Monday, July 6, 2009

Last Resort

I would like to say that I met with SuperDoc today and he said, "Well, it's obvious that the problem is X, and therefore, we simply have to do Y, and voila! You will be cured and you'll have a baby in 9 months."

I would like to say that I met with SuperDoc today and he said, "I absolutely know that this next cycle is going to work for you."

I would like to say that I met with SuperDoc today and he said, "You are the most straightforward patient I've ever treated - clearly textbook diagnosis X. I know just what to do next."

I would like to say that I met with SuperDoc today and he said, "I know this has been a long and frustrating road, but with this new protocol, I believe you have an 80% chance at achieving a successful pregnancy."

I would even like to say that I met with SuperDoc today and he said, "If you look at all the things you have going for you in Column A and all the things you have working against you in Column B - Column A clearly outweighs Column B."

I would like to say a lot of things, but none of those things would be true. So what really did transpire? Well, honestly, it's a bit late now, and I've got a fair bit of pain medicine in me right now, so I'm not sure I'll do it justice, but I'll do my best.

First, I noted that he had a lovely new desk for his office. I told him I'm clearly paying him too much, and that we simply must cut that out. I brought him fudge, for which he thanked me, and I said, "well, we'll see - I'm not sure you deserve it." He agreed. "I don't deserve it - I'm not at all happy about what we've failed to achieve for you." I told him to stop being so hard on himself - after all, that's my job, and it's fun for me. He wouldn't want to take away my fun, would he?

SuperDoc is definitely frustrated. He acknowleged that I'm a "challenge" and said he knows that I don't want to be the "interesting" patient. Oh please. Who wants to be the "boring" patient, anyway? If I were boring I wouldn't get to spend so much quality time with such a wonderful person like him! Um... He talked through all of my cycles (including my response to stims in my IUI cycles) and he put the items in my favor into one column, and the items against me in another column:

AgeAverage to low response to stims (luteal phase lupron protocol)
(some good)Mixed embryo quality (majority poor)
successful triplet pregnancy5 failed IUIs; 3 failed initiated IVFcycles

He said if he were only looking at the response that I've had to the initiated IVF cycles that I've had this year (in other words - most of the second column), and he didn't know my history (in other words, most of the first column) - he'd probably be talking to me about egg and embryo quality issues. But the fact that I have had a successful pregnancy before, and the fact that I'm (relatively) young-ish does change things a bit for him. But on the other hand (there were many "other hands" in today's consult), he said that there's still the question of why did it take so many IUI cycles to conceive the triplets in the first place? And why triplets after so long and so little success? (There were, by the way, a lot of unanswered, rhetorical questions asked in today's consult)

When we were cancelling IVF#2, Take 2 I had asked SuperDoc about considering an Antagonist Protocol (Ganirelix). He said then that he felt that Ganirelix would give me a lower quality cohort of embryos, and that he didn't think there would be an advantage to changing the protocol at that time. At the time, he said he wasn't opposed to trying an antagonist protocol if he was forced to - but that it would be a last resort.

Today, he talked through some of my history and my options for moving forward. It seems clear that I no longer respond like a woman with polcystic ovaries, which, he says, is extremely unusual - apparently this doesn't normally just "get better". Still, all signs point to me maybe not really having PCOS right now. He does still want me to stay on metformin, on the off-chance that it's doing me some good - but he said he doubts that it is. It can't hurt, though. In IVF#1, they treated me like someone with classic PCOS (lots of Lupron, low stims) - I didn't stim particularly well, but I did have a reasonable outcome with the retrieval. Fertilization was fine, embryo quality was terrible, I had one good quality blastocyst, nothing to freeze. IVF#2, Take 1 was canceled before I got to Stims. IVF#2, Take 2, they treated me with less Lupron, more stims but still pretty conservative - and had to cancel for under-response. Clearly, I wasn't behaving like a PCOS patient. IVF#2, Take 3 I was treated like a typical average-to-low responder, very low Lupron dose, moderately high stim dose. Good retrieval numbers, reasonably good fertilization, great Day 2 embryology report compared to IVF#1, everything went to hell on Day 3.

