Advice Needed and need to vent (*loss mentioned)

mtpbadger · December 2015

Alright ladies, I need some advice and assistance and really just need to vent (so sorry if this post is all over the place).

I have a meeting with my RE on Monday to discuss our next steps and how to proceed. The options as I understand them are either trying a 4th IUI with a change in meds or IVF. I want to have a list of questions going into the meeting and was hoping you all might have some good questions or ideas that I haven't thought of yet. A little background:

Diagnosed with PCOS and hyperprolactinemia (currently under control with meds). I don't think I have over ovulated on my own. No issues with DH.

IUI#1: August 2015, Clomid 50mg, lining was around 5.5ish (can't remember exactly) didn't do trigger shot as my LH surged but did IUI and prescribed prometrium and estrace suppositories- BFN

IUI#2: Sept 2015, Clomid 50mg, lining was still thin at 5.9, started estrace 2 days prior to IUI, prometrium and estrace suppositories - BFP but ended in chemical

IUI#3: (aka cycle from hell): Nov 2015, 50mg Clomid and started estrace vaginally on CD9 which ended up slowing my follicle growth, took 100mg clomid, lining ended up being 6.8 and IUI on CD31 - BFP but another chemical pregnancy that is just finally resolving itself.

I had asked my RE about a med change after IUI#2 due to my thin lining but she was hesitant since my follicles responded really well to the clomid and she didn't want my ovaries to produce too many and then have to cancel and thought starting the estrace earlier may help. She did indicate that a change in protocol would happen should we move forward with another IUI and she is open to doing up to 6 IUIs if we want to go that route.

My mind is spinning with the decision to do a 4th IUI or just move onto IVF. Obviously I am able to get pregnant as it happened twice in a row, but for some reason, neither was viable which is beyond frustrating. My insurance covers 50% of all fertility treatments but with copays each IUI has still added up to about $800, give or take. Part of me knows the IUI is the less invasive route and it CAN work, but also part of me thinks we have already put all this money into IUIs and instead of doing another one, put that money towards IVF.

My husband is beyond optimistic and keeps saying "Well, each IUI has gotten us a little bit closer!" He is open and extremely supportive to either another IUI or IVF and will give his input but is leaving the ultimate decision up to me and I am not very good at being decisive, lol.

So far, here is my list of questions for my RE:

1. Major concern is thin lining, would this be the most likely reason for not being successful with the two CPs?

2. Taking the estrace vaginally doesn't seem to thicken my lining at all (every time I started it, there was hardly any difference in my lining prior to the IUI); is this a concern and are there any other medications or would taking it orally change the outcome?

3. With two CPs, am I at a higher risk for another and/or miscarriage?

4. What would be the protocol for a 4th IUI in terms of medication changes and trying to build up my lining?

5. What would an IVF protocol look like regarding meds, timeline, and recommendation of either a fresh or frozen transfer?

Do you all have any other questions/ideas that you would recommend I bring up at my appointment? The though of moving to IVF is daunting (both emotionally and financially) but if that's what's needed, I'm all in.

Sorry this is so long! Happy Friday everyone!

amos1417 · December 2015

Good morning! I am so sorry for all of this. IF really stinks. My RE said 3 tries with femara (He doesn't even use clomid) and then up to 3 tries with injectables.

However, in your case, I wouldn't take clomid again. At all. I have read that it is the number one cause for thin lining and after using it for 3 months, the changes could start to be permanent.

I did 4 IUIs and in the middle on a FET now. The first 3 IUIs were with Femara and my lining was great. I had a chemical with the second IUI. The 4th IUI was low dose injections that was BFN. 5th IUI cycle was converted to IVF when I had more than 4 mature follicles. I didn't have a fresh transfer because I hyper stimulated.

I would move on to IVF if you can afford it. It's really the only way to examine egg quality and your chances will be better. I speak from experience - all of my tests looked great! My AMH is 5.15 (I am 35 and with some PCOS symptoms), my testosterone is normal, I am healthy, not overweight, etc. It was not until we converted my last cycle from IUI to IVF (because I responded very well to the injections) that we noticed a potential issue with my egg quality. I had 24 eggs retrieved, 15 fertilized, 9 made it to day 5, but only 3 made it to freeze and they are fair to poor quality. My RE will not say at this time that it's an egg quality issue because it was only my first retrieval. If the FET of all 3 embryos on 12/15 fails, he suggests doing another cycle of IVF to see how the eggs do a second round. I have been doing back to back IF treatments since May, so that could affect the eggs.

If you chose to stay with IUI, I would consider switching to injections. They do not have the same thinning effect on the lining.

IVF protocol is pretty simple. You will inject for about 10 days, add an injection so you do not prematurely ovulate, have the retrieval and then a fresh transfer at either 3 days post or 5 days post retrieval. The injections are not bad at all, I do my own. My RE thinks that a frozen transfer is just as successful as a fresh. Preparing for a frozen transfer takes a while, but so far I like it because my ovaries have been able to rest for the last 2 cycles.

