Click here for episode 1

Caroline and Darryl have come a long way. After several IUI cycles, they are pregnant. But they realize that it is a never-ending journey. After discovering that they had twins, they found out that this good news was short-lived. On the previous ultrasound, it was discovered that one of the twins had stopped growing and was without fetal heart motion. This is sometimes known as the Vanishing Twin Syndrome.

The good news is that Caroline’s pregnancy went on without further incident and she went on to delivery a beautiful baby girl.

Here is her final prenatal ultrasound:

I’m currently just a beginner with video editing so look for improved quality in future video clips and audio clips, as I learn more!

This morning, we had a 5.8 earthquake centered pretty much where we are. I was in my office doing charts and by the time I made it to a doorway, things had stopped. I called up the embryologists, concerned about my patients’ embryos and got the good news. Everything had held up. We had taken the precaution of bolting the incubators to the walls and that move had paid off big time. A few alarms went off, probably because of the incubators sensing there was motion. There had also been a crashing sound from the back of the embryology lab, but nobody ever figured out what caused that. Hmmmm. Anyway, it was reassuring that our precautions had been fruitful, and that we could feel safe about our embryos even in the midst of a significant quake. Now if only I could get rid of this recurring nightmare about the big quake and my dogs wandering the countryside fending off danger and hopelessly searching for me.

As I discussed before, the success rate of IVF depends on many factors including the status of the embryos, the status of the uterus and the nature of the transfer. Furthermore, the first component, the status of the embryos is determined by four factors: the patient’s characteristics, the embryology lab, some random factors and the stimulation protocol, which is the subject of today’s post.

Why is it helpful to stimulate the ovaries rather than just let the eggs develop naturally?
- For one thing, there actually are some IVF cycles in the world done without stimulation. This is called natural cycle IVF. I discussed this in detail in an earlier post. However, the overwhelming majority of IVF cycles are done in conjunction with some sort of ovarian stimulation. The main reason for this is markedly greater success rate and greater number of surplus embryos to freeze for the future. There are also some patients, who just don’t ovulate at all on their own and as such, absolutely require stimulation in order to grow eggs.

What does it mean to stimulate a follicle?
- Eggs remain in storage throughout a woman’s reproductive lifespan. They are encased in structures known as follicles. A follicle is an egg surrounded by a special layer of cells, called granulosa cells. The granulosa cells release estradiol.
- Stimulating an follicle causes it to fill up with fluid, making it visible on ultrasound. On the day of the egg retrieval, a needle is stuck into the follicle and the follicular fluid, along with the egg, are all sucked out into a container.

What is an IVF stimulation protocol?
A protocol is a combination of medications taken in a certain sequence. Think of it a recipe for making the eggs ready for removal.

What are the components of an IVF stimulation protocol?
There are five components.

1. Time-regulating component.
2. Stimulation component.
3. Ovulation prevention component.
4. Endometrial support.
5. Supplemental adjuncts.

What is the purpose of each component?
- The time-regulating component usually consists of birth control pills. Because IVF is not a one-day process, but rather a multi-week process, it is important to plan things out. Obviously patients have daily lives and must mesh the duties of doing and IVF cycle with their work and travel commitments. Having the patient take birth control pills allows the RE to better control when a patient will have a period and therefore, when an IVF cycle with start. There are other advantages of taking the birth control pills, including fewer cycles postponed because of cysts.
- The stimulation component is the bread-and-butter of an IVF cycle. It is what drives the follicles to grow. Although Clomid can be used, it rarely is, because of its relative low potency and because of deleterious effects on the endometrium. Therefore, the main stimulation medications used in most protocols are injectable medications, such as Gonal-F, Follistim and Bravelle. Dosage is very important. You want to use a high enough dosage to get a good number of follicles, but you also want to use as low a dose as possible because excessively high doses can compromise egg quality.
- The ovulation-prevention component is crucial. Before the standard usage of Lupron, Cetrotide or Antagon, IVF cycles were easily messed up if the patient happened to ovulate on her own before the eggs could be surgically removed. Nowadays, with the liberal use of Lupron, Cetrotide or Antagon, this rarely happens any more.
- Endometrial support usually consists of progesterone of some sort, whether by injection or by vaginal insertion. This is crucial in helping the lining be at its best. Some RE’s also add estrogen supplementation.
- Supplemental adjuncts include minor medications added to tweak the cycle into having a higher success rate. None of these medications are critical, but each RE has a favorite set of these extra ingredients that may or may not boost IVF success rates. In any case, the effect is minor, at best. It’s sort of like cooking something and adding a dash of MSG. Some examples of adjuncts include antibiotics, dexamethasone, baby aspirin or Viagara.

