UPDATE: Caroline and Darryl are infertile. Caroline has had regular periods, but her ovulation kits don’t turn positive, leading us to suspect an ovulation problem. She underwent one monitored cycle where she received medication to help her ovulate. In that cycle, she not only took Clomid, but also injectables. Sadly, she did not grow follicles well. She comes back to discuss the game plan for the next cycle.
It is helpful to discuss things in terms of options. One option is to give up and do no further treatment. That is always an option. If we were to take this path, Caroline would be banking on the hopes that she could someday ovulate on her own and get pregnant naturally. The odds of this are low, but might improve as long as she continues to lose weight. In any case, it would likely take a very long time to have good news, if any.
A second option is to increase the dosage and try again. The natural evolution of treatment choices would dictate giving injectables from the beginning rather than to start with Clomid.
A third option is to increase the dosage but to patiently wait until Caroline loses some significant weight. This is not a bad plan, with the only downside being the delay in treatment.
After some discussion, Caroline and Darryl opted to do another cycle immediately.
Carolyn came in on day #2 of her cycle for a baseline ultrasound. It showed that both ovaries were quiet and without activity. She then started taking 150 IU daily of Bravelle. We switched from Gonal-F to Bravelle this cycle for the simple reason that the company was running a special discount program. It was simple. Buy 20, get 10 free. Caroline would need it, because she was taking 2 x 75 IU amps daily ( 75 IU x 2 = 150 IU).
Caroline took 150 IU of Bravelle from day 3 to day 7. This is what we saw on day 8:
Right ovary: (7×7) (6×6)
Left ovary: (7×7)
Lining: 9mm triple layer
Estradiol = 82 pg/ml
At this point, it’s still uncertain how things will progress. We forged ahead with a dose increase to 225 IU daily from day 8 to day 10. This is what we saw on day 11:
Right ovary: Nothing
Left ovary: (14×12) (10×9)
Lining: 9mm triple layer
Estradiol = 95 pg/ml
Usually, when a follicle makes it to 14mm, that’s the point where it is likely that it will continue to grow, so as painstakingly slow as this was all going, there was hope. The daily injections were not painful, but the fact that it was costing over $100 in medication (not counting the discount) every day was emotionally painful. But if those two follicles would keep growing, then next visit we will start thinking about when to trigger the follicles for ovulation. The fact that the estradiol level barely went up didn’t make me too happy, but we kept going. Caroline took 225 IU of Bravelle from day 11 to day 13. This is what we saw on day 14:
Right ovary: Nothing
Left ovary: (17×14) (11×11)
Lining: 11mm triple layer
This was it! The one follicle was almost at a mature size. I told Caroline to grow the follicle one more day with 225 IU of Bravelle and then I had her launch her ovulation with 10,000 IU of hCG at 5PM. She came back in two days for her IUI. Darryl’s sperm sample was excellent, with 28M total motile sperm injected. Ultrasound right after the IUI showed that the follicle was gone. Successful ovulation!
For once, maybe the first time in her life, Caroline had ovulated! We waited 12 days for her pregnancy test.
