When to see an RE?

NamelessAria · April 2016

Hey everyone, I lurk here but I've predominately been posting over on TTGP. Since I'm not active enough here for anyone to really know my story I'll go through a quick summary. I'd also like to give a general TW as loss is mentioned throughout.

DH and I started TTC back in January 2015. Or well, we started having unprotected sex with the idea that we'd like to have a child. I didn't start temping, charting, etc till August 2015. We're both fairly young (I'm 28 and he's 31) so we didn't really expect to have trouble. I got my first BFP in October 2015 and then had a MC at 6w4d. My doctor cleared me to start TTC again as soon as my hCG dropped to normal so DH and I started TTC again pretty much immediately- 3 weeks or so after the MC. I got another BFP in March that ended up being a chemical ending at 5w3d. I got another two days of positives last month only to have my period start right on time.

So now what I'm wondering is when should I start considering making an appointment with an RE? I know the diagnostic criteria for RPL is 2 clinical losses, which I haven't had. But is there some point in time when chemical pregnancies should be considered problematic? I guess if something is wrong I don't want to keep waiting and having losses if I could just find the problem and fix it. But I also don't want to take up an appointment with an RE for something that could still be totally normal and just bad luck. I know some of the ladies over on TTGP with infertility had to wait 3+ months just to get an appointment with an RE. So I'd feel terrible if there is absolutely nothing wrong and I took an appointment spot that a lady who really needed it could have had.

My insurance won't cover anything I have done at an RE unless it can be filed as something other than a fertility issue. Like, for example, if the RE found and treated a thyroid problem. Because my insurance won't cover anything anyhow I'm not too worried about getting a referral. I could just skip that step and go straight to the RE. Just to be clear I wouldn't be seeing an RE because of trouble getting pregnant. I'd be seeing an RE for trouble staying pregnant. I know as far as seeing an RE for trouble getting pregnant goes I'd need to have tried unsuccessfully for a full year after the most recent loss. And clearly I'm no where near that yet.

I guess I'm just hoping that someone will either make me feel better about waiting to see the RE instead of making an appointment to start trying to figure things out now. Or that someone will make me feel better about going ahead and seeing an RE instead of waiting for the second clinical loss. Because right now neither option seems like the right thing to do and I just can't seem to come to peace with either decision.

catiecatp · April 2016

This is a tough one - I like the sensitivity you're showing by talking about not wanting to take someone else's appointment. It speaks to strong lurking

It sounds to me as if you've had 1 clinical miscarriage and 2 chemical pregnancies - I'm not super familiar with the term "clinical miscarriage" but based on the context it sounds like a non-chemical pregnancy. I see some similarities between your story and mine - so perhaps what I'm doing will help you decide - or give you food for thought.

A bit of my story - I went off of BC at the start of October, got a BFP in my second cycle (November) and then had a MC at Christmas. My LP have averaged about 9 days if you ignore the very first cycle post loss. I'm worried that my LP isn't giving us a chance to get pregnant, so I went to my GP (I think y'all call them PCP in the US) - and she agreed to some bloodwork without me really pushing for it (though I had to suggest what I wanted). GP says they look for a regulation in the cycle by at least around 6 months after going off of BC, and the MC could be messing with that timeline. Other symptoms around AF and through the rest of my cycle suggest that I'm getting closer to what I was like before BC (and those symptoms weren't present in the cycles before my MC).

A short LP is usually linked to progesterone - so I'm having bloodwork on 6DPO (endocrine panel - FSH, LH, estrogen and progesterone) - and IF I get AF again I'll ask for another requisition for an endocrine panel for CD3 (naturopath recommended it - to check that I'm ovulating and egg quality - likely not an issue for you given you're getting pregnant which means you're ovulating...). The GP and naturopath aren't convinced they'll be able to tell much with the progesterone levels - the norms they have access to are for the full LP not specific days. An RE would be able to interpret those results better - but it is a start. And I figure if down the road I need an RE we'll have an early set of data to compare future values to.

You could start with an endocrine panel in the LP... that would be cheaper and an easy check - and IF you do need an RE could be useful data... But I'm not a doctor.

BornReady · April 2016

I'm currently working with an RE. I have been TTC #2 for about a year and have had 1 loss in November. In my state for insurance coverage the year "clock" does not start over with a loss and the RE was not concerned at all that I had, had a miscarriage in that time period.

If I were in your situation, I would set something up with the RE, just to start the conversation. If you really wanted to give it your all on your own, you could wait until August, but I don't think it is necessary. I know you said you don't have trouble getting pregnant necessarily, but you have not sustained a full-term pregnancy out of 3 times in which you have gotten a positive pregnancy test, so in a pretty short period of time that seems notable to me.

