The Saga of Becoming Fruitful

Archive for the ‘In Between Cycles’ Category

Where is Wisdom Found?

DH and I are currently leading the Experiencing God study with a small group composed of MIL, FIL, BIL, SIL1, SIL2 and a couple friend, F1 and F2. In one of our previous lessons, we learned that God could speak through the church, so we “coveted” their prayers so they may be able to guide us based on what the Lord may impress in their hearts.

So 2 weeks ago, DH and I decided to ask them to specifically pray with us as we make decision regarding IVF although we know that they were already praying for us to have a baby.

DH was the one who spoke about it. He gave an overview of the what we are faced with. Their reactions were not what I expected.

MIL asked rhetorically why we had to go through IVF . SIL1 echoed a statement from our study “What I believe about God will determine what I do.” . Reading those statements now looks like they are harmless. However, what I perceived in their voice tones and body language were lacking grace. What I perceived was - we are not trusting God.

BIL and F1 had more open stances. BIL said that maybe in the future, IVF will be treated like the treatment of vaccines - initially, there were many, many questions. Now, it is a common practice void of any no moral and ethical questions. F1 only suggested that we might want to consult with a bioethicist so we can have any of our questions clarified.

I felt that with the little overview we gave them, we were immediately judged. So I had to interject and say that the reason why we are sharing this is to request for their prayers since as a church, the Lord deals with each one of us. I added that we are not asking for their approval and permission.

I have to say I was disappointed with what I saw in their reactions - specially the ladies.

Someone watching the discourse might think that I am overreacting to their reactions. DH did say he could understand their reactions since they did not know a lot about IVF and perhaps were operating under many misconceptions.

Which is exactly why I was disappointed in their reaction. Had they been in my position, I would be more graceful in inquiring.

The Lord pulled me aside though and later gave me this verse: “Pride only breeds quarrel, but wisdom is found in those who take advice.”

I realized I was being prideful because I had researched this IVF topic extensively and here they are just getting less than 20 sentences in description and they are able to make a conclusion about it and about us in less than a few minutes. I thought that was being arrogant and judgmental. And of course, my pride was hurt!

Nevertheless, we did ask for their prayers in the hopes that the Lord speak through them as well on this IVF thing that we have been praying for some time. So I, we ought to be humble and ready as well to receive what they get from the Lord.

SIGH….

National Infertility Awareness Week

Oct 19-25, 2008 is the National Infertility Awareness Week. Most, if not all, people who visit this blog are struggling or have struggled through infertility, and thus we are the best spokespeople for infertility and raising awareness to it.

Some of us are pretty open about the process we are going through in our quest for a baby - we talk and write about it to friends and family and we let them know of our blogs so that they can visit it on their own conveniences.

Some of us are going through this journey to baby secretly, with a lot of friends and relatives not aware of what we have to go through.

Some of us are somewhat in the middle. I think I fall under this category. I answer to queries about us having children but most of the time though, I do not volunteer information about our “saga of becoming fruitful”.

I have an answer to people who really want to know what is going on and who I trust to hold those answers confidentially. I also try to weigh how much I share since not everyone is interested in the whole nine yards.

I have a different answer to people who I am not comfortable with - those who think they know it all on how to make babies, those whose personalities treat stuff lightly or those who just want to know but cannot hold their tongues (use the information to share to others who have no business of knowing).

I (We) have spent a lot of time culling information about our diagnosis, treatments and of our fellow infertiles’ experiences. Maybe even too much information, TMI in infertili-tese. We can probably teach lessons on this now.

My simple mind tells me that there are 4 types of people we are interacting with in our everyday infertile lives:
1. Tactful people who know about infertility - We like them because they “understand”.
2. Tactful people who do not know about infertility - Potentially, these are the people who are open to be educated more about infertility and become our friends, allies and advocates.
3. Tactless people who know about infertility - These ones I would avoid because they do not have a compassionate heart for our sufferings (that they already know of).
4. Tactless people who do not know about infertility - They may still have hope

So there really is an opportunity and value in having an Infertility Awareness Week (Why not a month?) and making people more aware about infertility…

So what am I going to do in connection with National Infertility Awareness Week? Well, I just wrote a piece in my personal blog about it in the hopes that friends and family become more aware of this thing called infertility.

