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!

It might be boring, but still, it's progress!

Now, let me put you to sleep with the details... I finished my last Provera pill (10 of 10) on Sunday. In the past when I've taken this to induce a cycle, I only take 5 and then 2 or 3 days following AF will arrive. I expected the wait to be the same in this case, but it wasn't at all; instead it showed up the middle of the next day. Surprise! As instructed, I contacted my clinic to let them know it was CD1. They called in a BCP prescription (for Aviane to be exact, which contains ethinyl estradiol

and levonorgestrel, two forms of the female hormones estrogen and progesterone) and I was told to start my first pill no later than CD5. I have read before about CD3 being a common day women begin the regime, so I decided I would too and popped it late last night.

Everyone always talks about how funny it is that you're TTC and you are on BCP. :-) To me, if it seems weird or crazy, it pretty much fits right in with IF. hahaa! Actually, what I hate about the BCP, which I completely forgot about until right when I opened the pack, is that I feel nauseous from the stupid things. Years and years ago when I was on the pill, I dealt with this constantly. It would always take a good 4 days or so for my body to get used to the low-dose hormones. Even if I take them with food or at night, my stomach will hurt pretty much the entire next day. Ultimately, this is why I stopped taking them and switched to the Nuva Ring. Anyway, is it annoying - yes. Will it be worth it - yes indeed! This is mild to what these next couple months will throw at me, I'm sure, so I best get used to it now. *grin*

Why do most people take BCP during an IVF cycle?
Most of the time, and I fit right into this personally and because I'm cycling at SIRM, women with unpredictable cycles are put on the BCP to sync their body with the rest of the women who are cycling that same month. I believe that sometimes even women with regular cycles will be put on this because they want the ability to do ER & ET around the same days for scheduling purposes. Also, in women who are known to be classified as "high responders" (where they will recruit lots and lots of eggs), the pill is thought to lessen the risk of dangerous OHSS. Since I am PCOS, I fit into this category as well.

A little clarification from my last IVF update...
I spoke with Mary again. Based on her previous note, she cleared up for me that the ER will fall on 8/5 or after (not 8/3). Beginning around 8/3, I'll be in their office sometimes daily for monitoring to see how the follicles are doing. I’ll then have approximately a 2-day break between the HCG and ER and then a 3-6 day break between ER and ET. So, knowing this, I am able to get a better idea that the first two weeks in August will be when I'll be taking quite a bit of time off work for appts, procedures and bed rest.

Things you never thought you'd tell your boss :P
I am fortunate enough to work for a wonderful company. We're a fairly small group (just 13 of us) and the owner/my boss is a young guy himself. I have always been able to be extremely open about family priorities, career goals, etc. and everything as always been very well received. I'm happy to report our upcoming IVF is no exception. I filled him in on the general idea of how things will work, which tells the story of when I'll need to be out of the office and sometimes the very short notice of when I'll need time off (take those two weeks in Aug for example). He was fine with everything and was more interested to say things like "Are you ready for this?" and "I'll be crossing my fingers for you." With IVF, I feel like we have to put our best foot forward and the last thing I need to do is stress about about my job too. It's such a relief to know that isn't a concern - I consider it a blessing from God!

What's next?
I'm waiting to get a call from my IVF cycle coordinator, Peggy, who will then set up our IVF calendar review. I was told on Monday she would be contacting me within a week or so and to mention it to them if I hadn't heard anything. So, I wait. If nothing by, say Tuesday of next week, I call. I think that's fair, don't you ;-)

Oh and - let the countdown to shots begin!
It was also confirmed that down-regulation (also known as ovarian supression) with Lupron will begin on or around July 15 (like I posted way back when). That's now less than a month away - hooray!

Patience... I know it's around here somewhere.

Still speculating... still wondering. What will my exact IVF protocol be? If you can't tell, I'm getting a little antsy!

My goal by the end of this weekend is to continue educating myself enough so that I'll be able to understand if the protocol I'm given seems right for me. No, I am not a doctor, nor will I claim to be once I'm thru researching. We are, however, investing a lot in this cycle: physically, emotionally and financially. I see no reason why I shouldn't be proactive with this as I am with buying a home or switching jobs. This is just as important, and arguably MORE important, than either of those. Our family tree is at stake here!

Why is the IVF protocol so important?
As Dr. Geoffrey Sher's states in his book on IVF, titled The A.R.T of Making Babies, "In order for any organism to attain an optimal state of maturation (ripening) it must first undergo full growth and development. A fruit plucked from a tree before having developed fully or a poorly developed fruit might still ripen (mature) on the shelf and might even appear as enticing as one that had previously undergone proper development, but it will lack the same quality. The same principles apply to the development and maturation of human eggs."

