Posted by: birdsandsquirrels | March 22, 2009

the WTF appointment

I feel like all I do is complain. Well, in reality, that is all I do lately. So, my appointment with the RE was supposed to be at 9:30am Friday morning. I called them on Wednesday to add a screening ultrasound, as my period had just started.

The receptionist said “Oh, didn’t someone call you about changing your appointment time?”  Um, no. Apparently the RE had a transfer to do at that time and I was getting pushed off. I made this appointment three weeks ago. She tells me “Oh, it looks like he has ten minutes available at 10:20. Do you want that? Otherwise he’s booked through the rest of the day.” Being in my current state of rage mixed with sadness, I had to restrain myself. I told the poor receptionist that we’ve spent 7 months and six thousand dollars with them with nothing but a miscarriage, failure, and canceled cycles to show for it, I haven’t seen the doctor since my initial consultation (in September!), and this appointment is to discuss what went wrong/what to do do next. Do you really think we’ll be able to cover all that in ten minutes? She said she’d have someone call me back.

Eventually I get a call back asking me to come in at 7:20am. Very early, but whatever, at least I’ll get to have a plan for this cycle. I showed up bleary eyed, grumpy, and pissed off and I had to remind myself that I needed to be somewhat pleasant while getting to the bottom of the questions I had. When he first came in, he mentioned how it had been a while since I’ve seen him. He said that sometimes that happens, that they like to be able to do some of the ultrasounds or IUI’s once in a while,  but that one of the RE’s reviews the charts every visit during the monitoring. Okay, I give him credit for addressing the fact that I hadn’t seen him once in six months. He went over our options:

1. Keep trying FSH + IUI. Since I did conceive once, he said we could try a few more times if we wanted. He also said that at some point, it would be more cost effective to do IVF since the success rates are much higher.

2. Do a lap. I don’t have any symptoms of endometriosis, so he doesn’t recommend doing surgery at this point.

3. IVF with ICSI. He would lean towards this.

I told him that I’d like to try Femara. S and I have planned a very last minute vacation and we will be out of town during the time I would need monitoring and the IUI, so we can’t do injectables this cycle, and I wanted to give Femara a try. He agreed that we could do that. I told him that I’d like to try another one or two cycles of FSH + IUI before going on to IVF. He said that was fine and that it was up to us.

I asked him about the three previous cycles and what went wrong. He did agree that the timing for the IUI we did around Christmas wasn’t great. He said that ideally they like to see 2 follicles at least 15mm before triggering. He said that 15mm follicles are generally very likely to ovulate with the trigger. He said that our sperm counts are good, even though the morphology is still around 3%. He said that they see people with 1, 2 and 3% morphology get pregnant naturally – it can happen. That made me feel better. He explained that they look at 200 sperm and count the normal ones. Clearly they can’t count all 75 million, and those 200 that they look at might not have a lot of normal sperm in it, but there could be more out there, and it is variable. We talked a little about IVF. He would recommend doing ICSI if we do IVF.

Now here is something that I found a little strange. They do day 2 transfers for IVF. I asked about this – why do they do that when most clinics do day 5 blastocyst transfers now? Why not day 3? My guess is that their lab is not good enough to culture to day 5 (of course I didn’t say that to him). He said that they have very good success rates with day 2 transfers – as good as clinics that do day 3 transfers. He said they can do day 5 transfers, but that embryos that are grown that long in the lab are exposed to unnatural environmental conditions and they are waiting for studies to make sure that is safe. He went on to tell me that in animal studies, cows that were conceived through IVF ended up with enlarged hearts and other defects and that the DNA can change because it’s exposed to the environment. I don’t remember exactly the words he said, and I was quite tired, but it was weird shit.

Now, I am a biologist. I took just as many biochemistry and genetics classes as a premed student. I know plenty about DNA and chromosomes. Are you seriously telling me that many of these babies born from all of these other (quite good) IVF clinics that were day 5 blast transfers are going to have birth defects? Seriously? Isn’t it fairly standard to do day 5 transfers these days so you can see which embryos are the best quality because many embryos arrest in those first few days? I am aware that some day 3 embryos might not make it to day 5 in the lab, but might have done better in the uterus. I get that. But don’t tell me that a day 5 blast is going to mutate in the lab, when in reality you guys don’t want to have the extra work and cost of taking care of the embryos for a few more days. I thought all of that in my head, but kept my mouth shut and nodded.

