IVF #4: The Insurance Dance

I swear... the most stressful part of going through IVF isn't going through stims... or having endless monitoring appointments. It's trying to get the darn approvals through my insurance.

What an absolute headache.

Medical Insurance

I received my approval for infertility coverage, which was good. But then I found out that they would not cover ICSI. Why? Because they said they only cover it if there is a semen analysis (SA) issue. The reasoning is: I'm using donor sperm, therefore there is no SA issue. Doing traditional insemination with IVF isn't really that reasonable since ideally you would have more sperm. The donor I have is an ART vial, meaning there are less sperm in the vial. It's itty bitty. I'm contesting the decision, but I can't help but be annoyed / irritated that they would say any one using donor sperm doesn't qualify for ICSI coverage. There is a reason people use donor sperm.

Reminder of what ICSI does:

Pharmacy

I ordered my meds last week and I barely just received them today. Why? Apparently they needed all these approvals and they didn't let me know they needed them and they didn't try to get them on their own. When I finally figured it out, I had to wait for them to go through their process of approving the coverage. Then, they ended up shipping my meds at the wrong time. Just an absolute mess.

Cycle Pay Day and Injections Training - 10/11/18 

Which led to my cycle "pay day" and injections training. I ended up having to pay for ICSI, which was unexpected and more than I budgeted for. Costs breakdown:

IVF Clinic: 

• Co-Insurance: $330 
• PGS Biopsy: $2,250 
• ICSI: $1,525

Meds: $1,579.55

Total for this week: $5,864.55 
Total Year to Date: $6,018.67

Costs TBD: PGS Testing - $150 per embryo + $150 Shipping

I've officially hit my max out of pocket for my insurance for the year. Even with insurance coverage, not a lot is covered. 

I had my injections training... which you would think wouldn't have been a big deal - but you'd be amazed at how much I've forgotten. It was a nice refresher! Also, all the paperwork!!! Oh my... Signing my life away with waivers and deciding what would happen to my embryos "if" such and such happened. 

They even talked to me about "family planning" and if I wanted to choose a boy/girl for transfer... I think most people expect me to say "I want a girl" considering I have two boys. But really, I just want another baby. Boy or girl. It doesn't really matter to me. I also don't know if I'm going to have options, so I don't want to get stuck on a boy/girl just this moment. 

Before the injections training, they did do a quick ultrasound to check for cysts. No cysts, I'm in the clear. But they didn't count the follicles, so I feel kind of in the dark about how many follicles I'm working with this cycle... if we go off what they found last month - there were 9. 

BOB Arrived 

Even though the week kind of sucked trying to deal with the insurance and pharmacy issues... hours and hours on the phone. (Just to note, I had a stressful week at work and worked over 50+ hours - so it sucked just that much more trying to find the time to call.) Receiving the Big ol' box of meds was... amazing! 

There's something about receiving all my meds that made this feel so real. It also made me start feeling all the feels about, "I really want another baby." I may have shed some happy... anticipatory tears... at the possibility of this potential baby. 

Piper Patch IVF Notebook

A local SMC friend, that went through IVF, developed this amazing IVF notebook!! I was so excited to receive one. I loved the package and the cover. I'm absolutely loving the notebook for tracking this IVF cycle, I feel so organized :) I really wish I would've had something like this when I was cycling the first time, it's super useful. I'll be sharing some pages from the book as I use them. 

Link to the website: https://www.piperpatch.com/

My IVF Notebook: 

My IVF Calendar

Here's my calendar spread from the Piper Patch IVF notebook: 

Next step is to stop birth control tomorrow, 10/13/18.

Feelings

My relaxation going into this cycle is completely gone and is non-existent after this week!! Dealing with the insurance, the extra costs, the pharmacy, the approvals, work deadlines, and work "issues" -- I've just about had it this week.

I'm also really feeling the "I want another baby" feelings... which worries me if the cycle doesn't turn out the way I hope it does. Would I even be able to afford another cycle at this point? I don't know if I will... But I also don't know if I won't try anyways... My heart is "all in" with adding to our family, I just have to make sure I keep my head in the game and make good decisions.

After a rough week, I'm going to try and get back into a more mellow frame of mind and relax. I'm going to try and enjoy spending time with my boys this weekend.

Here's to hoping and wishing and dreaming...

