Youch

Seriously?

Ow.

And I feel like this shouldn't still hurt.

On a Scale of 1 to 10...

Holy Crap, I'm still in so much pain from today's HSG that I think I might throw up. It comes and goes in waves, but this is really not feeling great. I'm not enjoying this.

Update (6am, Wed.): The pain has subsided quite a bit, but I'm still really nauseated. It is possible the nausea was unrelated to the pain and HSG entirely.

The Plan and the Insurance Sitch

First, see my previous post for the latest on my girly parts.

Second, here's the latest on the insurance situation:

I am definitely switching to the insurance at Big Large Corporation (BLC). It is unquestionably better coverage. If I exhaust my coverage under BLC, I can go back to my husband's insurance and then exhaust his coverage. Sneaky, eh?

Unfortunately, the insurance with BLC, which uses Well Known Insurance Company (WKIC), does not include Dr. McB as a preferred provider. In order to continue seeing him, I would have to see him as an out-of-network provider, which would completely defeat the purpose of having kick-ass benefits under BLC/WKIC. This is, of course, not an all together bad thing, what with the 30-40 mile drive (depending on whether you're driving from my house or my office), but you know? I had really begun to like Dr. McB. And we had a plan. And a timeline. And we were moving forward. And it was all good. Except the geography. But everything else was pretty good. Okay, so his SART Stats weren't great, but SART Stats, to be honest, aren't everything. Even SART says flat out that the stats can be deceiving because some clinics have a habit of purposely weeding out patients that will pose a greater challenge, and some clinics specifically see those patients that are more of a challenge, so their stats may be lower. So you see? It's all a little deceiving.

That being said, even the raw data for my old clinic is better - over 10% of their transfers are elective single embryo transfers, which is well above the national average of 3%, and well above the Hatchery's 0%. And the number of cycles initiated is vastly bigger - nearly 1200 compared to 36 in my age group. Bigger isn't necessarily better, but it does make their data easier to interpret since their sample size is bigger. There is defintely something to be said for the smaller clinic and the single doctor who isn't going to forget me. But I never felt like my doctors didn't know who I was at the big clinic, either. I never felt like a patient number at the old clinic (though I still know my patient number by heart).

Anyway, it's the right decision to make - to go back to the old clinic. Geographically, financially, and probably in terms of success rates. But it sucks because I had a plan, and now the plan has changed and because I really did like Dr. McB as it turned out, and I think he would have done good things for us. I hate that money stands in the way of the things we want in life. Or in this case, money and geography.

So the plan:

1. Get HSG done - either clinic could use the same HSG results anyway - CHECK
2. Schedule a pre-pregnancy consult with perinatologist - CHECK (Dec. 15th)
3. Schedule consult with Dr. Amazing at old clinic - CHECK (Jan 5th)
4. Go on BCPs when next period starts - I'm still going to do this in anticipation that Dr. Amazing will be on board with my plan to go forward with IVF and that way I won't be delayed in waiting to start a cycle - I'll already be on BCPs. Sneaky, right?

And now we wait.

The Plot Thickens

So I had my HSG today. Truthfully, an HSG wasn't strictly necessary, since we knew we were going to do IVF no matter what the HSG indicated, so I could have just done a sonohystogram, since all Dr. McB really needed to see was the uterine cavity, but he left it up to me to decide what I wanted to do. Me being me, I'd prefer to know what the status of all the girly parts is whenever possible, even though my last HSG was totally clear back in 2005 and there's no reason to think anything has changed. But really, my last HSG didn't cause me any true discomfort, except when threading the catheter through my cervix and that was short lived, and I'm not really all that concerned about the invasiveness of the procedure. Truly, you don't get much more invasive than a high-order-multiple pregnancy and subsequent c-section, to be honest. Frankly, my comfort level for one procedure is not my main concern here - getting the baby on the other side of all of this is my main concern. So bring it on, doc.

Which brings us to this morning. I hauled my tushy all the way up to The Hatchery, 33 miles away, arrived 30 minutes early (whoops), and waited. And waited. Okay, I didn't wait that long - they were running about 10 or 15 minutes behind, so it wasn't so bad, but considering how early I was and the fact that I'd failed to bring any books with me and the Radiology Center at the University doesn't have any decent magazines... it sure did feel like forever.

