RE Update/Advice Needed

bocaburger

We finally had our first RE appointment today.  It went pretty well.  He spent about an hour taking our history, talking to us about the possible causes for my lack of ovulation, and formulating a preliminary plan.  He thinks it is all hormonal and that inducing ovulation should work within 6 months.

I'm getting CD2 bloodwork done tomorrow.  I'd appreciate advice on the other aspects of our plan:

1. Preliminary HSG, or only if treatment doesn't work?  He said I have no risk factors for structural issues/blockage and because it can be pretty unpleasant he doesn't recommend it until after 3 failed medicated cycles.  I feel like I have a fairly high pain tolerance and I'd rather know if I have a structural issue before wasting money and time on treatment.  Opinions?

2. He says that many patients with hormonal imbalances respond well to acupuncture and we could consider trying acupuncture for a few months before starting medications.  I always prefer to stay away from meds if possible, and these seem to have some intense side effects that could be pretty tough while I'm in school... but on the other hand it might just be three months of expensive, frequent appointments that don't do anything.  Does anyone recommend that I try acupuncture first?

3. Clomid vs letrozole?  I have heard a lot about Clomid (mostly positive from doctors, and negative from all of you) but I know very little about letrozole.  He says it's up to me which I want to try first.

Is there anything else that I should be doing or thinking about that he didn't bring up?

THANK YOU so much for your feedback and advice, as always.

shirleymaeby

1. So I'm no doctor, but I find it highly suspect that he would tell you to put off an HSG until 3 failed medicated cycles.  Giving you medication won't make any difference if you have a blockage.  Also, from what I understand an HSG is only painful if you DO have a blockage...mine was seriously no big deal, just some mild discomfort.  I personally would not put it off...at the very least it could give you some piece of mind.

2. I have no experience with acupuncture.  It may very well help you, but without an HSG or an SA you could be wasting money.

3. I don't know anything about Letrozole but my experience with Clomid has been mostly positive.  The only negativity I have toward the drug is actually about how OBGYNs throw it around like candy and make women believe it's some kind of miracle pill.  I think there are significant risks involved if no monitoring takes place.  I don't have PCOS but I think I've read that Clomid doesn't work so well with women who have it.

Good luck!

BKBABY3

1. I would say go for the HSG first. Even if a blockage is unlikely, if there is one you'll do those medicated cycles for nothing. It wasn't sunshine and lollipops but it also wasn't that bad (for me).

2. Did my first acupuncture session last week. I have no idea if it will help with this cycle, but I did find it relaxing and it made me feel like I was taking more control over things and expanding my options. That's just my personal feeling, though. 

3. I started with Clomid and am now on Letrozole. I responded great to Clomid at first, but then not all that much. My first cycle response to Letrozole was good (2 dominant follicles). All I can really say about differences is that I have had fewer side effects on the Letrozole. I also hear that Letrozole is supposed to be better for CM and for your lining. Can anybody else back that up?

Good luck!!

curve31

I didnt know there were risk factors to having blocked/messed tubes. I thought it just kinda happened. I would do the HSG for sure.

I have PCOS and clomid didn't work for me. Just gave me a big ole cyst and wasted a cycle.

shirleymaeby

Seriously...everything that @iputketchuponketchup just said is exactly right.  I don't really understand how an RE could tell you to forego an HSG and also leave the medication decision up to you.  I might look him up online and see if you can find some feedback or reviews from other people who have seen him. 

Hollowvic

Like everyone else said, don't skip the HSG. Leave no stone unturned. You never know and could waste time if there is a problem. Did he suggest a SA? Your RE seems a little vague, just MO. Good luck!!!!

bocaburger

Thank you so much everyone for your feedback.

iPutKetchupOnKetchup - I actually liked him a lot and don't think he's as irresponsible as you say.  I didn't want to write too much in my original message because then it would be even longer.  DH has already done an SA in the past and had very good results, so we don't need that.  I've had bw in the past but he's ordering more extensive bw.  

Any treatment we choose (Clomid or Letrozole) would be monitored by u/s, both for safety and to confirm ovulation.  He did not officially diagnose me with PCOS (because my androgen levels haven't been tested yet, and he wants to rule out congenital adrenal hyperplasia) but I've had two separate OBGYNs tell me they believe I have PCOS and I've had an u/s showing multiple follicles, so that's my working assumption until told otherwise.  He usually starts with Clomid, but when I said I've heard a lot of bad things about Clomid he told me we could try Letrozole if I prefer and that they have similar success rates.

