Need advice please: Endo & IVF

[starryfish]

I had my monthly apt with my RE yesterday and it went really well. Since DH's SA #s are normal now, we are worried about me. Background on me: Endo (not sure what stage, but maybe stage 2?) was discovered 10 years ago during an emergency appendectomy. Endo wasn't a huge surprise as I was put on BC at 16 because of terrible periods where I would stay home from school. I also have kidney disease that I cannot treat while TTC or PG. My data (AMH, etc) are all good numbers and have responded well to menopur.

Ok, so talking with RE yesterday, she recommended one of these courses of action:
1). Have a HSG/Lap/Endometrial Scratch/etc next cycle. She can do all of these during the lap surgery. She would clear out any endo, see the extent of it, etc. She recommends doing this prior to our next (and most likely last) IUI. I see the benefit of the lap since it has been 10 years and I have other bladder issues that might stem from endo on the bladder too. 

2). Move on to IVF (would do HSG during IVF cycle, but not sure if she wants to do lap or not with IVF, nurse is asking her today). IVF *might* be covered under my insurance (from the plan description I read before it says it is not covered, but the RE office called and insurance says it is covered, so they are double checking today). If it is covered, I think we would definitely do this choice, but for your answers, pretend it is not covered. 

She gave me two schedules (one for IUI and one for IVF). The schedule for IUI is the same as last time (letrazale and menopur) but the IVF is a protocol I have not seen on here before. It is 2 weeks of BC, then cetrotide, then mini HCG (with adding cetrotide once follies>12.5mm), then ER and ET. 

So my questions are:
1). Which would you do for the above options?
2). If you have endo and did IVF, what was your protocol?

Thank you for your help in this, I am overwhelmed! ETA: tagging boiler717

[starryfish]

Mar 22, 2016 7:31:05 GMT -5 spearmintleaf said:

Are you emotionally ready to move on to IVF?

yes. We tried to do an IVF trial in Oct/Nov but my AMH was lightly below the cutoff. 

[awick14]

Mar 22, 2016 7:31:05 GMT -5 spearmintleaf said:

Are you emotionally ready to move on to IVF?

This.

I would also want to know how much the endo would change your chances of an IUI working? (I don't know much about endo so forgive me if this is a stupid question.)

We're your IUIs covered through insurance?

[starryfish]

Mar 22, 2016 7:39:25 GMT -5 awick14 said:

Mar 22, 2016 7:31:05 GMT -5 spearmintleaf said:

Are you emotionally ready to move on to IVF?

This.

I would also want to know how much the endo would change your chances of an IUI working? (I don't know much about endo so forgive me if this is a stupid question.)

We're your IUIs covered through insurance?

IUIs are mostly covered by insurance. They are around $300 plus $200 for meds. I did call my insurance company this morning and she said IVF was not covered. 

From my googling research....if you have stage I/II endo, you have around 10-15% chance a cycle working? If for some reason my endo is worse now (it has been 10 years), and I have stage III, then IVF is a better bet. 

[whodey]

How many IUIs have you had? How expensive is an IUI for you? I see you already answered ~$500

My thought would be to have the surgery to check out the extent of the endo first – and then decide IVF or IUI depending on the results. But now that I type it, I’m leaning towards IVF. Say you have the surgery and the endo has spread a great deal (involved fallopian tubes, etc) – you’ll want to move to IVF. Or, say you have the surgery and the endo extent is minimal, but you’ve already tried a number of IUIs and they haven’t been successful then you would still want to move to IVF. Is there a certain result or finding that would increase your odds of a successful IUI?

[starryfish]

Mar 22, 2016 7:49:26 GMT -5 whodey said:

How many IUIs have you had? How expensive is an IUI for you? I see you already answered ~$500

My thought would be to have the surgery to check out the extent of the endo first – and then decide IVF or IUI depending on the results. But now that I type it, I’m leaning towards IVF. Say you have the surgery and the endo has spread a great deal (involved fallopian tubes, etc) – you’ll want to move to IVF. Or, say you have the surgery and the endo extent is minimal, but you’ve already tried a number of IUIs and they haven’t been successful then you would still want to move to IVF. Is there a certain result or finding that would increase your odds of a successful IUI?

We just finished 2nd cycle. Beta is on Monday. 

She recommends only doing 2-3 cycles of IUI for me anyways. 

For the surgery, yes if it was bad we would do IVF, but if it wasn't so bad and she was able to "clear" it out, then we might do one more IUI-she said it should be more successful then bc of surgery? I would listen to what she would recommend. I am also slightly interested in the surgery bc of my related bladder issues (which could be caused by endo or kidney disease or both). 

Also, I forgot to mention, but apparently with the first IUI I had a cp. 

[whodey]

FX for positive beta on Monday!

The fact that you’ve had a CP I’d assume is a good sign that your tubes are ok, and at only $500 per attempt vs. the cost of an OOP IVF cycle – it may be worth it to try one more IUI cycle especially if all your CD3 numbers are good. How many follicles are you getting per IUI cycle?

[starryfish]

Mar 22, 2016 7:59:34 GMT -5 whodey said:

FX for positive beta on Monday!

The fact that you’ve had a CP I’d assume is a good sign that your tubes are ok, and at only $500 per attempt vs. the cost of an OOP IVF cycle – it may be worth it to try one more IUI cycle especially if all your CD3 numbers are good. How many follicles are you getting per IUI cycle?

Thanks. 

I don't remember the total follicle count, but i usually have 3-6 larger follicles (>12-14mm) that they are watching for IUIs with several smaller ones. 

Also, I did have an HSG last july and it was clear. 

