Chart Stalk/Questions September 2021

bows22 · September 2021

Ask away!

jellie603 · September 2021

@bows22 thanks for making this and directing me haha!

Most have seen/answered me in this week's WTO. But I'll post here (some spoiler and some free floating) as well.
I am looking for any questions that you can prepared with for your first visit with your OB while TTC. Or any information you think I should share - obviously aside from what I've been tracking, family history. etc. See spoiler for our situation.

We had our DS 4.5 years ago and I haven't been on any form of BC since then. We haven't taken any sort of precautions to prevent pregnancy - we weren't actively trying but, again, also were not preventing it. My husband will tell you it is because we "haven't been wicked active" and to that I can insert 12 giant eyerolls haha. He just turned 40 and I'm about to turn 31.

If we do end up getting referred to an RE, what kinds of things can we expect? What tests get done? What kinds of information do they share with you? How long is a wait for any further treatment?

inthewoods23 · September 2021

@jellie603 here's a bit of my history.

I talked with my OB and for 2 cycles we did progesterone checks on CD21. Those showed I was ovulating so the next step was an HSG to check if my tubes were blocked and a semen analysis for DH. His SA came back with only morphology out of range but my OB referred us to a urologist to check for vericocele since his count was on the low end of normal. From there we got referred to the RE who runs a bunch of hormone labs on somewhere between CD2-4. That'll indicate you fertility like egg quality and give them an idea of how high your meds need to be to get follicles to grow. The RE also does an ultrasound to count your AFC (antrial follicle count).

At the same time we also did genetic carrier screening but that's not required.

Usually the wait list to have the initial consultation with an RE can be a few weeks to months. After the testing you'll have a follow up appointment and decide what to do. They'll tell you to call at your next CD1 to do treatment based on what you decide.

jellie603 · September 2021

@inthewoods23 thank you for sharing, this is helpful! Some follow up questions: A littler personal maybe, but what did insurance cover/not cover? How was the scheduling for the tests with just the OB, were there waits like for the RE? Did they explain things well to you so that you could understand?

bows22 · September 2021

@jellie603 Every insurance is different obviously but usually testing is covered by insurance (subject to deductibles, etc) but when you move into actual treatment then that’s where things can differ. If I was in your specific situation, and your age, if your OB wants you to go to an RE versus doing the testing themselves, I would ask your OB if they can at least order a semen analysis for YH. Like @inthewoods23 said, the wait for the RE can be months and I think that would be helpful information to have going into it.

And as far as your question about if they explain things well, I think that will vary by doctor, but that’s what you have us for! Haha

bumblebee0210 · September 2021

@jellie603. So when you first go to your OB, it's likely she will test you for "day 3" hormones (FSH/LH/AMH) which measure ovarian reserve, and "day 21" which tests for progesterone to see if you have ovulated. Some OBs will prescribe clomid or letrozole, which are pills that increase FSH to encourage ovulation, and can sometimes cause women to ovulate more than one egg, so there is a reasonable risk of multiples, but if your ovarian reserve is low-ish, they can help. She will probably also recommend a semen analysis, which is pretty cheap and easy. It's possible that these tests will reveal something, but most likely they won't. She may also test you for thyroid issues or celiacs, which are also easy blood tests and can be linked to infertility.

If you get referred to an RE (reproductive endocrinologist), they will likely do the same tests, plus some tests for structural issues, which typically involve a slightly more invasive procedure to test if your tubes are open, and a quick and easy ultrasound to test for your antral follicle count (another test of ovarian reserve). From there, they will likely discuss treatment options, which typically include medicated cycles, IUI, and IVF.

A couple of notes:

(1) You will most likely not get a diagnosis. Most infertility is unexplained, and especially if you aren't going in with a known issue like PCOS or endometriosis, you will probably not come out with one. Sometimes there are borderline things, especially with sperm that is ok but not great, or ovarian reserve that is a little low, but still in the normal range, etc. I just think it's good to know this going in.

