Phone Consult with SIRM

I had a really productive phone consult with Dr. Albert Peters of SIRM (Sher Institutes for Reproductive Medicine) this afternoon. He was very personable and let me ask as many questions as I needed to ask him. After I provided him with my a summary of my medical history and a more detailed TTC history, he told me that he would put me on an LA8E2V or LA10E2V protocol. These protocols are basically the same with the exception that the LA10E2V uses a higher does of stims. The letters correlate to Lupron, some sort of Antagon med (e.g., Antagon or Cetrotide), and Estrogen. Each of these drugs would be administered prior to starting a rather aggressive dose of stims (between 600 - 750 IUs/day). I just realized that he didn't tell me what the V represents. This protocol sounds similiar to the MDL flare protocol and I'm wondering if this protocol name is a name that is used just within the SIRM network. I'll have to consult Dr. Google for some more information on this.

When I told him that my RE wanted to put me on the Ganirelix Acetate protocol, he said that his practice typically doesn't like to use this protocol because the Ganirelix has to be administered at the right time - it can't be too early, nor can it be too late.

The conversation was very informative and I really appreciated his taking the time to talk to me, even though I'm not his patient. I like that SIRM also puts a lot of emphasis on immunological testing, which makes sense if you want to make sure that you have the best chance for a successful pregnancy that makes it to term. If I lived closer to an SIRM location (and if I wasn't worried about any insurance transition headaches), I think I probably would change clinics - mostly for the personalization aspect:

Why Choose SIRM?

Despite my frustrations with Shady Grove up to this point, I am willing to continue working with them - at least until I can actually make it to an egg retrieval. They have great success rates, a top notch lab, and I have developed a better working relationship with the staff. I am hoping that now that they know me on a more personal level, they will be more on top of things and not let things fall through the cracks. My RE has started to show that he is more invested in my success, so that's a good start - I just wish it didn't take a year of TTC. I hope that he will be able to be more personally involved in and in charge of my treatment decisions. Having at least five other doctors' input, who don't even know what my diagnosis is or the journey I have traveled so far, simply can not be effective.

I am trying to give Shady Grove as much credence and faith as possible. One thing that concerned me about Dr. Peter's suggestion is the high dosage of stims they would use on me. My research has led me to believe that, in most instances, anything over 450 IUs/day is ineffective. So why inject so much more into your body if it's not necessary? I actually did better when I was on 225 IUs/day of Follistim for my first IUI than I did when I was on the 300 IUs/day of Follistim for my second IUI. I think the general dose won't make that much of a difference - it all depends on where you body is at the beginning of a cycle to know if it's going to respond well or not. Shady Grove doesn't go over 450 units - SIRM would put me on something between 600-750 units. I think I'm starting to see a trend with Shady Grove - and it's not necessarily a bad one (unless you don't have much time left). I think that they do not like to be too aggressive unless they simply have no other alternatives. That's probably why they didn't do anything about my TSH level or aspirate the cyst right away. It seems that they like to wait and see if our bodies can naturally take care of stuff before forging ahead because, in most instances, things will work themselves out. I can actually see the benefits of that because you don't want to put yourself through stuff unnecessarily if you don't have to - unfortunately it looks like in my case, we may have to do so.

A Lesson in Patience - The Cyst Saga Continues

Well my cyst is still there - it actually grew a bit to 35mm. So, I have to wait for my bloodwork results, but it looks like I'll either have to stay on the double dose of BCPs (which is doubtful considering the cyst didn't get any smaller) or will have to have is aspirated. After they do that, I can start stimming right away, so that's actually good news.

What I'm even more thrilled about is that Shady Grove really seems to have stepped up things in the TLC department. It seems as though they've done a complete 180 in providing personalized attention and showing genunine compassion and empathy. Maybe this change is due to the fact that (in my opinion) they weren't monitoring me closely enough along the way and feel bad about that so now they know they need to pay closer attention to me. Whatever the reason, I'm happy with the way things are going now and I will let bygones be bygones. Joyce, the morning nurse on duty, looked as though she wanted to hug me when I came in to meet with her after she found out that my cyst was still there. She told me that she and my nurse Dana had actually been talking about me yesterday and saying how I just couldn't catch a break. After I had checked-out, she actually called me over to her office again and told me that things WILL work out. So that was comforting. Whether they will or not, I appreciated her confidence in my situation.

