Thursday, March 14, 2013

First RE Appt Today

I had my first RE appt today!  It went well and was...enlightening. It also totally gave me the sense that with this appt, I just voluntarily hopped aboard a fast-moving train and there will really be no slowing down until I'm pregnant or if we happen to hit some sort of unavoidable roadblock. I guess I'm just gonna hang on and hope for the best.
Warning: This is probably going to be a SUPER long post because A) I want to write things down before I forget in case I want to review it and B) I want to provide details in the off-chance that someone reading this who is in a similar situation might actually get something from it!
So here's what happened today:
Hubby & I had a good discussion with the RE and I got to ask all my questions (more about that in a minute). They drew blood to make sure I'm not a carrier for cystic fibrosis and SMA (? I can't remember what that is).  They also tested something with my liver to make sure my body can handle Metformin. As long as the b/w results are good I will be starting Metformin (extended release) tomorrow night. The plan is to start with one 750mg pill every night before bed and once my body is used to that dose (he said it would likely take a few weeks) I'll add a 2nd pill each night so it'll be 1500mg/day every day, through (at the VERY least) 10 weeks into my pregnancy since he said it cuts down the chances of early miscarriage. I also will be having my HSG next week on either Tues or Wed so that we can make sure my tubes are clear and my uterus is shaped correctly. (It ended up being a very good thing that I timed the most recent dose of Provera to make sure I was only a couple days into my cycle at this point so that we can get the HSG done now instead of wasting another 2+ months until I can be at the beginning of my cycle again.)  I'll also have a pelvic exam and ultrasound to determine just how cystfull (totally a word) my ovaries are.  I think that's all that's scheduled for now. Once it's all done I will be going in to meet with him again in another 4-6 weeks and I will be starting Clomid shortly after that (more about that below).

The other big thing is that I will now be very focused on trying to lose weight since he said that my chances of becoming pregnant would increase dramatically with weight loss and that I should focus on getting my BMI into a healthy range.  I asked if the Metformin could help with that and he said if it does it would really just be because of appetite suppression and since the Met will almost undoubtedly give me diarrhea, I likely won't feel like eating as much or the same kinds of foods I have been. So that will be tough but I am motivated.

So here's some not great news: (And let me first preface this by saying that I really do trust that he knows his shit, understands the cutting edge research, and has proven success regarding his patients' pregnancy rates. He has stellar credentials and works at one of the top hospitals in the COUNTRY. His bedside manner is somewhat lacking but I don't mind if it means I am receiving great care. In spite of all that, I WAS surprised at some things he said and asked him many questions, and do not plan to just blindly follow exactly what he says without first doing some more research on my own.) Okay, so:

1. Apparently with PCOS, not only is it harder to get pregnant but my chances of miscarriage are greater as well. Direct quote: "The problem won't be GETTING you pregnant, it will be KEEPING you pregnant." Silly me, and I thought this was the hard part. Now I have something else to worry about.

2. He doesn't think depression and PCOS are really linked and that I should ask my PCP about it if I'm having a problem. He doesn't know if it's connected to my hormones and said if it IS, it would be due to increased progesterone but based on my charts, that doesn't really make sense when I look at my most depressive days (it looks to me like increased estrogen and/or LH and/or FSH cause it). So I don't know what's up there.  Hopefully eating better/exercising/losing weight will help. If is doesn't, I guess I'll go back to my incompetent PCP.

3. He puts zero stock in charting BBT, etc. and seems to think it is outdated.  I brought copies of my charts for him and he was completely uninterested. Charting over the past 10 mos was helpful in that I was able to confirm that I do NOT ovulate but other than that, now that I've 'graduated' to fertility medications, it seems like he thinks there is no need. (I plan to still chart while on meds even though my temps may be elevated, in order to see if I can still capture a temp shift to confirm O.)

