Mid Cycle U/S - WWYD? Update in OP with Question

LindseyM2012 · December 2014

I completely understand that nobody can make this decision for me, but I wanted to get some feedback on my mid-cycle monitoring appointment. My first medicated cycle was 2.5mg Letrozole that resulted in 1 mature follicle and 1 borderline mature follicle. Triggered, did progesterone support, BFN. My 2nd medicated cycle is 5mg Letrozole. I went in for the u/s this morning and have lots of follcles growing: 2x 17mm on the right, 1x 17mm on left, 1x 16mm on left, 1x 19mm on left. Like I said, LOTS of follicles. My RE cancels cycles if there are more than 5 mature. So I have 1 mature, 3 that will probably be mature tomorrow morning (my RE considers 18mm mature) and 1 that will probably be mature in 2 days. The nurse said to trigger tonight and do TI tomorrow & Thursday. Phew....lots of numbers.

My husband is against selective reduction. That is the piece that is giving me pause on this cycle. There is always the chance that not all those follicles have an egg inside. There is always the chance that the sperm will just not meet the egg. But there is still the chance of multiples, which scares me. So I'm kind of on the fence about cancelling this cycle myself (even though my RE is comfortable with me going ahead with it) and avoiding intercourse. So my questions: 1) If I skipped the trigger shot, would that lessen the chance that all the follicles ovulate or no? 2) What do other REs consider too many follicles (is more than 5 a standard for cancelling a cycle or do some cancel for less)? 3) Knowing that my husband is against SR and I am not crazy about the idea of multiples, should I go ahead and roll the dice? I wouldn't be sad to get a BFP with multiples (I'd probably be thrilled), but I do things better one at a time.

Again, I understand that this is ultimately my decision with my husband, but I'd just appreciate some objective outsider feedback. Thanks ladies!!

***Update*** I just got off the phone with my nurse. My estrogen level was 130 with 5 good sized follicles. That is why my RE is comfortable with moving forward with this cycle, but they had to do the standard "risk of multiples" disclaimer even though the E2 number indicates all 5 are likely not ready to go. I took my trigger shot last night and this level is supporting my decision to go ahead with TI tonight and tomorrow. So now my question is this: that number seems really low for 5 good sized follicles. I was under the impression that they want the E2 level to be at 200 per mature follicle. Does 130 seem TOO low?

mshandlebar · December 2014

My friend just went through something very similar. She had 5 mature/almost mature follicles. She absolutely does not want multiples (her husband is quite a bit older than her), so she was terrified when she heard about how many follicles she had. She cancelled her cycle because she didn't want to take the risk. Her (now former) RE had no problem going through with the IUI, and he actually pressured her against cancelling. He turned out to be kind of a crazy pants.

There were a lot of factors that went in to her decision, and I am not telling you this because I think you should cancel your cycle. For her, the fact that she doesn't think she could handle more than one baby and an older husband at the same time was a huge factor. She also took into account how many cycles she had gone through, how she felt emotionally about this cycle, and her feelings about her RE. It was not a simple decision, and I am sorry that it is one that you have to make. I am not entirely sure what I would do it your place. Although, since I am at the point where I would do a happy dance for twins, I might be inclined to go through with it. We haven't really had to talk about SR yet, so I am also not sure how I or MH feel about it if it was a case of more than 2.

There is no wrong answer. I don't think there is anything wrong with skipping this cycle, especially if it will make you or YH anxious. On the other hand, like you said, when you get that BFP, you will be happy no matter what. So, maybe it is worth the risk. I wish you the best of luck! Please let us know what you decide to do.

LindseyM2012 · December 2014

@mshandlebar‌ and @DaydreamSam‌ - thanks so much for your really thoughtful responses. I know for sure I'd cancel if we were doing IUI since the sperm would be washed and probably not concentrated (for lack of a better term). But we're doing TI which is why I'm on the fence. Last cycle I definitely ovulated (confirmed by labs) with the two follicles and ended up with nothing. So I'm thinking either sperm just didn't meet egg or there were no eggs in those follicles (the RE said that is completely possible to have an "empty" follicle...who knew!!), or both.