Click here for episode 1

Summary: Caroline returns today for her second prenatal ultrasound. The first one was done at around 6 weeks and showed two gestational sacs.

Today, Caroline is 8 weeks pregnant. Her last ultrasound showed two gestational sacs, but heart motion was not yet seen. She chose this particular day for her ultrasound because her husband was able to get time off from work today to be with her.

This is what we saw: 

First, I did a general scan to look at the big picture. Right away, I saw two sacs, but something was wrong. One of the sacs was normal in size and contained a healthy-looking baby with positive fetal heart motion. The second sac was much smaller and contained what appeared to be a small yolk sac. However there was no sign of a fetal pole and there no motion of any sort detected within the sac. Just a look at the disparity between the sizes of the two gestational sacs made it clear that something was different between the two. Even Caroline and Darryl were able to tell.

Sac A, seen here on the left contained a fetus with positive fetal heart motion. Sac B, seen here on the right is much smaller and just more "shriveled" in appearance. There does look like there’s something in there, but it appears to be a yolk sac only. The actual fetal pole is too small to be seen and there is no fetal heart motion.

I then focused on visualizing sac A from a different angle. This second picture shows the same baby as the one seen on the left in the first picture. The measurement of the baby from head to butt is known as the Crown Rump Length. According to the table of average fetal sizes, it was expected to be about 16mm today and when I measured it, it was indeed 16mm. The yolk sac ( not seen in this picture) was measured to be a very small 3mm, which was good news, as we don’t like it at this early gestational age if the yolk sac is very enlarged, as that can lead to a higher risk of miscarriage or fetal abnormality.

You can visualize the very early outline of a baby as the head tilts downwards and to the left. The circular area with blackness inside is the baby’s head, with normal fluid seen inside it. You can see what look like two little angel wings. Those represent the arm buds. In this angle you can’t see the leg buds, but there are there.

So, I explained to Caroline that one baby was super healthy and looking as perfect as it could, but the other one had ceased to grow and was no longer living. When a woman becomes pregnant with twins, or triplets or more, there is always the possibility of something happening to ONE baby, but not to the others. Most of the time, this is because something is genetically not quite right with that specific one. This is a source of mixed feelings that can be very confusing. On one hand, if you told Caroline last month that she would be carrying a single healthy baby, she would given anything for that to come true. However, it’s normal human nature that once that notion of twin babies enters your imagination, then anything less feels like a loss. Fortunately, Darryl was there to comfort her.

The next challenge is to stay positive while awaiting the next ultrasound. It is a common, rational fear after losing one baby, that the next ultrasound could reveal similar devastating news. Caroline dried her tears and she and Darryl left the office holding hands with ultrasound pictures of their baby in the other hand.

Check here for episode 13 when published.

While this is outside my area of medicine, I’m impressed by the excellent detailed analysis of a recent unfortunate event in this blog post. This case has many implications for the state of medicine and lawsuits in the US and impacts your future medical care, so it might be in your interest to brush up on the facts before the next time you vote. Enjoy.