4. He told me that he does not prescribe Metformin without also prescribing Clomid (except he did make the distinction that I need to take the Met alone for 6 weeks to get it fully into my system before starting the Clomid), because he says there is not much point and we'd just be wasting more time. He says it's proven time and again that the two work very well in conjunction with one another so that is the path he follows. I take it to mean that he takes a more aggressive approach to infertility than some other drs might. I guess that is not a problem for me.

5. The thing that MAY be a problem for me is that he does not think monitoring on the first dose of Clomid (i.e. CD3 & CD10 b/w and u/s) is necessary. (Note that he DOES monitor each dose after the first) The reason why he said he never does it is because the risks are SO rare that it's not necessary and in his thousands of patients, not ONE has ever had a problem. When I mentioned the risk of large and/or ruptured cysts he said that if I have a problem I will have pain so we will know something is not right and that the monitoring would not head that off. When I mentioned the risk of overstimulated follicles (i.e. too many follies and increased risk of multiples) he said having a lot of follies is what we WANT because I would have a higher chance of getting pregnant and that the risk of actually getting pregnant with multiples (esp. 3+) is very low anyway.  And when I mentioned uterine lining thinning he said that is really only a concern if you take about 12 rounds of Clomid which he would NEVER let happen, and that the generally accepted "limit" of 6 cycles among medical professionals is not truly a limit but just the consensus they came to based on the hard "limit" of 12.

So this was very surprising to me since I've been on The Bump for almost a year now and have seen it repeated time and time again that you "MUST BE MONITORED EACH AND EVERY TIME!!!".  After a year, that kind of got drilled into my head.  So I'm not sure what to think now.  Is this dr just extremely headstrong, has seen what works, has never had a patient with serious issues and so he is convinced that this is the best/right way to do it? He IS the professional... is he right and the women on TB are just overly afraid? I don't know. He DID say that if I really want to have the monitoring done (even though he made a point to restate that he finds it completely unnecessary) then we can do that. So that's good I guess.  I haven't made up my mind about it. He told me about some studies regarding this that I can take a look at and I will be doing some more researching on my own as well.  Thankfully, it's just the first dose that he finds no need to monitor so if it is taking a chance, it is only ONE chance, not every month. We'll see.

Okay, I think those are the main points.  HSG early next week, and I should be starting the Metformin tomorrow night! Let the diarrhea commence!


  1. Glad you were able to get your questions answered by your RE!

    I think you are right to question not being monitored on the first dose of clomid because of the things you have mentioned but also:

    1) when will you know when you are ovulating? Will he not do CD12 ultrasound to see how large your follicles are?

    2) We do want a few follicles to up our chances of getting pregnant - but usually we want 2-4 (4 being the max for mature follicles) Although it would be unlikely to have a bunch of mature follicles on your first dose of clomid, it could happen and if high order multiples can be avoided with a simple ultrasound, then you might as well do it!

    Good luck to you - it is a tough road and I wish you the best!

    1. Thank you for your comment! I really appreciate the help.
      1) No, the first round he does not plan on a CD12 u/s and said that with 1st dose of Clomid, pee sticks are sufficient in letting me know if I'm going to O. I told him that currently I have multiple +OPKs each cycle but no O and it seemed to me like that make him pause for a split second but he didn't change his stance. I think he really just places a LOT of trust in the fertility meds doing what they are supposed to do (based on lots of experience I guess). This is part of why I still plan to chart temps to ensure that I actually did O. Also, since we're just going to time sex for the first Clomid cycle (no trigger or IUI) I am wondering if it is less important (to him)on which day I O and he just assumes I will? I didn't ask too many questions about that but I will ask more detailed ones on the next visit (before starting Clomid).

      2)I think your point that it would be "unlikely to have a bunch of mature follies on the first dose" is what he's focused on. I tend to agree more with you, that an u/s is simple so why not do it?, but I don't think he's in the same camp.

      I do feel like i have some solid arguments so I'm going to take the next few weeks and research and figure out what I feel like i really need and then push him if I feel strongly enough about it. I really appreciate your insight!