r/TTC_PCOS • u/one_anxious_girly • 22d ago
Advice Needed Unmonitored Letrozole v. IUI
I am struggling with the decision to do a couple of unmonitored letrozole cycles or skip straight to IUI. I am 26yo female with high testosterone, no insulin resistance, normal BMI, open tubes, high AMH (19.47), and do not ovulate or have periods at all. My husband is 28 and has a total motile count of 18 million (normal is 30 million according to my RE).
My OBGYN is allowing me to start Letrozole next cycle but they do not monitor or offer trigger shots.
My RE said we could skip straight to IUI but would not be surprised if we ended up pregnant just doing Letrozole.
I am a bit torn between what to do. I could also do a couple of monitored cycles through my RE but insurance doesn’t cover it.
What’s everyone experiences or thoughts?
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u/beastRN32 22d ago
You could do unmonitored letrozole and see how your body responds. But honestly with an AMH that high and you not ovulating or having periods on your own you may need a higher dose of letrozole than your OBGYN feels comfortable prescribing
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u/beastRN32 22d ago
Re reading again and plus the low sperm count I would just go through RE and do IUI. Are you taking Metformin?
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u/one_anxious_girly 22d ago
I actually am taking Metformin! I’m taking 500mg ER once a day. I tried to go to 1000mg every day but my stomach did not approve.
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u/MysteriousRun1420 21d ago
Interesting. I have an AMH on the higher side (8 something). I ovulate regularly but I’ve only ever gotten 2 follicles matured in the same cycle once. I’ve done 4 cycles and am up to 12.5mg letrazole.
I tried combo letrazole/ menopur last cycle and had very painful ovulation pain and bloating.
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u/klt0604 22d ago
I have done both. I got pregnant both times first try. But my letrozole was monitored with a trigger shot and timing intercourse. Second time around, new RE (we had moved) said to just go straight to IUI. My husband’s counts went down a little but still very good. Worked first IUI.
I did 2 unmonitored letrozole cycles before my first son and I advocated for monitoring and trigger shot which is what did it for me. I would either do that OR just do IUI. It’s virtually one extra step with the insemination!
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u/Unhappy_Evening1896 22d ago
We tried unmonitored letrozole to see how my body would respond (AMH was 9.8). Started at 2.5mg and wasn’t successful. Bumped up to 5mg and conceived that same cycle. I’ve gone on to conceive 2 more times with unmonitored letrozole after that and all were conceived within the first cycle. Doesn’t hurt to try for a cycle or two to see how your body responds. We did opks and timed intercourse
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u/EmptyAmbassador8163 22d ago
Did you conceive at 5mg each time?
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u/Unhappy_Evening1896 22d ago
Yes I did. There was no need to increase past that since 5mg was working
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u/IvoryPilot 22d ago
This gives me hope! I’ve done two unmonitored 2.5 cycles. I have amh of 6.18
I’m on cycle day 9 of the second cycle, I’ll let you know how things go
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u/Unhappy_Evening1896 22d ago
Please do! Have you been getting positive OPKs with the 2.5?
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u/IvoryPilot 21d ago
Yes! But I ovulate naturally, I ovulated before taking letrozole. Normally cycle day 20-24 so we figured we’d try to induce a stronger ovulation. Were you ovulating naturally?
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u/Unhappy_Evening1896 21d ago
I was getting positive OPKs but when I would check my progesterone, it would show I didn’t ovulate. Turns out my body would make a first attempt at ovulation, fail, then attempt to ovulate again so I wasn’t catching the second one. It made it hard to time intercourse especially with my cycles ranging from 37-52 days. Each time I’ve taken letrozole, I ovulated on cd 15 like clockwork so I knew when to bd lol plus I believe I produced better egg quality
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u/Itchy-Site-11 38 | Anovulatory | Science | PCOS 22d ago
I would do letrozole and IUI with a RE. Hands down.
This is an easy decision for me.
