Case of the month June '08: Episode #6
Caroline and Darryl have been trying to get pregnant for almost two years now. The most obvious problem is Caroline’s failure to ovulate. First, she was started on metformin to correct address her insulin resistance. Then she was tried on a combination cycle of Clomid and injectables. She didn’t grow a mature follicle. Next cycle, it took quite a bit of injectable medications, but Caroline ovulated. We even did an insemination to give that egg the best chance.
However, according to today’s blood test, Caroline was not pregnant.
It is very normal to have fleeting thoughts of giving up when things don’t go our way. Caroline had worked hard to lose weight (now down to 228#), spent hundreds of dollars on medications, endured the daily needle injections, had gotten her hopes up with the egg that we saw, only to have it all end with a negative pregnancy test.
We reconvened to talk about options.
ME: How are you feeling?
CAROLINE: Trying to see the bright side. (smiling) I really thought this was going to do it. I mean seeing that egg on ultrasound made my eyes tear up, with joy. I realize now that one egg isn’t guaranteed to give a baby and I’m prepared to get more eggs until one takes.
ME: Hmmm. You have a pretty good attitude. And you’re right. While it’s optimistic that you got the one egg last cycle, it’s not always enough just to have one. So now we have a few choices. We can do another cycle, with a high enough dose to get multiple eggs. We can check your tubes to make sure that they’re open. Or we can wait for you to get into better shape. You’re doing a great job of that, by the way.
CAROLINE: Well, Darryl and I discussed it. We want to try one more cycle. If it doesn’t work, we might take a break. So can we be aggressive?
ME: Of course. I’m going to start you on 225, because that’s what got you going last time. Remember we don’t want to give you too much, or else you’ll end up risking having TOO many babies.
CAROLINE: Honestly, I wouldn’t mind having triplets and just getting this all over with.
ME: A lot of women say that. Many of them don’t really mean it. Haha.
CAROLINE: I know. I know.
We started the cycle.
Day 3 baseline ultrasound:
RIGHT OVARY: Nothing.
LEFT OVARY: Nothing
Good start. From her friends and online friends, Caroline knew the disappointment of finding a cyst on the baseline scan. Luckily, this wasn’t one of those months. The next decision is what dosage to start her on. Last month, nothing really happened until we raised the dosage to 225 IU, so this month I decided to start her off with that. Another tweak is the decision to have Caroline take the injections into her arm IM. I’ve tried this in the past on women with a lot of abdominal body fat with mixed results. It was certainly worth a try. There just might be better absorption of medication when given this way. Caroline took 225 IU of hMG from day 3 to day 7 and returned on day 8. This is what we saw.
RIGHT OVARY: (9×9) (9×9)
LEFT OVARY: (10×10) (9×9) (8×8) (8×7)
Estradiol = 200 pg/ml
This was a great start! There appeared to be six promising follicles. If the estradiol level would have been a bit higher, I would have been tempted to drop her dosage. But I would have met with some great resistance from the patient. Caroline was stoked and eager to continue the same dose. I warned her that if all six grew and we wound up with some additional follicles, then she would be at big risk for twins or more. She acknowledged the risk and we trekked forward. On day 8 to day 11, Caroline took another 225 IU daily. This is what we say on day 12:
RIGHT OVARY: (21×17) (11×11)
LEFT OVARY: (19×18) (18×17) (9×9) (9×9)
I was very happy with the three mature follicles. Caroline was disappointed. She had wanted all six to grow. I reminded her that this was a great stimulation and furthermore, it was SAFE! She eventually cheered up, especially after we checked her weight and found out she was down to 226#.
I launched her ovulation with 10000 IU or hCG and brought her back in two days for an IUI.
Again, it was a great sperm sample (20M total motile sperm) and again, US showed that she did indeed ovulate everything. Caroline had a lot of questions right after the IUI. She wanted to know her restrictions on activity, like what she could eat, how much she could lift and how much stress she could permit herself to be exposed to at work with her students. After we covered all her questions, I added that if she didn’t get pregnant this cycle, I would give serious thought to getting an HSG to check her tubes.
Click her for episode 7
