Advanced Maternal Age

One week ago I turned 35. In pregnancy terms, this makes me officially old.

Visit with the genetic counselor

On Thursday, to celebrate, I got to meet with a genetic counselor through Kaiser (a meeting recommended for AMA women like me). Here’s what I learned:

At 35, my risk for chromosomal abnormalities is much higher than it was at 25. (Okay, so I already knew that!) The counselor was kind enough to point out that – despite the medical community’s black-and-white labeling method – there is nothing magic about the age 35. My risk increased slightly every year, so that now my risk of conceiving a baby with:

  • Down Syndrome (aka Trisomy 21) is 1 in 296
  • Edwards Syndrome (aka Trisomy 18) is 1 in 1152
  • Any chromosomal disorder is 1 in 134

(When you think about the fact that a few months ago, I was looking at odds of successful IVF with my eggs as about 1 in 4, 133 in 134 odds of having a chromosomally-normal baby really don’t look all that bad…)

I also learned a bit about the different disorders. Down syndrome (a disorder arising from three copies of chromosome 21, hence the name trisomy 21) is the most common, but is actually somewhere in the middle of the spectrum in terms of severity and prognosis.

Trisomies 13 (Patau syndrome) and 18 (Edwards syndrome) are more serious. The vast majority of babies with these disorders don’t survive a year. Those that do have severe disabilities.

Then there are the ‘milder’ sex chromosome disorders, like Klinefelter syndrome (in which baby boy gets an extra X chromosome, to get XXY) and Turner syndrome (in which baby girl gets an extra X, to get XXX). These may lead to slight reductions in cognitive function, health problems (e.g. diabetes in the case of Turner syndrome), abnormal physical characteristics (e.g. webbed neck in the case of Turner syndrome, small testicles and man boobs in the case of Klinefelter syndrome) and infertility. (I have to admit to finding it perversely amusing to think about infertility as the most minor of possible birth defects.)

(In case you’re wondering, XYY is also a possibility, but one that apparently doesn’t lead to any noticeable difference in cognitive or other abilities…)

 

Prenatal Screening Tests

To find out my likelihood of having a baby with one of these disorders, I was offered a variety of screening options.

I. California Prenatal Screening Program (PNS)

The first was the California Prenatal Screening Program. The charge for this test is $160 (fully covered by my insurance), and I found it interesting that that the money from all the women who get screened gets thrown into a communal pot. Uninsured women who get a positive screening test are eligible to use funds from the pot to pay for follow-up tests (like amniocentesis), and further prenatal care. Kind of cool.

Anyway, the California Prenatal Screening includes up to three different elements:

A.  A first-trimester blood test that measures levels of two molecules:

  1. human chorionic gonadotropin (hCG) – the protein hormone that’s used to confirm pregnancy in both home pregnancy tests and blood pregnancy tests, and
  2. pregnancy-associated plasma protein A (PAPP-A) an enzyme that chops up other proteins

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First trimester hCG levels tend to be a bit higher in Down syndrome pregnancies than in normal pregnancies, while PAPP-A levels tend to be a bit lower in Down syndrome pregnancies than in normal ones. Here are some figures I found on the interwebs showing the rough trends. In one-dimension:

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In two-dimensions (hCG is on the x-axis; PAPP-A is on the y-axis):

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Notice that there is a large overlap between Down syndrome and normal pregnancies in each plot. The genetic counselor also assured me that the levels change significantly over the course of the pregnancy, so a correct pregnancy date is crucial for an accurate result. Ultimately, this one blood test alone is insufficient to reliably predict Down syndrome risk, which is why the CA screening folks won’t give a result until they have at least one other piece of data, such as the following:

B.  A high-resolution ultrasound called nuchal translucency (NT) ultrasound is used to measure the thickness of a fluid-filled ‘translucent’ layer in the baby’s neck. More fluid in the neck is correlated with higher risk of congenital heart defects, which in turn is correlated with Down syndrome.

Here’s a figure showing normal (right) and Down syndrome (left) NT scans:

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As with the blood test, this is all based on correlations, and just gives probabilities. (We infertiles just love probabilities…) Anyway, it is far from diagnostic.

These first two tests are sometimes referred to as the first trimester screen.

