In the infertility world "What The F*ck (WTF)" refers to the consult with your RE after a failed cycle. I had mine today, and I am really really happy with the outcome.
I am one of those patients that most doctors get annoyed with. I research everything (Dr. Google is my BFF). I make lists of questions and I will sit there and go through every single question until I am satisfied I understand the answer and the reasoning behind the doctor's answer. One of the many reasons I love Dr. F is that not only does he put up with my questions, he encourages patients to do research on the Internet. So, instead of just sitting here with one long run on paragraph about the appointment I am just going to list my questions here and give his answers. Then at the end of the post I will tell you all what the plan is from here. So if you don't care about my questions just scroll to the bottom.
- In your experience at this office, do more people get pregnant on the second time? Or are my chances decreasing as we go? the pregnancy rates for IVF #1 and IVF #2 are pretty equal. The fairly straight forward cases tend to get PG off the first IVF, the cases where we find something during the coarse of the cycle that we didn't know about (like we did with me) have increased odds for #2 to work after a few adjustments. But if IVF# 2 doesn't work odds do start going down with every cycle.
- Lining: How has my lining been in the past, what should it be? Have I ever had the triple stripe? How can I improve my lining? (never knew the stats on my uterine lining always just heard "it looks good") Dr. F actually went and got my u/s pics to look at instead of just looking at his notes. Lining was great with IVF #1. They like to see it above 6mm, mine was 12.5mm, and the three stripes were clearly visible. He said we couldn't have asked for a better lining.
- Was I on BCP too long? Could I have been over-suppressed? Dr. F is in the school of thought that BCP does not do a lot to suppress your ovaries, it just syncs you up with other patients to streamline things (different REs have different opinions on this). However I will only be on BCP for 3 weeks before the next cycle which makes me feel a little better since I was on it for 7 weeks the first time around.
- Can we test my AMH? At this point AMH would only be useful if I was trying to decide between using my own eggs and using donor eggs. Since I know I want to use my own eggs for IVF #2 it is a non-issue. My FSH has always been fine, and he suspects my AMH would be as well.
- Would taking DHEA be beneficial for me since I seem to have some egg quality issues? Dr. F does not buy into the DHEA hype. He says that there are conflicting studies and information about DHEA and he prefers to err on the side of better safe then sorry, so we won't be using it for now.
- After my response during IVF#1 is my diagnosis the same? Do you think I have a diminished ovarian reserve or just egg quality issues? It is possible I have a slightly diminished reserve, but he wouldn't put the label on me yet. He thinks I am a "weird responder" My follicles grow great, but 50% of them were empty, and even though the follicles were the size they want them to be for ER, 75% of my eggs were immature. He thinks we need to have a big burst of FSH right at the beginning of stims, then step down as needed. He also believes my eggs are good quality, but we need to get more mature eggs to be sure. He plans on letting my follicles grow a little bigger than he normally would to try and get more mature eggs.
- Will the protocol be the EXACT same? What will you change? Higher doses? We are going with MUCH higher doses next time. The first IVF I was on 225iu of Gonal F and 75 iu Menopur, which was appropriate for the response they saw on u/s and in blood work. Knowing now that I produce a lot of empty follicles he wants to put me on 525iu Gonal F from day 1 and then step down as the cycle progresses.
- Given my horrible response should we consider the Estrogen Priming Protocol? How does the EPP work exactly? No, he does not want me on the EPP. He said EPP is for women who have issues with their lining development and who have trouble with their estrogen levels. On both accounts I am good, and increased estrogen when it is not needed can actually impede follicle growth so he thinks it would be a bad idea for me.
- Are there other methods of stimming that could help me get more eggs of better quality (ie step down vs constant)? Yes, we will be doing the step down method of stimming.
- I was on 10,000 iu HCG for my trigger, I have read that obese women should be on double the dose. Would this be an option for me? He said it could be possible that increasing the HCG trigger shot would help mature my eggs more so we will be doing 20,000 iu HCG next time.
- Do you think the fertilization rate was a egg quality issue or could there also be a sperm quality issue. Would a SCSA/DFI be use? He said my fert rate wasn't as horrible as I thought it was. This is kinda interesting actually. I only had 1 mature egg, they performed ICSI on that egg and it fertilized abnormally (had 3 pronuclei instead of the normal 2). I had 3 immature eggs. When they retrieve immature eggs they can not ICSI them because it requires stripping cells off the egg that could help it mature the rest of the way. So instead they left the immature eggs alone and put the sperm in the dish with them. Our embryo came from one of those immature eggs that matured and fertilized without help. He said there is no indication that Garry's sperm has any quality issues, and it would be a waste of money at this point to do the tests.
- Considering I am already diagnosed with one auto-immune disease (Crohn’s) would it be smart to test for other immune problems such as Reproductive Immuno-Phenotype, Anti-Thyroid antibodies, Thrombophilia, and Repeated Loss Testing (NKa etc.)? He said it is possible I have more immune issues and we are running all of the tests I listed plus some more that he added. I should have the results back in 2 weeks from those tests.
- What do you think the odds are of getting pregnant with my own eggs? He said he doesn't like putting odds on cycles, but he thinks I have a good chance of my response being better this time around, which will in turn increase my odds that it works.
- Would my sister be a good egg donor? How would that work with my insurance? What would she need to have done as far as testing to become a donor? We didn't talk too much about the possibility of using my sister as a donor, but he said that from the basic information I gave him about her it sounds like she would be a good donor for me. If IVF #2 doesn't work we will get all the testing needed for my sister to be my egg donor and then make a decision from there.
The Plan: I am taking all of April off from any drugs other than my vitamins. As soon as my next cycle starts I will call and they will have me start the Pill on CD 7. In the beginning of June sometime we will do the baseline US and blood work and I will start on 525 iu Gonal F and 75 iu Menopur. Normally you trigger when your lead follicle reaches 18mm. That was the size my follicles were at trigger, yet only 1 was mature, so this time we will wait until my follicles reach 20-21 mm to trigger in the hopes that we will get more mature eggs. The trigger dose will be doubled to 20,000iu HCG. He wants to do everything we can to push it to a 5 day trigger this time around. We both agreed that if I have 2 good embryos growing we will put both of them back, but neither of us are comfortable with 3 embryos at this point.
I am also thinking about getting a consult with a Reproductive Immunologist. Unfortunately the only one near me is almost 4 hours away, so I am hoping to get a phone consult with him sometime in the next month. Hopefully running some tests with him will shed some light on whether or not I have more issues than we currently know about. I have no faith in my immune system at this point (thanks Crohn's).
I am excited to get things rolling again, but but also terrified that I am setting myself up for another failure. But I trust my RE and really believe he is doing everything he can to get me knocked up, and at this point that is all I can ask for.
In other news: I made a decision about the Facebook coming out issue. We have decided to come out on Facebook (well I will come out, Garry doesn't want the people he works with to know yet because he barely knows most of them). However, I am not going to take the blog to Facebook. I don't want everyone in my life to know exactly when we are doing everything as far as treatments go. And since I don't want to cut down on the details or number of posts on here, I am just going to do a very generic outing. Maybe if I get pregnant I will eventually post this on Facebook because I do think it would be helpful to others going through all this, but that is down the road.