Sunday, June 29, 2008

20 - What we learned at the IVF work-up

What we learned at the IVF work-up:

-CCRM deserves to hold the title of #1 fertility clinic in the US. While not all the testing was exactly pleasurable, the day felt more like a day at the spa than a day of infertility testing. The staff was very professional and compassionate - we felt very cared for.

-Check to see if your insurance company will cover any of the testing. Since our insurance is not that great in most cases, we just assumed that they wouldn't cover a dime of the process. We were wrong - they covered 80%. This saved us about $2,000.

-Do not waste your time getting checked for communicable diseases with your regular doctor/obgyn. CCRM requires that these tests are completed on site.

-Don't stress about the shots...I am a big baby when it comes to shots and medical procedures in general, and I found the first set of shots to be painless (and I gave one to myself in the office). The shots that everyone talks about is the second set of shots that are required just prior to implantation (and then continuing for a couple of weeks minimum). These are the inter muscular shots. However, there is another option to these shots - vaginal suppositories...messy, but not a inter muscular shot.

-If they don't offer you a break during the days testing and ask you if you are okay to "push through", tell them that you would like a break. This break (for us) kept the day stress-free.

Now it's just the wait game until our July 1st phone appointment.

19 - Hysteroscopy (June 18th, 2008)

Well, they saved the best for last (not really). The last test of the day was the hysteroscopy. This was different from the hysterosalpingogram (HSG) and the sonohysterogram because those two tests were primarily used to see if my tubes were open by filling the cavity with fluid (either saline or iodine). This test actually use a small scope to look very closely inside the uterus. Prior to this, they also did a "trial transfer". My understanding of this test is that they do it to make sure there aren't going to be any anatomy issues that may hinder a smooth embryo transfer - and if there are, this is their opportunity to figure out those issues.

This test was done by Dr. Surrey, and my husband was not allowed to go into the room. A speculum is used. VENTING MOMENT: I HATE that thing...I seriously believe it is a manifestation of the Devil. After they did the trial transfer, they needed to thread the scope through the cervix. My cervix was too small for them to do this without dilating it - so they numbed, then dilated it. The whole process took about 10 minutes. I must be honest and say that it hurt more than the other two (the HSG and the sonohysterogram), but wasn't unbearable because it was only 10 minutes long. The doctor did not give me the results from this test immediately - he will give them to me when we have our phone consultation. They then gave me a prescription for an antibiotic to take for the following 4 days (along with a coupon to get it for free - it is included in the cost of the days testing) - doxycylcine. Also, no intercourse for 5-7 days if they have to dilate your cervix. Couple that with the 5 days of abstinence prior to the semen can be a challenging week following this ivf work-up appointment :-).

With the completion of this test, we had made it though our work-up appointments! I'll tell you - it felt like quite an accomplishment. We were in good spirits in that the first real step for us having a child was complete and successful (as far as we knew at this point). We set up another phone consultation with the doctor for July 1st and went on our way. On July 1st, Dr. Surrey will lay out his recommendation and time frame for the next step in the process.

**Near the end of our appointments, we got a nice surprise. The receptionist discovered that our insurance company, United Health Care, would actually cover 80% of the day's testing (testing only - anything after the work-up would be out of pocket). CCRM had just signed an agreement with United Health Care in May.

18 - Base Line Ultrasound (June 18th, 2008)

After our break, I had the baseline ultrasound. NO CAFFEINE FOR 72 HOURS PRIOR TO THIS TEST. This ultrasound was painless (does not require the use of a speculum). I had my husband come into the room with me. They were checking two things with this ultrasound:

-They were checking to see how many resting follicles I had. These are your potential eggs for that particular month (the exact number of resting follicles varies slightly each month). I had about 17-18 total. I guess for my age, this is a pretty reasonable number. This means that, with the fertility drugs, they have the potential to retrieve 17-18 eggs. The coolest thing was that this was Day 9 of my cycle and you could clearly see the one egg that was maturing to be released for this cycle (via my right ovary) - it was A LOT bigger than the resting follicles. Ahhh....the magic of the human body.

