Friday, April 28, 2006

title? do you want EVERYTHING now?

This post is going to have to be much shorter than I would like, because I barel have time to breathe today, let alone idle away time in front of my computer with a glass of OJ before I've even gotten into the shower. Yesterday we had our injectibles lesson followed by a pre-injectibles/IUI consult with Dr. Quixotic and then a bunch of speedbumps in the pharmacy. And I need quite a bit of advice (or assvice, whatever) from my friends inside the computer, so please be sure to take notes as we go along.

Injectibles lesson: cool. I'm going to be using the Gonal-F pen, and my HCG trigger shot will be from a pre-filled Ovidrel syringe, sub-Q. Yay! No butt-shot! Ezra was quite relieved.

Consult: Not bad, but also not exactly as expected. There was a fellow sitting in for most of the appointment, and she piped up with a few questions about us and our treatment. I found it somewhat disruptive, but on balance I do think it was good (for the greater good, I mean) to have the fellow there. She has to learn somehow, right? But that wasn't really my issue.

First issue: they're starting me at a dose of 37.5. 37.5! Is that even....medication? Are my ovaries going to just ignore the stuff, or, worse, cackle contemptuously? But Dr. Quixotic felt strongly about this, especially given my (young) age and his fear of hyperstimulation, so we're going to go along with it. My first monitoring will be the morning after my third or fourth dose, so we can change the dosing fairly early on if necessary.

Second issue: Dr. Quixotic is not sold on the idea that we need to do an IUI with this cycle. Ezra's semen analysis came back normal, and Dr. Q has a general philosophy of treating the problems you know about first, before moving on to anticipatory treatments for problems that may or may not be there. I don't ovulate, therefore we have no reasaon to think there will be any problems with fertilization once I do ovulate, so with the (small) risks of adverse reactions to the insemination, why add this to the mess? We (well, I) pressed him a bit on the issue, so he did add "IUI" to the treatment plan on my chart, telling us we could always change our minds later. (There's a chance we won't have an IUI anyway, since on this first cycle we don't want to go through the trouble involved in having it done on Shabbat.)

Third: Dr. Q is recommending I not have an HSG done this cycle. He said that given my age and medical history (no abdominal surgery or anything likely to have caused scarring and severe - or even moderate - menstrual pain) there was only about a 5% chance I had any sort of tubal blockage. Remember what I just wrote about his treatment philosophy? So, yeah, he doesn't want to dive into this right away. He said we could do one next cycle, whether I'm undergoing treratment or taking the month off (which he will require if my ovaries go into overdrive). Ezra seems to lean toward this option as well, but mainly because I've been under a lot of stress, and the next few weeks will be adding a lot more. I'm really torn - I'd like to just get it out of the way, and I'm going to be right pissed if I do ovulate this cycle and we discover later that I'm blocked in both tubes or something. On the other hand, it would be nice to have one fewer thing to worry about next week.

Fourth and final: we need to decide abou converting to an IVF cycle if I end up producing too many large follicles. Apparently this is the sort of decision we'll have only a few hours to make, as the treatment plan will need to change as of that day, but if we opt to convert to IVF we'll have about two days before retrieval to back out of the decision. I think this is something we also need to discuss with Rabbi Spock, but any advice from others who considered such a decision would be welcome.

OK, that was Dr. Q. After the appointment, we went on a hunt for Nurse Kid Gloves and/or Nurse Space Cadet so that we could have my prescriptions called in at the pharmacy downstairs. it was only then that I learned (from Nurse Spacey) that Dr. Q was also prescibing a progesterone cream for post-ovulatory support. Hmmm, would have been nice for someone to have told me that before, but I'll deal. Nurse Spacey assured me that I could get an HSG appointment with about a week's notice, so we'll make that decision Monday and schedule for either Friday or the following Monday. Then we headed downstairs to the pharmacy...

...where, after much waiting, we learned that our insurance company was requiring payments for the medications that were higher than the pharmacy's cash price. Ezra got on the phone with our insurance company, and after about half an a hour of phone trees finally spoke to a person who pretty much refused to budge on the issue (even though we're pretty damn sure this is supposed to be covered, both in his insurance plan and by law in our state) and told him to speak to HR tomorrow. So, no meds. But, we did learn something else quite valuable. The Friendly Pharmacist showed us the price lists for our medications, and it was at this point that we learned that Nurse Space Cadet (true to her name) had called in a scrip for twenty 75-unit vials of Gonal-F. Twenty! and: Vials! No and no, lady! I'm using the pen - I don't know how to mess with these vials, nor do I want to learn. And 1500 units total? At my starting dose? Are you high? I'll come back for a refill if I need it, rather than taking that much stuff home all at once.