How about you? How are you going to make the people in your circle of influence more aware of infertility?

My First “Reproductive” Acupuncture Experience

So today was my first (ever!) acupuncture session.

I did not go to those clinics which called and/or advertised themselves as having expertise on ‘reproductive’ acupuncture. Instead, I chose to go to one of the earliest acupuncture clinic in town because of 2 reasons - 1) they are in-network with my insurance, 2) the acupuncturist/s are real Chinese … so maybe they are the “genuine” articles.

(That’s not meant to be reverse discrimination … it’s just my way of crooked logic. Maybe I should go to those “reproductive acupuncture” experts… I’ll try the “real Chinese” guys first and see what happens…)

My acupuncturist recommends herbs but I refused them since their interaction with fertility medicines are not known. She said that my ovaries and uterus may be “cold” so she recommended that I do not eat nor drink anything cold.

Anyhow, I got needles on my inner ankles, knees, elbows, wrists …..

… and my stomach (one on each side of the belly button).

And I had a warmer directed on my belly area, too. Remember… my ovaries and uterus are suspected to be “cold”.

Anyway, it wasn’t bad at all. I did not feel most of the needles while some I felt antbite-like sensation when the needles were tapped in. I was soooo relaxed that I think I dozed off during the 30 minutes that the needles were in.

And I could still drive after the session, contrary to what I read in the internet (Cleveland Clinic).

…..

And once again, those 1-800 folks from my insurance told the acupuncture clinic that I still need to have a co-pay (despite meeting my Out-of-Pocket Maximum already) …

GRRRRR…

The office girl at the acupuncture clinic was the only person on the office that day, so she was kind enough to hold off charging me…

My plan is to call the insurance next time I go there and get them to talk to the office girl. I hate having to go through another “They told me (office girl)” vs “They told me (me)” cycle again…

…..

Hey… for those of you who are doing acupuncture for enhanced reproductive health, where are the acupuncture points where they put in the needles?

Update on “Free” Chiropractic Services

The post on the Geriatric Pregnancy caused a bit of a stir, huh?

Here’s a quick update on the insurance coverage issue I mentioned in previous posts - that my “copay counts towards my Out-of-Pocket (OOP) Maximum”.

I finally pinned down United Health Care on not paying (even) any copay for my chiropractic treatments since I have met my OOP for the year. So now, I don’t have to pay anything…zero….zilch…nada… woo hoo!!! Well, at least for the rest of year 2008 since I have 20 sessions allowed. 18 more to go…

UHC is “wise” though… they want the chiropractic service provider to re-file and re-assess the case (moi!) after every 7 sessions. I guess to make sure that I’m not just there for the massage… which I am there for mainly

Anyhow, it took a total of 2 calls from me and 2 calls from the service provider to establish this - the last call being at the chiropractor’s office where both the office person and I had to speak to the insurance’s 1-800 folks. For some reason, those 1-800 folks somehow end up reading the family OOP… every time … instead of my individual OOP. I’m not sure if those were honest mistakes or if they are trying to avoid paying.

Well, you just have to “know your rights”…

Woman - Are You a Geriatric Case???

I went to see the Chiropractor - only the 2nd in the last 12 months of my 40 year-life. It was my first time to see her and she is good! She massaged my back, eased my very knotted shoulders and adjusted a lot of my bones! Crack and pop! Whoa, I feel much better!

Guess what? After NOT trying for 11 years, she had an unplanned pregnancy early this year but miscarried. She is 35 years old, 3 months pregnant again and still cracking bones.

