Do you trust your spouse? Do you trust your parents? How about your doctor?

Before you can answer these question honestly, it’s important that we define what we mean when we use the word, TRUST. In everyday life, the word, TRUST, just like the words, LOVE and HAPPINESS, is one that people use to mean many different things. The ambiguous and inconsistent use of these words is responsible for much of the confusion and miscommunication in this world, such as when the boyfriend says to the girlfriend, as he is breaking up with her, “Honey, I DO love you, but I’m just not IN love with you anymore.” What’s with that?

I’m hopeful that we’ll tackle the words, LOVE and HAPPINESS in future posts, but today, let’s focus on TRUST. In an attempt to study this analytically, I recently asked a random sampling of my friends what the word “trust” meant to them. In order to get a more precise answer, I posed the question, “How would you explain the meaning of the word, trust, in terms that a 5-year-old child might understand.” Their replies ranged from being interesting and insightful all the way to being confusing and contradictory. All in all, the answers were quite varied, but I was able to piece together the following common themes.

We use the word trust in at least three ways.

TRUST - Meaning #1. TRUTHFULNESS: When somebody whom you trust tells you something, you can believe that it is the truth. Conversely, when an untrustworthy person tells you something, you can’t quite be sure if they are being truthful or not. On the far extreme, there are those people for whom you can assume that most of what comes out of their mouth is a lie. There’s a certain occupation of people for whom this is often the case and the word for their occupation sounds a lot like the word, LIAR.

Example:
A: I tried calling Bob all day yesterday. He never answered and I have no idea where he was. I finally reached him today.
B: Oh, really? What did he say?
A: He said he left his cell phone at the office and didn’t realize it until this morning. And the reason he didn’t hear it ring while he was at the office was because the battery had died.
B: I see. Do you believe him?
A: I have no reason to doubt him, but somehow, I‘m not sure. I guess I still don’t trust him yet. After all, we’ve only been dating for six years.

Example:
A: Did you find the missing cash?
B: No, I asked everyone in the office who had a chance to take it and none of them said that they took it.
A: What do YOU think?
B: I trust all of them. I guess I must have miscounted it myself.

In general, it is preferable in life to interact with someone who can always be trusted to tell the truth, even if you don’t always like what they say.
Example:
GIRL: So do you think I’m prettier than Megan?
BOY: Yes. You’re prettier.
GIRL: Do you think I’m prettier than Amber?
BOY: Yes, yes. You’re much prettier than Amber.
GIRL: Am I prettier than Kelly?
BOY: Of course. Without a doubt.
GIRL: Do you think I’m prettier than Erika?
BOY: Er…hey, can we please stop playing this game? I’m getting hungry. So where do you want to go for lunch? By the way, do you know if the Lakers are playing tonight?

TRUST - Meaning #2. RELIABILITY: When you say you trust somebody to do something, you are expressing how reliable you think they are.

Example:
A: We can’t join you. We couldn’t find a babysitter.
B: Aww, that’s a shame. Hey, isn’t Keith’s brother staying with you? Can’t you just have HIM watch the kids?
A: Are you kidding? The last time we asked him to babysit, we came home and found him passed out drunk while the kids were in the kitchen making chocolate syrup sandwiches and setting each other’s hair on fire. No, we just can’t trust him to do that.

TRUST – Meaning #3. BALANCE OF YOUR BEST INTERESTS VS HIS/HER BEST INTERESTS: The final meaning of the word trust is the most difficult to describe. It has to do with how much value that person places on your best interests in balance with his/her own best interests. For example, let’s set a scale of 1 to 10 with 10 meaning that the person in question places YOUR best interests completely over THEIR OWN best interests and 1 being the opposite, with that person’s OWN best interests completely predominating over YOUR best interests.

So in the case of the world’s most devoted mother, her baby can TRUST her at a level of 10. That mother would step into the path of speeding bullet to shield her baby from harm. That mother would walk ten miles barefoot in the snow to fetch food for her hungry baby. Of course, some extremely unfortunate children can only trust their mothers at a level of 1, because their mothers would sell them into slavery in exchange for a hit of crack cocaine.

