Ultrasound and fire truck update

Well, the spotting increased to full-on bleeding Wednesday afternoon, so C and I both canceled each of our evening plans and stayed home to mope. The bleeding slowed overnight, then started again Thursday afternoon, this time accompanied by cramping.

Ever the pragmatist, I emailed Dr. R before driving home from work:

“In the last hour I’ve started cramping and bleeding more heavily. Do you think I should still come in tomorrow if it continues/increases? Should I try to save any tissue for testing?”

She replied that I should still come in, and that I should save any tissue if I could.

Again the bleeding slowed that evening and overnight.

On Friday I got up and got ready for work. I taught my class (OChem II), replied to emails, prepped for Monday’s class, and represented my department at an event for prospective students. As I realized that it was time to leave, a feeling of dread settled into the pit of my stomach. I said a grim goodbye to my friend/department assistant (who is ‘in the know’ about everything going on), and drove home to meet C.

C and I drove to Kaiser, making small talk. I mentioned Dr. R’s email, and speculated that she might recommend a D&C so we could test the embryo and see if there was a genetic reason why things went wrong.

We arrived, checked in, and waited. A nurse took me back in to get my weight, blood pressure and urine sample, then brought me back to the waiting room because Dr. R was behind schedule and she thought I’d be more comfortable waiting there.

Eventually the nurse came back for us and as we walked down the long hallway to the very last exam room, I leaned over to C and told him it felt like we were walking to the firing squad. I undressed and sat on the exam table, feeling both literally and figuratively naked.

Dr. R came in and hugged us both. She said how nice it was to see us, that it had been too long. She asked if I felt pregnant, and I explained that the only pregnancy “symptoms” I had were feeling weepy and very tired…both of which could easily be attributed to depression over our apparently failing pregnancy.

Mercifully, she suggested that we postpone the usual prenatal visit stuff and skip straight to the cervical exam and ultrasound.

Dr. R did her thing as gently as humanly possible. She realized that the probe was disconnected from the ultrasound machine and had to start over. She tried again and focused in on the dark oval (the gestational sac) and said, matter of factly,

“I see a heartbeat!”

What?!

She carefully showed us – skeptical as we were – what she was looking at. She checked the rate and declared it to be a normal heartbeat, then she measured the embryo, twice, and showed us that it was measuring 6 weeks 5 days. (We were at 6w6d by my count.)

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Dr. R was so visibly happy; she just about started crying. Meanwhile, C and I displayed no emotion at all. We were (and still are) dumbfounded.

I had already been anticipating how I would tell my department chair that I needed to change my fall teaching schedule back to a normal schedule. (I had jumped the gun and moved some courses to accommodate a November due date, prior to student registration starting last week…) I had planned to console myself with a delicious cadillac margarita at the Mexican place behind our house, watch the depressing movie about stillbirth I’ve been wanting to see, and ugly cry on the couch by myself…

That I could still be pregnant was, and is, so unreal.

Of course, we know we’re not out of the woods – that we will never be out of the woods.

But that doesn’t stop this me from feeling like getting this far is a miracle.

Dr. R suggested I lay off the aspirin for a couple days and then start back on it again Monday and see how it goes. She said I could go to a ‘normal’ prenatal visit schedule and come back in a month…or that I could come back sooner if it would help me feel less stressed. C answered for me that of course I would want to come back. (He told her I’d just move in to the clinic if she’d let me!) So Dr. R set up an appointment for next Friday, and said we could “play it by ear” after that. It sounds like she plans to let me come in as often as I want!

We talked about other things, including how (and when) I should deliver, but it was pretty much consistent with what she had already recommended when we met back in September.

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In other news, on Thursday I heard back from the sales rep for Kompan, the Danish company that we contracted to make Jane’s memorial fire truck. He said he had just confirmed that the pieces of the truck had arrived at our local Parks & Recreation office! We don’t know when they’ll get around to assembling it and removing the current fire truck, but this was unexpected good news!

He went on to say that while he didn’t know all the details, our story had touched the hearts of many of the people at Kompan who worked to make it happen. He shared that many years ago, he had lost an adult son (age 25), and that he was honored to be able to contribute to Jane’s memorial. ❤

Here were the plans for the memorial again. We can’t wait to see it in place at our local park!

Inconclusive ultrasound

Today, at 5 weeks 6 days, I went in for my ultrasound. More precisely, I raced from work to my ultrasound, where I arrived 3 minutes late. C was out of town for a meeting in NorCal, and was texting me to see when he should step out of his meeting to Facetime me…

They got me back into the room quickly, and when the nurse practitioner came in, she said it was fine to Facetime with C, and I called him up. She said that my blood tests had looked really good, and she wished for good news for us, since we “have had enough heartbreak.”

The good news:

  • We saw the gestational sac.
  • It is located in the uterus.
  • It measured at 5 weeks 4 days (within the error range of the measurement, according to our nurse practitioner).
  • We saw something resembling an embryo, which had something resembling a yolk sac, and something resembling a fetal pole, which measured at about 5 weeks 5 days.

The less-than-good news:

  • We did not see a heartbeat. Our NP prepared us for this even before she went in, so we know it doesn’t mean anything…but with C. Samuel we saw the heartbeat at 5 weeks 5 days, and we would really have liked to see it today.
  • More alarming was the nurse’s demeanor. She clearly didn’t like the appearance of the embryo, saying “I would like to see it more defined at this stage.” She reassured us that “I have seen pregnancies that looked like this at this stage, and then developed into healthy pregnancies,” which, frankly, wasn’t very reassuring at all.
  • Ultimately, she gave us 50:50 odds that this pregnancy would progress.

