To lap or not to lap, that is the question.

Hi folks!

I have so much information to process right now and decisions to make.  Most of the details below are to help me think things through -- there will be a brief summary at the end if you want to skip it.  :)

I think bullets will do it best:

• We really like the new RE (gonna call him Dr. Smiles).  He has a much better bedside manner than my old RE (renaming her Dr. Six-times -- Dr. Six) and seems to genuinely care about what he's doing.  Like I think he might actually remember who I am from appointment to appointment kind of "caring."  On first impression, the old office is fancier (i.e. more nicely decorated) and seems more "official" but the new one seems much more personal and the doctor is more involved in everything. (I think he knows how his office looks in comparison to the other one because he mentioned how he is building a new space across the street but that his office is state of the art. I think he almost feels like he has to defend himself against it.)  He is private practice while the other office is part of a school.  And, I honestly don't care what it looks like as long as it works!  I think his office is busier, though, and has far more cycles going on.  He, obviously, knows the other doctors (it's not that big of a town), and has mostly good things to say about them, but I think he understood why we were there.
• He seemed pretty surprised at how casually we'd been treated at the old office.  He felt like there were several red flags that were popping up in my file that showed that something was up and that we should be moving forward more aggressively than we have been so far. He was surprised that Dr. Six wasn't more aggressive when she did the hysteroscopy last year and was disappointed that she didn't investigate more to see what was happening with my left tube.  He asked with a quizzical look "So, this last beta in July is still from the pregnancy in April?  They just tested until it was zero?  And then just let you go?  Huh."  Yeah, that's what I thought, too.
• He started off essentially saying that looking at my chart he thinks there is a decent chance that I have some degree of endo. Which is interesting. He thinks it could be the cause of my intense mid cycle pain and pain during sex. When I've asked other doctors about this (basically every OB/Gyn or RE I've had since I became sexually active), they've brushed it off as ovulation pain that I must just be more sensitive to. Yes, I know it is due to ovulation, but it seems like it shouldn't be so painful that it can hurt to walk when I'm about to ovulate -- even when I'm not on fertility drugs.
• He did an u/s and talked a lot about what he was seeing. First off, can I tell you how much I appreciated that he did the scan himself and showed me what he was seeing and what it meant while he was doing it? I liked the u/s techs at the old RE's but I felt like I never knew what was happening. The tech would do a scan, I'd go sit in a room, the nurse would come to me with a report, some time later that day the nurse would show the scan to Dr. Six and sometimes I'd get a "correcting" phone call in the evening. I realize that they're all very busy, but I never felt like I had any idea what was going on.  And, obviously, Dr. Smiles won't always be able to spend that much time with us, but I feel like he'll always be willing to talk with me about what we're looking at.  He recognized that my DH and I are intelligent, well-educated scientists and that we can be trusted to understand medical terminology and statistics. (And, even if we weren't, I think anyone would like to be treated like they deserve to know what is going on!) 
• He found a decent sized fibroid that he says is in a "gray" area -- not a definite issue but could be. He said he was surprised at the number/size of follies I had while having an extremely thin uterine lining (would have expected there to be more estrogen present) and wants to do some blood work. He's concerned about my uterine lining in general and wonders if there is something hormonal going on.
• He took lots of blood for both hormone levels and vitamin deficiencies, etc.  (Woohoo for someone actually thinking data might be helpful when making decisions without my having to ask...imagine that.)  Hopefully results will be in tomorrow.
• He said that my DH's sperm count/quality is in the upper 3% of patients he has seen and that he should keep doing what he's been doing.  He said he seems to have contributed enough sperm in our previous 4 IUIs for 20 women.  (At least one of us is "excellent.") He said "you're having sex with a very fertile man -- something is wrong if you aren't conceiving."
• He doesn't seem too concerned about the miscarriage and is focusing on the positive side of it.  I am, too, at this point... at least I'm trying to.
• He's recommending injectable IUIs.  ("High octane" as he called them.) Surprisingly, I think I'm OK going that way. I felt more comfortable with his recommendation than I have with the info we've gotten from Dr. Six in the past. It seemed like he thought it through and thought it would give us a good chance. And, he knows the multiples risk and will be cognizant of that throughout.  But, he also seems to have a reasonable idea of how long we should try it before moving on. And, if we were to try IVF, we'd probably need to wait until the summer, anyway, so we might as well try this, now.
• He's recommending a lap because he wants to see what is happening with my tubes and investigate the possibility of endo.  He seemed less certain of the endo by the time he'd finished the examination, but still suspect.  I'm not sure what we're going to do there. If we can get our insurance to understand that it is for pain I will likely do it -- before we try any treatments because after that I'm certain they won't process it. But, we've had problems with my insurance before, so I'm not sure if it will happen.  For one thing, we've learned that they seem to refuse to pre-approve anything but might suddenly "un-approve" it after the fact. (There's also a possibility that our insurance company is about to drop the hospital he works for -- we're really hoping that a last minute negotiation keeps that from happening.) We can't afford to put all our money into a surgery that could very well find nothing and then have nothing left over for treatments. I'm not sure what to do.  I'm both afraid to do it and afraid not to do it.  (I was in this exact position about 14 months ago...)
• I like the staff -- the nurse was really nice and did an excellent job of drawing blood.  The rest of the staff seems really friendly, too.  
• There was a woman in another room that we could hear singing along to her iPod as she waited for something and Dr. Smiles and the nurse were both just really sweet about it.  They said "She's really happy and I hope that vibe gets to her ovaries, too."  I don't know, it just made the whole office seem really comfortable and made us all grin. 
• Did I get all my questions answered?  No.  Despite having them written down in front of me, I still managed not to ask some of them.  Yeesh.  I got so taken in by the discussions we were having with him that I got distracted and didn't manage to ask some of it.  But, I'll be talking to them soon and asking some of what I forgot. (Specifics about costs, pregnancy loss tests/differences "next time.")

My DH says that it's pretty obvious we should "officially" switch to Dr. Smiles.  The way he put it was that "He said everything you wanted to hear."  I asked him if that meant I was being taken in by a spiel?  (Dr. Smiles is definitely a good salesman.)  He doesn't really think so, but does think that it is obvious that I feel more comfortable with him than with Dr. Six.  So, I think that's where we're going no matter what we decide to do.  

Interesting side note -- his wife had five m/c in between their son and her current pregnancy (over 20 weeks after their fourth or fifth IVF -- he has all her u/s pictures on a board in his office).  I'm not sure if this makes him *too* understanding about this process or if it is a good thing.  I think it is a good thing.

I also realized I've come to a decision -- I'm willing to throw everything we can at this for one more year.  After that, I need us to move on with our lives one way or another.  So, it's time to be aggressive.

So, in summary: 

• We are happily switching to Dr. Smiles.
• We're waiting for some bloodwork.
• We're likely going to start doing injectable IUI cycles for a few tries.
• We may or may not be doing a lap -- any thoughts out there?  

Thanks to everyone for checking in on me! :)