Pessimistic

I wonder if it's normal to go through a cycle of "This will all work out great!" and then "I don't think this is going to work At. All."  I'm in the latter part now.

Argh. One step forward, two steps back.

We got my labs back today and they don't look so great.  Here's how they came out:

Estradiol – Normal – 58.3 (normal is 80 or less)

FSH – 11.6 – slightly elevated (11.3 or less is necessary to be considered fertile, below 9 is best)

TSH – 1.55 - normal - (between 0.4-4.0 is normal)

Prolactin 17.3 – normal (25 or less is normal)

So, things aren't looking so rosy.  The FSH means that my ovulation is probably messed up, or my eggs are, or I'm not ovulating properly.  I have to research that more.  In short, the RE is now recommending that we do just one round of IUI, mainly to see if Mark (new name picked!) has had any improvement in his counts.  If he has, then we can still do the four IUI's.  If he hasn't, then we're doing one IUI, then straight to IVF. The only weird thing is normally estradiol is high with FSH, so it's strange that the estradiol is normal.

Oh, the journey. Got upset about it for the first time today.  But then I ran through little things I've learned through reading books by Pema Chodron and pulled myself out of it.  Onward.

A New Name for Joe

A few posts back, I gave a pseudonym of "Joe" for my husband. Those of you who know us may know where that name idea came from, but I've decided that he just isn't a "Joe". So, I need to pick out a new pseudonym for him.  Any suggestions?  "Nick" is striking me as a good name for him, but I'm not sure yet.

First Official Step - Bloodwork

Today I took the first official step to either IUI or IVF - I had my blood taken. This had to be done on day 2, 3, or 4 of my cycle. Day 3 is the goal, but since today is not a work day, I opted to go in today (day 2).  The clinic I'm going to is open weekend mornings for just this sort of thing.

Giving the labs themselves was very simple - just like giving blood for testing at a normal doctor's appointment. I was in and out of the office within five minutes.  By the way - the flat rubber-ish tourniquet they wrap around your arm before they take the blood makes a wonderful jar opener at home.  If you can get your lab technician to give it to you, do it and keep it in your kitchen drawer.  Very handy!

The labs they are testing are:

Follicle Stimulating Hormone (FSH) - This is a hormone that is released from the pituitary gland near your brain.  It signals your ovary to begin maturing the follicles and eggs.  They test this hormone to make sure your ovaries are healthy.

Estradiol (E2) - One of three types of estrogen that a woman produces.  Estradiol indicates whether follicles are developing. It should be lower in the beginning of the cycle and gradually increasing. It's a good hormone to measure to see if a woman is entering menopause, because it will be very low in menopausal women.

Thyroid Stimulating Hormone (TSH) - Having an underactive or overactive thyroid can result in fertility problems.  If the thyroid is underactive, the hypothalamus and pituitary glands increase levels of TSH and a hormone called thyroid-releasing hormone (TRH).  TRH both prompts the pituitary glad to release TSH and to release prolactin. Prolactin is a hormone that can interfere with ovulation by suppressing leutanizing hormone and FSH.  This is a common problem with fertility. There can also be a problem with excessive thyroid hormone.  It can block estrogen's effects, which causes problem with the uterine lining.

Prolactin - Mentioned above, prolactin is a hormone released from the pituitary gland. It's also tested at this time, and a substantial elevation indicates there may be a pituitary tumor.

So, that's what they tested today.  I should get results in the next day or two and will keep you posted!

First Appointment with RE - Didn't Go How We Expected!

We had our first appointment with the reproductive endocrinologist today and it didn't go at all how we expected it would.  That said, it went very well and I feel really good about the clinic we chose.  Here's what happened (in blow-by-blow detail for those about to go through it themselves).

When I arrived at the clinic, I filled out the registration form and waited with Joe to be called in. When it was our turn, the medical assistant took us into what was called a Consultation Room. It wasn't a normal exam room, it was more like a small office with a desk for the doctor with a computer on it and two chairs for us. We left Joe there for a minute and then went and got my weight and blood pressure. That was it in terms of medical examination.

After I returned to the consultation room, the doctor joined us. He seemed pretty familiar with our file and pulled up Joe's semen analysis to go over the numbers.  He then started talking about trying IUI instead of going straight to IVF. We had originally thought we would go the IUI route, but the nurse practitioner had encouraged the IVF path instead.  We had been against IUI, because the success rates are pretty low for IUI and we thought the cost was several thousand dollars. Plus, we thought that with low morphology, we would be out of the running from the very beginning.

