Appointment with YAD/Dr. Amazing

So I saw Yet Another Doctor (YAD) today. I like him a lot and have always appreciated his care and explanations when I've seen him in monitoring appointments. He is well respected and is the practice director, I believe, and quite competent. I went in thinking that anything less than agreeing to IVF immediately was unacceptable and knowing that Yet Another IUI (YAIUI) was likely going to be the answer I got. In fact, I got a compromise answer, which I think I can live with.

But I'm getting ahead of myself. I left work at 4:30 and arrived 15 minutes early for my 5pm appointment. I had failed to bring a book and they have the lousiest magazines in the waiting room there, but I had plenty of things with me to keep me busy. I wrote some notes about things I wanted to talk to the doctor about, and read some reports that I'd brought from work, making corrections as I read. My nurse came out around 5pm and told me that YAD was running quite late and he was very sorry. She couldn't stay long enough to meet with me after the consultation, but she said she'd talked with him about me and given him some history and that he would let her know what needed to be done for my protocol in the morning and she'd call me and talk about it and mail me any forms I need. Fair enough. Mary and I work very well together via phone and mail, so I'm not worried.

At 5:25, YAD called in the patient before me. I knew he was running late, so I wasn't concerned. I had already called my friend who was picking up J to let her know I'd be later than expected. YAD did something quite unexpected, though... he sent the other patient down to his office and stopped to introduce himself to me and apologized for running late and said it would be about 20 minutes. No problem at all. I was not stressed, but it was exceptionally nice of him to stop and tell me personally what was going on.

At 5:45 YAD came to get me and brought me back to his office. And that's where the fun begins.

YAD had clearly reviewed my chart very carefully, because he referred back to things that I discussed with Dr. T. at my first visit with her a year and a half ago. It was nice not to have to retell the whole story. Again. He was a little surprised I'd made it so far in the pregnancy before I miscarried, but then, I've NEVER been on the good side of fertility odds. He talked a bit about my mother's history of miscarriage (she had 7 or 8 known miscarriages, and since home pregnancy tests weren't available back then, she probably had other early miscarriages that she didn't know about). Other doctors have brushed off my suggestion that I have a clotting panel done to rule out a thrombophilia, saying that unless I've got recurrent miscarriages, it's unlikely to be an issue. YAD, who I think I will soon re-name Dr. Amazing, said right off the bat that the two most common causes of recurrent miscarriage are balanced translocation and thrombophilia. Rather than getting pregnant and miscarrying again, he'd rather rule those out. Good for him.

Well, we already know that I don't have a balanced translocation because Dr. T. ran a full karyotype on me after my first consult. But doing a clotting panel is a brilliant idea. I'm glad someone thought of it. (You know, like me, half my infertile friends, and now an actual Doctor!) Fine. So now we have a first step:

Step 1: Get bloodwork done. Again.

Now, the next question, of course, was whether he'd consider skipping straight to IVF. I'm not eager to do IVF by any stretch of the imagination. It's no fun. I'm not looking forward to finding out just how much harder IVF doses of follistim would be on me than the IUI doses. On the other hand, I'm running out of time. Dr. Amazing (yeah, I think that will stick) listened to me and was sensitive to my concern. He reiterated what Dr. S. had said about the fact that since IUI worked, it's really for the best to return to IUI first. Dr. S. didn't know about the insurance factor, though, because that all came to light after I met with him. So Dr. Amazing didn't say anything too shocking there... yes, more prudent to return to IUI. No kidding. I'm 31, can clearly get pregnant eventually via IUI, no need to put my body through all that, right? Right. It certainly can't be said that this clinic pushes IVF as a way to raise their bottom line.

However, Dr. Amazing was quick to point out that there's a balance between working with the slow and steady and simple approach and recognizing the practical concern which is that the clock is ticking on my coverage. Therefore, he said, I clearly can't spend too much time on IUI. He pointed out that squeezing in two IUI cycles takes less time than two IVF cycles since they can be done back to back and IVF cycles can't be. I voiced my concern that I've tended toward very long cycles (case in point: my second IUI was on cycle day 33, when typically you'd expect it around CD 14-16). And he didn't brush me off, though he could have. He looked back at all four of my cycles and read the doses and notes about response. He remembered having met me in several monitoring appointments when things were moving at a snail's pace. And after reviewing everything he said what he would do is start me at a higher dose than the last cycle (every cycle I've had has started at a progressively higher dose, so this isn't a surprise). Since they know how I respond to tiny doses and such, he anticipates that they'll be able to manage mydosing schedule pretty agressively and have no more than 7-14 days of injectibles before the hCG trigger. That's a far cry from 30 days of injectibles.

