Exercising on Hormones

So one of the first things the nurse told me during my "training session" with her is that when I start my hormone cycle, I will need to take it easy with exercise.  Why?  Because the hormones are stimulating the ovaries, and they will enlarge as they grow more follicles than usually do.  If I were to do bouncy exercise or do inversions in yoga, I run the risk of ovarian torsion, which is when ovaries do a somersault and the fallopian tubes holding my ovaries in place get all twisted up.  If this were to happen, I'm told that I will feel severe pain in my abdomen, and that I should go to the ER.  They should be able to untwist the ovaries, but there is a chance that I'd lose an ovary (if blood restriction were severe) and/or do permanent damage to my reproductive organs.

Right, so no exercise during stims.  I'm not a gym rat to begin with, but I do enjoy doing yoga a couple of times a week, and I was hoping to continue this during my cycle.  However, I spoke with my (amazing) yoga instructor, Stephanie, who said that during hormone injections (and also when women are pregnant), their connective tissue grows elastic and is therefore susceptible to tearing and stretching.  And ligaments don't "stretch back".  Stephanie suggested that I not attend class during my cycle and for a week or two afterwards until the hormones have left my body, and instead, she helped me shape a home practice that is suitable for my condition.

Some general "Do's":

• most standing poses will be OK, but I may want to work with my feet wider than usual
• symmetrical poses are ideal; try to avoid asymmetrical poses
• side bends are great because they elongate the iliopsoas muscles in the abdomen, which help create "space" for whatever is going on in my belly
• go easy on the ligaments; my body is different under the influence of hormones, so I have to be more gentle

Some "Don'ts":

• No twisting, deep forward bending, or core exercises in general (compresses the ab area)
• No inversions
• No sun salutations, especially with jumping (in addition to risk of torsion, she thinks there's too much risk for ligament damage in my hormone-filled state)
• Only do what feels good

Here are some examples of poses, she said are great:

• Downward-facing dog, or the modified versions of "Wall dog"or "Chair dog" (doing a "down dog with your hands against the wall or back of chair)
• Warrior 2 (up to seven breaths on each side)
• Triangle (up to seven breaths on each side)
• Ardha Chandrasana or "Half Moon" (one of my favorite standing poses!  apparently very good for fertility in general)
• Supported Bridge Pose with a block under my low back for support
• Supported Fish Pose with a rolled up blanket under my shoulder blades, knees, and head for support
• Side Bends from either supported Virasana (sitting on a block) or sitting on the floor with your feet out in a V
• Supta Baddha Konasana or "supported reclining bound ankle pose"- I must modify this pose by setting up a bolster on a block so it's almost like a leanback.  Then I sit with my back against the bolster (my butt should be hanging off) so that I'm sitting up more than the guy in this picture.  I must also support the knees with blocks or blankets so that I don't overstretch my hip or knee ligaments.  I can sit in this position for 15 minutes or as long as I like.  Stephanie said that if I do one pose, this should be it for its therapeutic and calming benefits.

In terms of other exercise, my nurse said that leisurely walks are fine, and that I shouldn't be concerned about running up or down the stairs to catch the subway.  I also plan to go for gentle bicycle rides-- hope that isn't considered too "bouncy".   I will ask my nurse before I do that though.  It's too hot this weekend anyway!

Cycle Day 3: AM shot

Today it's another 100+ day in New York City, a fun day to be undergoing hormone stimulation.  I have visions of myself drenched on the subway today, after a hot flash attack.

I couldn't bring myself to stab myself quickly with the Gonal-F needle again.  I watched with horrible fascination as the needle entered my skin slowly...  and I definitely felt the Gonal-F needle go in this time-- I think I may have been pinching the injection site too hard.  Next time, I might try just injecting the needle without pinching at all.  And the thought I had to help alleviate the sting from the Menopur shot is to, 1) bring the diluent-- the solution I use to mix up the Menopur powder-- to room temp before using it tonight, 2) ice the injection site before inserting the needle.