-The second thing that they were testing was blood flow to the uterus (hence the no caffeine rule). My blood flow looked normal. They said that if blood flow looks weak, they may suggest acupuncture following implantation. There is no hard core scientific evidence that acupuncture following the procedure is a solution to weak blood flow to the uterus, but there are some general studies that suggest that it can be helpful. There are no studies that indicate that acupuncture is harmful. I may do it anyway when the time comes...

17 - More blood (June 18th, 2008)

The next appointment was getting blood drawn for both my husband and myself. I got a lot of the blood testing done through my ob/gyn in Michigan (my husband get has done through his general practitioner) because, at the time, we did not think that our insurance company would cover any costs at CCRM (they eventually did - see "What we learned at the work-up" post). However, CCRM requires all communicable testing (HIV, HEP B, RPR) be done in their lab...we did not realize this until we arrived in Colorado, so I had to get these tests done again at CCRM.

One thing that I have learned through this ivf process is that I have really small and difficult veins. On several occasions I had to be poked in both arms before they could get any blood. Word of advice - if you know you have bad veins, ask them to use a butterfly needle. This worked every time, first try.

After we had our blood drawn, we got about a hour break...thank goodness. This was about 1PM in the afternoon. It wasn't that we were starving or anything- we were just overstimulated by all the information we received in the morning and needed some time away from the clinic to breath and reconnect with each other. If they try to push you through the day, insist on a break (they will be happy to accommodate this).

**After I finished lunch, I remembered to take 800mgs of Motrin (over the counter) for the hysteroscopy that I would be having around 3:00PM.

16 - Shot practice (June 18th, 2008)

The next appointment was meeting with a nurse. She handed us a very large binder, with a ton of info (we haven't been through the whole thing yet). She mainly explained the drugs and the medical aspects of the ivf process in detail. A large part of this time was spent going through the motions with practice drugs (just saline)...including giving yourself (or having your partner give you) a shot. Basically, the shots prior to egg retrieval are relatively painless. They can be given in your stomach or upper thigh (the nurse said you should probably rotate them to avoid getting sore). The needle is not much longer than a 1/2 inch. This practice session really put my mind at ease.

The night prior to retrieval, you do have to get a larger, inter muscular shot in the rear...less fun. You can either give yourself this shot, have your partner give you this shot, or, if neither of those options sound appealing, you can call for a CCRM nurse to come to your hotel room to give you the shot. Option three, please....I mean, if it is available, I might as well take advantage of it.

I believe the horror stories about the ivf shots are a result of the second part of the ivf process - the progesterone shots. These are the inter muscular big shots in the rear that must be given every day for up to several weeks - starting just prior to retrieval. However, there is another option - vaginal suppositories of progesterone. This is the messier option and must be done three times a day. However, it is a nice alternative to those who have an adverse relationship with the needle. I haven't decided which one of these options I will do.

15 - Financing (June 18th, 2008)

After paper signing marathon, we met with someone to discuss our plans for financing. Prior to coming to this appointment, we discovered that you can get loans specifically for infertility treatments through Capital One (just Google Capital One and infertility loans). We applied for our desired amount over the phone, and they were able to give us an approval immediately. They have a variety of payment plans, each with low interest rates (the quicker you choose to pay it off, the lower the interest rate). Capital One then contacted CCRM and confirmed that we were patients. The money was then automatically transferred to CCRM. If you need to use some of that loaned money to purchase the fertility drugs, Capital One will cut you as separate check, made out to you, which you can deposit in your personal account to cover the cost of the drugs.

We again signed a bunch of papers (this time all were related to payment). I was impressed with how detailed the costs were broken down and explained to us.

Saturday, June 28, 2008

14 - The Hard Ethical Questions (June 18th, 2008)

Some of the paperwork we were required to sign had to do with the actual ivf procedures; other parts of the paperwork had to deal with the hard ethical questions. A friend of ours gave us a heads up about these decisions, and I was SO grateful that we had an opportunity to discuss them in advance. Here are the big ones:

-There is a chance (higher the chance the younger you are) that you will have left over embryos after the procedure. Do you want to freeze them for possible future use? (This will cost around $1000 a year for up to 5 years).

-If you eventually decide not to use all the frozen embryos (or fresh embryos if you decide not to freeze them), what do you want to do with them - donate them to someone, donate them to research, or discard them?

-Who has the right to use the embryos if the other person involved dies or, in the case of a married couple, you get a divorce?