I asked her until when she will be able to do that (as I like her already even if it is just our first appointment and I don’t want to be passed on to the other practitioners). She said she does not know yet and will just have to wait and see…

Anyway, her doctor called her a case of “geriatric pregnancy”. Hu-wat??? Say it again… GERIATRIC PREGNANCY. If she, a 35-year old woman , is considered a geriatric pregnancy case, that means I, 40-years old, fall in that same category also (I am not pregnant though, I just wish though…)

Wow, I never thought of my case being “geriatric”. Somehow, I reserve that term to the really, really old people - all wrinkled, gray hair, slow-moving and stooping. Yes, we all go that way in the future…but meanwhile, I just never thought of myself in that way at this time.

Hmmm… the Reproductive Endocrinologists do call our cases “Advanced Maternal Age” - are they just being nice??? Or does the terminology change once they turn us over to the OB/GYNEs???

…..

When she learned that I was trying to get pregnant too, she mentioned that she had a couple of friends who had difficulty conceiving and were able to get pregnant after going through acupuncture. She specifically mentioned one who was getting periods 2x a year only and got pregnant!

I’m not easily affected by such statements but hmmm…. I’m just wondering if acupuncture is the new “just relax and you’ll get pregnant” or “if you adopt, you’ll get pregnant” statements?

…..

Now, I mentioned in my previous post that the insurance’s 1-800 number said that since I have met my Out-of -Pocket max expense for the year, that I do not have to have co-pay. Well, the Chiropractor office asked me for a co-pay since their system showed that I still need to have co-pay. I’m disappointed but I’d like to go back and continue my “therapy”, so I paid the co-pay.

I called the insurance 1-800 number again and they did confirm my original understanding. I called the Chiropractor’s office and they said they will look into it. I told them that I would like to have that settled before my next appointment because I do not want to keep paying if I do not need to (even if they will refund it).

After I confirm that my insurance does take over 100% and no copay after meeting my Out-Of-Pocket, Acupuncture is next!!!

…..

Ohhhh… all the blogging ideas coming to me when I am laying on my tummy and getting my back massaged!

What To Do When Your Insurance Doesn’t Cover Infertility Treatments

Infertility treatments not covered by your insurance? There are many ways to get back at them.

No, this post does not tell you how you can fund your Infertility Treatment. What it does tell you is how you can maximize the use of your insurance!

A Little Background…
Our health insurance provider is United Health Care (UHC) from DH’s job. It does have Infertility DIAGNOSIS coverage but does NOT have Infertility TREATMENT coverage.

UHC also offers discounted services through their Extra Benefits programs such as Parent Steps for Infertility Clinics. The good news is that CCRM is one of the included providers. The bad news DH’s big company has not availed of Parent Steps as an Extra Benefit.

Well, I was not going to stop there… I’ve spent almost $6K on medical expenses already this year, there must be something that the insurance company can do for me…

I have met my Deductible ($250) and Out-of-Pocket (OOP, $1500) max expenses for the year since as early as February. So, I called the insurance’s 1-800 number and found out that my co-pays count towards my OOP for the Chiropractor and for Acupuncture.

So that meant that once I have reached my OOP, I do not need to do co-pay anymore. That meant that for the rest of the year, I can go to the Chiropractor and the Acupuncturist for FREE!!! Woo hoo!

Well, at most 20 visits per year. But there is just about 10 more weeks until yearend, so I think the rest of the year is covered.

So, if you have met your Deductible and Out-of-Pocket expenses, go get yourself a Chiropractor and an Acupuncturist!

Thoughts After IVF Orientation

DH and I went to the IVF Orientation last Wednesday.

What I liked about it are:
1. They described (albeit briefly) the 4 drug protocols they use for the IVF Stimulation and had timeline schematics that described how each one differed. The timeline differences was clarified for visual-me.
2. That was the perfect opportunity that DH had to get the big IVF picture aside from the information that I have been sharing with him. He did say that the info are pieced together well and he understands the IVF process better now.

What I did not like was that our clinic does not offer CGH yet. Since they do offer PGS and test of 9 chromosomes only, I assume that they ask their provider labs to do FISH. We talked briefly to the embryologist and he said that CGH was “interesting, but it is still very new”. I guess they are more conservative in adopting newer technologies.  DrB did actually mention a couple of times that there is a tendency of “let’s not change this since it is apparently working anyway”.

