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When to see a specialist?

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justtryingthisout Posted: Wed, Mar 15 2017 8:12 PM

Please give me advice before the site shuts down! Surprise

Almost two years ago now, I had surgery for endometriosis, and at my post-op appointment, the surgeon told me that if we don't conceive after 6 months TTC, I should have an infertility consultation. We didn't TTC right away, and now we are in the middle of our 6th cycle TTC. I'm about ready to make an appointment. My surgeon has unfortunately transferred out of the country, so I can't ask her advice. I saw a CNP last summer who recommended a particular doctor to me. She said he specializes in endometriosis related infertility. I looked him up and he is in the department of Obstetrics and Gynecology, in case that makes a difference. (ETA: I believe he is an RE.)

Basically, I am wondering if I should go straight to him, or if I should see a regular OB first. I don't have an OB that I have been seeing. I was seeing the surgeon and her CNP, and my plan was to go with a midwife group for prenatal care. My insurance doesn't cover infertility at all. 

For those of you who have gone down this road before, what can an OB do? How do you know when it is time to see a specialist? And if you don't mind sharing here or in a private message, can you give me a ballpark on costs? Thanks in advance!

DH: 34 Kiss Me: 30

History of endometriosis

TTC #1 since Aug. 2016

My Chart

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MellieC replied on Thu, Mar 16 2017 8:55 AM

I would say:  it depends.  We were new to the area we live when we started TTC so had to get all new doctors.  

I first saw a gyn after ~6 months of trying and she threw up her hands and sent me straight to an RE (for my spotting issue).  Said she couldn't help at all and wasn't even willing to give me progesterone.

My RE is great, but codes EVERYTHING as infertility.  Also I always get the feeling that she sees a few IUIs then IVF as the answer to everything without being willing to try much else.  

I then started seeing another (NaPro) gyn who does endometriosis (lap) surgeries and medicated cycles (clomid, femara, HCG shots, progesterone, etc.) and codes as much as possible as women's health type visits (not infertility).  

Soooo, since you don't have infertility insurance I would say you should be okay to start with a gyn and that can save you a lot of money.  HOWEVER, it has to be the right gyn.  One that is willing to try and help you themselves and better yet to code as much as possible to your health vs infertility.  Some up front research on that could save you a ton.  If you can't find a gyn like that - then probably best to go ahead to the RE as otherwise you are just wasting time and money on an unhelpful gyn. 

I am not sure the difference in costs between gyn vs RE so hopefully someone else can weigh in there.  

Good luck!

Me (Mel): 33  DH: 36

Charting since 1/14, TTC #1 since 11/15!!  

6/16 - working with RE due to spotting throughout the LP

2/17 - stage I endometriosis dx and removed; also removed uterine polyp

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soon2be_mrsd replied on Thu, Mar 16 2017 9:13 AM

Hello!

I would see a specialist now in your case.  Skip the OBGYN unless they specifically talk about having an interest in fertility, pre-conception, or endo in your case.    OBs are great for caring for pregnancy and overall women's health, but they really are not the experts in understanding fertility beyond some basics in my opinion.   You want to look for a RE-  Reproductive Endocrinologist  - yes they are OBs so they would be in an Obstetrics department like you said, but they should list the specialty.    OBs can do some basics- they can get you through baseline tests (ultrasound and bloodwork), coordinate an HSG if needed, do saline ultrasound if needed and even do ovulation induction with Clomid or Femara -- some even do IUIs depending on the practice.  The OB group I'm with now does IUIs  - the one I was previously at (midwife/ob combined group) did clomid with monitoring only.   Monitoring would be going in CD2-3 for a baseline (to make sure no cysts before starting meds), then going in about a week after your last pill and seeing where follicles line up and they can estimate how close you are to ovulating and help you with timing intercourse.   Or identify that perhaps that medication is not working for you.   So as far as when you know- I think with a documented case like yours, after 6-7 months it's time to at least go talk to someone about steps you could be taking to improve chances or seeing what steps might be necessary to check in on the endo you previously had (since it has a way of coming back).   I was 34 when we started TTC and after 5-6 months I knew something was wrong (even though I was having normal cycles then)-- right at that point my cycles then became weird (strange timing!) and I had to deal with getting my cycle in line before I could really seek help conceiving.  At the time, my OB/midwife told me to wait a full year of trying -- which we ended up doing because of the odd cycles I was having.  It depends on where your priorities are -- mine were to conceive ASAP basically and after 5-6 months of trying I was definitely ready to move forward with help.... some people are more comfortable waiting a year.  

