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.

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.

She's back... and, again, I couldn't be happier!

The world really does know way too much about my life. :) The thought of sharing what seems like really private information to you all, when I stop and think about it, is pretty funny. All in the name of infertility and trying to, not only figure out my body, hopefully help another woman who might be reading this, better understand her body, too.

In the arena of TMI
I'm here to announce that I have somehow managed to start another cycle on my own. Yes, another. Twice in a row!! AND, this time, instead of my cycle being 90-something days long, was only 43. Quick, somebody give AF a gold metal, because I think she deserves it :P

In my little pre-IVF world, this is GREAT news! Not because I think this means we'll now get pregnant on our own (because we still have tube scarring and sperm count issues), but because it does open the door a bit wider to the *possibility* of a miracle happening one day, provided this trend continues (crossing fingers and toes on this one!). Otherwise, it would have been close to impossible, aside from any miracle that God might assist in ;)

This is also good because, honestly, I just feel better! My body actually feels more in sync with itself, which I'm sure has something to do with the fact that my hormone fluctuations are more "normalized" (going up and down as they should in a "normal" woman's cycle).

I assume most people who stumble on this blog already know how to chart their cycle (because more than likely you too are having issues getting pregnant), but I also appreciate the fact that there are "newbies" who are just getting started on this whole roller coaster like I once was.

For those who are new to this...
Or, didn't know that you could track symptoms and know more about what's happening with your body - well you can! By simply being more in-tune with your body and keeping an eye out for fertility signs you can tell WAY more than you ever thought you could. I won't go into too much detail on here about the ins and outs of what to look for, because honestly, FertilityFriend.com does a fantastic job of covering everything you ever wanted to know about how your monthly cycle works.

If you'd like to learn more, I'd recommend checking out their site. In particular, they have both an online e-mail course you can sign up for (where they will e-mail you daily lessons for a few weeks - I did this first and it was fantastic!) or they've also put together an online handbook which takes you through the process in one fell swoop.

Below is my chart for this past cycle... see more TMI ;)
What's neat about it is that you can get really close to figuring out when you most likely ovulated. Last cycle I was SURE I ovulated... this cycle I'm pretty sure, but I didn't have the typical O pains like I did before. I DID, however, have lots of other tell-tell signs, as you'll see highlighted in the O window I've plotted below.



In the end though, this is just as much for me as it is for a newbie. A girl can't possibly recall everything! And, I find that if I don't write it down, I will never truly be in tune with my body, let alone notice what happens from one cycle to another. As you can see from my chart, I've long sense stopped obsessing about taking my temp daily (was never a good indicator anyway, since I have PCOS) and have found that this is the perfect happy-medium!

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

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

Our final list of questions were:

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

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

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

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

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

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

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

Diagnostic test follow-up appt made!

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

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

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

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

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

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

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

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

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

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

Day 3 Bloodwork for Infertility

I should have posted this a long time ago... really for my own records, but also because you never who who might stumble upon this and see something that I didn't from these numbers. Here is a guide I found online that helps to interpret these numbers. Not all were listed, however. I've also listed the ranges that were noted as acceptable on my lab paperwork, since I'm sure this is what they also go by to gauge if there is a problem or not. Even still, I know that varies from lab to lab.

Below are the hormone results I got back from my CD3 bloodwork I had done back in Dec '08. At the time. I expected to see the typical PCO results, as described here, saying "While many women with PCOS still have LH and FSH still within the 5-20 mlU/ml range, their LH level is often two or three times that of the FSH level."

Unless I'm reading into these numbers incorrectly, there are really no other cause for alarm other than the PCOS indicator mentioned, so that's good. If your reading this and feel like I've overlooked something, please don't hesitate to speak up. In fact, I welcome it, as always. :)

LH: 23.7 (try four times higher than my FSH)
follicular phase is 1.9-12.5

FSH: 5.5
follicular phase is 2.5-10.2

TSH, 3rd Generation: 0.81
normal range for my age is 0.40-4.50

Fasting Glucose: 77
From 70 to 99 mg/dL (3.9 to 5.5 mmol/L) Normal fasting glucose

17-Hydroxyprogesterone: 50
Normal levels are 3-90 ng/dl in children, and in women, 15-70 ng/dl prior to ovulation, and 35-290 ng/dl during the luteal phase.

Androstenedione: 218
follicular phase: 35-250

DHEA Sulfate: 243
range of 45-320

Insulin: <2
*this seems low... which I guess is ok? Here is an interesting article on lean PCOS women with normal insulin levels. Not sure if it really means anything at this point or not though.