Since we do want to do the egg CGH, this may mean out-of-state IVF treatment. I can think of 2 challenges for going that route. I am sure there are more but these are what we could potentially be facing sooner:
1. Finding a local physician who is willing and able to collaborate with the out-of-state physician. I could go back to DrH but I am not comfortable with it right now. (She’s nice but I do not know how she will react to our potential plans. I will probably have to think about this more later, if we do proceed out-of-state.) Meanwhile, I have scheduled to go see 2 OB/GYNEs to check them out.

For those of you who are doing/planning out-of-state, what has been your selection experience for a local physician?

2. DH’s paid-time off are already spoken for for almost the rest of the year - 5 days in New York this month (woo hoo vacation!!!) and 3 days forced vacation due to facility shutdown. He seems to get the idea that he cannot do unpaid-time off… He has the assignment to check out if and how FMLA can be used.

For those of you who are doing/planning out-of-state, how does FMLA, if at all, figure into the treatment schedule planning?

SIRM’s IVF Outcome Based Reporting System

As mentioned in my earlier post re More Research About IVF in SIRM, SIRM locations do not report to SART (except for the Dallas, TX location). 2 locations - Las Vegas and New Jersey - report to CDC instead; and the rest, are not listed in SART.

I also mentioned that the SIRM website has an article criticizing the current reporting system for lacking the verifiability of a clinic’s self-reported IVF statistics and for its inability to compare “complex” vs straightforward IVF cases.

Instead, SIRM has the Outcome Based Reporting System (OBRS) which breaks down the stats into Category A-D based on relative categories of complexity (# failed IVF cycles, FSH level, #IU gonadotropin/day, # eggs retrieved) broken down by age. This is useful then when comparing case complexities.

Here is the latest OBRS for 2007-Q1-Q4.

Now, patient-me will try to eyeball where I fall under and what the table is saying…

- I think I am Category A since I have no IVF experience yet and thus no retrieved eggs yet as well. Also, I have FSH 3.5<9 and I needed 150-75<600IU/day Follistim to stimulate me.

- The stats are 58% clinical pregnancies, 8% miscarriages, 57% ongoing pregnancies and 25% multiple pregnancies based on 62 cycles. The average age from the 38-40 yo patients is 38 which means that all those who cycled are 38 years old. So I guess, this is not who I should compare myself to.

- Going worse case to the 41yo column - the stats are 25% clinical pregnancies, 33% miscarriages, 16% ongoing pregnancies and 0% multiple pregnancies based on 12 cycles. Not too different from TFC stats…

……

One disadvantage I see on the OBRS is that live births are not updated even for the earlier years where there is already sufficient time to gather information already.

Also, it is not clear which clinic/s is/are included in the stats. Having OBRS for each clinic could be more helpful for consumers like us.

Eventually, numbers are just that - numbers. Each case will be unique on its own. To me though, it does not hurt to know the numbers!

Whaddaya think?

Detailed SART IVF Stats Comparison

I’ve been looking at IVF stats from SART for sometime now and just like last Saturday’s post, I thought that was it. This weekend was the only time I stared at it long enough to discover that the IVF stats can be sliced further according to the diagnosis of the IVF patients. The per Diagnosis-sliced data was very interesting.

I lined up our known diagnosis to the Diagnosis Types in the SART database:

• Tubal Factor
• Ovulatory Dysfunction - Anovulation
• Diminished Ovarian Reserve - Advanced Maternal Age
• Endometriosis
• Uterine Factor
• Male Factor
• Other Factor
• Unknown Factor
• Multiple Female Factors - Anovulation, PCOS, Advanced Maternal Age
• Female and Male Factors -Anovulation, PCOS, Advanced Maternal Age, Low Sperm Morphology
  

I used 2006 SART IVF data from:

• TFC - Texas Fertility Center
• CCRM - Colorado Center for Reproductive Medicine
• SIRM-D - Sher Institute of Reproductive Medicine in Dallas, TX (since they are the only ones who publish to SART among the various locations of the SIRM. I’m showing how SIRM stats are presented later.)

