Green light

Today we had our baseline sonogram for IVF#1. As you may recall, our goal for today was:

  • lots of antral follicles (‘lots’ is relative; the most I’d ever had was 6, the fewest was 3…; more follicles ≈ better IVF outcomes)
  • no ovarian cysts (I had a cyst visible on my last sonogram, and if it hadn’t resolved by now, we would have to delay IVF; small cyst + stims = really big cyst)

And [drumroll please…] I’m happy to announce that Dr. Y observed 7 follicles, and no cyst! We have been given the green light to proceed with our IVF protocol for this month.

My inner skeptic: To be fair, 7 is still a pretty terrible number for IVF and Dr. Y really really had to hunt to find the last one… Dr. Y also made a point of saying,

“There’s no guarantee that everyone on the guest list will show up to the party.”

Translation: Not all the follicles that we see today will be successfully harvested as mature eggs (and not all those eggs will successfully fertilize to embryos)…

My inner Pollyanna: It’s still the best AFC I’ve ever had and I’ll take it! My usually lazy right ovary doubled its production from last month (from 1 follicle to 2). Maybe it’s all the CoQ10 I’ve been taking. Maybe Dr. Y is being more liberal in his interpretation of what a ‘follicle’ is (Hell if I can see what he’s pointing to!) Maybe all your well-wishes/prayers/baby dust found their way through the ether to motivate my ovaries… Whatever it is, I’ll take it!

So now the plan is to continue my estrace and testosterone-priming for now, and start stims (injections and other goodies) at the end of next week. This also means that I no longer have an excuse to postpone forking over $1K for my non-Kaiser-covered drugs. You can expect upcoming posts on the chemistry of these new (to me) drugs, the biology behind my unconventional protocol (I’ve been doing some more research into this lately), and the finances of all this (I finally talked to the clinic financial administrator)…

 

But before I go, I’ve been thinking about this lovely post from Rain Before Rainbow. In it, redbluebird explains why she has chosen to keep her blog anonymous and not to share it with her IRL (in real life) friends and family.

By contrast, I’d say that this blog is semi-anonymous. I’ve avoided using any real names or photos of my face and have tried to be vague enough to minimize the temptation to find me out. But to be fair, anyone who knows me even a little bit who happens to come across this blog will easily figure out it’s me (my dogs and wedding photo are easy giveaways). Academics or chemistry-types who don’t already know me but who have even a slight detective bent could also find me using information on this blog. And if that weren’t enough, I’ve shared the blog with select friends and family members who want to follow along with our journey. (Judging by our IRL conversations, I’m pretty sure that only a small fraction of them actually read it.)

The downside of having some IRL acquaintances reading this blog is well articulated by redbluebird. For one thing, I can’t go into ‘angry infertile rant mode’, however much I might want to. (Not that I’d ever rant about anybody I’ve shared this blog with, but I’m afraid to rant about other people, lest someone I love even think that I might be ranting about them…) I also find myself watching my language (a bit) and being careful about TMI (a tiny bit).

But there are also clear advantages to sharing my blog with my IRL friends and family. The first is a major reason I started this blog – to avoid having to tell the same bad news, and explain the same sad lessons in reproductive biology over and over. In this regard, the blog has already served me quite well.

One unforeseen – and amazing – benefit is that a few especially empathetic IRL friends have used information from my blog to anticipate my moods and do exactly the right thing to make me feel awesome (or less awful, depending on the situation). Such was the case a few weeks ago, after a particularly demoralizing RE appointment. My friend A invited us over for dinner and had a bottle of good red wine waiting for me. 🙂

Or last night, when I arrived home from work to find a beautiful bouquet of flowers and a card from S & Q, wishing us Good Luck for our appointment this morning. I didn’t even know that they knew we had an appointment today!

ImageThank you S & Q for the amazing flowers! I hope at the end of all this we have some gorgeous hapa babies just like yours! And thank you to everyone (IRL and cyber friends alike) who are reading this and wishing us well. I firmly believe that it makes a difference!

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Seeking book recommendations

While it’s still ICLW, I’m hoping to get your input!

I love to read. When I got my first teaching job, I spent the next year reading every book I could get my hands on about teaching, mentoring students, navigating academic politics, setting up a research program, and so on. Not surprisingly, I took the same approach when we started trying to conceive.

