We're a go! Doing IVF with SIRM in August!

It's official, though I'm not sure if it's quite set in yet! Our appointment with Dr. Ahlering on Monday went well, as I anticipated, but I don't believe we learned all that much new. Prior to our appt, I made a list of questions that were slightly different than what I posted previously. I find that when I make the list it is a chance for me to run down the conversation in my head, with the goal that I don't forget any major points. By the time we actually get to the appt, I pretty much have the list memorized, but it's nice to have in front of me so that I don't get caught up in the conversation and leave something out. As you'll see, I do need to learn how to set-up my questions better so that, hopefully, they are answered a bit more on target... oh well, there will be plenty more appts for me to try this out on, I'm sure. :-P

Our final list of questions were:

1) What is positive that we have going for us, and what will be our challenges?
As I look back on how this question was answered, I don't think we had a definite clear answer on this from the doctor. Not because he was trying not to answer it. I should have framed my conversation better. After I asked the question, he was like "well that depends..." and then I backed up and stated IVF and he took time to elaborate on how he thought that really was the best approach for us, given our IF issues, and from a monetary standpoint and controlling multiples standpoint. When it comes right down to it though, I do feel fairly confident that I know what we're up against. My husband's issues can be "fixed" via HRSS (high-res sperm selection) ICSI. My issues will be a matter of getting a good number of eggs from the one ovary and then getting them to fertilize into embryos, all the while trying to avoid OHSS. Right now, age is on our side and the fact that my one ovary has so many follicles is a good thing. We won't really know how I'll respond to stims until we try it.

2) Are there any other tests we can do to gauge how I'll respond to meds, besides my FSH (5.5), Estradiol (55) and antral follicle count (15+), which are all within good, normal ranges.
When I framed this question I, again, was wayyy too wordy. I tend to do this sometimes when I get nervous. As a result, it's too much for the other person to remember and they end up not answering everything in the manner I'd hoped. So, scratch that question. From what I'm finding online, there isn't really a way to tell this, other then the above things already mentioned. I think they just begin a protocol that they feel will best address your issues and then adjust throughout the cycle and, if no BFP, further adjust in the next cycle. Not the best scenario possible, but it is what it is. If anyone is reading this and knows of any additional things they can test for, please comment and let me know!

3) Regarding the issue of hydrosalpinx tubes, is the FUS (fluid ultrasound) enough to rule this out, or should we do an HSG? If we ended up needing to do a laparoscopy, would that only cause more pelvic scarring, thus risking further damaging my ovary?
Ok, so this is the point in the appt that I must have woke up (about time, don't ya think!). I remember this answer quite clearly and even took notes on it. He basically confirmed that, yes, he doesn't feel we should be worried about a hydrosalpinx, because our FUS didn't show signs of an enlarged tube. He said that, yes, we could do a laparoscopy and that he would for sure if he thought there was a real cause for concern, but as of now we'd be don't it just because and since I have had a previous abdominal incision (a long vertical one), it makes it more challenging to do a laparoscopy and increases the risk for bowel injury. He said that at this time, it's not a risk that would be worth taking.

4) What about our personal infertility issues lead you to believe we should only purchase a 2-cycle package?
Honestly, he didn't form an answer that was extremely directed to our situation. Rather, he focused on their success rates and the fact that a majority of their BFP cycles happen within the first or second transfer. Based on that, he said he believes that would then be the most cost-effective path for us would be the 2-cycle. We did want a more direct answer, however, we're realistic and know it would be difficult to give a highly pinpointed answer (I don't believe they ever truely know how a cycle will turn out).

5) Should we consider CGH, given that PCOS are high responders and tend to have a disproportionate percentage of eggs which are chromosomally abnormal (or aneuploid)?
He said he doesn't recommend this for us at this point in time. The PCOS isn't cause enough to do CGH as a first line approach. He said he would do it if we asked for it, but he doesn't think it's the best way to spend our money right now. That it wouldn't tell us all that much more, other than the exact one we should put in, vs. transferring 2 embryos. He did say though that in rare cases were tons of eggs fertilize, it can be challenging to determine which 2 of the bunch to put back in. Typically, there may only be one or two babies in the entire group, so it's difficult and often becomes a trial of elimination. CGH, in that situation, would be helpful. I'm guessing we would cross that path if that ended up applying to us.

6) IVF Protocol - What is the likely path for my circumstances?
Dr. Ahlering said that he would most likely start me out on the the "classic" Lupron protocol, or L3C Protocol, as they refer to it as SIRM. More to come on that. I don't know specifics from SIRM yet, but you better believe I've been googling my heart out :-)

So... good news!! August will be here before we know it I'm sure!

We've decided to move straight to IVF!!

