There is a friend of mine,who insists patience is a virtue,has compelled me to be patient and leave my quick fix ways.And I am inculcating the habit.Patience is a virtue in personal life,professional life and life of even the patients we treat.
As always my posts are all motivated by real life posts.In last one month I came across 4 prescriptions showed to me by patients who had come to me for a second opinion regarding their subfertility treatment.Except for one,all three had 8-9 follicles > 16 mms ,were already given 10.000 IU of HCG and were ready for a spontaneous conception or IUI.It can be dangerous.Really dangerous.Multiple pregnancies are no fun neither is OHSS.
In this post I wish to talk of how much is too much for stimulation in cycle meant to be an IUI(Intrauterine Insemination)?I won't site specific cases as I realise that way the patients reading the posts can identify themselves and might not feel too comfortable.
IUI is known treatment for
Mild Male factor infertility
Unexplained infertility
For Mild factor Infertility(I will disscuss what is mild factor in next post) with no female factors even an unstimulated cycle is good enough and there is no advantage of using clomiphene citrate or Gonadotrophins
For Unexplained Infertility stimulation with Gonadotrophin + IUI gives maximal percentage of success.(more than Gonadotrophin alone or CC + IUI).If treating unexplained infertility my first line of treatment would Gonadotrophin + IUI but one needs to be cautious about the dose.
AMH levels give a fair idea about the initiating dose for IUI as well as IVF stimulation cycle.
THE AIM SHOULD BE TO DEVELOP NO MORE THAN ONE BUT MAXIMUM TWO LARGE FOLLICLES.Any thing more than that increases the level of multiple pregnancy and it's complication significantly.One way of acheiving it is by giving low dose FSH for 14 days straight(Now you know why I remembered my friend?He has made me understand the virtue of patience) and if need be increase the dose another 37.5 for a week and give trigger when we have a nice follicle ready for it and plan IUI.
If bychance you have give gonadotrophin in a dose higher than needed....well recognise the problem.Either ask the patient to abondon the cycle.Or talk with the couple if they are willing to get it converted to an IVF cycle.with 6-7 > 15 mm follicles and a trigger of 10000IU HCG,she would be definitely safter with an IVF than an IUI.One can control the number of embryo transfer as well as prevent OHSS by sucking out the follicle and follicle fluid.
