Case of the month June '08: Episode #9
June’s story has spilled over a bit into July 
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