I love, love, love this analogy. Comparing the ripening of fruit to a woman's eggs just makes so much sense to me. This is exactly why I am taking the time and energy to try and make sure the protocol I'll be given is the right one for me - especially since I have PCOS. The protocol, or meds, they put me on will directly contribute to how my eggs will develop which is a HUGE part of whether or not we will be successful (not the entire variable, but a big one none the less). Don't misunderstand me, please. I do fully trust my doctor. He is a brilliant and very kind man. I am sure that he and his staff will do whatever they possibly can to insure we have successful cycle. Even still, I know I will rest easier knowing that I fully understand his decision and that I've researched enough to have full and complete faith that what we go forward with really does make the most sense for us.

Attempting to avert regrets

What if we don't have a successful cycle?

In truth, this is hugely possible, so I think the "what ifs" make a lot of sense here. If that happens, we'll naturally wonder what might have gone wrong. I'm sure we'll have a follow-up appointment with the doctor in order to review and develop a game plan for #2. If at that point in time something in our conversation comes up that I questioned internally prior to and during that cycle, but didn't say anything about, I won't be able to forgive myself. We are investing way too much in this cycle to not do our homework and feel good about things going into, during and after. However, if I DO research and ask questions about anything I am curious about or feel uncomfortable with and get those things resolved, and we still don't have a successful cycle (which I know is very possible), I will feel good that everyone involved did what they felt was right.

I'm only half way through this book, but I cannot say enough great things about it. (I promise to do a book review on it soon! It's too good to keep secret!)

____________________________________________________________________________________


The day following down payment, I e-mailed Mary, the clinical coordinator at SIRM. I was told to call her on day 1 of bleeding, but since I'm an irregular cycler, I needed further instruction. My first impression was FANTASTIC! She was quick to respond with a very detailed and personable e-mail. She asked what day I'm currently on (at the time it was CD 30) and then a day later, she responded to let me know she phoned in a script for Provera. Today is day 7 of 10 pills total. My husband's response to Provera, "So I guess that means we're officially starting our IVF protocol"... yeah, I guess you COULD say that!!

How our IVF cycle will work from a high level
Then, because I couldn't stand not knowing and all the girls on the SIRM forum recommended it, I e-mailed her again to ask how the process works from a high level (since we're new, I have no clue other than what I've heard). She said (paraphrased): You will find out your protocol at your calendar review and will be getting a prescription for all meds then as well. The cycle begins on 8/3 so that week and the following week, you will be in our office sometimes daily (especially the first week) for ultrasounds. The egg retrieval (ER) will fall over the first weekend, then embryo transfer (ET) will fall 3, 5, or 6 days after the ER. Peggy will be your IVF coordinator and should be contacting you soon to set up the calendar review appt. You will go over everything at the review. Between now and then, it looks like all your pre-cycle testing is complete with the exception of your husbands blood work. Be sure to contact me on day 1 of your next period so that you can start the BCP. From that point on, all will fall into place. You'll be seen for the calendar review and again on 8/3 for the first of your monitoring ultrasounds. As mentioned earlier, you will be in the office frequently from that point on 10-14 days. You'll find out if you're pregnant about a week or so after your ET.

Sooo... now I am informed, but still have a lot of questions. Based on this, that makes it seem as though I will NOT begin as early as I last thought. Clearly, this just re-enforces the fact that I have a lot of research to do. We (yes me AND my husband) have been reading Dr. Sher's book every night this week! At my request, of course ;) I feel like we have a small window of time in which we both need to learn a lot and be on the same page with our information. So, after a little push, he agreed to do so. I am so thankful for this because he is MUCH sharper than I am and it is so nice to have a second brain processing all of this info. My hope is that we'll have enough questions formed by early next week so that I can dig a little deeper to see what is next for us.

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.

You see... there's this list and WE'RE on it!

My heart was racing. Palms sweaty. Me, my phone and a small notebook stepped away from my desk this afternoon and snuck off to an empty suite where I would make "the" phone call. The call that makes it officially, official.

When the time came, I was happy and fully prepared to relay my CC # to my clinic; today was "down payment day." Refundable if something happens and we need to back out; otherwise it will be applied to the lump sum. Even that I've learned to accept. By now I've come to the realization that no company health insurance will be there for us in our time of need. It's up to us to turn over hard earned cash accumulated over the last year and will be up to us to pay off the remainder owed during the next several months. It's worth it because THIS - August IVF at SIRM St. Louis - is OUR chance. Our long awaited shot at having OUR baby. I was pumped and ready!

What I was not prepared for was what came next.
I was told final payment would be due July 8. I doubted that in and of itself will be a problem, but it did make me curious. The clinic cycle calendar I was given in early January of this year said final payment would be due July 22 - approximately one week prior to starting meds. My next natural thought was... so, is the August cycle date still August 17th (like my previous post stated)?

