Is There a Code for That?

So I'm expecting to start Follistim and Estrace next week. To give you an idea of the cost, according to Walgreen's specialty pharmacy, they'll bill my insurance $1,800 for 6 days of Follistim.

Anyhow, my insurance will cover Follistim if it's not being used for procedures related to IVF. So, IUI & related procedures = covered. IVF = self pay.

I am not doing IUI or IVF. I am taking drugs and having sex.  (As a relatively prudish straight-arrow, those are words I never expected I would type!)

The insurance company, because of the IVF limitation, will not authorize Follistim unless I can provide a procedure code. Because the procedure code tells them if it's for IVF or not. There's one big problem here: there is no procedure code for "have sex!"

I am stuck in this infinite loop. First, insurance assures me it will be covered, since I'm not doing IVF, so my doctor should submit an authorization request. As soon as my doctor submits the authorization request, insurance requires a procedure code. Then, insurance tells me there's no procedure code for sex, and I remind them that sex is not IVF, at which point they agree it should be covered.

GAH!

I've now wasted spent more than two hours on the phone with the various parties to this BS.

"Just relax and it will happen" - a phrase that is applicable to neither getting pregnant, nor getting insurance preauthorization.

Verdict is. . . .

There are times when I feel truly bad for medical professionals. They spend years, decades even, studying and training. They continue learning as they practice and complete CE. Still, the human body is an amazingly complex system, and not every human's complexities follow an expected pattern. That means there are times when the best explanation a medical professional can give is, "I don't know" or "It doesn't make sense."

So, what was the outcome of my follow up appointment? Well, the saline sono, taken in early May, and the HSG from last Friday both suggest a horrendous case of Asherman's syndrome. But both of those are imaging techniques that don't directly visualize the uterus. The hysteroscopy, with photos taken after the saline sono but before the HSG, shows a normal uterus. The surgical notes written by the doctor who performed it didn't indicate any evidence of Asherman's, or anything other than mild scarring. The actual pictures should be the gold standard, but they are completely inconsistent with the sono and HSG. So the verdict? "It doesn't make sense."

Where does that leave us? Well, we could keep doing tests. Maybe we'd start getting consistent results, maybe not. Either way, we've now done all the tests that can be done, so we'd have to start repeating things. Verdict: probably not enough incremental value to be worth the drawbacks. Alternately, we can go back to the original plan: an injectable cycle in July, with monitoring of lining and follicles. Verdict: This approach will should tell us how my lining responds, which is a critical part of the question. The risk is that it won't tell us if both tubes are open. We could spend the money and the time on the cycle, and ovulate on the left side, where we don't know if my tube is open.

Total cost of more testing versus an injectable cycle will probably be similar. If they run multiple tests, that would be more expensive. It all comes down to a question of what really matters? And what really matters is: can I grow a lining that will support an embryo? Going the injectable route should answer that, because if I do have severe Asherman's syndrome, I won't grow sufficient lining no matter what medications they throw at me. If my uterus is healthy enough to grow a lining, it probably means the HSG was flawed, and I'm not as worried about tubal patency.

So, we will try the old fashioned way this cycle. We'll pray for a healthy, fully implanted embryo out of that. If I do get a positive test, we'll monitor the hell out of it! I am not optimistic, since I've had continued spotting since the HSG, but hey, I'm not going to turn down the excuse to spend some quality time with DH. ;) If this cycle doesn't work out, I call C.CRM on Day 1 and go in for Day 2 or 3 labs and an ultrasound, and then we start drugs and see what happens.

How will it all work out? Well, I'll give the most common answer from my own profession, which also deals with human beings and their irregularities: "It depends!"

Before and After

So, I love me a good before & after picture. Home reno before and after? Yes! Haircut before and after? Check! Recipe ingredients before to beautiful meal after? Bring it on! Today's before and after might not be for everyone. Today's before is my uterus at the start of the operative hysteroscopy. The after is my uterus after the scar tissue was cleaned up. If you don't enjoy viewing pictures of people's internal organs, don't scroll down.


So, here's the before photo. It looks rather like a tunnel, no? To the left and right are the ostia, or the openings to the fallopian tubes. From what the doctor explained, some of the white patches are scar tissue. Overall, there isn't much white where it shouldn't be, which means there wasn't much scar tissue from the January d&c.

Now for the after photo. In this photo, you can see everything is smooth and pink. There's less scar tissue, and the pink suggests that my endometrium is healthy and should be capable of a pregnancy.

There are two layers of endometrium in a healthy uterus, a basal layer, which remains at all time, and a functional layer, which is shed monthly. We're pretty sure I have trouble with my functional layer not getting thick enough, or having the correct pattern, to support a pregnancy. However, based on these photos, which were taken May 23rd, there shouldn't be anything blocking my uterus. This is what makes Friday's HSG so inexplicable.

At this point, I'm praying for an answer that isn't the end of our journey, and I'm focusing on the after picture, because it looks like it should.

Cause or Effect?

Just over five years ago, shortly after I became unable to eat gluten, I had an incident. One afternoon I started having extreme bloating, and the kind of horrific gas that usually accompanies gluten-poisoning for me. By the early morning hours, I was in the bathroom, while my digestive system emptied itself in waves. Once again, that's what normally happens when I come into contact with gluten. That's why I religiously avoid it! Along side the normal symptoms was intense abdominal pain. It hurt to touch  my stomach. It hurt to put on clothes and have my seatbelt across me. Going over bumps hurt. That was something I'd never experienced before.

