Need Advice: When to start using Clomid and other medical interventions

[elenapatata]

Hello community

I am TTC, my wife and I have tried inseminating 3 times at home using frozen washed sperm from the sperm bank with anonymous donor (two ICI, one IUI - two inseminations per cycle) with no success.  I just went to see the doctor at Kaiser and was left with more questions than answers.  The doctor immediately prescribed Clomid (without even asking about my cycle or looking at my charts) and is all set to get me going on HCG shots and follicle scans, etc.

Problem is, my insurance doesn't cover any of it, so cost is definitely an issue.  But also I am not sure if/when it's time to start going through all that.  I am 36, my cycle is generally pretty normal (except since we've started TTC it's gotten a little more irregular and I'm not feeling confident anymore in my ability to know when I am ovulating).  I've been taking Vitex, going to acupuncture, drinking fertility tea.  The doctor did say I have low progesterone, so I am going to start taking a natural supplement.  But other than that everything seems to look normal, says Dr.

Any of you have experience with this decision point?  Advice about what to try next?

Thanks

e

[Friederike]

I personally decided against Clomid for the first maybe 5-6 tries. I don't feel it is necessary if you're ovulating normally and the risk of multiples and overatimulation isn't worth it to me. It also probably creates more need for check-ups during the stimulation phase which creates extra costs. My doctor also advised not to use Clomid without apparent need.
I do like using a ultrasound about 2 days before I expect O plus a trigger timed according to follicle size to make timing easier. Frozen only lives for 12-24 hours so timing is crucial imo. The cost of the trigger + ultrasound is much less than 1 vial of sperm that might potentially be wasted. Also, could you get unwashed sperm if you're doing at-home-ICI? Unwashed has an easier time fighting their way through the cervical mucus and they live longer.
Did the doctor run blood tests to determine your low progesterone levels? Do you have a short LP? In that case I would definitely take progesterone to make sure the egg has a chance to stick. A trigger helps stabilize progesterone levels, too.
I think the degree of medical intervention one uses is a very individual decision. Some people like a more natural, less invasive way better and have the patience to wait it out, others might need the feeling of doing everything that is medically available and max the chances with each try. Statistically three tries isn't that much yet. I totally understand how frustrated you're getting though! There is a 6-10% chance with ICI (14% for IUI) for each of the first 6 tries. My doctor doesn't suggest a more agressive approach until those 6 tries.
Good luck with you decision!

[granite]

elanapatata!

When I had my initial consultation with my RE, we found out that I have mild PCOS, which causes my long cycles.  So while I do ovulate on my own, it can take anywhere from 30 to 60 days to happen (and sometimes just doesn't, for up to 6 months!). Living in Canada, I only pay out of pocket for some costs (sperm, shipping, storage, washing, IUI procedure, clomid), while others are covered by our universal health care (doctor's visits, blood tests, monitoring including u/s). Given these circumstances, I decided to go with clomid from the start, because like Friederike said, I want to max the chances with each try. While I don't have to pay upfront for much of my TTC-specific costs, it still adds up to around $1000 per cycle, and on top of that there's my lost wages from the inevitable missed hours of work due to appointments. Add in the unpredictability of my cycle, and the drugs just seem to make sense to me.

All of the holistic stuff you've been doing sounds great! I don't have much of an understanding about how your health care system works, so I'm not sure what your other options are, but your doc doesn't seem to be on the same page as you.  Could you get a second opinion? Is there a midwife or naturopathic doctor in your area who specializes in TTC and could treat you instead?

[elenapatata]

Thank you Friederike, this is helpful. By trigger do you mean the HCG shot? Does that work without being combined with Clomid?
I did get the blood tests that showed I have low progesterone, I'm goin to try a natural supplement to see if that helps.
Any other advice/insight is welcome!

[elenapatata]

Thanks Granite. I did find a midwife nearby, I will let you know what she advises.

[mrsandmrs]

I agree that the level of intervention you decide on is a very personal decision. I'm only 30, but due to pcos-ish conditions, I basically don't ovulate on my own. I could take a less aggressive approach. For example, metformin makes me ovulate, so theoretically we could use a less aggressive protocol if I'm on it. However, my wife is 36 and our older kid is a teenager, so we wanted to be more aggressive. Every family and situation is unique.

You can use the trigger (hcg) shot without clomid. Timing is critical with frozen sperm.

[mrsandmrs]

Oh , and regarding progesterone. It depends on how low your progesterone is naturally, but I have struggled to get mine up with prescribed pills three times a day. I am skeptical of the efficiency of the otc creams if your prog. is really low. And you cant stay pregnant without sufficient progesterone. But a naturopath or midwife could help with that decision and more info.
Edited by mrsandmrs - 12/24/12 at 1:37pm

[pokeyAC]

Your situation sounds a lot like mine.  I had the work up at Kaiser and only found low progesterone.  I was 36 then.  We did 3 cycles without medications and then moved on to Clomid.  The doctor recommended Clomid at first too, but I think that is just their standard protocol because they are used to dealing with infertile people and we are not really infertile.  If you do take it, the monitoring is important because you can see how your lining is.  My lining got progressively thinner each time I used Clomid.  I got pregnant the 3rd time, but had a very early loss.  I couldn't really say what caused it but the lining may not have helped.  I wish I had started with letrozole.  You get fewer follicles, but it doesn't affect your lining.  It sounds like you are doing things right with acupuncture and the tea.  Vitex can be tricky sometimes and I think, should be used with some professional advice.  We worked with a midwife who consults on fertility.  Vitex definitely has an effect that can be good, but I don't know if it is always the way to go.  I got pregnant the cycle I didn't take any after taking it for a long time.  One thing I tried that seemed to work was taking 100mg of b6 every day.  I didn't do it for very long, but I didn't have any spotting the first cycle and I got pregnant the next.  Spotting is often a sign of low progesterone.  It's good for morning sickness too so it's ok to keep taking.

One thing I would say is if you have no coverage at Kaiser, it might be cheaper to go somewhere else.  Many doctors will give you a deal if you are paying out of pocket whereas Kaiser is not set up for that.  I'll send you a PM with my info if you have any questions.

[elenapatata]

You are right about Vitex, I decided not to take it this month and my ovulation was actually more clearly predictable than with it.
I got a bill in the mail from Kaiser and it made me firmly decide to stick with midwives for now.