Last week, I was catching up with some of my fellow IF bloggers posts that I have missed in the last 2 months. One thing that caught my eyes was Mamasoon’s CGH results - or should that be “no results”.

So I sent an email to my IVF Nurse and asked her about a “recent botch up of CGH test” and whether microarray is applicable for my egg (not embryo) case, does CGH and microarray differ in cost, and whether microarray is “safer” than CGH. She did not send me an email response but when we talked on the phone she told me she would get me the answers to my questions.

Last Monday, I got a surprise call from Dr Sch instead He sounded a bit miffed (I think) but he does understand that we in the IF blogosphere have a unique culture such that word gets out fast here. He said that it was not a botch job (like someone dropped an embryo or someone skipped work, etc.) but was instead attributed to the variations in the enzyme/reagent used. (I used to work with chemicals too so I understand what he means. It is still is not acceptable not to have quality control on the incoming enzyme/reagents though.)

Dr Sch stated that the choice of CGH vs microarray was typically made by them based on which lab has a shorter turnaround for the load that they have at the time that the samples are available. He also stated that they do not favor one test over the other and in fact, consider them equivalent. (I wonder if they did a study on this?) I do remember him saying these on our first phone consult though so he is still consistent. He did say that if I wanted to choose one over the other that I was welcome to do so. Based on what he said though, I would like to go for whichever would have faster results when my samples are available. Any of you have an opinion?

I told him that I needed to ask those questions I asked because of the “data” I got from the web. And I backtracked, I called it “information” instead of data. And that’s when he gently laughed and said “that anything you read in the web, you should not treat it as “data”". I agree. But I still would ask. No harm in asking, right? I’m paying good money for all these!

Guess where I am right now? Yes, I am now in Denver and probably will be for the next 10 days.

I had an appointment for Ultrasound and bloodwork at 8:15 am earlier today. I thought I had plenty of time but guess what greeted me when I opened the curtains:

SNOW!!! Yaix!!!

I wasn’t prepared for it. I knew it was going to get cold that’s why I packed my thick winter jackets and turtle neck shirts.  But not snow!

That explains the brush inside the rental car! I was wondering why they left their “cleaning” stuff inside the car! Now, I’m glad they did. I further gave away my being snow-ignoramus though when I opened the driver seat door and snow went in and deposited on the seat!  (I started to get worried that when I turn on the car heater that my seat would be all wet!) Anyhow, I actually enjoyed brushing off the powdery snow off the car - it was easy-peasy!

When I was done brushing off the snow, I only had 10 minutes till my appointment. So I drove off … and when I made the left turn into the major street… I lost control of my car and made a 180 degree!!! It was a good thing that there was no car right behind me… I guess they stayed away because the rental car had an Oklahoma plate.

There I was in the middle of the road, facing the wrong direction!!! I was shaken but I couldn’t help but grin. I waved at the oncoming traffic and they let me maneuver.  Then I was on my way… I was a bit frazzled but I thought it was more funny than embarassing. I just praise God for protecting me!

I got there on time - ultrasound showed my ovaries were on track. They should call in later today what my Follistim dosages are for the next 2 days.

Here’s my schedule in the next few days:
3/12 Thu - Ultrasound/Bloodwork. IVF Physical
3/13 Fri - Genetic Counseling with Danielle
3/14 Sat - Ultrasound/Bloodwork. Back-up Freeze #1
3/15 Sun - Ultrasound/Bloodwork
3/16 Mon - Ultrasound/Bloodwork. Back-up Freeze #2

Will keep you posted, I promise!

Well, gals, I am still very much alive! I’m sorry I have not been posting here but life goes on.  The details did not seem very exciting and I was busy working on some goals that blogging fell into the wayside.

Anyhow, after the one-day work-up in CCRM end of last year, we basically followed through with the necessary things to be done:
1. Physical exam and Mammogram - all clear
2. Clomid Test - I did it anyway so that I don’t need to redo it, just in case. All good.
3. Waited for my period to arrive to start the birth control pills
3. Paid for the IVF/ICSI/CGH - $$$ (I asked about “recession pricing or payment plan”.  They have none.)
4. Started the Lupron/Dexamethasone/Menopur/Follistim protocol - 1st ultrasound today show both ovaries responding as expected - 8-10 eggs @~10mm on the left and 10-12 eggs @~10m on the right.