-Do you want genetic testing prior to the procedure to see if your baby would be at risk for a variety of genetic diseases?

13 - Day of IVF work-up (June 18th, 2008)

We arrived at 8:30AM. They were expecting us and the building was very inviting. The receptionist handed us a schedule of the day's "events" which would take us through about 4PM that afternoon.

-Our first appointment was with Dr. Surrey. It was general in nature; mainly explaining that the ivf work-up would determine the protocol for further treatment. He talked a little bit about the possible benefits of the use of acupuncture immediately following the implantation process and advised us that this option would be available. He also reminded us of the decision that we would be making in regards to how many embryos we would decide to implant. He advised that based on the day's testing results, we may really want to consider implanting one embryo (because the various risks associated with carrying twins). I gave that doctor the paperwork from the tests we had completed in Michigan then we were off to our next appointment...

-The next appointment was the semen analysis (need I explain further?...).

-The next appointment was meeting with a lab assistant to sign and review A LOT of legal paperwork...this requires an separate blog entry.

12 - Where to stay while at CCRM (June 2008)

After our initial consultation with CCRM (and after we made the decision to head to Colorado for the work-up), they sent us a packet of information including several hotel choices. CCRM has several special rates with near-by hotels. We decided to stay at the Staybridge Suites. This was a great choice - very clean, friendly staff (and quite new). Each room had complete kitchens, sitting area, desk, and a large bathroom...and comfy beds. We were only there two nights, but I this would be a very comfortable place to stay for the duration of the ivf process (10 days - 2 weeks). Here are some details:

-breakfast included, 7 days a week
-dinner included on Wednesday, Thursday, and Friday nights
-small swimming pool and exercise facility
-about 10-15 minutes from CCRM
-plenty of stores/restaurants near by
-CCRM rate is $79.00 a night

Staybridge Suites
Phone: 303-858-9990
7150 S. Clinton St.
Englewood, CO

Saturday, June 14, 2008

11 - What we've learned so far - (April 2005-June 2008)

Here are some of the important things we've learned in this process so far:

1) LEARN, LEARN, LEARN as much as you can about infertility and the IVF process. This is why I knew I needed Day 3 blood work and questioned that it wasn't checked off on my IVF work-up sheet. It is also why I insisted on having an antibiotic prior to my HSG exam.

2) ASK MANY, MANY QUESTIONS. We asked a lot, but I wish we had asked more. I wish we had asked more about the insemination (if this is an appropriate step when the issue appears to be the sperm morphology). Also ask a lot of questions about the costs - insist on having detailed cost statements printed up front.

3) IF THE ISSUE IS SPERM MORPHOLOGY, INSEMINATION IS NOT A PRACTICAL SOLUTION...YOU MAY WANT TO TRY IVF RIGHT AWAY. I read this online, and then our doctor at CCRM confirmed it. Basically, we wasted $2,000 on our insemination. Ouch.

4) IF THE DOCTOR REQUESTS THAT YOU GET A SONOHYSTOGRAM, INSIST ON A HYSTEROSALPINGOGRAM (HSG)instead. The cost is the same, the hysterosalpingogram is more accurate...and it doesn't hurt nearly as bad as many of the horror stories claim. Just take 800mg of motrin 1 hour prior to the procedure and insist on an antibiotic (doxycycline).

5) SEE WHICH PROCEDURES/TESTS CAN BE COMPLETE THROUGH YOUR OB/GYN OR GENERAL PRACTIONER'S OFFICE. There is a much greater chance of insurance covering some of the costs when it is through these offices instead of the fertility clinic. Some clinics, however, require that a lot of the tests are performed in their office. Check with the clinic you are working with.

This is a summary of what we've learned so far. The rest of the posts on this blog will be current. We leave for Colorado on Tuesday, June 17th and our ivf work-up on June 18th.

10 - Background - More prep before trip to CCRM (May/June 2008)

Once the HSG was complete, I only had a few more blood tests to complete here in Michigan before heading out to Colorado for our ivf work-up scheduled on June 12th, 2008. Again, I had these completed through my ob/gyn (my husband had his completed through his primary physician)...and, again, the costs of these test were covered through our insurance. CCRM sent a sheet indicating the tests that needed to be completed prior to going to Colorado and Day 3 testing wasn't checked off. I knew this was an important hormone test, so I called them and asked if I indeed needed the Day 3 testing. They said "yes" - I'm glad I checked. I ordered a very convenient blood shipping kit through the lab that works with CCRM ($70) and waited for my cycle to start.

