Green for go (and money)

Today, finally, was my baseline ultrasound and estradiol blood work appointment. I drove there feeling both nervous and sick to my stomach...what would this appointment reveal? Another cyst and cancelled cycle? No follies? Some follies?

Sitting in the ultrasound room, with the smell of the disinfectant used on the ultrasound wand in my nostrils, the hum of the machine next to me, the feel of the paper drape across my lap, I got teary remembering being in that room nearly a year ago, undergoing our first egg retrieval (oh, the horror!), and then, weeks after that, seeing our babies' heartbeats and little shrimp-shaped bodies on that same machine for the first time, and hearing that precious wish-wish-wish-wish sound of their rapidly beating little hearts. Hurry up and get in here, I thought to myself, checking my watch repeatedly as the minutes ticked by...ten...fifteen...twenty.

Finally, Dr. M. burst in and got right to work. Uterus looks great. Right ovary looks good...four pre-antral follicles. Left ovary, hmm, a little quiet...two pre-antral follicles. Ok, good, see you across the hall in my office when you're dressed.

He methodically began updating my chart notes like he always does, slipping the ultrasound photos of my uterus, uterine lining measurements and ovaries into their plastic sleeves and setting them aside. Then, he pulled out a file folder containing photocopied articles and two stapled chart notes. These he used to determine my protocol. After all, it's worked for him before.

So, tonight I started my 2cc of mini-Lupron. I'll need to pick up a fresh bottle from him tomorrow. I forgot today in the hubbub I'll tell you about in a second. Tomorrow morning we'll start my stimulation drugs: 1 ampule (75iU) of Menopur and 150iU of Gonal-F in the morning, and 2 ampules (150iU) of Menopur in the evening, with 2cc of mini-Lupron morning and night. He has me continuing the Estrace (estrogen) pills, too, but cutting back to just one at night through Thursday night. Based on his prior experience with this protocol, this "fake" estrogen should leave my system within two days of stopping the pills, then my own growing follies should pick up production. The "bottom" is called the Nader, apparently, and he's most concerned with when it'll happen, because he wants to be sure I have enough in my system to really get things moving. (In all my prior injectibles cycles, my peak estradiol was fairly pathetic, which is what has earned me the title of Poor Responder. We're hoping this protocol changes that.)

My eyes bugged out at seeing the injection schedule written down. This is far more (150iU more!) drugs than I've ever taken in a day...let alone doing this for several days in a row. Apparently, this schedule should coax some more pre-antral follies - those that aren't clearly visible yet - to show, and once he gets everything to grow together to 12mm, he'll hit me HARDER with even more drugs to get as many as possible to grow to the appropriate stage. Then, we'll trigger with hCG and head toward egg retrieval. He said I can expect to stim for 8-10 days before my follies are ready (for comparison, I stimmed for 5.5 days in Feb. 2011 and May 2011, and 12 days in December 2011...that was the worst cycle ever!). I have plenty of drugs on hand so running out shouldn't be a concern. If things go as "planned" (as much as one can plan how I'm going to respond, given we have no idea), we will hopefully be looking at egg retrieval next weekend (the 15th or 16th). He only does 5-day blastocyst transfers (more on that later, if we get there), so that would put embryo transfer into the third week of April...hopefully.

But - and there's always a but, isn't there?! - we had one major hitch in our appointment. See, as I'm sure I've mentioned (because it's what we talked about/agreed upon!), this conversion to IVF is what we're hoping to do, IF I respond well. If I don't, then we proceed with superovulation IUI like we've done before.

Why is that important?

Well, because after he wrote my injection protocol in my chart, he grabbed a three-page IVF packet out of his desk drawer, discarded the first page, set the third page (injection schedule) aside, and put page 2 in my chart. It was blue. It said, "Required IVF Deposit" and had two signature lines. He crossed out $5000 and wrote in $4000.

Um, HELLO????!!!!

I said, "Um, Dr. M., I'm confused as to why you placed that deposit sheet in my chart. We are operating under the understanding that we're hoping to convert to IVF, not that we ARE doing full IVF, and therefore are not prepared to pay you a deposit today."

"Well, this is a discounted deposit. We normally charge $5000," he said.

"Yes, I see that," I said, "but based on our prior conversation when Paul was here, we're expecting to pay $3000, tacked onto the rest of our bill, if we actually get to convert to IVF. I don't have $4000 to give you today."

"Well, it's up to you. Do you want to do IVF or not?"

[OMFG, are you KIDDING ME right now?!]

"Dr. M.," I said, probably sounding a bit frantic, "If we'd known we'd have to pay you a deposit to do this thing, I wouldn't be sitting here right now. We would have had to make other plans...like not do this cycle. We understood we'd be hoping to convert, if I respond well - and we don't know how I'm going to respond, do we? - and then having your $3000 conversion fee added to our bill if that happened."

He took the blue sheet back out and threw it in his recycling, then picked up his pen and proceeded to write down my injection protocol on the third page as he talked me through it. Meanwhile, I sat there, about to cry, with a knot in my stomach. There's nothing that sets me off more than pushing my freaking Bag Lady buttons...and now you're doing it in discussion about whether or not we might conceive our rainbow baby/ies? Holy shit, Batman. For real.

(The fact is, Paul and I have already discussed that if we have to go full blown IVF, then we're going to have to switch to OHSU in Portland, where we can do the Attain financing program with the multi-cycle discount. Yes, it's more expensive per cycle (like $5000 or more, plus, likely, 50% more for meds since we'd probably have to buy domestic instead of imported), but that financing plan is a big deal, and doing multiple cycles in the plan reduces the cost per cycle. I didn't tell Dr. M. any of this, though.)

At the end of the conversation, still feeling sick about it, I put on my big girl pants again and said, "Dr. M., I need to check in with you about this money thing, because I don't feel good about this at all. If we'd known this was your actual plan rather than an experiment, we would have done this differently."

He looked me in the eye and said, "Really, the money part is minor to me. What's most important to me is getting you pregnant again." Sigh.

We proceeded to the front desk, made my follow up ultrasound appointment and got the blood draw done. I was teary as I drove back to work. I called and told Paul what had happened. He didn't feel good about it, either. We figured we'd sit and talk with him Saturday at my blood draw, since he's the one likely to do it (and we go back Sunday, so if not Saturday, then Sunday).

By 2:00, though, I couldn't take it anymore. My brain had spent the previous four hours spinning, thinking, Great, so did he just agree to the conversion fee without wanting to and will he now change our protocol because of it? I'd much rather be sitting at home ON MATERNITY LEAVE right now with my nearly 3-month old twins than doing ANY of this crap! I know, I know, unreasonable, but that's how my deranged brain works. (Paul thought the same thing, so at least I'm not alone!) I put my big girl pants back on, called the office and talked to Jeri, the billing person, told her what had happened and why I was concerned. I wanted to know how much Dr. M. was planning to charge us for what we were doing. "Um, yeah!" she said, totally getting how big the difference between $3000 and possibly $10,000 is. I waited while she checked my chart; he didn't write a price in there. She said she'd ask him directly and call me back.

And when she did? "He's charging you $3000," she said.

What a relief. So. One mini-Lupron shot on board currently, many, many more shots to go. I hope Paul remembers the imaginary targets on my butt cheeks. Meanwhile, I feel like I need to load up on sugar or something to make my stressed out emotional self feel better tonight. :)