Wednesday, December 31, 2008

RE suggests IVF after ultrasound reveals scar tissue

Our appointment with Dr. Peter Ahlering, our RE, yesterday went better than I expected in the sense that my fluid ultrasound (FUS), which I also think is called a sonohystogram, didn't hurt one bit. I had taken a pain killer I had left over from when I got my wisdom teeth removed, figuring it was a good precautionary since I read some women seem to experience a decent amount of pain, but I don't think I even needed it. Basically, once they had the speculum in, I must have been distracted enough to not even notice when they put the catheter in, which was nice. I also didn't have a problem with cramping afterwards, so all in all the actual procedure itself went well.

Ok, so that's pretty much where the good news ends. Honestly, going in I didn't think we'd actually learn all that much from the ultrasound. I knew he was going to count follicles and all, but I thought that it would pretty much just be a confirmation that I had a PCO ovary. Which I did, and I guess in the case of considering IUI or IVF, that is a good thing because each will have the potential to mature into a large, viable follicule.

The big news was that my left ovary, my only one, is right on top of my uterus, rather than off to the side with it's own breathing room. He said he tried to use the ultrasound wand to poke it a little, trying to move it, and that typically he would be able to do so, however, in my case, my ovary didn't really move, which means there is probably some sort of scar tissue that is now bonding my ovary to my uterus... much like super glue I guess. He said that he's not that surprised to see that, considering my history. He asked again the nature of my incesion (mine is vertical and stretches from my belly button down to my pelvic bone) and said that it's pretty common when the pelvis area is opened up so much to have some adhesion occur (from the surgery, and I suppose also from the large, grapefruit sized ovarian cyst that was in me for a short time). Whenever there is adhesion, there is some amount of scarring upon healing. That scarring, or new tissue, can occur on or around organs.

So what does this all mean? Well, he said that this more than likely means that my ovary won't behave in a normal manor. He still thinks they can get me to stimulate and produce viable follicles, however since we're probably seeing signs of scarring, there is more than likely scarring or an irregularity to my only remaining tube on that same side, therefore, it will not work properly. His words were, and I quote, "I'm going to be so bold as to say I would recommend skipping the laparoscopy surgery (and therfore also skipping IUI) and going straight to IVF". The reason for this is because the laparoscopy would only be a diagnostic surgery designed to determine if there is actually scarring or damage to my tube. In his opinion, since this already seems to be the situation as shown in this recent ultrasound, there isn't much reason to do it, other than to confirm that what he believes to be true is in fact true. I did ask if this also meant I would have a problem carrying a baby to term, if I did ever get pregnant, and he said that no he doesn't believe it will have any bearing on that. That, at least, is a bit of good news.

As you might guess, we didn't expect to hear IVF is our only real option at this point in time. I have mixed feelings about the whole situation. On one hand it's nice to know, plain and simple, what we're really most likely dealing with so that going forward we are making decisions that are sound. I mean, why waste our time with things that most likely won't work. On the other hand, I had begun to have a glimmer of hope after hearing how much an IUI was. Before this appointment, we were feeling like we could financially swing 3 or 4 rounds of IUI without it taking too much of a toll on our savings. IVF is different - in fact so different, we could do about 5 rounds of IUI for what it will cost us to do one round of IVF.

I am honestly not sure where we'll go from here. Next Wednesday we have a follow-up appointment with the RE to go over the results from all of our tests - my bloodwork, the semen analysis and my ultrasound. Depending on what the findings there are, it could change things slightly. If the SA comes back normal and my bloodwork isn't too out of whack, it might be worth geting a second opinion on my scar tissue situation before deciding to completely rule out IUI as an option. Even with that said, knowing my ovary has issues, and knowing that PCOS women tend to have problems with producing good, viable eggs (PCOS women apparently produce lots of follicles but generally are of poorer quality), that might be another reason to opt for IVF, since it's the only way to really watch the egg during the fertilization process to see if it's maturing properly. After the follow-up appointment, we will most likely sit down with one of their financial coordinators to get an idea of what our financing options would be, should we decide to move foward at that clinic.

Obviously we have a lot of thinking to do about where we will go from here. At this point, I really feel like in my heart IVF or adoption will be our only way to have a child. I know that both of those will require a lot of time, money and potentially emotional strain on us and our relationship. I also know that ultimately it will mean our family will grow not only larger, but hopefully closer and stronger in the process, and that is what I truely hope and dream for.