It actually turns out that an IUI cycle would only cost us about $450 and because all signs are that I am likely fertile, I wouldn't have to go on any medications - we would just do it on my regular cycle. So, we would have a few months to save up for the big hit if we have to go to IVF and we might get lucky in the meantime and not have to go to IVF at all!  The downside to the IUI is that the success rate is only 13%.  But, the doctor pointed out that trying naturally only has a success rate of 20%, so it's really not that low, comparatively.

AND: Since I don't have to go on medications, I wouldn't be at increased risk for multiples!!!

So, in terms of decisions, we've decided to try IUI for four months. To be honest, I don't think it will work due to our low morphology. However, it's worth the gamble and it gives us time to set up finances better for IVF. Plus, the removal of the risk of multiples is a huge plus.

Questions I had during the appointment and the answers:

1. When would we begin the BCP or stims?

We won't have to do the birth control pill or stimulating hormones because we switched to IUI for now. We can start our first round of IUI as soon as my next cycle begins (within a week or so).

2. What medications would I be on and can I get a list of them with a calendar for usage?
N/A

3. What are the side-effects of the different medications?
N/A

4. How much time might I need to take off from work in a cycle?
Very little - I only go in once on day 3 for bloodwork (can go in as early as 7:00 am) and once when I ovulate at about 8:30 or 9:00 in the morning. The procedure will probably take about an hour or so and I can go back to work afterwards.

5. What are the stats for success for male factor issues when a single embryo transfer is done?
N/A - no embryo transfer!

6. Should we do PGD?
No! Preimplantation genetic testing could be done, but it's very expensive and the older technology has been found not to be all that reliable. The newer technology could be pursued, but unless there's a known genetic problem in our family histories (I don't know of any, but I also don't have a full medical history on my side) it's not necessary and not indicated.

7. If we do PGD, do we have to pay for it again if we do further FET's later?
N/A

8. What can we expect to pay, bottom line, all-inclusive?
For the IUI, $450 per cycle, plus labs prior to the first cycle (~$300)

9. Do I need to change diet or exercise?
Not anymore than I already have - stay on prenatal vitamins, eat healthy, all the normal pregnancy precautions.


We actually had a pretty long conversation about the different options and procedures. When it was all over the doctor explained that I likely won't be seeing him for the actual insemination unless we happen to do it on a weekend day when he's on call.  It's more likely we'll see a nurse practitioner or another doctor on a weekend. I thought it was nice that he pointed that out - in reading reviews of other clinics, people get really upset when they don't see much of the doctor, but I can see why it would work that way. I appreciated that he didn't want us to be surprised.


I also really appreciated that he didn't try to talk us into anything and actually talked us out of more expensive options. We had thought we would do a refund plan for IVF, where you pay more up front and can get some money back at the end if it's not successful. He says that they offer that because some people want it, but really our chance of success is such that we would end up spending $6,000 more going that route.  He also talked us out of PGD, which would have been several thousand dollars. I really felt like he was being very straightforward.


So, different than I expected, but we feel great about the appointment and are ready to start the new cycle next week!


Amount spent:  $0.00 (still haven't gotten a bill for anything yet)

A Lull

I don't have much to say until the 20th when I have my first appointment with the reproductive endocrinologist (RE). It's a 2 hour appointment that includes a tour of the embryology lab and a meeting with the financial advisor. I originally thought that we wouldn't be able to start a cycle for another month, but I've been doing more reading and if they can test my day 3 hormone levels while also putting me on the birth control pill, it may be that we could start in February.

After the appointment on the 20th, I'll post a full description of what happened. Until then, I keep looking at websites about raising twins with a sense of impending doom. I have to keep reminding myself that there's a 60% chance that I'll get a singleton. I'm really worried about getting pregnant with twins. So, I also have to remind myself that if I actually do get pregnant with twins, I'll probably be excited.

Conversations

It's been really interesting having conversations with different people about the idea of IVF and whether or not it's a good idea to go through it, or whether or not it's a good idea to pursue other options.

Most of the people who I've spoken to about IVF have said that they know someone who has gone through the process and had a good result. One person I've spoken with went through the process herself and it didn't work, so she adopted. All of those people seem comfortable with the idea itself.

