Tuesday, November 25, 2008

When to see an RE...

Well, with the 2nd cycle of clomid being anovulatory, we are getting closer and closer to when we need to decide how much further to go with our OBGYN, verses seeking out the opinion of a more experienced reproductive endcronologist. If it wasn't for our insurance not covering any diagnostic tests or treatments, we would have gone a long time ago. However, we're trying to start with a few basic things and get those done with the OB. The only problem is I'm worried we're wasting time and energy and are putting my body through things that might end up doing it more harm than it's worth.

Today is cycle day 37 with no sign of ovulation or my period. We're pretty much assuming nothing is going to happen now, although it could still I suppose, and have an appointment set up for two Tuesdays from now to go see the new OB (since my old OB up and moved on us!). Before then, we need to do some serious talking and figure out what our ideal next step is based on our research and then come up with a list of questions to get answered that day.

In the meantime, I found another online radio show program (yes, I LOVE that site!) where an infertility specialist talked specifically about when and how to go about choosing an RE. My notes are below!

A little of the subject, but here is a handy guide of one Infertility Center's quick "diagnosis to treatment" comparison. http://www.makingbabies.org.uk/index.aspx?pageId=11

Success Rates of Infertility Centers
Missouri: http://apps.nccd.cdc.gov/ART2005/clinlist05.asp?State=MO
Find your state: http://apps.nccd.cdc.gov/ART2005/clinics05.asp

Local Infertility Centers of Interest (use the above site as a good resource for other centers)
1) Washington University (St. Louis) Infertility and Reproductive Medicine Center at Barnes-Jewish Hospital - http://www.infertility.wustl.edu/fpp/infertility.nsf
2) Sher Institutes for Reproductive Medicine in St. Louis -http://www.haveababy.com/index_stl.cfm?&city=stl&site=stl

When to Seek Help from a Reproductive Endocrinologist

Please note: This is my personal synopsis of the free online radio program hosted by Kim Haun, founder of Conceive Magazine, with guest Dr. Peter Ahlering, an ob/gyn and medical director of the Sher Institutes for Reproductive Medicine in St. Louis. To listen for yourself, go to this site and find the show in the archive on the left, dated 8/2/07, titled "Know When to Seek Help").

If you can't retrieve a decent number of good eggs, then chances are slim of success. (10-15 eggs are best). These non-ideal patients can be identified. The things that doctors look for are: high FSH (over 9), late 30s or older women, low ovarian reserve (via ultrasound during early part of cycle - antrafollicle count, which is similar for the next several months; this count is indicitive of how many max eggs you can get, typical 70-80% of the count).

Patient Example
1st Transfer - no baby; 2nd Tranfer - good quality by appearance, but no baby - look for embroy problem (after 1st failure)

Remember: IVF removes factors of a natural pregnancy - tube picking up egg, egg fertilizing in tube, egg coming down tube to fertilize in uterus.

IVF success depends on (should figure this out before hand)
1) eggs - how many and quality (FSH, antrafollicule count, age of patient)
2) sperm - how good
3) uterus - physical characteristics, and implantation factors: thickness, blood flow, emunological factors on uterine level

Stories of women having many many IVF cycles with no success... you should be finding out where there are issues. After 2 cycles of an otherwise good IVF, you make sure to not have any techincal factors.

When to see a RE, when to select one, how to be prepared for 1st visit
(Dr. Alering used to be an OBGYN) Old standard of HSG, etc. is not necessarily a good thing. Most people start with OB's because of insurance issues. Ends up being a big delay and they get lost and delay can be critical in becoming pregnant. One office visit for male and female can cover initial diagnosis. Or, you can take a letter to your OB and have them do it. Testing normally includes:

The Blank Slate (has had no tests before)

1) ultrasound: check tubes (for tubal patency) ovaries for ovarian funcation (for antral follicle count), uterine anatomy (like you would with HSG - fluid ultrasound); takes about 10 minutes. Ultrasounograpy you can tell if you have blocked tubes, instead of an HSG
2) blood test: CD 3, 4, or 5 of cycle - tells all you need to know about fertility situation, except endo and pelvic disease

Pelvic disease - to proceed with laproscopy at a different time, but not necessary in most patients. Depends on what you've done already. Lap is mainly done for diagnosis of endo; has limited value. If you're going to do IVF, you don't need this. Lap might help you determine if you want to do IUI or IVF.


Semen sample: semen analyis (count, motility, morphology + dna testing, which takes a week to get back)

Natural vs. IVF Now Days...
Block tubes, natural conception is out. Unblock? Not very often this way - tubal surgery usually isn't the way. 10 years ago, IVF wasn't as good so it made sense, but now it doesn't make much sense. 3 months of shots and IUI might work, but when you come back in 305 months IVF will have a smaller chance b/c you did the shots.

OB vs RE
The difference as to the education. Yes, they do go to school more, but a lot are self taught - doing ultrasounds, fluid ultrasounds. Depends on a person's interest. If interested, their office will be set up as such, up to a point and they might be able to give a fairly thorough exam.

How to find the RE that's right for you
Matter of shopping around to find a center with experience, technology and lab on site and offer a wide of services to be able to do all of the things you might need. It also suggests a level of sophistication. Experience in doing procedures is important. You need to like the office, the system and the doctor and provide information. Patients need access to physicians and personnel and you can get that impression from the moment you contact them.

What is an acceptable level of access to their RE? At SHER...
1) They have a website to communicate with doctors anytime they want. 2) Every client has the doctor's e-mail, and all of the staff. These would be for non urgent, and within a few hours they typically answer. Is someone answering an e-mail, or the doctor? No, the doctor answers their own e-mail, forwards it on if that is necessary. 3) Providing effective evaluation and diagnosis in a quick format.

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