The RE was great: the right balance of concern, empathy, and scientific reasoning. She said that given my husband's numbers, while the morphology was low, there was no reason to believe that we couldn't get pregnant naturally. That being said, she said that she understood how we must find this inconceivable given all that we've been through this past year. She suggested the following:
Protocol change: My AMH and low response did indicate that I had an ovarian reserve issue and she thought that we needed a different protocol that did not include lupron, as it was likely oversupressing me. In addition, she would pretreat the ovaries with a "different agent" to coordinate the growth of the follicle (estrogen priming protocol?). She said that she would also start us at a higher dosage of FSH stimulating (for example, follistim) and limit the FSH/LH stimulating (menopur).
Day 3 versus Day 5 Transfer: She suggested that we do an "aggressive" Day 3 transfer, i.e., transfer 3-4 embryos. She said that there has been a shift in protocol to using Day 3 transfers again and that the body is the best incubator for the embryos, which is why Cornell does co-culture of embryos with endometrial cells from their patient.
No PGD, Immune Issues, Endometrial Implantation Issues: She also said that she didn't believe that we had any genetic issues that impact the quality of the embryos and wouldn't suggest PGD. She said they don't know the long term impacts of PGD and that PGD might identify one cell with an issue, but that other cells may be chromosomally normal. She said embyros have an ability to "heal" themselves and that if the embryos were given a chance to survive on their own, they may overcome any of the issues in one or more cells. She also doesn't believe that we have any indicators of immune or endometrial implantation issues.
So, now what?
We don't have any insurance coverage with Cornell and would have to pay out of pocket. IVF costs $15,000 (co-culture, ICSI, assisted hatching), which I believe doesn't include the cost of the drugs, so tack on another $5-7,000.
We would have insurance coverage for RMA and would likely only have to pay for the PGD ($4,500) if my husband's insurance doesn't cover it.
Do we try one more cycle at RMA since we would basically have to pay nothing and then if that doesn't work go up to Cornell? Or do we just go to Cornell now and suck it up?
Do we do PGD? Is it just a waste of money? If we don't do PGD does it make sense to go to RMA?
Decisions. Decisions.
HELP!
I am getting caught up on your posts. I just wish I could give you a big hug. And I could slap myself for complaining about my situation. I don't how you've been going through this for so long. You are one tough lady.
ReplyDeleteIs this Secret Sloper and Pumpkin's Dr. Wonderful at Cornell? Because I HEART HER!!! Awesome stuff, and you have a ton to be hopeful about!!! This is all good, good, GOOD news.
ReplyDeleteCan you get RMA to adopt the Cornell protocol (no Lupron, day 3 transfer of 3 to 4 embryos)? FYI, Dr. Awesome doesn't use Lupron in most of his patients. He is a fan of PGD, but only in patients he really thinks need it. He highly recommends ICSI no matter how good or bad sperm quality is. VentingVagina.wordpress.com just went thru the decision to PGD or not, you might try checking out her blog if you don't already read it.
You are doing awesome, hang in there. Plow through these decisions, your time is coming very very soon. I know it in my heart of hearts.
tough decision for sure! you know what my feelings are on PGD. we still don't have answers but the cycle we did PGD we got pregnant. if i were you i think i would give RMA another try (because it's practically free) and then go to cornell if you need to.
ReplyDeletewas that helpful at all? i think not, but good luck in your decision!
so glad you have hope!! that is a tough decision. i have gone to one doctor to get a protocol and then told my other doctor if she would do it and she was agreeable... my point is that if you would rather go to a cheaper place, you could try to get them to do a protocol you believe in more. i'm happy hope is back. its nice to have it :-)
ReplyDeleteDecisions, decisions. I agree that given the choices, see if RMA will proceed with Cornells protocol, and if it doesn't work you can consider moving to Cornell.
ReplyDeleteBut even as I say that I am seriously SERIOUSLY tempted to switch my from my local RE to either SIRM or CCRM which will cost us at least 3x as much. Good Luck with whatever decision you make!
Gosh, glad you got more information! No idea what you should do, of course, and I'm sure your mind is just swirling with all of the information. Thinking of you much!