The typical level you might trust your best friend is maybe a 8. Sure, if you were stranded and emergently needed a ride home, she would instantly get out of bed at 2:00 in the morning and drive an hour to come pick you up. If you desperately needed $1000, she would sacrifice her own rent check to give it to you. Now if you needed a kidney transplant, well, maybe she’s not THAT good of a friend.

In most of our interactions, the level we can trust someone is probably between a 3 and a 6. The reason we can trust even that much is not necessarily a function of that person’s character or that person’s fondness for you, but rather a function of the rules and laws our society have set up. If you work in a grocery store, it’s unlikely that someone will come in, steal the food without paying, grab the money from your cash register and run off. You can trust them not to do that because of the law and the enforcement measures that society has in place. Even “untrustworthy” people will be hesitant to do that. This can change, in certain times of war or natural disasters, when there is no effective law. Then, many people whose actions were held in check during peacetime will become looters and thugs.

Bear in mind that these three components of trust don’t always go hand in hand. In some situations, somebody’s regard for your well-being (meaning #3) may force them to be untruthful to you (meaning #1). Let’s say your child is singing in a school play and messes up badly. Inconsiderate parents sitting all around you are saying how terrible that performance was and how it was the worst part of the entire play. Later, your child asks how he did and you tell him he was wonderful and that everyone in the audience loved it.

Or say that you are a mean boss and your employee hates your guts and wishes you would suffer a cruel fate involving the fleas of a thousand camels. Yet, when you have an important task for him to do, and your job and the fate of the whole company’s well-being rests on this task, he will reliably carry it out. You can trust him to do his job 100% (meaning #2), even though you can’t trust his intentions toward you in other ways (meaning #3).

Now that we’ve defined trust a little more clearly, next time we’ll discuss the specific topic of trusting your doctor.

Click here for The Nature of Trust: Part II

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

Dear Dr. ,

ELIZABETH
Johnson City, TN

Dear Elizabeth,

I certainly hope your husband is OK and continues to stay healthy after his chemotherapy. It was so wise of you to freeze his sperm ahead of time. Those two vials are precious and should be used very wisely. Bear in mind the possibility that his sperm could naturally return to normal or at least to some detectable levels. If so, then it’s not quite as worrisome. I’ve known patients whose husbands froze their sperm before chemo. Then before we could plan out their treatment, they end up getting pregnant on their own. So it might be worthwhile to do a semen analysis, say four months or so after the final treatment to see what we’re dealing with. There might be a pleasant surprise.

It’s expected that five months after going off BCPs, the periods should return to the pattern they showed prior to starting the BCPs. A day 3 FSH of 8.2 with a E2 of 91 is a little higher than expected in someone so young, but it’s not something that would send me into a panic. However, short of a grizzly bear rapidly headed my way, there is not much that sends me into a panic nowadays. You should look into OTHER possibilities that your periods have not returned. Instead of just looking at the hardware (the ovaries themselves) investigate the software (hormonal programming of the ovaries). Without knowing more about you, such as your BMI and medical history, I can’t tell you directly what to investigate, but some potential testing would include your thyroid function, prolactin level and the possibility of PCOS.

If it turns out that all these are normal and we are left only with the FSH and E2 as suspects, then realize that there are many other ways to estimate someone’s ovarian age. I wrote it all up last year on a post for my old blog.

Taken literally, your question of "Do I need to be concerned about my levels?" is one I can’t answer, because nobody can judge whether someone should worry about something or not. That is a personal choice. A better way to focus our energy is to ask "Given my D3 FSH and estradiol and all my other relevant clinical information, how should that guide my actions?". I know it’s picky of me to say things this way, but I hope you see my point.

