SIRM Consult Recap - take 2

In an effort to feel completely comfortable with our plan moving forward, I decided to get some additional consults. Again. It really baffles me that this area of medicine can garner so many different opinions. This was actually my second consult with Dr. Peters. I had spoken to him right before our second IVF cycle and he actually seemed to have the same insights as my RE so we went ahead and stayed at the clinic we are at.  This time around though, the consult was $200 bucks - last time it was free, so that was a bit of a bummer. I do know his time is definitely worth $$ but to go form $0 to $200 seems a little high.

Basically he advised that I for sure go through with the lap and hysteroscopy combo. If I truly have hydrosalpinx then after it's fixed, we should just go ahead and transfer again.  PGS tested embryos are as good as it gets he said, but hydro can decrease your pregnancy rate by about 50%.  So that 70% success rate I thought we were working with was really only 35% when you do the math.   

If hydro is not the issue when they get in there and open me up, I should probably get retested for APAs and NK cells. He said that because I've been pregnant before, it's highly unlikely that I am experiencing an immunologic implantation issue, but yet it's not out of the realm of possibilities.  Apparently, because my body has been introduced to so many embryos over the course of my fertility treatments, it's theoretically possible to have developed an autoimmune or alloimmune issue over time. If hydro is not the issue, he'll test me for both those things.  Since I don't have any markers for other immune related issues based on my testing from 2 years ago, those are the only tests I need to repeat. If NK cells comes back positive (alloimmune), then intralipid IV infusion would be the course of action. If APAs are positive (autoimmune), then baby aspirin plus lovenox or heparin is the answer.

I asked about lupron depot.  He said he doesn't really do it and doesn't know if it really helps.  He did say that if my NK cells came back positive then the lupron depot might help quiet those down by suppressing the estrogen, but he wasn't overly enthusiastic about that option. 

I asked about the endometrial receptivity array to test timing of transfer. He said its new and he doesn't have that much experience yet with it thought he's planning his first next month. He thought my current RE (not a believer) might be open to this testing though. 

I ought to keep any eye on AMH and FSH if we're planning any more stim cycles- the ever present biological clock issue!  Stim protocols, egg #s, blasts and # of normals all look really good so no changes suggested there. No need to consider egg donation yet which is generally reserved for DOR patients. 

He was super nice on the phone and our consult was about 35-40 mins. I would definitely feel comfortable cycling with him.  If I want the intralipids,  I would need to cycle with him and transfer my embryos. If I did cycle there, it sounds fairly easy for an FET-maybe only 3 trips total including 1 for the blood work, 1 for an ultra sound to check lining and then another for transfer.  The clinic is about 4 hours away so it's not completely out of the question that I could do this, it would just be a big commitment.  The intralipids could be done here at home.  I would only need 2 because E and I are not a DQ-HLA match. 

So here we stand. I am considering getting the blood work done regardless just for peace of mind. But that would still entail a day of driving 4 hours to NJ and then 4 hours home. This doesn't sound appealing at all.  My current RE already mentioned (before we knew about the hydro) that he'd be willing to add the Lovenox and/or Heparin so if I can cover that base without doing the testing, is it worth it to just risk that my NK cells aren't elevated? 

Who knows the answers here?  Of course, if hydro is not found, well then we have an even bigger incentive to get tested. I could also try going back to the one and only local RE who is an immune system believer and see if she'd test me again in the meantime. So many questions, so many contingency plans. I can barely keep my head above water these days.