Last night's IVF group meeting was nerd heaven. I'm not sure what other people got out of it, but I loved the fact that it was so in-depth with the entire scientific process...exactly what I was lacking in my own knowledge. I was surprised that more people didn't have questions, but of course my hand kept going up. Here are a few of the questions I asked....
Q: As someone who's gone through an ectopic pregnancy, I'm concerned that I could have another ectopic with IVF. What are the chances for someone who's experienced an ectopic to have another ectopic through TI, IUI, and IVF respectively?
A: Chances for a repeat ectopic for someone trying again naturally with timed intercourse or through IUI would be the same (15-20%). We know that something prevented the safe passage of the embryo out of the fallopian tube already once and so likelihood that it can happen again is increased. In fact, repeat ectopics become even more dangerous the second time, and patients are at a greater risk of having their fallopian tube rupture and/or removed altogether in those cases. IVF would decrease the chances of a repeat ectopic to only 1-2%.
Q: Just so I understand, we are bypassing the fallopian tubes completely with IVF. How would an ectopic pregnancy still be possible, even if the chances are very small?
A: The embryo once transferred into the uterus could possibly "float" back up and then down into the fallopian tube, although this is rare. The embryo is deposited directly into the middle of the uterus during IVF and is not naturally attracted to the openings of the fallopian tubes. Again, it's possible but highly unlikely.
Q: Is ultrasound guidance used to monitor placement of the embryo in the uterus?
A: Not all physicians use ultrasound guidance with every IVF. In cases where the uterus is shaped oddly or placement is not "easy" ultrasound is used more often. Of course, you can absolutely request that ultrasound be used when transferring your embryo no matter what, even if you are considered an easy patient.
Q: All patients need evaluation of the uterine cavity to take measurements, etc. prior to IVF. Is an HSG fine to do this, or is having a saline sonohysterogram or hysteroscopy better?
A: Hysteroscopy is probably the best way to evaluate the uterine cavity out of the three. However, they are such an expensive addition just for the sake of IVF. An HSG is perfectly fine and will give us the information we need, along with performing a mock transfer prior to the actual IVF embryo transfer. We have never had a problem transferring for patients who have done the HSG and the mock transfer. We require at minimum, an HSG less than 2 years old for the purpose of evaluating the uterine cavity...most women already have this done.
Q: For someone who has never done any injectable medications whatsoever, how do you determine their meds protocol?
A: We use 4 main protocols for IVF, and 9 out of 10 times we will use the same protocol [BCP's, Lupron, FSH (Follistim OR Gonal-F), Ovidrel, and Crinone gel] In some women who are older with DOR, we use something called a microflare protocol, where the amount of Lupron is reduced (microdosed) so that we don't overly suppress the ovaries and the timing of the FSH injectables is tweaked slightly.
Q: For someone such as myself, who has good FSH & E2 numbers, but has been diagnosed with DOR due to low AMH, is the microflare protocol one you'd want to go ahead and use to be "on the safe side" in regards to possible poor response.
A: Probably not. We only use this protocol rarely, and in fact most clinics around the country don't even try it. We have had quite a bit of success with it when we've used it in women who are "more difficult" responders...over 40+ with DOR and perhaps prior unsuccessful IVF attempts. You would most likely use the standard protocol and we would just be increasing your dosage of FSH injections if you require further stimulation.
Q: Do you find, as a physician, that you have more success with patients
whom you've been able to do injectable/IUI cycles with previously...because
you have a better idea of how they will respond?
A: No, even women who may have already had injectable cycles will respond differently once you add Lupron to the equation. We will be monitoring E2 bloodwork every 2 to 3 days as well as doing ultrasounds to monitor response, and we adjust accordingly to those results. We will add more, less or add no additional meds to stimulate the ovaries appropriately as we go. We see equal success rates in women who "have experience" with injectables and those who have never done fertility treatments.
It was a 1.5 hr. meeting, and there were some great videos of the actual egg retrieval process, PGD/PGS procedure, and transfer process once the strongest embryos have been chosen...my favorite part! So cool to see how microscopic everything is! One thing the embryologist stressed was that having frozen embryos "is a privilege, not a guarantee". She repeated that a few times, which I think is worth repeating because so many women just expect to have frozen embryos left over to use at another time, and there are just no guarantees that will happen. There was some very detailed statistically analysis of their success rates and factors which affect success rates. I like that they just laid it ALL out and that they gave a realistic picture of what our expectations should be.
At the end, the woman next to me turned to me and gave me some reassurance. Suzette said she was a patient of Dr. Vaughn's, had never done any treatments (not even Clomid or Femara) prior to this and had gone straight to IVF. She got pregnant on her very first try but unfortunately miscarried and was trying now for a second time with IVF. She and her husband are also paying completely out of pocket with zero insurance coverage, so hearing that always makes me feel better in some weird way....like maybe we're not the only ones on the planet with zero coverage! Suzette kept saying how wonderful Dr. Vaughn was throughout the entire process. She said he even called her on a Saturday morning out of the blue to give her some words of encouragement, because he remembered she was to start her injections that day. Wow...I think that says A LOT about the kind of doctor we are working with, and I feel like God sat that girl right next to me to just give me that friendly feedback.
Another woman gave comments at the end to the whole group saying, "I don't want to sound like some sort of commercial here, but I am half way through the IVF process right now and I have just been blown away by the entire staff and the way they've just held my hand throughout this entire process. I can't say enough good things about the professionalism." I highly doubt she was a hired actor. The importance of finding a clinic and doctor you can trust is paramount in the decision making process, and I was happy to hear how impressed she was with the whole process.
So this is it...looks like we have most all of the info. we need and are going to move forward. I'll be calling to speak with their financial department this week to brainstorm our best options in making this dream become a reality!