Tag Archive | RE

A La Dr. Young

I had a successful appointment with my RE this afternoon. I went there feeling jittery with nerves. I was expecting to leave feeling discouraged, after hearing nothing but gloom and doom and being told that our only hopes of conception are IUI or, worse, IVF. I got none of that.

We came up with a plan going forward, which I’ll get to in a minute, but first, we talked about plenty of other things. A *quick* summary:

  • Dr. Young thinks it’s probably wise to quit taking all the vitamins that we are on as they aren’t well regulated and there is not solid research proving that they are beneficial for reproduction. She thinks the only ones to continue with are the prenatal, omegas, and vitamin D (because of the climate we live in).
  • She would advise me to discontinue baby aspirin until after my BFP. I am young and healthy, so it is unlikely that I’ll develop an ulcer or bleeding issues from the aspirin, but it’s still possible and she always likes to error on the side of caution.
  • She will gladly prescribe progesterone suppositories, but she stressed the importance of taking them at the right time in my cycle. If I am being monitored and doing a trigger shot, I can take them three days after ovulation. If I am just predicting date of ovulation by OPKs, she wants me to wait a week just to be on the safe side.
  • She reviewed my 2009 2 hour glucose tolerance test. One value was abnormal and had me worried about possible insulin resistance, but she doesn’t think one abnormality is a concern. She would still recommend stopping the Metformin (I have been reluctant to thus far). She says she used to give it out like candy ten years ago, but after a study was done with Metformin and Clomid proving only a very few people benefit from it (by ovulating) in taking only Met, she thinks it’s unnecessary and worries about long-term safety.
  • Dr. Y reviewed my husband’s semen analysis with us and says his motility and count are excellent (which we already knew). The morphology is a concern and some doctors would automatically recommend IVF, but she says she’s not one of them. In a perfect world (where cost and time aren’t a consideration), she would say go with IVF w/ ICSI because it would give us our best chance. I’d probably be pregnant in a month or two, she predicted. But with the amount of money and time that must be invested in an IVF cycle, and with our prior two successes (BFPs), she doesn’t think it’s warranted yet. Nor is IUI. She wants to continue on the same road we have been.
  • She is billing my insurance under “PCOS” and “irregular periods,” but she did warn me that the insurance company can do with that information as they want. They could still deny coverage if they find out I’m taking Clomid. Fingers crossed that they don’t decide to be jerks about this!

Basically, from all of this, I got that my doctor is conservative in the drugs/supplements she encourages and describes, and likes things to be as simple as they can be. I respect that and I respect her. She’s got fantastic bedside manner, is open to all questions, and I appreciate that she seems well-read and well-informed. I truly trust her. However, that does not mean I necessarily agree with every recommendation. At this point, I’m going to continue baby aspirin and Metformin. I’m just too scared to quit right now. But I will re-evaluate the vitamins we’re taking and start with progesterone suppositories — but next cycle. This one, since I don’t have much hope for it and it’s already 9dpo, I’m just going to relax and take things easy.

And now for the plan… When my period comes, we will try 150mg (instead of 100) of Clomid in hopes that it may help my body to respond and ovulate sooner than CD20+. There is a greater chance of side effects, none of which I am particularly concerned about except possibly the elevated risk of cysts (because I’ve had them in the past) and the thinning of my lining. However, my last u/s (on CD16) showed a multi-layered lining of 11.5 (and that was after many months of Clomid), so Dr. Y is very encouraged that it may not affect me too much. And if the 150mg doesn’t work? We’ll do a combo cycle with Clomid (or Femara?) and an FSH shot.

I am pretty comfortable and happy with this plan. We’re moving forward, trying something new, but not doing anything too drastic. I’m slightly freaked out by taking Clomid for so many cycles and about the cost of the FSH and about giving myself an injection (eek!), but one day at a time, right? One step at a time. Breathe in. Breathe out.