Click here for episode 1

Summary: Caroline is now pregnant after doing an aggressive IUI cycle in which she had six mature-sized follicles. It was roughly estimated that she had close to a 40-50% chance of getting pregnant and close to a 1-2% chance of triplets. She was clearly informed and she chose to take the risk. Now that she is pregnant, we are not out of the woods yet. There is always the risk of miscarriage, ectopic or multiple gestation and the only way to detect this early is with close monitoring of the pregnancy. We talked at her first ultrasound.

ME: Congratulations! You know, you were right. You didn’t need an HSG after all.
CAROLINE: I told you about my dream, right? But before we talk, Darryl and I just want to thank you and your staff. We’re just in awe!
ME: You’re very welcome. Regarding your dream, yes, you told me that you knew your tubes were open because of the dream, but forgive me for not writing that into your medical chart. Haha. Anyway, I know that you and I haven’t spoken in person since you got the good news, so today, you can ask questions after we do the ultrasound. My staff have been keeping me up to date. I see that your beta-hCG values have been rising very strongly. That is certainly good news. And how have you been feeling?
CAROLINE: Honestly, I don’t feel anything different. Maybe a bit tired, but I was expecting bad morning sickness. Sometimes, I ask myself if I’m really pregnant.
ME: No, don’t worry. Most women do have some symptoms, but  there are some who have perfectly healthy pregnancies and yet, have no real symptoms. Today, you are 5 weeks and 5 days so we’re going to do your first ultrasound to count how many sacs you have. Are you nervous?
CAROLINE: No, not in a bad way. But I’ve very curious to see what we have.
ME: OK, let’s see then.

ULTRASOUND FINDINGS: There are two sacs seen! One measures 7mm in size and the other 5mm. They are both in the perfect location in the center of the uterine cavity. The ovaries are somewhat enlarged and measure about 5 cm each with multiple cysts seen. There are some faint yolk sacs in each gestational sac. No fetal heart motion is seen.

ME: Well, I see two sacs.
CAROLINE: That’s it? Only two?
ME: Only?
CAROLINE: I mean, whew. We were prepared for news of more, just in case, we braced ourselves for the possibility.
ME: Well, right now, there are two sacs. Now bear in mind that this doesn’t necessarily mean that both will survive. I try not to be negative, but I want to tell you the possibilities. Most likely, next visit, we will see two heartbeats, but anything is possible, including seeing no heartbeats. It’s sometimes even possible that a third sac will show up next week, although today I searched pretty thoroughly and I don’t see any evidence of a third sac. Sometimes, we see a small fluid pocket and have to wonder if that’s a small sac, but in your case, I don’t see anything other than those two big ones.
CAROLINE: Darryl will be relieved. And he is going to be so excited that we’re having twins.
ME: Well, remember, I caution you about telling too many people at this early stage. In fact, I wouldn’t necessarily tell casual friends about your pregnancy. You may tell your closest family members, but a lot could still happen at this point. And especially don’t tell them that you have twins yet. OK?
CAROLINE: (smiling with tears) I am just speechless.
ME: Do you have any questions?

I gave Caroline 10 minutes to call Darryl and returned to field her questions. Most of them were routine, concerning her progesterone, her activity limits and her dietary recommendations. She was on progesterone supplementation and was continued on her metformin. She was on prenatal vitamins and fish oil. I printed out three copies of the ultrasound pictures - one for the chart and two for Caroline. She was scheduled to come back in about a week.

Check here for episode 12 when published.

I’m proud of my staff. They are the best. The first time I heard this said, I wasn’t sure of its sincerity or if it was just something nice that pharmaceutical reps say. However, after hearing it spontaneously from three different reps, I’m pretty convinced. Plus, I agree with its truthfulness. According to one rep, we are really different and seem like a happy family rather than a corporate office. In the words of another rep, we have a really sharp bunch, who ask smart medical questions, much smarter than any other offices called on by that rep. Still a third rep noted that while a lot of practices had some pretty dysfunctional staff politics with low morale and high turnover, ours seemed like such a cohesive happy team.

