The Second Opinion-Pre-IVF-New Patient Consult

This is me working through our treatment plan:

Last week F and I drove 6 hours to the clinic where we will do IVF, if it comes to that, to meet with Dr H. We thought it would be a good time to get a second opinion regarding our timeline, treatment options and treatment so far.

Here is what was presented to Dr H:

excellent SA results
a normal HSG taken on 6/10
normal thyroid levels
borderline low progesterone levels on a natural, ovulatory cycle and normal levels with clomid
Day 3 FSH of 9.3 and E2 of 38
a chemical pregnancy resulting from IUI #1
a mis-timed, unmonitored IUI #2 with late ovulation on 50 mg of clomid

Our plan was to continue with 2 more clomid IUIs, monitored, then move on to injectable IUIs and then move onto to IVF in 2012, the conventional trajectory. We wanted to discuss this plan with Dr. H.

Given our success with IUI #1, he confirmed that 2 more tries with clomid + IUI could work for us. Given the failure of IUI #2, he recommended increasing the dose of clomid from 50mg to 100mg, and, of course, monitoring.

He acknowledged that my FSH was slightly higher than expected for my age but couldn't draw any conclusions based on that number. He recommended a clomid challenge test if I were to become his patient.

As for the timeline, our treatment options on that timeline, Dr H discussed the reasons why we might want to skip injectable IUIs and move from clomid IUIs to IVF. They sound a bit like word problems from math:

1. Cost. We pay $400 for an unmonitored clomid + IUI and around $800 for a monitored cycle. The price of injectable IUIs are estimated around $3, 000-$4000 a cycle. The estimated cost of IVF at this clinic, including meds, is $10,000. Their shared risk/refund plan is $15, 000, not including meds and anesthesia. If we qualify and I have not given birth within 2 years or 3 fresh and 3 frozen cycles, we will be refunded 70% of $15, 000.

2. Success Rates for my age group. IUI + clomid carries a success rate of somewhere around 8%-15%. IUI + injectable meds carries a success rate of somewhere around 12%-25%. Not a huge difference. IVF, of course, carries a much higher success rate and at this clinic it is between 60%-70% (SART) for my age group.

3. Travel. We will have to travel as much for an injectable cycle as we would for an IVF cycle.

When we put all of these factors together--cost vs success rates, success rates vs travel--injectable IUIs do seem, for us, more risk than they are worth in time, travel and money.

I use the word risk not just in reference to the gamble of choosing a treatment path, but also because we expressed our fear of multiple gestation with Dr H. This has been a long standing fear of mine in my treatment for infertility and I have always associated it more with injectable IUI than with IVF or clomid. Do I put that fear aside and try just one injectable IUI cycle before moving onto IVF or do we pull together $15, 000-$20, 000 and go for the shared risk program in 6-8months?

F is all for skipping injectable IUIs. I say, "Why didn't we talk about this back in November when I wanted to, or even a year ago when I wanted to start treatment? We could have planned our treatment for IVF this summer!" But that argument is a side note and irrelevant to the planning and decision making at hand.

OLD PLAN:
4/11: clomid IUI #3
Summer 11: clomid IUI #4
Fall-Winter 11: 3 injectable IUI cycles
summer 2012: IVF

NEW PLAN:
4/11: clomid IUI #3
Summer 11: clomid IUI #4 or injectable IUI
Fall-Winter 11: begin IVF with Dr H, hopefully shared risk program

Meanwhile, we are in the midst of IUI #3. Yay, clomid headaches. Follicle check next week.