An RE, an OB, & a Plan...

My husband and I climbed into the car and set out for an hour and a half drive to Durham, NC to see a Duke Reproductive Endocrinologist.  I was so nervous.  I was worried he'd tell me that my uterus sucked and I would never be able to successfully carry a baby to term.  I know, that sounds crazy.  But when you've been trying to have a baby for three years and have had two miscarriages, you tend to worry.  Trust me.  We arrived an hour early so that we could fill out paperwork, but to our surprise they got us right in. 

The RE came in, introduced himself and got down to business.  He had looked over all of the records that were sent to him from my OB's office and said he thinks my biggest problem is poor ovulation and

"Even with the Clomid, you're not getting an acceptable success rate." 

He's changed me over to Femara for my next cycle which he said should increase my successful follicles from 1/cycle to 3-4/cycle. He still wants us to use the hCG trigger. He also has scheduled a sonohysterography (AKA Saline Ultrasound) to check for uterine septum and evaluate how much of an effect my fibroid is having on conception.

He also said that he's worked with my current OB before and will be calling him today to let him know what our new plan is.  He said he'll have my OB to do all of the follow-up ultrasounds for follicle checks and hCG shot administration so that I don't have to travel so far as often. He thinks they will be able to work "real well" together.  The RE did say though that the saline ultrasound will be done by him in Durham and if I have to have a myomectomy to remove the fibroid that he too would be doing that. Actually, what he said was,

"If you needed a hysterectomy, I'd send you to Dr B because that's what he does.  If you need a myomectomy, I'll be doing it because that's what I do." 

Of course, if I get a positive pregnancy test at the end of this cycle (which we guess would be next weekend), the Femera and the saline ultrasound will be on hold pending outcome.  The RE seems to think that once we find out what role my fibroid is playing and increase the number of follicles I produce, the greater chance I have of getting and sustaining a pregnancy!  Oh, and it is very important to say too that he was very insistent on answering all of our questions, and he and his staff were awesome.

Now a little information about Femara and Sonohysterography:

Sonohysterography, (from the website http://www.radiologyinfo.org/en/info.cfm?pg=hysterosono) also known as saline infusion sonography, is a special, minimally invasive ultrasound technique. It provides pictures of the inside of a woman's uterus.  It is a valuable technique for evaluating unexplained vaginal bleeding that may be the result of uterine abnormalities such as: polyps, fibroids, endometrial atrohy, endometrial adhesions (or scarring), malignant lesions or masses, and congenital defects such as uterine septum.  Sonohysterography is also used to investigate uterine abnormalities in women who experience infertility or multiple miscarriages. 

It is best to perform sonohysterography one week after menstruation to avoid the risk of infection. At this time in the menstrual cycle, the endometrium is at its thinnest, which is the best time to determine if the endometrium is normal. The timing of the exam may vary, however, depending on the symptoms and their suspected origins. Sonohysterography should not be performed if you are pregnant.  No special preparation is required prior to the exam. You may be advised to take an over-the-counter medication shortly before the procedure to minimize any potential discomfort. 

For sonohysterography, sterile saline is injected into the cavity of the uterus, distending or enlarging it. The saline outlines the endometrium (the lining of the uterine cavity) and allows for easy visualization and measurement. It also identifies any polyps, fibroids, or masses within the cavity. Saline and air may also be injected into the uterus so that the physician can look for air bubbles passing through the fallopian tubes, which would indicate their patency.  A baseline transvaginal ultrasound procedure is usually performed first to view the endometrium, or the lining of the uterus, including its thickness and any associated ovarian abnormality.  Transvaginal ultrasound is performed very much like a gynecologic exam and involves the insertion of the transducer into the vagina after the patient empties her bladder. The images are obtained from different orientations to get the best views of the uterus and ovaries.  Following the baseline exam, the transvaginal probe will be removed, and a sterile speculum will be inserted.  The cervix will be cleansed, and a catheter will be inserted into the uterine cavity. Once the catheter is in place, the speculum will be removed, and the transvaginal probe will be re-inserted into the vaginal canal. Sterile saline will then be injected through the catheter into the uterine cavity as ultrasound is being performed.

This ultrasound examination is usually completed within 30 minutes.  During the sonohysterogram, you may feel occasional cramping as a result of the introduction of the saline. Over-the-counter medication should be sufficient to minimize any discomfort associated with the procedure. You may have vaginal spotting for a few days after the procedure, which is normal.

Femara: (From the website http://breast-cancer.emedtv.com/femara/femara-for-infertility.html) also called Letrozole, is a prescription medication licensed to treat breast cancer in postmenopausal women. It is part of a group of medications called aromatase inhibitors. Femara may also be recommended in an "off-label" fashion to treat infertility. Early studies have shown that it may be at least as effective as Clomid (Clomiphene) in treating infertility. These studies have also shown that Femara may be effective in women who did not become pregnant while taking Clomid. (Clomid is a prescription medication often used as a standard infertility treatment.) 

How Femara Works for Infertility:  Femara is part of a group of medications called aromatase inhibitors.  Aromatase is an enzyme found in various places in the body. These enzymes help produce estrogens (particularly, a certain estrogen called estradiol). As the name implies, aromatase inhibitors block these enzymes. By doing this, Femara helps to decrease the amount of estrogen in the body.  When a woman uses Femara for infertility, the medicine is taken for a few days near the beginning of the menstrual cycle. Temporarily decreasing the amount of estrogen in the body sends a message to the brain to increase the production of substances that stimulate the ovaries. This often causes ovulation in women who do not normally ovulate or who do not ovulate regularly.  In many ways, Femara works similarly to Clomid. However, Femara may be less likely to cause certain problems with cervical mucus. Clomid often causes cervical mucus problems, leading to vaginal dryness or cervical mucus changes that interfere with the motility of sperm.  Femara is also less likely to cause the lining of the uterus to thin, as Clomid sometimes does. A thin uterine lining can make pregnancy less likely.

Armed with a plan, information on what the plan details, and answers to all of my questions, we still find ourselves in the middle of our two week wait.  Ugh!  This time is so stressful.  TMI WARNING:   Top that off with diarrhea and nausea... this is turning out to be a lovely wait.