IF-related XP from TTTC grads

[maybebabiesrus]

**Warning - Very Long**



For those of you who lurk or participate on TTTC, you may have some background already, but I'll give you the basics here:



Me: 33, DH: 32, Married 8 years



Off BCP since spring 2013, diagnosed with PCOS at 19 and had history of anovulation/irregular cycles/missing cycles.



My understanding was that the "rule of thumb" was that BCP could take a while to get out of my system, so I gave it 6 months before I pursued any treatment. In that time, I had long, irregular, heavy, or missing periods for the whole time.



In December of 2012 I went to a new OBGYN to discuss these issues, and she ordered blood work and an ultrasound. My first ultrasound was scheduled for January, but I missed it to to a weather-related travel issue. I rebooked for late February, and she saw suspicious areas on the ultrasound that could have indicated a uterine polyp. She said a polyp could lead to my heavy bleeding and could also act as a defacto IUD, so I had a follow up ultrasound and eventual HSC and polyp removal.



Following recovery, my husband did an SA (all normal), and I did three cycles of 50 mg Clomid, unmonitored (June-August). I caught a positive OPK in June and July but not August and had a very long cycle (40+ days) before a long and heavy period. When I didn't have a positive OPK in the August/September cycle on day 20, I called my OBGYN to see if she would do "day 21" blood work to see if I missed it, and she instead referred me to the RE.



I met with the RE for the first time last week. While we know that I will have trouble ovulating on my own, so I'm sure that we'll have some sort of drug protocol to induce ovulation, he roughly explained the odds of success with a variety of therapies. Since I have not had any tubal views done yet, he obviously can't specify the odds in our case, but it seemed pretty clear to me that he views Clomid/Clomid+IUI/injections/injections+IUI on a narrow spectrum of success rates (i.e. not a whole lot of data proving one is significantly better than the others for patients with clear tubes and good SA) as compared to the significantly better success rates with IVF.



Since we are 100% OOP, finances will obviously impact our decisions. Also since we're 100% OOP, insurance won't require us to do X number of IUIs prior to IVF or anything like that. My doctor seems to be willing to go straight to IVF, if we decide that's the right choice for us.



Clomid/Clomid+IUI/injections/injections+IUI all range from about $800 to about $2400 per cycle, where as IVF is more like $18,000 per cycle.



I realize we could do multiple cycles of the non-IVF treatments for much less than one IVF cycle, but if we were not successful, we might still pursue IVF and would have been better off saving that money for the more expensive treatment.



Obviously this is a position far too many of us have been in, as we deal with IF. I'm sure every couple has their reasoning for the decisions they make.



If you knew, at the beginning of your treatment, what you know now, following a positive pregnancy test, what do you wish you would have known?



From a wholly economics standpoint, I have to imagine that IUI cycles must usually result in a cheaper overall fertility treatment plan, since they are so often required by insurance companies, who are watching their bottom line and wanting to make a profit. That fact leads me a bit toward the IUI-type treatment, but maybe it's too simplistic a view.





Read more: pandce.proboards.com/thread/381384/knew#ixzz3Goa9Zo25

[yourmother]

If you knew, at the beginning of your treatment, what you know now, following a positive pregnancy test, what do you wish you would have known?

I did 6 IUI's and 1.5 IVF cycles and am finally successful with a pregnancy. The first three IUI's were done by my OBGYN and looking back, I should have gone to a RE for these treatments. My RE finally discovered the problem during my IUI treatments (my follicles wouldn't release the egg). So, had I gone to the RE first, we would have discovered this earlier on and would have pursued IVF a lot sooner.

[bluelikejazz]

I was extremely lucky to have success on Clomid (Cycle 2 of 50mg) with my OB/GYN. I would have done a third prior to visiting an RE as it was $30 OOP for each cycle.

Had Clomid alone not worked, we would have likely saved for IVF (or adoption), as nothing is covered by insurance, and DH has some SA issues (low morphology), and from the (somewhat limited) research I did, I came to the same conclusion as your RE.

Good luck with your decision and treatment!

[krystee]

I have ovulation issues and H has a good sperm count/motility, so it sounds like we're in a similar situation (same ages and years married too!) and I think similar weights from your TTTC posts. IUI #2 was successful for me (also took Pregnitude, Clomid and an Ovidrel trigger shot, plus progesterone).

I would personally try at least one IUI and probably three before moving on to IVF. The cost is so much better and there are fewer meds. You could ask them to pull out the big guns with the IUIs rather than just doing Clomid so that you have the best chance at success possible.

[laurenh]

I have PCOS and didn't get my period naturally for 2 years after going off BC, so I knew I wasn't ovulating. I went straight to an RE when we were officially TTC.

I have been extremely fortunate to have very good luck with femara + an ovidrel trigger and only timed intercourse, which was my RE's suggestion for up to 6 cycles based on my age (26). I got pregnant on my first cycle but miscarried and DD was the result of my second medicated cycle. I did have an HSG between the 2 cycles to make sure tubes were open and there weren't any uterine abnormalities.