So now we wait until next Friday, praying that this coin flip goes our way…

A perfect storm

Last Wednesday, I ran into a mom of one of C. Samuel’s classmates for the first time since we lost Jane. Reflexively, she asked, “So, what happened exactly?” then immediately seemed to regret it, saying “You probably don’t want to talk about it.” I suspect this is the thought process most people go through when they hear our daughter was stillborn.

For the record, I don’t at all mind talking about it.

At the time of Jane’s birth, we knew extremely little. Dr. R suspected a placental abruption: I had no risk factors for stillbirth aside from maternal age; even with the close monitoring that came with going past term, I showed no indicators of an underlying cause; and my labor progressed extremely quickly (a classic sign of abruption). Moreover, Jane came out looking perfect, with no signs of cord injury (the other likely cause for demise of an otherwise healthy pregnancy).

Six weeks after my due date, we went to our follow-up appointment with Dr. R. By then, the results had come back from the dozens of tests performed on me…

The verdict?

Dr. R said that to the best of her knowledge, Jane’s death was the result of “a perfect storm.” I Googled the expression, and found it defined as “A situation where a calamity is caused by the convergence and amplifying interaction of a number of factors”. Sounds about right.

What were the factors converging to result in Jane’s demise?

Dr. R said there were three contributors that we know of, namely:

  • We know that Jane had a small, insufficient placenta, although we don’t know why. Risk factors for this include drug use, high blood pressure, pre-eclampsia, gestational diabetes, advanced maternal age, and infertility. Dr. R said she had looked into the infertility link further, and found that it has only been demonstrated for pregnancies achieved through IVF…so not Jane. The only known risk factor I had was advanced maternal age.
  • Jane had a shorter-than-normal umbilical cord. I’ve learned that the normal range is 35-80 cm, and that Jane’s was 30 cm after being cut. Dr. R freely acknowledged that some may have been lost in the cutting. So definitely on the short side, but not far outside the normal range. She said that a short cord increases the risk of a cord injury.
  • The main vessel of Jane’s placenta contained some “old, organized clots”. Dr. R suggested this may be due to an event that pinched the cord. (More on this in my placental pathology report, reproduced in part here.)

Dr. R suspects one additional contributor to Jane’s death:

  • Dr. R still believes I had a placental abruption. She said she can’t prove it (for example, my test for maternal fetal hemorrhage was negative), but supporting evidence includes my crazy, tumultuous labor (from 1 – 10 cm in less than 2 hours), old brown blood in my amniotic fluid (which was visible upon dilation), and “port wine-colored” blood delivered with Jane in my amniotic fluid.

Would Jane have been okay otherwise?

There’s no way to know if Jane would have suffered from my crappy placenta and blood clots if she had been delivered earlier. She looked perfect at delivery, so…perhaps not.

Was Jane “growth restricted”?

Dr. R said we can’t tell if Jane fit the definition for intrauterine growth restriction (IUGR) or if she was just small for gestational age (SGA).

Was there an underlying cause?

Kaiser did tons of tests on me. All came back essentially normal. I do not have a clotting disorder. I did not appear to have any relevant infection during my pregnancy with Jane. Dr. R promised to send me my test results by mail. (She did, and I summarized them here.)

How could we prevent this from happening in a future pregnancy (assuming we can get pregnant again)?

For any future pregnancy, Dr. R would recommend that I take low-dose aspirin through 36 weeks to prevent clots. (I actually took the low-dose aspirin through the first trimester with both Jane and C. Samuel, on the advice of Dr. Y. Given my test results, she does not currently recommend heparin.) We would do monthly growth ultrasounds, along with additional Doppler scans to check the baby’s blood flow (specifically the cord flow and “mid-cerebral artery flow”). We would do “intense testing,” including a repeat of my blood clotting tests. If anything looked bad once the baby reached viability, we “will act” (that is, deliver him or her early). Dr. R also recommends a scheduled C-section, rather than taking the risk of fetal distress or an accident during labor.

When should we try again?

Dr. R gave me the all-okay physically. She mentioned that some studies suggest that a shorter break between pregnancies correlates with shorter umbilical cords, but she didn’t think the quality of evidence was good. She indicated a desire to talk to Dr. Y more about this.

I’d like to write a longer post on the subject of trying again. Suffice it to say that neither C nor I want to wait long.

Are you going to retire?

Dr. R answered confidently, “Oh I’m going to see this through!” She also shared (perhaps unprofessionally, although I hardly fault her for it!) that she had a dream that we had another, healthy child. I hope her dream proves to be prophetic!

On our way out the door, I handed Dr. R a Thank You card, in which I shared our feelings of gratitude to her, along with a photo of us with Jane:

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When I got home, there was an email from Dr. R in my Kaiser inbox:

Hi, K and C! I rushed out to catch you but you were too fast and got away. The card was so touching and beautiful! Thank you so very much for the picture. It means so much to me, more than any words can express. I am here for you in any way that I can help. Please feel free to reach out at any time. In peace, Dr R

Halfway there

It’s funny, when you can’t get pregnant, it feels like all you do is wait – for test results, your period to come, the next treatment cycle, or the dreaded two week wait. Time crawls by, marked by morbid milestones like big birthdays (Hello, Advanced Maternal Age), would-be due dates, number of years spent trying to have a baby, and so on…

But ever since I’ve made it past the nail-biter of a first trimester, time has flown by. Suddenly I’m halfway through the pregnancy wondering where the last two months went!

After the third email from a bloggy friend checking whether everything is alright, I have no choice but to admit that it has been far too long since I’ve written. For that I am sorry. (As always, I have been reading – celebrating, mourning, and above-all praying – right along with each of you, bloggy friends!)