Prolactin: 13.0
non-pregnant women range 3.0-30.0

Estradiol: 55
normal follicular phase range is 11-212

Testosterone Total: 36
range is 2-45

Testosterone, Free, as a percent: 0.88%
range is 0.50-2.00%

Testosterone, Free: 3.2
range is 0.1-6.4

My blood type is: A Positive (can you believe I didn't know that!)

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.

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.

RE suggests IVF after ultrasound reveals scar tissue

Our appointment with Dr. Peter Ahlering, our RE, yesterday went better than I expected in the sense that my fluid ultrasound (FUS), which I also think is called a sonohystogram, didn't hurt one bit. I had taken a pain killer I had left over from when I got my wisdom teeth removed, figuring it was a good precautionary since I read some women seem to experience a decent amount of pain, but I don't think I even needed it. Basically, once they had the speculum in, I must have been distracted enough to not even notice when they put the catheter in, which was nice. I also didn't have a problem with cramping afterwards, so all in all the actual procedure itself went well.

Ok, so that's pretty much where the good news ends. Honestly, going in I didn't think we'd actually learn all that much from the ultrasound. I knew he was going to count follicles and all, but I thought that it would pretty much just be a confirmation that I had a PCO ovary. Which I did, and I guess in the case of considering IUI or IVF, that is a good thing because each will have the potential to mature into a large, viable follicule.

The big news was that my left ovary, my only one, is right on top of my uterus, rather than off to the side with it's own breathing room. He said he tried to use the ultrasound wand to poke it a little, trying to move it, and that typically he would be able to do so, however, in my case, my ovary didn't really move, which means there is probably some sort of scar tissue that is now bonding my ovary to my uterus... much like super glue I guess. He said that he's not that surprised to see that, considering my history. He asked again the nature of my incesion (mine is vertical and stretches from my belly button down to my pelvic bone) and said that it's pretty common when the pelvis area is opened up so much to have some adhesion occur (from the surgery, and I suppose also from the large, grapefruit sized ovarian cyst that was in me for a short time). Whenever there is adhesion, there is some amount of scarring upon healing. That scarring, or new tissue, can occur on or around organs.

So what does this all mean? Well, he said that this more than likely means that my ovary won't behave in a normal manor. He still thinks they can get me to stimulate and produce viable follicles, however since we're probably seeing signs of scarring, there is more than likely scarring or an irregularity to my only remaining tube on that same side, therefore, it will not work properly. His words were, and I quote, "I'm going to be so bold as to say I would recommend skipping the laparoscopy surgery (and therfore also skipping IUI) and going straight to IVF". The reason for this is because the laparoscopy would only be a diagnostic surgery designed to determine if there is actually scarring or damage to my tube. In his opinion, since this already seems to be the situation as shown in this recent ultrasound, there isn't much reason to do it, other than to confirm that what he believes to be true is in fact true. I did ask if this also meant I would have a problem carrying a baby to term, if I did ever get pregnant, and he said that no he doesn't believe it will have any bearing on that. That, at least, is a bit of good news.

As you might guess, we didn't expect to hear IVF is our only real option at this point in time. I have mixed feelings about the whole situation. On one hand it's nice to know, plain and simple, what we're really most likely dealing with so that going forward we are making decisions that are sound. I mean, why waste our time with things that most likely won't work. On the other hand, I had begun to have a glimmer of hope after hearing how much an IUI was. Before this appointment, we were feeling like we could financially swing 3 or 4 rounds of IUI without it taking too much of a toll on our savings. IVF is different - in fact so different, we could do about 5 rounds of IUI for what it will cost us to do one round of IVF.

I am honestly not sure where we'll go from here. Next Wednesday we have a follow-up appointment with the RE to go over the results from all of our tests - my bloodwork, the semen analysis and my ultrasound. Depending on what the findings there are, it could change things slightly. If the SA comes back normal and my bloodwork isn't too out of whack, it might be worth geting a second opinion on my scar tissue situation before deciding to completely rule out IUI as an option. Even with that said, knowing my ovary has issues, and knowing that PCOS women tend to have problems with producing good, viable eggs (PCOS women apparently produce lots of follicles but generally are of poorer quality), that might be another reason to opt for IVF, since it's the only way to really watch the egg during the fertilization process to see if it's maturing properly. After the follow-up appointment, we will most likely sit down with one of their financial coordinators to get an idea of what our financing options would be, should we decide to move foward at that clinic.