So, it's back to the waiting game for me for now. If they do decide to aspirate the cyst, Shady Grove might be able to get me in to their Rockville office (the only office that does the aspirations) either tomorrow or Friday. Believe it or not, I'm actually feeling more hopeful about things again because there's a good chance that this cycle may not be a bust, after all.

Possible Good News, Yet Losing Some Hope

I got my TSH re-test/additional test results back last Friday. My TSH was a 1.530!!! Here are my other results:

T4: 11.4 (normal levels are 4.5 - 12.)
Antithyrodlobulin Ab was < 20 (normal levels are 0-40)
Thyroglobulin: 7.7 (normal levels are 0.5 - 55)

My question is this - if my TSH level came down that much after just being on the medication for two weeks, does that mean that I'm now in danger of having HYPERthyrodisim? LOL. If it's not one thing, it's something else. While I'm trying to stay as positive as I can about being able to start the IVF process, considering all of the obstacles I've faced so far, until that day actually comes, it will be hard to believe that I made it there.

Regarding acupuncture, as much as I have truly enjoyed my past two appointments (last Tuesday's appointment was simply heavenly), I think I'm going to postpone any more until after my IVF cycle if it results in a BFN. $95/session is too expensive for us right now and the impression I'm getting from my acupuncturist is that he can help me more if he does acu for me in conjunction w/ herbs (which I won't be able to do while stimming). So, I plan on taking a good three month break IF my IVF cycle doesn't work. During that time, I will go whole hog w/ the acu and herbs and see if I can get a natural BFP while my body is not all whacked out on meds and artificial manipulation.

As for how I'm feeling as I'm gearing up for yet another baseline appointment on Saturday, I'm starting to lose a bit of hope. I'm not really feeling confident that I actually will be able to cycle again. My cycles typically are about 23 days. These birth control pills (BCPs) have artificially put my body on a 28 day cycle and I have a feeling that my body wants to stick to the shorter cycle (I've been experiencing cramps during times that I shouldn't be experiencing them and I feel like I was having PMS symptoms last week meaning that I should get AF this week (but can't because of the BCPs); therefore, my body won't respond to the stims the way that other ladies who experience regular cycles do. Considering I have been on BCPs for two cycles, I also have a nagging feeling that I will be too repressed or I may have even developed cysts. At this point, I really have absolutely no confidence in my RE at all. Why does Shady Grove put everyone on 21 days of birth control pills prior to their assigned protocols? If my cycles are shorter than other women's cycles and my follies probably start to develop even before I get AF, wouldn't being on 21 days of BCPs confuse my body even more? I'll be especially upset if I can't proceed with this next cycle because he didn't do anything to address my high TSH level prior to when I was supposed to start last cycle. I didn't have any cysts and my other blood levels were good to go, so last cycle could have been my successful one. I really have a feeling that my RE has no clue as to what he's doing. Maybe I'm mistaken and judging unfairly, but he has given me no indication that he knows what he's doing. A phone call to alleviate any of my fears and misguided assumptions would be greatly welcomed, but we all know that won't happen since when has my Shady Grove office ever taken the iniative to show that they care or know what they're doing?

IVF # 1 - Cancelled Due to High TSH

That's right - cancelled not because of high FSH, but TSH!

I saw my wonderful PCP (Dr. Ian Shantz) on Tuesday and expressed my concerns about my TSH level that could be impacting my fertility. (If you remember, my levels have ranged from a 3.4 to a 4.3 and my RE was "keeping an eye on my levels"). So, he ordered a TSH test in conjunction with some other routine bloodwork I ended up getting drawn on Thursday. When I got home from work yesterday (Friday), I received a voice-mail message from Dr. Shantz's associate, Dr. Freas. I was surprised that someone, especially a doctor, had gotten back to me so quickly. Dr. Freas informed me that all of my bloodwork came back fine -- except for the TSH, which shows that I could have an underactive thyroid gland (a/k/a hypothryoidism) and which could have a great role in my infertility problems. I didn't know what the level was and it was too late to call him back, so I pondered whether or not I should bring this concern up with my nurse during today's "Lupron Evaluation" / IVF baseline appointment. After consulting with my wonderful Fertile Thoughts forum ladies, I reluctantly decided to let her know since the general consensus was if my TSH level was too high, it could impact my IVF cycle. And why go into an expensive IVF treatment if my chance for success wasn't as optimal as possible? Yes, it would really stink to have to wait for yet ANOTHER cycle, but what's another month of waiting in the broad scheme of things if it means that I will have a greater chance for that cherished BFP?