C.  The final data point that can be used as part of the California screen is a blood test in the second trimester. This test is sometimes called the quadruple test or quad screen, as it measures the levels of four molecules:

  1. human chorionic gonadotropin (hCG, see above)
  2. α-fetoprotein (AFP) – the most abundant plasma protein in human fetuses; its function in humans is unknown; AFP levels are elevated in pregnancies of babies with certain birth defects, including Down syndrome and neural tube defects like spina bifida.
  3. unconjugated estriol (UE3) – a  steroid hormone produced in pregnancy; low levels of UE3 may indicate chromosomal abnormalities
  4. inhibin A – a protein that inhibits follicle-stimulating hormone (FSH) production; inhibin levels are especially high in cases of Down syndrome, and especially low in cases of Edwards syndrome

 

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Like with the first trimester screen, the specific levels of these molecules can either more closely resemble a ‘normal’ or a ‘Down syndrome’ (or other chromosomal abnormality) pregnancy.

Even with all three data points, the best the CA screen can do is give probabilities of an abnormality. A probability of 0.5% (1 in 200) or greater is considered a positive test. In other words, the vast majority of women who get a ‘positive’ screening result will go on to have normal babies.

 

II. Non-Invasive Prenatal Test (NIPT)

The genetic counselor informed me that I’m also eligible for a very new blood test called the Non-Invasive Prenatal Test (or NIPT). This test is so new that Kaiser just began routinely offering it to women over 35 in June (which may explain why my OB failed to mention it in our first prenatal visit…even after C and I had made it clear that we wanted every non-invasive test available…)

This test is also a blood test, but instead of measuring the levels of proteins and small molecules in my blood, the NIPT looks at fragments of DNA in my blood. This post is getting rather long, but I’ll try to give the basic gist.

Apparently if you looked at all the DNA in my blood right now, about 10% of it would actually be pieces of DNA from my baby’s blood. Unfortunately, there’s no easy way to recognize which DNA is from me and which is from baby.

It is, however, possible to extract the DNA soup (including mine and baby’s) from my blood, and then make copies of certain portions of DNA from certain chromosomes. (For any biology types, they use quantitative PCR for this.) To detect Down syndrome, they make copies of a piece of DNA that only appears on chromosome 21, along with copies specific to several other chromosomes. Then they compare the amount of chromosome 21-specific copied DNA to the amount of other chromosome-specific copied DNA.

  • If the amounts are the same, it suggests that there weren’t ‘extra’ copies of chromosome 21 floating around to begin with, and that my baby probably does not have Down syndrome.
  • If there is an excess of chromosome 21-specific DNA, it suggests there were extra copies of chromosome 21 in our combined blood. Since we are pretty sure I don’t have Down syndrome, the most likely explanation is that my baby does.

This test catches a higher percentage of Down syndrome cases than the California screen (99% versus 90-95% for the combined CA screen), and has a much lower false-positive rate. (The detection rate is a bit lower for some of the other chromosomal disorders, for reasons that I haven’t taken the time to investigate.) It doesn’t, however, give any information about neural tube defects (which the California screen does), and it still does not give a definitive yes or no answer. For that, one would have to do chorionic villus sampling (CVS) or amniocentesis, both of which actually look at the full set of chromosomes in baby’s cells.

 

What I did

So, if you’ve been reading this blog for long, you know that I’m a sucker for data, so perhaps it comes as little surprise that I requested both tests. I gave blood for part A of the California Prenatal Screening right after my first OB visit three weeks ago. No doubt my results are sitting on a computer somewhere, but they won’t release them until I’ve completed my nuchal translucency ultrasound (part B)…which I’ll do bright and early tomorrow morning.

Last Thursday, after my meeting with the genetic counselor, I gave a blood sample for the NIPT. I’m told the results of that test should come back to me within a week. (Oh, and did I mention, the NIPT will also tell us baby’s gender?!)

Given that the NIPT is so much more accurate than the California screen, one might argue (as the genetic counselor sort of did) that the NT ultrasound is a waste of time. For one thing, there’s a decent chance that the CA screen may indicate an abnormality, while the NIPT may come back normal. If that happens, it may indicate that baby has a chromosomal disorder but is in the very small percentage of cases that are missed by the NIPT. Or, it may mean that baby has no chromosomal disorder, but has an unrelated congenital heart defect (giving rise to the thicker-than-usual nuchal translucency). Or (most likely) it may mean that baby is fine and the CA screen gave a false positive.