Obviously we have a lot of thinking to do about where we will go from here. At this point, I really feel like in my heart IVF or adoption will be our only way to have a child. I know that both of those will require a lot of time, money and potentially emotional strain on us and our relationship. I also know that ultimately it will mean our family will grow not only larger, but hopefully closer and stronger in the process, and that is what I truely hope and dream for.

New Doctors. Lots of Appts. Full Steam Ahead!

Boy do I have a lot to talk about this time around!

Meeting the new OBGYN
So, as you may remember, my last OB left the St. Louis area and left me high and dry. I had only been going to her for a little over a month. At first I was really bummed because I thought she was "the one" - she too only had one ovary and one fallopian tube, and she was able to get pregnant without too much trouble. However, at my last appointment with her, I realized she might not really know all of what she's talking about. She said she doesn't do mid-cycle monitoring while on clomid, so we had no way of knowing if my follicules were maturing properly the on the first round. She would also talk down to me a bit... more like giving me the look of "you silly girl"... which got old quick.

This idea of going to a new OB wasn't the worst thing ever as a result. I was hopefully she would know more about infertility - she was older so one would think that would mean more knowledgeable. I was wrong - again.

Maybe it's too much for me to be judging her too much too early, but in this type of situation it's half gut feeling and half what plan or advice she recommends. I didn't get a warm fuzzy on either of those. My gut told me "this isn't the one"... it was pretty obvious too because my husband said afterwards "I thought that if she told you to calm down one more time you were going to scream". I guess my body language is pretty outspoken.

I DID like the fact that she asked more about my female history than any other doctor ever has. It's amazing how reassuring that alone can feel. When she took a look at my chart and saw that this second round of clomid was, at the time, 52 days long, she said "that is unacceptable". She was baffeled as to why the clomid didn't work and asked why the last OB upped my dosage. (Remember that was done with the intention of it upping my ovulation date). I honestly think she thought I might have hyperstimulated and asked that we do an internal ultrasound that day. In the ultrasound room she took the time to show my husband what we were seeing - again my uterus looked good and I think she said my lining was at 5mm (not sure what this means for CD52 and she didn't really say much either).

Then she asked what ovary I still had intact. I am embarassed to say I can NEVER remember the answer to this question. I mean really - it's not like I dress it every day! For the record, if you must know, I have my left ovary (and apparently a little of my right still). I believe that she said I had around 5 or so follicules, but I don't remember for certain. I do know that she said there were several follicules that were not ovulatory follicules (were too small I think) and that there was one larger one, but it was oddly shaped. She said she thought this was because it was on the verge of being absorbed and there was nothing to worry about. She did confirm that there was no PCOS "string of pearl" style cysts present and thought that meant that the clomid was doing something, just not enough. She didn't know why this cycle was so wacky.

I asked about doing an HSG because I was concerned about my only tube being blocked (have read scar tissue from past surgery causing this). She said we shouldn't be looking into this right now because I'm not even ovulating or having a normal cycle. That we should first solve the ovulation issue and go from there. I didn't wholy agree with her - what if it IS blocked and all these months and clomid cycles are for nothing?

I also asked about whether we should have a post-coidal test done, since my cervical mucus was slim to none this time around (wasn't super great the first time either). She again stressed that we shouldn't do this now - it would be too premature because we don't even know if I'll actually ovulate and we would need to time the test around when we think I'm ovulating. I also didn't completely agree with her on this one either. My question is, isn't there another way to still do the test... like have me do the OPK testing and when I get a positive, schedule the post-coidal? Or, since OPKs detect an LH surge, wouldn't it make sense that if I get a positive OPK, I could come in to have bloodwork done to see if my LH is actually high and, if so, do the post-coidal then??

Of course that's assuming that we have Day3 bloodwork to measure from. Which we don't. In all fairness to her, I never mentioned this when she asked if I have had any bloodwork done. I just whipped out the results from the one test I had ((FSH 4.8, LH 18.3, TSH 1.58) which was actually done on CD13 by my OBGYN (3 OBs ago... can you believe I've been to some many different ones in the past 8 months!). That OB said "you can get it done any day", so I did. Honestly, at the time, I think she was simply looking for the FSH to LH ratio to determine if I had PCOS. As you can see it my LH levels are clearly more than 3x what my FSH is. I still think I should have these done again on the correct day - CD3.

