We Need to Talk

"So, can we arrange to have the IVF talk?" I asked my RE, as I rose out of lithotomy position at my recent monitoring appointment. "Sure, we can talk now." he replied to my surprise. I was expecting to need to set up a separate visit, which would require insurance authorisation. I had a dentist appointment (for real) following my scan, but I figured since I was already nearly a year overdue for my cleaning, I could be a few minutes late. I wasn't going to pass on an opportunity to pick my RE's brain. I've outlined some of the details of our conversation, but I would really appreciate some insight from any IVF veterans!

Getting Started
Would need to start planning a month ahead. As I went into hypertensive crisis on birth control pills, he would prefer to start Lupron in my luteal phase. I offered that I could re-challenge the birth control pills by taking my blood pressure meds at the same time, as I did respond (relatively) quickly to them. I just have an aversion to Lupron, based on the experiences with my patients. He did point out that this is not Lupron in the way that I'm familiar with it, a 3.75 mg monthly injection or 11.25 mg three month depot, which is often used to treat endometriosis or fibroids, but rather a micro dose. It still gives me a little concern that the Lupron could over suppress my ovies, and I'd rather take my Labetalol and deal with my blood pressure to avoid Lupron if I can!

Ick-See!
Intracytoplasmic sperm injection (ICSI) is considered the standard of care for male factor infertility issues, my RE explained, also noting trends towards widespread use. "In you were only to apply indications, it's use should be about 20%, in the state of California it is performed in about 70% of IVF treatments." He commented that his own ICSI rate is about 65%, but some large facilities such as Massachusetts General have nearly a 99% ICSI rate.

Initially, I was dead set against doing ICSI as each week my Medscape update would feature some article regarding risks of ART and especially ICSI. A study published in May 2012 examined 309,000 Australian children and found 9.9% of ICSI conceived children had some birth defect, compared to 7.0% of conventional IVF babies and 5.8% of offspring that resulted from a roll in the hay. Interestingly, my greatest fear about procreating in general is autism. We're the typical prototype: Late thirties, Caucasian, middle class and educated. I don't know how I would handle the guilt if our progeny has autism. There was a reason why you weren't meant to conceive! This is what happens when you defy the natural scientific order! Those thoughts would haunt me for the rest of my life. One study found that there was no increased association between ART (did not distinguish conventional IVF vs ICSI) and autism spectrum disorders in singleton births. However, it was an observational study that only looked at 370 autistic children, so it doesn't reassure me that much. Looking through the UptoDate.com database, they note an increase risk of inherited structural chromosomal anomalies, which makes me wonder if we should karyotype Husband. Beyond that, studies examining ICSI conceived children until the age of 10 note no significant psychological, neurological or other health related differences. Christos Coutifaris, the REI Department chair at the University of Pennsylvania, concludes that outcomes for adverse health effects of ART are still incredibly small. "Even if there is some underlying process that makes some of these [children] susceptible to certain condition, the vast majority appear to be normal." Thus applying the infamous quote from David Grimes, "two times a very small number...is still a very small number."

Here's where the blogging community has made me so much wiser. A year ago, I was looking into minimally stimulative IVF options. Now I want to stimulate the hell out of these puppies and get as many eggs as I can produce. One of my father's best pieces of advice that he gave me was, "the more shit you throw against a wall, the more that's bound to stick." (Mind you I was only 10 or 11 and it was probably controversial to say 'shit' in front of your child...) However it seems so relevant now. My RE commented that he would strongly advise against even a split ICSI cycle. I shared that I estimate I may get a dozen eggs from my ovies and if half fertilise, we'll have 2-3 maybe 4 at the most with which to work. He thought that was pretty accurate. Leftover embryos? Oh, I won't even entertain that thought. I sure as hell won't let them be adopted by a fertile pastor and his wife.

To GPD or not to GPD
I expressed an interest in genetic preimplantation diagnosis. As per usual, my RE gave a very methodical answer that we didn't have a true indication; we're not carriers of an inherited condition and we haven't been through recurrent losses. He even noted that I wasn't at too high of a risk for aneuploidy at my age. Um, I'm an old bird, I thought to myself, but didn't interrupt him. I responded that I wouldn't want to receive abnormal screening results or discover a trisomy on a pathology report after a D+C. If we're taking the scientific approach, I want to exploit every advantage. He pointed out that it would cost an additional $3,000 - 5,000. Oh, and after referencing my age for the second time, he asked me to remind him just how old I am. I was flattered. Having someone think you're on the underside of the advanced maternal age status is akin to being carded in your late twenties.

I am having trouble selling Husband on the idea. As he just tends to see dollars and figures, he looks it as increasing the cost by 1/5 to 1/3. I see it as insurance protection to what is already an expensive investment. If we're going down this road, I want to get in right the first time. I tried to rationalise in terms of dollars and cents for him; we could get pregnant on the first try, only to discover after the fact that there is a chromosomal abnormality and need to start over with a frozen embryo (if we have one) which also costs $3,000 - 5,000, thus negating the GPD investment. This doesn't account for any of the emotional anguish. How hard would be be kicking ourselves if we were to encounter that situation? More so, what if we have no normal embryos? We would avoid all the financial and emotional costs associated with transfers. However, both my RE and Husband pointed out that transferring normal embryos still doesn't guarantee successful implantation and a miscarriage could still happen. They both seem to be on the page that we could just roll the dice and have a reasonable chance for a good outcome. I'm not sure I'm comfortable with that. It's not an abstract concept for me. I've scanned patients at nine or ten weeks and confirmed the absence of a heartbeat. I've delivered the diagnosis of an abnormal karyotype. For fertile couples, this provides some relief; an explanation for their loss. Once they recover emotionally, they just jump back in the sack and call with a positive pregnancy test in a few months. In our situation, the devastation is compounded by the frustration that we could have prevented this occurrence. We're still debating and discussing this item.

'Neat' or 'On the Rocks'
I pretty much already had an answer to this question. If an embryo makes it to day 5 and survives freezing and thawing, it is perceived to be a good quality embryo. Additionally, performing a frozen transfer at a later date allows optimal priming of the endometrium, which can sometimes be compromised during ovarian stimulation, especially in cases of OHSS. My query was based on the fact that their pricing structure designates a day 3 transfer.

A Weighted Concern
I know it is completely shallow, but one of my greatest fears about the IVF process is the potential for weight gain just from the stimulation process. I took notes on two of my patients who presented for their first prenatal visits after conception was achieved with IVF and both were ten pounds above their baseline weight. One was a triathlete, who had earned the 140.6 sticker on her car, the other was a gym rat. My RE just shifted in his chair and pointed out that I'll be gaining even more weight with my pregnancy. Damn it! this is the same response I give to my patients who ask about weight gain with birth control methods. there is nothing more annoying than hearing the echo of your own counseling. I quickly countered by referencing the stats on my patients and pointing out that ten pounds represents half of my allotted weight gain. He just sort of muttered "with exercise, you'll be fine".

I had some other questions such as benefits of endometrial injury, what point would we no longer consider a single embryo transfer, but would need to leave those to another day as I was seriously late for my dental appointment. Fortunately, they were able to still see me and I had a good check-up. Another item for my Resume of Life: Neglected dental health without any serious consequences. Score!