And waited...and waited...and waited...the one month that I really needed my period to start on time, it was four days late, arriving June 9th. It needed to arrive by June 8th for us to keep our original June 12th appointment...the one day ivf work-up must be completed between cycle days 5-13....based on my June 9th start, June 12th would have been Day 4 of my cycle. This was my first indication that our lives and schedule will be truly controlled by this infertility beast for the next couple of months. So I called CCRM on June 9th and rearrange our work-up for June 18th. They then sent (via email) a specific schedule for the day - starting at 8:30AM ending at 3:30PM. It felt good to finally be done with the logistics on this end prior to heading to Colorado.

Wednesday, June 11, 2008

9 - Background - Sonohystogram vs. Hysterosalpingogram

In the fall of 2007, once we decided to go forward with our first insemination, I had a sonohystogram done. This was a prerequisite to the insemination - they needed to make sure my tubes weren't blocked. The sonohystogram is supposedly much less painful than its counterpart, the hysterosalpingogram (HSG), however, it is also considered less accurate. Both exams cost about the same - around $600-$900. WORD OF ADVICE: if you need to get one of these exams, insist they perform the HSG instead of the sonohystogram. Because the HSG is so accurate, there will not be a need for the sonohystogram. However, if you only have the sonohystogram and you continue to have problems (or switch clinics like we did), they will probably insist on a HSG. The sonohystogram is performed by injecting saline; the HSG uses iodine.

I needed to complete the HSG prior to heading to Colorado for our one day IVF work-up. I went through my ob/gyn with the hope that insurance would cover it - it did. The HSG needed to be scheduled on cycle days 7, 8, or 9. I tentatively had mine scheduled for day 7...then, of course, my period was a day late. I called to see if I could have the test on day 6 - I could as long as I wasn't actually bleeding on day 6.

Despite the horror stories, my HSG exam was painless. I was really scared and informed the radiologist of my fears. The exam was performed at the imaging center at the hospital. They basically numbed the cervix, pushed a catheter through the cervix, and pushed the iodine through the catheter into the uterus and fallopian tubes. I didn't feel any pain, but I did take 800mg of Motrin about 1 hour prior to the procedure. I also took an antibiotic - doxycycline (just 2 pills). My ob/gyn was reluctant to give it to me, but everything I read said that it should be taken as a precaution, so I insisted. No pain or cramping after the HSG; just a lot of bleeding that evening. The hospital said they would get the results to my ob/gyn within a couple of days. Well, about 10 days passed (I was calling every other day) and my ob/gyn still hadn't received the results. I called the hospital and, sure enough, the results were never sent. The hospital faxed the results to my doc that day and two days later she called with the results - everything was fine. I picked up a copy of the report and the actual film to take with me to Colorado.

Tuesday, June 10, 2008

8 - Background - Phone Consultation with CCRM

The phone consultation was set up for 4:30PM on April 24th. My husband was home and so we both had the opportunity to speak with the man who would eventually be our doctor - Dr. Surrey. He had all of our previous records in front of him as we spoke, so he was already well aware of our infertility history. He basically said that based on the information he had in front of him, not only would we be candidates for IVF, but we would actually be candidates for ICSI (intracytoplasmic sperm injection). ICSI is where they pick a quality sperm and inject it into the egg - it is commonly used when sperm morphology is an issue. After answering a few of our questions and we agreed that we would like to pursue treatment through CCRM, he transferred us to someone who would set up our 1 day IVF work-up. We would have to go out to Colorado for a full day of testing (some new tests, some tests that we already did, but they wanted to do them again). This would be much more testing than the University of Michigan ever required, but CCRM claims that this is one of the reasons that their rates are so good. So we then set up a tentative date based on my current cycle - Thursday, June 12th would be our one day work-up. We had a couple of tests that we would try to get done here - the hysterosalpingogram and some blood work.