She did, however, want to check my prolactin (which could help tell us if I have a pituitary abnormality) and estrodial levels (produced by the ovaries and the brain and will help tell us the baseline of estrogen in my body). The estrodial level is important in part because I have amenorrhea (lack of menses). Apparently estrogen monitoring during fertility therapy is also helpful to assess follicular growth. Seeing as how right now we have no way of knowing if the clomid is actually doing anything, that might be something to check out, though she certainly didn't suggest that. While I'm greatful she mentioned wanting these levels checked, she said I could get the blood work done anytime in the cycle - however, that simply isn't the case. Pretty much any infertility clinic website you read states clearly that estradiol (and others like FSH and LH) must be drawn on CD3. Prolactin can be any day of the cycle. The fact that she said any day makes me really doubt her expertise.

Oh, and I didn't mention that since my cycles are so unpredictable, and therefore my ovulation date is as well, she doesn't want to monitor follicule growth mid-cycle like she normally does. She said it would be "too difficult" and said to just wait it out to see what happens and to call her if it's day 40 and my period hadn't shown. I also don't agree with this decision. I don't really want to keep going with clomid if I have no measurable data with which to make a decision on what to do next cycle. Given the fact that doctors don't like to do clomid for more than 6 cycles (she also practices with this rule), this would mean I am getting ready to embark on my 3rd cycle and come out of it with very little new valuable data. That just doesn't sit right with me.

After talking it over with my very patient, and I do mean patient because I over-talk things, husband, he too agrees it would be silly to continue on the same path with no new info. We came up with few scenerios about what to do (since I'm now on my 4th progesterone pill and will start my period soon, which means that IF we want to immediately do another round of clomid, we'd be starting that on Dec 23, CD3). In the end, we decided I would call around this week to try and find another OBGYN who is more compassionate (I don't think me and this last lady would get along, let alone the fact that I don't think she's very knowledgable in infertility) and has more expertise in infertility. We also wanted to begin calling around to see how long it would take to get in to see a reproductive endocrinologist (RE) and how much an initial consultation would cost.

I had some extra time on my lunch today and was able to get a lot accomplished... drum roll please.... :)

New, new :) OBGYN Appointment Made - He does IUI's!
Dec 30 at 2:30 pm - I came across a local St. Louis baby forum with some OB recommendations and saw the name of a doctor located in O'Fallon, Missouri near Progress West Health Center. The poster said "he does IUI's". I was floored and thought there was no way! So I called and, yes, all three doctors in their practice do them. Not that that's what we will end up doing, but it does make me think that if they do a more advanced procedure like that, surely they know more than your average OBGYN. I have to admit - the only thing that bugs me is that he's a dude. I've never gone to an OB of the opposite sex, but, if he knows his stuff, then I guess it will be worth it. At least my husband will be there with me on the first appointment!

For your reference, the name of the doctor I'm referring to is:

Allied Associates OBGYN
830 Waterbury Fall Dr. O’Fallon, MO 63368 (near Progress West Hospital) (314) 569-2751
Dr. Craig Boyd - 21 yrs experience; board certified OBGYN; can do IUIs!


Appoinment Made with a Reproductive Endocrinologist!
Get this - Dec 23 at 9 am. I am so amazed that he could fit me in so soon! And, hold on to your pants, the consultation cost is: F-R-E-E!!!! Whoo hooo!!!!!!!!! I actually had to ask her to repeat herself and then, when I called back to make the appt, I asked the other girl who answered to confirm that. I just couldn't believe it. Especially since I had just got off the phone with another Infertility Clinic in the area who couldn't get me in until the end of January and who's initial appt cost would have been $300-400. Believe me, I'm still asking myself what the catch is with this other one I found. What's even cooler is that this is the same doctor that I listen to quite frequently on Haveababy.com Life's Online Infertility Talk Radio show. I always make note of who the guest was on the show when I take my own personal notes, in case you're curious what he has to say. It has been a great way to sort of get to know how he probably talks with his patients at the clinic and makes me feel much more at ease. Thus far, he seems to be very kind and knowledgeable.

