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Regulating your Menstrual Cycle

Since IVF treatment starts from Day 1, it's important for you to be able to predict when your next period is going to start, so that you can schedule your travel plans ; book your tickets and hotels; and inform your boss . This is especially important if you need to travel to India for your IVF treatment from overseas. While many women have regular clock-work cycles and know exactly when their next period is going to start, this can become a complex problem, especially for women with variable cycles; or irregular menstrual periods.

Here are some simple techniques you can use to regulate your menstrual cycle, so that you can plan your travel without any problems.

You need to remember that the reason you get a natural menstrual period is because of a drop in the circulating blood levels of the reproductive hormones, estrogen and progesterone hormones. When these levels drop, the uterine lining loses its hormonal support, as a result of which it is shed as a menstrual period. The reason for irregular menstrual periods is a problem with the normal balance between estrogen and progesterone in your body. This is typically seen in women who are perimenopausal; and women who have PCOD. The solution is easy - we try to reproduce the natural situation, by giving you the required hormones !

The most reliable way is by taking the estrogen and progesterone hormones sequentially, thus mimicking a natural cycle.

This is what a typical prescription would look like.

Estrogen tablets from Day 1 - Day 25. There are many options available. The least expensive is Tab Ethinyl estradiol (Lynoral), 0.05 mg daily. Other choices include:
Tab Premarin, 1.25 mg daily; or
Tab Progynova (estradiol valerate, 2 mg), 2 tab daily. You may feel some nausea and have some temporary fluid retention while taking the estrogen.

Progestin tablets, from Day 16 - Day 25. There are many options available. These include:Tab Provera (medroxyprogesterone acetate), 10 mg, twice a day.

This regimen is called Hormone Replacement Therapy , and is available commercially in some countries in the form of a pack, called CycloProgynova.

The withdrawal period (menstrual period) will start approximately 3-6 days after you take the last tablet, as the levels of the administered hormones decline in your body because they get excreted in the urine.

The easiest way of regulating your cycle is by taking birth control pills. Since birth control pills contain both estrogen and progesterone, and are inexpensive and easily available over the counter, this is often the easiest option for most women. (Many manufacturers sell pills in the form of a 28-day "pack" . This contains 21 days of "active" pills (which contain the estrogen and progesterone hormones); and 7 days of "inactive" (placebo or sugar pills).>

There are many types of birth control pills available, and it's best to take the old-fashioned monophasic birth control pills, which contain a sufficient amount of estrogen and progestins (combined together in one "active" tablet). A typical choice would be Ovral, which contains 50 ug of ethinyl estradiol and 500 ug of norgestrel (a type of progestin).

You take 1 active tablet daily from Day 1 - Day 21, and your period will start 3-5 days after the last tablet. If you miss a tablet by mistake, just take 2 the next day. You may have some spotting while taking the active tablets. This is called break-through bleeding and can be ignored.

If you can only find the modern "low-dose" oral contraceptives (which contain lower doses of estrogen and progestins), then it maybe better to take 2 tablets of these daily from Day 1 - Day 21.

The real beauty of taking these tablets to regulate your cycle is that you can manipulate your period to suit your convenience ! Thus, if you want to get a period after 35 days, then you just need to continue taking the active birth control pill for 31 days (instead of 21 days), since your period will start 4 days after taking the last pill.

The withdrawal bleeding induced when you take birth control pills may be scanty as compared to a regular period. This is normal.

Please remember that taking these pills will have no harmful effects on the IVF cycle whatsover ! In fact, many clinics routinely use birth control pills prior to starting an IVF cycle, in the belief that these will allow the ovaries to "rest", thus improving ovarian response in the IVF cycle.

The period usually starts 3-6 days after stopping the last tablet. Since every women is different, it might be a good idea to start these tablets 2-3 months before you actually come for IVF treatment. This will allow you to know exactly how your body responds to the pills, so you'll be able to predict precisely when your period will start.

If these tablets do not work, we do also have more powerful medications available to induce a period. Often the first step is to do a vaginal ultrasound scan to find out why your period is delayed. The vaginal ultrasound scan should check for the following.

  1. ovarian volume
  2. antral follicle count
  3. uterus morphology
  4. endometrial thickness and texture

For example, the scan may show you have an ovarian cyst (called a functional cyst). The key finding is to check the thickness and texture of the endometrium (uterine lining). If the lining is thick, this means a period can be induced by taking 5 days of progestins, such as medroxyprogesterone acetate. This is called inducing a withdrawal bleed with progestins.

We can also use the powerful antiprogestin called Mifegest (mifepristone) to induce a period . These are the same tablets which are used to terminate a pergnancy medically, and will be able to induce a period within 4-5 days for practically all patients.

If the scan shows the uterine lining is thin, then we can check your estradiol blood level. If this is low, this means you are naturally downregulated , and we do not even need to induce a period and can start with treatment straight away !

What if you need to adjust your cycle dates so that you can match your treatment cycle with your leave? Remember that it's easier to postpone a period, rather than prepone it. Also, it's a good idea to do this at least 10 days before your period is expected, so hat the hormones have enough time to act. If you want to postpone your period, just start taking birth control pills (at least about 10 days before your period is due), and continue taking it until you want your period to start. The next period will start about 3-5 days after taking the last tablet.

It's also possible to prepone the period. Start birth control pills from Day 1 of your cycle; take them for at least 10 - 15 days; and stop them about 3-5 days before you want your period to start. It's a good idea to use a regular dose birth control pills; or to take 2 tablets daily.

What if you need to adjust your cycle to match that of your surrogate or your egg donor? This is also quite easy to do. Both of you start taking birth control pills from Day 1 of your respective periods. The trick is to take the pills for at least 20 days; and to stop taking them on the same day, so that the period starts for both of you on the same day. This way, the one's whose period comes later will take the pills for about 20 days; while the one whose period came first will take them for a longer duration.

What if your periods are irregular because you have PCOD? In this case, it's much easier to induce a period by just taking progestins. Since you produce a large amount of estrogens, and don't get regular periods because you do not ovulate (as a result of which you do not produce any progesterone), you simply need to take progestins (such as Tab Provera, medroxyprogesterone acetate, 10 mg, twice a day ) for 5 days to induce a period. The withdrawal bleed will start 3-8 days after the last tablet.

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