To which she said "No. No it's not. The new, correct date is now August 3rd." However, even that date isn't when I'll start meds. That date is for the actual retrieval.

Come again. Retrieval on August 3? Yep. "And you'll start meds around July 15th." :-|

Basically what you're telling me is the entire August IVF process is ONE MONTH SOONER than I'd originally expected?! It was then that my blood pressure sky rocketed, a wave of heat came over me and then cold sweats. THIS IS IT! It's really happening! And SOON!

To celebrate I first did what must have looked like the stupidest happy dance ever (good thing I was in a room by myself :P) and then I told a few close friends and relatives. I don't think the high left me for several hours. I'm not sure I've ever felt this type of combined excited and totally scared in my life!!


That's all fine and great, but what's next?
I was told to call Mary on Day 1 of my next cycle. Since I'm a very irregular cycler, I asked what if I didn't start my cycle by a certain date and she said I should e-mail her to find out what to do in that situation. So, that e-mail will go out tonight.

On a related note, Dr. Ahlering just so happened to e-mail me yesterday to see if everything had been addressed properly during our last meeting, which I think means he had an old e-mail of mine in his inbox and noticed he hadn't seen me come up on any of the recent IVF cycles. I'm just glad he saw my name and thought of our situation, especially for being as busy as he is. I did let him know I will be coming his way soon! I feel so fortunate to be able to cycle under his care!

For tonight, I will rest better knowing that somewhere there is a list with OUR name on it, and that list is titled "August IVF". For the time being, that alone makes me beyond happy.

Almost... but not quite official

I know, I know. Make that week number two of not being a good blogger. I confess. My apologies! I've been preoccupied I suppose. Between either feeling unmotivated or busy with sudden projects, I've just not dedicated any time to this. But I'm back! And it's time to get down to business.

This is the week, as I last mentioned, that we wanted to put our deposit down for our August IVF. Seeing as how tomorrow is Thursday, I'm not sure if that will be happening. First it was that we didn't have our final fancy spreadsheet made (not to worry, it's about 95% done now). Then it was that we needed to check with CapitalOne (who we were going to get our infertility loan through), to see if we should expect a similar rate and approval amount to insure something hasn't massively changed. As of tonight (thanks to a few wonderful IF girls in my local infertility group), I learned that CapitalOne is no longer lending these types of loans due to the state of the economy. How wonderful is that. Like we need one more thing. I was bummed, but was assured that you can used a home equity line of credit for these types of things too (also thanks for that tip!... these girls are good!).

Our new line of attack - Pursue a line of credit
When I mentioned it to Jay, he nicely reminded me (my memory is horrible) that he already brought this up as an option before, but I was very adamant about not wanting to use our home as collateral on anything. Right. It's all coming back to me now. Yes, ideally, I'd still like to avoid this (it just seems so risky I guess), but if that's our only option at this point, then I suppose we need to consider it. The more he explained it to me, the more I suppose it's not as bad as what I imagined it to be. The rate is better than what we would have been getting with the CapitalOne option and we don't have to take it all out at once, but instead just take out only what we will actually need as we go along.

Another reason we're behind schedule is that Jay has been super busy this week at work with a new project that is wrapping up on Monday. He's been doing a little when he has time, but it's not been much. So, when I got home from my IF meeting, I wrote up a doc with local banks and credit unions and their HELOC rates/terms. Yes, I will be bugging the heck out of him tomorrow to make sure he checks into at least a few of them... bugging IS a wifely "right", right? :)

Ok, so after doing ALL of that (a lot of stuff to figure out in a matter of a couple hours), I checked back in with the docs I received several months back from our clinic. Specifically, I was looking to see when the IVF August cycle date was and when their "off" month during the summer way. Up until now, for some reason, I was thinking their off month was the cycle before ours - but, it's not. That was the May cycle. Which hopefully means August won't be *quite* as full already as I thought it might be. Which is nice, however their doc clearly states "We encourage you to put down a deposit two months in advance to the cycle you wish to participate in. A list of our cycles is outlined below. Final payment dates are also included." And just like that too :) I'm guessing that if it's important enough to emphasize, we ought to take it seriously. Then I read, "A refundable deposit of $2,000.00 is required to secure your cycle of treatment with SIRM and the deposit is applied towards the total fees. " which to me is nice because it tells me that we might be ok to go ahead and put our deposit down now (without having figured out all of our stuff precisely), because it is in fact refundable. Again, nice!

Now, onto IVF calendar stuff...
The August IVF cycle at SIRM St. Louis begins on August 17, 2009, which I'm guessing means I would start my first injection of Lupron that day. We will have to have our final payment in full submitted on July 22, so as long as we get everything ironed out well before that date, we should be good to go. I really don't know why I hadn't marked this day until now... I guess it never dawned on me that THAT would be my date and exactly what that meant. It's so nice to be able to mark something more specific on my calendar!