Another reason I know that our staff is different is that I’ve worked with different staff in the past, during my training and before I started my own practice. And even after I started my practice, I have a lot of contact with different practices and have even shared weekend call with other practices. So I do know what other offices are like. Most importantly, PATIENTS notice the difference, especially those who have been patients elsewhere. They often ask me what our secret is. The “secret” is really many different small secrets.

One secret is emphasizing selection over development. In other words, when people want to know how to train a staff to be so great, I remind them that it’s much easier if you first make some extra effort to CHOOSE the right people to start with. In the past, I used to go through an average of 40 resumes for each position. Lately, it’s been more like 1 out of every 25. This is attributed to better efforts at clearly announcing the details of the job description, so as to get fewer resumes from totally unqualified applicants. So, one secret to getting your staff to be excellent is to hire people who are fundamentally good in the first place. So, given a choice of applicant A: Someone who is very experienced, but not as great a person vs applicant B: Someone who is a hard-working, smart, good-hearted person with no experience, I would take B. It’s much easier to train a sharp, industrious, caring person the details of infertility treatment than to train an experienced infertility nurse how to be smart, hard-working and caring.

However, in all honesty, no matter how great a team is, there are always going to be moments of friction, especially when you are running a high-stress task such as competitive sports, fighting a war or providing high-tech fertility treatment. Recently, one thing that has really helped was to take into account everyone’s personality type. Many of you are familiar with the Myers-Briggs classification system. Well, there is one I like even better, called the Enneagram system. If you haven’t tested yourself yet, take a few moments to do so. If you also test your partner, you might gain some valuable insight into the dynamics of your interaction.

I started having all job applicants take the Enneagram as part of their application process. Right now, our office is a good mix. Just as a good NBA basketball team is not going to have eleven speedy point-guards nor eleven big centers, a good medical team is not going to have people all of a single personality type. In case you’re interested, we happen to be a Type 7 / Type 3 (me), a Type 7 / Type 9, Type 2 / Type 9, a Type 6, a Type 2 and a Type 2 / Type 8. In order to see how each of these types interact, check out these write-ups. The other day, when we were having some conflicts, I printed out these descriptions and had everyone read them. The tension melted and was replaced with rolling-in-the-aisles laughter regarding how uncannily accurate those descriptions were.

Click here for episode 1

I knew something was up. Even as I sat in my private office, going over patient charts and answering email, I could hear happy shouts coming from the outside my door. I looked at my schedule. We had just finished the last ultrasound of the morning and I was pretty sure the screams of joy were coming from my staff in response to the pregnancy tests that just rolled off the machine. The schedule showed six blood draws for pregnancy tests that day, four first time beta-hCG’s and two repeats. I sent an instant message to my staff and asked for the results. They replied quickly with each of the six results. Four of them were followed by a and the other two were followed by a . I saw that Caroline’s was one of the happy ones! Now there would be friendly negotiation between my staff to see who got to call the patients with the good news and who had to call the ones with the bad news.

Caroline’s beta-hCG value was 111 IU/L. This was twelve days after her IUI. For the first time ever in her life, she was pregnant. It has become our office policy that my staff are always the first to break the news, good or bad, to the patients. Within that same day or the next, I usually call back the negatives. I rarely call back the positives, even though that’s always a fun thing to do. Instead, I put my time to better use, consoling the negatives and preparing the detailed plans for the next step in their treatment. As per routine, Caroline was scheduled for a repeat beta-hCG in two days.

This is the standard way of doing things in our office after a positive pregnancy test. First we run a progesterone (P4) test for all the patients with positive pregnancy tests. Caroline’s P4 was 40 ng/ml, which was fine. She was already on progesterone supplementation via Crinone 8% gel, so she was kept on the same dose. If the value would have been low, we would have been alerted that this might be an abnormal pregnancy (miscarriage or ectopic) and we would watch her more carefully. We would also consider increasing her progesterone.