In terms of side effects, none noticeable yet, except I feel like my face looks really bloated-- but that may be my imagination.

I've written my doctor this morning asking him to contextualize my course of treatment.  I do not expect tons of attention from my doctor, but I do expect someone to let me know why I'm taking the amount of medicine I'm taking, and what exactly the follicle count pronouncement means ("six on each side").

Cycle Day 2: My First Shot

I arrived at the doctor's office this morning to a room overflowing with women waiting to have their blood tested (testing hours are 7am to 8:30am).  It just hit me how many women need reproductive help these days (including myself), and what a business reproductive medicine is.  It was hard for me to think about the situations some of these women were in, potentially at the end of their options...  I hoped for most, that they were just starting an uncomplicated journey towards a happy reproductive outcome.  I spotted a woman I'd met before, the wife of an acquaintance of mine, but thankfully she did not recognize me.  That would have been an awkward conversation.

While I waited for a half hour, I settled up my bill.  You know, the took a casual swipe of my new credit card with the 0% APR to charge $9000, and I handed over a check for $750 made out to the anesthesiologist.  I was relieved that the credit card went through on its maiden swipe with no hitch-- thank you, Chase Slate Visa, for the no interest loan and for arriving just in time (yesterday) so that I could use you to pay for my oocyte cryopreservation cycle.

Then I got called for my blood test which was quick and painless.  After waiting some more for an exam room, I was seen by a doctor (not my usual doctor) for a quick pelvic ultrasound to see how my ovaries are doing.  She said that she saw about "six follicles on each side", that I'd likely start my meds tonight, and that I should expect a call from a nurse later today after my blood results come in.

At first I was a bit upset to hear that I only have about 12 follicles because, to recap, each follicle holds only one egg, so I thought that this would be the maximum number of chances I'd have at egg retrieval.  Also, sometimes a follicle holds no egg, or the egg it holds will be immature at the time of retrieval and therefore unusable.  It is highly unlikely that 12 follicles will result in 12 mature, retrievable eggs, which is why we want to see a higher follicle count.

But reading up on various IVF forums, it seems like part of the reason I'm taking the follicle stimulating hormones is to encourage follicles to grow, including small ones that may not have been visible on the ultrasound.  It seems like many women produce more visible follicles as the cycle progresses, so I just have to hope that the hormones do their magic, and that the next time I go in, there will be more follicles.

So I got the call around 2:30pm, and I am to start on 150 IU of Gonal-F and 150 IU of Menopur tonight.  Starting tomorrow, I just take the Gonal-F in the morning and Menopur at night, and then I go in three days later (Monday morning) for another round of blood tests and ultrasound.

I attended what will be my last yoga class for a little while this evening, because I can't do "bouncy" things while I'm on stims (for risk of "torsion", when the enlarged ovaries get all twisted up).  I thought it was an appropriate sendoff to my cycle.  Goodbye, headstands, I will miss you...

I'm relieved that I'm starting my cycle over a weekend so that I can process what is happening to my body in relative peace quiet.  I can let my body adapt to the medication, and I will have the time and head space to be good to myself, do restorative yoga poses (at home), etc.  

I braced myself for the administering of the medication.

I decided to start with the Gonal-F first because seemed more manageable, because it comes in re-usable "pen" form.  Each time I use it, I add a new (small) needle, adjust the dose, inject, and discard the needle.  To change the dose, I just twist the arrow to the amount I need.

I wanted to stab myself quickly as the nurse instructed me to and the woman in the injection training video did so efficiently, but after staring back and forth at the needle and my intended injection site for about 50 seconds, I realized that the two were not going to come together unless I did something, so I resorted to slowly pressing the needle into my skin.  It didn't even hurt, just a tiny pinch.  Pretty simple!  This is the one I'll do in the morning, so it's good to know that it's no fuss and pretty painless.