IVF #4: IVF Calendar has officially arrived

It feels like such a long time to get this IVF cycle started... and here I am -- ALMOST there!

Since the last time I wrote: 

1. I stopped birth control on 9/17/18, as directed from my RE. 
2. AF arrived on 9/20/18. I called my RE's office and my next directions were to start birth control again on 9/22. 
3. TODAY I received my IVF calendar. 

Some random things I forgot: 

• I tend to spot while I'm on birth control. So, it was kind of hard to determine if I was having the start of my period or just spotting from the birth control. 
• The WAITING for everything feels so very long... like insanely long. I thought I'd get my IVF calendar right away. Nope, just got it. 
• I have to give up caffeine during stims.... oh no... what ever will I do without my one cup of coffee in the morning... I feel total sadness over this, which is silly. LOL. But man, I love my morning coffee! 
• My mood swings on birth control are so bad. I swear, I hate being on it. I know it's going to get worse when I start stims. 

Things I didn't know: 

Apparently I needed to register with my insurance for something called the "Women's Health Program." I don't recall having to do this before. Maybe I did? Maybe I didn't? Maybe it's new? Who knows... But, this has to be done in order to get my insurance fertility benefits to kick in. So they asked me all these questions like, "have you been trying long to have a baby," "Do you have irregular periods?" etc etc. It takes about 5 days before they approve it. I'm waiting for the call back from a nurse to see if they'll even approve my fertility coverage... which I think is odd since I don't believe my employer has any stipulations on the lifetime max fertility coverage. 

My response: "I have not been trying long as I'm single and will be using donor sperm, so not like I could be trying." Then: "I've also been diagnosed with unexplained infertility, which should be in my records." Because umm, my insurance provider has not changed. Man... insurance companies annoy me. Jump through hoops, I swear. I'm concerned they're going to deny coverage or something, say I need to try 6 times before coverage kicks in or something like that. But I'm not going to stress about that at the moment and cross that bridge if it comes. I have low AMH, so I believe I can also use the "diminished ovarian reserve" argument as well. Will see. 

Medication Order: 

My medication order was submitted to a different pharmacy... which I thought was weird. I had to call them to request them to send it to my normal pharmacy. Which means I should be getting my BOB (aka Big Box of Meds) either late this week or early next week... When I receive that... it'll start feeling extremely real to me. 

IVF Calendar: 

1. 10/10/18: Injections Training and Cycle Pay Day 
2. 10/13/18: Stop Birth Control 
3. 10/16/18: Start Microdose Lupron 
4. 10/18/18: Start Stims - Protocol: Microdose Lupron Flare Protocol  
5. 10/22/18: Stim Day #5 - First monitoring Appointment 
6. 10/29/18: Estimated Day of Egg Retrieval 

Thoughts: 

Everything with IVF is so completely unpredictable. I have no clue if I'll respond well to the protocol or not. If I'll even make it to egg retrieval. I want to say I'm optimistic... and I am, in a way. However, with everything that I went through before - I know I need to be real with myself. I'm trying not to have too many expectations and just go with the flow. So far, I've managed to do that and just roll with it. But at the end of all this... I really want another baby. I feel totally invested in adding to my family. 

So... fingers crossed and baby dust sprinkling all around that there's at least one good egg in there. 

IVF #4: Saline Ultrasound

I had my saline ultrasound (SHG) this week. I’ve had this test two times (?) prior. The first time was with my initial fertility tests when I first started back in Dec 2014/January 2015. At that SHG they found some uterine defects, which they thought were fibroids: 

https://creatingfamilyc.blogspot.com/2015/01/sonohysterogram-fibroids.html

This finding delayed TTC since I had a hysteroscopy and turned out that I had a polyp: 

https://creatingfamilyc.blogspot.com/2015/02/surgery-i-survived.html

That was my first ever surgery (besides wisdom teeth removal). 

Going into this SHG, I didn’t really think much of it. I wasn’t really nervous or worried too much about the results. Mostly because worrying doesn’t change the results. I actually expected them to find polyps. 

The actual SHG wasn’t too bad. Some cramping and discomfort, but nothing crazy. Well, turns out I have a lot of uterine defects this go around. Like a bunch! They are most likely polyps. 

The suggestion is to have another hysteroscopy to remove them a cycle prior to a transfer. 