Maybe I should make one of those silly paper chains or something to count down... or would that actually be bad to focus on it that way? I'm going to give this one some more thought. I'd like it to be a preparatory/celebratory thing. Something fun - like looking forward to vacation. After all, it will cost about 3-4 times as much as our jaunt to Turks & Caicos last year did. Yikes!! Hopefully we'll have the best souvenir EVER to show for it.

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

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

Our final list of questions were:

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

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

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

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

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

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

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

More from our RE regarding IVF

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

My questions were:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My RE affirms IVM isn't beneficial, compared to IVF

Wouldn't you know that AFTER my husband and I thoroughly discuss the positives and negatives of IVM and decide that it's just not for us, I ran across a show produced by the infertility radio show I listen to discussing new infertility technologies and one of the subjects was IVM. The guest on the show was none other than my own RE, Dr. Peter Ahlering. What's funny is that his position on IVF vs. IVM is pretty much the exact reasoning we arrived at - that ultimately it's not effective enough, or cheap enough, to be sensible. We were worried that if we went down that road and didn't end up with a baby, we'd have no money left to try what I call the "end-all-be-all" for infertility - IVF. Anyway, it was just good to hear a trusted medical opinion on this topic and I wanted to share it with the rest of the world.

As usual, below are my notes from the show.

Disclaimer - Please note that the information below 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.

Listen for Yourself

Scroll down in the archive to:
Date: 1/29/09
Title: "New Fertility Technology".

Dr. Peter Ahlering's thoughts on In Vitro Egg Maturation (IVM): IVM is where you stimulate the ovaries with drugs when they are very small. Egg retrieval of immature eggs, probably two steps behind where you'd be with IVF. In order to be competent for fertilization, they have to mature these immature eggs in the lab. This procedure has been around for many years and it's an extremely complex process still that involves maturing an egg to the point that it's capable of being fertilized. With the process of IVF, you wonder if people really need to do IVM. Yes, successes have been reported, but not that many because it's not that applicable to that many people.

Is IVM safer for PCOS patients?
People talk about how it's safer for women who have polycystic ovaries because they can avoid hyperstimulation... this is true, but there are other ways to avoid this through IVF and still have very high outcome. Prolonged coasting and other types of protocal medication alteration to avoid hyperstimulation. In Dr. Ahlerings opinion, less than 1% of patients would suffer from hyperstimulation.

Is IVM more affordable than IVF?
What about cost? Isn't it more affordable? Isn't it easier on the woman? Yes, the process itself is cheaper, but if you're trying to save money on the goal of having a baby, it just won't work because you'll have to try more times, so the cost goes up and is most often higher. Do we even know how the eggs will respond to this outside of the body? You have to get a lot of eggs to make a baby with IVM (25-30 mature eggs), compared to IVF (10-12 mature eggs) because a lot of them are lost through the process. An article about IVM where success rates are in low teens. That same young PCOS patient would have a 50-60% single cycle chance.

Egg retrieval for IVM
How do you retrieve the eggs given they're so small? It's just like IVF in a lot of respects. A mature follicle at the time of ovulation is 18-22mm, whereas an immature follicle is much smaller - more like 5-6mm because it's an immature egg. Those immature follicles are always there in a PCOS patient. You can go get eggs and you retrieve just like you would during IVF. During an IVM retrieval you might get 30 immature eggs. And after 24-48 hours you would have a certain number of mature eggs.

Genetics of the egg following IVM
Have we seen enough babies yet to know if we're harming the baby? There haven't been enough studies done. It's doubtful that the process itself would increase birth defects. The problem is that most eggs won't make it to the point of baby.

Is hyperstimulation deadly?
Can women die from hyperstimulation? Maybe that's why a lot of women find IVM appealing. No, practically speaking I don't know how it's possible where you would run into a circumstance where hyperstimulation would be so bad that she would end up in the hospital and be close to death. People who have lots of follicles and eggs are prone to a condition called ovarian hyperstimulation syndrome. For all women who undergo IVF, to a large degree we create a controled hypersimulation of sorts in the sense that they are creating lots of follicles (not just one like you would during a typical non-IVF cycle). The common rule of thumb is that you get a lot of follicles and there is no illness from it.

IVM success rates too small, so we're back to IVF

Our basic, personal conclusion on doing IVM in Canada or the UK is this: Looking at statistics, at the end of 4 tries of IVF with Dr. Peter Ahlering, we would have an 80% chance of walking away with a baby. It sounds weird to put it in those terms, but it's true. Those odds are pretty high if you think about it and it really doesn't get any better than IVF, in terms of mecical infertility capabilities.