One suggestion is to get the truth about your husband’s CURRENT sperm status. As I said earlier, a good time to test is four months after the final chemo treatment. Remember that sperm takes 74 days to develop, so any toxic injury could leave its mark for as long as that time. If there is sperm detected, that is cause for celebration. If there is none, then I would think twice about wasting one of two vials on just a simple IUI cycle, even with Letrozole. By the way, while there was a time in the past where I tried Leterozole as an alternative to Clomid, I now have almost stopped using Letrozole all together. The data is limited, but there have been reports of at least 12 women who took Letrozole DURING PREGNANCY inadvertently. Out of those, two delivered their children with birth defects and two lost their pregnancies. A larger study looked at Letrozole use prior to pregnancy and the birth defect risk was found to be similar to baseline, so opinions are mixed. Since Clomid has been in use for a much longer time, I feel safer using it, mainly out of fear of giving it to someone who is already pregnant. There might be some specific cases in patients who don’t respond as well to Clomid where Letrozole is worth the risk, but in general, I now stick with Clomid. You might want to discuss with your RE why the choice of Letrozole. An even bigger question is this. If the two remaining vials of sperm are so precious, why even risk them on IUI as opposed to saving them for IVF? (Especially if one vial is used in an unsuccessful IUI and only one vial remains)

Back to the issue of your ovarian aging, the most revealing information about your ovaries will surface once you begin stimulation. If you make a lot of eggs and get pregnant, then the whole FSH issue would be put to rest. So if you are physically, emotionally and financially ready to be parents, then get started now. Your FSH level of 8.2 cannot reliably predict what will happen. You could be fine and not go into menopause until age 49, or you could be menopausal within a year. The test does not say for sure one way or another, although my first guess is that you’ll be fine even for another 10 years. I hope this information helps guide you in your next conversation with your RE. Good luck and thanks for your question!

Click here for episode #1

SUMMARY: Cora and Anthony have just failed their first IUI cycle and are here to discuss the next step.

Failing a single IUI cycle is not necessarily the end of the line when it comes to IUI’s. Just because the first one failed doesn’t necessarily mean it’s time to give up or to go to IVF. However, there is something special with Cora in that we know her tubes are not in the best condition. I told them that if we’re going to try IUI again, let’s at least consider doing it more aggressively, so that we get a lot more eggs than we did last time. The downside to this strategy is a higher risk of twins and multiples and a higher risk of Ovarian Hyperstimulation Syndrome. But with careful monitoring, we can avoid too high of a risk. In actuality, I reminded them again that I still think IVF is best for them, but they opted for an aggressive IUI.

IUI CYCLE #2

Day 3: Cora came in and got a baseline ultrasound. Both ovaries were quiet. There were no cysts. Her lining was thin (as would be expected since she just got done bleeding away her lining). Many times, right after a failed cycle, there are cysts left over from the previous stimulation, but not in this case. Very good.

Cora was instructed to take 150 IU of Menopur every day for five days and then return for another ultrasound. 150 IU is not necessarily a high dose for everyone, but for a 25 year-old, that is a pretty high dose. I would not be surprised if she made six or more mature follicles.

Day 8: Cora came back after five days of injections. This is what we saw.
RIGHT OVARY: (14×12) (14×13) (11×11)
LEFT OVARY: (15×12) (12×12) (12×12) (12×12)
Lining 8 mm triple-layer.

This is a good start. Maybe it’s not as vigorous as I would have guessed, but if the 12’s and 11’s all grow, we’ll have seven, which is a healthy number of eggs. I toyed with the idea of lowering her dose. Why? If I lowered her dose, I might be able to keep it very safe at just three follicles. However, that’s not what we wanted. We wanted more this time, so I maintained her on 150 IU for the next three days. Had we really been worried of her overstimulating, I could have brought her back in two days, but as it was, the plan was set: 3 more days of Menopur 150 IU.

Day 11: Cora came back after three more days of injection. I asked her if she was feeling bloated with a lot of eggs and she answered "not really". This is what we saw.
RIGHT OVARY:  (19×15) (17×14)
LEFT OVARY: (17×15)
Everything else was less than 12mm on both sides.
Lining 10 mm triple-layer.

