Archive for November 19th, 2008

Meeting with Dr. McBrusque

Yesterday, my husband and I met with the reproductive endocrinologist (RE) at our new clinic, henceforth referred to as “The Hatchery”*, yesterday. Not to be unoriginal or anything, but we’ll refer to the doctor as Dr. McBrusque, because, well, that’s what he was: brusque.

I should note that I had to fight very hard not to walk into this clinic with a chip on my shoulder. There are so many things I don’t like about the clinic without even having walked in the door, that I had to actively work against walking in with a negative impression without even having met the doctor. It was an extremely difficult exercise, but I think I had some success in walking in the door with a relatively open mind.

The clinic is about 35-40 miles away, which is one strike against it. It is, admittedly, one block from my husband’s office (he works for the same hospital), which makes it convenient for him, but unfortunately he’s not the one who has to be there nearly so often as me. The clinic has only one doctor; another strike against it. They do batched IVFs, which I don’t love because it takes a lot of control and flexbility on timeline away from me. Three strikes against it before I’ve even walked in the door. But we’re keeping an open mind, remember?

So I drove up to the clinic, which is located in one of my least favorite cities in the entire world, and we were early enough that my husband and I were able to grab a late lunch together. One point in the clinic’s favor – close to yummy kosher food… it’s a very, very small point since it is very rare that I’ll have the time while I’m there to do anything about it, but hey, it’s worth noting. I arrived at the clinic and walked in, noting that the fertility clinic is actually housed within the Women’s Health Center for the hospital. This means it is the OB/GYN and midwives offices. Yeah. This would be another strike against the clinic. I know I’ve already got a gaggle of kids, but that doesn’t mean I want to be sitting next to a pregnant woman when I’m in the middle of a cycle, or right after a negative beta, or an early loss, or whatever. I just want no part of that. I’ve never had a normal pregnancy and I still have a hard time with that. So I don’t really want to be sitting in an OB/GYN’s waiting room every time I need to go for cycle monitoring. I guess the one good thing is that the fertility practice is very small, so hopefully the waiting times won’t ever be very long.

I was called back to get vitals taken and fill out a fertility history form (you know the one, been there, done that). I hadn’t finished filling out the form when Dr. McBrusque called us back. No biggie, he’s perfectly capable of taking a history all by himself. He informed me that he had a med student in his office. Now, I know this is nitpicky, but while I recognize this is a teaching hospital – and I would never say she couldn’t sit in on the consultation – I expect to be asked if I’m okay with having a voyeur in on my consult (particularly a physical exam – which happened at the end of the appointment, which she was also present for).

Dr. McBrusque asked what brought us into the office and I told him we have a set of high order multiples (point in his favor: he did not laugh us out of his office right then and there) resulting from 6 IUIs, and we’re just crazy enough to want more, but one at a time. I explained that I hadn’t wanted anything to do with IUI in the first place because of the risk of multiples, and that we’d spent as much on 6 IUIs as we could have spent on 1-2 IVFs. So, he said, you want to do IVF now. No problems there. First hurdle crossed – I was worried I’d have to have the old argument all over again: “But IUI obviously works for you! Why not try it again?” Yes, it works for me, all together too well! (plus, each individual cycle odds are too low… it took 6 cycles to have a successful pregnancy)

And then we hit a bit of a wall.

“So how many embryos do you want?”
“You mean in general? or to transfer?”
“To transfer.”
“Oh, I want Single Embryo Transfers.”
“Wow. Um. Wow.”

I’m telling you, I thought he might fall out of his chair right then.

“I know. You’ve never done an elective single embryo transfer.”
“No, I haven’t. How do you know that?”
“I’ve read your SART Stats. Don’t think I don’t know them forwards and backwards. And don’t think I’m not walking in here not loving that you’ve never done an elective single embryo transfer. I can be your first.”

We talked for a while about why he wouldn’t recommend a single embryo transfer, and why I don’t agree with him (the data right now is clearly supporting single embryo transfers in patients my age with my history, ASSUMING that I end up producing decent embryos when the time comes). While I was there, I really felt like he wasn’t going for it, but in retrospect, he really did say he would do his best to keep an open mind about it come transfer time, which is really all I’m asking. I’m definitely of the opinion that if there’s a compelling medical reason to transfer two come transfer time, that’s what we’ll do. But I just want to go into this with the mindset that we’re going to try to consider single embryo transfers if at all possible, even understanding that we may be taking a greater risk of negative betas per individual cycle. He also said that maybe with me he’d consider doing blastocyst transfers, which he normally doesn’t do. This surprised me, but he said he used to do blast transfers, which resulted in a very high pregnancy rate, but didn’t result in any more babies, so they stopped doing it. Their pregnancy rate went down a little once they stopped doing blasts, but their live birth rate stayed stable. Weird, huh? Anyway, he said for me, it may be a consideration, so he was definitely keeping my specific circumstances in mind when he was talking to me.