The bottom line is that their statistics are indeed quite good. According to the CDC website, in 2006, their percentage of fresh cycles (non donor eggs) in women under 35 resulting in pregnancy was 55.6% The national average was 44.6%. Their percentage of cycles resulting in live births (again, under 35) was 47.4% and the national average was 38.7%. My clinic did almost 500 cycles (over all age groups) in 2006. The only other fertility clinic in my town only did 80 total IVF cycles in 2006. Their success rates were 37.7% percentage resulting in pregnancy/30.2% live births. I know that statistics aren’t everything, but it is good to know that whatever it is that my clinic is doing, regardless of their goofy explanations, it’s working. I think I have chosen the best clinic in my town.

The nearest other RE’s are about 200 miles away in either direction, one in another state. If I have to do IVF, the clinic I’m already at is my only realistic choice without traveling. The good thing is that their prices are on the lower end for IVF. There are a number of drawbacks though. They aren’t open on Sundays, are only open half days on Saturday. They don’t treat single women, which doesn’t affect me because I’m married, but it’s just plain wrong. I’m sure there are other things, but I can’t think of them all right now. My husband gave me his cold and my brain is not working well currently.

I got my RE to sign my free Femara voucher and I started it on Friday night. I have no idea if it will even make me ovulate, but I figure we might as well try it. He had me cancel the screening ultrasound, saying I didn’t need it since we weren’t doing injectables. Awesome. That saved me $150. I was kind of curious about how my ovaries looked after all those follicles that grew last month, but oh well. It would probably just have been depressing to see a bunch of cysts. I guess he doesn’t care too much about checking for cysts before starting Femara. I get the feeling that he doesn’t like Femara. He said it’s weaker than Clomid. It seems like it works pretty well for PCOS women though, and I never tried it before moving to injectables, so I’m excited to try it. And it’s free. You can’t beat that.

Emotionally, I am starting to feel a little better. It may take us some time to get comfortable thinking about IVF as a step we may need to take in the near future, if we can somehow make it happen financially. S has some vacation time he has to use or he loses it, so we threw together a last minute vacation. We leave on Thursday for 6 days. I think he is hoping this vacation will distract me from infertility for a little while. I hope he is right. I am so sorry that I have been slacking on the comments and ICLW. I have been reading  and thinking about all of you and I hope I can catch up on some commenting before we leave. Thank you so much for the support and kind comments. I don’t know how I would get through times like these without you lovely bloggy people.

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Responses

  1. Just found you through ICLW. Good that you insisted on a long appointment with your RE. Hope everything works out for you

  2. sorry things are shitty lately. i hope you are able to enjoy your vacation. good luck with your next cycle!

    i noticed you trigger at 15mm. my doc doesn’t let me trigger until my follicles are 18.5 or bigger….

    ICLW

  3. I hope Femera helps you O and that you and your DH have a lovely vacation!!

  4. i’ve never heard of a 2-day transfer before. i’m also surprised your clinic would let you trigger with a 15mm follicle. my clinic won’t trigger with anything under 18mm. i really hope your next cycle works out!

    iclw

  5. Maybe Femera will work it’s magic. I’m starting it in a couple of weeks as well.

    What dosage did they put you on. I’m supposed to take 3 pills a day (2.5mg).

  6. Ungh.

    I hope the Femara works. That would be sweet.
    Oh, and… Enjoy your vacation 🙂

  7. Oh, wow, I’m surprised that receptionist had the gall to offer you a 10 min time slot! No, that won’t be long enough! Makes you feel like a valued customer, ah?

    Well, I hope you don’t have to go through IVF, but your clinic def sounds like the best choice around, but the 2 day transfer thing is pretty weird.

    I hope you have fun on your vacation and that the femara works for you! Wouldn’t that be awesome?

    By the way, I’m worried about our girl Celia.

  8. It took us awhile to be ready for IVF/ICSI- in fact, about 1 1/2 yrs from being told we needed it to believing we did.
    I think day transfers only make sense if there are few embryos, otherwise, how do they know which are growing best?
    Good luck.
    *here from iclw

  9. Just a thought– it is possible to have endometriosis WITHOUT symptoms. My RE found stage 2 during my lap, and I have never had a single symptom. I, like you, have PCOS also.

    Here’s hoping that you two are able to conceive again (soon) without having to go to IVF.

  10. I’m glad you got to have a nice long chat with your RE and get a new plan in place. I am about to go to my first RE appointment, so I appreciated your thorough description of this conversation!