This was a bit unexpected. Out of all the 12’s and 11’s, I would have expected at least 1 or 2 of them to have continued. Instead, we saw that all the of the three lead follicles did fine, but everything else fizzled out. Cora had mixed feelings. She had been a little nervous about the plan of aggressive stimulation, but once she got her mind set on it, she was now disappointed that the stimulation was so light. This was even less of a stim than her previous cycle, which as you recall, was a combination of Clomid and 75 IU of injectables.

One thing to keep in mind is the unpredictability of the human body. Yes, you would expect that a higher dose would mean a better stimulation. However, haven’t you all had an experience when you studied much harder for a midterm exam than you had for the previous one, but wound up doing more poorly than the one that you hadn’t studied for? Those of you who are basketball fans might remember game five of the 1997 NBA playoffs between the Chicago Bulls and the Utah Jazz. The Bulls had just lost the last two games, allowing Utah to tie the series 2-2. Michael Jordan woke up that morning deathly ill with the flu or food poisoning. He had the big game that night and he could barely sit up. He slept until a few hours before game time and miraculously crawled out of bed. Even though he made it to the game, he was clearly wobbly, pale and weak. So what happened? The rest is history. He wound up playing almost the entire game (44 out of 48 minutes), scoring 38 points and leading his team to a 2-point win before collapsing into his teammates’ arms. The point is that the performance of the human body is unpredictable. There is a random factor that makes you bowl 120 one week and 189 the next without anything having changed about your skills.

I consoled Cora that this was not something terrible and that this did not say anything bad about her ovaries. In fact, it could just be a fluke. She was instructed to continue one more day of 150 IU and then take the trigger shot of hCG the next day. Triggering today would have been OK, but it was slightly better to grow them out one more day.

On Day 14, she came back for her insemination. It was another good sample with 10 million total motile sperm present. I don’t believe I mentioned that Anthony’s sample last month had consisted of 11 million total motile sperm.

Ultrasound right after IUI showed that everything had ovulated. The largest follicles anywhere were an 11mm on the right and an 11mm on the left. She had successfully ovulated and we began the long wait.

Twelve days after the IUI, Cora was scheduled to come back for her pregnancy test. I acknowledged that this stimulation didn’t appear on the surface to be any more vigorous than her first IUI, but it did have the advantage of been untainted by any Clomid.

Click here for episode #6

Baltimore Orioles third-baseman Melvin Mora is father to well-behaved quintuplets.

Hi there Dr!

VIRA
Chicago, IL

Dear VIRA,

The situation you describe is a common one. We have somebody with over a year of infertility, despite regular periods. A workup has been done. Treatment has been tried. But still, there is no pregnancy yet. What are the options at this point. Let’s break it down logically.

Should we do more testing?
What do we know with respect to the three factors that contribute to infertility? SPERM problems. EGG problems. ANATOMICAL problems.
You share that your RE has evaluated your husband’s sperm and has told you that he has "perfect counts".
Because you are doing monitored cycles, we are getting a good idea of your ovulation.
You also share that you have had an HSG and that it came out great.
With this limited information, I agree with your RE’s decision not to pursue any further advanced testing at this point.

Another IUI vs IVF?
This is always a tough decision. There are many factors to consider.
COST DIFFERENCE: Some people have full insurance coverage for IVF. So for them, the cost of IVF and IUI are the same — zero. Many of these people choose to go straight to IVF because they can pregnant faster at no cost. On the other extreme, some have full coverage for IUI, but no coverage for IVF. These patient usually ask me to keep trying as many IUI’s as possible. There are also many people who have worked hard for many years and therefore have great financial resources. Most of these will choose to do IVF fairly early.
PAST TREATMENT FAILURE: All other things being equal, someone who has never tried either IUI nor IVF would be better off with IUI as compared to someone who has already failed IUI eight times, for example.
TUBAL DIAGNOSIS: All other things being equal, someone with known tubal problems or with endometriosis would be better off trying fewer IUI cycles than someone with no tubal problems.
SPERM DIAGNOSIS: All other things being equal, someone with low counts or unproven fertility would be better off trying fewer IUI cycles than someone with great sperm and proven fertility.
PERSONAL SENSE OF URGENCY: Those who have more patience and are not desperate to get pregnant "this very month" can try more IUI cycles than someone who is insistent on absolutely getting pregnant right away. A lot of this has to do with age also. Someone younger has more time to play with, so may try more IUI cycles before going to IVF. Someone older would be wise to consider IVF sooner than later.