Doing the HSG at The Hatchery is different than at my old clinic (I'll have to think of a new pseudonym for the old clinic...). The Hatchery uses the University hospital services for everything they do - so the HSG is done downstairs at the radiology center, retrievals and transfers are done in the main hospital (I think in a regular OR, but I could be wrong about that). The old clinic was a self-contained unit - everything they did was in their own suite, their own labs, their own surgical center, their own facilities, period. So I was taken to a changing area where I changed into a gown, but then from there I had to walk down a hall to a room where they took a flat, pelvic xray, and then down the hall to another room where they did the actual HSG. Both times I walked through the hall, there were several gentlemen sitting in chairs waiting in the hall. Not really who I want to be walking past as I'm walking in a gown with nothing covering up my nether-regions ifyaknowwhatImean... (I mean, I know the GOWN covered up my nether-regions, but I still felt a might bit TOO exposed for comfort's sake.

The equipment that this radiology center used for the HSG was different than my old clinic, also. Rather than being on a bed with stirrups, I was on a flat x-ray table, and rather than having this adjustable floaty thing above me that was attached to a computer screen showing my uterus in real time and all that like last time, there was a more normal x-ray machine (just smaller) that slid out over me when the time came (still attached to a computer thingy with live shots, but they took several still shots rather than having the computer capture the pictures). It seemed... less modern, but it did get the job done, so I don't know if it was less modern, or just different. I am certainly no doctor, and I will say that my husband works at this hospital and is the pharmacy manager for technology and they are anything but archaic in the pharmacy department, so I can't imagine that this was archaic - it was just different.

Dr. McB came in and was really very pleasant. Honestly, I really feel badly for calling him brusque after our first meeting - in retrospect, while his manner was quite matter-of-fact, he was probably at least partly responding to my manner, which was pretty much, "I know why I'm here, I don't need you to hold my hand through this, let's get on with the show." It's just that any consult with an RE is a bit... I dunno... demeaning in a way. It feels like it strips away a bit more of my femininity each time I walk into an RE's office and I get a bit more defensive each time, I think, even though I don't mean to, and I know it's not their fault I'm there.

Wow. Tangent, much?

Anyway, Dr. McB came in and gave me my consent form and ran down the list of risks that there are associated with an HSG, but I've been there, done that. Kudos to him for explaining them very clearly and explaining exactly what they do to mitigate those risks. Needless to say, I wasn't worried before, I am not worried now. We joked around for a bit as everyone was getting ready and then it was time for me to assume the position, which isn't as easy as it sounds on a totally flat table, but whatever. I told him that this was certainly MY idea of a good time on a Tuesday morning, and he said it's certainly a typical Tuesday morning for him. It's only my second HSG, but I sure hope it's not just his second... he assured me that although I was only his second of the day, I was not his second HSG ever.

Now, next bit of kudos to Dr. McB - he did a really good job of always letting me know what he was about to do next, which I really appreciate in a doctor. Not all doctors think to do that, but it's a nicety that really helps patients feel like they matter. So if any doctors ever read this blog - by golly, take that as a lesson to you! He told me he was about to insert the speculum and I said, "You do what you need to do, doc!" But holy smokes, that hurt. And it didn't stop hurting until the end of the procedure when he pulled it out. Could it have been pushing against my cervix or something? Whatever it was, it hurt! "Now I'm going to wash your cervix with betadine," he said. "Okay, hold it right there, doc. Now I think you're getting just a little too up close and personal, don't you think?" Hang on there, kiddo, it's about to get a lot more personal than this! Then he told me he was going to give me something to numb the cervix. Hey, I don't remember my old clinic doing that - apparently he's just nicer than them. "You won't even notice this..." YEOWCH! Big huge, horrible, ouchy pinching! "really? The last woman didn't even notice me doing that!" Clearly, I'm just a sensitive soul.

He let his resident inflate the balloon, which she seemed to have a little bit of difficulty with, but I have no problem with that - you have to learn somehow, right? And he was in total control of the situation the whole time, which was abundantly clear, so I wasn't in the least bit concerned. There was some discussion about catheter sizes. Apparently my cervix wasn't as cooperative as one would l ike. Tell me about it. I felt exactly the same way when it shortened from 4cm to 1cm overnight while I was pregnant. Uncooperative, indeed! Mind you, all the while I'm still in some pretty fine pain from the damn speculum. Dr. McB asked a couple times "How you doing up there?" "Just as great as could be, doc!" "Well, I just like to keep the lines of communication open down here!" And good for him. How dare I judge him at our last appointment? No really, how dare I?