AngM123 · December 2014

*****pregnancy/loss mentioned*****

I can tell you what my SIL did and you can take it however you want. They had been trying for 2 1/2 years. On their 5th round of clomid IUI plus trigger they finally got pregnant but unfortunately miscarried. On their 7th round, she had 8 mature follicles. They had always only had a couple the previous cycles. The RE wanted to cancel, but they decided they wanted to risk it. The RE made them sign a document agreeing to do SR if needed. I honestly don't think they put too much thought into it, they just wanted something to work. And it did, and they had one healthy girl. Soo...there's that. Im not saying it's right, I'm not saying it's wrong. Clearly it can go either way. Personally, I don't know how I feel about SR as I've never been in that position or had to consider it. Coming off a failed IVF I'm willing to do about anything, so I would go for it.

emmuffy · December 2014

My RE cancels anything over 3, and considers 1.7 and up to be mature, although she has also said you can't count out anything over 1.5 (small chance they'll have a viable egg). Good luck with your decision

Tiko99 · December 2014

I had three medicated cycles with clomid and had 3-4 mature follicles each cycle and all ended in BFN. So personally if my RE is OK with moving forward with treatment with multiple matured follicles I'm good with it. If I had ended up with twins or triplets we would have proceeded with the pregnancy.

Tiko99 · December 2014

I had 3-4 follicles per each clomid cycle and was given 10,000 unit trigger shot and ovulated all follicles 2 cycles and was given 5,000 unit trigger shot during a TI cycle and did not ovulate all follicles (which meant a cyst for me and a jacked up cycle). Maybe ask for less units for the trigger shot?

LindseyM2012 · December 2014

Thank you all so much for chiming in with your thought processes! @lemonliz - unfortunately I wasn't able to speak with my nurse (she left a message when I was in session with a client and the office closed as that session ended...ugh!) and she didn't leave my actual E2 level. My husband and I have discussed multiples a little previously and he is completely comfortable with it. I'm not necessarily uncomfortable with multiples, its just an intimidating idea. He's totally against SR (except in extreme life-threatening circumstances) and I will not go against that or pressure him to change his mind.

So our dinner conversation was an "oh man, this is real" conversation. He wants to go ahead with the cycle. Like Ketchup said, the likelihood of all 5 ovulating, fertilizing and implanting is not huge and I think I would kick myself more if I self-benched than took the chance. Since 2 follicles last cycle didn't take, hopefully having 5 will increase the likelihood that one will take.

Thank you, too, to those who pointed out that not triggering can leave leftover cysts! Not something I thought about!! I guess if I did decide to self-bench, I would still trigger but just not have sex for several days.

BunnyBerry · December 2014

Based on these two points: 1. there are 5 follicles that are likely to be mature, and 2. YH is against SR, in my opinion the only option is to abstain until fertile window has passed.

Since YH said he wanted to go forward with it, I wonder if he really understands the risk? Sure, the chances of all 5 are so, so slim, and even 4, but there is a known chance.

That's the way I look at SR, that if we trigger with 3 follies and 2 split into identical twins or something, we would have to put it on the table for the safety/health involved - but I could not live with myself if we were looking at SR due to a knowing choice we made (like not abstaining with 5 follies). We are very similar in age to you guys, with MFI that's prevented pregnancy for 6+ years and 4 IUIs, and without even asking our view on SR the RE said he would never let us try with more than 3 follies at 15mm or above.

That said, everyone has his or her own perspective on the issue, so I'm not trying to tell you how YH should feel about it...just that he probably isn't on TB and Google all the time like we may be and the reality of the situation might not be totally clear to him. It could be as simple as, he hates the idea of SR but is comfortable risking it on the path to making new life with you. In which case, please disregard what I'm saying - not trying to guilt anyone!! Just make sure that he's sure he wouldn't have to live with guilt if it got to that point.

dancerspose · December 2014

I don't really have any advice to offer, but I wanted to stop by and wish you the best of luck with whatever you decide. My REs office says with 4 mature follies or more they cancel. I'm not entirely sure I agree with that, but having not been in this position before I can't really talk.

Again, good luck!

deelopi9 · December 2014

This is a tough one. I had a similar situation where I had 4 mature follies and RE wanted to cancel (she cxl if more than 3 mature follies) and we decided to move forward anyways. Mine resulted in a BFN, however, we were okay if it came to multiples. We were already 2 years into TTC so at that point we just didn't want to go through the emotional/financial aspect if we didn't continue on.

It's not an easy decision and I wish you all the best.

catlover790 · December 2014

I hope you don't mind if I post. Grad warning ********

I had 3 mature on the ultrasound for my letrozole TI cycle. I was worried at the ultrasound because I was nervous of having triplets or one splitting. However, my E2 was only a little over 200 so they thought only one and maybe the second really were mature and we decided that we would go ahead with it since the chances were small and it seemed that my E2 was pretty low to have 3 that were really mature. I know you have more follies so it's more of a difficult decision but I just wanted to say I think calling about the E2 will really help with your decision!

This is a very hard decision and I wish you the best in deciding what to do.

Edit: I just saw this was yesterday, so I'm sure you've already made your decision. Sorry, I probably wasn't any help but I hope you made a decision you are comfortable with.

