Case of the month May '08: Episode #8
Click here for episode #1
When I saw their names on my morning schedule, I smiled at the surprise. Six years ago, when they left our practice, I had said a silent prayer for this sweet couple. Now, six years later, Anthony and Cora were back. It’s not unusual for patients to come back after several years. Often, it’s because they are back for a second or third baby. It’s usually very fun to catch up on what they’ve been up to, how the new kids are doing and what type of cute baby stories they have to share. Unfortunately, Anthony and Cora did not have a baby yet. They both looked great. The years had not packed any extra weight on them. If anything, Anthony looked lighter and Cora was the same. I was eager to catch up with what had been going on.
For an infertile couple who were still childless, they were just bubbling with positive energy as they eagerly got me caught up on the past six years. Cora had done 5 more IUI cycles with her HMO. She had also attempted to have laparoscopy to fix the endometriosis and open up the tubes more. Obviously, there had been no success at all. That was the medical part. On a personal level, they were doing great. They had a huge house, many friends and a fulfilling mix of charitable projects to keep them busy. Anthony’s career was very successful. Cora recently decided to quit working and stay at home in preparation for having a baby. They acted like a couple who were still very much in love. Then Cora said, "I bet you can guess why we’re here". I had almost expected to say that they had broken away from the Catholic church, but instead, it was the opposite. From their descriptions, they had given even more of their time, resources and money to support their church. And that, ironically, is how they came to the decision that they wanted to proceed with IVF. Huh? I didn’t quite understand, so I asked for clarification. Apparently, they began taking on more of a leadership role and started counseling other married couples. In the course of doing this, they encountered many fellow parishioners who were now parents via IVF. They shared that, at first, many of the couples didn’t want to "confess" how they had gotten pregnant, but when Anthony and Cora shared their sadness at not being able to have kids, many couples felt the burden to share their own IVF stories in the hope that it could help Anthony and Cora come to terms with their decision. Cora always faithfully supported Anthony’s hard stance against IVF. Anthony, on the other hand, could no longer stand to see his devoted wife so sad. They prayed diligently for a sign and they said they clearly got one and that’s why they declared their intention to have a baby with IVF. They apologized to me that part of the deal with God was that they wouldn’t share the details of "the sign" with anyone, not even me. I didn’t mind at all. I was just thrilled they were here. We discussed certain restrictions, such as avoiding left-over embryos and avoiding the possibility of fetal reduction. They had done their homework. I acknowledged their wishes.
After making sure this was their final decision, we started the cycle. I made a protocol schedule and started Cora on birth control pills. (Since we were using the BCP’s for cycle-regulation and not for birth control, it was OK with the Vatican). Towards the second half of her cycle, I did an uneventful trial transfer and checked her ovaries for cysts. Immediately, Cora started on Lupron. When her period came, she got another ultrasound prior to starting stimulation. No cysts. We were good to go. She was started on Gonal-F 225 IU and Menopur 150 IU daily, beginning on cycle day #3. We were being relatively aggressive. They promised that they would eventually transfer any frozen embryos, leaving nothing to discard. They were prepared to do this, even if it meant eventually having ten kids.
After four days of stimulation, this is what we saw:
Cycle Day #7. (Stimulation day #5)
RIGHT OVARY: (9×9) (8×8) (8×8) (8×8) (6×6)
LEFT OVARY: (9×9) (9×9) (9×9) (9×9) (9×8) (7×7) (6×6)
Estradiol level = 588 pg/ml
This was an excellent start! I lowered her dose to Gonal-F 150 IU + Menopur 150 IU and told her to come back in two more days.
Cycle day #9. (Stim day #7)
RIGHT OVARY: (14×14) (13×13) (13×13) (13×13) (11×11) (12×11) (12×12)
LEFT OVARY: (13×13) (13×13) (11×11) (11×11) (9×9) (8×8)
Estradiol level = 1251 pg/ml. Progesterone = 0.5 ng/ml
Still going great, yet not out of control either. The low progesterone value reassured us that the eggs were not in any immediate danger of getting prematurely "stale", or post-mature, as we say. I lowered her dose to Gonal-F 75 IU + Menopur 150 IU for the next day. And then I dropped it to just Menopur 150 alone for the next day after that.
Cycle day #12. (Stim day #10)
RIGHT OVARY: (19×19) (19×18) (22×20) (19×19) (18×18) (18×18) (17×17) (16×16) (16×16) + 5 smaller ones
LEFT OVARY: (20×19) (19×19) (18×18) (18×13) (17×17) (16×16) (15×15) + 4 smaller ones
Lining = 9mm triple layer
Estradiol level = 4122 pg/ml. Progesterone = 0.8 ng/ml
This was the perfect day to launch her ovulation. She was given 5000 IU of hCG to launch the follicles and her egg retrieval was scheduled to occur in two days.
Two days later, I was able to retrieve 19 eggs. Because of the unproven status of Anthony’s sperm, we had planned all along to do ICSI. Since we had many eggs, we had the option of doing ICSI on some, and not doing ICSI on the others, but we decided not to play around with that idea. This month’s yield was enough to make us completely discount Cora’s previous understimulated cycle six years ago. Her ovaries were great! Anthony reminded me about the field goal story I told him way back. "Hey, doc, thanks for the 19 footballs. Take care of them, OK?"
We awaited the next day’s fertilization report, very happy with today’s retrieval.
