Case of the month May '08: Episode #3
preantralf="http://fertilityfile.com/2008/05/01/case-of-the-month-may-08-episode-1/" _fcksavedurl="http://fertilityfile.com/2008/05/01/case-of-the-month-may-08-episode-1/">Click here for episode #1
Baseline Ultrasound:
CORA’s period started on Thursday, so she was here Saturday morning on D#3. The baseline ultrasound is helpful in confirming that it’s safe to start stimulating the ovaries.
Here’s what we COULD HAVE seen:
There’s a 21 mm cyst in the right ovary and nothing in the left ovary.
Because of the cyst, we have to postpone the cycle. A cyst that large is out of sync with what the ovaries should be doing this early in the cycle. Trying to force the cycle this month would leave us vulnerable to a lot of unpredictability. The cyst could be producing a lot of estradiol and therefore cause a diminished ovarian stimulation at a time when we want the ovaries to stimulate well. It could also end up producing progesterone at a time before we want any in the system. It could also grow larger and rupture in a way that caused great pain and even internal bleeding.
In this case, we would have Cora and Anthony just try on their own this month. Cora would wait for her next period and come back in on day #3 to check if this cyst is gone. If gone, we could proceed as originally scheduled.
Here’s what else we COULD HAVE seen:
There’s a 12mm cyst in the right ovary and 2 cysts in the left ovary measuring 11mm and 10mm respectively.
Even though there are cysts, they are relatively small. Also the fact that there are three at nearly the same size makes it likely that a stimulation will affect them in a similar manner, so that all three will mature at about the same rate. This makes it OK to proceed.
Here’s what we ACTUALLY saw:
Both ovaries were quiet with no early follicles that were any bigger than 5 mm each.
This is the ideal starting point. Not only are there no large cysts, the presence of tiny cysts (known as pre-antral follicles) is a good sign. For a quick review of cyst terminology, check out this previous post.
Now we needed to decide on a particular stimulation protocol for this cycle. You might recall a previous case where I discussed the logic involved in deciding the choice of stimulation medications. After some discussion, we agreed on a combination of Clomid followed by injectables. I had a preference to be aggressive and go with straight injectables, even though this was a first cycle. This was because of what we knew about Cora’s tubes being so bad. When the tubes are really suspicious, we lean towards trying to get more eggs than fewer. When the tubes are clean, the patient is young and/or has a high fertility history, we would lean towards trying to get fewer eggs rather than more. However, even with a very small chance of twins or triplets, Cora and Anthony were justifiably nervous in their first cycle. They chose instead to go with a milder protocol.
On Days 3-7, Cora took 100mg of Clomid by mouth. Then on Day 8 to Day 10, she injected 75 IU of Menopur. We could have just as easily used some different brands, such as Follistim or Gonal-F. Except for certain special situations, I start out with the general view that the brands are pretty interchangeable with regards to the drug effect. This is not 100% true, but for all practical purposes, we can often treat them as similar. However, they are clearly different with regards to cost and with regards to ease of administration.
FIRST FOLLICLE CHECK:
After taking her meds as instructed, Cora came back on Day 11 for another ultrasound.
This is what we COULD HAVE seen:
Both ovaries are completely absent of any follicles greater than 6mm in size. This is a bad sign. Despite all that medication, the ovaries are not responding. This is something that you often see in someone over 37 or in someone with diminished ovarian reserve, but you would certainly not expect it in someone Cora’s age. One thing to think about is this. Is she taking the medications correctly? I would also check her estradiol ( E2 ) level to see if maybe I’m missing something with my ultrasound. There are occasional cases when a woman’s ovaries are very deep and difficult to see. In that case, there is the remote possibility that there are good follicles, but they escaped my sight during the ultrasound. As unlikely as this is, if it were the case, then the estradiol would be high. If the estradiol is low, then it confirms that this is a bad stimulation. We would likely cancel the cycle and reevaluate the situation.
This is what else we COULD HAVE seen:
Cora has 6 follicles on the right all between 10 and 14mm. She also had 8 follicles on the left in that size range. This is a HYPERstimulatory response. It is seen once in a while with PCOS patients. While it’s good to have this many eggs growing for an IVF cycle, it is considered to be less safe in many IUI cycles. Since Cora is on such a low injectable dose, we would have a hard time lowering the dosage. We would have to cut her down to 37.5 IU which is half of a standard ampule.
This is what else we COULD HAVE seen:
Right Ovary: (25×22) (15×12) (16×14)
Left Ovary: (12×11) (12×11) (11×11) (11×11)
With this scenario, there is an obvious mature-sized follicle on the right. We could try and push it a few days to allow the 16 and 15 to catch up, but doing so risks messing up the timing in case the 25 decides to ovulate on its own. I would most likely just go ahead and trigger the ovulation with hCG and schedule an IUI in two days.
This is what we actually DID see:
Right Ovary: (12×11) + 4 small follicles (9×9) (9×8) (8×8) (8×8). I typically wouldn’t measure these last four precisely, but would rather lump them into the category of "small follicles", so we would say that there is a 12 plus 4 small ones.
Left ovary: (13×12) (11×11) (11×11) + 3 small ones.
This is not bad at all, for being on such a low dosage. Cora was instructed to continue the 75 IU daily injection of Menopur and come back in 4 days, on Day 15.
