Case of the month June '08: Episode #7
The pregnancy test was negative again. As sad as this is, let’s temporarily depart from the obvious emotional aspects of this failed cycle and tackle the decision process scientifically.
Caroline is 35 years old. She was presumed to not have ovulated regularly by virtue of her consistently negative ovulation tests. Her husband’s sperm looks fine. In the past few months, with the help of medication, she has been able to successfully ovulate. In three treatment cycles, she grew 0, 1 and 3 mature follicles, respectively. She still has not had an HSG to test her tubes.
What are our choices?
- Give up and/or consider adoption.
- Suspend treatment until another 20 pounds of weight loss
- Move on to IVF
- Get an HSG
- Try another IUI cycle
- Try homeopathic methods
Out of all these choices, my personal favorites would be #2, #4 or #5 followed by #3. But a lot would depend on Caroline and Darryl’s personal preference.
Choice #1 would be understandable, but not recommended. Sure, they have been through a lot. They have spent a lot of money. They have spent a lot of time. Caroline has endured many injections. All this has resulted in no pregnancy. It HAS, however, resulted in progress. We now know that Caroline can ovulate. She has lost a lot of weight and is physically feeling better than ever. Caroline and Darryl made it clear to me that they had zero intention of giving up.
Choice #2 is reasonable. Caroline has shown evidence that she can get healthier. Whether or not the metformin gets the credit for her amazing weight loss is not the point. The point is, she is succeeding. So whether this is due to the medication or just to a new mental attitude, we are just happy that it’s going so well. Caroline and Darryl expressed that they wished to keep going without resting.
Choice #3 would be an even better idea if they had insurance coverage for IVF or if they had $13K in discretionary spending available. While I think that their chances of a successful IVF cycle are excellent, I am still optimistic of her chances with IUI, given that she has only failed with four eggs total so far. I would however, like some assurance that her tubes are patent and her uterus is normal.
Choice #4 is probably my top choice. An HSG will reassure us that Caroline’s tubes are open and that there are no polyps or fibroids in the uterus. If the test is normal, then we can return to do another IUI. Caroline, however, was very against this. Her reasoning, while not scientifically sound, was certainly understandable. She stated that she knew of three people who had excruciating pain with their HSG’s and she didn’t want to go through that at this time. I reminded her that those friends of her are clinically very different from her. In my experience, I’d say 1 out of 10 women have severe suffering during their HSG’s. I make it a point of surveying my patients after their HSG’s and the majority have mild discomfort only or no discomfort at all. In Caroline’s specific case, there are no risk factors for her having bad tubes. She has no history of a sexually transmitted disease. She has had no previous surgery. She does not have painful periods at all. In addition, after her IUI’s, I would do an ultrasound trying to see an image of her uterine cavity after it was distended by the IUI specimen. This allowed me a peek at her cavity and gave some additional evidence that it was normal. Because of all this, I gave in to Caroline’s request to postpone her HSG until after one more IUI cycle.
Choice #5 then becomes the most likely option.
Choice #6 is something that we’re already doing. By losing body fat and improving her overall wellness, Caroline is helping boost her chances of pregnancy, both naturally and with treatment. With regards to taking herbs or nutritional supplements, there is no proof at all that this would be worth the money.
After going over all the pros and cons, we decided to put off the HSG and do another IUI cycle. This time, we’re going to use 300 IU, which is a very high dose for an IUI cycle. However, everything we’ve learned from the previous failed cycles adds to the evidence that this is a good plan.
Day 3. Baseline scan shows no cysts. Caroline started on Bravelle 300 IU daily from day 3 to day 7. Before we reveal what we actually saw, I should add that an ideal finding on this date would be 3-5 follicles of size 12-14mm. This is what we actually saw on day 8:
RIGHT OVARY: Not clearly seen
LEFT OVARY: (8×8) (7×7) (6×6) (7×6)
It’s only a little odd that we can’t see her right ovary clearly today when we’ve seen it easily in most of the previous scans. Sometimes things shift and move. The very fact that it’s hard to see suggests that there are no large follicles contained within it, and for all practical purposes, that’s all I need to know for today. This reassures me that we don’t need to drop her dosage for safety reasons. I keep her on the same dose for day 8 to day 11 and bring her back on day 12. This is what we saw.
RIGHT OVARY: (11×9)
LEFT OVARY: (13×11) (9×9)
Estradiol = 125 pg/ml
Yikes! This is extremely disappointing. Caroline is on her highest dose ever, and yet her stimulation is less than her previous cycle, when she was on a lower dose. Because the lead follicle on the left has made it to 13mm, we forge ahead, rather than cancel the cycle. I keep in mind that Caroline is still taking her injections in her arm, which is a little more brutal than the usual shots that go into the fat pad of the stomach area. She bravely continues 300 IU from day 12 to day 14 and this is what we see on day 15:
RIGHT OVARY: (12×11)
LEFT OVARY: (22×20) (17×17)
Today, there is some relief that we have not one, but two mature sized follicles. I give her 10,000 IU of hCG that afternoon and bring her back for an IUI in two days. We have a discussion about how it sometimes happens that a higher dose results in a lower stimulation. We also keep in mind that it only takes one follicle to get a pregnancy. I remind her that there have been times when patients fail to get pregnant with 5 follicles and 4 follicles in their first two cycles, only to get pregnant on a third cycle when there is only one follicle. Anything is possible.
Two days later, we inseminate with 27M total motile sperm, confirm that both follicles are gone and we begin the waiting game.