Rest assured, all is well with me and Baby.

The day after my last post, I went in for the nuchal translucency ultrasound (part II of the so-called California Prenatal Screen). Seeing our baby in high-def should have been extremely cool, except that:

1)      I hit unexpected traffic on the way there, which caused me to panic that I would lose the appointment. (If you’re late at all to the full-bladder appointments, you have to reschedule…and get your bladder uncomfortably full again.)

2)      Despite following instructions to the letter, my bladder wasn’t full when I got there (maybe the traffic stress slowed things down?), and the technician made me feel rotten about it.

By this point, I was so stressed out that when the baby appeared on the screen, I found myself asking whether the technician could tell us if it was alive. She gave me a weird look as the baby on the screen proceeded to wave its arms and swallow gulpfuls of amniotic fluid…

3)      Then, I outsmarted myself…or not. After writing my previous post, I was convinced that I knew what I should be looking for – namely a nuchal translucency that was around 2 millimeters (or less) in width. So far so good, except that the measurements the technician was making were in centimeters. Embarrassingly, when this so-called-scientist saw the numbers creeping up to 0.18, 0.19, 0.21 cm, I was convinced that this was the equivalent of 18-21 millimeters! (For those of you who aren’t up on your metric system, 0.20 cm is equal to 2.0 mm.) Worse, my husband – the pediatric dentist who works on millimeter scale every day (or did, prior to the accident) – didn’t catch my error.

It wasn’t until we were outside the hospital that we realized something had to be off with our calculation.

Think about it, how could a baby the size of a peach (~3 inches from crown to rump) have the skin on the back of his neck be 21 millimeters (nearly an inch) thick?!

About an hour and a half later, I got the call from Kaiser telling me that everything was totally normal. Based on the combination of the 1st trimester blood test and the ultrasound, they adjusted my probability of having a baby with Down syndrome (from my original age-based estimate of 1 in 296) to an adjusted estimate of 1 in 5,000; and the probability of a baby with Edwards syndrome (originally 1 in 1152) to 1 in 95,000.

Several days later, on Friday afternoon, I got the call with the results from the NIPT blood test. (This was the brand new, more-accurate, qPCR-based blood test that I described here.) The test revealed that we were having a chromosomally-normal boy!

Great news…which I again managed to mess up in translation. But first, some unsolicited advice:

Do not tell your husband the gender of your baby-to-be in a text message.

I should explain. After waiting impatiently for the results of the NIPT scan, I finally got the call on Friday afternoon – while in a one-on-one meeting with my boss. Unwilling to wait until Monday for the news, I apologized to my boss and quickly left to take the call. Then, after learning such amazing news, I wanted to tell C immediately. (Somehow me knowing for more than a few minutes longer than him seemed horribly unfair.) But, I also felt an urgent need to return to my boss to apologize and continue our meeting…

So I sent C a text message.

He will never let me live it down.

Anyway, that was all our test news. I’m sorry to leave you with a cliffhanger for the last 7 weeks!

Other highlights of the last two months:

  • I ‘popped’ during Thanksgiving dinner. Once I switched to maternity pants, there was no going back…
  • I felt the first fluttering of movement on Christmas morning. It felt kind of like an upset, rumbly stomach, except without any feelings of queasiness. Feelings increased over the last weeks, so that now it actually feels like something is lightly tapping on me from the inside. After so much uncertainty, it is the most reassuring, wonderful feeling to know that he is alive and kicking in there! His most active time is from ~5-7am each day. The last few mornings I swear he has been doing cartwheels in there…
  • The Board of Trustees approved my promotion to Associate Professor (starting in Summer 2014)!
  • Saturday we hit 20-weeks. Say what?!
  • C felt movement for the first time on Sunday morning (during one of Baby’s gymnastics sessions).
  • We celebrated our 2nd wedding anniversary on Tuesday. Thanks in large part to our struggles with infertility and C’s life-threatening traffic accident (10 months later, it’s still causing him considerable pain), we’ve never been closer. I’m so glad I get to spend the rest of my life with this man!
  • Yesterday was our 20-week high-resolution ultrasound. The ultrasound technician wasn’t allowed to make any evaluative comments, but she narrated as she went, so we were able to count: two arms, complete with hands and five fingers on each; two legs with two adorable feet and ten toes; one stomach; one, four-chambered heart; two kidneys; one placenta; one umbilical cord (with blood flowing to the placenta); one head with a two-hemisphere brain (measuring 20w6d); and – oh yeah – a penis. (No surprise there, given our NIPT result, but it was nice to see it nonetheless!)

That’s about it. Now that my belly is swelling and I can feel ‘Baby Lou’ doing gymnastics in there, I’m actually letting myself believe that this is going to happen (although that doesn’t prevent me from middle-of-the-night panic attacks that something is wrong, like yesterday at 4am…) I’ve even relaxed enough to allow myself the occasional half-glass of wine, coffee, or Diet Coke. (Before you sic the Pregnancy Police on me, read this, or, if you prefer, this.)