The skeptic in me still wasn't loving losing all that time with YAIUI, but I didn't say anything. Clearly, though, he understood my anxiety about it, because he drew out a timeline. He suggested going in for pre-provera bloodwork on December 18th and assuming all is looking fine, taking Provera for five days, which would put CD1 around Christmas. Can I just tell you HOW MUCH I LOVE THIS MAN? Only five days of Provera?? That's awesome. Normally I do 10. Not because 5 days doesn't work for me... just because some doctors prefer 10 days, some doctors prefer 5 days. I'm not sure if Dr. Amazing noticed me doing my happy dance in my chair, but if he did, he was kind enough not to say anything about it.

Okay, so steps 2 and have come to light:

Step 2: Pre-Provera BW on December 18th.
Step 3: Provera 5 days

If CD1 happens around Xmas... worst case scenario (he did the math, I'm not going to repeat it), if I did two back to back IUIs and then started an IVF cycle, I'd be looking at an egg retrieval in mid-March. If, however, I went straight to IVF right now, I'd be looking at an egg retrieval probably in late January (maybe as late as early February). "So what you're really losing by doing two IUIs is about six weeks." Well, when he puts it like that, I can handle that. Six weeks I can handle. 12 weeks I cannot. He acknowledged that my per cycle odds with IVF are likely about double my per cycle odds with IUI. But he reiterated that it's so much harder on the body that if the simple approach can work, it's best to explore it.

For a brief second I wondered if I should simply go to another clinic who would do IVF without asking any more questions. But I realized by the time I could be seen by another clinic, do whatever preliminary things they wanted me to do and started an IVF cycle, I could be halfway into an IVF cycle at Shady Hell with the strategy that Dr. Amazing was laying out for me. And certainly, if the IUI works, well, I've saved myself a whole lot of trouble, expense, agony, pain, and irritation.

I asked if there would be any advantage to staying on Metformin for longer if I get pregnant again. He said in patients with no history of miscarriage, he takes them off metformin when they get a positive pregnancy test. But with a history of miscarriage, he keeps them on it through the first trimester since there may be a benefit and there doesn't appear to be much, if any, risk. He believes, however, that the bulk of the benefit of metformin on miscarriage rates occurs before implantation... that it aids in the follicle development process, and some such voodoo and what not. He acknowledges that there's some possible benefit to metformin in the first trimester, but thinks that metformin mostly does its job before implantation. I can understand this, but I appreciate that he gave me a serious answer. I wasn't questioning Dr. T taking me off of it. I don't think that was the cause of the miscarriage. But I figured it couldn't hurt to stay on it if I get pregnant again, and he agrees. So he's made a notation in my chart to stay on metformin for the first trimester. That works for me.

All in all, it was a positive appointment. I went into it knowing what answers I wanted, and what answers I was likely to get. I came out of it with a compromise, but also with a doctor who was truly sensitive to the practical side which has me twitching right now.

I love Dr. T and I want to stay her patient. But she's transitioning to practicing only at the Columbia office, and that's just too hard for me. I love her. I think she gave me excellent care. She treated me like a human being, like a person who mattered, and like a member of the decision-making team in my care. I felt like I got the same sort of vibe from Dr. Amazing. He's lovely, really. A nice South African Jewish man. Very soft-spoken. Very clear. Very likeable. And he made me feel like I was listened to.

Okay. So Step 4, assuming steps 1-3 work out...

Step 4: Start IUI#5 Late December/Early January

I can do this.

Comments

[Erin]

That sounds like a fabulous appointment and a great plan to help compromise between IUI and IVF. I hope that it all works out for the best!

[ms. c]

You sire CAN do this! Your appointment sounds really productive, and Dr. Amazing seems to have struck a good balance of trying what he knows what might work, and moving on efficiently if it doesn't.
(About the long injection cycle... I wish I had found you blog 2 weeks ago when I passed CD 14 and I found myself thinking: should't my follies be bigger by now? Thanks for writing, I know I'm not alone...)
Good luck, and keep us posted!

[My Reality]

Yes, you can do this. How fantastic that YAD listened to all of your concerns. I will hope that the IUI does the trick for you and you don't need IVF. Good luck with this cycle!

[Thalia]

Thank heavens for doctors who listen. Makes it all worthwhile.

[Heartbeat]

I'm glad you found a doctor you feel comfortable with -- he sounds wonderful. I feel like I've learned something about my own cycles after reading this (could never get a clear answer about the metformin thing). Anyway, lots of luck as always. I'm glad you get to start sooner rather than later.

[Malky B.]

I am curious to know how your doctor monitored you to know that you weren't ready for IUI until day 33? Did you have any foliclies visable on day 14? My doctor just does one sono at about day 14 and if there's no folicle by then she considers that a failed cylcle and I have no more monitoring for that month and move on to stronger drugs. I want to know how your doctor works - the same way or does he/she do later sonograms to see what's really happening.