Miles and Terra have nothing wrong with their fertility. Nothing other than for the fact that they haven’t gotten pregnant in three years. The most abnormal finding, after all their testing, was cervical mucus that was not the best. I’m not totally convinced that this is the real problem, but if it is, then insemination should solve it most readily.
Terra called with her period and came in for a baseline ultrasound. This is a necessary step prior to starting the ovulation medications to stimulate Terra’s ovaries. In the event that a large cyst was seen, we would have to postpone her cycle. This is something that happens in about 1 out of 10 cycles. Well, Terra was very unlucky. There was a cyst on her right ovary measuring 16mm, well above the usual 12mm-13mm cutoff. I explained to her that she would have to wait another month before starting stimulation. However, the good news was this. Most likely, the cyst would go away on its own by next month. Also, this meant they would have another month to try to concieve naturally. Many times, couples who have to take a month off due to cysts somehow end up getting pregnant naturally. Whether this is just coincidence or not is still unclear. There is the thought that a cyst somehow rotates the ovary and changes its position so that it could end up in a more strategic location to have the released egg get captured by the tube. In any case, this did not happen for Terra. A month later, she called with her next period and came in, eager to start her IUI cycle.
Baseline scan showed both ovaries clear. The cyst was gone. Hooray! Sometimes, with really bad luck, the cyst is gone, but then a new cyst is seen in the opposite ovary. Fortunately, this was not the case and we were clear to start. The next decision was what stimulation protocol to use. We could do anything from a natural cycle with no medications all the way to straight injectables. The progression goes something like this:
No medication
Clomid only
Clomid followed by injectables
Straight Injectables (moderate dose)
Straight injectables (higher dose)
On one end you have greater safety from twins (or triplets or more), lower cost and less medication. On the other end, you have a higher chance of pregnancy. After careful deliberation, Terra and I agreed to go with straight injectables, moderate dose. She was started on 150 IU’s of injectable gonodotropin. In a first time cycle, the choice of brand of medication (for example, Bravelle vs Repronex vs Gonal-F vs Follistim) is based a lot on cost. Certain patients might have certain insurances that ally themselves with one drug company or another. There are other factors to consider, such as ease of administration and flexibility of dosing. In any case, we chose a brand and monitored her progress with ultrasound.
Day 03 Both ovaries clear.
Day 08 After 5 days of injections. Righ ovary (15×14) (12×12). Left ovary (13×10) (14×13)
Day 12 After 4 more days of injections on the same dose. Right ovary (18×15) (18×14) (12×12) (12×11) (12×11). Left ovary (19×15) (17×15) (11×11).
Day 13 Ovulation triggered with 10,000 IU of hCG at 5PM.
Day 15 IUI performed at 8AM. Sperm sample 15 MILLION total motile sperm. Ultrasound after IUI confirms deep passage of specimen into the uterine cavity. Lining 10mm triple layer. Right ovary (31×24) (22×17) (18×15) (17×17). Left ovary (23×21) (22×17) (14×13). Minimal free fluid.
Day 16 Another IUI performed at 9AM. 12 MILLION total motile sperm. Lining 10mm triple layer. Right ovary (30×26) (28×22) (24×20)CL. Left ovary (32×25)CL (12×11)
COMMENTARY:
When a woman takes ovulation medication for the very first time, the results are a lot like Forrest Gump’s box of chocolates. You never know what you’re gonna get. Sure, just knowing Terra’s age and the dosage of medication, I could guess that she would possibly have 2-3 eggs, but I would not have been totally shocked had she made zero nor would I have been shocked had she made 8 eggs. After her first US on day 08, the largest follicles was the 15×14, followed by the 14×13. The other two were smaller and more likely to stop growing. In general, we like them to grow to about 18mm. On the next visit on day 12, four mature follicles emerged as the leaders (they are highlighted in BOLD lettering). The other four are smaller and not likely to result in pregnancy. On that day, I could have chosen to trigger her ovulation, but instead, I decided to wait one more day before triggering, just to allow those four to grow a smidgen more. So she continued with another 150 IU of medication that night, before taking a different medicine, the hCG, on the night of Day 13.
The hCG is a medication that is given to trigger ovulation. It is also the same hormone that is tested in a pregnancy test. Therefore, if you were to do a pregnancy test too soon after taking the hCG shot, it would give you a false positive pregnancy test. In general, for a first cycle, I time the hCG shot about 40 hours prior to the insemination.
On the day of the IUI, I did another ultrasound, right after putting the sperm in. This enables me to confirm that it went into the cavity. Sometimes, if the volume of IUI specimen is high enough, it can distend the uterine cavity and give me a free peek to make sure there are no polyps or fibroids in it. I also use the ultrasound to see if the follicles have ovulated. In Terra’s situation, none of her follicles had ovulated. This was evident, because all the big follicles were still there. In fact, they each had gotten quite a bit bigger. Also, there was not a lot of free fluid seen behind the uterus. If the follicles would have ovulated and released their fluid, one would expect more free fluid to be seen. Many times, the patient also reports a lot of pain right near the time of ovulation.
It would not have been wrong to stop there. Even though the follicles had not ovulated, at least some of them were expected to do so shortly. However, Terra was in an extra-diligent mood and when I offered her an optional second insemination the next day, she and Miles clearly stated that they wanted it. Miles was confident he could produce another stellar sperm sample, and it turns out he did.
On Day 16, after the second IUI, it was clear that at least one follicle had successfully ovulated on the left, seeing how there was only one large one remaining, when previously there had been two. In addition, some of the follicles, even though they were still there, were filled with echogenic shadows, suggesting that they had already ovulated, but just refilled with blood. This is called a CORPUS LUTEUM and is what’s left over of a follicle after ovulation. So it was clear that we had successful ovulation.
So optimistically, Terra was routinely started on progesterone to help support the lining and we waited for the scheduled pregnancy test in about 11 days. With about four mature follicles, her expected chances of pregnancy were good, while still maintaining a pretty safe threshold against having twins or triplets. On paper, this had been a great cycle. Terra and Miles eagerly awaited some good news on the day of the pregnancy test.