Here is his information:

SHER Institute, St. Louis
456 N. New Ballas, Suite 101, Creve Coeur, MO 63141

Dr. Peter Ahlering
Obstetrics & Gynecology - 16 yrs experience

Sub-specialty: Reproductive Endocrinology

So... where does that leave us? Well, our tenative plan is to play some massive doctor toss-up. Meaning, on Dec 23 at 9 am I will go see the RE. We will probably talk about my history and he will recommend a battery of tests he'd want done before laying out a game plan. I am going to mention where we're at with our OB currently (getting ready to start a new round of clomid) and see if he has any opposition to that. If not, I will go the appointment that afternoon at 1pm with my current OB to have my CD3 ultrasound done prior to starting clomid that night. Then, on Dec 30 at 2:30 pm, CD10, I will go to the new OBGYN. We wanted to get in to see him before the time when I should hypothetically be ovulating so that if he wanted to do mid-cycle monitoring, we would still have time to do that. Though it just dawned on me that we'll be in Chicago at that time!! I can't believe I didn't think of that until now. Looks like we have something new to talk and think about. Oh well, not going to let it ruin my day. I am on cloud nine with the free consultation and the new OB am just going to trust that it will all work out. If we don't immediately do another round of clomid, then that might be ok, depending on what the new doctors think.

Ok, off to do some last minute Christmas shopping and grocery shopping for holiday parties. Should be fun :P

Which to Use & Why: IVF vs IUI

Dislaimer - Please note this is my personal synopsis of the free online radio program hosted by Kim Haun, founder of Conceive Magazine, with guest Dr. Peter Ahlering, an ob/gyn and medical director of the Sher Institutes for Reproductive Medicine in St. Louis. It is in no way meant to quote the either of the parties mentioned above.

To listen for yourself, go to this site and find the show in the archive on the left, dated 7/3/08, titled "IUI or IVF - Which to Use".





Ways to try and get pregnant are somewhat limited. They are:

1) Natural/No intervention - OPKs, timed intercourse
2) Ovulation Induction - various meds (clomid, injectables, metformin)
3) IUI
4) Artificial Insemination, often used with 2 & 3
5) IVF

Nature of problems determines what you do. Sometimes treatments are used when they shouldn't really be - when it wouldn't really do anything more than they're already doing.

Breakdown chances of IUI vs IVF

If used in the right circumstances, IUI is helpful.

Patients need to understand what they're trying to achieve. Pregnancy is ultimate, but in reality with ovulation induction you're trying to get multiple folicles to grow and ovulate. You have two ovaries and two tubes (normally) and sperm go both ways down each tube. If you have one or more follicules on each side, you're going to improve chances.

IUI is getting isolated, concentrated and putting it closer to where it needs to be for fertilization (half way there - bypassing barrier of the cervix). Limited because you're not influcing the initial steps of fertilization called ovum pick-up, where ovulated egg is picked-up by the tube and fertilization occurs at the farthest point of the tube from where it's picked up at the uterus. Embroy if the egg is fertilized, it needs to move back down the tube to grow and divide (about 5 day time) and implant into the uterus. All needs to occur still.

In terms of producing more eggs, what are the differences between the various drugs.

Pills - similar to shots, but they are designed to get at least one follicule to grow and ovulate (better than nothing). If you're already ovulatory, the pills don't work real well to get multiples. Clomid isn't very effective at this - in most cases you're getting one or two.

Most doctors don't monitor because they know hyperstimulating or multiple babies is very low, but this still isn't effective because you don't know if it's working.

You wouldn't use clomid in older patients (mid 30s or older). You would go to shots immediately. Pregnancy rates on shots is about double that of clomid. Why? Clomid is better at getting multiple follicules to grow and doesn't have the side effects, including thinning of lining or hostile ferticle mucus because of anti-estrogen effects you get with clomid.

Shots vs Pills - Shots are always more effective for any person.

Clomid & Letrozol - Generally with individuls with ovulation issues.
Metformin - PCOS (not to be used in all ovulation dysfuncation patients); is also used in conjunction with other things like clomid.

If you don't get scanned and you take clomid, and if it doesn't work, and then going straight to IUI probably doesn't make sense. (Jon & Kate + Eight?) Always use ultrasound monitoring because is it doing what you want to do - 1) growing follicles, and 2) not to many follicles.

Taking shots gives you multiple follicles which gives you higher chances. Pills is for women who are having problem ovulating. By the time you generally go to a RE, you've already tried clomid and it didn't work. However, when a person comes and hasn't tried anything, it depends. In young patients who don't ovulate, you probably still start with clomid and do and ultrasound around day 11 or 12 to find a dominate follicle and, if there is one, do an HCG injection and then you know when he window of opportunity is.

