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Thread: Questions about cancelled cycle.

  1. #1
    Join Date
    Jun 2011
    Posts
    2

    Default Questions about cancelled cycle.

    I would like some feedback from a professional outside of my clinic. I am 34, have PCOS, and have an AMH of 43. I have done 8 cycles of oral meds, only two of ended with triggering. Both were 10 days of high dose femara. Subsequent attempts failed to produce dominant follicles.

    This cycle I did 12.5 mg femara days 3-7 and 150 IU follistim days 5-8. At cd 9 I had no dominant follicles and my estrogen was 20. They upped my dose to 175. On cd 12 an ultrasound showed 8 or 9 follicles starting to develop. My estrogen came back at 172. Today, on cd 14, the monitoring doctor had trouble seeing all areas of my ovaries, and they shadowed the image of the uterine lining so that he was not confident but thought my lining was measuring at 6. He could confidently see one follicle at 18, one at 17, and four between 14 and 16, but there were areas he could not get a good visual on.

    He told me that they would do my estrogen and if it was above 1500 they would cancel the cycle. My estrogen came back at 785 and they still wanted to cancel because my estrogen tripled in two days. I do not understand the mentality. Having friends who have triggered with estrogen exceeding 1000 and having almost as many follicles as my doctor was able to see on the u/s, each having produced one baby, it's hard for me to believe that I am at such greater risk than they were for HOMs. I don't want to do anything stupid, but this is my third shot at getting pregnant in almost two years, and it's hard to accept this decision, especially considering that the doctor who conferenced with the monitoring doctor was not my regular RE, because my RE is in Haiti right now.

    He seemed to believe that without triggering I will still release all of those follicles. Is this true? Or does my risk decrease without triggering? I'm trying to make a decision based on reason over emotion, but it's very difficult after you've poured time and money into all of this.

  2. #2
    Join Date
    Oct 2008
    Posts
    103

    Default

    If you are less than age 35, then we expect that the quality of the eggs you will release to be very good, and as the lack of ovulation appears to be the only problem you have been facing, you are at a particularly higher risk of multiples than other women. You apparently have not ovulated at all on simple oral medications, and this month, the initial course of femara did not help, as it seems that follicles have only started to grow with the use of the Follistim. For some women, this is the only medication that can effectively stimulate ovulation, but for those with PCOS, a vigorous response can occur with multiple eggs potentially leading to a triplet or higher pregnancy.

    If your ovaries are high in the pelvis and difficult to visualize, then it is even more difficult to know how many follicles may be developing and producing eggs. The estrogen level is rising rapidly, and with 6 follicles already to a point where growth is likely to continue without the need for more medication, there are real risks involved here. With the incomplete visualization of the ovaries, you may have 10-12 follicles at the point where ovulation will occur. These risks are often not worth taking.

    For women with poor egg quality, advanced age, or who have released many eggs with lesser treatments and have advanced to the use of Follistim, the risks of multiples is still there, but lower. Those cycles are often continued with very similar responses to medication. But your oocytes may be very good--you haven't had many (if any) opportunities to have one available for fertilization, and is is not wise to start with 6-12 eggs for the first time.

    You will likely ovulate spontaneously, as the estrogen levels have been rising (this is the trigger for spontaneous ovulation), however for some women, this does not occur. So even intercourse during this time can still lead to multiples, as these eggs can be released without any other treatment or monitoring. If multiples occur, and you are faced with the options of a multifetal pregnancy reduction or the risk of prematurity leading to infants with profound life-long issues that may not allow them to lead an indepedent life, these risks were obviously not worth taking. This is the time that we have the ability to prevent those situations, and if it means a longer delay to ultimately have a healthy child who has been given the best chance with a normal prenatal period, then it is well worth it.

    The use of follistim or Gonal-F in women with PCOS is difficult to manage. Sometimes it is not the safest treatment, and if the number of oocytes that grow cannot be controlled, then the use of combinations of oral medications (such as metformin + clomid, or Actos+ clomid) may allow a safer ovulation. Or alternatively, IVF with the transfer of only 1-2 embryos can help prevent HOM's even if you have a vigorous response, and this is often the safest route to a healthy child.

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