A few things to consider: 

1 - I won’t be doing a fresh transfer. There won’t be time to do the hysteroscopy prior to the October retrieval week (unless I pushed it back - which I don’t want to). 

2 - when do I have the hysteroscopy? If I do it this year, the cost is significantly lower because I’ve met my deductible and have almost met my co-insurance. If I wait until next year, it would be approx $1400 vs $250 this year. 

3 - it’s better to do the hysteroscopy the cycle prior to a transfer because it’ll serve as an endometrial scratch. Which I did for my successful FET that led to my son: 

https://creatingfamilyc.blogspot.com/2016/08/fet-2-cycle-11-endometrial-scratch.html

4 - I wasn’t planning a transfer until summer 2019. Do I move it up? Maybe do the hysteroscopy in Dec and a FET in Jan? 

So... I’ve been thinking about all these different scenarios / possibilities. I’ve decided not to really make a decision until we see how my cycle goes. Since I’ve had 2 failed IVF cycles before, I’m still really cautious to keep my expectations realistic. Nothing in my lab work is leading me to believe that I’ll have an easier time this cycle. 

Right now, the plan is to still wait until summer 2019 for a FET. I think the age difference between baby #2 and potential baby #3 is more important to me. 

Lab Results 

My AMH went down since Dec 2017 from 0.75 to 0.64. Which is bad. 

My FSH went down since July 2018 from 10 to 7. Which I think is good. 

A low AMH is supposed to show diminished ovarian reserve (DOR) and also that I may not respond well to follicle stimulation... 

Costs 

I received the cost for my cycle and it’s not too bad, considering I am in co-insurance land. I also have a lifetime max fertility coverage from my company, which I will exhaust with this IVF cycle. If I need another IVF cycle, it’ll be completely out of pocket (~$13k + ~$5k for Meds). 

- Cycle Cost: $1300 My out of pocket co-insurance - includes IVF monitoring + retrieval 

- PGS Cost: $2250 to my clinic + costs to the PGS testing company. $150 per embryo + $150 shipping 

- Fertility Meds: TBD 

Thoughts 

In a way, a lot of stuff is riding on this cycle working! Between DOR, polyps, & costs... Things can go so many different ways... I almost can’t wait to get it over with, just so the mysteries of the “what if’s” can be resolved. 

I’m still not feeling too overwhelmed with the cycle yet. However, I am pretty short-tempered on birth control and I’m also retaining a lot of water. I really hate being on birth control! 

Overall though, I’m doing ok. I just want my IVF calendar so I can start planning. I should get it next week / week after, once AF starts. 

Next Steps: 9/17 stop birth control and wait for AF 

IVF #4: Baseline Ultrasound + Bloodwork

My cycle is officially underway... kinda. 

Waiting for AF

AF finally came 11 days after my last provera pill. I always wonder if provera stalls my period from coming naturally and delays it. 

When AF finally came, I made the call to my RE to schedule my baseline ultrasound and blood work. It’s so strange... but it was really exciting to schedule my appointment and to begin prepping for my cycle. 

Baseline Ultrasound 

My ultrasound was with a different RE. She’s the newest RE at my fertility clinic and was there for one of my IVF procedures when she first started. She’s nice and all, but I really do prefer my RE. Interestingly enough, I had 9 follicles - 6 on the right and 3 on the left... which is the same number of follicles I started with when I had my one and only retrieval. 

Blood Work 

Had massive blood work taken....! Interested to see what the results show with my AMH & FSH. I really do hate having my blood drawn. 

IVF Calendar 

No “official” IVF calendar yet... they started me on birth control, which I’m supposed to take from 9/4 until 9/17. I’m only taking the active birth control pills. Then, I’m supposed to call when I start my next period. After that — I am supposed to get my “real” in-depth IVF calendar. 

I scheduled the saline ultrasound for 9/10. 

Thoughts 

It kind of feels surreal starting down the IVF path again. I guess it’ll start feeling more “real” when I start injections. But right now... it just feels far away - if that makes sense! Life is so busy with my boys and work, which keeps me pretty occupied. 

My oldest son keeps talking about having a baby sister and also has said he wants another baby brother. He brings it up himself from time to time, which is interesting! 

I am most anxious to see how the cycle turns out... I’m not sure how many times I’m willing or able to go through IVF this time. I’m really hoping that 1 retrieval will do the trick. 