The uncertainty could easily cause a lot of stress, which is why the genetic counselor was careful to make sure I didn’t choose it blindly. I’m probably being a bit naïve (or arrogant?), but I’d like to believe that I could think logically about the likelihood of each possibility and handle any ambiguity that might arise.

Also, I really want to see my baby in high resolution.

 

What if?

In all this talk about the science behind these screening tests, I’ve conveniently avoided the most important question that all this brings up.

Namely, what will we do if the screening tests (particularly the NIPT) show a chromosomal abnormality?

The short answer is, I don’t know.

After all that we’ve been through, it’s hard to imagine choosing to terminate this pregnancy under any circumstances. In particular, I don’t think I’d terminate if faced with any of the ‘mild’ abnormalities (Turner or Klinefelter Syndrome). I don’t even think I’d terminate in the case of Down syndrome. (The way I see it, this may be my only chance at genetic parenthood, and I’d rather be mom to a child with Down syndrome than to no child at all…)

The decision gets harder for the ‘severe’ chromosomal abnormalities – trisomy 13 or 18. Could I continue with all the emotional and physical pains of pregnancy and childbirth, knowing that my baby would in all likelihood not survive infancy?

On the other hand, could I choose to end a life – my baby’s life – even knowing that it wouldn’t live long anyway?

I just don’t know.

And then there’s the fact that this isn’t just my decision. This decision would affect C too, and we’d need to somehow arrive at a plan together.

It’s enough to make me think that the people who refuse to test are on to something. Perhaps mothers like me – who aren’t prepared to terminate yet do decide to test – are just betting on a negative test result so that we can enjoy rest of our pregnancies with one less thing to worry about…

Well, I’ve already placed my bet, so all I can do now is wait and hope that my big gamble pays off.

I’ll keep you posted.

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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)…

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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Old procrastinating reneger

I have a confession to make. I’ve been procrastinating from writing a sequel to my post on Supplements. I’m long overdue on an entry about antioxidants (a category that includes most of the pills I’m taking).  I’ve been working on it off and on for a few weeks, but just can’t seem to find the motivation to finish it!

In place of that post (for now), here are a few odds and ends:

1)      I forgot to mention that Dr. Y gave me copies of all my medical records at my appointment on Monday. I had asked for these to send to CCRM in advance of my upcoming phone consultation. Of course, I couldn’t resist the temptation to read the records in detail. Most of it seemed run-of-the mill but I noticed two things that caught me off guard. The first was that I was listed as having a diagnosis of “secondary infertility”. I thought this term referred to people who already had one or more kids. Does one early miscarriage really mean I don’t qualify as “primary infertility”? The other surprise was that the embryology report listed me as having “Advanced Maternal Age”. I’m 34. I thought I had at least a few more months before graduating to the “Advanced Maternal Age” club. I did a Google search and learned that apparently the definition applies to women who are 35 or older at the time of childbirth. So apparently I do belong…assuming I ever get pregnant. I feel old! (No offense…)

2)      AF arrived today, making this a whopping 18-day cycle. (Has anybody else had such a short cycle after egg retrieval?) Anyway, that leads me to believe that my fertility monitor was actually working properly, and I didn’t ovulate this month. We’ll try natural IUI again next month…

3)      I planned poorly and just realized that I am going to be a bad ICLW-er this week. Tomorrow we’re leaving for a camping trip to Pinecrest in northern California. I just learned that they don’t have WiFi or reliable cell service, so I’m probably not going to be able to blog or comment until I get back next Wednesday. I’ve been trying to ‘bank’ lots of extra comments in the first half of the week, but I still feel like a schmuck for reneging on my commitment… Sorry!

Have a great week everybody!

Message to my fertile friends

Not too much has been happening here. We finally finished up the 10-week summer research session, and I am officially “off” for the rest of the summer. (By “off,” I mean I get to sit on my couch in my PJs working on my promotion portfolio and prepping for fall classes…) It’s nice.