The next thing we always do is to repeat the hCG, usually two days later. In a healthy pregnancy, we usually expect the value to rise by at least 70%. If the rise is slower than that, we have to suspect a miscarriage or even worse, a tubal pregnancy. If the value drops instead of rises, then that’s even more suspicious for an impending miscarriage. Pregnancy losses happen in about 1 out of 6 pregnancies, whether they arise spontaneously and naturally, without a doctor’s help or whether they are with IUI or IVF. So at this point, Caroline still had a possibility of losing the pregnancy, just as anybody else would.

Two days later, we celebrated her repeat beta-hCG. It was a 378. It had more than doubled! This was excellent news. However, while we love it when the rise is very good, in Caroline’s case, in the back of my mind, I started to have a nagging concern about just how many babies she could have.

Before we go on, let’s review the standard terminology regarding how far along someone’s pregnancy is. As you may well know, the standard pregnancy lasts 40 weeks. Very few women deliver exactly on their due date. Most of the time, anyone delivering after 36 weeks has a pretty unremarkable outcome. Even though the baby is considered as having delivered earlier than their due date, they usually go home with the mother when they have made it that far and if they have no complications. When pregnancies go beyond 41 weeks, the OB’s get nervous and often induce, so as to lower the risk of something bad happening to the baby, so you rarely see pregnancies go beyond 42 weeks. The tricky part, which often gets patients confused is that we start counting the pregnancy dating by calling the day of ovulation as TWO WEEKS PREGNANT. Technically, the patient isn’t pregnant yet, because we won’t know the outcome until about two weeks after ovulation. However, at two weeks after ovulation, we refer to it as FOUR WEEKS PREGNANT. So, in Caroline’s case, even though it’s only two weeks after ovulation (after IUI), she is considered to be four weeks pregnant already.

We continued to check her beta-hCG levels. The next one was done four days after the 378 value and it came back at 1677. Again, an excellent rise because it was more than doubling every two days. For those of you who love math, I’ll try to explain the way we calculate beta-hCG rises. Those of you who get bored by semi-complex mathematics are free to skip the next section. I am proud to say that everyone in my office can now do this calculation in their sleep, from the newest medical assistant to my office manager. OK, I’m not sure if my billing manager can do this, but I wouldn’t be surprised if she could.

In order to calculate the rise in hCG from two consecutive values we need to know three things. We need to know the first value, the second value and the number of days in between the two. We always speak of the rise in terms of how many % it rose per TWO-DAY period. The reason we use this terminology is because we know for a fact that beta values that rise more than 70% or so every two days are a pretty good indicator of a healthy pregnancy.

Back to the calculations. This is how we get the rise value. We start with the later value, which of course should be higher than the earlier value and we divide it by the earlier value. This gives us the absolute rise. Let’s call this R. Next, we take the interval between the two tests (in number of days) and divide by two. This essentially tells us how many two-day-intervals are between the two values. Let’s call this value T. Then we pull up the calculator that comes with our Microsoft Windows or Vista. If you hit the VIEW button on the toolbar, it should give you a choice between STANDARD and SCIENTIFIC. You will want to choose the Scientific Calculator. We then enter the value we got as R, check off the box that says INV, hit the button that says x^y and then enter the value that we got as T. This will spit out a final answer like 1.29 or 1.86 or 2.89. If this final answer is greater than 2, we relax, because it tells us that the values are more than doubling. If the answer is something like 1.86, it tells us that there is a 86% rise every two days, which is fine. If we get an answer like 1.29, then that tells us that the rise is only 29% every two days and that’s very concerning and not good at all.

So let’s calculate Caroline’s rise for the last four days. We take R = 1677 / 378 = 4.44. We then calculate T by figuring that there were four days between the two tests and dividing by 2. So T = 4 / 2 = 2. We then enter 4.44    INV    x^y   2   =   2.10, which tells us that Caroline’s values are more than doubling every two days. Hurray!

