprogesterone. The last is a test for congenital adrenal hyperplasia, a rare disorder that can create a picture like PCO. If the blood tests are all ok, then you can consider the hysterogram and semen analysis. It is OK to start Clomid without these 2 tests, may patients do. Just understand that these tests need to be performed eventually. It’s really bad if you get a Clomid prescription for 6-12 months. A few months are fine and if you’re not pregnant, then check the tubes and sperm.
How do you know if the Clomid is working? If the time in between cycle is greater than 35 days and Clomid gives you cycle that are around 28 days, it’s working. If you still rarely get a period, it is not working. There are more accurate ways to check. If you take your temperature (temperature charting is too much work, but I know some of you are regular temperature takers) there is usually no clear rise mid cycle, but there is when Clomid is working. Progesterone causes the rise and progesterone is only present after ovulation. No ovulation, no progesterone, no temperature rise. The ovulation predictor kits are another option. These are hard for women who get cycles far apart because it’s difficult to know when to start testing, and testing can go on for weeks if ovulation is not happening. But if you were getting 50 day cycles and now they are 29 days, you are ovulating. It becomes easier to use the kits and time intercourse if your cycles become more regular. The best way to prove that you have ovulated is a blood test for progesterone. The problem with this is people get hung up about the level. This is not important. If your level is 6, 9 or 21 it does not matter. Progesterone levels vary throughout the day anyway. As long as it is elevated above baseline (2-3 depending on the lab) you are OK. More next time and please read the disclaimer 5/17/96.
Dr. Licciardi

References:

  • Legro RS, Barnhart HX, Schlaff WD, Carr BR, Diamond MP, Carson SA, Steinkampf MP, Coutifaris C, McGovern PG, Cataldo NA, Gosman GG, Nestler JE, Giudice LC, Leppert PC, Myers ER; Cooperative Multicenter Reproductive Network. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007; 356(6):551-66.
  • Misso ML, Costello MF, Garrubba M, Wong J, Hart R, Rombauts L, Melder AM, Norman RJ, Teede HJ. Metformin versus clomiphene citrate for infertility in non-obese women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2012 Sep 6. [Epub ahead of print].
  • Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2009 Oct 7 ;(4):CD003053.

A Little More about IUI

Should you have one or two at each ovulation? We don’t think there is an advantage if 2. Since the egg is good for 1 day and the sperm 2, one well timed iui should cover it. However, I have many patients that would just feel better having 2 iuis. I have no problem with this. Sometimes it’s hard to figure out when to do the first. If you are getting an hCG shot and want 2, probably the first iui should be the day after the hCG. If you are using a kit, it’s a little harder because the actual time of ovulation is less. So the day of the first iui is really up in the air. If you are using you partners sperm, and the counts are low, you really want to make the first iui the day of ovulation because sometimes (not always) the counts are lower the second day in a row.
For donor sperm, should you use 1 vial or 2 at each insemination? It depends on the recommendations of your lab and the counts from each vial. You would like to get around 10 million motile sperm for each iui. If you are a little under that’s ok. So if one vial is giving you 13 million, that’s enough. If you are getting 6.5 million, maybe 2 would be better. You may need to do your first iui, see what you get, and change plans for next time.
Can your doctor provide iui on the weekends? Many can not. Most patients don’t realize that the timing of their iui may be based on the doctor’s schedule. If you think you should be inseminated on a Saturday or Sunday, and the doctor finds an excuse for you to wait till Monday, head for he hills (or at least to another doctor who can get you services when you need them).
Can a nurse do the iui? Yes, an experienced nurse is an expert at iui.
How long do I need to stay on the table after the iui? It does not matter. Getting up immediately will not change your outcome.
Should I have a cap or sponge in my vagina to hold the sperm in? No, most of the sperm is above the cervix, in the uterus.
Dr. Licciardi

References:

