Cycling in the US from abroad

When we first started TTC when I was making plans for my life I would plan my future travels, adventures, and activities around the fact that I might be pregnant.  After “might be pregnant” stubbornly refused to happen (at least in any longer-term fashion) I realized that it was kind of a waste of my life if I was not doing things I wanted to do because I might be pregnant when pregnancy was about as common around here as a whole herd of rainbow-farting unicons (as Kymberli so eloquently puts it).  I decided I was going to do with my life what I wanted to do, d*mn it, and infertility could s*ck it.  So that is how I ended up doing two and a half cycles in the US while living abroad, in two different countries.

Since I was used to cycling at clinics that are far from my tiny, RE-less home town,  I didn’t expect that cycling from other countries would be all that different, they would just involve longer travel time.  But there are a bunch of special pitfalls and issues that arise, particularly when you are working with a US clinic from different medical systems. In this post, I wanted to note what the issues were and how we learned through trial and error to handle them.  This post is written from the point of view of a US resident working with a US clinic from afar, but some of the material is likely also relevant to foreigners who want to work with a US clinic.

1. Consider carefully whether you should cycle remotely from abroad or use a local clinic in the foreign country where you are residing.

This is obviously the first question you need to answer.  In our case the answer was pretty simple, because we are doing DE w/ an unknown, but contactable donor, and due to regulation that was pretty much impossible in or near the countries where we were living.   But even if we could have cycled locally, we probably wouldn’t have, because we would have had to start the difficult process of searching for a clinic we trust all over again.

More generally, in deciding whether to cycle locally, you need to know something about the regulations used for IVF and how they are going to affect your choices about your cycle and the resulting success rates.  For example, Italy recently passed strict regulation of IVF which allows no more than 3 embryos to be created and which requires all 3 embryos to be transferred.  Obviously limitations in the number of embryos that can be created are going to reduce the success rate of an average cycle, and depending on the circumstances regulations that allow the transfer of only a limited number of embryos may affect your success rate as well.  There are certainly legitimate reasons why countries may want to regulate IVF in tighter ways than is currently the case in the US, but what you need to think about is whether you will be able to cycle the way that is right for you in the country you are planning to stay.

Another issue, of course, is cost.  I do not need to tell you, my dear infertile reader, that the US is a very expensive place to cycle, and if you add onto that the costs of international flights and the need to stay in hotels for a substantial amount of time during your cycle it doesn’t look pretty.  Often cycles in other countries may be substantially less expensive.

2. Use a clinic that is used to cycling from abroad and has a system in place to deal with it.

A prior clinic that we used had its systems set up with the expectation that you were a local resident (despite the fact that it had a ton of out-of-town patients).  When you did tests away and had them faxed in, they always lost them and it would take several phone calls and faxes before they had the results.  It was extremely difficult to reach people by phone and you were always waiting for callbacks.  Email seemed to be a foreign concept.  “My” nurse had no clue who I was unless she had my chart in front of her and would have to reread it.

These things are annoying if you are an out-of-town patient in the US, but they are really going to be a kink in the works if you are also dealing with a substantial time difference.   There are a thousand ways something can go wrong and if you don’t have good communication set up with your clinic the window of fixing the problem may disappear before they even realized something was up.

Our current clinic advertises on its home page that it can handle cycles from abroad, and it can.  It has a great communication system – I can reach people easily by phone and by email, and I usually get a response the same day, even from the RE and even about non-urgent stuff (and email is really super helpful for communication across radically different time zones).  When they say they didn’t get a test result, I know they really didn’t get it – they have never lost anything.   Even though I almost never see them in person, I feel a close sense of contact with them and all my health care providers  know and respond to my individual situation.

3.  Find a local health-care provider who can help you navigate the foreign health care system – ideally an RE.

When I did remote cycles from within the US, it was always pretty straightforward to deal with things like bloodwork and ultrasounds – I would just walk into an urgent care center, show them the paperwork from my RE (and my credit card), and we’d be off to the races.  And, for the meds, my clinic would call in prescriptions to my local pharmacy or a mail-order pharmacy and there they would be.

This does not work out so well when you are abroad.  Sure, I’d had a couple of HCG tests abroad and done it this way (the worst was when I showed up at Christmas time at a hospital in Mr. Nishkanu’s home country asking for a beta test, and the nurse cheerfully said “Weren’t you here for one of these last Christmas too?”  Yeah, and it was negative then too.  Thanks for the reminder.)  But for the full gamut of pre-cycling needs you really need someone who is connected into the system.

In my experience, other medical care systems are simply not ‘customer-focused’ in the way I was used to in the US, and it frequently takes a professional who knows what they are doing to get results.  In one case, I was not able to actually get my beta results (either given to me personally, nor told to my clinic) for 5 days, until I found a local nurse who just made one phone call and told me the result.  This while I knew I was not pregnant yet had to keep giving myself PIO shots “just in case”.  Grrrr.

In practice, a general practicioner is the minimum you need – someone who can prescribe medication, ultrasounds, and bloodwork for you.  But if you are at all able I would strongly recommend that you find an RE who is willing to do your cycle monitoring.  This will save you many explanations and possible errors made by well-meaning but fundamentally clueless health providers (trust me, it is a bit worrisome when you realize that you know a lot more about infertility treatment than the person who is your gatekeeper to meds and tests).