About three days after our phone consultation, we received a big packet of info - our ivf workout sheet, hotels in the area, consent forms to sign, who our assigned nurse would be, etc., etc.. I noticed that "Day 3 Blood Draw" wasn't checked off. I knew that this we an important test, so I called to see if that was just a mistake. It was. I did need to have Day 3 blood drawn. I'm glad I called because day 3 would occur while we were in Michigan - if I missed it, it would have delayed our whole process an entire month.

Monday, June 9, 2008

7 - Background - Feb/March/April 2008

Although it wasn't in the original plan, we considered doing another insemination in February. However, with this insemination the sperm would have had to have been frozen (because of my husband's schedule). The doctor informed me that the rate for success does decrease when the sperm used for the insemination has been frozen, so we opted to just try naturally in February.

By end of February, we realized that the situation would have to be similar in March - we would have to use frozen sperm again which we really didn't want to do because of a decreased chance of success. Right around this same time, a close friend of my informed me that she knew some people who had great success out at a reproductive center in Colorado. She said she had heard that this place was ranked #1in the country for infertility treatments. I did some of my own research and confirmed that this was true. There was a great write up in Parents magazine (in addition to statistics on the CDC website):

The place was the Colorado Center for Reproductive Medicine or CCRM, located in Lone Tree, Colorado (just outside of (Denver). Not only did I find positive information about CCRM, but I also found out (through research and word of mouth) that the University of Michigan has below average success rates. I actually had the opportunity to speak with a woman who went through IVF at CCRM (after several failed attempts though a couple of places) with much success (twins!). My husband and I discussed it and decided that since we would be spending so much money in the process, we would go to the #1 place. I made a phone call to CCRM the next day to set up a phone consultation for April 24th, 2008. If you are out-of-state they will give you a 1/2 phone consultation for free. Once we set up the phone consultation, they sent us a ton of paperwork to be filled out and sent back prior to the consultation. We were also required to send the results of all of our previous testing and fertility treatments.

Sunday, June 8, 2008

6 - Background - Insemination results (Dec 2007)

Result of the iui - a big fat negative. We were surprised at the time, but since then I have done a lot more researched and have realized that the iui actually only increases your chances for conception by 5% (5% more than trying naturally). It ended up costing about $2,000. WARNING: the price sheet we were given stated it would cost around $1,000, but there were a TON of other costs that weren't really explained to us. For example, they gave us a quote on the premise that we weren't going to be using medication. Without medication, you don't need an ultrasound the day before - you just do the at home ovulation testing, wait for a positive result, then call the clinic to schedule the insemination the next day. With mediation, they want to see how many eggs will be releasing. They never gave us a new quote with the ultrasound. Granted, we never asked either. My advice is to consistently go through all the processes with a fine comb and constantly ask questions - this is serious stuff and serious money.

So now the decision was what next? My husband was starting training for a new job from January through March (2008), so we knew our next chance for another procedure would be in late March. At this point, we spent a lot of time deciding if we wanted to pursue adoption or reproductive procedures - we didn't have the money to pursue both simultaneously. We had decided that we would try two more inseminations (in March and April) then reevaluate.

Saturday, June 7, 2008

5 - Background - Actual Insemination (Dec 2007)

The actual intrauterine insemination, which took place on the morning of Dec. 8th, was pretty painless. My husband gave his sample about two hours prior to the insemination. They cleaned and sorted the sample, then handed us a piece of paper with a bunch on numbers and percentages on it. All I know is that they said the sample "looked great". That comment, along with yesterday's prediction of possibly four eggs releasing, gave us great hope.

The insemination was a little more painful than the sonohystogram. I was surprised because I had read that the insemination was usually much less painful than the sonohystogram. I then remembered that I took 600mg prior to the sonohystogram and nothing with the insemination. After we varified that they had the right sample, they simply put the sample in the catheter and inserted the catheter through my cervix...the idea being that the sperm were being given some extra help. I then laid on the table for about 15 minutes and thought baby thoughts. My husband was allowed to be in the room with me through this whole process.

Later that day I felt some strong cramping, but more in my ovaries as opposed to in my uterus. This was normal and was probably a result of multiple mature eggs being released.

Next step - wait game for two weeks.