Recently, I’ve been tutoring a few of my friends who are studying for the MCAT, so my mind is very much in calculation-teaching mode. For those of you who were bored silly with all these calculations, let’s just go back and celebrate that Caroline and Darryl are ecstatic at this point and looking forward to their first prenatal ultrasound, what we traditionally consider to be the "let’s count how many babies we have" ultrasound.

Click here for episode 11

We received a phone call this morning from a couple who wished our help to get pregnant. They said they were ready to do IVF using donor eggs. It’s not often that you come across someone who expresses their readiness to commit $25K or so to having a baby. However, before the patient could make an initial appointment with us, we knew enough to know that we were not willing to take on their case. The problem? The couple was in search of an IVF program that would be willing to do an egg donation cycle using a relative who was 16 years old. They said that the donor was willing and had her parents’ approval as well. In the past, we had a stated policy that our preferred egg donor age range was 18-27, but now have amended it to 21-27. In any case, I support the freedom we have in the United States, where doctors are the primary decision-makers in such matters, rather than non-medical lawyers and politicians. So we exercised our responsibility to say NO and explain that all egg donors have to do so willingly of their own consent, which necessitates that somebody must be of an age that CAN give consent and 16 was too young.

The caller than asked if we could refer them to another program that would take their case. I knew right away about another center that in the past has taken on cases that we had refused on ethical grounds, but again, we made the decision not to be accomplices in this, no matter how remotely. Given how much that other center spends on marketing, it’s likely that this couple will find them on their own. We can only hope that my colleagues adhere to the general guidelines and act accordingly out of the desire to practice sound ethical medicine, even though these guidelines are not 100% strictly enforced.

June’s story has spilled over a bit into July

Click here for episode 1

Caroline is set to start her fifth attempted IUI cycle. Three previous cycles failed to result in pregnancy and one previous attempt was cancelled, never making it to the ovulation stage. My recommendation was to do an HSG to make sure her tubes are patent and her uterus was clean, because it would be a shame to have her keep making eggs if her tubes are blocked. Somehow, she felt confident her tubes were OK. Caroline strongly believed that the best thing for her is to do is to get some really good egg production, if possible.

As usual, we started her cycle by doing a baseline ultrasound on day 3. She had called us the day before to report that her period had started. Both her ovaries were quiet, meaning there were no cysts nor any early-growing follicles.

We had a discussion. I made it clear to Caroline that if we were not successful this month, we would not do any more IUI cycles, until and unless we checked her tubes and uterus. When I chose the starting dosage, I took into account that she grew 3 follicles on a starting dose of 225 IU and 2 follicles on a starting dose of 300 IU. I would have to really search my memory to recall the last time I put someone on 375 IU or higher for anything other than an IVF cycle. Another factor to consider was Caroline’s weight, which was now down to 221#. In none of her previous cycles was she ever this light. I warned Caroline about the possibility of overstimulating if we put her on 375 IU. She laughed it off. I repeated my warning a bit more seriously, reminding her that YES, I realized how she had stimulated on 225 IU and 300 IU, but that it was certainly possible to have a huge boost in response with just a small increase in dosage. She humored me this time and calmly acknowledged the risk. Logistical reasons (how quickly she could get the medication) led us to start her on Gonal-F instead of Bravelle and to start on day 4 instead of day 3. She took 375 IU of Gonal-F for four days and came back for an ultrasound. This is what we saw on day 8:

