Even before starting their first IUI cycle, Aimee encountered disappointment. She has a cyst. She had called with the first day of her period and eagerly came in for the baseline ultrasound before starting her cycle. This ultrasound is important because prior to stimulating the ovaries, it is important to establish a baseline and confirm that the ovaries are in the early resting phase. Just as prior to a race, it is important to make sure all the participants are at the starting line without any who are already half way around the track, so it is important to make sure that no follicles are already developed at the time we are starting the cycle. I know that the terms, FOLLICLE, CYST and EGG are often used in a confusing interchanged manner. For clarification regarding these terms, please refer to this previous post.
So, on day 3 of her cycle, there was a cyst seen on ultrasound in her right ovary. We were hoping to see nothing or at the very least, only the smallest of cysts. This one was 15x13mm and was above the cutoff for what I judged to be optimal for Aimee this month. Now, medical care is best conducted with flexibility and individualization, not with a cookie-cutter approach. So while, I would still say that something this big prevents us from starting the cycle, under certain circumstances, I might have permitted her to proceed. For example, if this was her last chance at treatment before her husband was being deployed to Iraq for three years, then we might reconsider. But since we were not pressed for time, I told her again that we would be wise to wait a month when conditions are more perfect. This would at least give them another month to try on their own. After overcoming the initial disappointment, Aimee agreed to call next month with her period.
Not being able to do a cycle because of the presence of a cyst is something that happens in about 5-15% of initial baseline ultrasounds, so having cysts is not unusual. Often patients ask why they have a cyst. One answer is that the ovaries are just "out-of-sync" that month. The ovaries are counted on to grow follicles and release eggs with perfect timing month after month. For most women, most of the time, they do. However, just as a professional shortstop in baseball will make an occasional error, so do the ovaries. In patients with infertily problems, these errors might be more frequent.
When Aimee called with her NEXT period, it turned out that she and Boyd had Boyd’s cousin’s wedding to attend on the East Coast and the dates for it fell near the time when she would be ovulating, so we skipped yet another month, leaving them to try on their own once again.
Aimee called the following month. This time, there were no cysts and we finally were able to start her first treatment cycle.
Let’s review what’s going on. Today is day #3 of Aimee’s cycle. She is just finishing up the final portion of her menstrual flow. If we completely left her alone with no medical help this month, she would be predicted to grow ONE follicle. This would give her one chance to get pregnant. This is how it has always been for the past few years. Because this has not been working, we now have made the choice to help this couple "cheat" to get the odds more in their favor. One way to do this is to get more than just one egg.
In a previous post, I described how the odds of getting pregnant can be similar to the odds of drawing a winning card in poker. Aimee and Boyd’s deck of cards is clearly not normal. Instead of having a 25% chance of winning a baby each month, as a fertile couple would, they might only ahve a 2-3% chance. By doing an IUI and sending Boyd’s purified supercharged sperm sample deep into Aimee’s uterus, we hope to be boosting these odds to maybe 5-15% per egg. Not only that, we are hoping to get more than one egg. So the rules of the game change in their favor now. Instead of drawing one card out of a deck that has 2-3% winners, we hope to get them the opportunity to draw 3-4 cards from a deck that has 5-15% winners.
As we plan for this cycle, we have to decide on a starting dosage of stimulation medications. This is a very tricky task to do in a first-timer. It is impossible to predict with 100% accuracy how someone will respond to injectable medications on their first cycle. I can give the same dose to 4 different women. One could make no eggs. One could make two. One could make six. And the last one could make 20. However, I am not just wildly guessing. I do have some information, such as their age, their diagnosis and their body weight. If she overstimulates, we will have to cancel or subject ourselves to the risk of triplets. If she understimulates, then her chances of getting pregnant are not as good.
Imagine you are a bartender at a party, entrusted to making sure everyone is happy and slightly buzzed, but not excessively inebriated. If your guest does not feel a thing at all, then you fail. If your guest is so drunk that they are singing at the top of their lungs and knocking over furniture, then you also fail. So the first guest comes up to the bar. He is a boisterous 300-pound college football player and he’s wearing a Budweiser hat and a T-shirt that boasts "I only drink on days that end in Y". After careful consideration, you decide to serve him an extra large pitcher of beer and a shot of whiskey to start off with. The next guest is a young 104-pound woman whom you recall works as a librarian and teaches Sunday School. She tells you that she gets dizzy from taking strong cough medicine. You pour her a quarter glass of Chardonnay. As you can imagine, you probably can do a pretty good job of keeping everyone happy based on your clinical estimates of how much alcohol they can tolerate. However, in a party with 100 guests, there are bound to be some guests for whom you overestimate and some for whom you understimate. If this becomes a regular job for you that you will do week after week for the same crowd of guests, then you can keep records on each patron for whom you misjudge and do a much better job readjusting next time. However, without past performance as a guide, you will often misjudge the proper dosage during the guests’ first encounters.
So anyway, I decided to start Aimee on a daily dosage of 150 IU (International Units) of injectable gonadotropin. I could have chosen different brands of medication, such as Bravelle, Gonal-F or Follistim. For Aimee, there was no glaring differences between the three of these as far as the pharmocological properties. There are differences with respect to price and convenience of administration. I chose to go with a drug that is a little different from these — Menopur. The difference is that the first three are composed of nearly pure FSH and no LH. Menopur, on the other hand, contains a signficant amount of LH in addition to FSH. I could have just as easily chosen pure FSH for Aimee, but the Menopur is also a little less expensive for her.
After the baseline ultrasound was done, one of my nursing staff sat down with Aimee and Boyd and taught them how to do their own injections. After four days of injections they were scheduled to come back for their first follicle check. Bearing in mind that we never completely know what to expect, we are prepared for anything. We won’t be surprised to to see no follicles, three follicles or even eight follicles.