Once Upon an RE…

As many of you know, I went to to visit an RE for my very first time on Friday. It was a frantic morning because they had to move my appointment to the 8 a.m. slot at the last minute, which meant waking my daughter an hour before she usually gets up and making an hour-and-a-half commute to get there in rush hour traffic. We had to park a block away and ran to the office (and I did not wear running shoes!). We arrived three minutes late, which I really hated and it left me feeling out of breath…which would probably explain why my blood pressure was 150/88 when the pregnant (of course!) medical assistant took it (it’s usually around 110/70). Ugh.

But the appointment went well, for the most part. My doctor, whom I will call Dr. Young because she is (late 30s? early 40s?), is straight-forward, easy to talk to, and open to questions. Since I’ve only spent an hour with her so far, it’s hard to have a real opinion, but I think I will like her and feel comfortable with her and I certainly do have confidence in her expertise. And surprisingly, she is in agreeance with much of what my OB/GYN, Dr. Smiles, already told me, which was unexpected but reassuring. We talked about a lot in the time that we spent with her, so please forgive me if this isn’t organized well. I think I’ll do it with bullet points (to at least give the illusion of organized thought):

  • PCOS: Yes, she thinks I have it. She says I am not a “classic” PCOS patient in appearance or labs, but she diagnoses PCOS through the process of elimination (every doctor has different criteria, I have found…I’ve seen four different doctors and they’ve all told me something different!). When someone has irregular periods, she rules out thyroid disorders (check!), prolactinemia (check!), and perimenopause (check!). If someone has no signs of those but doesn’t ovulate regularly, then she diagnoses PCOS. And it’s possible that the only sign of PCOS could be irregular cycles. So yeah…I guess that means I join the PCOS Club. Officially. My biggest fear in being diagnosed with PCOS was the high risk of miscarriage, but she assured me (just as my OB did) that there is no connection between the two. The studies that linked them were old and did not take into account diabetes and severe insulin resistance (which can cause miscarriage). If you exclude diabetics from the studies, the miscarriage risk would have been proven to essentially be the same as anyone else. So that was a relief to hear. I know there will be differing opinions on this, as Dr. Young reminded me there always will be, but I’m choosing to believe what she’s telling me. I need to believe for my own peace of mind.
  • Metformin: This is not a drug she prescribes, unless someone is clearly insulin resistant. Recent studies have shown that there is no proven benefit in helping with ovulation and she is hesitant to prescribe any drug that isn’t proven to be useful and has no long-term studies about it’s safety. I asked her if I should stop taking it and she says she thinks I should because, while I am lucky to suffer no GI side effects, there is the potential for liver and kidney problems…they’re rare but possible. And after thinking it over, I think she’s right. I have been taking this drug for three months and haven’t seen one bit of change in my cycles. I’m not insulin resistant, so why take a drug that I probably don’t need? Even the pharmacist told me that I was taking a very high dosage when I picked up my prescription last month. So I think it’s time to quit. I’ll wean myself off of it over the next few weeks and be done. I’m a little nervous about that because I know some do believe that Metformin can lower m/c risk, but Dr. Y doesn’t and I have to keep reminding myself that I didn’t need it while pregnant with Cupcake, so I probably don’t need it now either. Right?
  • Blood work: I successfully completed all the preliminary bloodwork through my OB and my RE doesn’t think any of it needs to be repeated at this time. Yay! This also means there won’t be any delay in starting treatment. Go me for totally being on top of this!