I still owe you stories about the 1 day work-up. I’ll try to recall that but if not, then I’ll just tell you stories about what’s going on now!

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?

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?

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.

In the last ICLW, I noticed a couple of infertility bloggers who are going to Colorado Center for Reproductive Medicine (CCRM). I dug up a bit about CCRM and noticed that their stats show very high percentages of live birth compared to TFC where I am going.

STATS TFC (SART 2006)

STATS CCRM (SART 2006)

With stats like these, CCRM must have a lot of infertility patients coming in for the higher probabilities. They even have a page in their website for out-of-state patients.

Anyway, I commented on a couple of these CCRM’ers a few weeks back but did not hear from any of them until this week (Thanks Christi!) . I was hoping I could ask them more in-depth questions about their experience.

…..

Since digging more into “best IVF clinics”, I have heard of Sher Institute of Reproductive Medicine (SIRM). I checked out their website briefly and it was cool to have their patients chatting in a forum within the website - it sounded like the patients had automatic support system within their month’s cohorts.

SIRM has multiple infertility clinics within the US. I wonder how alike they really are, how best practices are proliferated and where the famed Dr Sher most frequents  - all these and more… I still have to dig into.  The nearest SIRM site to me being in Dallas, TX (3 hours away). However, that specific site’s stats are not comparable vs TFC where I am currently at.

STATS SIRM-Dallas (SART 2006)

…..

I have also stumbled upon Northwest Center for Reproductive Sciences (NWCRS) in Kirkland, WA which has comparable performance as CCRM, but with a lower “sample size” …

STATS NWCRS (SART 2006)

…..

Should I open all the SART stats of the various clinics to find those with >25% live birth for my age group? That’s a lot of work… I don’t like to go there! So… if your infertility clinic has good IVF stats, please sound off and leave me a comment so I can explore it more.

So meanwhile, I will concentrate on learning more about CCRM and SIRM for now.  Also, I will piggy back with Polly (Hi Polly!) on her consult with the top doctors - even if her case sounds more complicated than mine.

AMA is not exactly complicated. It just is what it is… OLD!

Prior to this week, I have not been blogging here since nothing much is going on at the infertility front. No medical activity, that is… but I am continuing to read infertility blogs of my fellow ladies.

Specifically, I have been trolling the blogs of my peers - those of the Advanced Maternal Age category. Or as Mel calls us - “Over 35 and TTC”.

Here are the most significant takeaways I have from all that reading:

• Of the ladies who are of advanced maternal age as I am, I have not read of anyone who had a baby through IVF except Raggedy Ann (and if what I pieced together from her blogposts, she had her boy when she was less than 35 years old). It’s depressing not hearing about “success stories” from my peers.

• I read of some ladies in the comments sections who mentioned that they did get pregnant without medical intervention. How I wish I am one of these ladies. But as you can see, my cycle counter is now at 50 days and my period has not arrived yet. Classic anovulation there for me!

I just want a ray of hope…

We had our consult with DrH and she was very accomodating. She answered all our questions - I didn’t necessarily like all her responses, but it is good that she didn’t sugar coat it. She said that she would have discussed most of the topics anyway but appreciated the questions I sent in because it gave her an idea where we were coming from.

She said that she wished there were more couples who were more concerned on what would be done to their embryo.  She just gave me some more additional things to dig more on too…

Anyway, I wrote all that I could remember from our consult … yes I forgot the recorder… and writing it down resulted into a very long post, so I am broke it into 3 parts.

OUR INFERTILITY FACTORS
The factors we are facing are Advanced maternal age, PCOS/Anovulation and Low sperm morphology:
- PCOS/Anovulation can be “tricked” by controlled ovarian hyperstimulation (COH).
- Low sperm morphology effect would be minimized with IVF.
- So, the only factor that we cannot do anything about is the advanced maternal age - that determines the egg quality. (I got the usual talk about “women are born with all the eggs for their whole lifetime. As the woman ages, the quality of the eggs “deteriorate”.” In essence, my eggs are old… my raw materials have deteriorated.