  • Guzick DS, Carson SA, Coutifaris C, Overstreet JW, Factor-Litvak P, Steinkampf MP, Hill JA, Mastroianni L, Buster JE, Nakajima ST, Vogel DL, Canfield RE. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. National Cooperative Reproductive Medicine Network. N Engl J Med 1999; 340(3):177-83.
  • Osuna C, Matorras R, Pijoan JI, Rodríguez-Escudero FJ. One versus two inseminations per cycle in intrauterine insemination with sperm from patients’ husbands: a systematic review of the literature. Fertil Steril. 2004; 82(1):17.
  • Cantineau AE, Heineman MJ, Cohlen BJ. Single versus double intrauterine insemination (IUI) in stimulated cycles for subfertile couples. Cochrane Database Syst Rev. 2003.
  • Bagis T, Haydardedeoglu B, Kilicdag EB, Cok T, Simsek E, Parlakgumus AH. Single versus double intrauterine insemination in multi-follicular ovarian hyperstimulation cycles: a randomized trial. Hum Reprod. 2010; 25(7):1684.
  • Rahman SM, Karmakar D, Malhotra N, Kumar S. Timing of intrauterine insemination: an attempt to unravel the enigma. Arch Gynecol Obstet. 2011 Oct; 284(4):1023-7.

When and How to time the IUI

Thanks for asking me to write about this. I have requests for other topics too. I’ll get another blog out about PCO as soon as I can.
Let’s start with iui in a natural cycle: how should it be timed? It’s nice if iui can be performed on the day of ovulation. The egg is good for about a day after is released. The sperm can stay in the tubes (where fertilization takes place) about 2 days. Sperm may stick around even longer than that as there are reports of pregnancy up to 6 days after ovulation. {I know some of you are thinking “I should be so lucky”.} Six days is really a stretch, so let’s stay with 2. So if the egg is good for a day, and the sperm is good for 2, maybe precise timing isn’t so important after all. Probably correct, but we do try to get is as close as we can. The point is the sperm and egg don’t have to collide in the tunnel. The sperm can be hanging around waiting for the egg and the egg can be moving through the tube waiting to be chased by sperm.
“Natural” testing using mucus, temperature and the calendar can work ok, but that’s because we just said getting the timing perfect may not matter much. I mean to say it’s not accurate.
Then there are the kits and the monitor. I find the kits easier that the monitor. Just because the monitor is more expensive does not mean it’s better. The ovulation predictor kits do just that: they predict ovulation. One day there is a color change and the next day is ovulation. The kits measure the hormone LH. This “spikes” about 36-24 hours before ovulation. Because you are not testing every 10 minutes, you don’t really know when the spike occurred. We just know it has occurred since we last tested and ovulation will take place at the most 36 hours later, but probably in the next 24 hours. So the best day for iui is the day after the color change. Some kits say the best time to try for pregnancy is the day of the color change. The day of the color change may be a good day, but the next day is better.
What if your doctor gives you an hCG shot? This is a chemical that is almost like LH and it also causes ovulation when given once when the egg is ready. hCG just helps with the timing. If you have an ultrasound and the follicle looks ready, we give hCG. You will probably ovulate without the hCG, but getting it avoids you needing more days of blood tests and ultrasounds, plus you avoid missing your natural ovulation. Even with careful monitoring, occasionally the ovulation is missed, which is understandably upsetting for patients, but it does happen. A little more next time, and please see disclaimer. Dr. Licciardi

References:

  • Guzick DS, Carson SA, Coutifaris C, Overstreet JW, Factor-Litvak P, Steinkampf MP, Hill JA, Mastroianni L, Buster JE, Nakajima ST, Vogel DL, Canfield RE. Efficacy of superovulation and intrauterine insemination in the treatment of infertility. National Cooperative Reproductive Medicine Network. N Engl J Med 1999; 340(3):177-83.
  • Osuna C, Matorras R, Pijoan JI, Rodríguez-Escudero FJ. One versus two inseminations per cycle in intrauterine insemination with sperm from patients’ husbands: a systematic review of the literature. Fertil Steril. 2004; 82(1):17.
  • Cantineau AE, Heineman MJ, Cohlen BJ. Single versus double intrauterine insemination (IUI) in stimulated cycles for subfertile couples. Cochrane Database Syst Rev. 2003.
  • Bagis T, Haydardedeoglu B, Kilicdag EB, Cok T, Simsek E, Parlakgumus AH. Single versus double intrauterine insemination in multi-follicular ovarian hyperstimulation cycles: a randomized trial. Hum Reprod. 2010; 25(7):1684.
  • Rahman SM, Karmakar D, Malhotra N, Kumar S. Timing of intrauterine insemination: an attempt to unravel the enigma. Arch Gynecol Obstet. 2011 Oct; 284(4):1023-7.