Tomorrow is another big day!

Our newest set of instructions came in today around noon.

Tonight
Stim again - this time Follistim 50 IU

Tomorrow
Lupron in the AM
Oral Meds
Another E2 blood draw before 8 am
US appt at 1 pm

At this rate, I’d say that we’ll, more than likely, have a Saturday egg retrieval (ER), since they’re still having me stim tonight, but maybe that’s too much to assume. Either way, it makes no difference to me. Any day is a good day for ER!!

I did ask how my E2 numbers came out and was told they look good: "we just want to bump up the follicles a bit more". She gave the numbers to me - 3,230 and 3,124 - but I’m not sure which one she said was Monday and which was today (sheesh). I am reading online and it sounds like it’s plausible the lower number is today and that it’s ok that it’s lower because they are controlling it by the level of stims they’re giving me (stims went down slightly and so didn’t the E2, is the idea). If the E2 goes down on its own though at this stage, it sounds like that’s not a good thing, but I don’t think that’s what’s happening here. Here is the reference I used to come to this conclusion. Surprisingly, there's not a whole lot of info on estradiol numbers as it relates to IVF circulating out on the net. What I got from SIRM regarding my estradiol was, when I asked her if the numbers are on track, and she said, yes, the numbers look good. So there you have it. I'm not really going to think to hard about it and just trust they know what they're doing. My, my how I am changing. :)

In other related news, it officially hurts to walk too fast. I knew that day would come soon. And I have been visiting the ladies room WAY more than I'd care to, but darn it if all that extra pressure just adds to the discomfort, so in I go, and back again I return about 30-40 minutes later. You'd think I would have stopped or lowered my liquid intake by now, but I've heard that extra fluid is good for growing follicles. Maybe it's an old infertile wives tale, but it seems like it would make good sense, so I've been downing as much as I can.

Ok, and yes, I know this is TMI, but gosh darn it, who cares. This is my blog! You know how they say you're supposed to get EWCM during your most fertile phase (i.e. right around ovulation). Well my silly little body must think I am getting ready to have the ovulation of a lifetime (which I guess is actually correct!) because ever since Saturday, I have had more EWCM than I've ever had in any cycle in my life. Hahaa! I'm going to chalk that up as a good thing. That maybe these hormones aren't too drastically different from what my own body would produce, if it was, say "normal". :)

Ok, I've had a good laugh, at my own expense, and my belly is poking out like I'm about 3 months along (from what I've heard anyway), so I'm going to think about retiring early for the night. You know... a little extra beauty sleep for these super fantastic eggs that are cooking, just waiting to break out and join their other half in a few short days.

Will update again tomorrow, and this time, will hopefully have a date/time for trigger & ER!

Still stimming, eagerly awaiting our next scan!

Hooray for the weekend! And for the fact that Friday marked exactly one week, or right around there, until egg retrieval. Time has F-L-O-W-N by!

We had our second US scan on Friday
And thank goodness! It was hard to tell at first what Dr. Ahlering was thinking... we were all looking at the monitor, seeing lots of follicles, but his reaction just wasn't what I thought it would be. That's because I think he expected to see something other than what was there. This time around, he measured some of them, with the biggest coming in around 11 or 12 mm. He said that, come next week, we'll be looking for them to be anywhere from 16-20 mm in size. He did point out others that were there, but weren't as far along in size yet. In total, he said I had around 12+ follicles, but I didn't really get the impression that he counted one by one.

He said that, overall, there really isn't much to say at this point. Monday is when we'll have our next scan and, at that time, is when he'll be counting, measuring and deciding where I'm at in terms of meds and such. Before he left the room he also said my uterine lining is looking good and that he was going to take a peek at my calendar and check to see if anything needs to be adjusted.

With that under our belt, I went back into the waiting room and Jay went to "produce" (hahaa! I love it when our coordinator calls it that) his back-up sample. As I was waiting, a friend who's doing her cycle in September came in the office. Such a small world! We chatted for awhile and then before long, out came Peggy with a new calendar in hand.

Dr. A decided to change our stim dosage again!
We're back up to practically where we were when we first started. Friday was supposed to be the first day of our stims going down in dosage, but he kept us at 225 every day except the last day. That day we go down to 150 IU. I guess that while things looked good, they didn't look as good as he thought they could. Jay's theory is that he wants to try and get the other follicles that aren't quite as mature yet to catch up. I've heard follicles do mature at different rates, so this definitely seems logical, but I'm sure there is more to know than that, so this is one area I definitely want to do some more reading on over the weekend.

In the end, I'm glad we went yesterday. I would hate to have just waited until Monday to possibly find out that the one ovary wasn't producing as much as we hoped... though I think that 12+ for one ovary is pretty good. The thing is, at SIRM, they don't typically see patients until the Monday before ER, during stimming. We were seen only because we asked specifically, due to concerns we have since I have only one ovary. The good thing is that when we expressed a concern in our calendar review, there was no hesitation whatsoever to add in the extra appointment. Thankfully we asked! It definitely made me feel better going into the weekend knowing what is going on down there.