And then came the dye. At my last HSG, the worst of it was getting the catheter through my cervix. After that, it was smooth sailing and I never noticed the rest of the procedure. So I figured that the rest of this procedure would be a piece of cake. Not so.

Holy Crap! They actually had to remind me to breathe, because I really couldn't move a muscle it hurt so much. I wanted to squirm but knew I shouldn't and I wanted to writhe, but knew I couldn't. They started taking pictures and I said yeowch a few times (as calmly as I could) and Dr. McB said, "Well there's an obstruction there on the left side." Huh wha? Excuse me? That's a new development. And so not okay. Well, said Dr. McB, it doesn't really matter since we're doing IVF anyway. But that certainly doesn't mean I wanted there to be something else wrong with me just for the heck of it, now does it? He kept taking pictures and asked if I could roll a bit over on to my left side and I swear I was in so much pain that I couldn't remember which side was my left side, but I did figure it out in time. Yep, definitely obstructed.

WTF, people?

I mean, seriously! I'm supposed to be doing this IVF thing because IUI works too well - not because I actually need IVF! Okay, that's a little harsh, since I almost moved on to IVF twice the last time around, so clearly I did have indications for IVF regardless. But it does change my perspective a little bit. Somehow, I feel just a little bit more "legitimately infertile." This is ridiculous, of course, because the 5 years of infertility, the $20K, the 5 cycles of clomid, the 6 IUI with Follistim cycles, the miscarriage, the hundreds of injections I gave myself - those all should have been clues that ... hello? I'm infertile. (And don't anyone go pointing out that I have a gaggle of kids so I must not be infertile - infertility and barrenness are not the same things - I am SO tired of people saying, "You're not infertile, look at all those kids!")

So it turns out that I need this IVF thing after all. Not just to avoid another set of multiples, but because without it, I'd only have a chance at getting pregnant whenever there was a dominant follicle on my right ovary. What a pain in the tushy.

Meanwhile, the plot thickens on the insurance front also, so more on that later - this post is long enough in and of itself.

*SCREEEEEEECH!*

Change in Plans.

Let me back up.

I've been working at my current job as a subcontractor to BIG LARGE CORPORATION (BLC) since January. As a subcontractor, I did not have medical benefits (or any benefits, for that matter), which was fine, because I have medical benefits through my husband's employer. I was recently hired on as a regular employee with BLC. Before I agreed to explore permanent employment with BLC, I reviewed their benefits packages to see what I was in for, just to see if there was anything exciting about it. The corporation is based in a state that mandates fertility coverage so my hope/expecation was that they would cover fertility treatment. Alas, it appeared that BLC "self-insured" and it said quite clearly on their benefits summary data sheets that fertility coverage was specifically excluded from their plans.

In fact, the exact wording under "What is Not Covered" was:

Actual or attempted impregnation or fertilization including, but not limited to, in vitro fertilization and artificial insemination, ZIFT, GIFT and injectables, except for initial diagnosis

That seems pretty clear that fertility treatment is excluded, no? However, when I was looking at the plan information back then, I was looking at information that described the BLC "Total Health Plan" which was pretty clearly a "self-insured" plan.

My first official day at BLC was last Monday and in my over-the-phone orientation with my HR manager (I work several states away from my manager), she kept talking about plans with Well Known Insurance Company (WKIC). I couldn't for the life of me figure out how they were getting around my state's mandated insurance coverage if they weren't self-insuring. Over the weekend I finally got my benefits package in the mail and was able to access the website today with all of the plan data on it.

I searched and searched for the information about fertility coverage, but found nothing. NOTHING. Nothing about coverage, but also nothing about exclusions. What could this mean? I couldn't find anything anwhere on the site that talked about plan exclusions at all. And the summary plan descriptions were pretty high-level and just didn't give me enough information to know whether fertility treatment was covered.

Soooo.... I called the Benefits Service Center (BSC) at BLC and asked them if they had a listing anywhere of Plan Exclusions. The representative helping me had no idea what I was talking about and referred me to the summary plan descriptions. No, I countered, those are too high level and don't really explain exactly what is covered, nor do they address plan exclusions. She didn't have any further information for me, but would be happy to research the information for me and get back to me. Meanwhile, if I wanted, I could contact WKIC directly if I wanted. Oh! That would be lovely, thanks.

