Stims

Yesterday at 7:45 am I had my first IVF monitoring appointment. Since Kaiser doesn’t cover IVF, Dr. Y does all his IVF appointments in the early morning, across town from his main office. Lucky for me, this is only about 10 minutes from my house. (The Kaiser office is about 10 minutes from my work, so it’s been pretty convenient all-around.) I liked my new clinic. The waiting room looked much nicer than the Kaiser facility: lots of good magazines, friendly staff, and a beautiful aquarium. I sat and watched the fish eating their breakfast while C studied his iPhone.

And… my follies are growing, but slowly (which Dr. Y insisted isn’t necessarily a bad thing). The biggest one measured 8 mm. Estradiol level was 83. Dr. Y said to keep taking the same dose of Clomid & Menopur (and dexamethasone, although he didn’t mention that), and to come back on Saturday.

Oh, and we paid the first big bill: $10,115 “Global Fee” for IVF + ICSI. This amount covers all the monitoring appointments and labs, the egg retrieval, and the embryology part. The Global Fee does NOT cover meds, “Embryo Banking” (freezing and storing the embryos), or frozen embryo transfer, so a complete account of the full cost will have to wait.

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Given where I’m at in my cycle, it seems like my stims would be a good science topic for today, but first the usual:

I am NOT an endocrinologist, or any kind of medical professional! This blog does NOT purport to offer medical advice, medical opinions, or recommendations. Please take this for what it is – the ramblings of an infertile woman trying to make sense of her complicated treatment protocol!

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So, stims…

My ovarian stimulation regimen is low-dose menopausal gonadotropins (Menopur, 150 IU), and clomiphene (Clomid, 100 mg). The goal is to get my ovaries to produce not one but several large, mature, healthy eggs. To understand how these drugs are supposed to accomplish this goal, it would probably help to provide some background. And I feel the need to point out, once again, that I am not an expert. (This blog is not called ‘the infertile endocrinologist’! But if you find a blog with that title, please let me know. I’d love to read it.) So anyway, here’s how I think it works:

Sex hormone signaling 101

Normally, when my body wants to produce estradiol (the most important of the estrogens), my brain sends a signal to my pituitary gland. The pituitary responds by sending a signal to my ovaries, which respond by doing a bunch of things, including making estradiol. The estradiol itself acts as a signal that travels around and tells various body parts to do things.

The carrier pigeons transmitting all these signals are hormones. So, more precisely, my brain produces a hormone called luteinizing hormone releasing hormone (LHRH, also known as gonadotropin-releasing hormone or GnRH), which travels to my pituitary and tells it to produce two more hormones: luteinizing hormone (LH) and follicle stimulating hormone (FSH). These hormones travel to my ovaries and stimulate them to do a bunch of things – like grow eggs and make estradiol…which itself helps to prep the uterine lining, and so on.

Image

Feedback

As the level of estradiol increases, it circulates through the bloodstream and some of it reaches my brain. Once there, the estradiol tells my brain to stop sending the signal to make more estradiol (in other words, to stop making LHRH). This is a natural “negative-feedback loop”.

Estrogen signaling under the influence

While I’m on my stims, the goal is to get lots of follicles to grow at once. This takes high levels of FSH in there, for an extended period of time. There are two main ways of doing this:

  1. Make more of my own FSH. This is what Clomid aims to accomplish. Clomid blocks estradiol from telling the brain to STOP making LHRH. In this case, two wrongs do make a right, and blocking a stop signal is effectively the same as telling the brain to GO! The brain makes LHRH, which stimulates the pituitary to make LH and FSH, which stimulates the ovaries to grow follicles. Nice.
  2. Add in FSH from the outside. This is what I’m doing when I inject Menopur into my belly each night. Technically, Menopur is a mixture of both FSH and LH, but I think FSH plays the bigger role in follicle development (at least, that’s what its name would lead me to believe…)

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The downside of Clomid is that it doesn’t just block estradiol from talking to my brain. It blocks estradiol from talking to anyone…including my ovaries and uterus (who it’s supposed to tell to start prepping the uterine lining for implantation and making lots of sperm-friendly eggwhite cervical mucus). Clomid steals the entire message from the estradiol carrier pigeon.

Enter my weird protocol. Since the Clomid will prevent my uterine lining from being ‘embie-proofed’ in time for transfer this month, we’ll flash freeze those little guys (hopefully lots of them!) and let them chill for a month. This should give me time to do some nesting and get everything nice and ready to welcome the little tykes!

Why such a low dose of Menopur?

It seems counterintuitive that I would be using a low dose of Menopur, since the conventional wisdom is that patients with diminished ovarian reserve are generally less responsive to stims, and should therefore need more stims… For reference, I used 300 – 375 IU (4 or 5 vials) per day for my IUI cycle…more than twice as much as I’m using for IVF. From what I can tell from my limited reading of the literature, it sounds like for DOR patients with few eggs that are available for stimulation, adding more stims doesn’t increase the number of eggs recruited…and might harm egg quality.

