Ultrasound monitoring of Clomid cycles
Monday, December 31st, 2007I am doing fertility medicine with a doctor here in Jacksonville, FL.
I have done two rounds of insemination with Clomid and a shot of HCG of
which neither took.
I then had to take a month off because I had to have hand surgery. The
next Cycle day three i started taking my Clomid, I went in on Day 12 and I
had a small 13mm follicle on my left ovary and a large 28mm. The doc said
that the larger one indicates it is probably left over from the previous
cycle and should go away for the next cycle. I said ok and he canceled me
after taking the Clomid.
Day three of my next cycle, last week, I went in to check for cysts and
there was the same round figure on my left ovary, approx 28mm and the
doctor, who was a substitute that day, said it could either be a cyst or a
left over follicle.
What happens on the cycle day 3 if that follicle/cyst is still there? How
can they tell? How do you make a follicle/cyst absorb, without taking BCP.
I do not want my cycle to be postponed again. I was just curious because I
saw your discussion on here about cysts and follicles.
Thanks for any information you can provide.
Stephanie
Hi, Stephanie. Thank you for your email. I think a lot of readers can benefit from the discussion of this topic. I’m going to address the reply to everyone in general, but there should be some food for thought in this discussion that you can toss around with your own RE.
Just a reminder for those of you who have decided to see RE’s — You are already getting the ultimate in specialist care, so take advantage of the chance to ask them questions, especially when something unexpected, like a cyst, occurs. You should expect to have your questions addressed to your satisfaction. If they don’t have time to answer in great detail at that very moment, they can always talk with you on the phone later in the day. Set a time to do so if you ever have nagging questions. Some of you have vented that you’re getting your treatment through an HMO, and citing that as a reason why your questions aren’t getting answered. The quality of HMO doctors is not necessarily any different. It’s just that they have many more patients with whom you will have to compete for their time and attention. The tradeoff is that your service is usually close to free, so it’s not all bad. =) But if this is the case, be vocal. You have a right to have your questions answered, regardless of whether you’re seeing an RE or not.
In a monitored cycle, one of the first things to do is to check for cysts prior to taking the Clomid. If you have already read the previous post on cysts, it might help give you some basic understanding of the terms used. There are many different ways to approach ultrasound monitoring of a clomiphene (Clomid) cycle. Some people opt to take Clomid with no monitoring at all. This is the cheaper way. However, keep in mind that the more diligent the monitoring, then the more information you have with which to make better decisions, so it is a tradeoff.
It is acceptable in most cases to take Clomid without monitoring. So starting around cycle day 3, 4 or 5, depending on your doctor’s preference or depending on your convenience factors, most doctors will prescribe five consecutive days of Clomid. Then you are on your own as far as having sex, either just every 2 days or by timing with assistance from ovulation kits. The downside to this is that you never know for sure if you are ovulating and you never know how many follicles you have.
ADVANTAGES OF MONITORED CYCLES: A monitored cycle is a more deluxe version of the standard Clomid cycle. It adds some inconvenience and cost in that you have to go to the doctor for ultrasounds, but it has some clear advantages:
- Ability to avoid cysts. For all women, there will be an occasional month in which things are "off". You might end up with a leftover cyst which has not fully gone away yet from your previous cycle. Or you might have a fast-growing out-of-sync follicle that is growing much quicker than normal. These problems are more likely when the previous cycle was a medically-stimulated one. In either case, it would not be optimal to take Clomid that cycle because of decreased efficacy. There is also the slight concern of the cyst growing excessively large under the stimulation of the Clomid and causing other problems. By getting monitoring prior to starting the Clomid, you can catch these cycles and avoid taking the Clomid. I find these cysts at the start in about 5-15% of my patients’ cycles. In general, I use 12-13 mm as the cutoff size for postponing a stimulation cycle, but there are other several factors I take into account as well. In general, if the cysts are smaller than that, then we go ahead with the cycle.
