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!

Diagnostic test follow-up appt made!

This is a long time coming. Having had our tests done all the way back in late December, I just finished marking our calendar for Monday, April 13 as the day. Boy does it feel good to be moving forward. We both agreed we would prefer to have a face-to-face with Dr. Ahlering to go over our collective tests that were run. Yes, I already did this once, but hubby was unable to attend, and truthfully it was a phone follow-up so I didn't feel like everyone was entirely focused. Now that we have a lot of the other things nailed down, we're ready to get down to business!

At our appointment, we hope to have the following answered...

1) Specifically what about our personal infertility issues lead him to believe we should only purchase the two-cycle package?

2) Are any other tests or things they can do to gauge how I'll respond to meds, besides antral follicle count?

For example, what about the Clomid Challenge Test? We want to know this because if there ARE other test we can do BEFORE making a decision on how many IVF cycles to purchase, we should do pursue them. I wonder though, if a test came back as questionable, would they still allow us to buy the 3-cycle Refund Package? I would assume not, if it goes against what is in the agreement you sign when you purchase that package. So, given that, is there any point to doing the tests? Wait, did I just answer my own question? :) Better ask the professionals at least!

3) What unique approaches will he recommend for our IVF protocol, taking into consideration PCOS, one ovary and sperm quantity and abnormality issues?

More about the Clomid Challenge Test
I just ran across a write up on IVF1 Infertility Clinics's website and wonder if I might be a good candidate for this as a pre-IVF test, given that I've had an ovary removed and therefore may have egg count issues. The article does say that "There is one concept that must be stressed above all else. A normal clomid challenge test tells you nothing. It does NOT prove that your ovaries are working well. It simply fails to prove otherwise. The clomid challenge test is not a sensitive enough test to identify every woman with decreased ovarian reserve. Some women with very poor egg quality (this may apply to me because I have PCOS) are going to be missed."

However, according to their website, "an abnormal clomid challenge test has specific predictive value. These predictions are very accurate and have been confirmed by a number of different studies from a large number of investigators. It is well documented that women with an abnormal clomid challenge test: *Respond poorly to injectable fertility drugs (gonadotropins), *Have higher cancellation rates in IVF, *Have fewer eggs retrieved in IVF, *Have much lower pregnancy rates in IVF and IUI, *Have higher miscarriage rates and *Increased risk for chromosomally abnormal embryos."

If we did this test (which would be fairly inexpensive to do) and found out that it was abnormal, while we may still have to buy a 2 cycle simply because we may then be disqualified from buying the 3-cycle Refund Package, it might tell us if we need to pursue other things like CGH testing on our embryos. I also wonder if it will help inform my RE as to how he should structure my injectable protocol.

In the end, maybe Dr. Ahlering won't tell us anything that we haven't already discussed, but either way, it will be nice to get his undivided attention and hear everything coming directly from him. Following our appointment, our plan is to be equip enough to make a final decision on how many cycles we'll buy at once and exactly when we'll start!

More from our RE regarding IVF

Following up to my two most recent blog posts, I wrote Dr. Ahlering on Saturday with three questions (yes, he does answer his own e-mails... not always as thorough as I'd like to receive, but they are coming from him, so I'll take what I can get for now).

My questions were:

1) Knowing that we had testing done in Dec '08, do you feel it would be detrimental to our IVF success for us to wait until next January to begin IVF?

This was left unanswered. My feeling is that, no it probably wouldn't impact us that much, given our ages and health issues. However, there is always the small *chance* that something could happen to my only ovary. This past week I have been having soreness near where my ovary is located (like soreness when I push on my stomach from the outside). Who knows what is going on... maybe I'm actually going to ovulate on this 90 day (and counting) cycle I've been on since the beginning of January. Anyway, taht type of thing always gets my nerves jumping thinking "what if" some gianormus cyst is forming on my ovary and will forever kill my only chances at conceiving. I try to block this out of my mind and pray for the best.

2) Without us knowing how my one ovary will respond to fertility drugs, what is your professional opinion as to if should purchase the 2 cycle or 3 cycle package?

To which he answered "I think the 2 cycle plan is best for your situations."