Sunday, December 28, 2008

Multiple Blessings - A Great Inspirational Read

Last night I finished reading Multiple Blessings: Surviving to Thriving with Twins and Sextuplets
by Jon & Kate Gosselin and Beth Carson. As most of you know, Jon and Kate (from the TLC show Jon and Kate Plus 8) are the proud parents of twins and sextuplets, complements of shots/injectables & IUI. Like myself, Kate also had PCOS and didn't ovulate on her own. What is neat about this book is that it tells their story from Kate's first person point of view and takes you on a journey through the early years - from getting married to the birth of their twins, their journey through infertility and the birth and first year of their sextuplets. Since I'm a big fan of their TV show that focuses on current day life, it was neat to go back a little and find out where they've been since then. For me personally, it was also nice to learn more about their bout with infertility.

In reading this book I was overwhelmingly struck by a few major points. One, I am completely and utterly amazed that a woman's body can go through the things that her body went through both before, during and after pregnancy, both mentally and physically. Her story gives me great hope and a belief that I too can keep marching on through even what might seem the toughest of times.

Secondly, and on a related note, it is quite clear to me that the only way she has been able to keep her strength and sanity is to have complete and utter faith that God is in control of all things and His will, will absolutely be done. It is just amazing how He has provided for this family. Kate mentions in this book, and it's pretty obvious on the show, that she is a very controlling and take charge type of person. While that is good, it is also very challenging at times - I too share this same blessing/curse. I have such a hard time just "letting go and letting God" take care of the situation. I think that if something needs to be done, I will map out a plan and will begin to see the outcome before I've even started on step 1. Oh if I can only learn to just relax a little and trust that everything will work out as He has planned. I can say, however, that already through this journey I have noticed a change in myself in this respect. Not that I feel I've "arrived", but I have definitely learned that infertility is a one-day-at-a-time process and that in and of itself requires a little letting go. I continue to pray for peace that things will work out as He has planned and that I simply cannot stress over every little detail.

Another very huge, and concerning, concept that I took away from this book is the concept of "selective reduction". Honestly, until I read this book, I hadn't really given any deep thought to what it entailed, however, it could potentially be a very monumental part of the ART process. For Kate and Jon, their position was very cut and dry from the beginning - they wouldn't consider selective reduction for a minute. Selective reduction, in case you are unfamiliar, is when they reduce the number of fetuses in a multi-fetal pregnancy by way of injection during the first trimester (but usually after 12 weeks) in order to reduce the risk of complications in a pregnancy. As you might expect, this procedure is highly controversial.

I came across a Washington Post article by Liza Mundy entitled, "Too Much to Carry?" that follows a few couples through this process. I have to say that their stories put a very real situation around this issue. She also wrote a book called "Everthing Conceivable: How Assisted Reproduction is Changing Our World". I think I am going to get myself a copy and make myself read it. I should mention the fact that the odds of the mother and/or babies having a complication from a multi-fetal pregnancy is more than double that of a singleton. This fact is what pushes some people to undergo selective reduction, but what very huge, and heavy thing for a person to be faced with considering. If we are going to go through infertility procedures we need to be prepared for anything that might come our way and we need to know where we stand on such important issues.

At this point, let me just say that there is one part of Mundy's article that echos in my mind and in my heart: "Some of these people tried to get pregnant for the past five years and prayed to God. And now that they are pregnant, they are telling God: You gave me too many. I sometimes feel like we are playing God, and that is very emotionally stressful."

Our First FREE Appt with an RE!

I should really learn to update this more often so that I don't have to write a book every time! I have an excuse this time I suppose - Christmas!

As you know, we went to our first RE appointment this past week. Prior to doing so, I had a couple questions in regards to insurance and decided to call Fertility Lifelines (see sidebar) back, since they were so helpful the first time. I spoke with Barb again, the same person I worked with before, who helped me understand a little more about infertility states and how the coverage works. She confirmed the point about if a company is self-insured they don't have to offer infertility coverage. She also told me that it is possible that a company would be located in an infertility state, not self-insure, but still not have coverage simply because the state they purchased the policy from was somewhere other than that state (and they probably aren't an infertility state). As you can see, it seems there are several loop holes that companies might be taking advantage of. If we were to consider moving, the only way we would know for certain if a new employer offered coverage was to ask for a policy book during or after the interview. I also asked Barb if we went to an RE now, and tried to switch insurances in the next year (or after), would we likely be turned down or have our infertility issues labeled as "pre-existing". She said that as long as my doctors are continuing to bill my care as something other than an infertility diagnosis, I wouldn't. However, once that changes (also when our current insurance won't cover any procedures), we would be at the mercy of any stipulations. She said they (new insurance companies) typically don't refuse you, but you would be held to any pre-existing clause that exists, which is usually a timeframe of anywhere from six months to a year from the coverage start date. That I pretty much expected.

