Diagnostic test follow-up with RE

You're never going to believe this - our follow-up appointment was TODAY, not tomorrow! Man, I really, really think I'm losing it.

I did a similar thing yesterday - went to the dentist and asked for the wrong doctor! One of my fake teeth, yes I unfortunately have three of them, fell out again - fun, fun. Another expense not covered by insurance. (Sorry, just had to whine about that!) Anyway, in my defense, it was the doctor I had seen up until the last appointment when I found out he wasn't in-network anymore, but still. Total brain fart!

I did end up calling him back, however, my husband wasn't able to be there. Basically he said all our tests came back looking good - though he didn't have any specific things to say about that. I think he was away from his desk on his cell and didn't have the numbers in front of him. I'm going to call tomorrow to get a copy of everything.

He pretty much said the same thing as before - we appear to have a substantial pelvic issue, based on the sonohystogram ultrasound, where scarring looks to be an issue. We can certainly try IUI, though he doesn't think we'd have much success. He recommends bypassing the IUI and going with IVF. I asked him about the tubal condition called hydrosalpinx (where it fills with fluid and can spill back into your uterus). He confirmed what I had read - that severe cases can be picked up via ultrasound and that he didn't pick up anything on my sonohystogram. He said it's not a super common occurance and he's not particularly concerned about it affecting IVF results if it's not severe. In his words "In 10 cases with tube damage, 2 will be blocked, and 1 of those 2 will be hydrosalpinx."

I asked him if it was worth considering doing the laparoscopy, since he's 99% sure it will be covered by our insurance, to try and correct any scarring so that we can pursue IUI. He said that we could try that, but again, he doesn't see much success in treating adhesion issues. They used to do this a lot years ago, but in retrospect it just didn't prove to be that successful unless it's super minor damage (which isn't very common) so they don't recommend it any longer. The scarring could be so far gone that the organ never works quite right again. Also, new scarring can occur from the surgery. He's not against going in and looking to confirm scarring and treat a hydrosalpinx, if it exists, if that's what we choose to do. All in all though, he just doesn't see much point in that when we'd probably not have a lot of success with in it and would end up doing IVF anyway.

He's going to have a financial coordinator call us so we can set some time up to learn more about our financing options. In the meantime, we need to chat amongst ourselves and think about if we want to have the laparascopy done, if we want a second opinion, or if we're going to go
straight to IVF without any additional information.

And, in the meantime, I'm going to try and find my brain. I must have left it somewhere in Chicago.

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.

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!

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

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".





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.

What Infertility Tests are REALLY Necessary?

Ok, I can't get enough! That radio show was so informative that I had to listen to another one this afternoon. This one is also VERY relavent because we are trying to decide next steps. My first thought was that we try and figure out what test are critical and get them done with our OB now, before moving on to an RE. After listening to the show and what the doctor had to say, I definitely am thinking of things a little differently. Please note that the notes below that I've taken are my (hopefully close) interprutation of the thoughts expressed by Dr. Dlugi and should not be taken verbadem. Please refer to the show to draw your own conclusions on what he has to say. The show can be found here.

Avoiding Unnecessary Testing and Treatments, Hosted by Kim Hahn talks to Alexander Dlugi, M.D., SIRM New Jersey. Dated 3/27/08. (located in the scrollable column on the left-hand side).

Which diagnostic tests are necessary before beginning advanced infertility treatments?

Male Tests
Semen analysis (key because 40% of infertility are male related, 10% combined factor). DNA testing of semen doesn't matter all that much, but costs a lot. FWIW, we don't know a lot about sperm because most types of testing kills the sperm. Infertility centers are probably doing it the same way (rather than a one-off lab), and is of good quality and understands results well. One-off labs are more unreliable. Can a semen analysis change with time? Depends on the situation. Results will fluxuate for sure, but if you find signifigant abnormalities, it will probably still be present. Retesting is sometimes encouraged.

Female Tests - "Old-Fashioned" (thru 80s to early 90s) Standard Testing...

1) HSG (hystosalopingogram - used to look at uterus and tubes).
2) post coidal test (cervical mucus, are sperm getting there)
3) endo bioposy (uterine lining changes) not done much anymore
4) laporsocopy (look inside pelvis and perform surgery if needed). Everyone got testing and then tailored treatment according to results.
5) Basal Body Temps (BBT) - To track ovulation.

Of these, it depends on couples history and what they are willing to consider (IVF, etc). If they're not willing or want to do IVF, then yes, it makes sense to do some of the below.

Thoughts about Diagnostic Testing and What is Actually Helpful

1) HSG: Hystosalopingogram - Used to look at uterus and tubes. Make sense to do.

