Poked by needles

No stims yet, that will be March and April, but I just finished my first acupuncture session!  After talking with a great friend who has gone through two rounds of IVF (first without acupuncture and failed, second with acupuncture that was a success), I decided to start my sessions now.  She had a great point – if it has been around for this long and fertility offices actually have acupuncture within their office, it must have some benefit.  Plus, there is research to show IVF success is linked to acupuncture.  That doesn’t mean I didn’t (and sometimes still) have my doubts.  I have always had difficulty getting on board with almost any meditative session, be that yoga, straight meditation and positive thinking, or acupuncture.  I have a very hard time taking down my go-go-go nature a notch and quieting my thoughts (which typically include worrying and fixating on something).   However, since I also go into “fix-it” mode all the time, I am completely open to anything that would help our plan (IVF) by successful (baby).

The first appointment was in another SGFC office and I was happy with all of it.  She asked why I came, what my history was, and general information on my lifestyle habits.  Then, I went in for my first session.  I felt the very faintest needle pokes and then nothing .. until about 10 minutes in.  Then I could feel slight pinching type feelings at some of the needle locations.  About 10 minutes later I felt this pulsing and gushing and tingling feeling through my left side/arm.  It was kinda cool.  Nothing painful.  I just really started to relax.

So we will see.  They recommend 1x/week.  It isn’t cheap though.  I am thinking about going every other week until March.  Maybe half way through March I’ll start every week and go every week until our first beta in April.  Any thoughts out there? See any success with acupuncture overall or a certain schedule?

Insurance – Round 1

Our first bout of the back-and-forth between insurance and the RE’s office started.  Nothing too bad, considering.

We received our benefits verification from the RE’s office which was a huge relief.  As well as our deposit information.  The value on our deposit was $4,000, not including meds!  I know I know. Compared to those who have no coverage it is a drop in the hat, but I was floored for a second.  Then then engineer came out in me and I started in with formulas and calculations to confirm their values were correct.

  1. We are on a Health Reimbursement Account (HRA), which means that T’s employers deposits X amount of money into the account to cover a portion of the deductible.  Our deductible = $3,000 before insurance starts picking up the tab (no copays here).  That $3,000 comes straight out of our pocket.  However, T’s employer covers half, so really only $1,500 comes out of our pocket.
  2. Then, our insurance covers 80% of IVF expenses (all things related to IVF including meds, which I verified after a few phone calls).  We cover 20% of the cost until we hit our yearly out-of-pocket max of $6,000.  Key word = yearly!

After a few back and forth emails with the RE’s office, the financial advisor confirmed that our HRA balance was not taken into account.  So, our deposit is about $2,700 which is due before our first monitoring visit.  Then all remaining expenses that accrue will be billed accordingly.  I still want to get a better idea as to what our meds cost will be.  I used $5,000 as a typical cost, multiplying by 20%, we would owe about $1,000 for meds.  All in all, I expect we will get to $6,000 pretty quickly.

T wasn’t as concerned about when and how much money we owe.  However, he did pick up on the yearly part of our benefits.  That $3,000 deductible/$6,000 max out-of-pocket re-sets each January 1st.  Happy New Year, ehh.  So, he would like us to keep at it if we have failures.

The other thing I meant to ask insurance is whether an FET is considered an attempt in the eyes of insurance, as in we only have 3 attempts per live birth.  I would think so.  I’ll ask if we get to that.

On the subject of communication with everyone.  Honestly, my talks with insurance have been very helpful and informative.  I hope it continues this path.  The RE’s office hasn’t been quick to respond (as in day of), but they are swamped with new year confirmations, so I will give them some slack.

IVF Consult Appointment

I didn’t do quite a good job at writing down everything during our appointment on Wednesday, so I need to get this out of my brain asap.  I have summarized the general gist of the appointment and, to satisfy my Type A, I have written answers to all the questions I wrote down. Summary of Appointment

  • We’re healthy and don’t need to add on too many supplements.  However, with a little nudge, my RE said that I could take 25mg/3xday of DHEA and 600mg of CoQ10 to quiet my need to “do something”.  No major lifestyle changes needed.  Keep the coffee and alcohol consumption in check and, his words, “try not to obsess”.  Great advice, but umm, fixating on things is part of my personality.  An IVF cycle is not going to cure me of this.
  • Protocol – EPP and Antagonist.  My nurse went over our general timeline and the meds we will use.  EPP will start beginning of March and IVF cycle will be April.  I originally was hoping to do a Feb/March cycle, but we are on vacation the first week of February and some other odds and ends so March/April is probably best.  Plus, it will take some time to get the pre-authorization from insurance.
    • Mock embryo transfer as soon as possible.  I want to do this in Feb, but I think that is when we will be on vacation.  Ahh.
    • Vivelle Patch
    • Ganirelex, Gonal-F, Menopur are all listed on my worksheet.  We’ll start on a high dose
    • Expect 6-7 eggs
    • ICSI due to T’s morphology.  80% fertilization is typical
    • No PGS this cycle.  If I continue to miscarry / embryos don’t develop we will discuss for a possible IVF #2 cycle.
    • Transfer 1 or 2
    • Light activity for 2-3 days after transfer

Detailed question and answers below.