And now, I’ll leave you with a picture of the beautiful flowers C got me for our anniversary. I’m enjoying the soft scent of lilies as I type this. 🙂

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My worst fear

Okay, so that’s probably an unnecessarily alarming way for an infertile pregnant woman to title a post. Rest assured, all is fine with the baby, as far as we know.  (Why do I always feel the need to add that qualifier?!) We had our first OB appointment last Tuesday. Aside from being super nervous, cranky, and cold, (Seriously, why would you keep an office in which your client is always naked at 60 freakin’ degrees?!)  the appointment was good. We heard the heartbeat (holy miracle moment!), saw actual toes, and as a bonus, we found out our obstetrician has a master’s degree in chemistry. 🙂

Since becoming spontaneously pregnant two weeks before my one-day-workup at CCRM, my “worst fear” (you know, aside from something awful happening to baby), is that people who hear my infertility story will try to use me as an example to support their bad advice. I just imagine well-meaning friends “comforting” their other infertile friend with the story of the girl-they-know who had abysmal AMH, who was counseled by three different doctors to consider donor eggs, and then spontaneously conceived once she “finally relaxed/stopped trying/[insert insensitive cliché here]”…

Last weekend, that fear came true.

I went to Palm Springs for my friend R’s bachelorette party extravaganza, and, as happens all too often with me, the subject of infertility & IVF came up. (It’s amazing to me how many infertiles come out of the woodwork whenever I open up about it!) One girl, who is currently struggling with secondary infertility, listened intently while I told our story. Then, as I finished, she declared triumphantly,

“I’ve heard so many stories like that. As soon as you relax and decide to leave things up to the experts, you get pregnant!”

Yes, because traveling across the country two days before the fall semester starts is so relaxing…

And what exactly what was I doing during the two IUI cycles, and IVF cycle? Apparently not “relaxing and leaving things up to the experts”…

In this situation, my post on infertility math came in handy, as I tried to explain why a natural conception after three failed ART cycles was evidence of nothing except that we had a helluva lot more months of trying ‘the old-fashioned way’ than anything else. (Believe me, I have the FertilityFriend chart – complete with BBT, EWCM, OPK and CBFM data – to prove that I was still trying damn hard!)

This challenge to the authenticity of my infertility made me want to whip out this little beauty:

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In her defense, I’m sure that the woman who said this desperately wants to believe that just relaxing might work. She’s been struggling for two years to get pregnant with her second child, and mentioned that her husband is opposed to both IUI and IVF (because they’re “not natural”).

I sincerely hope that putting her fertility in the (somewhat tied) hands of her reproductive endocrinologist is all it takes for her to have a spontaneous pregnancy!

But in the mean time, please DON’T use my story as evidence of anything other than that sometimes weird shit happens!

Lastly, as my contribution to the onslaught of cute Halloween costume pics, here are my two “babies” in their costumes:

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Graduated, and a touch neurotic

Sorry it’s been so long. Once again I want to reassure you all that I have been reading your blogs…on my iPhone (which is my lame excuse for not commenting). I’ve also been keeping you all in my thoughts and nightly prayers. On nights when I’m totally exhausted, the prayer goes something like “God bless all my infertile bloggy friends and local Resolve group members”. When I’m a little less sleepy, I try to mention you each by screen name and by situation – stims/egg retrieval/transfer/TWW, etc. I know many of you aren’t religious, but given the lengths we all go to, I figure it can’t hurt!

So, two weeks ago, we had our third and final ultrasound with Dr. Y. The ultrasound looked great. Although we were at 7w5d by my count, baby measured 8w0d and we could see a nice big noggin, along with spinal cord, booty, and a limb (not sure if it was an arm or a leg at that point). I’d share the video, but C’s iPhone video technique has improved significantly, and in the later videos my full name and clinic location are crystal clear on the screen. (I’m not quite ready to dispense with the last semblance of anonymity here…)

After the ultrasound, Dr. Y gave me some instructions regarding the baby aspirin and progesterone suppositories (Yee haw! No more suspicious bruises or greasy cooch!)

Then Dr. Y put his arms out to the side…

In retrospect, I think it was a gesture of “well, I guess that’s it!”, but at the time, I was convinced he was reaching out for a bear hug, and – without thinking – I went for it.

Which was weird, given that my lady bits were covered by a thin paper sheet, which kind of raised up during the hug…

 Like Lentil, we brought cookies to say Thank You to Dr. Y and his staff (but waited to give them to him until after the ultrasound and awkward hug). And with that, we graduated from the RE’s office.

I kind of wish he had kept us for another week. Our first prenatal appointment was originally scheduled for October 22nd (hence the timing of our RE graduation). But during that last appointment, Dr. Y asked us which OB we had chosen, and when I told him that we had an appointment with one of the Kaiser nurse midwives, he hemmed and hawed and said “Well, that should be fine. Technically, you’re not high risk, so you don’t need to see an obstetrician…” Which of course led C to insist that we cancel our appointment with the midwife and make one with an OB. And that’s how our first appointment ended up scheduled for a week later, on October 29 (this coming Tuesday).

 So we haven’t seen our little prune in two weeks. I actually was fine with it, until my acupuncture appointment yesterday. My acupuncturist said my pulse was “fine” when I asked her, but then when I was leaving, she said, “Fingers crossed for your ultrasound!” And her assistant asked if I wanted to schedule my next acupuncture appointment then, or wait for the results of my ultrasound.

 Um. What does that mean?!

 So, naturally, I’ve been running through the list of pregnancy symptoms.

 Still here:

  • Unsettled tummy in the morning, and inability to eat a large meal in one sitting
  • Sore boobs
  • Tummy pooch
  • Constipation

Absent the last few days:

  • Exhaustion
  • Crazy acne
  • Waking up starving in the middle of the night to eat my night peanuts

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Needless to say, the next four days can’t go fast enough.

Fortunately, I have a ridiculous pile of grading and course prep to keep me busy…

which I should probably get back to now…

Tired

Thank you all so much for your kind response to my news. I’m sorry it’s taken me so long to provide an update. Lest you think ‘No news is bad news’, I’ll spoil the punchline by telling you that all is well (as far as we know).