I called WKIC directly and spoke with an absolutely lovely representative who was happy to help me sort this all out. No, they didn't have a list of plan exclusions, but was there a particular service I was looking to find out about? Ahem. Well, yeah, actually, there was. What about fertility treatment? Oh, well, fertility treatment is covered just like any other medical claim - same copay, coinsurance, deductible, etc. There's a $100K cap on coverage for fertility treatment/medications, etc. A limit of 6 IUIs per lifetime. Limit of 3 IVFs per live birth. No coverage for ICSI or Assisted Hatching. No coverage for freezing or storage of embryos (this is pretty typical).

This is way better coverage than my husband has, particularly when you factor in that I'm not limited to the one clinic that is 40 miles away, which makes life logistically difficult. So the choice is clear. Or it should be. I mean, obviously, I'll switch to BLC's insurance pronto.

It's just... Gosh. I'd really decided that I do like Dr. McBrusque. And that while his manner may not have been perfect, I did like that he was willing to hear me out and he was willing to think about doing single embryo transfers despite the fact that he's never done them before, and the fact that he had an innovative solution to the hyperstimulation problem. I liked that he called me himself about the metformin/breastfeeding problem. The things I didn't like were basically out of his control. With Dr. McBrusque, I have a protocol laid out, a timeline set, and all I have to do is wait for my next period, and we're ready to get started as soon as the first of the year rolls around.

I don't deal well with change. So obviously, I'll change plans and start over, but it's going to mean delays and changing mindsets and reorganizing my thoughts, so it's going to mean a bit of whinging on my part. I apologise in advance.

So here's the current plan:

• I will still have my HSG tomorrow.
• I still plan to schedule a pre-pregnancy consult with my perinatologist to determine whether it would be wise to even consider allowing more than single embryo transfers.
• I will schedule a consult with another RE... I have to decide who this will be - should it be my old clinic? Should it be someone entirely new? I don't know! And if it's my old clinic, should it be the first doctor I saw there, or the second doctor? I love them both, but one moved to a location further out, which is the only reason I stopped seeing her. The second doctor was great, but he definitely didn't love that I didn't reduce the HOM pregnancy. I dunno.
• I will find out if the current clinic (the one that is 40 miles away) accepts the insurance that I'm switching to. If so, I'll continue to proceed as planned with them, until I determine whether I should be switching to a clinic closer to home.

That's the plan so far. I can work with plans. I always need a plan. This can work, right? I mean, after all, it's GOOD news that I've got coverage, and that I've got better coverage, and that I can now have my choice of clinics, even though it throws off my entire timeline, right?

Weaning

Well, I know that it had been my plan all along, but my babies are weaned now. And I hadn't really meant for it to be today, but they decided it all on their own. I was figuring that we'd get down to the day I started BCPs with me gnawing my fingernails off trying to figure out how to get them to stop without traumatizing them. I had these grand plans of how I was going to gradually reduce their feedings, but it didn't really work that way, I still let them nurse whenever they wanted to, but you know? I think they just knew it was time to stop nursing, because they really stopped wanting to nurse, even when I was offering. Yesterday they nursed sort of fitfully for the last time, but really weren't all that interested and kept pushing me away. Today, no one was remotely interested.

So I guess that makes things a lot easier. And certainly means I don't have to worry about the HSG (which, by the way, is absolutely not a problem with breastfeeding, and yes, I do have to stop taking the metformin for the HSG, which means it was completely stupid for me to START taking it on Wednesday, but whatever... I have to stop taking it Sunday and resume taking it Thursday... Gah!).

I wonder what I'll do with all this free time on my hands now? No more pumping, no more nursing. All done. 14 months of my life suddenly over with no fanfare whatsoever. Do I get some sort of award for this? A good stiff drink, perhaps?

Batching

One thing I keep forgetting to post... when I spoke with the infertility nurse coordinator on Wednesday she cleared up one thing that had really, really, really bothered me about The Hatchery and made me feel much, much better.

The Hatchery batches their IVFs, which really bugs me because it gives me less control over my timeline. It especially bugs me because they used to batch their IVFs quarterly! I was feeling incredible time pressure with a quarterly timetable. I had forgotten to ask Dr. McB if they still batch their IVFs quarterly when I saw him on Monday, but when he was talking, he'd made it clear that he batches his patients, so clearly, something was up.