Because Fertility Lifelines is a subset of the Gonal-F injectable medications, she also updated me on the two savings plans they have going right now. One is their FertilityAssist2, where you can save up to $500 on your second round of Gonal-F shots, and the other is a word-of-mouth program called Compassionate Care that is income based and you can only apply once in your lifetime. However, if you are accepted into the program, you get 1 free cycle of shots (Both Gonal-F and Ovidrel which are needed to stimulate follicles - more info here) for use in either an IUI or IVF cycle and you must have a start date for these cycles from your doctor at the time of applying. To apply, they need a 1040, last two pay stubs and a copy of the front of your insurance card. She said it typically takes about 2 weeks to know if you are accepted (faster if you have a private fax to correspond with). I think I got most of that correct from talking with her, but if you're interested you'd want to call them yourself for full details.

Ok, so with that information, we headed to our first appointment with the Reproductive Endocrinologist (RE), Dr. Peter Ahlering (pictured at left) with the SHER Institutes for Reproductive Medicine, about 25 minutes from home. Our appointment was at 9am and I woke up with a pretty decent head cold. I had taken Nyquil before bed and was still loopy when I woke, so that whole morning was a bit of a haze. The good thing is that it probably kept me from being so nervous!

Anyway, I filled out the patient questionnaire on the way. When we arrived the staff was very pleasant and check-in was a breeze. We waited only about 8 minutes or so and was taken to Dr. Ahlering's office for about an hour long discussion. He was very nice and took the time to not only read through the questionnaire we'd filled out, but also asked a good deal about what we'd done thus far in TTC and made sure to educate us a little on how an ideal cycle would work. While I new most of that, it was good that he didn't want to assume we new everything. The two things he spent the most time talking about with regards to our situation was the fact that I'm not ovulating and that he was concerned my remaining tube might be damaged from my past surgery. He said the ovulation issue is pretty easy to overcome - I'm still young and with the right does of stimulation (shots), he is confident he can get me to ovulate. The tube issue, however, is something that could really be a determining factor as to what we do going forward. He said he will more than likely want to do a laparoscopy, which will allow him to get a good look at how the tube might be functioning. I honestly wasn't expecting him to say that - I was thinking he'd want to do an HSG, however, since that would only tell us if it's open (not if it's damaged), this totally makes sense. He said they usually do the surgery on a Friday and generally people are back up and running by the following Monday, so hopefully it wouldn't be too bad. I'm expecting that the surgery will be sometime the first, second or third week in January.

Last week, on Christmas Eve actually, I went in for new CD3 bloodwork - and LOTS of it... almost a pint! Let's just say I almost passed out and threw up they took so much blood! At least it's over with and I should get my results back this next week. Also this next week, (either Tues or Wed afternoon), we go in for a semen analysis (MSA & SDI - DNA testing), my fluid ultrasound (FUS) which is also known as a Sonohysterogram, my antral (AFC) follicle count via transvaginal ultrasound and for a financial consultation. They think that my lap will be covered by insurance, but we need to look into this more. IF the SA comes out normal and my lap looks good, he said we have a good shot at being successful with doing shots and IUI, especially since we're still young. IF there is a major problem with either the SA or my tube is damaged, our only real chance at pregnancy will be to do IVF. Generally speaking, he said that it would be $1,500 to $1,700 to do shots and IUI and $9,000 to 10,000 to do IVF - each of those is per cycle and the general rule of thumb is to expect to be in either one of those for 3-4 rounds before knowing if it will work or not.

We still have a lot of questions (many of which will hopefully be answered next week), but I can't begin to tell you how much of a sense of relief I feel after talking with him. It was so refreshing to, for once, feel like we're in good hands and that the person helping you actually knows more than you do (what a concept!). I think we probably went at a good time too - we've done just enough for him to know that clomid isn't working for us (he said the signs are pointing to me not reacting to the drug in a positive manor) and are ready to move onto bigger fish. I pray that we can find a way to make this work financially and that mentally I will be able to just turn it over and let God do the rest. Oh yeah, and that my body reacts well to all the poking and examining. I am already a little anxious about giving myself shots in the tummy, but if it helps us get pregnant, I am trusting God will get me through it!

Oh and needless to say, we're not doing another round of clomid - essentially this will pretty much be a cycle off while we do all the tests. And I'm totally fine with that - finally we'll have answers to so many questions and will know where to go from here.

Well, that certainly doesn't cover everything, but it's a start. I'll have to update later about how our holiday went. For now it's off to get showered and then we're headed to one last get-together!

Wednesday, December 17, 2008

New Doctors. Lots of Appts. Full Steam Ahead!

Boy do I have a lot to talk about this time around!