This time around I followed the same protocol, with a new RE due to a move, and am pregnant with twins from my second medicated cycle.

I realize I am not the typical success statistic for this protocol but if money is a consideration I wouldn't hesitate to try a couple cycles of timed intercourse, then maybe 2 IUIs based on how you responded, and finally move to IVF if you didn't have success. I probably would ask the RE about doing an HSG though to make sure your tubes are open so that you aren't wasting time and money.

Good luck with your decision and treatment!

[Deleted]

I did 8 IUIs. I think 5 were with Clomid. (Relatively unmonitored) and 3 with injectables and monitored with an RE.

I would get the HSG done (if you haven't) and see if you're a candidate for IUI with injectibles. Your RE may have a reason why one may be better than another. My thinking is that you can see how your body responds to injectibles - a little less trial and error if you do move to IVf. IUIs are a lot cheaper than IVF and less invasive (IMO). I was about to move to IVF when I got PG.

I had up to 20k in insurance coverage (1/2 for meds, 1/2 for procedures). I think I ultimately landed somewhere around 5k, so we still have some coverage left if I don't leave my company and we try again.

Eta: I would not have spent any time with my OB/GYN and would have gone straight to the RE.

[starburst604]

At my RE appointment she said that she thought IVF was going to work best for us (based, I think, on my advanced age, low AMH and high FSH) and would have started out with that if she could. But my insurance required 2 IUIs before proceeding to IVF so we had to start with that. I was pretty annoyed to have to do the IUIs, because I felt that if I was already ovulating and Clomid didn't work, why would IUI+injectables?

Obviously I was shocked to have the first IUI be successful. I guess as a result I have a bias when it comes to Clomid vs injectables, because in my case it seemed I just needed that extra boost. I do remember her saying that she didn't feel Clomid was strong enough for me at all. Now, I was 100% ready to go straight to IVF if I'd had my way, but that was also largely driven by it being paid for by insurance. Had we been OOP, I'm sure I would have had IUI first.

I wouldn't rule out IUI (with injectables if possible). In your situation, financially and physically it will be so much kinder on you.

What I would change, would be to go straight to the RE instead of trying Clomid with my gyn, once I knew my HSG was clear and that H's sperm was fine.

[genet313]

Definitely do an HSG.  I had one done 1.5 years before my eventual IVF with an old RE - at the time my tubes were open, but it was painful so they may not have been open all the way.  

When I started seeing my new RE, he didn't repeat b/c it was less than 1 year since the first HSG.   I did 1-2 cycles of TI + Clomid and (I think) 3 IUIs with Clomid (honestly can't remember).   Before IVF, he did another HSG and saw that at least one tube was definitely closed and the other one was barely open (hence the failed IUIs).   I really don't fault my RE at all for not repeating it, his judgment was 100% reasonable.   But since you're just starting out, it's worth it.  IUIs would not have worked for me.

Now 26 weeks with a singleton from first IVF.  

[maybebabiesrus]

Oct 21, 2014 19:32:06 GMT -5 genet313 said:

Definitely do an HSG.  I had one done 1.5 years before my eventual IVF with an old RE - at the time my tubes were open, but it was painful so they may not have been open all the way.  

When I started seeing my new RE, he didn't repeat b/c it was less than 1 year since the first HSG.   I did 1-2 cycles of TI + Clomid and (I think) 3 IUIs with Clomid (honestly can't remember).   Before IVF, he did another HSG and saw that at least one tube was definitely closed and the other one was barely open (hence the failed IUIs).   I really don't fault my RE at all for not repeating it, his judgment was 100% reasonable.   But since you're just starting out, it's worth it.  IUIs would not have worked for me.

Now 26 weeks with a singleton from first IVF.  

My doc doesn't want to do HSG. He prefers HSC with scope of tubes, but I think your point still stands. I know this discussion is a bit preemptive, since my hsc is not done yet, but I wanted time to think about the options.

[genet313]

Oct 21, 2014 19:44:49 GMT -5 maybebabiesrus said:

Oct 21, 2014 19:32:06 GMT -5 genet313 said:

Definitely do an HSG.  I had one done 1.5 years before my eventual IVF with an old RE - at the time my tubes were open, but it was painful so they may not have been open all the way.  

When I started seeing my new RE, he didn't repeat b/c it was less than 1 year since the first HSG.   I did 1-2 cycles of TI + Clomid and (I think) 3 IUIs with Clomid (honestly can't remember).   Before IVF, he did another HSG and saw that at least one tube was definitely closed and the other one was barely open (hence the failed IUIs).   I really don't fault my RE at all for not repeating it, his judgment was 100% reasonable.   But since you're just starting out, it's worth it.  IUIs would not have worked for me.

Now 26 weeks with a singleton from first IVF.  

My doc doesn't want to do HSG. He prefers HSC with scope of tubes, but I think your point still stands. I know this discussion is a bit preemptive, since my hsc is not done yet, but I wanted time to think about the options.

If you decide to go straight to IVF, you can skip the HSG.  But if you do opt for IUIs, it may be worth doing (I honestly don't know much about HSC, but if that checks tube openings, that's probably enough). 