If you do decide to go to the RE you could get some basic testing that will let you know that things are OK or not with both of you, including an SA for your DH. If all is good and they think you could keep trying on your own, great. If something is going on that points to a challenge, at least you know. I know in my case I wish I had gone sooner while TTCing #1. We have a sperm issue that would have saved us a lot of time and sadness over not being successful.

I know you don't have insurance coverage for infertility, but here is the link to the resolve insurance page. It has some info on what is considered "infertility" for different states etc. It's interesting to see what the criteria is, and it might help you make your decision.

Good luck in what ever you decide

catiecatp · April 2016

@NamelessAria I like @bornready 's logic - and sorry if my post made my advice for your issue sound like it was about me (by detailing my story and current solution).

NamelessAria · April 2016

@catiecatp and @BornReady Thank you both for your replies. I very much appreciate you both sharing your experience and insight. It sounds like I should probably at least contact my PCP and ask for some basic blood work and such.

@catiecatp your post was just fine.

I have a tendency to answer questions with my own experiences so I can definitely understand and appreciate that approach. I feel like sometimes in this crazy journey all we can really do is share where we've been and what we learned from it in the hopes that someone else will benefit. I'm sorry that you're struggling also. I hope you're able to get some answers soon that will get you get the BFP for your take-home baby.

ETA: Also thank you @BornReady for the link to the resolve page on insurgence. I'll definitely look into that.

RiverSong15 · April 2016

If you've been having regular unprotected sex since January 2015 (as in, frequent enough sex to hit at least one day in your FW), then that counts toward your year anyway. It's not a year of trying while charting. Between that, and three losses, I think you meet the criteria to see an RE. Losses, for most doctors I've heard of, don't reset the clock, particularly if you never made it to the point where you saw a heartbeat. I totally appreciate your hesitation, and I struggle with that when trying to decide what to do myself. But given your history, I don't think you should hold back from doing what's best for you and your H.

Wishilivedinflorida · April 2016

I have had two losses (neither chemical) and my RE won't see anyone until after three. In order to be proactive, my OB did agree to a basic RPL panel. This included blood clotting disorders and thyroid function and antibodies. Everything did come back within normal limits. If there was a clotting issue, I would have been referred to hematology, referred to PCP if a thyroid issue. I followed up with my PCP who added a prolactin (which was also normal). The next "layer" of tests would be more invasive, such as SA for DH or imaging for me. Since we have no trouble getting pregnant, only staying pregnant, we are holding off on this for now. If we have a third, I go to the RE.

Basically, I started a little work up on my own. Maybe your OB or PCP would be willing to do the same for you. This way you are being proactive without taking up an RE appointment. The tests I have had are the least expensive ones of the bunch also, so there's that. Plus, if the basic bloodwork uncovered anything, you still wouldn't necessarily need an RE referral OR it would make it easier to see an RE if you so wished. I felt just like you did and I found this way to be a happy medium.

cooaladolly · April 2016

This was a truly hard question for me too, and a sweet humble nature may lead you to say there are others out there worse off than you, but that doesn't mean you don't need just as good of care as they do, and just as soon as they do. I actually found my lurking on that issue hindered me somewhat as I thought it was straight up protocol that no RE will see you without those certain conditions you mentioned, but apparently different clinics have different admission criteria. The RE office I spoke with said they take anyone that has been trying over a year and that they don't count the losses as a stop clock, OR the RPL criteria no matter how long you've been trying. For me, even luckier, after 35 they only need a 6 month block of trying (my loss was not even a full 3 months ago so that didn't count against me either). And whether it is a getting pregnant issue or a staying pregnant issue, they appear to take each as seriously as the other. I suspect, though I didn't ask, that different clinics also might have different criteria about whether CP's count toward your losses. Either way, if you were in my neck of the woods, this RE would see you as you qualify by having tried for over a year without a successful pregnancy.

Have you researched any of the nearby clinics to you? I was so afraid to make the call to them, not knowing what to say, what they would ask, I ended up doing a doctor search through my insurance website. This led me to the RE's website, and they had a consultation request form where I entered my pertinent information and then they gave me the call back. That way I wasn't hyperventilating from fear trying to make the call myself, lol. I'm sure not all RE clinics have that option but definitely worth looking into as it could put you in a little more of a zen place. Plus they laid out the process on the website so nicely, making it so easy to understand the steps that I would be going through. Oh, and many clinics also have someone on staff that you would meet with to go over all of the insurance ins and outs.

Side note, my insurance covers infertility the same way. I used the chat feature on their website to get my specific details about coverage and when the woman said that I was so confused... "You mean if the doctor I go to to see about my infertility, gives me a diagnosis of infertility, then I'm not covered. Am I understanding this correctly? Well, why would I go to them if that wasn't the problem?" Yeah, insurance is weird sometimes. But a lot of RE clinics have someone on staff that works through the insurance part with you.