So, I went to today's appointment not feeling very optimistic. Here I thought all I had to worry about were cysts and if I had any antral follies, not hormone levels already! While I was getting my blood drawn (they just test for pregnancy, progesterone (p4) and estradiol (e2) during the "Lupron Evaluation"), I mentioned my most recent TSH test. The nurse told me that Shady Grove just changed their TSH IVF cut-off from a 3.9 to a 2.5! That means that I could NEVER have been able to cycle if my levels varied from a 3.4 to a 4.3 in the past! So why didn't they do anything to address my levels back in the beginning of the year? And they would have let me cycle this time because testing for TSH is not part of their standard protocol. Someone dropped the ball. Anyway - since I didn't yet have Thursday's TSH result, my nurse said that they would check my TSH level today, too.

While I was waiting for a call-back from Shady Grove, I contacted Dr. Freas, who turned out to be incredibly informative, supportive, and kind. He told me that my level was either 4.8 or 4.9, which was way too high. He told me of a story of a patient he had who had who was trying to get pregnant and had a level similar to mine. Soon after she started her thyroid medication, her levels stabilized and she got pregnant immediately. He offered to call a prescription of Levoxyl into my pharmacy in case I would be allowed to start my IVF cycle in conjunction with the thryoid medication. However, he did advise that it would probably be best to hold off on cycling until my levels came down to ensure the best possible response to my IVF, not to mention that a high TSH level could cause ovulatory problems, problems w/ implantation, and problems with the development of the baby. He also told me that he was going to go ahead and see if the lab could do a full thyroid work-up with my blood from Thursday (hooray if I don't have to get poked again!) to get a more complete picture of what could be going on to affect my fertility. I can't tell you how much I appreciated Dr. Freas' call and his proactive approach in helping me.

Back to my Shady Grove results -- Lo and behold, they were too high -- 3.19. [Sidenotes of Interest: 1) This is actually the lowest reading I have had so far (and BCPs typically cause levels to be higher) and 2) This reading differs by 1.61 from Thursday's bloodwork! Hmmm.] The doctors told me that I should not proceed with this IVF cycle in order to get my TSH levels under control. I informed the nurse who called me back that my PCP had already sent a prescription for me to take 75 mcg/daily of Levoxyl. She relayed the information to the RE on call who said that was a good plan and that I was to follow-up with my nurse on Monday in order to see what's next. In the meantime, I should discontinue my BCP and baby aspirin.

So, while I am disappointed that I can't join the "varsity" ART league, I feel at peace with waiting until I know that I will be at my best for my IVF cycle.

IUI # 2

I had my second IUI yesterday and the procedure itself went well. We got 4 million swimmers again post-wash, but I feel that this IUI was timed better since I feel as though I ovulated yesterday afternoon after the IUI. Dr. McKeeby, the only RE in SG's Annapolis office that I had not yet met, performed the IUI. I liked him. He seemed nice enough and explained that they like to have 5 or 6 million swimmers, but didn't seem overly concerned with just having 4 million ones. He was also very quick and gentle - I could barely feel a thing during the IUI and it took less time than a sonogram takes. Although I only produced one follicle this time, I feel much more relaxed and more hopeful about this cycle. I will try to be as patient as possible in waiting for my BFP - whether that's after this 2WW period, after the next one, or several years down the road. While a child will probably enrich our lives, life truly is good right now and I should cherish the moments we share as a couple without children.

I return to SG on May 12th for my Beta. However, I will take a HPT on the 11th. :)

The Journey Begins.....