I hate to use a lame pregnancy excuse, but I am so tired that I can barely keep up with my work responsibilities, which is why working on a blog post has been out-of-the-question…

Suffice it to say that I am having some pregnancy symptoms:

  • Extreme exhaustion (coupled with difficulty sleeping…awesome!)
  • Moodiness (poor C has been dealing with some serious crankiness, punctuated by tearing up every morning during some story on the Today show…)
  • Acne (enormous, sore, pressurized zits…possibly worse than when I was a teenager)
  • Constipation (‘nuff said)
  • Unsettled stomach (I wouldn’t call it nausea per se, but more an uncomfortable feeling and general lack of enthusiasm for food)

As those of you who have miscarried can appreciate, I’m actually grateful for every symptom. (I had very few and very mild symptoms last time…) But nonetheless, it feels like all I do is work, sleep, and go to appointments (acupuncture or RE’s office)…

Here are some pictures to fill out this post:

ImagePhoto from the black-tie wedding in Chicago where we made a baby! (Well, an embryo anyway. Doesn’t C look handsome in a tux?)

ImageEating a Chicago Dog at Wrigley Field with my buddy R. (Meanwhile, my little embryo was on its way to becoming a blastocyst…)

Image“Umm. Wake up, C! Wanna hear something weird?!…”

ImageWhen my temperature didn’t drop by 10,11,12 dpo, I thought something was up. Then when it did drop at 15 dpo, I. FREAKED. OUT!

ImageBut I kept going in for blood tests, and my betas looked good…

ImageWhen I got to work the day of the ultrasound, I found these from my thoughtful colleague K! Notice the graduated cylinder ‘vase’.

ImagePrayed a lot to St. Gerard, and wore my lucky socks to the first ultrasound appointment. By my estimate, baby should be ~ 5 weeks 5 days old…

C and I were blown away to see this. “Baby Lou” (as my mom has taken to calling it in her nightly prayers) measured 5 weeks 6 days, with a steady heartbeat! (You can see the yolk sac ~6 seconds.)

This was HUGE news for us. Last time, we learned at our 8 week ultrasound that the baby was only measuring 5 weeks 5 days (no heartbeat). I miscarried naturally about a week later. That one extra day means that we’ve at least made it farther than last time.

And we’ve got a heartbeat.

We know that we are still so far from out of the woods, but we’ve decided to be hopeful. I even went out and bought another copy of The Belly Book to stick our ultrasound pics in.

And now, we wait.

Fortunately, a ‘perk’ of being an IF patient with Kaiser is that I get weekly ultrasounds until I ‘graduate’ to the OB (~9 weeks). So we’ll do it again on Friday (6w6d)…

Is DHEA making me fat?…Why my ovaries are like dogs…And other stories.

Has anybody else put on weight while on DHEA? I’m up ~4 pounds since midsummer (and ~7 since 15 months ago when I was pregnant, but I can’t really blame DHEA for those extra 3 lbs…) DHEA is an anabolic steroid, and anabolic steroids cause weight gain, so I think it’s possible. The other reason I’m inclined to blame the DHEA is because of where the weight has been going. Not to my hips, thighs and butt (like usual), but straight to my belly. I have a beer gut. And now that I have to start dressing professionally again, all my work clothes are either unflattering, uncomfortable, or both. Ugh.

So, as you all know, we had our phone consultation with Dr. Schoolcraft on Monday. Overall, it went pretty well. (You can find his answers to my long list of questions here.)

Here are some other tidbits from our conversation with Dr. Schoolcraft that didn’t directly pertain to our questions:

  • Dr. Schoolcraft was late. He called us almost 40 minutes after our scheduled time. This wasn’t so much a problem in itself (the nurse had warned us that it was often the case), but – ever the healthcare practitioner – C pointed out that if he was that far behind schedule (it was 5:40pm his time), he almost certainly didn’t stop to look over our file before he called.
  •  Judging by the conversation, Dr. Schoolcraft almost certainly hadn’t reviewed our file. Again, this might have been fine in itself. (His answers were thorough, and he didn’t make us feel like he was in any rush.) But we found it annoying that we went to so much trouble to get our records, and to fill out an annoyingly detailed (and poorly designed) health history form online, if he wasn’t even going to read it. And, we now have one more question…which wouldn’t bother us if we felt like he had actually read our file before calling. (Specifically, we spent a lot of time with him talking about low-stim versus high-stim, the underlying assumption being that we had only tried low-stim and don’t know what would happen if we increased the dose…somehow we all forgot to consider the fact that we in fact tried IUI with pretty high doses of Menopur – 5 vials per day – and only got 2 follicles developing. I know that IUIs are different – I couldn’t take stims for as many days because I wasn’t taking anything to suppress ovulation – but still, the scientist in me is frustrated to think that we neglected an important piece of data!)
  • Dr. Schoolcraft thinks I have a “poor prognosis”. He just sort of let that slip out in the context of some comments about comparing SART stats between clinics. Not that it came as any big surprise, but it was more direct than Dr. Y has ever been (though not as bad as when Dr. L said I would go through menopause before 40…) I think it’s a good sign; it’s consistent with what I’ve heard from other patients (who described him as “direct” and someone who “doesn’t mince words”) and the last thing I want is a doctor who’s going to blow smoke up my ass…but it still stung.
  • I thought Dr. Schoolcraft’s advice for comparing SART stats was very interesting. He mentioned (and I’d heard before) that some clinics manage to inflate their stats by refusing to take patients with a poor prognosis (especially older patients). His advice, therefore, is to compare the ‘% of cycles resulting in live birth’ specifically for women under 35 (where there will have been the least selection bias). If you want to compare the quality of different embryology labs, then look at the success rates for donor cycles. It’s not perfect, but I thought it was an interesting way to get around some of the stat manipulation.
  • Naturally, the first thing C and I did after getting off the phone with Dr. Schoolcraft was to compare the SART stats for our local clinic to those for CCRM in the categories of women under 35 and donor cycles…and while CCRM was better on both counts, there really wasn’t a huge difference. So our lab really does seem to be quite good. But we also considered Dr. Schoolcraft’s point that CCRM sees mostly out-of-state patients who have already failed one or more IVF cycles. In other words, they see a disproportionate number of ‘hard’ cases. And yet, their stats (in just about every age group and diagnosis) are higher than anybody else’s I’ve found. This seems to back up Dr. Schoolcraft’s claim about having the best lab.