One close friend of mine took the opposite view - he argued that if nature is telling us not to have biological children, then perhaps we shouldn't interfere with that. There's a certain amount of logic to the position. I argued that you could take it to the extreme - you could end up arguing that any medical intervention for any purpose is interfering with the way nature is telling us things should go. So, have a headache? Don't take aspirin or advil, Nature wants you to have a headache! My friend pointed out that the slippery slope argument doesn't hold up as well with IVF because you're not trying to fix something that's gone wrong, you're trying to create something new and bring it into the world. And that takes us back to adoption, because the obvious solution to that would be to skip IVF and go find a kid who is already in the world.

Another friend of mine, upon hearing that I would consider adopting out of foster care before doing a private adoption had the most vocal reaction of concern I've experienced so far with any option. She wasn't flipping out or anything, but she was very, very concerned about the issues facing kids in the foster care system and whether or not it's a good idea to take those issues on.

I kind of figure that I know the kids in the foster care system pretty well, I work with them directly every day, and I know that at their most basic level, they're just kids, just like everyone else. So, it might be that instead of bonding to a dad or mom, they bond to a strong older kid who lives on the streets, and they continually run from foster placements back to whoever that older kid is. Is that safe? Nope. Good idea? No. But is it any more of a surprise than a non-foster kid who would go to extremes to get back to his own family if someone tried to separate them? I don't think so.

The scenario can be painted two ways by the adults in the situation - a popular description you might hear for a runaway would be: "The youth continually defies the foster parents and refuses to return to their home. The youth is suspected of being involved in street prostitution and drugs. A warrant should be issued for the running behavior and the youth held in contempt of court." The facts would likely be true. The legal sufficiency for the issuance of a warrant would be met. The youth would likely be held in contempt if/when he/she got picked up. The other way of looking at the same scenario would be: "The youth has bonded to a prominent older street kid. The youth feels safe and connected to that person, who is encouraging the youth to engage in risky, unsafe behaviors. The youth trusts the older kid to keep him/her safe, but does not trust the foster parents to do the same." All of those facts would also likely be true, but there's no neat way to sum it all up. We don't yet have a way to fix that problem, so instead we send the kid to jail for a few days and tell them to write a paper about how unsafe it is to live on the streets.

The first scenario disconnects us from the actual experience of the youth and makes him/her just seem like a huge problem. The second scenario connects us to the experience of youth and makes us see that the problem is the emotions of the youth driving him/her to make bad decisions. I don't really view my youth clients solely in light of the first scenario (although I recognize the facts of my cases). I try really hard to see the second scenarios, and because of that I think I see them just as kids with the same needs that other kids have (in this example, the need to bond). Because I see them that way, I don't really have a fear of them or their problems. Do I think it would be easy to bring a troubled teenager into my home? Not at all. In fact, I think it could be really chaotic and stressful. But any kid can grow to be troubled, any kid can turn into a runaway, or a drug addict, or a prostitute, regardless of how well you raised him/her. That doesn't mean that those kids aren't deserving of homes or families.

But. Not everyone feels the way I do, not everyone works with the kids as much as I do, so there's a lot of fear around adopting foster kids. I understand that. I also just think the concrete idea of how that would play out is really foreign - all of a sudden some 6 year old kid moves into your house and you're a parent? You look around and there sits a little boy on your couch watching tv, and he's not going anywhere? How discombobulating!

I like having the conversations. I like thinking about the options and analyzing the pros and cons. I'm not defensive of any choice, and I wonder if I will remain this way.

Military Hospital Option?

I read online today that some of the military hospitals (Walter Reed and Madigan) do IVF at a reduced price. It's only $8,000 (only! ha!) for a cycle, as compared to our $18,000. Joe is in the inactive reserves, so he's going to look into whether we can get on the waitlist at Madigan, which is not that far from Seattle. He's not sure he's eligible since he's not active duty, and the wait list is, unfortunately over a year long. It's only something we would do as a back-up plan if we're eligible and should our IVF cycle with our current provider not work out.

Nice to have options, though. Any military people out there should definitely look into the military hospitals for IVF.

I need to figure out how to put a little box to the side of my blog for the tracking of the money. So far, still $0.00.

Length of Treatment

I shouldn't have promised to write about the impact on my job, because I really don't know yet. So instead, I'll write about how long we're willing to try this and how many cycles we're willing to do.

In an earlier post, I gave a top-level view of the financial commitment involved in IVF. Here's a more detailed explanation of how it's stacking up for us:

We have three options.
1. Pay as We Go: We would pay $18,000 for the first round of IVF. They would freeze any leftover embryos. We then pay between $3,000 and $5,000 for each subsequent round of frozen embryo transfer (FET), where you don't do the full IVF procedure, you just have the frozen embryos thawed and implanted.