Still, he'd said some things that made it sound all so flexible, like, "So when do you want to get started?" and "What kind of timeline do you want to look at?" And then when the nurse called me on Wednesday she was also asking me similar things... she was asking me if I wanted to start BCPs this month to do my IVF next month or if I was waiting. Finally, after all my important questions had been answered, I asked if they still batch their IVFs. "Yes, we start cycles every two weeks now."

Wow. Every two weeks. Well, that's practically all the time! That kind of batching I can totally handle. No time pressure, I can still pretty much pick when I start. She said this just helps him control his schedule a little better, because it gives him one procedure weekend and one ultrasound weekend. Whew. With only one doctor in the practice, I can totally understand that. I'm really all about it.

Glad I cleared that up.

Metformin

Metformin? Sucks.

dye with HSG

Hey this may seem really stupid, but does anyone know what kind of dye is used with an HSG? And do you know whether there's any problem breastfeeding after an HSG? My guess is there's no problem since it's injected into the uterus, not into the bloodstream, but, of course, it goes out through the fallopian tubes (assuming no blockages) and absorbs into the body, so who knows.

Clearly I can ask my doctor this, and obviously the two best doctors to ask this are the radiologist who does the HSG and my pediatrician... but I'd rather ask before the day of which means the radiologist isn't the best candidate and I can't really ask my pediatrician without knowing what kind of dye they use. I guess I'll go acquaint myself with Dr. Google...

Clearly if I manage to wean before then, this will not be an issue.

Edit: As Chris noted, it's an iodine dye used, either water based, or oil based. I can't find any article suggesting that there's any issue with breastfeeding, but I'm sure my husband will be able to answer that for me in about two seconds once he gets home. I can't, for the life of me, think of ANY reason why iodine would be incompatible with breastfeeding, though occasionally (rarely, even) women have allergic reactions to the dye, so I guess your babies could too, if there was any way it could be excreted in the breastmilk, but my guess is that even if it could be excreted in the breastmilk it would be in such a small concentration it would be nearly irrelevant.

Money Matters, Labwork, and Moving Forward

I talked to the financial coordinator at The Hatchery on Tuesday. She went over my benefits for fertility coverage. We're covered so long as my husband and I have been married for at least a year (check) and he's been employed by the hospital for at least two years (check). I have to fax a copy of our marriage license to her to prove we've been married at least a year (are you KIDDING me?).

• We are covered for 4 IUIs, with no dollar limit on those. No thank you. Not walking down that road again.
• We are covered for IVF up to $30,000: approximately 2 IVF cycles.
• We are covered for $10,500 for medications.
• We are NOT covered for embryo freezing and storage ($1100 for freezing and $540/year for storage).
• We have a $1000 copay per IVF procedure.

This is very good coverage, but far less than I had under my previous coverage. Since we're hoping to do single embryo transfers, being limited to two covered IVF's is a bit daunting, but it's definitely better than nothing. I am somewhat concerned about it, but I'm trying not to let the financial consideration get in the way of the medical data that I know supports my stance on this matter.

I had my CD3 and Infectious Disease Labwork drawn yesterday. I don't think they're planning to call me with the results of all of that, since I'm not actively cycling. I did schedule my HSG for next Tuesday, so maybe while I'm there, I'll ask how it all turned out. I like to know these things. It was a two hour ordeal to get it drawn, between the 50 minute drive up there, the 45 minute wait, the 15 minutes sitting in the chair, getting it drawn, and getting out of the lab, stopping over at my husband's office a block away to get a bottle of water and some moral support, and the 50 minute drive back. Yippee.

I spoke with the Infertility Nurse Coordinator yesterday morning before I went out there for my bloodwork and scheduled the HSG, as I noted already. She said I could just do a sonohystogram (sp?) if I'd prefer, because the only reason to know whether my tubes are unblocked would be if we convert my IVF cycle to an IUI (over my dead body) and since I've had an HSG before, they could assume my tubes are unblocked unless something's happened since then. But I'd just as soon know what we're working with. The HSG didn't bother me so much the first time around, and frankly, even if it had, uncomfortable tests don't bother me. It's not about my comfort, it's about the end result. I want the baby in the end. The singleton, preferably.