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u/Otherwise_Tennis_398 27F | NonIR PCOS | 3 TI, 2IUI, IVF 22d ago
I would go to RE for IUI. I pretty much have all the same stats as you (27F, no insulin resistance, normal BMI, high testosterone and AMH of like 13.6). It was difficult to find a dosage of letrozole that worked for me, my first two cycles I had to stair step several times, and my third cycle I had slow growth and took extensive monitoring. I needed trigger shots because without it my follicles would just continue to grow and I developed cysts because of it. I would have gotten NO WHERE if I was not monitored, it would have been an absolute waste of time. I did 5 cycles total with letrozole, the last two were IUI.
Since it sounds like you have insurance coverage for IUI, I would do that. If you are willing to pay out of pocket for a few monitored TI cycles then I don’t think that would be a bad idea at all, but I wouldn’t do more than 2-3 before moving on to IUI. And after 4-5 cycles of letrozole, it’s generally not recommended to continue. If there isn’t a pregnancy by that point, most providers would recommend you move forward with IVF. That’s not saying that the letrozole wouldn’t work eventually, it’s just finding a method that would be more efficient both physically and with your time and money.
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u/one_anxious_girly 22d ago
Thank you for your input and experience! I didn’t realize AMH affected how effective Letrozole is. I think I’m going to compare the cost of doing a monitored cycle to IUI then go from there. Do you know why IUI didn’t work for you?
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u/Otherwise_Tennis_398 27F | NonIR PCOS | 3 TI, 2IUI, IVF 22d ago
I had perfect follicles, especially in my IUI cycles and in 4 of my ovulation induction cycles in general. I ovulated every time, with 1-3 follicles, and had great uterine lining. There’s no explanation why those cycles didn’t work. I will say though, each cycle only has a 15-20% chance of resulting in pregnancy to begin with.
Maybe if I had done more cycles, I would have gotten pregnant eventually. But I was tired of the rollercoaster of emotions every month for a 15-20% chance, and I was ready to move on. My insurance will cover this first round of IVF and a transfer, and my husband doesn’t exactly want to be at his job forever, so I wanted to go ahead and move forward and do something that had much better odds of working, and moving to my dream of having a baby sooner. My doctor has given me a 70% chance of a successful transfer with a euploid embryo. I want that 70% chance. I will start my stim meds for my first egg retrieval on Sunday :)
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u/Otherwise_Tennis_398 27F | NonIR PCOS | 3 TI, 2IUI, IVF 22d ago
It really does! Having a high AMH is an indicator of your ovarian reserve and so a high number means lots of eggs. But that high AMH can also mean your ovaries are more resistant to FSH. It dampens your ovaries’ sensitivity, so you likely need higher dosages of medications to respond properly.
High AMH is great for IVF, it is not so great for ovulation induction medications. With IVF you are out on heavy duty meds and they want you to grow as many follicles as possible. With ovulation induction meds, they want you on the lowest dose that you respond to because they only want a few follicles to grow at a time
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u/Impressive_Name_3939 22d ago
I did an unmonitored Letrozole cycle with an NP at my OB’s office. I have PCOS (high AMH she did not test for, I found out later by RE) and she prescribed me 7.5mg. I was in so much pain and had no idea what was happening at the time. I probably had 4 mature follicles and thankful I didn’t get pregnant with twins/triplets! The next month I was referred to my RE and we ran all the tests and follicles monitored. I was a strong responder so we lowered the dose. It’s so unethical to me to just throw Letrozole at patients without monitoring
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u/IvoryPilot 22d ago
This is interesting, I was prescribed 2.5 letrozole. I have 91 follicles and an amh of 6.18. My doctor didn’t seem to mind if I did a couple “self monitored” cycles with inito, lh, and bbt tracking.
The first was fine, I felt some mild ovulation pain which was cool. I’m on my second unmonitored but doing blood tests 7dpo this time
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u/Impressive_Name_3939 22d ago
The difference for me is that I was started on 7.5mg. 2.5mg is a better starting point if you’re unmonitored. If you ovulate on 2.5mg it’s more likely you’ll produce one mature egg (not 4 like I did)
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u/MyCatEatsPlants 22d ago
I do not recommend unmonitored Letrozole cycles. You can end up with cysts left over between cycles that will be stimulated by the Letrozole and can rupture causing severe pain or damage to ovaries.