I remember going into my fertility clinic when I first started and seeing all the pictures of babies on the walls... I have to say, seeing the pictures still brings so much emotion out of me. Babies are such miracles... and it’s pretty amazing how fertility clinics help these miracles come into the world. 

My miracle IVF baby is a happy and healthy 15 month old now! 

So grateful and thankful  for my boys. 

Next Steps: Sonohysterogram (Saline ultrasound) on 9/10/18 

Delay in IVF #4

It’s funny... I almost forgot how crazy doing fertility treatments can make you and how nothing ever goes as planned! 

My Period is Late 

After my consult, I was started on Provera to try and induce my period. I had just weaned and I guess my hormones are all out of whack because my period decided not to make an appearance. I started to worry, but there’s really nothing that can be done. It needed to come by 8/26 in order to make the September retrieval dates. 

The Plan: October Retrieval 

Since my period didn’t happen, my cycle will be pushed back to October. The reason October sucks: retrieval week is the week of Halloween. 

I’m hoping I’ll be able to get a retrieval date AFTER Halloween... Halloween is a big deal for my son & I don’t want to miss any of the fun stuff we do as a family. 

If I waited for the next retrieval, it would be the week of my son’s birthday. So way worse than Halloween week! Both weeks are not ideal, at all. Which... is so typical of doing fertility treatments. 

How I Feel 

I’m a bit disappointed that I didn’t make the September retrieval... it was the best one that fit into my schedule and my life. I also had a pretty crappy week! 

1) The baby got Hand-Mouth-Foot Disease (HMFD) for the 2nd time in one month. The odds? Very slim. I’ll write a separate entry on HMFD. 

2) No childcare provider will watch children with HMFD. So no daycare and no backup childcare. 

3) I had deadlines at work, so had to work from home with a VERY clingy baby. Meaning I didn’t get much done and had to work after he went to sleep. Then, he wasn’t sleeping well - so I was operating with very little sleep. 

4) My older son had major issues at daycare, behavior wise. 

5) My older son ended up getting HMFD as well. 

6) I had a drama filled week at work.

7) Then - my period didn’t come and the cycle got delayed. 

Crappy, crappy week. 

But it’s funny... because even with all the variables - it didn’t feel “too” bad, like it was unmanageable or anything. Just very inconvenient! 

Where the cycle is concerned... yeah, sucks to delay it. But I figure it’s going to happen when it’s meant to happen. I’m way more relaxed about it (at the moment anyways!). Easy to say now when I’m not on fertility Meds! Lol. Really though, this stuff never has gone as planned and when things don’t go as planned it can be stressful. It doesn’t feel stressful yet. I’m really hoping my “relaxed” state will continue as I go through fertility treatments. 

Next steps: Wait for AF... 

Back on the TTC Wagon - Trying for Baby #3 - IVF #4 Begins

A few months ago I posted that I was thinking of Baby # 3 (post link: Thinking of Baby 3). Well... Ive decided to move forward!!!!

Initial RE Consults

December 2017 - Consult with different RE
When I started thinking about trying for baby #3, I started to consider another RE. I have a few friends that used another RE and they absolutely loved him and say only great things about him. I thought, hey - let me give it a try. The RE had a LONG wait list. I got on the wait list almost right after I gave birth, just to get an appointment. I scheduled the appointment in July of 2017 to get a December 2017 consult. Things that were really cool about this RE:

• All paperwork was electronic. They gave me an iPad to fill out my new patient paperwork. 
• The office is 15 minutes from my house!!! My old RE's offices are 30-40-and 60 minutes away. 
• His prices can't be beat. He's a couple grand cheaper than my RE. 
• The RE is really engaged and nice. I really liked him, very personable. 

Seems perfect, right?

Well... a few things happened that brought me concern:

1. I had my AMH blood work drawn. They were supposed to provide the results within 1 week. It took them one MONTH to get me the results. Additionally, they used a lab that wasn't covered by my insurance. I spoke to them prior to my blood work being drawn to make sure it was covered (ran into this issue before with my old RE when I switched insurance companies one year, not realizing the laboratory wasn't covered - post here - Sticker Shock). Receiving a almost $500 bill for ONE blood test - sucked. When I called the clinic, they refused to help me and said I had to contact the blood work company. Not helpful. 
2. I asked them to provide me an estimate of my out of pocket costs. They provided me a quote that did not include my insurance benefit of infertility treatments. I called and the billing lady said that's what the insurance company told her. I had to be very clear that my insurance coverage includes a lifetime max of fertility treatments. After some fuss (and a few weeks), she finally got me the quote. However, the quote was very "unclear." There was a lot of crap on the quote. I just wanted to know what the bottom line was. 
3. They required a nonrefundable $500 deposit to secure the cycle month. They required this after I had issues #1 and #2 - so I was very hesitant to give them any sort of money that I wouldn't be able to get back. Plus, I had some variables (like weaning) I had to consider and I wasn't sure I could commit to a set month. 