Thursday night we did our first injection of LH - Luveris
Boy did that suck. The needle was the same as the micro-fine you use for Lupron, but the medication itself stung and had a slight burning sensation the entire time he was injecting it. I, being the one pinching my skin, had a really hard time cooperating. When something stings like a bee you want to react and pull away from it, not stand there and take it. I accidentally moved a little just as we were finishing and looked down to see my skin had instantly swollen a semi-hard bulge appeard. It took about 15 minutes for the lump to go away, even with a hot washcloth over top.

Since we elected to do that first, we had to follow it up with a separate Follistim. The last time we did this, the 225 IU seemed to pool up under my the surface of my skin for awhile. It didn't hurt, but it was sorta freaky! Last night it wasn't near as noticeable and the injection itself went pretty smooth, thankfully. Tonight we'll do another vial of Luveris, perhaps our last (let's hope!). This morning it occurred to me that we're running out of spots to give injections, or at least it feels like it anyway. I do not, however, have any desire to explore giving them in my thigh or the back of my arm, so we'll just have to make do!

Tomorrow is CD 9: That means another E2 check and US
I am really anxious to see what this ovary has been up to. On Thursday I noticed some light twinges, on Friday during the US I could tell things were definitely more tender and yesterday it was pretty obvious that I have started gaining a little extra fluff in my tummy. Today I'm markedly more sore when I sit or put pressure on my stomach. "Just how big are those things getting?!" is all I can think. So we wait with lots of anticipation. Depending on what Dr. Ahlering sees determines if I'll stay on stims longer, when my next appointment will be and even when he thinks I might do the trigger shot prior to ER. Speaking of trigger shot, I just realized last night that I'm not sure if that injection has been ordered yet or not, or what injection I'll even be doing to trigger. All it states on my current calendar is "HCG shot" and there are several different types. So, that will for sure be asked tomorrow.

This has been a wonderful weekend full of things-not-planned: lazy days of board games, movies, afternoon naps and snuggling with the three loves of my life (my pups and my husband, of course). It has been VERY stress-free and a much needed way to begin a new week full of lots of things yet to be determined. And, of course, there have been tons of things on my mind. Each night before I drift of to sleep I've seemed to grasp onto some scenario surrounding IVF or pregnancy and imagine us in the middle of it all. Your mind races when there is so much that lies ahead! Things like the excitement of getting our final beta in just a few short weeks and those darn PIO intramuscular shots that I have been sorely dreading, both of which deserve their own post. More to come!

And the verdict is in...

Regarding the nasty cortisone issue: Our cycle is still a go!! The plan is that my husband is will go in this Friday, a week before retrieval, and produce a specimen, which they'll freeze, as a back-up to the second specimen he'll give on retrieval day.

How did we arrive at that conclusion?
Well, I posted a question to the SIRM forums (totally love that place), and four other RE's gave me their take. The opinions really are pretty varied, which is crazy in an of itself, but it just goes to show you that one good doctor and another good doctor can still have a different take on things. Makes me really value second opinions all that much more. Anyway, their replies were:

The injection of steroids will have no short term ill effects. Don't worry!
Good luck! Geoff Sher

His count is low to start with and any steriod treatment can negatively affect or change hormone release and related events such as sperm and testosterone production. He can collect once to see what the parameters are and then decide whether to move forward or not. Good luck.
Aykut Bayrak, MD

Unlikely to negatively affect sperm, so I wouldnt worry.
Drew Tortoriello, MD

Dear Cathy,
This would be a great question for you to direct to your RE. In most situations, this sort of a treatment should have no impact upon your cycle. If there is a concern however your center should be able to freeze a back up sperm specimen or two now for you to use in your upcoming cycle. That might give you an additional peace-of-mind which can be important in minimizing your stress hormone level.
Best thoughts, ~Robert; Robert Greene, MD

I called my clinic this AM and ended up leaving an embarrassingly long voicemail with Peggy, our IVF coordinator. She called several hours later and I was so totally impressed. It was clear that she had listened to my entire message, even the part where I mentioned I posed this question to the doctors at other SIRM clinics and had received mixed replies. She said that she went and spoke directly with one of their andrologists on staff to get her take.

The andrologist said that while, yes, this type of steroid can possibly affect hormones like testosterone, if it was going to have an impact, it likely wouldn't show itself in this upcoming cycle because the sperm that will be produced have already been recruited several weeks before now. If we were to see an effect, it would be a couple months from now, if it does happen. She said that knowing my husband has had a somewhat lower count before, if it would make us feel more comfortable, we could do two specimens - one this week, frozen and ready to go as a back-up if the specimen he produces in two weeks at retrieval isn't sufficient in quantity. I'm sure this will cost us a bit more money, but, for peace of mind sake, we've decided to go forward with this plan.