So, Ezra and I each have our tasks for the day. He will contact HR and his insurance company again and see if he can get the prescription coverage sorted out. I will contact Nurse Space Cadet and get the prescription itself sorted out. Oh, and also schedule my day-25-ish appointment, at which point apparently we apparently will treat my uterus as if it contains Schroedinger's cat.

UPDATE: Apparently meds are not covered under our insurance. I was under the impression that they were, but Ezra just verified this with both the company and his HR department. I actually have the opportunity to switch to an insurance plan through my work as of July 1; I need to make that decision within the next two weeks. We're going to research plans this weekend, but the truth is that I think there some major drawbacks to the switch. Maybe there's a future post in there.

In other news, Nurse Glovely is handling all of Dr. Q's patients today, and she's straightened out the pen/vial situation. So now all we have to do to get the right meds is pop over to the pharmacy and put a hefty charge on a credit card.


At 8:26 AM, April 28, 2006, Anonymous ruth said...

{{hug}} wish i could do more...

At 9:29 AM, April 28, 2006, Blogger DD said...

I would say Dr. Q is starting you VERY conservative. And with what other concerns you have, it really does seem to come down to how he perceives your age and what issues/non-issues with the infertility diagnosis.

Before our RE would even agree to see us, we had to have the results of the HSG in our hands so she knew she wasn't wasting hers (and our) time w/blocked tubes. It stinks that there's no one sure protocol to follow.

At 9:59 AM, April 28, 2006, Anonymous Erin said...

I know nothing about doses, so I can't help you there. As far as the HSG, that was the second test I had done when I first started fertility treatments, preceded only by d3 bloodwork. There may be only a small chance of blocked tubes, but how would it be in, say, 3 cycles of good ovulation, with or without IUI, to do one to find out why you're not conceiving and find out that you do have blocked tubes. Not that I think you do--the odds are very much in your favor. But wouldn't it be lousy to look back and find that out? It's a simple test (albeit not painless), can be done with this cycle (so you wouldn't have to take one off to have it done), not expensive in the grand scheme of fertility treatments (especially with insurance), and it will rule out one more thing so that you never have to look back and say "If only we'd known." And there have been some studies that show an increase in conception rates the cycle of and the one after an HSG.

Anyway, good luck with getting the meds figured out!

At 11:55 AM, April 28, 2006, Blogger Just another Jenny said...

assvice - yea!
Gonal Pen - fabulous. Best invention ever. Doesn't hurt a bit. The pre-loaded Ovidrel (same as I had) does not go in as easy as the gonal pen so make sure to give it a good poke.
I had to do the vial mixing for my last shot because I only need one more 150 and it wasn't worth buying a pen. It sucked cause it was different but it wasn't hard. You will like the pen.

That's all the assvice I have. We didn't get a crack at IUI so I am not sure about converting a cycle. How would your insurance handle that?

Wishing you nothing but the best!

At 12:54 PM, April 28, 2006, Blogger electriclady said...

Well, in my case we also had no reason to believe that an HSG would turn up anything (young, no pain, no endo, no infections or surgeries, saline sonogram looked normal). But my RE wanted to, in his words, "make sure there isn't something obvious wrong" before wasting time with any treatment that might not work. And lo and behold, the HSG revealed my MAJOR uterine anomaly and lack of one tube, which now has a huge impact on all treatment decisions we make.

So for me, it was well worth it to have it done sooner rather than later. I did it at the same time I was doing a letrozole cycle (you do it around day 7-11), so it didn't delay anything. And as Erin pointed out, it can improve your chances of conceiving for a few months afterward--the theory is that if there's partial blockage, the dye clears everything out.

But if it's just going to add way too much stress for you to do it this cycle, then you don't really lose anything by waiting. Do what works best for you.

Good luck with the insurance stuff. I hate, hate, hate health insurance companies, with the heat of a thousand suns.

At 1:00 PM, April 28, 2006, Blogger persephone said...

OK, I wouldn't worry too much about the 37.5 yet. As you say there should be time to adjust the dose if need be. And while overstimulation on the low end of doses might be milder or unlikely altogether, the cascade of effects could get pretty upsetting if it happened during IUI... if it was severe there'd be no way to remove the eggs and wait till your ovaries calm down, unless you converted to IVF.

I hear what he's saying about waiting for IUI until you try a good ovulatory cycle alone, but I'm not sure his logic is right for your plans. Weren't you seriously considering moving straight on to IVF after one injectibles cycle? If you're really set on that, seems to me it makes sense to give this one cycle your all. Otherwise I guess you need to be open to at least a second cycle.

