Controlled Ovarian Hyperstimulation: Pergonal #2
This (successful) cycle of controlled ovarian hyperstimulation (COH) with intrauterine insemination (IUI) also illustrates
progress throughout a COH cycle. Comments about this particular cycle might include:
1. This couple has a moderate male factor as the primary reason for treatment using COH/IUI. The thinking in this situation is that with less “reproductively capable” sperm available, (a) the greater number of mature eggs developed per cycle with COH may give the available sperm “more targets” to aim at, and (b) the IUI brings the sperm right under the fallopian tube where they only need to travel into the proximal tube to meet and fertilize the egg. In general, COH/IUI may increase fertility rates during the treatment cycles by several (3-5) fold. Fertility rates seem to increase once there are at least a few mature eggs (a greater number of mature eggs than during a natural cycle) but these rates do not appear to increase much (correlate well) with further increases in the number of mature eggs. The IUI also may increase fertility rates when coupled with COH. In the presence of a male factor, there may be several million motile sperm per ejaculate, which can be washed free of the seminal fluid and placed into the uterine cavity near the fallopian tubes. With vaginal intercourse and a normal sperm count there is a tremendous dropoff in the numbers of sperm that make it into the cervical mucus and finally up to the tubes (only a few thousand sperm normally make it to the tubes). Therefore, placing a few million sperm (from a man with a male factor) directly under the tubes during IUI can theoretically enhance the reproductive potential of those sperm (by giving them a “ride” to the end of a very difficult journey)
2. This woman was started on 4 ampules of menotropin a day since she had previously had a poor response to these medications. After 3 days of stimulation, the estradiol concentration was 420 pg/mL (very high) and the dose of menotropins was reduced to 2 ampules a day.
3. After 2 more days of stimulation medication, the estradiol concentration plateau’d with an insignificant increase from 420 pg/mL to 435 pg/mL. Therefore, the menotropin dose was increased to 3 ampules per day for 1 day. The clinical importance of these odd changes (increases) in estradiol concentration is not clear, but they are generally not considered to be beneficial.
4. Following the 6th day of medication, the estradiol concentration rose (aggressively) from 435 pg/mL to 710 pg/mL and the follicular growth was also rapid. Therefore, it was decided to reduce the menotropin dose back to 2 ampules for 1 day.
5. Following the 7th day of stimulation, the estradiol concentration “doubled up” from 710 pg/mL to 1515 pg/mL and the lead follicles were 18 mm in average diameter. 5,000 IU rather than 10,000 IU of hCG was given to trigger ovulation (to reduce the chance of ovarian hyperstimulation syndrome) since the estradiol concentration was relatively high and there were several smaller follicles within the ovary (at the end of the cycle) -- which are associated with an increased chance for ovarian hyperstimulation syndrome.
6. The initial positive hCG titer was normal (about 100 IU/L) for 2 weeks after insemination, rose normally, and the ultrasound revealed a viable singleton intratuterine pregnancy. At 4 weeks after ovulation (6 weeks gestation) I most often find the embryo’s crown to rump length (CRL) to be 4 mm, at 5 weeks after ovulation (7 weeks gestation) the CRL is often about 10 mm, and after 6 weeks (8 weeks) the CRL is about 17 mm. This woman had a normal rate of growth for her gestation.
Additional Case Studies: COH Cycle 1 | COH Cycle 2
| COH Cycle 3
| COH Cycle 4 | COH Cycle 5