IUI Success depends on...
Success of IUI, is it dependent on the more follicules, with out a dangerous level, will increase her chances because a lot of eggs are abnormal and don't produce, but sometimes they can all fertilize. Three is an ideal number to give you the max benefit by getting pregnant, but still minimizing high order multiples (more than twins). If you are older you can do 4-5 follicles, but often these patients don't produce this many because the reserve is lower. These people though probably need to move to IVF.

Why does it increase your chances if you do IVF?
Because IVF bypasses all the things that occur inside - tubal pick-up, fertilization is largely taken out of picture as a problem. Can monitor embroy development and you can select embroys (sperm with ICSI) - you remove the potential stumblling blocks. Goal is to get as many as you can to grow, so you get more eggs (if you can) 10, 12 or more. If you have that many during IUI you don't go forward.

If you were planning on doing an IUI and you produce that many, you can turn it into an IVF pretty quickly, if patients wants. Doesn't happen too often.

What happens when you cancel a cycle?
If you have to cancel a cycle, one method is to prevent ovulation with an injection called Antagonist which stops the LH surge rapidly. Then you take birth control to bring on the next cycle in a timely manner. Then you do the process over again.

Listener Question #1:
Situation: One IUI $1,400 failed. IUI or IVF again?
Answer: IUI three in a row gives a positive result. If you go down IUI and meds route - be in it for 3 or 4 because that's usually what it takes if you have a good cycle - multiple follicules and good sperm specimin. If you get a "good" cycle, most patients who get pregnant will do so within that time. Various problems do determine the outcome.

Listener Question #2:
Situation: If you want to get pregnant, and if money isn't an issue, should you go through all the initial steps, or go straight to IVF?
Answer: Some people prefer to do this to get pregnant sooner and to control high multiples (twins still common), and for other things like gender selection. Age does matter - in both quantity and quality.

Success on First Try with Infertility Treatment?
Should someone walk in an expect to get pregnant on the first try? No, not normally (in best patient profile, 25% chance, say ovulation dysfunction problem) You need to be willing to be in it for 3 or 4.

Listener Question #3
Situation: Husband's sperm analysis 43 mil count, 34% motility, 4% morphology (a subjective assessment). 4th one high as 11% and as low as 3%. Should she rush into IVF or give IUI a chance?
Answer: Wouldn't base all on this. Ask, 4th part of test (DNA fragmentation), you have to find out this answer. "unexplained if" is often related to acult DNA male factor. Is an independent predictor of infertility. If DNA is ok, shots and IUI would be reasonable to try.

Can sperm that has a DNA problem, can it fertilize, but then have a problem down the road? It more effects embroy development. Looking at how the DNA is packed together in the cell itself. Needs to be tightly organized to fit into cell. If it's not packaged together, once it unwravels inside the egg after, it won't develop right. This test has been around for about 6-7 years.

Listener Question #4
Situation: Does accupuncture help if you're doing IUI or IVF? How do you know if someone specializes in infertility - I will ask, but is there one way to check?
Answer: Isn't the make or break. Doesn't really increase chance with infertility treatments. Isn't a problem to do, and there isn't a negative... you might gain other things from it - stress reduction, etc. Is welcome, but not highly suggested, and definitely not required. Has been more popular in last year or two, and no higher increase in pregnancy rates, in this doctor's opinion.

Listener Question #5
Situation: Up until Jan, I had failed to respond to ovulation induction. LH 18.2 FSH 9.6. After ovarian drilling (older before metformin was around as treatment to PCOS), GNRH aganist (lupron), follicules did grow and an IUI was scheculed. Too many so was converted to IVF. 7 eggs retrieved, 5 fertilized (2 grade A put back) no success and no embryos to freeze. Instead of doing IVF again, suggested IUI instead. Does this make sense?
Answer: No not really. Is hindered by the fact that if you did the right protocol with IVF and it sounds like you have PCOS or have a high response to meds you half did IVF with this converstion. In this case IUI might be a step backwards.

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).

Looks like I might ovulate after all :)

So, the newest series of events in the clomid round two saga is that the temperature rise (which made it look like it dipped) must have been a fluke due to my cold and I actually haven't ovulated, yet anyway. I had been going back and forth in my mind, really wishing and hoping it wasn't true and that I had ovulated, and figured it would be a good idea to just run my chart past my new doctor and see if she wanted to do a progesterone test. I did end up having it done and my results were that of an anovulatory cycle - 1.2.