Meeting the new OBGYN
So, as you may remember, my last OB left the St. Louis area and left me high and dry. I had only been going to her for a little over a month. At first I was really bummed because I thought she was "the one" - she too only had one ovary and one fallopian tube, and she was able to get pregnant without too much trouble. However, at my last appointment with her, I realized she might not really know all of what she's talking about. She said she doesn't do mid-cycle monitoring while on clomid, so we had no way of knowing if my follicules were maturing properly the on the first round. She would also talk down to me a bit... more like giving me the look of "you silly girl"... which got old quick.

This idea of going to a new OB wasn't the worst thing ever as a result. I was hopefully she would know more about infertility - she was older so one would think that would mean more knowledgeable. I was wrong - again.

Maybe it's too much for me to be judging her too much too early, but in this type of situation it's half gut feeling and half what plan or advice she recommends. I didn't get a warm fuzzy on either of those. My gut told me "this isn't the one"... it was pretty obvious too because my husband said afterwards "I thought that if she told you to calm down one more time you were going to scream". I guess my body language is pretty outspoken.

I DID like the fact that she asked more about my female history than any other doctor ever has. It's amazing how reassuring that alone can feel. When she took a look at my chart and saw that this second round of clomid was, at the time, 52 days long, she said "that is unacceptable". She was baffeled as to why the clomid didn't work and asked why the last OB upped my dosage. (Remember that was done with the intention of it upping my ovulation date). I honestly think she thought I might have hyperstimulated and asked that we do an internal ultrasound that day. In the ultrasound room she took the time to show my husband what we were seeing - again my uterus looked good and I think she said my lining was at 5mm (not sure what this means for CD52 and she didn't really say much either).

Then she asked what ovary I still had intact. I am embarassed to say I can NEVER remember the answer to this question. I mean really - it's not like I dress it every day! For the record, if you must know, I have my left ovary (and apparently a little of my right still). I believe that she said I had around 5 or so follicules, but I don't remember for certain. I do know that she said there were several follicules that were not ovulatory follicules (were too small I think) and that there was one larger one, but it was oddly shaped. She said she thought this was because it was on the verge of being absorbed and there was nothing to worry about. She did confirm that there was no PCOS "string of pearl" style cysts present and thought that meant that the clomid was doing something, just not enough. She didn't know why this cycle was so wacky.

I asked about doing an HSG because I was concerned about my only tube being blocked (have read scar tissue from past surgery causing this). She said we shouldn't be looking into this right now because I'm not even ovulating or having a normal cycle. That we should first solve the ovulation issue and go from there. I didn't wholy agree with her - what if it IS blocked and all these months and clomid cycles are for nothing?

I also asked about whether we should have a post-coidal test done, since my cervical mucus was slim to none this time around (wasn't super great the first time either). She again stressed that we shouldn't do this now - it would be too premature because we don't even know if I'll actually ovulate and we would need to time the test around when we think I'm ovulating. I also didn't completely agree with her on this one either. My question is, isn't there another way to still do the test... like have me do the OPK testing and when I get a positive, schedule the post-coidal? Or, since OPKs detect an LH surge, wouldn't it make sense that if I get a positive OPK, I could come in to have bloodwork done to see if my LH is actually high and, if so, do the post-coidal then??

Of course that's assuming that we have Day3 bloodwork to measure from. Which we don't. In all fairness to her, I never mentioned this when she asked if I have had any bloodwork done. I just whipped out the results from the one test I had ((FSH 4.8, LH 18.3, TSH 1.58) which was actually done on CD13 by my OBGYN (3 OBs ago... can you believe I've been to some many different ones in the past 8 months!). That OB said "you can get it done any day", so I did. Honestly, at the time, I think she was simply looking for the FSH to LH ratio to determine if I had PCOS. As you can see it my LH levels are clearly more than 3x what my FSH is. I still think I should have these done again on the correct day - CD3.

She did, however, want to check my prolactin (which could help tell us if I have a pituitary abnormality) and estrodial levels (produced by the ovaries and the brain and will help tell us the baseline of estrogen in my body). The estrodial level is important in part because I have amenorrhea (lack of menses). Apparently estrogen monitoring during fertility therapy is also helpful to assess follicular growth. Seeing as how right now we have no way of knowing if the clomid is actually doing anything, that might be something to check out, though she certainly didn't suggest that. While I'm greatful she mentioned wanting these levels checked, she said I could get the blood work done anytime in the cycle - however, that simply isn't the case. Pretty much any infertility clinic website you read states clearly that estradiol (and others like FSH and LH) must be drawn on CD3. Prolactin can be any day of the cycle. The fact that she said any day makes me really doubt her expertise.

Oh, and I didn't mention that since my cycles are so unpredictable, and therefore my ovulation date is as well, she doesn't want to monitor follicule growth mid-cycle like she normally does. She said it would be "too difficult" and said to just wait it out to see what happens and to call her if it's day 40 and my period hadn't shown. I also don't agree with this decision. I don't really want to keep going with clomid if I have no measurable data with which to make a decision on what to do next cycle. Given the fact that doctors don't like to do clomid for more than 6 cycles (she also practices with this rule), this would mean I am getting ready to embark on my 3rd cycle and come out of it with very little new valuable data. That just doesn't sit right with me.