2. Refund Plan #1: We would pay $24,000. They would do one full IVF round. If that failed, they would do as many rounds as necessary to either succeed or implant all the embryos they were able to get. After 1 year if you haven't successfully gotten to the second trimester of a pregnancy, you get $14,000 back.

3. Refund Plan #2: We would pay $24,000. The process would be the same as #2, except that at the end of the year, instead of giving us money back, they would do one more IVF treatment. If that treatment failed, we would then do pay-as-we-go to implant the remaining embryos.

So, all that to say that the decision about how long to keep trying rests largely in the finances. I think my husband (who will be called Joe from here on out) mentioned that he would be willing to sign up for the full IVF treatment twice (so probably plan 3 above?) but I'm more inclined to sign up for plan 2 and hope for the best. That way I know I'm done in a year and I can move on to other solutions. I could probably be talked into trying again, though.

Joe found out today that when our insurance company says they don't cover infertility at all, they mean it. They don't even cover diagnosis. So, we'll be receiving our first bill soon. Joe wants to keep track of the finances in this blog so people can get a realistic picture of what it actually ends up being from beginning to end. That sounds like a good idea to me, so I'll keep a running tally in each blog.

So far:
Financial Outlay: $0.00

Decisions, Decisions

Turns out we lost our motivation to go to the gym, so now I have time to write a little more...oh, and I've posted a link to this blog on a support website I've joined as well as emailed the link to close friends and family. Most of these blog entries are intended for people who are going through the same thing, so friends and family may find them boring...or not.

We have a number of choices to consider. We could do the IUI or IVF (with or without ICSI). We could just ignore the analysis and keep trying the way we have been. Or, we could switch tracks entirely and adopt either a child in the foster care system or adopt through a private adoption. Finally, we could just choose not to have children at all. This post is all about the pros and cons of each choice, as I see them.

1. IUI - The best part of IUI is definitely that it's one of the cheaper options and since we don't have coverage for fertility issues in our medical insurance, this matters. I think you can do IUI for $3,000-$5,000 per try (not positive about those numbers). It's less invasive than IVF. The downside is that it's not as likely to result in a successful pregnancy, and we could end up spending a whole lot of money on IUI just to have to switch to IVF anyway. If the problem was mostly motility, IUI would be a lot more enticing.

2. IVF - The best part of IVF is that the success rate is the highest of all of the intervention options (the success rate is still around 30-50%, so not a sure thing). That's pretty much the only benefit to it. It's more invasive than all other options, it's more likely to result in multiple births (which would be cute and all, but it makes the pregnancy higher-risk and as a practical matter I don't know how people handle two babies at once (or 4, in the case of my mother-in-law who had a boy, then twin boys a couple years later, and then a girl a couple years after that!)). The worst part of IVF is the financial hit - well, and the potential repeated disappointments.

3. Natural Pregnancy - We could just keep trying. This would be the cheapest option, but it's also the one that is a complete unknown in terms of chances for success. I do frequently read that people in very similar circumstances go through fertility treatments, take a break, and then conceive naturally (just got a note about one today on another website I subscribe to). This would be the best thing we could have happen, and so we are still trying, but I have to admit that my instincts have been telling me for a while that this just isn't going to work that way. That said, I could be wrong.

4. Adoption through Foster Care - Those of you who know my line of work must have guessed that this is an idea that has been seriously considered. I even found a little guy on the Northwest Adoption Exchange website who I think would be a great match for our family. He looks like a miniature version of my husband. Because of my history, I've thought a lot about whether adoption is a choice I would make for myself, and I've gone back and forth. In the last year, I've become more and more open to it, but I'm mainly open to adopting out of the child welfare system rather than a private adoption. My husband would really like to have a biological child and if it ends up that we can't do that, he's open to adopting but would rather go through a private adoption. The best part of this option is that we could quickly have a child (a 6 year old son, to be specific). The scariest part is that we could quickly have a child (a 6 year old son, to be specific).

5. Private Adoption - So I could be talked into a private adoption as long as it would be an open adoption. The drawback here is mostly that my husband would prefer to have a biological child and if we can't do that I would like to adopt out of foster care. So, it's not really the top choice for either of us. However, if we ended up going down this route, the typical drawbacks would likely involve a lot of waiting and some financial outlay as well. The best part is definitely that you end up with a baby!