 

The only other factor I see for you if you wanted to wait a few more months is that you were on birth control for a while.  It can take 6+ months for things to stabilize after that  It's possible you are just still working through hormone changes from that, but it's also good to make sure your endo is kept under control too so it's definitely not too soon to see someone.

 

Alot of insurance will cover "diagnosis and treatment of underlying medical condition" - this is somewhat vague.   Endo removal/treatment would be considered treating an underlying medical condition.  So if you were to have another surgery or do some sort of medical treatment to help your endo, even if you were seeing an infertility specialist, if they coded it as treating Endo-- it should be covered.     Blood Tests (it's a good idea to do a basic CD3 blood testing (FSH, TSH, LH, Estrogen, Progesterone, Prolactin, Testosterone, AMH, maybe Vitamin D, maybe Glucose/Insulin)   You will probably also be asked about an HSG to check your tubes and uterine cavity (they inject dye in and see how things look on X-ray)- this is good for endo because scarring, endo, adhesions could create problems with the tubes.    This SHOULD be covered because it's diagnostic, but if the doctor codes it wrong it would not be.  And if you are like me with a high deductible plan you are paying out of pocket for the first bit of stuff anyway until you hit your deductible.  A basic baseline ultrasound should also be covered because your doctor (OB, RE, etc) can use a coding for painful periods/endo/irregular cycles.    I'm a nerd and I like looking at my benefits statements-- my RE usually codes things that are diagnostic in nature as "Irregular Periods"  or "pain during menses"  and my insurance would cover those (after deductible).

So because I'm subject to deductibles, I had to pay out of pocket for baseline/diagnostic stuff. Ultrasounds ran from 180 - 300 (depending on where you go- my OB's office was more expensive than my RE!)   Bloodwork was a few hundred for the CD3 testing.   Semen Analysis is usually between $80-$150 from what I've seen.  They'll likely require the guy to do this to confirm it's not a male factor issue or combined female + male factor.   Clomid is not covered AT ALL by my insurance becase it's used only for fertility purposes.  However it's really cheap at places like Walmart (I've heard)-- so really only about $15-20 I've heard.  Femara was covered by insurance because it's used for other things.  It was usually $5 for a cycle for me.  If you need to go into things like Trigger Shots (~$100), low dose FSH injections (~$75 per day you use them), or IUI  (about $1000 on average).    Many places have "Cycle Fees" for cash paying/non insured patients -- this cycle fee would include all ultrasounds, blood work, office visits, and a pregnancy test at the end  -  so even though your insurance might cover the baseline ultrasound because it can be coded in such a way, it was explained to me that once the doctor starts TREATING you with something (like a clomid), they now have to code it as treatment of infertility -- so that first ultrasound might be covered but it's actually cheaper to accept these "cycle fees" or cash patient payments.  Hope that made sense.    Cycle Fees at my clinic range from $500 to $1500 depending on what you are doing (timed intercourse vs IUI)  -- Meds are generally not included in any special bundled fees.

Me: 35   DH: 33

TTC #1 since February 2015

Diagnosis: ovulation disorder, pelvic adhesions, tubal dysfunction:  4 medicated cycles with femara + FSH injections (2 timed intercourse and 2 IUI) - all BFN.  We are done with treatments now (Nov 2016).  Trying naturally for a bit while exploring other paths to parenthood.