"What if" IVM didn't work?
With IVM in Canada (I can't speak for the UK, because they don't provide very detailed success rates), you would have to try about 7 times to have those same odds. Seven times! That is a heck of a lot. If they were next door it might not be as big of a deal, but by the time you add in travel seven times over, it is just as expensive as IVF. PLUS, and this is my big hang up, say we did 3 rounds of IVM, but were unsuccessful, would we have the stamina to stick it out to 7, or would we get scared that we'd "waste" all our money on something that just doesn't have as good proven success? Trying to think way in advance, I personally think I'd get a little worried that in the end, after 7 rounds of IVM, if we still didn't have a baby in our arms, that I would have wished and would wonder if IVF would have been the thing to do the trick.

Having only one ovary most likely makes our odds even smaller
Then, there is my own personal health issues that have to factor in. Given that I only have one ovary, that isn't even accessible from all sides (remember it's glued to my uterus on one side), they might not be able to retrieve all of the eggs they need for the maturation process. When I e-mailed the clinic in Oxford, their reply was "Mr Child has said that for IVM you would need a total antral follicle count of 20-30 with all being reached with a needle via the vagina." While I've had many internal ultrasounds, I have never "officially" had my antral follicles counted. Even my RE just said you you have a "good number of follicles in the one ovary" - obviously that's not nearly specific enough, but I still highly doubt I have 20-30.

IVM live birth rates almost half of some IVF clinics
Yes, in IVF they also do a retrieval which is very similar, however, because you've gone through all of the stimulation drugs, the follicles are larger and therefore easier to see and access. Having said that, I would imagine that my personal "success rate" would be quite a bit smaller than the average woman with two ovaries. Maybe not half of what her chances would be, but still enough that it would probably have large impact, seeing as how the chance of success for a "live birth" in a given IVM transfer is only around 21% for women under the age of 35. Who knows how much lower it would be for me - this factor alone would mean that I would need even MORE than 7 cycles of IVM to have the same chance at a live birth, compared to IVF. In truth, this is my opinion having researched things and I don't know for certain my chances will decrease that much.

Ugh. So really we're more than likely back to square one. I mean I still want to ask Dr. Ahlering how our chances will be affected with any treatement, including IVF, because we will need to know going forward how many trys we'll more than likely need to make this happen. The last thing I want to do is buy a single cycle at a time and end up paying WAY more as a result, as Dr. Ahlering's office offers what I like to call a "bulk discount". If you buy 2, it's technically cheaper per cycle - same with buying 3 and with 3 you get a small fraction of your money back if you don't have a live birth at the end.

At this point it's just frustrating. Frustrating that there seems to be some other safer form of treatment that is ultimately most likely unattainable because of my health, the distance from those particular clinics which are far and few between and that this is one situation where it really probably doesn't pay to find something cheaper. If we're going to do this, we should find someone who is really good at baby-making and just go for it because in the end, if we didn't end up being able to have biological children, we'd want to look back and know that we gave it our best effort at the time.

First we're selling. Now we're not... Finding a way to pay for IVF.
This has been a weird past two weeks. First we thought this stupid recession stimulus bill would have a house credit in it and, as a result, we were pretty for sure we were selling our home. Then Congress took that out of the bill and the economy continues to worsen, including the housing market. So our choices were - refi our current home which will drop our monthly bill down quite a bit OR still try and get our house ready and see if it will sell. The main difference between the two was that with a new house we would save just slightly more each month on our bill, we'd have to pretty quickly get our home ready to sell ourselves and then we wouldn't have much room to move on price if we did get an offer. The refi would allow us to skip some of the unknown, the stress and the headache of dealing with a new house. Every person that's close to me pretty much thought refi was the way to go. While I still have mixed feelings (I wondered if we should at least "try" to sell first, but that would cost us each month we wait to refi), but ultimately my husband feels like this is probably the way to go.

The other part of that story is that we might have to wait a bit longer to do IVF - mostly because we may need to build our savings up a bit more so that we have more money to live off of in the situation where we have twins and I can't bring any income in. Ultimately I only want to work part-time (and WAH if possible) so that we don't have to put our baby in childcare, so we need to do what makes the most sense for the long run. Man is it hard to be ok with just waiting another solid year. Waiting while friends and relatives get pregnant, have babies and watch their kids take their first steps. I am starting to feel like I'm in some weird time warp where I'm standing still and everything else is moving right along before my eyes.

Even still, I need to be mindful that so many people are faced with so many things right now that are far worse than what we are dealing with. I need to be humbled and keep things in perspective for sure. God give me the strength!!

A side note - I'm now 27 and the sound of that just freaks me out. Why does that have to seem so much older than 26??!!

We're considering doing IVM at a clinic in Oxford!

Ok people. I'm super excited about this. In fact, I don't think I've been this excited in quite a long time. After getting some financials from the IVM clinic in Chicago (IVF1, w/ Dr. Morris), it revealed that doing IVM really wouldn't be more cost effective compared to doing IVF with SHER. In fact, per single cycle it was a bit more expensive simply because they don't have a true multi-cycle "discounted" package like SHER does. Instead, they said they offer a $2,000 discount for each additional IVM cycle. Even that isn't enough to make it worth my wild.