I was also surprised that he did not require an HSG, but I told him I would like one before starting treatment and he wrote me the order - I just wanted to make sure that people here agree with me.  He made it sound like a lot of his patients have really complained about the HSG (mostly the cramping after, not the procedure itself) so he doesn't order it unless he has a reason to suspect structural issues.

Do other people think he seems irresponsible?  I'd hate to keep using him if he's not good but I liked him a lot and don't want to keep bouncing from doctor to doctor unless I need to.

shirleymaeby

OP - I'm happy you gave a little more information about your meeting with him.  It helps me understand that he wasn't just like "Hey here's some pills or you could take this other stuff.  Whatevs, it's up to you."  That to me is what sounded irresponsible.  

I still disagree with his stance on the HSG though.  It may be uncomfortable but it is like infertility testing 101...everyone has to pass before they can move on to treatment.  I can understand him not wanting to put you through any potentially painful tests, but honestly this is one that just shouldn't be skipped so I am happy you insisted on having one.

He may very well be a good doctor who just made a questionable call.  That's why I suggested looking him up online to find out what past patients have had to say about him.

Hollowvic

I agree, the HSG was one of the first things my RE had me do, along with all the initial testing. She wouldn't move forward without it. That's troublesome to me.

bocaburger

Thanks for your feedback everyone.

LindseyM2012

I will second @iputketchuponketchup on everything. 

My RE recommended I go with Letrozole for PCOS because of less likelihood of multiples (the RE and I agree that multiples is not a great idea so we're shooting for one at a time) and less of the roller coaster side effects.  

kushie77

Hi. 

Sounds irresponsible to me.  He's the one with the medical degree and training, yet he's leaving decisions up to you.  Why put you through medicated cycles and IUI without checking to make sure your tubes are open.  That just seems crazy to me. 

What does this guy's SART data look like?  I'd take a closer look at that

As for the SA, well our first one was borderline, the second was awful and the third showed nothing usable.  All were within a year.  I'd ask for a repeat SA unless the first showed some super awesome swimmers on there.  And make sure you physically looked at it yourself.  If it was done by your OB and you were just told everything was "good"  get your eyes on it and make sure the RE has seen it also.  

Champs28

Hi there! 

1. Get the HSG!!!! I had a very painful experience because I had several issues that were only discovered in my HSG. Seriously, if it's not an issue of coverage or payment (and actually even if it is), get the HSG. At least you'll be able to rule out any issues there. 

2. I have been doing acupuncture all summer! I like it for a few reasons -- it is 45 minutes a week that I can relax and focus on myself, my insurance covers it completely, and it got me to have one period so far! (I don't ovulate and I don't get my period, by after an acupuncture session I ended up getting a period on my own exactly one time! So i'm still hopeful)

3. I am going to undertake the Clomid vs. Letrozole debate myself this fall. I don't think it's that rare for an RE to ask you which one you prefer. So many women have such strong opinions one way or the other, so maybe he's assuming you have an opinion. From what I know, most RE's start with Clomid and switch to Letrozole when Clomid doesn't work. 

lisa89760

My HSG was no big deal and I'm a huge baby.  It was the second test I got done, after just a normal ultrasound.  

I've also heard good things about acupuncture but I have never done it because I'm terrified of needles and I don't think that it would relax me at all lol 

I've only been on clomid and femera.  Clomid didn't really affect me until I was at 150 MG a day and then I felt the side effects.  I like femera a ton better. 

BunnyBerry

Have to say, I am a little weirded out by your RE, that he's not using his expertise and knowledge of the most relevant research to tailor your plan and give you some advice!

1. Get the HSG! Known risk factors are only one part of the puzzle, there are congenital issues that could be there, random fibroids or polyps or whatever, and it's always possible to have had pelvic inflammatory disease without knowing it. I would never want to medicate my body for 3 months without knowing if the hardware is good to go.

2. Since you already have an IF diagnosis, I personally would not spend 3 months doing acupuncture. Medication is much, much more reliable and effective.

3. Letrozole is easier on the body because instead of blocking estrogen production, it just blocks your brain's ability to perceive how much estrogen is there, preventing your brain from sending the hormonal signals to the ovaries that shut down development of other follies. Therefore, side effects are less troublesome. Also, it doesn't have the same issues with thin lining and cysts like Clomid has. There is a smaller chance of multiple follies on Letrozole. For some women, Letrozole doesn't work and then Clomid makes sense. A good RE should be able to predict your body's response to some extent and recommend a first drug of choice.