I went to the doctor the next morning. She was worried about my appendix, so she sent me for an MRI. The MRI showed such extreme swelling in my intestines that the "T" shape of my IUD, and the uterus containing it, was actually horizontal instead of vertical. My intestines had pushed my uterus out of the way with their swelling.

What caused that? Well, after the MRI, a different doctor, a DO, sat down with me and asked me what I did for a living. When I told him I was a manager, he held my hand, and while gently patting it, informed me that I had an intestinal blockage caused by too much stress and not enough fiber in my diet. Then he turned to my husband and told him to "take better care of her." Mind you, he never asked about my diet, or about my stress level. I guess he just assumed a woman manager must be stressed, eat crap, and need care from her male protector.

I saw a GI specialist shortly thereafter. He looked at my films, then asked me detailed questions about my diet (30 grams of fiber a day via beans, brown rice, almonds, and fruits & veggies - documented via months of My Fitness Pal logs) and my stress level (pretty low as I'd just gotten my dream job managing an awesome team of people doing work I loved). When he had the answers, he politely told me I was an idiot for eating week-old leftover rice. He thought I'd gotten food poisoning, which explained the swelling and pain.

To this day, I don't know which of them was right, but although my stress level has gone up at times, and my fiber intake has gone down, I've never again had the issue - and I've stopped eating brown rice!

The day before the HSG, I was feeling oddly bloated. I had assumed it was because I'd upped my intake of gluten-free oats, which I have trouble with. I'd made a mental note to change my breakfast meal plan next week. In the hours after the HSG, I moved from slightly bloated to massively bloated, and in substantial pain. I couldn't take a deep breath without pain. I couldn't stand up straight without pain. I spent hours in the bathroom early Saturday morning, alternating between the floor and the toilet, in agony. It was like the experience 5 years ago, only worse.

I'll ask my doctor when I see her, but I wonder if I had swelling in my digestive tract before the HSG? If my uterus had been extremely compressed due to unhappy intestines, might that have produced the never-before-seen disappearing uterus on the HSG? Alternately, it's possible the digestive symptoms could have been caused by stress or a reaction to the contrast. Ugh. No clear answers, just more unhappiness.

Reeling

The HSG went catastrophically badly. To quote my RE, "I've never seen an image like that in my career." The radiologist was also mystified.

Instead of seeing a normal uterus and two fallopian tubes, or hell, even a unicornate uterus and one tube, there was the tiniest nodule of a uterus and one tube. In other words, the HSG showed fundamentally no open uterine cavity. No uterine cavity means no pregnancy.

I had a hysteroscopy a month ago - I have the images from it and the OB who did it said everything looked great. The hysteroscopy I had to remove my first IUD back in 2012 also ended with being told I had a good looking uterus. How the fuck did I go from there to an image with no uterine cavity and only one tube? The only HSG images even remotely similar to mine are ones with tremendously severe Asherman's - and my HSG showed even less of a uterine cavity than those.

If this isn't just a fuck up in the testing, which is what I'm praying for, then I'm scared we're at game over. I'll regroup with my RE next week if I can get an appointment. Meanwhile, I'm spending the weekend  trying to remember to breathe.

I will get through this. Somehow, I will get through this.

Not Gonna Be A Problem

I'm supposed to start taking antibiotics for the HSG tomorrow. I went to the pharmacy to get them today. The pharmacist gave me the use instructions (take two before the procedure, one each day after). Then before I left, she asked me "Oh, are you on oral birth control?"

I knew, immediately, that she was asking so she could warn me that antibiotics reduce the effectiveness of birth control. So I did the only thing I could: I laughed. I couldn't help it.

After that, I told her that no, I wasn't on bc, but even if I was, I'm pretty sure the efficacy wouldn't be lowered any for me by antibiotic use!

Some times you just have to laugh.

Wish me luck tomorrow?

What Goes Up, Must Come Down

Am I the only one whose moods can shift on a dime?

Yesterday, I felt really good after my appointment. I had a game plan. I trust this doctor, even when her advice conflicts with something I might be willing to try, because she refers to research. Everything seemed to be going well. I dropped DH at the airport after the RE appointment and then headed home to finish up work that needed to be sent out that day. Things were looking up.

Then I pulled onto my street to find the beautiful tree in our yard blocking half the street. Not going to lie, that sight took me back down. I love our house for the many trees here. The tree in the front was beautiful. Instead of getting my work done, I scrambled, at 4:30 pm, to find a tree service to come out and remove it.

While I was making calls, the next storm moved in, with thunder, lightning and heavy rain. Thus, it should not have surprised me to get a text from DH saying his flight might be cancelled. Half an hour later, he confirmed that he wasn't heading out that night, but would be on the 4:45 am flight the next morning. Thus, I drove through the flooding to bring him home, worked until 9:00, then slept for a few hours before getting up at 3:00 to take him back to the airport.

Now, tired, cranky, stuck working from home so I can meet the tree guys, and out $1,500 for the tree work, I'm feeling vastly more down. I'm grateful to be able to work from home and afford the cost, but it's still a bummer. I guess the up(side) is that I'll have fewer leaves to rake this fall?