After I get my next period in December (assuming that happens), I'll start birth control pills, and sometime in January, I'll start my IVF protocol. Holy cow. This is a huge deal.

One more point before moving forward. I've decided that in light of Dr. McBrusque's preference to do a two-embryo transfer and in light of the fact that I have a limited number of IVF attempts in front of me, which might, unfortunately, affect the game day decision for how many to transfer... I've decided that I definitely need to have a pre-pregnancy consult with my perinatologist. I had been planning on doing this regardless, but I felt fairly stupid doing so with the prospects of most likely having a singleton, but if we're facing much higher odds of twins, I am a little more worried. I had such a horrendous pregnancy (not that I didn't love it, mind you!), and I don't know how much of it was attributable to the high order multiple factors, how much of it was attributable to just being a multiple pregnancy in general, and how much of it was attributable to my body just not doing pregnancy well in the first place. There was some thought throughout my pregnancy that I probably would have had serious contraction activity, even with a singleton, but I imagine there's no way to predict whether those contractions would have affected my cervical length so drastically in a singleton pregnancy. I also don't know if I'm at a more significant risk of developing preeclampsia in a subsequent pregnancy now that I've had it before, and if so, whether that risk increases if it is a multiple pregnancy (I'm sure the risk increases if it is a multiple pregnancy). I do think these are questions that at least need to be asked before I go putting myself at a very real risk of ending up with a twin pregnancy. If my perinatologist says "Twins would be a very high risk for you," then that ends the debate; there will be no game day decision to make, and we'll only consider SET's (Single Embryo Transfers) .

The important thing to note is that the more removed I get from Monday's appointment, the more I realize that it wasn't an all together negative appointment. I had a two-hour post-mortem lunch with LJ and it really helped me put a lot of it into perspective and focus on the positive. I know that a lot of what is colouring my opinion of the whole thing is the 40mile commute, and I definitely didn't love his bedside manner. But he is otherwise an excellent doctor with a lot of experience and I do trust his medicine, even though he doesn't always do things in the way that I'm used to having things done. Change, after all, is not always a bad thing. It's just that I don't always deal very well with change, so it's taking me some time to adjust.

Meeting with Dr. McBrusque

Yesterday, my husband and I met with the reproductive endocrinologist (RE) at our new clinic, henceforth referred to as "The Hatchery"*, yesterday. Not to be unoriginal or anything, but we'll refer to the doctor as Dr. McBrusque, because, well, that's what he was: brusque.

I should note that I had to fight very hard not to walk into this clinic with a chip on my shoulder. There are so many things I don't like about the clinic without even having walked in the door, that I had to actively work against walking in with a negative impression without even having met the doctor. It was an extremely difficult exercise, but I think I had some success in walking in the door with a relatively open mind.

The clinic is about 35-40 miles away, which is one strike against it. It is, admittedly, one block from my husband's office (he works for the same hospital), which makes it convenient for him, but unfortunately he's not the one who has to be there nearly so often as me. The clinic has only one doctor; another strike against it. They do batched IVFs, which I don't love because it takes a lot of control and flexbility on timeline away from me. Three strikes against it before I've even walked in the door. But we're keeping an open mind, remember?

So I drove up to the clinic, which is located in one of my least favorite cities in the entire world, and we were early enough that my husband and I were able to grab a late lunch together. One point in the clinic's favor - close to yummy kosher food... it's a very, very small point since it is very rare that I'll have the time while I'm there to do anything about it, but hey, it's worth noting. I arrived at the clinic and walked in, noting that the fertility clinic is actually housed within the Women's Health Center for the hospital. This means it is the OB/GYN and midwives offices. Yeah. This would be another strike against the clinic. I know I've already got a gaggle of kids, but that doesn't mean I want to be sitting next to a pregnant woman when I'm in the middle of a cycle, or right after a negative beta, or an early loss, or whatever. I just want no part of that. I've never had a normal pregnancy and I still have a hard time with that. So I don't really want to be sitting in an OB/GYN's waiting room every time I need to go for cycle monitoring. I guess the one good thing is that the fertility practice is very small, so hopefully the waiting times won't ever be very long.