Here’s a list of the books I read in the last year or so (in the order I read them), and what I thought of them:

  1. Taking Charge of Your Fertility by Toni Weschler. This book is the charting bible. My only suggestion is to excise the chapter on choosing the sex of your baby, since it is pretty much nonsense. The rest is fantastic. We got pregnant the first month we charted according to the instructions in this book…(We miscarried a few weeks later, but I don’t blame Weschler or this book for that!)
  2. The Mayo Clinic Guide to a Healthy Pregnancy. After successfully getting pregnant, I was interested in a book other than the ubiquitous, alarmist What to Expect When You’re Expecting. For a fabulously concise rationale for not trusting Heidi Murkoff, see this post by Yeah Science!
  3. Belly Laughs: The Naked Truth About Pregnancy and Childbirth by Jenny McCarthy. I had heard this one was funny, and bought it for my Kindle before learning that Jenny McCarthy was an anti-science wack-job. (As much as I hate to offend any readers, as a card-carrying scientist, I have to call it how I see it: Jenny McCarthy and her anti-vaccine buddies are anti-science, and I can’t help but feel anti-Jenny McCarthy.) I did read her book, though, which I think pre-dated her anti-vaccine stance, and was amusing.
  4. The Impatient Woman’s Guide to Getting Pregnant by Jean Twenge. I bought this book after learning that we were about to miscarry. This book is awesome. It is a brilliantly written, funny, thoroughly researched (Twenge is a psychology professor at San Diego State), and concise guide. I especially appreciated her thoughts on age and fertility, and her discussion of antral follicle count (she got pregnant naturally…twice, after having the same crappy AFC as me). This book – along with TCOYF – impressed upon me the importance of visiting a specialist soon, especially if you know you’re timing things right. The one thing Dr. Twenge’s book doesn’t include is a detailed discussion of ART, as she didn’t end up needing it.
  5. Preventing Miscarriage: The Good News by Jonathan Scher. I expected more from the founder of one of the world’s top ART clinics. This book was dreadful. It is anecdotal with no citations or scientific support for Dr. Scher’s claims. Worse, Dr. Scher seems to imply that women who don’t quit their jobs and submit to 9-month bedrest are at fault for their miscarriages! This book also had the feel of an advertisement for the Scher clinic. Blech!
  6. The Infertility Survival Handbook: Everything You Never Thought You’d Need to Know by Elizabeth Swire-Falker. Another excellent book, well-written and researched, and yet personal and touching. (Swire-Falker is a former attorney, and, like Twenge, knows how to do proper research.) The one downside of this book is that I found it a little depressing that despite years of attempts at ART, she was ultimately unsuccessful in carrying a pregnancy to term. She did however successfully adopt (and breastfeed!) In this book, Swire-Falker convinced me not to save IVF as a ‘last resort’ treatment, and also suggested making and stashing little self-care baskets to pull out as a pick-me-up on the inevitable rough days of an ART cycle…
  7. Conquering Infertility: Dr. Alice Domar’s Mind/Body Guide to Enhancing Fertility and Coping with Infertility by Alice Domar. I liked this book a lot. There were parts that felt like an advertisement for her program, but it wasn’t nearly as bad as Scher’s book. Dr. Domar was honest about acknowledging which of her recommendations are controversial (like giving up exercise). I especially appreciated her treatment of the emotional difficulty of IF and miscarriage.
  8. What to Do When You Can’t Get Pregnant: The Complete Guide to All the Technologies for Couples Facing Fertility Problems by Daniel Potter & Jennifer Hanin. This book was fine. Not great (it had type-os and some slightly misleading information), but fine.
  9. If at First You Don’t Conceive by William Schoolcraft. This book has some of the same shortcomings as Dr. Scher’s book (weird organization, shameless plug for Dr. Schoolcraft’s clinic – The Colorado Center for Reproductive Medicine, and not a single reference for any study or literature support for his claims – apparently having a medical degree means you don’t have to bother with proper use of sources?!), but I liked it a million times better than Dr. Scher’s book. Unlike Scher’s book, Schoolcraft’s contains lots of interesting and useful information, including cool figures like these:Image    It also contains a section on Traditional Chinese Medicine.

And that’s it! I’m almost through with Dr. Schoolcraft’s book, and I want to know what to read next. I have a slight preference for TTC-related (particularly IVF-related) nonfiction at the moment, but I’ll entertain all suggestions (fiction? websites? movies?).

So…what do you recommend?

Roid Monkey

So, on Monday I started rubbing Androgel on my upper arm each morning…and taking two Estrace (orally…phew!) each night. This is the hormone priming step of my IVF protocol. Add these to the Pulmicort inhaler that I use to keep my asthma under control and the progesterone that my corpus luteum is dutifully excreting, and you’ve got quite a steroid soup warming in my innards… I keep checking in the mirror for facial hair, bacne, or increased muscle mass. Aside from my pesky chin hair (excuse me while I find my tweezers…erm…got it!) I haven’t noticed anything.

ImageA sampling of roids in my system. You can read about progesterone, and what makes a steroid a steroid, here.