Lifestyle – Am I taking the right set & doses of supplements? (I have seen DHEA, Vitamin E, Vitamin C, coq10, prenatal, folic acid.  Right now I take a prenatal with DHA, B-complex, 1,000 IUI Vitamin D, and 400 mg coq10).  My RE is of the opinion that there isn’t strong research to suggest that additional supplements would improve  our results and chances.  He did say that it doesn’t hurt anything, and if I want to try it, that he has no objections.  So I can take 25mg/3xday of DHEA and 600mg of CoQ10.  He indicated that T’s low morphology results likely won’t be improved with supplements.  I still want T to take them, he has objections.  More on that in another post.   – Should I be avoiding alcohol? Caffeine? Exercise? For three months prior to cycling? During my cycle? During stims?  The RE said we are both healthy and have nothing to really worry about.  He said to keep caffeine and alcohol under control.  My plan is limit caffeine and alcohol during our stim cycle.  I am sure that once my ovaries blow up I won’t want to run and exercise too much so that too will likely be when I start taking it easy.  Exercise relaxes me, and I need a ton of that right now.   – Update: Is there a way to get T’s morphology up with supplements and lifestyle (reduce caffeine and alcohol?).  Could his low morphology explain the RPL?  I have read that there could be a relationship to DNA fragmentation and then to mc?  We really didn’t get into this too much.  But supplements likely won’t drastically improve the morphology rate.  We didn’t address how morphology could cause RPL.  

Protocol – In your experience, does taking the aforementioned supplements actually make a difference? In AMH/FSH levels? In number of eggs retrieved? In embryos that make it to blast? In ultimate pregnancy outcomes?  The RE doesn’t see a strong correlation in his experience.   – Do you recommend low stim vs high sim given DOR?  (I have seen various protocols for DOR be fellow bloggers.  By far, I typically see antagonist (Ganirelex) some with EPP to increase quantity (in lieu of BC, or if BC is used it is over shorter time period to not over suppress my ovaries).  Common stims seem to be Bravelle and Menopur (to help with egg quality).  Alternate protocols are microdose Lupron, mini-IVF (to not affect quality), agonist/antagonist conversion (need to read more up on Dr. Sher’s research).  My protocol will be EPP (Vivelle Patch), Antagonist.  He doesn’t want to over suppress the ovaries, hence the EPP.  He expects to only get 6-7 eggs (ugh), but we will be doing ICSI due to the morphology and he expects to see about an 80% fertilization rate.  

– What kind of medicine dosage can I expect and how many monitoring visits are needed? Because of the DOR, he plans to start me out on a high dose, monitor, and make adjustments as needed.  

– What kind of results (# eggs, # embryos fertilized, # potentially available to freeze) do you expect, given my test results?  If only a few eggs are retrieved would you recommend banking and doing an FET later?  6-7 eggs expected, 80% fertilization with ICSI so about 4-5 embryos.  70% of that (I think 70% is what typically makes it to 3-day or 5-day blast (?), is about 3-4.  

– Do we need any additional testing/procedures (like mock embryo transfer) before starting the IVF stims?  We will do the mock embryo transfer in February. That will be tricky timing since we go on vacation the first week of February and it needs to be done within 5-10 days of the start of my next cycle.  This will give us time to fix anything prior to the March EPP/April IVF cycle.

– Do you recommend ICSI (single transfer of sperm into one egg) or AH (assisted hatching, where they blow a hole in the outer shell of the egg) or PGS (pre-implantation genetic screening) for us?  I am especially interested in hearing more about ICSI and AH.  Does ICSI eliminate the poorly shaped sperm (you pick out the best?) to ensure good fertilization rates.  Would you also recommend PGS based on DOR and low morphology?  ICSI – yes because of morphology; AH – if needed; PGS – not this cycle.  We discussed doing PGS and the RE said he doesn’t think it is worthwhile for the first cycle.  We would definitely consider for IVF cycle 2, if there is one, if I miscarry more or if the embryos look poor prior to transfer. 

