January 24, 2018

Case of the Month October ’10: Episode #2

Click here for Episode #1

To summarize, we’re facing a case of infertility – no baby despite one year without birth control. The sperm looks OK. There is evidence of an egg problem as noted by the elevated FSH. It’s generally good when the FSH is less than 10 or so and M’s level is 14. For the sake of completeness at this point, we test the uterus and tubes with an HSG. It came back normal. Specifically, the cavity was normal and both tubes appeared to be open. The injected dye flowed easily out both ends.

What do we do now? For the past year, M and her husband have been trying on their own as well as going through five months on clomiphene citrate (Clomid). I explained their options. They could go back and try on their own. They could take injectable medications in an attempt to get better egg quantity and quality. They could do IUI. They could do IVF.

M and her husband were very open and honest. They very much wanted to do a cycle of IUI with injectable medications, but they had just got done with some significant home repairs costing a few thousand dollars. They also had an adjustment on their tax bill and were now obligated to give more money to the IRS. Because of this, they decided to try on their own for 3 more months, during which time they would save the $2000 required for their IUI cycle. We set a firm deadline. If those three months went by and they were still not pregnant, they’d come back and discuss things.

Three months passed and there was still no baby yet. She opted to do an IUI cycle. Our goals are to get multiple eggs to give her multiple chances to get pregnant. If she gets four eggs and three fail, she can still have another chance with the fourth one. In addition, each egg gets a higher chance individually if it is better stimulated and if the sperm is delivered more efficiently to the target.

The next decision to make is what dosage of medication to give. Each day of injectable gonadotropin is about $60 to $150 depending on what brand (Bravelle, Menopur, Follistim or Gonal-F) we give and whether we give 75 IUs or double it to 150 IUs.  Again, financial considerations predominated and we decided to do a combination of Clomid + injectables. This has the advantage of requiring fewer days of injections because the first few days are replaced with the super-inexpensive Clomid instead.

She called our office on the second day of her period and we scheduled her to come in D#3. The baseline ultrasound showed the right ovary to be quiet. No prematurely growing follicles were seen. No residual cysts left from the previous month were seen. The left ovary was also quiet. She took Clomid 100mg for five consecutive days on days #3 to #7. She was not expecting hot flashes nor moodiness because she had been on Clomid in the past with no problem. She was taught to start injections of 75 IUs of Menopur for days #8 to #10 and come back for another ultrasound. On that visit we hope to see some good follicular development with a target being 2-4 good-sized ones.

Click here for episode three

  • Ada-Marie

    Thanks for this case of the month. I can’t wait to hear the rest — sounds like this may be my course of action in the next 2 months or so.