Follow Up Consult

24 November 2010

I had my follow up consult with my RE over the phone yesterday. He took the time to honestly answer my many questions. I'm glad I e-mailed them ahead of time because he obviously read them over and came well prepared . Here's the synopsis of our discussion:

What happened? Basically, as we already knew, this last cycle bombed. My ovaries just did not respond well to an aggressive protocol often used for poor responders. Sometimes it just happens with high FSH levels, and there's no surefire way to predict this. All of the usual signs that things were going along as planned were there in the beginning (antral follicle count was good, estradiol levels were in check) but it just didn't progress. He canceled me because he thinks I can do better another time.

His best hypothesis as to why we have never conceived is that there is an egg problem. With the low reserve there are less eggs to chose from. Being only 33, the eggs are probably of good quality, but we don't know for sure until they see them perform in the lab. The key is finding the right egg, and he does think it's in there somewhere. At this point, IVF still gives us the best chance of weeding out that egg. There may come a time when the chances with IVF are no greater than they would be naturally, but we're certainly not there yet. He still wouldn't be at all surprised if we did conceive on our own out of the blue somewhere along the way.

As for any diagnostics to be done before the next cycle, we discussed the AMH testing again, and decided that it wouldn't provide anything different to the situation, and would just cause me stress. The same with repeating my FSH again.

I get spotting before my period fully starts on some cycles but not others. I have no spotting at all when I take the progesterone. He said there can be many causes of this -endometriosis, inflammation, polyps, fibroids, hormone levels. Since I have leftover progesterone, he suggested taking it in half the dose from days 17-27 for the next 3 natural cycles as it wouldn't hurt.

My lining was slightly irregular on the sonohysterogram and the texture wasn't ideal, but it's not a serious problem. It had been fine on all of my previous ultrasounds since the last surgery. He is suspicious that the polyp I had removed back in April may be growing back. The thickness of the lining itself is not a concern.

The hysteroscopy + D&C is scheduled for Feb 8th. If my cycles line up as predicted, I will not have to be on the BCP prior to the surgery. He wants to insert a laminaria 24 hours before to dilate the cervix slowly. It may cause cramping. He has to use a larger instrument for the hysteroscopy than he sometimes does, and does not want to risk damaging the cervix. I should be able to get my pre-op bloodwork, a pap, and an ultrasound done on that same visit to reduce the number of trips to Victoria. I will need 2-3 days following the surgery to recover (In my experience, Dr.'s usually underestimate this, so I'll anticipate about a week).

Vitamin wise he doesn't want me to add anything to my current regime (prenatal vitamin, 2000 IU of Vitamin D, 2 fish oil capsules, and an extra iron). I started taking DHEA as he prescribed and will be on that for the next 3 months. I can try melatonin to see if it helps with getting my sleep better regulated.

So, drumroll.... the plan for the next IVF cycle is:

A natural cycle start, antagonist based protocol with higher doses of stims.

After the surgery, when my next period arrives, I'll start right into the cycle with no birth control pills prior. The plan is to go ahead with the egg retrieval with whatever number of follicles are there.

OK, so as hard as it is to hear some of these things, it's good to finally have it all out on the table. I'd rather have the frank facts than only getting the rosier part of the information. It's nothing I didn't already suspect or know, but I'd never heard my RE say it before. At least now we are on the same page, and there is a plan in place to move forward.