But... Today is CD30 and I think I will ovulate any day now. I had my first positive OPK on Saturday and have had a positive every day since (3 days, not counting today, which I won't know until this afternoon). They say you could ovulate anywhere within 12-36 hours from either the beginning or end of your LH surge. So, again - we wait.

In the past week or so, I have continued to have side effects from the clomid. I had hot flashes about 4 or 5 days in a row, mostly in the evening. And then, the previous two days, I had been nauseous in the AM and in the PM. Yesterday I came home with a headache and sat down to eat supper, thinking that would get rid of it. As I was finishing my last bite, I was thinking "I feel like I'm going to barf if I eat this". I did some googling and it seems that some women experience nausea around ovulation time. Weird. Maybe it's not due to the clomid after all.

As with every cycle, you can't help but wonder what the next step will be if the current cycle doesn't bring a BFP. With this cycle, even though I haven't even met my new doctor, if we don't get pregnant, I believe she will want me to do at least a month of birth control to try and suppress the cysts that are present. I believe the idea is that we might be more successful if we can just get them to go away and try the clomid without all of that present. Someone did bring up the question - is there another TTC friendly way of doing that same thing, instead of doing BCP, where you have no chances of getting pregnant that cycle. Good point. It had crossed my mind once, but I forgot to look into it.... my initial thought was is there some regimen of hormones (customized based on your personal, current levels) that would get rid of them. I still need to google and ask my doctor about this, if we end up needing to go that route. If I do have to go with BCP, I wonder which particular one will be right for me in my circumstances (for example, one that is better about clearing your system so that we can TTC the next cycle).

I decided while I am writing this that I would look into the suppression alternatives now - why wait :) I came across a site that tates "The oral contraceptives suppress gonadotropins which support "functional cysts". So, if the idea is to suppress gonadotrophins, and that is the only way to get rid of cysts, then I don't think that it's possible to get pregnant. I think you need gonadotrophins to be released for the rest of the key hormones that encourage ovualtion to work. So, I'm betting that a BCP alternative is out of the question, but I will definately still ask. The worst that could happen is that I get a weird look from the doctor, and I'm used to that by now!

I also came across this, though, and now I'm wondering if BCP would even work. When asked if BCP or injectable progestins (DepoProvera) prevent the formation of ovarian cysts, Dr. Frederick R. Jelovsek replied "Oral contraceptives are known to block ovulation in women with polycystic ovarian syndrome as well as lower the circulating androgens which can cause excessive hair growth. They are also used as pretreatment to decrease cyst formation when giving LHRF for in vitro fertilization. Thus they can be used to lessen the risk of new ovarian cyst formation even though they will not suppress any currently existing cysts. Neither oral contraceptives nor injectable progestins totally suppress all follicle development but they do suppress large follicles in the range of 3.0cm." I'm so confused. I know you can't believe everything you read, on the internet especially, but I am very curious now.

Anyway, I need to stop and focus on the here and now. Please be praying that I ovulate soon!! :)

I started my second cycle of clomid this week!!

Well, I saw my OB on Wednesday. We did actually - that's right, me and my husband! I was so happy about that... it made me feel so much more collected mentally when I was there and it was just nice to have him move involved.

She agreed that I did ovulate last month and I had a perfect temperature rise, which is great news. The not so great part is that I ovulated late on clomid (50mg), which isn't ideal, however I have read mixed reviews on this...

This RE thinks that only short cycles are a cause for concern, and that long cycles usually indicate excess ovarian reserve, which is a good thing.

Whereas, this ART company's site states that "too late" could be anything after CD20 which simply means that there are fewer cycles in a given time period to try for a baby, and that you may be releasing eggs that haven't properly matured, or that the other parts of the reproductive system aren't in sync with the egg. You can conceive late, but your chances are just reduced.

With that in mind, she wasn't sure what to do next really. We asked her if I ovulated late because of PCOS and excess cysts, and she said it's really hard to say why. She said we DO know that the Clomid did "something" because I ovulated and my temps looked good. That's when she started debating on whether or not to do another round of clomid or do supression with birth control. She ended up doing another transvaginal ultrasound to see what my ovaries looked like, and I still had cysts - no more or less than last cycle really, which she said was fine - and the good thing is there were no big cysts. She ended up polling the other OBs in her office to see if I should stay at 50mg or up the dosage to 100mg (the vote was split), and she ended up deciding to up it and move my start date to CD3 - both in hopes that I will ovulate sooner. From what I've read it's hit and miss. I am concerned that the larger dosage might do two things - cause large cysts to develop (which I want to look into more, and to see if metformin actually descreases this chance) and that it might dry up my cervical mucus, which you need so that the sperm can travel through your vagina and into your cervix to wait until the egg pops.