After talking it over with my very patient, and I do mean patient because I over-talk things, husband, he too agrees it would be silly to continue on the same path with no new info. We came up with few scenerios about what to do (since I'm now on my 4th progesterone pill and will start my period soon, which means that IF we want to immediately do another round of clomid, we'd be starting that on Dec 23, CD3). In the end, we decided I would call around this week to try and find another OBGYN who is more compassionate (I don't think me and this last lady would get along, let alone the fact that I don't think she's very knowledgable in infertility) and has more expertise in infertility. We also wanted to begin calling around to see how long it would take to get in to see a reproductive endocrinologist (RE) and how much an initial consultation would cost.

I had some extra time on my lunch today and was able to get a lot accomplished... drum roll please.... :)

New, new :) OBGYN Appointment Made - He does IUI's!

Dec 30 at 2:30 pm - I came across a local St. Louis baby forum with some OB recommendations and saw the name of a doctor located in O'Fallon, Missouri near Progress West Health Center. The poster said "he does IUI's". I was floored and thought there was no way! So I called and, yes, all three doctors in their practice do them. Not that that's what we will end up doing, but it does make me think that if they do a more advanced procedure like that, surely they know more than your average OBGYN. I have to admit - the only thing that bugs me is that he's a dude. I've never gone to an OB of the opposite sex, but, if he knows his stuff, then I guess it will be worth it. At least my husband will be there with me on the first appointment!

For your reference, the name of the doctor I'm referring to is:

Allied Associates OBGYN

830 Waterbury Fall Dr. O’Fallon, MO 63368 (near Progress West Hospital) (314) 569-2751
Dr. Craig Boyd - 21 yrs experience; board certified OBGYN; can do IUIs!

Appoinment Made with a Reproductive Endocrinologist!
Get this - Dec 23 at 9 am. I am so amazed that he could fit me in so soon! And, hold on to your pants, the consultation cost is: F-R-E-E!!!! Whoo hooo!!!!!!!!! I actually had to ask her to repeat herself and then, when I called back to make the appt, I asked the other girl who answered to confirm that. I just couldn't believe it. Especially since I had just got off the phone with another Infertility Clinic in the area who couldn't get me in until the end of January and who's initial appt cost would have been $300-400. Believe me, I'm still asking myself what the catch is with this other one I found. What's even cooler is that this is the same doctor that I listen to quite frequently on Life's Online Infertility Talk Radio show. I always make note of who the guest was on the show when I take my own personal notes, in case you're curious what he has to say. It has been a great way to sort of get to know how he probably talks with his patients at the clinic and makes me feel much more at ease. Thus far, he seems to be very kind and knowledgeable.

Here is his information:

SHER Institute, St. Louis

456 N. New Ballas, Suite 101, Creve Coeur, MO 63141

Dr. Peter Ahlering
Obstetrics & Gynecology - 16 yrs experience
Sub-specialty: Reproductive Endocrinology

So... where does that leave us? Well, our tenative plan is to play some massive doctor toss-up. Meaning, on Dec 23 at 9 am I will go see the RE. We will probably talk about my history and he will recommend a battery of tests he'd want done before laying out a game plan. I am going to mention where we're at with our OB currently (getting ready to start a new round of clomid) and see if he has any opposition to that. If not, I will go the appointment that afternoon at 1pm with my current OB to have my CD3 ultrasound done prior to starting clomid that night. Then, on Dec 30 at 2:30 pm, CD10, I will go to the new OBGYN. We wanted to get in to see him before the time when I should hypothetically be ovulating so that if he wanted to do mid-cycle monitoring, we would still have time to do that. Though it just dawned on me that we'll be in Chicago at that time!! I can't believe I didn't think of that until now. Looks like we have something new to talk and think about. Oh well, not going to let it ruin my day. I am on cloud nine with the free consultation and the new OB am just going to trust that it will all work out. If we don't immediately do another round of clomid, then that might be ok, depending on what the new doctors think.

Ok, off to do some last minute Christmas shopping and grocery shopping for holiday parties. Should be fun :P

Friday, December 5, 2008

Which to Use & Why: IVF vs IUI

Dislaimer - 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. It is in no way meant to quote the either of the parties mentioned above.