So, despite our mild annoyance, and “poor prognosis”, C and I decided that we should at least make the appointment and do the one-day workup. It’s not cheap, but it’s thorough, and after getting the results, we’ll be able to have a better sense of whether it’s worth our time to continue with my eggs…

C made the point that every month to my ovaries is like years to a normal set of ovaries. (My ovaries are like dogs, apparently.) And also reasoned, “We’ll probably spend money on a lot stupider things.”

I’m not feeling very optimistic about our chances of getting pregnant – even at CCRM, but it feels like something we have to do to feel like we’ve done everything we can.

A rousing game of ‘Guess Dr. Schoolcraft’s Answer’ [updated with results]

Thanks to all of you for your help compiling questions to ask Dr. Schoolcraft during our upcoming CCRM consultation. Per your suggestions, I added some questions and prioritized them to make sure we get to my most pressing questions first. Then, during my run this morning, I got a little cocky and found myself thinking that I probably can guess Dr. Schoolcraft’s answer to most of my questions. Next I thought, why not make it interesting?

So I’m putting my educated guesses in writing, here on the interweb for all to see. [Gulp!] If you have guesses of your own, please share them in the comments! After our phone consultation on Monday, I’ll update I updated this post with Dr. Schoolcraft’s answers – so don’t forget to check back and see how well (or poorly) we all did!

[Insert cheesy game show music]

Deep announcer voice, building: And now it’s time. Let’s play…

Audience shouting in unison: GUESS! DOCTOR! SCHOOLCRAFT’S! ANSWER!

[Applause]

* My answers are shown in black. Dr. Schoolcraft’s answers (as best I can remember them) are in blue.

1. What do you estimate our chances of success with my eggs to be?

Actually, I have no idea what his answer to this one will be, which is why I want to ask it first. My fear is that he “won’t be able to say without the information from my one-day-workup.” (The one-day workup is the full set of tests that CCRM conducts – in one day – for all new out-of-state patients. If he defers to the one-day-workup as an answer to each question, then I’m going to wonder why I went to all the trouble of sending my medical records and completing the detailed medical history. I’ll also be bummed to have spent $250 for what amounts to an elaborate advertisement…)

<<DING!>>

I won’t have enough information to say until we have your results from the one day workup. I can say that between the options of 1) doing IVF again with your eggs, 2) doing nothing, and 3) doing IVF with donor eggs, your best chance of success would be from IVF with donor eggs.

2. If you think it’s worth trying with our eggs, what new information would change your mind? At what point should we seriously consider donor eggs?

Aside from perhaps deferring to the one-day-workup, I imagine that he would recommend trying at least one cycle at CCRM with my own eggs before moving on to donor eggs. Seeing how I respond to a new protocol, after 3 months of supplements, would provide additional data to inform our next steps.

<<DING!>>

I would recommend trying IVF at least once with a conventional [i.e. high-stim] protocol. That would give you the greatest chance of recruiting the maximum possible number of eggs. And then we’d know how many eggs/embryos each subsequent cycle is likely to yield.  Your response to the stimulation, as well as the results of genetic testing on any embryos retrieved, will help us to know whether your problem is with egg quality [in which case egg donation might be a good option] or if there is another issue.

3. What do you think accounts for CCRM’s remarkable success rates?/What can CCRM do to improve my prognosis relative to my local clinic?

I’m guessing he’ll say some combination of the following three things: (a) world-class embryologists (In general, I’m told the embryology lab is the biggest factor in determining IVF success rates.); (b) genetic testing (A procedure called Comprehensive Chromosomal Screening or CCS – which permits selection of only embryos with the correct number of chromosomes – was developed at CCRM. Transfer of selected embryos dramatically increases success rates, as can be seen here.); and/or (c) experience (CCRM did 2464 ART cycles in 2011, about 5 times as many as my local clinic. Such a large number of cycles per year means that the embryologists are constantly honing their skills, while the doctors have more data to draw from in choosing appropriate protocols, etc.)

<<DING!>>

The lab. The embryology lab makes the biggest difference for IVF outcomes, and we have the best lab. This is especially true in your case, where you can only afford a low margin of error. For example, if you had 17 eggs retrieved, and six make it to blast, and you get pregnant, it looks like a success, even though more than half of the eggs didn’t make it. But you’re not going to have that many; you may only have one or two eggs. You want the best embryology lab to maximize the odds that those eggs make it to blast. At CCRM, we’ve also developed several specific techniques that improve outcomes, like embryo glue [and others that I didn’t hear because C was whispering that my typing was too loud…]

4. What other kinds of tests will CCRM do? Do you recommend genetic testing in our case?

I’m not sure what all the tests they do are, but I’m pretty confident that it is more than I’ve had so far (namely Day 3 FSH, AMH, and E2 testing; antral follicle count; HSG; and saline sonogram). I’m guessing that he will recommend CCS (since I turn 35 in November), but probably not PGD/PGS (since C and I are different races and have no family history of genetic disorders).