Re my 3.5 FSH - DrH said that what it means is that for a 40-year old woman, that was good. However, it still does not compare to a 25-year old woman’s eggs who tests as 3.5 FSH. My eggs are still 15 years older!

WHAT OUR IVF WOULD LOOK LIKE
Since I am a good responder to the gonadotropin, DrH expects to be able to harvest a lot of eggs if I undergo COH in preparation for IVF.  However, she said that fertilization and viability of embryos from eggs of someone my age may not be very good, so just fertilizing a few eggs will not make sense and that the procedure will not be worth it. She also recommends to transfer back 3-4 embryos since the implantation of embryos for someone of my age may not be very good as well. (So that means the “fate” of embryos that are not transferred is a real key question.)

As for typical reasons for IVF cancellation, DrH mentioned 3:
- low stimulation
- overstimulation (typically for younger women)
- ovulated early (or early LH surge)

What to expect with Lupron?
- Before starting, ultrasound to make sure there are no cysts
- Start Lupron. Attend IVF Orientation
- Expect period
- Baseline ultrasound

DrH said that the Follistim dosage she would use for IVF would be at the same level as our 1st Follistim stimulation (that was cancelled) which showed I was a good responder. So instead of the $3K medicine cost estimate, she thinks I would only be using $1.5K worth of meds.

Progesterone is going to be intramuscular (IM) injection…on the butt? on the thigh???. (I was hoping it was just suppository even if it was a bit messier.) Uuuggghhh…

These topics are really the ones that have a lot of sticking points for me…

EGG/EMBRYO FREEZING
DrH also said that egg quality cannot be predicted and since I have old eggs, there is no point in egg freezing. They are able to assess the quality of the embryo through morphology to determine which will be transferred.

I don’t know if I picked up correctly on the discussion on Day 3 vs Day 5 transfer…

If there are only a few good Day 3 embryos, transfer is usually done on Day 3.  If there are more than a few good Day 3 embryos, those can tested for PGD (preimplantation genetic diagnosis) or embryo screening.

DrH clarified that PGD is taken on the Day 3 embryo and results will be in for a Day 5 transfer. (So I am just realizing it now that if PGD is desired, that would automatically mean that it would be a Day 5 transfer - unless there is only a few good Day 3 embryo which forces a Day 3 transfer???)

On what is done to embryo and blasts that are not transferred - they are either frozen or discarded.  They will freeze only those that are judged to have a high chance to survive the freeze/thaw.  They give the blast up to Day 7 (which I suppose would be enough time/chance for the rest of the “lesser” blasts to survive before arresting) and will discard them.

Not sure if I captured that last statement accurately but that sounded a bit harsh… If I may quote from their clinic’s literature - “Only embryos that have fertilized abnormally, stopped dividing or have completely fragmented are discarded.” “Each embryo in our IVF laboratory is treated with the utmost care and respect…” DrH also mentioned that they are actually lean more leniently in judging the embryos to be frozen.

PGD OR EMBRYO SCREENING
DrH said that through PGD, they are able to determine if there are chromosomal abnormality (for 9 chromosome pairs only, not the 23 pairs) in all the embryos. This will isolate which embryos that have normal chromosomes from embryos that have abnormal chromosomes which lead to miscarriage. DrH also said that although PGD reduces the probability of miscarriage, it does not increase the pregnancy/live birth success rates.

The PGD is able to determine the gender of the embryo even at that point. (I read somewhere that there are some who practice gender selection using this method.)

DrH also said that as PGD will not be able to screen all chromosomes and I am of advanced maternal age, she recommends that if I do get pregnant, to have an amniocentesis for all the chromosomes since they cannot screen for Trisomy 21 (causes Downs syndrome) or Trisomy 17 and the like. (I don’t think I will do that since however the baby will be, I will accept. I will not terminate.)

I need to dig more into these.  Please pray for wisdom and discernment that we make a decision that is according to God’s will.