Conservative stimulation vs Aggressive stimulation?
You bring up a very good question. How many eggs should you be trying to get? The answer to this also depends on many factors.
PREVIOUS TREATMENT FAILURE: For patients in their first IUI cycle, it’s generally better to be conservative, because you never know how powerful treatment can be. For patients who have failed IUI many times with many eggs in total, it’s less dangerous to have multiple eggs, so one can afford to be more aggressive. For example, it’s almost impossible for someone to fail with 2 eggs, fail with 2 eggs, fail with 3 eggs and fail again with 3 eggs and then, in the next cycle, when they have 5 eggs, all of a sudden get quadruplets. However, while still rare, it’s more likely for someone who has never tried any treatment to get 5 eggs in the first try and wind up with triplets or quadruplets. In your case, VIRA, after failing one year of trying on your own, three cycles of Clomid with her OB, 3 Clomid/IUI cycles and one injectable/IUI cycle, you have demonstrated that you are at less risk of having higher order multiple gestation as compared to someone who has never failed any treatment.
TOLERANCE FOR MULTIPLES: I have some patients who are absolutely against the idea of twins and want to avoid them as much as possible, even if it means taking much longer to achieve pregnancy. For them, I would recommend a conservative stimulation. On the other extreme, there are those who WANT twins and who are willing to take up to a 10% risk of triplets! For those, once I am convinced they know what they are saying, I would be willing to be more aggressive.
AGE: In younger patients, I’m more hesitant to give a strong stimulation. For older patients, I’m much more willing to stimulate aggressively.

Is there anything non-medical I should be doing to help increase my chances?
These would fall under the area of quitting smoking, reducing stress and optimizing body weight towards a BMI of 21-24.

Vira, as I said earlier, your dilemma is a common one and very vulnerable to second-guessing. Now that you have failed so many IUI’s, you are wondering if you should have done more aggressive stimulation in those past cycles. If you go ahead and do two injectable/IUI cycles with an aggressive dose and still don’t get pregnant, you will have wished that you had gone straight to IVF. However, if you get pregnant on your next IUI, you will be so glad that you didn’t do IVF. Such is the nature of the art of medicine. Thank you for your email and good luck!

Click here for episode #1

SUMMARY: Cora and Anthony are a very happy and affectionate young couple who have now been infertile for three years. The primary suspected problem is Cora’s endometriosis and subsequent tubal damage. Despite all this, her tubes are not completely blocked. They had a choice of IUI vs IVF and chose to do IUI. Cora is currently stimulating her ovaries with a sequential combination of Clomid followed by Menopur. It is day #15 of her cycle and she is here for an ultrasound.

RIGHT OVARY: (21×17) (11×11) (10×9)
LEFT OVARY: (25×18) (19×17) (11×11)
LINING: 10mm triple-layer

The target size for follicles is anywhere from 16 mm to about 22 mm. We see that there is one beautiful mature follicle on the right and two on the left. Once the optimal size has been reached, then it become time to launch the follicles. Before making that decision, we should ask ourselves if there is any advantage to going one more day. In this case, the next largest follicles are in the 11 mm range and therefore not likely to benefit from just one more day of stim. Had there been some 14 or 15 mm follicles, we might have considered extending the stimlulation, but not with what we see here. Today is the perfect day to launch.

When the ovaries are stimulated with injectable gonadotropins such as Follistim, Gonal-F, Bravelle, Pergonal, Repronex or Menopur, we give an injection of hCG in order to get the follicles to ovulate. The previously-mentioned drugs grow the follicles. The hCG releases the eggs from follicles. Once the injection is given, ovulation usually happens around 36-40 hours later.

Cora was instructed to take her HCG injection at 4PM and come back in the morning two days later with Anthony’s sperm specimen.

