Jessi asked on my last post what happens in an injectable cycle, and you know... that's a good question! This is my fifth injectable cycle, so I'll lay out the basics... but let me tell you, no inject cycle is the same, and how everyone reacts is different too! This is only my experience! Our response dictates how our cycle goes down, and influences how much it'll cost, and how long it'll last... while injectable FSH give us more control over things, it takes that same perceived control out of our hands.
First of all, injectable cycles begin with a typical cycle day three baseline. You go in, you get an ultrasound to make sure you have no cysts and your lining is thin. Usually you'll get an estrogen draw (E2) too. If things look good, you can start stimming that very night. You usually have to wait until the afternoon to start stimming though, because for future scans you'll be waiting for your clinic to call you back with your E2 level (which usually happens in the evening). I'll get to that though!
Injections can be scary the first time around. I had a needle phobia, which I promptly got over. No choice. The needles are small, and you inject them subcutaneously (in the fat, not muscle). When I did my first injectable cycle I iced beforehand and used a Gonal-f pen... didn't realize I had already stuck myself and pulled it out on accident! Didn't feel a thing. Some medications come premixed in pens, while some require mixing- also not a big deal. I mix my Bravelle at every injection, and it's very simple.
After your first scan they'll have you stim for a few days at whatever dose they deem fit- I believe most clinics will start a first timer out at 75iu a day, but it really varies from clinic to clinic. Since we know what dose I need (a whopping 225iu*) we start there straight from the get go. On a first cycle they'll have you come in more often, because they don't yet know what dose you'll need or how you'll respond. This is where the control comes in- unlike with oral meds, they'll be adjusting your dose daily pending your response. If your dose isn't doing enough, they'll increase it, if it's doing too much they'll dial you down. We have a ballpark idea how I'll respond, which is why we can wait 4-5 days before bringing me back in, but on my first cycle we were coming in every 2-3 days. First cycles tend to take longer, and are more expensive, because of all the uncertainty.
When you come back in, you do another ultrasound and an E2 draw. The ultrasound shows what has already happened, if there are any follicles maturing or taking the lead, or even already matured. The estrogen predicts what's going to happen, or rather it tells them what's going on behind the scenes. Your estrogen rises in response to the dose you're on- if your dose is too low, it will barely rise. If your dose is too high, it will sky rocket. My clinic likes to see it double every couple days. So at your follow up appointment they look at both sides of the issue to figure out the whole picture- this in turn decides your continuing dose. My clinic always calls in the afternoon after they've looked at my E2 level, and let me know what to do from there. If things look good, you come back in however many days seem fitting. If one is almost mature, they may have you come back sooner. If it looks like things are going slow or taking longer, but dose looks good, you may come in later. If they're upping your dose, you could come in sooner because they don't know how you'll respond to that dose...
See, this is where that perceived control comes in! It sounds like a bunch of guesswork, and in a way it is, but it's educated guesswork. They have studies and reasons for the dosage changes, and the extra monitoring is necessary so that you get enough mature follicles but not too many mature follicles- it's a very fine line to navigate!
They keep walking this tightrope however long it takes for you to get a mature follicle. How many scans you have depends on your response, and how long you stim depends on all the factors mentioned above. Some clinics like to take the slow and steady approach, which is great for a first cycle, but you do have to be careful that they aren't overcautious.
My first RE was overcautious, he refused to up my dose despite no response, and he made me stim until cycle day 28... I wasted a lot of medicine and money on scans. We pay out of pocket, I have no coverage, and at the time we made less money than now. I spent $2k on ultrasounds, and another $1k on blood work, and wasted all my donated meds (from an assistance program)... to ultimately have a complete cycle failure (trigger failed). If I had known what I do now, I would have demanded better care. That cycle was the reason I left my clinic. First cycles can be trying, but they shouldn't be like mine was. There is a difference between being cautious and being overly cautious. If your E2 isn't rising, ultrasound shows nothing, and they're refusing to raise your dose- question it. Never be afraid to question the care you're receiving, or even at times demand a change in treatment. I learned a valuable lesson from that first inject cycle, albeit an expensive one- advocate for yourself. Always. Speak up, and make your wishes known.
Now, as you get towards the end of the cycle you may have to worry over how many follicles you have- I've seen many women cancelled because of over-stimulation. I almost was myself, and it's a real worry of mine even now. Every RE has their own cut off for over-stimulation, most don't like to trigger with more than three but some will allow more. You have to address these concerns with them, and discuss the risks involved. This is why they monitor you carefully and why you come in so often though- to minimize your risk. They take into account your age, history, what your reproductive issues are, and try their best to prevent high order multiples (HOMs) or ovarian hyper-stimulation syndrome (OHSS). Injectable medications carry the risk of multiples because you have less control than with IVF, but they do what they can to bring your risk down.
Once you get the right number of follicles and estrogen, you're RE should allow you to trigger. Either you'll be instructed to have intercourse, or opt for an IUI. Without male factor infertility (MFI) an IUI only adds an extra 1-3% to your chances. I usually opt for an IUI with injects since we pay so much out of pocket for the whole cycle; I mostly add one for the peace of mind and timing insurance, as we don't have MFI.
After that, the waiting game begins.
Hope that all made sense and was helpful/informative! Remember, I'm no expert and this is just my experience... but if anyone has questions, feel free to comment or email me.
*which isn't a lot for IVF, but is a rather high dose for an inject/IUI cycle
Photo is from one of my 2009 Bravelle cycles, haven't taken any from this one yet!