3) I also asked him about the CGH plan I mentioned in my last blog post. My question, specifically, was: Can you tell me, would this be something you would think our situation (one ovary, PCOS and male factor) could greatly benefit from?

His answer: "CGH is something to consider for anyone that has RPL (Recurrent Pregnancy Loss), or IVF failures and decent ovarian response. Or, if someone is looking at fertility preservation/egg freezing. The thing that people do not like sometimes is that one has to freeze the embryos for later transfer."

It's worth mentioning that RPL or IVF failures doesn't apply to us (not at this time, and hopefully never) and we don't yet know how my ovaries will respond, since I've never undergone a cycle with injectables. I'm not sure how the mandatory freezing of embryos would affect our situation. I know they have improved the freezing/thawing techniques so that fewer are lost in process, but if we don't respond very well and get a lot of embryos, it may hurt if we loose even one. I suppose something to think about is that they stated if you don't produce at least 5 ovarian follicles, you could opt out of the CGH plan and covert your cycle to a fee-for-fee service, which is basically like going with one of the plans we'd already been considering. I'm assuming that if you had to convert, you would be converting at the single cycle cost (not the "buy in bulk costs" of the 2 or 3 cycle plan), which would mean it would cost more if you had to do another fresh IVF cycle.

I'm still digesting all of this. I can't help but rethink things a little, knowing Dr. Ahlering is thinking about our health situations and recommending the 2 cycle to us, vs. the 3. I would think that he feels pretty positively about us getting pregnant in 2 cycles or less, otherwise he wouldn't have said it.

Not wanting to be pushy, I brought it up again with my husband via IM today at work. As you can imagine, IM isn't the best way to talk about these things, but sometimes it just has to be that way. Our conversation starts by him commenting on something else entirely, that happened to mention us in relation to IVF... (sorry sweetie, but I'm putting our convo in my blog!)

[14:25] cathy@thinktpi.com: "as we prepare to start IVF in January"
[14:25] cathy@thinktpi.com: that means that Dr. Ahlering's comment from yesterday didn't change anything, did it?
[14:26] Jay: I thought we were waiting on pricing information
[14:26] Jay: I'm all for starting sooner if it's cheaper for the risk
[14:27] cathy@thinktpi.com: well, yeah, i mean there were two things. 1) this whole CGH thing... we are waiting on pricing for that package 2) but then there's the thing where he said "with your situations, i would recommend the 2 cycle", which is seperate from the CGH.
[14:28] cathy@thinktpi.com: i mean that's his opinion and we just have to consider how much we want to factor it into how we feel
[14:28] Jay: sure, but we'd already gone over how two cycles this year leaves us in a bad spot financially if we do somehow end up with multiples.
[14:29] Jay: we can do a two-fer in january to save even more money, but that's about all that his comment really changed.
[14:31] cathy@thinktpi.com: oh... see it thought it may have changed the timing. especially if he's recommending 2, and that, or less than that really does work. (which i would assume he's betting it would, otherwise he wouldn't recommend it, but who knows). anyways, i just wanted to see how you felt about it. i still feel that if we did 2 this year, we'd have to agree to wait until some time next year to do another 2... and we haven't really even played out that scenerio financially, so who knows. i just wanted to make sure we thought about it enough, since he did give us his opinion, that's all.
[14:32] Jay: His comment basically makes me feel good that, were we to do it this year, we'd probably be successful.
[14:32] Jay: The other stuff I mentioned is really unchanged by his comment.
[14:38] cathy@thinktpi.com: i just hope you can see where i'm coming from... the idea that he believes we could be successful with less tries, just makes me wish all the more that it was happening sooner than later. i just wonder what it would look like if we got pg on the first cycle and had twins... i mean, less money towards IVF, so more money left over if i had to go on bedrest... i suppose it seems that it could even out somewhat, but i don't think we've done the numbers for that. sorry to open the can again... just want to really make sure we've thought this through.
[14:39] Jay: Doing a two-fer this year becomes viable if... a) The cost goes down substantially, b) the probability of multiples drops substantially, c) we find a way to make substantially more money.
[14:40] Jay: If CGH comes back as a reasonable option, I can see us strongly considering this year since we'd have a dramatically lower chance of multiples.
[14:41] cathy@thinktpi.com: k
[14:41] Jay: *kisses*
[14:41] cathy@thinktpi.com: :(
[14:41] Jay: Kisses are good things...
[14:56] cathy@thinktpi.com: fwiw, CGH doesn't really have an impact on multiples for us, since the most we'd ever put in are 2 (at least right now anyway, because of my age and no failed IVF history). Where it cuts down on multiples is when women have a hard time getting pg so their Dr puts in a handful, just hoping one takes. the only way it could impact us is if we did CGH and had one embryo that was "perfect" so we only decided to transfer that one. doing so, though, in and of itself lowers our chances because you're lowering the odds, so to speak.
[14:56] cathy@thinktpi.com: so yeah, i think i just shot myself in the foot
[14:56] cathy@thinktpi.com: whatever

