Tough decision

I am going to give a warning that likely this will be a long post!!!

Well we met with the RE this morning. Paul suggested we go out to breakfast prior to our appointment. We both enjoy a hot breakfast and very rarely have one. So we went to Cracker Barrel before our appointment, and I said to Paul let's make sure we have our questions ready that we want to ask the RE. Well as we started to talk about it I almost starting crying, and so I asked that we change the topic so I wouldn't be crying in public. Then we went to the RE and after sitting in the waiting room they had us sit in an exam room while we were waiting for the RE to call us back to his office. It was really hard for me to sit there. I did cry a little and felt like bawling my eyes out. I sat staring at that ultrasound screen and thought how I have had more than 50 ultrasounds in this very room and none of them were the happy kind where we saw a gestational sac or a heartbeat or anything on the screen. I even had several ultrasounds in that room during my brief pregnancy in 2005, but the only thing they could see in the uterus was the corpus luteum. Anyhow it was tough.

Then we went back to talk to the doctor. He said I stimulated very well (26 eggs) and to have 18 mature eggs was excellent. He said the quality of our embyros was outstanding. I said that most clinics seem to use an A, B, C type rating scale and how would ours be rated. He said they use a scale of 1-4 (four being the best) and he said 3 of our embryos were "fours." I was surprised. I expected him to say they were "threes." He said the other 4 embryos were a mix of "twos" and "threes." He said the worst part of our cycle was that we had such a low fertilization rate. He said it might be a problem of egg quality. I guess my age is already a factor. He said if I hadn't stimulated so well and produced so many eggs he would not advise us to ever do another fresh ivf cycle but would advise using donor eggs. He said he frequently advises couples to use donor eggs but was not recommending that for us since #1 I produced so many eggs that even with a low fertilization rate we still had 7 embyros and he said many couples don't have 7 embryos that make it to the 3rd day and since #2 we had such high quality embryos. He said many couples our age have only very poor embyros (all ones and twos). So he wouldn't recommend donor eggs for us.

Personally, I still feel like they must not do a great job at picking the best sperm for ICSI. For example the clinic in IL advertises an 85% fertilization rate with ICSI. This clinic told us their average with ICSI is 50% and in our case it was 39%. The fact that this clinic's average fert rate is much lower makes me think that likely if we did ivf/icsi elsewhere that our fert rate would be higher than 39%. He said it could have been a fluke and if we did ivf again at their clinic it might be higher than 39% the next time.

Paul asked him about assisted hatching. It's funny because 2 weeks ago that was high on my list to talk with the RE about but I totally forgot about it this morning so I am glad Paul remembered. We were VERY strongly leaning toward wanting AH done on our one embryo if we did a FET. Well he was VERY opposed to the idea - thought there was a greater risk of damaging it. Well that again to me shows the quality of this clinic as most clinics seem to do AH on everyone and I am sure they wouldn't do it if they thought there was a high risk it might damage the embryo. He said if we did another fresh transfer at 3 days he would recommend doing AH, but he was not recommending doing AH on a 6 day blast.

I asked him what their thaw rate was. He said it was higher than 90% for blasts. I said but the national average is 50%? He said that some freeze the embyros at day 3. He said if we had frozen the other 4 embryos at day 3 then yes likely 50% or less would have survived the thaw, but since we only froze a 6 day blast he said it was very close to 100% chance that it would survive the thaw and be able to be transferred.

I asked him what happened to the other 3 that weren't frozen. I admit I was nervous that maybe they had still been alive but not made it to blast and been destroyed. I really, really, really didn't want any of our embyros destroyed. I was very, very, very relieved when he told me they had already stopped growing on their own. He said none of those 3 even made it to the morula stage (which they are supposed to get to on day 4) let alone the blastocyst stage. So I am very glad to hear that their deaths were of natural causes so to speak.

Then we talked to one of the nurses. She explained their FET protocol. Ugh. It involves more shots than most FET protocols do. I come in on day 21. If my progesterone is at least 3 then I start the Lupron shots and continue on those for 10-14 days. If my progesterone is less than 3 (which it would be if I hadn't ovulated yet) then I take Provera for several days and then start the Lupron shots. Then I have my baseline u/s and b/w. Then I am on Lupron for an additional two weeks during which time I also will have two estrogen shots a week (intramuscular). Then I will have another u/s to make sure my lining is thick enough. If it is then I stop the Lupron and start the PIO injections 5 days before the transfer. So it's going to be about the same amount of shots as last time although there aren't any FSH shots (and I had 21 of those last time). We asked her if we could do the u/s and b/w here if we did an IVF cycle in another state. She said she wasn't sure, and we'd have to check with the head nurse.

As we walked out we talked about it and although we both went into the appointment thinking we were strongly leaning toward doing a fresh cycle first, we both left a little more undecided. The RE was very hopeful that this FET might result in a pregnancy. The fact that they have a 90%+ thaw rate definitely swayed our thinking some. I said to him but isn't the FET success rate much lower than the fresh one? He said that in his mind 3 embyros transferred at 3 days had as much chance of success as 1 high quality blast transferred at 6 days. He feels our chance at pgcy is equal although of course the chance for multiples is now extremely low (only an identical twin is possible which is rare when AH isn't used). He viewed that as a "plus" although I don't necessarily feel that way. He said the most blasts he allows to be transferred in a woman under the age of 40 is two so we are talking about transferring one instead of two rather than one instead of three. He did a pretty good job at making us feel like there was a reasonable chance of success with this one frozen embryo.