I know I won't be happy with myself if I don't put this behind me as we continue to move forward. Luckily, we had the chance to sit down tonight and talk about what happened yesterday. Ok, it was more me just getting stuff off of my chest, but he was great. He listened and really let me just say what I needed to say. There are many times in a marriage when I feel that you just have to talk about the "moral of the story" when a given issue arises. It was less that this happened specifically, and more that I just want him to think more first before making such a huge decision. A decision that will impact both of us. I never want to put myself in a position where I would be apt to blame him for something, nor do I want him to ever be in a position where he feels a huge sense of guilt for something that happens.

After 8.5 years of marriage, I put good communication at the tip top of my list on the things that have kept our relationship so strong. I am always thankful each and every time we're able to reconnect on issues and move foward, growing from the past.


Hooray for Follistim
Today marked the start of 6 evenings of Follistim. I'm not too keen on trying out the top of my thigh or my sholder as an injection site, so all around the belly button we go! I did notice the Follistim was a bit more "stingy" than the Lupron. Most likely because there's just more of it that goes into my skin. All in all, still very bearable. Now it's time to see what this ovary can do! I'll go in this Friday to have my second US. This appt was something that wasn't supposed to be a part of the original protocol, but we wanted to be checked on extra time during stims since I have PCOS and the one ovary. Really rather not take too many extra chances if we can help it. Hopefully this will give us some extra peace of mind going into the weekend, which will be nice. I can't wait to see how everything looks!

One down... lots more to go!

I'm happy to report today went pretty well, even after all of the months of curiosity and anticipation. We got up a tad late, but got moving right away. I wanted to eat a little something before pumping my body full of meds, so that was the first line of business.

The night before we reviewed the video that came with our meds, going over the how-to's one last time. We actually found it to be a pretty beneficial way to refresh all that we had been told in our review. When it came time, we did just as we were instructed. Found a flat surface, disinfected it, laid out all the supplies and then Jay got down to business. I was really proud of how well he remembered everything.

At this point, I was searching for ways to stall. Yes, I'll admit it. The syringe was primed and ready to go and I was being a baby. "But wait..." "Hold on one more second..." I literally did this for somewhere around eight minutes. It was sad :P

First I said... don't count it. Don't even mention that you're going to do it. I don't want to know. Then after about 6 minutes into stalling, I decide that I DID want him to count to three. Hey, I'm a woman. I can change my mind, right? I even pushed him to the point that he said "you want a baby right?" and I do believe he hummed some sort of familiar high school pep cheer at one point. :-D

Finally - I give the go. Of course I looked away. There is no way I'm ready to see that at this point. Maybe never. The actual "stick" itself wasn't bad at all. It felt different than any other needle I've ever been stuck with. A tiny pinch and then I could slightly feel it slide in. Little creepy, yes, but better than it hurting the entire time. The part I felt the most was when, after he stuck me, he moved the needle around a bit (not meaning to). Again, that wasn't even that big of a deal, but it made it more obvious that something was in there. Yes, I prefer to be oblivious, thank you very much!

Whew! Finally that first stick was over. I'm sure it will be that much easier tomorrow for our next go around. What remained was a blotchy red spot and a little bit of itching around the site for about 10 minutes or so.

(yes, that's my beautiful scar below my belly button,
post ovary and tube removal many years ago)

After the stick came the pills. As my Mom and Dad can attest, I am and have always been horrible at taking pills. I may have pushed someone to the point of frustration that they threw a coffee cup through the wall. Maybe. ;-)

I have gotten better through the years but even to this day, sometimes even the thought of swallowing a pill literally gives me the chills. Isn't that just stupid! It is what it is I guess. Maybe after all of this I'll finally be over it. In the meantime, I have to find a way to deal with it. So, I bring you the Reduced Fat Oreo and Pill Combo. A surefire way to make taking pills enjoyable. It's my plan A for this part of the cycle. So far, it's working beautifully.


No side effects to report yet, though I think time will really be the determining factor here. Please body, be good to me! Do what you need to do to get us a baby and nothing more (I wonder if it can hear me :-P).

On that note, I'm tired (probably the reason for the extra dose of sarcasm and the multitude of smiley faces) so off to bed I go. Thanks to everyone for the nice thoughts and comments today. All are very much appreciated!!

Will it be Bravelle or Follistim?

Anyone who has gone through, contemplated or will soon go through IVF knows just how important your protocol is. While is not the entire determining factor of success, it is a HUGE part of it.

A protocol should be specifically designed with the woman's infertility factors in mind: any and all conditions or family conditions, past surgeries, current blood work, ultrasounds, any past incidents of miscarriages, and probably many other things I'm forgetting. Point being, your protocol shouldn't be out-of-the-box. Everyone's body is different and in order for you to get to the outcome you desire (yes, a BFP!), your protocol should be one that is custom-fit for your issues in mind. Even then, there is no exact science, but it's a great place to start.