Based on that, unless I sit down and run the numbers again and want to rehash this all, it's probably still that we're waiting until January, because we know the cost for IVF most likely won't go down and there really isn't a way for us to make more money, given our economy right now. Unless of course I win the lottery! (that I don't play, but hey, you never know!) And I don't see how this CGH thing will be cheaper, but we'll see. I'm still waiting on financial numbers for CGH cost from SHER.

Sorry for the long winded post, only to find out we're back at square one, but it helps me to write it all down, for sanity sake.

SIRM's New CGH-Risk Sharing Plan = Increased IVF success rates!

How interesting.... The Sher Institutes of Reproductive Medicine (SIRM), otherwise known as SHER, announced on March 9, 2009 the the world’s first CGH-Risk Sharing Plan that guarantees qualified IVF patients a baby or offers a full refund of the clinic’s medical fees. Read more here.

What is CGH?
Well, the article above does a good job of describing what it is, however, I'd like to elaborate. CGH testing is supposed to be better than Pre-Implantation Genetic Diagnosis (PGD), which in the past was "the" way to detect chromosomal abnormalities. CGH is better than PGD is because they test for these chromosomal abnormalities at the embryonic stage, rather than testing just the egg (which is what PGD does), allowing them to catch defects in the embryos and transfer only the most viable ones. The somewhat new process of vitrification (the process they use to cryopreserve/freeze and thaw eggs or embryos), vs. the old and more widely used "slow-freezing" method helped to pave the way to improving this process. SHER clinics have been using this vitrification technique for quite some time now and together, with CGH, it's looks as though it could really greatly improve future IVF success rates. For more technical info on how this has all come about, check out this article written by Dr. Geoffrey Sher of the SIRM, back in early 2007. Additionally, here is a video on CGH from '07 that explains the impact it can have on success rates. As you'll see they've been working towards this for quite a long time. Personally, I think that if SIRM is willing to offer this money-back guarantee, they must have quite a lot of faith in it's success.

What does that mean for us?
Well, I'm not exactly sure just yet. Bare minimum it means that without a doubt our chances for IVF success rates per transfer go up significantly. In turn, that would mean we would need less tries, or transfers, to achieve success and bring home a baby! I suspect that the cost for this plan is fairly high... maybe as high as SHER's 3-cycle refund plan, however, it might be better to go this route because of those benefits.

As usual, I hate to get all worked up. But, I was definitely super excited to stumble on this today. We both were. We agreed, the more things you can do prior to transfer (and after for that matter) to up your chances, the better. Which means, pursuing CGH is probably very real for us. Especially since PCOS women are know for producing questionable quality eggs, which in turn often result in embryos that are less than perfect quality. My instinct is that this would help to counter act that.

How the CGH-Risk Sharing Plan would work?
The article goes on to say.... "If the patient does not have a baby after all her CGH-normal embryos (from the same IVF egg retrieval) are used up, she will be eligible for a full refund of SIRM’s medical services, as well as for a second try should she so choose. Moreover, if following stimulation with fertility drugs the participant does not produce at least 5 ovarian follicles, she can elect to opt out of the plan and convert to fee-for-service IVF."

I've e-mailed Dr. Ahlering to see if he thinks we'd be good candidates for this and to get some additional info about costs. I'm excited to hear back and will fill you in when I hear more!