 

Speaking of progesterone, I’ve relapsed into another of my pre-IUI TTC habits, namely, charting. I keep track of each morning’s BBT (basal body temp) measurement, my CBFM (ClearBlue Fertilility Monitor) reading, any eggwhite sightings, and sexual encounters on a little paper chart on my nightstand. Recording it on the paper chart has a certain old-school charm about it, but can be a bit tricky to analyze and doesn’t quite satisfy my appetite for data.

Enter FertilityFriend. I type in my data to this website and it uses an algorithm that incorporates the data from my temperature, cervical fluid, fertility monitor, and OPK (when I use it) to determine when I ovulated. Actually, there’s a ridiculous amount of other data I could enter, but even a data junkie like me has to draw the line somewhere…

charts aMy paper chart for this month (left), and the FertilityFriend version, with est. ovulation shown as a red vertical line (right).

If you spring for the VIP membership (or if you are a new member, in which case you get a free ‘teaser’ VIP membership), the website will evaluate how well you timed intercourse. C and I apparently did ‘Good’ this month

ImageAnother feature of the VIP membership is that it will overlay up to 7 charts and show you the average BBT pattern. I’m not sure what this would be useful for, but it looks pretty cool:

Image

The average line (in blue) eliminates some of the noise of individual monthly charts to reveal a general trend of low temps pre-ovulation, followed by progesterone-elevated temps post-ovulation, which drop off just before the next cycle start (bonus benefit of charting – no surprise visits from AF!)

 

And this brings me to my newest dilemma: when to pick up my meds. Obviously, I already have some of them (including the Androgel and Estrace), but there are still ~$1K-worth of meds that Kaiser pharmacy doesn’t carry, which I have to pick up. If it weren’t for traffic, I would have picked them up the day Dr. Y prescribed them. But now that there is a chance – however miniscule – that I might be pregnant, I can’t bring myself to shell out that $1K until I’m sure I’ll need it…

So it’s one more thing on my ‘to do’ list. If FertilityFriend is right about my ovulation date, and if I follow my usual luteal phase of 11 days, then AF should arrive on Monday, and I can swing by the pharmacy after that, with plenty of time before I need those particular stims… On the other hand, maybe I should wait longer – until my baseline ultrasound (next Thursday) to make sure there are any follicles to stimulate with those drugs…yes, I think that makes more sense.

It’s a plan! And thank you, bloggy friends, for inspiring me to think this through, and patiently reading while I do. 🙂 Yet another perk of blogging…it forces me to think before shelling out C’s hard-earned money!

 

p.s. Welcome ICLW visitors! You can read my TTC resume here, but in brief: I’m a 34-year-old chemistry professor with diminished ovarian reserve, who has been TTC for about 15 months, including one missed miscarriage at 9 weeks. After 1 unsuccessful round of IUI, we are moving ahead with our first IVF next month. I use this blog as a form of therapy, and as a repository for interesting chemistry (and biology) that I learn along the way!

Why my husband rocks!

As we go through this infertility business, it’s easy to focus on myself – after all, I’m the one who has to take my temperature every morning, pee on countless sticks, miss work, strip from the waist down to get violated on a regular basis, check my panties every time I pee, overcome my needle phobia to give myself nightly injections, and on and on. But over the last few months, I’ve come to appreciate C more than ever before. Here are a few reasons why:

C has to put up with constant reminders of our infertility. I’m a college science professor, which means that the vast majority of people I interact with each day are either (a) 18-to-21-year-olds who haven’t started trying to make babies yet (not great for my body image, but an advantage nonetheless when it comes to IF), or (b) 40+ year-old men. Of the colleagues I come in contact with on a regular basis, only one is pregnant (to my knowledge), and two have a very cute children whom I welcome on the rare occasions when they bring them to work. C, on the other hand, is a pediatric dentist. When he’s not recovering at home from senseless injury accidents, he sees kids all day, every day. He gets asked every day whether he has kids and (when he says no) whether and when he plans to. The fact that he doesn’t have any kids yet is somewhat of a professional liability. (What kind of weirdo trains for a job that puts him in constant contact with kids but doesn’t have any of his own?!)

On top of that, C has to put up with his aunts who have no qualms asking about our babymaking plans and sharing their wisdom. (Incidentally, C’s parents have been awesome. C is Vietnamese, and wasn’t surprised when his dad sat him down after our wedding to impress upon him the importance of focusing on having a baby…preferably one born in the Year of the Dragon. Sadly, I miscarried that Dragon Baby while staying at their house; and C’s parents brought me heating pads and ibuprofen and said all the right things. Since then, they haven’t asked once about grandbabies, or given any family-building advice, or commented on my work hours or nightly glass of wine, or…)

C has been present and supportive through all this. He was with me at my first OB appointment last June, where we learned of the missed miscarriage. C held my hand through the appointment, walked me down to the lab for my hCG blood draw where I started crying (to the bewilderment of the phlebotomist), and later told me that he had never loved me more than in that awful moment.