(2) If you are "unexplained", the treatment will depend a lot on your insurance. Typically, they progress from pretty minimal treatment (like timed intercourse with clomid or letrozole) to IUIs, to IVF, without ever really knowing what was wrong.

(3) However, if there is an issue (like polyps in your uterus, or a thyroid condition), usually those can be treated, and then you can get pregnant naturally without too much issue. Similarly, if there are sperm issues, you may have to go straight to IUI or IVF. So even though the testing is usually inconclusive, if it does find something, that can help a lot.

inthewoods23 · September 2021

@jellie603 some insurances have lifetime maximums for fertility coverage. Ours was $10k. I don't get how insurance really works so I can't explain how, even after 3 IUIs, IVF, and 1 FET that we were only then reaching close to that $10k. IUIs for me were pretty cheap. I think considering all the ultrasounds plus meds and the IUI itself, it was less than $500 that we paid after the insurance claims.

Scheduling tests with the OB was easy since I had brought up being on month 10 when I had a pap smear. I think it's similar in that you'll schedule the appointment once you get your period so they know what day CD21 is to check progesterone/ovulation. The HSG is kind of a procedure so that may be a bit before you can do it and I think you again need to be in a certain CD range to have it done (after AF but before ovulation).

For reference - pap with my OB mid-May, progesterone checks in June and July, HSG in early/mid-August. I couldn't do the HSG while also doing a progesterone test in the same cycle. We saw the urologist in September (so couple week wait), then had to wait about another 3-4 weeks for the initial consult with the RE (October). CD3 tests in November and did an IUI in the cycle that started in December. IUIs can be done back to back just like meds and timed intercourse.

jellie603 · September 2021

What a freaking wealth of knowledge we have here - thank you ladies so much for being so willing to share your journeys so that I can better understand where I am going!

@bows22 thank you for suggesting too push the OB for testing that they can do there as opposed to with an RE. I'd rather have it done there for insurance purposes I can assume.
@bumblebee0210 this is so great and detailed, thank you! So to dumb it down - (in theory) after the day 3 and day 21 tests, that is when they would prescribe the clomid or letrozole based on their findings (if needed)? Can I request the thyroid test then and there? I have a feeling there is something up with my thyroid as it is but haven't been to get it tested. And for the dumbest of all dumb questions - where does MH go for a semen analysis? Can we do this through my OB or does it have to be done through his PCP which would send results to the OB?
@in@inthewoods23 thanks for the info on timing! I'm hopeful that given our situation that they will approve the tests after this initial appointment. It kind of sucks that AF just finished so I'm too late for this cycle. Also, the insurance $ info is not as scary as I thought. I know all are different but I just assumed, through horror stories, that it cost you like S20k out of pocket all the time.

bows22 · September 2021

@jellie603 the insurance coverage for testing should be the same at either place. I just know that my OB does not do testing - they refer everyone to their affiliated RE. But if the wait is going to be a long time I just think the semen analysis is something easy you can knock out of the way during your wait. MH did his SA through my RE - right in their office - but I think that’s something that differs through different doctors. I’ve seen some people on here that their OB ordered it, some had to go through their PCP, etc.

bumblebee0210 · September 2021

@jellie603 Yes-- though I think this is becoming less common-- OBs prescribing clomid, etc. If you live in a place with any sort of real RE presence (I seem to remember maybe you are a fellow New Englander?), then most OBs will send you to the RE after any initial testing (or even before). MH did his semen analysis through our RE, but if you don't have one yet, he may need to go through his PCP.

On insurance: it does vary dramatically from plan to plan. Some states do require infertility coverage, but there can be limits or other restrictions (like you can't do IVF until you've had 3 failed IUIs, etc). I am extremely lucky that my insurance basically covers everything, and we pay 20% coinsurance, with no maximums and almost no rules.