    ICLW

  11. Why do nurses think that 10 minutes would be enough time??! Reminds me of when my doctor sat us down, then said he had to get his car out of the parking lot within 10 minutes…would that be enough time for us? SURE, because we both took half-days and drove three hours round trip for a 7.5 minute meeting. Ugh.

    I’m glad you’re feeling good about the Femara cycle. And, it’s so wonderful that you are taking a vacation!! Where are you going? Hope you have a really great time.

  12. 1. I’m glad you got more than that 10 minutes she was offering you at first! A consult/wtf meeting takes waaaaaay longer than that!
    2. Day 5 transfers are standard! I’ve heard of Day three if the embryos arn’t doing well, but day 2?
    3. Who ever heard of an IVF clinic not being open on Sundays? Women ovulate, monitor, have retrievals and transfers EVERY day of the week!

    Hmmmmmmmmm. How far away is that other clinic?

  13. arg. sorry it took so long to get an actual apointment! glad that he seemed to take some time and answer your questions though. i totally agree with you….i don’t think that keeping embryos out until day 5 *increases* their risk for mutation.

    also…femara isn’t weaker than clomid…it’s just different. 🙂

  14. Here from ICLW.

    I am glad you got a nice, long appointment with your RE, but I have to say that I had some warning bells go off in my head when you described what he said.
    *Um, yes, day 5 is the standard for women who have over 5 embies developing at day 3.
    *No, IVF babies don’t have more mutations just because they are IVF. If that is his theory, then day 2 embies would also have mutations.
    *With day 2 embies, the theory is that you’ll need to transfer more to have a higher pregnancy rate. How many would he recommend for transfer?
    *No monitoring on Femara? Now I admit that I am not familiar with the drug (except that it is like clomid, which I took and was monitored on and nearly canceled when I made 5 mature follies), but monitoring is essential to ensure that you don’t produce too many mature follicles (and how does he know you won’t if you haven’t had the med before) and end up with high order multiples.

    I don’t want to scare you off from this clinic, but I do think you should ask a few more questions from your RE before you invest so much into IVF.

    Maybe you could pose some questions about others’ experiences on Femera on Mel’s Lost and Found page?

    Hugs and good luck.

  15. Sounds to me like your doctor knows just as you do, that he’s the only one in the area and he thinks he can do whatever the hell he wants. But if his stats are that good, I say try it. Maybe he knows something the other places don’t? Good luck, sweet pea! ICLW

  16. I haven’t seen my RE since Oct., and only talked to her on the phone twice, since then! It’s funny how that happens. I’m glad you were able to see the RE, in any case! GL. ICLW

  17. I’ve only seen my doc twice–the initial consultation in July and the HSG in December. He was in the office during our last IUI but for some reason another doctor did the insemination. I hate it!

    I’ve done 5 cycles of Femara. 3 alone and 2 with FSH and IUI. I like Femara because it’s out of your body faster than clomid.

    Good luck and hang in there!

  18. At my RE’s office there were 3 RE’s and I only saw my Dr about a third of the time, they were always rotating shifts. It’s good that at least your Dr. acknowledged that he hadn’t seen you personally in a while instead of glossing over that fact.

    I hope this next cycle brings you better results. In the meantime I hope you have a nice vacation!

  19. Ug – what would make them think that 10 min would be enough time? I tell you, it makes me crazy when I feel like I’m giving them enough money for a car and they won’t give me the time of day. Our first clinic was like that and in the end, we left them. Am so much happier at clinic #2.
    I know IVF is a big step mentally – lots to think about there. My clinic does everything they can to do day 5 transfers and never once mentioned anything about birth defects. Sounds fishy to me.

  20. Ugh, sorry you have such a bad dr. I wish these clinics and treatments were easier to access. There is only one in my area as well that does IUI and IVF.

    I found you through ICLW

  21. Weird. I have quite a few comments, please forgive how long this will be …

    1. Weaker than clomid? It’s different than clomid. And for some women, like me, it works better. I don’t have pcos. I’m 36. I ovulate fine. I generally make one egg. On clomid I make 1 egg. On femara, I make 2-3. I don’t understand how he can say one is weaker than the other when it works totally different in different women. And there are pros/cons to it, like anything else. For a woman like me, it’s better because clomid wrecks havoc on my lining. I’m not saying femara is better, but it should be given a try.