And now, time for Menopur.  I watched the video at the Freedom Pharmacy Teaching site about three times and re-read my notes from my injections class with the nurse to make sure I understood what I needed to do, and I was still nervous.  The tricky thing about Menopur is that it comes in powder form, so you have to mix the powder with a liquid solution called "diluent" before you can inject yourself with it.  My dose is "two vials" (each vial is 75 ml so it was a 150 ml dose), so I had to go through the mixing procedure twice.  I kept seeing air bubbles in the syringe that I couldn't get out, so I was a bit concerned.

Finally, I injected myself.  This time, the needle hurt going in, and the entire time I was pressing down on the plunger, I felt that unpleasant sting that certain shots have where you really feel the medicine going into your body.  I wonder if it's because the Menopur was cold-- I'm going to try to bring it to room temperature the next time I use it.  (I don't need to store Menopur in the fridge like I have to with the Gonal-F and Ganirelix, but it was 101 degrees in NYC today, and the nurse told me that it never hurts to keep everything in the fridge.)  The Menopur was a really unsettling experience.  I highly encourage the makers of Menopur, Ferring Pharmaceuticals, to work on a "pen" solution like the Gonal-F people have.

I reiterate that I can't believe that they let just anyone administer this kind of medication to themselves because it's a little complicated.  The most anxiety-producing aspect is how sterile everything has to be, and I'm scared that I'm not disinfecting correctly and introducing germs.

The injection sites were sensitive immediately after the shots, but no blood.  About an hour later, all redness went away, and my skin felt normal again.

After the mildly traumatic Menopur incident, I administered myself a scoop of pistachio almond ice cream from Blue Marble which I had ready to go in the freezer (bought as a post-injection reward earlier today).  I might need ice cream after every Menopur shot.  Thank goodness I don't have to do Menopur for another 24 hours.

Meds Today, Shots Tomorrow?

My hormones arrived today at the office!  It wasn't as fun as receiving a shipment of shoes from Nordstrom's, but almost.  

It was 97 degrees in NYC today, and I was a bit concerned because the Ganirelix and Gonal-F need to be refrigerated (or at least at room temperature), but fortunately, the chilled pouch it came in was still cool, though the ice packs were very melty.  I brought frozen gel packs into work from home, and I kept the packs and the meds in the office fridge during the day, and then repackaged everything (surrounding the Ganirelix and Gonal-F with icepaks) so that they'd stay cool on the sweltering commute home.

Today is Cycle Day 1.  Tomorrow morning, Cycle Day 2, I head into the doctor's office to have my blood test to check hormone levels and ultrasound to check how my ovaries are looking, and that afternoon they will call me and let me know if I should begin my hormones that night, and what the appropriate dosage is.  I continue to go in about every other day so that they can monitor follicle progress and adjust meds until I'm ready to take my final shot, the Ovidrel, which triggers ovulation.  I should be on meds for eight to ten days, but it might be slightly longer.

All of my injections are subcutaneous (i.e., fleshy part of the skin) instead of intramuscular (inside the muscle), which is good because it should hurt less.  Subcutaneous shots are generally administered in the abdomen or thigh area-- I'm aiming for the abs because I'm plenty fleshy there!  No injections in the butt like in the movies-- those would be subcutaneous.  I think where you administer the shot and how deep depends on the type of medication.

Why am I taking hormones in the first place?  Usually your body produces one mature egg a month during ovulation.  For my purposes (and for IVF patients who go through this same hormone stimulation process), they want to produce many more eggs to scoop them out all up at once.  During my cycle, they want to suppress all of my natural fertility-related hormones during this time and use synthetic hormones instead in order to grow my eggs (which grow inside of egg "follicles"), as many as possible (within reason), at the same time, so that as many mature eggs can be retrieved when the time is right.  The more responsive you are to hormone stimulation, the better your chances are of a successful outcome, primarily because then the doctor has more in his control over your fertility environment.  