Anyhow… Using these Diagnosis Types, I went to Select Diagnosis on the upper right corner of the SART stats (under the Diagnosis Frequency). For each of the related Diagnosis above, SART gives the stats for that particular Diagnosis alone. Here are the captured images of each clinic’s start for each of the related Diagnosis.

I summarized what I got from these captured images below:

CCRM had the most patients (91 vs 47 TFC) aged 38-40 years old with potentially related cases as mine. It might be a long shot, but this comparison may mean that CCRM has more experience on cases similar to mine. And perhaps may be able to help me more???

CCRM had the highest % cycles (78% vs 36% TFC) and most number of patients (964 vs 243 TFC) of all ages who had ICSI. This may be an indication of how much ICSI opportunity/experience the embryologists have for the clinics and thus how skillful they are.

CCRM also had the most # of cycles where PGD was used AT 234. Although TFC has 5X more cycles than SIRM-D, they have almost the same # of cylces where PGD was used (about 20). This may be an indication of how much biopsy and freezing/vitrification opportunity/experience the embryologists have for the clinics and thus how skillful they are. This may also be an indication how cutting edge or on top of technology the clinics/labs and doctors/embryologists are.

CCRM has the highest live births per cycle, followed by TFC and SIRM-D

Of course, doing this is tricky because:
1) Without clear knowledge on how each of the SART Diagnosis Types are defined, I am guessing what my diagnosis corresponds to.
2) Unless the SART Diagnosis Types are defined clearly with a common standard reference to be used by different clinics, different clinics may have different interpretation of the SART Diagnosis clinic and thus categorized their cases differently. This would be a major error in assumption when making “apple-to-apple comparison.

This is all I’ve got, so I’m going to use the information for making the comparison anyway. It is better than nothing at all.

More Research About IVF in SIRM

In my “Best” IVF Clinic post last Saturday, I mentioned about wanting to know more about SIRM. So I spent a couple of days exploring the SIRM website. This post contains what I gleaned from all that computer-staring…

This is how they introduce themselves:

LOCATION
Take note that each location is independently-owned. I wonder how much sharing of practice standards goes on really. As for a centralized management system, I wonder why that is necessary if each is independently owned. I noticed that they have set cycle dates per clinic. Could this be in some way related to the centralized management system? Anyhow, here are examples of 2008 Cycle Dates., for example:

SIRM - Dallas : Jan 17, Feb 11, Mar 24, Apr 14, May 5, Jun 9, Jul 17, Sep 2, Oct 13, Nov 10
SIRM - New Jersey: Jan 21, Feb 25, Mar 31, May 5, Jun 9, Jul 21, Sep 8, Oct 13, Nov 13
SIRM-Mosaic:
Las Vegas - Jul 14, Aug 18, Oct 13, Dec 8
New York - Jul 28, Sept 15, Oct 27
SIRM - New York: Jan 21, Feb 18/26, Mar 24/30, May 27, Jul 7, Aug 11/18, Sep 15/22, Oct 27/30, Dec 1
SIRM - Las Vegas: Jul 21, Aug 18, Sept 22, Oct 27, Dec 1

Take note also that SIRM-Mosaic is listed as a separate bullet in their list of nationwide SIRM centers. However, if you look at the addresses , the SIRM-Mosaic center shares the same address as the LV and NY clinics. What is common instead is that Dr Sher goes to both the LV and NY clinics. So perhaps the Mosaic term was added to identify the patients that are being personally seen by Dr Sher? Probably… I’ll find out as I communicate with them more…

Another thing about this multiple locations… If you check SART, only the Las Vegas, New Jersey and Dallas locations are listed in SART. The first 2 locations submit to stats to CDC while the last location submit to SART. The SIRM website has an article criticizing the current reporting system for lacking the verifiability of a clinic’s self-reported IVF statistics and for its inability to compare “complex” vs straightforward IVF cases.