He said that there are a very small number of women (about 5%) who simply make crappy (my word) embryos with Lupron, for whatever reason. So he could consider doing a "Lupron Stop" protocol where they just stop the Lupron on Day 1 of stims (no suppression after that), but he doesn't want to go there, because he thinks the Lupron could be partially responsible for my crappy embryos. (He's not discounting the likelihood that I simply make crappy embryos - three beautiful babies snoozing in their cribs notwithstanding).

He would, instead, like to move to an antagonist protocol. Shocking! Compared to the 5% of women who make crappy embryos with Lupron, about 20% of women make crappy embryos with Ganirelix. He said that with Ganirelix, you run the risk of a certain amount of unevenness in the cohort, which is something he's particularly concerned about with me, given my propensity to have lead follicles in my cohort -but he's hoping that without any Lupron on board at all, we'll see a different trend than we've been seeing. He believes that we have a 30% chance of seeing a lower quality cohort with the Ganirelix and a 50% chance of seeing a better quality cohort. I believe we have a 100% chance that this is all a crapshoot no matter what.

As for his overall recommendation - he said this is really about my personal stamina - and what I think I can handle. He said that he thinks he knows me well enough by now to know the answer to that, but that it's really up to me. We talked around the insurance issues a bit and I told him that I have one covered cycle left in my insurance and that after that my husband's insurance covers us, but only at The Hatchery. Interestingly - the Hatchery is merging with Ye Olde Fertility Clinic in the next few months, and this may seriously impact whether we'd be able to pursue additional cycles after this one. It was actually quite comforting to know that we may not be as limited in options as we thought after this cycle. I thought about it for a few minutes and told him that my husband and I were both committed to wanting another baby. But that most likely what we would do is do this next cycle and then take some time to re-group and consider the insurance implications of continuing on with another couple cycles under his insurance. Even with the merger - which would mean taking away the logistical nightmare of forcing me up to a city an hour away in the wrong direction at all the wrong times - my husband's insurance still isn't as good as mine, and the upfront cost is still significantly greater than mine, so that's still a lot to swallow. But ... I do like knowing that we're not at the end of the road come August if we don't choose to be.

SuperDoc said pretty clearly that "this cycle is going to be very telling - we're going to learn a lot from it.... of course, hopefully you'll simply be pregnant at the end of it." It wasn't lost on me that the pregnancy possibility wasn't the immediate thought, and was more of an... afterthought. Just as it wasn't lost on me that SuperDoc's recommendation to move to an antagonist protocol - once his "last resort" - was now his next step.

I asked about whether I should be considering a 2 embryo transfer on Day 3 - rather than continuing to dig my heals in about the Day 5 blast eSET transfer. He said that we need to look at what the embryo quality is with the antagonist protocol - if there is an improvement in embryo quality, he would still encourage me to transfer one embryo (Day 3, Day 5 - we'll see when we get there). But if we're still looking at the same embryo quality issues - then it's a matter of talking through the statistics and making an informed choice when the time comes. With embryos of the quality I've been looking at on Day 3 these last couple cycles? He'd have put me at 5-10% odds of having a twin pregnancy - odds I can live with. If we were looking at transferring 2 high grade blastocysts, the twin odds would be closer to 50% - odds I could not live with.

And so... Friday I'll be getting my progesterone drawn to see if I've ovulated on my own (my period was 14 days ago- if I am, we'll wait for my period to come. If I'm not, I'll start progesterone for five days. When I get my period, I'll start birth control pills for 21 days - go in for BW and U/S, and start stims 3 days later.

He's starting me at 375 units of Follistim, 75 units of Luveris. Once I start the Ganirelix, this is going to mean 5 shots per day. Awesome.

He doesn't sound super optimistic, and I'm not either. He and I are both realistic about the fact that nothing with me has gone quite the way we've expected. He's been doing this a long time and has never quite been able to predict what's going to happen with me, and that ... is frustrating, and a little worrisome. I'm beginning to realize that I'm ... not the boring PCOS patient I always figured I was.