My doctor hopes for "ten to 12 eggs" from me.  I'm hoping for more, because ten eggs doesn't give me a lot of chances.  I read somewhere that 15 eggs seems to be the ideal number (though I'm not sure the basis of that study-- IVF -- correlates with what I'm trying to achieve here), and many more eggs than that can mean that the patient was overstimulated (learn about ovarian hyperstimulation) and doesn't necessarily result in good quality eggs.  According to the article, in this study, during 2006-2007, if they retrieved 15 eggs for an IVF cycle, a woman age 18-34 had a 40% chance of a live birth, which was considered.  That number is quite low, so I'm hoping that technology has improved a lot since 2007 (I think it has) and that fertility rates are better at private clinics than UK public ones...

So here's what I'm going to take:

• Gonal-F -FSH, taken in the morning throughout my entire cycle, used to stimulate follicular development
• Menopur - FSH and LH, taken at night throughout my entire cycle, used to stimulate follicular development
  
• Ganirelix - taken at night starting around Day 7, prevents the pituitary gland from secreting large levels of LH which would trigger ovulation
• Ovidrel - Just a single shot that I administer timed 36 hours before egg retrieval for final egg maturation and release

Here are the amounts I've been prescribed, but I may take more or less depending on how my follicles are progressing:

• GonalF:
• 2 x 300 IU pen (2 refills)
• 1 x 900 IU pen (1 refills)

•  Menopur:
• 25 x 75 IU vials (1 refill) 
• plus syringes and needles because I have to mix these myself

• Ganirelix:
• 4 x prefilled syringes, 250UG/0.5ml each (1 refill)

• Ovidrel:
• 1 x prefilled syringe, 250 mcg (no refills)

You can see videos here of how the medications are administered.  The Ganirelix and Ovidrel are prefilled syringes so that's straight forward.  The Gonal-F is a prefilled pen and you can adjust the dose by twisting the pen to the appropriate dose.  That seems easy enough.  But it's the Menopur that's the most complicated.  I have to put together syringes and needles, mix multiple vials of medication, change needles, and then inject myself.  I can't believe that they actually allow just anyone to administer this medication to themselves-- there are a lot of careless people out there, and I could see them making a mistake in the dosage.

My biggest fear was the dreaded air bubble-- I mean, haven't many characters in books and movies died tragically from the unseen but deadly air bubble in their shot?  I asked my nurse this, and apparently air bubbles are only deadly when introduced into bloodstreams, not flesh, so I am at low risk of inadvertently offing myself.  Small comfort when I think of all the shots I have to give myself.

Cramps, Crankiness, and Countermeasures

I've been on the Pill for about 18 days now, and today I started getting really bad cramps, as if I were about to get my period.  I'm certain that my body is rebelling against the hormones, which makes me a little bit nervous because I am more likely to produce more/better eggs if I respond well to the hormone medication (rather than fighting it).  I'm already feeling so bloated and I'm wiped out by 10pm every night, plus I'm definitely a bit cranky and hypersensitive.  I have to be careful about acting as normal as possible at work.  I'm seriously wondering what's in these pills-- and what will happen when I switch to hormone injections!

So I end my Pill popping on July 18.  On July 22, I will go in for a blood test, and assuming all goes well, I will begin my twice daily hormone injections.  I am going to be on Menopur, Gonal-F, and Ganirelix (which starts a few days in).  I'm told that I should be consistent with my injections.  Given that I need to go in for bloods every other morning by ~8:00am, I will probably be getting up at 6:30am to give myself injections.  Ouch.

I am nervous about pumping my body full of hormones and not being able to regulate my mood through regular exercise.  I turn to yoga in these trying times, especially headstands, and unfortunately, due to the hyperstimulation of the ovaries, I'm at risk for "torsion", i.e., when your ovaries get twisted up from too much movement.  "Bouncy, repetitive motion" is forbidden during hormone stimulation, and nevermind inversions like headstands.

So I took a private yoga lesson with one of my yoga instructors who taught me a number of cool poses I could do in my delicate state (I sound like I'm preggers).  She says that the hormones will make my ligaments stretchier so I have to be careful about protecting them more.  The one pose she said is absolutely the best for relaxation and quieting the body is supta boddhakanasana aka "reclined bound angle pose" or "Goddess Pose", as my instructor calls it.  Here's an example of it.  For me, my instructor said that I should lay on a propped up bolster for more support (so instead of flat on the ground, so like I'm sitting up more).  See the blocks under the knees-- these are to support the hip joints lest my hip ligaments overstretch in my hormonal state.  She said that doing this pose for ten minutes a day is all the yoga I need.