Isn't that exciting!!

I have given a lot more thought to whether or not I should do laparoscopy. Initially, I was leaning more towards having it done, since it's covered by insurance, with the goal of going in and confirming scarring and fixing a hydrosalpinx (if it existed) to increase IVF results. However, after doing some more research, it appears that disconnecting a tube from an ovary (which is what they'd probably do if I did have a hydro) could harm the blood flow to the ovary (2nd reference site here) and ultimately cause it not to work as well. Seeing as how the that is my only ovary and only chance of having our own blood children, and that with the scarring that exists the doctor said it probably won't function normal anyway, I really don't feel like taking any more chances, especially since the sonohystogram didn't detect a hydrosalpinx. One site I found reported on a study done in 1999 stated "salpingectomy prior to IVF can be recommended to women with ultrasound visible hydrosalpinges, but a general recommendation to all women with hydrosalpinx is not justified".

Ultimately, if it really needed to be done I believe Dr. Ahlering would have suggested it, however, I am the one who continues to ask him questions about it, when all along (after he detected the presence of scar tissue via fluid ultrasound) he has recommended skipping the lap and moving straight to IVF. His position is if we really want to try for IUI, which he thinks we may have success with simply because we're young, the lap would be worth doing, but that he believes IVF is the real way to go in this scenario, given my pelvic issues from the past surgery.Right now our goal is to come up with a way to pay for IVF, as it is more than likely the only real way we'll be able to conceive.

We talked to the financial coordinator at SHER on Monday. We learned that this is going to be quite a bit more expensive than we had originally been told though. I don't think that Dr. Ahlering was trying to mislead us or anything, I just think he was referring to the relative base price for package services for IVF. In reality, once you add in the not-so-optional "options", each cycle could be an anywhere from $5,000 to probably around $10,000 on top of the already high package prices. If it sounds complicated already, your absolutely right. To respect the clinic, I won't post their prices here, but if you come across this and are looking for a general idea, you're welcome to contact me and I can provide you a bit more insight. Keep in mind, their consultation is totally and completely free, so really the best thing to do is contact SHER Institute of Reproductive Medicine directly to set up an appointment.

Now comes the hard part where we decide how we're going to pull off affording this. We have to take in to account that the possibility of having multiples is fairly high and would be silly if we didn't factor that in. If we had anything more than a singleton I would want to stay home full-time with them. Even if we have one I'd like to work only part-time. Right now we're looking at how much we'd save by refinancing our current home (which we've only been in a little over one year) given the low rates right now and if we could get rid of one of our vehicles and just buy a junker as our second car. Truthfully, I feel like that won't get our expenses down low enough to where we could live soly off one income, but it's worth checking into. The other option is to try and sell our home in the spring. While I love our home - love the location, neighborhood and charm - I am not opposed to moving again if it means having the family and life I want for my family. I refuse to let a material thing stand in the way of our happiness. Our house is too much house to clean anyway :)

And all of that pretty much just scratches the surface on the work that needs to be done. We still need to become more IVF savvy, talk with Captial One Financing, think of what needs to be updated around the house before we could put it on the market... if I only had more hours in the day. Well, like my mom reminded me last night on the phone - we don't have to have all the answers tomorrow. Very, very true.

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!

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 Haveababy.com 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

PCOS Support Group St. Charles IES - First Meeting this Wednesday

I am really looking forward to this Wednesday! It's the first meeting for the newly formed PCOS Support Group in the St. Charles, MO area called St. Charles IES (Infertility and Education Support). Shout out to Meghan for organizing and leading this group :) (Yes, I just did a shout out :P). It will be great to meet other women locally who are going through a similar situation. I can't tell you how tough it's been for me not being able to really talk to very many people about what's going on.

Who you talk to and how you talk to those people can be difficult - I haven't told my parents yet because I really want to be able to surprise them, rather than have this be a stressful or "expected" thing for them. I did tell one of my close girlfriends, but she and her husband just had a baby and I'm not sure that she totally gets what I'm going through. The only person at this point who I've told and who has been super supportive is a good friend I work with. I can't tell you how thankful I am to have her as a friend. Even though she has never been through something like this before, she is always there for me when I need someone to vent to or bounce medical theories off of (ie. maybe "this" is what's wrong with me!). She definitely has never said "just relax and it will happen" and for that I'm very thankful. The whole "relax" thing sounds great and might be true, but you cannot relax when you don't have a plan or any idea about what's going on with your body.

If you live in the St. Charles County, Missouri area and wish to join or learn more about the PCOS Support Group, St. Charles IES, check us out the following ways:

Facebook: http://www.new.facebook.com/group.php?gid=21658117660
MySpace: http://www.new.facebook.com/group.php?gid=21658117660