As far as the SA - a repeat SA is definitely in order if it's been more than about 6 months, especially if you're starting meds now. Your RE should want to be sure what he is dealing with. It really irks me when a medical professional finds one possible cause of IF and just decides to move forward with the assumption that everything else is fine.

You say you "like" him a lot, but I wonder if you are happy with more than his personality? Judging from his medical decisions (and lack of) so far, it's hard to find something to admire about him. I have so much faith in our RE's decisions because he makes it very clear what he's basing his decisions on, and he has predicted and caught many issues that we never imagined we had. Comparing to that, I would be a fretting, anxious mess if I had to switch to an RE telling me things like yours does. Of course it's up to you, and switching doctors is a big pain and a huge step. If you do keep working with him, just maybe make that choice with your eyes open that there's a good chance he'll waste your time, trouble and money unless he just gets lucky.

bocaburger

Thanks everyone for the feedback.  This is very helpful.

DH's SA was actually stellar - all results were well above the necessary range.  The RE went through them with us.  My mom (who is a doctor but not a fertility specialist) also looked them over.  They were done in March and he hasn't had any major health changes since then.  Do you think we still need them repeated?  Financially I'd prefer not to have any unnecessary procedures but obviously getting adequate treatment is the highest priority.

I had CD2 bloodwork and baseline u/s done today.  Surprisingly, the ultrasound was totally normal and did not indicate PCOS (unlike my last ultrasound, done about a year and a half ago) - so I'm interested to see what the bloodwork shows.

We have a f/u appointment in a few weeks (once all the blood results come through) so hopefully he will go into more detail about risks and benefits of each med.  He originally just said Clomid, and when I expressed that I had heard bad things about Clomid he said we could use Letrozole instead...  So I think he was really just trying to work with my input.

@BunnyBerry, thanks for that last paragraph - I think it helped me look at the situation more honestly.  I think the biggest reason I liked him is that he took an hour to sit down with us and explain the hormonal aspects of fertility clearly, with diagrams; that he didn't push me into anything I wasn't comfortable with and gave me input into my treatment plan (even though other people have a problem with that aspect); and that he is at least responsible enough to monitor during medicated cycles.  This is in stark contrast to the 3 OBGYNs I saw before him, one of whom kind of dismissed my concerns and told me to take a supplement and keep trying naturally (which cost me months), and two of whom basically tried to push Clomid on me with no discussion, no explanations, no monitoring, and very little bedside manner.  On the other hand, I think there is a part of me that's just tired of going from doctor to doctor and maybe I just liked him because I really wanted to like someone.

Regardless, this discussion has definitely proven to me that I need to keep my eyes open, ask a lot more clarifying questions, and push back against him a little bit to make sure I am really getting the best care.  Thank you everyone for your guidance.

BunnyBerry

Wow, so sorry you have had such awful experiences with OBs.

As far as giving the patient input - I agree that it is important to give the patient clear options with pros and cons and allow them to make choices in terms of how aggressive to be, for example. However, I think there is a big difference between giving you excellent medical advice and room to choose between options, and just putting it all on you with nothing to go on except the advice you get from the 3T board.

bocaburger

That is very true.  Hopefully he will go over the options much more in depth at our follow up... If not, I will need to really talk to him and clarify expectations for this process.  Thanks for your feedback.

saritacw

I don't know anything about acupuncture. Nor do I have any first hand experience of Clomid. But this might be helpful:

The order of testing that my doc had me do was the following

Step 1: Me to do blood work and ultrasound to look at "lay of the land" while also taking a bunch of supplements just for being healthy (prenatal, D3, DHA, L-Arginine, baby aspirin, Folgard, Fish Oil) Once those test came back "normal' we moved on to step 2.

Step 2: Husband to do SA; because it came back normal we moved on to Step 3

Step 3:  Me to do HSG

Only after the HSG came back normal did she recommend a plan. Initially she suggested IUI but DH didn't feel read for that leap so instead she suggested a couple rounds of Letrozole, TI and Progesterone.

According to all my reading-- Dr. Google and what I've read on this board, her approach seems pretty much inline with common initial steps.

bocaburger

Thanks everyone!  Going in for my HSG tomorrow morning!!!