– How often are 3 day vs 5 day transfers? We didn’t discuss. – With my DOR, T’s low morphology, and history of miscarriage would you recommend transferring 1 or 2 embryos? (following national standards it seems 2 would be preferred, but SGFC pushes for 1 even for <35 age and unfavorable diagnosis)  He said 1-2, but it will be a gametime decision (we agree).  He wouldn’t recommend 3-4 (T and I don’t want this)

– What kind of medicine is needed before/after egg retrieval & transfer?  Didn’t discuss.

– Will I be on bedrest after egg retrieval/transfer?  At what times during the cycle do you recommend bed rest/time off work?  Likely will take off work the day of and after the retrieval and the day of the transfer.  They recommend 2-3 days of taking it easy after the transfer.  

– What are your thoughts on testing before beta?  Didn’t discuss

– If the first IVF is unsuccessful, what’s the protocol for a FET?  Didn’t discuss in detail.

Supplements

This post has taken me the whole weekend to write.  I have been so torn as to whether I bite the bullet and buy additional supplements I believe will help our situation.  Everything I read indicates that you should be on 3 months of supplements before your IVF cycle.  I am hoping that will be March for us, in which case we should get with it.

What I currently take –

  • Prenatal + DHA (w/ 100 mg Vit C, 11 IU Vit E, 2.6 mg B6, 4mcg B12, 800 mcg Folic, 25 mg Zinc, 228 mg omega 3, 200 mg DHA, 28 mg EPA)
  • 400 mg of CoQ10
  • 2000 IU Vitamin D
  • B-complex (150 mg Vit C, 2mg B6, 15 mcg B12, 400 mcg Folic)

What T currently takes –

  • religiously, B-Complex (150 mg Vit C, 2mg B6, 15 mug B12, 400 mug Folic)
  • when he feels like it/remembers/I nag him, a Centrum multi (with 90 mg Vit C, 45 IU Vit E, 2 mg B6, 6 mug B12, 11 mg Zinc, 100 mug Selenium)

Our lists are not too bad.

Now, I am not trying to “self medicate” and plan on asking our RE on Wednesday, but the following supplements are pretty big in the infertility world at some level.  It is (from what I have found) CCRM’s current DOR and male fertility supplement list.  I have compared several bloggers’ and forums’ lists and these all make their appearance:

CCRM’s DOR supplement list:

Poor Responder Supplement for Women

  • DHEA – 25mg x 3/day
  • Myo Inositol 2g (twice a day)
  • Melatonin 3mg (at bedtime)
  • Co Enzyme Q10 – varies from 200 mg x 2/day or 3/day and 400mg x2/day
  • Omega-3 fatty acid 1000mg (once daily)
  • Vitamin C 500mg (once daily in the AM) (I have also seen 200 mg)
  • Vitamin E 200IU (once daily)
  • L-arginine 1000mg (twice a day)
  • Pycnogenol 100mg (once daily)

Male Fertility Supplements

  • Co Enzyme q10 200mg (3 times a day)
  • Omega-3 fatty acid 1000mg (once daily)
  • Vitamin C 500mg (once daily in the AM)
  • Vitamin E 400IU (once daily)
  • L-arginine 1000mg (twice a day)
  • Pycnogenol 100mg (once daily)
  • Folic acid 400mcg (once daily)
  • Centrum with minerals (once a day)

T seems to be pretty wary of taking so many pills (his exact expression was “I have to take what?”).  So,  I have condensed his list down as much as possible.  The lists below are what I am currently thinking we should start taking.  I haven’t purchased everything yet though, so I have annotated what we currently take, and what I just bought.  I may buy the rest before Wednesday, after talking with the RE, or never, who knows.

Me

  • Prenatal 1x/day (currently take)
  • B-complex (currently take) but get one with Vitamin C 500mg
  • CoQ10 200mg 2x/day (currently take)
  • Vitamin D3 2000 IU (currently take)
  • Ova-Boost 2x/day (bought)
    • Vitamin E 200IU
    • Myo-inositol 2mg
    • Propietary blend with Melatonin and CoQ10 484mg
  • DHEA 25mg 3x/day (I am very curious about this one!)
  • L-arginine 1000mg
  • Omega-3 1000mg

T

  • Centrum multi 1x/day (currently takes)
  • FertilAid 2x/day with the following totals (bought)
    • Vitamin C 500mg
    • Vitamin E 300 IU
    • Folic Acid 1000mcg
    • Zing 60mg
    • Selenium 200mcg
    • Proprietary blend w/ L-Carnitine and CoQ10 1780mg
  • CountBoost 1x/day for now (website says take 2x/day) (bought)
    • B6 25mg
    • B12 500mcg
    • Blend w/ L-Arginine, L-Carnitine, and CoQ10 1455 mg
  • Omega-3 1000mg 1x/day

SA#2 Results

The nurse called me today with T’s SA#2 results:

  • Count = 26 mill (SA#1 24 mill, normal > 20 mill)
  • Motility = 59% (SA#1 49%, normal > 50%)
  • Morphology = 1% (SA#1 1%, normal > 5%)

Looks like I will do more research on how to get morphology up.  I have read other bloggers whose husband have taken Wellman’s Conception (similar to FertilAid).  FertilAid claims to help count and motility, but doesn’t specifically say anything about morphology.  Also plan on asking RE whether we can get morphology up with vitamins / lifestyle.