    2. I don’t know your history with ovulation, but my RE will not do IUIs w/ injectibles if oral medications work. Meaning, if clomid or femara allows a follicle to grow, he doesn’t use injects. Reason being is injects can cause more than 2 follicles, which is too many in his book (he cancels at 3 follicles w/ IUI) and why go to injects to get more follicles than he should inseminate with? Now, you may need those inject cycles, but you certainly should try femara to see if it works with your IUIs instead of spending so much on injects – injects that when working for a woman, are decreased so they don’t do their ‘real’ job, making many follicles. Instead, their dosages are decreased so they only give you a couple follies. Waste of money. (again, don’t know your ovulation past, but letting you know that if femara works, that would be awesome for you!)

    3. 15mm follies at trigger time? I’m gasping here. I have a few things to say about it …
    ~ Okay, at 15mm, my RE explains those are the smallest follicles that are usually successful in producing ovulation. But the HCG is going to go to an immature follicle, making it either grow a bit more before ovulation or just release an immature egg. Either/Or, it’s not going to be the “best” type of egg – it’s a baby egg (no pun intended) meaning it’s not matured properly. yes, it CAN fertilize, but it’s not got the best chance.
    ~ At 15mm, you probably wait 24-36 hours to insemination, which is risky as your body may ovulate sooner or even later. With a follicle that is not at “perfect” size to ovulate and having non-perfect sperm due to morphology issues, you want to have PERFECT timing. My RE said an egg really only lasts 12 hours from ovulation, even though they can survive longer, this is the window for best fertilization.
    ~ A follicle is usually deemed mature at 20-22mm. My RE will NOT trigger until the follie is 21mm. Then he’ll have us trigger at 10p, 11p or midnight and get us in for insemination at 7am. When the follie is that mature, the HCG will usually cause ovulation within hours, so timing can be perfect. No guessing. No saying “well, I bet that timing wasn’t the best” months later.

    I have more reservations about what what said, but those are the 3 topics I know more than normal about. I would definitely talk to him about those things. Especially #3.

  22. I hope the Femara does the trick. I think you asked a lot of good questions. I”m always impressed by what an advocate you are for yourself.

    The success rates for your clinic look very good with IVF.

  23. ICLW

    It’s not fair that in such an important area as infertility, that there are so many RE’s who seem to just dismiss our questions and concerns. I’ve noticed that about my own RE from time to time.

    I hope that you will have a successful cycle that ends with a real live baby.

  24. Hi.. just wanted to add that your RE couldn’t really mean that femara is weaker than clomid? it is altogether different in how it works on the ovaries 🙂 What is the dosage you are on? If you do move onto injectibles, you can take femara with FSH.. it helps recruitment of follies according to my RE. BEST WISHES TO YOU, glad you had that chat with your RE.
    Anna in CA

  25. Have a fantastic break. Sounds like you need it.

    ICLW

  26. I were great in advocating for yourself. It took me a long time to learn that lesson. I hope you have nice few days away.
    ICLW
    Erica

  27. Best of luck with the Femara, and have a fabulous vacation!

  28. Okay, so the plan sounds great – especially the part about the trip. 🙂 I hope you’re going somewhere warm. I’m dying for a little warm weather in the NE right now. Damn spring – where are you?

    Good luck with the Femara – I don’t know anything about it, but I’m keeping my fingers crossed for you.

  29. I’m sorry your appointment was so early, that sucks. Sounds like your RE really listened to you, though. Good luck with the Femara! I hope it works for you, plus it’s FREE! Have SO much fun on your vacation.

  30. If it helps, it’s the standard to do d2 transfers where I live. The success is still good, and there are more frozen embryos which are more likely to survive a thaw than day 5 embryos.

    The feeling is that you lose more than you gain sometimes in going to day 5.

    J

  31. Hey Bird! I missed you. We finally have internets again.

    I have my RE appointment on Friday.

  32. UGH…sorry you’ve had all those appointment time issues. I’m glad your RE seemed to listen to you and I hope the Femara works for you.

    ~Kristin from Dragondreamer’s Lair

    ~ICLW

  33. Well done you for sticking up for yourself RE appointment time.. good luck and enjoy your vacation !

  34. Ugh, sorry for the delays in your appointment time, but it seems like you pushed through and got some good answers to your questions. We ended up doing IVF w/ICSI, so if you have any questions, please feel free to ask. Enjoy your vacation!!!!!! ICLW.

  35. Hey, I think I just made a connection of some kind. I read ISO the Golden Egg and I wonder if she used your same clinic. They do 2day transfers and won’t treat unmarried women, which has caused her all kinds of problems. Well, you should check out her blog sometime. If you get to IVF it would probably be helpful to know someone who has used your clinic. http://isothegoldenegg.blogspot.com/


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