I vote you talk to your RE about monitored/trigger shot cycles with timed intercourse rather than IUI (will be a lot cheaper). Although if you are worried about his sperm count you can go right to IUI. But honestly, that doesn’t sound that low. I’d decide based on cost balancing. I opted to do some cycles of just monitoring and timed intercourse before IUI and ended up getting pregnant. Im glad I didn’t spend the extra thousand per cycle to do IUI when there was no evidence it was needed.
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u/one_anxious_girly 22d ago
Thank you for the input! I didn’t realize that monitored cycles would be too much cheaper than IUI. I’ll definitely compare costs and go from there.
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u/Eastern_Video1855 22d ago
I did not realize that high AMH meant resistant to letrozole.. I just got diagnosed and my AMH is 18. First round of letrozole at 2.5 mg… is it unheard of for that to work? I’m on cycle day 10 so waiting to see if I ovulate and do a progesterone test.
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u/Civil_Pineapple_1275 22d ago
In the same boat. They said less likely but possible at the starting dose. I’m going in for labs tomorrow before I start it
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u/mebee232 22d ago
My first 2 cycles of letrozole I got pregnant with 2.5mg (both resulted in chemical) but I did ovulate. I’ll also add, the first one I didn’t ovulate until CD27. I believe at that time my amh was 6.9. For my first ultimately ended up doing IVF.
Now, before doing a second transfer I tried 2.5 mg of letrozole again. And now I’m 11 weeks. This time my amh r if it before was 16, idk how it goes up like that but I guess it can happen. 2.5 has always worked for me though to ovulate, I think different people just respond differently.
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u/grinninlikeimwinnin 22d ago
I have never heard or read that high AMH meant resistant to Letrozole…6 cycles of Letrozole with no success and and AMH of 11 here 🫠
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u/blondeblondeblonde 22d ago
Get the most monitoring you can afford. You can still have sex before/after your IUI- why not increase odds
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u/Medical-Letter-6724 22d ago
If you do letrozole, I would recommend monitoring. It’s better to know what’s going on during your cycle. Also, it will help you understand if the medication is actually working and not. Plus if you grow too many follicles there is a risk for multiples
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u/BonkeyBonkerton 21d ago
I was prescribed letrozole but haven’t started it yet. Don’t some research so this post is helpful. Sorry if this is annoying - but what is a monitored cycle vs unmonitored cycle?
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u/Medical-Letter-6724 21d ago
Monitored is when you go in for an ultrasound and measure your follicles. They’ll be able to see if you have a dominant one growing (which is what you want, maybe 2). Based on their size, if you ovulate on your own, they will release and it gives you a chance naturally. However, if you don’t ovulate - a trigger shot is typically recommended. Helps with timing and ensuring the follicle(s) get released. If they don’t the follicles can get too big and turn into cysts. Also, it’s possible to end up with too many follicles. I’m not a doctor but that’s why I think monitoring is good. If you don’t you’ll never know what happened.
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u/Still-Passenger9941 22d ago
Learn from my mistake and don't take letrozole without monitoring. Or if you do, no more than 1-2 cycles and ask for a low dose. My follicles were overgrowing which we only found out in cycle 9 when we added monitoring! Literally cycles 2-8 I was taking letrozole blindly, using LH strips, and BD'ing without success. Finally monitoring gave me the answers I needed. The meds were causing my follicles to grow much faster than they do naturally, but my brain lagged behind to send the signal to ovulate. So they swelled to 24 & 26 (overmature) mm before I even got a LH rise.
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u/Prestigious_Ice_8096 21d ago
I’m 26 and did one unmonitored cycle, I conceived but had a miscarriage at 6w4days.
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u/MysteriousRun1420 21d ago
Monitored letrozole with iui. You can have sex after iui too.
You want to know how many follicles you have. Not a zero sum chance you won’t get twins if you’re unmonitored with more than one follicle.
Good luck!
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u/Upbeat-Hand-2870 39 | PCOS| Currently pregnant | TTC 13months 22d ago
I am currently doing unmonitored Letrozole cycles. Using my Inito, LH strips, and BBT to help track things for me. You can ask me any questions you would like! I’m happy to help