We did, by the way, talk briefly about the shabbos incident with Dr. Hate. I may write more about it later, but the long and the short of it is that SuperDoc handled it appropriately, and with the care and sensitivity that I needed. He assured me that he would do everything he could to be the doctor who was present for all of my procedures no matter when they are, but that if he can't be there for whatever reason, he will ensure that whomever is on call will be well-versed ahead of time in what needs to be done to accomodate the religious restrictions that I have on Saturdays, should it come up again. I assured him that I don't expect him to be at all of my procedures - it's a big practice, and I know how the practice works - different doctors are on call for procedures on different days, and I know that.

"After all you've been through, the least you can expect is that I'll be there for your procedures. I will always do my best to be there for you," was SuperDoc's reply.

Take that all you ridiculous competing clinics out there with your radio commercials calling Ye Olde Fertility Clinic a "revolving door of doctors" - implying that my clinic is impersonal, without contact from individual doctors. Take that!

And this, my friends, is why I love SuperDoc. Why I love my clinic. Why I sing their praises. Why I'm willing to put myself on television and in print media for them. Why I refer patients to them consistently and frequently.

Because they care.


Rachel said...

I'm glad you have a plan, and a door left ajar for the future if this is not the cycle which works. Although I am sure it is no solice at all, I have gained a lot of information reading your protocols now that you are no longer a boring ol' PCOs patient. I actually enjoy reading your descriptions of your cycles because they are so clear and you can point out the risks and benefits of each protocol.

tovarena said...

I just wanted to pop in and send hugs. I've been following but not had a chance to comment in quite a while.

Interesting - our upcoming IVF will also be using an antagonist protocol. Apparently due to my age.
...but that's not till after the yom tovim. In the meantime, thinking of you...

B. said...

I'm a little jealous of your relationship with Superdoc. Not in a way that says if I can't have that kind of relationship then no one should. It's more like I wish we all had a similar relationship. I still get the impression that, aside from my impact on her statistics, my doc really doesn't care at all... what happens happens.
Wishing you great success!

Jendeis said...

Wish I had something witty to add, but just wanted you to know that I'm here with you.

decemberbaby said...

Damn, it sucks to be the "interesting, challenging" patient. I'm sorry it's coming to this.

I'm very glad, however, that you have such an awesome doctor.

Lori said...

I'm glad you finally have a plan. The merger with the Hatchery certainly could be a good thing too.

For what it is worth, my friend was in a similar situation. She did 2 IVF cycles on Lupron with crappy embryo quality and no pregnancies. She switched to an antagonist protocal for try #3. She got pregnant on tries 3, 4 and 5. Two children, one miscarriage. Hopefully you will have the same success.

Carrie said...

I wish you were an "easy" case to figure out but your doc sounds so committed and on the ball. I did an Antagonist protocol since Lupron did not suppress me but gave me giant cysts, and it worked for us.

I have a friend who also could never make blasts on Lupron and did with her first antagonist- preggers. Not trying to be obnoxious with these stories, just know that it can make a huge difference for some people.

Thinking of you, sending a hug!

Anonymous said...

Your doctor sounds absolutely awesome. I'm really jealous.

I'm so glad that you have a plan. For me not having a plan always left me uneasy and even if the plan was the "last resort" I still felt better just having one.

Wow...5 shots a day? There's no way to mix any of those together so you have less sticks per day? You will be a human pin cushion!

I hope that you did ovulate this cycle and can get going on things soon. Also glad to hear about the two clinics joining for future endeavors, but of course hoping you don't even need to worry about that.

In and Out of Luck said...

I'm glad you have a plan. And a doctor who seems to have both a heart and a brain. And, thank you for your comment to me.

Anonymous said...

I think it is good that you are trying something different with the protocol.

And I am glad to hear that things may not be as over as you had thought if this next cycle doesn't pan out.

Beth said...

SuperDoc sounds incredible. He sounds so caring and you two seem to be an excellent team.

As always, thinking of you... and looking forward to hopefully seeing you again soon!!!

amber said...

I'm really happy that the door has at least been left open for additional cycles, if necessary, with your husband's insurance. Still keeping you in my prayers.

Erin said...

SuperDoc really does sound incredible. He clearly cares about you as a person, as well as being committed to seeing you become a mom again. I'm glad that you have him in your corner. And I'm glad that corner has a plan.