Case of the month May '08: Episode #6
Click here for episode #1
SUMMARY: Cora and Anthony are infertile. The biggest concern is a history of endometriosis and tubal adhesions. While it’s true that Cora’s Fallopian tubes are patent, they are suspected to be less than optimal. They failed their first IUI cycle. In their second, although she was on a stronger dose of stimulation medications, she did not produce significantly more eggs than in the first time.
There are many things I appreciate about being an RE. Having to break the news to patients about a sad outcome is certainly not one of them. Cora’s pregnancy test for her second IUI cycle was negative.
Over the years, we’ve been able to fine tune the best system for telling pregnancy results. My staff are always the first to notify the patient with the news, positive or negative. Then I will follow up with a call myself, usually within 24 hours. I usually don’t call the positives back unless they have questions that can’t be answered by my staff. There are some patients that I don’t call back at all. For example if somebody took 3 IUI cycles to conceive their first child, then took three IUI cycles to conceive their second child and are now back for their third pregnancy, then if their first cycle fails this time around, I have a pretty good assumption that this veteran couple know the routine, which in THEIR specific case is to go forward and do another cycle. So they would just call when the period starts and we can get back to work on their next cycle. The reason I’m not the first to call every patient is because we run the tests in our office and can get the results back in minutes, often before I’m done seeing patients. Rather than wait until I’m free later in the afternoon, we get the news (good or bad) to the anxious patients "hot of the presses", because they’re often waiting by the phone, ready to pounce on it and answer in 0.2 seconds. I COULD try to squeeze in the calls between patients, but there’s nothing worse than calling a patient to tell them they’re not pregnant and then having to cut the call short after one minute. "HiSusieSorryButYou’reNotPregnantCallUsWithYourNextPeriodAndWe’llTryAgain.Bye". So this is why we have my staff break the news initially and then I follow up later.
That morning, there were seven pregnancy tests. Five first-timers and 2 repeats. The repeats were good, all doubling within 2 days. Of the first-timers, 2 were positive and three (including Cora), were negative. At the end of the day, I called the first two patients who had negatives and then saved Cora for last.
As instructed by the couple, I was to call Anthony, not Cora. He took the news very much like a "numbers man".
"We knew the odds, so we had lowered our expectations," he said."So what do we do now? Would we be able to try again?"
I told them that we certainly could do another IUI. Even though the stimulation was a bit disappointing last cycle, it did not predict that there was anything wrong with Cora’s ability to produce eggs.
Cora came in on day 3. She did not appear sad on the surface, but that’s the way many brave patients project themselves, holding it in, not wanting others to feel bad, even though they themselves were suffering inside. We spoke in the consultation room, sitting on comfy leather couches. I told them that we really should consider IVF.
They expressed that they understood me, believed me and trusted me. However, they want to try IUI again, at least one more cycle. They said they weren’t prepared to talk about In-Vitro just yet. "Would it be feasible to try just one more insemination?" they asked. I gave them the consistent answer. Yes we can, but the odds are slim. Each failed cycle decreased the predicted chance of success when using the same treatment. After further discussion, we decided to try again, but with a higher dose.
I made the judgment call to only slightly raise their dose. We would put them on Menopur 225 for the first three days, drop the dose back to 150 for a day and then do an ultrasound early so we could adjust the dose as needed.
Cora came back for her first follicle scan after the four days of stim. This is what we saw.
DAY #7
RIGHT OVARY: (13×13) (11×11) (14×10) (12×10) (11×9) (11×11) + 5 small ones
LEFT OVARY: (13×13) (15×14) (12×12) (12×11) (12×10) + 5 small ones
Estradiol level = 360 pg/ml
Lining 7mm triple layer.
Cora’s relatively low stimulation last cycle had been a fluke. What we saw THIS month was more in keeping with a woman her age. The higher dosage may have contributed to the improvement, but the difference was greater than would be explained by just a dosage adjustment. In other words, this consistently suggests that the bad stim last month was just a random fluke, and that this month is more in keeping with Cora’s true abilities.
I kept the dosage at 150 and brought her back after three days.
DAY #10
RIGHT OVARY: (16×14) (14×14) (17×15) (15×15). The rest were smaller than 12.
LEFT OVARY: (19×18) (15×15) (14×14) (14×13). The rest were smaller than 12.
I explained to Cora that this was a wonderful stimulation. Had it not been for her tubal problem and her long history of infertility, we would NOT want her to have so many eggs out of fear of triplets. As it stood, I felt fairly certain that her chance of triplets was less than 2%. Was that acceptable to them? She replied yes, the risk was low enough that they would be willing to gamble on it. She smiled and joked, besides drinking, the second favorite thing that Anthony’s family liked to do was gamble.
Her dosage was dropped to 75 IU and she came back 2 days later.
DAY #12
RIGHT OVARY: (20×19) (18×15) (18×17)
LEFT OVARY: (22×20) (18×18) (17×17) (18×14) (16×16)
Again, this would be a big gamble in someone Cora’s age who had perfect tubes or a past history of spontaneous pregnancies, but as it was, this was an acceptable risk, in my professional opinion, after logically taking in all the clinical information. We launched with a reduced 5000 IU dose of hCG and brought her back in 2 days.
For Anthony’s sake, I explained that using the 8 mature follicles in our calculation if we were to assume that the BEST CASE scenario was a 10% chance of pregnancy per egg, then their chance of triplets would actually be a bit higher, around 1 in 30 and their odds of quadruplets would be around 1 in 200. Their chance of any pregnancy at all, of at least one baby would then be 55%. If I really felt that their odds per egg were that high, then I wouldn’t advise going forward with it. However, I believed that their odds per egg was closer to 4% per egg, if even that. That would make their odds of any pregnancy no higher than 27%, their odds of triplets less than 1 in 340 and their odds of quadruplets less than 1 in 6570! As scary as it would be if they did get quads, especially because they would absolutely never consider reduction, the odds were small enough that they were willing to take the chance.
Anthony and Cora were not nervous even when I gave them one last chance to change their mind as I held the syringe of prepped sperm. They calmly said, even if it was a 1 in 1000 chance of quads, they would be willing to do it. Hearing that, I injected the sperm.
Any RE who heard me say that I did an IUI on a 25-year old with eight mature follicles might pass out before I could finish my sentence, but this is where the importance of individualizing care comes in. No cookie cutter program would allow this because it would violate their standard hard-stamped protocol. If I was not convinced that Cora’s tubal status and long-standing infertility were abnormal, I probably wouldn’t have done it. If I was not convinced that Cora and Anthony were intelligent rational adults who confidently embraced the risk they were taking, I would probably not have done this. If I hadn’t had the chance to have lengthy intimate conversations with this couple to really get to know them, I would probably not have done this. If I didn’t trust Anthony and Cora not to sue me in the event of the 1 in 6570 occurrence of quads, I know I wouldn’t have done this. Call me naive. Call me fearless. Call me in 12 days when the beta is done running.
Click her for episode #7