As many of you know, our current plan, in the wake of failed IVF#1, is to spend three months trying to improve egg quality through supplements, while also doing natural cycle IUIs. I’ve been using my CBFM, and was supposed to call the office to schedule insemination as soon as the monitor indicated impending ovulation (by displaying a little egg). We also made a just-in-case appointment for cycle day 16, in the event that the egg never appeared in the monitor window.

Today was cycle day 16, so I went in for that just-in-case appointment. The dildo cam showed no lead follicle: either this is an anovulatory cycle, or we missed ovulation. (Once again, I find myself regretting getting lazy on the BBT charting; if I had kept up, I’d know for sure which it is.) But I’m actually not that disappointed. There’s a very slim chance that we could get pregnant this month, but if not, I’m fine trying again next month.

I’ve also been dutifully taking my long list of supplements. While I have definitely NOT been “living like a monk,” I have been trying to eat well whenever possible. I’ve cut back on coffee, Diet Coke and alcohol – to 2-3 servings of each per week…instead of 1-2 servings per day. (Shoot! Does that make me sound like a lush? I just like my nightly glass of wine!) Thanks to my sister’s persistence, I’ve also started running again. We’ve gone three times in the last week; it’s only been 2.5 to 3 miles each time, but a huge improvement over the absolutely nothing that I’ve been doing for the last year and a half…

*****

But the real reason for this post is that I got an email this week that was equal parts delightful and heartbreaking, and made me want to think carefully about how my words are received.

I hope A will forgive me for sharing parts of her email here:

Hi K,

I’ve been following your blog and seeing that things are not going as you might have wanted.  I’m sorry.  I also realize you sometimes feel ‘ill-will’ according to one of your previous posts about people who have some success.  Knowing that — I still need to tell you …

that we are 18 weeks pregnant and close to going ‘facebook public.’  I didn’t want you to find out on facebook. What you’re going through is emotionally and physically draining, but as you well know — I don’t really know… I don’t understand — regardless of how much I think I might or try.  It’s very personal and I’m really happy for you that you’ve found a support network of women through your blog who do understand.  It’s also wonderful to read about how your relationship with ‘C’ has strengthened and deepened through this difficult time.

…Anyway, I’m emailing you because I didn’t want you to be surprised on facebook and wanted to tell you that you do not need to respond.

I look forward to seeing you again (someday) and I am always thinking happy, reproductive, follicular, warm fuzzy thoughts in your direction.  🙂

Your friend,

A

This message was delightful, because I’m so happy for my friend, who had been trying for awhile for a second child, and suffered a sad loss shortly before ours. I was also deeply touched that she had given so much thought and time to writing such a compassionate message.

It was heartbreaking that such an amazing friend could possibly think I might feel the slightest bit of ill-will towards her or her baby.

So this message is intended for my fertile friends. (The sentiment is equally true for my ‘lucky’ infertile bloggy friends who are now expecting.)

When I shared my blog with you, I made a choice to let you in on my most personal, raw, and unfiltered thoughts. I didn’t do this by accident. It was a sign of just how much I love and trust you.

So, please believe me when I say that I do not, will not bear you or your children any ill-will.

  • If you decide to outdo the Duggars and have 30 kids,
  • If, in your genuine attempts to comfort me you say all the wrong things,
  • If you go on to have an absolutely perfect life full of glitter and unicorn farts with your gorgeous brood of children,*

I will NOT bear you any ill will.

Believe me. It’s the truth. (And if you know me well enough for me to have shared this blog with you, then you know that I’m a terrible liar!)

Now, you may wonder, to whom do I direct all my anti-fertility ill will? Most fall into one of the following groups:

  1. Anonymous pregnant women that I see everywhere. Yes, I know. It’s totally unfair. I have no idea what they’ve been through, or the kind of parents they’ll be. I’m sure if I meet them in the future, I’ll be happy for them then. But for now, I hate them.
  2. People I never liked in the first place. If they never bothered to make time for me or show the slightest interest in developing a friendship before they were pregnant, then I feel no obligation to wish them well in their baby-making efforts now.
  3. Bad parents. These include stupid and/or oversharing parents (STFU, Parents has all the examples you never wanted to know), neglectful-to-abusive parents (Tan Mom gets to be fertile? Seriously?), and truly evil ones (The rumor that World’s Worst Mom Casey Anthony is pregnant again may have been a hoax, but that doesn’t change the fact that she never deserved to be a mom in the first place!)