Natural BFP 12/17/16!   Ectopic Loss 5w5d  on 12/26/16

Feb 2017: Starting IVF Cycle:  Antagonist Protocol with 375IU Gonal F and 75IU Menopur, Added Ganirelix day 6.  Stimmed for 9 days total.   24 eggs retrieved, 17 mature, 14 fertlized, 10 made it to blast and were frozen!  Transfer in April\

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soon2be_mrsd replied on Thu, Mar 16 2017 9:24 AM

MellieC:

My RE is great, but codes EVERYTHING as infertility.  Also I always get the feeling that she sees a few IUIs then IVF as the answer to everything without being willing to try much else.  

 

The other RE practice in town (I originally had a referral there but chose to go on my own to a different place because I got a better feel from them) sent me this whole patient manual thing and it talked about how they code things and listed procedures and items that were "always" considered infertility-- things like an HSG or even bloodwork -- so I got a bad feeling about their coding and ability to work with me on my limited insurance.    My current RE like I said is willing to bill my insurance for things -- like our IVF consult - he coded that as "office visit estabilished patient" and it was just a $80 fee.   (which is kind of annoying because he DID tell me he'd do the consult for free, but I didn't make a big deal about it due to some other circumstances and he gave us other discounts on the actual IVF).   And when I'd go in when I first started seeing him and we were trying to figure out why I was having irregular cycles, he coded those as irregular menses so it would go against my insurance deductible.

 

I do agree though- once you do go to an RE, there is only so much they can do for you and that's one thing I learned-- you definitely don't HAVE to do anything you don't feel comfortable with -- but you have to realize their goal is to get you pregnant-- and quickly.    It can happen very quickly in some cases- you can feel overwhelmed right away because they want to get going with treatment.  (but you have not had baseline tests so they will take a month to do all that)   My RE has reminded me of that a few times over the course of treatment -- not in a pressuring way persay, but just "you have to make a decision here" type way.  We got to the point where he said  it's IVF or nothing and he reminded me that ... hello, I'm sitting in his office right now, I still want to be pregnant right?  and it kinda made things clear.  Now that's not to say I just blindly follow and do whatever he tells me to do, but you have to realize the goal of seeing a specialist and realize their methods.   Like Mellie said, a Napro doctor is different in their methodology and options of treatments -- an RE doesn't pull on the same things -- if you go to an RE, expect them to offer things like IUI, IVF, exploratory lap surgery, donor eggs (for those older folks in the forums).  They have to work with the tools they have.     And just for the record, my RE and I did have that "so it's IVF and nothing" conversation 2 other times and I walked away both of those times.  It was the 3rd time when I found myself STILL back there with him that I realized ok...so it's IVF or nothing.  and I chose IVF that time.

Me: 35   DH: 33

TTC #1 since February 2015

Diagnosis: ovulation disorder, pelvic adhesions, tubal dysfunction:  4 medicated cycles with femara + FSH injections (2 timed intercourse and 2 IUI) - all BFN.  We are done with treatments now (Nov 2016).  Trying naturally for a bit while exploring other paths to parenthood.

Natural BFP 12/17/16!   Ectopic Loss 5w5d  on 12/26/16

Feb 2017: Starting IVF Cycle:  Antagonist Protocol with 375IU Gonal F and 75IU Menopur, Added Ganirelix day 6.  Stimmed for 9 days total.   24 eggs retrieved, 17 mature, 14 fertlized, 10 made it to blast and were frozen!  Transfer in April\

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SRRP replied on Thu, Mar 16 2017 6:56 PM

I went with an OB/GYN for the first few months and got no where.  While she did the basic testing, it did not go any further and she kept wanting me to wait and see saying that most women get pregnant within 3 months of an HSG and that I shouldn't stress.  I finally gave up after a year with her and found an ANP who specializes in infertility which was the PERFECT combo.  She billed everything as normal when it came to blood tests and visits and then I paid out of pocket for the meds and my IUI.  If you can find something like that, I would go for it since your insurance does not cover infertility.  I only found this ANP through word of mouth, so ask around.