The morning of her insemination, Cora arrived with the sperm specimen. My assistants processed it and I performed the insemination. Twelve days later, the pregnancy test was negative.

We met again to discuss the next step.

Click here for episode 5

An Arkansas woman is now pregnant with child #18.

Several of my friends have asked me if I had seen last week’s #1 movie, Baby Mama. I guess it shows how much my job has become part of my persona. Whenever my friends hear of anything related to fertility, they will ask me for my expert opinion, even when it comes to fictionalized misrepresentations of fertility treatment. The last time this was prevalent was during all those episodes of Friends with Chandler and Monica’s surrogate baby. I’m not sure why they do that to me. I don’t ever ask my marine biologist friend what she thought of Finding Nemo.

So today, as with many Thursdays, I try to take a half day, if I can. Fortunately, it was feasible today for me to meet a friend for a good lunch of Thai food. Afterwards, she suggested seeing an afternoon movie and while I would have preferred to see Iron Man on the big screen, she had already seen it and suggested we go see Baby Mama instead. I took it as a sign of fate that I was destined to see this, no matter how much I had tried to avoid it. I must admit, I went into it with a prejudice that this would be yet another Hollywood attempt to get some cheap laughs on the back of the popular topic of fertility. And what did I find? Hmm, since I don’t often get a chance to play movie reviewer, I will seize this opportunity and give my thoughts from a reproductive endocrinologist’s perspective.

The first few minutes started out promising. A recap of the life of the central character, played by the talented Tina Fey, described her career as a successful executive, including the decisions she made regarding postponing childbirth in favor of climbing the corporate ladder. I was almost convinced that this would be a quality treatment of this very relevant topic. However, it went downhill from there. Sure, I might be biased and nit-picky, but the portrayals of the clinical scenes played fast and loose with reality and medical accuracy. Tina’s RE was a goofball and very insensitively and demeaningly criticized her T-Shaped uterus. When she was choosing a sperm donor, it was the doctor who sat with her and personally reviewed the sperm donor profiles with her on a computer screen. Er.. we don’t really do that. Not only did the profiles all show pictures of the donors (and again, sperm donors don’t reveal their pictures), with a press of a button, he was able to morph the donors’ pictures with Tina’s picture to create a composite prediction of what the baby would look like. Neat idea, but far from reality.

When Tina’s embryos were transferred into the surrogate’s womb, instead of a small syringe, he used a gigantic 60cc syringe attached to a catheter that looked two feet long. Still, I did get a slight laugh out of it. I also smiled when they poked fun at the reality of how the stresses of infertility really bring out a lot of worry and pessimism. One of the books that Tina bought at the bookstore, after the pregnancy was confirmed, was a book whose cover read in huge letters "101 Things That Can Go Wrong with your Pregnancy".

Most of all, I tried to quell my disturbance at the fact that this was a surrogate who smoked, ate junk food, and was in an unstable relationship with an emotionally abusive boyfriend. The reality is that surrogates who work with reputable agencies are meticulously screened and someone like Amy Poehler’s character would NEVER have been chosen. I don’t want to spoil things for those who haven’t seen the movie, but the twists and turns are not as they initially seem. I can imagine that the movie might even be emotionally disturbing to those who suffer infertility as it callously presents an unlikely scenario which could be extremely heart-breaking.

On the bright side, it wasn’t TERRIBLE. There were enough sprinklings of comic moments that managed to keep my attention throughout the entire film (barely) including some funny scenes with the childbirth coach. A very special treat was the fantastic performance of comedic genius, Steve Martin, as a New Age health food mogul. It reminded me of my childhood and how much I loved his work back then. That, for me, was worth the price of the matinee tickets. I think the next time patients visit me with their babies, I will hold the baby to my forehead and transfer my aura and mojo to them the way Martin did in the movie, just for a good laugh.

In summary, those who are searching for an intelligent treatment of the topics of infertility and surrogacy had best look elsewhere. Those looking for some typical SNL humor from a talented cast might not be as disappointed, but still, I think they would be better off waiting for the DVD.

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.

Click here for episode 4