Count my issues, and blessings, one by one
Luckily, I have age on my side. My ovarian count, or FSH level, appears to be good and my AFC is good (15+). What I'm working with is the fact that I have only one ovary (appears to be slightly damaged due to surgical scarring) which means they may get less eggs and I have PCOS. At this point, it might be good that I have PCOS to some extent because it likely means I'll still produce a good number of follicles and eggs during IVF. The problem is, however, those eggs may be of lesser quality than your average woman.

Along with most other PCOS women, my FSH to LH ratio is out of whack
Normal values should be a 1:1 ratio, where as PCO women have an LH that is more like 2 to even 3 times as high as their FSH. Mine is 4.5 times as high!! This means that my body is ultra sensitive to LH. If there is too much, this can cause an over-production of androgens (male hormones), which can have a negative impact on the quaility of the eggs the retrieve. Poor quality eggs can sometimes lead to a lesser potential that they will fertilize well and turn into healthy embryos for transfer. No healthy embroys, means no BFP.

So, how does this relate back to my IVF protocol?
Well, I am - for certain - going to be on the Long Lupron Protocol. Lurpon is designed to suppress your pitutiary so that your body doesn't make it's own LH or FSH. The idea behind this protocol is that between BCP clearing up most cysts and by taking the Lupron for an etended period of time, my body's hormones and natural androgen production should be at a minimum. Once the ovaries are quiet, then they'll add in the drugs stimulate the ovary(ies) to do it's thing and from there the idea is that we'll recruite between atleast 8-15 healthy eggs, or more if we're super lucky. Yes, the time before stimming is critical for someone with PCOS, but stimming itself is JUST as important.

This brings me to the concern that came about in our calendar review.
As we were handed out calendar, we saw a familiar, but unexpected stim with our name on it - Bravelle. We had read about this drug in many places, including Dr. Sher's book (wow, I still haven't reviewed this...) and SIRM's Dr. visited forums, but couldn't for the life of us think about what the difference between this drug and Gonal F or Follistim were. We knew for certain that the latter two were 100% FSH because, in truth, that's what we expected we'd see on our calendar.

Instead, it was six days of Bravelle (3 vials each day to be exact). To be sure I understood before we went any further, I asked our coordinator what the difference between that and Follistim was. She started by explaining that everyone is given specific protocols and that our doctor wouldn't put us on something if he didn't think it was "the" way to go. Ok - I buy that. Afterall, we think Dr. A is swell and he has wonderful success rates. No need to be convinced on that one - it's one of the main reasons we chose him. Ok, so after being assured our protocol is custom and carefully selected, my husband mentions that we were just surprised to see it on our calendar and that we happen to have been gifted Follistim. Now... give me a little "eeeeerrrrr" breaks sound effect and spin your little car around into a 360. "Oh, you have Follistim. Well if you have Follistim, then we'll use that for sure."
Wait just a sec. A minute ago Bravelle was "the" stim for us that had been specifically selected from a host of drugs. We both say to her in unison, "If Bravelle is what Dr. Ahlering things will be best for us, then we, by all means, want to use that instead. Even if it means having to buy different drugs. We're ok with that." To which she assures us it's no problem to substitute an equal amount of Follistim for the units of Bravelle we were supposed to be on. Again, I ask - what is the main difference between Follistim and Bravelle (half of me wished I'd brought our book with us, but I can only imagine how that would have come off), to which she replied something like "they're the exact same thing". I really wasn't up for arguing and I was putting my trust in the fact that she does this nearly every day. So, we continue on.

Back at work that afternoon, I decided to do one last inquiry on the matter and low and behold, it is what I suspected. While Follistim and Gonal F are the same thing (FSH only), Bravelle is FSH + 2% LH. With my body's natural sensitivity to LH, my instant reaction is to think that an FSH only stim would be the way to go for me. Additional research also seems to support this. However, even so, I want to keep an open mind. Afterall, I DO trust my doctor. He really does seem to put his all into each and every cycle. Knowing we're all human, I don't expect my coordinator to remember every little fact there is surrounding IVF. So even that I'm willing to keep an open mind about. I do think, though, that the doctor should always give the final OK, even in situations where it seems safe to switch something up.

In an effort to stay on the same page with our coordinator, I sent her an e-mail asking that we better understand the "whys" behind the protocol that was selected for us. I also brought up our concern about having too much LH given my circumstance. In the end, we are really just seeking peace of mind. To know that we're going into this cycle with a game plan that feels, within our depths, like "the" protocol is sooo extremely important.

Our doctor's been on vacation this past week, so we hope to hear back sometime this week about what lies ahead for our stim. In the meantime, we start Lurpon next Wednesday!