As you can see, there is no shortage of targets for my infertility bitterness and ill-will.

You, dear reader, are not one of them!

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* References to glitter and unicorn farts are shamelessly stolen from the amazing Jenny at Stupid Stork.

Infertility math*

This post was primarily inspired by a recent, lovely post by Jane at Mine to Command who confronted the myth that stress causes infertility. She delves into the medical literature on the subject, so I won’t provide my own (undoubtedly less eloquent) rehashing of what she’s said there. Go read it! Then come back, if you like.

The myth that stress causes infertility is a pervasive one. And, its logical consequence – namely, that infertiles should “Just relax, and you’ll get pregnant – has lead to a laundry list of charming little chestnuts of advice including:

  • Just adopt, and you’ll get pregnant.
  • Go on vacation, and you’ll get pregnant.
  • Get drunk, and you’ll get pregnant.
  • Don’t try so hard, and you’ll get pregnant.

and so on…

This myth originated – and continues to be fueled – by the observation that indeed many infertile couples get pregnant when they stop trying.

Although I’m not a medical practitioner and haven’t consulted the scientific literature on this particular topic, my intuition (aided by some basic mathematical understanding) tells me that this observation is probably true: many infertiles do get pregnant when they “aren’t actively trying”.

Before you chase after me with torches and pitchforks, please let me explain…

While I do think that the probability of getting pregnant while not “trying” is significant (in some cases rivaling the probability of getting pregnant through medical intervention), the often-touted “logical consequence” of this observation – that infertiles should stop trying to get pregnant…in order to get pregnant – is complete and total hooey!

I’m a chemist, but I nearly minored in math. I’m particularly grateful that I took statistics (both math stats and biostatistics), which comes in quite handy in situations like this…

So, why do so many couples get pregnant when they aren’t actively trying?

As Jane pointed out, this is kind of a silly question. Anybody who is having sex without birth control is, on some level, trying to get pregnant. So immaculate conception and birth control failures aside, everyone who gets pregnant is technically trying. But any infertile knows that there’s a wide spectrum of “trying”, all the way from “pulling the goalie” (aka unprotected intercourse) to spending tens-of-thousands of dollars for the privilege of being poked with needles, pumped full of hormones, subjected to minor and/or major surgery, and violated on a regular basis by an ultrasound wand, among other things…

Statistics provided by reproductive endocrinologists – the infertility experts – tell us that our odds of conceiving are significantly increased by all these interventions. Consider the following per-cycle odds of conception for several common interventions:

Intervention Per-cycle odds of conceiving** Source
timed intercourse 5% Health.com
natural cycle IUI 5-10% Babycenter.com
medicated IUI Up to 20% Babycenter.com
IVF 46% SART

I couldn’t find any odds for “not trying”, but I think it’s safe to say that they would be less than 5% per cycle.

So, how on earth is it possible that so many infertile couples get pregnant after they’ve stopped trying, even though their odds are so much less – more than 9 times less compared to IVF?

The key words here are per cycle. The odds, per cycle, of success from IVF are nine times that for timed intercourse (and >9 times that for ‘not trying’). But how many cycles of IVF do people actually do? Looking around the blogosphere, I can find lots of examples of people who have done IVF two, three, four times. But at over $10K a pop, few people have the financial means (or an IVF clinic willing to risk hurting its SART stats) to do many more cycles than that.

On the other hand, an infertile couple might have 5-, 10-, 20-years of “not trying” to get pregnant. For a woman who ovulates regularly every 28-days, that corresponds to as many as 65, 130, or 260 cycles of not actively trying to get pregnant.

So, how do we do the math to figure out the odds of getting pregnant by “not trying” versus using a technology such as IVF?