To also stay relevant, I should say that we recently (like as of this past weekend) decided to not try and sell our home. After many, many, MANY exhausting hours of considering the advantages and disadvantages with selling/buying or refinancing, we've decided that refinancing will probably be the most predictable solution. Given the awful housing market we really don't know what we could expect from selling and would probably get a very low price for our home as a result. We decided that if we want to sell in 5 years (or so), hopefully it will be worth the wait. So, long story short, while it felt good to have an decision made, it made me a little sad. In making our decision, we also came to the conclusion that it also probably made sense to wait a little longer to pursue IVF. The longer we wait, the more we can save each month so that we have more of a reserve to fall back on once we do have our baby.

We were still in the middle of coming up with that time frame when I heard back from the IVM clinic in Oxford, UK, known as the Oxford Fertility Unit, a non-profit clinic (how cool is that!). As a long shot, I e-mailed them almost a week ago to see if they thought I would be a good candidate for IVM, since I only have one ovary that is probably partially blocked due to scar tissue and it being adhered to my uterus. The main reason for e-mailing them was the fact that their website listed the prices for their services - prices that are more than half of what they cost here in the U.S. Even with travel factored in, it would still be about 40% less than an IVM or IVF cycle here in the U.S. I was a bit sceptical as to if the prices were even accurate. So, with those things in mind, I sent my e-mail off.

And today, I received this response -

"Mr Child's reply to your email is: If both ovaries are accessible vaginally and of polycystic appearance then IVM should be possible. We do treat patients from abroad and the costs are correct."

I don't want to get too excited. I still need to confirm that my only having one ovary wouldn't disqualify me. However, I wanted to outline the costs a little more precisely to make sure I wasn't looking at something incorrect. The price difference just seems too good to be true. For approx. $10,000 we could undergo a single IVM cycle - that includes pretreatment testing, retrieval, ICSI, transfer, drugs and travel costs (flight, hotel, food and an misc expense allowance)!! That is compared to $16,000-$18,000 per IVM/IVF cycle here in the U.S.

Months ago when my husband mentioned the idea of doing a "vacation infertility treatment" my reaction was "no way! absolutely not". I couldn't imagine doing something so major outside of the U.S. - it just doesn't seem safe. My mind is slowly changing for three reasons:

1) This is Oxford, England, not a third-world country. I would feel safe while traveling and would trust that the hospital would be held to high standards.

2) This is the clinic that pretty much pioneered IVM and is a part of the renowned Oxford's John Radcliffe Hospital. I would actually feel safer in the hands of Dr. Child's, vs. Dr. Morris in Chicago, only because Dr. Child's had an extensive amount of experience in this arena, in comparison.

3) The fact that we would be able to get away from it all and focus on this experience and nothing else - a little "infertility vacation" if you will - seems like icing on the cake. I do think we should be mindful of the possible effect flying and the time change could have on the success of the treatment and would need to discuss this more in depth with the doctor before making our decision.

Speaking of... once we hear back about my ovary situation, and provided we're still a candidate, I'm guessing that would be our next step - to make a phone consultation with Dr. Child's to talk about the big picture and what exactly this might mean for us.

EEEeeeek! Again, I really shouldn't be getting all worked up about this but the possibility of saving money, avoiding potentially risky injectable meds, possibly moving treatment time frame up and traveling to England is way too cool!!

In the end, I still need to be mindful of how good God is, regardless of how this IVM Oxford thing turns out. I mean when I break it down - yes, we are dealing with some pretty big things. Yes, we are making sacrifices in order to secure a better future for our family. Yes, we may have to undergo some uncomfortable procedures. Yes, our heart breaks from time to time with a feeling of emptiness. BUT, we are so lucky to have a warm and comforting roof over our heads. To have two fur babies that make me smile the minute I walk in the door. To have good paying jobs. To have supportive parents and a few close supportive friends. To have each other. God is the only one we have to thank for that - he is looking out for us well before we know we'll be confronted with an issue. I'm trusting that even as we deal with this, he is looking out for our future and this is just part of our journey. We will be stronger for it!

Ok so now on to the details of doing IVM in Oxford with Dr. Tim Child. Here are some resources you might find helpful. If you have any additional info to add, please let me know!