And yes-- I would ask your doc to check thyroid. It's a super easy blood test, and it can affect fertility.

keikilove · September 2021

@jellie603 Chiming in to add to all the great advice you’ve gotten so far: You can still do the “Day 21” progesterone testing during this cycle if you are sure of where you are in your cycle and if your doctor is able to fit you in. It really is supposed to happen around 7 days after ovulation; it’s called “Day 21 testing” on the assumption that everyone ovulates on CD14–which obviously isn’t the case. So, if you’re tracking ovulation and your OB can order you the tests, you could go this cycle (7 days after ovulation) to have your progesterone checked. You could also have your blood drawn to have your Complete Metabolic Panel run at the same time, which can check thyroid, prolactin, VitaminD, Iron, and other things that can impact fertility. Sometimes those tests need to be added to a CMP—just depends on what your blood draw clinic considers “complete” in the panels they run.

fantasyflyte · September 2021

@jellie603 the biggest thing I can suggest is call your insurance company to find out exactly how your individual plan works with regard to infertility. For example, even though we have an SA with an issue detected, our insurance will not cover anything infertility until a year, so we've got the RE appointment scheduled for November, when we hit a year. Also, our plan required EVERYTHING infertility to get prior authorization, including the initial consult, so if this next cycle isn't the one for us, then I will be calling the RE to make sure they submit it for PA before our appointment.

Also, once you find out at what point your insurance covers infertility (6 months, 12 months, etc.), try to call the RE's office about 3 months before that mark (so if nothing's covered until a year, call when/if you're at 9 months) to set up your initial consult right at that one year mark. You can always cancel the appointment if you get pregnant in the meantime, but that way you won't need to hit a year, and THEN another 3 months for an actual visit.

ETA also, my OBGYN had already diagnosed me with PCOS, so she was completely willing to do CD3 bloodwork for me and prescribed metformin. She also planned to do a medicated cycle and monitoring with me, but then we got my husband's SA back with low morphology numbers, so she told us we'd be better off skipping to the RE at the one year mark rather than trying a medicated cycle on my end.

jellie603 · September 2021

@keikilove good to know! So you can have the "Day 21" testing done without having the "Day 2-3" testing done beforehand?

@fantasyflyte that is a good strategy, thank you! I am definitely a planner and when I want something, it needs to be right now haha. So depending on my visit on Friday, I will take whatever information that they give me and if I need an RE, I will schedule now. I feel like there will be slim pickings in my neck of the woods (literally...woods) and if I want to get on there for a year (in theory) I will probably need to call now.

jellie603 · September 2021

Thanks for all the info and advice ladies! Just got back from the OB. They did a pap because it has been about 5 years. She said that she doesn't typically order the "21 day" test if it is pretty clear that I am ovulating. But she ordered a US and full blood panel for CD 5 ish of next cycle so I will go in for those on the same day. She ordered a SA for MH and I didn't realize how sensitive that is haha. He needs to produce and transport the sample to the lab within 30 minutes.....but we live further than 30 mins away from the lab. I asked the nurse and she was like, well he will have to provide the sample closer to the lab and we both laughed a little 😂 She doesn't want to refer me anywhere yet until everything comes back but did encourage me to have MH come in with me to go over the results together so that is nice.

inthewoods23 · September 2021

@jellie603 oh yeah, there's some kind of liquefaction time that they look at for how long before the semen becomes liquid (normal is under an hour). Does your OB not have a room that can be used for collecting samples? Like how you leave your urine sample in a bathroom? I would think you could do the same with collecting for an SA.

Guess you'll just have to pull over to the side of the road halfway there

jellie603 · September 2021

@inthewoods23 that was literally my thought... I as like uh so which parking lot are you/we pulling over for this 😂. My OB's office is at the hospital that my husband works at but, unfortunately, they don't process the SA samples there, they use another lab like 15 mins more south. I guess he could J it at work but that is so so weird to think about haha!

inthewoods23 · September 2021

@jellie603 yeah DH was weird about where he did his SA's too. At the clinic he didn't use the room with all the dirty magazines, etc. He opted for a bathroom down the hall lol. When we got a 2nd opinion last year at a different clinic they wanted the sample collected at home and brought in and instead of like, taking care of it in the bedroom he also used the bathroom at home lol.

jellie603 · September 2021

@inthewoods23 apparently he felt at home with his cup in the bathroom 😂

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