Let’s take an example of a couple that tried IVF three times unsuccessfully, adopted a child, then had unprotected sex for ten years:

First, let’s calculate their odds of a pregnancy resulting from three rounds of IVF. (In statistics, it’s actually slightly easier to calculate the odds of something not happening, and then to convert that to the odds of that thing happening…)

  • According to SART, the average odds of a pregnancy resulting from one cycle of IVF for a woman under 35 are 46%. We can express this value as the decimal 0.46.
  • That means the odds of not getting pregnant from one IVF cycle are 100-46 = 54% or 0.54.
  • The odds of not getting pregnant after two rounds of IVF are 0.54 x 0.54 = 0.29 or 29%.
  • The odds of not getting pregnant after three rounds of IVF are 0.54 x 0.54 x 0.54 (or 0.54 to the third power, 0.54^3), which equals 0.16 or 16%.
  • Now, to get the probability of a pregnancy resulting from three IVF cycles, we just subtract from 100% the probability of not getting pregnant: 100-16 = 84%. (Not bad odds! It seems our hypothetical couple – like many of us – was on the unlucky side of these stats…)

Now let’s calculate the odds of getting pregnant from ten years of unprotected sex.

  • For the sake of argument, I’m going to estimate that the couple’s per-cycle odds of pregnancy are a mere 1% (0.01). (Given that the per cycle odds for infertile couples practicing timed intercourse is estimated at 5%, I think 1% odds for “not trying” is actually pretty conservative…as long as the couple is having sex…) If the odds of a pregnancy are 1%, that means the odds of not getting pregnant are 99% or 0.99 per cycle.
  • The odds of not being pregnant after two cycles are 0.99 x 0.99 = 0.98, or 98%.
  • The odds of not being pregnant after three cycles are 0.99^3 = 0.97. In other words, there is only a 3% chance of a pregnancy resulting from three cycles of “not trying” – not even close to the 84% odds from three cycles of IVF.

Like interest on a long-held bank account, things start to get interesting as these paltry odds compound over large numbers of cycles…

  • The odds of not being pregnant after 13 cycles (one year) are 0.99 to the thirteenth power (0.99^13) or 88%. That means the odds of a pregnancy resulting from those 13 cycles is 12% (100 – 88 = 12). In other words, more than one tenth of “infertile” couples will be pregnant after a year of “not trying”. (Thereby supplying ample anecdotal “evidence” for annoying fertiles to misinterpret and hold up to their infertile friends…)
  • The odds of not being pregnant after 130 cycles (0.99^130) are 0.27, or 27%.

In other words, after ten years of “not trying”, this “infertile” couple had a 73% chance of achieving at least one pregnancy. (And remember, that pregnancy could occur randomly at any time during the ten years of not trying…)

How do you suppose most people interpret this series of events?

The facts: a couple failed to get pregnant from three rounds of IVF, adopted a child, and then got pregnant after a few years of not actively trying to get pregnant.

I can think of a couple of likely interpretations:

“After becoming parents through adoption, they were finally able to “just relax” and get pregnant!”

“In adopting, they were able to resolve the karmic imbalance that had previously interfered with their attempts at pregnancy!”

Nonsense! The real reason is far less romantic:

Over the course of many years of regular unprotected sex (albeit without officially “trying”), chances are that at least once, healthy sperm would meet with healthy egg at the right time to fertilize, and travel through the fallopian tube to find a uterus in just the right condition for implantation.

As Jane would say, “it was just their time.”

For women with diminished ovarian reserve (like me) the odds of conceiving by IVF are far below the 46% average I used in the example above (see this post for the depressing stats). Yet it’s not known how significantly DOR affects our chances of success through natural conception (which only requires one good egg each month…) In such cases, it’s easy for me to believe that the odds of conceiving from 100+ cycles of “not trying” could exceed the odds of conceiving from a handful of IVF cycles!

Am I saying we should all “just relax” and abandon assisted reproductive technologies?