From a high level, here's what our IVF protcol looks like, currently:

• Continue BCP. When I come to the sugar pills, I'll skip those and start a new pack.
• On 7/15, begin daily prescription prenatal vitamin, Dexamethasone in the AM (a low dose steroid that enhances the implantation process by positively impacting the immune receptivity of the embryo; I was told this can cause insomnia. Let's hope not... I think I'll be needing all the sleep I can get during this time) and start the first of our daily Lupron injections in the AM (Lupron is designed to suppress the pituitary which produces your body's own key hormones - FSH & LH).
• I should get a period around 7/22-7/24.
• 7/23 I go in for a baseline ultrasound to check out my ovary
• Still on Lupron, on 7/28 I'll add in my injectable stim of FSH in the PM- actual stim type still TBD. Hmm... TBD? Yep. I'll expand on this in a sec.
• Still on Lupron and stim, on 7/31 add in a 3rd injection of LH (Menopur).
• Skip a day of Menopur and on 8/2 add in another dose of Menopur (LH).
• On 8/3, I'll go in for an US and E2 check. This is, what they consider to be CD9 and it marks the last day for Lupron. It's also the last of the true concrete part of this calendar.
  

I will scan my updated calendar, once we here back regarding our stim. It really is crazy to see it all mapped out in one solitary calendar.

As for what's not on the calendar yet... the rest is still very much up in the air. Generally speaking, the first week in August I will likely be in my RE's office for a daily ultrasound and perhaps blood work. Our coordinator thinks that I'll respond nicely to the stims (I guess since I'm PCO?) and that I'll probably do the HCG trigger shot during the mid morning on 8/5, which would put my retrieval sometime Friday. The trigger time and retrieval procedure will be precisely timed and I might not have too much advance notice as to when we'll trigger. If, I do in fact, have that sort of timing on retrieval, and they get a good number of eggs and then embryos to fertilize, she is guessing I'd do a 5 day transfer of two embbies on Wed 8/12. Even still, all of the stuff just mentioned is a total guess at this point.

Ah, the suspense! And we're not even in the thick of things yet.

The What & How: Recapping our IVF Calendar Review

The first big step into the land of IVF - the Calendar Review. Yes, I believe this must make it even more official, than the last official thing I posted. :-) Even though the full payment hasn't been made, or we haven't started pumping the heavy meds into my system, this is the foundation for the weeks to come.

We were the first appointment of the day. I should stop here to make a mental note that even though we left the house at 7:45 for our 8:45 appt, we arrive unnervingly early - 8:15 to be exact. Full steam ahead we walked through the doors and were soon greeted by our coordinator, Peggy. After greeting us with a smile, she asked if we wanted any coffee (umm... no thanks, we're trying to get pregnant :D) and showed us to an empty office. Things were a bit disheveled there that day; they recently experienced a water leak on the 3rd floor of the building they occupy, so lots of men were scattered about putting new drywall in and getting the place back in order. We didn't mind, though she apologized repeatedly. Later she was sure to mention that none of the fancy equipment was harmed (whew!)

Going over the "playbook"
Once in the room, Peggy started by breaking down "the playbook", otherwise known as our IVF calendar. This thing comes complete with a rainbow of what to inject, when and how much, all squeezed tightly into a month's time frame - and this doesn't even cover the entire process. Apparently, we'll receive additional, super critical information during the first and second weeks in August via phone and e-mail. Lord help us if there is a power outage or major disaster. I'll be pumped full of meds with no one to release my precious eggs to.

That aside, the first set of instructions seems pretty straightforward. Peggy took the "you might not know much about IVF" approach (which I fully appreciated) and took the time to explain every step in great detail. It was nice to have us all on the same page going into each phase of the cycle. Along the way, I stopped to ask if they would allow us to replace the intramuscular injection of Progesterone in Oil (PIO) for vaginal suppositories. While the latter doesn't sound fun, it has to be better than super deep shots in the butt, right? No, they don't like to do that. If come two weeks after a BFP, they are just too much to handle, we can consider switching it up then, but the first approach will be to stick it out and take one for the team. At the end of the day, if that truely is what's best, then I suppose I'm up for it. Luckily those don't start until the day of the transfer and they are every three days only (+ suppositories), so it could be worse. She did mention the trick of using ice to numb if we needed to. I even asked about the numbing cream. She said that yes, we could use it.

At this point, she must have detected a little "internet forum" speak or something, because it was then that she gave me a small lecture on how it has been their experience that most patients only seem to get stressed out by them. In some ways, I needed to hear it, I really did. She had the unique ability to be "mother-like", when my Mom wasn't able to be present. The other part of me wanted to let her know that I really only make a practice of going to SIRM's forum or keeping my nose in good, reputable books like the one written by Dr. Sher, but I just couldn't get the words out in time. We were onto the next line of business. Which was...