- Assurance of follicular growth. Some times when you take Clomid, you don’t even make any mature follicles at all. Monitoring catches this problem early and avoids the scenario of you wasting time taking 3 or more cycles of Clomid when in fact there is no chance of pregnancy, due to complete failure of the Clomid at initiating ovulation. In this case, it’s time to switch strategies to something stronger or to do additional testing.
- Optimal timing of intercourse and/or insemination. The only 100% accurate way to document ovulation is with ultrasound monitoring. Theoretically, if you get your ultrasound done at precisely the right time, you can pinpoint ovulation to the exact second. That has only happend to me twice in over ten years. I was doing an ultrasound on a patient and we all clearly saw a large follicle on one side. I went to scan the other side and when I returned to the original side, the follicle was instantly gone and there was increased fluid in the pelvis, a sign of recent ovulation (follicular rupture). Temperature, mucus evaluation and urinary ovulation-kit testing can only give you a crude estimate. In fact, by adding the strategy of taking an injection of hCG to trigger your ovulation, you can actually control ovulation so that you can time insemination close to the exact hour.
- Assurance of ovulation. Sometimes, patients will have all the signs of ovulation (temperature change, positive ovulation kits, pain, rise in progesterone), but the follicles themselves do not actually physically burst, thereby causing the egg to remain trapped inside the follicle until it’s too late to be viably fertilized. Ultrasound monitoring will pick this up if this is the case and alert the need for different strategies. One way in which monitoring gives my patients peace-of-mind is by providing confirmation that their follicles have successfully ovulated.
So let’s go back to the issue of what to do when you DO see a cyst. There are two main options. One is just waiting for the cysts to go away on their own. Over 80% of the time, new simple cysts WILL just go away on their own by the start of the next menstrual cycle. The other option is to take birth control pills. This further raises the odds that the cyst will go away. It also serves to lower the chance of developing new cysts. You can imagine the frustration of my patients who have their cycle postponed because of a cyst on their right ovary only to come back next month and find a new cyst on their left ovary, even though the original cyst on the right had resolved successfully. The decision whether or not to take BCPs is one of personal preference between you and your doctor. I usually suggest my patients wait one month for the cysts to resolve naturally and if they’re not gone by then, we can start BCPs, but some more proactive patients opt to start BCP’s right away.
Now what happens if months and months go by and the cysts are still there, unchanged, neither growing nor shrinking? At some point, the option of doing surgery has to be considered. I usually don’t advise surgery for a cyst unless it is clearly persistent and not going away (over 4 months) or if it looks suspicious. By this, I mean that not all cysts are simple cysts as seen on ultrasound. Some cysts are echogenic meaning there are shadows on the inside. This might indicate that it is filled with blood, or with medically dangerous components, such as cancerous tissue. This is rare, but certainly not impossible.
One more general tip. There are some patients who consistently end up with cysts and consistently fail to ovulate their follicles. One area I explore in these patients is the remote possibility that they are taking high doses of aspirin, Motrin, Advil, Aleve or other related drugs known collectively as Non-Steroidal Anti-Inflammatory Drugs. This usually happens in patients with chronic back pain or migraine headaches. High dose aspirin or NSAID’s block prostaglandins, which are substances in the body that regulate many things, one of which is ovulation. I had a patient once who consistenly failed to ovulate, despite making many nice follicles each month. It turns out she was taking massive doses of Exedrin for her migraines. After taking her off those medications, she has gone on to have three babies with us through insemination.
So, in summary, the decision whether or not to have your cycles monitored is based on many factors. I hope this information was helpful.
Happy New Year! I’m looking forward to many new pregnancies in 2008!
By the way, I should very importantly add that the average BMI of our entire office staff is an amazingly trim 21.4!!! And that’s counting my own contribution of 24.8 as the highest one. I guess the hectic pace at which their jobs keep them racing burns off a lot more calories than is readily imaginable. I know for a fact, that I’m not the one in the office eating the bulk of all that candy.