However, if there is a problem found with an HSG, here are the senerios:
a) Uterus (polip, fibroid, etc) - fix is surgical
b) Tubes - surgery to fix tubes or IVF

10 years ago, recommendation would have been to operate, but because IVF rates are so high these days, that is the way to go. With the surgery, there is recovery time and it takes 1-2 years after surgery to be able to get pregnant, typically, and these problems also will come back. Therefore, surgery doesn't make much sense unless there is a mass or there is pain. Then it's totally different. If for fertility, there isn't much point.

2) Post Coidal Test: Checking cervical mucus to see if are sperm getting to uterus. Not done much anymore.

Problem with this one - you don't really know what the definition of "normal" is. Is a role where a couple uses clomid because it could dimish CM and make it hard to get pregnant. It's good to get one of these done at least to see what findings are. If test is abnormal, you do IVF with clomid, or something else. You will see treatment options come down to trying IUI with fertility meds or move to IVF. So, if you are going to do this anyway, why bother doing the tests if you're going to do the same treatments anyway. If there is a tubal issue, go directly to IVF.

3) Endometrial Bioposy (uterine lining changes) Not done much anymore.

4) Laprosocopy (look inside pelvis and perform surgery if needed). Case by case, but usually not useful.

To check for endo and tubal disease. A lot of people do this before going into something else, but why put people through surgery unless they're having pain. Again, it can take around 2 years before you know if it worked or not. If you're going to turn to IVF anyway, then why mess with it. Probably more successful for people who didn't have much going on, but for people with a lot going on, it's probably not extremely effective.

5) Basal Body Temperature chart and OPK kits - Recommendation to not bother doing those because they are useful for 1-2 cycles, but if you are having regular cycles and you check a chart a couple cycles and if LH surge is fairly consistant, you don't really need to do it. If you do this, you can fall into a trap every month and be more stressed. I'm not sure what his comment would be if you are NOT regular. My feeling is that it can't hurt really to go ahead and do it!

Blood Tests - Used when clinically relevant.

If finding dictates a change in course. A lot of places run the tests purely to get money. Clinically they don't make sense. Where are most blood test applicable? Knowing FSH, Thyroid, Prolactin are important.

Immunological issues should be screened if you have multiple miscarriages or if you've done 2-3 IVF cycles with no success then you should ask is there something else going on when embryo arrives in the uterus and it is being rejected, this is where immunological test are key. This is very
controversial. This doctor wasn't in agreement when he first started working with the SHER Institute. If you are going with IVF, you might want to rule this out and have this test. But, is it cost effective - how many people do you need to screen to rule things out. $1,000 for
screening usually.


New Procedures - Genetic Testing
Genetic testing of egg and embryos. If there are no sperm issues, the egg is doing most of the work. Now you can biopsy the polar body which is a mirror image of the egg, in terms of the genetic. You can see if the egg has all of its chromosomes. Good for fertility preservation and egg donors - you can go to egg repository and pick out the good ones.

The success rates of IVF depend on
if the 1) embryo is normal 2) is uterus receptive and able to accept an embryo and propagate a pregnancy. So it's basically, do we have a normal embroy. One of the reason why miscarriage happens is that the embryo isn't good.

More on Advantages of Skipping Some Tests
Will now get results quicker because these test might not be necessary. When they do test, they might have a mild male factor. Maybe try a few IUI's and then go to IVF. If you don't ovulate regular, yes then try infertility drugs. But, if you haven't found anything, most people would say to look towards clomid and injectables because it's easy to do and doesn't hurt and some get pregnant. The problem is that we dont' know what that really accomplishes. If you ovulate and have normal sperm, then drugs and IUI don't do much that you aren't already doing. The pregnancy rates for unexplained infertility with clomid IUI is only about 7% or up to 10% with injectables. People do it because they have been told to do so, or are afraid of IVF. A lot of patients ask for it, so it is often done. If IUI and drug induced cycles are done for 3-4 cycles and it hasn't worked, it's probably not going to work so you should move on. For most who choose this route, by the 3rd cycle people are fed up and end up moving to IVF.

For people who don't have mandated coverage for IVF, what do you do then? He would say that then it makes even more sense to go to IVF because if you add up all the potential costs throughout each of the procedures, it easily amounts to $1,500 to 2,000 per cycle if you divide by 7% success rate you get a high number - and then 6-7 K later and still not pregnant, you've already paid a lot and haven't tried IVF yet which yields a MUCH higher success rate of 70% or more.

Increase in pregnancy rates from clomid to clomid with injectables is small. Skip injectables move to IVF is becoming more of the rule.

In Summary
Endless months and money spent doing tons of treatments which might not work and will probably end with IVF anyway is a route that some are beginning to take. In my opinion, this doctor is leaning towards doing less tests and moving to IVF sooner.

Free Infertility Radio Show - PCOS and Infertility Treatments

Frustrated with my current cycle (I think it's a total bust, but I'll post more about that later), I have been surfing the net to try and find some answers. Answers for what to do next, what various tests and procedures cost, etc. I came across Haveababy.com's live one-hour online radio show, which I hadn't heard about before. It seems like they do a lot of interviews with reproductive endocrinologists, so it seems like a good opportunity to get some reputable info.