Cost Analysis - A spreadsheet I created to take a closer look at the overall costs.
http://spreadsheets.google.com/ccc?key=pRJsuX3UYPXuOMcguqjqDMw

A link to the Clinic's Prices - Costs listed on site are in British Pounds. Above doc converts them to U.S.)
http://www.fert.org.uk/index.php?option=com_content&task=view&id=13&Itemid=41

Oxford Fertility Clinic
http://www.fert.org.uk/

IVM Procedure in Detail - These sites explain the overall steps and timeline for an IVM cycle

http://www.babyworld.co.uk/information/trying/infertility_treatments/in_vitro_maturation.asp

http://www.articlesbase.com/men%27s-health-articles/ivm-in-vitro-maturation-in-thailand-442035.html

IVM Cycle Compared to IVF - A short news article on IVM as a whole
http://www.dailymail.co.uk/health/article-1084447/The-new-fertility-treatment-double-womans-chances-getting-pregnant.html

IVM babies - News story about a couple who underwent IVM with Dr. Tim Child
http://www.fertilityauthority.com/news/2009/jan/17/ivm-british-mother-births-twins-after-new-treatment

For the record....
Here is the link to the Chicago clinic that does IVM: http://www.ivf1.com/in-vitro-egg-maturation/
And here is another clinic in the U.S. that claims to also do IVM (It doesn't seem like many clinics are doing IVM yet, so I've had trouble locating another one besides the one in Chicago). I will most likely e-mail them as well just to see what they charge, but haven't done so yet. http://www.startfertility.com/

How are embryos tested and how many should you transfer in IVF?

I guess you could say that a few factors led me to look into the topic of embryos.

For one, we're don't feel very informed on what it really goes into determining how many embryos will make to a quality high enough for transfer, from those that do make it, how you and your doctor determine how many will be transferred. This is important for us because we're trying to consider how many tries we think we would need at IVF in order to be successful. We're also not sure how much my having only one ovary and PCOS factors in. And of course there's the topic of the new octuplets who were just born and the question of why her doctor would have ever transferred that many embryos in the first place.

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Disclaimer - Please note that the information below 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.

Listen for Yourself

Scroll down in the archive to:
Date: 7/24/08
Title: "How Many Embryos to Transfer in IVF".

Embryo Fertilization and Selection
The selection of many embryos is made for you by nature because so many eggs and embryos are abnormal and don't survive past a certain stage. With medications, you can get a woman to produce a lot of eggs but can't get them all to fertilize. If you had someone who had 20 eggs, why wouldn't you want to put to use ICSI with every egg to get them all to fertilize? Even if you do this, you can't always get them all to fertilize because there maybe be chromosomal abnormalities with the egg or problems with the sperm, but you can't often tell by looking at them. Certain people do ICSI on every patient. SHER uses ICSI with every In Vitro Fertilization (IVF) patient and the results are just better in order to optimize fertilization. If you fail at that, you're out at the get-go. This concept has been around for years and SHER believes this is better, even when there's no evident male factor. By doing ICSI, the percentage of eggs fertilized is better (under high magnification) - choosing the ones with minimal abnormalities, and thus has better potential to fertilize and make a higher quality embryo, which translates to more ongoing pregnancy. SHER has been doing 100% ICSI has been doing this for at least 10 years. Not every clinic does this.

If there is a male factor (qualitative or quantitative abnormalities of sperm), the only option you have is to do ICSI. The selection process is really very key.

Women get excited when they get scanned and have a lot of follicles, but get disappointed when very few become fertilized. While ICSI helps, the fact is, the majority of eggs are not going to make a baby. Starting with more eggs will be to a patients advantage to some degree because you will have more that make it through the fertilization stage, then to day 3 and 5, but nature weeds out the abnormal ones as the process goes on. The goal is to maximize the process and attempt to make sure a good egg will make it - thus doing ICSI.

When to Transfer Embryos in IVF - Day 3 or Day 5?
Are physicians and doctors still transferring at day 3, or are they waiting until day 5? The overall thought is if an embryo is going to make a baby, then it will, regardless of the day. However, as technology has advanced, you can take the embryo to a farther stage to allow (the blastocyst stage) you to select embryos that will have a better chance. Before, technology wouldn't allow you do this. The problem is you are trying to reduce the number of multiple pregnancies. Day 5 is the best way to go these days. For example, if you have 10 embryos on day 3, that all look good and the same under the microscope, you pretty much know that only half will make it do day 5. Your chance of picking the wrong ones increases when you have so many embryos. So a patient who only has 3 on day 3, it doesn't matter when you put them in (if you wait until day 5 or not), but it does increase higher multiples. So between day 3 and 5, you let them natural deselect.

Grading Embryos?
How do you compare at day 3 to see what will be the best? Two easiest and cheapest to help select embryos:

1) Natural Deselection - letting nature choose

2) Morphological Appearance at a microscopic level (chance for implantation, checking for fragmentation, etc. This is where experience of an embryologist comes into play). A high number of good quality embryos on day 3 makes it more difficult. Is there any medical reason to transfer on day 3, rather than day 5? No. The only reason is if the patient wants the doctor to (perhaps the belief that they are better on the inside than the outside). If you only have 2 or 3 good embryos on day 3, you should still wait it out.

