I've realised that I need to change the category on these posts, since the IUI isn't happening. Something to do later.
Well, the amount of research I've done in the last 48 hours has surpassed the intensity of many days when I was writing my PhD. Funny how things are different when you have 'skin in the game'. I thought it would make sense to write it up here so someone else can benefit if they find themselves in the same position.
Where indicated with a star, the full article can be read for free by going to Pubmed. Where not marked with a star, just the abstract is available on Pubmed, unless otherwise indicated by the link.
IUI and multiple follicles
- A multifollicular ovarian response to clomid/HMG (ie FSH) resulted in better treatment success than a monofollicular response. Other factors contributing to success included female age of less than 40, infertility duration of less than 6 years, and no evidence of endometriosis. Nuojua-Huttunen et al. Human reproduction 14.3, 698-703, 1999. *
- Risk factors for higher order (ie more than twins) implantation after FSH stimulation and IUI are serum oestrodiol >=862 pg/mol, female age =<32, and total number of follicles. For a woman over 32, with 4-5 follicles and eostradiol >862, the risk is 13%. If oestrodiol is <862, the risk is 4.3%. I was in the latter category (although only just). Tur et al. Human Reproduction 16.10, 2124-2129, 2001*
- More recently, Tur et al have applied the methodology indicated above to manage the cycles at their clinic. Application of these three variables has resulted in an 8% reduction in pregnancy, but a 290% reduction in higher order multiple pregnancies. Tur et al, Fertil. Steril. 2005 (don't have the rest of the info)
- For patients 35 or older, pregnancy rates in hMG and clomid+hMG cycles doubled when six or more follicles were =>12mm, or E2 levels were >1000 pg/mol, but incidence of higher order multiples was not increased. In women under 35, the same conditions did increase the incidence of three or more implantations. Dickey et al. Fertil. Steril. 75.1, 424-426, 2001
IUI in general
- A good summary of all the factors contributing to IUI success, too much info to summarise here. Duran et al, Human Reproduction Update, 8.4, 373-384, 2002 *
- Another overall summary, not as good and I had to pay $35 for it - won't do that again! Email me if you want to know more about it. Balasch, Reproductive Biomedicine online: 9.6, 664-672, 2004
Use of HCG versus LH to trigger ovulation in IUI
To decide what to do today after Pamplemousse's comment on the last entry, I looked into this in detail. Sadly, the evidence is not conclusive. Here are the better articles that I found, you'll see they have somewhat contradictory results. After reading this, and realising from an OPK this afternoon that the LH surge was beginning, I went ahead and gave myself the shot. Let's see. The downside some authors have mentioned is that HCG may have an effect on the receptivity of the endometrium. However, it's not clear and I wanted to give every chance to those 5 (or 4, realistically) follicles.
- Across a wide range of stimulation protocols, administration of HCG (whether with an LH surge or without) leads to increased pregnancy rates. In most cases (although they didn't get statistical significance with all the differences) the LH surge plus HCG shot was the most effective method. When FSH is used in the stimulation protocol, an HCG shot was beneficial. Mitwally et al, Reproductive Biology and Endocrinology, 2.55, doi:10.1186/1477-7827-2-55, 2004* (this seems to be an online journal so usual page numbers don't apply)
- No statistical difference between LH-timed IUI (measured through urine) and HCG-timed IUI. However, many authors have commented that urinary monitoring is v inaccurate and will miss the LH surge in about 35% of women, so this study is probably not well designed. Zriek et al, Fertil. Steril., 71.6, 1070-1074, 1999. Several other studies published, all the ones I've seen say no difference between the two methods
- Possible effect of HCG on endometrial receptivity. This relies on the longer half life of HCG in the blood than that of LH, as well as a slightly different effect on endometrial physiology. Fanchin et al. Seminars in Reproductive Medicine, March 2001. I had to sign up for medscape access to get this, but I didn't have to pay. I just said I was a doctor. Hell, if all this googling isn't good for something...
I hope that helps someone. I will make sure we have sex tomorrow night, which will be 28-ish hours after the HCG shot and LH surge. This all feels like such a mess, I have no idea whether we have a chance. But we have to try, right?
I've also used this research to write a long letter to Dr Candour, describing what went right and what went wrong from our perpective with this cycle. I'm going to email it through and hope he doesn't just see us as trouble-makers. Let's see.
Thanks again for all your support.