I'm also considering going to acupuncture for treatment, if only it will help me to relax.  I once sought acupuncture treatment for lingering pain from a minor hernia surgery several years ago, and I will never forget how the acupuncturist was able to help "melt away" some of the tightness and pain in the surgery area in a way that no doctor, medication, or massage would.  I've heard that acupuncture can help with "fertility", so I figure it can't hurt.

I may also treat myself to a full body massage to help with relaxation as well as improve circulation in my body.  I'm assuming that this can only help, not hurt, fertility.

In the last few weeks, I have avoided caffeine and greatly reduced my alcohol intake after reading this Guardian article, and I think this is making me cranky.  I have few vices, but I miss my chilled wines and iced teas in this hot weather. 

So tired, need to go to bed now.

How I'm Paying For It

UPDATE, July 22, 2011:  I took advantage of a second credit card offer for a 0% APR on all purchases for over 12 months, so instead of the Citibank balance transfer, I will just charge my entire cycle and hormones on the two 0% APR credit cards.  Even better.

Original Post:

I was hoping for some beneficent loan program at RMA that would allow me to borrow $15,000+ at 0% interest, but no such luck.  I was handed a brochure during my initial consultation for some financial options provided by a third party company, but the interest rate wasn’t low enough to interest me.

I am in the fortunate position that I have some liquid assets, but as most of it is in stock that I don’t want to sell right now, I’m trying to come up with other options.

So I am going to do what may be a very foolish thing and charge this on no interest credit cards and pay it back before the APR goes up. 

I am a Citibank Platinum cardholder and was planning to take advantage of a current promotion: 0% on all balance transfers until November 2012 (with 3% balance transfer fee).  My credit limit on that card is sufficiently high enough to cover these costs, but I was a bit bummed that I’d have to pay 3% in balance transfer fees to borrow $15K (so $450), plus my debt to credit ratio on that card would not be at the ideal ~30% level.  I was all prepared to do it anyway.

Then a good and caring friend who is aware and supportive of my egg freezing plans forwarded me a Citibank “Dividend” credit card offer that she received—0% interest for 12 months, including purchases!  I applied immediately and got a $9,400 credit limit, which has the added benefit of lifting my credit ceiling (which means my debt to credit ratio is suddenly lower).  I plan to use this credit card for the entire $9000 egg freezing cycle.  I'm not sure if my FICO score is impacted by the high debt to credit ratio on a single card or if it's about the aggregate debt-to-credit ratio across all my credit lines, but at least it's an interest-free loan.  I may consider charging $8K on this credit card and put the $1K on my AmEx for some breathing room.

Then I plan to borrow $5K from the other Citibank “0% on balance transfers” offer and suck up the 3% balance transfer fee (now only $150 since I'm borrowing less on this card).  This amount should cover the hormone medication, anesthesia, and the anticipated $300 for FSH/Estradiol blood tests before I begin my cycle.  I will actually charge the meds to my American Express Cash Back card so that I can get 1.25% cashback on this amount, and pay the AmEx in full next month with the proceeds of the balance transfer (so I get 1.25% savings on the hormones). 

If there are any additional costs that crop up, I should have enough cash to cover it (I hope).

My overall debt-to-credit ratio should be ~35% so I hope that's an acceptable number.  And that number should go down by 2.3% each month as I chisel away at the principal.

I wonder of Suze Orman would approve of my strategy or yell at me.

In terms of paying back these amounts, I’ll make sure to keep up with minimum payments for both Citi cards, but I will begin by paying off the new Citibank “Dividend” card first since the 0% offer expires sooner (12 months from today) and I’m trying to improve the debt/credit ratio on that card ASAP, in case that matters.  The hope is that if I pay off $1000+/month, I will be able to pay off the Dividend card by May 2012 at the latest, and then I can focus on paying of the $5K left on the Platinum card between May and November 2012 (when the 0% expires).  