FSH = 31.4. That's how this all began. What in the world is FSH and what does that number mean? Well, in the past three months, I have learned a whole lot. Unfortunately, what I learned was not good when it comes to trying to conceive a child.DH (Dear Husband) and I got married in April 2008 in a lovely wedding ceremony in the Riviera Maya Mexico. I was 35 years old; DH was 31. I waited a long time to find the man of my dreams and it was well worth the wait. I would have waited even longer for him if I had to. We seemed to have had the perfect relationship timeline. We went out on our first date in June 2005; DH proposed to me in January 2007; and we wed in April 2008. We figured that we'd enjoy a few years of marital bliss as a couple before adding any children to the mix. The media had led us to believe that women could have children in their 40s with no problems, so we thought we had plenty of time. However, I always had a sinking suspicion in the back of my mind that I didn't have as much time as every other woman did to have children. That's what led me to tell my OB/GYN at an appointment in October 2008 that after six months of not having been on any birth control, I was not yet pregnant. Since I was then 36 (and she had told me the year before that after 35 a woman's eggs "fall off a cliff," she immediately advised me that it was time to see a Reproductive Endocrinologist and referred me to Shady Grove Fertility Clinic. We met with Dr. Gilbert Mottla of Shady Grove's Annapolis office in November 2008. He didn't seem to be overly concerned since I was still on the "younger" side of seeking specialized help. He prescribed the basic infertilty tests for DH and me (CD3 ultrasound, CD3 and other bloodwork, and an HSG for me) and told us that if the results all come back normal, DH and I could get some OPK test strips and then just have timed intercourse and be on our merry way for another six months.Well on November 10, 2008, I got the call about my CD3 bloodwork results. All of the things they tested for were pretty much normal....except for my FSH level. 31.4. The nurse told me that it was high and advised me to come back in to speak to the doctor about the results. Of course I didn't wait until our next doctor's appointment because I am an immediate gratification kind of girl, so I immediately started googling everything I could learn about FSH. That's when the panic started to set in because my research basically found that having a high FSH level (mind you, anything over 10 is high, let alone 31.4) is a death sentence for eggs. Here is a very simple and unscientific definition of FSH from the highfshinfo.com website:"FSH stands for follicle-stimulating hormone. It is a hormone that is produced by the pituitary gland that, in the female, stimulates the ovaries to develop a follicle (the housing that accompanies the egg prior to ovulation) – each month. It can be thought of metaphorically as the gas pedal which causes the ovaries to ovulate each month. As women age, it becomes more difficult for the ovaries to ovulate as the supply of eggs gets reduced and so the level of FSH rises (in order to push down the gas pedal further) over time. When a woman enters menopause, her ovaries are depleted and the gas pedal stays depressed permanently; that is to say the FSH level remains high. It is also possible for young women to have prematurely high FSH. "I was also led to believe that having a high FSH was probably the worst case scenario that a woman who wanted to get pregnant could ever have. Pretty much anything else would be fixable or workable. But since a woman is born with all of the eggs she will ever have, once she runs out of them, she can not get pregnant. Period. I also read that many doctors suggest that the only way a woman with a high FSH can conceive is by using donor eggs -- which is something that DH and I were not willing to consider -- at least not anytime soon.Luckily, during our follow-up appointment, Dr. Mottla did not tell me that he couldn't treat me. While he did bring up the donor egg schpiel, he also expressed that he would take things as far as we wanted to go to help me get pregnant. He also said that he was not as concerned about FSH numbers as he was about the number of antral follicles -- because if you don't have any follices, you don't have any eggs to fertilize. Unfortunately, my antral follicle count corresponded with my high FSH number -- but at least I had a few! I asked Dr. Mottla what our course of treatment would be and he said that he'd put me on FSH injectible drugs and try an IUI (intrauterine insemination) on me. He told me that he didn't want to put me through an IVF (invitro fertlization) if I couldn't get enough eggs for the procedure. However, after additional research, I learned that IVFs are the better way to go with girls with high FSH, so I'm not sure why he didn't want to go this route with me first. I will do what he suggests as first to see how my body responds to the medications, but if after one or two attempts, the IUIs don't work, I will push to go the IVF route.Anyway, I could go on and on and on about everything I've learned thus far about FSH, but I will spare you any more details for now.