I asked how he would deal with the increased risk of OHSS (ovarian hyperstimulation syndrome) since I have PCOS. I said I’m a very high responder to stims, and this was something that my old clinic was planning to address by keeping me on Lupron longer than typical. He said he would take the opposite approach and not use Lupron at all. He said that he has long suspected that Lupron is actually a contributing factor to hyperstimulation in patients like me and that there is now some emerging data to support that suspicion that has been presented at some recent conferences. The reasoning is this: if the Lupron keeps you suppressed, then you have to aggressively use the stims to overcome the effects of the Lupron, but then you can’t control it. Even if you back off a little bit, your body is already responding to the high doses of stims you pumped into it. So it hyperstims as a result. This actually makes sense to me. He prefers, instead, to use an antagonist protocol instead of the agonist protocol because you can control it. This sounded like a reasonable approach to me, and Lupron is evil, so I’m all about skipping the Lupron.

He prescribed me metformin again. I haven’t been on it since early in my pregnancy, but I did get benefit from it before, and it makes sense to be on it again, because the last time I was in treatment I was on it, so I’ll respond differently to stims this time if I’m not on it. I really did want to be back on metformin anyway, so it’s win-win all around. Even better… Dr. McBrusque may be brusque, with not much of a bedside manner, but he did do one thing really, really right. After I’d left the office and I was driving, he called me on my cell phone and said he just wanted to let me know that metformin is not recommended for breastfeeding mothers. I really appreciated this follow through, because I’m certain that he rarely thinks about drugs and breastfeeding, since really… how often is he faced with a breastfeeding mother? And also, that he took the time to call me on my cell phone says a lot… he could have
just left a note for his nurse to call me in the morning. (Anyway, he and I talked more about it and he said it boils down to not knowing whether it’s okay, but that it does show up in breastmilk, but my pediatrician had more thorough information about it, and they’re fine with me using it, particularly since the babies are not nursing very much anymore…just 1-2 times per day, and they’re going to be weaning very soon regardless)

After we finished talking, and he wrote up a lab slip for a pile of lab work (did I mention that yesterday happened to be CD1? How convenient!), he took me to the next room over to do an exam. I’ve never had this at a consult with an RE… and it caught me by surprise. It was particularly frustrating because, hello? CD1! Ick. But whatever, I’m sure he’s dealt with more disgusting things in his life. I didn’t love that the med student was again in the room without my permission being asked. There were a lot of people in the room – Dr. McBrusque, a nurse, the med student, me… and it was a tiny little exam room. Again, I wouldn’t have said no, but if you guys are going to be all up-close and personal with my lady-bits, don’t you think you could ask my permission?

And that was pretty much it. I was on my way. The whole appointment, including the exam, took about an hour. So I’ll admit, he was thorough. Unfortunately, I didn’t have my records from my old clinic with me, because they haven’t sent them yet. But he said whenever I get them, he’ll review them carefully, but admitted that he wouldn’t get SO much out of them, since I’m changing from IUI to IVF.

The hardest thing is having to get all the way up there for appointments. And the fact that they do their monitoring appointments between 8 and 9am. That’s utterly ridiculous… I won’t get to work before 10am if that’s the case. I don’t know HOW I’m going to explain this one, and I don’t really want to tell my job I’m going through fertility treatment. If I only had ONE other kid, that would be one thing, but I already have a small gaggle, so people look at me a little funny if I tell them. So how am I going to explain a doctor’s appointment that keeps me out of the office every couple of days for a couple weeks? Sigh.

Our insurance essentially covers 2 IVF cycles, plus $10K in medications. I know I’m very lucky to have insurance coverage at all. I know I’m very lucky to have this opportunity to try. But I definitely feel the pressure.

Next steps: CD3 bloodwork tomorrow, precertify everything with the insurance (their financial coordinator is working on that now), wean the babies, new semen analysis, repeat HSG (mine is 3 years old), mock embryo transfer, and… IVF.

*Kudos to my friend, J, for the pseudonym, “The Hatchery” for the new clinic. Even if I wanted to disclose the name of the clinic… the real name of the place is so long and boring and stupid, I can’t even stand saying it in real life, so I was looking for something catchy to call it anyway.

And hey… while I’m giving credit where credit is due, I owe LJ big time for the blog name. She rocks.

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