And now I want to take a time-out to write a little Ode to Joy about how great our local RE is on this cycle.  We chose him 100% because of his proximity to our home – after all, he is just doing some bloodwork and ultrasounds, we don’t need anything special from him.  But special is what we got.  Here are some of the amazing things he does.  He takes endless time for our appointments, even though we are ‘just’ monitoring patients.  He calls personally with all test and blood results, even boring things like estradiol levels.  He gave us his home number to call when our meds got stuck in customs and we were worried our cycle was going to be derailed (see below).  Although he was only supposed to be monitoring,  he cheerfully wrote me prescriptions  for the meds that would not arrive in time.  And everyone in the office is so nice.  I *heart* them.  But I digress.  And speaking of medications…

4. Purchase as much as possible of your medication (including ‘things I might need, you never know’) in the US beforehand and/or while you are there for your cycle.

As is blindingly obvious once you think about it, yet did not occur to us beforehand, American doctors cannot prescribe medications abroad (i.e. a prescription from a US doctor will get you nowhere, at least legally, at a foreign pharmacy).   This leaves you with three options: order your meds from the US; get your local provider to supply you with meds; or play it safe and buy the meds when you are in the US (even if you have to e.g. buy 10 weeks of PIO before you know if you got pregnant).

Now if you order the medications from your favorite US mail-order pharmacy, they will get hung up in customs.  Trust me, we learned this one the hard way.  In one case, our sent-by-express-mail meds arrived a month after they were sent (though our BFN in the meantime had conveniently rendered the medication not needed).  In another case, we did desperately need the meds and spent a harrowing week on the phone with fed ex trying to get the meds out of customs, which had declared them illegal for importation (this was after our pharmacy had assured us that they could definitely, no problem, send us the medication to where we were living).  We did finally get them out by showing lots of proof that I was a US resident only temporarily in the country.   But we got them too late to use one of the medications, and had to buy a local version of it in addition to what we had ordered.  If you know the cost of fertility meds, then you know – ouch.

Now if you have followed suggestion #3, you have a local doctor who can write up all your prescriptions for you.  That is certainly a good option and is really important if anything unexpected comes up in your cycle.  The one caveat is that you may not actually be able to get prescriptions for the medications your clinic wants you to use.  For example, in one country where I lived it was not possible to get Lupron.  Instead, I got Decapeptyl.  Decapeptyl is similar in action to Lupron, but not the same thing.  And the further you get away from the drugs your US doctors are used to using, the less benefit you are getting from their experience.  Their protocols are optimized for the drugs they normally use, not whatever drugs you might be able to get.

In my opinion, if you are spending all the time, effort, sanity, and money to go through a cycle, then it’s best not to add any complications that might reduce your chances.  For this reason, whenever possible we planned ahead and had the meds shipped to us when we were on American soil.

5.Don’t forget about jet lag.

Whether this is an issue will depend, of course, on how big a time difference there is to your clinic.  One thing I can tell you from sad experience, though, is that if you have a time difference that is normally at least somewhat challenging to overcome, you will have a much greater challenge overcoming it during your cycle.  This is because, at least for me, it is a lot harder to get over jet lag when you are stressed out.  And when you are cycling, there is a certain amount of stress involved.  I expected to be over my jet lag in a day or two, but I have been home for almost a week and I have yet to be able to sleep more than 5 hours a night, and often substantially less (I usually need 8 hours to function)***.  I am now intimately familiar with the part of the night from 2 AM onwards.  There’s not much you can do about it, but it might be smart not to plan that you will get too much done for a while after you get home.  My major goals for the day right now are: (1) remember to eat and (2) remember to take my meds – and believe me, that is sufficiently challenging.

  • ** Update to add: just found out my thyroid values are screwed up.  So maybe that’s why the adjustment has been so hard.  But I still hold by the stress = bad jet lag adjustment from previous experiences…

Things to consider if your cycling method is illegal in the country you are in (e.g. donor egg/donor sperm):

One  of our DE cycles was done in a country where DE is illegal.  I didn’t anticipate any problems since the actual DE part was done in the US.  But there were some tricky issues for my health care provider, since it was not clear whether it was actually legal for him to help me with my DE cycle.   Fortunately he was willing to do it for me anyway, and I found out later that it is very common for doctors in this country to do cycle monitoring for out-of-country DE cycles.  But to avoid problems you may be wise to do the following:

1. Research the IVF regulations in the country ahead of time so you know if there is anything they would consider unkosher about your cycle.   Note: I wouldn’t think that technical issues like how many embryos that country allows for transfer are anything you need to worry about.

2. If there is something that could be legally problematic about your cycle, make sure your local health provider knows about this up front.  The last thing you want is to get part-way through the cycle and then find out that your health care provider is uncomfortable with continuing to treat you.  Find out from your health care provider whether s/he thinks this will be an issue in any way.

3. If your health care provider indicates that it could be a problem, remove references to the legally problematic aspects from any written records you give your doctor to avoid putting them in a compromising position.  In our case, the referral letter from my US RE did not say anything about donor egg in it.  When I gave my doctor my cycle schedule, I went in and edited it to take any references to donors out – fortunately my clinic sent me this stuff as an Excel spreadsheet.

Have you cycled from abroad?  Are there things I am wrong about, or didn’t include?  Please add in the comments.

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2 Comments »

  1. Just stopping by to say hi. i saw you are new on Mel’s blog list.

  2. circlesbecomeme said

    This is super helpful! Thanks for posting it. I

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