  • Chances of success: She reminded me that, with every cycle, there is only a 25% chance of success. I was very lucky to conceive on my first Clomid ovulation with both Cupcake and Teddy Graham, but I can’t expect it to happen every time, so this process is going to require some patience on my part. While I may be growing tired of Clomid because it’s not “working” (i.e. no BFP), it is doing it’s job and producing an ovulation. Now, it’s just a game of wait and hope.
  • Semen analysis: My husband asked about having one done. Honey had one come back as normal two years ago, but Dr. Y doesn’t think it’s a bad idea to have a recheck and we agree, so we’ll go ahead with that. Last time, my hubs got to do his business at home and take it in afterwards, but this time he’ll be doing it at the lab, which I can tell he is uber-excited about. He’s so fantastic, though, and hasn’t complained for even one second. It will cost us $110, which seems like nothing compared to everything else.
  • Short luteal phase: Dr. Y does not think this is a problem for me. She considers a luteal phase too short if it is less than 9 days. My shortest one has been 10 or 11 days and she doesn’t feel this needs any treatment. I asked why sometimes my LP is so much shorter than it is in other cycles and she said it’s just based on different hormone levels produced for that particular ovulation. Hmmm…
  • Baseline scan: I had a meet ‘n’ greet with the dildo cam at the end of our visit. It was the first time I had ever had that done during my period and can I just say…ew, gross? It was really, really gross and I’m sure much more so for my doc, but she’s used to that, right?  Anyhoo…she did conclude that my ovaries look polycystic (with 10-12 visible follicles on one side and 12-15 on the other, when the most she should see is 10 and that’s in someone much younger than myself). Also — there are no ovarian cysts or visible uterine fibroids. Good news! She also determined that my lining got plenty thick in my last cycle because, when she measured it, it was 11mm…and that was on CD2, after a full day of bleeding. So Clomid isn’t causing problems with that at this point. More good news!
  • Progesterone levels: In September, my P4 was 11.0 at 8dpo. I was less than excited about that number, but the doc doesn’t think I have a reason to worry. She says she only orders a P4 test to see if someone has indeed ovulated (anything over a 3.0) or if she is concerned about a very, very short luteal phase. She never bothers with the actual number and doesn’t monitor it in her patients because she doesn’t think it provides enough information to be worth it. Which means she doesn’t think I need progesterone supplementation of any kind at this point. She did say, though, that a trigger shot will probably help my body to produce more progesterone.  Which leads me to…
  • Treatment: I asked about switching to Femara, but for now, Dr. Y wants to stick with Clomid. She says that “they” say you shouldn’t take it more than twelve times in your lifetime, and this current cycle will be number 12 for me, but she is willing to let me go two more after this one. She really wants to do a monitored cycle and a trigger shot for this round, to see how my body responds. So I’m scheduled for a scan on day 12 (Nov 12) and we’ll go from there.  Hopefully, I’ll be ready to trigger and then we wait. If not, I’ll have to return for another scan and keep doing so until I am ready for the shot. And if this cycle doesn’t end happily, we will do two more rounds of Clomid, of which I will have to decide if I want to do monitoring or not (not recommended, but allowed).  After that, I’m a bit confused about where we go from there. There was talk of Femara, IUI, and IVF, which raised my level of anxiety and panic to unknown heights. I do know there won’t be any injectables (maybe if I beg?) because, when combined with PCOS, the risk of multiples is just too high. I have a follow-up scheduled with Dr. Y for Dec. 4, where we will create a long-term treatment plan. Which scares me to death.

So I feel pretty good about most of this, but there are a few concerns I have:

  • I felt a bit rushed at the end of the appointment and had to speed through my final questions, which was a bit irritating. I know Dr. Y had a procedure to get to (which is why my appointment had to be moved up), but I’m a new patient and have a lot to talk about…don’t I deserve her time and focus while she is with me?
  • I’m not thrilled that I won’t be getting progesterone suppositories. Dr. Y doesn’t think I need them, which is great, but what if she’s wrong? I want a safety net. One thing that will let me breathe a little easier and say, “At least I don’t have to worry about that.” So I may push her on this a bit more down the road.
  • Monitoring and especially the cost of it. One u/s scan on day 12 and a trigger shot? I think we can afford that (definitely can if my insurance picks up any of the cost). But I am fairly confident in saying that I don’t believe I’ll be ready to trigger on day 12. I normally ovulate days 19-23…a whole week (or more) earlier than this seems too optimistic to me. Which means I’ll probably have to return for another scan. And what if I’m still not ready and have to go back for another? The costs will just keep climbing and, while we can do this for one month, I’m not sure it’s something we can do over the span of several. Not to mention the exorbitant time that will be required, especially with the holidays nearly here and with a toddler in tow. It takes at least an hour to get to my RE…and an hour to get home. That’s a lot of time, especially if I have to do it more than once a week.
  • Too much too soon. In other words, taking an approach that becomes too aggressive too quickly. I am willing to stick with Clomid or Femara for a good few months and maybe do monitoring and a trigger for those cycles. But to go straight from Clomid to IUI in just three months? That’s when I start to feel my panic rise. Because I know that IUI is the end of the road. There will be no IVF for us. This is not something I’ve discussed before because I haven’t thought I would need to, and it’s something I will explain more if it comes to that, but I just know that, right now, we have drawn the line there and IUI is the last stop. And so in three months, if Dr. Y wants to move on to IUI, it will be my final and only hope and that is just too scary. I am not ready to arrive there yet.

So over the last couple days, since meeting with Dr. Y, I’ve been feeling overwhelmed. Overwhelmed by the money and time all of this will require. And overwhelmed by the possibility that none of it may work. That the bills will pile up and it won’t be worth it in the end because I won’t have another baby. But as my mom keeps reminding me, I need to take it one step and one cycle at a time. Why worry about IUI in three or six months when this very cycle could be The One? So I’m taking lots of deep breaths, praying, and just trying to balance hope with expectations. Faith with realism. Not worrying about what hasn’t happened yet, and still preparing for the worst case scenario. It’s a very fine line.

And so there you all go…the story of the day I met my RE. Fascinating and heart-warming, isn’t it? So sorry about the neverendingness of it. I do promise you that one day — one day very soon! — I will publish a post that doesn’t take me three hours to write…or you a whole hour to read.

Check!

Well, I guess it’s a three-post kind of day. Sorry to fill up your readers with my babble.

But I’m proud to announce that one more thing has been checked off my list. I have found an RE! In the last few weeks, I have searched high and low, researched all five fertility clinics in our area, spoken with two out of my top three, reviewed yelp.com to see what past and present patients were saying, and come to a decision. And today, I made an appointment with my top choice who I am, so far, very pleased with.

What won me over? you ask. I’ll tell you. It was quite a few things really. Their doctors and their lab are both in-network for my insurance carrier, which means that diagnostic procedures will be covered in full. They got the best patient reviews on Yelp. They were able to schedule me immediately (though I chose to wait a while for my appointment). They responded to my e-mail (one clinic did not). They allow children to come to their clinic (one clinic has a strict “no children” policy). They told me that they don’t often bill under the “infertility” billing code, which might mean that my insurance will cover more than I think. They have several female RE’s to choose from. They are not too small (i.e. expensive) nor too big (i.e. a baby-making factory). They do prescribe Femara and allow unmonitored Clomid and Femara cycles. And the particular doctor that I requested is their clinic expert on ovulatory disorders and pregnancy loss. All of this has led me to believe that I will be in very good hands.

This is a huge step for me as I have never come this far in the process. While it took over a year to conceive my daughter, I never had to see an RE to do it. I just kept taking Clomid until it worked. I could almost pretend that I got pregnant like a normal person. But in going to a fertility clinic, that illusion will be gone with the wind. So I’m scared, but excited as well. Not so excited that it has come to this, but excited that I have a plan and that I have confidence in the clinic I have chosen.

My appointment is scheduled for November 2 at 10am. This should be at the end of my next cycle or at the beginning of the cycle after it. I’ve already completed most of the initial bloodwork through my OB, so I’m hoping we’ll be able to move forward with treatment quickly. Of course, what I’m really hoping is that I’ll get the joy of calling to cancel that appointment thanks to a positive BFP in the next month or two. But if not? I’m ready.

I’m ready, come what may.