Their shows broadcast every Thursday at 10:00am PT/1:00pm ET. They also keep a database of past shows, so you can listen to the topics that are of real interest to you. I came across the following topic, which really hit home for me, and took a few notes while I was listening... sorry for the incomplete sentences and/or misspellings. :)

Goodbye PCOS, Hello Fertility Treatment, hosted Kim Hahn and Dr. Drew Tortoriello, Medical Director of SIRM-NY. Dated 10/30/08 (archived in the scrollable column on the left).

In PCOS patients, excess androgen test worthwile. Remember, just because you have a period, doesn't mean you ovulated. Even if women do ovulate, they might be at an increase for abnormal oocytes. Excess androgen causes problems with eggs. So, even with women who get pregnant with IVF, their risk for miscarriage is 2x more, due to the androgen excess their eggs are under.

Are OPK tests or OV Watch good for PCOS patients? Yes still good to use. LH elevation in pcos patients cause false positive in opks though, so it just depends on that particular person.

Mid-cycle Follicule Check via Ultrasound while on Clomid
Recommend starting with monitoring with ultrasound to find out when a follicule is developing to give better guidance. Rather than only do ultrasounds, start on clomid. Are people monitored a lot on clomid? Always recommend both scanning and clomid because you don't want to waste time if you don't have response to the clomid and you won't know unless you get your period or if it doesn't come, you then have to figure out what to do next. If clomid is working within 10 days of last pill you should see evidence of this by an enlarged follicule through an ultrasound. If it's not enlarged, then start new dose (higher) the next cycle.

If your partner has normal sperm, it's ok to not to IUI as the first option because the problem is due to anovulation in the woman. But, IUI's are good if you have unexplained infertility because clomid by itself and insemination by itself really didn't do much, but the two together have shown better results. IUI's are fairly inexpensive, easy to do, and invasive, so these combined treatments can be very benefitial.

Things that Mimic PCOS
1st thing - rule out other things that might mimic PCOS, like congenitial adrenial hypoplasia (when adrenial gland pump out excess androgens), cushings syndrome (too much cortosol), insulin resistance b/c 40-50% can be insulin resistance (not necessairly diabetic, but their body pumps out too much insulin to fight off the diabetis; an insulin problem might cause an ovulation problem.

PCOS and Metformin
With PCOS, should metformin be used together? Open for debate. Connection between the two was discovered by a guy named Nesslin. High androgen levels can be due to not ovulating. Metformin can bring androgen levels down. However, it shouldn't be exepected to work alone (without an ovulation inducing drug).

Clomid vs. Injectables
Why is clomid the best? Why aren't injectables even better than clomid? Related to heirarchy of treatments. Injectables are an option, but most people would start with clomid first because it's easier, shorter duration, cheaper and it works for about 70% of women. Clomid is also pretty gentle - as in you don't have to cancel a cycle most of the time because they don't produce too many follicules. 25-30% of each follicule turning into a baby.

Injectables cost more, and could cause a much more troublesome response, even with low dose because the produce too many follicules. It's an option for sure if clomid has failed. Also, sometimes if you do injectables you should strongly consider IVF because you control how many embroys go into the uterus. If you can just get a PCOS patient to ovulate you don't have too many other issues getting pregnant.

Increase in Miscarriage due to Excess Androgens Present
However, there may be an increased risk in miscarriage regardless of IVF, clomid, IUI.. because oocyctes have grown up with excess androgen, which does bad things to egg quality. If you're going to to injectables you should consider doing birth control or lupron injectables to bring down androgen levels for a month or so, so that you can have eggs that grow up in an environment without all the excess androgen. Lupron PCOS users have shown a reduced rate in miscarriage (though, I've read there can be bad side effects with Lupron).

Next Steps after Ovulating on Clomid, but no BFP
If you do about 4 cycles with clomid and are ovulating but don't get pregnant, then you should consider injectables with IUI, or move straight to injectables and IVF. Most people feel comfortable with that because there's not much difference between clomid and injectables (just ovulate in a different way).

Hyperstimulation Risks
Are these people at risk of hyperstimulating? It's rare with clomid only patients, but people using injectables DO have a higher risk. In IVF you usually are at a bit higher risk because you are trying to encourage as many eggs as possible because you can control how many go back in.

Excess Testosterone?
Having more testosterone - Does your body just create this or do you get it more for hormones or steroids (possibly in food). Likely no, it's just your body. Some studies do show DHEA supplements (a weak androgen which has quality of life benefits) encourage androgens, so you should avoid this if you have PCOS. Mostly genetic that we don't completely understand. Not many meds to bring those levels down except for things like Lupron and Birth Control, which only brings it down for a short time (while on the meds and shortly after).