<<DING!>>

I would definitely recommend that you do chromosomal screening [CCS]. If the cycle doesn’t work, you want to know whether it’s because of a genetic issue [which would be resolved by using a donor] or if there is some other factor – a lining issue, etc. [which would not be]. The goal is to “get a baby or get an answer.”

5. How would we go about scheduling a cycle with CCRM, given my & C’s work schedules? (I can’t exactly take off for 10 consecutive days in the middle of the semester!)

I’m not sure what he’ll say about this. Assuming he recommends a fresh cycle, I’m guessing that he’ll say I should schedule retrieval & transfer between semesters (in December/January). Alternatively, if he recommends a freeze-all cycle (as would be the case if we do CCS), maybe it wouldn’t require so much time off and I might be able to time something around Fall Break?

<<DING!>>

C would only need to be here for one day, and assuming you did most of your monitoring appointments at home, you would only need to be here for 4-5 days [since I recommend freezing all for CCS]. One possibility is that we might time it so you could come over Thanksgiving break.

6. If, due to scheduling constraints, we opt to do another cycle locally before cycling with CCRM, do you have any recommendations for our local cycle? (With regard to stims? freeze day? other?)

No idea what he’ll say to this… I’m guessing he’ll push for going straight to CCRM, but I’d love to be surprised here.

<<<BUZZ!!!>>>

Not really. Our lab is here. There’s no way to take it with you.

7. How much variability do you expect from cycle to cycle? In other words, is it worth trying a particular protocol again if the first cycle yielded nothing?

I think he’ll say that there can be variability from cycle to cycle even with the same protocol, although I’m guessing that he will also suggest a protocol change…

<<<BUZZ!!!>>>

The outcome is not likely to change much if you use the same protocol. But I would recommend changing the protocol.

8. Do you recommend trying low stim (like last time) vs. high stim? What do you think about ‘natural cycle IVF’?

Based on what I’ve heard from other CCRM patients, I think he’ll say, “There are no scientific studies to suggest that high levels of stimulation drugs damage eggs, nor any that show better outcomes for low-stim or natural cycle IVF (whether for DOR sufferers or others).” He might also add that IVF is a numbers game, and that the goal is to get as many mature eggs as we can, and that high doses of stims are our best bet to get them.

<<DING!>>

Natural cycle IVF is “a total waste of time.” You’re not taking anything to prevent ovulation, and there’s a 40% chance of ovulating prematurely. With mini-IVF [low-stim], you’ve basically decided, “I’m gonna be happy with 2 or 3 eggs.” I suggest that you give this “one really good try” [meaning with high-stims]. If you try the “Bazooka” protocol and only get 2 or 3 eggs anyway, then you’ll know that mini-IVF is just as good in your case…plus it’s a lot cheaper.

9. What particular stims would you recommend in my case? What sort of suppression drugs would you use? (Ganirelix? microdose Lupron (agonist)? Other?)

I have no idea what he’ll say. Since my cycle with Clomid/Menopur + Ganirelix yielded just three eggs and no embryos, I might expect that he would suggest trying something different, but who knows.

<<<BUZZ!!!>>>

Your particular protocol will be determined using the results of your one-day-workup.

10. Should I be avoiding alcohol? Caffeine? Exercise? For three months prior to cycling? During my cycle? During stims?

I’m guessing – okay, I’m hoping – that he’ll say something along the lines of, “As long as you’re practicing moderation (defined as 1 alcoholic beverage, 1 cup of coffee, and 1 hour of exercise per day), and assuming that you’re at a healthy weight, there’s no reason to believe that these things would hurt fertility. However, to be safe, we recommend abstaining from all three during your IVF cycle, starting at Day 1 of stims.”

<<DING! DING! Hallelujah! DINGGG!!!>>

Moderate consumption of caffeine and alcohol (up to 1 cup per day of a caffeinated beverage, and up to 3 glasses per week of wine) shouldn’t be a problem. [I volunteered that I would stop when we start stims, so he didn’t say anything about that.]

11. Is limited exposure to organic solvents (in the context of teaching lab courses) a problem?

Again, here’s what I desperately hope he will say: “In the spectrum of organic solvent exposure, working as a lab chemist or chemistry teacher (where you are educated about safety and working in rooms designed with appropriate ventilation and fume hoods) is actually quite safe. Workers at hair and nail salons, dry cleaners, janitors, exterminators, and (non-organic) farmers all have much more dangerous levels of chemical exposure, yet no link has been discovered between these professions and infertility.” I don’t actually think he’ll say this, but I’m confident that it’s true, and it would be so nice to hear (and have C hear) it coming from a world-renowned infertility expert… Sigh!

<<DING!>>

I don’t think that your exposure to chemicals caused your diminished ovarian reserve. [Boo ya!] It’s mainly a concern when we get to the point of embryo transfer. At that point, you will want to avoid chemical exposure, as you would when you’re pregnant.

12. Am I taking the right set & doses of supplements?

I think he’ll say ‘yes’, since my list is essentially the same as the CCRM-recommended list. (The exceptions are that I’m taking a higher dose of CoQ10, along with aspirin, and a high antioxidant drink powder called Nanogreens.)

<<DING!>>

Probably. When you schedule your one-day workup, we’ll give you our list of recommended supplements.

13. Should I be taking PQQ (recommended by my acupuncturist) to promote mitochondria generation?

I’m guessing he’ll say something along the lines of, “There is no evidence to suggest that PQQ improves pregnancy outcomes for patients undergoing IVF.”

<<DING!>>

There are no human studies on PQQ.