C was with me at the first couple of RE appointments…including the one when Dr. Y informed us that I have diminished ovarian reserve. And since his accident in March, C has accompanied me to every single RE appointment, no matter how minor.

C is bankrolling our IF treatment. Yeah, yeah. I know. It’s ‘our’ money, not ‘his’ money, and infertility is ‘our’ problem, not ‘my’ problem. But that doesn’t change the fact that his choice of career and his success at that career make ART a viable option for us. Consistent with his Vietnamese heritage, C is very price-conscious. He’s willing to spend money when he’s confident of what he’s getting for it, but he hates to waste money. So, it came as somewhat of a surprise when Dr. Y was going over our protocol options and mentioned cost as one advantage of the particular protocol he was recommending. Without hesitating, C said,

“Price is not a factor in our decision.”

It turned out that Dr. Y thought this particular protocol was the best for our situation regardless of cost, but it was awesome to know that we were going with the option that Dr. Y thought had the greatest probability of success, not merely the one that would be easiest on our pocketbook.

Money has also come up a few times in our discussion of how long to try IVF with my (scarce, presumably crap) eggs before considering other options…namely donor eggs. Not surprisingly, C was a fan of the donor egg option; it has a much higher probability of success, allows C to have a biological tie to our child, allows me to carry and give birth to our child, and (perhaps most significantly) leaves open the possibility for siblings, since a donor ought to yield a greater number of viable (or, more precisely, vitrifiable) embies.

But C surprised me in a conversation a few days ago. He started out with his thoughts about donor eggs, then pointed out that he hadn’t been thinking about how I might be feeling. He said something to the effect of:

“I thought about how I would feel if it was my sperm that was the problem and we were considering donor sperm…

If we try IVF enough times, it should eventually work. At about $10K per cycle, if it takes us 10 cycles, that’s $100K. So what?! It’s the cost of a basement. I mean, if we can’t have kids, we don’t need a basement anyway!”

Now I’m not so cavalier about spending $100,000 on IVF – or with the emotional toil of ten cycles…yikes! (In truth, I’m sure he doesn’t feel quite that way either.)  But I knew what an amazing turnaround that was for him. I knew that he was working hard to empathize and understand what this must feel like for me. And I loved him SO MUCH in that moment, and told him so.

I could go on and on with reasons why my husband is awesome – like how he jumped through all the hoops to get married in the Catholic Church (he’s agnostic), and went with me to mass the Sunday after the ill-fated OB appointment; or how he listens to me talk NONSTOP about infertility (I try to come up with other stuff to talk about, but it’s like IF is all I think about right now!); or how he never asks me whether I think my job is the reason for my DOR. (I’ve wondered whether breathing low levels of solvent vapors throughout most of my adult life is a factor, and I’m sure he has too, but he’s kind enough not to say it out loud!)

I have no idea how, after four weeks on Match.com, I met this gorgeous, brilliant, rich, generous, stylish and fun guy, who, inexplicably, has a thing for uber-geeky, clutzy, introverted girls. (On our first date, I used the expression ‘rate-limiting step’ in a conversation.) It’s sort of like when Dermot Mulroney’s character on the New Girl fell for Zooey Deschanel…except that I’m no Zooey Deschanel! In terms of cuteness-to-dorkiness ratio, I’m closer to Alyson Hannigan in the first American Pie movie (not in How I Met Your Mother; she’s adorable on that show), just substitute her sexual worldiness and flute skills for some old-fashioned Catholic guilt and chemistry knowledge…

I was already amazed to have met and married C, and I am even more amazed to see how this man – who up until last summer led a charmed life – reacts with grace and humor in the face of shitty circumstances. C has missed the past 9 weeks of work due to excruciatingly painful injuries caused by a cop’s reckless behavior, and he calls this time his “sabbatical”, and spends it taking online classes to improve the efficiency of his business, practicing on the guitar, and designing our future home (hence the basement comment above)!

As much as IF sucks, I’m grateful to be going through it with an amazing man at my side. And the past year – including a miscarriage, infertility, and a car accident that almost took him from me – has only made me appreciate that fact even more.

Image

The two of us on our wedding day, bowing to request our ancestors’ blessing during the traditional Vietnamese wedding ceremony.