Do you think that day 5 will be the max for how long you can grow and embryo in a dish? There are reports of people doing day 7, but it all comes back to when fertilization takes place. Going to day 6 isn't unusual, but it's more like 5.5 for Dr. Ahlering's clinic. The embryo has to hatch and once it hatches it has to attach to an endometrial lining and begin the process of implantation. Going beyond day 6, practically speaking, it probably isn't happening. It will need to be cryopreserved or transferred at that point because it will die off if it can't implant after it hatches.

New Techniques for Selecting Embryos
Day 3 objective techniques to select if you have more than 4 or 5 encourages better pregnancy rates. If you don't have a good number of embryos on day 3, you simply put them in and let nature decide. If you do have a good number, you can use these new techniques on day 3:

1) PGT or CGH - which assess the chromosomal abnormalities. The number one reason an embryo fails to implant and make a baby is due to chromosomal issues, so accessing the status is very helpful.

2) HLAG Testing - A protein marker that can be tested on day 2 to access the presence of HLAG in the culture medium of the embryo. This involves taking out the fluid that has been nurturing the embryo and testing the fluid, and leaving the embryo untouched. If there is the presence of HLAG in certain amounts, it suggest it will have better developmental potential, thus reducing the number of embryos you have to put back in. So if you choose 1 or 2 embryos which test HLAG positive, you increase the likelihood that you will will have as good or better pregnancy rate. This is a non-invasive procedure because the embryo itself is untouched - only really using about 50 micro liters, a very small amount, to test with.

Keep in mind, one of the main reasons any of the above is done is to prevent the need to put back in a large amount of embryos, thus keeping the higher multiple probability down.

How many Frozen Embryos to Transfer?
Is there a typical number of embryos transferred in a frozen cycle? Factors which will help determine this are:

1) Age
2) The day the embroys were transferred on
3) What happened with the previous fresh cycle and some of the medical issues that might factor in - successful pregnancy? Date of transfer?

General guidelines, assuming it was blastocysts that were cryopreserved, the big question - does cryoproservation negatively affect the potential of any given embroy? The answer - yes, it can probably affect the embroys viabliltity depending on how it was frozen. For example, using a process called vitrification, vs. the old-school cryopreservation. So assuming they were vitrified as blastocysts, let's use a 34 year old as an example. You would thaw and culture let, meaning you them set for 4 hours to see if they survive. Most will survive the immediate thaw, but sometimes one or two will drop out which is why you culture them - then you put in what remains. In the case where you have a lot of embryos you can use a combined approach - culture 4 and if you have only 0 or 1 that makes it thorough the culture process, you might do a quick thaw and add in 1 or 2 embryos to get a total of 3 and then do the transfer.

It definitely gets more tricky with a frozen cycle, which is why you need to work closely with your doctor to decide which strategy to take. However, using a strategy like this you can optimize the per transfer outcome and minimize the number of transfers to go through all of the embryos - thus being better on the patient and ultimately keeping costs down. You are thus optimizing the chance for an ongoing pregnancy per transfer. In summary you can afford to be more aggressive in the number that are transferred, factoring in the fact that cryopreservation can degrade somewhat. However, if you are freezing normal-grade embryos, you are probably working with a very similar playing field, however, not all embryos are tested before they are frozen.

In the example of a 34 year old, Dr. Ahlering comments he doesn't recommend putting in more than 4 cryopreserved blastocysts, because you increase the odds of having a higher order multiple. If you are comfortable putting that many in, its all in how you go about getting those 4, as mentioned in the previous techniques.

Ultimately, Dr. Ahlering likes to ask his patients how many they want to put in. The patient typically ask him how many he recommends, and he then factors in their entire situation and makes a suggestion.

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Closing Thought...
After knowing what I know now, I find it very hard to believe that a doctor would ever find it ethical to transfer 8 embryos with today's technology. The fact that so much testing can be done now days prior to the transfer would indicate that you would have no need to "increase the odds" by way of putting in more than enough. With new technology, we have come so far in the last decade even that the increasing the odds method just doesn't seem to make sense after a certain point. For most people it would seem that "point" is 2-3 and anything above that (4 to perhaps 6 max) is a very rare occasion.

I know I said in a previous post that I would leave the technical medical debate about the octuplet situation up to doctors, and while I still agree to that, I have now formed enough of an educated opinion that I find it hard to be OK with what she requested and what her doctor ultimately executed. I hope most people recognize that this isn't the norm, nor the accepted standard for this part of the medical community, and that infertility isn't given a bad name going forward. Most everyone involved, including myself, wants a happy healthy baby to be conceived and born under the best circumstances possible. It's not simply about what the patient wants but also, and most of all, it's about the new life that is being brought into the world thanks to these treatments.