Learning how to self/spouse-inject
This part made my stomach turn just a wee bit. As Peggy rightly pointed out most of these particular type of needles are made for those who don't work in the medical field. They are super thin and not very long; basically the same type that are used for insulin shots. At least that's the speech I was given... I think I bought it! :P I'm sure that after the first one or two, it won't be too big of a deal, but it's getting over that hump that's the hard part. We were able to use a test dummy - a wonderful invention of fake flesh on a portable pod that I could hold up to my stomach and pinch the "fat" of, similar to what we'll do for the real injections. I went first, pretending to look like a natural. She called Jay the "back-up". Right. How about he'll be the go-to guy on this one - at least at first. I'm not sure how I'll feel about shoving that thing into my body willingly. We both had a good laugh because when he did it, his needle almost stabbed my thumb that was holding up the dummy. She was like "you might want to stand to the side when you actually do it, and hold it a bit closer." When she told him to hold it like he was holding a dart, I think he thought that meant to "throw it" like he was throwing a dart too. Yeah, not so much. This, folks, should be quite interesting!

Ending our injectable conversations, she mentioned which ones will come pre-primed and which ones we'll have to mix and prime on our own. I just hope we don't get confused and inject the wrong dosage. Let's not think about that for now... The only other injection she didn't go over much was the PIO shot. She said they'll show us how to do an intramuscular (IM) when I have my first one on transfer day there in the office.

Things you never think you'd decide
After all the talk, it was time for some paperwork. Of course you can't do something this major without having to sign your life away. Some of the questions we were totally prepared for... How many eggs do you want to have fertilized. All. What do you want to do with any excess embryos. Freeze. What we didn't expect was - What do you want us to do with those extra embryos in the event both parties dies. Ok, so even though it was creepy, the answer was obvious. We'd want to do an anonymous donation. The one that was super weird was, what do you want to do if just one of you dies. That was so uncomfortable to think about. Peggy said that she has had to walk out of the room before because couples have started arguing back and forth trying to come to a resolution. Luckily we were able to talk it out and decide that really in any event like that that we'd want the other to have the power to decide to keep or to donate anonymously. I mean it makes sense that they would ask these questions, but talk about super creep factor. That is the farthest thing from your mind when you're at this point and it, for a split second, it was sorta like a little dark cloud surrounded by a sea of wonderful possibles. Blah. Out with the bad vibes, in with the good. Out with the bad, in with the good.

Touring babyland
After finishing awkward paperwork, we had the opportunity to take a little tour of the clinic. With it being a slow, out-of-the-ordinary Friday, we had a fun surprise of being able to meet the soon-to-be "man of the hour". No, sorry sweetie, I don't mean you. I mean one of the embryologists. He probably thought I was one odd duck when I said "thanks for everything in advance" or something Corny like that. Hey, he's talented and this was, quite possibly, our one chance to suck up. You would have done it too :-P AND, what's even cooler, is that we were able to peek our heads in the embryology lab. I'm not sure if he was referring to just himself or the lab too, but he said he'd been on the Discovery channel twice. Pretty high-tech stuff!

What I loved about the clinic is that it doesn't feel very "hospitally" at all. Warm, soothing colors on the wall. The space, overall, wasn't very big, which made it feel more approachable. The procedure room where they'll do the retrieval and transfer was right next to the lab and they have this little window they slide the important stuff through when it's go-time! The recovery areas were small, but seemed to contain all of the important stuff. Bed for relaxing, guest chair and a small TV for taking your mind off everything.

Everyone has a role
Our coordinator was really good about explaining what she does in all of this. She specifically said "Don't worry. That's what I'm here for. I'll do the worrying for you." Anytime I have a question or concern I am to call her directly during business hours, or the exchange line during after hours. She assured me someone will be there to answer any question. Then, when it comes time for retrieval, she'll be present in the room assisting Dr. Ahlering in immediately labeling the egg filled pipettes to the lab where they will inspect and count each egg that is retrieved. I believe she said that before we leave we should know about how many were retrieved and later that day she will call us to give us a fertilization report. Then, that next week will be filled with getting updates from her on how they are progressing -which ones make it through ICSI and mature into little embryos. For a 3-5 days we'll watch their progress to see which ones divide and continue to blossom, ideally hoping for 8-10 celled embryos by day 5 for a two blastocyst transfer. She's thinking we'll stim quickly and be ready for retrieval on Friday 8/7 and things we will make it to a day 5 transfer, which would put that on 8/11. Each of these we won't really know until the day or morning of. Those first two weeks will be filled with so, so much. I'm glad to know Peggy will be there every step of the way.