Old habits die hard

As you may recall from my last post, the current plan is IVF homework this month; stims and ER next month; detox in July; and FET in August. Not wanting to waste a single egg (what if it’s my only good one left?!), I naturally asked Dr. Y for permission to try ‘the old-fashioned way’ this month. Ever the gentleman, Dr. Y refrained from sharing his thoughts (Why not just enjoy the break? Don’t you realize how low your chance of success is?), and he politely said that would be fine.

So I pulled my BBT thermometer, pen, and a blank chart out of the nightstand drawer, and dug around in the bathroom cupboard for my ClearBlue Fertility Monitor and a stash of test sticks. (Okay, so I may have used the phrase ‘the old-fashioned way’ a tad liberally…) I had skipped all this during our IUI cycle thinking it would be a relief not to have to trouble myself with the morning routine, but I actually ended up regretting it. Throughout the cycle I found myself missing all that precious data! I wanted answers:

  • Would the Menopur injections cause a ‘peak’ reading on the monitor?
  • What about the hCG trigger shot?
  • How long after the trigger shot did my BBT rise?
  • Did the progesterone suppositories cause a higher BBT than usual?

I don’t know! And that bugs me a little bit.

Anyway, I’m back to collecting my precious data this month (and probably will through IVF too, because, why not?!)

And to everyone who wondered how the ClearBlue Fertility Monitor works, the rest of this post is for you. (Wait, nobody is wondering that? In that case, read this hilarious post by Stupid Stork instead…)

Still here?

So, the ClearBlue Fertility Monitor…

Like OPKs, the ClearBlue Fertility Monitor (or CBFM for short) monitors the levels of hormone in my urine. While OPKs detect luteinizing hormone (LH) that surges 24-48 hours prior to ovulation, CBFM detects both LH and estradiol (E2). E2 rises a bit sooner, and a bit more gradually than LH, which means the CBFM can give me more advance warning before ovulation. (This makes it easier to have some semblance of romance in this whole TTC thing. I can say ‘It’s been awhile since we’ve gone out; let’s make Wednesday a date night,” instead of “Wake up! Sexytime! Now! NOW!”)

Each morning starting on CD6, I POAS, cap the little stick, and snap it into the appropriate slot on the monitor. The monitor waits 3 minutes for the stick to develop and then shines a little red light on the stick ‘reading’ the result. For the scientists reading this, I assume the monitor works like a visible absorbance spectrophotometer; I’m looking forward to taking it apart to investigate once I’m sure I don’t need it anymore…

Anyway, after reading the stick, the monitor displays one of three possibilities:

  • Low: low E2 and LH levels. You can have sex today for fun or romance, but you can’t in good conscience use TTC as an excuse.
  • High: high E2 but low LH levels. You can use TTC as a pretty good excuse to have sex today.
  • Peak: LH surge. Ovulation is imminent. Sex today is pretty much required.

The sticks (which you have to purchase separately) look a lot like OPK sticks. But there’s no ‘control’ line – just one line for E2 and one for LH. And the color changes (particularly the E2 color change) are definitely more subtle than for OPKs – hence the need for the monitor to read the result.

I tried, unsuccessfully, to figure out the chemistry (or biochemistry) behind how CBFM works. I imagine that the LH line works using antibodies in a way similar to what I described in this post about how HPTs work, but I don’t know for sure. The mechanism for detecting E2 has to be somewhat different since (a) it’s not a protein hormone, and (b) the E2 line gets lighter as E2 levels increase, instead of darker.

Anyway, here’s a figure showing my monitor & corresponding test sticks for each possible fertility reading:

Image

Note the cute little egg symbol on the display for ‘peak’ fertility.

I color coded the hormone labels in the figure above to match this diagram I found on the interwebs showing how the menstrual hormones rise and fall at varying stages in a cycle. Note the gradual estradiol rise (blue), peaking a day or two before the LH surge (green):

Image

Incidentally, while doing a Google image search for LH and estradiol levels, I found the coffee mug above right, which I would want…except that I don’t think I’m gutsy enough to use it in public. They also sell a hat…

My colorful protocol

Today, C and I went in for our IVF medications “teach class”. I’m not sure why they need to add the word ‘teach’ in there. Are there classes that don’t involve any teaching that they need to distinguish this one from? Are they distinguishing this class from a “learn class”? (Our legal counsel informs us that we can’t promise that you’ll learn anything, but by God, we’ll teach you!) Actually, maybe I can use this…I think I’m going to rename all my courses “teach classes” to spare myself any responsibility for my students actually learning anything…

Anywho, it turns out IVF is a hell of a lot more work than medicated IUI. (Once again, I can hear all the seasoned IFers in unison…No shit!) The list of medications that I have to take is long and expensive, and I can see why my insurance drew the line after IUI…

It also seems like my protocol is a little unusual, so I thought I’d share the details of it here:

First, my calendar for May:

Image

And my calendar for June:

calendar a

Here’s my limited understanding of what everything is for:

  • Zithromax – to ensure that C & I are infection-free prior to beginning the cycle
  • Estradiol – to help me recruit more eggs and to prevent any new cysts from forming (which would force me to delay the cycle)
  • Testosterone (gel & patch) – to try and recruit a few more eggs (In explaining this one Dr. Y was careful to say “in theory” several times, leading me to think that this claim has not been proven…)
  • Aspirin – to improve blood flow to my uterus
  • Menopur – to stimulate multiple follicles to grow
  • Clomid – to stimulate multiple follicles to grow
  • Dexamethasone – to help with implantation
  • Growth hormone – to help the eggs develop/mature fully (to achieve better egg quality)
  • Ganirelix – to prevent premature ovulation (We don’t want those eggs to drop; we want Dr. Y to suction them out with a needle instead…)
  • Follistim (FSH) – same general idea as (and one of the ingredients of) Menopur; I think this serves as a little boost to get the eggs ready to go for retrieval the next day
  • hCG – stimulates ovulation; I’m guessing this finishes getting the eggs ready to drop, but that we’ll time it so that I go in for retrieval before they actually drop
  • Doxycycline – antibiotic prophylactic to prevent infection from the retrieval
  • Prednisone – not sure what the purpose of this steroid is…maybe prevent inflammation?

Has anybody else used testosterone in their cycles? From the mysterious way that Dr. Y talked about it, I get the idea that it’s not part of the typical IVF protocol.

I think another unusual (weird?) thing is that I’m using pretty low doses of stims (especially considering the fact that I’ve got diminished ovarian reserve): 100 mg of Clomid and 150 IU of Menopur per day…that’s less than half the daily dose of Menopur that I used for IUI. Dr. Y says that they’ve found that success rates with the low stim protocol are comparable to those with high stim, but at much lower cost.

Lastly, you may have noticed that the calendar above doesn’t include an embryo transfer. Dr. Y insisted that an important feature of this protocol – and one that he recommends for old lady patients (and patients with old lady ovaries, like me) is that it does NOT involve a fresh embryo transfer following retrieval. Instead, the plan is to flash freeze (vitrify) my embryos and store them for a full cycle while my body purges itself of the colorful drug cocktail listed above. In particular, the Clomid is supposed to make for a somewhat hostile uterine environment. According to Dr. Y, for older women, postponing the transfer for a month actually gives higher pregnancy rates.

My read of the clinic stats seems to validate Dr. Y’s claim: In 2011, the % of FETs resulting in clinical pregnancy was 58.3% for 38-40 year-olds, compared to 56.3% for fresh transfers for the same age group – despite transferring more embryos on average for the fresh transfers (2.1 per transfer versus 1.8). For younger women, the fresh transfer is definitely better, so the only question is whether this 34-year-old with diminished ovarian reserve will behave more like the average infertile 38-40 year-old, or like the average infertile <37 year-old…

I guess we’ll see! Anyway, I trust Dr. Y and am perfectly happy to go with his professional judgment. (Of course, my trust for Dr. Y’s judgment didn’t prevent me from trying to mine the SART data to answer this question, but it turns out that my clinic didn’t treat enough <37 year-olds with DOR to give meaningful data…)

The punch line of this is that assuming my sonogram in two weeks looks good (crossing my fingers for lots of follicles and no more cyst!), I’ll be moving ahead with the egg retrieval in mid-June, and assuming we get any good embryos (fingers crossed yet again), I’ll take a uterus-cleansing drug holiday in July followed by a frozen embryo transfer in August!

Hypothetical of a hypothetical

So we’re moving along with Plan D – completing our IVF homework. Here’s what I’ve accomplished in the last week:

  1. Repeated my day 3 bloodwork. This revealed virtually the same bad numbers as before. Actually, to be fair, they were a smidge better…but probably not statistically significant; FSH went from 13.7 to 13.5, E2 went from 24.6 to 27.2; AMH went from 0.17 to 0.22. More importantly, they didn’t get worse in the past 4 months, which I’ll take as good news. (Funny story about the blood draw: after so many IF-related blood draws, I decided that I was now a needle badass and would therefore watch as the phlebotomist drew my blood…naturally, that was the first time ever that someone missed the vein and had to stick me a second time! I did NOT watch the second stick. So much for being a badass.)
  2. Took blood pregnancy test. No surprises here. This test was a liability necessity before they’d do #4.
  3. Start Zithromax with C. Apparently they want to make sure neither of us has any infections prior to IVF (not sure why this isn’t required for IUI…) I’ll write about the chemistry of Zithromax below…
  4. Saline sonogram & mock transfer. Dr. Y filled my uterus with saltwater and observed it by ultrasound to make sure there were no obstructions that might pose a problem for an embryo. (Kind of like the HSG, except with saltwater in place of the dye and ultrasound instead of x-rays.) He also practiced inserting a catheter to get the ‘lay of the land’ for the real transfer. The whole thing was very anticlimactic. The most uncomfortable part was that I had to do it with a full bladder. (I have a very small bladder and practically live in the bathroom…) I would have asked C to take a picture of this, but it didn’t really look like anything. My HSG photo was much cooler.
  5. Sign & initial 9-page informed consent document. The first 6 1/2 pages of the thing discussed various aspects of the medical interventions involved. Yes, I understand that there may be side-effects of drugs, complications of surgery, that I may have multiples, and that the whole procedure may fail miserably…The unsettling part was the other 2 1/2 pages, which consisted of depressing hypothetical scenarios and our decisions about what we would want to do with our hypothetical embryos. For example, what should happen to our hypothetical embryos…
  • if we fail to pay our embryo storage bill?
  • if one of us dies?
  • if both of us dies?
  • if we are legally separated or get a divorce?
  • after I exceed my “normal reproductive life”? (defined as age 50; phew!)

C was no help at all, and I struggled with how seriously to take the whole thing. On the one hand, I was making a decision about what would happen to our precious embryos – C’s and my potential children (and the only that I might ever have). On the other hand, we were planning for a doomsday hypothetical of a hypothetical. Given my antral follicle count, we’ll be lucky to get one or two ‘good’ embryos to transfer. What are the chances that we’ll have ‘extras’ to store and worry about in the event of further hypothetical catastrophes? In the end, I tried my best to take the questions seriously…If we stop paying our bill or don’t use the hypothetical embryos by the time I’m 50, we’ll donate them to research; if one of us dies or we get divorced, they’ll be made available to the partner who wants them (probably only pertains to me, since if I die or we get divorced, C can make cheaper babies with his new wife!), and if we both die, they can be donated to another couple. Gosh I hope this post is the last time I have to think about such bummer scenarios!

 Still on our ‘To Do before IVF’ list:

  1. Submit C’s semen culture (after we finish the Zithromax course) to confirm no infection.
  2. Attend a ‘teach class’ with the nurse to learn how to do our new injections.
  3. Call the finance lady at the IVF clinic to work out arrangements for payment.
  4. Start taking estrogen (estrace) and testosterone gel.
  5. Do a blood draw (including a progesterone test, and others?) to confirm that my hormones are ‘turned off’ before officially beginning our cycle.

And finally, here’s your IF chemistry lesson for the day:

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Azithromycin (aka Zithromax) is a macrolide antibiotic. That just means that it contains a large (15-member, in the case of azithromycin) lactone ring (shown in blue). Actually, a lactone is defined as a cyclic ester, so “lactone ring” is redundant…kind of like “ATM machine”. Anyway, azithromycin is a synthetic analog of the natural product 🙂 erythromycin, produced by the soil bacterium Saccharopolyspora erythraea. Like erythromycin and other macrolide antibiotics, azithromycin has a sugar part (technically, two sugar parts, shown in green) that dangle off of the lactone ring.

Plan D

I made a mistake in my post about progesterone… Despite the suppositories, AF showed up a few hours after my last post. So yesterday morning I snuck out during my students’ final to call the clinic right when they opened.

C and I had decided our plan was to do a baseline ultrasound on cycle day 2 or 3, and see how many antral follicles were visible – if it was 3 or fewer, we would do medicated IUI again; if there were more, we would try for IVF. But when the advice nurse called me back, she said that Dr. Y wanted me to come in on Tuesday – too late for medicated IUI.

When I explained our ‘plan’, she said that upon further reflection, Dr. Y really felt that IVF was our best option and we should just go ahead with that. At this unexpected disruption in the plan – and to my complete surprise – I burst into tears on the phone. (I should probably mention that I have never been a very emotional person. For our first year together, C teasingly referred to me as ‘The Robot’. But infertility is doing its damnedest to change that.) Anyway, the nurse ultimately relented and said they could squeeze me in at 4:30.

The ultrasound showed 6 follicles (lame by most standards, but tied for my best count). It also showed a small cyst (Dr. Y said that wasn’t surprising after coming off a medicated IUI cycle), which means we couldn’t do medicated IUI this cycle anyway. We all agreed to move ahead with IVF, assuming the cyst goes away before next month. (We need a month to do our IVF ‘homework’ anyway.)