[maybebabiesrus]

Oct 21, 2014 20:04:18 GMT -5 genet313 said:

Oct 21, 2014 19:44:49 GMT -5 maybebabiesrus said:

My doc doesn't want to do HSG. He prefers HSC with scope of tubes, but I think your point still stands. I know this discussion is a bit preemptive, since my hsc is not done yet, but I wanted time to think about the options.

If you decide to go straight to IVF, you can skip the HSG.  But if you do opt for IUIs, it may be worth doing (I honestly don't know much about HSC, but if that checks tube openings, that's probably enough). 

Hsc is actual tiny camera looking around vs. HSG using dye test and ultrasound to see tubes, from my understanding.

[feistypants]

DH and I did three cycles of monitored Clomid before we were fully prepared to move on. If your HSC is clear, you may want to consider starting there. You don't mention if you've triggered before, but since the cycles were unmonitored, I'm guessing not. For some people, the big difference is the trigger. Also, ask your RE how he feels about supplements. You're young, so it might be a moot point, but it's definitely a discussion worth having.

If you're kind of over Clomid and have no tubal factors, then I think it would be reasonable to start with an IUI or three. You'll be able to see how you respond to meds, plus as you've said, it's a financial savings.

I'm assuming that your RE is going to do new CD3 blood work, too. The other thing that would change what I would do is if you have low AMH or high FSH. If that's the case, it's probably worth it to move to IVF sooner rather than later. And obviously, if your HSC shows tubal factor issues, IVF is the best option.

Navigating all of this is so hard. My best advice is to have all of your testing done and then sit back and take a look at it all as a whole. Once your results are all in front of you, one option may emerge as a clear better choice. I wish you all of the luck in the world.

[maybebabiesrus]

Oct 21, 2014 21:14:32 GMT -5 feistypants said:

DH and I did three cycles of monitored Clomid before we were fully prepared to move on. If your HSC is clear, you may want to consider starting there. You don't mention if you've triggered before, but since the cycles were unmonitored, I'm guessing not. For some people, the big difference is the trigger. Also, ask your RE how he feels about supplements. You're young, so it might be a moot point, but it's definitely a discussion worth having.

If you're kind of over Clomid and have no tubal factors, then I think it would be reasonable to start with an IUI or three. You'll be able to see how you respond to meds, plus as you've said, it's a financial savings.

I'm assuming that your RE is going to do new CD3 blood work, too. The other thing that would change what I would do is if you have low AMH or high FSH. If that's the case, it's probably worth it to move to IVF sooner rather than later. And obviously, if your HSC shows tubal factor issues, IVF is the best option.

Navigating all of this is so hard. My best advice is to have all of your testing done and then sit back and take a look at it all as a whole. Once your results are all in front of you, one option may emerge as a clear better choice. I wish you all of the luck in the world.

All blood work is within normal range (no low amh, no high FSH). You're correct to assume that no monitoring meant no trigger.

I'm sure he'll do more blood work, but we haven't discussed it yet.

[JayhawkGirl]

I did 7 monitored IUIs.

6 w/Clomid, 5 of those also with dexamethasone steroid. All with estradiol and trigger. One loss after #4.

1 w/Follistim. She's asleep in my arms now. I was ready to move off Clomid after the third round. Then a give it one more try led to a bfp that we lost. RE went back to Clomid since it did technically work. I wish we had punted on Clomid and moved to injectible IUI sooner.

We had no ins coverage, but to our surprise, testing and monitoring were considered diagnostic, so some of each cycle did go through ins and apply to our deductible.

Do you have cost estimates from the re? Ours had a nice spreadsheet showing costs of the various protocols. They were pretty accurate. Good luck - it's all so much to process.

[azurely]

Knowing what I know now, I would have gone to IVF much sooner.

We did multiple IUIs, 5-6 with Clomid with the OB and 4 more with injectibles with the RE. Since we were dx with unexplained IF and are both pretty healthy, I think my doctors kept thinking that trying one more wouldn't hurt and maybe it would be the one that worked. We spent most of 2012 doing IUIs with the OB and most of 2013 doing IUIs with the RE. I had three m/c in there too, and had to take off a few cycles for cysts, but I feel like those two years were basically wasted.

When we finally did go to IVF after 3.5 years of TTC, we figured out that I have crappy egg quality for whatever reason. It took 30+ eggs to get six blasts, and 5 of those were slow to develop, not becoming blasts until day 6.

So for us, I wish we'd gone straight to IVF, since it's the only thing that worked. I had no way to know that though, three years ago. IUIs are much cheaper and do work for a lot of people, so I don't know that I'd skip them completely. If I were you, I would start with an IUI doing Clomid, since it's pretty cheap and easier than injectibles. If you don't have a great response to Clomid, I'd go to an IUI with injectibles. That will give you and your doctor an idea of how you respond to the meds you'd likely be using for IVF, and if you have too many eggs for IUI, you could always convert to an IVF cycle.

Good luck! These decisions are tough.