To listen for yourself, go to this site and find the show in the archive on the left, dated 7/3/08, titled "IUI or IVF - Which to Use". Live

Ways to try and get pregnant are somewhat limited. They are:

1) Natural/No intervention - OPKs, timed intercourse
2) Ovulation Induction - various meds (clomid, injectables, metformin)
3) IUI
4) Artificial Insemination, often used with 2 & 3
5) IVF

Nature of problems determines what you do. Sometimes treatments are used when they shouldn't really be - when it wouldn't really do anything more than they're already doing.

Breakdown chances of IUI vs IVF

If used in the right circumstances, IUI is helpful.

Patients need to understand what they're trying to achieve. Pregnancy is ultimate, but in reality with ovulation induction you're trying to get multiple folicles to grow and ovulate. You have two ovaries and two tubes (normally) and sperm go both ways down each tube. If you have one or more follicules on each side, you're going to improve chances.

IUI is getting isolated, concentrated and putting it closer to where it needs to be for fertilization (half way there - bypassing barrier of the cervix). Limited because you're not influcing the initial steps of fertilization called ovum pick-up, where ovulated egg is picked-up by the tube and fertilization occurs at the farthest point of the tube from where it's picked up at the uterus. Embroy if the egg is fertilized, it needs to move back down the tube to grow and divide (about 5 day time) and implant into the uterus. All needs to occur still.

In terms of producing more eggs, what are the differences between the various drugs.

Pills - similar to shots, but they are designed to get at least one follicule to grow and ovulate (better than nothing). If you're already ovulatory, the pills don't work real well to get multiples. Clomid isn't very effective at this - in most cases you're getting one or two.

Most doctors don't monitor because they know hyperstimulating or multiple babies is very low, but this still isn't effective because you don't know if it's working.

You wouldn't use clomid in older patients (mid 30s or older). You would go to shots immediately. Pregnancy rates on shots is about double that of clomid. Why? Clomid is better at getting multiple follicules to grow and doesn't have the side effects, including thinning of lining or hostile ferticle mucus because of anti-estrogen effects you get with clomid.

Shots vs Pills - Shots are always more effective for any person.

Clomid & Letrozol - Generally with individuls with ovulation issues.
Metformin - PCOS (not to be used in all ovulation dysfuncation patients); is also used in conjunction with other things like clomid.

If you don't get scanned and you take clomid, and if it doesn't work, and then going straight to IUI probably doesn't make sense. (Jon & Kate + Eight?) Always use ultrasound monitoring because is it doing what you want to do - 1) growing follicles, and 2) not to many follicles.

Taking shots gives you multiple follicles which gives you higher chances. Pills is for women who are having problem ovulating. By the time you generally go to a RE, you've already tried clomid and it didn't work. However, when a person comes and hasn't tried anything, it depends. In young patients who don't ovulate, you probably still start with clomid and do and ultrasound around day 11 or 12 to find a dominate follicle and, if there is one, do an HCG injection and then you know when he window of opportunity is.

IUI Success depends on...
Success of IUI, is it dependent on the more follicules, with out a dangerous level, will increase her chances because a lot of eggs are abnormal and don't produce, but sometimes they can all fertilize. Three is an ideal number to give you the max benefit by getting pregnant, but still minimizing high order multiples (more than twins). If you are older you can do 4-5 follicles, but often these patients don't produce this many because the reserve is lower. These people though probably need to move to IVF.

Why does it increase your chances if you do IVF?
Because IVF bypasses all the things that occur inside - tubal pick-up, fertilization is largely taken out of picture as a problem. Can monitor embroy development and you can select embroys (sperm with ICSI) - you remove the potential stumblling blocks. Goal is to get as many as you can to grow, so you get more eggs (if you can) 10, 12 or more. If you have that many during IUI you don't go forward.

If you were planning on doing an IUI and you produce that many, you can turn it into an IVF pretty quickly, if patients wants. Doesn't happen too often.

What happens when you cancel a cycle?
If you have to cancel a cycle, one method is to prevent ovulation with an injection called Antagonist which stops the LH surge rapidly. Then you take birth control to bring on the next cycle in a timely manner. Then you do the process over again.

Listener Question #1:

Situation: One IUI $1,400 failed. IUI or IVF again?
Answer: IUI three in a row gives a positive result. If you go down IUI and meds route - be in it for 3 or 4 because that's usually what it takes if you have a good cycle - multiple follicules and good sperm specimin. If you get a "good" cycle, most patients who get pregnant will do so within that time. Various problems do determine the outcome.

Listener Question #2:
Situation: If you want to get pregnant, and if money isn't an issue, should you go through all the initial steps, or go straight to IVF?
Answer: Some people prefer to do this to get pregnant sooner and to control high multiples (twins still common), and for other things like gender selection. Age does matter - in both quantity and quality.

Success on First Try with Infertility Treatment?
Should someone walk in an expect to get pregnant on the first try? No, not normally (in best patient profile, 25% chance, say ovulation dysfunction problem) You need to be willing to be in it for 3 or 4.