My OhMyGoshThisCouldREALLYHappenMoment
Oh, and how could I forget to mention. The "moment" I had while we went through our calendar. Following all of the meds, all of the procedures, there will be the wait. At this point in the conversation, Peggy started using words like "when we find out you are pregnant," I started to loose it. I don't generally allow my brain to get too far down that path. It just isn't safe. It was all too much when she started saying around the time when we'll be able to hear a heart beat(s) and find out if there is more than one sac - more than one baby!! At this point, I was looking around like a scared puppy dog for a box of Kleenex. Peggy could see it in my eyes and felt really bad that there wasn't anything to be found in the office we had borrowed (hers was being worked on). Moments like that are few and far between, but it was crazy to think that in less than two months from now we would not only find out if we were pregnant, but how many we were having. Totally crazy. I am so ready for this!!!!!!!!!!!!! Bring on the shots!

Ok, so on and on I've went and I've not gotten into the protocol or dates one bit. I'm going to pause and go get some sleep, but I'll be sure to write soon, complete with a pic of our very bright and color laden calendar. The first time I saw one of these I did second take. Lots of instructions, lots of meds and the biggest concern that came out of our appt. More of the really important stuff to come - promise!

Wake up and smell the coffee... Decaf, please ;)

Today began by checking my blogroll to catch up on what everyone had been up to the past couple days. AF just arrived for my friend Fran and she outlined what was ahead of her over these next few weeks for her IVF protocol. Fran and I will practically be cycle buddies (though she's a week or so ahead of me), which is neat. (By the way, Fran: I tried commenting to your latest post, but had no luck... the darn comment button just doesn't appear to be functioning. Anyway, just wanted to say "Hooray for starting!")

After reading her post, my progression of thoughts went like this:
Fran knows what's ahead of her, which is awesome!
I wish I knew.
... I know.
I'll see what Dr. Google has to say.
Then, with limited knowledge of what type of protocol I'll be on,
I type: "how does a typical lupron ivf cycle work?"
To which I stumble on a site and find this:
Gulp. If this DOES represent what my protocol will look like, then I'm starting even SOONER than I thought with injectables (Lupron could begin around July 2nd!!). The only thing I've been told so far about my protocol was what Dr. Ahering said in our last appointment with him back mid April. He said at first glance he imagines he'll put me on a "classic" Lupron protocol, or L3C (as it's referred to at SIRM). What you see above is considered a "classic" Lupron protocol, according to that particular clinic; I would assume my clinic's would be nearly identical.

Without confirmation from my clinic, here is what COULD lie ahead for me. These conclusions are based on the above chart/clinc info noted below and a sample calendar from another clinic. My thoughts are in blue.

1. Menstruation starts. (Should be around June 16 for me.) Baseline labs such as FSH can be drawn on day 3. (Around June 18 for me?)
   
2. Birth control pill (Begins on CD 3?) is used to suppress the pituitary and to resolve any residual ovarian cyst from previous cycles. The pill also allows flexibility in IVF scheduling. Women who start menses at different times can have their cycles synchronized by the pill in order to start IVF treatment as a group.
3. Lupron, an injectable medication, is started near the end of the pill cycle to further suppress the pituitary. (This could be around July 2 for me!?) The pill is eventually discontinued while Lupron is continued into the next phase to maintain pituitary suppression. Ovarian stimulation is initiated once there is sufficient suppression of the pituitary, as evident by a low estradiol level and quiet ovaries on the sonogram. (Based on this sample calendar, from yet another clinic, it sounds like I might just continue Lupron up until the time everyone else starts their stims, so July 15... I guess there's no harm in "over" suppressing my ovary, especially since I have PCOS?)
   
4. Ovarian stimulation is initiated once there is sufficient suppression of the pituitary, as evident by a low estradiol level and quiet ovaries on the sonogram. The injectable medications used to stimulate the ovaries (Bravelle, Follistim, Gonal-f, Repronex - I believe I'll be doing Follistim or Gonal-f) are actually LH and FSH, the same hormones normally produced by the pituitary. Close monitoring of the ovaries with blood works and sonograms is essential during this period to ensure optimal egg development and avoid complications.
5. Human Chorionic Gonadotropin (HCG) injection is given when the follicles reach mature sizes. HCG induces the eggs to undergo the final maturation. It also causes the eggs to be detached from the wall of the follicles to facilitate their removal.
6. Egg retrieval is performed about 36 hours after the HCG injection. The procedure takes 20 minutes and is conducted under IV anesthesia. A long needle is introduced into the pelvic space through the vagina under ultrasound guidance. After their aspiration, the eggs are inseminated or injected with the sperm in the same day. (ER for my cycle will be on or around August 3.)
   