Once I realized that u/s and b/w were part of the process, I figured that likely our total cost would drop. So I called the financial lady this afternoon and she said yes the breakdown is $750 for monitoring and $1,500 for the transfer. So we would get reimbursed about $700 from our insurance so likely we are talking about (including meds) $1,600 total cost instead of $2,300. Paul doesn't know that yet. Finding that out definitely was swaying my opinion even farther toward doing the FET first. If this FET would work it would be much cheaper than doing a fresh cycle + a FET. Of course if it doesn't work doing another fresh plus 2 FETs is more expensive - but this clinic charges $1,500 whereas Chicago charges $2,900 plus we'd have to pay to have our one frozen embie shipped which would cost at least $200. So it's not really like we'd pay for two FETs at the Chicago price but rather sort of 1 1/2. So at that point I was leaning toward saying YES to doing the FET.

So then I called the head nurse to make sure our dates were falling in their "up" time for doing transfers (they have what they call up and down weeks as far as when they are and aren't doing ER and ET). The nurse we spoke to at the office made it sound like it was rarely a problem - only if Dr. Shabanowitz (who is in charge of the lab and not our RE) was going to be away at a conference or something. Well that didn't prove to be true. The head nurse said it wouldn't work to start the Lupron in 10 days or so because whether I need Provera or not - either way my date of transfer would fall in a down week. I was sooo deflated by that news. I don't know why but when I heard that I almost broke into tears. You might think I cry all the time, but trust me - in a typical year I probably cry about once about something unrelated to adoption/ttc. I am not one who often cries much. And frankly I haven't cried much about ttc the last couple of years. I used to cry EVERY time I realized I wasn't pg. Anyhow it was frustrating to realize we can't do the FET in October. I know some women who have done a FET within 3 weeks of finding out the fresh IVF didn't work. This clinic has you wait at least 8 weeks and now it's looking like it will be at least 13-14 weeks.

Then I asked her if we could do the u/s and b/w there but have the results faxed to a clinic in another state and that office would call me with the med instructions and we'd fly out there for the ER and ET. She said typically they do not allow this, but she could ask the RE if he'd give us special permission to have the u/s and b/w done there. They still will get paid over $1,000 for those services. Why would they say no??? I guess they don't want to make it easier for you to take your business elsewhere. Well I have been going to this clinic for over 3 years and still not pg. Of course I haven't gone there every month, but I have done 6 inj cycles with them and now also 1 ivf. If they say "no" then this increases the cost of doing IVF in Chicago by $1,400 plus means I need to stay out there an additional 10 days or so.

So I guess in light of the better than average thaw rate PLUS the fact that the cost of the FET just dropped $700 (we'd have to pay $2,250 up front but eventually we'd get $700 back just like we paid $8,200 for the IVF and I'm expecting to get about $1,000 back eventually) I am now leaning toward doing the FET first. The curve ball in all of this is that in light of not being able to do an October FET, I don't think a fresh ivf in Dec/Jan will be possible if we aren't doing the FET until November. If we had done the FET in October and it didn't work, we still could have done a fresh IVF in Dec/Jan. I am not sure if it's possible now. I guess first I need to find out when is the soonest I could do a FET if we did that first. It really is a big advantage to pay for the fresh ivf in 2007 if we're ever going to do another fresh ivf. It saves us about $2,000. Of course we would get the tax savings from the FET so actually that would drop the cost another about $400 so maybe true out of pocket expense for the FET after subtracting what we'd save in a tax deduction would be about $1,200.

So bottom line is that *at the moment* I am leaning toward doing the FET first even though we only have one blast. If we had two, I would not have even given it a moment's thought. I would have been 100% sure I wanted to do the FET first. But I know one little girl who was a student in the school where I was principal who was the result of IVF. Her mom did a fresh cycle and transferred three embryos back and lost all three. They only had one frozen embyro and transferred that one back and it resulted in a healthy pgcy. So maybe we will have a similar result? Who knows. I know the odds are not in our favor. I know that although he tried to make it sound really hopeful, I know the odds are probably at best 30% that it will work. That's this clinic's success rate for fresh cycles for my age so it's certainly not higher than that.

I just went online and looked up the stats for the clinic. I included the thawed (non-donor) transfers for women under age 35 PLUS those age 35-37. For those two age brackets from 2003-2005 they had a 25% pgcy rate per transfer with an average # of embryos transferred rate between 2-3 (which contradicts what he told me today that they only transfer 2 blasts at a time). But I guess I'm willing to pay $1,200 for a 25% chance that this embyro will finally lead to me seeing a heartbeat on an ultrasound screen.

The nurse hasn't called me back yet as far as when we could do the FET since we can't do it in October, and of course I need to talk with Paul. But my feeling at the moment is that probably we'll do the FET. The one big downside to doing this first, is that I have a gut feeling that I might never do another fresh cycle if we do this FET now in part because of the fact it's going to cost about $2K more to do it in another tax year and in part because I am not hopeful that they will allow us to do the u/s and b/w here which adds $1,400 to the cost of another fresh cycle. So I really hope and pray this little blast STICKS!!! Sorry I was so verbose...