RIGHT OVARY: (15×12) (13×13) (11×11) (10×10)
LEFT OVARY: (7×7) (6×6) (6×6)
E2 = 329 pg/ml

Decision time. Do we lower her dosage or do we keep going with the same? If I lower the dosage and she comes back next time with no growth, we’ll be kicking ourselves. If I keep the same dose and she comes back hyperstimulated, we’ll be equally upset. Tough call, but I do know one thing. I’m not going to skimp on monitoring. Whatever I decide, she’ll be back to check again in 2 days. Frequent monitoring helps us adjust things more precisely. I decided to keep the dosage stable and bring her back in two days. Here is what we saw on day 10:

RIGHT OVARY: (18×17) (14×14) (13×13) (10×10) (10×10)
LEFT OVARY: (15×15) (13×13) (13×13) (11×11) (10×10)
E2 = 699 pg/ml
This was great! At this point, I was happy with keeping her on the same dose and not dropping it. She switched to the donated Bravelle and continued at 375IU. After two days, she came back on day 12 and this is what we saw:

RIGHT OVARY: (22×22) (19×19) (18×18) (16×16) (14×14)
LEFT OVARY: (18×18) (16×16) (13×13)
E2 = 1077 pg/ml

Decision time again. There are 6 mature follicles today, which is quite a lot. I reviewed the mathematics with Caroline. We don’t know exactly what the odds of pregnancy are PER EGG. However, if we assume a good-case scenario and a bad-case scenario, we come up with the following numbers.

Good case scenario: Each egg has a 20% chance of becoming a baby. Odds of at least one live-born baby = 74%!! Odds of triplets or more= 9.8%
Average case scenario: Each egg has a 10% chance of becoming a baby. Odds of at least one live-born baby = 47%. Odds of triplets or more = 1.6%
Bad case scenario: Each egg has a 3% chance of becoming a baby. Odds of at least one live-born baby = 17%. Odds of triplets or more = 0.001% = 1 out of 874
Worst-case scenario (ie tubes blocked): Each egg has 0% chance.

I estimated that if these eggs were each high probability (20% chance each), her risk of triplets could be as high as 8-10%!! Was that really acceptable to her? Even if this would give her a 70%+ chance of at least one baby.
And if things were more along the average case scenario (10% chance per egg), then she would have a decent 47% chance of a baby with just a 1.6% chance of triplets.
If she were the bad-case scenario (3% per egg), then her chances of triplets are very safe (1 out of 874), but then her chance of pregnancy would drop to 17%.
And of course, if her tubes were blocked, then all this would be a moot point.

With these numbers in our heads, it was a bit easier, but still difficult to make our decision. Caroline called Darryl to discuss it with him, and gave me the answer 20 minutes later. They would be willing to take the risk. They wished to go ahead.

The fact that the E2 was a little lower than expected given the number of follicles we see would tend to suggest that some of these follicles are not as mature as we would like. This further emboldens us because it lowers the pregnancy rate and the triplet rate.

The decision was final. We would launch her ovulation today and do an IUI in two days. She and her husband were taking the risk of triplets in exchange for a good chance at pregnant. The nice thing is that things go in parallel. If the real chance of pregnancy is low, then the real chance of triplets is low too. It goes hand in hand. A 9.8% chance of triplets would give her a 74% or pregnancy, although realistically, this combination is not likely to be the case. More likely, she has a situation closer to the combination of 47% chance of pregnancy and 1.6% of triplets or the lower combination of a 17% of pregnancy and a 0.0011% chance of triplets. Personally, this would be my favorite scenario.

Caroline was instructed to launch her ovulation at 5PM with 10000 IU of hCG. She was scheduled to come back in two days for her IUI.

Darryl’s sample was excellent and we were able to process it to get 20 million total motile sperm. The IUI was easy. Ultrasound done after the IUI confirmed that all the follicles had successfully released except for one and that the sperm was deeply placed in her cavity. Caroline was started on progesterone supplementation and scheduled for her pregnancy test. Everyone in the office came out to say goodbye to Caroline and to wish her the best. I also took the opportunity to congratulate her that her chances this time were pretty good, but if it didn’t take, then HSG was the next step.

Click her for episode 10