But a couple more points: remember that even a healthy fertile couple, ovulating, good sperm, tubes open, uterus receptive, has only a 20-ish % chance of conceiving in one cycle. That's why it often takes up to a year to work. Again, if you're only giving this one cycle (or even two), it seems like anything that bumps your chances up a few percentage points is well worth it.

And while IUI does have some risks, they're not the ones you're personally at highest risk for, namely OHSS or longterm ovarian effects, right? In fact I personally saw it as reducing my family cancer risk. For any month that I was putting hormones in my body I wanted to give them maximum chance to work, so as to shorten the total exposure I'd end up with.

Oh, and then there's the fact that if you ovulate before mikvah, IUI would be your only chance to catch it. Does he know this?

OK, that's enough rambling about that. I have very little idea what to say about the HSG. All other things being equal, it would probably be smart to have it done first, but I know you were pretty tense about it messing up everything else you wanted to do this cycle... I guess it's a question of what will make you less frustrated: if it ends up giving you niddah stress now, or if you find out later that you wasted an egg.

Converting to IVF: um. I don't know about it from experience, but I'd say you want to find out what the odds are of it doing you any good, then balance them against the stress of last-minute IVF. Would it make sense to freeze them, and do an FET another month? If there are only just enough to make IUI too risky, say 6 eggs, would you really want to spend the full cost of ER and ET just on them?

Man, I'm so groggy today I have no idea if any of that made sense. But I tried! :D Good luck and keep us posted.

At 1:05 PM, April 28, 2006, Anonymous statia said...

If I could offer only one bit of advice(assvice), it would be to not wait on the HSG. My dr didn't do mine for nearly a year, just basing it on my age, history etc. I kept telling him I knew something was wrong. Sure enough, blocked tube, and I always ovulate on that side.

Good luck on the cycle.

At 1:06 PM, April 28, 2006, Blogger persephone said...

Oh: electriclady reminded me that my HSG was also the only thing that revealed I had a septate uterus. Uh, not that it revealed it exactly; the first doctor who looked at the films said it was normal, and the second one said it was arcuate, which is just a variant of normal... still, when they did a hysteroscopy later for something else and found it was actually a septum, it was a lot less of a surprise to me. For whatever that's worth...

At 1:34 PM, April 28, 2006, Anonymous Lucy said...

I agree that having an HSG done early is a good thing. Speaking as a gal who had a tubal blockage (tube was subsequently removed), I'd have been really ticked if we had wasted time/money/eggs before dealing with the tubal factor.

With my first IUI, my Gonal-F started at 37.5 ... we ended up with four GREAT follicles. So you don't always need that much.

As for insemination vs. not ... we talked about it with our first IUI and my attitude was, if we're doing all of this other stuff to make sure that we're doing everything possible to get pregnant, why wouldn't we also do the sperm washing/insemination to make sure that the *best* sperm are put where they need to be, for optimal results?!

Each RE is so different - mine is pretty aggressive (which I like), and I was pretty gung-ho to just get on with it, already. There's nothing wrong with a slower, piece-by-piece approach if that's what you guys want to do. However, if you want to be aggressive, then I'd recommend making sure you make that clear to your RE. :) Good luck!

At 5:36 PM, April 28, 2006, Blogger projgen said...

As usual, I can't add to anyone's advice, so I'll just add my 2 cents to the HSG topic. Personally, mine was fine, thankfully I had no problems, but I prefer to get all the diagnostic stuff out of the way right at the beginning. It's one less thing for you to think about later on, one less thing to worry about, and Gd forbid there are any issues, you know about them before "wasting" a cycle.

Sorry about the insurance stuff. Insurance companies suck.

At 10:36 AM, April 29, 2006, Blogger Beth said...

Big fan of the gonal F pen - and I do agree with Jenny that the Ovidrel requires a teensy more of a poke - but still easy.

What a pain about the insurance - and what is up with this nurse? Vials, smials.

At 4:18 PM, April 29, 2006, Blogger silversonic said...

HELP! Do any of you know the accuracy of the 'Day 21' blood test?

I just did my first round of Clomid 50 mgs this month and on Day 21 had the test which came back 'no ovulation'.

I should have started my period about 3 days ago (though after my miscarriage in August, I have not had a period without using medication). Instead, I started lightly spotting (brown) and have really sensitive breasts/nipples which I usually didn't have with periods in the past.

The advice I need is... if the test is accurate, and I did NOT ovulate, these 'symptoms' I am having (slight queasiness, breast tenderness, spotting) could NOT be pregnancy, right? I shouldn't bother 'wasting' a test on this...? (I called my doc yesterday - Friday and didn't get a return call, so I need any info any of you may have -- please!)


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