Case of the month June '08: Episode #4
Summary: DARRYL and CAROLINE have been infertile for 19 months. The most likely cause is Caroline’s failure to ovulate. This was suspected because her ovulation testing always remained negative, despite the unexpected finding that she has fairly regular periods. Caroline’s ovulatory problem seems to be a result of PCOS and the effect of PCOS on Caroline’s body weight. We have a plan in place to tackle the problem from both directions. Caroline is actively losing weight, through diet, exercise and metformin. In addition, we are going to give her ovulation medication to further help her ovulate. Although she has already failed several cycles of Clomid with her OB, she requested to do one more Clomid cycle, in the belief that her decreased weight and her successfully being on metformin will give a different result this time.
I picked up the chart. We still defy the temptation of going to electronic medical records, and there are many good reasons for us to keep from doing so. I saw that Caroline had gotten her period five days ago and was here for her baseline scan. The purpose of today’s ultrasound is to make sure she doesn’t have any cysts at the moment. The presence of cysts would make it wise to wait another month before doing a cycle.
I walked into the room and Caroline greeted me enthusiastically, sharing that she had lost more weight and was now down to 234#. I congratulated her and proceeded to do the ultrasound. Both ovaries were quiet. The lining was thin. No real surprise. The results were exactly as we hoped for.
As I was about to leave the room, Caroline asked if she could talk to me. I told her I would have to do two more ultrasounds, but I would be available after that. She dressed and met me later in the consultation room.
CAROLINE: Guess what! I’ve changed my mind about the Clomid.
ME: What do you mean?
CAROLINE: Remember you didn’t want me on just Clomid. I’m sick of not being pregnant. I want to move forward and be more aggressive.
ME: So do you want to start injectables today?
CAROLINE: Can we do the combination that you talked about?
ME: Absolutely. We’ll start you on 150mg of Clomid and then add injectables.
CAROLINE: Perfect!
ME: What made you change your mind?
CAROLINE: I never told you, but i have a cousin on the East Coast who is trying. She failed Clomid for four cycles, like me, but on her first cycle of injectables, she just got pregnant.
ME: Great for her! OK, let’s try and get good results.
So, DAY 6 to DAY 10, Caroline took 150mg of Clomid. Starting day 11, she took 150 IU of Gonal-F. On day 14, she returned for an ultrasound. This is what we saw:
RIGHT OVARY: Nothing
LEFT OVARY: 7mm follicle. 6mm follicle.
LINING: 11mm triple layer.
While this was disappointing, it was not surprising. There are many different things that we could have seen today. It was possible that she would have so many eggs that we would have to consider cancelling the cycle. She could also have had 3-5 promising follicles, which is what would have been ideal. Instead, she had two follicles, both of which were quite small. I checked an estradiol level on her. It was 122 pg/ml. This led me to give her a few more days. I increased the dosage to 187.5 IU per day. With the Gonal-F or Follistim pens, it’s possible to easily do intermediate dosage, rather than be limited to multiples of 75 such as 75-150-225-300. She continued on this for three more days and then checked again.
RIGHT OVARY: Nothing
LEFT OVARY: 7mm follicle. 6mm follicle.
LINING: 11mm triple layer
E2 = 145 pg/ml
It was time to cancel the cycle. Yes it was good that we did injectables this time, not because it did anything positive, but because we saved ourselves from wasting any more time.
Caroline wound up negotiating with me to try 2 more days of injection, since she had enough left in her remaining Gonal-F vial to do so. I gave in to her request. She continued on 187.5 IU for three more days and then returned for ultrasound.
This is what we saw.
RIGHT OVARY: Nothing
LEFT OVARY: 9mm follicle. 6mm follicle.
LINING: 11mm triple layer.
E2 = 170 pg/ml.
We sadly cancelled the cycle and waited for her to call with the next period.