Once again, it feels good to have a plan, and to feel like we are moving forward (to what, I don’t know, but I’ll settle for movement toward anything at this point). I would title this post ‘Plan B’, except IVF was certainly not our plan B. By my count, we are on Plan D. Here’s a summary of our plan/backup plan/backup to the backup plan, etc:

Plan A: Pull the goalie and get pregnant “the old fashioned way.”

Plan B: Timed intercourse, using charting (phase 1), charting + OPKs (phase 2), and charting + OPKs + Clearblue Easy Fertility Monitor (phase 3)

Plan C: Medicated IUI with Menopur

Plan D: IVF with my (scarce, presumably crap) eggs

Plan E: IVF with donor eggs

Plan F: Adoption

Plan G: Wait for Guy on a Buffalo to drop off a prairie orphan. (If you don’t know what I’m talking about, click below.)

Plan H: No idea. Suggestions?

Rookie mistake

I made a rookie mistake this week. Since I was feeling so optimistic about this cycle, I decided to test early – at 8 dpo (that’s 8 days past ovulation, for the non IFers). I saw the faintest second line, and woke C. to tell him that we were pregnant. I tried not to get TOO excited (after all, C. and I know all too well that a BFP is a far cry from a live baby…), but in my head, I had calculated the due date, lamented the end of my blog (okay, not much of a lament, but I thought about it nonetheless), and imagined how quickly all this ‘infertility stuff’ would be a distant memory. Not wanting to burst my bubble, C. gently asked “What’s the chance that it could still be due to the trigger shot?” to which I replied, “It’s been 10 days. There is no way that protein could still be detectable in my pee after 10 days!!!) I fantasized about our rainbow baby all the way to work, and then decided to Google it. And guess what?

hCG can totally remain at detectable levels…for up to 14 days following a trigger shot!

Ugh. I’m sure all the seasoned IFers out there are like “Duh!”

So what did I do? I tested again at 9dpo, 10dpo, and 11dpo. And the second line was like faint, fainter, gone. 😦

So today C. and I went to meet with Dr. Y. to plan our our next step. (One ‘perk’ from the accident: C. is available to go with me to all my appointments!) I found this meeting super depressing, which is to say, it was exactly like every other meeting at that office… “Yadda yadda yadda, diminished ovarian reserve, yadda yadda, born with all the eggs you’ll ever have, yadda, let’s do another day 3 blood test and antral follicle count, yadda yadda, we can try IVF but you’ll be lucky to get 5 eggs out, yadda yadda yadda…” You get the idea.

Rather than rehash the rest of the conversation, or the tear-filled ride home, I’d prefer to learn and then write about the biochemistry behind how home pregnancy tests work.

Here’s a nifty image I found online. I’ll attempt to caption it in my own words.

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(A) So the purple blobs are hCG, which is present in the urine of pregnant women (and of wannabe pregnant women who had a trigger shot 10 days ago…)

Capillary action carries hCG along the stick (or down in this particular figure; nevermind that HPT instructions definitely do not say to hold the test with pee end up like that…) Anyway, capillary action carries hCG toward where the action is.

(B) The reddish things that look kind of like lobsters holding a blue balloon are the anti-α-hCG antibodies which were pre-deposited on the stick (between the pee end and the viewing end). The antibodies have a pigment attached (in the case of the test I used – FRER – the pigment is pink, not blue). They will grab the hCG (specifically the alpha subunit of hCG – for more about the structure of hCG, see this post) and hold on tight…and be pink.

Now, capillary action will carry the bound-to-hCG anti-α-hCG antibodies, and the free anti-α-hCG antibodies (there are extras that don’t get any hCG) along the stick.

(C) At the ‘test line’, there is a line of anti-β-hCG antibodies (blue lobsters in the figure, although they are actually colorless) that are fixed to the stick. These antibodies also grab onto hCG (specifically, the beta-subunit) and hold tight…and don’t go anywhere. Everybody holds on tight, and the resulting group of anti-β-hCG—hCG—anti-α-hCG sandwiches appear as a pink line on the stick.

Meanwhile, the free anti-α-hCG antibodies (that is, the ones that didn’t get any hCG) continue to be carried by capillary action along the stick.

(D) Finally, the free anti-α-hCG antibodies reach the ‘control’ line, where there is a line of antibodies that specifically bind to the anti-α-hCG antibodies (no hCG needed). These antibodies are the green turtle-heads in the figure, and are themselves fixed to the stick. The resulting antibody—anti-α-hCG complex appears as the pink control line.

I go in for a blood pregnancy test (which works a bit differently; but I’m too lazy to figure out how right now…) on Saturday, but with a negative HPT at 11dpo, I’m decidedly not optimistic about it. I’m also not optimistic about moving forward with IVF, but I’m sure that will pass. In the mean time, I think I’ll console myself with a glass of wine tonight.