I am not making any changes to my monthly 401K contributions in order to pay back credit cards soon-- my company generously provides a match for my contributions, and it's stupid to turn down that match money in order to pay back 0% credit cards sooner when I have reasonable time to pay it back.  Suze Orman would surely approve of this decision.

I know that this payment strategy may tarnish my sterling credit in the short term because of the higher debt/credit ratio, but I think it’s the smartest way to do it given my options, and I don’t think I will be using my credit scores any time soon for a major loan.

If I could do one thing differently, I would have maxed out my Flexible Spending Account contributions for this year.  I absolutely thought about it at the time I was enrolling in FSA, but I didn’t want to risk maxing it out because I wasn’t sure if FSA could be used for egg freezing expenses.  But seeing how FSA debit cards are used, it seems like they're not that closely monitored, and in many cases, it's difficult for card issuers to assess whether the expenses are for infertility (covered) or proactive fertility treatments (probably not covered).  In Cigna’s list of eligible expenses, the only time anything egg freezing-related is addressed is under Donor Egg Extraction (which does not apply to me):  

Donor egg extraction - Procedural expenses paid for the process of donor egg extraction to treat infertility are reimbursable. 

And Infertility (which also does not apply to me):

Infertility - Medical expenses related to the treatment of infertility are reimbursable. Eligible expenses may include egg storage, egg donor costs, infertility monitors, in-vitro fertilization and sperm washing. Surrogate costs associated with a qualified dependent of the taxpayer are reimbursable and may include such things as blood compatibility testing and psychological exams. If the surrogate mother is not a qualified dependent of the taxpayer, the costs that the surrogate mother incurs are not reimbursable. Storage costs associated with the freezing of blood cords, embryos, placentas and sperm (sperm banks) are generally reimbursable when a specific medical condition exists. Additionally, these costs are reimbursable only for a limited period until they can be used to treat the existing condition (generally up to one year). Physician's diagnosis letter required.

Maybe next year I can use my FSA for the cost of keeping my eggs on ice...

The Bill(s)

Update

So I have been terrible about updating the blog, but I swear that being on the Pill makes my head fuzzy and drains my motivation in general.  (I'll explain shortly why I'm on the Pill.)

As it turned out, the 2009 RMA video was outdated and RMA has since entered the new age of vitrification, a huge relief to me!  This goes to show how new vitrification really is.

While I did check out NYU as a backup plan while I anxiously awaited an answer from RMA, I learned that NYU use vitrifications and/or the slow-freezing method depending on what’s called for upon examination of the retrieved eggs.   A nurse told me this, so no idea if this is accurate or not.

In any case, I’m moving forward with having my eggs vitrified at RMA.  My treatment cycle is to be on the Pill for 24 days, then go off of it for four days (to get my period), and then begin ~10 days of hormone injections to stimulate the follicles, and then egg retrieval/freezing.  

Not all women go on the Pill prior to their egg freezing cycle, but because my hormone levels were OK (FSH 8.36, Estradiol 31.2 based on the bloodwork done prior to my consultation; then FSH 7.1 right before I began the Pill), I guess they think that the Pill, which suppresses the ovary function for this month, can actually help the ovaries be more responsive to the hormone stimulation I am about to undergo next month.

I'm on Day 18 of the Pill.  I take my 24th Pill on July 18.  I go in for more bloodwork on July 22nd, and assuming my hormone levels are OK that day, I begin my injections that night.  Egg retrieval should be around the first few days of August, but actual date will depend on how my follicles respond to the hormones.  The progress will be monitored at least every other day during my hormone injection cycle to determine optimal retrieval date.

So all this means that I need to figure out how to actually pay for it since I have some big bills coming up soon.