PS - I think I just stared at your cat with the fish gif for like 5 minutes. That's hilarious!

ETA: Thanks for the link on the resolve page @BornReady! My apologies, I didn't realize it was a State set criteria as opposed to being set by the specific insurance carrier or clinic. Either way, my original lurking assumption still had been wrong about my particular state I guess. I'm hoping maybe the same for you @NamelessAria.

BrightenMySky · April 2016

I guess I will first say that as someone who has been working with an RE for trouble getting pregnant, I do appreciate your tone and respect in your post. But I will also say that there will always be someone on a harder journey than you, but that does not mean that you do not deserve to get care, too, or in any way diminish what you are feeling. I have definitely had times where I feel like we had *only* been trying for a year and a half or we *only* needed to do IUI for our first BFP, not IVF, and that is just not a helpful path to go down.

I think that trying for a year (if you're under 35) with no successful pregnancy is the criteria for seeing an RE, so it sounds like you're there, physically.

I would suggest asking around and getting recommendations for REs in your area, then seeing what wait times are like. If it'll take you several months to get in with your preferred doctor, maybe go ahead and make the appointment, just so you leave the option open. We were actually able to get in to see my RE relatively quickly. I got his name from my PCP, and I am so glad we started when we did. He is one of the most compassionate and knowledgeable medical professionals I have worked with, and at this point it is reassuring for me to know that I have more people in my corner.

NamelessAria · April 2016

@Wishilivedinflorida If you don't mind me asking what all was your OB/GYN willing/able to test for? I do think I'd probably want to start with basic testing because it just makes the most sense to start with the simple things first. So if I can have all that done before seeing an RE I may just do that.

@RiverSong15 I didn't actually know that losses don't reset the clock. That is definitely good to know. I talked to my husband about it since he is always on team "start with your PCP and go from there." I was honestly really surprised when he told me he thought I should go ahead and see the RE. Obviously he has no idea about when a woman "should" see an RE but I was expecting him to say we should wait or that I should at least start with my PCP. Since he feels so strongly that I should just start with the RE I may do that. Thank you for making me feel less guilty about seeing an RE, if that ends up being our decision.

@cooaladolll I've done a little research into the clinics in the area and I know one of them says that while they recognize that the textbook definition of RPL is two clinical losses that they frequently see women with two losses, not clinical or even after just 1 MC. So I'd assume, though I haven't confirmed this yet, that they would probably see me. That fertility clinic seems to be pretty highly rated on my insurances "provider finder." So I may call them and see what the wait time would be to see a doctor there. I've heard really great things about one of the other fertility clinics in the area also. I started seeing an acupuncturist that specialized in fertility because why not, and she recommended some REs with whom some of her former patients had worked to achieve a successful pregnancy. So I may call that clinic also and just see if they'd be willing to see me and if so what their wait time looks like. I guess once I know who all will see me and what the wait times are I can sorta go from there. I really like the idea about filling out the contact form on the website. I do that same thing where I don't know what to say or what all they'll ask and start freaking out about making the call. I usually end up deciding it is just too stressful and procrastinate.

@BrightenMySky Thank you for your response. It makes me feel a bit better knowing that if I do end up scheduling an appointment with an RE that it isn't something where I should feel guilty for taking someone else's appointment just because I was impatient or whatever. And you're right, there will always be someone with a situation worse than my own. Even if I waited for another loss there will always be someone who has had more losses, or had to do IUIs/IVF to even get the BFP that led to those losses, or whatever else.

Wishilivedinflorida · April 2016

@NamelessAria I'm sorry it took so long to reply. I wanted to look everything up for you. My OB just ordered our lab's "recurrent loss panel," which included the following:

Factor V leiden mutation, prothrombin (factor II) gene mutation, lupus anticoagulant, cardiolipin IgG and IgM antibodies, protein C and S activity, B2 glycoprotein IgG and IgM antibodies, antithrombin III activity, PT/INR, and aPTT. (these all are tests for clotting disorders)
Additionally that panel included a TSH and thyroid peroxidase antibody level.

Additional tests that may be helpful include a fasting blood glucose (I already had this done recently and was normal) and prolactin (my family doc ordered, this was normal as well). I know others here were tested for MTHFR but I was not. It's still very controversial as far as its role in loss. I figured that even if I had it, the treatment is aspirin (which I'm allergic to) and changing to a methyl-folate supplement from folic acid (which I can do just because--I take the Smarty Pants prenatal gummies that have methyl-folate).

I felt this was a good start.

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