14. In your experience, does taking the aforementioned supplements actually make a difference? In AMH and/or FSH levels? In number of eggs retrieved? In embryos that make it to blast? In ultimate pregnancy outcomes?

I’m not sure what he’ll say. I haven’t found any good scientific studies that say these supplements help, but the fact that CCRM recommends them suggests that they at least believe it may help. Dr. Schoolcraft has seen enough patients that he may have an opinion about what the supplements do, even if he hasn’t gotten around to conducting and publishing a study to that effect.

<<DING!>>

Nobody knows. There isn’t good data to support it, but it probably won’t hurt. The groups of common supplements including the antioxidants (of which you have many choices, including pycnogenol, vitamin C, vitamin, E, melatonin, etc.) These decrease reactive oxygen species, which are thought to cause a deterioration in egg quality. Another supplement is CoQ10, which is thought to affect mitochondrial function. However, this has not been shown in human studies, only in a mouse study. Based on the results of the mouse study, the corresponding effective dose in humans would be 600 mg/day.

In the case of DHEA, there is retrospective data, but no good prospective data. There is good prospective data showing that testosterone priming (for at least 21 days) improves outcomes, so we will likely put you on testosterone for 21 days prior to starting stims. Based on the results with testosterone, it looks like androgens are good; it may be that DHEA is just too weak an androgen to show the same result…

15. What do you think about estrogen- and/or testosterone-priming?

Again, no idea.

<<<BUZZ!!!>>>

[See answer to #14, above.]

16. Assuming we were able to get any embryos, would you go for a fresh vs. frozen transfer?

I’m guessing that he’ll suggest we do CCS (see #s 3 and 4, above). In that case, they have to freeze the embryos while performing the testing.

<<DING!>>

I recommend doing CCS, which requires that you freeze all embryos for testing.

17. Do you recommend trying to do multiple retrievals to try and ‘bank’ embryos? How many embryos is ‘enough’?

Given my poor response on my first cycle, I think he will recommend banking embryos. Also, since the cost for CCS is ‘per test’ rather than ‘per embryo’, the most economical option is to bank a bunch of embryos and then test them all at once. The question of ‘how many is enough’ is tough to know up front. If all my embryos test normal, then I may not need that many. On the other hand, odds are good that half or more might not be. The limiting factors for determining ‘how many embryos are enough’ will probably be time and money…

<<<BUZZ!!!>>>

It depends how your first cycle goes. If you only get 1 or 2 embryos, I would probably suggest banking them to have more for CCS; if you get more, it may be worth testing them immediately.

18. What causes DOR? In other words, what could I have done differently (besides have babies in my twenties…)? Could my career choice (organic chemistry) have contributed?

I think he’ll say that he has no idea. It may be a combination of genetic and/or environmental factors, but the only environmental factor that is known to cause a decrease in egg quantity and quality is smoking (which I don’t). On the topic of chemistry and DOR, see my wishful answer to #11.

[I didn’t technically ask this question, but see his answer to #11…]

19. What would be the cost per cycle with CCRM?

I don’t need to ask this one anymore, as I found the answer here.

————————————————————————————————————-

Deep announcer voice: Well done, knalani! You correctly guessed 12 answers out of 17! Bambi, show her what her prize is…

Sultry assistant voice: It’s…a no-expense-paid trip to the lovely city of Denver!

Audience: Ooh! Aah!

Deep announcer voice: Thank you for playing, and we’ll see you next time on…

Audience shouting in unison: GUESS! DOCTOR! SCHOOLCRAFT’S! ANSWER!

[Cheesy game show music]

My fortnight in pictures

I’m sorry for being a bad blogger lately. My excuses are many: we’ve been busy with visitors and travel, I’ve been ‘using up’ all my writing juices on my promotion portfolio (due September 5), and not much has been happening on the infertility front.

Rather than a long, disjointed ‘catch up’ post, I bring you my fortnight in pictures:

1) Got these beautiful flowers from my mom’s college roommate. She suffered with unexplained infertility for 10 years before having two amazing children, now grown.

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2) Did lot of head scratching mid-month. My fertility monitor (which reads the lower stick) never gave a peak reading this month. (It never even gave a ‘high’ reading!) But the cheap-o OPK (upper stick) did give a positive, so we moved ahead with our plan to do natural cycle IUI.

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3) I snapped this shot just after insemination. As you can see, I forgot my lucky socks. 😦 I put a pair in my glove compartment now so I’ll be prepared next time!

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4) Here’s a selfie of me before giving the sperm to the nurse to wash it. I think the recommendation of sticking the ‘sample’ in my bra to keep it warm in transit probably works better for bustier women than me…

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5) I’m proud to say that I’ve been running regularly, thanks to my sister’s nagging encouragement. Nothing anywhere near my marathon days (my longest recent run was 4.3 miles), but it adds up after awhile. I’m just proud to be doing something active again!

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6) A view from one of my runs… Makes me wonder how on earth I waited so long to run again!

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7) C and I decided to take a trip to northern Sonoma for some wine tasting. We stopped on the way up to enjoy the view.

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8) Funny enough, this is about as close as we got to any wineries on our ‘wine trip’.

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9) Instead of wine tasting, we spent a lot of time beer tasting at Russian River and Bear Republic (below), two of our favorite breweries. I didn’t manage to snap any pictures at Russian River – probably because we were enjoying the beer and company too much! (Our friend M is a brewer there and he and his wife J gave us the deluxe tour.)

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10) Aunt Flo showed her ugly face yesterday morning. For what it’s worth, it didn’t catch me off guard, since I’ve started charting again. Anyway, how could I be sad when I’ve got this joker to cheer me up back at home?

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