Before starting a stimulated treatment cycle with clomiphene citrate (Clomid), with injectables or with a combination of both, we customarily do a baseline ultrasound sometime around day #1 to day # 5. What are we looking for with this? Actually, it’s more of what we’re NOT looking for. We’re specifically looking to see that there are no cysts. In other words, we’re looking to see that there are no follicles that are beyond a certain size. For clarification of these terms, you may consult this post.

Remember that this early in the cycle, all the follicles for that month should be very small. I tend to use 13mm as a cutoff, but I have colleagues who have a slightly smaller or slightly larger cutoff. The rationale is that if we already see something larger in size, then the cycle will be suboptimal because that cyst can grow and disrupt the course of development of any new upcoming follicles.

Another purpose of this visit is to discuss the exact formula or protocol to use for the upcoming cycle. There have been times when a patient came in to start injectables and after discussion relating to her particular case, we change our minds and decide to do Clomid-only or a combination of Clomid with injectables. We may make our final decision regarding doing IUI or just timed intercourse. We might have some adjustments regarding the dosage, as well.

By the way, sometimes for the sake of convenience, we can actually do the baseline scan a few days BEFORE the period starts. Let’s say for example that the patient is here to pick up some medications or settle her account and hasn’t started her period yet. However, she is expecting it to come any day now. We can do the baseline ultrasound today; then she can call with her period and get instructions on when to start her meds.

Nine years ago, I was referred a patient by an OB. He had performed laparoscopic surgery on her and told her that her tubes were both blocked and were “unsalvageable”.  So, we did IVF and she got pregnant with twins on her first cycle. She came back a few years later to use her remaining frozen embryos, but nothing came from it.

Recently, I got a message from her that she wanted to share some good news about her new baby. When I returned the call, I was curious why she didn’t come back to us for THIS cycle of IVF. To my surprise, she bubbled enthusiastically about an amazing miracle. She shared that she had given birth to this recent baby after getting pregnant spontaneously without any medical treatment. She shared that her son (one of the original twins) had told her last year “Mommy, I’m going to pray real hard for a brother or sister this year”.

From a medical perspective, it is not entirely implausible for a woman diagnosed with blocked tubes to ever conceieve. Having blocked tubes diagnosed via laparoscopy or HSG does not mean 100% sure that they are blocked or will always stay blocked. Having said that, I would certainly put it at less than a 1% probability that a patient in this situation is going to get pregnant naturally. Put that together with the finding of all the years that went by without her getting pregnant and you have the occurrence of something that is estimated to have less than a 1 in 1000 chance of happening. No, I don’t recommend that women with blocked tubes should wait patiently for a miracle to happen, but I also recognize that sometimes, miracles DO happen.