Thanks & Stuff

First, I want to say a couple big thank yous…

To those of you who responded to my post on faith…thanks for the stories you shared, the support you offered, and the prayers you have said. I do so need and appreciate them.

And to those of you who responded to my post about my many overwhelming worries…thanks as well!!! You guys offered some great advice and gave me a lot to think about.

And with that being said, I present to you my plan going forward (though, being a woman, I have the prerogative to change my mind at any time):

My next cycle (#2) will proceed as planned. I finished the progesterone yesterday and am now waiting for the flow to begin. I will then take “just” 100mg of Clomid and annoy God with my constant prayer (i.e. begging and bargaining), while also crossing my fingers and hoping for the best. Part of why I’m choosing this route (no monitoring, RE, trigger, etc.) is for the simplicity of it (less stress, I imagine, though certainly not stressless) and also for practical reasons as it will be a busy month and I’ll be out of town for a few days next week. Not to mention, I have always taken this route and it has always worked. So far.

If this cycle ends with a glorious BFP, I will then request for a beta draw every other day until I see a heartbeat, at which point I will ask for a quick u/s every other week until the end of my first trimester (when I may just buy a doppler, so I can find a new way to obsess). I guess then I will not only be annoying God (please God don’t let this baby die too, please let there be a HB, please protect my embryo, please have mercy, please please please pleeeease), but I will also be irritating my OB with my paranoia. I’ve warned him already…but I don’t know if he really understands what he’s in for. And that is, of course, only if I build up the courage to demand what I want and need. I’m a bit like a timid twelve-year-old girl in that way — not very good at standing up for myself or being assertive. Work in progress, remember?

If this upcoming cycle ends with the stupidest-of-stupids BFN, I plan to have all my blood work redone so PCOS can be ruled out once and for all, maybe also have a baseline u/s done on my ovaries (to verify there are no cysts), and perhaps request to be monitored for my third cycle.  I may also try to charm my doctor into letting me try dexamethasone or Metformin…and/or increase my Clomid dosage.

And if I don’t ovulate at all? Well, the plan will probably compare to the BFN plan, except I will most definitely be begging the doc to increase my Clomid or try Femara and give me a trigger shot…anything that will just get my body to release a damn egg.

As for going to see an RE, I’m still hesitant, mostly because of money matters. Our health insurance does not cover infertility. Like, at all. And so I’m scared that once I go see a fertility specialist, all coverage will stop. So far, we’ve been lucky enough to have every ultrasound and all lab work covered 100%. Not to mention, seeing my OB only costs us a $30 copay. I like having money. I like having no doctor bills. I like being able to, instead, save for baby items and a stay at the Labor & Delivery unit sometime in the future. I don’t want to spare every penny possible in order to expand our family. I will, if necessary…but I’m not ready yet, and I’m still hopeful it won’t come to that. After all, I’ve been pregnant twice and have not needed an RE thus far. After two cycles of Clomid at 100mg and two at 150mg, though, I think it will be time. Sigh. I know all of you RE-veterans will laugh to hear this, but the thought of it sort of makes me want to barf.

Also, one other note…as arminta suggested, I took a pregnancy test. A good suggestion, but futile in my case. It was a BFN. In fact, that single control line was so dark and bold and in-your-face with “You’re NOT pregnant,” I found it sort of rude and obnoxious. So no worries, guys…I’m not pregnant. Go figure. I mean, really? A surprise, unexpected pregnancy? That only happens to OTHER people.

Which means I was getting a close-to-positive OPK for one of two reasons: 1) My LH was just wonky for a few days for whatever lame reason. Or 2) I actually ovulated. I’m pretty sure #1 is the winner, but either way, the tests have gone back to being completely, undoubtedly negative and that has helped me to breathe a sigh of relief. And so now I just wait for my period. And in honor of the Olympics, all I have to say about that is this:

Let the Games begin!

(Okay, I know that was cheesy and hardly even accurate, as all of this is more akin to torture than a game, but it was the only closing to this post that came to mind. Please forgive my lameness.)