I am not very comfortable with the multiple location thing. Each location may be benefiting from bearing the SIRM name but ultimately, the knowledge, skill, procedures, practices and facilities of each location will vary. So unless the individual location’s stats are published, I would not go to any other clinic. I would go where the motherlode is - in this case, it means the SIRM-Mosaic where Dr Sher is.

I wonder how much SIRM-Mosaic/Dr Sher charges for the IVF procedures compared to the SIRM-NY and SIRM-LV where he shares facilities?

I wonder if Dr Sher is fully booked???

CGH (Comparative Genomic Hybridization)
SIRM shares a lot of information on CGH. (CGH is another method of PGD (Pre-implantation Genetic Diagnosis) which analyzes all the 23 chromosomes, unlike the current standard right now, FISH (Fluorescent In-Situ Hybridization) which tests 5-12 chromosomes only.)

The information they share include their own studies and realistic expectations on this technology. One thing I noticed is an omission of 1 fact in their study that 6 women cancelled because of 0 normal eggs (as tested by CGH). Although it may sound trivial, it does de-emphasize that it is possible to get ZERO normal eggs.

Also ReproCure which does the genetics testing is just next door to SIRM-LV. (I would not be surprised if they are sister companies!) Could cycling in SIRM-LV make it possible to avoid a Staggered IVF???

I am very inspired by Polly’s strategy on Egg PBB1 - I am assuming that is done using CGH since she previously cycled with a SIRM location. (Polly mentioned in her Consult 2 of 3 that CCRM/Dr Schoolcraft said they could do that too (egg PBB1 only) although technically, a PBB2/Blastomere CGH is usually with it.)

I am looking to explore those option as well… still got to talk to DH though!

OBP (Outcome Based Plan)
This is another very interesting thing about SIRM. Here are the relevant quotes from their website:

“The Outcome Based Plan (OBP) entitles qualifying, patient/couples for whom IVF is medically indicated, to a maximum of three (3) completed IVF/ET attempts at an SIRM location . Each complete IVF attempt comprises one (1) egg retrieval procedure and as many embryo transfers (ET’s) using fresh or frozen/thawed embryos as needed to achieve a viable pregnancy or deplete all available embryos, whichever occurs first. ”

“OBP enables women/couples to be reimbursed up to 100% for in-house clinical and laboratory services associated with IVF/ET (excluding medication and anesthesia costs) if the transfer of all embryos does not result in a live birth.”

“Qualifying patients/couples pay the same up front amount regardless of their age or circumstances. The difference lies in the amount that is refunded (refund plan amount) in the event that IVF does not result in the birth of a baby. Patients may apply for outside medical financing of OBP-related IVF services (see below). Since pregnancy rates are profoundly influenced by the age of the woman producing the eggs, the amount refunded in the event that a live birth does not occur is determined by the woman’s age.”

“Over 90% of all IVF candidates would qualify for the OBP, either by using their own eggs or a donor’s. Even severe male infertility, requiring intracytoplasmic sperm injection (ICSI), or testicular sperm extraction (TESE) to obtain sperm in men who have no sperm in the ejaculate, or repeated failure to conceive in another IVF program does not preclude a couple’s eligibility for the OBP. If the woman experiences a first trimester loss, whether through miscarriage or medically indicated therapeutic abortion, the couple is still entitled to a refund.”

I wonder how expensive the OBP is. It does feel better to have a refund if you don’t take home a baby. Will have to get more information though and do the math to see if this is worth what it seems to promise.

Communication and Discussion
SIRM has a Bulletin Board that is open to everyone, not just exclusive to their patients. And the great thing is that the doctors respond to the questions. Well at least that’s who they are logging in as…

Based on my limited sampling of the BB, Dr Sher answers on weekends as well and asks the message poster (presumably his patient) to call him at his cell phone on a Sunday! Yay!

(I just got reminded of the posts I read from other bloggers that the CCRM doctors also makes follow-up calls to their patients.)

……

Alright, that is plenty of information already. I’ve got my thoughts organized on SIRM. Still need to get more specific info from CCRM and SIRM though to make a better decision analysis discussion with DH on Thurday night on this topic!