Decisions

So...I waited for a bit (but not long) for the PA who had given me the bad news the day before. I'm not entirely sure how this clinic works as far as deciding who you see for any given appointment - it's an academic medical center, so usually it's a resident/medical student + an attending at each clinic appointment. But the PA was the one who took my appointment on Thursday. She came in and said that they weren't able to get a good look at whether I had a septum during the HSG - that the position of my uterus wasn't conducive to getting the views that the previous doc had requested. But ultrasound had an open room right then, and was I okay with having another one? I said yes, of course, because in my mind, more information is always better. She asked how I was after the procedure the day before and I told her I was still having twinging pains, mostly on the left. She thought that was weird, since the hydrosalpinx is on the right. I told her it wasn't enough that I needed to take anything for it - but I definitely noticed it.

We went up to the front desk so the administrative person could put the request for the u/s in. The PA went back to the u/s room to let the tech know we were coming back - then they both came to the front desk and told the admin not to bother, they were just going to squeeze me in and not charge me for it (very nice!). We went back to the room, and I did the usual empty-the-bladder, take-off-the-pants, replace-with-this-sheet dance. Of course, I always wrap myself up like a burrito, and then they have to partially unwrap me to get the scan. Whoops.

She started scanning, and said that she couldn't see the hydrosalpinx on the right. Great, but it was definitely visible on the HSG the day before. Then she said something like "Whoa, I've never seen THAT before!" Um, okay. Not what you want to hear when someone is looking at your baby making parts with an ultrasound wand! She had the PA come around the end of the table, and she said the same thing. Apparently I have a very anterior cervix, but a very posterior uterus. Which is why the HSG hurt so much - they were trying to yank my uterus so that it flipped forward, so they could get a better shot of it on the x-ray. No dice - my uterus refused to move. So that, plus the pain of the dye going through the hydrosalpinx, was why the HSG hurt so, so, much.

The tech asked the PA to get the other tech, who had done my initial ultrasound (the one where they debated fibroids vs. septum vs. arcuate uterus) to "come and see this". So I had three people staring at the pictures of my apparently oddly placed and shaped uterus. She did, finally, get a view of the septum, and they decided that it was just a bit of a dent in the wall. It measured at less than 1 cm, which is the cut off for having to do something about it.

After that, we went back to the exam room, and the PA pulled up the HSG pictures on the computer. I was curious as to whether the hydrosalpinx was really on the right, since I was having so much pain on the left. Sure enough, it was -they had labeled it wrong during the scan, but it was definitely my right side. She showed it to me again, and then said that they typically recommend laparascopic surgery to examine the diseased tube, and likely take it ou, and also to take a look at the other tube, in case it is also diseased. She said that they think I probably have endometriosis. I think that's very strange - not impossible, but strange - because I have friends with endometriosis and my cycles and cramps were never as bad as theirs. My college roommate had it bad enough that she had two surgeries, one just after high school and one while we were in college. I gave her Lupron shots to try to keep the growth down during the year that she had surgery. Me? I never had cramps that were that bad that I had to skip school, or that made me sick. Sure, I have to take anti-inflammatories around the clock on the first day of my period, but that didn't seem that unusual to me. I did pass out from cramps when I was in high school- that was fun - but overall? It is really strange to me that this would be bad enough to cause this much tubal disease, but that I wouldn't have that much pain. Hm.

I talked with the PA about what I had read -about how the diseased tube can cause problems for pregnancy, and how I wanted to know as much as possible about what was going on. She said that this would allow them to remove that tube, and maybe the other one if it, too, was diseased. If that happens, we would definitely have to move on to IVF if I were ever to get pregnant. If they left the other tube in, then we could do monitored IUIs with ultrasound - to make sure I am ovulating on the correct side. But most likely we're looking at IVF. Not a place that I really wanted to go - what if I get pregnant with twins? What will that do to my career plans? And N's career plans? One baby is what we had agreed on - we both thought that one child would fit in well with the life we had planned for ourselves. But since we won't be able to get pregnant without help, well...I guess we have to reconsider all of this. We haven't made a decision about IVF yet - we want more information - but it does look like that is what we will be doing.

So we talked about the surgery - the risks, the benefits - and I told her that I thought it was a reasonable next step. Particularly since removing the tube would presumably help me to carry a pregnancy to term - that was one of the major arguments in favor of the surgery. She told me that their clinic numbers indicate that younger women (< 35) with hydrosalpinx who do not have the tube removed have a lower rate of successful pregnancy even with IVF. The numbers come close to those women without tube disease if the tube is removed. So. I made the decision that surgery was the next best step. I felt kind of bad that I didn't directly consult N about this, but we had talked about it the night before, and I had told him that I thought that would be a good step before trying anything else as far as conception goes.

So, the PA sent the nurse in to do the pre-op education. Hilarious, since I used to work in the recovery room. It's the usual stuff. Oh, we scheduled it for 12/12, which is a Friday, a week before my parents and in-laws are coming to town for my graduation. They will try to do the surgery laparascopically, but they might have to open me up if there is endometrium/disease that they cannot access through the surgical openings. I will definitely be up and around by the next week - so that is why I chose to go ahead before graduation. Even if I have to stay in the hospital over the weekend (which I really, really hope doesn't happen). So anyway - preop education was fine, the nurse was nice and didn't make me watch the video (seriously? a video? I think I have it down, thanks...). They have to do a computer-based questionnaire to evaluate your risk for anesthesia - I came in at low risk, despite the diabetes. Woo hoo. So I don't need to have a pre-op appointment in anesthesia clinic, just a phone call the day before surgery and then a day-of check in with the anesthetist.

The person doing my surgery is the head of the Infertility clinic and a gyn surgeon. So, not a bad person to be doing this! And the resident on that day is a third year. So, whew. I'd rather have someone who must have a bit of a clue by now. ;)

The PA came back in to do a physical and everything checked out fine. She couldn't feel anything - the hydrosalpinx, etc - on bimanual exam, which is why no one ever thought that something might be wrong. It has occurred to me since this appointment that the fact that I was on birth control pills for so long (7+ years) might also have limited the cramps and pain that I have each month - even on the pill, I needed to take anti-inflammatories round the clock on the first day of my period, or I was completely miserable.

So I am set for surgery - the appointment took forever, I don't think I left until almost 1 pm. They talked to the billing office - the surgery will be covered under my new insurance's infertility coverage. It should be about $7000, which isn't too bad. That still leaves enough that we could get in an IVF or two if we choose to go that route. I do have to call Monday -the first day of my new insurance - to see if I need to get preapproval/clearance for the surgery. She put it in as a diagnostic laparoscopy, with dysmenorrhea. We'll see - I'm sure there will be a co-pay, but as long as they cover the majority of it, that will be good. And, I get paid again starting Monday, so that is even better. We're cutting our spending a bit close since I haven't been paid in 2 months. Whew.

More in the next post re: telling the parents (NOT fun, since they didn't even know we were trying!), etc.