7. Embryo culture typically takes 5 days after the day of retrieval, the same duration an embryo takes to travel from the tube into the uterus under natural condition.
8. Embryo transfer usually takes place on the fifth day of culture (otherwise known as the blastocyst stage). Two best blastocysts are transferred into the uterus using a soft catheter. The procedure is similar to an IUI and requires no anesthesia. The remaining embryos, if there are any, can be frozen for future use.
9. Endometrial support with progesterone and estrogen supplements is important to prepare the uterine lining for implantation. Progesterone is started on the day after the retrieval. Progesterone transforms the endometrium into a rich environment to prepare for embryo implantation. Progesterone is usually administered in oil (PIO) form by deep muscular injection into the buttocks. (Our patients use progesterone vaginally instead of by injections. Our decision to use vaginal progesterone is based on numerous scientific researches that showed the superiority of the vaginal route over the intramuscular or oral route in endometrial maturation. I think my clinic normally recommends PIO, but I'm going to ask about suppositories or Endometrin inserts instead.) (Estrogen is added back to maintain hormonal balance within the endometrium. The estrogen level usually drops after egg retrieval since many estrogen producing cells are also removed along with the eggs. Estrogen can be used as a patch or as tablets. (I don't know if my clinic gives Estrogen supplements like this.)
10. Pregnancy test can be performed 12 days after embryo transfer (Not sure if this is the typical number of days my clinic likes to test on). Once the test is positive, progesterone and estrogen are continued until the 11th week. A vaginal sonogram is performed at the 7th week to confirm the pregnancy.

In short, that's a lot of "what if's," but it definitely tells me that I need to get thoughts in order and begin to ask questions to my clinic. I am a prefer-to-know type of girl so I know I'll feel better once everything is confirmed. I also want to find out what supplements/vitamins we can be taking in order to help my husband's sperm and my egg quality, due to PCOS. Need to start that regime ASAP I'd imagine. Lots to do and learn!

Also, it's time to cut out caffeine and alcohol. Not that I was ever a big consumer of either, but I ought to eliminate this just to be safe. This weekend was full of enjoying a little of both. My mom came over on Friday to visit (we had a wonderful time!) and we bought some Teavana tea - very expensive, but it was so unique it will be a nice little treat from time to time. I bring it up for those who are undergoing, or about to undergo IF treatments. Their Tarocco Ruby Orange Herbal Tea/Apple Lemon Pomegranate Rooibos Tea combo is completely caffeine-free and is absolutely AMAZING! It tastes exactly like super yummy fruit juice and is fairly thick, for an iced tea. If you're looking for something different and IF friendly, I'd highly recommend it.

All in all, it was a great weekend. Lots of time spent with family and friends, which I always love. I even got to celebrate our upcoming IVF with my husband on Saturday and then with my good friends Sunday. What more could you ask for!! Going into a new week, please pray that we get good news back about our loan situation. This is the last big nail biter in terms of something that would be able to hold us up from starting. We applied last week and should know early this week if we'll be able to get the financing we need to pay for our upcoming cycle. We've gotten ourselves excited enough already that it would definitely be tough to let go of our hope now.

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."

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 is Lupron and how is it used?

After reading about women using Lupron to suppress cysts, and then after hearing a doctor mention it in passing on a recent online radio show I tuned into (see two posts ago about PCOS and Infertility), it make me wonder what the heck Lupron even is and how it's used in infertility.

From what I've gathered thus far, it seems like Lupron is used in a few different ways: to treat of endometriosis, used prior to IVF and combined with other infertility meds. My only concern with it is that, as drugs.com reads, the "FDA pregnancy category X. This medication can cause birth defects. Do not use Lupron if you are pregnant."

In any case, here are some more links I found regarding Lupron and it's use in infertility.

Here is a general overview of what Lupron is, how it's often used and common side-effects:
http://www.parentinged.com/fertility/What-Is-Lupron-And-How-Can-It-Help-Address-Fertility-Issues.html

Here is one doctor's take on Lupron:
http://infertilityblog.blogspot.com/2006/12/what-is-lupron-and-why-are-only-some.html

Some posts:
http://forums.fertilitycommunity.com/endometriosis/252273-what-lupron.html
http://wiki.answers.com/Q/Can_you_become_pregnant_while_on_Lupron

Personal Infertility Story:
I met one woman through soulcysters.net (a PCOS forum) who shared her experience with me..."I had been seen by another RE for years (TTC for years total). I did 6 cycles of Clomid up to 250mg and 3 cycles of Bravelle (no Lupron). None of which ever even got having mature follies without overstimming. I never even got to trigger with any other cycle before. I just started seeing this new RE in July. DH and I reloacted to another state due to him being military. First cycle with this new RE on this protocol resulted in my BFP. So I am a firm beleiver in this Lupron protocol."

Here is the Lupron protocol she is referring to:
9/2008-Hysteroscopy~Removed large fibroid & polyps & D&C
10/4-Started Lupron 10u
10/13-Follistim 150u started, Lupron decreased 5u
10/21-Follistim increased to 200u
10/28-Follie U/S~6 follies 13-16mm
10/31-Follie U/S 20 & 18mm follie~TRIGGERED!!! BD TIME!!
11/14-BFP!!!
11/17-Beta 128!
11/19-Beta 298
Baby Dust and Lots of Prayers!!

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).