Despite her usual cheery nature, Aimee’s smile and chatter on the day of her ultrasound hid her underlying nervousness. This was the first monitoring visit after she started her stimulation medications. And although she went into this, optimistic about her chances of a good response, she had been properly warned about potential unpredictable outcomes as well.
Just as is the case with the majority of fertility patients, she was now quite accustomed to having the ultrasound probe placed internally. What was very strange and stressful the first time, was now second nature.
This is what we found:
Right ovary: (19×13) (12×12) (12×12) (11×11)
Left ovary: (14×14) (13×12) (8×7)
Lining: 8mm triple-layer
After four days of stimulation, this is a response that is above average, but certainly not out of the ordinary. The dominant follicle is the large one on the right. The large one on the left is not bad either. It is extremely likely that both will go on to mature in a few days. The rest of them may or may not, and herein lies the dilemma. If we continue at the same dosage, she may end up maturing all seven, which would make for a somewhat risky first cycle. If we drop the dosage too much, we might end up losing most or even losing all of them.
Again, the situation was explained to Aimee and just as I expected, she opted to proceed on the aggressive side. We continued her on 150 IU and saw her back in three days.
This is what we found:
Right ovary: (24×14) (17×16) (16×14) (13×13) (12×12)
Left ovary: (20×14) (19×15) (14×12) (11×10)
Lining: 9mm triple layer.
In general, follicles that are over 15mm in size have a reasonable chance of being mature. The optimal size that I personally like is close to 17-19mm. Different RE’s may have different preferences based on their own experiences and based on their own ultrasound measurement tendencies. For example, the same patient could experimentally get back-to-back ultrasounds from two different doctors and end up with measurements that differ by 2mm. The optimal follicle size may also differ from patient to patient. Some patients get pregnant with IUI and then 2 years later, get pregnant with IUI again. If they took three cycles each time to conceive, we have six cycles to look back on, 2 successful ones and 4 unsuccessful ones. If we see that the follicles were generally larger, like around 22mm in the successful cycles, then we might infer loosely that this patient tends to do better when her follicles are triggered at a size that is larger than average.
Because this was the first cycle ever for Aimee, we didn’t have the luxury of past information and have to make decisions based on our best judgment. She clearly has five follicles (highlighted in bold above) which are in the mature range. We might even be generous and call the 14×12 a potential as well, but that might be stretching things a bit. So with five mature follicles estimating that each has a 10-20% chance of becoming a baby, the chance of pregnancy is quite good, the risk of twins is moderately high and the risk of triplets is low, but possible. Aimee phoned Boyd and got his confirmation that they wished to proceed. Had this been a couple that told me that they really didn’t want twins, I would have counseled them to cancel this cycle and restart next month at a lower dose. But based on their wishes, Aimee was instructed on how to take an injection of hCG at 5PM later that afternoon.
Injecting hCG is like lighting a long fuse on a firecracker. Once you inject it, the countdown begins. In general, about 36-40 hours after the injection, the follicles will release the eggs in a process known as ovulation. This is an estimate only. Some patients might release them earlier and some might release them later. And as you can guess by now, the exact same patient might ovulate in different time frames from month to month.
Since this was on a Thursday, Aimee will come back in two days on Saturday for her first insemination. She was given a specimen cup to take home.