Why Clomid?

I haven’t been able to find a clear reason why Clomid is a good choice in my case. The best I can think is that maybe in poor responders using two strategies for increasing FSH levels will work better than just one? Obviously, the fact that we aren’t doing a fresh transfer is a large part of why Clomid becomes a viable option.

What I know for sure

Clomid plus low-dose Menopur is much cheaper than the high-stims alternative.

Aside from a small crop of pimples on my forehead (which I’m guessing is due to the dexamethasone), I haven’t noticed any side-effects so far. I’m grateful for this!

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That’s where we are for now! We’ll see how the follies are doing bright and early Saturday morning!

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23 Comments

  1. Your friend IRL : )

     /  June 13, 2013

    I am learning so much! I’ve decided I want some bloggy friends AND I look forward to your blog title changing to “The Expecting Chemist”. We are cheering for those lil’ hapa eggies every day.

    Reply
  2. Yay for the first monitoring appointment! One step closer to your take home baby! I had to read and re-read some of the things that you explained about the FSH that the body produces and outside FSH. You explained it clearly, but it’s just my brain that usually shuts down when it comes to scientific terms. Good luck with growing follicles! Can’t wait to see the updates!

    Reply
  3. I’ve said it before, but I am fascinated by this DOR protocol. I’ve been wondering if my last protocol of max doses of Gonal F and Menopur effectively cooked my eggs and made them even poorer quality than they were on their own. I was also always a slow stimmer and apparently that’s to be expected with DOR. Our numbers are so similar…can’t wait to see how this works out and wishing you the absolute best of luck!

    Reply
  4. 1) Hormones! Feedback cycles! Aaaaaaa!

    2) Ah, Kaiser.

    Reply
  5. Wow, no symptoms so far? Awesome!! I definitely had a few night sweats with the clomid, and also enhanced emotions. I’m glad you like your new clinic and I am wishing you the best of luck!

    Reply
  6. This is such a great blog – so helpful in understanding what I’m about to walk into!!! Oof to the pricetag, but at least the offices are close? (so trying to see the good!)

    Reply
    • Thanks for the kind words! The whole cost thing is pretty interesting. Yesterday I heard from a local IFer (not with Kaiser) that the sticker price they gave her for a similar treatment at the same clinic was going to cost something like $23K! So my $13-14K total sounded like a bargain…

      Reply
  7. I haven’t had any side effects the two times I’ve used Clomid. Hopefully you don’t either. I love reading about how all of this stuff works. I’m sure you understand it better than most of the doctors I’ve encountered.

    Reply
  8. Haha, BYOFSH… classic. Not sure if your doc has said anything about the number of rounds of Clomid he’s willing to keep you on — it seems like Clomid is used a LOT more in the U.S. than in Canada for some reason; I didn’t know about the cost factor, but I have heard from doctors that after four or five rounds of it, your chances of getting breast cancer really skyrocket. Something to think about if you have to do multiple rounds of stims. I was on Letrozole (Femara) + Gonal-f and responded really well to that combo, but each case is of course very unique. Btw, I would LOVE to come across a blog written by an infertile endocrinologist — that would be AMAZING!

    Reply
    • To be fair, the first blog I read was actually written by an infertile endocrinologist (not an RE; her specialty was obesity). http://tracysue.wordpress.com/ It was great, but her target audience was a few friends, and she didn’t go into the nitty gritty details of the biology stuff…

      Reply
  9. I wish you had taught my chemistry classes.

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  10. I am wishing you so much good luck. It is so exciting to go to your first monitoring appointment. I can’t wait to see you coming out the other side pregnant!

    Reply
  11. I love your comments! It’s not all about the estrogen!

    Reply
  12. Justpassinthru

     /  August 17, 2014

    Super great post. It’s actually hard to find much information about the high-level mechanisms of these drugs, without diving into academic journals. All the other websites that come up are just rehashes of standard patient leaflet information along with repeated admonishments to just “take as instructed.”

    However I stumbled on something, um, kind of scary…apparently there is enough of a risk that drugs purified from urine contain “other” stuff, like specifically CJD proteins (i.e., a similar protein-based disease to mad cow disease), that the UK has at some point banned their use, and/or has required donors (who apparently aren’t paid and do this on a volunteer basis (!) – um…why?) to state they’ve never been to the UK. And, has apparently banned many recipients of menopur from ever being blood donors.

    Yikes. The only disclosure I saw in the patient leaflet said the substance was “made from the urine of postmenopausal women.” A bland, terse statement that doesn’t make you concerned, until you think twice about that statement, and are actually curious enough to figure out what kind of women think it’s an awesome idea to pee in a cup, how many times a day, for how long, to get this substance out? And then you find out, oh, boy, maybe taking that is not such a good idea. Hello, late-life brain disease possibility.

    Reply
  1. Staying the course…for now | the infertile chemist

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