Ovulation Induction With Follistim Keeps Failing & Estradiol Remains Low

Question:

We are currently TTC our 2nd baby. My daughter who is 2 was conceived on our second cycle of follistim75iu. We are currently on our 4th cycle of Follistim 75iu. Each cycle I'm told my estradiol is low and they end up increasing my dose of Follistim to 150 iu and even by the time I trigger it's still on the low side.

I understand that ideally estradiol should be 200-250per mature follicle. But this cycle it is 110 with follicle sizes of a 14 and a11. So at this point of my cycle what should it be since they are not mature follicles? Also last cycle they had me do hcg booster shots after ovulation because I had a low estradiol (it was 80) 7 days after ovulation the cycle prior. The boosters helped increase my estradiol to 354. My concern is do the boosters really help achieve pregnancy or are they just masking a bigger problem?? Thanks in advance, S. from Pennsylvania, U.S.A.

Answer:

Hello S. from the U.S. (Pennsylvania),

There is no fixed protocol when using gonadotropins such as Follistim. Basically, these medications are the hormone FSH which is the hormone that your brain produces to stimulate the ovary to produce a mature follicle for ovulation. If the amount of hormone is insufficient to do this, then it has to be increased and this is usually done on an incremental basis. Please see how I do ovulation inductions here: "Ovulation Induction".

For example, it may be started at 75IU but every three to four days, and estradiol level can be drawn and checked to see if it is increasing. If it is increasing then starting on cycle day #9, an ultrasound is done to evaluate the ovaries and see how many follicles are present, what their sizes are and when to trigger. In your case it sounds like that is not being done. For some reason, your doctor is fixated on keeping the same dosage. I'm not sure I understand why.

You are correct about the estradiol level of a mature follicle. If your follicle does not reach the mature size18-20 mms, then the estradiol level will not reach the appropriate size either. Basically the follicle increases in size by increasing the number of cells. Think of it as a chain of cells in a circle. These cells to increase in size, rather, more cells are added to the chain and each cell produces some estradiol. That is why as the follicle increases, more estradiol is emitted. In order for the follicles to grow more cells, increasing amounts of FSH is required. So, if your doctor stops the dosage at 150IU and it is not enough FSH to stimulate follicular growth, then nothing will happen. He needs to keep increasing the dosage until the follicle grows appropriately. Once the follicle reaches the ovulatory size of 18-24 mms, then ovulation can be triggered with HCG (a substitute for the LH surge you would produce in a natural cycle).

The "HCG booster shots" do nothing to help the estradiol rise. Rather, this was merely a coincidence. The growing follicle causes the increased estradiol. The HCG can be used after ovulation to help prime the enodmetrial lining for ovulation. Some clinics use this instead of progesterone. It is also used to trigger ovulation, as I've mentioned previously.

Based on the information you have given me, I'm wondering if you are seeing the right doctor. Your doctor may be comfortable with using Follistim, but is he really an infertility specialist i.e. have a thorough knowledge of the gonadotropins to use them for IVF (in vitro fertilization) if he has to? There are many Ob/Gyn docs that feel comfortable with ovulation induction and use gonadotropins like Follistim on a protocol basis, but in reality, don't know what they are doing. Could you be in that type of situation? Maybe it is time for a second opinion. The best way to find an infertility specialist is to simply ask the clinic or doctor, "Do you do IVF?".

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.