Listener Question #3
Situation: Husband's sperm analysis 43 mil count, 34% motility, 4% morphology (a subjective assessment). 4th one high as 11% and as low as 3%. Should she rush into IVF or give IUI a chance?
Answer: Wouldn't base all on this. Ask, 4th part of test (DNA fragmentation), you have to find out this answer. "unexplained if" is often related to acult DNA male factor. Is an independent predictor of infertility. If DNA is ok, shots and IUI would be reasonable to try.

Can sperm that has a DNA problem, can it fertilize, but then have a problem down the road? It more effects embroy development. Looking at how the DNA is packed together in the cell itself. Needs to be tightly organized to fit into cell. If it's not packaged together, once it unwravels inside the egg after, it won't develop right. This test has been around for about 6-7 years.

Listener Question #4
Situation: Does accupuncture help if you're doing IUI or IVF? How do you know if someone specializes in infertility - I will ask, but is there one way to check?
Answer: Isn't the make or break. Doesn't really increase chance with infertility treatments. Isn't a problem to do, and there isn't a negative... you might gain other things from it - stress reduction, etc. Is welcome, but not highly suggested, and definitely not required. Has been more popular in last year or two, and no higher increase in pregnancy rates, in this doctor's opinion.

Listener Question #5
Situation: Up until Jan, I had failed to respond to ovulation induction. LH 18.2 FSH 9.6. After ovarian drilling (older before metformin was around as treatment to PCOS), GNRH aganist (lupron), follicules did grow and an IUI was scheculed. Too many so was converted to IVF. 7 eggs retrieved, 5 fertilized (2 grade A put back) no success and no embryos to freeze. Instead of doing IVF again, suggested IUI instead. Does this make sense?
Answer: No not really. Is hindered by the fact that if you did the right protocol with IVF and it sounds like you have PCOS or have a high response to meds you half did IVF with this converstion. In this case IUI might be a step backwards.

Monday, December 1, 2008

The economy isn't helping our infertility...

These past two weeks have been a whirlwind. Let me recap - in reverse :)

Thanksgiving this year was surprisingly good. Not that it's ever bad, but this year nothing felt rushed and people were in a talkative mood, so it was nice to be able to just catch up. One of my favorite moments was when we had the chance to talk with my Grandma after everyone left to for the annual coon hunting festivities. It was so neat to hear her talk about finances. I've always known my grandparents were money savvy, but it was neat to hear her say... My daddy always said, "It's not how much money make, it's what you do with what you have." It's so true, and in economic times like these, it's nice to hear very basic investment rules. Simple things like this go such a long way... I hope my generation starts returning back to some of the basics.

I was able to skirt by without anyone asking directly "when are you guys going to have a baby", which was a relief. Well, it was, but it wasn't. It was definitely nice to not have to talk about it, but sometimes it's good to just get it out. I don't always feel comfortable just confiding in people, so it's helpful if someone just asks. Don't get me wrong, it's a case by case situation, but I guess I feel like if they ask they must really care, which makes me feel good. It's all in how they bring it up and what kind of week I've had I suppose.

In the short work week before Thanksgiving (remember... working backwards!), my spirits were down, to say the least. My pathetic cycle was making me into a Debbie downer and I was irritated that I was feeling like that right before the holidays. Then, on top of it all, my husband got some not-so-great news at work. It goes like this - we've been waiting for two years now, hoping he'd get hired on by the company he works for (right now he's a contractor and technically works for a middle-man). Normally this wouldn't be the biggest deal ever, except that the company has awesome benefits - great 401k matching and best of all - infertility benefits! Yes, believe it or not, infertility coverage is so close we can taste it. Bad news is that the chances of him actually getting hired on are slim to none now, with the horrible economy. In fact, he just got word last week - here comes the bad news - that he's not only not getting a raise for the second year in a row, he's getting a pay decrease! Seriously - one of the worst scenarios, aside from him getting let go, which goes without saying.

With no hope of a job providing us extra money to save for infertility, or insurance coverage, I felt totally empty. Devoid of any glimpse of what the future might look like - and that, in my little world, is pretty freakin scary. Like it or not, I am the type who much prefers to have not only today pretty much figured out, but at the bare minimum a framework for the future. On one hand I feel like I'm getting carried way with this. I mean, technically, we were fine before the thought of a child came into our lives, right? So why, now, does this have such a strong hold over me? For one, our hearts were never quite in that place before. We'd always wanted children and made decisions in our lives so that we were setting ourselves up to be able to provide a good life for our kids (probably one of the main reasons we up and moved from Illinois, an infertility state, to Missouri, where jobs are more plentiful). Anyway, we are now ready, have been ready, and don't want to give up the desire. I guess we could try to burry our longings and pretend that we are fine either way, but the truth is - at least the truth for me is - that I'm not sure if I would be fine with that. And even though I'm still young, I think of the timing of it all. I want my kids to be fairly close in age, so even if I would get pregnant sooner than later, it might take me quite a while to have the second. I really don't want to be in my mid-30s and still trying to have a child... but you never know. I guess I'm not open minded enough sometimes, admittedly.