I was called back to get vitals taken and fill out a fertility history form (you know the one, been there, done that). I hadn't finished filling out the form when Dr. McBrusque called us back. No biggie, he's perfectly capable of taking a history all by himself. He informed me that he had a med student in his office. Now, I know this is nitpicky, but while I recognize this is a teaching hospital - and I would never say she couldn't sit in on the consultation - I expect to be asked if I'm okay with having a voyeur in on my consult (particularly a physical exam - which happened at the end of the appointment, which she was also present for).

Dr. McBrusque asked what brought us into the office and I told him we have a set of high order multiples (point in his favor: he did not laugh us out of his office right then and there) resulting from 6 IUIs, and we're just crazy enough to want more, but one at a time. I explained that I hadn't wanted anything to do with IUI in the first place because of the risk of multiples, and that we'd spent as much on 6 IUIs as we could have spent on 1-2 IVFs. So, he said, you want to do IVF now. No problems there. First hurdle crossed - I was worried I'd have to have the old argument all over again: "But IUI obviously works for you! Why not try it again?" Yes, it works for me, all together too well! (plus, each individual cycle odds are too low... it took 6 cycles to have a successful pregnancy)

And then we hit a bit of a wall.

"So how many embryos do you want?"
"You mean in general? or to transfer?"
"To transfer."
"Oh, I want Single Embryo Transfers."
"Wow. Um. Wow."

I'm telling you, I thought he might fall out of his chair right then.

"I know. You've never done an elective single embryo transfer."
"No, I haven't. How do you know that?"
"I've read your SART Stats. Don't think I don't know them forwards and backwards. And don't think I'm not walking in here not loving that you've never done an elective single embryo transfer. I can be your first."

We talked for a while about why he wouldn't recommend a single embryo transfer, and why I don't agree with him (the data right now is clearly supporting single embryo transfers in patients my age with my history, ASSUMING that I end up producing decent embryos when the time comes). While I was there, I really felt like he wasn't going for it, but in retrospect, he really did say he would do his best to keep an open mind about it come transfer time, which is really all I'm asking. I'm definitely of the opinion that if there's a compelling medical reason to transfer two come transfer time, that's what we'll do. But I just want to go into this with the mindset that we're going to try to consider single embryo transfers if at all possible, even understanding that we may be taking a greater risk of negative betas per individual cycle. He also said that maybe with me he'd consider doing blastocyst transfers, which he normally doesn't do. This surprised me, but he said he used to do blast transfers, which resulted in a very high pregnancy rate, but didn't result in any more babies, so they stopped doing it. Their pregnancy rate went down a little once they stopped doing blasts, but their live birth rate stayed stable. Weird, huh? Anyway, he said for me, it may be a consideration, so he was definitely keeping my specific circumstances in mind when he was talking to me.

I asked how he would deal with the increased risk of OHSS (ovarian hyperstimulation syndrome) since I have PCOS. I said I'm a very high responder to stims, and this was something that my old clinic was planning to address by keeping me on Lupron longer than typical. He said he would take the opposite approach and not use Lupron at all. He said that he has long suspected that Lupron is actually a contributing factor to hyperstimulation in patients like me and that there is now some emerging data to support that suspicion that has been presented at some recent conferences. The reasoning is this: if the Lupron keeps you suppressed, then you have to aggressively use the stims to overcome the effects of the Lupron, but then you can't control it. Even if you back off a little bit, your body is already responding to the high doses of stims you pumped into it. So it hyperstims as a result. This actually makes sense to me. He prefers, instead, to use an antagonist protocol instead of the agonist protocol because you can control it. This sounded like a reasonable approach to me, and Lupron is evil, so I'm all about skipping the Lupron.

He prescribed me metformin again. I haven't been on it since early in my pregnancy, but I did get benefit from it before, and it makes sense to be on it again, because the last time I was in treatment I was on it, so I'll respond differently to stims this time if I'm not on it. I really did want to be back on metformin anyway, so it's win-win all around. Even better... Dr. McBrusque may be brusque, with not much of a bedside manner, but he did do one thing really, really right. After I'd left the office and I was driving, he called me on my cell phone and said he just wanted to let me know that metformin is not recommended for breastfeeding mothers. I really appreciated this follow through, because I'm certain that he rarely thinks about drugs and breastfeeding, since really... how often is he faced with a breastfeeding mother? And also, that he took the time to call me on my cell phone says a lot... he could have just left a note for his nurse to call me in the morning. (Anyway, he and I talked more about it and he said it boils down to not knowing whether it's okay, but that it does show up in breastmilk, but my pediatrician had more thorough information about it, and they're fine with me using it, particularly since the babies are not nursing very much anymore...just 1-2 times per day, and they're going to be weaning very soon regardless)

