I’m going to start this post very differently from how I thought I would, since I have lots of fun fertility updates after my appointment yesterday. It’s been pushed aside a little though, because, BECAUSE! You guys! I think I just figured out what I want my (hypothetical, future) lab to work on! It’s 8:30 am, I’m awake on a Saturday working on the $*#^%@ book chapter (which is due, it turns out, on April 1st, not “in April”. Cue mild panic.). I have had a flash of insight and excitement and delight. This idea, this wonderful shiny exciting idea is perfect for me and my skill set, my interests, and the things that keep me up at night. I have passion and drive for it already, and it’s only been in my brain for about five minutes. It has scope and scale and human interest (while I do not care about humans much, this is necessary for funding these days). It leverages all of the things I know, and all of the things I want to learn. It might lead to doing some good in the world too, and certainly to some exciting experiments. There are minimal existing publications on it, and from what I can see, the area needs the style of research that I do. The only caveat is that my field sites will be, in a word, gross, and grad students may not flock to attend sampling trips in the same way than if I were sampling, say, the Mediterranean sea basin.
Ok, I had to get that out. I’m so excited.
My fertility clinic is very fancy. The waiting room has a panoramic view of the water and both bridges, which, given they are at a right angle to each other on the peninsula, is no small feat. My fertility specialist is very nice, and frank, and funny, and does not condescend to me (which my ob/gyn inevitably does). I like her muchly. She grew up in Frigid Boring City in Canada, which is exciting, as I am Canadian, and I have relatives who somehow eke out existences in Frigid Boring City. She loves that I am a biologist, saying “you guys get it, and I can really explain things to you”. She then got mad at me for using my sister as anecdotal evidence, but I deserved that.
She was pretty sure I am a PCOS case given my blood work. The ultrasound we did showed some lovely pearl necklaces as well (15-20 antral follicles per ovary, along the outside edges: textbook PCOS). Here’s the thing: I watched both my ultrasound last January and this ultrasound, and my ovaries look EXACTLY the same. I even asked the tech in the previous ultrasound “are those all little cysts” to which she replied “oh, ovaries always look cystic”. I looked up photos after and had to concede that I don’t know much about reading scans, but with lingering doubt. A string of pearls is a pretty apt descriptor, and I had seen them clearly. So, my suspicions are borne out. I’d be annoyed, but it really wouldn’t have changed anything….. oh, no, writing that out made me think about it more, and I think I would have started with an ob/gyn and medicated cycles earlier if I knew last January I was PCOS for sure. Huh. Well, bygones.
We could see the corpus luteum on my right ovary from this ovulation, which was also neat.
She recommended we try three cycles of letrozole (femara), an oral ovulation induction medication that often has better success with PCOS patients. I’ve been ovulating on clomid, but it’s still quite late (cd 21-24), and letrozole often results in multiple follicles, which can increase odds. We’ll monitor the cycles with ultrasound. She’d like us to use IUI in addition to trying at home, to make sure the timing is right. I do have an LH surge of my own (yay OPKs for that knowledge!), but she is going to consider an hCG trigger as well. I’m on board with all of these things. (Is it weird that I am mildly excited to test out a trigger? More tests! Data!) I think we trigger if my follicles look ready and my opks are not +ve yet, while if I suddenly get a +ve at home, I am to trot off to the office with sperm in hand (or Pea by hand, whichever).
Things I have to do in the next week include phone appointments with their cycle scheduler and financial advisor, bloodwork #1 (basic infectious disease screen and cystic fibrosis marker screen. Pea has to do this bloodwork as well.), bloodwork #2 (only after menses starts, final pieces of a PCOS panel (testosterone, insulin fasting, etc.)), IUI training (?), and a baseline ultrasound appointment. It’s unlikely I can get all of this done before Monday, which is when my period is due, especially as IUI training is only offered on Thursday mornings, but my doctor is fine with it taking even up to a week or more into this new cycle before I start any letrozole, etc. The baseline ultrasound at that point will show if I’m recruiting a follicle all on my own (possible, as clomid often sticks around for another cycle or two), and if I’m not, then it doesn’t matter if we wait a while to get started. All of this will be 50% covered for me under my insurance, so it should be relatively affordable for these three cycles at least. She doesn’t think I need an HSG, nor does Pea need any further semen testing (fragmentation, etc.) at this stage. We’ve really only had three chances to get pregnant, so it’s not the same scenario than if we’d been trying for the same year but with the expected 13 eggs.
I am less happy about her attitude about injectables and IVF. She opines that PCOS ovaries are very hard to appropriately stimulate with injected FSH – they need a lot to get going, but even a hair too much and they overstimulate pretty severely. The drugs are expensive, and it’s annoying to have to cancel the cycle if things get into hyperstimulation territory. Plus the success rates for injectables if you were ovulating on the oral meds are really not very high. Their main niche is for people who don’t respond to the oral meds. She recommends that after the three cycles of letrozole we move directly to IVF. Pea and I both share some doubts about IVF, so we shall see how this all goes.
I talked to Pea about all of this last night. He didn’t come with me to the appointment, since we’ve decided minimizing the collective time drain of this process is smart, so he’ll only come to the appointments he really has to. He’s fine with the letrozole plan, and is pleased there is still an oral option (he’s more scared of needles than I am). He blanched a bit at the IUI, since performance on command is not his favorite (fair enough), but he’s on board. We talked a little about finances: as we don’t share finances generally, we’ll need to decide how to split this up. I’ve paid for everything so far (doctor appointment co-pays and clomid/progesterone costs), which has been minimal/affordable for me. We’re swiftly getting out of that range though. Pea suggested “our usual split: one part you, four parts me!” *big grin* (our usual split is actually 1:2 or 1:3 depending on how stubborn I am being, and Pea is continually gently trying to shift it more towards his burden. He’s wonderful.). Pea’s main thought process was that he was annoyed we had to pay to do what comes free for most other people, and mostly annoyed that things are SO expensive, seemingly unreasonably so. Which was separate from his willingness to do the treatments, and the fact that we can afford it. We are very very lucky in that we can even consider IVF, given it is 0% covered by my insurance, and we can still afford it. I’m really still hoping it won’t be necessary.
How I am feeling: all of this was what I expected, and I like my doctor. The clinic is a bit far away, so I might buy a bike, a prospect that fills me with glee, as I’ve been sorely missing my bike here. I’m sad that I’m the reason we have to spend money we could otherwise either continue to hoard or spend on gallivanting around the world. I’m a bit stressed about all the different things I have to accomplish next week, but I think I can do all the bloodwork at once which will help.
How I’m feeling for this cycle: I am 9 dpo today, and feeling normal. This LP my nipples have been severely sore from day one, but otherwise I’ve been mostly symptom-free. Yesterday I was endlessly thirsty, but I also had Pho for lunch. Giant bowls of salty broth are a good probable cause for thirst. IF I make it to Tuesday (12 dpo), I will consider testing, as Monday would be my expected cd1.