How Much It Actually Costs

There are so many hidden costs in the egg freezing process.  They’re quick to toss around “$15K” as a number, but it really is closer to $20,000 depending on your treatment cycle.  NYU seems to charge even more (see their fees for services here), and the nurse told me that some of these fees are outdated, meaning that fees have gone up!

These are the initial costs I incurred to determine my eligibility for egg freezing:

• $300 blood tests for FSH, Estradiol (taken prior to consultation in order to evaluate and discuss results at consultation)
• $375 initial consultation fee 
• $200 pelvic ultrasound at time of initial consultation

>Initial Consultation Total: $875

This is the cost summary that RMA gave me once I decided to go ahead with egg freezing:

• $9,000 – Single Egg Retrieval and Freezing Cycle (includes cycle management fee; office visits, blood tests, and ultrasound during cycle; post-operative visit; freezing costs for one year) 
• $300 - Psychological Orientation 
• $750 - Anesthesia
• $4000 to $6000 - Hormone medication for stimulating follicle growth (variance is due to the fact that different women require different cocktails of meds; rule of thumb is that the more meds you need to stimulate the follicles, whether due to declining fertility or lack of hormone response, the higher the cost)

>Egg Freezing Costs: $14,050 to $16,050

The following future costs are not included, which I never expected to be included:

• egg freezing after the first year ($500/six months)
• egg fertilization and embryo transfer services (~$15K to $20K?)

Here’s the fine print:

• The services covered under the egg retrieval/freezing cycle (cost: $9,000) only begin from the start of your first injectable medication until Oocyte Retrieval.  Any services performed prior to the start of your medication is not covered.    This means that if you have any blood tests taken to measure your FSH and Estradiol levels prior to the cycle to determine how your hormones are doing, these are additional fees (for me, $300 each time).  If they check your bloods to see if it’s a good time to start your cycle and the levels are no good, then you have to skip that month and take the blood test again the following month.
• Before you can begin your cycle, they require a battery of blood tests to screen for infectious diseases such as HIV, Hepatitis, gonorrhea, etc.  Because many of these tests aren’t standard, your insurance won’t cover it unless there’s reason to believe you’ve really been exposed to unusual viruses.  This bloodwork cost me $637.
• Another pre-cycle requirement: they require a recent pap and culture results (I think within the last six months).  I was able to transfer these records gratis from my OB/GYN to RMA because they’re both within the Mt. Sinai network, but if that were not the case, I may have had to pay a fee for document transfer. 
• For my particular treatment cycle, I am on the Pill for 24 days prior to hormone stimulation.  So I will need to obtain two months of the Pill (since each pill pack only contains 21 doses).  My insurance will cover this, but if yours won’t (or if there are restrictions on how soon you can refill the second pack), you will go out of pocket.  For me, it’s a $10 copay for me for each pill pack. 
• I will be on antibiotics for a week after the egg retrieval—it is surgery, after all.  Again, insurance should cover it ($10 copay for me).

These are the unexpected expenses I will incur (those marked with * are anticipated costs to come):

• $300 – check for FSH/Estradiol levels before I began the Pill
• $300* – I expect that I will have to pay to check my FSH/Estradiol levels on July 22 before I begin my hormone injections [UPDATE July 22, 2011 - I had bloods/ultrasound this morning to see if I would begin my cycle today, and they did not charge me for any of the tests they ran today, so I guess this is not a charge that is incurred unless the plan is to push the cycle by one month]
• $637 – infectious diseases pre-screening
• $20 – two pill packs (co-pay for insurance)
• $10* – copay for antibiotics

 >Unexpected Costs Total: $1267

So here's my Grand Total:

• Initial Consultation Total: $875
• Egg Retrieval/Freezing Total: $14,000 (my meds seem to be coming in <$4000, fingers crossed)
• Unexpected/Hidden Costs: $1267

>GRAND TOTAL: $16,142

Gulp. 

And this is on the lower end of my estimates because I'd slotted in a $5K estimate for the hormones.

But I have a plan to pay for all this which may be either very stupid or pretty strategic.  Or both.  More on that tomorrow.