6. Live Child-Free - This would definitely be the least expensive of all options! We could travel and be independent. However, I can't imagine not having a child at all and I can't imagine growing older and not having any family following behind.

In writing out these options. I ended up putting them almost in the order in which we've thought of them. I guess we could move natural pregnancy to the beginning since we thought we originally were going to go that direction. The plan is currently IVF. Current concerns about IVF are:
1. How will this treatment protocol effect my job?
2. How long or how many cycles are we willing to try?
3. Should we do genetic testing and if so, for how many genetic disorders and should we do gender selection?
4. What are the medications going to do to me?
5. Are IVF pregnancies more likely to result in miscarriages?
6. How many embryos should we have implanted?
7. What if I end up pregnant with triplets?
8. Am I being too obsessive about all of this? (I already know the answer to this one)

Next post will be on how this treatment protocol may effect my job.

What We've Learned So Far

As I mentioned in the introduction, our urologist recommended IUI, while the nurse practitioner at my ob/gyn has recommended IVF. Here is what we've learned about these two different techniques - please keep in mind that I am not a doctor and a lot of the information I have is still kind of sketchy. In other words, it may be somewhat inaccurate or it may be completely wrong. Please don't rely on it for your own purposes!

My understanding is that IUI is a process by which sperm are collected, washed, and then injected into the woman's uterus. I think it's primarily used when the sperm are having a tough time making it all the way to the egg. The urologist recommended this method, and I think he did so because it's a less expensive and less invasive method than IVF. It does still involve the woman going through injections and Clomid medication in order to make sure she is ovulating at the time when the insemination of the sperm through a catheter will be made.

IVF is a more invasive and much more expensive method. In IVF, the woman first takes a series of medications (oral and injection) to stimulate the growth of extra follicles in order to try to harvest numerous eggs. After she starts taking the medications, she goes in for ultrasounds and blood tests to see if the medications are working and to track potential ovulation. The hope is to get a lot of eggs, so the woman's ovaries may grow from the size of a walnut to the size of a human fist with the medications. When it is determined that it is the right time, the woman goes in to the doctor and has the eggs extracted. At that point, the eggs are either placed in a petri dish with a bunch of the sperm to allow fertilization or the eggs are individually fertilized by a specialist in a process called ICSI. The eggs are then monitored for several days to determine which ones successfully were fertilized and which ones are growing into blastocysts or embryos. Once the successful embryos are identified, they may be tested for genetic disorders (this is optional) and then the woman will return to the doctor to have between 1 and 3 embryos implanted. Two weeks after the embryo(s) are implanted, the woman returns to the doctor for a pregnancy test.

We think we're going to end up doing IVF plus ICSI because the problem for us is that our sperm don't have good morphology. Morphology describes whether the sperm are shaped properly for fertilization. When the sperm have the wrong shape, it may be difficult for them to fertilize an egg. Our sperm count is at 15 million sperm per milliliter. In order to be considered to be officially fertile, you need to be at about 20 million per milliliter, so we are low but not terribly low. Similarly, our motility (the movement of the sperm) shows that 30% are moving fast enough. Again, low, but not terrible. The bigger problem for us is that our morphology is only 2%. That means that only 2% of our sperm are shaped properly for fertilization. To be considered fertile, you need to have at least 14% shaped properly. Therefore, our best chance at a successful fertilization may involve locating the healthiest sperm and injecting them straight into the egg via ICSI.

Tomorrow (or maybe later tonight if I'm motivated), I'll talk about the financial differences and challenges and the other options we have.

An Introduction

A disclaimer: This blog is likely to be too much information for many people. I've decided to write it anyway, because while I can find numerous forums for questions and answers, I've had a really hard time finding information online about what it's like to go through this process from beginning to end, and I think it would be useful to others. Be forewarned, and please be kind.

My husband, and I have recently begun trying to have a baby. We had put it off as long as possible, mainly because neither one of us were really ready yet for the major changes a baby would bring. I've also never been sure how it would work to have a child and still be able to work (I really love my job) and he has been going through residency, so he wanted to wait until that was over.

After we finally started trying, we ended up having no luck. I was surprised because I always thought that it would happen pretty much instantly. I went through several months where I was convinced every month that I was pregnant, only to be completely wrong. We decided to go in to make sure that everything is okay with us medically, and found out that my husband's sperm counts and types are not good enough to fertilize an egg. His urologist recommended IUI (intra-uterine insemination),and my ob-gyn recommended IVF (in-vitro fertilization). This blog will be about the process we go through as we navigate our choices and attempt to have a family.