[oneslybookworm]

I'd say see how bad the endo is prior to making the decision. With you having a CP before, it sounds like you have a good shot with another IUI working, and if IVF isn't covered, I wouldn't want to jump into that huge spend when there is a decent shot at IUI working.

That said, I completely understand the feeling of wanting to move on and try something else. You'll have to go with your gut on this one, good luck!!

FX that the beta is positive and this isn't even an issue!

[awick14]

Fx that you get a BFP this cycle!

[boiler717]

Why do you need an HSG if moving on to IVF? Have you had a uterine cavity eval?

[starryfish]

Mar 22, 2016 10:12:00 GMT -5 boiler717 said:

Why do you need an HSG if moving on to IVF? Have you had a uterine cavity eval?

Mine is out of date. Has to be 6months or newer. 

[boiler717]

Mar 22, 2016 10:19:30 GMT -5 starryfish said:

Mar 22, 2016 10:12:00 GMT -5 boiler717 said:

Why do you need an HSG if moving on to IVF? Have you had a uterine cavity eval?

Mine is out of date. Has to be 6months or newer. 

Is it serving the purpose of evaluating the uterus instead of a saline sono? My REs both skipping HSGs for IVF because tubal function isn't needed.

[starryfish]

Mar 22, 2016 10:23:22 GMT -5 boiler717 said:

Mar 22, 2016 10:19:30 GMT -5 starryfish said:

Mine is out of date. Has to be 6months or newer. 

Is it serving the purpose of evaluating the uterus instead of a saline sono? My REs both skipping HSGs for IVF because tubal function isn't needed.

Yes

What kind of protocol did you have for IVF? Did you do the long lupron protocol?

[boiler717]

Anyways, to your question. Given your AMH is low I would not do a lap because it could further reduce egg quantity and quality. I would potentially do a 3rd IUI since they are inexpensive and it checks the "3 IUIs" box, but otherwise move to IVF.

[boiler717]

Mar 22, 2016 10:24:43 GMT -5 starryfish said:

Mar 22, 2016 10:23:22 GMT -5 boiler717 said:

Is it serving the purpose of evaluating the uterus instead of a saline sono? My REs both skipping HSGs for IVF because tubal function isn't needed.

Yes

What kind of protocol did you have for IVF? Did you do the long lupron protocol?

I did antagonist because I also have pcos. Neither RE I went to uses long Lupron for any patient I believe, but I'm not sure why. If your AMH is on the lower side I would ask about over suppression risks.

[starryfish]

Mar 22, 2016 10:24:52 GMT -5 boiler717 said:

Anyways, to your question. Given your AMH is low I would not do a lap because it could further reduce egg quantity and quality. I would potentially do a 3rd IUI since they are inexpensive and it checks the "3 IUIs" box, but otherwise move to IVF.

My AMH is not low, its 4.5. For the IVF study, they wanted "high responders" with a 5 or greater for AMH. 

Thanks 

[boiler717]

Mar 22, 2016 10:26:25 GMT -5 starryfish said:

Mar 22, 2016 10:24:52 GMT -5 boiler717 said:

Anyways, to your question. Given your AMH is low I would not do a lap because it could further reduce egg quantity and quality. I would potentially do a 3rd IUI since they are inexpensive and it checks the "3 IUIs" box, but otherwise move to IVF.

My AMH is not low, its 4.5. For the IVF study, they wanted "high responders" with a 5 or greater for AMH. 

Thanks 

I'm sorry, I misunderstood! Both of my REs were very adamant I not have laps again. But that was likely case specific since I had such a poor experience during my first lap.
I think still I would only do the lap if I wanted to commit to 6 months of expectant management because that's where the data is. There isn't evidence that a lap prior to IVF improves outcomes, so I wouldn't want the risk of surgery and chance of reducing egg quantity and quality during surgery prior to IVF.

[starryfish]

Mar 22, 2016 10:29:49 GMT -5 boiler717 said:

Mar 22, 2016 10:26:25 GMT -5 starryfish said:

My AMH is not low, its 4.5. For the IVF study, they wanted "high responders" with a 5 or greater for AMH. 

Thanks 

I'm sorry, I misunderstood! Both of my REs were very adamant I not have laps again. But that was likely case specific since I had such a poor experience during my first lap.
I think still I would only do the lap if I wanted to commit to 6 months of expectant management because that's where the data is. There isn't evidence that a lap prior to IVF improves outcomes, so I wouldn't want the risk of surgery and chance of reducing egg quantity and quality during surgery prior to IVF.

Thanks, I feel like I need another apt with the RE again, since what we discussed yesterday I was not prepared for! 

[King26]

If you are doing iui get thr lap. If you are ready for ivf there is no realnreason for the lap as it bypasses everything. This is the reason i havent had one, they told me it would make little to no difference with ivf.

[thoseareradishes]

A recent HSG is also good to have to make sure your tubes are clear of fluid. During my 3rd IVF, my left tube looked wonky, so I had to have an HSG to see if there was fluid there (there wasn't, thank goodness). Fluid in the tube can be poisonous to the embryo and reduces the chance for a successful pregnancy. I'm not sure if a saline sono can detect this, since it is more for looking at the uterus.

Hugs starryfish, you have a lot to think about. If you are having pain, I would consider the lap. My quality of life is so much better since my lap.

[brewco]

I am making the same decision as you right now, except I've already had 2 laps and have known stage 2 endo. My RE is suggesting the IVF because injectable meds can stimulate the endo. She thinks the higher chance of success is worth the IVF protocol vs doing IUI first. I did 3 cycles of clomid before going to RE then, RE had me do 3 cycles letrozole without success.

I am meeting with 2 new RE next week for a second opinion and because I don't like my nurse and can't get a new one since current RE office is small. Good luck to you - this whole process is so draining and stressful!