LindseyM2012 · December 2014

@catlover790 - Thanks for posting! I did go ahead with the trigger shot last night, but we didn't have sex and are planning to tonight and tomorrow...and the next and the next

However, I am going to call my nurse in a couple mins to ask what the E2 level actually is. I'm still probably going ahead with this cycle, but that number will just give me more information about the chance of multiples. If I hear that number and become more uncomfortable with the idea of risking multiples, I'll talk to my husband about skipping this cycle.

catlover790 · December 2014

Grad warning********

I'm glad to see you were able to get your E2 levels. It does seem that all 5 are not mature/have an egg. When I had mine I was a little concerned it was low too since I was supposed to have 3 follies. I did a little "research" as in Google and the bump and what I read was that femara can suppress E2 levels a little. I can't remember the exact wording that I read but something that lower E2 on femara was acceptable. Try searching the bump, I think there were some older threads about it.

I'm glad that you're able to continue with the cycle. FX!

LindseyM2012 · December 2014

Thanks @catlover790 and @BlueFairy5 ! I'm going to do a little research about Letrozole suppressing E2 levels. My AMH was super high so my ob/gyn & RE thought my egg quantity and quality should be good. I was initially excited about this cycle because 5 follies means that much more chance of success, but now the low E2 level has me completely discouraged! @NariaDreaming - you're so right that if this cycle is a bust, I'm definitely raising this as a concern about next cycle! Now I'm just upset that this didn't seem to be a red flag for anything. Maybe they just factor in that Letrozole could be suppressing the E2 level, but I want to know that. Or maybe @lemonliz is right that the test was off for some reason. Whatever way, I am definitely going ahead with TI and then confronting the discrepancy in this level if there is a BFN (which now I'm anticipating)

Thanks so much for helping me think through this, ladies! I probably wouldn't have called my nurse for the E2 level if @lemonliz didn't bring it up. And now I can adjust my expectations to be more realistic.

LindseyM2012 · December 2014

For anybody who is interested - This is what my initial research about Letrozole and estrogen levels has found:

"For fertility purposes, the lower levels of estrogen in the blood stream stimulate an increased production of FSH, the hormone that stimulates egg development. This is how letrozole works as a fertility drug." (From: https://infertility.about.com/od/infertilitytreatments/fl/Letrozole-Femara-for-Getting-Pregnant-Side-Effects-Success-Rates.htm)
My take away from this article (and some others that I skimmed): Letrozole is FDA approved to treat estrogen-induced cancers so its primary function is to suppress the production of estrogen in the blood supply. This allows FSH to increase and that is how it can be used as an ovulation-induction drug. This makes sense to me. I am planning to call my nurse tomorrow to see what E2 level they expect to see with a Letrozole cycle knowing that Letrozole works in this way.

LindseyM2012 · December 2014

Hi ladies - sorry to keep bumping this thread, but I'm learning a lot about Letrozole & estrogen levels and thought I'd share. I emailed my nurse this morning asking about my low estrogen level (130 with 5 decently sized follicles) and that I'm concerned, but that I also know that Letrozole works to suppress estrogen levels so FSH can take over. I asked what kind of estrogen level they look for per follicle on a Letrozole cycle. This was her response:

Because the medication is known to decrease your Estrogen level there is not a certain level we look for, we base when you are ready for trigger on the size of your follicles. I did ask and the risk of twins is <10% and triples is less than 1%. I hope this helps answer your question. Have a wonderful day!

I also want to get some feedback from other ladies taking Letrozole - does your RE base the decision to trigger on estrogen levels or do they leave that out of the equation?

Thanks so much, everyone! You all have been so helpful so far!!!!!

SND1231 · December 2014

My RE didn't even test my estrogen level mid cycle. He based the decision to trigger on size of follicle.

catlover790 · December 2014

Grad warning *******

I promise this will be my last response !

I only keep answering since we were doing the same protocol, and I have everything crossed so much for you this time!

My RE also only went by size of follicles. I was checking my patient portal when I saw my E2 levels and started wondering /googling. I hope that means that some of those follicles you had were mature but not all of them!

LindseyM2012 · December 2014

@SND1231 and @catlover790 - makes sense that they would only go of follicle size. Now I'm wondering why they're even taking a vial of blood to check my estrogen if they're not using that for anything.

@catlover790 - I definitely welcome your input! I said this before and I'll say it again, I feel a little kinship with you because we intro-ed on this board within days of each other and had/have pretty much the same issues (although I did get the definitive PCOS diagnosis and you are "possibly PCOS"). It made me so happy when you got your BFP on your first medicated cycle and it makes me so happy to hear of your progress! It gives me hope

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