No way! I can think of several good reasons to take a more aggressive approach:

  1. I don’t want to wait ten years to have a decent chance at a pregnancy! (Since I didn’t start until 33, I don’t even have 10 years of trying left in my old lady ovaries anyway…) I want my child yesterday! I want to change her diapers, not ask her to change mine. ART gives me the best odds of a child soon!
  2. Unlike in my simplified example, our odds of success are not static. My odds of pregnancy with my eggs – whether via ART or natural conception – are decreasing every month. With that fact hanging over me, it’s hard to justify waiting around for years for a natural conception. I can always try (or “not try”) for a natural conception after trying other family-building options (IVF, adoption, etc.) But ten years from now, if natural conception doesn’t work, I can’t go backwards and do IVF (at least not with my own eggs, which will have long dried up by then…)
  3. It’s not an either/or situation. If the odds of a pregnancy in my hypothetical example were 84% for three rounds of IVF, or 73% for 130 cycles of “not trying”, the total probability of a pregnancy – given that this hypothetical couple used both methods – was an almost unbelievable 96%! (1 – 0.16 x 0.27 = 0.96). Carefully timing intercourse instead of “not trying” should increase the odds further. Trying a combination of aggressive treatment (using ART) and regular unprotected intercourse will give me the very best odds of a biological child.
  4. There’s comfort in knowing that I’ve “tried everything”. If things don’t work out, and I end up on the unlucky end of all these statistics, at least I won’t wonder whether I might have been a genetic parent, “if only I’d tried X…” I’d rather go ‘all in’ now, and then move on to the next family-building option (or child-free living) without regrets.

As you’ve probably figured out by now, my plan is to continue with high-tech treatment…and to break out the Marvin Gaye around ovulation time every month in between!

It’s a plan that will mean a lot of two-week waits,…

a lot of peeing on sticks,…

and charting temps,…

and reading signs…

You’ll understand if I get tired of all the effort and decide to “take a break” and skip the meticulous timing for a few months…

And if, by chance, I happen to get pregnant that cycle,…

For heaven’s sake, DON’T use me as an example of how you “know this girl who got pregnant as soon as she stopped trying!”

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*I can’t write about Infertility Math without acknowledging this brilliant post by Aramis at It Only Takes One.

**Odds shown are for infertile couples (that is, couples who have been trying unsuccessfully for at least a year) in which the woman is less than 35 years old. Other factors can dramatically change these odds. For example, when fertile couples are included, the per-cycle odds are much higher – as high as 25% per cycle for timed intercourse. For older women, the per-cycle odds are lower in each case. Also, note that these stats show approximate pregnancy rates. The live birth rates are (sadly) lower due to miscarriage…

Family reunion

Sorry for being a bad bloggy friend this last week. I just got back from my family reunion in Colorado. My dad’s side of the family has a reunion in the mountains of Colorado every 3 years. This year, 65 of us – all direct descendants of my 90-year-old grandmother – made it to the YMCA of the Rockies in Estes Park.

This was my first post-infertility reunion. And it was hard. Our crew of 65 included 22 kids. And not just any kids, but freakin’ adorable, sweet, funny kids. The kind of kids that I want to have. The weekend also included a large amount of marveling at genetic parenthood – how virtually everybody there owed their life (or their spouse’s life) to this one woman – my grandma. Now don’t get me wrong, my grandma is awesome! But it still stings to think that I likely won’t have any genetic children…or grandchildren…or great grandchildren…

But enough of this pity party. There was a lot to be thankful for. For one thing, not one single person asked when we would have kids, or why we didn’t have any yet.

(I suspect this has something to do with a little incident last summer… After getting my positive pregnancy test, I texted my parents a photo…which my dad immediately posted on Facebook! I called him and made him take it down right away, but several relatives had already seen – and ‘liked’ or commented on – it. Seeing as there is now no baby, I can only assume they figured out what happened and had the decency not to comment on it. Either that, or everybody thinks I’m still in my twenties and have plenty of time – neither of which is true, but who can keep track when there are so damn many of us?!)

Another plus of the weekend: my adorable husband. A few weeks ago, I casually mentioned that wheatgrass juice is allegedly supposed to help with egg quality. The next week, I got home from church to find this in my kitchen:

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A couple weeks later, C decided that blending and straining the wheatgrass wasn’t good enough, and ordered a mechanical wheatgrass juicer.

This sweet man couldn’t imagine me going for almost a week without any wheatgrass, so he packed the juicer and a bag of wheatgrass in a little cooler, brought it along, and made me wheatgrass juice each day that we were there, cleaning the juicer in our room sink after each serving. 😉

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He also offered to “live like a monk” with me, giving up alcohol and unhealthy food for the next three months. (Okay, so part of the reason is that he wants to lose weight, but I still found it adorable.)