After all that, I decided to schedule a consult with my old RE and see if I had a better experience. IVF is way too stressful and I think my old clinic totally spoiled me with how efficient and helpful they are! 

February 2018 - Consult with old RE 
Going to see my old RE was... refreshing. The office was organized, they were helpful, they were able to provide me quotes and a clear "this needs to happen in this order before starting" - which I felt was lacking at the other RE's office. Most importantly, my insurance/costs were quoted correctly. I decided at that point that I would do my next cycle with my old RE.

Weaning Delays = IVF Delays 
The original plan was to do an IVF cycle in June or July 2018. Obviously, that didn't happen! I was supposed to wean my baby by his first birthday, which didn't really go as planned (blog entry coming on that soon). I couldn't start fertility supplements or fertility drugs while breastfeeding, for obvious reasons! So... IVF has been delayed.

The funny thing was, I didn't mind! I started to question if I should really go for baby #3. I ran into some health issues (blog entry coming on that soon) and it made me reconsider. I decided to tackle my health issues first before jumping back into IVF. I also considered the possibility of doing IUI's again vs. doing a new IVF cycle. But I didn't really want to get pregnant "now" - I want to wait until 2019 for a bigger age gap between my baby and potential baby #3. My fertility between next year vs. this year, would seriously decline... So, IVF it would be.

August 2018 - Consult #2 with Old RE 
I had another consult with my RE just this week. I wanted to talk about 1) mini IVF and 2) timing. It's funny... In June, I wasn't sure if I wanted another baby. Then in July, I knew I for sure wanted a baby - so I really focused on weaning.

I wanted to talk to my RE about mini IVF because I think that the high dosage of meds just messes me up and maybe that's what resulted in my poor response. I don't know... but I wanted to talk it through. After we discussed it, we chose not to go that route. With my age, we want a higher number of eggs because I'm going to have a higher number of eggs that are not genetically normal.

Can I just say that meeting with my RE is like seeing an old friend! He remembers the names of my boys, he remembers personal conversations we had and specifics. I know he has a lot of patients, so it's very nice that he remembers me and my story. I showed him pictures of my boys. He's such a nice person.

Well... we aren't sure how I'm going to respond to IVF again. Considering that I did the same protocol twice. The first time led to a retrieval with 4 embryos and 1 pregnancy (my son) and one cycle was cancelled for low response. Also, my fertility is way down now vs. what it was back then.

Lab Work (so far): 
AMH: 0.75
FSH: 10

I'm not really sure how many cycles I can afford this time... So, I'm not even going to think about that! TTC has so many variables. I'm hoping to be a little more relaxed this go-around and maybe have a little more luck this time too!

Things to think about and consider: 

• What if I don't respond well, would I want to do an IUI? 
• If I get less than 2 embryos, should I test them? 
• If the embryos don't look good, would I defer to a fresh cycle? 

The reason these things are important to consider is, that changes my IVF protocol and fertility testing. Since I'm technically not planning to transfer until June/July 2019, I don't have to do some of the other testing now (i.e. saline ultrasound, uterine lining biopsy, etc.). I haven't decided the best course of action... as doing a IUI or a fresh transfer would mean my youngest kids would be closer in age than what I want (if it's successful). However, would I totally waste the cycle and not do anything? 

Lots to consider and decide! 

The Plan

• Start CoQ10 and DHEA 
• Continue taking prenatal vitamins 
• Started on Provera to get AF coming (AF needs to start by 8/26 for a September retrieval) 
• Call on Day #1 of my period to schedule Day 3 tests and baseline ultrasound 
• Egg Retrieval would be the week of September 24 
• Protocol: Microdose Flare - same as IVF #2 and IVF #3 
• Freeze all and planning to do PGS testing 

Yup - SEPTEMBER... like in a few weeks September! Eeek. It's what I wanted... as the other options were: October during Halloween week or December during my Little Guy's birthday week. But geez, talk about jumping right into a cycle! And to think - it'll be almost exactly 2 years from the FET that brought me my son. 