Hope this helps you!

mskeenan · December 2015

Hi there! I am so so sorry you have had to go through this. I think you have a great list of questions for the RE! I second @amos1417 I wouldn't take Clomid again. I feel like all I have heard is bad experiences with it! Femara doesn't thin your lining as much and has less side effects. I think injectables are a great route to take. There is a higher chance you will overstimulate but as long as your doctor is careful with your doses ideally you would only end up with 1-3 follicles. I have responded well 4/4 times with anywhere between 1-3 follicles.

For me the deciding factor to move to IVF was money and time. I've been through 4 IUIs with injectables (including 1 chemical pregnancy). I had faith that I could keep going with more and be successful but was just worried that I would be trying for quite awhile and putting my body through months and months of injectables. I see IVF as just getting the injectables over with (as long as everything goes well with IVF, God willing). My husband and I have access to a flex spending account in the new year which will cover a HUGE chunk of the cost of the procedure. So, that's a HUGE reason why we are moving forward. I don't think there is a right or wrong answer... you just have to weigh in a lot of different factors. I know this decision is REALLY tough but follow your heart! I had contemplated IVF before but just wasn't mentally ready. Now, I'm taking a break from meds for 2 months to mentally and physically prepare.

I've heard so many different perspectives on when to pursue IVF. I saw my general OBGYN (who does some fertility work) and asked his opinion and he told me to do 6 medicated IUI cycles (following my medicated TI cycles) before I should even CONSIDER IVF. I wish things were black and white!! Good luck to you!! Let us know what you end up deciding. I'll be praying for you!!

riveridgional · December 2015

I would personally stick with at least one or two more IUIs if you can. I'm no doctor, but I do believe your CPs were caused by your thin lining. I'm surprised your RE kept you on Clomid with its effect on your lining. I believe your next step would be either Femera (Letrozole) + injectables or injectables only. If she's worried you will over respond to injectables, she'll probably chose option number one. Femera alone could also be an option but from what I've read, it generally produces less follicles than Clomid. Sorry estrace vaginally didn't work to help your lining. Do you know what your lining is typically at on a natural cycle? It's possible your lining is just on the thinner side or maybe you just don't respond as well to estrace. Were you taking 2mg vaginally 2xs a day? That's the dose I had with my only Clomid round that helped me.

KidShrink · December 2015

I would agree with riveridgional that maybe the reason they ended in a chemical is because there just wasn't enough to hold onto. I would try Femara or Femara with injects for another IUI or two at the most. Also agree with checking whether you have any idea of what your lining was pre-Clomid. I always had a thin lining, despite progesterone. It turns out that for me, the thin lining was due to a small anomaly with my uterus (slight t-shape) which prevented proper blood flow and therefore, prevented my lining from getting thick enough. After the hysteroscopy, I was finally able to have my first cycle with a lining above 8mm.

mtpbadger · December 2015

Thanks everyone, you definitely gave me and dh some stuff to talk over the weekend! I am both anxious and excited for my appointment this morning. I think I'm more anxious for this appointment than I was for the initial consultation. How would I know if my lining is just on the thin side? I've never done a natural cycle and don't ovulate on my own. That thought has crossed my mind though, that it is just on the thinner side to begin with. I was on 2mg 2x day of the estrace and it didn't do too much. I will keep you all updated!

dreamcatch-her · December 2015

I agree with @riveridgional and @mskeenan I tried clomid once and it was a wasted cycle. Femara and injections have been the most successful for me, and much less side effects.
Honestly, your doctors sound like they're being too conservative. I don't think you're at risk for multiples, and even if that did happen, there are other options to help with that. I know canceling a cycle doesn't sound great, but neither does slim chances and thin lining. A thin lining to me is a waste of a cycle.

mtpbadger · December 2015

Just got back from our appointment and we decided to move forward with IVF! We decided to go this direction since there is more control in the variables and the odds are more in our favor. I expect I'll start the cycle in early Jan but it all depends on when my HCG goes back down and then I will start BC for two weeks. Hopefully there aren't any hold ups with insurance as well.

I am excited (and nervous!) that there is a new plan in place. My RE said I'll start at a low dose to avoid over stimulation but still expects a good response, based on my IUI cycles. They will monitor my lining and if it's not looking good, we will convert to a frozen cycle to help it improve more before the transfer.

I sent all the paperwork home with dh so I wouldn't continue to pour over it at work and of course now I can't log into the system and can't get any work done until IT comes down.....I'm itching to read over everything again and this would have been the perfect time!

oxinfree · December 2015

Congrats on making the decision @mtpbadger ! We're all here to answer any questions that come up along the way!!!

xx

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