ReplyDeleteIt's my opinion that the real key to a successful IVF cycle is really the protocol and transfer strategy. Everything else seems to add on incremental chances of getting pregnant, but really the key is the protocol.
ReplyDeleteI'd take what you learned at Cornell back to RMA and see how your doctor responds. If s/he's game for changing the protocol and being more aggressive with transfer, then might as well do one more free(ish) cycle with them before you put up the $15,000 for a cycle with Cornell. Because it might work, and then you'll never have to put up the $15K.
But if it doesn't? You'll have the benefit of having DATA on how you responded to a different protocol which you can take back to Cornell. They might be able to tweak it from there, you know?
Just my two cents - honestly, I'm not certain there's any wrong answer here, either. Hard to know what the right choice is without a crystal ball, eh?
Fingers crossed.
xoxo
I agree with those that say it might be worth seeing if RMA will adopt the Cornell protocol. My doc did EPP with me twice (I'm a poor responder). I think it's a pretty-well accepted protocol. Tough decisions here. Hang in there!
ReplyDeleteSo glad you have good news and a good experience! That is awesome!
ReplyDeleteSo my thoughts...i agree with the others in bouncing Cornell's protocol off on RMA. That is a pretty significant cost difference. One other thought about suppression.... This past cycle, my doc didn't have me do BCPs. While they help the timing and line everything up, they also suppress and we wanted as many eggs as possible. They basically had me come in around Day 2 or 3, do the antral follicle count and if it looked good, start stims. You may want to ask about that as well.
PGD is a tough call if you don't have any proof there is something chromosomally wrong because it does add additional cost and is invasive to the embryos. That being said, it also gives you a lot of valuable information about the embryos. One thing about her comment that one cell might not be representative of the whole. That is called "mocaism." She is right that it can be a risk when doing a Day 3 biopsy, because you are taking one cell from a 6-8 cell embryos and that one cell may not be representative of the whole. I think the accuracy rates are still very good, but for that very reason, some clinics are moving to Day 5 trophectoderm biopsy which means they are actually taking a cluster of cells from the outer layer of the embryo that becomes the placenta. So theoretically it's less invasive to the embryo and you have multiple cells so you have much less risk for mocaism.
Her thoughts on the Day 3 versus Day 5 transfer are interesting. I have actually heard that most clinics are going more and more to Day 5 and even Day 6 transfers. That being said, if you don't have a lot of embryos to work with or they aren't doing well, Day 3 is a better choice.
Overall, I totally agree in trying to get the ideal protocol for your situation and making as many quality eggs as possible.
Hope that helps a little. Keep us posted. I will be anxious to hear what you decide!
I think the best part of this post is that you have so many choices!!! Choices are amazing, insurance coverage (even if it isn't a lot) is a great thing. Just trust your heart--wish I had more concrete advice to give.
ReplyDeleteHi, just found your blog! I have gone to RMA, Cornell and Sher as well. I dabbled in the immunity stuff at Sher, did a few IUIs (dumb) with Cornell and have cycled with RMA. We are looking at our 3rd fresh IVF with RMA (I have also done 3 frozen). I would highly recommend RMA for a cpl of reasons - If you do decide to do PGC/CGH, RMA uses RMA Genetics in Jersey and they are one of the most progressive and best testing labs in the country - CCRM uses them for some of their embryo testing. Sher sends their embryos to Israel (too far!!!). "Infertile Farmer's" points about PGD testing were correct and since Cornell isn't a big proponent of it, it's no wonder that RE didn't have the latest and greatest news to share with you about the testing. I do have to agree with those that say you may not need to do the testing - I have had a trisomy 21 pregnancy, a chemical and 3 consecutively failed cycles with "great embryos" - which clearly leads us to believe that we may benefit from transferring back only chormosomally normal embryos. It's a personal choice, but pricey one at that.
ReplyDeleteI also like that RMA-NJ are into acupuncture - here in NYC they are not.
I do think your Dr will work with you on the protocol. If they are a good Dr, they will want to partner with you on making this next cycle successful... at least I hope so.
I am wishing you all the very best on your journey and I look forward to following your blog :)