OB/GYN's are not geared towards infertility most of the time and finding one who will navigate it to an extent is harder.  An RE is focused solely on you conceiving which is wonderful but expensive and as MrsD said, jump to IVF pretty quickly when the more conservative treatments don't work out.

If you go to your OB/GYN first, set a timeline of what you would like to see happen and ask if they can help with that.  If not, do they have a recommendation for someone else who can?  That is where I would start.

http://www.ovusoft.com/members/SRRP/charts/2.aspx

Me:29  Kiss  DH:32

TTC #1 Since Dec. 2015

MMC in May 2014 @ 10 weeks, measured 6.2 weeks and no HB 

10/16 Femara & IUI= BFP @ 11DPO!  1st beta 31 2nd beta 116 with 37.25 doubling time

173bpm @ 8W 5D, measuring at 9w!

 

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tmonee replied on Mon, Mar 20 2017 1:00 PM

I wouldn't waste time with the OB/GYN and go to the specialist who was recommended to you for the condition you have.

I had a negative experience with my OB/GYN when I tried to talk with them about how they were coding diagnostic testing as infertility instead of diagnostic (how do they know before the results what it is, right). They basically accused me of asking them to do insurance fraud, so recognize that not everyone is going to be receptive to that conversation.

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luv1mo replied on Tue, Mar 21 2017 12:21 PM

TMonee, the EXACT same thing happened to me at my OB/GYN, who I'd loved before that. I left her practice afterward.

 

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justtryingthisout replied on Tue, Mar 21 2017 8:01 PM

Thanks for sharing tmonee and luv1mo! I would think that maybe the same thing could happen with either an OB/GYN or an RE? Or maybe an RE would be more used to dealing with patients without insurance coverage and would at least be more sensitive in explaining it, even if they don't change how they code it. I'm just guessing.

DH: 34 Kiss Me: 30

History of endometriosis

TTC #1 since Aug. 2016

My Chart

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soon2be_mrsd replied on Wed, Mar 22 2017 6:45 AM

Well, like I said in my post, since REs are used to dealing with non coverage, they have price lists for cash paying patients... So in some regards they are less willing to code things a certain way.  My re explained it to me that once a baseline is complete for a cycle and we decide we will be "treating" something that cycle -- be it with oral meds, a trigger shot, an IUI ... The rest of what he does that cycle is treatment.  So he just includes the baseline visit in the "cycle price" too rather than bill insurance the $200 or whatever for that stand alone visit which in itself could be coded as such. 

 

The other RE practice in town seemed to just say anything we would do would be out of pocket because once I was a patient, they were treating my Infertiilty. 

 

 

I did did not do anything besides diagnostics with my OB office. Just ultrasounds to monitor lining, follicles, or cysts. So there was never any question about what was covered.  All the bloodwork they ordered was covered. 

Me: 35   DH: 33

TTC #1 since February 2015

Diagnosis: ovulation disorder, pelvic adhesions, tubal dysfunction:  4 medicated cycles with femara + FSH injections (2 timed intercourse and 2 IUI) - all BFN.  We are done with treatments now (Nov 2016).  Trying naturally for a bit while exploring other paths to parenthood.

Natural BFP 12/17/16!   Ectopic Loss 5w5d  on 12/26/16

Feb 2017: Starting IVF Cycle:  Antagonist Protocol with 375IU Gonal F and 75IU Menopur, Added Ganirelix day 6.  Stimmed for 9 days total.   24 eggs retrieved, 17 mature, 14 fertlized, 10 made it to blast and were frozen!  Transfer in April\

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Posts 1,030
justtryingthisout replied on Wed, Mar 22 2017 1:09 PM

Thank you for the advice, ladies! I just called and made an appointment to see the RE. It's not until May, so I guess we will keep trying in the meantime and then see what he has to say.

DH: 34 Kiss Me: 30

History of endometriosis

TTC #1 since Aug. 2016

My Chart

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