My Thoughts
It's funny... even though I had to go through 11 cycles to get my son... I feel so optimistic and excited to move forward with adding to my family. I'm really hoping for a great response to this IVF cycle and that I'll have PGS normal embryos to work with... I'll write more on my feelings in a separate blog post.

But man... trying for baby #3 feels so "right" to me. It feels good. I have absolutely no doubts that this is the right decision.

Next Steps: Waiting for AF to arrive to scheduled day 3 blood tests and initial ultrasound.

Our Breastfeeding Journey, Part 2 - Pumping

Man oh man... pumping at work was extremely hard to adjust to!!! It took me a few weeks to really get down a rhythm. Here's what ended up working for me:

Work Days: 

• Nurse baby when he woke up. 
• Early days: Pump before I left home (I had an oversupply and would leak on the way to work). Eventually I would cut out the morning pump, when my supply regulated and my baby started waking up/nursing closer to the time we left home.
• Pump at work 3x's a day, every 3 hours (scheduled on my work calendar). 
• Nurse baby at daycare pickup or right when we get home. 
• Nurse on demand throughout the night. Night feedings stopped when my baby was about 6 months old. When he stopped nursing at night, I would sometimes pump at midnight (or 3 hours after his last nursing session) because I was engorged and leaking. 

Weekends: nurse on demand and pump (1-2x's, if engorged) 

My baby started daycare a little after he turned 3 months old. He started with only 3 oz of breast milk, every 3 hours. This would start increasing to 4 oz. By the time he was 10-12 months, he was drinking 5-6 oz. Never went above 6 oz. 

Anything I pumped would be saved for the next day. If I had excess (in the beginning), I would either freeze or carry over to the next day. Monday's I used what I pumped over the weekend or used frozen milk. 

Kiinde System 

I used the Kiinde system and LOVE It. I was pumping directly into the bags, but then I stopped doing that and would pump into the bottles - then transition to the bags. The reason was, I was trying to get the right ounces in each bag. My baby used the slow nipple that came with the Kiinde and we never changed that. 

Daycare

I will say, I love our daycare. I really do. But they are very uneducated on breast fed babies. I tried to teach them to Pace feed - but I know that they didn't always do it - would depend on who was feeding him. They told me to change to a fast pace nipple, I told them no. The told me to up his ounces, I told them no. I tried to educate, but didn't force anything. Just told them why we weren't going to change anything. 

Low Supply Issues 

Eventually, my supply started to go down. It started when we started introducing solid foods at 6 months and he stopped nursing throughout the night. I went from an oversupply to barely being able to pump enough for the next day. By 6-7 months, I had almost used ALL of my frozen supply - which freaked me out. 

However, even with low supply issues - I managed to make it to one year without having to supplement. I did add extra pump sessions in, when I could, to make up for the gap. 

Nursing Attire 

The one big challenge I had with nursing and pumping is that I had to wear nursing clothes all the time. Since I was pumping at work, I needed "access" - so always wore a nursing bra and clothes everywhere. I stopped using a nursing cover for various reasons: 1) it was too hot, 2) my baby hated it and would push it away, and 3) I became more comfortable using the double shirt method. I always wore a tank top under my shirt. I nursed in a lot of public places and never had anyone comment on it. It wasn't always comfortable for me... but really, you couldn't see anything. I never thought I would be comfortable nursing without a cover... so was very surprised that I managed to do it for so long. I think we ditched the nursing cover at about 2-3 months old.

Pumping Supplies

• 3 sets of flanges (I left one at home and brought two to work) 
• Extra duckbill valves (replaced every 3 months)
• Dry/Wet bag to put my pumping items into and place in the refrigerator 
• Pumping bag 
• Milk bag
• Bottles 
• Kiinde bags 
• Labels (I would label the Kiinde bags at work) 
• Blue ice packs 
• Pumping bra 
• Manual pump 
• Medela sanitizing bags 
• Extra nursing pads (disposable and reusable) 
• A burp rag to protect my clothes (had instances where breast milk spilled on my work clothes) 

Next Breastfeeding entry: Nursing an older infant