And on our last night there, after an abrupt and heavy downpour, the sun came out to reveal the most amazing double rainbow I’ve seen in years! (I would say ever, but I grew up in Hawaii, so I’ve seen some pretty amazing rainbows…)

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I’m not sure when or how, but in moments like this, I know that everything really is going to be alright!

This and that

AF arrived yesterday, so I went to see Dr. Y for a baseline ultrasound this morning. While we are waiting for my supplements to take effect, we figured it couldn’t hurt to do a few cycles of natural IUI. (As C puts it, “so we can feel like we’re doing something…”) Originally, Dr. Y had suggested taking Clomid during the IUI cycles, but I had second thoughts about pumping my body with drugs when I’m supposedly trying to use acupuncture, supplements and diet to achieve a monastic zen-like state that will maximize the quality of my remaining eggs (or something like that…) Dr. Y quickly jumped on board with the plan, especially since he spotted a large ovarian cyst on ultrasound. The cyst would have precluded using any drugs anyway, so natural cycle it is!

The plan is for me to use an over-the-counter ovulation predictor kit (I’ll probably just stick with my CBFM) to detect my natural LH surge, and then to call the office to schedule insemination (aka turkey baster) the next day. The way I figure it, each month we get a chance (however small) that this egg might be ‘the good one’. If this month’s is the good egg, delivering C’s little swimmers directly to my uterus might slightly increase the chance that it gets fertilized.

Plus, summer research is almost over, so I’ve got time to kill. And Kaiser covers it. So, why not?

*****

I went to my second Resolve meeting last week. It was awesome. I got a lot of support in my decision to schedule a phone consultation at CCRM. More importantly, I also got a healthy dose of “it could be worse.”

Not that anybody would have said anything so insensitive, but hearing stories from my sisters in infertility helped remind me that, crappy as DOR is, it is not the worst diagnosis possible. The fact remains that C & I still have one very good option – IVF with donor eggs. Yes, it would mean giving up on genetic offspring (those adorable little hapa babies with my nose and C’s hand-eye coordination…) But it would bring our odds of success with IVF up to 70% or more per cycle. It would also ‘stop the clock’ on our fertility issues, meaning that we could have as many kids as we want, and time them as far apart as we want (well, almost… I think legit clinics refuse to transfer once I turn 50…) And our risk for age-related chromosomal issues would drop to whatever they are for our twenty-something donor.

Oh, and while I’m counting my blessings, I should probably mention that we are in the fortunate position of being able to afford egg donation as an option. (The same might not be said for a gestational carrier, which runs around $100K per try. So, we’re thankful that my uterus seems to be in good shape!)

Don’t get me wrong, I’m not giving up on my eggs just yet, but it’s nice to know that we have a good option tucked away in the sock drawer, waiting for us to pull it out whenever we’re ready. It’s also nice to know that there will be a great group of gals (and guys) down in the trenches with us who will support us, whichever path we choose.

*****

Last but not least, I got the sweetest gift from our fertile friends, S & Q. (These are the same ‘thoughtful ninjas’ who dropped off gorgeous flowers the night before a doctors visit, and a delicious care package of tasty treats on retrieval day.) Last week, the ninjas struck again, this time leaving this St. Gerard keychain:

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(It was timely, as I got it a few hours after reading this post by Risa at Who Shot Down My Stork? about the St. Gerard medal she got from a friend.)

As many of you know, I’m a practicing Roman Catholic (which I wrote about here), and St. Gerard is the Patron Saint of Motherhood. The Church uses a rather broad definition of motherhood here, including expectant mothers and mother-wannabes like me; as a result, couples trying to conceive will often pray to St. Gerard. (Another option is St. Gianna Beretta Molla, Patron Saint of Mothers, Unborn Children, and Physicians.) For any of you who are Catholic (or just willing to try anything at this point), here’s a common Prayer to St. Gerard:

O good St. Gerard, powerful intercessor before God

and Wonder-worker of our day,

I call on you and seek your help.

You who on earth did always fulfill God’s design,

help me to do the Holy Will of God.

Beseech the Master of Life,

from whom all paternity proceeded,

to make me fruitful in offspring,

that I may raise up children to God in this life

and heirs to the Kingdom of His glory

in the world to come. Amen.