After we finished talking, and he wrote up a lab slip for a pile of lab work (did I mention that yesterday happened to be CD1? How convenient!), he took me to the next room over to do an exam. I've never had this at a consult with an RE... and it caught me by surprise. It was particularly frustrating because, hello? CD1! Ick. But whatever, I'm sure he's dealt with more disgusting things in his life. I didn't love that the med student was again in the room without my permission being asked. There were a lot of people in the room - Dr. McBrusque, a nurse, the med student, me... and it was a tiny little exam room. Again, I wouldn't have said no, but if you guys are going to be all up-close and personal with my lady-bits, don't you think you could ask my permission?

And that was pretty much it. I was on my way. The whole appointment, including the exam, took about an hour. So I'll admit, he was thorough. Unfortunately, I didn't have my records from my old clinic with me, because they haven't sent them yet. But he said whenever I get them, he'll review them carefully, but admitted that he wouldn't get SO much out of them, since I'm changing from IUI to IVF.

The hardest thing is having to get all the way up there for appointments. And the fact that they do their monitoring appointments between 8 and 9am. That's utterly ridiculous... I won't get to work before 10am if that's the case. I don't know HOW I'm going to explain this one, and I don't really want to tell my job I'm going through fertility treatment. If I only had ONE other kid, that would be one thing, but I already have a small gaggle, so people look at me a little funny if I tell them. So how am I going to explain a doctor's appointment that keeps me out of the office every couple of days for a couple weeks? Sigh.

Our insurance essentially covers 2 IVF cycles, plus $10K in medications. I know I'm very lucky to have insurance coverage at all. I know I'm very lucky to have this opportunity to try. But I definitely feel the pressure.

Next steps: CD3 bloodwork tomorrow, precertify everything with the insurance (their financial coordinator is working on that now), wean the babies, new semen analysis, repeat HSG (mine is 3 years old), mock embryo transfer, and... IVF.



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*Kudos to my friend, J, for the pseudonym, "The Hatchery" for the new clinic. Even if I wanted to disclose the name of the clinic... the real name of the place is so long and boring and stupid, I can't even stand saying it in real life, so I was looking for something catchy to call it anyway.

And hey... while I'm giving credit where credit is due, I owe LJ big time for the blog name. She rocks.

Inaugural Post

This blog is for the sole purpose of writing about my return to fertility treatment, now that I already have a set of high order multiples. Am I crazy? Yeah, probably. Am I asking for more than I have a right to ask for? Definitely. But I love my children, all of them. And I always knew I wanted a big family, though I definitely expected to build that family one at a time, one pregnancy at a time. I definitely didn't want it all over with in one pregnancy, and I definitely didn't want my messed up biology dictating my family size for me.

In many ways I feel selfish and horrible for wanting this and pursuing it. But I also know that I would never be asked to justify my desire for more children if I was able to conceive without my legs up in stirrups.

I made this blog so that I could document this return to fertility treatment away from my regular blog, because I don't need the nitty gritty details of my cycles and my biology to be fodder for friends and family to gawk at right now. I don't want failed cycles to be public knowledge. And I don't want a positive pregnancy test to be news spread around my neighborhood until I'm ready for that news to be spread (I already had one relatively late loss that everyone I knew was privvy to... I don't need to repeat the experience on purpose).

I'll post the details in a new post, but the basic background is this:
I am 32 (33 in Jan), my husband is 36.
I have PCOS.
We previously experienced five years of primary infertility and went through 5 clomid cycles and 6 IUIs with Follistim, which resulted in 2 pregnancies: 1 which ended in miscarriage and 1 which produced a set of high order multiples.
We also have a foster son.

Our children bring us more joy than we ever imagined possible. We are incredibly blessed and obviously if we never had another child, we would consider ourselves lucky to have the blessings that we already have. Still, I know that I have room in my heart to love another and I desperately want that for my family. I'm clearly certifiable.

This time around, we're turning to IVF, hopefully with single embryo transfers, though obviously, that may be a game-day decision. We have a new doctor, a new clinic, a new insurance company, and a lot of new waters to navigate. Let the games begin!