Taking Robitussin to Increase Cervical Mucus
To address the last problem, I am going to give Robitussin a shot. I didn't have but one day with egg white cm last month on the lower dosage of clomid and don't want to chance it being worse.

I did a little research and BabyHopes.com states that you should take two teaspoons (200mg), three times per day. When taking it during a clomid cycle, you should begin the day after your last clomid pill is taken. The site also suggests to take each dosage with a full glass of water. An alternative to liquid that I might explore (if I can't stand to swallow that stuff) is Mucinex, as it comes in a pill form. IMPORTANT: No matter which one you choose to take, the key is that the one and only ingredient it can have in it is Guaifenesin. If it has anything else in addition to this, it could have an adverse affect on your cm. And, yes, you can get the generic form of these drugs - you just have make sure it only has the one key ingredient.

On my last Clomid pill and hoping for ovulation!

As you can tell, my ultrasound went well and so far so good! I've not had any symptoms of being on Clomid (knock on wood) and feel quite fortunate. My ultrasound went well - again, revealing typical "string of pearl" ovaries - yes, you heard me right - ovaries, as in two! The most revealing part of that test is that she said I actually have part of the ovary that I thought was completely taken out. Of course, it had cysts on it as well, but it has to be good that it's there. If I'm lucky it still contains a few eggs, but I'm not holding my breathe I suppose.

Something else worth mentioning... I took a voice recorder to my appointment so that I could remember everything my doctor had to say and it worked like a charm! I figured no need to make a big deal of it so I left it in my purse and just reviewed it when I got home with my husband. It was nice because it's sorta the in between - he can still hear exactly what her feedback is, without taking time off work. I always had such a hard time remembering exactly what was said and in what order the doc mentioned things in, so this should work out nicely!

Here's what I got out of this appt:

• Yes, I have lots of cysts, but nothing to large to give clomid a try for one round (at least)
• My uterus measure an average size and shape
• The doc wanted to start clomid on days 3-7, but Monday was day 4, so we're doing days 4-8
• We were told to start having sex no later than day 9 and to NOT have sex each day, but rather every other day.
• If nothing productive happens this cycle (ovulation or pregnancy), it seems as though my OB is recommending I go back on birth control for a month to see if the cysts will go away, before trying another cycle with the clomid; I'm not sure how hard I'll push for upping the dosage first before doing that. Maybe if I don't ovulate I'll be apt to go that route, but if I DO ovulate but don't get pregnant, I might see if we can try upping the dosage first.
  

In other news :) after talking with Meghan, a friend I've made connections with through St. Charles IES, she's reopened my eyes to actually trying to get at the root of my PCOS. She recently had a success story where she changed her diet to South Beach and is taking some alternative natural supplements (such as taking soy early on in the cycle, which mimics clomid) and no longer has cysts present, etc. Such great news! While I still want to keep up with the clomid and such, I am definitely curious and want to find out how and what I can incorporate into my diet to try and correct the underlying cause, rather than simply masking the symptoms. For more good stuff, check out her blog.

Also, I came across a few articles that are worth sharing - all of which tie back to the above... I hope to read them more in detail and write about it later when I have more time. In the meantime, here are the links:

• What are cysts (cysts and follicles... does a good job of explaining the "difference")
• Help for women with Annovulatory Androgen Excess (AAE, also known as PCOS)
• Cyclic Progesterone Therapy (a way to treat AAE)
• Natural Supplements for PCOS
• Progesterone and it's Role in Getting Pregnant (**important info about miscarriages and progesterone, as well as ovulatory dysfuncation and progesterone)
• Fertility and Ovulation Day-by-Day (nice explanation of what does what and when)

Live Radio Interview with PCOS Expert

Information about this was posted to a group I'm a member of and I wanted to pass along the info:



Today's Creating a Family internet radio show, August 13, 2008 will be on Polycystic Ovarian Syndrome (PCOS), and the guest will be Dr. Marcelle Cedars, director of the University of California at San Francisco Center for Reproductive Health. Dr. Cedars specializes in the diagnosis and treatment of PCOS. As always, the show is live from 12-1 Eastern Time, but you can listen to it anytime after it airs at the radio page of www.creatingafamily.com (click on radio page, then click on the play button) or download it as a free podcast from iTunes.



Update: Here is today's PCOS show from the archive.