Case of the month Mar '08: Episode #5
For eleven days, coming down from the high of a highly optimistic first IUI cycle, Terra was full of anticipation for her pregnancy test. She was so anxious that she did a home pregnancy test the day before coming to our office. I saw her look of devastation when she confessed to having tested. It had been negative. She was not the first patient to "cheat" in this manner and I told her the truth. If the test would have been positive, that would have been great news, because that means the blood test would confirm the pregnancy. However, a negative urine test USUALLY, but not always means a negative blood test. There have been some memorable times when a patient came in despondent from a negative home urine test, but was surprised to find out that the blood test was positive, signaling the beginning of a nine-month healthy pregnancy. In Terra’s case however, her blood test came back the same as her urine test - a big negative.
We had a long conversation over the phone later that day. The good news had been that she had stimulated very well and the sperm sample had been very good. But, understandably, that doesn’t mean all that much when the result is a negative. At this point, we made the decision to do a second cycle, knowing that about 50% of patients will get pregnant with this treatment approach (ovarian stimulation and IUI) within three cycles. Three failed cycles would tell us something, that it’s probably time to move on to IVF. But ONE failed cycle does not tell us that at all.
Her Day 03 ultrasound showed three large cysts (over 25mm) left over from this past cycle. This was not a huge surprise. Many times, after a vigorous stimulation, there are cysts left over. Because of the cysts, we could not do a cycle right away this month. At least this gave Terra a one-month break to try on her own again. She called a month later with her period.
Taking what we learned from the first cycle, we modified things a bit in this second cycle.
Day 03 Right ovary clear. Left ovary two 6mm cysts.
Day 08 After 2 days on 225 IU and 3 days on 150 IU of injectable gonadotropins. Right ovary (15×13) (10×10) (9×9) (7×7). Left ovary (12×10) (11×11) (11×11) (10×10) (10×7) (9×7). Lining 8mm triple layer.
Day 11 After another 2 days on 150 IU. Right ovary (17×13) (15×15) (8×8) (8×7) (7×7). Left ovary (19×15) (24×18) (18×14) (14×14) (15×13). Lining 10mm triple layer.
Day 13 After 2 more days on 150 IU. Right ovary (19×17) (17×17) (10×10) (11×10) (12×11). Left ovary (21×19) (27×21) (21×16) (16×16) (16×16) (13×12). Lining 10mm TL.
Day 14 After 1 more day of 150 IU. Launch ovulation at 2PM with 10000 IU of hCG.
Day 16 IUI #1 with 25 MILLION total motile sperm. Right ovary (23×19) (21×21) (13×11). Left ovary (22×22) (40×28)CL (23×21) (20×16) (19×19) (13×12). Lining 10mm TL.
Day 17 IUI #2 with 20 MILLION total motile sperm. Right ovary (24×24)CL. Left ovary (39×32)CL. Lining 12mm TL.
COMMENTARY:
Immediately after her first cycle, Terra had 3 large cysts on day 03. They were well over the cutoff size, so it was an easy decision to postpone things and wait a month. When she came back a month later, she had two tiny cysts, which were so small as to be of no consequence, so finally we could proceed with cycle #2. As per our discussion, we would be a tad bit more aggressive, but not much more. We started with a higher dose for the first 2 days to try and recruit more follicles. Her day 08 US showed a good response but nothing too vigorous, so we continued the same dose.
By day 11, there were 2 maturing follicles on the right and five on the left. However 2 of those 5 were still at an immature size. Then, by day 13, we had 2 mature ones on the right and 3 clearly mature-sized follicles on the left. Remembering that there were a few unpopped follicles last cycle, I told Terra that normally, I would trigger ovulation now. But because of what happened last cycle, I would grow her out one extra day this time. We would also give the hCG a few hours earlier to give the eggs more time to release before the IUI. We used the full 10000 IU of hCG. A lot of times, with this many eggs, it is safer to give just 5000 IU to lower the risk of hyperstimulation syndrome. However, in Terra’s first cycle, she had no bloating at all and surprisingly, no indication of hyperstimulation.
Despite all our attempts at adjusting the duration of stimulation and the time of hCG, when Terra came back for her IUI, most of the follicles STILL were not ovulated. The only one that might have done something was the very large corpus luteum on the left. So mildly frustrated, we scheduled another IUI the next day. True to form, Miles gave another excellent sperm sample.
The next day, there was great news. Almost everything was now ovulated! There were two CL’s left, one on each ovary. The rest of the follicles were gone, meaning that the eggs had released and were somewhere outside the ovary now. Hopefully, they were in the tube. We were once again optimistic. This cycle was definitely better than the first in that we had more follicles and the ovulation was more definitive. Of course, with a total of seven follicles, we were also facing the opposite problem, the risk of twins or triplets. For many patients, this cycle would have been managed more gently or cancelled all together. However, Terra and Miles clearly stated that they were aware of the risks and wanted to aggressively go forward with it.
Again, the long waiting period began, leading to the day when we would once again do a pregnancy test.
