January 24, 2018

Case of the Month Nov 2010: Episode #5

Click here for Episode #1

RECAP: Patient “M” excitedly completed her first IUI cycle and became pregnant for the first time in her life. In order to follow the health of the pregnancy, we did routine hCG levels. In a healthy pregnancy, the hCG levels should rise briskly, often doubling every 2 days. In M’s case, instead of rising, her hCG levels dropped. Her happiness quickly changed to disappointment. We repeated another hCG level in a week and got a value of “less than 2”, meaning there was no longer any pregnancy hormone detectable in M’s blood. During this week, she reported having bleeding similar to period. The lost pregnancy was short-lived and was now resolved.

The first question that M’s husband wanted answered was what had happened. What do you do when you have a positive pregnancy test at the designated testing time two weeks after the IUI, but then the values go down? The first thing you do is resolve the lost pregnancy, meaning you follow the HCG values all the way down to zero.  We did this. The next thing is to decide whether or not it is worth doing a miscarriage workup. Well, sometimes a miscarriage just happens because of bad luck. It can be a normal expectation for an average infertility patient that 1 out of 6 pregnancies could result in a miscarriage. Therefore, if it happens one time, it does not necessarily warrant a complete expensive workup. However, we can actually pick and choose the different components of a miscarriage workup and not necessarily do all or none. One thing I suggested was to test for Lupus Anticoagulant and Anti-Cardiolipin Antibodies. These are standard blood tests. They came back normal. We did not do any further miscarriage workup.
The next decision is whether to take a break or to try another cycle. M and her husband chose to take one month off and then come back for another cycle.

M called us on the first day of her period one month later. She came in for an ultrasound on day 3. She shared that she had a very sad two weeks, but later came to the realization that she had been pregnant and it gave her hope because it was the first time in her life that she had gotten this far.

By now, all of you know how an IUI cycle begins. We started with a baseline ultrasound, which fortunately revealed both ovaries to be quiet. No cysts. There was every reason to do another cycle using a protocol similar to the first cycle. M was started on clomiphene citrate (Clomid) for five days (day 3 to day 7) and then transitioned to injectable Menopur (day 8 to day 10) for three days.
Here’s what we saw on day 11.
Right Ovary: 15x15mm.
Left Ovary: 16x16mm. 14x10mm. 9mm.
Lining: 7mm triple-layer

People are not like computers. They don’t run the same program exactly the same each time. This month was different from last month. The follicles are smaller on the same day (day 11) than in the previous cycle. In addition, there is now a good follicle on the right side when previously there was nothing before.

I chose to have her grow the follicles two more days and come back on day 13 for another ultrasound.

Continued next episode……….

  • Julie

    I just stumbled upon your blog. I’m currently undergoing fertility treatments. I just triggered tonight for IUI #2. I just wanted to say thanks for having this blog. It’s really nice to have a detailed perspective from an RE.

  • Josephine Wilson

    What happens next?! You’ve left us with a cliffhanger!!!