IVF Consult Questions

Our IVF consult appointment is next week, Wednesday 1/14.  I am trying to work on writing down all my questions, instead of letting them float in my brain.  Here is what I have come up with so far, through google, the BabyCenter groups, blogs, etc.  I would love any advice from you guys out there – any questions I should add to my list (standard IVF and/or specific to DOR), what should I do to prepare (when to start acupuncture, diet changes, exercise), etc.

My List

References:

Lifestyle

– Am I taking the right set & doses of supplements? (I have seen DHEA, Vitamin E, Vitamin C, coq10, prenatal, folic acid.  Right now I take a prenatal with DHA, B-complex, 1,000 IUI Vitamin D, and 400 mg coq10)

– Should I be avoiding alcohol? Caffeine? Exercise? For three months prior to cycling? During my cycle? During stims?

– Update: Is there a way to get T’s morphology up with supplements and lifestyle (reduce caffeine and alcohol?).  Could his low morphology explain the RPL?  I have read that there could be a relationship to DNA fragmentation and then to mc?

Protocol

– In your experience, does taking the aforementioned supplements actually make a difference? In AMH/FSH levels? In number of eggs retrieved? In embryos that make it to blast? In ultimate pregnancy outcomes?

– Do you recommend low stim vs high sim given DOR?  (I have seen various protocols for DOR be fellow bloggers.  By far, I typically see antagonist (Ganirelex) some with EPP to increase quantity (in lieu of BC, or if BC is used it is over shorter time period to not over suppress my ovaries).  Common stims seem to be Bravelle and Menopur (to help with egg quality).  Alternate protocols are microdose Lupron, mini-IVF (to not affect quality), agonist/antagonist conversion (need to read more up on Dr. Sher’s research)

– What kind of medicine dosage can I expect and how many monitoring visits are needed?

– What kind of results (# eggs, # embryos fertilized, # potentially available to freeze) do you expect, given my test results?  If only a few eggs are retrieved would you recommend banking and doing an FET later?

– Do we need any additional testing/procedures (like mock embryo transfer) before starting the IVF stims?

– Do you recommend ICSI (single transfer of sperm into one egg) or AH (assisted hatching, where they blow a hole in the outer shell of the egg) or PGS (pre-implantation genetic screening) for us?  I am especially interested in hearing more about ICSI and AH.  Does ICSI eliminate the poorly shaped sperm (you pick out the best?) to ensure good fertilization rates.  Would you also recommend PGS based on DOR and low morphology?

– How often are 3 day vs 5 day transfers?

– With my DOR, T’s low morphology, and history of miscarriage would you recommend transferring 1 or 2 embryos? (following national standards it seems 2 would be preferred, but SGFC pushes for 1 even for <35 age and unfavorable diagnosis)

– What kind of medicine is needed before/after egg retrieval & transfer?

– Will I be on bedrest after egg retrieval/transfer?  At what times during the cycle do you recommend bed rest/time off work?

– What are your thoughts on testing before beta?

– If the first IVF is unsuccessful, what’s the protocol for a FET?

Test Re-do and Christmas Presents

So T is scheduled to drop off his semen analysis re-do today.  I am hoping for better results.  I have been urging him to take all his vitamins (nothing special, he typically takes C, B-complex, and a multi mainly to just fend off colds).  I also kindly requested he cut back on the caffeine and alcohol, but that didn’t go anywhere.  It is definitely one of my questions for Doc next week – when to cut back and how much.

When I stopped by to pick up the collection cup I gave the front desk our new insurance cards (T’s renewal and my new card).  I asked if they could run the benefits before our appointment next week.  The financial counselor is out sick, and I am sure she has received a ton of similar requests.  The front desk is emailing her and I am to follow up by the end of the week.

We visited friends this weekend who have been through IVF.  She knows we started seeing a Doc at SGFC.  It was nice to chat about our next steps.  To “normal” people it may be weird, but she gave me the nicest Christmas present.  Leftover needles and Ganirelex 🙂  I am not sure what our exact protocol will be, but hopefully I can use it.  If not, I will return to SGFC for others to use.  She did make a good point that insurance may consider the suppression (BC) or EPP cycle as part of our protocol.  In which case, we are looking at a March/April cycle vs a Feb/March cycle.  Another question to ask.