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Miscarriage after IUI pregnancy. Endometriosis, laproscopy and histeroscopy done. Why the follicle is not rupturing?

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case history of my wife age: 29
PO+2 miscarriage-8 week-2011, Miscarriage- 7 week-2012,both IUI pregnancyHistory of endometriosis,laproscopy & histeroscopy done in october'12,cystic mass at right ovary removed,fimbrial dilation done for partial chocking at right tube .left tube ok.some of test done before laproscopy of my wife,reports are as follows
Lipoprotein A : 7.6 mg/dl
Prolactin: 24.94 ng/ml
Prolactin after peg preparation: 22.83ng/ml
Homocystene: 7.32 micromol/l
LA1 screening: screening test does not reveal lupas anticoagulant
Toxo plasma IgG: 0 iu/ml IgM: .08 index
RUBELLA IgG: 88 iu/ml IgM: 0.15 index
CMV: IgG: 25 au/ml IgM: 0.21index
PROTEIN C: 138.9%
PROTEIN S : 115%
Antithrombin: 104.5%
APA: IgG: 0.9 u/ml IgM: 0.99 u/ml
ACA: IgG: 0.99 gpl/ml IgM: 0.98 mpl/ml
CULTURE OF HIGH VAGINAL SWAB: no pathogenic micro organism grown
FSH :on 4th day of last mens period:19mIU/ml
E2: on 2nd day of last cycle:61.86 pg/ml
History of mine(husband)age : 34
Semen analysis(08.04.2011):
Sperm count: 9.1 million
Active Motility: 30%
Semen analysis(17.08.2012 after taking PRODUCTIVE M): 40 million
Active Motility: 50%
chromosomal test done for both: found ok
we have tried for IUI in this month after laproscopy in october.for this she has taken 4 nos of foligraf 75 iu inj for 4 days. after that only one follicle has been generated. after reaching the follicle size of 16x17 she has taken one hcg trigger. again after 30 hours she again taken one hcg trigger. but after 15th day follicle size was 26x27. it has not ruptured. so IUI not done in this cycle.
what is the reason behind not rupturing the follicle?
what will be our next course of action in the next cycle? pls elaborate
Posted Mon, 4 Feb 2013 in Infertility Problem
Answered by Dr. Dattaprasad 1 hour later

Few of the main problems in having a baby are

1. Your wife's tube was partially chocked, which was cleared during laparoscopy by fimbrial dilatation. Normally such tubes don't remain open for long time & there is chance of re-blocking the tube again. So we must act fast.
2. Cystic mass in right ovary was removed, which decreases the number of eggs in the ovary.
3. Her FSH on Day 4 was 19mIU/mL. It indicates a reduced ovarian reserve, that is reduced capacity to form eggs & she might go into menopause early.
4. Previous history of two miscarriages, for which many of the investigations were done & almost all are normal. The only investigation remaining is anti beta 2 glycoprotein antibody levels, which if comes positive, she can take some injections to avoid miscarriage in the next pregnancy.

Considering the reduced ovarian reserve & status of tubes, its better to go for 1-2 more cycle of inj FSH (Foligraf) along with IUI, and if conception doesn't occur, to proceed for IVF.

Regarding your last IUI cycle,
1. It would be better to give higher doses of FSH to stimulate more than one follicle (preferably two OR three).
2. Take Injection HCG after follicular size of around 18 - 20mm.
3. Not to wait for ultrasound documentation of follicular rupture, as rupture is not always visible on ultrasound. (The corpus luteum which forms after follicular rupture may look similar to the follicle).

The reason for non rupture of follicle can be manifold: Follicle might have ruptured & corpus luteum formed, OR it might be due to adhesions around ovary not allowing follicle to rupture. (These adhesions may rarely form after cyst removal). Also follicle sometimes doesn't rupture in an occasional cycle without any reason, which generally doesn't repeat in future.

Hope this answers your query.
Let me know if you have other concerns.
Awaiting your reply.

Above answer was peer-reviewed by
Follow-up: Miscarriage after IUI pregnancy. Endometriosis, laproscopy and histeroscopy done. Why the follicle is not rupturing? 24 hours later
dear sir
kindly give the details of the IUI cycle with fsh injection doses,number of injection that has to inject. is there any chance of hyperstimulation?
Answered by Dr. Dattaprasad 7 hours later

As online prescription is not allowed I can't prescribe injections for the whole cycle. But broadly speaking, Inj FSH can be started on Day 2/3 of cycle in doses of approximately between 112.5 to 150IU, given daily & cycle progress monitored with frequent ultrasound (First ultrasound on day 2/3 before starting injection, second after 4-5 days of injections & thereafter on alternate days depending on progress).

After follicles mature with largest being 18-20mm, she can receive hCG trigger & IUI can be done between 36-48 hours after trigger, irrespective of rupture documented on ultrasound. More important is to continue to have daily intercourse during IUI cycle(even the day before & after IUI you should continue it).

Regarding chance of hyperstimulation, if cycle is monitored & controlled stimulation is given by expert doctor (preferably who has experience in handling IVF cases), hyperstimulation doesn't occur.

So you can go ahead with 1-2 such cycles & if unsuccessful go for IVF.

Hope this answers your query.

Let me know if you have other concerns. If you do not have any clarifications, you can close the discussion and rate the answer.

Above answer was peer-reviewed by
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