Case of the month Feb '08: Episode #3
To summarize, Gabriela and Ross have been infertile for a little over a year. They have finished an initial round of testing. The basic testing is not complete, because we still don’t know for sure that Gabriela’s tubes and uterus are normal. However, we have found another problem to address first, namely a severe case of insulin-resistance, one of the most classic components of PCOS. Ross’s sperm count is also on the low side, but certainly within the limits of normal. All other findings have been negative so far. It’s time to make some decisions regarding what to do next. We discussed the advantages and disadvantages of each choice, keeping in mind that these are not necessarily mutually exclusive, meaning it’s OK to come up with a plan that combines two or more of the following choices:
- Continue trying on own for another 6 months. You might wonder why this is a choice. If patients come see a reproductive endocrinologist, doesn’t this mean they are ready to dive into full blown treatment? Well, not necessarily. I’ve had patients who felt a little anxious and didn’t want to wait a year to find out that there’s a problem. So sometimes, they come in after 5-6 months for a basic checkup. If the sperm is good and ovulation appears normal, only THEN do they feel comfortable going back to trying on their own. A lot of them will get pregnant on their own this way. However, Gabriela and Ross are not good candidates for this option. First of all, she is over 35. They have been trying over a year already AND they have a clear problem with regards to their insulin resistance. It’s possible we could try to address the insulin resistance problem and then let them try on their own, but they expressed that this option is not aggressive enough to their liking. They want to do more.
- Get an HSG to test the tubes. As mentioned in the previous episodes, we still don’t know for sure that her tubes are even patent. This is a reasonable thing to do. However, given the fact that there is another strongly suspected problem (PCOS and insulin resistance) and that there are no risk factors for tubal problems, I recommended holding off on this test for now.
- Take metformin. Given that her most obvious problem is the PCOS / insulin resistance, this is a smart choice. Metformin is the oldest drug used to address insulin resistance. There are new agents out now, but there is limited experience with those. Based on Gabriela’s dramatically abnormal blood tests, her symptoms and her family history of insuiln resistance, it is strongly suggested that she start a trial of metformin.
- Take Clomid. Metformin addresses the insulin issue. Sometimes, that is enough to get women to have good ovulation. Other times, it’s still not enough. In those cases, it is sometimes helpful to combine metformin therapy with Clomid, which is a gentle way to help stimulate egg development.
- Take injectable FSH. Injectable medications are stronger and more effective than Clomid at stimulating ovulation and getting a successful pregnancy. However, it is much more expensive and much riskier for getting twins or triplets. I advised her to not take injectables yet, but I forewarned her that if she doesn’t develop good eggs on Clomid and metformin, that we might have to add some injectables.
- Do insemination. Doing IUI increases the chance of pregnancy and is especially important for patients on Clomid in whom their cervical mucus gets adversely affected. This is best done in conjunction with ovarian stimulation using either Clomid and/or injectables.
- Do IVF. If the fate of the earth depended on this couple getting pregnant immediately next month, then we would do IVF as the ultimate best treatment. However, for this couple, it would be overkill and they should start with more conservative measures first.
After a lengthy discussion and answering all their questions we agreed on the following plan. First, Gabriela would start taking metformin. Then after three weeks, she would come back and discuss how it was working. Meanwhile, we also planned that with her next period, we would start her first treatment cycle with Clomid and IUI.
We were all satisfied with the decision. Gabriela’s liver and kidney function were checked already, so we knew she was safe to start the metformin. Her weight was checked and documented: 160 lbs. I warned her about the side effect of diarrhea that was commonly seen with metformin and advised her to start cutting back on sweets and fast carbs. She will be back in three weeks.