4 - Background - Insemination Prep (Dec 2007)

On December 8th, 2007 we had an intrauterine insemination (iui) at the University of Michigan Reproductive Center. When I started my period (Day 1) two weeks prior, I called the clinic and discussed with my doctor if I should go on a fertility medication to increase my egg production prior to the insemination. She basically said it was my call - I could or I could try up to three iui cycles on my own and then use a fertility drug for future iui tries. My mind could not even contemplate more then three iui cycles, so I opted to go on the medication for the first cycle. She put me on a drug called Femara - the traditional drug for this process is actually Clomid. So I did some research to find out why she put me on Femara instead. Femara is traditionally used as a drug to treat breast cancer and has not yet been approved as a fertility drug, therefore, it IS covered by insurance (Clomid usually isn't and is quite expensive). Although the science behind how it works is different, the end result is the same - more eggs are produced and hopefully released. I took the drug for 5 days - Day 5, 6, 7, 8, and 9 of my cycle. I felt a little sick while I was taking it - nausea, headache, and fatigue - nothing unbearable. I started ovulation testing at home (Clear Blue Easy tests) on Day 11 and went in for an ultrasound on Day positive ovulation test yet. Per the ultrasound, I responded well to the Femara and it looked like 4 eggs could possible release. They gave me a pretty painless shot in the stomach on Day 13 of a hormone that would release the egg with 36 hours and we scheduled the actual insemination for the next day.

3 - Background - Varicocele Surgery (April 2007)

So in the end of April of 2007 my husband had surgery to remove the varicocele (on both sides). This was an out patient surgery, and he spent about two days on the couch in recovery. The insurance covered the surgery because of the discomfort he was feeling as a result of the varicocele ;-) - which was great because it was about a $9,000 surgery. Most insurances do not cover any costs associated with infertility, so be very intelligent on how you word your issue.

The urologist said that we could start to see improved sperm morphology within the first 3-6 months. My husband had a follow-up appointment/second sperm analysis at the beginning of September of 2007. Unfortunately, the morphology numbers had not improved. I felt like crying in this appointment since the surgery was such an undertaking for my husband. The urologist was not too concerned, however. He said that the morphology numbers often do not improve until after 6 months. Why were we told to get another sperm analysis before the 6 month mark then? My husband said that it was probably to be sure that they didn't snip the wrong vein. Good point.

At this follow up appointment I asked the urologist about when we should consider interuterine insemination (iui). He definitely was discouraging us from having an iui in the near future and was encouraging us to try naturally for awhile longer. I was really open to his advice until I realized that he was involved in research about the success of varicocele surgery without additional fertility assistance. Immediately following this appointment, my husband and I decided that we would continue to try naturally until December of 2007. If we were not pregnant by December, we would schedule our first iui.

Thursday, June 5, 2008

2 - Background - General (April 2005)

A little background - my husband and I have been trying to conceive since April 2005. At the time, I was 31 years old and he was 34 years old. After a year of trying without success, we decided to pursue some infertility testing. One of our added challenges was that because of the nature of my husband's job (pilot), we actually only had the opportunity to truly try about 3-4 of the months within that year. The common advice to seek help if you haven't conceived within a year is really based on having a chance to conceive every month (not our case). Nonetheless, we decided to take a more aggressive approach and go through some of the preliminary testing through the University of Michigan Reproductive Center. This early testing involved Day 3 hormone testing and a sonohysterogram (more on this later) for me and a sperm analysis for my husband. The results of the sperm analysis indicated a lower than normal morphology. Basically, the heads of many of the sperm were not shaped in a way that was conducive to penetrating the egg. A common cause of this is something called a varicocele - which is a large vein (veins) in the scrotum that can heat up the sperm causing the morphology issue. We were referred to a urologist and, sure enough, this appeared to be the problem. Surgery was recommended and, although there was not a guaranteed outcome of improved morphology, we decided to go through with the surgery because this varicocele was also causing my husband discomfort.

1 - This blog

I have decided to create this blog to document our process of going through invitro fertilization (ivf) at the Colorado Center for Reproductive Medicine (CCRM). We live in Michigan, so there are extra logistics that we are dealing with because we live out of state. So far, we have only had a phone consultation with Dr. Surrey at CCRM, and we head to Colorado next week (hopefully, June 12th) for our final ivf work-up (we will have a few more tests and then set up a plan of action). I will blog the whole process....hopefully, all the way through birth and beyond!