Enough rambling. So where does that leave us? That was my big question for the Thanksgiving holiday. In effort to keep this short (I always try, but never quite achieve that), here's the tentative game plan.

1) Go to new OBGYN appt on Dec. 9 - Meet, get her opinion and next step recommendations.
2) If we like her plan of action, we'll proceed as such. As of now we're thinking our push will be for trying to get bloodwork done and other such initial things done (as described in the post below). Not entirely sure about this though, as we still need to have this discussion before our appt.
3) If we don't care for the new OB and/or her suggestions, or if she thinks it's best, we might make an appt. to go see an RE to have some initial testing done.
4) Hopefully at some point in the near future (couple/few months), we'll know more about our infertility situation to get a more solid idea of what we're up against.
5) Then, we'd like to get an idea of the types of things we can try, given our situation. If appropriate (health and money wise), we might stay put with jobs and our home and try those out with what money we can scrape together. At this point, we feel like taking out a loan is not really an option. Scary economic times and an additional $20k or so loan isn't really a good situation. Not to mention, we're already not super flexible with our finances. Yes, we have wiggle room and we are saving, but it's not tons. (I like to spend, but I like to save even more... especially the older I get!) And, I really really want to be able to stay home at least part time with our kids one day. Especially with us not living close to our relatives. With my current job, I believe this would be doable (part time work from home mainly), but I definitely couldn't stay home full-time. I shouldn't be scared by this, but I am a little. I guess I want the ability to do that, but the flexibility to work if I desire. Anyway, the only reason I mention this is so you can get a good idea of my work/home situation. Good, but not the best situation ever. Our home is a bit bigger, and older, than we probably bargined for - especially with kids not being in the picture yet.

See! I told you this wouldn't possibly be short! There is no hope for me I'm afraid.

6) Here's the thing that changes everything. If all signs point to us needing to do IVF (say, for example, if my one and only tube is blocked or damaged, that would be my only option) or if the doc says we can try all the other routes but it doesn't have a high probability of working, then we have to consider what to do next.

It seems almost foolish to not consider moving back to Illinois, given that it's an infertility mandated state. The only problem is that with my husband's current career path, web analytics, there are very few opportunities in the STL area, and absoutely zero opportunities on the IL side (near STL). This means that if he wants to stick with this, we would need to be open to moving to the Chicago area. My family would totally hate me if we moved that far away, and that is one of my biggest fears. It's also one of my biggest heartaches - I know how much it would mean to my Mom, for instance, to have us be somewhat close (where we live now is about a 1.25 hour drive) and I feel like I would be the world's worst daughter if I took that away from her, especially when it would come time for us to have a baby.

That has been one of my biggest struggles from day one, when this thought popped into my head, and one that I continue to loose sleep over.

The only other option is that he give up his career path (which is a bit more interesting and pays a decent amount more), and return to finance. At which case, he could probably find a job in the STL area, probably still not many on IL side, which means we could down-size our home and work our butt off for a year or two to save up as much as we could and then try something. Or, for it to really work, one of us would need to get full-time benefits from an IL company, and I would hate to lock us into a situation where that person is me. Then we're just creating a new problem for after we get pregnant the first time and try for a second.

Do you see how there is no good answer.

And on top of it all, the housing market is also down, which means it will be TONS harder to sell. I'm talking we'd ultimatley be shooting for breaking even on what we paid originally (if push came to shove and we had to lower the price). And, we'd need to save for some type of down payment for our next home, which means if we wanted do to things kinda quickly, we'd probably need to rent for a year or so. Which, if we moved to Chicago, that would most likely be best and would give us a chance to get familiar with the area. The only condition on that - our dogs! What in the heck would we do? I couldn't bare to part with them (the cats I could - sad but true), but never my dogs.

And these are the things that run through my brain from day to day, with no end in sight. No quick turn-around. No easy conclusion. Sadly, the economy is playing a huge role in our ability to be flexible in our lives in order to do what is necessary to provide a way for our family.

Even with the way things are, we arn't giving up hope. We will continue to push ahead and are willing to step outside our comfort zone in order to provide a good life for our family, in the hopes that one day it will grow.

In the meantime, here are a few resources that might be helpful when seeking out companies who offer infertility insurance coverage:

Here is a list of states who mandate infertility insurance coverage, in some form or another:

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